Abstract
This qualitative research sought to establish the impact of an 8-week program combining football and one-to-one psychotherapy on young males’ mental health, determining the factors that predict help-seeking behaviors in this group of men. Pre- and post-participation focus groups were used as the method of data collection. Six males (19–35 years old; M = 25.5) completed both pre-intervention and follow-up focus groups. Help-seeking behaviors were influenced by the appeal of football and the perception of the counselor being accessible. Barriers included gender norms, socialization, financial difficulties, and challenging social landscapes. Post-participation focus groups revealed that positive social and counseling relationships facilitated improved mental health. Sport was deemed an acceptable medium to deliver a mental health intervention as it increased social connections and facilitated help-seeking. Findings support previous research indicating that combining sports and psychotherapy positively impacts young males’ mental health.
In 2018, the rate of male deaths by suicide (282 deaths) in Ireland was approximately 60% higher than that of females (70 deaths by suicide; Central Statistics Office [CSO], 20191). And despite an overall drop in the suicide figures in Ireland, men remain disproportionately represented in national suicide statistics. For example, a 2018 report found that eight in every 10 suicides in Ireland were male (Ryan, 2018). Younger males are most at risk, with a report showing that young Irish males had the highest number of suicides in Europe (Richardson et al., 2013), while the highest rate of suicide in Ireland for males was among those aged 20–24 years, with alcohol and drug use contributing to the majority of young male suicides in Ireland (Arensman et al., 2016). Therefore, finding novel ways to positively engage young males in mental health services remains a goal of the Irish health-care system.
Research by the National Suicide Research Office (Begley et al., 2010) found that young men in Ireland are the least likely to access mental health services. This is in line with international research, which has consistently found that men have poorer mental health literacy than women (Cotton et al, 2006; Rickwood et al., 2005, 2007) and young males are also found to have less sufficient knowledge of available mental health services (Begley et al., 2010; Bird et al., 2019; Burke & McKeon, 2007). Furthermore, men are less likely to disclose or seek help for mental health difficulties (Cleary, 2012; Clement et al., 2015; Dooley & Fitzgerald, 2012) and less likely to access mental health services, even when experiencing suicidal thoughts and ideation (Begley et al., 2010).
Young males with mental health difficulties experience various barriers to help-seeking, including stigma and gender norms/socialization (Bird et al., 2019; Burke & McKeon, 2007; Cleary, 2012; Clement et al., 2015; Möller-Leimkühler, 2002). Young males have demonstrated the perception that professional help-seeking is compromising to the “masculine identity” (Bird et al., 2019; Burke & McKeon, 2007; Lynch et al., 2018), and fear that disclosure of mental health difficulties is linked to the perception of being weak or vulnerable (Bird et al., 2019; Grace et al., 2018). In addition, it is suggested that an element of dominant masculinity, such as being self-reliant, is a strong catalyst of suicidal ideation amongst males (Pirkis et al., 2017). Recent research into help- seeking behaviors among young Irish men indicated that young men perceive services as not being mindful of how strongly reluctant young men in Ireland are toward disclosing mental health difficulties (Bird et al., 2019; Grace et al., 2018). These findings are consistent with international research suggesting that young males experience various barriers to help-seeking for mental health distress, including concerns of personal challenges, acceptance from peers, cultural and environmental influences, fear of homophobic responses, and perspectives around seeking professional help (Lynch et al., 2018). It is argued that health-care professionals need to acknowledge the extent of the gender-specific challenges facing this group when it comes to seeking help for mental health difficulties (Bird et al., 2019; Grace et al., 2018).
Poverty and socioeconomic disadvantage have also been found to be risk factors for poorer mental health and suicide for young men in Ireland (Bird et al., 2019; Cleary, 2012; Department of Health, 2006), and are cited in the literature as barriers to help-seeking amongst at-risk males (Bird et al., 2019; Fergusson et al., 2000). Young men from disadvantaged backgrounds are generally more disconnected from their families and communities, compounded by issues such as unemployment, lack of routine, the absence of meaningful relationships, and financial difficulties (Bird et al., 2019; Grace et al., 2018). In addition, the absence, or loss, of positive male role models has been highlighted as particularly detrimental to well-being in the Irish context previously (Bird et al., 2019; Grace et al., 2018).
Psychological interventions, inclusive of various psychotherapies, are vital in the treatment of a wide variety of psychological disorders. The efficacy of psychotherapeutic interventions has been shown for depression in both primary (Linde et al., 2015) and specialized mental health services (Cuijpers et al., 2011). Both short-term and long-term psychotherapy is effective in reducing psychiatric symptoms (Laaksonen et al., 2013). Short-term psychotherapy can produce more immediate benefits (Knekt et al., 2008; Lindfors et al., 2015), while long-term psychotherapy has been shown to be more beneficial with long-term follow-up (Knekt et al., 2013; Lindfors et al., 2015). However, men are less likely to seek psychological treatment for all disorders, except disorders specifically linked to being male (Mackenzie et al., 2012; Wang et al., 2005). As the efficacy of psychotherapeutic interventions in treating depression and other psychological disorders has been repeatedly demonstrated, it is necessary to develop services with an aim to increase help-seeking behaviors and participation of young men in such psychotherapy.
The variety of gender-specific obstacles observed amongst young men engaging with mental health services in Ireland has resulted in calls to develop gender-specific treatment options (Bird et al., 2019; Grace et al., 2018; McArdle et al., 2012). Previous research has suggested that traditional psychotherapeutic interventions can be tailored to be more gender-aware to increase male help-seeking and participation in therapy (Liddon et al., 2018; Spendelow, 2015). Some possible modifications include incorporating physical activity (Bird et al., 2019; Spendelow, 2015). Due to the psychological, physical, and social benefits associated with physical activity, engagement with organized activities has the potential to mediate suicidal ideation and suicide attempts in young males. In addition, Kiselica and Englar-Carlson (2010) argue that from a psychotherapeutic perspective, males respond well to working together in groups. Group interventions provide an opportunity for social learning from other men to occur (Mahalik et al., 2012). Group settings also provide access to social networks and supports (Bird et al., 2019), with greater social support previously found to predict better outcomes for participants in a variety of therapeutic settings (Hoberman et al., 1988; Lindfors et al., 2014; Ogrodniczuk et al., 2002). Thus, there is merit in the argument that organized sports and group therapy amongst male peers have the potential to alleviate help-seeking barriers and stigma associated with psychological distress in young males (Swann et al., 2018).
Research indicates that sport is emerging as a medium through which young, at-risk males’ mental health can be positively affected (Begley et al., 2010; Bird et al., 2019; Grace et al., 2018; Swan et al., 2017). Mental health promotion programs based in sporting contexts can contribute to the normalization of help-seeking for young males (McArdle et al., 2012; Pringle, 2004). Sports coaches can act as important “gatekeepers” for mental health support for young people, providing a mentoring and supportive relationship that can facilitate help-seeking (Bird et al., 2019; Ferguson et al., 2018; Kazdin, 2018). Sporting contexts also provide an opportunity to meet with other men and provide the platform to form new social networks (Bird et al., 2019). Previous research indicates that young men have a preference for more informal community-based interventions and services (Bird et al., 2019; Cutcliffe et al., 2013; Stevenson et al., 2013), and programs that “piggyback” mental health interventions onto pre-existing programs or activities are more appealing to young men (Bird et al., 2019; Grace et al., 2018).
A previous evaluation of a “piggyback” program, the Breakthrough Program, found that combining sport and psychotherapy positively impacted upon young males’ mental health. Mixed martial arts (MMA) provided an acceptable doorway to psychotherapy for young at-risk males, providing space to explore personal issues (Bird et al., 2019). The program provided what could be considered a “masculine” gateway to mental health services, while offering unique supports through access to psychotherapy, male role models, and increasing participant self-esteem and confidence through the complementary processes of physical activity and psychotherapy (Bird et al., 2019).
Despite research indicating the positive impact of sport on mental health, few studies have combined sporting programs with overt mental health interventions. The studies that have, have shown largely positive results. These studies combined sporting activities with planned activities aimed at improving mental health and well-being, including teaching participants cognitive behavioral techniques (McGale et al., 2011). Results of previous research reveal that male participants view sport as a positive medium for promoting mental health, hence supporting the need to develop gender-specific mental health interventions in order to both engage and entice young men to seek help and engage with services (Bird et al., 2019; McArdle et al., 2012; Swann et al., 2018).
The Current Research
Research to date has shown that young males are at a higher risk of suicide, and that mental health difficulties are a growing concern for this group. Men are less likely to seek help when facing psychological distress, with the accessibility of “gender-aware” services and/or gender-based norms being identified as some of the challenges to help-seeking in this group. Previous research indicates the efficacy of therapeutic interventions in treating the psychological distress of young men. There is also a growing awareness and recognition that physical activity and/or sport can play an important part in improving psychological well-being. The current research aims to provide insight into the possibly complementary effect that therapy and participation in team sport have on young at-risk males, mental health outcomes. Through examining the impact of a team sport iteration of the Breakthrough Program, which combines football and one-to-one psychotherapy, we aim to extend previous research in this area and explore team sports value in this area. The study asks the question: What is the impact of the combination of psychotherapy and sport, on the mental health of the young male participants?
Methods
Research Design
A qualitative repeated-measures research design was employed in this study. The participants were assessed via semistructured focus groups. Thematic analysis techniques were used to analyze results. Qualitative analysis was chosen as the method of analysis to yield high-quality personable data. The design aimed to gain an understanding of participants’ perceptions of their own mental health and the difficulties they may have had in life. In addition, the potential impact of the program on mental health outcomes amongst the participants was a goal of the research design. The reason for this is that future development of the program aims to be informed by its participants.
Data Collection Method
Data were collected in the current research through focus groups with participants at two time points: prior to participating and after completing the program. A semistructured interview schedule was used to guide focus groups. The researchers went out to the training venue to meet participants in order to complete the focus groups. At time one, topics explored included the socioeconomic and cultural backgrounds of the participants, their life experiences with a specific focus on their communities of origin, as well as their perceptions of their current mental health. At time two, topics explored included the impact, if any, of having taken part in the program, with emphasis on both the sport and counseling aspects of the program. Also explored were the participants’ perceptions of their mental health after the program, and potential improvements that may have occurred for them in any aspect of their lives outside of the program. Focus groups with participants were taped with their permission and transcribed verbatim.
Data Analysis Method
Thematic analysis was employed to analyze the data. Themes and patterns within the data were identified and coded, which were guided by the research questions. Initial codes were refined into themes. Two of the researchers coded and analyzed the focus groups and developed a set of themes for each. These themes were then compared for agreement to achieve inter-rater reliability and to finalize the resulting set of themes.
Participants
Participants in the present study consisted of eight males. Participants were aged between 19 and 35 years (M = 25.5) and were recruited by referral from primary care, community-based, and specialized mental health services. All males were seeking treatment for mental health difficulties at the time of the study,
Procedure
Once the initial screening for the program was undertaken, participants were invited to participate in the research. They provided written and verbal consent. Prior to initiating the program, participants were interviewed through a focus group, using a semistructured interview schedule to explore their experiences and perspectives on participating in the program, and the challenges they faced in the current program. Those same participants took part in another focus group the after completing the 8-week program to explore their experiences of having completed the program.
The Breakthrough Program
The Breakthrough Program was devised in 2016, in response to anger management, depression, suicide, addiction, and antisocial behavior of 18–30-year-old males in West Dublin. The program was devised with the aim to encourage men to access local counseling services: specifically for anger management/anxiety/addiction/depression/suicide risk. The program specifically targets 18–30 year- old males to offer dual support in relation to their mental health, combining physical training in conjunction with one-to-one psychotherapy. The
Results
Several broad themes emerged from the data following the thematic analysis of participant interviews. The themes in the first cohort of interviews are related to the barriers and facilitators of help-seeking behavior in young males. Various barriers include social isolation, absence of role models, gender norms, and lack of “gender-aware” services. Whereas, help-seeking behavior was facilitated and enhanced through sport being perceived as an acceptable activity for males to participate in. In addition, the findings indicate that participants have positive perceptions of taking part in the breakthrough program and noticed mental health improvements that translated to other aspects of their life.
Barriers to Help-Seeking
The young men talked about social, financial, and personal challenges that stopped them from seeking help.
Social Challenges
Participants identified a number of social challenges facing young men in their communities, and the cultures within. Participants spoke about the isolation and health effects of not fitting in within the culture of their communities, which led many to seek help for the resulting mental health difficulties: …just sitting in your gaff fuckin isolating yourself you know what I mean it’s kind of when the mental health kind of starts kicking in you know what I mean.
Other social challenges associated with help-seeking barriers included the gender imbalance in the services available and the advertisement of services that suggest that men’s health should not be spoken about: There’s a lot more aimed at women like than there is for men, they just think that men don’t need to share their feelings.
Participants hoped that programs like the Breakthrough Program would lead to improvements in terms of better access to and greater promotion of mental health services for men.
Participants hope to see society “more balanced out” in what was readily available to them. Participants theorized that if more services were available and advertised, young men might “be more . . . open.”
Finances
Some participants identified finance as contributing to their own mental health difficulties, and acting as a barrier to accessing services to help them with their mental health difficulties. One participant noted the general fee of a counselor was too much for many young men to pay, particularly those from a socially disadvantaged background—approximately “60/70 euro a session.” Participants felt this compounded the stress of the person seeking help, especially those who were suffering from depression and anxiety, which derived from preexisting financial difficulties.
The people that are depressed or have anxiety over money or financial reasons how are they supposed to go get help if they can’t afford the help.
Stigma of Help-Seeking and Mental Health Difficulties
Participants spoke about perceived gender expectations in society and how this impacted young men’s difficulties in talking about mental health and accessing services. Participants described how traditionally and historically men have been perceived as having to “be that big dominant figure,” describing having to aspire to be like “stone” in order to stay masculine. One noted the gender stereotypes that can be seen in the modern film industry.
I was watching a film there on Netflix and it came out in 2003 and someone was like do you want to talk about it and he went no talking’s for whimps.
Participants noted that these types of opinions and beliefs were still dominant in society, and within their communities of origin. Statements like this acted to reaffirm the belief that there are societal barriers that discourage young men from speaking about their mental health.
Impact of Negative Male Role Models Within the Local Community
The range of role models available to the young men was also a perceived challenge to addressing mental health. For example, one participant described a regular occurrence of walking through his neighborhood and witnessing drug use on the street.
Yeah like you walk around . . . [and] some fella just shooting up in the corner like some days it’s hard to walk through. . .
Another issue noted was that the range of role models that the participants had access to in their lives are an older generation who traditionally are less open about their feelings.
I think it’s an older thing, older men won’t do it [won’t talk about it] and when the younger see that they don’t, they don’t do it.
This has had an impact on the younger generation’s willingness to discuss their feelings openly and seek help for mental health difficulties.
Facilitators of Help-Seeking
Poor, and Sometimes Unaddressed, Mental Health
Participants identified a range of specific mental health challenges that they found difficult to deal with. Some of the identified struggles included anxiety, depression, isolation, aggression, and addiction. These challenges were what prompted the young men to seek help. For example, one participant noted that his “really bad anxiety” led him to engage with the service and the program. Other participants identified their issues with drug and alcohol addiction as the main challenge to their mental health.
Social Isolation
All participants indicated that the social component of the Breakthrough Program was an important factor that led to their involvement. Due to societal habits, such as a large drinking and drug culture in their areas, participants who do not wish to partake in this culture are left isolated in their communities. For example, participants currently in recovery from addiction felt severely isolated as many of their friends were actively involved in substance abuse majority of me mates are still using now . . . that’s why I’m doing this programme like cause I can’t go out to them.
For them, recovery had become an isolating experience, as they no longer fit in with the social norms in their communities of origin. This view was mirrored among all participants; they did not wish to partake in this culture and their communities offered no alternative other than staying at home and becoming socially isolated.
I suppose I’m just here really because I can’t do anything else other than stay in me house.
In addition, participants raised the issue of having a stigma associated with their social backgrounds and communities of origin, adding to their feeling of isolation. Participants acknowledged that the feelings of societal isolation contributed negatively to their mental health but also felt that the program would provide them an opportunity to “integrate” more into society, thus facilitating their participation in the program and the process of help-seeking for their mental health.
Appeal of Football/Sport
Sport was noted as the key to these young men accessing help. Participants noted an interest in football as a reason to why the program appealed to them and encouraged them to engage with the service.
I just really wanted to get into it you know get back into football it’s something I just like doing you know.
Among the group there was a general consensus that their “love to play football” impacted their decision to get involved in the Breakthrough Program: …a lot more people grew up playing football and might be a bit more comfortable. . .might be an easier starting programme. . .
Football was perceived as a particularly accessible and comfortable activity for young males, which enticed them to take part in the program and in turn seek help for their mental health difficulties.
Improving Physical and Mental Health in Combination
The research indicated that the combination of physical and mental health activities was attractive and it facilitated help-seeking. All participants indicated they were taking part in the program in order to address their physical and mental health challenges.
It’s good for the mental health as well get exercising you know.
This suggests that the dual nature of the Breakthrough Program, which offers both counselling and physical activity elements, is an important factor for the young men who decided to do the program. Some participants showed a clear acknowledgment of the benefits of sport for their mental health, noting that playing football with teammates allows their “problems [to] go away for 90 minutes” describing sport as a way that allows their issues to “come off.”
While not all shared equal enthusiasm toward what they knew would be the challenge of addressing their mental health difficulties as part of the counseling aspect of the program, all participants were notably enthusiastic about the physical aspect of the program, considering it “very important” in their decision to join the program. Participants agreed that “getting out getting fit” would be “good for your body.”
Perceived Similarity or Accessibility of Counselor
Participants discussed the pros and cons of certain types of counselors, that “some [were] bad, some [were] good.” All agreed, however, that having a counselor who understands your community and is of a similar background can be quite helpful in aiding the client to become open, honest, and actively engage in the counseling.
Just meeting like councilors that were in addiction before they understand a lot more than someone reading out of a book.
Impact of the Breakthrough Program
Following the 8-week Breakthrough Program, participants were interviewed and the impact of the program was assessed. A thematic analysis of the results indicated that participants revealed improvements in their mental and physical health, benefits in other aspects of their life, and a perceived positive impact of the role of social support provided through sport and counseling.
Improvements in Mental and Physical Health
All participants reported that the program had a positive impact on their mental health. They reported an improvement in their overall sense of general well-being, coping skills, and an increase in confidence. One participant noted: Yeah its’ good yeah you can notice the difference in just in general in my mental state.
Participants noted, in general, that taking part in the program increased their levels of confidence and improved their overall outlook on life. In addition, participants noted that key figures from both the sporting and counseling elements of the program had fostered this confidence in all the participants of this program.
I can’t commend the two lads [coaches] enough and I think they build confidence even [counsellor], they build confidence in us.
Impacts on Other Aspects of Life
Participants noted a number of other unexpected effects of participating in the program. For example, the program afforded participants the opportunity to receive a football coaching qualification upon program completion. Participants noted that this was not only important in incentivizing them to take part in and complete the program, but also had an impact on their self-image and confidence.
You get the incentive in my opinion out of here you get something at the end of this, a paper stating your qualified now in something, and that just gives you confidence.
The confidence that participants developed as a result of the program also provided them with the confidence to pursue other personal, academic, and career goals, which had seemed unrealistic or unachievable prior to taking part in the program.
Yeah social work. I’d like to . . . be able to coach kids and manage kids.
The Role of Social Support Provided Through Sport and Counseling
One of the most impactful aspects of the program as described by all participants was the social support provided through both the football and counseling aspects of the program. As well as developing strong social connections and friendships with the other participants in the program, the participants described feeling supported and encouraged by the coachers, counselors, and all staff associated with the program.
They made us feel welcome, a personal welcome even when they’re just talking about listen if yous want to go on and do this we’ll support it.
This support from the program was something that would last long beyond the point of completion of the program—something that reassured participants as they went on to progress through their mental health journeys afterwards.
My counsellor said if you ever leave you can still make sure that if you need that counselling that I’ll always be available, so for me that was good.
All participants noted that there was no limit to the support that was provided to them through the Breakthrough Program. This support was seen to stretch far beyond the actual program itself and into all aspects of the participants’ lives.
There’s more to it than just the counselling or the football like . . . I mean just going that extra mile for us.
For participants, the Breakthrough Program provided them with the social support they had previously been lacking both in terms of healthy friendships and social relationships; it also provided them with role models, or positive male influences, in the forms of the counselors and coaches in the program. These men presented a different type of role model to the participants, one who was open and willing to both talk about mental health and also support their help-seeking and recovery journeys.
Discussion
Engaging young men in mental health services remains a growing concern in Irish society. Recent figures indicate that men are 60% more likely to die by suicide than females (Central Statistics Office [CSO], 20192), and young males are consistently found to be less likely to seek help when experiencing depression or other mental health difficulties. There is a need to understand why young men do, or do not, seek help, and the ways in which mental health services can engage young men in a more meaningful and “gender-aware” way. The current study sought to understand male help-seeking behavior and the role that sports along with psychotherapy play in supporting young men’s mental health outcomes. The results reflect previous research when considering help-seeking behavior, with the findings indicating that stigma and gender norms contribute to male participants’ hesitancy to seek help (Bird et al., 2018; Burke & McKeon, 2007; Cleary, 2012; Clement et al., 2015; Möller-Leimkühler, 2002). For example, young males perceived help-seeking as compromising to their masculine identity, in a similar way as observed by Lynch et al. (2018) and in a previous investigation of the efficacy of the Breakthrough Program (Bird et al., 2018). Findings also indicate the intersectional nature of young men’s decisions to seek help; the socioeconomic disadvantage leads to feelings of being disconnected from their families and communities, which is compounded by issues of unemployment, lack of routine, absence of meaningful relationships, and loss or absence of positive male role models (Bird et al., 2018; Grace et al., 2018).
The results extended the current understanding of the role that sport can play in supporting the mental health of at-risk males. To date, research on such interventions have used sport as a context to improve mental health, with participation in sport being linked with improving self-esteem (Biddle & Asare, 2011; Eather et al., 2016), lowering depression and anxiety (Brunet et al., 2013; Kvam et al., 2016; McMahon et al., 2017; Weinstein et al., 2017), and reducing in aggression and violent behaviors (Zivin et al., 2001). While some studies have employed techniques that promote positive mental health through the medium of sporting contexts such as CBT (McGale et al., 2011), and mindfulness and guided imagery (Cai, 2000; Milligan et al., 2017), these programs do not combine sport with one-to-one psychotherapy. The findings from the current study and the previous Breakthrough Program evaluation (Bird et al., 2018) show that sports, combined with psychotherapy, has a positive and independent effect on how young males feel about themselves, providing a space for confidence and positive mental health growth. Sports also provided a gateway for young males to feel “safe” when accessing help, mitigating the impact that gender norms have on help-seeking behavior, and provided them with access to positive male role models. Results indicate that combining sport with psychotherapy positively impacts males’ mental health outcomes, with sports providing a “masculine” gateway into the mental health service, while offering unique supports through access to psychotherapy, male role models, and confidence.
Limitations
The current research adopted a qualitative approach, which provided rich and detailed information both on the impact of the Breakthrough Program on young men’s mental health and help-seeking behaviors in this population. The findings further support those of a previous investigation of the efficacy of the Breakthrough Program (Bird et al., 2018). The sample size in both studies was relatively small; however, when taken together, they provide support for this model of intervention, adopting the complementary process of combining sport with a mental health intervention. While qualitative, semistructured research of this type produces rich data, it offers reduced methodological control. Therefore, it is difficult to ascertain the extent to which the findings apply generally, or only to this small sample of interviewees in both evaluations. Second, it is important to consider that participants in the present study were all males from low socioeconomic backgrounds, which offers a critical insight into help-seeking behaviors amongst this cohort. However, it also limits the ability to generalize these findings to the wider population of all young men in Ireland. Further research is needed, which employs larger numbers and a more varied sample in terms of demographics, to further explore the findings of the current research and evaluate the Breakthrough Program’s potential impact for the wider population.
Future Research
The current evaluation of the program included supporting those with more complex needs, including those who were in active recovery from addiction. Going forward, if the program wishes to continue a participants with such complex needs, will require further resources, and input from the fields of psychiatry, clinical psychology, and occupational therapy. Currently the scope of the program is narrow, targeting young males (aged 18–35), as they are seen as an “at-risk” group. The program could, however, potentially work well with females and other age groups of men also, but further evaluation and research of the efficacy of such a program with these groups would be necessary. The previous examination of the Breakthrough Program suggested that the program required a larger platform and possibly expansion to other sports in order to widen the appeal to a larger population. A partnership with the Football Association of Ireland (FAI) and
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.
