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American Journal of Men's Health logoLink to American Journal of Men's Health
. 2019 Feb 27;13(1):1557988319832121. doi: 10.1177/1557988319832121

Exploring the Effectiveness of an Integrated Mixed Martial Arts and Psychotherapy Intervention for Young Men’s Mental Health

N Bird 1,, G McCarthy 1, K O’Sullivan 1
PMCID: PMC6440068  PMID: 31068064

Abstract

This research sought to establish the impact of a 10-week program combining mixed martial arts (MMA) and one-to-one psychotherapy on young males’ mental health and determine factors that predict help-seeking behavior in at-risk males. Preparticipation and post-participation interviews were employed as the method of data collection. Seven males (20–35 years; M = 24.57) completed preparticipation interviews and five completed follow-up interviews. Thematic analysis of preparticipation revealed that help-seeking behavior in at-risk males is impeded by the presence of male gender stereotypes, the absence of positive role models, as well as difficulty navigating challenging social landscapes. Post-participation interviews revealed that the sport provided structure and fitness for at-risk males, while the counseling was pivotal for personal growth. Improved relationships, work life, and self-esteem were also observed. The sporting element of the program helped to reduce stigma associated with engaging in psychotherapy, and positive male relationships were noted as particularly impactful. Findings support previous research indicating that combining sports and psychotherapy positively impacts young males’ mental health. Sport provides an acceptable doorway to psychotherapy, providing space to explore personal issues.

Keywords: male, mental health, mental health services, counseling, psychotherapy, sport, Ireland


Engaging young men at risk of suicide in mental health services is an increasingly important goal for Irish society. Provisional figures indicate that there were 392 deaths by suicide in 2017 (Central Statistics Office [CSO], 2018). The rate of male deaths by suicide was 3.9 times higher than that for females (CSO, 2018). Despite an overall drop in suicide figures in Ireland, men under the age of 35 years remain disproportionately represented when considering national statistics. Figures from Ireland reflect European Union (EU) trends with most recent Eurostat figures indicating there has been a slight decrease in the number of deaths by suicide across EU states, but with males remaining overrepresented accounting for 77% of deaths by suicide in Member States (Eurostat, 2018).

According to a National Suicide Research Office report (Begley, Chambers, Corcoran, & Gallagher, 2010), young men are the least likely to access mental health services. Men are also consistently identified as having poor mental health literacy (Cotton, Wright, Harris, Jorm, & McGorry, 2006; Rickwood, Dean, & Wilson, 2007; Rickwood, Deane, Wilson, & Ciarrochi, 2005) and lacking knowledge of services (Begley et al., 2010; Burke & McKeon, 2007). Young men are less likely to disclose having or seeking help for a mental health difficulty (Cleary, 2012; Clement et al., 2015; Dooley & Fitzgerald, 2012) and are less likely to access mental health services, even if suicidal (Begley et al., 2010), often demonstrating a preference for dealing with their problems alone and generally having poor strategies in doing so (Department of Health, 2015; Dooley & Fitzgerald, 2012). Engaging young men in mental health services is imperative to improve their well-being and mental health literacy. In order to do, we must develop ways to tackle the barriers associated with seeking help for mental health difficulties and increase help-seeking behaviors.

The specific barriers to help seeking in young, at-risk males include stigma and gender norms/socialization (Burke & McKeon, 2007; Cleary, 2012; Clement et al., 2015; Möller-Leimkühler, 2002). Robertson (2006) asserts that conflict occurs between masculinity and the want to appear as if you are indifferent to health concerns and the want to be considered a “good” citizen who takes responsibility for his or her own health and minimizes risk to it. This creates a “don’t care/should care” dichotomy (Robertson, 2006). For example, research indicates that young men perceive professional help seeking as compromising their masculine identity (Burke & McKeon, 2007; Lynch, Long, & Moorehead, 2018) and fear that disclosure of mental health difficulties will cause them to be perceived as weak or vulnerable (Grace, Richardson, & Carroll, 2018). This challenges simplistic explanations asserting that men are merely innate risk takers (Robertson, 2006). In contrast, a 2018 review of Irish women’s mental health reported that Irish women are willing to seek help, predominantly from their general practitioners (GPs), who will prescribe medication at this point, and are often unlikely to be engaged with psychiatric services (National Women’s Council of Ireland, 2018).

There is emerging evidence that males who do seek help may be met with services that they feel are not “gender aware.” A recent study of Irish service providers’ perceptions of young Irish men’s disconnection from mental health services indicated that services are not mindful of how strongly reluctant young men in Ireland are to disclose mental health difficulties (Grace et al., 2018). The National Men’s Health Policy (Richardson & Carroll, 2008) acknowledges the necessity of taking a gendered approach to the implementation and evaluation of health promotion policy in Ireland, taking into account three core areas—settings (where the intervention is situated), populations (e.g., age groups of men), and topics (e.g., physical or mental health; Richardson & Carroll, 2008).

Furthermore, poverty and socioeconomic disadvantage are risk factors for poor mental health and suicide (Cleary, 2012; Department of Health, 2006) and are also cited in the literature as barriers to help seeking in at-risk males (Fergusson, Woodword, & Horwood, 2000). Young men from disadvantaged backgrounds are often disconnected from their families and communities, compounded by issues of unemployment, lack of routine, and the absence of meaningful relationships (Grace et al., 2018). The absence or loss of a father figure or of a positive male role model was also highlighted as particularly detrimental to well-being (Grace et al., 2018).

There is consensus that psychological interventions such as psychotherapy play a role in the treatment of a wide variety of psychological disorders including depression. A number of meta-analyses indicate the efficacy of a wide variety of psychotherapeutic interventions for depression in both primary (Linde et al., 2015) and specialized mental health services (Cuijpers et al., 2011). Both short-term and long-term psychotherapy are reported effective in reducing psychiatric symptoms (Laaksonen, Knekt, & Lindfors, 2013). Studies have reported that short-term psychotherapy can produce more immediate benefits (Knekt et al., 2008; Lindfors et al., 2015); however, long-term psychotherapy has been reported to be more beneficial with long-term follow-up (Knekt, Lindfors, Sares-Jäske, Virtala & Härkänen, 2013; Lindfors et al., 2015). These effects have been identified for both male and female participants. As we know, however, men are less likely to seek psychological treatment for all disorders, barring those specifically linked to being male (Mackenzie, Reynolds, Cairney, Streiner, & Sareen, 2012; Wang et al., 2005). Given the observed efficacy of psychotherapeutic interventions in treating depression and other psychological disorders, it is imperative to increase help-seeking behaviors and participation of young men in psychotherapy.

Given the specific obstacles observed in supporting young men to engage with mental health services in Ireland, there have been policy calls to develop gender-specific treatment options (Richardson & Carroll, 2008). Studies have suggested that traditional psychotherapeutic interventions can be tailored to be more male-friendly to increase male help seeking and participation in therapy (Liddon, Kingerlee, & Barry, 2018; Spendelow, 2015). Suggested modifications include incorporating physical activity and making the therapeutic environment male-friendly (Richardson & Carroll, 2008; Spendelow, 2015). Research has indicated that men engage well with group therapy and other settings (e.g., sporting contexts) that encourage interaction with other men. Group settings also provide the opportunity to develop social networks and supports, with greater social support previously identified as predictive of better outcomes for participants in a variety of therapeutic settings (Hoberman, Lewinsohn, & Tilson, 1988; Lindfors, Ojanen, Jääskeläinen, Knekt, 2014; Ogrodniczuk, Piper, Joyce, McCallum, & Rosie, 2002).

Robertson (2006) asserts that “lay persons” understand health as something that is incorporated into daily life. These perceptions have led to a cultural shift toward a more integrated and holistic approach to the promotion of health and well-being (Robertson, 2006). With research also indicating that young men have a preference for more informal community-based interventions and services (Cutcliffe, McKenna, Keeney, Stevenson, & Jordan, 2013; Stevenson, Cutcliffe, Keeney, & McKenna, 2013), it has been suggested that programs that “piggyback” mental health interventions onto preexisting programs or activities, which are community based and more acceptable to young men are more likely to succeed (Grace et al., 2018). Sport is emerging as a medium through which young, at-risk males’ mental health can be positively affected (Begley et al., 2010; Grace, et al., 2018; Swan et al., 2017). Mental health promotion programs based in sporting contexts have been seen to normalize the process of help seeking for young males (McArdle, McGale, & Gaffney, 2012; Pringle, 2009). Sporting contexts also provide participants the opportunity to meet with other men and form new social networks (Mason & Holt, 2012).

Sport in itself has been consistently identified as having a positive impact on mental health and is associated with lower instances of depression and anxiety (Brunet et al., 2013; Kvam, Kleppe, Nordhus, & Hovland, 2016; Weinstein, Koehmstedt, & Kop, 2017). A review of qualitative literature on sports interventions for improved mental health highlighted the importance of a number of themes including social interaction and support; safety; improved symptoms; providing a sense of meaning, purpose, and achievement; and the role of the facilitating personnel (Mason & Holt, 2012). The review concluded that service users identified sporting interventions as socially inclusive, non-stigmatizing, and an effective aid to recovery (Mason & Holt, 2012).

Despite a plentiful research indicating the positive impact of sport on mental health, few studies have combined sporting programs with overt mental health interventions. The studies that have, have presented largely positive results, however. A number of studies have combined football with mental health interventions (McArdle et al., 2012; McGale, McArdle, & Gaffney, 2011; Pringle, 2009; Pringle & Sayer, 2007). These studies combined sporting activities with planned activities aimed at improving mental health and well-being, including teaching participants cognitive behavioral techniques (McGale et al., 2011). Results revealed that male participants viewed sport as a positive medium for promoting mental health, hence supporting the development of gender-specific mental health interventions as a means to both engage and access young men (McArdle et al., 2012). Results from a recent qualitative study completed as part of the English Premier League health promotion work also indicated that an intervention, which combined regular physical activity with health promotion strategies contributed to positive psychosocial developments, the development of structure, social interaction, and social capital in hard-to-reach male participants (Curran, Drust, Murphy, Pringle, & Richardson, 2016).

One form of physical activity whose benefits to mental health have been well researched is martial arts. Martial arts are credited with providing participants with enhanced self-esteem, self-control, mental and physical relaxation, and decrease in anxiety and depression (Cai, 2001; Fuller, 1998; Weiser Kutz, Kutz, & Weiser, 1995). Martial arts are also linked with greater emotional stability and assertiveness (Fuller, 1988; Konzak & Boudreau, 1984) and reductions in aggression and violent behaviors (Nosanchuk & MacNeil, 1989; Zivin et al., 2001). A small number of studies have integrated martial arts with interventions designed to positively impact on mental health. Cai (2001) reported that participants in programs that integrated guided imagery with martial arts and self-defense demonstrated significantly lower depression and anxiety than control groups. A more recent study by Milligan et al. (2017) stated that a program, which combined mindfulness with martial arts training, increased academic outcomes, social competence, emotional regulation, and self-confidence in adolescents. These benefits were observed for both low- and high-risk participants (Milligan et al., 2017).

The Current Research

Research to date has identified that young males are at a higher risk of suicide, and mental health difficulties are a growing concern for this group. Men are also less likely to seek help when facing psychological distress, with the accessibility of services and/or gender-based norms being identified as some of the challenges to help-seeking behavior. Research indicates the efficacy of therapeutic interventions, and there is a growing awareness that physical activity and/or sport can play an important part in psychological well-being. However, to date very few services have combined therapy and sport to support at-risk males, with most programs developing separately or as individual interventions. Furthermore, there has been little or no examination of the combined effect of psychotherapy and sport on young, at-risk males’ mental health outcomes. The current research aims to provide insight into the complementary effect that therapy and sports participation have on young, at-risk males’ mental health outcomes, through examining the impact of the Breakthrough Programme, a 10-week, community-based program, which combines MMA and one-to-one psychotherapy. The program consists of weekly one-to-one counseling sessions as well as group martial arts training sessions. Peer support sessions are also facilitated by Breakthrough Programme mentors, in the form of previous participants of the program. The design of the Breakthrough Programme acknowledges the recommendations of the Men’s Health Policy (Richardson & Carroll, 2008) targeting the three core areas for health promotion in men: the setting—providing the intervention through a sporting context aims to make the program more accessible to participants; the population—the program targets young men (<35 years) as they have been identified as a key target group; and the topic—targeting mental health and well-being of this group as they are one of the most at-risk groups within the Irish society for suicidal behaviors. The policy also acknowledges the lack of safe social spaces for men and how this can contribute to harmful health and risk behaviors of young men in particular (Richardson & Carroll, 2008). The program offers them a safe social space to meet and interact with other young men in a structured way.

The research addresses the following questions.

  1. What factors impact help-seeking behaviors in young, at-risk males experiencing mental health difficulties?

  2. What impact does a 10-week program, which combines one-to-one psychotherapy with MMA, have on young males’ mental health and personal outcomes?

Methods

Research Design

A qualitative repeated measures research design was employed. The study consisted of semistructured interviews with participants. Thematic analysis techniques were used to analyze results.

Data Collection Method

Data were collected in the current research through interviews with participants at two points, prior to participating in the program and after completion. A semistructured interview schedule was used to guide interviews. Interviews with participants were taped with their permission and transcribed verbatim. Thematic analysis was used to analyze data.

Data Analysis Method

Thematic analysis was employed to analyze data. Themes and patterns within the data were identified and coded, guided by the research questions. Initial codes were refined into themes. The resulting themes were discussed in relation to the research questions.

Participants

Participants in the present study initially consisted of seven males. Five of them completed the 10-week program (n = 5). Participants were aged between 20 and 35 years (M = 24.57 years) and were recruited by referral from primary care, community-based, and specialized mental health services.

Procedure

Participants were referred to the program from primary care, community-based, and specialized mental health services. Once initial screening for the program was undertaken, they were invited to participate in the research. Participants provided written and verbal consent. Prior to initiating the program, participants were interviewed, using a semistructured interview schedule to explore their experiences, perspectives on taking part in the program, and the challenges they faced in the current program. Those participants who completed the 10-week program took part in another set of semistructured interviews to explore their experiences of having completed the program.

Results

Thematic analysis of the interviews conducted prior to participation revealed several broad themes relating to the challenges facing at-risk males when seeking help; participants identified lack of social support, absence of role models, and gender norms as specific challenges. Help-seeking behavior was facilitated through sport being perceived as an acceptable activity for males to participate in and a desire to improve their lives. The following section describes the themes:

Barriers to Help Seeking

Social challenges

All participants described numerous social and personal challenges, which hindered their ability to seek help. Many reported having particularly difficult home lives including eviction and parents and/or siblings with mental health issues. There was a sense that the young males felt a responsibility not to add to the family issues; this is exemplified in the following quote:

It’s like, you don’t really want to bring it up with people, like with your friends or your family really, ’cause like you don’t want to bring people down … That’s why, that’s my experience with it, like … But I wouldn’t bring it up like … I wouldn’t bring it up. I just kinda keep myself to myself.

Participants described the intersectional nature of these challenges; they talked about their family issues as well as community issues and there was evidence that taken together, these factors reduced the likelihood that they would ask for help. The young males talked about what they observed as the norms in their communities; one participant stated: “There are drug dealers and trouble makers all over the place and it’s kinda hard to avoid them sometimes”; they indicated that this made it more likely that they would turn to substances for their mental health rather than to therapeutic help. This participant states, “[It is] easy to ah get roped into like dealing with it [mental health] through drugs.”

Lack of male role models

A further barrier to help seeking, which emerged from the interviews was the lack of male role models who were seeking help or had positive strategies for managing their mental health. In many cases the young males reported having limited access to positive males and could not readily identify positive male role models: “I never really had a role model to look up to … I generally always had to learn stuff myself.” Male role models were not always reliably present in the lives of participants and when they did describe the role models in their lives, they were often negative ones from within their families. One participant described how his father had mental health difficulties and refused to seek help; for him this spurred him into action because he did not want to be like his father:

I think, because I didn’t want to be … like my Da is … So, I just like I went to the community officer and asked for it [help]. So I obviously wanted to seek out help or whatever.

Most participants described a lack of positive role models within their communities with drug use, crime, and alcohol abuse being described as the common behavior observed: “There’s usually like the young fellas usually … drinking or smoking weed or just kinda up to no good or whatever.” In most cases sport was the only place where the young males experienced positive role models. One participant talked about looking up to the men on his football team: “I used to play football, like, so of course I probably would have looked up to the older boys that were playing on the senior teams and that,” while another talked about seeing a sportsman from their community “make it” and being inspired by them: “When your man (SPORTS STAR) first came out … he spoke about, like he was just a lad coming from my area … You know and that he’s made it big time.” The readiness of participants to identify athletes as positive role models is significant in light of the sports aspect of the program, the positive connection with the sporting heroes facilitating their ability to participate in the program. Conversely, the absence of positive male role models was identified as a barrier to help seeking by participants, as they noted having no example to follow other than coping with their mental health difficulties with maladaptive behaviors such as alcohol or substance abuse.

Gender norms and socialization

All participants spoke about perceived gender expectations and how this impacted on young men’s ability to talk about mental health: “Yeah we’re [young men] meant to be this unbelievable like force of don’t show … But we all have a breaking point I believe.” Statements like this affirmed a belief that societal barriers exist, which discourage young men from speaking about their mental health. This, is turn, was seen as making it difficult to disclose a mental health difficulty and seek help. Participants spoke about the very real phenomenon of young men trying to manage their mental health alone and in silence: “’Cause they don’t really talk about it [mental health], like … Don’t, like, listen to you … They just, they just try to have a ah diagnosis … But they don’t want to know about how you’re doing or anything like that.” Contrary to research indicating that young men don’t want to talk about their mental health, participants believed that no one wanted to listen. Another described what it’s like being a young man and not wanting to talk about mental health difficulties: “I wouldn’t mind speaking about it if someone like was asking me about it. But I wouldn’t bring it up like … I just kinda keep myself to myself.” Statements like this again affirmed a belief that young men were not encouraged to speak about their mental health by society, making it difficult to disclose or seek help for mental health difficulties.

Facilitators of Help Seeking

Improving physical and mental health in combination

Most participants noted the opportunity to train in a state-of-the-art facility and take part in the MMA element of the program as a reason for doing the program, because they felt that “martial arts … it’s good for physical health and discipline.” Some participants who were otherwise more indifferent in their responses were notably enthusiastic about this aspect of the program: “I can’t wait for it [the martial arts training], yeah.” Although not all participants were initially looking forward to taking part in the counseling aspect of the program, they all indicated they were taking part in order to address their mental health challenges: “Just something I really wanted to do … to talk a counsellor about ongoing anxiety … And a bit of depression … Um, and a small bit of addiction.” In this way, the sporting element of the program enticed participants to take part, in turn opening the door to engaging with the counseling element of the program. Many said the program provided an opportunity to talk with someone about their mental health, noting that it was often difficult to speak about their struggles with friends and family due to other challenges and how, prior to the program, they “haven’t really had an outlet to kinda someone to speak to.” Participants identified the dual counseling–sports aspect of the program as what made it stand out. Participants noted that the fact that the program differed from traditional counseling interventions was appealing: “I feel like if I’m like doing something, I’m gonna feel much more a part of it myself, rather than sitting on a couch just talking to someone.” This suggests that the dual nature of the Breakthrough Programme, offering both the therapy and sporting elements, is an important factor in the young men deciding to do it. The participants felt that the opportunity to take part in physical activity was not only beneficial on its own but also complementary to improving mental health. In this regard, the sporting element of the program broke down barriers and helped to mediate traditional gender norms for participants. One participant illustrated this when he said: “’Cause it’s (MMA) a real blokey think to do, you know.” It was evident that providing an activity that the men perceived as acceptably “masculine” provided a doorway to seeking help and taking part in the counseling element of the program.

Qualitative analysis of initial interviews with participants revealed a number of important factors, which impacted their help-seeking behaviors. Themes that emerged as facilitators of help seeking in the current study included combining physical and mental health, improving routines, self-discovery, and hope for the future. Thematic analysis also revealed a number of perceived barriers including gender norms and socialization, the absence of positive male role models, as well as the difficulty of navigating a challenging social landscape. The present study therefore contributes to the literature on help-seeking behavior in males, offering new insights, which are particularly relevant in relation to young men from low socioeconomic backgrounds or originating from communities with particularly challenging social landscapes.

The Impact of the Breakthrough Programme

Thematic analysis of the interviews conducted after the participation revealed several broad themes relating to the overall impact of the Breakthrough Programme. The following section describes these themes:

Improvements in mental health and well-being

All participants reported the program had a positive impact on their mental health. They reported an improvement in their overall sense of well-being and coping skills, and increased confidence. One participant noted: “I’m better than when I first came in … now I think because I done it I’m better now, I’ve more control … and certain things that have come up I’ve learned how to deal with them.” Taking part in the program provided the participants with the skills they needed to regain a sense of agency and to effectively cope with the difficulties they were experiencing. The same participant also noted that his depressive symptoms had improved and he was regaining interest in other activities as a result of the program: “I don’t feel depressed to a certain extent … I feel like I want to get up and get out and do normal things I don’t want to just sit in.” Participants noted in general that taking part in the program increased their levels of confidence and improved their overall outlook on life: “I feel more confident and I feel more positive and I think I just think my outlook on life has changed and it’s helped me a lot.” The same participant also noted that this newfound confidence was helping him to take on new challenges: “Every chance I see to challenge myself I’m going for it because I think it has helped me improve.” One participant highlighted the particular importance of combining mental and physical health into one intervention and the positive impact of this on well-being:

I feel over the ten weeks as each week goes by I can feel myself improving in every way, mental health physical health everything. I feel since I’ve started it has just been a good impact on my life over all.

Statements like these indicate that the benefits of the program were far reaching, with participants noting not only improvements in specific symptoms but also in their overall well-being.

Positive effects of taking part in sport

When asked about the sporting element of the program, participants highlighted a number of benefits. One participant noted that the physical activity was not only enjoyable but also provided a distraction from worries:

I enjoyed the physical activity in the MMA … it was something to look forward to and when I was there I felt I wasn’t worrying about anything else I was just focusing on the training and that is very unusual for me, as my head is usually going 90.

Another noted the important role of sport as providing an outlet in difficult times: “Yeah, if I am feeling frustrated or anything like that it’s good for blowing off energy.” The weekly training sessions gave participants an opportunity to engage in physical activity, which has is known to reduce stress and improve well-being. Other participants noted: “[The gym] teaches you how to channel your aggression into something that you would really enjoy.” Another noted: “I have learned how to control my anger.” The sporting element of the program provided a healthy and acceptable way to channel their aggression in a controlled environment: “The routine was great for people like me you know young adults … who may have problems with their aggression and have anger issues.” Prior to taking part, many participants noted having either no or very unhealthy routines. The weekly sporting sessions in combination with the weekly counseling sessions were seen as supplementing this and providing an outlet and structure to the participants’ lives.

Impact on other aspects of life

Participants also noted some ripple effects of the program including positive outcomes in relation to employment and education. One participant had just began his first ever job: “Yeah, I don’t think I would have got the job if I … never came to the Breakthrough Programme I don’t think I would have ever applied or even bothered.” He stated that the program had given him the vital confidence he needed not only to pursue employment but also to put himself into situations he would have previously avoided:

Since I’ve started it, I’ve constantly been putting myself in situations where I would have felt uncomfortable and I’m kind of learning much more about myself … I feel I am improving more as a person in that way, that’s how the programme has helped me.

The positive impacts of the program on participants’ mental and physical health caused a “ripple effect” that permeated into all aspects of their lives. They noted being happier and healthier and having better levels of functioning across all areas including their personal relationships, academic studies, and work lives.

Role of counseling relationship in facilitating change

All participants spoke positively about the counseling element of the program. Participants noted that counseling was instrumental in helping them to learn “how to deal with things” and developing positive coping skills. They also identified the importance of simply having someone to talk to who would listen and provide feedback to them: “Well it always helps to have someone to talk to about anything that’s bothering you,” and “I feel like it is having someone to listen to you, just listening to what you have to say and giving feedback.” Participants described the benefits of having a newfound outlet, a place where they could bring to the table issues they might not otherwise discuss: “So it was nice to have an outlet and someone to speak to about stuff, so I do think that has helped me a lot.” They highlighted the importance of being able to unburden themselves by leaving what was discussed in counseling sessions: “Yeah because when I was speaking with [name of counsellor] I’d be telling him things and I know I could just leave it there and walk away,” and also feeling secure in the confidentiality of the client–therapist relationship: “It’s not going to go anywhere … what you and your counsellor talk about is just between you two.” Participants indicated they felt more at ease discussing personal difficulties with a counselor than with family or close friends, as they felt they didn’t want to burden them further: “I think the counselling really worked for me as I didn’t really have an outlet at home because I didn’t want to put the weight on anything I had on my shoulders on someone else.” Counseling sessions were seen as collaborative and directed by participants, with one noting that it was easier to talk to a counselor than family or friends, as the counseling relationship allowed him explore issues at his own pace: “Telling a family member it would be picked up upon they would want to go into more detail and I would think no I am not ready to share that type of thing.” Several participants expressed hope to continue counseling in order to continue with the personal growth they had achieved so far: “The ten weeks is great but I think you’re only getting the ball rolling.” They acknowledged the achievements they had made in the short term, but also recognized it was a long-term process for them. The program provides an important “taster” or introduction to counseling, which in many cases resulted in a longer term commitment to counseling. The counseling sessions provided a safe and secure environment where the young men could unburden themselves of worries and stresses they had been dealing with alone, at a pace and time that was comfortable to them. This was particularly impactful in supporting change and personal growth.

Impact of positive male role models

Some participants noted that due to the close and trusting counseling relationships they developed, their counselors became positive male role models for them. They felt they could relate to their counselor and that he was someone they had things in common with:

Yeah he has been through some of the same stuff I have been through so he gives you advice, so he is a role model to you and he says I have gone through this kind of stuff and I can get through it you can get through it.

The ability of the counselors to identify with the participant’s lived experiences, through sharing of their own, was particularly important in building trust in the counseling relationship and encouraging disclosure. Participants also noted that the sports coaches and mentors on the program were positive male role models to them. One participant noted that he had a lot in common with a particular mentor and that it helped him to see how the program could benefit him:

I was chatting to one of the lads and … he is training up in [the gym] full time now and he was saying how it really helped him and that he has a kid now and he is only a year older than me. It was cool to talk to them and see how it has helped them.

Being able to see another young man from a similar background having benefited from the program encouraged him to value and engage with the program. Another stated the staff, coaches, and mentors at the gym created a welcoming environment, and he hoped to progress the relationships he had made there: “I made good friendships with the people at [the gym], they were actually brilliant I do be talking to people and I do be making jokes, I hope I can make good friends.” In this way, the program, through the martial arts training, provides the participants with new social networks and social capital, which have been reported to increase attendance at psychotherapy and improved outcomes for participants (Hoberman et al., 1988).

Counseling was seen as being pivotal for personal growth, and positive male role models were noted as particularly impactful. Participants noted relationships of an exceptional quality with the counselors on the program and viewed them as important positive male role models. The same can be said for the sports coaches and mentors of the program. Participants also highlighted the importance of their counselor being from a similar background and having similar experiences as particularly important in building a meaningful counseling relationship. Participants’ statements indicate that having an opportunity to share in male camaraderie and build positive relationships with other men was extremely important for personal growth. Again, this is an important insight for consideration when designing interventions for young men.

Discussion

Engaging at-risk young men in mental health services remains a growing concern in Irish society. There is a need to understand why young men seek help and how mental health services can engage with young men in a meaningful way. The current study sought to understand at-risk males’ help-seeking behaviors and the role that sport, combined with psychotherapy, plays in supporting young men’s mental health outcomes. The results reflect previous research when considering help-seeking behavior, with the findings indicating that stigma and gender norms acted as barriers to young men seeking help for mental distress (Burke & McKeon, 2007; Cleary, 2012; Clement et al., 2015 Möller-Leimkühler, 2002). For example, the young males perceived help seeking as compromising to their masculine identity, in a similar way as observed by Lynch et al. (2018). This supports the idea of the “don’t care/should care” dichotomy as described by Robertson (2006). The young men were aware of the fact that they needed to engage with the mental health services but had concerns about the potential stigmatization attached to doing so as a young man. Findings also indicate the intersectional nature of young men’s decisions to seek help with socioeconomic disadvantage resulting in feelings of being disconnected from their families and communities, this being compounded by issues of unemployment, lack of routine, the absence of meaningful relationships, and the loss or absence of positive male role models (Grace et al., 2018). This highlights the complex nature of help-seeking behaviors in young men and again challenges simplistic explanations that assert that men are simply innate risk takers (Robertson, 2006). The current program provides a “gendered approach” to promoting positive mental health in young men, in line with national policies (Richardson & Carroll, 2008). Results support previous research and policy that indicate that the setting of men’s health interventions is important. The program provides a “masculine” but safe social space, which facilitates participants to make the initial contact with services (i.e., one-to-one counseling) and also to expand social networks and develop social capital.

In relation to the sporting element of the program, to date, research on such interventions have used sport as a context to improve mental health, with the participation in sport being linked to lowering instances of depression and anxiety (Brunet et al., 2013; Kvam, et al., 2016; Weinstein et al., 2017) and reductions in aggression and violent behaviors (Nosanchuk & MacNeil, 1989; Zivin et al., 2001). While some studies have employed techniques, which promote positive mental health through the medium of sporting contexts such as cognitive behavioral techniques (McGale et al., 2011) and mindfulness and guided imagery (Cai, 2001; Milligan et al., 2017), these programs do not combine sport with one-to-one psychotherapy. This makes the approach of the current research novel. The findings from the current study show that sport, combined with psychotherapy, has a positive effect on how young, at-risk males feel about themselves, providing a space for self-esteem and belonging to grow. The sport also provided a gateway for young males to feel “safe” when accessing help, mitigating the impact that gender norms have on help-seeking behavior. The sport and the therapy also provided the young men with access to positive male role models. Results indicate that combining sport with psychotherapy positively impacts upon at-risk males’ ability to talk about mental health and engage with services in a meaningful way. This achieves one of the goals of Ireland’s National Men’s Health Policy of supporting men to become more active advocates of their own health (Richardson & Carroll, 2008). Through sport, the program provides a “masculine” gateway to mental health services, while offering unique supports through access to psychotherapy, male role models, and self-esteem.

Limitations

While the current research, adopting a qualitative approach, provided rich and detailed information both on the impact of the Breakthrough Programme on young men’s mental health and on help-seeking behaviors in young men, the findings are limited in their generalizability. First, the sample size was relatively small. While qualitative, semistructured research of this type produces rich data, it offers reduced methodological control. Therefore, it is difficult to ascertain whether the findings apply generally or only to this small sample of interviewees. Second, while the fact that participants in the present study were all males from low socioeconomic backgrounds was important in offering insights into help-seeking behaviors in this group, it also limits the ability to generalize these findings to the wider population of all young men in Ireland. Further research is needed, which employs larger numbers and a more varied sample in terms of demographics to further explore the findings of the current research and evaluate the Breakthrough Programme’s potential impact for the wider population.

Future Research

It is envisaged that the program could be adapted to support those with more complex needs, but this would require further resources and input from the fields of psychiatry, clinical psychology, and occupational therapy. Currently the scope of the program is narrow, targeting young males (aged 18–35 years), as they are seen as an “at-risk” group. The program could however potentially work well with females and other age groups of men also, but further evaluation and research of the efficacy of such a program with these groups would be necessary. The Breakthrough Programme needs a larger platform and possibly expansion to other sports, which would widen the appeal to a larger population. Using the Breakthrough model of combining weekly sporting sessions in combination with one-to-one psychotherapy, it is envisaged that the program could be developed within other popular Irish sporting contexts such as football, Gaelic games, and rugby through partnership with national governing bodies. This will aid the expansion of the program to different communities and participants.

Footnotes

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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