Abstract
In this study, we conducted interviews with 12 working-class men employed in industrial and manual labor to identify their constructions of help-seeking in response to feeling depressed or sad. The semistructured interview format explored participant men’s understanding and reactions to depression or sadness, their experiences of depression and reluctance to seek help, and their own and others’ reactions to seeking help for feeling depressed or sad. Utilizing the consensual qualitative research methodology, four domains emerged: Concern About Threat and Stigma, Being a Man Means Not Seeking Help, Experiences of Safety and Relief, and Conditions That Reduce Threat and Stigma. The results suggest the need to account for men’s experiences of both negative influences (e.g., masculinity injunctions, stigma, and threat to manhood status), as well as adaptive influences (e.g., contexts that reduce stigma) when addressing men’s help-seeking for depression and sadness. The domains are illustrative of several theoretical frameworks including social-psychological models of social norms and stigma, precarious manhood theory, inclusive masculinity theory, as well as convergence with other research examining working-class men. Implications are discussed for outreach and practice addressing men’s depression and help-seeking.
Characterized by persistent sadness, depression is an important medical illness to address because of its prevalence and devastating negative effects (Center for Disease Control and Prevention, 2017). Approximately 16 million adults in the United States experienced an episode of major depression in 2015 (Center for Behavioral Health Statistics and Quality, 2017), with 300 million people living with depression worldwide, an increase of more than 18% between 2005 and 2015 (World Health Organization, 2017). In addition to the personal suffering and impact on families and communities, depression is associated with chronic disease and impaired functioning (Pratt & Brody, 2014), and with economic costs in the United States ranging between $210 and $317 billion in annual direct (e.g., treatment) and indirect (e.g., lost productivity) health costs (Greenberg, Fournier, Sisitsky, Pike, & Kessler, 2015; National Institute of Mental Health [NIMH], 2019).
Epidemiological studies consistently report that the prevalence of major depressive episodes is higher among women compared to men (NIMH, 2019), with 8.7% of women in the United States in 2017 reporting major depression compared to 5.3% of men (NIMH, 2019). Men’s depression is also thought to be underestimated, as major depression in men may be “masked” (Rabinowitz & Cochran, 2008), manifesting with externalizing symptoms such as aggression and substance abuse (Magovcevic & Addis, 2008). Clinicians are also less likely to diagnose depression in men compared to women (Potts, Burnam, & Wells, 1991), and men have lower levels of mental health literacy (Swami, 2012). Regardless, we know that men and their families suffer significantly from depression including the fact that men are four times more likely to die from suicide (Curtin, Warner, & Hedegaard, 2016).
Although the effects of depression can be devastating, it is “eminently treatable” with psychotherapy, medication, or their combination (Hollon, 2016, p. 295). Despite the efficaciousness of treatment, however, it is estimated that only 29% of depressed persons in the United States seek help (Olfson, Blanco, & Marcus, 2016). While this low rate of help-seeking for depression in the general population is concerning, men are even less likely to seek help for mental health problems compared to women across races, ethnicities, ages, and other social backgrounds (Addis & Mahalik, 2003).
In trying to understand this phenomenon, the social norms model has been useful in investigating men’s help-seeking (Berkowitz, 2003; Sieverding, Matterne, & Ciccarello, 2010). The model views norms as influencing both pursuing and not pursuing help for depression, and posits that the act of getting help for feelings of depression or sadness is embedded in two types of social influence: (a) what is commonly approved of by important others, known as subjective norms and (b) what is commonly observed as done, known as descriptive norms (Sieverding et al., 2010). Applied to talking to someone about vulnerable feelings, men may hear from important others (e.g., family members, coworkers, male friends) that it is important to get help for depression and they may observe men they know get treatment. Alternatively, men may hear from important others that “big boys don’t cry,” and they may notice that they do not know of anyone that gets help for depression. Thus, if feelings of sadness and help-seeking are perceived as non-normative, men are more likely to feel deviant for feeling depressed or sad and risk rejection from the group if they deviate from the norm of avoiding help (Cialdini & Trost, 1999).
An array of explanations addressing masculinity have also been offered to understand men’s help-seeking. Some perspectives reflect hegemonic masculinities where men gain privilege and power through being emotionally controlled, self-reliant, and tough such that rejecting help is done as a way to assert power and masculinity (Bunton & Crawshaw, 2002; Courtenay, 2000). There is significant support for this framework with many studies reporting that masculinity expressed through emotional control and self-reliance predict less help-seeking behaviors and more negative attitudes toward help-seeking in men (see Seidler, Dawes, Rice, Oliffe, & Dhillon, 2016).
The Precarious Manhood model reflects this view (Bosson & Vandello, 2011; Bosson, Vandello, Burnaford, Weaver, & Wasti, 2009; Vandello & Bosson, 2013) by positing that men’s reluctance to seek help for depression is part of managing the threat to manhood status, or the loss of power, that being depressed or sad represents. Because manhood is understood “as a precarious social status that is hard won and easily lost, and that requires continual public demonstrations of proof” (p. 101, Vondello & Bosson, 2013), men must remain vigilant of “social transgressions and shortcomings” that might jeopardize their manhood status (p. 28; Bosson & Vandello, 2011). Recent research supports this as men reported greater gender status loss and more distress in response to gender-atypical psychological disorders such as depression and anxiety compared to gender-typical externalizing disorders such as aggression and substance abuse (Michniewicz, Bosson, Lenes, & Chen, 2016). Feeling threat from this transgression, men would be more likely to take action (e.g., display courage through “toughing out” the feelings), rather than seek help because “seeking professional help is itself a socially risky act given that men risk being seen as less manly for such behavior” (Vondello & Bosson, 2013, p. 106). This phenomenon likely contributes to men’s stigma about psychological help-seeking which plays a significant role in men’s help-seeking behavior (Lindinger-Sternart, 2015). For example, research confirms that greater levels of self-stigma predicted more negative attitudes toward men’s help-seeking (Galdas, Cheater, & Marshall, 2005; Vogel, Wester, Wei, & Boysen, 2005).
Another perspective on masculinity that may be helpful in understanding men’s constructions of help-seeking is the Positive Masculinity Paradigm (Kiselica, Benton-Wright, & Englar-Carlson, 2016; Kiselica & Englar-Carlson, 2011). This point of view focuses on men’s strengths emphasizing the positive aspects of masculinity. From this perspective, men’s positive masculinity expressed in the form of male courage may help men get help for difficulties such as depression and sadness, or positive masculinity expressed as generative fatherhood may lead them to get help to be a father who is healthy and available for his children. This perspective views masculinities connected to the protector or provider role as influences on men to engage in self-care (Robertson, Williams, & Oliffe, 2016) because men connected to those roles may become concerned about how their depression or sadness jeopardize those roles. From this perspective, focusing on men’s strengths is necessary to understand the importance of social determinants of men’s health outcomes (Macdonald, 2011).
Other theories of masculinities recognize that “many men now practice ‘softer’ or ‘more emotional’ forms of masculinity” (de Boise & Hearn, 2017, p. 779) because men have increasingly developed a capacity to express themselves emotionally. For example, Inclusive Masculinity Theory (de Boise & Hearn, 2017) posits that as society has become less “homohysteric” that men’s gender can be based on more emotional openness, softening of gender restrictions, and close, supportive friendship centered on emotional disclosure. Thus, masculinities can be supportive of the exploration of feelings of depression and sadness with seeking support as inherent in one’s construction of gender.
In trying to understand men’s constructions of help-seeking for depression and sadness, it may be useful to hear the voices of men who have historically been rejecting of help-seeking and yet may be particularly at risk for mental health concerns. One such group is working-class men employed in manual and industrial labor. This group of men work in employment settings that are primarily male and engaged physical labor, typically earning lower to middle class wages. We argue that they may be particularly important to understand for several reasons. First, the male-dominated work setting has been described as a culture reflecting restrictive beliefs about masculinity with high levels of stigma related to mental health problems (Broadbent & Papadopoulos, 2014). Research supports that men in male-dominated work places are also more likely to endorse restrictive masculine norms associated with more negative attitudes toward help-seeking (Houle et al., 2015; Levant & Richmond, 2007), and more likely to view asking for help for emotional problems as a sign of weakness or failure (Dolan, 2007).
Second, Connell (2005) argues that while men usually benefit from the division of labor, those men who embody marginalized and subordinated masculinities suffer disproportionately from negative health effects, such as higher rates of suicide for workers in industry and labor (Milner, Spittal, Pirkis, & LaMontagne, 2013), particularly in construction (Milner, Niven, & Lamontagne, 2014). Given that research has largely overlooked this group of men whose perspective on help-seeking for depression has not been explored, a consensual qualitative research design (CQR; Hill, Thompson, & Williams, 1997) can help give voice to these men’s experiences through taking an inductive approach to understanding phenomena by organizing participants responses to interviews into larger domains, and categories within those domains. The purpose of this study is to give voice to men employed in physical labor using a CQR methodology to explore their constructions of help-seeking when feeling depressed or sad.
Method
Recruitment and Description of Participants
Participant men were recruited through newspaper advertisement in a large metropolitan area in the northeast United States. The ad described our interest in interviewing men working in manual or industrial labor (e.g., factory workers, construction) between ages of 21 and 70 for a research study about men’s health. The ad stated that participants would complete short questionnaires and a 1.5–2 h interview about their health behaviors but that there were no physical exams or medical procedures. Selected participants were compensated $150 for their time and travel. Twelve men participated in the study with jobs including: construction worker, contractor, deleader, forklift operator, laborer, landscaper, mail-handler, mason, paint contractor, screen printer, truck driver, and warehouse worker (see Table 1 for description of participants).
Characteristics of Study Participants.
Interview Protocol
A semistructured interview was developed by the first author and two graduate students in psychology to explore men’s constructions of eight health behaviors (i.e., alcohol use, seatbelt use, physical violence, tobacco use, exercise, diet, getting exam from physician, and help-seeking for feeling depressed or sad). For this study, we examined the data concerning help-seeking for feeling depressed or sad.
An initial set of questions for each health behavior were developed and then piloted to learn men’s reactions to answering the questions and get input about the interview with feedback being used to modify the interview. The final semistructured interview format used open-ended questions to explore men’s constructions of help-seeking for feeling sad and depressed asking about both their own experiences and their perceptions of others. Two example questions were: “What comes to mind when you think of a person talking to someone about being depressed or sad?” and “You said you get help when you feel sad or depressed (refer to his answer of from ‘never’ to ‘always’). Could you tell me about why you answered that way?”
Procedure
Telephone screening
Approximately 50 interested men responded to the newspaper advertisement within a 3-day period. The lead author conducted initial phone interviews with interested persons until 12 participant men were scheduled for data collection. He described the purpose and procedures of the study, identified the health behaviors being assessed, explained why men working in manual and industrial labor were being studied, explained procedures for keeping material confidential and the limits of confidentiality, and provided the opportunity for the men to ask questions. He then gathered information related to inclusion criteria, exclusion criteria, and demographic information. Inclusion criteria include being male, between the ages of 21 and 70, working primarily in manual or industrial labor positions, having worked for at least 6 months during the previous year, and being English speaking. Exclusion criteria included a psychiatric diagnosis for a psychotic disorder or having received a medical diagnosis that requires lifestyle changes (e.g., diabetes, cancer, heart disease, high blood pressure, Crohn’s disease, emphysema).
Interview Procedures
The lead author met individually with participant men in his university office where he reviewed the procedures of the study, encouraged questions about the study, obtained written informed consent, completed other paperwork for payment, and then conducted the semistructured interview. This study was approved by the Boston College Institutional Review Board (approval no. 06.038). After completing a short survey assessing demographic information, masculine gender roles, information about their health behaviors, and what “codename” the participants would like to have used when referring to their interview. Following the survey, participant men were interviewed using the semistructured interview described above. After the interview, participants were given the chance to ask questions, were debriefed about the study, and also provided with educational information about men’s health resources. At the completion of the 12 interviews, all material was transcribed verbatim with code names chosen by the participants and generic labels substituted for all identifying material in the interview (e.g., “Name of Brother” instead of brother’s actual name).
Coding procedures
Interview data were analyzed by nine graduate students and the two authors using CQR methods (Hill et al., 2005; Hill, Thompson, & Williams, 1997). To help identify how differences and similarities between participants and researchers may affect the research process, the nine raters and both authors engaged in discussions about our biographical backgrounds. This led to greater awareness of how our gender, class background, race/ethnicity, and age may contribute to our feelings and reactions to the interview material. The first set of raters, five graduate students in psychology (four women, one man), divided the transcripts into sections in rotating teams of three raters. To code domains (i.e., what topic was addressed in the section), the rotating teams of three raters independently read each section and identified a domain label (e.g., Concerns About Threat and Stigma). The team of raters then met to review the domain labels each identified then discussed the domain until consensus was reached. The team then met to collapse similar domains into more inclusive domain labels.
Transcripts were then organized into domains by each participant, and a new set of graduate raters (one woman, four men) read the transcripts to audit each domain and to abstract the core ideas from the transcript. Core ideas are succinct summary statements of all of the content within each domain across all cases attempting to capture “the participant’s perspective and explicit meaning” (Hill et al., 2005, p. 200). The team met weekly to discuss the core ideas they each had independently constructed, examining a variety of ways to understand the content and word the core ideas, until consensus was reached on the most accurate and concise phrases for each of the participants’ ideas. After meeting and reaching consensus on core ideas, the raters developed categories from the core ideas that best represented specific themes. This stage of the process was iterative, in that as categories were created and modified to best represent the core ideas, the core ideas that had been placed within them were reevaluated and placed accordingly, sometimes into a newly constructed category. To check the domains and cross-analysis, the first author examined all data organized by domains and themes reviewing the wording of domains and themes and the accuracy of rater categorization. The auditor discussed suggestions with the leader of the research raters (the second author in this study) concerning reclassification of some content, and revisions to some of the categories. Categories were then labeled based on how frequently they occurred using Hill et al.’s (2005) labels of general, typical, variant, and rare. General describes a category that was identified by all or all but one of the participants (in this study, 11–12 participants). Typical describes a category that was identified by more than half of the participants (7–10). Variant describes a category identified by more than one through half of the participants (2–6), and rare describes a category that was identified by one participant. As rare categories included only one case, they were not included in the presentation of findings.
Results
The results are organized around the domains presented in Table 2. In presenting the study’s findings below, we follow the procedure used in CQR studies (Hill et al., 1997) of providing examples of categories for the primary domains. Four broad coding domains were identified from analysis of the content of the interviews. Table 2 presents the categories within the first domain and frequencies of cases identified these categories.
Domains and Categories for Men’s Talking to Someone About Being Depressed or Sad.
Concerns About Threat and Stigma
The first domain examines the observations by the participant men focusing on issues of stigma and threat if they talked to others about depression or sadness. The categories in this domain reflected an array of factors including perceptions of being weak, not disclosing as a strategy to protect oneself, concern of being stigmatized with negative labels, and perceptions about damaging relationships by sharing their depression or sadness. Four categories are identified within this domain.
Seeking help is weak
This is the most frequently occurring category identified in the study.
Discussions around weakness in seeking help centered both on concerns about
being perceived as weak by others, and thought of as weak by oneself. In
Case 5, MH: Yeah, I think it goes back to before, a sign of weakness. I think
that’s basically, it’s a sign of weakness. You know, you’re supposed
to be, men are supposed to be strong and up front, ready to go type
of people and I guess when you’re, I guess that’s why men tend to
not to go, not to go to see somebody for help.
Some men articulated that the perception of weakness was around how others would look at that man. SM identifies this during the interview in Case 10, “Society doesn’t like them to, cause it makes them look weak and a whiner, you know.”
Being perceived as weak by other men was also viewed as something that may put a man in a riskier position around other men. In Case 6, M says,
A typical interaction on the inner city streets rarely emotion gets involved. Whether it’s business or pleasure, it’s just kind of fastpaced and always potentially violent, so. It’s not the type, you don’t become the type of person to talk with people about your emotions.
And if you do…
It’s seen as weakness.
And if you’re weak then you’re much more likely to get hurt, or,
Terrorized. Exploited. Exploited more than hurt really.
In what ways exploited?
Robbed. Beaten-up.
It was also noted that a man’s own perception of himself as weak may be hard
to tolerate. In Case 10, SM says, Because they think they’ll be perceived as weak. And they don’t want
to think of themselves as weak, it’s more of a, it’s not so much
what they think other people will think of them, it’s just, it’s a
blow to the ego, they don’t, you know, they think they can help
themselves.
The source of this fear of being perceived as weak came from various sources including fathers. Addressing this, T says, “It shows weakness. You’re not supposed to…you’re supposed to be stronger. You’re the guy. The head of the house the man of the family, whatever, you’re supposed to be strong. And, like my dad said suck it up and deal with it. And, I think most guys that is the attitude.”
Keeping things to myself is safer
The focus in this category was the utility of not talking to others about depression and sadness to protect oneself. In Case 5, MH says, “No, no. I keep it to myself but, over the years they always would call me, sit down, and talk about their problems, but um, no. I keep mine to myself, I’m just a private person, I guess.” After discussing this issue for some time, the interviewer summarizes MH saying,
So in general, your feeling is if I did kind of share kind of some of the problems I was struggling with there’d be positive reactions, and there are people who would be willing to kind of help me out with things, but my feeling is I’m not going to do that because I’m a little concerned that it would then somehow, everybody would find out about things and that’s none of their business.
Exactly. You hit it right on the nose.
Some men shared that the rationale for this strategy was that they felt it
safer to keep things to themselves because they did not trust others to
learn about their depression or sadness. For example, in Case 12, TG says, Because, I don’t feel I should air my personal events out to people,
or my feelings to people, I’m sure they would like to hear it, but
plus I don’t really trust anyone to tell, I mean obviously this day
and age where people just can’t keep their mouth shut. So, I don’t
feel comfortable telling anyone.
Fear of being stigmatized by others
This category reflects the negative labels of the help-seeking man as somehow defective. In Case 9, SR says, “they’d say it’s kind of positive, it’s going to help you out, they’d say that in the open but then again, they’d probably think that, there might be something wrong with him though.” TK puts it more directly in Case 1 when he says, “The fear is that you’ll be, it can go from, be shunned by friends, family, peers, colleagues, to, you’ll be labeled, which will hinder you in relationships, both professional and personal.” In Case 4, CJ articulated this fear to not wanting others to view him as gay, which would feel pejorative. He believes he would be stigmatized if he sought help for sad feelings saying, “and their reaction would be like, you know, some people would think that I’m gay.”
Don’t want to damage relationships
In Case 11, T says, “sometimes it feels like…I tell myself they don’t, people don’t want to hear. Cause, that’s mine to deal with. They don’t want to hear it, they don’t want to be depressed.” In Case 7, the feeling is that his request for help might be rejected because the other person feels burdened, so he does not want to risk that relationship by taking that chance. MN says, “Nothing’s worse than asking help from someone and having your own friend tell you no. So I think they, there’d be some concern if I was taking advantage of the situation.”
Being a Man Means Not Seeking Help
The second domain addresses how masculinity injunctions operate to keep men from seeking help. The four categories in this domain emphasize that talking to others or getting help with depression or sadness is something that women do, whereas men should have certain qualities including being self-reliant, “toughing things out” when suffering, and being stoic.
Help-seeking gendered as female
In this category, women were contrasted with men as they address feelings and talk to others. Many men identified their wives, mothers, and sisters as persons who they knew who were likely to talk to others about their feelings of sadness or depression. For example, TK reports, “my wife is very close to her sisters, one in particular, and she will tell her is something’s getting her down, or she’s got trouble at work with the kids, or whatever, with me, anything, stuff that she has trouble with it’s her sister that she’s talking to.”
In Case 8, P characterizes women as generally eager to get help. He both derides it and also recognizes the wisdom in it. He says,
Oh, them women, man, them women are something else man, they fucking wanna run to the hospital for everything!
Yeah, yeah. And why is that?
I just, just being a woman!
What about being a woman leads them to kind of seek out help, a lot?
They probably, like I said, they always say women are smarter than men! They might be right! (laughs)
In another case, SM both genders help-seeking as something women do and views women as important educators about health for him. He says, “the women in my family, three of them are nurses, one of them being a deceased aunt, and so, I was always told it was very important to be seen by the doctors, you know, and also that I shouldn’t keep my feelings in.”
Self-reliance
In this category, participant men viewed their own feelings of wanting to be
self-reliant, and other men’s need to be self-reliant, as an important
reason men may avoid talking to others about feelings of sadness and
depression. In Case 1, TK says, I find that a lot of men don’t even like to seek any kind of help,
not just for mental health issues, for physical health, for
directions, for anything, it’s more an independent attitude, I can
take care of this myself, I’ll build this house by myself or die
trying rather than ask a home builder to come and help me, or do it
for me.
One participant, MN, talked about learning this approach from his father. He says, My father was a lot like that, if you’re doing something, there’s
some things going on in his life that I wasn’t aware of, being a
young kid, and he’d handle the problem, and then I found out later
on there was a problem and he resolved it, he didn’t talk to me
about it, he just.…
Tough it out
Men who addressed this category discussed the importance of just enduring the experience of depression until things got better. In Case 8, SM says,
You just suck it up, and try to just live your daily life man. It’ll get better, you know what I mean?
So, time will pass, and it’ll get better, and in the meantime, suck it up.
Suck it up. You’ll be alright. That’s what I think. That other shit is bull.
In Case 11, T says, “a few times were, I’d get down for a little while on like the anniversary of my daughter’s death or her birthday, the anniversary of my little brother’s death, um…and I know I should talk about it, but I also know it’s going to pass.” T says he learned this from his father, “you’re supposed to be stronger. You’re the guy. The head of the house the man of the family, whatever, you’re supposed to be strong. And, like my dad said suck it up and deal with it. And, I think most guys that is the attitude.”
Important to be stoic
In this category, the emphasis was on not being affected by vulnerable
emotions. In Case 11, T says, I was playing little league, and I…we lost on the last batter, we
ended up not getting to go to the playoffs because we lost. The last
batter, it was, the last batter the last inning, and we lost, [a lot
of disappointment] everybody did the best they could, the kid got a
great hit, and we lost, and, I was crying I was probably 8-9 years
old, and my father said shake it off. You lost. Guys don’t cry.
And…ok. Get over it, and you suck it up.
Experiences of Safety and Relief
The third domain reflects men’s constructions about what leads them to talk to someone about their feelings of depression and sadness. The categories address developing trust over time to make help-seeking positive, experiencing relief, and the idea that holding feelings in ultimately does not help with the problem. Three categories are identified within this domain.
Experiences of trust
Men who identified this category discussed how speaking to someone about their feelings was predicated upon their ability to trust the person with whom they were talking. The persons that they identified as trustworthy were in a variety of roles. For example, BK discussed some close friends and says, “They’re close. I just trust them. They’re closer than other people that are in my life. They wouldn’t judge me, they’d listen without judging.”
In another case, T highlighted the fact that building trust takes time when discussing talking with his AA sponsor. T says, “He shared a lot of his own things with me, personal experiences, stuff he went through. And he made it obvious to me that I could talk to him about anything. I knew I could trust him with anything. And it took time.”
It feels better when I talk to others
Some men also recognized that talking with others helped them to feel better,
and therefore were more likely to do so when feeling sad or depressed. For
example, in Case 11, T says about talking to the important people in his
life about his feelings during difficult times in his life that, At the point I was at and with the people I had around me it was a
godsend, and I don’t know how I would have got through it otherwise
because I was able to talk to people, about what I was going
through, and that was hard, but I was able to do it instead of just
shutting it off.
Other men recognize the value of talking about feelings on a more everyday basis, not only in crises. In Case 2, B highlights how talking about feelings more frequently leads to feeling better and has brought about a connection with a small group of men at work.
And, they taught you about slush bucket your slush bucket fills up
with emotions and then eventually that last drop just tips you and
just sends you over the edge and I always try to empty my slush
bucket, so to speak, you know what I mean? Try not to keep it full.
And I just have a better day, I always talk. I always talk. I’ve got
guys at work that we talk honest, we have a couple guys we call it
the “honest club”. There’s three of us and we talk about everything,
you know?
Speaking from his own experience in Case 3, BK succinctly summarizes what appeals to him about getting help.
But that guy who uh, that guy who thinks that he’ll be seen as weak if he talks to someone, what’s, it seems like you got a different message than him. How did you get that different message?
It feels better.
Holding it in doesn’t work
Men who identified this theme discussed how their initial response was to
keep their feelings to themselves and hold things inside. After having
experiences of talking to someone, they reported reaching a different
conclusion about the best way to handle feelings. In Case 7, MN says, MN: I was going through some, you know, I’d been married for 18 years
and that kind of stuff and, I had some friends come to me and want
to, you know, talk to me and say how are you doing kind of thing,
and I kept, I was, my game plan was to keep everything in myself.
And then I learned, maybe a couple years later that, that wasn’t the
way to go.
This sentiment was also shared by SM in Case 10. He says, Well I had to, cause I was having panicking attacks all the time, and
I was depressed, so I had to get through high school, so I started
talking more and more, and I started weight lifting, and seeing,
hanging out with more friends, and it gradually got easier to cope
with life.
Conditions That Reduce Threat and Stigma
We identified four categories that made up the last domain. The categories address factors that reduce threat and stigma in talking to someone about feeling depressed or sad. They address the nature of the problem, who they disclose to, changes in society, and changes in their selves over time.
When someone in your family dies
Men who identified this category described how the death of a loved one was
an allowable reason to talk about sad or depressed feelings. Some of the men
discussed the specific experience of having a family member die then talking
to family members or a mental health professional about the experience. Case
11 said, T: after Name of Brother died I went back to see the counselor again,
because as much help as my wife was, I needed more, I needed to talk
more, and it was good that I had that because there’s still day to
day things that she needed to do, it would be more difficult for her
to deal with if I’m constantly just burying her with negative
emotions that I’m feeling.
Other men identified this category around losing a family member as a legitimate reason to talk about sadness and depression but did not do so themselves when faced with the loss of a family member.
Well, my nephew that passed away, got killed, remember. I mean, my mother, she went to talk to my sister, of course, her son, a few other of my family members they talked to somebody, but, I didn’t. Not that I felt macho or anything, it’s just, I’m the kind of person I just try to handle it on my own.
In that situation maybe, it might have been good or ok to talk to someone about it, as you look in hindsight.
Yes, probably yes. I would say definitely.
Prefer to talk to women about their problems
Men who discussed this theme addressed how they tended to turn to the women in their lives when talking about problems, usually describing women as being more supportive about vulnerable feelings. For example, M reported that he views women as being easier to talk to.
Is there a difference with her being a woman, and that makes a difference or if she was a man, it would be the same thing you’d still talk with her?
No, I think it makes it easier that she’s a woman.
In what ways?
It’s just, I have a perception of women as being softer and easier to talk to, so.
Another participant, TG, suggests that women are more interested in feelings so it is more natural for him to respond with feelings.
I would think the activities she would want to talking to people, if I had more, for example, probably more female friends I’d probably be more talkative, with my emotions. They seem to, they seem to bring out more emotions in my opinion, talking to a female.
Why is that?
Cause they seem to be more interested in the situation.
Less stigma in today’s society
For men who identified this category, they pointed to general attitudes in
society becoming more accepting about mental health issues, along with the
increased attention that soldiers returning from Iraq and Afghanistan have
had connected to treatment for PTSD symptoms. For example, in Case 11, T says T: More people, do, I think nowadays more guys will get help, or talk
to somebody or whatever. [Why’s that?] Because there’s not the
stigma or the red letter against you because you did go to talk to
somebody, a counselor or whatever or you talked to somebody close to
you about what you’re actually feeling.
While recognizing that stigma still exists, MH discusses how the increased attention of soldiers returning from war is one factor in changing attitudes about mental health services. He says, “It’s pretty much the same as it was, I think it’s changing a little bit because you can see the people getting out of the military, they go through that traumatic stress syndrome.”
Increased help-seeking with age
Other men discussed a greater willingness to get help at a later point in the
lifespan. They focused on how seeking help would have been more threatening
when they were younger men, or that they learned lessons that led them to
get help to be more effective now. For example, in Case 7, MN says, Yeah I’ve, what you said, I felt that way in my 20s. I feel less
about it that way now. I’m more apt to ask for help now, than I
would have been back then. Yeah, I used to think if I’m not quite as
in control, if I need your help than I haven’t solved my own
situation.
Discussion
Our findings identified four domains that encapsulated working-class men’s constructions of help-seeking when feeling depressed or sad. The first and second domains reflected factors inhibiting help-seeking, whereas the third and fourth domains reflected factors promoting help-seeking. The findings from the first domain are dominated by concerns about the negative consequences from talking to someone about depression or sadness. The categories of this domain strongly supported an array of studies finding that stigma plays a significant role in men’s help-seeking behavior (Galdas et al., 2005; Lindinger-Sternart, 2015; Steinfeld & Steinfeldt, 2012; Vogel et al., 2005), and that threats to manhood status inhibit help-seeking (Vandello & Bosson, 2013). Both of these frameworks were clearly illustrated in the category Seeking Help Is Weak, which was the most frequently occurring category in the study. In this category, participants addressed how stigma resulted from other people viewing one as weak or a “whiner.” Feelings of threat arose from losing manhood status if viewed as weak by others, with the threat even including the possibility of physical danger to self. Viewing oneself as weak was also a threat in the form of a “blow to the ego.” Although participants never used words like “stigma” or “threat to manhood status,” they described stigma through their anticipation of negative judgments from others, and threat to manhood status through failure to meet the masculine ideal of being strong and able to bear up when in pain.
Other categories in the first domain highlighted the role of stigma and threat to manhood status reflected in the efforts participant men made to protect themselves from being perceived negatively arising from personal disclosure of vulnerabilities. The Keeping Things to Myself Is Safer category was a strategy men used to mitigate stigma, whereas the third category highlighted the salience of avoiding negative labels reflecting their masculine status (i.e., “some people would think I am gay”). The last category, Don’t Want to Damage Relationships, emphasized wanting to reduce the threat of being shunned. It reflected concerns about others’ reactions if one asked for help, supporting the social-psychological framework (Addis & Mahalik, 2003).
It might be useful to view identifying sources of stigma and threat from an ecological systems perspective (Bronfenbrenner, 1977). To illustrate, participants identified fathers (a micro-system) and work-place/occupation (a macro-system) as sources of their fear of being perceived as weak. Research efforts might more comprehensively assess the interacting systems ranging from micro to macro-systems (e.g., family, peers, workplace, neighborhood, mass media, region of country, culture, economic system) determining their influence on men’s perceptions of depression and help-seeking. Prevention oriented efforts could help them address these sources. For example, parenting skills training could educate fathers about their impact on children’s health, or workplace settings could address factors that may promote help-seeking.
On a macro level, interventions such as the NIMH’s public service “Real Men, Real Depression” campaign aimed to influence societal norms in the United States about men’s help-seeking (Rochlen, Whilde, & Hoyer, 2005). This type of approach provides accurate, normative information that depression and sadness are normal human experiences, that a large number of men experience them, including men who have the same backgrounds (i.e., “men like you”). This last idea of putting men in contact with others like them who have had depression and sought services was advocated by Corrigan and Penn (1999) who also suggested that psychologists should speak up when we see inaccurate representations of psychological treatment and clients experiencing depression (i.e., protest), and provide accurate information to the public about therapy and depression (i.e., educate).
The second domain supports previous research on the role of social norms and masculinity injunctions on help-seeking. In the Help-seeking Is for Women category, getting help is viewed as a feminine activity making it non-normative for men (i.e., prohibited). This finding is reminiscent of O’Neil’s (1981) premise that men’s fear of being perceived as feminine leads men to construct their identity in contrast to women, doing the opposite of what they perceive as normative for women (e.g., not talking to others about depression or sadness). As seen in the interview data, some men conflate being perceived as feminine with being perceived as gay, and behavior associated with either is viewed as inconsistent with masculine norms and thus avoided.
The other categories in this domain highlight how certain masculine injunctions, namely Self-Reliance, Tough it Out, and Important to Be Stoic, all constrain men from talking about vulnerable feelings and getting help. These findings support a large literature on the relationship between traditional masculine norms and help-seeking (e.g., Bunton & Crawshaw, 2002; Courtenay, 2000; Seidler et al., 2016). To paraphrase Bunton and Crawshaw (2002), to be self-reliant and stoic while toughing out feelings of depression and sadness is to act like a man by showing a lack of concern for taking care of yourself.
The findings about masculinity injunctions can also be understood from the precarious manhood model. If feelings of depression and sadness make a man feel as if he has lost manhood status, he may feel required to publicly demonstrate self-reliance and stoicism, so as to “tough out” his feelings to regain that status (Bosson & Vandello, 2011; Vandello & Bosson, 2013). Put more succinctly, being stigmatized threatens their status as men, which leads to overconformity to masculine ideals in ways that precludes seeking help.
Although trying to live up to some masculinities may interfere with help-seeking, some suggest it might be efficacious to appeal to men about using treatment to preserve or restore masculine identity (O’Brien, Hunt, & Hart, 2005). For example, a group of fire-fighters in O’Brien et al.’s study viewed help-seeking as a way to restore them to a valued masculine role (i.e., working as a fire-fighter). In this case, seeking help “was a way of preserving, not threatening, masculinity for this group, a means of safeguarding their place in an archetypically masculine occupation” (p. 514). Taking this cue, it might be useful to re-frame men pursuing psychological treatment for depression from a positive masculinity perspective (Kiselica & Englar-Carlson, 2011) as a way to restore them to be more effective in their roles as providers for their families or successful in their field of work.
Contrasted with the first and second domains that focused on negative judgment from others and externally imposed standards of emotionally restrictive masculine behavior, the third and fourth domains reflect factors that promoted help-seeking. In the third domain, the categories Experiencing Trust and It Feels Better to Talk reflect more of an Inclusive Masculinity perspective (de Boise & Hearn, 2017) where emotional disclosure is valued in men. The findings also support the premise from Addis and Mahalik (2003) that men would be more likely to ask for help if they believed others would react positively to them. As men indicated that they viewed getting help positively when they spoke with someone they could trust, we might consider efforts to educate the public about confidentiality in professional relationships. As men were positive toward talking to others when they believed or experienced it to be helpful, outreach should emphasize the fact that depression is “eminently treatable” with psychotherapy, medication, or their combination (Hollon, 2016, p. 295).
The fourth domain addressed factors that mitigated stigma for participants, supporting the idea that men would be more likely to get help if the problem was viewed as normal (Addis & Mahalik, 2003; Berkowitz, 2003). It was interesting for us to note that men identified it would not be stigmatizing to talk to someone about feelings of depression or sadness if they lost a family member. A death in one’s family has several notable qualities that seem to make it more allowable to seek help. Losing a family member to death is a public event (i.e., it is observable to others), and it is also a normative reaction to feel sad in response. Men’s depression may be stigmatizing because it is a subjective experience and men often hide their depression from others making it non-normative.
Relatedly, we believe the findings from the study potentially shed light on understanding men’s “masked” depression (e.g., substance use, irritability) as defenses that also reduce threats to manhood status (Vondello & Bosson, 2013). This idea would be consistent with earlier work recognizing how some expressions of masculinity, such as the suppression of vulnerable feelings, can be viewed as defensive in nature (Mahalik, Cournoyer, DeFranc, Cherry, & Napolitano, 1998; Möler-Leimkühler, 2002). For example, if getting help for depression engenders feelings of threat from fear of being perceived as weak, men may assert masculinity in response to the perceived weakness by self-medicating and being irritable in order to “tough out” their vulnerable feelings (Courtenay, 2000). As such, men’s “masked” depression may simply be masculine congruent psychological defenses that manage the threat that comes from feelings such as sadness, weakness, or shame.
The final three categories in the last domain all support that men construct help-seeking as more likely to happen when they experience less threat. In Prefer to Talk to Women, men are saying that women are more accepting of their depression or sadness, and thus less likely to create threat. In Less Stigma in Today’s Society, participant men attribute decreased stigma to a growing awareness in society about the prevalence (i.e., normativeness) of depression and the need to get help. In Increased Help-Seeking With Age, men report being less worried about threat to their manhood status as they age, reflecting developmental changes of gender roles as men age (see Levinson, Darrow, Klein, Levinson, & McKee, et al., 1978). All of these categories underscore the importance of addressing men’s experience of stigma to promote greater willingness to seek help for depression or sadness.
We note several limitations in the study. Participant men were asked about how they understood men’s reaching out for help for depression and sadness, generally. We did not distinguish between depression and sadness, nor explicitly sample depressed men or men who had sought treatment for depression, even though some men in the study addressed these experiences. Participants also volunteered and were paid for their participation and qualitative studies typically have small sample sizes making it important to exercise caution when generalizing these findings to a larger group of men. However, we were struck by how similar the themes in our study were to Dolan’s (2007) work exploring social capital for working class men from less affluent areas in north-east Coventry, UK. For example, our categories of Seeking Help Is Weak and Keeping Things to Myself Is Safer, echoed Dolan’s (2007) participants who viewed “asking for help with emotional problems as a sign of weakness or failure and, therefore, tended to keep their emotional needs hidden and rarely called on their social networks for personal support” (Dolan, 2007, p. 488). Similarly, the masculinity injunctions our participants identified in the categories Self-Reliance, Tough it Out, and Important to Be Stoic had overlap with Dolan’s conclusions. He noted that “normative aspects of working class masculinity relating to independence, self-reliance and emotional strength, could constrain men’s interactions with their neighbours and friends” (p. 489), and that “respondents shunned help in order to maintain traditional masculine definitions. Implicit in their accounts was distrust in other men not to ridicule them for their perceived limitations as men” (p. 489).
As such, there seems to be some convergence in the areas of concern for working-class men in these two studies. We view one of the strengths of this study as its utilization of a sample of men from an understudied group, with unique health risks, and who work in the traditionally masculine arena of manual and industrialized labor. Although our participants offered a unique and important perspective on the experience of being male and how that intersects with help-seeking for feelings of depression and sadness, generalization of these findings to other groups of men should be made with caution as the intersections among age, gender, race, immigration, language, sexual orientation, class, religion, and other social, political, and personal variables are likely to impact the ways in which men experience depression and help-seeking.
Future research should continue to address this understudied group as they tend to be more vulnerable to mortality and morbidity due, partly, to engaging in less self-care (e.g., Choi, Redman, Terrell, Pohl, & Duffy, 2012). Research on the intersectionality of race and gender should be particularly examined as the experiences of men of color related to depression and help-seeking is likely to be distinct. Research should also focus on the assets that men employed in these settings also possess. For example, the bonds of social support for men working in the trades are usually strong (DuPlessis & Corney, 2011), such that focusing on social support and male bonds in work settings may have an important role as protective factors from promoting help-seeking (Milner, Maheen, Currier, & LaMontagne, 2017). For example, MATES has been found to be effective as onsite intervention program for construction workers to reduce suicide in Australia (Gullestrup, Lequertier, & Martin, 2011). The program utilizes trained co-workers as both peer “connectors” (i.e., someone trained to help keep someone safe in crisis and connect them to professional help) and a peer ASIST worker on site (i.e., someone listens to the person’s concerns and responds with goal of keeping person safe). Research efforts such as the MATES program more comprehensively engages larger systems intersecting with men’s lives. As such, research should be addressing the interacting systems that men experience ranging from micro to macro-systems (e.g., family, peers, workplace, neighborhood, mass media, region of country, culture, economic system) to help determine their influence on men’s perceptions of depression and help-seeking, and promote interventions to increase well-being.
Conclusion
Although women and men both experience stigma in response to mental health concerns and getting help, our results suggest a number of gender-specific influences on working men’s reluctance to seek help for depression or sadness. Although there was some variability about whether men viewed depression and sadness as atypical, participants tended to view help-seeking as atypical in men, creating threat and stigma, and violating masculine norms such as self-reliance and being tough and stoic. Because seeking help was viewed as deviating from normative male behavior, participants viewed help-seeking as creating an array of threats both in terms of reactions from others and feelings about oneself. Participants also viewed help-seeking as creating stigma by being labeled in pejorative ways. Several factors seemed to mitigate these threats including experiences of getting relief through talking to someone, experiencing safety in talking with another particularly if the other person was a woman, and anticipating less stigma in a changing society and as a result of getting older. In trying to address the suffering and costs caused by depression, research and outreach efforts could help men to reach out for help by reducing the gendered stigma and threat men experience from their perceptions of depression and help-seeking as reflecting their inadequacies as men.
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) received no financial support for the research, authorship, and/or publication of this article.
