A Strategy For Preventing Male Suicide

In this article I examine the issues contributing to male suicide and discuss strategies that can be used to reduce risk.  With 80% of suicide deaths in Canada, men, especially those in their late-40s, are vulnerable. This article examines the unique nature of male depression, manifesting in forms that are poorly recognized by current diagnostic approaches, and critical risk factors including men’s use of alcohol, characteristic ways of managing psychological suffering and under-utilization of mental health services. Male-oriented approaches to mental health service provision and programs or tools to foster more adaptive coping by men with psychological suffering are addressed. One such tool, the 5RF Psych Resilience Workbook, is commended. This self-care tool was developed through a study of first responders in the emergency health services domain and is freely available. 

Male suicide constitutes an astonishingly high proportion of all suicide deaths in the western world. This is certainly true in Canada where approximately 80% of suicide deaths occur in men. It is not only striking that such a high proportion of suicides are associated with being male but that this disproportion across gender has largely been accepted as somehow normal or not worthy of particular attention. This is also generally true for men’s shorter life span: as one researcher stated it, it’s as though men had a “kill switch” that ends their lives prematurely. But it has become increasingly evident that researchers, clinicians and social planners need to pay attention to these disparities and take action to reduce them.

In my 35 years of clinical practice and research within psychology, I have increasingly focused on understanding male psychology and the risks associated with men’s characteristic coping styles.^{1 2}  Over time, my psychotherapy practice has become primarily one focused on men. An overriding question has been “what is it about men that leaves them so vulnerable to psychological suffering and suicidal behavior?”

Let me be clear about my intellectual biases. First, I work within an existential/ humanistic model, focusing on how individuals develop a sense of meaning in their lives, which life experiences contribute to this sense of meaning and which internal or external events threaten this sense of meaning and raise the likelihood of suicidal action. Second, I apply a cognitive behavioral model of how individuals cope with their world and how this coping can be improved through psychotherapy (or good relationships and positive social engagement).

Suicide in men has been described by a leading researcher as a “silent epidemic.”³  It is “silent” because there is a low degree of public awareness regarding the magnitude of this problem, surprisingly little research has been done, there are few preventive efforts specifically targeting male suicide and men are reluctant to seek help for suicidality. 

It is “epidemic” because it has a disturbingly high incidence and is a major contributor to men’s mortality: between the ages of 15 and 44, suicide is among the top three sources of men’s mortality.⁴ Across all countries reporting these data (except China and India), males show a suicide rate that is 3 to 7.5 times that of women. In Canada, the male suicide rate is about 3 times that of women. ⁵

The male suicide rate increases fairly steadily with age until peaking in the late 40s, then falls significantly and rises again in the 80s.⁶ The peak in suicide rate among Canadian men in their 40s and 50s is surprising in light of past data showing a peak of suicide in younger age groups.⁷  However, a change in this suicide pattern seems to be underway.  It is apparent that our knowledge of men’s suicide is lagging behind changes in the age-specific incidence of this cause of death. Until we understand the underlying reasons for this relative increase in men’s suicide rates in middle age, including potential cohort effects, we will not be able to implement effective preventive action.

A literature review found that signs indicative of increased suicidal risk in men include “desperation and frustration in the face of unsolvable problems, helplessness, worthlessness, statements of suicidal intent”.⁸  However, the reviewers highlight the uncertainty regarding the sensitivity and specificity of these signs in identifying men’s suicidal risk. A recent longitudinal study found that men who strongly identified as ‘self-reliant’ had 34% greater odds of reporting thoughts of suicide.⁹ However, suicidal thinking alone is not a sufficient predictor of an imminent attempt. An intriguing qualitative study examined factors that interrupt suicide attempts in men, finding that “suicidal ideation may be reduced through provision of practical help to manage crises, and helping men to focus on obligations and their role within families”. ¹⁰

Although depressed mood is linked to suicide, the incidence of depression in men is half that for women.¹¹  Three main explanations have been suggested. First, men are simply less likely to experience depression, for unclear reasons. Second, men are reluctant to acknowledge depressive symptoms due to aspects of male socialization.¹²  Third, men experience depression in a specific way, with different symptoms, such that the standard operational criteria for depression (which typically emphasize internalizing symptoms such as sadness and worry) are not valid in a male population.¹³   This latter explanation is built upon the concept of male depressive syndrome, where externalizing symptoms (e.g. anger, alcohol misuse, risk-taking) are considered indicative of men’s depression, yet not diagnostically recognized as such.¹⁴

If men’s depression is qualitatively different, many men will not be diagnosed as depressed and will be absent from the literature. There is some evidence that men describe depression using language (e.g. ‘stressed’, ‘angry, ‘tired’) that does not concord with existing clinical criteria, or endorse different signs of depression (e.g. being ‘irritable’, ‘on auto-pilot’ and ‘more aggressive towards others’).

The overuse of alcohol, resulting in significant mental health impact and dependence, is disturbingly common in men. Men are two or three times more likely than are women to have a serious alcohol use problem.^{15 16}   In a 2012 study of mental health and substance use disorders in Canada, it was found that “males had higher rates of substance use disorders in the past 12 months…6.4% of males and 2.5% of females reported symptoms consistent with substance use disorder.” ¹⁷

Literature reviews have attributed negative male coping styles to the tendency of some men to adhere rigidly to stereotyped features of masculinity, especially concealing negative emotions and overvaluing self-reliance over support from others.^{18 19}  Such approaches can increase the risk of suicide, if manifest in withdrawal from relationships.²⁰

Some men report attempts to redefine notions of masculine coping, for example, where help-seeking allows for the maintenance of traditional roles such as providing for the family. A research group in Australia has studied positive coping strategies used by men: far from relying only on negative coping strategies, many men reported enacting a variety of prevention and management strategies for mood maintenance.^{18 21} These positive strategies fall along a continuum – some men are more comfortable with ‘typically masculine’ approaches (e.g. problem solving, achievements, structured plans, goal setting) while others are open to using less ‘masculine’ strategies (e.g. acceptance of vulnerability, talking openly about problems, seeking help). Crucially, some men describe becoming open to such strategies after significant periods of distress.

A considerable body of research has identified lower utilization of mental health care by men.²² One might assume that this usage pattern reflects a lower rate of common mental health conditions such as depression, but the available research data tends to point rather to men’s reluctance to access mental health care, i.e., a pervasive disinclination to seek help in dealing with psychological distress, whether help from the health system, family members of friends.²³

Taken together, the research points to a pattern where men do not perceive the need for care, support systems do not identify male-specific warning signs, diagnostic criteria do not detect men with mental health problems and men delay treatment until problems are severe. Efforts have been made to address this poor accessing of care (vs. access to care) and there are indicators of change. For example, in Australia, the proportion of men with mental health problems who used appropriate services increased from 32% in 2006-07 to 40% in 2011-12.²⁴ However, there is substantial room for improvement.

Although this is less well established as a risk factor for male suicide, it is worth focused attention in seeking to prevent male suicide. It does appear that relationship breakdown is a critical risk factor for male suicide. One study found that “Marital status, especially divorce, has strong net effect on mortality from suicide, but only among men.”²⁵

A policy review, Keeping It Real, emphasized the importance of implementing novel programs that reach out to men and designing care approaches that enhance men’s coping.²⁶

Examples of male-focused programs include:

• The Australian ‘Well@Work’ program, which aims to improve workplace mental health in male-dominated workforces (e.g. police, fire, and emergency services);²⁷
• A Canadian adaptation of the Australian Men’s Shed program, which focuses on the mental health of older men;²⁸
• DUDES Club, a ground-breaking program primarily targeting the health and well-being of indigenous men in Vancouver, BC’s Downtown Eastside, a group of men facing high risk of addiction, poverty, and homelessness.²⁹  The goal of DUDES Club is to promote health literacy and build a sense of “brotherhood”. It integrates traditional indigenous medicine and teachings, while providing access to healthcare professionals who facilitate interactive “health discussion”.³⁰
• The Canadian Centre for Men and Families (CCMF) provides an accepting environment where men will feel safe reaching out for help. It fosters communication, rather than a particular treatment modality: “We have men talk about intimate partner violence, suicide, family break up, etc, in public events and video, to show other men that they are not alone.”³¹

There is an opportunity to develop self-care resources which are consistent with existing clinical and research knowledge and which are easy to disseminate to a group that has been historically resistant to mental health treatment.³²  Use of self-care approaches is likely to be relatively acceptable to men in that it emphasizes self-reliance and does not require disclosure of personal struggles or vulnerabilities. Examples of male-focused self-care resources are:

• HeadsUpGuys, a website where men can access psychoeducation regarding depressive symptoms, practical tips for preventing and dealing with depression, how to access professional services and videos of men who have overcome depression;³³  
• BroMatters, which provides psychoeducation about stress, depression, and alcohol use, along with self-help in the form of CBT, mindfulness relaxation programs and strategies for workplace stress.³⁴

Given the barriers to men’s timely accessing of appropriate care, development of more self-care interventions is promising. I will present a resilience-focused self-care tool my research team developed: the 5RF.

The 5RF (5 Resilience Factors) Workbook

The 5RF is a self-care tool developed through a three-year study of workers in the emergency health services domain, including paramedics and dispatchers. This group is exposed to very high levels of stress on an ongoing basis. It is a significant challenge for workers in this field to cope with such high stress without being psychologically injured. We learned from these EHS workers what makes high stress more manageable and how to cope in a way to stay psychologically safe. Their wisdom needs to be shared.³⁵

The resilience factors were identified through a stress coping survey administered to the emergency health services workforce, elicitation of their personal experiences with stress management, statistical analysis of data derived from the survey and review of cognitive behavioral therapy literature to identify empirically supported means of building each of these resilience factors.   These factors are highly relevant to the enhancement of men’s coping with psychological suffering.

1. Balance. Maintaining a balance between work and personal life increases one’s ability to recover after a demanding experience. A propensity to over-identify with one’s occupational identity will contribute to men’s vulnerability to psychological suffering and thus to suicidal tendencies.
2. Self acceptance. Being harshly self critical or perfectionistic in evaluating ones own accomplishments or performance can leave one feeling demoralized and depressed. Teaching men to maintain a self accepting  attitude and judge themselves in a fair and compassionate manner will help to reduce unnecessary psychological suffering and thus suicide risk. This resilience factor is particularly relevant to men, who frequently are taught to set high standards for personal achievement and to be unforgiving in judgments of performance that falls below one’s self-expectation. This is perceived as a stoic approach to building men’s toughness. In my clinical practice, I have often seen the negative emotional impact of harsh self judgment in relation to self-imposed high standards, sometimes associated with active suicidal ideation.
3. Meaning in work. Maintaining one’s sense of meaningful work and a sense of purpose compatible with personal values is an important protective factor. If men fail to give sufficient importance to a sense of meaning in their work and lives, their risk of psychological suffering and suicidality will increase. Losing that sense of meaning in one’s work can be emotionally devastating, even where the loss of meaning reflects aspects of the job rather than yourself.
4. Trusted social support. Having a supportive social group whom they trust will help to protect men from undue suffering and suicidality. Enhancing men’s ability to connect with co-workers, friends or family members will increase their psychological safety.
5. Physical self-care. Protecting physical health though exercise, nutrition and rest will increase men’s ability to stay fit and energized. This coping factor will contribute to a general sense of well-being and a positive emotional state that will protect against psychological injury and suffering, thus helping to reduce  suicide risk.

Because the aim of our research group is to disseminate useful knowledge and tools as widely as possible, the 5RF Workbook is available online at no cost from the following link: https://psychhealthandsafety.org/the-5rf-resilience-project/

This approach of supporting psychological self-care is likely to be an effective means to disseminate relevant knowledge and skills to a male population. Note that our research group has previously developed a succinct and user friendly workbook for managing depressed mood, the Antidepressant Skills Workbook. It is available for free download from our website, In seven languages. Over the 15 years it has been posted for free download, we have seen approximately 3 million downloads of the workbook globally. To achieve such a high rate of uptake with minimal funding for dissemination indicates that that this approach is surprisingly effective. As noted above, the 5RF will be disseminated in the same way.

My own therapeutic  work with men has combined humanistic, existential and cognitive behavioral models. The humanistic model provides a compassionate and non judgmental approach which I have found to be most appropriate to men who are often engaged in harsh self judgment.³⁶  The existential model, specifically that introduced by Sartre, provides a powerful framework built upon the tension between situational facticity and personal freedom.³⁷  This is a helpful model for helping men to deal with real life challenges or losses in an accepting and effective manner, rather than with despair or bitterness. Finally, the cognitive behavioral model allows one to identify how problematic coping patterns trigger painful emotional states and to find new ways of coping that lead to greatly improved outcomes.³⁸

The main conclusion is that a high proportion of men in Western society have acquired psychological coping strategies that are often dysfunctional and leave them vulnerable to a number of negative psychological outcomes, suicide being the most severe.

• Overusing alcohol as a means to lessen emotional suffering
• Denying suffering, ‘sucking it up’
• Isolating or reducing social connectedness in times of distress

Each of these coping strategies can be appropriate – for example, indifference to suffering in emergency situations where certain tasks must be accomplished. Likewise, brief periods of isolation to relieve stress. However, using these strategies excessively or rigidly leaves men vulnerable to a wide range of negative consequences and less able to access the health buffering effects of diverse social support networks.³⁹   There is a need for men to learn adaptive coping approaches, long before they reach a crisis point.