Does shame mediate the relationship between Gender Role Conflict and

psychological distress?

Haymond Lee

Submitted for the Degree of

Doctor of Psychology(Clinical Psychology)

School of PsychologyFaculty of Health and Medical Sciences

University of Surrey

Guildford, Surrey

United Kingdom

September 2019

Abstract

Gender Role Conflict (GRC) correlated with different measures of

psychological distress. However, there has been little research investigating the

mechanism underpinning these relationships. Shame may be an important mechanism

due to conceptual relevance to GRC, and previous research had shown that shame

correlated with GRC and different measures of psychological distress. This study

aimed to investigate whether shame mediates the relationship between GRC and

psychological distress. A quantitative cross-sectional design was used to gather

questionnaires relating to the study variables from 204 male participants with a mean

age of 29.22 (SD=7.68). Using the causal step approach (Baron & Kenny, 1986) and

bootstrapping, the analysis found that shame mediates the relationship between GRC

and psychological distress. This finding has treatment implications for treating men’s

psychological distress, including targeting shame and deconstructing dominant

masculine norms. However, further research would help to establish support for the

causal inferences of the study’s findings.

Acknowledgements

It has been a real privilege to be accepted on to this course. I am very thankful

for all of the support I have received to help me complete this doctorate.

I want to thank all the staff at the University of Surrey Clinical Psychology

Training Programme. I am grateful for all their input to shaping a course that I am

proud to be a part of.

I want to thank my research supervisor’s Dr Kate Gleeson, Ms Linda

Morrison, and Dr Jason Spendelow for all of their input into my thesis. I am grateful

for their support, expertise, and kindness that they have shown me.

I want to thank the clinical tutors I had over the years, Dr Eli Joubert, Dr Lucy

Hale and Dr Michelle Gregory. I am grateful that they had challenged me and that

they had confidence in my abilities.

I thank to thank all my placement supervisors, Dr Khibza Jawaid, Dr Martin

Stent, Dr Sally Stapleton, Dr Tina Lee, Dr Amy Wood-Mitchell, Dr Georgina Heath,

and Dr Simon Wels. I have learnt a lot from each of you and will continue to take the

lessons I had learnt into my clinical practice.

I also want to thank my loved ones, who has enabled and supported me to

complete this doctorate. I like to thank my family for their loving support, especially

my parents who had sacrificed so much for my future. I like to thank my friends for

their support, friendships, and laughs, along the way. Lastly, I want to thank my

amazing partner, Adebola Fasusi. Thank you for everything you have done for me.

Your loving nature never ceases to surprise me.

Contents

Part one: Does shame mediate the relationship between Gender Role Conflict and

psychological distress?.............................................................................................................1

List of appendices to the empirical paper...........................................................................54

Part two: A literature review of the mediating and moderating role of shame for the

relationship between objectification variables and mental health difficulties in men...........84

Part three: Clinical Experiences............................................................................................122

Part four: Assessments.........................................................................................................124

Part one: Does shame mediate the relationship between Gender Role Conflict

and psychological distress?

Word Count - 9942

1

Statement of journal choice

The Psychology of Men & Masculinity is selected for journal submission.

This journal is selected because it states that Gender Role Conflict, Clinical

Psychology, and the Psychology of men and masculinity are the scope of this journal.

All of which are what this empirical paper relates to. The guidelines for journal

submission can be seen in Appendix A.

2

Abstract

Gender Role Conflict (GRC) correlated with different measures of

psychological distress. However, there has been little research investigating the

mechanism underpinning these relationships. Shame may be an important mechanism

due to conceptual relevance to GRC, and previous research had shown that shame

correlated with GRC and different measures of psychological distress. This study

aimed to investigate whether shame mediates the relationship between GRC and

psychological distress. A quantitative cross-sectional design was used to gather

questionnaires relating to the study variables from 204 male participants with a mean

age of 29.22 (SD=7.68). Using the causal step approach (Baron & Kenny, 1986) and

bootstrapping, the analysis found that shame mediates the relationship between GRC

and psychological distress. This finding has treatment implications for treating men’s

psychological distress, including targeting shame and deconstructing dominant

masculine norms. However, further research would help to establish support for the

causal inferences of the study’s findings.

3

There are differences between men and women in problems relating to

psychological distress. Research had shown that three quarters of suicides are

completed by men, men have higher rates of substance addiction compared to women,

and men have higher rates of violence compared to women (Men’s Mental Health

Forum, 2017; ONS, 2016). Concern is further raised by research showing that men are

less likely to present to psychiatric or psychological services than women (Addis &

Mahalik, 2003).

Masculinity

Theories of masculinity can help to explain the part that gender plays in men’s

psychological distress. Masculinity can be understood as a culturally defined set of

attributes or roles attached to the male biological sex (Kimmel, 2012). Most research

into masculinity had used a social learning perspective (Addis & Cohane, 2005). A

social learning perspective understands masculinity as a socialization process to

reinforce dominant ideas about male gender norms (Eckes & Trautner, 2000). This

process includes mechanisms such as observational learning, modelling,

reinforcement, and punishment (Eckes & Trautner, 2000). To further understand how

masculinity can contribute to men’s psychological distress, some of the most

prominent theories of masculinity and their respective evidence bases will be

discussed. These include Masculine Ideology (Thompson & Pleck, 1995), Hegemonic

Masculinity (Connell & Messerschmidt, 2005), the Gender Role Strain Paradigm

(GRSP; Pleck, 1995), and Gender Role Conflict (GRC; O’Neil, 2008). These theories

have their basis within a social learning perspective.

Masculine Ideology is a term proposed by Thompson & Peck (1995), which

relates to accepted social norms about masculinity. This approach asserts that

different societies will have different constructions of masculinity (Thompson &

4

Pleck, 1995). Indeed, research had supported this notion, with men from different

social groups valuing particular male gender roles differently (Levant & Richmond,

2007). However, despite these variations, there is support for a dominant Masculine

Ideology that had been promoted across different cultures (Gilmore, 1990). In an

ethnographic study, they found that males had been socialized into the roles of

procreation, provision, and protection across many different cultures (Gilmore, 1990).

The idea that there is a dominant Masculine Ideology had been further developed by

David & Brannon (1976). They proposed the term Traditional Masculinity Ideology,

to describe male gender roles within western society (David & Brannon, 1976). The

values of this Traditional Masculinity Ideology include not being feminine, striving

for success, not showing weaknesses and taking risks (David & Brannon, 1976).

Masculine and Traditional Masculinity Ideologies are helpful in understanding what

masculine norms are for a given culture. Although both approaches are based on a

social constructionist framework, they nevertheless identify many features of

masculinity that are consistent across a range of cultures (David & Brannon, 1976;

Gilmore, 1990). Identification of strongly shared ideas about masculinity may

contribute to a better understanding of men’s psychological distress. Indeed, research

had shown that conformity to masculine norms is correlated with a range of mental

health conditions (Wong, Ho, Wang, & Miller, 2017). Furthermore, men can find it

difficult to seek help during times of distress due to concerns about appearing weak

(Oliffe & Phillips, 2008). It is possible that values such as not showing weakness,

may mean that men are not seeking emotional support, and this may lead to the

development of mental health conditions.

Hegemonic Masculinity complements the construct of Masculine Ideology, by

providing a historical account of how men accessed power to dominate women

5

(Connell & Messerschmidt, 2005). Hegemonic Masculinity is defined as patterns of

practices that promote dominance over women and other marginalized notions of

masculinity (Connell & Messerschmidt, 2005). Part of these practices, involves

promoting a dominant masculine norm (Connell & Messerschmidt, 2005), which is

reinforced in practices such as gender related differences in pay and the expression of

homophobia in men (Bishu & Alkadry, 2017; O’Neil, 2008). However, strongly held

social norms for masculinity would not necessarily mean that most men conform to

the norm, but they would be aware of it as an ideal form of masculinity that most

aspire to (Connell & Messerschmidt, 2005). The implications of Hegemonic

Masculinity for men’s psychological distress, is that a large proportion of men may

not meet the ideals promoted by Hegemonic Masculinity and thus experience

psychological distress. In addition, it is possible that the use of male power can lead to

negative reactions from others and contribute to additional psychological distress.

Pleck’s theory of GRSP (1995) proposed that male gender roles are

problematic for many reasons including the pressure to conform; the fact that they are

contradictory and inconsistent; that a relatively high number of men do not achieve

the prescribed roles; and that there are negative consequences arising from these male

gender roles (Pleck, 1995). Pleck (1995) conceptualised the difficulties of male

gender roles as Gender Role Strain, that is the pressure or tension that gender role

norms places on men. Pleck (1995) proposed three main types of Gender Role Strain:

Discrepancy Strain; Trauma Strain; and Dysfunction Strain. Each of these types of

strain can help to explain men’s psychological distress, as they can be conceptualized

as different pathways though which masculinity can contribute to the development of

psychological distress.

6

Discrepancy Strain relates to distress caused when men do not meet the

standards of dominant masculine norms (Pleck, 1995). These dominant masculine

norms tend to include values such as men not being feminine, striving to be

successful, not showing any weakness, and risk taking (David & Brannon, 1976).

Pleck (1995) proposed that large numbers of men do not meet these norms. Support

for Discrepancy Strain comes from the Gender Role Stress (GRS) literature. GRS is

defined as stress arising from not adhering to traditional normative gender roles

(Eisler & Skidmore, 1987). Research has found that GRS is correlated with

depression, anxiety, anger, adverse health habits, and cardiovascular reactivity to

situational stress (Eisler, 1995). However, there are some limitations within this area

of research. Causality cannot be inferred statistically from studies using correlations.

These results are generalisable for men who conform to traditional gender roles,

however they are not generalisable for men who do not. Nonetheless, given that

traditional gender roles are relatively common across cultures (David & Brannon,

1976; Gilmore, 1990), the GRS literature provides support for Discrepancy Strain and

how it contributes to the development of psychological distress (Eisler, 1995).

Trauma Strain relates to traumatic events that relate to male socialization

which may include physical aggression, social condemnation, and feeling unable to

express emotional vulnerability (Pleck, 1995). Support for Trauma strain comes from

research that shows that men who do not conform to masculine norms, experience

more Trauma Strain compared to men who do conform to masculine norms. Research

had shown that homosexual and bisexual men experienced more bullying and social

condemnation compared to heterosexual men (Corliss, Cochran, & Mays, 2002). This

may be due to non-conformity of male gender norms (Harry, 1989). Trauma strain

highlights another area where psychological distress difficulties may develop. Indeed,

7

research had shown that bullying is correlated with the development of mental health

conditions (Arseneault, Bowes, & Shakoor, 2010).

Dysfunction Strain relates to how conforming to masculine norms can lead to

negative psychological consequences (Pleck, 1995). Research supporting the notion

of Dysfunction Strain comes from literature around Traditional Masculine Ideology

and GRC. In a review of the Traditional Masculine Ideology Literature, Wong et al.,

(2017) found that Traditional Masculine Ideology is correlated with a range of

difficulties such as lower relationship satisfaction, reluctance to seek psychological

help, fear of intimacy, and difficulties with identifying and describing emotions

within oneself. The literature regarding Traditional Masculine Ideology provides

support for Dysfunction Strain, however causality cannot be inferred as the data is

correlational. The conceptualization of GRC and its evidence base will now be

discussed to consider its support for the notion of Dysfunction Strain.

GRC is defined as a “psychological state in which socialized gender roles have

negative consequences for the person or others” (O’Neil, 2008). This psychological

state includes cognitive, emotional, behavioural, and unconscious domains. The

cognitive domain relates to how men think about their gender roles. The emotional

domain relates to how men express emotions in relation to their gender roles. The

behavioural domain relates to how men act in relation to their gender roles. The

unconscious domain relates to unconscious dynamics that drives gender role

behaviours (O’Neil, 2008). O’Neil (2008) proposed that GRC occurs in patriarchal

and sexist societies, resulting in male gender norms that are rigid, sexist and

restrictive. The impact of this are personal restriction, devaluation, and violation of

others or oneself (O’Neil, 2008). Restriction is defined as controlling the behaviours

8

of others or limiting the behaviours of oneself due to the influence of gender roles.

Devaluation is defined as the lessening of personal status, stature, or positive regard

(O’Neil, 2008). Violation is defined as harming oneself or others (O’Neil, 2008).

O’Neil (2008) proposed four patterns of GRC based on a review of the research

literature: restrictive emotionality (RE); restrictive affectionate behaviour between

men (RABBM); success, power, and competition (SPC); and conflict between family

and work relations (CBWFR). RE is defined as restricting one’s ability to express

their feelings generally (O’Neil, 2008). RABBM is defined as restriction in

expressing thoughts and feelings with other men and touching other men (O’Neil,

2008). SPC is defined as holding attitudes that success is achieved via competition

and power (O’Neil, 2008). CBWF is defined as restriction in balancing work/school

and family relations, resulting in stress (O’Neil, 2008). These patterns can also be

conceptualised as Dysfunction Strain (O’Neil, 2015).

Shame

Shame can be defined as a painful emotion stemming from negative global

evaluations of the self and beliefs about others’ perception of the self (Tangney,

1995). The phenomenological experience of shame has been described by Lewis

(1992) to include: intense pain, discomfort and anger; a desire to hide; and feeling

inadequate about oneself as a whole as opposed to aspects of oneself. The experience

of shame can also be differentiated as a state or trait (Tangney, 1995). State shame

refers to the experience of shame in the moment (Tangney, 1995). Trait shame refers

to a disposition to experience shame, which is also known as shame proneness

(Tangney, 1995).

There are empirical evidence that demonstrates that shame is correlated with a

range of psychological distress including depression, anxiety, and suicide (Lester

9

David, 2010; Tangney, Wagner, & Gramzow, 1992). As understanding theories of

shame may help to explain how shame is correlated to psychological distress, three

major theories of shame will now be discussed. These are the Functionalist (Barrett &

Campos, 1987), Cognitive-Attributional (Nathanson, 1992), and Object

Relational/Attachment theories of shame (Weinger, 1986). Functional theories of

shame stem from Darwin’s theory of evolution and suggests that emotions are

adaptive for survival (Barret & Campos, 1987). Shame can be conceptualised as an

emotion that motivates an individual’s response to adhere to group norms and

maintain one’s self-esteem (Barrett, 1987). Shame can affect this through three

different regulatory processes: Behavioural, internal and social processes (Barrett,

1987). Behaviour regulatory processes involve disengaging oneself to reduce

exposure to evaluation from others (Barrett, 1987). Internal regulatory processes focus

attention to see whether the self is meeting social standards (Barrett, 1987). Social

regulatory processes relate to communicating respect to others (Barrett, 1987).

Aspects of this theory had been supported in an experimental study (de Hooge,

Zeelenberg, & Breugelmans, 2011) where participants were more likely to engage in

an activity to restore their sense of inadequacy, following a shame inducing exercise

rather than a neutral activity (de Hooge, Zeeleberg, & Breugelmans, 2011). Whilst it

can be argued that this provides support for the function of shame and the behaviour

regulatory processes, it does not provide support for the social and internal regulatory

processes proposed by Barrett (1987).

Cognitive Attributional theories of shame refer to the type of cognitive

attributions people make that lead to shame (Weiner, 1986). The characteristics of

these attributions include attributions that are internal and global (Weiner, 1986).

10

Internal attributions relate to whether the self is responsible for negative events

(Weiner, 1986). Global attributions relate to the entire self being responsible, as

opposed to a specific attribute of the self or a particular action (Weiner, 1986).

Research had provided support for this theory, finding that internal and global

attributions were correlated with experiences of shame (Tangney et al., 1992).

Object Relation/Attachment theories of shame conceptualise shame as an

emotion that occurs when a relational bond is disrupted (Kaufman, 1989; Nathanson,

1992). These theories differ from Cognitive Attributional theories, as they state that

shame can be experienced without cognitive processes. Instead, shame had been

conceptualised in terms of its physiological properties (Nathanson, 1992) and as

memories of shaming experiences and related associations (Kaufman,1989). In the

context of shame, it has been suggested that shame operates by dampening positive

affect associated with basic needs and causes disengagement (Nathanson, 1992), and

use of defensive strategies to protect against a sense of the whole self being

inadequate (Kaufman, 1989). Nathanson (1992) claimed support for his theory of

shame based upon the “still face” experiments (Tronick, Als, Adamson, Wise, &

Brazelton, 1978). In these experiments, parents interact face to face in a responsive

manner to their infant and then suddenly interact in a non-responsive manner.

Research shows that infants typically look away and becomes distressed when their

parents are interacting with them in a non-responsive manner. Nathanson (1992)

suggests that these reactions are due to the biological experience of shame, which

includes loss of muscle tone in the neck and upper body, which leads to a sense of a

defective self. However, in a study that recorded and used a structured coding method

of infant’s facial expressions and body language to determine affect during the still

11

face experiment, the frequency of recorded shame was relatively low (Weinberg &

Tronick, 1996).

Masculinity, shame and psychological distress

Shame may be an important variable in understanding men’s psychological

distress. Whilst there are different theories, they all converge to suggest that shame is

related to a sense of the whole self being inadequate and the perception about how the

self is perceived to be inadequate by others (Mills, 2005). This is particularly

pertinent to Pleck’s theory of GRSP (1995), where there is empirical support for three

areas of Gender Role Strain: Discrepancy Strain, Trauma Strain, and Dysfunction

Strain. Each of these areas of strain may present challenges for men that may elicit

shame. Furthermore, if shame is experienced, there are correlational evidence to

suggest that shame is associated with a range of different mental health conditions

(Lester, 2010; Tangney, Wagner, & Gramzow, 1992).

To further our understanding of the relationship between masculinity and

psychological distress, this study will focus on GRC, as there is existing evidence that

shame is associated with GRC (Thompkins & Rando, 2003) and GRC can be

conceptualised as a measure of Dysfunction Strain (O’Neil, 2015). It aims to address

the gap in the GRC literature, by using mediation methods to ask whether shame

mediates the relationship between GRC and psychological distress. GRC will be

operationalised as the total GRC score, as opposed to the score for each pattern of

GRC (RE, RABBM, SPC, and CBWFR). Psychological distress will be

operationalised as depression, anxiety, stress, and a combined score to give an overall

measure of psychological distress. Given the conceptual and empirical relevance of

shame to both GRC and psychological distress, it is hypothesised that shame will

12

mediate the relationship between GRC and psychological distress and each of the

components of psychological distress (depression, anxiety, and stress).

Method

Design

The study used a quantitative cross-sectional survey design. Therefore,

correlations and mediations were examined at a single time point.

Participants

Participants were males over the age of 18. There were no other inclusion and

exclusion criteria. They were recruited from a university in the south of England and

online.

The sample size was determined by consulting Fritz & Mackinnon (2007).

Fritz & Mackinnon (2007) used simulation to give estimates for sample sizes needed

for mediation with 80% power at the 5% level. These estimates for sample sizes were

determined based on estimates for the effect sizes for paths A and B of a mediation

model (Fritz & Mackinnon, 2007). A review of the literature was conducted to

identify these. For the A path, GRC correlated with shame by r=.304 (Thompkins &

Rando, 2003). For the B paths, shame correlated with depression by r=.54, anxiety by

r=.45, and stress by r=.46.(Castilho, Pinto-Gouveia, & Duarte, 2017). In accordance

to guidance by Fritz & Mackinnon (2007), the minimum required sample size based

on the effect sizes for paths A and B of this study’s mediation model, was 115 for bias

corrected bootstrapping mediation. However, a more conservative criterion was

applied, because the correlation coefficients identified for the B paths did not contain

the actual measures used in our study to measure depression, anxiety and stress. This

meant selecting the next sample size required for the smaller effect sizes for the B

13

paths. A sample size of 148 was selected to detect a small to medium effect sizes for

both parameters. Therefore, the study aimed to collect a minimum sample size of 148.

Procedure

A convenience and snowballing sampling strategies were used to recruit

participants (Goodman, 1961). Recruitment posters were placed in community boards

and men’s toilets across a university’s campus in the south of England (Appendix B).

E-mails were sent to various societies belonging to the same university that

represented minority groups, which requested for an electronic version of the

recruitment poster to be circulated to their mailing list (Appendix C). These societies

included Lesbian, Gay, Bisexual, Transsexual society; and a range of international

societies that are not western countries. This was to access underrepresented groups

within GRC research, as most of the research has been conducted on participants who

identified as white and heterosexual (O’Neil, 2015). The study was also advertised

through the researcher’s existing network via a Facebook post (Appendix D). Both the

recruitment poster and the Facebook post included basic study details, a website link

to the online questionnaires, and details of an incentive which was that participants

would be entered in a raffle to win a £50 Amazon voucher. In addition, the

recruitment poster included a quick response code (QR) generated by Qualtrics, which

enabled potential participants to access the study’s link by scanning a code with their

mobile phone. The recruitment posters, Facebook post, and the online questionnaires

all requested potential participants to forward the study’s link to other men in their

social network. Therefore, the study also loosely incorporated a snowballing strategy

(Goodman, 1961). The winner of the raffle was selected by using an online random

number generator to select a winner. Each participant had a study number attached to

them, based on who completed the survey first. On an online random number

14

generator, the total number of participants who consented was entered, and a random

number was generated (Random, 2018). The winner of the raffle was identified by

matching the random number that was generated, with the participant with the same

study number. An electronic amazon voucher was sent to their e-mail address.

Data were collected using online questionnaires. An online survey software

package called Qualtrics was used to generate a website link for participants to

complete the questionnaires. When participants accessed the link, the sequence of

pages were the following: Information sheet (Appendix E); a consent page, whereby

participants had to tick a box to indicate that they gave consent in order to continue; a

page that requested that each participant entered their e-mail address in order to enter

a raffle for a prize draw; a page that requested that participants enter their

sociodemographic information (Appendix F); GRC Scale – Short Form (GRCS-SF;

Appendix G); Shame subscale from the Internalized Shame Scale (ISS; (Appendix

H); Depression Anxiety Stress Scale – 21 (DASS-21;Appendix I); and a debrief page

(Appendix J). Validation settings were used in Qualtrics for two purposes: To ensure

that the data ranges were entered in correctly; and to ensure participants could not

progress to subsequent pages of the questionnaires relating to the study’s variables,

without completing all the answers of the page that they were on. However,

participants were not required to enter all their sociodemographic data before

proceeding to the next questionnaire. This was because these data were not considered

to be essential for the study and enabled each participant choices about what

sociodemographic information they were willing to disclose.

Instruments

The following Instruments were used -

15

Gender Role Conflict Scale – Short Form (GRCS-SF; Wester, Vogel, O’Neil,

& Danforth, 2012; Appendix G). The GRCS-SF is a shortened version of the

GRC scale and measures GRC. It is a 16-item questionnaire, with each item

asking participants to rate how much they agree with each statement as applied

to themselves on a 6-point Likert scale. An example item is “I have difficulty

expressing my tender feelings”. The GRCS-SF has four subscales: Restrictive

emotionality (RE), Restrictive affectionate behaviour between men (RABBM);

Success, power, and competition (SPC); and conflict between family and work

relations (CBWFR). Confirmatory factor analysis on a community sample of

1031 participants, supported the construct validity of the four subscales

(Wester et al., 2012). The internal reliability has been calculated on a

community sample (O’Neil, 2015). The Cronbach Alphas for the RE and

CBWFR was .77, the RABBM Cronbach Alpha was .78, and the SPC

Cronbach Alpha was .8 (O’Neil, 2015). The total GRCS-SF was used in the

main analysis because most of the GRC research had also used the total score

and not their subscales (O’Neil, 2015). Therefore, there are limited GRC

research to base hypotheses relating to the GRCS-SF subscales.

The Internalized Shame Scale (ISS, Cook, 1987; Appendix H). The ISS

measures internalized shame. It contains 30 items and ask participants to rate

the frequency they experience each statement on a four-point Likert scale. An

example item is “"I have an overpowering dread that my faults will be revealed

in front of others". It has two subscales, shame and self-esteem. Only the

shame subscale was used for this study. Cook (1987) found that in a non-

clinical sample of 645 participants and in a clinical sample of 370 participants,

the Cronbach Alphas for the shame subscale were .95 and .96 respectively. The

16

Concurrent validity was assessed by Rybak & Brown (1996), who found that

the ISS correlated with the Multiple Affect Adjective Check List-Revised, a

measure of affective disorders.

Depression Anxiety Stress Scales- 21(DASS-21; Sinclair et al., 2012;

Appendix I). The DASS-21 is a shortened form of the DASS-42. It measures

depression, anxiety, and stress. It contains 21 items and ask participants to rate

how much each item statement applies to themselves on a three-point Likert

scale. An example item is “I found myself getting agitated “. The reliabilities of

the DASS-21 have been assessed using a sample of 1794 participants from the

community in the United Kingdom (Henry & Crawford, 2005). The Cronbach

Alphas were, .88 for the depression scale, .82 for the anxiety scale, .90 for the

stress scale, and .93 for the full scale (Henry & Crawford, 2005). The

concurrent validity was assessed using a sample of 1455 participants from the

community (Sinclair et al., 2012). The DASS-21 scales correlated with the

mental and physical component of the short form-8 Health Survey, a measure

of health and well-being (Sinclair et al., 2012). The Mental component

correlation coefficients ranged from .58-.69, and the physical component

correlations ranged from .16 to .34 (Sinclair et al., 2012). In addition, the

DASS-21 also correlated with the Rosenberg self-esteem scale, with

correlations ranging from .49 to .69 (Sinclair et al., 2012).

A custom made socio-demographic questionnaire was designed, which was

based on the United Kingdom (UK) Census questionnaire. The questionnaire

asked participants for their age, ethnicities, religious background, sexualities,

what qualifications they had, and whether they identified as having a disability

(Appendix F).

17

Ethical issues

Ethical approval was sought and granted prior to the start of the study

(Appendix K) from the faculty’s ethics committee of the university where participants

were recruited (ethics number: 1259-PSY-17) The procedure for consent involved

participants reading the information sheet, explicitly giving their consent online by

clicking on a tick box, and being able to withdraw from the study by not completing

the survey. All data were stored securely on the university’s server. The only

identifiable data stored were e-mail addresses, for sending the raffle winner their

prize, and these were deleted once the prize was sent. Psychological distress were

managed by the consent procedures and signposting information to sources of

support. At the start and at the end of the online questionnaires, participants were

informed of various sources of support they could contact if they were distressed by

the questionnaires. These included calling Samaritans for emotional support,

contacting MIND for local mental health support, and contacting their GP if they

required treatment (see appendix E and J). However, it was judged that it was unlikely

that the questionnaires would evoke significant psychological distress due to the

nature of the questions.

Analysis strategy

Data were exported from Qualtrics and analysed using International Business

Machine Cooperation (IBM) Statistical Package for the Social Sciences (SPSS)

version 24. Preliminary analyses were conducted to explore response characteristics,

sample characteristics, and variable characteristics. The response analyses referred to

exploring differences between participants who completed all the questionnaires and

those who did not. Variables were generated in SPSS to group participants who had

fully completed the questionnaires relating to the study’s variables and those who

18

partially completed it. The response analyses included the following: frequency table

of those who gave consent and completion rate of the questionnaires; independent

sample t tests to explore whether there were any significant differences in GRC and

internalized shame between those who completed the questionnaires and those who

did not; and a series of chi square analyses to explore whether there were any

significant differences in terms of sociodemographic variables between those who

completed the questionnaires and those who did not.

Sample characteristics were explored using frequency tables and histograms to

explore each sociodemographic variable. Variables characteristics were explored by

calculating Cronbach’s alphas of each measure’s total scores and each DASS-21’s

subscale score to assess for internal reliabilities. Calculation of Pearson’s correlation

coefficients were used to assess linear correlations between each measure’s total score

and each DASS-21’s subscale score.

The causal steps approach (Baron & Kenny, 1986) and a bootstrapping

approach (Efron & Tibshirani, 1993) were used to conduct the mediation analysis, in

accordance with the conceptual model shown in figure 1. The causal steps approach

stipulates four conditions that need to be met for a variable to be considered to be a

mediator (Baron & Kenny, 1986): The independent variable has to predict the

dependent variable (path c or total effect); the independent variable has to predict the

mediating variable (path α); the mediating variable has to predict the dependent

variable (path β); and the independent variable has to either no longer predict the

dependent variable or reduce its predictive power in predicting the dependent

variable, when the path of the mediator is controlled for (path c’ or direct path). If the

mediating variable completely accounts for the association between the independent

19

a b

c’

c

and dependent variables (path c), then this is known as complete mediation and if it

does not it is known as partial mediation (Mackinnon, Fairchild, & Fritz, 2007).

However, the causal approach does not determine confidence intervals and

whether the indirect effect is statistically significantly different from zero (Hayes,

2013). The bias- corrected bootstrap mediation analysis was used to do this. The

PROCESS macro was installed on SPSS to conduct the bootstrapping analysis

(Hayes, 2013). To test the hypotheses of the study, four analyses were run, each with

5000 iterations and using bias corrected bootstrapping conducted in accordance to the

model below.

Figure 1: The conceptual diagram of the study’s mediation model.

Direct effect

Indirect effects

20

Mediator measured by ISS shame subscale

Dependant Variables measured by

DASS-21 Full scale,

Depression subscale,

Anxiety subscale,

And stress subscale

Independent Variable measured by GRCS-

SF

Dependant Variables measured by

DASS-21 Full scale

Depression subscale,

Anxiety subscale,

And stress subscale

Independent Variable measured by GRCS-

SF

To examine whether any of the specific subscales of the GRC contributed to

the main results, 16 additional mediational analyses were repeated with each

subscales of the GRCS-SF as the independent variables (restrictive emotions;

restrictive affectionate behaviour towards men; conflicts between family and work

relations; and success, power, and competition), shame as the mediator, and the

DASS-21 full scale and each of its subscales (depression, anxiety, and stress) as the

dependent variables.

To examine potential effects of confounding variables, each mediation

analyses was repeated whilst controlling for ethnicity, sexuality, religion, whether

participants had a degree, and whether participants identified as having a disability.

This required collapsing the ethnicity, sexuality, age, and religion variables into two

levels such as: White and other ethnicities; heterosexual and other sexualities;18-27

and 28-63; And religious and not religious. The disability and degree variables

already had two levels, which were yes or no. Variables needed to have two levels

because the PROCESS command cannot incorporate potential categorical

confounders with more than two levels (Hayes, 2013).

Results

Response analyses

In total, 223 participants accessed the online questionnaires and 222

participants gave consent. Of the 222 participants, 204 (92%) participants completed

all the questionnaires relating to the study’s variables with 18 (8%) participants only

completing parts of the questionnaires.

T-tests were conducted to compare the ISS shame subscale and GRCS-SF

scores for participants who completed all the questionnaires and participants who only

21

partially completed it. No statistical significance in ISS shame subscale and GRCS-SF

scores were found between the two groups of participants (Appendix L). A series of

chi square and fisher exact tests were conducted to compare differences in

sociodemographic variables between participants who completed all the

questionnaires and participants who only partially completed it. No statistically

significant differences were found in sociodemographic variables between the two

groups of participants (Appendix L). The remainder of the analyses were restricted to

the 204 participants with complete data for this study’s variables.

Sample characteristics

Of the Participants who accessed the online questionnaires, most of the

participants identified as being White (82.4%), identified as being heterosexual

(87.3%), not religious (69.3%), had a degree (73.7%), had no disability (89.8%), and

were between the ages of 20-29 (68.8%). The mean age was 29.22 (SD=7.68). A

breakdown of the sample characteristics can be seen in table 1.

22

Table 1

A table showing the breakdown of sample characteristics for participants who completed all the measures relating to this study’s variables(N=204).

Sociodemographic Variables

Number Percentage

EthnicityWhite 169 82.8BAME 35 17.1Religious GroupChristian 46 22.5Other religions 16 7.8Not religious 142 69.6DegreeYes 151 74No 53 26DisabilityYes 20 9.8No 184 90.2SexualityHeterosexual 179 87.7Homosexual 17 8.3Other 8 4Age<20 5 2.520-29 141 69.130-39 33 16.240> 21 10.3Missing 4 2

Note. BAME= Black, Asian and Minority ethnicity.

23

The Study’s variables characteristics

Table 2 shows the descriptive statistics and alpha coefficients for each of the

study’s measures. Each of the measures had relatively high levels of Cronbach’s

alphas coefficients (>.8), demonstrating high levels of internal reliabilities.

Table 2A table showing the descriptive statistics and alpha coefficients of each of the study’s variables (N=204).

Scale Possible range

Sample Range

Mean Medians SD Alpha

1.GRCS-SF 16-96 19-87 46.16 45 13.03 .85

2. ISS-S 0-96 13-86 44.66 43 15.69 .9

3. DASS 0-126 0-120 32.06 23.00 25.63 .94

DASS-21 subscales4. Depression 0-42 0-42 11.28 8 10.84 .91

5. Anxiety 0-42 0-42 7.39 4 8.12 .83

6. Stress 0-42 0-40 13.38 11 9.83 .87

Notes. DASS-21=Depression, anxiety, stress scale -21; GRCS-SF=Gender Role Conflict Scale- Short Form; ISS-S=Internalized Shame Scale – Shame Subscale.

The sample contained a range of scores for each of the instruments used:

GRCS-SF; ISS shame subscale; and DASS-21. In terms of interpreting the scores, the

GRCS-SF contains no guidance for interpretation, whereas the ISS shame subscale

and DASS-21 does. For the ISS shame subscale, a score of 50 is indicative of painful

and possibly problematic levels of internalized shame, and a score of 60 is indicative

of extreme levels of internalized shame (Cook, 1994). One hundred and twenty-seven

participants (62.3%) had an ISS shame score below 50, 48 participants (23.5%) had

an ISS shame score between 50-59, and 29 participants (14.2%) had an ISS shame

24

score over 60. This shows that approximately two thirds of participants had levels of

internalized shame that were not problematic. For the DASS-21, guidance for

interpreting the scores is only for each of the subscales and severity is ranked into five

categories: Normal; Mild; Moderate; Severe; and Extremely Severe (Psytoolkit,

2018). The spread of severity of depression, anxiety, and stress can be seen in table 3.

This shows that between 56 – 63% of the participants reported normal ranges of

depression, anxiety, and stress. There was a spread of severity for reported depression,

anxiety, and stress. Between 9 – 13% of participants reported symptoms in the mild

range, 9-15% reported symptoms in the moderate range, 4-11% reported symptoms in

the severe range, and 5-12% reported symptoms in the extremely severe range.

Table 3

Table showing the spread of depression, anxiety, and stress severity in the sample (N=204).

Severity DepressionN (%)

AnxietyN (%)

StressN (%)

Normal 114 (55.88%) 127 (62.25%) 128 (62.75%)

Mild 22 (10.78%) 18 (8.82%) 25 (12.25%)

Moderate 30 (14.71%) 28 (13.73%) 19 (9.31%)

Severe 14 (6.86%) 9 (4.41%) 22 (10.78%)

Extremely Severe 24 (11.76%) 22 (10.78%) 10 (4.9%)

Table 4 shows the intercorrelations of each of the study’s variables. Each of

the variables significantly and positively correlated with each other with medium to

large effect sizes (R=>.3). Appendix M shows the scatterplot for the correlations of

each pair of variables. The fact that all the variables are strongly linearly related lends

support to progressing to the mediation analyses.

25

Table 4Table showing the intercorrelations of each of the study’s variables (N=204). Scale 2 3 4 5 61.GRCS-SF .49** .51** .45** .41** .49**

2.ISS-S - .7** .7** .56** .6*

3.DASS-21 - - - - -

DASS-21 subscales4.Depression - - - .66** .7**

5.Anxiety - - - - .7**

6.Stress - - - - -

Notes. DASS-21=Depression, anxiety, stress scale-21; GRCS-SF=Gender Role Conflict Scale – Short Form; ISS-S=Internalized Shame Scale Shame Subscale; *p<.05; **p<.01; ***p<.001

Mediation analyses

Mediation analyses was conducted to test the hypotheses of the study, that

shame will mediate the relationship between GRC and psychological distress and

each of the components of psychological distress (depression, anxiety, and stress).

Causal steps approach

The causal steps approach was used to determine whether the conditions of a

mediating variable had been met (Baron & Kenny, 1986). This involved a series of

regression analyses to determine the relationships between each of the study’s

variables. Results from the regression analyses (table 5 and figure 2) indicated that

GRCS-SF significantly predicted ISS shame subscale (path a); ISS shame subscale

significantly predicted DASS-21 and each of its subscales (path b); and GRCS-SF

significantly predicted DASS-21 and each of its subscales (path c).

26

The regression analyses also indicated that GRCS-SF reduced its predictive

power in predicting DASS-21 and each of its subscales, when the path of ISS shame

subscale was controlled for (path c’). As the GRCS-SF only reduced its predictive

power in predicting DASS-21 and each of its subscales and did not eliminate its

predictive power, this demonstrated partial mediation as opposed to complete

mediation. This shows that the direct path, GRCS-SF to DASS-21 and each of its

subscales (path c), were also significant. All the regression analyses results

demonstrated that the conditions for the causal steps approach had been met (Benny

& Kenny 1986). This supports the hypotheses, that shame will mediate the

relationships between GRC and psychological distress and each components of

psychological distress (depression, anxiety, and stress).

Bootstrapping

Bias-corrected bootstrapping were used to estimate the size of the mediating

indirect effects and whether it was statistically significant from zero. The assumptions

for bias-corrected bootstrap mediation are those for ordinary least squares regression

(OLS), which involves testing whether the variables residuals are normally distributed

and whether there are any significant influential data points (Hayes, 2012). The OLS

assumptions regarding homogeneity of variance and collinearity does not apply

(Hayes, 2012). These assumptions were checked by visually inspecting histograms of

the variables residuals and calculating the variables’ Cook’s distance. Variables were

considered to have an approximate normal distribution if they were unimodal, had

tails on either side, and were approximately symmetrical. All the variables residuals

were considered to be close enough to a normal distribution (Appendix N).

Significant influential data points were assessed by using Cook’s distance, whereby a

27

Cook’s distance of over one is considered significantly influential (Cook & Weisberg,

1982). There were no significant influential data points. There is no agreed ideal

standardised effect size, but the Pm was used following recommendation from Wen &

Fan (2015). This stands for proportion of the total effect that is mediated (Hayes,

2013). It represents how much of the total effect is operating indirectly through the

mediator (Hayes, 2013). The Pm is produced automatically as part of Hayes’s macro

(Hayes, 2012).

The indirect effects were tested using a bootstrap estimation approach with

5000 samples. Table 5 and Figure 2 shows the results of the regressions and

mediation analyses. These results indicated that the indirect effect was significantly

different from zero when the DASS-21 full scale score was the dependent variable.

The mediator approximately accounted for half of the total effect, Pm=.567, for the

relationship between GRCS-SF and DASS-21 full scale. The results also indicated

that the indirect effect was significantly different from zero when the depression

subscale from the DASS-21 was the dependent variable. The mediator could

approximately account for two thirds of the total effect, Pm=.671, for the relationship

between GRCS-SF and the depression subscale from the DASS-21. The results also

indicated that the indirect effect was significantly different from zero when the

anxiety subscale from the DASS-21 was the dependent variable. The mediator could

approximately account for half of the total effect, Pm=.547, for the relationship

between GRCS-SF and the anxiety subscale from the DASS-21. These results also

indicated that the indirect effect was significantly different from zero when the stress

subscale from the DASS-21 was the dependent variable. The mediator could

approximately account for half of the total effect, Pm=.474, for the relationship

28

b = 0.966 0.431 0.239 0.295

a = 0.588

between GRCS-SF and the stress subscale from the DASS-21. To summarise, the

results indicated that the indirect effects were significantly different from zero when

the DASS-21 and each of its subscales were the dependent variable in turn. The

bootstrapping analyses also lends further support to the hypotheses that shame will

mediates the relationships between GRC and psychological distress and each of the

components of psychological distress (depression, anxiety, and stress).

Figure 2: The conceptual mediation model with correlation coefficients for each path.

Direct effect

Total effects

29

DASS-21 Full scale (DV)

Depression (DV)

Anxiety (DV)

Stress (DV)

Gender Role Conflict (IV)

Gender Role Conflict (IV)

Shame (M)

DASS-21 Full scale (DV)

Depression (DV)

Anxiety (DV)

Stress (DV)

c = 1.002 0.378 0.258 0.366

c’ = 0.434 0.124 0.117 0.193

Table 5

Table showing the summary of mediation analysis with IV being GRCS-SF and M being shame subscale from the ISS (N=204).

Dependent Variable

Effect of IV on DV

Effect of IV on M

Effect of M on DV

Direct Path Indirect Effect Effect Size

DV Total Effect/ Path C

Path A Path B Path C’ A x b 95% CI Pm 95% CI

DASS-21 Full scale

B 1.002 .588 .966 .434 .568 .391 - .759 . 567 .414 - .75

Se .119 .074 4.848 .110 .094 .085T 8.42 7.963 10.622 3.964P .000 .000 .00 .001

Depression B .378 .588 .431 .124 .254 .175 - 338 .671 .502 - .94Se .048 .074 .040 .048 .042 .109T 7.238 7.963 10.919 2.613P .000 .000 .001 .010

Anxiety B .258 .588 .239 .117 .141 .09 - .202 .547 .365-.874Se .04 .074 .034 .041 .028 .13T 6.471 7.963 7.03 2.849P .000 .000 .000 .005

Stress B .366 .588 .295 .193 .174 .115-.248 .474 .321 - .68Se .046 .074 .039 .047 .034 .091T 7.897 7.963 7.55 4.096P .000 .000 .000 .000

Notes. DASS-21=Depression, Anxiety, Stress Scale – 21; DV= Dependent Variable; GRCS-SF=Gender Role Conflict Scale – Short Form; ISS=Internalized Shame Scale; IV=Independent Variable; M= Mediator; Pm= proportion of indirect effect relative to the total effect.

30

Supplementary analysesTo investigate whether specific subscales of the GRCS-SF were responsible

for the mediation effect, further mediation analyses using the causal approach (Baron

& Kenny, 1986) and bias-corrected bootstrap analyses were conducted. This involved

exploring whether shame would mediate the relationships between each of the

subscales of the GRCS-SF with DASS-21 and each of its subscales. Analyses

revealed that the conditions of the causal approach (Baron & Kenny, 1986) and the

assumptions of bootstrap mediation were met. Results of the regression and mediation

analyses shows that shame mediated the relationships between each of the subscales

of the GRCS-SF with each of the subscales of the DASS-21 (Appendix O). This

shows that none of the subscales of the GRCS-SF were solely responsible for the

mediation effect found in the main results.

To investigate whether the mediation effects still occurred whilst controlling

for potential confounders, all the mediation analyses were repeated whilst adjusting

for potential confounders. Each of the bias-corrected bootstrap analyses that has been

conducted, were repeated whilst controlling for age, ethnicity, religion, sexuality,

degree and disability. These socio-demographic variables were considered to be

potentially confounding variables based on conceptual and empirical reasons. Thus,

bootstrap mediations were conducted to analyse whether shame mediated the

relationships between GRCS-SF and its subscales with DASS-21 and its subscales,

whilst controlling for age, ethnicity, religion, sexuality, degree and disability. Results

showed that for each of the mediation analyses, shame remained a significant partial

mediator and there was no evidence of substantial confounding (Appendix O).

31

Discussion

Summary of results

The study investigated whether shame mediates the relationship between GRC

and psychological distress. The hypothesis was that shame would mediate this

relationship. The main results partially supports this, as shame was found to be a

partial mediator between the relationship between GRC and psychological distress.

Supplementary analyses support that this mediation did not occur via any specific

subscales of the GRCS-SF and mediation still occurred when sociodemographic

confounders were controlled for.

Interpretation of results

The results tentatively support a simple mediation model, whereby shame

partially mediates the relationship between GRC and psychological distress. The

results suggest that shame accounts for approximately half of the total effect between

the relationship of GRC and psychological distress. It is also assumed that the casual

direction is from GRC to shame to psychological distress based on the relevant

literature. GRC is assumed to be the independent variable because it provides the

context of how psychological distress may arise. Indeed, GRC has been defined as -

“a psychological state in which socialized gender roles have negative consequences

on the person or others. GRC occurs when rigid, sexist, or restrictive gender roles

result in personal restrictions, devaluation, or violation of others or self (O’Neil, 2008,

p362)” and is conceptualised as a measure of Dysfunction Strain (O’Neil, 2015).

Shame is assumed to be the mediator, due to its conceptual and empirical

relevance to both GRC and psychological distress (Lee, Gleeson, & Morrison, 2018).

Indeed, the phenomenological experience of shame involves painful affect, negative

evaluation of the self, and a desire to hide (Lewis, 1992). Furthermore, theories of

32

shame converge to suggest that shame is related to a sense of the whole self being

inadequate and the perception about how the self is perceived to be inadequate by

others (Mills, 2005). Therefore, shame may occur when men experience GRC, due to

the negative consequences that GRC produce. Shame may lead on to the development

of psychological distress, due to the phenomenological aspects of shame (Lewis,

1992). Other research had also shown correlations between shame and both GRC

(Thompkins & Rando, 2003) and a range of measures of psychological distress

(Tangney et al., 1992).

Psychological distress is assumed to be the dependent variable as it can be

conceptualised as the part of the negative consequences of GRC. It is possible that

psychological distress may arise due to each of the four patterns of GRC (restrictive

emotionality; restrictive affectionate behaviour towards men; emphasis on success,

power and competition; and conflicts between family and work relations). Indeed,

research had shown that psychological distress is correlated with GRC and shame

(Spendelow & Joubert, 2018; Tangney et al., 1992). In summary and in accordance to

this study’s model, it is assumed that psychological distress arises partly because of

the experience of shame in relation to GRC.

There are other possible interpretations of the relationship between GRC,

shame, and psychological distress within this study’s mediation model. It is possible

that the ISS shame subscale captured experience of shame not relating to GRC.

Likewise, it is possible that DASS-21 captured experience of psychological distress

not relating to shame. Especially as the wording of each item from the ISS shame

subscale is not related to GRC, and only one item of the DASS-21 relates directly to

the experience of shame. It is also possible that the order of each variable in

accordance with this study’s mediation model may be in different positions, especially

33

as the study used a cross-sectional design. For example, the independent variable may

be psychological distress or shame, the mediator may be GRC or psychological

distress, and the dependent variable may be GRC or shame. Whilst it is statistically

possible to have different designs of the mediation model, how meaningful these are

depends on the conceptualisation of different mediation models (MacKinnon et al.,

2007). It is argued that the study’s current model conceptually makes the most sense

in relation to the current literature on men’s mental health.

Findings in relation to the wider literature

The results of this study are relatively consistent with other studies. A

previous study had found that GRC correlated with shame (Thompkins & Rando,

2003). However, in this study the correlation was slightly higher by comparison (r=.5

and r=.3). This may be due to this sample being based in the UK as opposed to being

based in the US, this study using the short form of the GRCS as opposed to the full

scale, and this sample having a slightly older sample (M=29 versus M=22). Another

study had also found that shame correlated with DASS-21 (Corliss et al., 2002).

However, effect sizes found in the Corliss et al., (2002) study were slightly lower in

comparison to this study. In accordance to Cohen’s (1988) descriptions for correlation

effect sizes, the effect sizes for the relationships between shame and each subscale of

the DASS-42 in Corliss et al., (2003) study were between small to medium. Whereas

the effect sizes in this study for the relationships between shame and each subscale of

the DASS-21 were medium. This may reflect differences in the use of shame

measures, where we used the ISS subscale and Corliss et al., (2003) used the Other as

Shamer Scale (Allan, Gilbert, & Goss, 1994). In addition, the differences may be due

to differences in where the study was based (UK versus Portugal) and differences in

sample characteristics (all males versus females and males). The size of each

34

correlation effect sizes between GRC and each subscales of the DASS-21/DASS-42

were approximately similar to a previous study (Spendelow & Joubert, 2018), where

each correlation were in the medium range, in accordance with Cohen’s (1988)

description for effect sizes.

This study has identified shame as a mediator between the relationship

between GRC and psychological distress. This complements other studies that have

identified other mediators for the relationship between GRC and psychological

distress. Experiential avoidance, defined as avoiding unpleasant psychological

experiences that leads the self away from personal values (Hayes et al., 1996), was

identified as another mediator for the relationship between GRC and psychological

distress (Spendelow & Joubert, 2018). In addition, internalized heterosexism was

found to be a mediator between GRC and depression for sexual minority men

(Szymanski & Ikizler, 2013).

The results of this study can be conceptualised in relation to wider theories of

masculinity and theories of psychological distress, as these theories can be seen as

overlapping with each other. Hegemonic Masculinity refers to a pattern of practice

that allows men’s dominance over women and men who conform to other forms of

masculinity (Connell & Messerschmidt, 2005). It produces a cultural and honoured

ideal about how to be a man (Connell & Messerschmidt, 2005). This concept is

supported by gender inequalities such as gender differences in pay (Bishu & Alkadry,

2017). The socialization of men supports the development of masculine ideologies

which promote values of dominance (Eckes & Trautner, 2000). Research had shown

that traditional western male norms involves gaining dominance and power through

status; being strong, independent, and unemotional; taking risks, seeking out violence;

being adventurous; homophobic; and avoiding femininity (David & Brannon,1976).

35

Pleck’s theory of GRSP (1995), highlights some of the problems with adopting these

masculine norms and describe these as Discrepancy Strain, Trauma Strain, and

Dysfunction Strain. Discrepancy Strain relates to not conforming to male gender

stereotypes and receiving social condemnation (Pleck, 1995). Trauma Strain relates to

traumatic experiences of being socialized as a man (Pleck, 1995). Dysfunction strain

relates to experiencing negative consequences due to fulfilling male gender

stereotypes (Pleck, 1995). GRC elaborates further on Dysfunction Strain and what

these negative consequences are (O’Neil, 2015). Indeed, GRC is defined as “a

psychological state in which socialized gender roles have negative consequences on

the person or others” and the theory indicates four general patterns of these negative

consequences (O’Neil, 2008). These are restrictive emotionality, restrictive

affectionate behaviour towards men, conflicts between family and work relations, and

emphasis on success power and competition (O’Neil, 2008). This study’s mediation

model elaborates further on what these negative consequences may be and how it can

lead to psychological distress. The model suggests that psychological distress may

arise due to shame relating from GRC.

Theories of shame can further our understanding of how shame related to

GRC might lead to psychological distress. Cognitive Attributional theories of shame

suggests that shame occurs due to internal and global attributions about the cause of

negative events (Weiner, 1986). Internal attribution relates to attributing the

responsibility of a negative event to themselves (Weiner, 1986). Global attribution

relates to the entire self being at fault, as opposed to just their actions (Weiner, 1986).

Shame may be related to GRC, because the theory of GRC states that GRC occurs

when events causes personal restrictions, devaluation, and violation of others or self

(O’Neil, 2008). This creates opportunities for internal and global attributions to be

36

made, which may lead to the experience of shame. Object Relation and Attachment

theories of shame provides a different perspective that can complement the Cognitive

Attributional theories of shame (Kaufman, 1989; Nathanson, 1992). These theories

states that shame occurs due to disrupted relational bonds (Kaufman, 1989,

Nathanson, 1992). Nathanson (1992) suggests that shame alerts individuals when they

commit actions that can lead to rejection by others and motivates them to prevent

further rejection from occurring. In relation to GRC, shame may also be concerned

about being rejected from others, due to the negative patterns that GRC produce.

These include restrictive emotions, restrictive affectionate behaviours towards men,

conflicts between family and work relations, and emphasis on success power and

competition. However, there might be difficulties in acting in other ways to prevent

further shame, due to pressures of Hegemonic Masculinity and Masculine Ideologies.

Therefore, some men may feel trapped. This is because if they do not conform to

masculine norms, they may experience shame for not conforming (Pleck, 1995). Yet,

if they do conform to masculine norms, they may also experience shame due the

negative consequences of adopting masculine norms. If an individual experiences

shame repeatedly, this may lead to the development of habitual negative thinking

styles that may lead to depression (Beck, 1974). Furthermore, as men may experience

shame and possible rejection from others, if they do and do not conform to masculine

norms, they may also feel in a state of constant anxiety. Indeed, anxiety can be

conceptualised as lack of control regarding possible future threats (Barlow, 2002).

Both the experiences of depression and anxiety may also be experienced as stressful

for men.

The findings of this study support that GRC can lead to negative consequence.

However, this is not to say that men’s construction of masculinity always produces

37

negative consequences. Social constructionist theories of masculinity suggests that

masculine norms are created in relation to their social environment (Addis, Reigeluth,

& Schwab, 2016). As there are multiple social and cultural environments, multiple

masculine norms can exist and different types had been identified (Addis et al., 2016).

As a result, it is possible that adopting different masculine norms, may lead to other

consequences that are different to the GRC and which may be either positive or

negative. However, there are support that GRC does hold up cross-culturally and is

relevant for men from different cultural backgrounds (O’Neil, 2008). In addition,

masculinity can also have positive consequences. Indeed, the Positive Psychology

Positive Masculinity Framework (Kiselica, Benton-Wright, & Englar-Carlson, 2016)

highlights a range of strengths associated with masculinity including the values of

self-reliance and courage.

Strengths and limitations

There are a number of strengths in this study. The sample size ensured that the

study was sufficiently powered to detect small to medium mediation effects. The

validation settings on the questionnaires appeared to have facilitated a relatively high

response rate (92%). The psychometric properties of each measures from both past

research and from this study, demonstrated relatively high internal reliabilities

(r=>.8). The supplementary analyses provided further support that shame mediated

the relationship between GRC and psychological distress, by controlling for

sociodemographic variables.

There are also a range of limitations to this study, which is why it is argued

that the results only tentatively support a mediation model. The study design was

cross sectional, thus inferences about causality or direction of the model can only be

made based on conceptualisation and are not based on the data.

38

The study used a convenience and snowball sampling methods for

recruitment. It is likely that this have led to biases in terms of which part of the

population was accessing the questionnaires. Indeed, descriptive statistics of the

sample indicated that most of the sample identified as white, were between the ages of

25-30, not religious, heterosexual, had a degree, had no disability, and relatively

normal ranges of psychological distress. As a result, caution is needed in generalising

the results of this study to wider populations.

The measures of shame and GRC can also be critiqued. Blum (2008) reviewed

measures of shame and critiqued how some measures measure self-esteem as opposed

to shame. There are overlaps between the two constructs, however shame emphasise

the affective experience and a desire to hide, whereas self-esteem places more

emphasis on negative evaluation (Blum, 2008). This study used the ISS, which

contains both a shame and a self-esteem-subscale, but only the shame subscale was

used (Cook, 1987). The ISS describes self- esteem as “less dynamic” in comparison

to shame (Cook, 1987). This had been criticised by Tangey (1996) as a “hazy”

descriptions. Without a clear conceptual distinction between shame and self-esteem,

this can impact the items of the ISS shame subscale. However, on reviewing the items

of the ISS, it does appear that they relate to theoretical constructs and

phenomenological descriptions of shame, such as affective experience, desire to hide,

and negative self-evaluation (Lewis, 1992). Likewise, the full scale of the GRCS had

been critiqued for not always measuring conflict, devaluation, restriction or violation

(O’Neil, 2008). This is important as these relate to the operational definition of GRC

(O’Neil, 2008). Whilst the GRCS-SF had been designed to address these criticisms, it

can be argued that some of these criticisms can still apply (O’Neil, 2015). For

example, item two of the GRCS-SF is “Winning is a measure of my value and

39

personal worth”. It is not clear how this relates to conflict, devaluation, restriction, or

violation. In contrast, it appears that this item measures Masculine Ideology as

opposed to GRC. However, most of the items of the GRCS-SF does relate to conflict,

devaluation, restriction, or violation.

The mediation model for this study also contains statistical limitations. The

Pm was used to measure the mediation effect following recommendations from Wen

& Fan, 2015). However, there are no measure of mediation effect size that are not

without flaws (Wen & Fan, 2015). This includes the Pm, which has been critiqued as

having large sample variances (Mackinnon, Warsi, & Dwyer, 1995).

The supplementary analyses that involved conducting mediation analyses with

sociodemographic variables as confounders can also be critiqued. It can be argued

that the confounding groups were not that meaningful conceptually and statistically.

The confounding variables had two levels, typically a sociodemographic group

consisting of a majority group and a minority group e.g. heterosexual and other

sexualities. However, the minority groups often comprised of heterogenous groups.

Unfortunately, this was unavoidable with the use of the PROCESS macro to conduct

the mediation analyses, as confounding variables had to be entered with two levels

(Hayes. 2013). In addition, as the sample size was relatively homogenous, there were

relatively few participants who were not white, not heterosexual, religious, had a

disability, outside the age range of 25-30, and did not have a degree. As a result, there

would have been low power to detect any potential confounding effects.

Implications

The results suggest that men presenting with psychological distress may

experience shame relating to GRC. This may have implications for the psychological

treatment of men who present with psychological distress and for addressing issues

40

relating to GRC on a wider societal level. The findings suggest that it is important to

explore the presence of GRC when men present with psychological distress. For some

men, this may be a sensitive topic, especially as one of the pattern of GRC is

restrictive emotionality. During therapy, targeting shame may be helpful in alleviating

psychological distress, especially given that shame accounted for approximately half

the effect of between GRC and psychological distress. A range of therapeutic

approaches may be helpful with this aim. Compassion Focused Therapy specifically

targets the experience of shame (Gilbert, 2010). Cognitive Behavioural Therapy

(CBT) may be helpful to address assumptions and rules for living that may be

associated with GRC. For example, assumptions that men must be strong and not

express emotions. Cognitive Attributional theories of shame suggests that shame

occurs when attributions are made that are internal and global (Weiner, 1986). CBT

therefore may be helpful to challenge the cause of the shame and “black and white

thinking”. Likewise, the use of narrative therapy may be helpful in terms of targeting

shame and exploring masculinity (Morgan, 2000). The use of externalising techniques

may help men to talk about their masculinity in a way that is less shameful for them

(Morgan, 2000). In addition, narrative therapy can be used to deconstruct dominant

narratives around masculinity and thicken more helpful conceptualisations of

masculinity (Morgan, 2000). The use of the framework of Positive Psychology’s

Positive Masculinity may be helpful, where other positive aspects of masculinity have

been captured such as being a good father (Kiselica et al., 2016). Group treatment for

men may also be helpful to talk about shame.

On a wider societal level, it may be helpful to promote other types of

masculinity. There is evidence to suggests that public health campaigns such as time

to talk had helped to challenge stigma, promoted different norms regarding how

41

mental health is perceived, and had encouraged men to seek help for mental health

problems (Sampogna et al., 2017). Similar campaigns may help to reduce stigma

regarding the challenges of masculinity, may help to promote different norms for

masculinity, and encourage men with psychological distress to seek help. Likewise,

there are opportunities in schools to explore issues regarding masculinity. Personal,

Social and Humanities Education (PSHE) lessons may provide good opportunities to

discuss gender issues including masculinity.

Future research

Research regarding understanding the mechanisms of male related

psychological distress are relatively sparse and thin. Therefore, there are rich

opportunities for future research. Within the context of this study and its mediational

model, other designs and statistical analyses may be helpful to support causality,

direction of the model, and building a more complex model with more explanatory

power. Creative use of randomised experimental designs may help support the

causality of the model. This may involve the following: Measuring GRC at baseline;

Randomizing participants into two conditions; One condition involves an

experimental task that induce the feelings of shame, whilst another condition involves

a neutral experimental task; and then measuring symptoms of psychological distress.

However, careful consideration would be needed to minimise harm for this type of

experiment. Structural equation modelling can enable testing of different causal

directions, which was beyond the scope of this research. Qualitative research

regarding masculinity and shame can help support the link that shame is a mediating

variable that relates to GRC. Further research can also explore other potential

mediators and moderators that may be relevant in understanding the relationship

42

between GRC and psychological distress. In addition, the generalisability of the

study’s model can be enhanced by replicating the study with more diverse samples.

Research can also explore the relationship between shame and masculinity in

different ways. It would be helpful to explore whether shame is a mediating variable

between GRC and other dependent variables such as anger. Research can also explore

the relationship between shame and other aspects of masculinity in accordance with

Pleck’s GRSP (1995). For example, Discrepancy Strain that arises due to not

conforming to traditional masculine norms, may be tested by using the Gender Stress

Scale (Eisler & Skidmore, 1987). This is because the Gender Stress Scale measures

the stress of not conforming to traditional masculine norms (Eisler & Skidmore,

1987). Therefore, one might test the hypothesis that shame mediates the relationship

between gender stress and psychological distress and/or other dependent variables.

Likewise, retrospective studies may help explore the role of shame in relation to

Trauma Strain, this being that the socialization of men can be a painful experience.

Conclusion

The study investigated whether shame mediates the relationship between GRC

and psychological distress. The results of the study tentatively suggest that it does.

The findings contribute to the literature of men’s mental health by suggesting a model

of how GRC can lead to psychological distress. It is proposed that GRC can lead to

shame, due to the negative consequences of adhering to masculinity. These include

restrictive emotions, restrictive affectionate behaviours towards men, conflicts

between family and work, and emphasis on success power and competition. Shame

can also lead to psychological distress and this may be explained by cognitive models

of common mental health diagnoses and pressures from masculinity norms. The

study’s model may be useful in providing psychological treatment for men who

43

present with psychological distress. The model suggests that targeting shame and the

use of narrative approaches to deconstruct ideas around masculinity may be helpful

treatment foci. In addition, wider systemic approaches such as public health

campaigns and PSHE lessons, may help to challenge unhelpful ideas around

masculinity and promote more helpful norms. However, the study’s model is of a

tentative nature due to the limitations of the study. Further research can help support

the model by using experimental designs, use of SEM’s, replicating the study with

more diverse samples, and using qualitative studies to explore the relationship

between shame and GRC.

44

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List of appendices to the empirical paper

Appendix A – Guidelines for journal submissionAppendix B – Recruitment posterAppendix C – List of university societies emailed for recruitmentAppendix D – Facebook recruitment postAppendix E – Information and consent sheetAppendix F – Sociodemographic data collection formAppendix G – DebriefAppendix H – Ethics approvalAppendix I - Response AnalysesAppendix J – ScatterplotsAppendix K – Histogram of variables residualsAppendix L – Supplementary analyses results

54

Appendices

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Open Materials: All materials necessary to reproduce the reported results that are digitally shareable, along with descriptions of non-digital materials necessary for replication, are made publicly available.

 

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Appendix B: Recruitment Poster

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Appendix C: List of societies contacted for recruitment

African Caribbean Society Afghan Society LGBT Society Arabic Society Chinese Christian Fellowship Society Chinese Society Egyptian Society Filipino Society Indian Students Association Indonesian Society Islamic Society Japanese Society Malaysian Society Myanmar Society Nepalese Society Nigerian Society Pakistani Society Palestinian Society Sikh Society Singaporean Society Somali Society Sri Lankan Society Taiwanese Society Tamil Society Thai Society Vietnamese Society

Appendix D: Facebook recruitment post

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Hi all, I’m conducting research about men’s mental health, to help understand the

challenges of masculinity and how this relates to psychological distress. If you are an adult

male, I will be grateful if you could complete some brief online questionnaires on the link

below, where all responses will be anonymous, and you will be entered to a raffle to win a

£50 Amazon Voucher. I would be grateful if you could also help spread the link, through

whatever means that you feel comfortable with. Thanks !!

Appendix E: Information and Consent Sheet

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Participant Information and Consent Sheet

Masculinity and Mental Health: The relationship between Masculinity, Shame and Psychological distress.

Introduction

We would like to invite you to take part in a research project. Before you decide you need to understand why the research is being done and what it will involve for you. Please take the time to read the following information carefully and e-mail Haymond Lee (contact details at end) any questions about anything you do not understand.

What is the purpose of the study?

Research has shown that masculinity can present with challenges such as pressures to be seen as strong and successful. These pressures are associated with psychological distress. However, the reasons for this are not well understood, making targeted interventions to help men's mental health difficult to develop. It is thought that not meeting society's standards of masculinity can be shameful. This study will test whether shame can explain how masculinity is associated with psychological distress.

What will I have to do?

You will be invited to complete some questionnaires online twice over a period of two months. These questionnaires will last approximately 15 minutes in total; approximately 10 minutes for the first round of questionnaires and 5 minutes for the second round. We will ask you to provide your e-mail address, so that we can remind you to complete these questionnaires over the course of two months. The first round involves four questionnaires. These questionnaires relate to information about yourself (e.g. age, ethnicity, religion, sexual orientation, and education), a questionnaire on masculinity, a questionnaire on shame and a questionnaire on psychological distress. After two months, you will be asked to complete the questionnaire on psychological distress again.

What will happen to data that I provide?

Your data will be kept confidential. Your details will be held in complete confidence and we will follow ethical and legal practice in relation to all study procedures. Personal data [contact details] will be handled in accordance with the UK Data Protection Act 1998 so that unauthorised individuals will not have access to them.

Your e-mail address will be kept and deleted at the end of the study, which will occur by the 1/1/18. All other research data are stored securely for at least 10 years following their last access and project data (related to the administration of the project, e.g. your consent form) for at least 6 years in line with the University’s policies.

What are the possible disadvantages or risks of taking part? -

Some people may experience minimal emotional distress by completing the questionnaires. If you are distressed by the questionnaires, there are a number of different services that can provide support. If you like to talk to someone you can

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contact the Samaritans on 116 123 or jo@samaritans.org. For general information and support about mental health issues, you can also visit MIND at www.mind.org.uk. If you are concerned about your mental health, we recommend that you contact your GP.

What are the possible benefits of taking part?

Following the completion of all the questionnaires, you will be entered into a raffle to win a £50 Amazon Voucher. You will be informed via your email address if you have won this. The study also provides an opportunity to be involved in research that helps to improve our understanding of men’s mental health.

What happens when the research study stops?

Responses you provide will be anonymised, securely stored on University computer servers, and analysed. The information you provide may be used in written materials/publications (e.g. academic journals) and presentations (e.g. conferences). You will be not be identified in any publications or presentations. Updates and findings of the study will be posted on a facebook page: https://www.facebook.com/groups/1106837362700856/

What if there is a problem?

Any complaint or concern about any aspect of the way you have been dealt with during the course of the study will be addressed; please contact Haymond Lee, Principal Investigator at in the first instance or my Supervisor, Dr Kate Gleeson. You may also contact Dr Mary John, Practitioner Doctorate in Clinical Psychology Programme Director.

Who is organising and who has reviewed the research?

This research is organized by the University. This research has been looked at by an independent group of people, called an Ethics Committee, to protect your interests. This study has been reviewed by and received a favorable ethical opinion from the University’s Ethics Committee.

Full contact details of researcherHaymond LeePrincipal InvestigatorTrainee Clinical Psychologist

Appendix F: Socio-demographic form

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Dr Kate GleesonSupervisorResearch Director, PsychD programme

1-4 O levels/ CSEs/GCSES (any

Which of these qualifications do you have?

Tick every boxes that apply if you have any of the qualifications listed

If your qualification is not listed, tick Complete one section that best describe your ethnic group or background

What is your Ethnic Group?

When were you born?Day Month Year

Appendix G: Debrief

Thank you for your time.

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1-4 O levels/ CSEs/GCSES (any

Do you have a disability?Disability can be described as “long term physical, mental, intellectual or sensory impairments which, in interaction with various barriers, may hinder [a person’s] full and effective participation in society on an equal basis with others”

Yes

No

If you are distressed by the questionnaires, there are a number of different services that can provide support. If you like to talk to someone you can contact the Samaritans on 116 123 or jo@samaritans.org. For general information and support about mental health issues, you can also visit MIND at www.mind.org.uk. If you are concerned about your mental health, we recommend that you contact your GP.

If you have any questions, please feel free to contact me at haymond lee

Please forward the study link to any other males who you think can help with the study

Appendix H: Ethical approval

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1

Appendix I: Response analyses

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T-test comparing study variables between those who partially completed with those who fully completed the survey.

Measure

Data Available for Non-Complete

rs N

Complete Data N

Incomplete Data Mean

Complete Data Mean

t-value

p-value

             GRCS-SF 204 7 48.86 46.16 .54 .942

ISS-S 204 7 45.6 44.66 .13 .253             

             

Chi Square and Fisher Exact tests comparing differences in sociodemographic variables between those who partially completed with those who fully completed the survey

Sociodemographic Variables

Df X2 P Value

Ethnicity .715WhiteNon WhiteReligious Group .242ReligiousNot religiousDegree .636 1 .425YesNoDisability .374YesNoSexuality .686HeterosexualOther sexualitiesAge .3 1 .86218-2728-63

Appendix J: Scatterplots of each pair of correlation between each pair of

variables

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Notes. GRCS-SF= Gender role conflict scale short form; ISS-S= Internalized shame scale shame subscale; N= Number of participants

Gender Role Conflict (GRCS-SF) and Shame (ISS Shame Subscale) Scatterplot

Gender Role Conflict (GRCS-SF) and Psychological Distress (DASS-21 Full scale)

scatterplot

Gender Role Conflict (GRCS-SF) and Depression (Depression subscale from DASS-

21) scatterplot

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Gender Role Conflict (GRCS-SF) and Anxiety (Anxiety subscale from DASS-21)

scatterplot

Gender Role Conflict (GRCS-SF) and Stress (Stress subscale from DASS-21)

scatterplot

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Shame (ISS Shame subscale) and Psychological Distress (DASS-21 Full scale)

scatterplot

Shame (ISS shame subscale) and Depression (Depression subscale from DASS-21)

scatterplot

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Shame (ISS shame subscale) and Anxiety (Anxiety subscale from DASS-21)

scatterplot

Shame (ISS shame subscale) and Stress (Stress subscale from DASS-21) scatterplot

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Appendix K: Histogram of the study’s variables residuals

Histogram of ISS-Shame Subscale residuals

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Histogram of DASS-21 full scale residuals

Histogram of Depression (Depression subscale from DASS-21) residuals

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Histogram of Anxiety (Anxiety subscale from DASS-21) residual

Histogram of Stress (Stress subscale from DASS-21) residuals

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Appendix L: Summary of supplementary mediation analyses

Shame (ISS Shame subscale) as a mediator for the relationships between GRCS-SF full scale and DASS-21 and each subscale of DASS-21 (N=200).

Dependent Variable

Effect of IV on DV

Effect of IV on M

Effect of M on DV

Direct Path Indirect Effect

Effect Size

DV Total Effect/ Path C

Path A Path B Path C’ A x b 95% CI Pm 95% CI

DASS-21 Full scale

B .995*** .589*** .897*** .467*** .528.095

.357 - .721 . 531 .386 - .71

Controlled Se .117 .076 .091 .109 .094 .083Depression Controlled

B .385*** .589*** .41*** .143** .242.042

.161 - .327 .627 .448 - .861

Se .053 .076 .040 .049 .042 .108Anxiety Controlled

B .244*** .589*** .221*** .114** .13 .079 - .191 .533 .349 -.883

Se .04 .076 .034 .041 .028 .144Stress Controlled

B .365*** .589*** .266*** .209*** .157 .099-.23 .429 .279 - .63

Se .045 .076 .039 .047 .033 .091Notes. Controlled = Controlled for sociodemographic variables; DASS-21=Depression, Anxiety, Stress Scale – 21; DV= Dependent Variable; GRCS-SF=Gender Role Conflict Scale – Short Form ISS=Internalized Shame Scale; IV=Independent Variable; M= Mediator; Pm= proportion of indirect effect relative to the total effect; *p<.05; **p<.01;***p<.001.

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Shame (ISS shame subscale) as a mediator for the relationships between each GRCS-SF subscales and Depression (Depression subscale from DASS-21) (N=200).

Independent Variables

Effect of IV on DV

Effect of IV on M

Effect of M on DV

Direct Path Indirect Effect

Standardised Effect Size

IV Total Effect/ Path

C

Path A Path B Path C’ A x b 95% CI Pm 95% CI

RE B 1.01*** 1.37 *** .42*** .43*** .57 .38-.78 .57 .42-.77SE .13 .09 .04 .12 .09 .09

RE Controlled B .98*** 1.32*** .41*** .44*** .54 .35-.75 .55 .18-.34SE .13 .19 .04 .12 .09

RABBM B .55** 1.17*** .48*** -.02 .57 .27-.88 1.04 .63-3.57SE .19 .27 .04 .15 .16 30.63

RABBM Controlled

B .6** 1.24*** .47*** .03 .58 .29-.89 .96 .57-2.21

SE .19 10.47 .04 .15 .15 3.15CBWFR B .87*** 1.32*** .44*** .28* .59 .38-.8 .68 .49-.96

SE .14 .2 .04 .12 .11 .12CBWFR Controlled

B .81*** 1.23*** .43*** .27* .54 .33-.77 .66 .47-.98

SE .15 .21 6.21 .12 .11 .13SPC B .41* .7* .48*** .08 .33 .11-.58 .81 .41-2.19

SE .16 .23 .04 .12 .12 6.09SPC Controlled

B .48** .73* .46*** .14 .34 .11-.61 .7 .32-1.43

SE .17 12.01 .04 .13 .13 68.43Notes. CBWFR= conflict between family and work relations; Controlled = Controlled for sociodemographic variables; DV= Dependent Variable; IV=Independent Variable; M= Mediator; Pm= proportion of indirect effect relative to the total effect; RABBM= Restrictive affectionate behaviour between men; RE= Restrictive emotionality; SPC= Success, power, and competition; *p<.05; **p<.01; ***p<.001.

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Shame (ISS shame subscale) as a mediator for the relationships between each GRCS-SF subscales and Anxiety (Anxiety subscale from DASS-21) (N=200).

Independent Variables

Effect of IV on DV

Effect of IV on M

Effect of M on DV

Direct Path

Indirect Effect

Standardised Effect Size

IV Total Effect/ Path

C

Path A Path B Path C’ A x b 95% CI Pm 95% CI

RE B .56*** 1.36*** .26*** .21* .35 .22-.52 .63 .42-.99SE .11 .19 .03 .1 .07 .16

RE Controlled B .5*** 1.32*** .24*** .18 .32 .19-.48 .64 .4-1.09SE .1 .2 .03 .1 .07 .24

RABBM B .55*** 1.17*** .27*** .24 .32 .14-.52 .57 .33-1.34SE .14 .27 .03 .13 .1 1.19

RABBM Controlled

B .57*** 1.23*** .25*** .27* .3 .15-.5 .53 .29-1.25

SE .14 .27 .03 .13 .09 1.03CBWFR B .64*** 1.32*** .25*** .32** .32 .19-.5 .51 .31-.76

SE .11 .2 .03 .1 .08 .12CBWFR Controlled

B .56*** 1.23*** .23*** .28** .29 .16-.46 .51 .31-.84

SE .11 .21 .03 .1 .07 .15SPC B .26* .7* .28*** .06 .2 .07-.37 .76 -.12-5.57

SE .12 .23 .03 .1 .08 8.15SPC Controlled

B .25* .73** .26*** .06 .19 .06-.38 .76 -.73-4.76

SE .12 .24 .03 .11 .08 133.23Notes. CBWFR= conflict between family and work relations; Controlled = Controlled for sociodemographic variables; DV= Dependent Variable; IV=Independent Variable; M= Mediator; Pm= proportion of indirect effect relative to the total effect; RABBM= Restrictive affectionate behaviour between men; RE= Restrictive emotionality; SPC= Success, power, and competition; *p<.05; **p<.01;***p<.001.

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Shame (ISS shame subscale) as a mediator for the relationships between each GRCS-SF subscales and Stress (Stress subscale from DASS-21) (N=200).

Independent Variables

Effect of IV on DV

Effect of IV on M

Effect of M on DV

Direct Path

Indirect Effect

Standardised Effect Size

IV Total Effect/ Path

C

Path A Path B Path C’ A x b 95% CI Pm 95% CI

RE B .77*** 1.37*** .33*** .33** .45 .29-.64 .57 .39-.86SE .12 .19 .04 .12 .09 .12

RE Controlled B .74*** 1.32*** .3*** .34** .4 .25-.58 .54 .36-.81SE .12 .2 .04 .12 .08 .11

RABBM B .41** 1.17*** .38*** -.03 .44 .21-.71 1.07 .38-4.62SE .18 .27 .04 .15 .13 .05

RABBM Controlled

B .46** 1.23*** .35*** .03 .43 .21-.68 .94 .51-3.02

SE .17 .27 .04 .15 .12 104.09CBWFR B 1.14*** 1.32*** .27*** .78*** .34 .22-.53 .31 .21-.45

SE .12 .2 .03 .11 .08 .06CBWFR Controlled

B 1.07*** 1.23*** .26*** .76*** .32 .19-.49 .42 .22-.79

SE .11 .21 .03 .11 .08 .14SPC B .39** .7** .37*** .13 .25 .08-.45 .66 .27-2.05

SE .15 .23 .04 .12 .1 .04SPC Controlled

B .43** .73** .34*** .17 .25 .08-.48 .58 .2-1.48

SE .15 .24 .04 .12 .1 16.43Notes. CBWFR= conflict between family and work relations; Controlled = Controlled for sociodemographic variables; DV= Dependent Variable; IV=Independent Variable; M= Mediator; Pm= proportion of indirect effect relative to the total effect; RABBM= Restrictive affectionate behaviour between men; RE= Restrictive emotionality; SPC= Success, power, and competition; *p<.05; **p<.01;***p<.001.

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Part two: A literature review of the mediating and moderating role of shame for

the relationship between objectification variables and mental health difficulties

in men.

Word Count = 5390

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Statement of journal choice

The Psychology of Men & Masculinity has been selected for journal

submission for a number of reasons. The journal has a focus on the psychology of

men and masculinity; publishes clinical psychology articles; accepts review articles;

and specifically lists topics of interest including Gender Role Strain and Gender Role

Conflict, which are the focus of this review.

The journal is broadly interested in the ways in which sociological and

biological factors impact on the psychology of men. The contributors and audience

come from a wide range of disciplines, including clinical psychology. The guidelines

for journal submissions can be seen in Appendix A.

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Abstract

Research has found that men who scores highly on measures of masculinity

are associated with increased severity of mental health difficulties. However, there is

a need to improve our knowledge of the processes that lead and impact these

difficulties in men. Shame may be an important variable in understanding men’s

mental health, due to conceptual relevance with masculinity theories and correlations

with mental health conditions. In addition, Objectification theory may be helpful in

understanding men’s mental health, due to an increase of pressure to achieve ideal

masculine physique. This study aimed to review the evidence of whether shame

mediates or moderates the relationships between Objectification variables and mental

health difficulties. Four search terms relating to masculinity, Objectification, shame,

and mediators or moderators were used. A search of the following databases was

conducted: PsycINFO, PsycARTICLES, PsycBOOKs, Medline and the Psychology &

Behavioral Sciences Collection. Five articles met the review’s criteria and were

included in this review. The results were that body shame mediated the relationship

between Objectification variables and mental health difficulties (Eating disorders and

Depression). These findings have implications for the treatment of these conditions in

men. However, findings must be treated with caution as there were methodological

issues in these studies. These included concerns about the generalisability of the

findings due to relatively homogeneous samples across the studies, and limitations in

establishing causal relationships. The explanatory power of the statistical models used

in these studies may be improved, by including additional variables relating to

Objectification theory and masculinity. These methodological issues suggest a

direction for future research.

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Men’s health is at risk in comparison to women’s health, with studies

indicating that men on average die seven years younger than women and have higher

mortality rates for the leading fifteen causes of death (U.S. Department of Health and

Human Services, 1996). There is good evidence that men are at greater risk of poor

mental health than women. Approximately three quarters of suicides are completed by

men, and suicide remains the biggest cause of death for men under 35 (Men’s Mental

Health Forum, 2017; ONS, 2016). Research suggests a prevalence rate of 12.5% for

common mental health disorders in men (Men’s Mental Health Forum, 2017). Further

concern is raised by research showing that men are less likely than women to present

to psychiatric or psychological services (Addis & Mahalik, 2003)

Masculinity theories can help to explain men’s difficulties. Masculinity can be

understood as a culturally defined set of attributes or roles attached to the male

biological sex (Kimmel, 2012). Most research into masculinity had used a social

learning perspective (Addis & Cohane, 2005). A social learning perspective

understands masculinity as a socialization process to reinforce dominant ideas about

male gender norms (Eckes & Trautner, 2000). Whilst research had suggested that men

from different social groups value different male gender roles, there are also empirical

support that similar masculine gender roles has been promoted across different

cultures (David & Brannon, 1976; Gilmore, 1990; Levant & Richmond, 2007).

Research has found that men have been socialized into the roles of procreation,

provision, and protection across many different cultures (Gilmore, 1990). Within

western society, research had found that male gender roles include values such as not

being feminine, striving for success, not showing weakness and taking risks (David &

Brannon, 1976).

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Two prominent theories of masculinity, Gender Role Strain Paradigm (GRSP)

and Gender Role Conflict (GRC), elaborates how there are aspects of masculinity that

can be challenging for men (Pleck, 1995; O’Neil, 2008). These challenges may help

to understand how masculinity is related to mental health difficulties. Pleck’s (1995)

theory of GRSP highlights three patterns of strain that can cause distress for men

called Discrepancy Strain, Trauma Strain, and Dysfunction Strain. Discrepancy Strain

relates to distress caused when men do not meet the standards of dominant masculine

norms (Pleck, 1995). These dominant masculine norms tend to include values such as

men not being feminine, striving to be successful, not showing any weaknesses, and

taking risks (Mahalik et al., 2003). Pleck (1995) proposed that a relatively high

number of men do not achieve these prescribed roles. Trauma Strain refers to the

result of traumatic events related to the masculine socialization processes, which may

include physical aggression, social condemnation, and feeling unable to express

emotional vulnerability (Pleck, 1995). Dysfunction Strain relates to how conforming

to masculine norms can lead to negative psychological consequences (Pleck, 1995).

O’Neil (2008) further elaborated on Dysfunction Strain, with his theory of GRC.

O’Neil defined GRC as “a psychological state in which socialized gender roles have

negative consequences for an individual or for others” (O’Neil, 2008). His research

had identified common patterns such as Restrictive Emotionality; Restrictive

Affectionate Behaviour Between men; Conflict Between Work and Family Relations;

and a focus on Success, Power, and Competition.

Empirical studies of masculinity had shown that masculinity is correlated with

a range of mental health conditions, such as depression, anxiety, suicide, and eating

disorders (Mahalik et al., 2003; O’Neil, 2008; Wong, Ho, Wang, & Miller, 2017).

However, these studies tended to rely on correlational designs (Mahalik et al., 2003;

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O’Neil, 2008; Wong, Ho, Wang, & Miller, 2017). There had been a call to use other

methodologies to better understand the findings of these correlation based studies

(O’Neil, 2015). This is to advance knowledge by contextualising correlation based

research to understand the nature of men’s mental health (O’Neil, 2008). This will

also be helpful to develop treatments to minimise the negative effects of masculinity.

O’Neil (2015) had suggested the use of mediating and moderating methodologies.

Mediation tests for the presence of a mediator variable, a variable that explains how a

predictor variable leads to an outcome variable (Field, 2013). Mediators are therefore

the mechanism through which an effect occurs (Field, 2013). If a mediator completely

accounts for the relationship between the predictor and outcome variables, then

complete mediation has occurred (Mackinnon, Fairchild, & Fritz, 2007). If a mediator

only partially accounts for the relationship between the predictor and outcome

variables, then partial mediation has occurred (Mackinnon et al., 2007). Figure 1

contains a diagram of a conceptual basic mediation model.

Figure 1: Diagram of a conceptual basic mediation model from Field (2013).

Moderation tests for the presence of a moderator variable, a variable that alters

the strength or direction of a relationship between a predictor and an outcome variable

(Field, 2013). Moderators therefore explain interaction effects or how one variable

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depends on the levels of others (Field, 2013). Figure 2 contains a diagram of a

conceptual moderation model.

Figure 2: Diagram of a conceptual moderation model from Field (2013).

Structural equation modelling (SEM) or also known as path analyses, is

another method that can also test for multiple mediators and moderators (Hooper,

Coughlan, & Mullen, 2008). SEM uses techniques such as factor analysis, regression,

and path analysis to show how multiple variables are related to each other in complex

models (Hooper et al., 2008).

Objectification theory may help to understand men’s mental health.

Objectification theory states that sociocultural norms lead to the objectification of

people as objects, in such a way that means their value is based on perceived beauty

(Fredrickson & Roberts, 1997). In particular, the objectification of the self can lead to

body surveillance, which can lead to increased opportunities for shame and anxiety,

and then the development of mental health difficulties (Fredrickson & Roberts, 1997).

This theory was originally designed to understand female’s emotional and behavioural

responses to societal pressures on achieving physical appearance ideals (Fredrickson

& Roberts, 1997. As such, there has been a focus of investigating objectification

theory with female samples (Tiggerman, 2011). In a review of the research that

investigated the mental health risks of self-objectification in women, it was concluded

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that self-objectification and self-surveillance are related to disordered eating,

depression, and sexual dysfunction (Tiggerman, 2011). The types of studies included

in this review, included correlational, experimental and longitudinal studies

(Tiggerman, 2011). There is increasing evidence that Objectification theory may also

be relevant in understanding men’s mental health. Research suggests that men’s body

are increasingly becoming more objectified, with a muscular mesomorphic physique

being promoted (Thompson & Cafri, 2007). Indeed, the physiques of male action toys

have become more muscular in the last 30 years (Pope, Olivardia, Gruber, &

Borowiecki, 1999). The media also promotes the idea that men should enhance their

body (Ricciardelli, Clow, & White, 2010), which can lead to psychological distress in

men (Aubrey, 2006). Furthermore, two meta-analyses that included correlational and

experimental studies respectively, found that the pressure from media to achieve ideal

masculine physique was related to low self-esteem, body dissatisfaction, excessive

exercising, and mental health difficulties (Bartlett, Vowels, & Saucier, 2008).

Therefore, self-objectification and/or body-surveillance may be important variables in

understanding mental health difficulties in men.

Shame may be another important variable that can help to understand men’s

mental health, due to both theoretical and empirical reasons. Shame can be defined as

a painful emotion stemming from negative global evaluations of the self and beliefs

about others’ perception of the self (Tangney, 1995). Theoretical reasons that shame

might be important in understanding men’s mental health are related to

Objectification theory and GRSP (Fredrickson & Roberts, 1997; Pleck, 1995). In

accordance to Objectification theory, shame may arise following self-objectification

and body surveillance. GRSP can help to explain why shame may occur, which

relates to Discrepancy Strain. This is strain arising due to not being able to achieve

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ideal norms of masculinity, such as body physique (Pleck, 1995). Empirical evidence

also highlights that shame has been correlated with a range of mental health

conditions, including eating disorders and depression (Lester, 2010; Tangney,

Wagner, & Gramzow, 1992; Thompkins & Rando, 2003). In addition, shame is

correlated with self-objectification and body surveillance in females (Tiggerman,

2011) . Therefore, shame may be an important variable in understanding mental

health difficulties in men.

To further understand men’s mental health and to extend the current research

that has utilised correlational research, this literature review will focus on how self-

objectification variables (self-objectification or body surveillance) and shame is

related to mental health difficulties in men. It will use Objectification theory as a

framework in understanding men’s mental health. Therefore, the aim of this literature

review is review the evidence for whether shame mediates or moderates the

relationships between self-objectification variables and mental health difficulties for

men.

Method

Data source

The Psychology Cross Search database was used, which included PsycINFO,

PsycARTICLES, PsycBOOKs, Medline and the Psychology & Behavioral Sciences

Collection databases. Search terms were developed from preliminary searches of the

existing literature in masculinity and shame. This led to four search terms, which were

used in combination:

1. Abstract search for boy or male or men or mascul*

2. Abstract search for objecticat* or body surveillance

3. Abstract search for shame or self stigma or self-stigma

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4. Abstract search for mechanism or mediat* or moderat* or SEM or path

analys*

Two limiters were applied, which were that articles had to be academic

journals and in English. No other limiter was applied. A search was conducted on the

7/7/18. This identified 27 articles and following the screening process five articles

were left to be included in this review. The screening process involved applying the

inclusion and exclusion criteria at sequential stages:

1. Screening titles and abstracts

2. Screening full texts

3. Hand search screening of the references of the final five articles

No additional suitable articles were found after a hand search of the references

from the final five articles. A Preferred Reporting Items for Systematic Reviews and

Meta-Analyses (PRISMA) flow diagram of this procedure can be seen in figure 3.

Inclusion and exclusion criteria

The inclusion and exclusion criteria were applied when screening articles

based on their title, abstract, and full text. Some articles were excluded for not

meeting multiple criteria.

The following inclusion criteria were applied:

Sample included men

Statistical analyses used either mediation, moderation, or SEM

The predictor variable measured self-objectification or body-

surveillance

The mediating or moderating variable measured shame

The dependent variable was a measure of mental health difficulties.

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Articles were excluded on the following:

Analyses were conducted on pooled male and female data

Articles were not peer reviewed

Articles were not in English

Quality assessment

The quality of each study was assessed by using “Standard quality assessment

criteria for evaluating primary research papers from a variety of fields” (Kmet, Lee &

Cook, 2004). This assessed the quality of each study based on a range of criteria

which included: Having a clear research question; a suitable study design; there is

control for confounding variables; the sampling strategy and sample size were

adequately described; sample characteristics were adequately described; there were

reliable and accurate use of measures; appropriate analytical methods; clear reporting

of results; and an appropriate conclusion (Kmet, Lee & Cook, 2004). The possible

quality scores ranged from 0 to 1 (Kmet, Lee & Cook, 2004). Kmet, Lee & Cook

(2004) recommend excluding articles if they did not meet the quality score of between

0.55-0.75, depending on how conservative one wants the criteria to be. Each article in

this review was rated above the 0.75 threshold.

Figure 3: PRISMA Flow Diagram.

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Potentially eligible records identified through database searches (N=27)

Results

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Exclusion of duplicate records (N=4)

Titles and abstracts accessed for eligibility (N=23)

Exclusion of articles after screening (N=17):

Analyses were conducted on a pooled male and female data(N=3)

Analyses did not use mediation, moderation, or SEM (N=1)

Predictor variable did not measure self-objectification or body surveillance (N=8)

Mediating or moderating variable did not measure shame (N=13)

Dependent variable was not related to mental health difficulties (N=10)

Full text articles assessed for eligibility (N=6)

Exclusion of articles after screening (N=1):

Analyses were conducted on a pooled male and female data (N=1)

Articles included in the review (N=5)

Search results

The search terms found 27 articles, four of which were duplicates, leaving 23

articles to be screened. Following the first screening which involved reviewing titles

and abstracts, 17 articles were excluded. Three articles were excluded because the

statistical analyses were conducted on a pooled data consisting of females and males;

one article was excluded because the statistical analyses did not involve mediation,

moderation or SEM; eight articles were excluded for not meeting the criteria of the

predictor variable measuring self-objectification or body surveillance; 13 articles were

excluded for not meeting the criteria of having shame as a mediating or moderating

variable; and 10 articles were excluded for not meeting the criteria of the dependent

variable being related to mental health difficulties. This left six articles to be screened

by reviewing their full text. At this screening, one article was excluded because the

statistical analyses was conducted on a pooled data consisting of females and males.

This left five articles for review.

Quality assessment

The quality assessment highlighted that there was a relative homogeneity in

terms of study design: Each study used a cross sectional design; each study used a

convenience sampling method; three studies used online questionnaires1,2,4; and each

study had a reported Cronbach Alpha greater than 0.7, apart from one study’s measure

at one-time point3. Each study looked at the mediating role of body shame, which was

tested with SEM in three studies3,4,5, path analyses in two studies1,2, bootstrapping

methodology in one study4, and a Sobel test in one study3. Two studies combined

using SEM and either bootstrapping or a Sobel test of mediation3,4. The possible

quality scores ranged from 0 to 1 (Kmet, Lee & Cook, 2004). The quality scores for

the reviewed studies ranged from 0.77 to 0.95. The mean quality score was 0.88. The

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quality score was calculated by diving the total score with the total possible score.

The total score was calculated by the formula (number of ‘yes’*2) + (number of ‘no’

*1). The total possible score was calculated by the formula 28 – (number of ‘N/A

‘*2). Variations in the quality score were due to how clear the research questions

were, whether they controlled for confounding variables, whether they reported

estimate of variances, and whether the outcome measures were well defined. The

quality assessment for each study can be seen in table 1.

Table 1

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How each study was assessed for their quality

Quality Criteria Calogero (2009)

Dakanalis et al., (2012a)

Grabe et al., (2007)

Wiseman & Moradi (2010)

Zheng & Sun

(2017)1) Question / objective sufficiently described

Yes (2) Partial (1) Yes (2) Yes (2) Yes (2)

2) Study design evident and appropriate?

Yes (2) Yes (2) Yes (2) Yes (2) Yes (2)

3) Method of subject/comparison group selection or source of information/input variables described and appropriate?

Partial (1) Partial (1) Partial (1) Partial (1) Partial (1)

4) Subject (and comparison group, if applicable) characteristics sufficiently described?

Yes (2) Yes (2) Yes (2) Yes (2) Yes (2)

5) If interventional and random allocation was possible, was it described?

N/A N/A N/A N/A N/A

6) If interventional and blinding of investigators was possible, was it reported?

N/A N/A N/A N/A N/A

7) If interventional and blinding of subjects was possible, was it reported?

N/A N/A N/A N/A N/A

8) Outcome and (if applicable) exposure measure(s) well defined and robust to measurement / misclassification bias? Means of assessment reported?

Yes (2) Partial (1) Yes (2) Yes (2) Yes (2)

9) Sample size appropriate? Yes (2) Yes (2) Yes (2) Yes (2) Yes (2)

10) Analytic methods described/justified and appropriate?

Yes (2) Yes (2) Yes (2) Yes (2) Yes (2)

11) Some estimate of variance is reported for the main results?

Yes (2) Yes (2) No (0) Yes (2) Yes (2)

12) Controlled for confounding?

Partial (1) Partial (1) Yes (2) Yes (2) Partial (1)

13) Results reported in sufficient detail?

Yes (2) Yes (2) Yes (2) Yes (2) Yes (2)

14) Conclusions supported by the results?

Yes (2) Yes (2) Yes (2) Yes (2) Yes (2)

Total score 0.91 0.77 0.86 0.95 0.9

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Population

The sociodemographic breakdown of each study can be seen in table 2. The

combined total participants for all studies were 920. Four studies used a student

sample1,2,3,5 and one used a community sample4. Four of the studies reported

information regarding age1,3,4,5. The mean age was 21 and the age ranged from 10-70.

Two studies were conducted in the United States (US)3,4, one in the United Kingdom

(UK)1, one in Italy2, and one in China5. The only studies which gave a breakdown of

ethnicity were the two US studies3,4. Amongst these studies, 77-89% of the

participants identified with being white/Caucasian. Two of the studies reported

information regarding sexuality2,4. Of these studies, one study had 50% of the

participants identifying as heterosexual, and one study had 66% of its participants

identifying as exclusively gay. To summarise, most of the studies were based in

western countries1,2,3,4, the mean age was 21 , of the articles that reported ethnicities

most identified with being White/Caucasian, and there was a range of reported

sexualities.

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Table 2A summary of the sociodemographic breakdown of each study’s participants included in this review.

Author Study Number

Country Sample Size

Population Type

Age (M,SD)

Ethnicity Sexuality

Caloero (2009)

1 UK 113 Students M=19.92SD=1.3

- -

Dakanalis et al., (2012a)

2 Italy 255 Students - - 50.1 % Heterosexual

49% HomosexualGrabe et al., (2007)

3 US 141 Students M=11.2*R=10.49-

12.27*

89.4% White *3.4% American

Indian/Alaskan Native *

2.8% Asia American *2.2% Black *

1.7% Hispanic *0.6% Other (mix)*

-

Wiseman & Moradi (2010)

4 US 231 Community M=32.67SD=13.83R= 17-70

77% White or Caucasian,

5% Hispanic or Latino,4% Asian American or

PacificIslander

1% African American,11% multiracial or

other

66% exclusively gay

20% mostly gay12% bisexual

2% mostly heterosexual

Zheng & Sun (2017)

5 Chinese 180 Students M=20SD= 1.13R =17-24

- -

Note. *= Data pooled from males and females as these data were not separated. All other data extracted were from males only.

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Measures

All measures used were based on self-report questionnaires. They asked

participants to rate how much each item applied to them on a Likert scale. Each

measure had cited good reliability and validity in studies that evaluated their

psychometric properties. The measures used in each study can be seen in table 3.

For the independent variables, one study used the Self-Objectification

Questionnaire1 (Noll & Fredrickson, 1998). This measures how much individuals

perceive their body in observable appearance based characteristics (e.g. weight and

muscle tone) versus non-observable characteristics (e.g. strength and stamina). The

measure contains ten items, five of which relates to observable appearance based

characteristics, and five relates of non-observable characteristics. Participants need to

rank order each of these items in relation to how much importance they assign each

characteristic for their own physical self-concept, from zero (least importance) to nine

(most importance). The score is calculated by subtracting the sum of the non-

observable characteristics from the sum of the observable characteristics. The possible

range of scores is -25 to 25, with higher scores indicating high levels of self-

objectification. Four studies used the Body Surveillance subscale of the Objectified

Body Consciousness Scale, or an Italian or youth variant of it2,3,4 (Dakanalis et al.,

2012b; Lindberg, Hyde, & McKinley,2006; McKinley & Hyde, 1996). The Body

Surveillance subscale contains eight items and ask participants how much they

monitor their bodies. The language were adapted for the Italian and youth variant of

this measure (Dakanalis et al., 2012b; Lindberg, Hyde, & McKinley,2006).

For the mediating variables, each study included the Body Shame subscale of

the Objectified Body Consciousness Scale, or a youth and an Italian variant of it

(Dakanalis et al., 2012b; Lindberg, Hyde, & McKinley,2006; McKinley & Hyde,

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1996). This contains eight items and ask participants to measure the degree of shame

they have regarding their body. The Italian variant is translated into Italian and the

youth variant contains only five items (Dakanalis et al., 2012b; Lindberg, Hyde, &

McKinley, 2006). Additional mediating variables were included in two studies 1,5.

Body Surveillance was also included in Calogero’s (2009) study and Appearance

Anxiety was included in Zheng & Sun’s (2017) study. The Appearance Anxiety Scale

– Short Form contains 14 items and ask participants to rate how anxious they are

about their appearance (Dion, Dion, & Keelan, 1990). The Body Surveillance

measure has already been described, as it was used as an independent variable

measure in three studies 2,3,4.

For the dependent variables, mental health difficulties measures related to

Eating Disorder and Depression. Four studies measured mental health difficulties in

relation to Eating Disorders and used the following measures 1,2,4,5: The Drive for

Thinness, Drive for Muscularity (adapted from Drive for Thinness), Bulimia, and

Body Dissatisfaction subscales of the Eating Disorder Inventory first and second

editions (EDI-I;EDI-II; Garner, Olmstead, & Polivy, 1983; Garner, 1991); and the

Eating Attitude Test – 26 (EAT-26; Garner, Olmsted, Bohr, & Garfinkel, 1982). The

main difference between these measures is that the EDI measures overall eating

symptomatology (Garner et al., 1983;Garner, 1991), and the EAT-26 also measures

eating symptomatology, but was developed for non-clinical samples (Garner et al.,

1982). Three studies measured mental health difficulties in relation to depression 1,3,5.

They used the following measures: The Italian version of Beck Depression Inventory-

II (BDI-II; Ghisi, Flebus, Montano, Sanavio, & Sica, 2006 as cited in Dakanalis et al.,

2012b) ; Children’s Depression Inventory (CDI; Kovacs, 1985); and Zung’s Self-

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Rating Depression Scale (SDS; Zung, 1986). Each of these measures measured the

clinical construct of Depression.

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Table 3A summary of each study’s results in relation to their model that focus on the mediating role of shame for mental health related outcomes.Author Study

NumberIV (measure) Mediating Variable

(measure)DV (measure) Analysis Results

Calogero (2009)

1 Self objectification (SOQ)

Body shame (OBSC- Body Shame) and Body surveillance (OBSC-surveillance)

Eating disorder (The Drive for Thinness, Bulimia and Body Dissatisfaction subscales of the EDI-2)

Path analyses Significant paths from self-objectification to body surveillance (.56***), body surveillance to body shame (.34***), and body shame to eating disorder (.44***).

Dakanalis et al., (2012a)

2 Body surveillance (Italian version of OBSC-Surveillance)

Body shame (Italian version of OBSC-Body Shame)

Eating disorder (Bulimia, Drive for Muscularity, and Body Dissatisfaction subscales from the Italian version of EDI-II) and depression (Italian version of BDI-II)

Path analyses For homosexual men, significant paths from body surveillance to body shame (.06), body shame to depression (.32***), and body shame to eating disorder (.44***). For heterosexual men, significant paths from body surveillance to body shame (.01), body shame to depression (.49***), and body shame to eating disorder (.54**).

Grabe et al., (2007)

3 Body surveillance(OBC-Y)

Body shame (OBSC Youth edition- Body Shame)

Depression (CDI) SEM and sobel Body shame did not mediate the relationship between body surveillance and depression (t=1.6).

Wiseman & Moradi (2010)

4 Body surveillance (OBSC-surveillance)

Body shame (OBSC- Body Shame)

Eating disorder symptomology (EAT-26) SEM and Bootstrap

Body shame partially mediated the relationship between body surveillance and eating disorder symptoms (indirect effect=.06, 95% CI: .028–.099).

Zheng & Sun (2017)

5 Body surveillance (OBSC-surveillance)

Body shame (OBSC- Body Shame) and Appearance anxiety (AAS-SF)

Eating disorder (Drive for Thinness and Bulimia subscales of the EDI-1) and depression (SDS)

SEM Significant paths from body surveillance to body shame (.29***), body shame to disordered eating (.17***), body shame to appearance anxiety (.26**), appearance anxiety to eating disorder (.17***), and appearance anxiety to depression (.34*).

Notes. AAS-SF= Appearance Anxiety Scale – Short Form; BDI-II= Beck's Depression Inventory; CDI= Children's s Depression Inventory; EAT-26= Eating Attitude Test - 26; EDI-I= Eating Disorder Inventory I; EDI-II= Eating Disorder Inventory II; OBSC-Body Shame= Body Shame subscale of the Objectified Body Consciousness Scale; OBSC-Surveillance= Body Surveillance subscale of the Objectified Body Consciousness Scale; OBC-Y= Objectified Body Consciousness Scale for Youth; SDS=Zung’s Self-Rating Depression Scale; SOQ= Self-Objectification Questionnaire; *P <.05; **P<.01; ***P<.001.

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Main results

The focus of this literature review was to investigate the role of shame in relation

to self-objectification variables (self-objectification or body surveillance) and mental

health difficulties. The literature review showed that the dependent variables were related

to Eating Disorders and/or Depression. The results will be presented in relation to this.

The role of Body Shame in relation to Self-Objectification variables and Eating

Disorders

Four studies investigated the mediating role of body shame in a male sample, for

the relationship between self-objectification variables and eating disorders 1,2,4,5. Each of

these studies explicitly used Objectification theory to inform their conceptual mediating

models. This theory states that sociocultural norms lead to the objectification of people as

objects, in such a way that means their value is based on perceived beauty (Fredrickson &

Roberts, 1997). In particular, the objectification of the self can lead to body surveillance,

which can lead to increased opportunities for shame and anxiety, and then the

development of mental health difficulties (Fredrickson & Roberts, 1997). The explicit

model of Objectification theory has led to each study using the similar measures.

However, between the studies, there are variation in the degree of fidelity to

Objectification theory.

Three studies investigated in their model whether shame mediated the relationship

between body surveillance and Eating Disorder 2,4,5 . In addition, Zheng & Sun (2017)

proposed a model with appearance anxiety as an additional mediator, so that body

surveillance leads to both body shame and appearance anxiety, which then leads to Eating

Disorder. Zheng & Sun’s model (2017) depicted more accurately the Objectification

theory (Fredrickson & Roberts, 1997) compared to other studies that did not measure

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appearance anxiety 1,2,3,4 . Overall, three studies found that body shame mediated the

relationship between body surveillance and Eating Disorder 2,4,5. In addition, Zheng & Sun

(2017) found that appearance anxiety was also a mediator for this relationship. However,

Calogero (2009) found that body shame did not mediate the relationship between body

surveillance and Eating Disorder. Instead it was found that body shame and body

surveillance mediated the relationship between self-objectification and Eating Disorder

(Calogero, 2009). In particular, Calogero (2009) found that lower self-objectification led

to an increase in body surveillance, which went against her hypothesis based on

Objectification theory. She interpreted this finding as being due to gender bias in the self-

objectification measure (SOQ; Noll & Fredrickson, 1998). This measure was originally

designed to be used with women and it separates valuing observable appearance attributes

and non-observable attributes e.g. strength. Therefore, the finding that lower self-

objectification increased body shame, suggested that the more men valued non-

observable but potentially more masculine attributes, the more their body shame

increased (Calogero, 2009). It is unclear why Calogero (2009) did not find that body

shame mediated the relationship between body surveillance and Eating Disorder, but

three other studies did 2,4,5 . Nonetheless, these studies provided support for the mediating

role of body shame for the relationships between variables relating to Objectification

theory (body surveillance and self-Objectification) and Eating Disorder. The support for

this has been gathered across different countries (UK, US, Italy, and China), across

different sexualities (homosexual and heterosexuals), and with different measures of

eating disorder (EDI-I, EDI-II, and EAT-26).

Other studies varied in relation to whether body shame was a partial or complete

mediator for the relationship between self-objectification variables and Eating Disorder.

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Most of the studies found that body shame was a partial mediator 1,4,5. However, in

Dakalanis et al., (2012) study, they found that body shame, completely mediated the

effect when their analysis was done in a heterosexual sample. Whilst this may be due to

variations in samples, it may also be due to the adaptations they used for their measure of

Eating Disorder (Dakanalis et al., 2012a). For the Drive for Thinness subscale of the EDI-

II, they changed the wordings of the Drive for Thinness subscale so that it related to drive

for muscularity (Dakanalis et al., 2012a). In addition, for the Body Dissatisfaction

subscale of the EDI-II, they changed the wording from too small to too big. These

adaptations were made to reflect social norms for the ideal men’s physique (Dakanalis et

al., 2012a). These adaptations may explain why body shame was a complete mediator in

heterosexual men for the relationship between body surveillance and eating disorder.

However, it can be argued that these adaptations reduced the validity of these subscales as

measures of eating disorder. This is because eating disorder symptomology is not related

to being muscular or being too big (World Health Organization, 1992). These adaptations

may be more relevant if the authors wanted to measure muscle dysmorphia instead.

The role of Body Shame in relation to Self-Objectification variables and Depression

Likewise, two studies concluded that body shame mediated the relationship

between body surveillance and Depression 2,5. The only study whose conclusion

contradicted these studies was that of Grabe et al., (2017). Grabe et al., (2017) attributed

this to using an adolescent sample, where Objectification theory may not be as applicable

due to developmental issues. Overall, studies have suggested that shame mediated the

relationship between body surveillance and Depression in men but not for boys 2,3,5. This

finding has been replicated across different countries (Italy and China) and with different

measures of depression (ZDS and Italian Version of BDI-II). There was also a variation

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in terms of whether body shame was a partial or complete mediator for the relationship

between body surveillance and Depression. Dakanalis et al., (2012a) found that body

shame completely mediated the effect and Zheng & Sun (2017) found that body shame

was a partial mediator. Whilst this may be due to variations in samples, it is also possible

that the difference may be due to the cultural expression of depression. Zheng & Sun’s

(2017) study was based in China and research has shown that Chinese people may

somatise their psychological distress (Ryder & Chentsova-Dutton, 2012). As a result, the

severity of depression they identified using ZDS scale may be an underestimation. This

may have limited how much body shame mediated the relationship between body

surveillance and Depression.

Discussion

Summary

This review aimed to synthesise the evidence for whether shame mediates or

moderates the relationships between self-objectification variables and mental health

difficulties for men. The review found that body shame mediated the relationships

between self-objectification variables (body surveillance or self-objectification) and

mental health difficulties (Eating Disorders and Depression) for adult men, but not for

boys. There were variations regarding whether body shame was a partial or complete

mediator for the studies respective statistical models. This may have been due to

differences in samples and measures used.

Implications

These findings have theoretical and practical implications. Regarding theoretical

implications, these findings can be understood from Objectification theory, GRSP, shame

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models, and research regarding specific mental health difficulties (Beck, 1974;

Fredrickson & Roberts, 1997; Pleck 1995; Tangney, 1995).

Objectification theory states that sociocultural norms lead to the objectification of

people as objects, in such a way that means their value is based on perceived beauty

(Fredrickson & Roberts, 1997). Research has supported that men are increasingly being

more concerned with their body, with a muscular mesomorphic physique being promoted

(Thompson & Cafri, 2007), and pressure from the media to meet this ideal is related to

mental health difficulties (Bartlett, Vowels, & Saucier, 2008).

When the ideal muscular mesomorphic physique is not achieved, this may lead to

Discrepancy Strain (Pleck, 1995). Therefore, men may feel emasculated, when they do

not meet the ideal muscular mesomorphic physique. When men experience Discrepancy

Strain, this may lead to feelings of shame. Theories of shame converge to suggest that

shame relates to feeling inadequate about oneself as a whole, as opposed to a particular

aspects of oneself (Mills, 2005). Cognitive models of shame suggest that this could lead

to depression due to the development of habitual negative thinking styles (Beck, 1974).

Feelings of shame may also lead to eating disorders in order to manage emotional

distress or to reach physical ideals of masculinity. Regarding managing emotional

distress, cognitive models of eating disorders suggest that eating disorders are a way to

avoid emotions and manage negative feelings (Pennesi & Wade, 2016). Indeed,

traditional masculine norms encourage men to restrict their emotional expression (O’Neil,

2008). Regarding reaching a physical ideal of masculinity, research suggests that there is

an emphasis on men appearing muscular with low body fat (Jones & Morgan, 2010). This

could also lead to over exercising, which is strongly associated with disordered eating

patterns (Blouin & Goldfield, 1995). In addition, there is research to suggests that for

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homosexual men, there are additional pressures to have thin bodies, which may also

contribute to the development of an eating disorder (Siever, 1994).

The findings within this literature review, suggest that targeting body shame may

be important in alleviating symptoms of Eating Disorders and Depression for men, when

these presentations are in the context of body image. In addition to research, which

recommends the use of Cognitive Behavioural Therapy for Eating Disorders and

Depression (Roth & Fonagy, 2005), additional approaches or adaptations may be helpful.

These include using compassion focused therapy to target shame, cognitive behavioural

therapy to address unhelpful cognitions around masculinity, and narrative therapy to

deconstruct dominant narratives around masculinity and thickening more helpful

narratives of masculinity (Beck, 1974; Gilbert, 2010; Morgan, 2000).

Methodological issues

The strengths of the studies were that the statistical models were informed from a

theoretical basis, this being Objectification theory (Fredrickson & Roberts, 1997. In

addition, the measures used had good cited reliabilities (Cronbach Alphas >0.7) and

validities. However, there was a lot of homogeneity in terms of the designs of each study.

All studies identified in the review used a cross sectional design and each used

convenience sampling. These designs have a range of limitations including that causality

cannot be inferred statistically from a cross sectional design, and that recruitment bias

was likely due to the use of convenience sampling.

Most of the studies were based in western countries, with participants mean age

being 21 years old, and participants predominately identifying themselves as

white/Caucasian. Overall therefore, caution is needed when generalising the results of this

review beyond these participants characteristics. However, it is noted that there are a

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couple of studies within this review that contained participants characteristics that are

from different groups e.g. Chinese and homosexuals 2,5 . Likewise, few studies

characterised their sample from other sociodemographic variables such as socio-

economic class, sexuality, religion and disability. Without these findings, it is difficult to

ascertain whether the results of these studies also generalise to people from different

sociodemographic categories. The relevance of this is also important within the context of

masculinity. This is because masculinity is socially constructed (Thompson & Pleck,

1995). Indeed, research has identified different masculine norms from different cultures

(Levant & Richmond, 2007). Therefore, it is possible that body shame may mediate or

moderate the relationships between self-objectification variables and mental health

difficulties differently for men from different sociodemographic backgrounds.

Each study provided a statistical model informed by Objectification theory

(Fredrickson & Roberts, 1997). However, each of these models did not completely

include all the variables within Objectification theory. Objectification theory states that

the objectification of the self can lead to body surveillance, which can lead to increased

opportunities for shame and anxiety, and then the development of mental health

difficulties (Fredrickson & Roberts, 1997). Whilst measures of body surveillance, body

shame, and mental health difficulties were used in each study, only one study measured

self-objectification 1 and one study measured anxiety5. Therefore, the support for

Objectification theory for men’s mental health difficulties, has not been completed tested.

This review aimed to investigate whether shame mediated or moderated the

relationships between self-objectification variables and mental health difficulties in men.

However, there is a lack of information in these studies about whether men identify as

masculine and the extent to which they adhere to masculine norms. This may be

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important to increase the explanatory power of statistical models, especially as different

masculinity constructs are related to mental health difficulties and shame (Mahalik et al.,

2003; O’Neil, 2008; Wong, Ho, Wang, & Miller, 2017).Studies that are interested in

men’s mental health difficulties and do not use a measure of masculinity, may be making

assumptions regarding how homogenous men are in terms of what masculine norms they

endorse based on their sex. However, men vary in terms of how much they endorse

different socio-cultural masculine norms and this may have different implications

regarding mental health difficulties (Levant & Richmond, 2007). For example, men can

vary on how much they are willing to seek help, which is correlated with severity of

mental health difficulties (Levant & Richmond, 2007).

Future research

Further research can extend the findings found in this literature review by using

study designs to improve the limitations identified. These include replicating findings

with a population that are not predominately based in western countries, with participants

ages ranging from across the lifespan, and participants that do not predominately identify

as being white/Caucasian. Likewise, ensuring the sample is characterised by other

sociodemographic variables such as socioeconomic class, sexuality, religion and

disability, may be helpful in understanding how generalizable the results are. To enable

causal inferences, different study designs can be helpful such as experimental designs and

use of randomization where appropriate (MacKinnon et al., 2007). Lastly, the inclusions

of additional variables can be helpful to further test the application of using

Objectification theory to understand men’s mental health. Statistical models can be

modelled based on Objectification theory, which states that the objectification of the self

can lead to body surveillance, which can lead to increased opportunities for shame and

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anxiety, and then the development of mental health difficulties (Fredrickson & Roberts,

1997). Both self-objectification and anxiety has been used only once in this review. The

use of the Self-Objectification Questionnaire (Noll & Fredrickson, 1998) and the

Appearance Anxiety Scale – Short Form (Dion, Dion, & Keelan, 1990), can be used to

fully test Objectification theory. Likewise, the inclusion of masculinity measures may

provide further explanatory power to statistical models that are investigating the

application of Objectification theory to men’s mental health. The Gender Role Stress

Scale may be helpful, as it can be conceptualized as measuring Discrepancy Strain (Eisler

& Skidmore, 1987). This may be of particular relevance in relation to Objectification

theory, as it addresses difficulties of not being able to achieve the standards of masculine

norms.

113

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Part three: Clinical Experiences

Adult Placement

Setting: Adult Community Mental Health TeamLength: One yearExperiences:

Cognitive Behavioural Therapy (CBT) individual work and transdiagnostic CBT group

Service users’ presentations were predominately depression and anxiety New patient assessments and cognitive assessments Teaching on motivational interviewing to a multidisciplinary team (MDT) team,

and teaching on recovery to carers group

Learning Disability Placement

Setting: Community Learning Disability TeamLength: 6 monthsExperiences:

Acceptance and Commitment Therapy (ACT) individual work CBT individual work Bereavement work Service users’ presentations were predominately depression and anxiety Teaching on ACT Learning disability assessments including tests of executive functioning ADHD assessment Positive behavioural support work Consultations to care homes and day centres

Older Adults Placement

Settings: Older Adults Community Teams for Mental Health and Dementia, and Older Adults Inpatient Teams for Mental Health and DementiaLength: 6 monthsExperiences:

CBT individual work Dementia assessment Challenging behaviour work Service user’ presentations were predominately mood disorders and

neurodegenerative disorders. Literature review on record keeping standards Facilitated reflective practice groups Teaching on frontal lobe impairments Consultations to inpatient teams and care homes Supervision to assistant psychologist

Child Placement

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Setting: Child and Adolescent Mental Health ServiceLength: 6 monthsExperiences:

CBT individual work Teaching on behavioural activation Family therapy Service users’ presentations were predominately depression, anxiety, autism and

ADHD. Care coordinator role Facilitated Dialectical Behavioural Therapy Group Contributed to Autism Assessments ADHD screenings Consultations with schools

Specialist Placement

Setting: Medium and Low Secure Forensic Inpatient WardsLength: 6 monthsExperiences:

Individual CBT work Family Therapy Sex offenders’ treatment group Drugs and alcohol treatment group Mentalization based therapy introduction group Psychodynamic group Service users’ presentations were predominately psychosis, bipolar, and

personality disorders Presentation on personality disorders HCR- 20 training Consultation to inpatient ward teams

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Part four: Assessments

PSYCHD CLINICAL PROGAMME

TABLE OF ASSESSMENTS COMPLETED DURING TRAINING

Any names in assignment titles are fictitious and other identifiable information has been changed. This is to ensure confidentiality and anonymity.

Year I Assessments

ASSESSMENT TITLE

WAIS WAIS Interpretation (online assessment)

Practice Report of Clinical Activity

An Assessment and Initial Formulation of a male in his fifties presenting with symptoms of anxiety and depression

Audio Recording of Clinical Activity with Critical Appraisal

Audio Recording of Clinical Activity with Critical Appraisal

Report of Clinical Activity N=1

An assessment and CBT treatment of a male in his thirties with low self-esteem

Major Research Project Literature Survey

Defining Positive Masculinity and measuring its effects

Major Research Project Proposal

Does shame mediate the relationship between Gender Role Conflict and psychological distress?

Service-Related Project Staff perceptions on partnership working and what improvements can be made between a local Community Mental Health Recovery Service and Drugs and Alcohol Service.

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Year II Assessments

ASSESSMENT TITLE

Report of Clinical Activity/Report of Clinical Activity – Formal Assessment

Assessing whether a female young adult diagnosed with Autism and Velocardiofacial syndrome has a learning disability

PPLD Process Account PPLDG Process Account

Year III Assessments

ASSESSMENT TITLE

Presentation of Clinical Activity

Assessment and Treatment of Mary within an inpatient psychiatric hospital

Major Research Project Literature Review A literature review of the mediating and moderating role

of shame for the relationship between objectification variables and mental health difficulties in men.

Major Research Project Empirical Paper

Does shame mediate the relationship between Gender Role Conflict and psychological distress?

Report of Clinical Activity/Report of Clinical Activity – Formal Assessment

An integrated systemic and CBT interventions to support a boy with ADHD and anxiety to improve his school attendance

Final Reflective Account

On becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of training

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