23 November 2023
By Andrew K Kauffmann @JKaye82
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All You Need Is Love
You can learn how to play the game (It’s easy)
The inky night sky descended early that day I volunteered at the homeless shelter. It was Christmas, in the mid-2000s, and there was an icy chill in the air. The soft hum of sleeping men was punctuated by the grizzled clearing of throats. Echoing in my ears were the instructions we’d received from the team at Crisis, the homelessness charity. ‘If you straighten out any of the bed sheets or place them in the laundry, lift them cautiously. A syringe might fall out.’ Saddened by what I was seeing, I pottered about. Men struggling with alcohol addiction queued for food at the bottom of the stairwell. Passing by the dormitories, you could hear the steady rustle of coats.
The shelter was only going to remain open for a few more days. Those at risk of sleeping rough for the night were offered a place to keep warm. Podiatrists cut toenails. Volunteer masseurs soothed away knots in necks and lower backs. In the middle of my shift I started chatting to a middle-aged man. He could easily have been a neighbour of mine, or someone I might have commuted next to on the tube. He’d been successful, he told me. He wasn’t being boastful. His gardening business fell apart, and because the finance had been organised by his wife, who he was now separated from, in only a matter of months he found himself losing a roof over his head, and, unbeknown to his adult children, sleeping on park benches.
For the first time that disquieting afternoon I listened — properly. The man couldn’t admit to his kids it was despair he felt; a gulf between them had started to open. I wondered what it was that truly separated his story from mine, or that of my father. We too hoped to achieve a sense of security. I was occupied by the idea that, from one day to the next, a feeling of stability can indeed begin to crumble.
As I exited the homeless shelter that night in the mid-2000s, the image I was left with was of this shaven, unassuming man, whose mental health one day slid, and then worsened. I’d taken the time to listen, but as the wind stung my ears on entering Moorgate station, I felt deflated. Now I view the episode differently. Crisis had provided a space for this man, and other men like him. Here they could share their story, and feel that little bit less lost. The men at the shelter weren’t probed on their addictions, or their housing situation. The key – it seemed to me, that night in London – was when strangers started to listen, and no one with a difficult story was cast out. The men weren’t treated as rough sleepers, or as drinkers, but as people, with all their attendant needs and emotions.
Eleanor Rigby
All the lonely people. Where do they all belong?
The Campaign to End Loneliness, which has shared work on the psychology of loneliness, highlights how for many people a sense of purpose and self-worth is derived from their work, and when that disappears, it’s important to find purpose in new ways. They highlight ways to experience wellbeing we can all invest in, to avoid turning inward. These include to continue connecting (even when we don’t feel like it), and to continue taking notice of the people in our lives and the world around us.
When I look back at my volunteering experience at the homeless shelter I can see how this underlying philosophy informs services that neither seek to lecture men, nor use clinical language or label them, but to offer a listening ear. People who feel dispossessed might struggle to voice what they’re feeling, but designed in the right way, services can provide them with the conditions to normalise their feelings.
It is increasingly said that loneliness and a lack of social connection feel normal for some, but normal or not, loneliness is bad for physical and mental health. In a US context, the Surgeon General has recently issued a health advisory warning of the risks and the consequences of loneliness, pointing to evidence that “the odds of developing depression in adults is more than double among people who report feeling lonely often, compared to those who rarely or never feel lonely.”
It’s a relief to see more emphasis placed on loneliness, associated as it is with mental health difficulties such as depression and anxiety. Examining data from the English Longitudinal Study on Ageing (ELSA), Independent Age and the International Longevity Centre UK determined that almost one in four older men (23%) had less than monthly contact with their children, and close to one in three (31%) had less than monthly contact with other family members. For women, these figures were 15% and 21% respectively. Perhaps just as concerning, older men also had less contact with friends. Older men who live alone say they feel lonelier (compared to women who live alone). The Independent Age report, Isolation: the emerging crisis for older men, claimed that loneliness in older men is sadly set to grow.
Blackbird
Blackbird singing in the dead of night
One autumn day in 2023, a British writer and political commentator appeared on a BBC television show to share his concern that too many men take their own lives, and yet, too little seems to be said on the subject of men and suicide. The question posed by the programme, Politics Live, was intended to stoke debate: ‘should there be a Minister for Men?’ The UK’s Health Select Committee states that four in five suicides are by men. In the British context, suicide is the biggest cause of death for men under 35. It has been said there has been a sharp increase in the rate among men aged 35 to 64. Presumably someone in government could be charged with tackling the problem?
Geoff Norcott, the writer, was gently mocked by one of the other panellists, who didn’t deny what he was saying sounded serious, but commented that mental ill health is a population-wide problem. It wasn’t especially helpful, she argued, to look at mental illness in this way when mental ill health is endemic across the nation. She cited the challenges facing children and young people in need of mental health care.
Norcott felt a need to be self-effacing. He didn’t “…want to be this guy”. In other words, he didn’t want to be regarded as soppy, or a man who complains needlessly about men’s problems. Finding his words, he added: “The problem is, even as I’m saying this, in my mind it’s like I’ve got out the violin…You encourage…that men need to talk about their problems more, and then the moment you do it, it’s like, ‘alright, not quite so often, and not quite so loud’”. It’s telling that he felt the need to couch his concerns about men’s mental health in such an apologetic way.
Perhaps he felt a certain tentativeness, noting that in England one in eight men have a mental health problem, whereas the figures reveal that as many as one in five women have a mental health problem. Whatever was on his mind, the statistics Norcott tried to share do warrant attention. Ostensibly they tell us something stark and simple about the state of men’s mental health, but to my mind, the reaction that he faced on television also carries predictive potential.
If we continue to shame men into thinking that by sharing their concerns, they’re whingeing, we’ll do a disservice to people who aren’t just statistics, but individuals who feel they have no one to turn to, and no place to go. No man should feel a need to self-deprecate, let alone apologise for admitting as a man that they too may have a story about mental ill health to share. Norcott’s warning is the song of the spectral blackbird: of significance, I’d say, but so muted that as a society, we risk not heeding its call.
The question at stake, then, isn’t whether men ‘suffer’ less or more than women, which would be reductive and simplistic. The debate here isn’t whether men proportionately experience mental health problems less or more than women, but whether, as a significant sub-group of the population, they’re seeking help, and where they aren’t, what can be done to help them.
Help!
Help me if you can, I’m feeling down
The UK government says that the current suicide rate has not fallen in five years, and while the figures aren’t significantly higher than they were in 2012, they are still not falling enough. Examining the UK figures specifically for men, males aged 45 to 64 have seen the highest rates of suicide of any group (based on age and sex) since 2010. In 2021, the rate in this group was 20.1 deaths per 100,000.
The government’s new suicide prevention strategy in England has set out actions to support middle-aged men, which is a welcome start. What is sobering to note in the strategy is that, contrary to popular conceptions, men do often appear to reach out for support, more indeed than is imagined. What’s possibly not working are the ways in which various services are set up to respond to men’s needs when they do communicate concerns.
Looking at data from 2017, The University of Manchester’s research revealed that, of men aged 40-54 whose deaths by suicide or probable suicide were investigated, two thirds had been in contact with a frontline agency in the three months that preceded their death, principally primary care and emergency care. The question is how agencies, including primary care providers, subsequently support or refer men to get help, and whether these agencies collaborate in the way they could to optimal effect.
The government acknowledges that socioeconomic disadvantage is strongly associated with suicide among this demographic. Factors such as living in the most deprived areas, chronic physical ill health, recent adversity, plus experiences of unemployment, debt and housing difficulties have also been linked to suicide in this group. It should be no mystery which population sub-groups are thought to need additional support or outreach. The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) and multiple other sources point us to what we can do to prevent men from taking their lives, but opportunities are being missed. Learning about what works to prevent suicides needs to be disseminated, and more broadly, we need national warnings from coroners, including Prevention of Future Death reports, to be acted on swiftly.
I Feel Fine
and I feel fine
The idea that men rarely talk about their mental health isn’t merely anecdotal. It’s backed by the evidence. Controlling for prevalence, men are less likely than women to seek help for mental health difficulties. Of the men they surveyed, The Priory Group revealed two in five men won’t talk about their mental health and the same numbers said it would take thoughts of suicide or self-harm to compel them to seek professional help. Data from 2015 showed that just over a third of NHS referrals for talking therapy were for men.
The core issue that ended up obscured after the BBC Politics Live debate on whether we need a Minister for Men is that men might experience mental illness in ways we’re not yet sufficiently equipped to address, at least not consistently. We also need to confront a culture in which it’s seen as weak or possibly even indulgent of men to speak out about their mental health.
Roman Kemp’s documentary, Our Silent Emergency, details how Joe, his producer and friend, tragically took his life. Kemp explains how Joe hadn’t shown obvious signs that he was struggling, and for both family and friends, his death came as a shock. It’s a story that is sadly all too common. It’s a phenomenon that led Norwich Football Club to release a new video for World Mental Health Day in 2023, upending our expectations about which men might be considered most at risk of suicide. It’s a story that speaks to our assumptions that were a man’s mental health to be hit, he might look strained, or show other visible signs of distress, but highlights that we can no longer rest on making such simple assumptions.
A young man who had attempted to take his life highlighted in the ‘Our Silent Emergency’ documentary how he viewed himself as a ‘pillar of strength’ for his friendship group, but when this role was less available to him after moving to university, he felt extremely lonely. Other men talk about the sense of shame or guilt they can feel that they’re not meeting others’ expectations. Rory O’Connor, Professor at Glasgow University and President of the International Association for Suicide Prevention (IASP), highlights suicidal men’s sense that they’re a burden, and their belief that loved ones shouldn’t have to shoulder that burden. They can also feel a sense of defeat and entrapment. What’s more, men can appear ‘happy’ – central figures in a friendship group, say. One can’t easily surmise which men will experience mental health difficulties; they won’t necessarily show signs of introversion, let alone marginalisation. We still need to tackle this mindset – this cultural barrier – that means too many men fear it would seem weak to open up, even to their loved ones and friends.
And still too often, men have deeply ingrained attitudes that seeking help for mental health is somehow negative. On average, more men view this act of reaching out for help as a threat to their sense of invulnerability, their strength and their emotional control. Not displaying visible signs of distress isn’t something that necessarily distinguishes men from women, and we have to be careful to avoid over-simplified generalisations about whole swathes of the population. But it feels at times we don’t always respond well to men in distress. We might lack the right strategies. This can include mistaking the solutions they turn to, for instance alcohol or drugs, as behavioural choices. I am inclined to agree with those who claim we might be under-representing mental health problems in the male population, by only focusing on clinical diagnoses, and not other ‘externalising behaviours’ or life circumstances. The Men’s Health Forum points out that nearly three-quarters of adults who go missing are men. More than four in five rough sleepers are men. And men are nearly three times as likely as women to become dependent on alcohol and three times as likely to report frequent drug use.
Addressing the question ‘what can any of us do as individuals to better open up routine conversations with friends, colleagues or loved ones?’ I am struck by the simplicity that lies at the heart of advice the founder of Man:tra, who helps men in midlife, shared with me, “Don’t just ask someone ‘how are you?’ once. With men that might not get you far, ask them three times if need be, to really demonstrate you care and you’re there to hear their answer.” If we hear someone briskly tell us they’re ‘fine’, perhaps that’s all we need to know, but perhaps, in some cases, we could reassure them we’re ready to hear more.
The Long and Winding Road
Why leave me standing here?
Even when men do seek help, it might not be forthcoming. From the sample of men who took their lives (or probably died due to suicide) in the University of Manchester’s 2017 data, only 5% had engaged with talking therapies, “despite the higher than expected rate of contact with services”. This is consistent with other data. Looking at sex, men with a mental health problem were found to be underrepresented in IAPT services (now NHS Talking Therapies) with only 8% entering this service compared with 10% of women. The Office for National Statistics has said these differences are “statistically significant.”
Research elsewhere queries whether clinicians under-diagnose men with mental health conditions, and whether perhaps there’s even a bias in attitudes that causes clinicians to do so. Researchers have examined whether clinicians can suffer from the expectation that men should fulfil particular masculine stereotypes, and that if they don’t, problematic diagnostic practices can then emerge. I’ve even heard it said that clinical thresholds for psychological help could be lowered to redress imbalances that leave fewer men, proportionately, receiving a diagnosis of a mental health condition.
In a recent interview with Emily Maitlis on mental health, ‘What is behind our mental health pandemic?’ Roman Kemp lamented that for all the mental health awareness campaigns set up encouraging people to talk, there’s a dangerous mismatch in terms of the available mental health care. It’s almost akin, he says, to hearing the message ‘tell me if you have disease, but by the way I won’t have a cure for you‘. I worry that to compound this problem that men don’t always speak up, and support can be scarce, there appears to be a creeping culture accusing some of exaggerating their mental ill health when they do manage to talk. This isn’t just an issue facing men. Reforms being consulted on to the UK’s benefits system are taking place in a climate where Ministers question the numbers of people with mental health difficulties, suggesting that people are “too readily” being identified with a problem. This can only have the insidious effect of further silencing people who are struggling.
Yellow Submarine
And our friends are all aboard. Many more of them live next door.
There’s extensive evidence that dominant gender norms – what is sometimes referred to as ‘hegemonic masculinity’ – not only lead to fewer men reaching out for help, but see fewer men even acknowledging their mental health difficulties. On average, mental health literacy is said to be lower in the male population. And in one study, respondents were less likely to view men with symptoms of depression as suffering from a mental health difficulty, compared with women in similar situations. The researchers concluded that “hegemonic masculinities leave men with few resources with which to construct healthy attitudes toward mental health behaviours.”
There are signs of positive cultural change. Emmerdale, a British soap opera to be commended for sensitively portraying the mental health difficulties of character Paddy, joined a public conversation on men’s mental health early in 2023. The storyline followed Paddy attempting to take his life after a devastating relationship breakdown. What was even more powerful was how the storyline then shone a spotlight on the men in his community and their sympathetic response. Other male characters talked about their own mental health in a pub, admitting in one or two cases where they had also suffered. Supported by Andy’s Man Club, the programme researched what holds men back from talking, and the profound effect an accessible space to talk can have on men. A Lighthouse support worker , rejecting the idea that “young men don’t do this type of stuff” (talk about their feelings), said to the BBC’s Our Silent Emergency documentary, “provide the space, do it well, and you will see amazing results.”
Andy’s Man Club is an exemplar where men clearly welcome spaces to open up. A spokesperson told me that what supports the men they see in over 120 support groups, are safe, non-judgmental spaces where men can “get things off their chest and… gain support from their peers.” What they clearly do is to make this process of talking as easy as possible. They provide a weekly service for free – and this seems crucial – with no referral process. This means any man aged 18 and above can simply just turn up and see how the club goes. By providing this accessible space, Andy’s Man Club told me, they “break down the stigmas attached to men’s mental health” and allow men “to gain support, in their own time with like-minded men.” Crucial components include not rushing men into committing to take part over the long-term, and letting friendships flourish organically.
Love Me Do
Love, love me do
One thing that particularly troubled me in researching this topic was reading the Mental Health Foundation’s evidence to Parliament on the impact of body image on mental health. Their submission touched on high levels of body dissatisfaction in men – higher levels of dissatisfaction than many people might have realised were causing men problems.
The Health Select Committee received evidence that “body dissatisfaction is increasing for both teenage boys and girls”. However, the motivations behind this, they noted, “may differ.” Nearly one in three (28%) of men aged 18 and above have felt anxious about how their bodies looked, and in 11% of cases this has caused men to feel suicidal. This is staggering.
Mental health problems such as body dysmorphic disorder (BDD) and eating disorders are sometimes associated with girls and women, but body dysmorphic disorder and how it affects boys and men has come to mainstream attention. James McVey, singer with British band The Vamps was recently interviewed on body dysmorphia and depression as part of Mind’s partnership with The Mirror. “My life revolved around food, the continuous self-evaluation of whether I’m happy with my body. It wasn’t from a point of vanity.” He added, “I think it stemmed from a yearning to be in control of aspects of my life in an environment that was typically all over the place. My sense of trying to find control came in food and exercise.”
Data reveals that between 2017 and 2022, there was a 16% increase in the numbers of men aged 17 to 19 experiencing possible eating problems. Fewer young men overall find themselves in this vulnerable position (compared to women), but in this short time period, it is troubling to see such a big increase in young men.
The Health Select Committee on body image and mental health identified groups particularly “known to be affected by body image dissatisfaction.” LGBTQ+ people were one of the groups highlighted. Charlie King, a TV personality, gave evidence to the Committee: “Because I had not identified with my sexuality then, I was going above and beyond to try to be something that I was not… In that period of my life, there was a lot of focus on my image.” In his evidence he confirmed that he wasn’t asked questions by a plastic surgeon about how he was doing, and whether he had benefited from mental health care in the past. He felt the plastic surgeon he saw should have said “‘You don’t need this, unless it is medical or something. We need to make sure you are mentally prepared for this,’ because it is a big ordeal to alter your face and it can have psychological impacts — for some better, for some worse. Unfortunately, mine did not go to plan.”
To further underline the diversity of experience when we refer to men in difficulty, we might also note figures from the UK Anti-Doping Agency, which states there are more than one million steroid users in the UK, and these are predominantly male (around 98%). 56% of these users took steroids for “improving body image or cosmetic reasons.” They’re not looking to be elite sportspeople. In their evidence to the Health Select Committee, the UK Doping Agency highlighted that many of these steroid users were “white collar professionals”.
I think we need to be curious and open-minded in regularly interrogating what might be going on for men in diverse sets of circumstances. We need to consider which groups are at greater relative risk of experiencing mental ill health, and to compound that heightened risk, which groups of men seem to fare worst in accessing prompt care and support. We know racialised communities face huge health inequalities, with greater proportions of Black adults detained under the Mental Health Act compared with white adults.
We should also be taking the approach that for too long, certain types of men at risk of mental health problems have been hidden from view. Take new dads for example. I am a new dad, so this concerns me too. There’s research that suggests depression for new fathers in the perinatal period remains relatively under-researched, and yet, as with the other examples we have cited, none of these problems are experienced in isolation. Paternal depression can have an effect on children, signalling yet again why it’s our collective responsibility to take interest in men’s lives, instead of expecting them to steady themselves, stay silent and ‘man up’.
Come Together
Come together, right now
Interrogating what might be occurring for men quickly sees one consulting sources on male identity. I admire the work of JJ Bola, author of Mask Off: Masculinity Redefined who argues compellingly that for all the emphasis on ‘toxic masculinity’ in recent years, much of which was overdue and badly needed, we still need to recognise where men can be the victims. “When we talk about patriarchal society, we must focus on the ways in which women are oppressed as a result of the system. However, the notion that men benefit from the system, in all aspects of their lives, is misguided. It is clear that men are suffering, almost to the point of a national epidemic: toxic masculinity thrives on a vicious cycle where men contribute to it and also suffer from it.”
We still need to create a language for young men that fosters growth, and encourages, in JJ Bola’s words, “notions of positive and complex versions of masculinity.” We need to nurture young men so they’re not tarnished, or stunted, by what other men have done before them. It would be inappropriate for us to dismiss or trivialise men’s, or indeed any other group’s mental health challenges, just because in other aspects of their lives, they’re regarded as more fortunate, or because they might experience a degree of privilege. That would see us applying a peculiar approach to tackling what, in the end, are societal issues.
With a Little Help from My Friends
Oh, I get by with a little help from my friends
Samaritans highlight the extent to which men want services and support that aren’t clinical or sombre in nature. Instead they might prefer services designed around meeting peers, connecting through a shared activity, or an opportunity to contribute in some way. Finding common ground and normalising feelings by recognising that other men share similar problems is said to be key. Creative solutions might emphasise what men will work on rather than explicitly stating they’re a service designed to tackle loneliness or depression. The confidence to disclose emotions, and the emergence of friendships, is likelier, based on this analysis, to emerge over time, where men don’t feel overly pressured to talk about themselves from the get-go.
Whatever the setting or type of activity, it’s helpful when men can self-refer into these opportunities, without the barrier of first needing to see a GP. Graded introductions, so men are greeted with empathetic, non-judgmental conversations, are highly encouraged. Rather than place too much emphasis on words such as “therapy” or “psychiatry”, services can adopt a tone (and language) which doesn’t feel too pointed, or too prematurely focused on men finding preconceived solutions. It’s important questions are posed in such a way that they’re open and minimise the likelihood a man will be defensive in response.
Nearly a quarter of the way through the 21st century, progress can feel slow. As a football fan, I have been heartened seeing famous football players such as Dele Alli and Richarlison recently talk about their struggles with mental health, and the largely positive reaction to their statements. That said, men still too often don’t talk about their mental health due to embarrassment. Feelings of stigma are still bound up with the idea that it’s not nearly manly enough to reveal stress, anxiety, depression or any other number of mental health problems. And yet, in public health terms, we have seen enough cumulative evidence of the mental health challenges facing men – and their consequences. There’s been a gentle rapping at our door, but we have to be prepared to do more. In primary care, in mental health provision and far beyond, in our friendships, in our schools, in our workplaces, we need to be alert to what men might be telling (or not telling) us. They might not be shouting very loudly, and not often, but men do have mental health problems that badly need addressing.
Looking at this in less abstract terms, for the two weeks I have been editing this essay, I have put off talking to my Dad. I’ve felt frozen, unsure how to help my father, who’s in serious debt and frightened about his deteriorating health. A frightening sense of precarity hovers over the coming Christmas holidays.
I know he’s hurting badly. I struggle to contain my own emotions so I delay the telephone conversation, the one that only needs to begin with the words, “How are you?”, and repeats if need be, “No, how are you?” I will see him this week, but I have to be honest with myself. Confronting what at times feels irresoluble – his declining health, his financial distress – poses significant challenges to my own mental health. I try to remember the old days, the easier days, the ones when I was a teen and we listened to Beautiful Boy by John Lennon, or Here Comes The Sun, and tapped our toes as we listened to The Beatles. Now I avoid conversations, knowing for the most part, the conversations we need to have will be tough. While theorising what other men could or should do, I need to admit, it’s never in the slightest easy to talk about one’s mental health, or indeed to other men, when they’re the ones struggling. That doesn’t mean we shouldn’t try. For all our sakes, I think we have to.
‘Now and then
I miss you
Oh, now and then
I want you to be there for me…’
The Beatles
