Abstract
International research has identified young men as reluctant to seek help for mental health problems. This research explored barriers and solutions to professional help seeking for mental health problems among young men living in the North West of Ireland. A qualitative approach, using two focus groups with six participants each and five face-to-face interviews, was conducted with men aged 18 to 24 years (total N = 17). Data were analyzed using thematic analysis. Seven key themes of barriers to professional help seeking were identified: “acceptance from peers,” “personal challenges,” “cultural and environmental influences,” “self-medicating with alcohol,” “perspectives around seeking professional help,” “fear of homophobic responses,” and “traditional masculine ideals.” Five key themes of solutions to these barriers included “tailored mental health advertising,” “integrating mental health into formal education,” “education through semiformal support services,” “accessible mental health care,” and “making new meaning.” Interesting findings on barriers include fear of psychiatric medication, fear of homophobic responses from professionals, the legacy of Catholic attitudes, and the genuine need for care. This study offers an in-depth exploration of how young men experience barriers and uniquely offers solutions identified by participants themselves. Youth work settings were identified as a resource for engaging young men in mental health work. Young men can be encouraged to seek help if services and professionals actively address barriers, combining advertising, services, and education, with particular attention and respect to how and when young men seek help and with whom they want to share their problems.
Introduction
Mental Health, Suicidality, and Help Seeking
Help seeking, in counseling and psychology, can be categorically defined as a coping mechanism; the need to help-seek is triggered when task demands exceed people’s coping ability or resources (Chan, 2013). The process of help seeking can be understood as an intentional action that starts with awareness, problem recognition, and definition (Cornally & McCarthy, 2011; Rickwood, Deane, Wilson, & Ciarrochi, 2005). Once a decision to ask others for assistance is made, information is disclosed to others in exchange for help. When it comes to help seeking for a mental health problem, this process is ultimately determined by sociocognitive as well as individual and structural factors (Cornally & McCarthy, 2011; Rickwood, Deane, & Wilson, 2007) as psychological problems are context-bound being both understood and managed through social interactions and cultural routines (Biddle, Donovan, Sharp, & Gunnell, 2007).
Research has demonstrated that many people with psychological problems are reluctant to seek help from mental health professionals with young men being the least likely of all demographics to seek help (Barney, Griffiths, Jorm, & Christensen, 2006; Biddle et al., 2007; Biddle, Gunnell, Sharp, & Donovan, 2004; Mackenzie, Gekoski, & Knox, 2006; Nam et al., 2010). Evidence suggests that this demographic has a greater need for psychological intervention, because the onset of mental illness often occurs in early adulthood (Gonzalez, Alegria, & Prihoda, 2005), and reported rates of suicide are high among males aged 15 to 24 years (Klineberg, Biddle, Donovan, & Gunnell, 2011; Richardson, Clarke, & Fowler, 2013). Statistics released in 2013 reported that despite Ireland having a relatively low rate of death by suicide in the European Union, it ranked fourth highest among young people across Europe with the highest suicide rate among 20- to 24-year-old men (National Office of Suicide Prevention, 2013). Exploring, understanding and countering barriers to help seeking, in partnership with young men, becomes vital to improving young men’s health, increasing meaningful intervention and prevention strategies, which can assist with suicide prevention measures (Jordan et al., 2012).
Barriers to Help Seeking for Young Men
International literature has identified a comprehensive list of barriers to professional help seeking among young men. Denial of emotions and low mental health literacy are commonly reported contributors to non–help seeking (Hernan, Philpot, Edmonds, & Reddy, 2010; Rickwood et al., 2007; Vogel, Wade, Wester, Larson, & Hackler, 2007; Wilson & Deane, 2001). Problems with interpreting, managing, and communicating distress can result in young men becoming caught in a cycle of avoidance as reported by Biddle et al. (2007); often, waiting until severely distressed before seeking help (Cleary, 2012; Oliver, Pearson, Coe, & Gunnell, 2005). Perceived stigma is one of the most frequently cited barriers to professional help seeking in research literature (Clement et al., 2015; Rothì & Leavey, 2006); yet there is a lack of research exploring how young men experience stigma. Some studies have reported that young men may experience discomfort, embarrassment, fear, and shame around asking for help (Booth et al., 2004; Gonzalez et al., 2005; Hernan et al., 2010; Jorm, 2000; Rickwood et al., 2005). Other studies have identified that gender socialization (Rickwood et al., 2007) and macho ideals further inhibit propensities to seek help (Gonzalez et al., 2005; Möller-Leimkühler, 2003; Nam et al., 2010). Additionally, help-seeking intentions tend to decrease in young men who have suicidal thoughts (Rickwood et al., 2007).
Research on attitudes to professional help seeking has revealed that young men whose families have stoic or negative attitudes toward mental health services are less likely to seek help (Judd et al., 2006; Vogel et al., 2007). Other attitudinal barriers reported include negative attitudes toward professional help seeking (Gonzalez et al., 2005; Mackenzie et al., 2006; Segal, Coolidge, Mincic, & O’Riley, 2005); previous negative experiences (Rickwood et al., 2007); past experiences of professional help seeking that were unhelpful (Rickwood et al., 2005); not believing professional help seeking is beneficial or will exacerbate problems (Jorm, 2000; Rickwood et al., 2007; Rughani, Deane, & Wilson, 2011). Inadequate provision and lack of knowledge of services structurally prevent young men from professional help seeking (Begley, Chambers, Corcoran, & Gallagher, 2003; Rothì & Leavey, 2006). Young men have a greater need for confidentiality (Gonzalez et al., 2005; Oliver et al., 2005) and often feel a loss of control about disclosing personal information (Rothì & Leavey, 2006). Fear of dependency and feelings of incompetency also contribute to non–help seeking (Chan, 2013; Judd et al., 2006; Rickwood et al., 2007). Young men use alternative coping mechanisms in an attempt to relieve emotional and physical pain (Brooks, 2001; Oliffe, Ogrodniczuk, Bottorff, Johnson, & Hoyak, 2012). Alcohol, drugs, and aggressive behavior are common outlets for young men in cultures that encourage masculine ideals of self-reliance and denial of emotions which discourages young men from professional help seeking (Biddle et al., 2007; Cleary, 2012; Mackenzie et al., 2006; Möller-Leimkühler, 2003).
Theoretical Framework
This research uses two approaches as a framework for exploring the social and cognitive aspects of help-seeking behavior with young men. The first, Chan’s (2013) help-seeking model uses a constellation approach, which provides a multilevel perspective on how the individual, the task and situation factors influence individual’s decision to help-seek. This can aid in understanding how young men evaluate perceived private and public benefits and costs, both physical and personal, such as time, financial, indebtedness, dependence, damage to self-esteem, or damage to public image. This model is composed of social influences, specifically, normative beliefs and cultural expectations (Chan, 2013) and can aid in predicting whether young men will seek help or not.
The social identity approach (SIA) includes social identity theory (SIT; Tajfel & Turner, 2004) and self-categorization theory (Hogg & Turner, 1987). According to SIT, a young man’s self-concept is derived from his perceived membership of a social group which provides an important source of pride and self-esteem, social identity, and positive self-image. This often depends on in-group comparison with an out-group; the in-group will seek out negative aspects of an out-group and exaggerate them to bolster in-group identity and by proxy, the self-image of its members. Self-categorization theory explores the individual mechanics of SIT, explaining how the self can be categorized at various levels of abstraction. Young men can define themselves in terms of group membership and these “we” abstractions are as valid and as meaningful as the personal “I” identity. Vogel, Heimerdinger-Edwards, Hammer, and Hubbard (2011) emphasized the need to pay specific theoretical attention to how conformity to dominant masculine norms and self-stigma are linked to adverse attitudes toward help seeking in men. Thus, the SIA offers valuable theoretical frames from which to understand how young men’s choices, the “I” identity, on professional help seeking are influenced by the male in-group values, the “we” identity.
Rationale
Research on help seeking among young men has revealed a comprehensive list of barriers predominantly through quantitative studies (Nam et al., 2010; Rothì & Leavey, 2006) highlighting the dearth of qualitative research, specifically on young men aged 18 to 24 years (Begley et al., 2003; Biddle et al., 2007; Bradford & Rickwood, 2014; Johnson, Oliffe, Kelly, Galdas, & Ogrodniczuk, 2012; Wilson & Deane, 2001). Moreover, research on facilitators to professional help seeking is limited (Gulliver, Griffiths, & Christensen, 2010) with most research simply suggesting the mitigation of the barriers identified (Rothì & Leavey, 2006). However, an important finding on facilitators has shown young people need to have established and trusted relationships with those who can offer help (Rickwood et al., 2007; Vogel et al. 2007).
The aim of this research was to explore barriers to professional help seeking for mental health problems among young men (18-24 years) and to explore solutions proposed by them that are relevant to their lived realities. As this demographic is at high risk of suicide and the least likely to help-seek, qualitative research is necessary to directly explore and consult with young men around their perspectives and experiences of help seeking and associated culturally relevant solutions (Kelly, Jorm, & Wright, 2007; Richardson et al., 2013; Rickwood et al., 2005). Understanding the influence of the Catholic heritage on help-seeking perspectives can provide rich understanding on some of the unique cultural influences on young Irish men. This bottom-up approach is essential for the design and development of meaningful interventions, which can increase professional help seeking, increase quality of life for young men, and ultimately aid in suicide prevention measures (Barbour & Barbour, 2003; Rickwood et al., 2007).
Method
Research Design
This qualitative study used a constructivist epistemology. Understanding young men’s perspectives around mental health requires inquiry into many overlapping factors (Jordan et al., 2012). Constructivism values the multiple realities individuals possess, views knowledge as socially constructed and able to change depending on context (Golafshani, 2003). This design thus facilitated deeper inquiry into how young men examine and experience the physical and mental constructs, within their own culture that act as barriers to professional help seeking and to explore how young men negotiate possible solutions to their problems and create new meaning (Carson, Gilmore, Perry, & Gronhaug, 2001).
Participants and Recruitment
The sample consisted of 17 male (18-24 years) participants living in County Donegal, North West Ireland. Twelve participants were selected using purposive sampling, which sought to include participants from geographical and ethnic backgrounds that reflected the diversity of the population being studied (Barbour & Barbour, 2003). After data were collected from 12 participants, a further 5 men were recruited through a snowball sampling technique to ensure saturation was reached and no new themes were emerging (Bryman, 2012; Creswell & Miller, 2000). Recruitment took place in a local youth service in County Donegal. This service works with 5,000 young people throughout the county with a remit of personal and social development. An information session was organized in the drop-in center where information sheets were distributed to male service users aged 18 to 24 years. Those interested self-selected to participate in either a focus group or interview. As discussing mental health is a sensitive subject, providing an option can facilitate young men’s preference in participation, maximizing their contributions and helping reduce discomfort. Participants provided written informed consent prior to commencement of data collection.
Data Collection
As well as facilitating young men’s participation, data were collected from focus groups and interviews to compare the group and the individual realities (Golafshani, 2003). Face-to-face interviews helped obtain individual perspectives and provide confidentiality to participants (Bryman, 2012). Focus groups, although a manufactured setting, allowed for the exploration of attitudes within the social setting wherein they are created and exchanged (Litosseliti, 2003). Data were collected in two parts using a semistructured interview guide (Bryman, 2012). Part 1 began with an open-ended question to encourage general discussion: “If a young man had a mental health problem what reasons do you think might prevent him from getting professional help?” This evolved into a more focused discussion where participants volunteered personal experiences which were explored with probing questions such as “Can you tell me what you mean by . . . ” The researcher took notes throughout. Part 2 focused on solutions, using reasons from Part 1. Part 2 began with Question 1: “Regarding [reason identified] how do you think this can be changed so as to encourage them to seek help?” This question was repeated with every reason provided in Part 1 until all barriers were discussed. Question 2 asked “What could be done to help make young men more comfortable about speaking about their mental health?” The final question asked “Are there other recommendations that you have, or suggestions you would like to make?”
Procedure
Data collection took place in an interview room within the local youth service. On arrival ground rules, the style of questioning and session procedure was explained to participants. Notes were taken by the researcher throughout on “barriers” to be referred to later during the discussion on solutions. Sessions were audio-recorded for analysis purposes only. When sessions were finished, participants were thanked and debriefed with an information sheet detailing local mental health services.
Data were analyzed by the first researcher at a latent level using Braun and Clarke’s (2006) six-step guidelines to thematic analysis: (a) Familiarization with data through transcription of data; (b) Small chunks of raw data were then color coded with a brief verbal description for meaning; (c) Once a list of codes was identified across the data set, themes were collated and mapped; (d) Searches for relationships between themes and different levels of themes were conducted and then collated, refined, and mapped onto individual maps for barriers and solutions; (e) Themes were then named, defined, and further analyzed to identify the story each theme tells, emergent subthemes, and their place in the broader story of the research question; and (f) The write-up of the report and the inclusion of a reflective analysis section. This provides the lead researcher opportunity to self-disclose reasons for beginning the inquiry, bracket assumptions, and values entering the research process and minimize bias which can improve overall validity of the research (Braun & Clarke, 2006; Creswell & Miller, 2000). The third author checked and reviewed the data at each stage of the analysis process to increase trustworthiness. Member checking was also utilized; six participants were willing to return and review the refined themes. The researcher met with the participants individually in the youth center and showed them results which they read and discussed. All participants reported that the themes made sense, were realistic and accurate to what had been communicated. They also reported that participation had been beneficial and enjoyable.
Ethical Considerations
This research study received ethical approval from the School of Communication Filter Committee, University of Ulster, and the research adhered to the ethical frameworks of the British Association for Counseling and Psychotherapy and the Irish Association for Counseling and Psychotherapy. Participants were informed about their voluntary participation, their right to withdraw without adverse consequences, possible benefits of taking part in research. Anonymity was ensured though the removal of identifiers. All data were stored confidentially in accordance with the Data Protection Act (1998). Participants were informed of the potential for future publication of the findings.
Reflexivity
In 2013, the first author read a report which stated that the rate of suicide among young Irish men was amongst the highest in Europe (Richardson et al., 2013). As a professional youth worker, the first author, who interacts daily with young men, was deeply concerned about how to encourage young men to use mental health services. From conducting a literature search on barriers to help seeking, it was apparent that while there were connections between research findings and features from Irish culture, culturally specific research was vital.
The first author led the research conducting recruitment, interviews, transcriptions, and analysis of data. Young people’s input is central to the planning of programs and services in youth work and this ethos influenced the bottom-up approach used in the research to identify solutions.
To limit the impact of dual relationships, participants were recruited that did not have previous rapports with the lead researcher. During data collection facilitation and rapport building skills were employed to create a comfortable and informal environment. Anticipating bias from the review of the extant literature, the lead researcher consciously adhered to the interview schedule, asking only open-ended questions and probing for deeper exploration. Being from the same region and cultural background as the participants enabled the lead researcher to understand colloquial terms and cultural nuances, greatly aiding in aspects of the analysis and search for themes. A methodological approach was taken, inductively searching for latent themes in data, coding for meaning, mapping, and refining themes.
The lead researcher was aware that favorable bias may exist toward youth work as many participants were involved in a youth service. If the youth service was beneficial for participants, then this was a potential resource for exploration.
Findings
Participants
Two focus groups were conducted with six participants in each group, and the mean age was 21.3 years. The interview sample consisted of five participants, with a mean age of 20.8 years. Summary of participant demographics and coding are in Table 1. The data collected revealed no difference in depth of exploration or themes between the group and the individual responses and thus, results were analyzed together. This self-selection strategy was successful in showing that the methodology employed was ideal for mental health research with young men. From thematic analysis of the data, seven key themes of barriers and five key themes of solutions to professional help seeking were identified.
Participants’ Demographics and Codings (N = 17).
Note. P = participant; FG = focus group; I = interview.
Barriers
Acceptance From Peers
Participants discussed how help seeking can cause manifold social ramifications including labeling, negative reactions, perceived weakness, and potential rejection from the group. Diagnostic labels can damage public image: “It’s like being stamped on your face . . . as soon as you’re told that you’ve this condition, on the outside it wouldn’t have changed but from your perception everyone can see it then” (P1FG). Some participants reported previous negative reactions from peers: “I’ve tried talking before and I’ve been taken aback by the [negative] responses I’ve got” (P14I). Young men may learn from their peer group that professional help seeking is a sign of weakness, and fear that this behavior could cause them rejection and ridicule from the group. This group value can be a primary deterrent for young men in seeking help: “you would definitely be seen as a weak member of the group if you were [seeking counseling]” (P13I).
Personal Challenges
Several personal barriers were identified including issues with communication, symptom recognition, personal losses from asking for help and ineffective coping mechanisms. Many participants reported that communicating their emotions was challenging; in knowing what vocabulary to use and in saying personal feelings aloud: “When you get really personal . . . it’s hard to express it sometimes” (P16I). Participants linked these communication issues to difficulty with problem recognition and the intangible nature of problems: “I think you’re afraid that you can’t see what’s wrong with you” (P6FG). Asking for help can damage self-image through a perceived loss of self-reliance: “I should be able to take care of myself . . . if you’ve to go see a mental health service . . . then you can’t” (P14I) and in causing a profound feeling of abnormality: “It’s fear of actually finding out that you’re not normal” (P3FG). To avoid this, young men instead use familiar yet ineffective coping strategies, predominantly, minimization, ignoring and escaping: “I was trapped in my room the whole time . . . because nobody could comprehend . . . how I was feeling . . . all I did was play games . . . just trying to get my mind out of the world” (P16I). Help seeking as a strategy is not integrated into their coping framework and is often viewed as a last resort, with some participants describing enduring symptoms until they become too severe to tolerate: “It takes a point where I’m actually about to have a meltdown . . . to actually go see someone” (P14I).
Cultural and Environmental Influences
Key cultural and environmental barriers included religious influences, generational divides, and rural life. Participants reported that the influence of the Catholic Church, which traditionally viewed help seeking through prayer and confession, has encouraged reservation and stoicism within Irish families when communicating and dealing with problems: “Because it’s Ireland . . . families don’t talk . . . that whole Catholic guilt thing is still hanging around . . . the only means of self-betterment was through God” (P17I). Many participants felt that generational divides within families prevented support provision, in particular, from fathers who would only reinforce values: “If I said—Dad I’m not feeling well today, I’m feeling depressed . . . Dad would say—cop on, grow up” (P7FG). Participants living in rural and Irish-speaking areas discussed how close-knit communities inhibit privacy resulting in a general mistrust of speaking about personal information that extends to local doctors: “In quiet [rural] areas, everyone knows everyone’s business” (P6FG). Attempts to help-seek outside of the community is often thwarted by poor infrastructure: “We’re such a rural, underfunded, forgotten part of the country” (P17I).
Self-Medicating With Alcohol
All participants reported that self-medicating with alcohol was the most prevalent and accepted way of coping with and escaping difficult feelings: “They use alcohol to cope . . . alcohol numbs them, mentally and physically so that . . . they don’t feel those problems, it’s a little escape” (P15I). Participants stated that normal peer group restrictions around communicating emotions are relaxed while drinking: “It’s only when lads have a few drinks in them they can talk about it” (P5FG). While participants stated they felt more comfortable expressing emotions while drunk, they reported that what is expressed is often distorted or exaggerated causing undesirable behavior, such as crying, recklessness, or altercations with others. This method becomes ineffective, exacerbating problems, and often creating more barriers. As a coping mechanism, alcohol’s failure to relieve problems can result in some young men feeling hopeless, that they can not be helped: “Self-medication is a ludicrous idea that leads to nothing but further suffering and misery down the road” (P17I). Some participants discussed how self-medicating with alcohol is entrenched in a deeper cultural issue: “Let’s go shoot the elephant in the room here . . . the drinking culture in Ireland is . . . totally endemic to anyone actually realizing and discovering they have a fucking problem” (P17I).
Perspectives Around Seeking Professional Help
Some participants described not knowing how or where to go to get professional help. Many participants expressed negative opinions about mental health professionals: “You’re just another person . . . their [counselor] job is to get people through the door, make sure they’re grand, get them out, make money . . . ” (P11FG). These attitudes were emanating from both perception and previous negative experiences: “Most counselors are just absolutely useless . . . ” (P3FG). Most participants did not consider doctors as mental health professionals and avoided them due to fear of being prescribed medication: “That’s why I wouldn’t go to a doctor . . . if they gave you medication you’d need it to feel normal . . . I’d rather just feel how I’m supposed to feel, rather than have medication” (P3FG).
Fear of Homophobic Responses
Some participants, including one openly gay participant, discussed the impact of the stigma of being gay in a traditionally Catholic country. One participant reported: “We’re on a retreat [religious] . . . they talk about homosexuality like, it is a mental illness” (P2FG) and that this would be a barrier to young gay men seeking help. Young gay men have to disclose their sexuality in exchange for help, and based on previous negative experiences, fear homophobic responses from professionals:
You have to trust the person is not going to be angry or hateful . . . it’s a huge barrier for talking . . . there are people in the closet who cannot tell people, who are so afraid of the backlash . . . that they won’t talk about their problems at all. (P14I)
Traditional Masculine Ideals
The majority of participants reported that professional help seeking can compromise their masculinity: “When I moved here . . . I had to be a tough guy when I started going to secondary school, I had to . . . be a ‘hard man’” (P14I). Ideals of self-reliance and strength, which provide protection to self-image and public image, are in opposition to the expression of emotions and help seeking, which are viewed as dependent and weak, traits associated with femininity: “If you go and ask for professional help, you are not really a man” (P15I). These ideals are very much linked to in-group identity of being a man which young men are reluctant to jeopardize by asking for help.
Solutions
Tailored Mental Health Advertising
To tackle stigma and increase service awareness, participants envisioned direct, positive, and solution-focused advertising that was relevant to their lives and represented diverse young men: “None [advertisements] have really hit the spot . . . it has to be delivered in a very positive way . . . to really pull them in” (P16I). Using relatable and relevant public figures could help incorporate professional help seeking into masculine identity and reinforce the message that help seeking is a strategy for dealing with problems: “Someone that’s a tough guy . . . he said it’s cool, so it’s cool’” (P14I). Advertising should be targeted at specific times of the year, such as winter, and on gaming websites and through social media: “ . . . between football matches, shows, Facebook or major websites that probably coincide with guys who would not typically want to go see a mental health service” (P14I).
Integrating Mental Health Into Formal Education
Many participants stated that a consistent and secular mental health education program in schools, beginning in early childhood, could lead to the normalization of professional help seeking: “It’s [school] where a kid spends most of his life . . . and if everyone is able to know that if someone talks to someone, that’s fine . . . it becomes part of normal life” (P14I). Some participants reported access to a school-based counselor can reduce access barriers: “Our school now once a week has a professional counselor . . . I think stuff like that is fantastic” (P7FG). In particular, schools need to be more active in supporting young men with their sexuality through zero-tolerance policies to homophobic bullying and advertising support services.
Education Through Semiformal Support Services
Most participants reported that a supportive informal environment could tackle service-related and personal barriers. Talking to professional youth workers can help young men feel more comfortable as their relationship is not one based solely on their problems:
If . . . you’re talking to a youth worker . . . over a period of six months . . . you’re not just talking about your problems, you’re having the craic with them and then if you need to talk about something, you can. (P1FG)
The provision of mental health programs in community youth work settings could greatly facilitate mental health literacy in young men, increasing peer support and a culture of help seeking:
I have a large circle of friends who I would be willing to talk to . . . because, like myself, the majority . . . went through that same youth center I did so they all have . . . the fundamentals of recognizing mental health issues and why a problem arises. (P17I)
Accessible Mental Health Care
Participants stated that mental health services needed to reach out and support families and young men with information can encourage help seeking behavior: “Provide the right conditions and then provide all the right key information . . . I think eventually they’ll reach for the help and the support” (P11FG). Participants differed on whether they would like to speak to a stranger or someone familiar, in a group or one to one but there was a consensus that knowing someone cared about you was a priority: “You just need someone who can talk to . . . you can let it out to, who cares” (P8FG) and not feeling depersonalized was important: “You don’t want to feel like a client” (P1FG). Young men want to deal with their problems in an environment that provides some choice, control, and where there are equal power relations.
Making New Meaning
Participants expressed that the term “mental health” was too weighted with discriminatory connotations and that new terminology, such as mental fitness, could reframe stigmatizing language: “If you need to seek someone about your ‘mental fitness’ it seems not so much like you have a problem . . . you want to improve something” (P14I). Participants stated that it is possible to incorporate professional help seeking into masculine ideals creating new meaning for men around help seeking: “Just teaching . . . even the toughest of men can have problems . . . everyone can have a mental health problem . . . you’re only as strong as your mind” (P6FG).
Discussion and Conclusion
This qualitative study has provided an understanding of the perspectives and experiences of young men in the North West of Ireland when seeking professional help for mental health problems. The multifarious barriers that exist for young men involve complex and interrelated processes. Solutions, while explored separately, need to be considered from an integrative approach to reduce barriers (Jackson et al., 2006).
Barriers to Help Seeking
Low mental health literacy and stigma associated with having a mental health problem are the most common cited barriers to professional help seeking for mental health problems (Johnson et al., 2012; Nam et al., 2010; Oliver et al., 2005; Vogel et al., 2007). This research corroborates this, elucidating further how young men experience these factors concurrently. Without an internalized framework to place mental health concerns within, participants described that being physically unable to see or touch what they are feeling results in confusion and fear of their problems. Young men find it difficult to understand their emotions and look externally to their social world for context and definition, to help interpret what they are experiencing. The lack of conversation about mental health in Irish families, friends, and society in general results in young men perceiving that social stigma exists and that having a mental health problem is socially undesirable (Latalova, Kamaradova, & Prasko, 2014). If a young man cannot find accurate information or nonjudgmental support, he interprets that mental health problems are secretive and shameful and that there is something fundamentally wrong with him resulting in self-stigma (Chan, 2013; Latalova et al., 2014). Fear of how others would respond to this perceived abnormality was evident throughout participants’ narratives describing fear of ridicule, being labeled an attention seeker or “crazy” and a perceived loss of control. This interpretative process shows that help seeking goes beyond categorical descriptions having complex sociocognitive factors (Biddle et al., 2007).
Lack of psychological openness (Mackenzie et al., 2006) and lack of willingness to seek help (Gonzalez et al., 2005; Hernan et al., 2010) has been ascribed as a barrier to professional help seeking. By contrast, this research reports that participants were willing and open, in the right conditions. What attitudinally might appear as a lack of openness or willingness may actually be caution, as young men try to negotiate self-stigma, social stigma, peer group values, cultural norms, structural barriers, and personal fears (Booth et al., 2004; Jorm, 2000; Vogel et al., 2007). If young men perceive that their personal or public image may be compromised, they will not help-seek as predicted in Chan’s (2013) model. Moreover the research suggests they will engage in escapism and distraction through alcohol/drugs, computer games, the gym, and physical aggression as coping mechanisms (Biddle et al., 2007; Richardson et al., 2013). These methods are more acceptable within their male peer group than help seeking and are less likely to damage in-group membership (Hogg & Turner, 1987; Tajfel & Turner, 2004).
Participants reported that their professional help seeking framework included two options: going to a doctor and potentially being prescribed antidepressants or attending a counselor who would make them feel depersonalized. This research reports that young men fear psychiatric medication and would rather endure distress than take medication. Through exploration of the participant’s narratives, a deeper issue was identified behind the fear of taking medication; young men do not feel assertive or confident in discussing options with a doctor or refusing medication and so would not help-seek. Those living in rural areas fear local doctors could disclose confidential information to their family causing embarrassment which parallels Chan’s (2013) damage to public image findings. The lack of alternative and accessible services results in non–help seeking, meaning young men resort to using coping methods, that although ineffective, are a means of protecting pride, self-esteem, social identity, and positive self-image (Tajfel & Turner, 2004).
Participants stated that their male peer groups value non–help seeking and self-reliance and that this can override personal inclinations toward professional help seeking which corresponds with findings by Judd et al. (2006). Looking at these findings in line with SIA (Hogg & Turner, 1987; Tajfel & Turner, 2004), the traditional masculine in-group identity rejects help seeking as this constitutes as out-group, female behavior; in order to ask for help, young men would have to utilize out-group behaviors, which could damage self-esteem, their identity, and group membership. This research supports existing evidence which reported that fathers reinforce macho ideals thus further discouraging professional help seeking (Vogel et al., 2007). This is also compatible with Chan’s (2013) theory: If young men are expected to act emotionally inexpressive, then help seeking can cause substantial damage to personal and public image.
A behavior that is acceptable and compatible with male in-group identity is the use of alcohol to deal with emotional problems. Brooks (2001) and Oliffe et al. (2012) have also reported that men use alcohol to cope with difficult emotions. Participants stated that the only time it is acceptable for men to talk about personal concerns is while drinking. Alcohol mitigates responsibility for what is expressed. This permits an acceptable in-group outlet, which protects in-group membership, an important aspect of Tajfel and Turner’s (2004) SIT and prevents damage to personal and public image as predicted in Chan’s (2013) help-seeking model. These group values are rooted in a deeper cultural issue; the ubiquitous abuse of alcohol in Irish society to cope with emotional problems. This can result in young men’s distress going unnoticed by others, further inhibiting problem recognition, alcohol dependency, and the exacerbation of mental health problems (Cleary, 2012). This cultural acceptance of alcohol for coping parallels work by Leavey et al. (2004) who reported that cultural expression of illness and emotion contributes to decisions on professional help seeking. This research has also identified that young men want genuine care, and will not help-seek if they perceive a professional as uncaring (Jordan et al., 2012).
Another cultural influence identified in this research is the pervasive impact of the Catholic Church on personal environments and social group values around professional help seeking, which has contributed to stigma, fear, and ineffective coping methods (Booth et al., 2004; Jorm, 2000). Participants reported that the traditional Catholic help-seeking methods of prayer and confession have encouraged stoicism and has resulted in families not knowing how to talk about, or deal with mental health. Judd et al. (2006) also has reported the negative impact of stoicism on attitudes on help-seeking behaviors. With approximately 90% of state schools in Ireland under patronage of the Catholic Church (Department of Education and Skills, 2013), participants reported that they had been educated in an environment that does not accept homosexuality, with regular homophobic bullying going unchallenged by teachers and the removal of lesbian, gay, bisexual, transgender and questioning support groups posters by teachers. This reflects Maher’s (2013) study with young gay men in Catholic schools in America. Young gay men may not seek help due to fears around disclosing their sexuality and possible homophobic responses from professionals as well as damage to personal and public image (Chan, 2013). This subgroup of young men may even more vulnerable as they experience the compounded stigma of being gay and having a mental health problem.
Solutions
Participants were articulate in communicating ideas for solutions to the barriers they depicted. Unanimously they reported that a multitiered approach grounded within young men’s everyday context, is necessary to increase professional help-seeking behavior. Education, advertising, and service providers need a combined strategy to tackle barriers concomitantly and help cement professional help seeking as a norm (Jackson et al., 2006; Vogel et al., 2007).
Education, for intervention and prevention, needs to focus on increasing mental health literacy and proactive coping methods. Presenting mental health education as mental fitness skills development, that is solution-focused, positive, and voluntary, can increase engagement in intervention programs. Small group-based programs with professional youth workers can offer young men a safe and comfortable setting in which to explore, challenge, and reframe inherited traditional masculine ideals. This can also encourage social creativity in young men in creating new meaning and group values around professional help seeking while holding on to a positive self-concept (Hogg & Turner, 1987; Richardson et al., 2013). Group work can also help young men create an internalized framework of reference for dealing with their problems in a supportive group environment and facilitate the inclusion of help seeking as a positive strategy for coping, one that limits damage to personal and public image (Chan, 2013). Participants reported that the environment in which the focus group took place was ideal for mental health intervention work. Many participants stated a preference for the informal relationship offered by youth workers because they were treated nonjudgmentally and respectfully. Rickwood et al. (2005) stated that help seeking is facilitated through established social relationships that are based on understanding and trust and that youth workers can encourage help seeking to other professional services. In addition, all services need to reach out to young men and families, actively informing about and promoting professional help seeking.
In the long term, toward prevention, schools need to introduce a consistent, secular, and dedicated mental health literacy program into the existing curriculum at primary level. Kelly et al. (2007) have reviewed the impact of different school interventions with young people and reported that certain programs improved mental health literacy. This research suggests introducing programs earlier, thus normalizing mental health discussion as children grow, allowing for help seeking to become an acceptable value within peer groups (Tajfel & Turner, 2004). This could reduce stigma, damage to personal and public image, feelings of indebtedness and dependence, and increase professional help-seeking behaviors when they are young adults (Chan, 2013). Finally, regarding education, Maher (2013) stated that homosexuality needs to be addressed in Catholic education. This study recommends the support of the placement of posters that advertise lesbian, gay, bisexual, transgender and questioning support and that homophobic bullying is actively addressed.
Education and advertising should leverage traditional masculine traits rather than seeking to mitigate them, promoting the qualities of strength, and control among men who seek help (Johnson et al., 2012). Specifically, advertising needs to move away from stereotyped depressed males and instead use diverse males that communicate messages that are confident, solution focused, and introduce new language such as “mental fitness” which supports the recommendations of Kelly et al. (2007), Rickwood et al. (2007), and Richardson et al. (2013). Positive messages may also contribute to stigma reduction which supports the recommendations of Lally, O’Conghaile, Quigley, Bainbridge, and McDonald (2013). In education and advertising, it is vital that help seeking as a behavior is disassociated from the female out-group behavior and presented as a genderless trait of individuals who show strength and take control. Young men may then be more likely to adopt professional help-seeking behaviors into their masculine identity, which will not endanger their male in-group membership.
Overall, these measures can result in small cultural shifts in general attitudes around how young men can deal with mental health problems. Developing national strategies that utilize advertising combined with skills development, service provision and education can have the most effective outcomes and correspond with recommendations by Jackson et al. (2006).
Limitations
Due to the sensitive nature of the topic there was a lack of availability of respondents and recruitment was difficult. The sample mostly included young men involved in a youth center, who volunteered to discuss mental health. The voices of young men reluctant to discuss mental health issues were not included nor were the perspectives of young men from Irish-traveler backgrounds. The results of this research do not generalize to other countries and are not intended to. However, parallels may be drawn to other contexts that have a strong Catholic heritage. Despite the third author’s involvement in coding and analysis, member checking, and reflexivity, some latent biases on behalf of the lead researcher may exist.
Implications for Practice, Theory, and Research
This research has yielded four recommendations. First, in the interest of meaningful prevention, formal education providers need to implement mental health education into curriculums from primary level. Second, youth work settings are a potential resource, in engaging young men and encouraging professional help-seeking. Third, practitioners and services need to consult young men in the design of intervention or prevention strategies (Rickwood et al., 2007). Finally, professionals who want to foster professional help seeking must endeavor to show young men genuine care and respect, creating engaging environments with particular attention to power imbalances.
This research has addressed the lack of study on emotional inputs in help-seeking (Chan, 2013) by exploring the influence of fear, shame, and embarrassment. This research has also shown how the personal gains and losses of professional help seeking in Chan’s theory of help seeking (2013) can be understood within the social identity approach (Hogg & Turner, 1987; Tajfel & Turner, 2004). Young men prioritize their male group membership in personal decision-making processes, describing how help seeking affects their personal image, public image, and masculine identity, elucidating further the sociocognitive processes of professional help seeking. Young men will be reluctant to adopt professional help-seeking behavior unless there is a concerted effort to reframe help-seeking behavior as a genderless trait. Help-seeking is an important life skill but a new concept for young Irish men, one they will not easily utilize if it means jeopardizing their in-group membership, personal image, public image, or indebtedness.
Future research could focus on a few key areas. First, more investigation is needed into the mental health perspectives of key adults in young men’s lives, such as teachers, parents, and youth workers, who are important role models, educators, or gatekeepers to mental health services. Second, professional help-seeking for mental health problems research is needed with young men who identify as gay, bisexual, or transgender as they experience compounded stigma and may be the most at-risk subgroup of young men. Third, it is clear from this research that young men are both willing and able to talk about mental health and to create solutions to problems they experience, when consulted and encouraged in a supportive environment. Future research needs to adopt this approach and inquire about the perspectives of young men who are seldom heard. Evaluation is essential in all future research. An unexpected outcome was that five participants informed the first researcher, postresearch, that they sought help as a result of participating in this research; two are attending counseling and three have engaged in one-to-one youth work.
Conclusion
This research concurs with the extant literature on barriers to professional help-seeking for young men. This study contributes four important findings that deter young men from professional help-seeking: First, young men fear psychiatric medication; second, young gay men fear homophobic responses from professionals; third, this study highlights the impact of Catholicism on help-seeking behaviors of young men; finally, young men want genuine care from professionals. This research is both timely and valuable as any furthering of knowledge that can facilitate this at-risk group of men aged 18 to 24 years to seek help can only contribute to the reduction of death by suicide.
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.