Grief and groups: Considerations for the treatment of depressed men

Connecting loss, grief, and depression among men 

The incomplete repression of painful and vulnerable emotions associated with a death loss can create conditions that invite significant emotional turmoil (i.e., depression) and mobilize self-medication and acting out strategies to relieve the discomfort caused when these emotions threaten to break through into consciousness [3]. Consider the following quote from Kraepelin, which was made more than a century ago: “Specific external causes very frequently seem to foster the outbreak of melancholia (i.e., depression). Some such causes, which can be cited, are physical diseases (influenza, gastritis), operations, losses of fortunes, shock, worries due to business ventures, changes in living conditions, but above all, illness and death of the next of kin.” [4]. Since Kraepelin's observations about the importance of bereavement in the pathogenesis of depression, several investigators have provided empirical confirmation. For example, a meta-analysis of 20 prospective studies on late-life major depression found that recent bereavement was the most robust risk factor for the onset of a depressive episode [5].

Jolliff & Horne suggest that “grief work is the core element in men's work, because grief is the common denominator that ties men's experiences together” [6: pp. 58–9]. Similarly, the American poet Robert Bly has argued that “grief, rather than anger, is the doorway to a man's feelings”. Several authors contend that for men, issues related to loss and grief are of paramount importance at numerous points through the lifespan [7]. When contextualized in various life domains many men's therapy issues become, on various levels, issues of grief and loss [8]. This happens regardless of whether they manifest concretely, such as the loss of an intimate relationship, or symbolically in the loss of status and prestige associated with changes to employment. It is important to point out that these conclusions concerning the impact of grief on men are based on clinical opinions, as there has been no empirical work published on this topic.

Complications may arise in the manner in which boys and men negotiate sadness and grief associated with loss. Young boys, as they grow and develop, learn socioculturally prescribed male roles about gender-appropriate behaviours in the context of their early relationships. Studies have suggested that a constellation of dominant ideals of masculinity are organized around the prohibition of emotional awareness and expression in general and the proscription of sadness as a mood and crying as a behavioural expression of that mood in particular [9]. We all know that “big boys don’t cry” and those who do are marginalized amidst various labels including “sissy”. Such values, often unconsciously imparted by parents and other caretakers, profoundly shape a growing boy's identity and role and interpretation of his experience of loss and grief and have a long-lasting impact on the manner by which he eventually learns to mourn loss [10]. In other words, Western masculine norms prohibiting men's expression of vulnerable feelings can affect the manner in which they negotiate the grieving process. Thus, a developing boy may learn to dissociate himself from aspects of his emotional experience, specifically from any visible feelings of sadness. Anger, shame, and control-oriented defenses often arise as a means of self-protection. Consequently, many men develop powerful and ultimately problematic defenses around the complete and healthy resolution of what is in fact a common human experience: the experience of loss and sadness that arises from the making and breaking of human bonds. Certainly, as men age, there is often an accumulation of loss experiences. The compounding effects of these losses, coupled with constricting expectations to deny the inherent sadness that loss brings, can cripple men as they enter the later years of life.

Group therapy for depressed men 

Although men may seek help for their depression less often than women, there is evidence that men who do participate in psychotherapy benefit from it [2]. Psychotherapy can be provided in a variety of formats, the most common being individual and group formats. There is an absence of research investigating whether individual therapy and group therapy are differentially effective for men or whether men prefer one format over another. While available evidence suggests that individual and group formats of therapy can be equally effective, group therapy may be especially useful for treating men. Most writings about men in group therapy concern all-male groups. Several advantages of all-male therapy groups have been noted, including offering men a familiar terrain because groups of various kinds are salient in most men's lives. As Brooks contends, “men learn to be men in front of other men” [11: pp.104]. Whilst this scenario can lead to risk taking in which men jockey for position, it is also in the presence, and with the permission, of other men that masculine practices can be refined and relearned. Overcoming men's emotional isolation is another advantage of all-male groups. Because many men lead emotionally isolated lives, participation in an all-male therapy group can offer immense potential for interpersonal connectedness and recognition of common struggles [11]. Similarly, discovering emotional connections is an advantage of all-male groups. Erkel suggests that dominant ideals of masculinity preclude deep and emotional connections among men [12]. Their interactions are typically intense only when fighting or competing. However, providing men with a safe environment to discover and express intense and vulnerable emotions allows them to connect through their shared cathartic experiences [13]. Other advantages that have been described include countering overdependence on women, encouraging self-disclosure, instilling hope, and improving communication skills. As Cochran & Rabinowitz contend, effective therapy for men must: (1) explicitly demonstrate empathy for the men's experiences of loss; (2) direct attention to the existential aspects of these experiences; (3) be sensitive to the men's difficulty with the stigma that can accompany being in therapy itself; and (4) positively interpret the men's behaviours, values, and attitudes [8].

Despite the numerous clinical writings discussing the treatment of men in all-male therapy groups, research on such groups has been slow to accumulate. Nevertheless, there are several reports indicating that men can derive considerable benefit from all-male therapy groups. For example, in studies of groups for men with alcohol-related problems, all-male groups have helped men decrease their alcohol consumption and psychological distress, and improve their coping skills [14], [15]. Similarly, all-male groups led to improved psychological functioning and reduced unhealthy behaviours among depressed, HIV-infected men [16]. In another study, quality of life was enhanced and depressive symptoms decreased among men with problematic internet-enabled sexual behaviours who were treated in all-male therapy groups [17].

Sensitivity to the needs of men in psychotherapy 

As suggested in many men's health commentaries, men's experiences and expressions of illness and health-seeking practices are strongly influenced by dominant ideals of masculinity, as it intersects with factors including age, ethnicity, religion, and social class [18]. Therefore, working effectively with men requires an awareness of masculinity and how men may encounter problems in living as a result of gendered expectations and experiences, and the clinician's understanding of their own assumptions and biases about men.

Men's alignment to dominant ideals of masculinity contributes to gender identity and ways of thinking, feeling, behaving, and expressing problems. Within this context, masculinity likely plays a crucial role in a man's experience of psychotherapy (i.e., why a man is in therapy and how therapy is ultimately enacted) and requires that psychotherapists understand how to incorporate men's experiences (i.e., their masculine selves) into therapeutic work [19]. Kilmartin provides a succinct clinical summary of how masculinity affects men's engagement in psychotherapy together with suggestions for communicating and dealing with men in treatment [20]. For example, he recommends that therapists help men build an emotional vocabulary. Referring to body sensations can help in this regard. The therapist may talk of anxiety in terms of physical gut reactions and sadness in terms of facial expressions. The development of greater awareness of his feelings will help the man be more expressive of his emotional experiences, which the therapist can frame as an important life and self-management skill.

Conclusion 

In summary, early childhood experiences of disruptions in maternal and paternal attachments as well as real losses that inevitably occur in men's lives create challenges for men as they contemplate and attempt to counter these losses. Additional challenges for men exist in overcoming the cultural conditioning which frequently admonishes men to avoid self-disclosure and filter or mute their innermost painful feelings, which often leads to distance from others, reduced self-awareness, and emotional suffering. Thus, sensitivity to these issues in psychotherapy can help men engage in the self-examination required to navigate effectively through gender-related conflicts and strains. All-male group therapy may provide men with a safe environment to discover and express intense and vulnerable emotions associated with loss, grief and depression, and allow them to connect through their shared cathartic experience. This can offer immense potential for interpersonal connectedness and regaining a sense of purpose and well-being.