Submitted for the Degree Of

Do First Year Male Undergraduates from Poorer Families Suffer more Mental Health Difficulties due to Increased Financial Strain?

Clarence Bridglal Bissessar

Submitted for the Degree of

Doctor of Psychology

(Clinical Psychology)

School of Psychology

Faculty of Health and Medical Sciences

University of Surrey

Guildford, Surrey

United Kingdom

December 2016

Abstract

Objective:Both financial strain and socio-economic status (SES) or class have been found to be negatively associated with mental health for students. In the context of national changes to higher education funding, male students from low SES backgrounds may be at particular risk of developing untreated mental health difficulties because of the way such distress tends to manifest in men, and because of their lack of help-seeking.The first year of university study is a period of significant transition for young people, which can increase their vulnerability to psychological distress.This study aims to look at the association between financial disadvantage and psychological wellbeing in male first year undergraduate students, and to examine whether this is mediated by perceived financial strain and subsequent stress.

Design:A quantitative cross-sectional design was used.

Method:Data was collected from164 male students using an online questionnaire. This contained measures of financial strain, stress, depression, anxietyand family affluence. Pearson’s correlation coefficients were calculatedto examine associationsbetweenthe study variables.Bootstrapping analyses was conducted to test for the indirect effects of financial strain and stress.

Main Findings:Lower family affluence scores were not directly associated with increased scores for depression, anxietyor stress symptoms; however, they were indirectly associated with increased scores for depression symptoms, through increased financial strain. Greater financial strain was associated with increased scores for anxiety and depression symptoms, through increased stress. Serial mediation of family affluence scores to mental health symptoms through both financial strain and then stress was not found.

Conclusions:The findings support the broader idea that perceptions of financial circumstances are related to psychological wellbeing in the male student population. The study also supports the idea that male students have a stress-vulnerability that may lead those with higher perceived financial strain to experience psychological distress.

Acknowledgements

I would like to thank the staff at the University of Surrey Clinical Psychology Training Programme, in particular my research supervisor Linda Morison for her enthusiasm, expertise and encouragement. Thank you for having faith in me when others did not.

I would like to thank the Research Development Programme team and the Additional Learning Support team for theirguidance.

I owe a debt of gratitude to Jenny Hall and Carolyn Gent; I would not have completed the course without your input.

I would like to thank my family and friends, in particular my parents, Afrose & Charles Bissessar, and in-laws, John & Julie Harding, for their continued support throughout the course. I would like to thank Matthew Cowen for providing friendship when I needed it the most. I would also like to thank everyone at Centrepoint who provided their support.

I am especially grateful for my amazing and precious wife, Catherine Bissessar. Thank you for saying yes and I do. I could not have completed this coursewithout you.

Finally, thank you to my Father - no words could express my gratitude for all you have done.

Contents

MRP Empirical Paper...... 6

MRP Empirical Paper Appendices...... 65

MRP Proposal...... 97

MRP Literature Review...... 117

Summary of Clinical Experience...... 161

Assessments Completed in Training...... 164

Empirical Paper

Do First Year Male Undergraduates from Poorer Families Suffer More Mental Health Difficulties due to Increased Financial Strain?

Clarence Bissessar

Word Count (excluding reference list, appendices and abstract)

9894

Statement of Journal Choice

Psychology of Men & Masculinity®

“Psychology of Men & Masculinity®” is an APA journal that focuses on the dissemination of research, theory, and clinical scholarship that advances the psychology of men and masculinity. It was chosen due to its focus on men’s mental health.For more details, see Appendix A.

Abstract

Design:A quantitative cross-sectional design was used.

Introduction

Funding for universities has changed substantially over the last ten years (Bachan, 2014) which may have impacted upon students’ financial worries(Jessop, Herberts & Solomon, 2005),especially for those from poorer family backgrounds (Ibrahim, Kelly & Glazebrook, 2013). This research aimed to examine whether students from poorer backgrounds suffer greater financial strain and consequent adverse effects on their mental health. This research also aimedtoexamineif students suffering from financial strain experience mental health difficulties as a result of stress. The study focused on male students in their first year at university.

Male first year undergraduates

Men are at particular risk of experiencing untreated psychological distress because of their lack of help-seeking behaviour, and also because they present in ways which do not match conventional diagnostic criteria (Addis & Mahalik, 2003; Martin, Neighbors & Griffith, 2013). Most of the literature on gender differences in mental health suggests that women are more likely to be diagnosed with a mental health problem than men (Freeman & Freeman, 2013). However, more recently, attention has been drawn to other data which suggests that findings based on diagnosis do not paint a true picture of the state of mental health in males. For example, almost three quarters of people who commit suicide are men (Office for National Statistics [ONS], 2012a). Men are nearly three times more likely than women to become alcohol dependent (Health & Social Care Information Centre, 2015). Also, men are nearly 50% more likely than women to be detained and treated compulsorily as psychiatric inpatients (Health & Social Care Information Centre, 2013). These findings demonstrate that the reasons behindthe diagnostic gap between men and women in terms of mental health is perhapsmore complex than previously thought.As these statistics have been brought to the fore, much more public attention is now being given to the topic of male mental health; why men differ in the presentation of psychological distress; and the mechanisms that explain these differences (Seager et al., 2014). One mechanism that has been suggested is male role conformity, which is the idea that men’s behaviour is influenced by certain cultural norms, values, and ideologies about what it is to be masculine (Kingerlee, 2012). Key aspects of such norms are self-reliance and not displaying emotion. As a result, men often tend to engage in externalising behaviours when experiencing distress rather than seeking support from their social environment or professionals (Martin, Neighbors & Griffith, 2013). A literature review (Bissessar, 2014) outlined how men are less likely than women to seek help when experiencing distress, and found that there is a paucity of data examining what predicts whether a man will seek help. As a result, men are at particular risk of experiencing untreated psychological distress.

Worldwide, psychological distress has been found to be higher in students when compared to the same-aged normal population (Dyrbye, Thomas, & Shanafelt, 2006; Ibrahim, Kelly, Adams & Glazebrook, 2013). This has also been found to be true in the United Kingdom (UK) (Stewart-Brown et al., 2000). There has been a recent increase in interest in the mental health of students (Verger et al., 2009). Students, service managers and counsellors all report an increase in utilisation of university counselling services (Royal College of Psychiatrists [RCoP], 2011). The psychological health of students is a cause for concern (Bewick, Koutsopoulou, Slaa & Barkham, 2010, El Ansari et al., 2011). A number of theories have been put forward to explain why students are a particularly vulnerable population.

Stress-vulnerability models propose that a person’sgenetic, biological, cultural and psychological vulnerabilities interact with present ‘risk factors’, stressorsor demands in life (Ingram & Luxton, 2005). These ‘risk factors’ may result in developing into a mental health illness if they are not outweighed by‘protective factors’ such asresources or coping mechanisms (Ingram & Luxton, 2005). With this model in mind, students are a particularlyhigh-risk group given the many demands of the first year of undergraduate study (Macaskill, 2013). As they begin higher education, manystudents have to learn how to manage large workloads and study autonomously(RCoP, 2011; Verger et al., 2009). These academic demands are often in the context of living away from home for the first time (Scanlon, Rowling, & Weber, 2010). In addition, there are also social pressures at university which may include misusing alcohol or drugs, making new friends, and undertaking extra-curricular activities (RCoP, 2011). As a result, many students have reported feeling much more stressed having started university due to the demands that are being placed on them (Stradling, 2001).Given these added ‘risk factors’, stress-vulnerabilitymodels may explain why students have poorer mental health when compared to non-students.

There arealso developmental reasons why students are particularlypsychologically vulnerable, especially during the first year of study at university.The start of university represents a unique time in an adolescent’s life which is often treated as a ‘rite of passage’ (Scanlon, Rowling, & Weber, 2007). As adolescents separate from their parents, they go through a period of transition before fully integrating into student culture (Scanlon, Rowling, & Weber, 2007). During this period, many adolescents leave the consistent and dependable environment of their school and family home (Lowe & Cook, 2003) to form a new identity as a student(Scanlon, Rowling, & Weber, 2007);this change is often quiteabrupt (Scanlon, Rowling, & Weber, 2007). The pressure of this period is obvious in those individuals who feel they have failed to transition,who then end up dropping out of university or underachieving (Lowe & Cooke, 2003). This difficult period of transition has led many studentsto describe their university experience, particularlyduring their first year, as lacking in connectedness and involvement, reporting feelings of unhappiness and dissatisfaction, isolation and alienation (Scanlon, Rowling, & Weber, 2007).These developmental challenges are likely to add further stress, andmay explain why students have poorer mental health when compared to same-aged non-students.

In addition to the developmental, academic and social demands that students are under, some have argued thatthe recent economic and political changes that have taken place in the UK have put greater strain on students’ wellbeing (Cook, Bewick, Barkham, Bradley & Austin, 2006; Harding, 2011). Successive UK governments havepushed for more and more students to enter university (Harding, 2011). In 1998 the UK government introduced tuition fees and since then have introduced top-up fees (Briggs, 2006).Since Scotland was granted autonomy in 1999 tuition feeswere replaced with a graduate endowment of £2000 (Briggs, 2006) which is significantly less than what most English students have to pay. Many believe that changes in higher education funding in England have led to a funding crisis (Bachan, 2014).Perhaps in response to these changes, it has been found thatmany adolescents fear debt and as a result are deterred from going to university (Callender & Jackson, 2005). Also, many of the adolescents who do end up enrolling at university end up working, sometimes long hours, in order to fund their education (Roberts et al., 2000). In addition to the personal cost, huge financial changes in higher education have meant that universities have also been under greater levels of pressure. Lecturers have less time to spend with students (Scanlon, Rowling & Weber, 2007) which mayput further pressure on the individual. In addition to the changes in higher education funding in England, students experience many other financial challenges. Many students have to learn to manage their finances autonomously upon attending university (RCoP, 2011) and often without any preparation. Harrison (2006), in a qualitative study investigating reasons for undergraduate withdrawal, found that one main financial narrative was of students wanting to enjoy a highly sociable lifestyle that they were unable to finance. A UK-based study on a large sample of one university population found that increased financial difficulties led to increased levels of depression and anxiety (Andrews & Wilding, 2004). Also, Roberts et al. (2000) found that financial difficulties were related to poor mental and physical health for undergraduate students at two London universities.

The financialand developmental challenges that students experiencetogether can make the first year of university particularly challenging. Few studies have investigated how UK students’ wellbeing changes over time(Bewick, Koutsopoulou, Miles, Slaa & Barkham, 2010). A study by Bewick, Koutsopoulou, Miles, Slaa & Barkham (2010) found that, whilst levels of strain on psychological wellbeing increased for students from pre-registration to the start of university,an increase was also seen over the course of the three years of study, with the scores peaking at the start of each year.Bewick, Koutsopoulou, Miles, Slaa & Barkham (2010) used data from 2000-2002. A study using more recent data by Cooke, Barkham, Audin, Bradley & Davy, (2004), which looked at a large sample from one university in the UK, found that there was greater strain on students’ psychological wellbeing at the start of university compared to at other points preceding entry. Given the limited evidence, theory may inform when the periods of vulnerability are for undergraduate students. Stress-vulnerability models would suggest that students are more vulnerable at the start of university given the added stressors and demands that are being placed on them, in addition to the cultural pressure to transition to adulthood.

The potential vulnerability of first year students due to thefinancial and developmental challenges,coupled with externalising behaviours and a reluctance to seek help for mental distress amongst men,may mean that first year male students are at particular risk of untreated psychological distress. One study reported that 54% of male students metthe threshold of having a psychiatric disorder according to scores on the General Health Questionnaire (MacCall et al., 2001). Another study from the Office of National Statistics (2012b) showed that male student suicides were up 36% between 2007 - 2011.However, there appears to be paucity of research specifically investigating the psychological wellbeing of male students.Therefore, it is important to consider the factors that affect the development and maintenance of mental health difficulties amongst male first year undergraduates.

Social Class and Mental Health.

One particular factor to consider when looking at the mental health of male first year students is social class or Socio-Economic Status (SES). Previous research in the general population and among students suggests that those from lower SES backgrounds are at increased risk of developing mental health difficulties. Lorant et al. (2003) did a meta-analysis of 51 studies across several countries including the UK,and found that SES, defined mainly as educational attainment level (35 studies) and occupation (9 studies), was a moderate to strong correlate for depression in the general population. In addition, a study by the Samaritans found that men from the lowest social class, as defined by the area of residence,were ten times more likely to commit suicide than those from the most affluent areas (Samaritans, 2013). Several studies have shown that men from socially disadvantaged backgroundsalso suffer lower levels of healthcare provision in the UK (Conrad & White, 2010). Despite the evidence in the general population that those from lower SES backgrounds suffer poorer mental health, there is a paucity of research concerning the mental health of students from low SES backgrounds (Ibrahim, Kelly & Glazebrook, 2013). Drawing on a large sample size from Higher Education Statistics Agency (HESA) data, Powdthavee & Vignoles (2009) found a statistically significant difference in dropout rates after the first year of university between those from the most advantaged background (as defined by occupation and the level of deprivation in area of residence)to those from the least, with those from the least advantaged background having higherdropout rates. It has also been reported that those who drop out from university have higher levels of psychological distress (Harrison, 2006). Ibrahim, Kelly & Glazebrook (2013) found that students from more deprived areas,as well asstudents whose mothers were not highly educated, were more likely to have depression symptoms.