Why It's So Hard To Reach Males In Need Of Mental Healthcare

Feb 27, 2018

The recent deadly shooting at Marjory Stoneman Douglas High School in Parkland, Florida, by a 19-year-old former student has brought not only gun control into the national conversation again, but also the effectiveness of mental health care. Signals given off by the disturbed young man, who has confessed to police, might have connected him to the help he needed before the attack on the school. But they didn’t. 

That’s not necessarily unusual because men and boys often don’t interact with the mental health systems in this country. That’s what Dr. Wizdom Powell has found. Powell is a clinical psychologist and the director of the Health Disparities Institute at UConn Health. She recently sat down with Morning Edition Host Tom Kuser to discuss her work and why it's so difficult to reach males in need of mental healthcare and support.

Below is a transcript of their conversation.    

Dr. Powell, welcome.  

Thank you.

I know you spoke at a congressional briefing in January on men’s mental health, and I want to ask you about that, how it went. But first, why don’t males connect well with mental health care in America?

Yeah, I think it’s a pretty layered issue. I think it starts quite frankly with the early life socialization that boys and men receive around the disclosure of emotional distress. Boys are not encouraged to share their feelings and they’re not usually equipped with the emotional language to even describe what’s happening in their interior lives. So we have this sort of priming, if you will, for shutting down emotion and displaying emotional stoicism that puts men and boys at greater risk.

How did you discover this disparity? What led you to investigate this?

So, it was pretty apparent to me that if you look at the epidemiology of mental and physical health outcomes that there is a stark and glaring gender disparity. There is the often spoken about gender paradox in mental health where we see boys reporting less depression and also not likely to meet clinical criteria for major depressive disorder but committing suicide at higher rates than women. And that suggests that some men may be suffering in silence.

So the first signal that this area needed attention was a really sort of basic scientific, socio-epidemiologic gap, right? But then there’s the personal side, the fact that I am a mother, a wife, a daughter, an auntie, you know, and that I care deeply about the boys and men that are around me. And the fact that I realized quite early on in my own family system that we had lost, you know, some of the patriarchs pretty early due to premature death.

That leads me to wondering on a larger scale, what is happening to people who are not getting the treatment they need. What’s happening in our society as a result of this?

One of the issues that we’re seeing as a result of the implosion, if you will, of our community mental health system is that we don’t have enough providers, actually quite frankly, to meet the demand. And the providers that we have are usually not co-located with primary care physicians, which means that if you don’t know where to get mental health care, if you’re out of touch with the healthcare system as many boys and men are, then just simply locating a provider that you trust, who will accept your insurance and for which you actually have access to at hours that you can make it; there are lots of really systemic, you know, barriers to actually getting mental health provision that even if you have the will to go, sometimes that the access/outlets aren’t present.

But I think there’s also a larger issue in our society that we have to grapple with. We are a society that values emotion suppression above emotion expression. The disclosure of vulnerability for most Americans is not something that we encourage. We are all sort of buying into this dominant notion that we should shut down, you know, man up, even woman up, in the face of pretty significant distress. So I think the culture around silencing our emotions is giving way to this larger issue that we see among boys and men.

In your investigations, have you found that there are some groups among the people who aren’t getting the help they need? Are there some groups for which the problem is more severe?

So I think that when we look at boys and men as a whole, we do see this larger uptick in suicide completion, that’s across men from all racial/ethnic/socioeconomic status groups. But if you can think about mental health issues as a symptom of larger social issues, then you would imagine that there are some populations that might be more vulnerable. For example, men who are transitioning from the prison system. Men who are aging out of foster care. Men and boys who are returning from combat. Men and boys who are already marginalized, socially marginalized groups, like racial and ethnic minority men. On an average we see higher rates of substance use and misuse in African-American and Hispanic and Latino populations. And I like to think of those outcomes as not a failure of the individual, but largely an outcome, a symptom if you will of larger social issues, lack of access to opportunities for upwards social mobility, for example. Lack of adequate housing. And racism.

Is there any difference, have you run across any differences in attitude about seeking out this kind of help in different age groups? Millennials versus baby boomers versus Generation X, what have you.

So I personally haven’t studied the sort of generational differences, but if I were to speculate, I would imagine that millennials would probably have less of a difficult time with emotional disclosure because they’re growing up in an age of social media where every single emotion you experience can be captured in an emoticon or like, shared on Facebook, or updated on your Twitter status.

So, I would imagine that men of a certain generation, like my grandfather for example, would have a more difficult time disclosing what’s happening in their interior lives than younger men.

But we do also see that for certain racial and ethnic subpopulations that have a history of medical malice, large scale medical malice and mistreatment, that there are higher levels of mistrust. And, you know, that mistrust is rooted in some unfortunate social and historical realities and those have to be addressed if we’re gonna create more pathways to mental health care for those populations.

And you’ve answered this to some extent already, but in addition to men and boys just not wanting to violate social norms and seek out the help, are there gaps in the mental health system itself that make it more challenging for men and boys, versus women and girls, to seek support when they need it?

I think so. I mean, one of the things we’ve learned is that men are really concerned, and this is in a general sense, with being providers for their families. And if you take a situation where you have a man who is low-income and who is working in a position with very little job flexibility, he’s not going to take a day off of work to go for a preventive screen or to address an issue like feeling sad or down or you know, discouraged. He’s probably more likely to go to work and take care of his family than he is to pay attention to his own needs. And so we need more care provision outside of normal clinical hours. We need to flip the clinic, for example, offering services for men and for boys on weekends and at nights.

We also, you know, realize that men and boys come to our healthcare services/facilities less often than women, with less frequency, and so when they come in, we need to maximize those appointments. Reinforcing appointment maximization strategies are really gonna be, I think, helpful as we think about how we integrate and get men and boys connected to healthcare.

On a personal note, the company that we use for physicals, which is based out of New York, they send you the questionnaire. And a whole group of questions has to do with feeling sad or depressed or, you know, does it affect the amount of hours that you were able to do your work this week, and…next page, you’re not supposed to think about that. And I’ve often wondered is the same list of questions given to women and girls?

And you’ve hit on something really critical, Tom. You know, we’ve talked a lot in the mental health community about the ways that we even assess symptomatology in men and boys. For example, one common question on a depression inventory is “Have you been crying a lot?” Well, I think men get sad and surely men cry, at least we hope so, because that’s a healthy way to respond. But that’s not likely the way, the typical way that a man or boy might express distress. He may in fact be more outwardly expressing, he may become more angry, more irritable, and that kind of symptom display is something that we have to look out for.

And also we have to be cautious about how we respond to it because often that kind of behavior leads us to want to respond with more behavioral control. Like, for boys in classrooms for example. You know, if you’re acting out in a classroom with anger and rage or irritability, you’re more likely to be pushed aside into a detention or something like that, when in fact you might be displaying those symptoms because of undetected trauma exposure, undetected depression, undetected anxiety. And we just don’t do a good job at filtering out what those symptoms might look like for boys and men.

What then do you think needs to be done to fix or at least to improve our mental healthcare system? And I’m thinking on several levels, the institutional level, and maybe at a more basic, individual level?

Yeah, I think that from an institutional perspective, we have some clear opportunities, especially here in the State of Connecticut. We are now embarking on implementation and lots of innovation in the healthcare system space and transforming the way we deliver care. That transformation should include some attention to providing training to frontline healthcare services staff about how to interface/interact with and screen for mental health issues with this population.

I think we definitely need universal integration of primary and mental and behavioral health care. There is no way that we’re gonna solve this problem for boys and men or for any population if we don’t start thinking about it in that way. I think we also could really think about opportunities to deliver care where boys and men are in the communities where they live, work, play, pray and get educated. So I think that trying to be even more creative about services delivery in those spaces could help us a lot.

I’m wondering, what went through your mind when you heard about the shooting in Parkland, Florida, and about the gunman who was responsible for it?

Like most Americans, the first emotion is sadness, just deep, deep sadness and grief for the families, for the lives that were lost and for the missed opportunities to intervene, that I’m sure were present. This is not a condemnation because I think, again it’s really difficult to pick up on subtle signs and symbols. But it makes me wonder about the culture of violence that we promote and the tendency for boys and men to buy into that culture because we expect them to be strong and stoic and fearless.

I would love to see as an outgrowth to this, a response to this, would be not to think that every person who commits a crime like this is mentally disturbed because that’s unfair to the millions of Americans that are suffering from true mental illness. But I think it’s important for us to have a dialogue about the stuffing down, the repression of anger and emotion that a lot of us feel, and the implications for our society when we don’t address it. It’s kind of like whac-a-mole, you know, we stuff it down but it pops up someplace else, and sometimes it pops up in these kinds of violent outbursts.

You spoke to members of Congress in Washington on January 30. What do you think lawmakers at that level can do to change how the mental health system meets the needs of men and boys?

Well, we certainly see opportunities within the health reform efforts to increase the parity between payments for mental health services and payment for physical health services, I mean, that’s an opportunity that’s just wide open and kind of like low-hanging fruit. I have always thought that Medicaid expansion for example was one of the opportunities that we’ve...first that we’ve had in a long time to increase enrollment among childless men. It was the first time that men without children were newly eligible. And as a consequence of that we saw an uptick in insurance acquisition among men.

And so I think we have to think about the broader implications of the kinds of policies we enact and the ones that we disrupt because Medicaid is now a pretty vulnerable social policy. And so I would like for us to think not just about the kinds of policies that are gonna cost us something, but those that are also cost-neutral to address these issues. And policy makers have a lot of power and opportunity to influence the health care reform landscape and I hope they use it in a way that’s going to improve outcomes among populations like the ones I serve.

Were you able to get a feel for their reaction, the members of Congress you spoke to?

It’s really hard in these briefings to gauge, but I did sense in the room because of the opioid crisis, which is part of the reason they brought us to the room to discuss this issues, there were light bulbs going off. Because when you look at labor market participation, we see that there’s been a steady decline in male participation, and we know that some of that decline is explained by opioid abuse. We know that there’s social reasons why people are choosing to numb themselves. And so getting policy makers to think about the economic bottom line, the fact that when men and boys die prematurely as a consequence of these kinds of outcomes we all suffer. And there is an impact on our capacity as a nation to compete in the global marketplace. We cannot innovate and compete with the world on a global stage if half of our workforce is being compromised by untreated, undetected mental health issues.

Dr. Powell, thanks for your time today.

Thank you so much for having me and for really creating a space for this important conversation.