Hiding in plain sight: men’s mental health

By Dan Bilsker PhD RPsych (biography and disclosures) Disclosures: Psychologist with a private practice in Vancouver BC. Mitigation statement: Recommendations are consistent with published guidelines.

What I did before

In several decades of research and clinical practice I never viewed my male clients from a gendered perspective. I noted their inner conflicts and coping gaps, but not in the context of masculine identity (as defined by biology, culture and personal choice).  I knew that 80% of suicide and opioid overdose deaths occur in men, but that did not trigger me to prioritize men’s mental health.

What changed my practice

In 2010 my research group was commissioned to prepare a review of men’s health, A Roadmap to Men’s Health.[i] I took the lead on this ambitious project, rushing in where angels fear to tread. What I learned was eye-opening and heartbreaking. It is well-known that men die on average 3-4 years before women – but why? We identified three main factors contributing to Years of Life Lost by men compared to women: cardiovascular disease; suicide; and motor vehicle accidents. As a psychologist, I was intrigued by the substantial contribution of suicide.

Suicidality is affected by several male-predominant risk factors:

1. Men are not encouraged to articulate their inner experience of suffering, to share it with trusted others or to engage in collaborative problem-solving. The stoic acceptance of suffering is often socially-positive but can also be a barrier to addressing problems contributing to suicidality.
2. Men are encouraged to use alcohol to manage psychological suffering: 80% of alcohol-dependent individuals are male. The cognitive impairment and disinhibition created by alcohol intoxication contribute to despair and suicidal behaviour.
3. Men are less open to accepting therapeutic help. There are evidence-based interventions to reduce suicide risk,[ii] but men are much less likely to seek treatment.

What I do now

First, I have been speaking out on men’s mental health through clinical/research journals and media interviews, highlighting the need to approach this area with compassion and understanding rather than disdain and vilification (“toxic masculinity”).[iii] [iv] [v]

Second, I carefully assess and address coping patterns linked to male identity: expression of psychological distress through anger and aggressive behaviour, use of alcohol for emotional soothing, reluctance to articulate inner experience or reach out for support, etc. Screening for risky alcohol use can be based on excessive intake (above the 15 drinks a week currently recommended) augmented by the Alcohol Use Disorders Identification Test AUDIT scale. [vi] [vii] Screening for risky anger patterns is more difficult: I recommend administering the Clinical Anger Scale with follow-up questions about difficulty controlling one’s anger or negative consequences of angry behaviour. [viii]

Third, given the reluctance to accept therapeutic help, I recommend that physicians refer male patients to appropriate self-care resources:

• Rethinking Drinking, a self-care website by the U.S. National Institute on Alcoholism and Alcohol Abuse: https://www.rethinkingdrinking.niaaa.nih.gov.
• The free-download Antidepressant Skills Workbook: https://psychhealthandsafety.org/asw/.
• Another free-download module with specific relevance to anger coping: Managing Anger (web-search the terms “pchc managing anger”).

The message is that recognizing the mental health issues characteristic of men will better equip a physician to respond appropriately. Whether this involves making a persuasive case for acknowledging psychological suffering and accepting treatment or referring a distressed man to self-care resources, the potential for improved outcomes is substantial.

References:

1. Bilsker D, Goldenberg L, Davison J. Men’s Health Initiative of British Columbia. A Roadmap to Men’s Health: Current Status, Research, Policy & Practice. CARMHA – Centre for Applied Research in Mental Health & Addiction. Simon Fraser University. Published 2010. Accessed May 28, 2019. (View)
2. Tarrier N, Taylor K, Gooding P. Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis. Behav Modif. 2008;32(1):77-108. DOI: 10.1177/0145445507304728 (Request with CPSBC or view with UBC)
3. Bilsker D, White J. The silent epidemic of male suicide. BCMJ. 2011;53(10):529-534. (View)
4. Bilsker D, Fogarty AS, Wakefield MA. Critical issues in men’s mental health. Can J Psychiatry. 2018;63(9):590-596. DOI: 10.1177/0706743718766052. (View)
5. Peter Shawn Miller. A gender gap that’s a matter of life and death. Maclean’s. Published March 20, 2017. Accessed May 28, 2019. (View)
6. British Columbia Specific Information: Canadian low-risk alcohol drinking guidelines. HealthLink BC. Adaptation Date: 11/6/2019. Accessed: Jan 4, 2020. (View)
7. The AUDIT (Alcohol Use Disorders Identification Test). Accessed: Jan 4, 2020. https://auditscreen.org
8. Snell E, Gum S, Shuck L, et al. The clinical anger scale: preliminary reliability and validity. J Clin Psychol. 1995;51(2):215-226. DOI:  10.1002/1097-4679(199503)51:2<215::AID-JCLP2270510211>3.0.CO;2-Z (View with CPSBC or UBC)

Resources and Tools:

1. Snell W E, Gum S, Shuck R L, Mosley J A, Hite T L. The Clinical Anger Scale (CAS) 2013. Measurement Instrument Database for the Social Science. https://www.midss.org/sites/default/files/cas.pdf
2. The AUDIT (Alcohol Use Disorders Identification Test)  Check Your Drinking Test: https://auditscreen.org/check-your-drinking/
3. The AUDIT Decision Tree—simple method of putting Screening, Brief intervention and Referral to treatment (SBIRT) into practice. https://auditscreen.org/audit-decision-tree/

Billing:

The MSP billing code for mental health: 14043 for General Practice: $100: GPSC Mental Health Billing Guide January 2019 PDF1.pdf. Accessed Jan 5, 2020.

Additional Reading:

BC Centre on Substance Use. Alcohol Use Disorder. Accessed Jan 5, 2020. https://www.bccsu.ca/blog/news-release/guideline-supports-people-living-with-alcohol-addiction/.

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Hiding in plain sight: men’s mental health

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