Mental Health & The Myth of the American Cowboy
Access to mental health services and support is not the problem
It’s an iconic scene: a sunset-soaked Western plateau and the silhouette of the American Cowboy, surveying the land, having just rescued a family of westward migrants nearly swallowed by a flash flood, or vanquished a gunslinger terrorizing the local townsfolk at high-noon.
The American Cowboy doesn’t sleep, doesn’t eat and barely needs to stop for a quick rest under a lone tree. And the American Cowboy certainly never, ever asks for help. But – if persistently offered – the American Cowboy may humbly accept a hot meal and slice of pie, if it might otherwise spoil and go to waste.
This self-reliant trope – when the going gets tough, the tough get going – is a foundational truth that pervades our mental health crisis: asking for help is extremely hard for many, if not most. Asking for help is seen as a sign of weakness, shame, loss of control. While many even lack a social circle of friends and family of whom to ask for help.
This avoidance of mental health support is paramount to solving a problem labeled ‘access’, that is more complicated and nuanced than simply providing more and different points of entry to a variety of mental health services. And while support and service utilization of such services remains low, the mental health of the US workforce worsens. The solution is creating a support system for cowboys, who aren’t ready or willing to seek help for themselves.
This whitepaper covers a variety of topics that impact employee mental health benefit planning in 2025:
State of US mental health and employer concerns
Mental health access drivers
Mental health utilization challenges
Mental health benefits design considerations
The US mental health crisis persists
Despite increased awareness and appreciation of the need for improved access, since the mid-2010s, the mental health of the general population remains troubled, particularly for working-aged adults:
90% of people think there is a mental health crisis in the United States
Half of all adults (51%) say they or a family member have experienced a severe mental health crisis[1]
Only 31% of US adults considered their mental health “excellent”, down from 43% in the 2000s[2]
92% of workers said it is very (57%) or somewhat (35%) important to them to work for an organization that values their emotional and psychological well-being.
Furthermore, US Surgeon General’s last two reports highlight growing mental health concerns:
2023: the Loneliness and Isolation epidemic, states: “the mortality impact of being socially disconnected is similar to that caused by smoking up to 15 cigarettes a day”[3]
2024: the crisis of Parents’ Mental Health and Well-being[4], states: “33% of parents reporting high levels of stress in the past month compared to 20% of other adults. When stress is severe or prolonged, it can have a harmful effect on the mental health of parents and caregivers, which in turn also affects the well- being of the children they raise”
Employers’ response to calls for access.
The Business Group on Health’s 2024 Large Employer Health Care Strategy Survey[5] and Mercer’s Survey on Health and Benefit Strategies for 2025[6] found that benefit leaders recognized, reacted to and invested in a variety of mental health access points in the last several years:
94% offer mental health apps or online resources[5]
70% offer no- or low-cost access to tele-mental health services[5]
69% enhanced or extended their EAP benefits[6]
57% expanded their mental health networks[6]
Despite these investments, ‘access’ remains the top mental health priority for 79% of respondents to the Business Group on Health’s 2025 Employer Health Care Strategy Survey[6]. Why is it that access is still seen as a problem, despite apps and services aimed at closing the gap?
This whitepaper examines the issues to support employee mental health benefit planning to address their employees mental health access needs:
What underlies the access issue?
What’s working and what isn’t?
How to ensure people get the support they need?
Unpacking ‘access’
This paradox of increased access and flat utilization perplexes employee benefit directors; why aren’t employees using services despite the need?
Asking for help is hard. Accepting help is easier.
In a society that praises a “pull-yourself-up-by-your-bootstraps” mantra, many have difficulty finding the courage to ask for help because it makes them feel vulnerable and weak, and fear rejection. Layer on the stressors of daily life and a mental health condition, and asking for help isn’t just hard, it becomes impossible, as care avoidance is a symptom of many mental health conditions. Above and beyond others lack a social support system of whom to ask.
So, despite the availability of a growing set of mental health benefits and access points, utilization by working-aged adults is extremely low.
A proactive approach can be a far more effective engagement strategy, as people find it easier to accept help when offered.
The ‘human condition’ is the only one that matters.
The healthcare system is – to a large degree – built to treat illness and prevent death. Despite the recognized knock-on effect of root-causes on mental and physical health, there are no hospital departments for “I’ve lost my housing”, “I can’t pay my electric bill” or “how do I care for my aging parents”?
These symptoms of the ‘human condition’ are what drives most people’s daily actions and are often the greatest contributors to mental health concerns. This impacts the sequence of care: An individual will never be able to begin to address their physical conditions without first addressing those mental health challenges, which can’t be addressed before safety and security concerns.
The best way to support the ‘human condition’ is to see and hear every person as an individual, rather than take a blanket treatment approach for everyone. Every person faces his or her own challenges and life circumstances, so a programmatic workflow or protocol is only minimally effective. Meeting people where they are and helping solve their own unique and very personal set of problems builds a bond that can lead to lasting circumstances and behavior change.
What’s working. What’s not. Mental health in 2024.
Buoyed by the pandemic, employers have increased coverage for mental health benefits, including a cascade of self-help apps that have struggled to fill the access holes. A meta-analysis published in the Journal of the American Medical Association found apps’ impact are moderate[7] and “more effective for people with smaller problems who were not already in therapy… [and] were less effective, however, when it came to long-term problems like severe depression”[8].
Meanwhile, those seeking in-person or virtual therapy still face weeks’- and months’-long wait times. And those that do seek therapy often quit, as up to half of people do not return after their initial visit[9]. This may indicate that, for a large part of the population, traditional therapy approaches are not meeting expectations.
Fixing access utilization
If access is not at the heart of the utilization issue – and self-help apps only work for those on the higher-performing end of the continuum – how do we help those suffering silently, who can’t or won’t ask for help? Let’s look at some factors that drive use of mental health benefits.
Seeing the forest through the… soil? The role of ‘root cause.’
As reported in a 2023 Time magazine article[10], some psychiatrists believe that traditional therapy and medications don’t do enough to help develop “problem-solving” skills. Beyond problem-solving skills, however, are daily struggles or moments of crisis that become insurmountable and cause a rapid decline in quality-of-life, job presence and performance.
It’s not surprising that the CDC recognizes the frequent role of root-causes of mental health challenges from life stressors such as:
Family concerns or death
Financial stress
Going through a major life change, even if planned
Taking or changing medications
Physical injury[11]
Recognizing the root-cause-nature of many mental health issues is foundational to designing a support system that understands and attends to a wide variety of challenges and supports each person with life’s biggest problems.
Offer a lifeline.
As highlighted, asking for help is hard, even in the best of circumstances. This vexes the patient-initiated healthcare paradigm. The only solution is to flip the script: to seek out employees in need, to establish relationships, to build trust and provide meaningful support in times of stress and crisis.
When people are knocked down by life’s problems, a helping hand at the right moment can get them to their feet. Proactively identifying, seeking out and engaging people when momentous problems strike with the right support and guidance to make their everyday lives better can lead to sustained increased quality-of-life and lower medical costs[12].
Benefits designed to support.
Employee benefit managers are custodians of sometimes-dichotomous goals: improving employee health and well-being while being good stewards of company resources through wise benefit selection. A predictive and proactive approach to employee mental health and well-being can ensure that employees get the most from their benefits, and result in improved workforce quality-of-life.
When designing employee benefits with the goal to improve utilization of mental health benefits consider how you can help the ‘cowboys’ in your workforce:
Provide personalized outreach to help individuals silently suffering with life’s struggles to overcome resistance to seek support and create opportunities for significant quality-of-life improvement;
Support daily struggles, crisis and health and safety concerns that are frequently the root cause of mental health concerns and physical ailments, and;
Implement quantifiable workforce quality-of-life outcomes measurements to gain insight on the health of your workforce beyond accessibility and minimum levels of engagement.
Learn more about how a proactive approach to mental health may help your organization.
[1] Lopes, Lunna; Kirzinger, Ashley; Sparks, Grace; Stokes, Mellisha; and Brodie, Mollyann (5 October 2022). KFF/CNN Mental Health In America Survey”. https://www.kff.org/report-section/kff-cnn-mental-health-in-america-survey-findings/
[2] Brenan, M. (2024, February 7). “Americans’ reported mental health at New Low; more seek help”. Gallup.com. https://news.gallup.com/poll/467303/americans-reported-mental-health-new-low-seek-help.aspx#:~:text=WASHINGTON%2C%20D.C.%20%2D%2D%20Americans’%20positive,rating%20by%20three%20percentage%20points.
[3] Murthy, Vivek H. (2023). “Our Epidemic of Loneliness and Isolation.” U.S. Department of Health and Human Services, 2023, www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf.
[4] Murthy, Vivek H. (2024). “Parents Under Pressure.” U.S. Department of Health and Human Services, 2024, https://www.hhs.gov/sites/default/files/parents-under-pressure.pdf
[5] Business Group on Health (22 August 2023). “2024 Large Employer Health Care Strategy Survey”. https://www.businessgrouphealth.org/resources/2024-large-employer-health-care-strategy-survey-intro
[6] Mercer (2024). “Health & Benefit Strategies for 2025”. https://www.mercer.com/en-us/insights/total-rewards/employee-benefits-strategy/health-and-benefit-strategies-report/
[7] Business Group on Health (20 August 2024). “2025 Employer Health Care Strategy Survey”. https://www.businessgrouphealth.org/en/resources/2025%20employer%20health%20care%20strategy%20survey%20intro
[8] Hayoung Bae, BA; Hyemin Shin, MA; Han-Gil Ji, BA; et al (20 November 2023). “App-Based Interventions for Moderate to Severe Depression: A Systematic Review and Meta-Analysis”. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2812076
[9] northjersey.com part of the USA Today network (2 January 2024); https://www.northjersey.com/story/news/2024/01/02/mental-health-apps-work-nj-therapists-calm-betterhelp-headspace/71799362007/#:~:text=New%20findings%20published%20in%20the%20Journal%20of,1%2C500%20participants%20with%20moderate%20to%20severe%20depression.
[10] Bernard Schwartz, PhD and John Flowers, PhD (accessed 9 September 2024). “How Therapists Fail: Why Too Many Clients Drop Out of Therapy Prematurely”. https://www.psychotherapy.net/article/therapy-failure#:~:text=Here%20are%20some%20practical%20tips%20to%20increase%20your%20odds%20of%20success.&text=Depending%20on%20which%20study%20you,return%20after%20their%20initial%20session.
[11] Ducharme, Jamie (28 August 2023). “America Has Reached Peak Therapy. Why Is Our Mental Health Getting Worse?”. https://time.com/6308096/therapy-mental-health-worse-us/
[12] Center for Disease Control (13 October 2023). “Mental Health Conditions: Depression and Anxiety”. https://www.cdc.gov/tobacco/campaign/tips/diseases/depression-anxiety.html#:~:text=Experiencing%20traumatic%20or%20stressful%20events,Taking%20certain%20medications.
[13] Aircare Health data (2024).