Received date: 31 July 2012 Accepted date: 13 December 2012
In the UK, Black men are over-represented at the coercive end of the mental health system but under represented in terms of seeking help voluntarily. This situation reflects long standing inequalities that arise from multiple sources. Among these are the conceptions of well-being and help seeking that would enable Black men to access appropriate help at an early stage, and the ways in which mental health service providers could adapt practice to meet the needs of Black clients. The objectives of this study were to investigate the discourses that Black men draw upon in talking about themselves and their psychological well-being and in seeking help for psychological distress. Nine Black men were recruited via communitycentres in London, were interviewed, and the transcripts were analysed using Foucauldian discourse analysis. Four discourses were identified, namely oppression and discrimination, Black masculinity, communities and professional systems. These discourses demonstrate the ways in which Black men are discouraged fromseeking help for psychologicaldistress. The findings have implications for policy, service delivery, clinical practice and research.
Black men, help seeking, masculinity, mental health, well-being
Statutory and non-statutory organisations in the UK have highlighted the need to address the inequalities in mental health service provision for Black people compared with their white counterparts (see, for example, Care Quality Commission, 2009; Department of Health, 2003, 2005, 2009; Keating et al, 2002) (see Box 1). There is no doubt that Black individuals appear to have particularly negative experiences of the mental health system. Black service users express dissatisfaction with mental health services (Sandamas and Hogman, 2000), and they are more likely to be subject to over-diagnosis of schizophrenia (Fearon et al, 2006), more likely to be admitted to mediumand high-security mental health services (Jones and Berry, 1986), and less likely to be offered psychologically based interventions (Francis et al, 1989; McKenzie et al, 2001). Black people are less likely to seek professional help than their White counterparts (Ayalon and Young, 2005), and it appears that expectations of racist mistreatment within mental health services act as a barrier (McLean et al, 2003). There is evidence that attitudes towards help seeking for psychological distress become more negative as levels of distress increase for Black populations (Obasi and Leong, 2009).
The picture with regard to mental healthcare for Black men in the UK appears to be the bleakest. Black Caribbean men are most likely to experience coercive care in the form of detention under mental health legislation (Morgan et al, 2005a), and are more likely to arrive at mental health services via the criminal justice system (Morgan et al, 2005b). Black men are less likely than other groups to seek professional help for psychological distress (Neighbors and Howard, 1987; Snowden, 2001).
Broad gender differences in health service utilisation have been recognised for some time.Men are less likely than women to attend their GP, more likely to engage in risky and harmful behaviours (e.g. Griffiths, 1996), and less likely to seek professional help for psychological support (e.g. Addis and Mahalik, 2003). The term hegemonic masculinity has been applied to a particular culturally powerful way of being a man, which entails, among other things, emotional reticence and physical toughness (e.g. Courtenay, 2000). A related concept of hyper-masculinity, described by Mosher and Tomkins (1988, p. 69), is characterised as stemming from the ideology of machismo and as rejecting characteristics such as showing fear, being distressed or ‘displays of emotionality.’ Studies in the USA have examined the attitudes of Black men towards help seeking for mental health problems. Duncan (2003) examined attitudes towards help seeking among Black male college students and found that younger Black men had more negative attitudes than their White counterparts towards seeking help for psychological distress. Watkins and Neighbors (2007), when conducting a series of focus groups with Black men in colleges, found that participants felt that experiences of psychological distress were different for Black men, as they already had experiences of marginalisation to contend with. It is possible that the way in which Black men construct their identities, both as men and as members of minority groups, influences their conceptions of how to look after their psychological wellbeing. This position is also suggested in research conducted by Galdas et al (2005) on men’s lack of help seeking for physical health problems.
Watkins et al (2010) conducted a meta-analysis of qualitative research which focused on Black men and their conceptions of mental health and well-being. They identified male gender socialisation as being as important an influence on Black men’s mental health and well-being as experiences of racism. They also noted the absence of research in this area, with only nine studies meeting their inclusion criteria. It is noteworthy that all of these studies were from the USA, and that to date in the UK the only studies that have examined Black men’s views focused solely on their experiences as inpatients (e.g. De Maynard, 2007), and not on their conceptualisations of help seeking. There are important differences between the USA and theUKin terms of culture and the delivery of healthcare, which means that extrapolation from the US context to the UK is problematic.
Lent (2004) situates well-being as an essential but often neglected area within psychological health. Diener et al (1999) acknowledge that the wide variety of factors which affect well-being make it difficult to distinguish the crucial elements of this concept, and thus impede the construction of a robust theoretical model. Therefore, in an investigation of the construction of well-being, it is important to employ a method that is exploratory, rather than beginning from a preconceived notion of what well-being is. Research into conceptions of well-being and help-seeking practices is required in order to elucidate the relationship that Black men have with mental health services. This paper presents the findings of a study based on a social constructionist approach. Our aim was to contribute to current understanding of how Black men in the UK talk about the experience of being a Black man, and the interaction between this and their conceptions of wellbeing and help-seeking behaviours. The study aimed to address the following questions:
1 What discourses do Black men draw upon when talking about themselves?
2 What discourses do Black men draw upon when discussing psychological well-being and help seeking for psychological distress?
A social constructionist approach allows an exploration of the historical and social influences on Black men’s understanding of well-being and help seeking. From this perspective a qualitative research methodology is most suited to the aims of the research. Foucauldian discourse analysis (FDA) was chosen as the method of data analysis. FDA posits that the way objects are discussed has implications for how those objects are seen by society, what actions are afforded or denied, and the relationships between groups of people and social structures or society (Harper, 2006; Willig, 2008). Succinctly put:
Foucauldian discourse analysis asks questions about the relationship between discourse and how people think or feel (subjectivity), what they may do (practices), and the material conditions within which such experiences may take place.
(Willig, 2008, p. 113)
Although there is no typical format for carrying out FDA, the seven criteria suggested by Parker (1992) for identifying discourses (plus three supplementary criteria) were employed in this study (see Box 2).
Ethical approval of the study was granted by the University of East London Ethics Committee. An information sheet was supplied to individuals who expressed an interest in participating, in order to enable them to make an informed decision as to whether or not to take part. Written consent was obtained from all individuals who participated in the study.
In order to be eligible to participate in the study, individuals had to self-identify as being either Black African or Black Caribbean, male, and aged between 18 and 35 years. The participants who were recruited were aged between 23 and 34 years. Ethnicity was selfdefined by participants (Patel, 1999), and consequently they used a variety of terminology (see Table 1). Participants were offered a £5 gift voucher for taking part in the study.
A range of approaches were used during the recruitment process. Community centres in East and North London were contacted by telephone and requested to display a poster containing details of the study; in total, 10 community centres agreed to do so. Posters were also displayed at the University of East London, with a contact email address for individuals who were interested in taking part in the study. Eligibility for participation in the study was verified by email, and a variety of time slots were offered for interviews to take place. Participants were asked to inform others whom they thought might also be interested in taking part in the study (a process known as snowballing) (Faugier and Sargeant, 1997). In total, nine men were interviewed.
The interviews took place in a variety of settings, including rooms at the University of East London and community centres in various locations in London. Interviews lasted between 45 and 88 minutes, with a mean duration of 63 minutes. All interviews were audio recorded and transcribed. At the time of the interview, participants were asked to re-read the information sheet and sign a consent form. A semistructured interview schedule was employed that focused on three main areas, namely identity as a Black man, conceptions of well-being and conceptions of help seeking. On completion of the interview, participants were debriefed and encouraged to reflect on the experience of taking part in the study and ask questions. They were given a list of services that offered psychological support, including NHS services and services specifically for Black and minority ethnic (BME) groups.
The analysis identified four main discourses, namely oppression and discrimination, Black masculinity, community and professional systems. It is important to highlight that the four discourses which were identified do not represent all of the discourses employed by participants, but rather they are a subsection that is relevant to the research questions. In addition, the term discourses (in the plural) rather than discourse has been employed because FDA highlights the fact that only parts of discourses are ever seen in texts, and that discourses change over time and according to social context (Willig, 2008). As such, it is not assumed that these discourses are definitive of the constructs that they name. Pseudonyms have been used throughout in the following presentation of the findings.
All nine men who were interviewed spoke about oppression and discrimination and the effect that these have on the lives of Black men. In the following extract, Theo constructs oppression as a multimodal system, affecting not only Black men but also those with mental health problems. His description of stigma embedded in attitudes towards mental health problems constructs this type of oppression as the socially accepted, dominant position:
Theo: There’s a stigma attached to mental health, which everyone seems to know, so why would you then present as someone who needs help?
Theo: From services, and not only that, there’s also this thing about being Black, so you’re already oppressed in society
Theo: Why would you want to go and double your stigma attached to you?
Interviewer: Umm, indeed.
Theo: Or even triple it, cos you may be homosexual or have a disability or anything like that, so anyone who has ... a social factor attached to them which is frowned upon ...
Theo: ... wouldn’t want to relate to another group of people who have a similar situation.
For Theo, a combination of Black men as oppressed and people with mental health problems as stigmatised positions Black men who seek help as being doubly stigmatised and thus restricted in terms of help seeking.
Black men drew upon a variety of constructions to talk about how they saw themselves as Black men. This highlighted how these constructions interacted with their well-being and help-seeking behaviour. The construction of Black men as hyper-masculine, that is, embodying in a heightened form qualities that are typically associated with masculinity, was a salient theme within many participants’ accounts. This construct expands traditional conceptions of hegemonic masculinities in order to cope with experiences of oppression. In the following excerpt Kwame frames it as a strategy for managing life’s challenges as a Black man:
Kwame: Blacks we view things differently, honestly anything psychological is stigmatised in the Black community.
Kwame: You see it’s a very macho community and I guess when sudden changes or upheavals happen, from a very young age I think Black men are, you’re trained to, more or less carry on.
Kwame: No matter what, you’re meant to be for [want of] a better word a soldier.
Interviewer: A soldier, OK.
Kwame: You get accustomed to so many things, so stuff like poverty, there’s not really much going to, it’s not going to shake a Black man as much as a White person.
Kwame: You’ve seen this, you’re used to it, you can handle it.
The construction of hyper-masculinity is developed by Kwame’s statement that a Black man is ‘trained’ to be ‘a soldier’, thereby invoking concepts associated with a culturally potent form of masculinity while also drawing on and extending attributes of stoicism and physical toughness that are associated with conventional hegemonic masculinity. In this construction, life is framed as a battle and Black men are positioned as both battling and embattled. Kwame’s mention of ‘upheavals’ and ‘poverty’ may mean that the hypermasculine construction allows Black men to equip themselves to resist or fight against disadvantage and thus ‘handle it.’
Jamie also highlights this as he explores talking about psychological difficulties:
Jamie: It’s harder to talk about that type of thing because even as I say for us it’s, it’s a bit of a trust issue and it’s ... a sign of weakness because ...
Interviewer: Umm hmm.
Jamie: ... from what I see, it’s you know being tough and you have to have the tough exterior.
Interviewer: Umm hmm.
Jamie: What is your way to show that you ... have this tough exterior if you share your feelings?
Jamie: You know feelings, feelings are very feminine really aren’t they?
Jamie: They’re a (laughs) feminine thing, you know, have a chat about how I’m feeling today.
Jamie constructs talking about feelings not only as a sign of weakness but also as a feminine quality which it is undesirable for Black men to possess. The dichotomy of the construction of gender roles, with masculinity associated with toughness and femininity associated with weakness and emotionality, suggests that more power is afforded if a man positions himself as hypermasculine by having a ‘tough exterior.’ As a result, help seeking, particularly help seeking from professionals which involves having to talk about feelings and possibly acknowledging weakness, could be seen as a practice that challenges this power. It also leaves Black men, to continue Kwame’s metaphor, ‘unarmoured’ in their battle against the disadvantages of their social position. The hyper-masculine construction has been employed by Kwame and Jamie not only as a way of being but also as a performance. Black men may feel that they do not have any other choice because the implications of any other type of behaviour are too damaging or dangerous.
While constructions of Black masculinity render it difficult for them to seek help for psychological distress, other discourses were also relevant. In the following extract, Omari highlights community and belonging as involved in the negotiation of whether he is able to engage in the practice of talking about difficulties, and who to discuss these with.
Omari: It goes back to my point about community and belonging and so, less likely to say amongst your group of friends ‘Oh, I’m having a problem with this erm, any advice or who can I go to’, and equally that aspect of community and family of how you deal with stuff within the family.
Interviewer: Umm hmm.
Omari: You don’t go outside, to someone else, to sort of talk about your problems, not airing your dirty washing ... so there’s that constant built-in thing of like ‘Well, that’s not what we do.’
Omari constructs ‘dealing with stuff within the family’ as a rule inherent in Black communities by use of the idiomatic phrase ‘not airing your dirty washing’ (i.e. not talking to people outside of the family about problems). In stating ‘that’s not what we do’, Omari is constructing Black communities as unlikely to seek help from beyond either the family or the wider Black community, and implying that the benefit of the sense of belonging within a community or the fear of potentially stigmatising a whole community by ac knowledging distress outweigh any benefits to the individual of seeking help.
In the following extract Sean extends the construction of ‘communities as governed by rules’ when asked about Black men and help seeking:
Sean: I mean I guess this relates to the whole ability of men to open up.
Interviewer: Umm hmm.
Sean: And maybe deal with things much earlier.
Sean: Before they get to that point, and it doesn’t I can’t think of many of my Black male friends or even the idea of a Black male who would book themselves in to the GP and have a chat because they’re just not feeling great.
Interviewer: Yeah yeah.
Sean: You know they just don’t think things are going well, erm they wouldn’t. Maybe again the Black community doesn’t, their idea of mental health ...
Sean: ... as well plays into that, in that there isn’t really such a thing sort of thing.
Sean: It’s just feelings and get on with it and pick yourself up until if it gets to the extreme end where you’ve obviously got problems so I think maybe the idea of things generally you’ve either got problems, which is like (laughs) there is something wrong with the person, or you’re just going through stuff that everyone goes through, just get on with it! (laughs)
The implicit rule here for Black people is simply that life is hard and problems are something that everyone goes through. Sean’s talk portrays difficulties as not being out of the ordinary, and the dominant response to such experiences is to ‘get on with it’ and manage problems without additional support. Viewing difficulties as part of life may support a construction of mental health problems as non-existent within the Black community, as in ‘there really isn’t such a thing’, and as unimportant and insubstantial reactions to events, being ‘just feelings.’ Mental health is positioned in binary terms as manageable challenges (‘get on with it’) versus something clearly being wrong (‘it gets to the extreme end and you’ve obviously got problems’). Framing difficult experiences as integral to being a Black person implicitly problematises help seeking from professionals, and in doing so implicitly draws upon the discourse of an embattled Black masculinity. This discourse defines psychological difficulties in a way that makes it almost impossible for Black men to recognise or acknowledge a need for support, much less seek help. This might help to illuminate why Black men enter the mental health system at a later stage when it is ‘obvious’ that there is a problem that lies outside the boundaries of ‘everyday’ distress.
Many of the participants were not aware that their GP is intended to be the first point of contact for professional help seeking, or that psychological therapy is available free of charge in the NHS in the UK. Riley explains some of the difficulties encountered by a Black man seeking help from GPs:
Riley: To be honest it may even be better if you had somewhere specifically to go as a young Black male.
Riley: You know what I mean? So you would feel like this is somewhere for me.
Riley: So you might not go into that situation and feel like, erm, ‘Should I really be here?’
Riley: Like you know that other people would have come here for the same reason, speak to someone that’s, you know, that’s what they do, yeah a doctor may be able to give you advice on well-being and what not, but you’re still sitting there thinking ‘This is a doctor’, and you know that obviously you can’t just, just say ‘All he knows about is medicine, medicating me’, but that’s how you’re going to feel, you’re going to feel like this isn’t what you do.
Interviewer: Umm hmm.
Riley: Every time I come to see you, I get medicine and you tell me about my leg, how’s my knee or, you know what I’m saying (laughs), it’s not somewhere it’s not somewhere. I mean obviously I know that if I went to my GP to ask for help, someone I need to speak to, he would put me on to someone else.
Riley: But I still wouldn’t be confident ...
Riley: ... that he’s the person to even make first point of contact with.
Riley presents Black men as asking ‘Should I really be here?’, serving to identify a disparity between the accepted practices of Black men and professional help seeking. By suggesting the establishment of services specifically for Black men he introduces a material condition that would have different implications for Black men’s way of being in the world, that is, for Black men to feel that they are able to engage in the practice of professional help seeking. However, for Riley the discursive construction of ‘the professional system as inaccessible’ is also related to the medical system that GPs represent. The idea of seeing a GP for Riley implicitly means receiving medicine or having a physical health problem, and by saying that ‘this isn’t what you do’, Riley constructs psychological distress as something different from a physical illness, that requires something that amedical doctor cannot offer, such as talking therapies. Making GPs the first point of contact serves to reaffirm psychological distress as an ‘illness’, and positions Black men who seek help as ‘ill.’ This has implications for subjectivity. That is, where else is there to go for a Black man who seeks help, but who does not believe that he is ‘ill’?
The discourses identified in the analysis demonstrate ways in which seeking help for psychological distress is subjugated as a way of being for Black men. Participants spoke in detail about the need for Black men to be seen as tough and not show weakness. The concept of hyper-masculinity has similarities with the concept of the ‘cool pose’ described by Majors and Billson (1992), which refers to Black men adopting a persona of being in control and able to manage pressures and distress at all times. Majors and Billson see this construction as functioning as a defence mechanism, protecting against the societal stressors and negative perceptions that Black men face. Although the construct of hyper-masculinity is culturally relative, it appears that this way of being may undermine or prevent help seeking as a possible behaviour for Black men.
Central to the accounts of both Mosher and Tomkins (1988) and Majors and Billson (1992) is the role of ‘performance.’ Gender is constructed as a series of performances in accordance with particular ‘gender scripts’, which Butler (1990) has termed ‘performativity.’ In our research, for example, when Jamie talks of having to ‘have the tough exterior’, hyper-masculinity is constructed as an active and necessary performance. This is socially constructed in accordance with a social and historical context, explicitly described by Hall (2009, p. 533) as ‘the management of self-presentation skills that are necessarily acquired in a racist Western social environment.’ In this way, the discourses of Black masculinities and experiences of oppression and discrimination are intimately bound. It is possible that Black men are unable to realise (that is, to make real) other ways of being due to the dominance of these discourses.
Participants drew upon a discourse of oppression and discrimination in discussing well-being, which is consistent with the findings of other research carried out in this area (e.g. Pierre et al, 2002). Research has highlighted the negative impact of racism on the wellbeing of Black populations (Tovar-Murray and Munley, 2007), but the socially oppressive forces that Black men face are manifested in a variety of other forms, such as poverty, unemployment and educational disadvantage. Communities were represented by participants as providing a means of safeguarding well-being, which is consistent with research which has highlighted that being part of an established community has positive benefits for psychological well-being (McMahon et al, 2004). Black communities can also be seen as a source of empowerment against oppression (Graham, 2002). However, although participants spoke of communities as sources of support, this support was dependent on adherence to the ‘rules’ of the community (e.g. that Black people should not approach professional services for psychological support). In this respect communities can be likened to institutions that enforce what Foucault calls ‘regulatory power’ (McNay, 2009), endorsing and limiting actions and ways of being. Participants identified Black communities as constructing help seeking as a practice that ‘Black people don’t do.’ Much literature has discussed the stigmatising aspect of psychological distress (e.g. Wahl, 1999) and the negative effect that stigma can have on help-seeking practices (Corrigan, 2004). However, it is important to understand that an already stigmatised community may be acting to protect itself from further stigmatisation by wider society by attempting to conceal psychological distress.
The participants were generally not aware that visiting their GP could be the first step in accessing professional help, and felt that their GP was only there to deal with medical problems. The participants’ understandings highlighted conceptual differences with regard to distress and, in particular, the biomedical perception of distress as ‘illness’ which can be ‘treated’ with medication. The construction of mental illness from the biomedical perspective has been critiqued by many researchers for reducing experiences of distress resulting from social experiences to symptomatology, genetic predisposition or chemical imbalances (e.g. Rogers and Pilgrim, 2005; Szasz, 1994). The participants in our study positioned distress as being related to the everyday struggles of being a Black man. As a result, discourses of oppression and discrimination appear to be more useful than discourses of illness when reflecting on their conceptions of well-being and help seeking. The toll of the everyday struggles faced by Black people, referred to by Essed (1991) as ‘everyday racism’, means that psychological distress shifts from a problem that needs professional help to something that requires continuous adaption in order to survive. Thus it is entirely reasonable that Black men do not seek professional help for something that they do not conceive of as an illness, but rather which has a social cause and thus may feel beyond the control of both professionals and Black men themselves.
As Willig (2008) has noted, qualitative research, in accepting the subjective role of the researcher and the effects that this may have on the results, means that judgements about the validity of the research should be different from those of quantitative methods. Yardley (2000) outlines four criteria by which to evaluate qualitative research, which we have adhered to in undertaking this study. These include sensitivity to context, commitment and rigour, transparency and coherence, and impact and importance. In addition, in accordance with Patel (1999), we have ensured that participants both viewed and were able to comment on the research analysis, confirming that there is commonality between our findings and the views expressed by the participants.
The participants highlighted the difficult history of the relationship between Black people and mental health services. The notion that professional systems care for Black people in a manner that is actually detrimental to their well-being has been highlighted by the phrase ‘institutional racism.’ The MacPherson Report defines institutional racism as follows:
The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people.
(MacPherson, 1999, Chapter 6.34)
Behaviours of Black men aimed at resisting oppression and discrimination may be met with further acts of oppression by mental healthcare services, setting up a vicious circle. It is possible that Black men would feel less pressure to engage in constructions of hypermasculinity and to ‘act tough’ if the need to protect themselves from oppression and discrimination was reduced. In addition, greater emphasis on early intervention and public health approaches to mental health, such as psychoeducation within churches, schools and community centres, may provide a model for talking about issues such as psychological distress and highlight the subjugated narrative of distress of Black communities. Such an approach would also help to frame mental health problems as consequences of negative experiences such as oppression and discrimination rather than as the result of individual pathology.
Black men may not view primary care as an appropriate place to seek support for psychological distress, and outreach initiatives may be more appropriate. Clinicians should use systemic and community approaches to service provision that allow preexisting conceptions of mental health and mental health services within the Black community to be discussed. Such approaches should be interactive, encouraging open and honest dialogue about the attitudes that Black communities have towardsmental health services, the realities of current service provision and what professionals need to learn in order to support Black men more effectively. Clinicians should ensure that therapy does not replicate experiences of discrimination outside of the therapeutic relationship for Black men, and pay particular attention to the social factors that affect well-being. Finally, clinicians should be aware that the illness model of distress may be seen by Black men as another way of disempowering an already subjugated group.