Help-seeking prior to male suicide: Bereaved men perspectives

Highlights

• Bereaved men offer important insights to male help-seeking prior to suicide.

• Masculinities can intersect with health inequities to increase suicide risk.

• Men who are seemingly in care can be high risk for suicide.

• Masculine cultures and norms are key considerations for suicide prevention.

• Norming men's help-seeking may reduce suicide.

Abstract

Male suicide is a significant issue globally, and implicated are men's challenges around help-seeking and engagement with peer or professional mental health care. While men's reticence for help-seeking predominates as an explanatory gendered dimension for male suicide, there are significant caveats and complexities to fully understanding those practices in the context of men's mental illness and suicidality. The current photo-voice study offers considerable insight into such issues – through the eyes of the bereaved – retrospectively exploring accounts of the deceased's mental health help-seeking prior to the death. Using an interpretive design, and based on semi-structured individual photo-elicitation interviews with 20 men who had lost a male friend, family member or partner to suicide, three key dimensions were identified: 1) Entrapped by secrecy and concealing the need for help, in which the deceased hid their suicide risk and need for peer or professional mental health care; 2) Overwhelming illness that couldn't be helped, wherein the deceased had previously connected with an array of social supports and medical services but was estranged from peer and professional help ahead of the suicide, and 3) Services and systems providing ineffectual help, whereby the deceased was connected with mental health care shortly before the suicide. These themes reveal complex relations to help, and help-seeking in men lost to suicide, as well as bereaved men's reliance on normative masculinities as an explanatory framing of these practices. Discussed within a critical masculinities framework, the current study highlights the need to destigmatize men's mental illness and help-seeking as well as address significant health inequities to aid the efficiencies of men's suicide prevention programs.

Introduction

Claiming the lives of boys' and men across all age groups, suicide is a significant global health issue (Pitman et al., 2012). While an array of factors are implicated in male suicide, qualitative studies have consistently highlighted the gendered dimensions, and significant risk of men's reticence for seeking professional mental health care (Clearly, 2012, 2017; Johnson et al., 2012). Evident also are complexities in men's mental health help-seeking whereby some males who are seemingly in care are lost to suicide (Oliffe et al., 2019b). For example, population-based analyses of health care contacts among Canadian suicide decedents in Toronto reported that while 10% of men (n = 200) were not connected to any form of medical care in the year prior to their suicide, over 60% (n = 1792) had accessed professional mental health care in the year before their death (Schaffer et al., 2016). Similarly, a longitudinal US study, drawing health system contact data from 8 states, reported that in 47% (n = 1810) of male suicides the deceased had accessed health care services during the 4-weeks prior to the death, while a further 21.3% (n = 966) had contact with mental health care services in the year prior to suicide (Ahmedani et al., 2014). Despite being depicted as a binary (men refusing verses men receiving professional care) these practices co-exist reflecting men's mental health help-seeking as diverse, and operationalized across a continuum (Oliffe et al., 2019b). In deed, based on findings drawn from a systematic review, understanding men's attitudes toward, as well as their experiences of mental health care services were emphasized as critical to advancing targeted suicide prevention efforts (Seidler et al., 2016).

Better understanding the co-existence and intricacies of men's estrangement from, and engagement with mental health care is vitally important, and men bereaved by male suicide can offer unique insights in this regard. The current study, by offering men's perspectives about the deceased's help-seeking prior to the suicide, can inform and aid the effectiveness of men's suicide prevention programs.

Connell's (2005) masculinities framework has been used to offer critical analyses about how normative masculine ideals are implicated in the multifactorial character of male suicide. Central to empirical work have been linkages between masculine ideals of self-reliance and stoicism, and men's reticence to disclose mental illness vulnerabilities and/or resistance to seeking or sustaining professional mental health care (Yousaf et al., 2015a,b; Bevan, 2010; Wide et al., 2011; Pirkis et al., 2017). Hoy's (2012) review of qualitative studies addressing men's distress distilled 4 gendered barriers to help-seeking; 1) social stigma, including the judgement of other men, 2) apprehension about medical professionals and prescription medications, 3) difficulty or inability to communicate and share emotional problems, and, 4) preference for self-managing health and exhibiting strength and control over problems. These help-seeking barriers also reflected the interweaving negative effects of normative masculine ideals with interpersonal, social, cultural and structural factors: work and relationship problems; negative experiences due to ethnicity or sexual orientation; and distrust of health professionals (Hoy, 2012). Seidler et al. (2016), similarly predicted that men who experienced depression and aligned to masculine ideals (i.e., restricted emotionality, stoicism, self-reliance) were unlikely to seek help.

Men's reticence for seeking mental health care has also been highlighted in male suicidality research. A study of young Irish men reported that the use of alcohol to self-medicate distress while steadfastly resisting peer or professional help was valorized among participants who concealed their suicidality (Cleary, 2012). Cleary's work (2017; 2019) further highlighted men's help-seeking as complex cultural and socioeconomic issues, wherein some masculine communities experienced heightened risk for suicide as a byproduct of normative restrictions to expressing emotional pain. Amongst US based older men, Canetto (2017) emphasized how the indignities of aging and the masculinity-of-suicide scripts flowed from cultural influences to amplify men's vulnerabilities. Another study showed Canadian men avoided disclosing suicidality to health care providers for fear of discrimination and being seen as weak (Oliffe et al., 2012). Within the masculinities and men's suicidality research however, explicit considerations of health inequities have been conspicuously absent, and, as a consequence the multifarious structural barriers to men's help-seeking and engagement with mental health care have lacked nuanced social contexts (Griffith, 2018). Flowing from these knowledge gaps are calls to explore how other aspects of person, social structure and life context (including education, income and sexual identity) (Ferlatte et al., 2018) may critically mediate men's mental health help-seeking and engagement with care services.

Men who experience mental illness and do access mental health care have also drawn some research interest. Strike's et al. (2006) study of men with suicidal histories described fragmented mental health care pathways that were beleaguered with negative experiences of service providers and health care systems to the extent that most participants' service use was involuntary. Men reported discomfort disclosing emotional distress to providers, and on occasions when desperation prompted their self-disclosures about suicidality, they suggested providers mislabeled or underestimated their needs (Strike et al., 2006). Without perceiving a provider's genuine interest in their problems and a therapeutic or counselling alliance, men tended to discontinue usage and/or opt to self-manage their mental illness (often times ineffectually through substance use) (Strike et al., 2006; Johnson et al., 2012, Seidler et al., 2016). Möller-Leimkühler (2002) and Wide et al. (2011) also pointed out that health practitioners may miss or misdiagnose men's psychological problems due to their own normative gender biases. Gendered stereotyping and alignments to normative masculinities have therefore featured as barriers for some men who were seemingly in care and receiving treatment, revealing the potential for substantial suicide risk among male help-seekers (Strike et al., 2006).

Within the men's mental health help-seeking literature normative masculine ideals have been viewed as working in ‘both directions’, reflecting a desire to move beyond simplistic ideas about pathological masculinities and/or reductive accounts of men and help-seeking (Sloan et al., 2015). For example, reinforcing a more traditional account of gender normativities, masculine ideals have featured repeatedly in accounts of the barriers muting men's potential for self-disclosure about mental illness – and by extension increasing their distance from peer or professional help (Noone and Stephens, 2008; Courtenay, 2000; Galdas et al., 2005). Canetto (2017) and Cleary, 2012, Cleary, 2017, Cleary, 2019 have linked some men's reticence for seeking professional help, despite experiencing suicidality, as reflecting their alignment to cultural scripts of gender characterized by risk-taking and the denial of weakness. Yet, recent observations and scholarship across many different fields of men's health have ‘flipped’ the normative influence arguments (i.e., masculinities as disabling), to challenge the linearity of such normativities (Oliffe et al., 2012). This work builds on Connell's (2005) plurality of masculinities, adding to a sense of generational change and shifting values (Oliffe et al., 2019a), amid highlighting how some men can revision culturally informed ‘strength-based’ masculine ideals to disclose mental illness, vulnerability and the acceptance of help (Johnson et al., 2012). This does not shift the reductive/normative potentiality of gendered norms, but rather, adds nuance to understandings of the ‘work’ they do (and how this may change over time and context). Recent work has operationalized such ideas as affirming men's help-seeking as courageous and strength-based in tailoring male suicide prevention programs accordingly (Pitman et al., 2012).