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Abstract

Men are reluctant to seek psychological help as doing so may label them as weak and vulnerable. Thus, we tested whether a first-person storytelling video could buffer men’s self-stigma of seeking help associated with traditional masculinity ideology. Adult men (N = 396; M_age = 35.62) were randomly assigned and exposed to one of three conditions: (1) control (nothing), (2) male-sensitive brochure, (3) male-sensitive first-person storytelling video. Controlling for pre-existing depressive symptoms, multi-group path analyses with bootstrapping revealed that greater traditional masculinity ideology was associated with lower psychological help-seeking attitudes via increased self-stigma of seeking help, but this indirect effect was not significant for the video group. The direct effect was significantly lower in the video group compared to the brochure and control groups. The findings suggest that brief male-sensitive storytelling videos may be useful clinical and psychoeducational tools to help men re-examine their resistance toward seeking psychological help for depression.

Keywords

men depression online video narrative storytelling self-stigma

Although effective treatments for depression are available, studies indicate that men are significantly less likely than women to access such services and suffer from untreated depression (Coleman et al., 2020; Seidler et al., 2016). Untreated depression among men is particularly concerning given the risk of suicide. National statistics on suicide indicate that, compared to women, men are 4 times more likely to complete suicide (Centers for Disease Control and Prevention, 2019). In understanding men’s psychological help-seeking for depression, stigma has been an important variable (Vogel et al., 2006). The stigma associated with mental illness has been discussed as a leading cause of underutilization of treatment (Corrigan, 2004). In 2019, about 20% of the U.S. population experienced mental health issues but less than half of these individuals sought care, and men were represented in this group more than women (Substance Abuse and Mental Health Services Administration, 2020).

Literature suggests that men do not seek help due to the belief that doing so would label them as “weak,” “vulnerable,” and “unmanly” (Addis & Mahalik, 2003; Levant, Stefanov et al., 2013). These self-stigmatizing beliefs are rooted in men’s socialization around traditional masculinity ideology (TMI), or the need to internalize and endorse physical toughness, self-reliance, and restrictive emotionality as core concepts of how a man should appear and think to conform to societal expectations (Levant, Hall et al., 2013). As such, greater internalization of TMI has been found to evoke greater self-stigma of seeking help among men, which in turn reduces their propensity for seeking help for mental health issues (Levant, Stefanov et al., 2013; Vogel et al., 2011). Thus, the current study tested whether an empirically-informed first-person storytelling video exposure could help men work through their help-seeking resistance associated with TMI and self-stigma of seeking help, and improve their psychological help-seeking attitudes.

Research has shown that men who internalize TMI view psychological help as a threat to masculine norms (Vandello & Bosson, 2013) and develop negative attitudes toward seeking psychological help (Addis & Mahalik, 2003). In understanding the link between TMI and psychological help-seeking, studies have examined the mediating role of self-stigma of seeking-help (Covello, 2020). Self-stigma of seeking help is defined as the labeling and devaluing of one’s sense of self due to needing psychological help (Vogel et al., 2006). Self-stigma of seeking help is posited to stem from the public stigma associated with seeking mental health services, referred to as “the stigmatizing perception, endorsed by the general population, that a person who seeks mental health services is undesirable or socially unacceptable” (Vogel et al., 2006). For instance, Vally et al. (2018) found that public stigma on seeking help indirectly predicted attitudes toward seeking psychological help through self-stigma of seeking help.

For men who internalize TMI, self-stigma of seeking help may be salient as the thought that men will not be able to solve their depression or other mental health issues on their own is discrepant against the norms of TMI. Indeed, greater internalization of TMI was found to be indirectly related to lower help-seeking attitudes through self-stigma of seeking help among young adult men in the U.S. (Levant, Stefanov et al., 2013). Similarly, Wasylkiw and Clairo (2018) found that conformity to masculine norms was related to greater self-stigma of seeking help, which in turn was related to lower help-seeking attitudes. Given this mediating link, self-stigma of seeking help has received empirical attention as a malleable factor for interventions to target in helping men improve their help-seeking attitudes (Mittal et al., 2012).

Studies are limited on effective strategies to reduce the self-stigma of seeking help and approaches, a common element is psychoeducation, which involves delivering health information through didactic materials (e.g., brochures) and workshops. The effectiveness of psychoeducation strategies, however, has been mixed (Mittal et al., 2012), with some studies finding significant results (e.g., Hammer & Vogel, 2010) while other studies finding no effects (e.g., Alvidrez et al., 2009).

The mixed findings may be due to materials being impersonal to the audience (Janoušková et al., 2017). For example, print materials (e.g., brochures) on health information are often too general and created without regard for specific relevance to the readers’ background (Janoušková et al., 2017). In support of this limitation, Hammer and Vogel (2010) found that a male-sensitive brochure improved men’s attitudes and reduced their self-stigma of seeking counseling to a greater extent than an information-oriented brochure developed by the National Institute of Mental Health and a gender-neutral brochure developed by Rochlen et al. (2006). Compared to the other two brochures, the male-sensitive brochure incorporated language more compatible with masculine beliefs, such as replacing words like “therapist” with “consultant,” describing the client’s ownership and control in the counseling process, normalizing depressive symptoms within the context of masculinity, and explaining the value of associated costs and time for devoting attention to their mental health.

However, the impact of educational brochures may still be limited in their influence in comparison to other contemporary approaches such as the use of multimedia materials (Lusardi et al., 2017). Indeed, short-term interventions using didactic and print materials have been shown to have less effect in reducing mental health-related stigma than contact or video-based interventions (Janoušková et al., 2017). Video-based anti-stigma interventions have been on the rise to align with people’s increasing reliance on social media and digital media communication (Demyan & Anderson, 2012; Janoušková et al., 2017). Videos may be a promising strategy for facilitating a personally- and digitally-relevant medium for individuals to experience a more immersive influence on their beliefs and attitudes toward mental health (Janoušková et al., 2017). For example, Hackler et al. (2016) found that participants who viewed people discussing personal experiences with mental illness and experiences of having family or friends with mental illness resulted in significantly lower mental illness stigma than those who viewed a control video irrelevant to mental health issues. It appears that the videos provided positive experiences with people who have a mental illness, which likely fostered a more favorable view toward mental illness that detach from the pervasive stigmatizing norms in the public (Keum, Hill et al., 2018).

Yet, most of the studies on video-based interventions have focused on general stigma related to mental illness (e.g., negatively stereotyping people with mental illness as crazy or dangerous) rather than stigma toward psychological help-seeking (Janoušková et al., 2017; Morgan et al., 2018). Only one study (Demyan & Anderson, 2012) examined stigma toward psychological services, in which mass-media video intervention was helpful in improving positive attitudes toward psychological help-seeking but not effective in reducing stigma. It is possible that the generalized approach of using a commercial-type mass-media video intervention toward a broader college-aged population lacked personal relevance and specificity in conjunction with the viewers’ experiences with mental health issues and attitudes on mental health services. As noted in Hammer and Vogel’s (2010) study, although video materials may provide a more immersive and interactive medium, the efficaciousness of video-based interventions also likely requires the use of content that is tailored and sensitive to the context and unique experiences of the population and mental health issues being examined.

Building upon this lead and current evidence on video-based interventions, we sought to test a male-sensitive video intervention specifically for depression among men for potential improvements in help-seeking attitudes. One aspect that we incorporated to maximize the potential effects of the intervention was to use a video based on a man’s first-person narrative storytelling of experiences with depression. Storytelling is a powerful medium through which the storyteller’s personal narrative can stimulate the viewers to deeply engage with the intended message of the story (Heo, 2009). Narrative theory (Fisher, 1984) suggests that stories are a natural part of human experiences and a significant medium through which people can share and connect on various life experiences. The storytellers convey their life experiences through stories, and the listeners and viewers can develop interpretations and meaning from the narratives of the stories. Often, the stories contain powerful meaning-making and reflective elements that persuade and motivate people in certain ways (Kreuter et al., 2007). Specific to health-related stories, Harter and Bochner (2009) note that narrative storytelling can help the viewers and listeners to engage in meaning-making around the process of healing, which provides hope and agency for individuals to work through their health issues and seek support. For this reason, narrative storytelling is often used in health communication interventions and persuasive marketing to promote cost-effective attitude and behavior changes, including health-related outcomes such as quitting smoking (Lipsey et al., 2020; Pulizi, 2012), promotion of advocacy against gender-based violence (Mannell et al., 2018), and informing the public about health disparities (Lee et al., 2016).

Three factors of the narrative theory guide how narrative storytelling may promote men’s help-seeking attitudes for depression: transportation, identification, and realism. Green and Brock (2000) suggest that transportation occurs when viewers are absorbed into the narrative flow of the story and are aroused both cognitively and emotionally (Krause & Rucker, 2020). In essence, they are “transported” into the storyteller’s world. Identification also plays a significant factor as it allows the listener and the viewer to engage in perspective taking and visualizing of the storyteller’s positions (Bussell & Bilandzic, 2009). Finally, realism, or how authentic and plausible the story is for the listener and the viewer, helps to connect with the story in a realistic way (Murphy et al., 2013). These three elements help explain how storytelling can persuade listeners and viewers to re-examine their beliefs and encourage them to consider changes in attitudes and behaviors. Based on these mechanisms, it is possible that a man’s narrative storytelling regarding depression and help-seeking efforts may persuade other men to re-examine their core beliefs of TMI and self-stigma of seeking help, and ultimately consider seeking help for depression.

Applying this framework, we theorized that men who view a video of another man telling a real story about their depression and help-seeking experiences may connect with the storyteller at a deeper emotional and cognitive level, thereby being persuaded to form a more positive attitude toward psychological help-seeking. Specifically, we examined whether exposure to such video would be able to buffer the higher self-stigma of seeking help associated with higher TMI among men, which would otherwise result in more negative attitudes toward psychological help-seeking (see Figure 1; Levant, Stefanov et al., 2013). The effect of the video was tested with a controlled design in which the results for the video group were compared to (a) the brochure group, who were exposed to a male-sensitive depression resource brochure (Hammer and Vogel, 2010); and (b) the control group, who were not exposed to any material. We hypothesized that the indirect relations of TMI on psychological help-seeking attitudes via self-stigma of seeking help would be non-significant or significantly lower for the video group compared to the brochure and control groups. In examining the models, we controlled for depressive symptoms as pre-existing levels of depression may be associated with attitudes toward psychological help-seeking (Call & Shafer, 2018).

Figure 1.

Indirect relation of traditional masculinity ideology on attitudes toward seeking psychological help via self-stigma. Note. C = Control; B = Brochure, V = Video. *p < .05, **p < .01, ***p < .001.

Methods

Participants

Participants were 396 adult men currently residing in the United States. Participants’ ages ranged from 15 to 80 years old (M = 35.62, SD = 12.92, Mdn = 32). Most of the participants were White (n = 270; 68%), 10% Hispanic American/Latinx (n = 41), 8% Asian/Asian American (n = 33), 7% African American/Black (n = 29), 4% Multiracial (n = 14), 2% (n = 9) Native American/Alaskan Native, and 1% other (n = 4). About 83% were heterosexual (n = 319), 9% bisexual (n = 37), 4% gay (n = 15), 1% uncertain (n = 3), 1% asexual (n = 3), and 2% other (n = 6). In terms of religion, 51% were Christian (n = 201), 18% Agnostic (n = 73), 16% Atheist (n = 62), 3% Buddhist (n = 10), 2% Earth Religion (n = 7), 2% Hindu (n = 7), 1% Jewish (n = 5), 1% Muslim (n = 3), and 6% Other (n = 28). About 90% (n = 358) indicated that English was their first language.

Male-Sensitive Brochure

We used the evidence-based male-sensitive brochure (MSB) developed by Hammer and Vogel (2010). The MSB incorporated current knowledge from the psychology of men and masculinity and mental health marketing (Hammer & Vogel, 2010) and was developed to be sensitive to unique stigma and attitudes toward seeking counseling among men. The 6-page MSB included the following information: (1) information differentiating the “blues” from depression, (2) pictures of four men and their short accounts of depression experiences, (3) facts about men and depression, (4) a frequently asked questions section, (5) promotion of courage to seek help, and (6) pictures of the four men presented again with a note saying they took the courage to seek help.¹

Real Story Video

The real story videos hosted on HeadsUpGuys (Ogrodniczuk et al., 2018) were shown to the participants. The men in these videos told brief first-person stories about their depression and help-seeking experiences. The videos were 3–4 min long. Videos were racially matched as character identification likely plays a significant role in the impact of the contents (Bussell & Bilandzic, 2009). We used Mitchell’s video for White men and Rich’s video for men of color. These videos were selected as they provided a male-sensitive discussion on difficulties in seeking help for depression. The two stories also contained shared components and seemed particularly relevant to the general experiences of the younger adult men who may not have considered seeking psychological help. Rich talks about the impact of his father’s health tragedy on Rich’s own health, struggling with emotions and feeling alone, struggling at university, isolation, attempting suicide, reaching out, building support, and surrounding himself in positive environments. Mitchell talks about stress at school, feeling helpless from not being able to help an ill family member, not wanting to be a burden on his family, keeping his pain hidden, talk therapy, managing stress, and building a team of supports.²

Measures

Psychological Help-Seeking Attitudes

The Attitudes Toward Seeking Professional Psychological Help Scale-Short Form (ATSPPHS-SF; Fischer & Farina, 1995) was used to assess psychological help-seeking attitudes. The measure contains 10 items using a Likert scale ranging from 1 (disagree) to 4 (agree). Five items are reverse scored; higher scores indicate a more favorable attitude toward seeking psychological help. Validity has been evidenced by positive relationships with U.S. college students’ prior help seeking behavior (Fischer & Farina, 1995), intentions to seek counseling (Garriott et al., 2017), and negative relationships with self-stigma of seeking help (Garriott et al., 2017; Vogel et al., 2006). Internal consistency for the current study was .82.

Self-Stigma

The Self-Stigma of Seeking Help scale (SSOSH; Vogel et al., 2006) was used to assess self-stigma on seeking psychological help. The measure contains 10 items using a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Five items are reverse scored; higher scores indicate stronger self-stigma for seeking psychological help. Validity has been established by negative relationships with attitudes toward seeking professional psychological help and intentions to seek counseling, and positive relationships with public stigma for seeking psychological help (Garriot et al., 2017; Vogel et al., 2006). Internal consistency for the current study was .86.

Depressive Symptoms

Patient Health Questionnaire-9 (PHQ-9; Kroenke & Spitzer, 2002) was used to assess depressive symptom severity. Participants rate nine items on a 4-point Likert-type scale (0 = not at all to 3 = nearly every day). Scores range from 0 to 27 with higher scores indicating more severe symptomatology. Validity and measurement invariance of PHQ-9 with racially-diverse adults in the U.S. has been established (Keum, Miller et al., 2018). Internal consistency for the total scale score in our sample was .92.

Traditional Masculinity Ideology

We used the Male Role Norms Inventory-Short Form total score (MRNI-SF; Levant, Hall et al., 2013) to assess participants’ adherence to traditional masculinity ideology. MRNI-SF is a 21-item self-report measure of total traditional masculinity score and seven subscale scores: Restrictive Emotionality, Self-Reliance Through Mechanical Skills, Negativity Toward Sexual Minorities, Avoidance of Femininity, Importance of Sex, Dominance, and Toughness. Participants are asked to rate their agreement with each item on a 7-point Likert scale from 1 (strongly disagree) to 7 (strongly agree). Higher scores indicate a greater endorsement of traditional masculinity. Validity of the general traditional masculinity factor has been established with positive relationships with other masculinity-related constructs (e.g., Conformity to Masculine Norms Inventory-46; Levant et al., 2015). Internal consistency for the current study was .95.

Exposure Check and Perceived Persuasiveness

To check that participants actually viewed the brochure or the video, we included several exposure check items. For the video, participants were asked (4 choices) what precipitated the depression of the man telling his story in the video. Given that the men talk about the precipitation at length throughout the two videos, we expected participants to be able to adequately answer this question if they had watched the video. For the brochure, we included three attention check true or false items which were all true: (1) There were pictures of men in the brochure, (2) The brochure contained brief stories from men, and (3) The brochure had a frequently asked questions section.

To assess whether the brochure and the video had an intended persuasive impact on the participants (O’Keefe, 2018), we developed four items on a 6-point scale (Not at all to Very Much) that asked participants about their perceived persuasiveness after viewing the brochure/video. Sample items read: “The brochure/video was designed to persuade,” “The brochure/video was trying to advance a particular point of view.”

Procedures

The study was approved by the Institutional Review Board. Participants were invited to take an online survey hosted by Qualtrics. Recruitment messages were advertised through e-mail (e.g., listserves), discussion forums, and online social networks for men residing in the U.S. (e.g., Facebook pages, Yahoo groups, Google groups). Participants were told that they would be reviewing materials for mental health related materials. The survey contained the measures assessing pre- and post-intervention variables, demographic questions, and attention check items (e.g., “Please choose always”). The inclusion criteria for the study were: (a) 18 years or older, (b) identify as a man, (c) currently reside in the U.S, and (d) no previous counseling experiences. Upon consent, participants clicked on an external Qualtrics link and completed a 30-minute survey. Participants had a chance to enter a raffle to win a $50 gift card. At the end of the survey, all participants were provided with debriefing information and resources for depression. Those who endorsed clinically high PHQ-9 scores (>14) or endorsed the suicidality item were contacted to provide additional resources.

Following the pre-intervention measures (in the order of MRNI-SF, SSOSH, PHQ9), participants were randomly assigned to either a control (nothing), brochure, or video condition by the randomize functionality in Qualtrics survey. After viewing the brochure or the video, they completed post-intervention measures (in the order of ATSPPHS-SF, exposure check items of brochure/video, perceived persuasiveness of brochure/video). Participants in the control condition proceeded straight to post-intervention measures (only ATSPPHS-SF).

Analyses and Results

Data Inspection and Preliminary Analyses

Of the 580 participants who completed the survey, we removed 3 cases for not meeting the study consent/inclusion criteria, 69 cases for failing the attention/validity check items, and 112 cases due to missing more than 20% of the data and incorrectly answering exposure check items for the brochure/video. The final sample size was 396, among which 27 cases were missing up to 20% of the data. First, we examined the existence and pattern of missing values in the data set. Little’s missing completely at random (MCAR) test was significant, suggesting that missing data in our sample were not completely random, χ2 (1660) = 1901.85, p < .001. Correspondingly, we used the expectation maximization estimates for multiple imputation of the missing values in SPSS, and calculated the mean or total scores for the corresponding scales, which were used in subsequent analysis. Sample sizes were 149, 137, and 110, for control, brochure, and video conditions, respectively, which were adequate or close to the minimum sample size of 120 to detect at least a small effect based on the message persuasion literature.

We then inspected the distribution of the scale scores and checked the normality of the data. Using the criteria where kurtosis and skewness between −2 and +2 suggest univariate normality (George & Mallery, 2010); all the variables were considered to have a normal distribution. The descriptive statistics and bivariate correlations of the scale scores across the three groups are presented in Table 1. The mean PHQ-9 score for the whole sample was 7.82 (SD = 6.86). In terms of depression severity cutoffs, about 42% (n = 168) of the participants met the none-minimal category, about 21% (n = 82) for mild category, 18% (n = 70) for moderate category, 12% (n = 49) for moderately severe category, and 7% (n = 27) for severe category. We tested for pre-intervention differences across the three conditions by conducting a one-way ANOVA in SPSS. There were no significant differences regarding MRNI-SF, F(2, 395) = .251, p = .78, SSOSH, F(2, 395) = .466, p = .63, and PHQ-9, F(2, 395) = .059, p = .94, suggesting that participants randomly assigned to the three conditions had similar scores on the variables. For the perceived persuasiveness, the mean score for the brochure group was 4.47, (SD = .74; Range = 1–6), and 4.56 (SD = .73; Range = 1–6) for the video group, and independent samples t-test suggested that there were no significant differences between the two groups, t(239) = .96, p = .34.

Table 1.

Descriptives and Bivariate Correlations of Study Variables.

Variables	1	2	3	M	SD	Range	α
Control (N = 149)
1. MRNI-SF	—			3.5	1.31	1–7	.95
2. SSOSH	.47**	—		2.67	.69	1–5	.82
3. ATSPPH	–.48**	–.73**	—	2.7	.55	1–4	.79
Brochure (N = 137)
1. MRNI-SF	—			3.4	1.3	1–7	.95
2. SSOSH	.35**	—		2.66	.8	1–5	.87
3. ATSPPH	–.45**	–.70**	—	2.77	.59	1–4	.83
Video (N = 110)
1. MRNI-SF	—			3.4	1.32	1–7	.95
2. SSOSH	.37**	—		2.6	.77	1–5	.89
3. ATSPPH	–.29**	–.65**	—	2.83	.59	1–4	.83

Note. MRNI-SF = Male Role Norms Inventory-Short Form; SSOSH = Self-stigma of Seeking Help; ATSPPH = Attitude Towards Seeking Professional Psychological Help; PHQ-9 = Patient Health Questionnaire-9. *p < .05, **p < .01, ***p < .001.

Base Model with Full Sample

We used Mplus 8.0 (Muthen & Muthen, 2017) to first establish our base model of the hypothesized paths with the full sample using maximum likelihood estimation (Figure 1). Overall model fit indices suggested that our hypothesized model fit with the data adequately per the recommended thresholds (Hu & Bentler, 1999): χ² = 4.644, df = 1, p = .031; RMSEA = .096 (CI = [.023, .191]); CFI = .987; TLI = .936; SRMR = .036. We proceeded to examine the specific path coefficients and the specific indirect (i.e., mediation) effect. To calculate the indirect effect, we adopted the bootstrap method with 5000 random samples, which has the advantage of not assuming a normal distribution and using randomly generated samples to more accurately determine the standard errors, confidence intervals (CI), and the significance of the indirect effect (Hayes & Scharkow, 2013). We used the 95% CI to assess the significance levels: if the 95% CI did not include zero, the estimates were considered significant at the p < .05 level.

The direct path from MRNI-SF to ATSPPH was negative and significant (β = −.21, p < .05), and the path from MRNI-SF to SSOSH was positive and significant (β = .34, p < .05). The path from SSOSH to ATSPPH was negative and significant (β = −.63, p < .05). The path from PHQ9 to ATSPPH was not significant (β = .02, p = .61). Overall, we found a significant negative direct effect of MRNI-SF on ATSPPH (β = −.206, 95% bootstrapped CI = [−.270, −.142]) that accounted for 49.2% of the total effect, and a significant negative indirect effect via SSOSH (standardized indirect effect β = −.213, 95% bootstrapped CI = [−.265, −.161]) that accounted for the remaining 50.8% of the total effect. Results suggested a partial mediation pattern for the overall sample.

Multi-Group Analysis Across the Conditions

We first tested whether the structural paths were equivalent across the three conditions by conducting a multi-group analysis in Mplus 8.0. Specifically, we compared an unconstrained model that allowed the structural paths to be freely estimated across the three groups, and a constrained model that fixed the corresponding structural paths to be the same across the three groups. Model fit indices showed that, for the unconstrained model, the overall model fit was adequate: χ² = 8.121, df = 3, p = .044; RMSEA = .114 (CI = [.017, .211]); CFI = .984; TLI = .919; SRMR = .046. The constrained model also showed adequate fit indices: χ² = 20.058, df = 11, p = .045; RMSEA = .080 (CI = [.012, .133]); CFI = .971; TLI = .961; SRMR = .090. Because these two models were nested, we conducted a scaled chi-square difference test: Δχ²= 11.281, Δdf = 8, p = .186. This indicated that the overall fit for the constrained model was not significantly different than the unconstrained model when we fixed the structural paths to be equal across the three groups, and suggested that the structural path models did not show significant differences across the three groups. We retained the constrained model and estimated the bootstrapped (5000 random samples) path coefficients and the indirect effects for the three groups. The completely standardized path coefficient estimates are presented in Figure 1, and the significant total direct, total indirect, and specific indirect effects are presented in Table 2.

Table 2.

Estimate of Indirect Effects from Bootstrap Analysis.

IV	Mediator(s)	DV	Standardized Effect Estimate	SE	95% Bootstrapped CI
Control
Total effect
MRNI-SF		ATSPPH	–.502	.061	[–.621, −.383]
Total direct effect
MRNI-SF		ATSPPH	–.191	.066	[–.321, −.061]
Total indirect effect
MRNI-SF →	SSOSH →	ATSPPH	–.311	.050	[–.409, −.213]
Brochure
Total effect
MRNI-SF		ATSPPH	–.452	.065	[–.579, −.324]
Total direct effect
MRNI-SF		ATSPPH	–.236	.064	[–.361, −.112]
Total indirect effect
MRNI-SF →	SSOSH →	ATSPPH	–.215	.051	[–.316, −.115]
Video
Total effect
MRNI-SF		ATSPPH	–.271	.087	[–.441, −.101]
Total direct effect
MRNI-SF		ATSPPH	–.168	.073	[–.312, −.024]
Total indirect effect
MRNI-SF →	SSOSH →	ATSPPH	–.103	.059	[–.218, .012]

Note. MRNI-SF = Male Role Norms Inventory-Short Form; SSOSH = Self-stigma of Seeking Help; ATSPPH = Attitude Towards Seeking Professional Psychological Help; PHQ-9 = Patient Health Questionnaire-9; IV = Independent Variable; DV = Dependent Variable; SE = Standard Error; CI = Confidence Interval. *p < .05, **p < .01, ***p < .001.

For the control group, the direct effect was significant (standardized effect = −.191, SE = .066, 95% bootstrapped CI = [−.321, −.061]) and accounted for 38% of the total effect. The indirect effect was significant (standardized effect = −.311, SE = .050 95% bootstrapped CI = [–.409, −.213]) and accounted for the remaining 62% of the total effect. These results suggested a partial mediation pattern (see Table 2).

For the brochure group, the direct effect was significant (standardized effect = −.236, SE = .064, 95% bootstrapped CI = [−.361, −.112]) and accounted for 52.2% of the total effect. The indirect effect was significant (standardized effect = −.215, SE = .051, 95% bootstrapped CI = [−.316, −.115]) and accounted for the remaining 47.8% of the total effect. These results suggested a partial mediation pattern (see Table 2). The Wald test of parameter constraints suggested that the indirect effect on ATSPPH for the brochure group was not significantly different than the indirect effect on ATSPPH for the control group, χ² (1) = .817, p = .37. Between the control and brochure group, the direct path was not significantly different, χ² (1) = .463, p = .496.

For the video group, the direct effect was significant (standardized effect = −.168, SE = .073, 95% bootstrapped CI = [−.312, −.024]) and accounted for 62% of the total effect. The indirect effect was nonsignificant (standardized effect = −.103, SE = .059, 95% bootstrapped CI = [−.218, .012]) and accounted for the remaining 38% of the total effect. Hence, as hypothesized, with the video group, the nonsignificant indirect effect suggested that the video had a buffering role on the indirect relations of MRNI-SF and SSOSH on ATSPPH (see Table 2). Of note, the direct effect was approaching non-significance as the upper 95% CI was reaching 0. Compared to the brochure and control group, the Wald test of parameter constraints suggested that the direct path from MRNI-SF to ATSPPH was significantly lower for the video group compared to the brochure group, χ² (1) = 11.282, p = < .001, and the control group, χ² (1) = 8.745, p = .003.

Discussion

This is the first study to examine the role of online video-based narrative storytelling in improving men’s psychological help-seeking for depression. The findings suggest that exposure to a brief first-person storytelling video significantly buffered the negative impact of self-stigma of seeking help associated with TMI. In fact, self-stigma of seeking help was a non-significant mediator only in the video group, whereas both the control and brochure groups yielded significant partial indirect relation of TMI on psychological help-seeking attitudes via self-stigma of seeking help. The significance of the direct link between TMI and attitudes was also significantly lower in the video group compared to the brochure and control groups. Thus, in line with the framework of narrative storytelling (Fisher, 1984; Kreuter et al., 2007), the intended persuasive and immersive influence of a first-person storytelling nature of the video (Lipsey et al., 2020) may have been effective in encouraging men to be transported into the story, identify with the storyteller, and be aroused emotionally and cognitively. This experience may have ultimately allowed men to re-examine and reshape their self-stigmatizing beliefs in seeking help associated with TMI and become more open to considering psychological help-seeking (Levant, Stefanov et al., 2013).

As we speculated about content sensitivity and specificity, the use of male-sensitive and depression-specific video content may have been the major driver behind the findings. Whereas a generalized mass-media intervention had no effect in reducing the self-stigma of seeking help (Demyan & Anderson, 2012), the men in the current study were exposed to a more personally- and masculinity-relevant video that might have augmented the process of realism (Murphy et al., 2013) and identification (Bussell & Bilandzic, 2009). As we reviewed, perceiving the story and the storyteller to be authentic and identification with the storyteller are key requirements for effective persuasive storytelling (Bussell & Bilandzic, 2009). In the current study, to augment identification, racial matching was also conducted given the disparities in depression experiences between White men and men of color (Griffith et al., 2012; Vogel et al., 2011). Ideally, more specific racial matching among men of color would have been preferred, but the male-sensitive approach and racial matching, coupled with exposure to a powerful medium of storytelling, likely maximized the men’s identification with the storyteller and the favorable message toward psychological help-seeking.

One interesting finding is that while the video had a buffering role, the video and brochure groups did not significantly differ in the perceived persuasiveness. This is especially notable since the indirect effect in the brochure group was significant, and not significantly different than the condition group, even though the perceived persuasiveness of the brochure was similar to that of the video. This discrepancy may be reflecting the transportation mechanisms of the storytelling framework that was not assessed in the current study. For instance, exposure to immersive storytelling has been shown to increase empathy toward particular characters or issues presented in the story (Bang & Yildirim, 2018). In our case, it is possible that men in the video group may have developed greater empathy toward men experiencing depression.

Harnessing the intersection of online media and the power of persuasive narrative storytelling, our findings show potential for storytelling videos such as the ones tested in the current study for shifting the culture and narrative around men’s help-seeking for depression. This implication is particularly timely given the prevalence of untreated depression and completed suicides among men (Centers for Disease Control and Prevention, 2019). In addition to the role of untreated depression, studies suggest that impulsive and aggressive beliefs and behaviors associated with TMI may also contribute to completed suicides among men (Dumais et al., 2005). Against this concerning health disparities trend, online storytelling videos may be scaled up to drive national campaigns (Lefebvre et al., 2020) to encourage men to seek help for their depression and suicide risk. Doing so may also spread messages of hope and healing (Harter & Bochner, 2009) for men suffering from depression and validation for men to share their distress with others (Keum et al., 2021). This is particularly important as robust intrapersonal norms such as TMI and self-stigma of seeking help require group level interventions for more effective attitude and behavioral change rather than individual level interventions Keum, Hill et al., 2018). The narrative storytelling framework fits naturally as a potential group level intervention as it emphasizes community and relationship building through the power of shared stories (Kreuter et al., 2007). Furthermore, Online media is a promising and efficient avenue for disseminating stories and creating a reflective medium to change men’s beliefs, attitudes, and behaviors, given the cost-effectiveness of the method and the breadth of reachable population.

Despite the contributions of the current study, limitations call for further research for intervention application. First, although we tested an empirically established link between TMI, self-stigma of seeking help, and attitudes, we are not able to assess directionality given the cross-sectional design of the current study. In addition to examining causality, a longitudinal study would be needed to examine whether men who viewed the video actually sought help, and if so, what their outcomes were. Second, a longitudinal approach would also be important to delineate between the roles of self-stigma of seeking help and attitudes toward psychological help-seeking as the two constructs retain conceptual similarities and may influence the order of the variables in the model. Third, a longitudinal study would be able to better test the efficacy of the video by increasing the time between pre-test and post-test measures. In our study, the pre-test and post-test measures were given immediately before and after the brochure and video conditions. This may have affected how participants responded to the post-test measures, as the recency of the video may have persuaded participants to feel more improvements in their help-seeking. Future studies would need to test whether such a response would still hold if greater time has passed after viewing the video. Fourth, even though we theorized mechanisms associated with exposure to storytelling, other than perceived persuasiveness and exposure check, we did not assess for other indicators such as emotional and cognitive arousal, or state empathy. For instance, men with increased empathic reactions to other men experiencing depression reported greater intentions to seek psychological help (Keum et al., 2021). These variables would need to be examined given that they are linked to how people are affected by media messages and can be additional intervention points (Bang & Yildirim, 2018). Fifth, although the sample sizes were adequate or close to the minimum required to detect a small effect, the findings are limited in generalizability. Specifically, we assessed men’s general experiences with TMI, depression, and self-stigma of seeking help even though disparities are observed in men of color, and across specific racial/ethnic groups among men of color (Griffith et al., 2012; Levant et al., 2022). Furthermore, other demographic factors such as education and relationship status could play a role in men’s help-seeking attitudes. Thus, future studies with larger samples would need to test culture-specific and sensitive video content and variables to examine culturally-informed stigma and help-seeking attitudes. A larger sample would also provide more power to detect additional findings, such as a potential non-significant direct effect in the video group as the estimate was reaching non-significance. Last, we are not able to discuss whether the male-sensitive aspects of the video contributed to our findings as we did not include a general video group (e.g., gender neutral) to tease out the differences. It would be important for future studies to refine the effects of male-sensitivity and -relevance in video interventions.

In conclusion, findings suggest initial and promising evidence on brief male-sensitive first-person storytelling videos for reducing the self-stigma of seeking help among men who have not previously sought psychological help. Male-sensitive storytelling videos, such as the ones used in the current study, may be useful clinical and educational tools to help men reconsider their options for seeking psychological help for depression. It may be especially helpful to employ these videos for men who are experiencing depression but are unwilling to consider mental health services due to their belief that doing so would undermine their masculine self-concept. Given that these videos can be watched at their own leisure and privacy, the videos may be a gentle and non-invasive way to get men started on changing their attitude toward seeking psychological help.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Bruce C. Abrams Emerging Scholars Grant from Active Minds.

Ethics Approval

Ethics approval for the study was granted by the Institutional Review Board.

ORCID iD

Brian TaeHyuk Keum

Notes

References

Addis

M. E.

Mahalik

J. R.

(2003). Men, masculinity, and the contexts of help seeking. American Psychologist, 58(1), 5–14. https://doi.org/10.1037/0003-066x.58.1.5

Alvidrez

Snowden

L. R.

Rao

S. M.

Boccellari

(2009). Psychoeducation to address stigma in black adults referred for mental health treatment: A randomized pilot study. Community Mental Health Journal, 45(2), 127–136. https://doi.org/10.1007/s10597-008-9169-0

Bang

Yildirim

(2018). Virtually empathetic?: Examining the effects of virtual reality storytelling on empathy. In: International conference on virtual, augmented and mixed reality (pp. 290–298). Springer. https://doi.org/10.1007/978-3-319-91581-4_21

Busselle

Bilandzic

(2009). Measuring narrative engagement. Media Psychology, 12(4), 321–347. https://doi.org/10.1080/15213260903287259

Call

J. B.

Shafer

(2018). Gendered manifestations of depression and help seeking among men. American Journal of Men's Health, 12(1), 41–51. https://doi.org/10.1177/1557988315623993

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (2019). Web-based injury statistics query and reporting system (WISQARS) [online]. [Feb 17, 2022]. http://www.cdc.gov/injury/wisqars

Coleman

Feigelman

Rosen

(2020). Association of high traditional masculinity and risk of suicide death: Secondary analysis of the add health study. JAMA Psychiatry, 77(4), 435–437. https://doi.org/10.1001/jamapsychiatry.2019.4702

Corrigan

(2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625. https://doi.org/10.1037/0003-066X.59.7.614.

Covello

(2020). Stigma and help-seeking behaviours of men with depression: A literature review. Mental Health Practice, 23(4), 17–23. https://doi.org/10.7748/mhp.2020.e1474

10.

Demyan

A. L.

Anderson

(2012). Effects of a brief media intervention on expectations, attitudes, and intentions of mental health help seeking. Journal of Counseling Psychology, 59(2), 222–229. https://doi.org/10.1037/a0026541

11.

Dumais

Lesage

A. D.

Alda

Rouleau

Dumont

Chawky

Turecki

(2005). Risk factors for suicide completion in major depression: a case-control study of impulsive and aggressive behaviors in men. American Journal of Psychiatry, 162(11), 2116–2124. https://doi.org/10.1176/appi.ajp.162.11.2116.

12.

Fischer

E. H.

Farina

(1995). Attitudes toward seeking professional psychological help: A shortened form and considerations for research. Journal of College Student Development, 36, 368–373. https://doi.org/10.3389/fpsyg.2016.00547

13.

Fisher

W. R.

(1984). Narration as a human communication paradigm: The case of public moral argument. Communications Monographs, 51(1), 1–22. https://doi.org/10.1080/03637758409390180

14.

Garriott

P. O.

Raque-Bogdan

T. L.

Yalango

Ziemer

K. S.

Utley

(2017). Intentions to seek counseling in first-generation and continuing-generation college students. Journal of Counseling Psychology, 64(4), 432–442. http://dx.doi.org/10.1037/cou0000210

15.

George

Mallery

(2010). SPSS for Windows step by step. A simple study guide and reference (10. Baskı). GEN. Pearson Education, Inc.

16.

Green

M. C.

Brock

T. C.

(2000). The role of transportation in the persuasiveness of public narratives. Journal of Personality and Social Psychology, 79(5), 701–721. https://doi.org/10.1037/0022-3514.79.5.701

17.

Griffith

D. M.

Gunter

Watkins

D. C.

(2012). Measuring masculinity in research on men of color: Findings and future directions. American Journal of Public Health, 102(S2), S187–S194. https://doi.org/10.2105/AJPH.2012.300715

18.

Hackler

A. H.

Cornish

M. A.

Vogel

D. L.

(2016). Reducing mental illness stigma: Effectiveness of hearing about the normative experiences of others. Stigma and Health, 1(3), 201–205. https://doi.org/10.1037/sah0000028

19.

Hammer

J. H.

Vogel

D. L.

(2010). Men’s help seeking for depression: The efficacy of a male-sensitive brochure about counseling. Counseling Psychologist, 38(2), 296–313. https://doi.org/10.1177/0011000009351937

20.

Harter

L. M.

Bochner

A. P.

(2009). Healing through stories: A special issue on narrative medicine. Journal of Applied Communication Research, 37(2), 113–117. https://doi.org/10.1080/00909880902792271

21.

Hayes

A. F.

Scharkow

(2013). The relative trustworthiness of inferential tests of the indirect effect in statistical mediation analysis: Does method really matter? Psychological Science, 24(10), 1918–1927. https://doi.org/10.1177/0956797613480187

22.

Heo

(2009). Digital storytelling: An empirical study of the impact of digital storytelling on pre-service teachers’ self-efficacy and dispositions towards educational technology. Journal of Educational Multimedia and Hypermedia, 18(4), 405–428. Retrieved from https://www.learntechlib.org/p/30458/

23.

L. T.

Bentler

P. M.

(1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 1–55. https://doi.org/10.1080/10705519909540118

24.

Janoušková

Tušková

Weissová

Trančík

Pasz

Evans-Lacko

Winkler

(2017). Can video interventions be used to effectively destigmatize mental illness among young people? A systematic review. European Psychiatry, 41, 1–9. https://doi.org/10.1016/j.eurpsy.2016.09.008

25.

Keum

B. T.

Hearns

Agarwal

Nguyen

(2021). Online digital storytelling video on promoting men’s intentions to seek counselling for depression: The role of empathy. International journal of social psychiatry, 1–10. https://doi.org/10.1177/00207640211023532

26.

Keum

B. T.

Hill

C. E.

Kivlighan

D. M.

Jr. Lu

(2018a). Group- and individual-level self-stigma reductions in promoting psychological help-seeking attitudes among college students in helping skills courses. Journal of Counseling Psychology, 65(5), 661–668. https://doi.org/10.1037/cou0000283

27.

Keum

B. T.

Miller

M. J.

Inkelas

K. K.

(2018b). Testing the factor structure and measurement invariance of the PHQ-9 across racially diverse U.S. college students. Psychological Assessment, 30(8), 1096–1106. https://doi.org/10.1037/pas0000550

28.

Keum

B. T.

Oliffe

J. L.

Rice

S. M.

Kealy

Seidler

Z. E.

Cox

D. W.

Ogrodniczuk

J. S.

(2021). Distress disclosure and psychological Distress among men: the role of feeling understood and loneliness. Current Psychology, 1–10. https://doi.org/10.1007/s12144-021-02163-y.

29.

Krause

R. J.

Rucker

D. D.

(2020). Strategic storytelling: When narratives help versus hurt the persuasive power of facts. Personality and Social Psychology Bulletin, 46(2), 216–227. https://doi.org/10.1177/0146167219853845

30.

Kreuter

M. W.

Green

M. C.

Cappella

J. N.

Slater

M. D.

Wise

M. E.

Storey

Clark

E. M.

O’Keefe

D. J.

Erwin

D. O.

Holmes

Hinyard

L. J.

Houston

Woolley

(2007). Narrative communication in cancer prevention and control: A framework to guide research and application. Annals of Behavioral Medicine, 33(3), 221–235. https://doi.org/10.1007/BF02879904

31.

Kroenke

Spitzer

R. L.

(2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32(9), 509–515. https://doi.org/10.3928/0048-5713-20020901-06

32.

Lee

Fawcett

DeMarco

(2016). Storytelling/narrative theory to address health communication with minority populations. Applied Nursing Research, 30, 58–60. https://doi.org/10.1016/j.apnr.2015.09.004

33.

Lefebvre

R. C.

Chandler

R. K.

Helme

D. W.

Kerner

Mann

Stein

M. D.

Reynolds

Slater

M. D.

Anakaraonye

A. R.

Beard

Burrus

Frkovich

Hedrick

Lewis

Rodgers

(2020). Health communication campaigns to drive demand for evidence-based practices and reduce stigma in the HEALing Communities Study. Drug and Alcohol Dependence, 217, 108338. https://doi.org/10.1016/j.drugalcdep.2020.108338

34.

Levant

R. F.

Hall

R. J.

Rankin

T. J.

(2013). Male Role Norms Inventory–Short Form (MRNI-SF): Development, confirmatory factor analytic investigation of structure, and measurement invariance across gender. Journal of Counseling Psychology, 60(2), 228–238. https://doi.org/10.1037/a0031545.

35.

Levant

R. F.

McCurdy

E. R.

Keum

B. T. H.

Cox

D. W.

Halter

M. J.

Stefanov

D. G.

(2022). Mediation and moderation of the relationship between men’s endorsement of traditional masculinity ideology and intentions to seek psychotherapy. Professional Psychology: Research and Practice, 53(3), 234–243. https://doi.org/10.1037/pro0000461.

36.

Levant

R. F.

Stefanov

D. G.

Rankin

T. J.

Halter

M. J.

Mellinger

Williams

C. M.

(2013). Moderated path analysis of the relationships between masculinity and men’s attitudes toward seeking psychological help. Journal of Counseling Psychology, 60(3), 392–406. https://doi.org/10.1037/a0033014.

37.

Levant

R. F.

Wong

Y. J.

Karakis

E. N.

Welsh

M. M.

(2015). Mediated moderation of the relationship between the endorsement of restrictive emotionality and alexithymia. Psychology of Men & Masculinity, 16(4), 459–467. https://doi.org/10.1037/a0039739

38.

Lipsey

A. F.

Waterman

A. D.

Wood

E. H.

Balliet

(2020). Evaluation of first-person storytelling on changing health-related attitudes, knowledge, behaviors, and outcomes: A scoping review. Patient Education and Counseling, 103(10), 1922–1934. https://doi.org/10.1016/j.pec.2020.04.014

39.

Lusardi

Samek

Kapteyn

Glinert

Hung

Heinberg

(2017). Visual tools and narratives: New ways to improve financial literacy. Journal of Pension Economics & Finance, 16(3), 297–323. https://doi.org/10.1017/S1474747215000323

40.

Mannell

Ahmad

(2018). Narrative storytelling as mental health support for women experiencing gender-based violence in Afghanistan. Social Science & Medicine, 214, 91–98. https://doi.org/10.1016/j.socscimed.2018.08.011

41.

Mittal

Sullivan

Chekuri

Allee

Corrigan

P. W.

(2012). Empirical studies of self-stigma reduction strategies: A critical review of the literature. Psychiatric Services, 63(10), 974–981. https://doi.org/10.1176/appi.ps.201100459

42.

Morgan

A. J.

Reavley

N. J.

Ross

San Too

Jorm

A. F.

(2018). Interventions to reduce stigma towards people with severe mental illness: Systematic review and meta-analysis. Journal of Psychiatric Research, 103, 120–133. https://doi.org/10.1016/j.jpsychires.2018.05.017

43.

Murphy

S. T.

Frank

L. B.

Chatterjee

J. S.

Baezconde-Garbanati

(2013). Narrative versus nonnarrative: The role of identification, transportation, and emotion in reducing health disparities. Journal of Communication, 63(1), 116–137. https://doi.org/10.1111/jcom.12007

44.

Muthén

L. K.

Muthén

B. O.

(2017). 1998–2017 Mplus user’s guide. Muthén & Muthén.

45.

Ogrodniczuk

Oliffe

Beharry

(2018). HeadsUpGuys: Canadian online resource for men with depression. Canadian Family Physician, 64(2), 93–94.

46.

O’Keefe

D. J.

(2018). Message pretesting using assessments of expected or perceived persuasiveness: Evidence about diagnosticity of relative actual persuasiveness. Journal of Communication, 68(1), 120–142. https://doi.org/10.1093/joc/jqx009

47.

Pulizzi

(2012). The rise of storytelling as the new marketing. Publishing Research Quarterly, 28(2), 116–123. https://doi.org/10.1007/s12109-012-9264-5

48.

Rochlen

A. B.

McKelley

R. A.

Pituch

K. A.

(2006). A preliminary examination of the "Real Men. Real Depression" campaign. Psychology of Men & Masculinity, 7(1), 1–13. https://doi.org/10.1037/1524-9220.7.1.1

49.

Seidler

Z. E.

Dawes

A. J.

Rice

S. M.

Oliffe

J. L.

Dhillon

H. M.

(2016). The role of masculinity in men's help-seeking for depression: A systematic review. Clinical Psychology Review, 49, 106–118. https://doi.org/10.1016/j.cpr.2016.09.002

50.

Substance Abuse and Mental Health Services Administration . (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001). https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR1PDFW090120.pdf

51.

Vally

Cody

B. L.

Albloshi

M. A.

Alsheraifi

S. N.

(2018). Public stigma and attitudes toward psychological help-seeking in the United Arab Emirates: The mediational role of self-stigma. Perspectives in Psychiatric Care, 54(4), 571–579. https://doi.org/10.1111/ppc.12282

52.

Vandello

J. A.

Bosson

J. K.

(2013). Hard won and easily lost: A review and synthesis of theory and research on precarious manhood. Psychology of Men and Masculinity, 14(2), 101–113. https://doi.org/10.1037/a0029826

53.

Vogel

D. L.

Heimerdinger-Edwards

S. R.

Hammer

J. H.

Hubbard

(2011). Boys don't cry”: Examination of the links between endorsement of masculine norms, self-stigma, and help-seeking attitudes for men from diverse backgrounds. Journal of Counseling Psychology, 58(3), 368–382. https://doi.org/10.1037/a0023688

54.

Vogel

D. L.

Wade

N. G.

Haake

(2006). Measuring the self-stigma associated with seeking psychological help. Journal of Counseling Psychology, 53(3), 325–337. http://dx.doi.org/10.1037/0022-0167.53.3.325

55.

Wasylkiw

Clairo

(2018). Help seeking in men: When masculinity and self-compassion collide. Psychology of Men & Masculinity, 19(2), 234–242. http://doi.org/10.1037/men0000086

The Role of First-Person Depression Storytelling Online Video on Men’s Self-Stigma of Seeking Help,Traditional Masculinity Ideology,and Psychological Help-Seeking Attitudes

Abstract

Keywords

Methods

Participants

Male-Sensitive Brochure

Real Story Video

Measures

Psychological Help-Seeking Attitudes

Self-Stigma

Depressive Symptoms

Traditional Masculinity Ideology

Exposure Check and Perceived Persuasiveness

Procedures

Analyses and Results

Data Inspection and Preliminary Analyses

Base Model with Full Sample

Multi-Group Analysis Across the Conditions

Discussion

Footnotes

Declaration of Conflicting Interests

Funding

Ethics Approval

ORCID iD

Notes

References