Psychotherapy and Applied Psychology: Conversations with research experts about mental health and psychotherapy for those interested in research, practice, and training

Masculinity and Male-Type Depression with Dr. Simon Rice

• Season 3 • Episode 15

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Dan welcomes Dr. Simon Rice, Clinical Psychologist and Principal Research Fellow based at Orygen, Centre for Youth Mental Health at The University of Melbourne, Australia.

Dan and Dr Rice start the conversation on the complexities of men's mental health, particularly focusing on the unique aspects of male depression and the influence of masculine norms. Dr. Rice then covers the dual nature of masculine norms, generational shifts in adherence to these norms, and the cultural influences that affect how men express and cope with depression. The conversation emphasizes the need for better support systems and the importance of fostering strong social relationships among men.

Special Guest: Dr. Simon Rice

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[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to episode number 47 of Psychotherapy and Applied Psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way. If you find this show interesting, it would be much appreciated if you shared it with someone you know who might enjoy it too. It's a great way to spread the word and keep the conversation going. Today I couldn't be more excited to welcome one of the world's authorities on men's mental health. My guest is a clinical psychologist, a professor at the University of Melbourne, and the Global Director of the November Men's Health Institute. He's also won several prestigious awards, including the Australian Psychological Society's Early Career Researcher Award, and Australian and New Zealand Mental Health Award for Innovation. In part one of our conversation we discuss masculine norms, generational shifts, male type depression, substance use, social networks, and much more. This episode begins with my guest talking about how we got into studying men and masculinity. So without further ado, it is my pleasure to welcome my very special guest, Dr. Simon Rice. So I probably came to studying men and masculinity and men's mental health almost serendipitously. At the time when I was starting my master's training in clinical psychology, I opted to do the pathway here. There are a few pathways in Australia and one of the pathways is combining a master's with a PhD, which is a long course, but great training. I wasn't quite sure what I was going to do for my research component. There's a bunch of things that I was interested in. A colleague who was also in the master's cohort just happened to mention to me this paper that they discovered. It was the original paper on the Gotland male depression scale. It's only a fairly brief paper and it's work that derived from Sweden, the Swedish island of Gotland, where they had a real interest in better understanding men's depression and in particular men's suicide risk. They had taken the lens of really being interested in whether there might be something about the depression phenotype that is unique to men. Some of the foundational work that they did was developing this hypothesized construct of what became known as the male depression. I think it was initially the male depressive syndrome and this idea that it could be that depression looks a little bit different in men. It came about to your initial question. When I read this paper, it was just fascinating. Like I said, it was only a fairly brief paper, but just this idea that such an experience that seems fairly well understood within our diagnostic classification systems in psychology and psychiatry, there might be a whole piece to the puzzle that we're not really considering. That then connected to this world of understanding what the potential drivers of that difference in symptom presentation could be. Socialization adherence to masculine norms is part of that picture, so that was the point of entry into the field for me. Why don't we start by getting into the adherence to masculine norm stuff? Can you tell us what adherence to masculine, what does that mean? It depends on your perspective, really, because masculine norms mean a lot of different things to a lot of different people. Over many years, there's been different terms that have been used, but one that has been used to fear that the literature has been this idea of traditional masculine norms. I'm not sure whether that's really quite the right way to express it in the modern world. But what those norms have typically come to be known as expectations that boys and men experience that define their sense of being a man and their sense of manhood. And many of those, I guess from a research literature perspective, probably align with what we've seen through inventories like the conformity of the masculine norms. Inventory by James Mahalic and colleagues where they've stepped through these core constructs around the kind of typical notions of what it means to be a man. I should add though that much of what is in the conformity of the masculine norms inventory is a piece of the puzzle. And it's not the whole picture that those norms are fairly negative in their violence and the characteristics that align with dominance, with men's power over women, with men's appetite for the same. Sexual conquest and aligning with a playboy type culture. And there's no doubt that there are elements of that that resonate for some men in what they aspire to. But I think the picture is much more complex and nuanced than that. And I think the field has some work to do in understanding what modern adherence to masculine norms actually means and reflects, especially for a younger generation. And how that might be playing out. But again, coming back to the initial question, so historically adherence to masculine norms have been those more negative traits associated with masculinity. And it's little wonder that many of those correlate with worse and health and mental health outcomes. I think a critical piece of the puzzle that we've still got to explore is much more from a strengths-based perspective. What are the masculine norms that, excuse me, boys and men want to adhere to that can actually be pro-social, pro-supporting their health and the well-being of others? So do you think that we should... I mean, you're not... I don't hear you saying that's nothing. But I do hear you saying that's only part of the pie. What do you think... What's the other part of the pie that you're... What I'm hearing is you sort of hinting at? I think we've got some work to do to identify what that is. And the kind of positive values that men, young men, boys really aspire to. So we're seeing a significant movement through men and masculinity influences in the online space around fitness, well-being, looking after yourself, having fitness goals, getting to the gym on a regular basis. Lots of positives with those messages. There can be some complexities then if that does trip tip into the world of problematic exercise, the world of using performance in hand-sing steroids and the slippery slope that that might entail for some men. And definitely, I don't think that's the majority. So I think we've got some work to do around fitness, we've got a fair bit of work to do around relationships and what kind of positive, good social relationships men aspire to, both within same-send at six gender, relationships and cross-gender relationships as well. So I think it's going to be an interesting few years as we start to get a better understanding of this strength by this approach. So one of the things that you've written about, or at least something that sort of jumped out to me, was, this was my sort of paraphrasing or interpretation, was it's not so much like that, let me start over, that masculine norms or adherence to certain masculine norms can be a resource, but it's the rigid adherence to them that can get us into trouble. It's a great point. There's much around dominant masculine norms that is positive in the right circumstance. So you do want men to have a risk-taking propensity or to be self-aligned or stoic when we are entering into complex situations in the emergency services, for example, firefighters running into a burning building, really important traits that elements of masculine norms that have served men over many, many generations that they do absolutely need to shine through. If and when a young man or a man is only ever stuck in that mold of rigidly being self-aligned, rigidly only ever being entirely stoic, when they encounter significant challenges in life, like we all do, if those attitudes block formal or informal help seeking, that's when there can be some risk to health. So it is something about the rigid adherence to these particularly restrictive norms. It seems like being able to have an orientation towards greater psychological flexibility would be really useful. So you've done some work, at least my understanding, indicating that some of the adherence stuff has perhaps been changing over the generations and that the younger generations are perhaps like, I was curious like where you are in your thinking about that. I don't think we have a rock-solid understanding of that at this point in time. I think there's some studies that suggest that younger generations of men might be more flexible, other studies are contrary to that finding. So I don't think we know. But what we do know is that these broad constructs connected to masculinity, manhood and men's identity along those lines, are really powerful in the lives of boys, young men as they're transitioning into their adolescent and then young adult years and men throughout the life course. So if we are wanting to engage more men in better physical and mental health, then make sense that we're going to be attuned to those. And so that means from our messaging in terms of health promotion right through to our interventions, being conscious that these constructs play a major role in men's health, physical and mental and their help seeking pathways. And not to get too far down the trope rabbit hole of nurture versus nature. But how much of this do you think about as this is socialized versus this is more or less built in? I don't think we're ever going to be able to fully answer that. Who knows, maybe we will, but I don't see a full semance coming in my lifetime. I think we need to be realistic thinking through the lens of a biopsychosocial model that there are multiple influences. This is complex and equally so. The solutions need to be mindful of those complexities. Yeah, I think that you're one of the things having done some research in this area that I'm sort of constantly struggling with and talking to my graduates, students and colleagues about it's like the traditional masculine norms, if you will, that these are these are. That like a lot of this is sort of this cultural influence and way of thinking about things that we would expect that these are going to. Very from person to person and even from like culture to culture subculture to subculture. And so like it's sort of like what you were talking about in terms of some of the limitations of how we've always thought about it right here these five or six or seven traditional masculine norms of dominance and stoicism and you know that sort of stuff that. It's always it's this weird construct I always sort of feel like because it's like we would expect that this is going to be like ever developing and changing within in between cultures. And so a lot of times I have a student right now working on you know some projects and it's like I think I think a lot of times we're like I'm struggling with like trying to hold on to it and like mean make meaning out of it knowing that it has to be at least somewhat culturally dependent. I think culture plays a profound role in men's mental health particularly. You know high prevalence disorders depression anxiety probably most significantly. The way in which symptoms manifest as one question but the way in which men and boys talk about their experience of mental health in informal networks with professionals cultural norms have a profound impact on that so it you know it we have to be a tune to that I think. Yeah yeah so let's get into the male tape depression so you could could you start off start us off with just sort of what is male tape depression. So the broad construct as we talked about a little bit earlier is this idea that men or maybe subgroups of men we're not crystal clear exactly who went and why. And they experience a different cluster of symptoms when it comes to depression we have had a pretty robust understanding of major major depressive disorder from a DSM and an ICD perspective for some time and that's where you're talking about that prototypical sadness inability to experience pleasure and a range of psychological range of physiological symptoms including kind of it probably it's most severe form thoughts of suicide and wanting to harm oneself. So the idea is that whether it's through some biological process whether it's through socialization whether it's through a combination of those factors that some men may not necessarily adhere to the nine DSM type symptoms of depression and their experience might manifest through what is sometimes referred to as an externalizing set of symptoms. And by that we mean things like anger and aggression risk taking substance use where there's a more outward experience and expression of a potential internal distress. And this idea has been around for quite some time and there is growing support for it but it's definitely not it's definitely not a fully accepted idea within all circles within clinical psychology and psychiatry. It's interesting to note that there have been some relatively recent kind of national campaigns around what depression symptoms in men might look like and it is common that those national campaigns will talk about things like anger and aggression being a symptom of depression in men but when we look at our diagnostic criteria that doesn't pop up. So we've kind of got this mismatch between what some of our public health messaging is and then when any for a young man or a man attends primary care and they're presenting with some of these symptoms unless that physician that that general practitioner is particularly tuned to some of the research literature they're not going to be able to diagnose or identify a potential underlying depression because that's not what our diagnostic criteria says. We have this interesting flavor also within the DSM that irritability can replace one of the prototypical criteria for depression if and when the person is under the age of 18 but then once they reach 18 again it needs to be sad mood rather than irritable mood or depressed mood. The ICD 11 has taken the significant step towards relaxing that requirement just to be limited to 18 years and under and I think that's a really interesting step in recognition that that yes there can be a different picture of depression that can be represented and it's going to be fascinating to see whether the DSM follows suit once the DSM 6 is revised. So just to summarize what I'm hearing you say is that it's right so when we think about psychiatric disorders we think about like this this latent construct right so in this case a depression major aggressive episode, a press of disorder and then our symptoms these are the manifestations of depression right the ways that we observe depression in a particular person. Because we can't you know unlike some physical diseases we can't even that even in that case right but you we can't directly observe depression we can't say there's the depression that's it so we have to have these for some reason for me manifestations is always like a way for me to think about it that makes sense these these manifestations of these indications of the disorder. And so what I'm hearing you say is that the indications are manifestations that are in our traditional assessment guidelines words the ICD or the DSM that those miss out on a lot of these symptoms that men would have that would be an indication or manifestation of this latent construct of depression. That's the hypothesis exactly and there's evidence that supports that and it's going to be fascinating to see where the field moves within the next 15 20 years. Because you can also understand the perspective of relaxing some of this diagnostic criteria around a disorder like major depressive disorder which is highly prevalent prevalent in the community. And it's through adding a new criteria relaxing a criteria the numbers of people that would potentially qualify for that diagnosis significantly in crease. So there's probably some balance point that the authors of diagnostic criteria thinking about through the research evidence pragmatically around what our care systems can support. That said, I think we do have a problem at the moment that there's a cohort of young men and men who whether they're presenting to primary care or not are experiencing some form of psychological distress, disease and potential risk whether it's in the moment or in the near future to their own mental health through suicide risk and other harms. Who aren't necessarily being identified and so part of the construct of better understanding men's depression is can we get better at identifying this cohort who might be at significant risk of suicide or other adverse outcomes and can we identify them earlier and then provide support and intervention earlier in the piece. Obviously there would be some people who would push back on that idea and argue well that's not necessarily a justification to relax the diagnostic criteria for depression. We just need to be better understanding people's presentation from a psychosocial perspective. And I would argue, well yes and no because when we look at some of the qualitative research on men's experiences of depression, there is a lot of similarity with some of these constructs around irritability, anger, aggression, challenges with regulating emotion. Relating to others in challenging ways, using substances to cope, all of this is part of this broader constellation. I had Bob Kruger on here last year and he was one of the big players in the DSM-5 personality disorder stuff and for the DSM. In talking to him, I definitely developed more empathy for the people who are developing these criteria. He described it as like trying to repair an airplane mid flight. So I do have some sympathy for that sort of relaxed error for people who sort of push back and we relax everything it's going to be, you know, we're opening the floodgates and more and more come in. At the same time, the argument of we just need to train clinicians to better understand the sort of the social cultural factors that are impacting people's reporting of things, that seems like a pipe dream. It's a great one. I mean, like I'm not opposed to it in any way, but having done a lot of diagnostics and given structured clinical interviews and all, you know, done a lot of that sort of stuff. The reality is that it does come down to the symptoms that are articulated in the DSM or the ICD. It does and that becomes the lens with which people are trained and then the lens through which we make diagnoses and then support our interventions. A couple of quick points to add is it is useful to note that the text revision of DSM five did add some some sentences around sex and gender considerations that men with depression are more likely to experience challenges managing emotions substance substance use. So there is definitely a growing awareness of this literature from the committee who are working on, you know, revising diagnostic criteria for a major depressive disorder that hasn't translated into an actual change into the criteria themselves. And a point that with some colleagues I had recently made was even with, you know, the positive move with the ICD 11 being more open to the inclusion of your ability across the life course that does have obviously identification assessment implications and then by virtue of that treatment implications because what then are we thinking about. If many of our standard treatment protocols for depression have really focused on the anodonia or the sad mood component if that's now a beautiful mood. It raises some interesting questions there for what we need to be thinking about from intervention to so there are this work has tentacles going in lots of different directions. So why is it do you think or sort of the general thinking around why is it that depression manifests or can manifest differently in men rather than a very women. Again, we don't know and I do acknowledge that this is a contested area, a contested space. Much of the theorizing has been based on socialization. Okay, so it's mostly just that. Interesting. I'm thinking about if I'm thinking I'm sort of you know what interesting about doing one of the interesting things about doing work with you know on men of masculinity is it's I'm always able to like think about it relative to me. You know like where does this hit home for me personally or my I'm sort of thinking about that and you know Lord knows I can get irritable and I'm trying to think about how much of that is that that is how much of that is learned versus automatic. I have a I don't know in some ways it is a little bit you know I thought about it too much but a little bit of difficulty just sort of accepting it's fully learned. Yep. I don't know what are your thoughts and that that may well be the case. And if we thought a bit more broadly around you know another symptom cluster around problematic substance use so we know we know that men are more likely for instance to use alcohol to use alcohol to manage challenging experiences in life and often that can be attributed to less robust supportive social support structures. So it would be interesting to think if we were able to better support young men and men have closer supportive relationship structures that that buffered them throughout their life course that perhaps they might not need to turn into alcohol or other substances as a coping mechanism as much. And if that would have helped through we could see significant population health impacts. And much of our much of men socialization of this true with women but I would guess at least in much of the world more so with men is socialization is often surrounded by alcohol or involves alcohol or substances. So we're going to go over that there for sure and we also know across the life course that as men age for many men their social relationships and their social networks become thinner and some of those bonds become less strong. So it's the inverse impact for women that those social relationships often become stronger and the bonds deepen and so there's something going on at that largest social relationships level that might be implicated here as well. So as men get older their networks get thinner as you said decrease they do that's on average probably not the case for all men but for many men and a consequence of that can be that women female partners female family members become the person that navigates the social world of men and reminds them or organises their social contacts again not exclusively. But if that's if that does become the case men can sometimes become deskilled as the life course as they would their way through the life course. Are there any sort of reasonable explanations for that they've come across I don't know what the core drivers of that are but it's definitely something that the November Institute of men's health has a particular interest in that we want to see men and young men develop strong robust relationships that can buffer them throughout the life course that they can be supported. They can also support others around them and so thinking through ways that we can get a better understanding of this is going to be key before we can even start to think what the solution is. I don't know the literature on this but I've heard in popular media where folks will talk about young men now so people who are younger than me you know people in their teens and 20s men boys that they are struggling more to develop relationships than older generations of men were do you have any sense of that. I think we've seen some extraordinary shifts in the covid post covid world and disruption to education disruption to you know kind of social pathways for that cohort of young people. And you know the implications of that we're still working our way through I think what what has shifted seems to be this you know much of the shift to and the influence to online online worlds and the influence of particular masculinity influences in the online space. And I think that there is clearly a need that young men are experiencing whether that's a need for guidance mentorship even if it is through a person who they don't have a direct relationship with still being able to seek out and experience some benefit from that guidance. And there's great opportunity but there's also some risk there in terms of some of the voices that young men being exposed to and listening to and the motivations of some of those voices as well. So you've done a lot of work on suicide among men and we're not going to be able to get to all of it in our conversation but I just wanted to hit on a couple of things so one of the things is you did some work. Sort of finding that men sometimes they don't sort of disclose their pain was depression or their pain until they sort of hit this breaking point. I was curious if you could talk a little bit about that. Well I think again this comes back to our social norms around. That's a wrap on the first part of our conversation. As I noted at the top it would be much appreciated if you spread the word to anyone else who you think might enjoy the show. Until next time.[Music]

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Dr. Dan Cox

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Dr. Simon Rice

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