Psychology of Men & Masculinities

Where Do I Turn for Help? Gender Role Conflict, Self-

Stigma, and College Men’s Help-Seeking for Depression
Brian P. Cole and Paul B. Ingram
Online First Publication, October 3, 2019. http://dx.doi.org/10.1037/men0000245

CITATION
Cole, B. P., & Ingram, P. B. (2019, October 3). Where Do I Turn for Help? Gender Role Conflict, Self-
Stigma, and College Men’s Help-Seeking for Depression. Psychology of Men & Masculinities.
Advance online publication. http://dx.doi.org/10.1037/men0000245
 Psychology of Men & Masculinities © 2019 American Psychological Association
2019, Vol. 1, No. 999, 000 ISSN: 1524-9220 http://dx.doi.org/10.1037/men0000245

Where Do I Turn for Help? Gender Role Conflict, Self-Stigma, and

College Men’s Help-Seeking for Depression

Brian P. Cole Paul B. Ingram

University of Kansas Texas Tech University

Experiences of self-stigma and gender role conflict act as barriers to men’s psychological help-seeking.
Although previous studies suggest that violation of masculine norms and the desire to preserve
masculinity reduce men’s help-seeking behaviors, little is known about the ways in which specific
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

help-seeking behaviors are impacted. The current study examined relations between gender role conflict,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

self-stigma, and help-seeking for depression among a sample of college men from a Midwestern
university in the United States (N ⫽ 313). Participants engaged in a role induction based upon a vignette
about a man with depression and were asked the types of help-seeking behaviors they would engage in
(i.e., professional help, self-help, informal help, or avoidant behaviors). Results of this study indicate that
gender role conflict and self-stigma have different relations to help-seeking behaviors. More specifically,
(a) gender role conflict plays an incremental role beyond mental health self-stigma in understanding
certain types of responses to mental health needs, (b) there is a positive relationship between experiencing
gender role conflict and holding increasingly self-stigmatizing views, (c) self-stigma and gender role
conflict differ in their pattern of influence for mental health treatment responses, (d) gender role conflict
corresponds with increased avoidant behaviors and decreases social support utilization, and (e) self-
stigma predicts decreased social support and professional help utilization while also increasing avoidant
behaviors. Although gender role conflict and self-stigma had unique relations to professional help-
seeking for depression, utilization of social support was negatively impacted by both. Considerations for
help-seeking patterns in men and the influence of both stigmatized social views and conflicting gender
roles are discussed.

Public Significance Statement

This study suggests that men’s experiences of gender role conflict and self-stigma of help-seeking are
associated with their decisions to utilize self-help, to talk with friends and family, and to seek
professional help when depressed.

Keywords: help-seeking, men, depression, gender role socialization, health disparities

Supplemental materials: http://dx.doi.org/10.1037/men0000245.supp

College men are experiencing a health crisis (Davies, Shen-
Miller, & Isacco, 2010). Results from the latest executive summary
for the American College Health Association (ACHA, 2018) in-
dicated that most men on college campuses reported depressive
symptoms during the past 12 months. More specifically, 45% of
men reported hopelessness, 55% reported loneliness, 77% felt
overwhelmed, 58% were overwhelmed by sadness, 34% experi-
enced decreased functioning due to depression, and 10% consid-
ered suicide. Even with the prevalence of these symptoms, only
X Brian P. Cole, Department of Educational Psychology, University of
Kansas; Paul B. Ingram, Department of Psychological Sciences, Texas
Tech University.
Correspondence concerning this article should be addressed to Brian P.
Cole, Department of Educational Psychology, University of Kansas, 1122
West Campus Road, Lawrence, KS 66045. E-mail: bricole@ku.edu
11% of men in the sample reported receiving treatment for depres-
sion within the past 12 months (ACHA, 2018). Although the
ACHA’s finding that college women reported these symptoms at
higher rates than college men may suggest that men are “less
depressed” than women, others theorize that gender differences in
diagnosis of depression may not indicate a difference in prevalence
across genders (Cochran, 2005; Levin & Sanacora, 2007). It has
been suggested that the gender role socialization of men leads to
beliefs that depression is “feminine” and that it is unacceptable to
seek help or to show emotional distress (Cole & Davidson, 2019;
Levant, 2005).
Although there is a clear gender gap in the diagnosis and
treatment of depression, the course of major depressive disorder
appears similar for men and women in treatment (Addis & Hoff-
man, 2017). This may indicate that if barriers to male help-seeking
were reduced, men with depression could be treated successfully
before the development of other commonly occurring mental
health problems, such as substance abuse and externalizing behav-

1
 2 COLE AND INGRAM
iors (Cochran, 2005). Researchers in the field of men’s mental
health have begun to question the reasons for this gender gap and
have implicated the process of gender role socialization and mental
health stigma as culprits (Addis & Hoffman, 2017; Cochran, 2005;
Good & Wood, 1995; Rochlen, Whilde, & Hoyer, 2005). How-
ever, relatively little is known about the ways in which masculine
pressure and stigma relate to psychological help-seeking behav-
iors. Thus, the current study examines how self-stigma and gender
role conflict (GRC) in men impacts the utilization of different
types of help-seeking behaviors for depression through an ana-
logue design.
Self-Stigma of Help-Seeking
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Help-seeking behaviors involve relying on others, asking for
help, admitting the presence of a problem, and the emotional
expression of a problem. Stigma is one of the largest barriers to
men’s decisions to seek psychological help and engage in help-
seeking behaviors (Mahalik, Good, & Englar-Carlson, 2003; Sierra
Hernandez, Han, Oliffe, & Ogrodniczuk, 2014). Self-stigma is the
belief that one is inadequate or weak if he wants to seek profes-
sional help (Hammer & Vogel, 2010). Although societal messages
about help-seeking and mental illness are not always gender specific,
men engage in more self-stigma than women (Hammer & Vogel,
2010). This self-stigma predicts unwillingness to seek counseling and
attitudes about the value of counseling (Ingram, Lichtenberg, &
Clarke, 2016; Vogel, Wade, & Haake, 2006; Vogel, Wade, & Hack-
ler, 2008). Moreover, this internalization of stigmatizing beliefs be-
comes more pronounced for men during times of distress when
services for mental health needs are most critical (Vogel,
Heimerdinger-Edwards, Hammer, & Hubbard, 2011).
Although social messages about help-seeking and mental illness
are not always gender specific, men hold more self-stigmatized
views than women (Hammer & Vogel, 2010; Judd et al., 2006;
Mackenzie, Visperas, Ogrodniczuk, Oliffe, & Nurmi, 2019). This
is often as the result of psychological distress and the need for
help-seeking becoming a self-perceived threat to masculinity
(Schaub & Williams, 2007). Accordingly, men may feel a sense of
failure due to a perceived inability to solve one’s own problems, a
fear of losing autonomy, or a fear of being perceived as weak
(Addis & Mahalik, 2003; Sierra Hernandez et al., 2014; Vogel et
al., 2006). As a result, the decision to seek help may be perceived
as a last resort (Gough, 2016). Men often endorse numerous
gender socialized beliefs, such as thinking that it is more accept-
able for women to discuss their feelings openly and that being
emotional is not masculine (Sierra Hernandez et al., 2014). The
degree to which men endorse masculine ideology appears to in-
fluence the degree to which men experience self-stigma of help-
seeking (Hammer & Vogel, 2010), with men who endorse tradi-
tional masculine ideals being more likely to experience self-stigma
(Magovcevic & Addis, 2005). In the current study, masculinity is
defined as the possession of culturally informed social-role behav-
iors that are presumed to be necessary characteristics of a man in
the United States of America. Examples of these characteristics
may include stoicism, autonomy, and toughness (American Psy-
chological Association, 2007, 2018).
Stigma also appears to impact the types of problems that men
seek help for. Men are less likely to seek help for problems
believed to be stigmatizing, uncommon, or reflective of their
self-worth (Magovcevic & Addis, 2005). For example, men are
more likely to seek help for depression when it can be attributed to
an external cause (e.g., the death of a family member) than when
it is due to an internal cause (e.g., lack of meaningful relation-
ships). This is likely due to perceptions of the ego centrality of the
problem and the belief that external causes are less likely to reflect
upon the internal characteristics (e.g., strength, intellect, or will-
power) of men with depression (Addis & Mahalik, 2003; Mahalik
& Backus, 2011). Conversely, men report higher frequency of
engagement in help-seeking when they adhere less to traditional
masculine norms. Perceptions that other men are engaging in
health-seeking behaviors also increases the likelihood that one will
engage in healthy behaviors (Mahalik, Burns, & Syzdek, 2007),
making it important to assess men for self-stigma in addition to
attitudes toward help-seeking (Hammer & Vogel, 2010).
Gender Role Conflict
The decision to seek help varies because of the degree to which
men endorse male norms that may or may not be congruent with
help-seeking (Addis & Mahalik, 2003; Sierra Hernandez et al.,
2014). Aspects of help-seeking (e.g., relying on others, asking for
help, admitting the presence of a problem, and emotional expres-
sion) may conflict with societal messages that men receive about
the importance of self-reliance, toughness, and emotional restric-
tion (Addis & Mahalik, 2003; Mahalik et al., 2003). GRC (O’Neil,
1981, 2015) occurs when a person’s socialized gender norms limit
actions or behaviors (e.g., help-seeking) or lead them to feel
negatively for doing so (e.g., “Real men don’t get depressed”;
O’Neil, 2008). For instance, men experiencing higher GRC avoid
disclosure of personal information and emotions, whereas men
with lower GRC are more likely to self-disclose (Berko, 1995;
Pederson & Vogel, 2007).
Regarding GRC and help-seeking, Robertson and Fitzgerald
(1992) found evidence that men experiencing GRC are more likely
to have negative attitudes toward help-seeking for psychological
distress. Similarly, Blazina and Watkins (1996) found that GRC
accounted for 15.6% of the variance in attitudes toward help-
seeking. Men may be at a heightened risk for psychological dis-
tress because of the GRC that can occur following the onset of
depressive symptoms. Good and Wood (1995) considered these
men to be experiencing “double jeopardy” because their experi-
ence of GRC is predictive of an increase in depressive symptoms,
while at the same time decreasing the likelihood that they would
seek out treatment. GRC also predicts the expectations that men
have for therapy. For example, men reporting high levels of GRC
expect to be able to engage in therapy with minimal emotional
disclosures and still experience relief because of the counselor’s
expertise and direct suggestions about how to feel better. This
results from internalized beliefs that success in therapy is less
about personal responsibility and more about the clinician’s ex-
pertise. (Schaub & Williams, 2007). This is particularly troubling,
given recent findings that men who had successfully completed
treatment for depression indicated that increasing the level of
personal responsibility in treatment was a key factor in their
long-term outcomes (Chuick et al., 2009).
In a qualitative study of men with depression, it was found that
every participant reported efforts to conceal their symptoms from
others due to the pressure of societal messages. These messages
 COLLEGE MEN HELP-SEEKING
included beliefs that depression is not socially acceptable for men,
that it is inappropriate for men to seek help for depression, and
perceptions that men who seek help for depression are weak
(Chuick et al., 2009). Participants reported that they engaged in a
trial and error process with a variety of strategies to help alleviate
the distress of their depression, such as substance abuse, infidelity,
avoidance, and excessive focus on work roles. Most participants
also reported that these strategies eventually failed to conceal their
distress and instead escalated their depressive symptoms or pro-
duced additional problems resulting from negative coping behav-
iors. Relatedly, another qualitative study of men’s attitudes about
help-seeking for depression found that most men would not seek
help for depression, as seeking help signifies weakness and that
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they prefer to be self-reliant to avoid how others would react
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(Johnson, Oliffe, Kelly, Galdas, & Ogrodniczuk, 2012). Accord-
ingly, men are somewhat unlikely to seek professional help (Ma-
halik & Rochlen, 2006), with many indicating that therapy for
depression would only be acceptable when there was a clear
external circumstance that led to the depression (e.g., the death of
a family member; Mahalik & Backus, 2011). Instead, men are
more likely to seek help from a partner or a family member or to
wait and see if things get better on their own.
Types of Help-Seeking
Historically, men have been reluctant to seek psychological
help, but there is evidence that men have preferences for different
types of help-seeking (Addis & Mahalik, 2003; Padesky & Ham-
men, 1981; Weissman & Klerman, 1977). In an analogue study of
men’s help-seeking for depression, Mahalik and Rochlen (2006)
found that men were more likely to seek help from a partner or
family member than a psychologist when depressed. Furthermore,
men endorsing high conformity to masculine norms (e.g., power
over women, dominance, and pursuit of status) were far less likely
to talk to a mental health professional about depression and were
more likely to engage in self-medicating behaviors. Johnson and
colleagues (2012) suggested that this may be in part due to per-
ceptions that informal help-seeking is more confidential and less
vulnerable than professional help-seeking.
Theoretical orientation of the clinician is also associated with
help-seeking decisions. Although men have demonstrated a slight
preference for positive psychology approaches instead of cognitive–
behavioral approaches, previous research demonstrates that men have
nonsignificant differences in preferences for psychodynamic, person-
centered, and cognitive– behavioral approaches (Cole, Petronzi, Sin-
gley, & Baglieri, 2019). Furthermore, experience of self-stigma was
associated with less willingness to engage in person-centered therapy.
Although the role of self-stigma was limited, GRC predicted less
willingness to engage in psychodynamic, person-centered, cognitive–
behavioral, and positive psychology positive masculinity therapies
(Cole et al., 2019).
Professional titles also appear to affect the decisions that men
make about when and where to seek help (Brown & Chambers,
1986). In some cases, professional titles may act as a barrier to
seeking help (Mansfield, Addis, & Courtenay, 2005; Rochlen,
McKelley, & Pituch, 2006). Men may perceive that traditional
help-seeking approaches such as psychotherapy are inherently
“feminine” due to their emphasis on emotional expression and
self-disclosure (Boespflug, 2005). As a result, men may be drawn
3
to “masculinized” professional titles such as “executive coach”
because coaching is associated with a more directive and some-
times collegial relationship than media portrayals of psychother-
apy (Boespflug, 2005; Levinson, 1996). Similarly, the names of
organizations that offer psychological support appear to influence
the decision to seek help. Brownson (2005) reported significant
increases in utilization of campus mental health services after
changing the name from “Counseling and Mental Health Center”
to “Behavioral Health Center.”
Male Model of Help-Seeking
To synthesize research on gender role socialization and help-
seeking behavior in men, Perlick and Manning (2007) developed
the model of male help-seeking (MMHS) based on Lazarus
(1991)’s widely studied model of stress and coping. In the MMHS,
coping is influenced by a man’s assessment of the severity of his
problem or stressor, his perceived ability to manage that stressor
on his own, and his cultural beliefs and values about masculine
ideology and mental illness stigma. Cultural beliefs related to the
stigma of mental illness, masculine ideology, and GRC influence
help-seeking decisions by impacting the initial appraisal process
related to self-evaluation of symptom severity. Masculine ideology
and GRC also influence the secondary appraisal, which involves
acknowledging the need for help because of insufficient coping
resources. During these primary- and secondary-appraisal pro-
cesses, common male norms such as self-reliance and indepen-
dence act as barriers to help-seeking (Blazina & Watkins, 1996;
Graef, Tokar, & Kaut, 2010; Levant, Wimer, Williams, Smalley, &
Noronha, 2009). Men weigh potential benefits and drawbacks to
seeking treatment and must decide which is more important, get-
ting relief or avoiding increased GRC and potential loss of status
(Perlick & Manning, 2007). Thus, within the MMHS model,
acceptance of treatment is associated with short-term struggles
with GRC (e.g., discomfort with disclosure, shame, fear of depen-
dence on the therapist, and fear of being perceived as weak by peers).
Once men reach a point in the therapy process where help-seeking is
normalized and therapy myths are dispelled, men have similar rates of
success in treatment as women (Levin & Sanacora, 2007). Con-
versely, when men decline or avoid treatment, they are at increased
risk for GRC and are likely to experience continued psychological
distress (Perlick & Manning, 2007). To date, there are no published
studies that have utilized the MMHS as a framework for exploring
men’s help-seeking behaviors.
The Current Study
Although the MMHS proposed that experiences of self-stigma
and GRC uniquely influence decisions to seek psychological help,
relatively little is known about their unique contributions to help-
seeking behaviors. Thus, the current study utilized an analogue
design to explore the role of self-stigma and GRC on the utilization
of different types of help-seeking for depression. More specifi-
cally, the following hypotheses were tested:
Hypothesis 1: Higher self-stigma of help-seeking will be
associated with less willingness to engage in (a) professional
psychological help-seeking and (b) informal help-seeking
(e.g., friends and family).
 4 COLE AND INGRAM

Hypothesis 2: Higher self-stigma of help-seeking will be Table 1

associated with more engagement in avoidant behaviors (a) Participant Demographic Information
and self-help behaviors (b).
Variable n Percentage
Hypothesis 3: Higher GRC will be associated with less will-
Ethnicity
ingness to engage in (a) professional psychological help- European American 258 82.4
seeking and (b) informal help-seeking (e.g., friends and Asian American or Pacific Islander 17 5.4
family) Latino American 16 5.1
Other 12 3.9
Hypothesis 4: Higher GRC will be associated with (a) more African American 10 3.2
Sexuality
engagement in avoidant behaviors and (b) self-help behaviors. Heterosexual 296 94.6
Gay 8 2.6
Hypothesis 5: Higher self-stigma of help-seeking will have a Other 5 1.6
positive relationship with GRC. Bisexual 3 1
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Age
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18 54 17.3
Method 19 108 34.5
20 63 20.1
21 33 10.5
Participants 22⫹ 54 17.3

After receiving approval from the institutional review board,
participants (N ⫽ 313 men) were recruited to participate in a
“men’s health study” at a large Midwestern university. Most
participants (n ⫽ 307) were recruited from the undergraduate
psychology research pool and participated in exchange for course
credit. Additional participants were recruited from outside the
research pool via fraternities and campus advertisement (n ⫽ 6)
and were entered in a raffle for a $10 gift card. Although the
majority of recruitment took place in undergraduate psychology
courses, it should be noted that only 22% of the sample consisted
of psychology majors. Participants in our study identified as Eu-
ropean American (n ⫽ 258; 82.4%), Asian American or Pacific
Islander (n ⫽ 17; 5.4%), Latino American (n ⫽ 16; 5.1%), African
American (n ⫽ 10; 3.2%), or of another ethnicity (n ⫽ 12; 3.9%).
They were mostly heterosexual (n ⫽ 296; 94.6%), with the re-
maining identifying as gay (n ⫽ 8; 2.6%), bisexual (n ⫽ 3; 1.0%),
or of another sexual orientation (n ⫽ 5; 1.6%). Participants re-
ported being 18 (n ⫽ 54; 17.3%), 19 (n ⫽ 108; 34.5%), 20 (n ⫽
63; 20.1%), 21 (n ⫽ 33; 10.5%), or 22⫹ (n ⫽ 54; 17.3%) years of
age. Because age was collected categorically rather than continu-
ously, means and standard deviations were not able to be calcu-
lated. In general, participants were Caucasian, between the ages of
18 and 21, and identified as primarily heterosexual. See Table 1 for
participant demographic information.
Measures
Self-Stigma of Help-Seeking Scale. The Self-Stigma of Help-
Seeking Scale (SSOSH; Vogel et al., 2006) is a 10-item, self-report
measure of how much a participant believes her/his self-esteem
will be threatened by seeking psychological help (e.g., “I would
feel worse about myself if I could not solve my own problems”),
with items answered on a 5-point Likert-type scale (1 ⫽ strongly
disagree to 5 ⫽ strongly agree). The SSOSH has strong internal
reliability (␣ ⫽ .91) and a stable test–retest reliability (2-month ⫽
.72). It also has a negative relationship with intention to seek
counseling, a positive relationship with anticipated risks of disclo-
sure, and it effectively differentiates between those who sought
psychological services and those who did not during a 2-month
period. In the current study, the obtained Cronbach’s ␣ was .88.
Note. Age was collected categorically rather than continuously, making
calculation of a mean not possible. One individual did not report their
ethnicity or age.
Gender Role Conflict Scale. The Gender Role Conflict Scale
(GRCS; O’Neil, Helms, Gable, David, & Wrightsman, 1986) utilizes
37 items to measure stress related to conflict with masculine gender
role socialization (e.g., “I often have trouble finding words that
describe how I’m feeling”). Items are answered using a Likert-type
scale (1 ⫽ strongly disagree to 6 ⫽ strongly agree), with higher
scores signaling greater experience of gender-based conflict (O’Neil
et al., 1986). The GRCS has positive relations with other measures of
masculinity including conformity to masculine norms and male role
norms as well as negative relations to sex role egalitarianism (O’Neil,
2008, 2015). Across studies, the GRCS has demonstrated adequate
internal consistency (␣ ⫽ .70 –.90; O’Neil, 2015). In the current
study, the obtained Cronbach’s ␣ was .90.
Potential responses to depressive symptoms. Participants
were presented with a list of 28 potential ways to respond to
depressive symptoms (e.g., including 20 responses developed by
Mahalik and Rochlen (2006) and eight responses developed for the
current study to address additional treatment options; see the
online supplemental materials for the entire item list). Items de-
veloped for the current study were informed by research on the
impact of labels and titles on men’s help-seeking behaviors (e.g.,
therapist vs. coach or health center vs. counseling center; Mans-
field et al., 2005; Rochlen et al., 2006) as well as specific resources
available to students at the university where participants were
recruited (e.g., campus men’s groups). Utilizing a 4-point Likert-
type scale (0 ⫽ very unlikely to 3 ⫽ very likely), participants were
asked to imagine they were experiencing symptoms similar to a
vignette character (described in the following text) and to indicate
how likely they would be to engage in each behavior.
As these responses to depression did not have existing reliability
information, the development and psychometric validation of this
instrument was undertaken as part of this study. To develop and
psychometrically validate the responses to the depression scale, a
series of oblique geomin rotation exploratory structural equation
modeling (ESEM) analyses were conducted. ESEM is a form of
exploratory factor analysis that identifies the underlying relation-
 COLLEGE MEN HELP-SEEKING 5

Table 2
Descriptive Characteristics and Bivariate Correlations

Variable N M SD a 1 2 3 4 5 6 7

1. SSOHS 291 27.28 6.88 .88 —

2. GRCS 292 137.38 22.81 .90 .37ⴱⴱ —
3. PRDS- Inaction 289 8.25 2.14 .60 .33ⴱⴱ .29ⴱⴱ —
4. PRDS- Informal Supports 286 9.13 2.13 .62 ⫺.27ⴱⴱ ⫺.21ⴱⴱ ⫺.13ⴱ —
5. PRDS-Self-Help 284 6.54 2.42 .73 ⫺.02 ⫺.06 ⫺.06 .15ⴱ —
6. PRDS-Professional Help 284 6.06 2.66 .92 ⫺.36ⴱⴱ ⫺.15ⴱⴱ ⫺.25ⴱⴱ .32ⴱⴱ .40ⴱⴱ —
7. CES-D 292 10.33 8.43 .80 .12ⴱ .18ⴱⴱ .09 ⫺.19ⴱⴱ .07 .03 —
Note. SSOHS ⫽ Self-Stigma of Help-Seeking Scale; GRCS ⫽ Gender Role Conflict Scale; PRDS ⫽ Potential Responses to Depressive Symptoms;
CES-D ⫽ Center for Epidemiological Studies Depression Scale.
ⴱ
p ⬍ .05. ⴱⴱ p ⬍ .01.
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ships between the treatment-response behaviors for depression. other regression-based techniques, readers are referred to Brown
Nonsignificant items were pruned from the exploratory model, and (2015). As such, SEM analyses were utilized to test relationships
the depression scale was then validated using a confirmatory factor hypothesized between GRC, self-stigma, and depressive symptom
analysis (CFA). Subsequently, predictor variables were added to responses. Little’s (2013) interpretive guidelines for model fit were
produce a broader structural model examining predictors of male followed for this study. Those guidelines dictate that an acceptable
treatment-seeking. In general, analysis of the responses demon- fit is indicated when Comparative Fit Index (CFI) ⬎ .90 and root
strated good indications of internal structure and potential re- mean square error of approximation (RMSEA)/standardized root
sponses fell into the hypothesized four categories: (a) avoidance mean square residual (SRMR) ⬍ .08 and an excellent fit when
(e.g., “Wait to see if it goes away”), (b) informal supports (e.g., CFI ⬎ .95 and RMSEA/SRMR ⬍ .05. These fit index guidelines
“Talk to your wife or partner”), (c) self-help (e.g., “Look into are generally consistent with other interpretation standards in the
taking a class or a workshop that seems relevant to your symp- field, such as those of Hu and Bentler (1999), who recommend that
toms”), and (d) professional help (e.g., “Talk to a psychologist”). maximum likelihood estimation models be interpreted as excel-
Center for Epidemiological Studies Depression Scale. The lently fitted when RMSEA is close to .06 or below and CFI is .95
Center for Epidemiological Studies Depression Scale (CES-D; or greater. All modeling analyses were conducted using Mplus8
Radloff, 1977) is a 20-item self-report measure of cognitive (e.g., with the weighted least squares estimator (Muthén & Muthén,
“I thought my life had been a failure”), affective (e.g., “I felt 2012). Beta weights presented in the results and figures are stan-
depressed”), and vegetative symptoms of depression (e.g., “I could dardized values.
not get going”). The CES-D has adequate internal consistency
reliability (␣ ⫽ .85) and strong evidence of convergent validity for Results
depressive symptomology (Radloff, 1977; Santor, Zuroff, Ramsay,
Cervantes, & Palacios, 1995). In the current study, the obtained A univariate outlier analysis was conducted, and no outliers
Cronbach’s ␣ was .80. See Table 2 for mean scores and correla- were found in the data (Hoaglin, Mosteller, & Tukey, 1983). In
tions between the measures described earlier. addition, skewness and kurtosis for all the dependent variable
measures revealed a normal distribution of scores. Missing data
were handled through pairwise deletion.
Procedure and Data Analysis
Four ESEM analyses (one factor through four factor) were
After providing consent, participants completed a brief demo- conducted to identify the underlying pattern of treatment re-
graphic measure, the instruments described earlier, and were assigned sponses, and the four-factor solution showed evidence of the best
to read a vignette about a man with depression. The vignettes were fit (Table 3). This four-factor solution was then utilized to form the
created for the current study and were evaluated for content validity response to depression measure utilized in this study (see Table 4
by three licensed psychologists (Cole & Davidson, 2019). After
reading the vignette, participants were asked to imagine that they were
experiencing similar symptoms of depression. They then indicated
Table 3
their willingness to engage in various help-seeking behaviors to
Results of Exploratory Structural Equation Modeling
address the symptoms (as measured by the response to depressive
symptoms). Model RMSEA CFI TLI SRMR AIC BIC
Structural equation modeling (SEM) provides an analytic ad-
vantage because it enables the prediction of complex concurrent One-factor .12 (.11–.13) .62 .59 .11 20,177.8 20,492.5
Two-factor .11 (.11–.12) .70 .65 .09 19,867.4 20,283.2
relationships between multiple latent or manifest constructs. Through Three-factor .10 (.09–.10) .79 .74 .07 19,512.3 20,025.5
a simultaneous analysis of relationships between variables, SEM Four-factor .08 (.07–.09) .86 .80 .05 19,276.8 19,883.7
avoids potential conflicts of collinearity common to earlier multi-
Note. RMSEA ⫽ root mean square error of approximation; CFI ⫽
variate techniques while also providing a capacity to assess mea- Comparative Fit Index; TLI ⫽ Tucker–Lewis Index; SRMR ⫽ standard-
surement and structural models simultaneously. For comprehen- ized root mean square residual; AIC ⫽ Akaike information criterion;
sive summary of the analytic advantages offered by SEM over BIC ⫽ Bayesian information criterion.
 6 COLE AND INGRAM
Table 4
Treatment-Seeking Response Items and Final Parent Domains
Domain and item wording
Social
Talk to your wife or partner
Talk to a family member
Talk to a best friend
Inaction
Wait to see if it goes away
Have a few drinks
Distract self through activities
Self-help
Look into taking a class or workshop
Try to help yourself feel better using self-help book
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Use a computer program to monitor mood
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Visit blogs or message boards for the problem
Professional help
Contact a mental health professional
Talk to a therapist
Talk to a psychologist
for a list of items in each domain). These four factors were named
based on their emergent item-content themes. Using a pruned
ESEM model of the depression response behaviors, separate CFAs
were conducted for each vignette using a weighted least squares
estimator. Items were pruned from the ESEM model when they
loaded nonsignificantly or were below traditional loading thresh-
olds for inclusion (Brown, 2015). In addition to CFA, coefficient
␣s were calculated for each factor: Professional ␣ ⫽ .92; Avoid-
ance ␣ ⫽ .60; Informal ␣ ⫽ .62; and Self-Help ␣ ⫽ .73. Although
two factors were slightly below common cutoff values for devel-
oping scales (e.g., ⱖ.7; Nunnally, 1978), it should be noted that
coefficient ␣ is limited in its assessment of internal consistency for
low item-count instruments and for those with nonunidimensional
(e.g., oblique rather than orthogonal) factor structures (McNeish,
2018; Streiner, 2003a, 2003b), both of which are observed within
this study. In these cases, factor analytic techniques are preferred
(Brown, 2015). Accordingly, results of the CFA demonstrated
excellent fit, ␹2(59) ⫽ 101.30, p ⬍ .001, CFI ⫽ .97, SRMR ⫽ .05,
RMSEA ⫽ .05 (.03–.06), with all items significantly loading on
their respective constructs. In short, the response to depressive
symptoms demonstrated four different patterns of treatment-
seeking behaviors (e.g., formal psychological services, informal
social supports, self-help behaviors, and avoidant behaviors).
Next, SEM analyses were conducted with the abovementioned
four-factor depression response latent construct to test the hypoth-
esized ways in which self-stigma and GRC relate to each other and
the treatment behaviors. Model 1 used correlated manifest vari-
ables of self-stigma (SSOSH) and GRC (GRC) to predict re-
sponses to depression. Depressive treatment response domains
were allowed to correlate within the SEM model. Model 1 (Figure
1) achieved acceptable fit, ␹2(98) ⫽ 189.551, CFI ⫽ .93, SRMR ⫽
.07, RMSEA ⫽ .06 (.05–.012); SSOSH and GRC had a moderate
positive relationship (␤ ⫽ .37), consistent with previous research
showing a relationship between GRC (GRC) and self-stigmatizing
views (SSOSH). Consistent with relationships outlined in Hypoth-
eses 1 and 2, GRC is negatively associated with informal support
utilization (␤ ⫽ ⫺.14, p ⬍ .001) and positively associated with
avoidant behaviors (␤ ⫽ .25, p ⬍ .001). Anticipated relationships
between GRC and both professional psychological help-seeking
and self-help behaviors were not supported. Hypotheses 3 and 4
about self-stigma were also partially supported. Self-stigma neg-
atively predicted professional help-seeking (␤ ⫽ ⫺.35, p ⬍ .001)
and informal supports (␤ ⫽ ⫺.26, p ⬍ .001) while positively
predicting avoidance behaviors (␤ ⫽ .34, p ⬍ .001). Support for
the hypothesized relationship between self-stigma and self-help
behaviors was not supported. Consistent with Hypothesis 5, self-
stigma was positively associated with GRC (␤ ⫽ .37, p ⬍ .001).
With the exception of the avoidance behaviors, which did not
correlate with other types of help-seeking, the response to depres-
sion factors had generally moderate relationships with one another
(␤ ⫽ .16 –.44). These findings suggest that in addition to self-
stigma, GRC provides incremental utility in understanding help-
seeking behaviors in depression for men and that there is a gen-
erally modest relationship between types of help-seeking.
Model 2 expanded Model 1 and included depressive symptoms,
measured by CES-D, as a predictor of both self-stigma and GRC.
Inclusion of depressive symptoms in Model 2 allowed for the
examination of the degree to which participant experiences of
depressive symptoms predicted changes in SSOSH and GRC. It
also allowed us to determine if those change corresponded to
subsequent help-seeking behaviors. Because Model 2 (Figure 2) is
nested within Model 1, a ␹2 difference test was also conducted,
and results indicate an incremental utility in including CES-D into
the previous model, ␹diff
2
(5) ⫽ 34.46, p ⬍ .001, and achieved an
excellent fit, ␹ (93) ⫽ 155.09, CFI ⫽ .96, SRMR ⫽ .05,
2
RMSEA ⫽ .05 (.03–.06). Higher scores on the CES-D predicted
more self-stigmatizing views (␤ ⫽ .10, p ⫽ .04) and greater GRC
(␤ ⫽ .18, p ⬍ .001), supporting the notion that the experience of
depression is tied to GRC in men and is likely to influence
treatment-seeking decisions. Beta weights representing the rela-
tionship between the potential responses to depression item and
CES-D and GRC scales were unchanged, as were the correlations
between the potential responses to depression factors. As a result,
the hypotheses for self-stigma and GRC remain partially supported
in the same manner outlined previously. In short, Model 2 provides
evidence that the experience of depression corresponds to greater
self-stigmatizing views and more GRC which, in turn, predict
help-seeking intentions. Full loading information on Models 1 and
2, including standard error and p values, are located in Table A1 in
the Appendix.
Discussion
This study explored relationships between depressive symp-
toms, mental health self-stigma, and GRC to explore where college
men will turn for help when depressed. Using an analogue design
and vignettes about men with depression, we examined men’s
likelihood to utilize different treatment responses, including en-
gagement in avoidant behaviors as well as social support, self-
help, and professional psychological help.
Self-Stigma and Help-Seeking
Previous research suggests that men are less likely to seek help
for psychological problems that they believe to be stigmatizing
(Magovcevic & Addis, 2005). Consistent with Hypothesis 1, self-
stigma predicted decreased willingness to engage in professional
 COLLEGE MEN HELP-SEEKING 7

.76
.74*** Wait to see .45

.56***
SSOSH Avoidance Distract myself .69
.34***

Drink .79
.46***

-.26*** .88

.62*** Significant Other .45

Informal .75***
Family .66
-.02 Supports
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.57*** Friend .79

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-.35***
.37***
.96 .77*** Classes or Workshops .40
.25***
.76*** Self-help Books .43

Self Help
Technology Self-
.51*** .74
Monitor
-.14**

.48*** Men's Group .77

.87

-.06
.77** MH Worker .41

.94**
GRCS Professional Help Therapist .12
-.02

.94*** Psychologist .12

Figure 1. Treatment-seeking response to depression. Statistically significant paths are presented using solid
lines, whereas dotted lines represent nonsignificant paths. GRCS ⫽ Gender Role Conflict Scale; SSOSH ⫽
Self-Stigma of Seeking Help Scale. Model fit ⫽ ␹2(98) ⫽ 189.551, Comparative Fit Index ⫽ .93, standardized
root mean square residual ⫽ .07, root mean square error of approximation ⫽ .06 (.05–.012). ⴱ p ⬍ .05. ⴱⴱ p ⬍
.01. ⴱⴱⴱ p ⬍ .001.

help-seeking (Hypothesis 1a) and informal help-seeking (Hypothesis
1b) when depressed. The finding that self-stigma predicted decreased
willingness to engage in professional help-seeking behaviors is con-
sistent with the robust literature demonstrating that self-stigma con-
sistently predicts willingness to seek psychotherapy and attitudes
about the value of mental health services (Vogel et al., 2006; Vogel et
al., 2008). However, the current study is among the first to examine
self-stigma’s relations to other types of help-seeking for depression.
The finding that men experiencing self-stigma are less likely to seek
support from their significant others, family, and friends suggests that
societal messages about men with depression also lead to significant
barriers to informal help-seeking. Examination of informal help-
seeking is important because it may normalize depressive symptoms
and the help-seeking process for college men. This finding is partic-
ularly troubling because the majority of college students who seek
help for psychological distress do so after being prompted by others.
Furthermore, college students that have been referred to professional
help or know someone that has previously sought professional help
tend to have better attitudes about help-seeking (Vogel et al., 2007).
Although we had hypothesized that the anonymous nature of self-
help would make it more appealing to men experiencing high levels
of self-stigma (Hypothesis 2b), there was no evidence to support this
in the current sample. This finding is consistent with Gough (2016),
who reported a number of barriers to entry for men seeking online
support for depression. Additional research will be necessary to de-
termine the degree to which men experiencing self-stigma see poten-
tial benefits for self-help such as books, message boards, or the use of
smartphone apps. Finally, consistent with Hypothesis 2a, men report-
ing higher levels of self-stigma were more likely to engage in avoidant
behaviors (i.e., wait to see if the problem resolves itself, distraction, or
self-medicating behaviors). This finding may help to explain the
frequent comorbidity of substance use disorders among men with
depression as well as the tendency of men to report severe and
prolonged depression at the time of intake (Martin, Neighbors, &
Griffith, 2013; Warren, 1983).
GRC and Help-Seeking
Consistent with Hypotheses 3 and 4, experience of GRC was
associated with decreased willingness to engage in informal help-
seeking behaviors (Hypothesis 3b) and increased engagement in
avoidant behaviors (Hypothesis 4a). These findings mirror previ-
 8 COLE AND INGRAM

.76
.74*** Wait to see .45

.56***
SSOSH Avoidance Distract myself .69
.34***

Drink .79
.46***

-.26*** .88

.62*** Significant Other .45

Informal .75***
.12* Family .66
-.02 Supports

.57*** Friend .79

-.35***
CESD
.36***
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.96 .77*** Classes or Workshops .40

This document is copyrighted by the American Psychological Association or one of its allied publishers.

.25***
.76*** Self-help Books .43
.18**
Self Help
Technology Self-
.51*** .74
Monitor
-.14**

.48*** Men's Group .77

.87

-.06
.77** MH Worker .41

.94**
GRCS Professional Help Therapist .12
-.02

.94*** Psychologist .12

Figure 2. Depressive symptoms predicting self-stigma and gender-role conflict. Statistically significant paths
are presented using solid lines, whereas dotted lines represent nonsignificant paths. GRCS ⫽ Gender Role
Conflict Scale; CES-D ⫽ Center for Epidemiologic Studies Depression Scale; SSOSH ⫽ Self-Stigma of Seeking
Help Scale. Model fit ⫽ ␹2(93) ⫽ 155.09, Comparative Fit Index ⫽ .96, standardized root mean square
residual ⫽ .05, root mean square error of approximation ⫽ .05 (.03–.06). ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

ous research, which indicates that men experiencing depression
tend to become more socially withdrawn and engage in avoidant
behaviors in an effort to mask depressive symptoms (Nadeau,
Balsan, & Rochlen, 2016; Oliffe & Phillips, 2008). Although these
previous studies indicate that the experience of GRC influences the
expression of depressive symptoms, the current findings suggest
that it may also relate to men’s help-seeking behaviors. More
specifically, men experiencing high levels of GRC may be less
likely to discuss their experiences of depression with their signif-
icant others, family, and friends. The male model of help-seeking
(Perlick & Manning, 2007) suggests that these men may have
engaged in an appraisal process and determined that sharing their
distress with those in their social circles may lead to more risk than
reward (i.e., increased GRC). As such, attempts to minimize symp-
toms through avoidant behaviors such as waiting out the problem,
distracting oneself from the symptoms, and self-medicating with
alcohol may be more attractive alternatives that are deemed less
risky. Inconsistent with Hypotheses 3 and 4, higher rates of GRC
were not predictive of changes in willingness to engage in profes-
sional psychological help-seeking (Hypothesis 3a) or use of self-
help (Hypothesis 4b).
Self-Stigma and GRC
Consistent with Hypothesis 5, bivariate correlations and SEM
revealed significant relations between men’s experiences of self-
stigma and GRC. These findings are consistent with previous studies,
which have indicated that the experience of self-stigma has a modest
correlation to GRC (Pederson & Vogel, 2007). The relationship
between these variables mirrors Good and Wood’s (1995) suggestion
that depressed men may experience “double jeopardy.” Additional
research is necessary to understand the ways in which the reciprocal
relations between self-stigma and GRC negatively impact men’s
mental health and help-seeking behaviors.
Implications
These relationships between GRC, self-stigma, and help-seeking
behaviors have several notable implications for clinical practice and
research.
Implications for practitioners. Previous research indicates
that seeing other men violate gender norms related to help-seeking
improves utilization of mental health services (Vogel et al., 2008);
thus clinicians are encouraged to develop outreach programing and
psychoeducational materials to normalize the experience of de-
pression and utilization of psychological help-seeking when de-
pressed. This is especially important in light of the finding that
men experiencing high levels of GRC and self-stigma are less
likely to engage with informal supports that could normalize
professional help-seeking. Unfortunately, men continue to experi-
ence detrimental effects of gender socialization and mental illness
stigma after making the decision to seek help (Perlick & Manning,
 COLLEGE MEN HELP-SEEKING
2007). Although experiences such as GRC occur across race, ethnic-
ity, and sexual orientation (Wester, 2008), clinicians are encouraged
to consider individual differences and cultural context when consid-
ering the influence of masculinities on help-seeking behaviors. Thus,
in addition to assessing symptoms of depression through formal
assessments or clinical interviews, clinicians are encouraged to for-
mally assess for experiences of GRC and stigma when working with
male clients (i.e., administer the GRCS and SSOSH). In addition,
clinicians are encouraged to integrate discussions of the decision to
seek help, attempts at avoiding coping and self-help, and experiences
of GRC and self-stigma into the first session of therapy. Finally,
clinicians are encouraged to consider utilizing a “masculine-sensitive
therapeutic style” (Englar-Carlson, Stevens, & Scholz, 2010). For
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
example, clinicians might make therapy more “man friendly” by
This document is copyrighted by the American Psychological Association or one of its allied publishers.
integrating aspects of the positive psychology positive masculinity
model of therapy, such as reframing the decision to seek help as a
strength by tying it to masculine norms of courage and risk-taking
may be meaningful ways to empower and engage male clients in
therapy (Kiselica & Englar-Carlson, 2010). Although research on
“man friendly” therapy is scant, there is evidence that some men
prefer therapeutic orientations that focus on positive aspects of mas-
culinity. However, it is important to note that these approaches are not
“one size fits all” and that preferences appear to depend upon indi-
vidual differences in GRC, self-stigma, and help-seeking attitudes
(Cole et al., 2019).
Results of the current study provide support for aspects of the male
model of help-seeking (Perlick & Manning, 2007), including the
unique roles of GRC and self-stigma in influencing help-seeking
behaviors among men with depression. Although previous studies
demonstrated that men may struggle to engage in professional help-
seeking when depressed, the current findings suggest that willingness
to share distress with significant others, family, and friends is also
negatively impacted. Vogel and colleagues (2007) found that most
college students that engaged in professional help-seeking had been
referred by or had known someone that had previously utilized
services. Thus, the finding that GRC and self-stigma prevent men
from disclosing distress in their important interpersonal relationships
may deprive them of important dialogues that may provide emotional
support and normalize professional help-seeking behaviors by reduc-
ing stigma.
Implications for researchers. Consistent with previous studies
(Good & Wood, 1995; Vogel et al., 2006), GRC and self-stigma are
robust predictors of help-seeking behaviors. Results of the current
study suggest that college men’s experiences of GRC and self-stigma
are uniquely related to help-seeking behaviors. Thus, assuming that all
types of help-seeking behaviors are equally predicted by these factors
is inappropriate. Not only do the magnitude of effects vary across
types of responses to mental health needs, but so do the patterns of
influence by GRC and self-stigma. Efforts to understand help-seeking
need to be conceptualized as responses to specific types of behavior
(e.g., informal social support, formal service providers, and self-help/
self-direct behaviors). Researchers’ tendency to focus on only one
venue of mental health responses inadequately addresses understand-
ing of men’s response to increased mental health needs.
Limitations and Future Directions
Limitations of the current study include the lack of diversity among
participants, the use of self-report measures, and the analogue nature
9
of the design. The majority of participants identified as White and
heterosexual. As a result, findings cannot be generalized to more
diverse populations. Given cultural variations in masculinity, replica-
tions of the current study among samples that are more racially and
sexually diverse would expand the literature on men’s help-seeking
behaviors. Furthermore, the current study was interested in the help-
seeking behaviors of college men. Thus, the results do not tell us
about relations between these variables among older men or men with
varying levels of education. Future studies would benefit from includ-
ing cross-generational comparisons to explore potential differences in
gender role socialization and self-stigma. With regard to geography,
the sample consisted of students at one Midwestern university in the
United States. Future studies may benefit from exploring potential
regional differences in the relations outlined in the current study. This
could be accomplished by using online sampling techniques such as
Mechanical Turk or Qualtrics Panels, which include national samples
of men that are not necessarily college students. The use of self-report
measures raises questions regarding social desirability. With regard to
methodological limitations, although analogue studies have a high
degree of experimental control (i.e., high internal validity), general-
izing of results should be done so with caution (Heppner, Wampold,
& Kivlighan, 2008). Future studies should explore these relationships
with samples of men who are experiencing major depressive disorder.
Finally, although one novel contribution of the current study is the
integration of the male model of help-seeking (Perlick & Manning,
2007), the models presented do not measure recognition of problem
severity. The original model posits that men’s recognition of problem
severity is impacted by cultural factors and gender socialization and
suggests that it is an additional variable that influences help-seeking
behaviors. Addressing this issue in future studies will enhance the
utility of the model.
Conclusion
The current study explored relations between the experience of
depressive symptoms, GRC, self-stigma of help-seeking, and col-
lege men’s willingness to engage in different types of help-seeking
behaviors. Although relations between these constructs and pro-
fessional help-seeking have been established in the literature, little
is known about the influence on utilization of informal supports,
self-help, and avoidant behaviors. Results of this study indicate
that GRC and self-stigma have different relations to help-seeking
behaviors. Whereas GRC decreased treatment-seeking intentions
for use of social support and increased engagement in avoidant
coping, it was not predictive of changes in engagement in profes-
sional psychological help or self-help for depression. Furthermore,
as men’s experiences of self-stigma increased, they were less
likely to utilize professional psychological help or self-help for
depression. Consistent with Perlick and Manning’s (2007) male
model of help-seeking, these findings implicate GRC and self-
stigma as factors associated with gender differences in help-
seeking and the disproportionate number of men that avoid disclo-
sure of depression on college campuses. Researchers are encouraged
to continue to explore these relations so that we might improve men’s
psychological help-seeking for depression. Clinicians are encouraged
to attend to GRC and self-stigma when working with men in therapy.
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 12 COLE AND INGRAM

Appendix

Table A1
Standardized Loadings, Standard Error, and Significance Values

Model 1 Model 2
Model content Standard estimate SE p Standard estimate SE p

Avoidance by
Wait to see .74 .06 ⬍.001 .74 .06 ⬍.001
Distract myself .56 .06 ⬍.001 .56 .06 ⬍.001
Drink .46 .06 ⬍.001 .46 .06 ⬍.001
Informal support by
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Significant other .62 .06 ⬍.001 .62 .06 ⬍.001

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Family .75 .05 ⬍.001 .75 .05 ⬍.001

Friend .57 .05 ⬍.001 .57 .05 ⬍.001
Self-Help by
Classes/workshops .77 .04 ⬍.001 .77 .04 ⬍.001
Books .76 .04 ⬍.001 .76 .04 ⬍.001
Technology self-monitor .51 .05 ⬍.001 .51 .05 ⬍.001
Men’s group .49 .06 ⬍.001 .48 .06 ⬍.001
Professional help by
Mental health worker .77 .03 ⬍.001 .77 .03 ⬍.001
Therapist .94 .01 ⬍.001 .94 .01 ⬍.001
Psychologist .94 .01 ⬍.001 .94 .01 ⬍.001
Avoidance on
GRCS .25 .07 ns .25 .07 ns
SSOSH .34 .07 ⬍.001 .34 .07 ⬍.001
Informal support on
GRCS ⫺.14 .07 ⬍.001 ⫺.14 .07 ⬍.001
SSOSH ⫺.26 .07 ⬍.001 ⫺.26 .07 ⬍.001
Self-Help on
GRCS ⫺.06 .07 ns ⫺.06 .07 ns
SSOSH ⫺.02 .07 ns ⫺.02 .07 ns
Professional help on
GRCS ⫺.02 .06 ns ⫺.02 .06 ns
SSOSH ⫺.35 .06 ⬍.001 ⫺.35 .06 ⬍.001
GRCS with SSOSH on CES-D .36 .06 ⬍.001 .36 .05 ⬍.001
GRCS — — — .18 .06 ⬍.01
SSOSH — — — .12 .06 ⬍.05
Note. GRCS ⫽ Gender Role Conflict Scale; SSOSH ⫽ Self-Stigma of Seeking Help; CES-D ⫽ Center for Epidemiological Studies Depression Scale.
Bolded domains are those within the CFA of help-seeking behaviors.

Received April 4, 2019

Revision received August 28, 2019
Accepted September 3, 2019 䡲