It has long been recognized in both academic and clinical settings that mental health service use is related to a range of factors such as income, gender, pre-existing psychiatric disorder and lifetime exposure to traumatic events, and is not simply representative of need (i.e. the presence of a psychological disorder).  Anderson and Newman (1973, 1995) propose a model of mental health service use that highlights the mediating role of both predisposing and enabling variables, as well as simple need.

Need factors, defined as both perceived and evaluated psychological functioning, are the most immediate cause and strongest predictor of mental health service use. Within the Australian population, for example, Parslow and Jorm (2000) found self-report measures of depression or anxiety and CIDI-diagnosed substance abuse disorder to be predictive of increased use.  Enabling factors that predict mental health service use include cost of service (which relate to whether or not the individual has private health insurance), cultural appropriateness of the service, and level of awareness of the types and purpose of the services provided. Predisposing factors are the socio-cultural characteristics of an individual that exist prior to the development of an illness. Those with fewer psychosocial assets, pre-existing physical health problems and previous experience of mental health care are more likely to seek mental health assistance. Women and people who are single also report increased use. In traumatized populations, female trauma survivors have greater mental health service use than do male trauma survivors.

  Mills, Van Hoof and MacFarlane (2008) examined Mental Health Service utilization prior to the introduction of the Medicare rebate within South Australian and found females had significantly higher rates of mental health service use that did males, irrespective of need.

The Australian Government’s 2006 expansion of Medicare rebates to mental health services has rightly received bipartisan support. It has also been eagerly embraced by private psychologists and other allied health workers, with a substantial increase in the number of practitioners providing Medicare related services.  Given this increase, one would hope that those groups under-represented in the mental health system would start to increase their use of this more affordable system. However, two years on and Mental Health Council of Australia (MHCA) analysis obtained by AAP reveals that women remain  twice as likely as men to access Medicare-subsidized mental health services.
Unfortunately, then, the removal of cost has done little to reduce other barriers that result in men using minimal levels of mental health services. Instead, this low use remains a systemic issue related to cultural norms around help seeking behaviors and the stigma attached to mental health. To put it bluntly, men are not meant to have these types of problems, and they are defiantly not meant to talk about them! This is further demonstrated in the low numbers of men working in the mental health system. 
So how do we fix this? At its simplest, we need to be developing education programs for schools so that from a young age, mental health and help seeking behavior is destigmatised for the male of the species.   Introducing a broad support system for mental health support is a wonderful initiative. However, to be fully effective it must be supported by systemic change.
At Bower Place, we are fortunate to have a single member of that rare species “the male psychologist”. However, a glance into Clinical Psychology lecture room quickly shows that unless something changes, he may be the last of a much needed dying breed.

References
Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc. Winter 1973;51(1):95-124.
Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. Mar 1995;36(1):1-10.
http://www.mhca.org.au/documents/MHCAMBSV2lay08LRc.pdf Mills V, Van Hooff M, McFarlane AC. Predictors of Mental Health Service Utilisation in a Non-treatment Seeking Epidemiological Sample of Adults Exposed to Childhood Trauma. Aust N Z J Public Health (2008 in press).
Parslow RA, Jorm AF. Who uses mental health services in Australia? An analysis of data from the National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry. Dec 2000;34(6):997-1008.
 
 

Eric and his partner had been married for many years, had two young children, and were well positioned for a long future together as a family.  He loved his wife and enjoyed work and his children.  However he felt unfulfilled and that life was going nowhere. In the previous 12 months Eric had embarked on an affair, which he knew was a great risk, but it was exciting, and made him feel alive, sexual and returned a passion for life he had not felt for a while.

Eric decided leave the relationship, he moved out and continued the new relationship. It was not long before Eric began to feel similar feelings he had experienced while with his wife and family.  Eric ended the new relationship.

Eric and his wife came seeking help as they explored the question of whether or not to resurrect the marriage.  During discussions of how the marriage had been, and what they did not want to have present in the relationship in the future together, both spoke of the fact that they never talked about individual or relationship disappointments, and that it would not be a good idea to have this continue.

Barry Mason in an article in the Journal of Family Therapy, “Relational Risk-Taking, Men and Affairs” (November 2008) suggests that “in the context of (some) men and affairs, embarking on the affair is sometimes not a relational risk, but a singular individual risk.  The relational risk, that of talking to one’s partner about perceived, significant unhappiness in the relationship, has not been taken” (pg 949).  

A discussion with Eric and his wife ensued about the cost of not taking relational risks in their marriage and how this had led to a pleasant, albeit unsatisfying existence together which may have been a factor in Eric even considering the idea of having an affair when the opportunity presented itself. 

Barry Mason’s article suggests that for men there are a three levels of relational risk taking.  At level one there are men who have a history of taking no initiative to discuss emotional difficulties, believing the risk to the relationship isto be too great and that raising issues would only make things worse. Another group are willing to discuss emotional issues but only if their partner initiated the discussion while a third level of risk taking are men who were able to take part and share a reciprocal role in initiating and discussing emotional issues. 

Mason’s hypothesis is that men are more likely to embark on another affair if they are not able to engage and become skilled at taking emotional risks.  A task for therapy where an affair is part of the couple’s history, is to consider this question, to propose it to the couple and engage in working with them around their ability to take emotional risks, if not for the current troubled relationship, then for future relationships.

Mason,B., (2008) Relational Risk Taking, Men and Affairs, Journal of Family Therapy 30,4