David Peters, Editor-in-chief, JHH

Damien Ridge, Psychotherapist and social scientist

Published in JHH14.3 – Men’s Health

DP: Damien tell us about your research focus.

DR: It’s research about gender and mental health in general and particularly depression (Ridge, Emslie and White 2011; Ridge et al, 2015; Ridgeand Ziebland 2006). I’m a trustee at CALM (www.thecalmzone.net), the male suicide prevention charity. I’m very interested in men getting better access to therapy. Traditionally, its been accepted that talking, and talking about your feelings specifically, and that being vulnerable, are wrong for men. It’s been said that therapy feels feminising to men. But I think things are changing and men are more and more open to exploring emotion and vulnerability, and that when they are in distress more men are open to therapy as a way forward. At some point (I don’t know what age it was for you) boys suddenly start getting all these messages that it’s not OK to cry, or to show vulnerability, and that it’s time to close up and shut up; as we say now, to ‘man up’. Vulnerability goes underground then, but it is still there, it is still an important part of human growth. It becomes culturally OK for men to be angry, but not to express ‘weakness’ from that point on. So there’s a hidden rulebook.

DP: Actually not so hidden. Anger becomes a kind of default mode. Perhaps even a way of keeping a lid on what lies deeper down: sadness, fear maybe.

DR: We men go through this change, which is like a hidden rite of passage. Whereas in other cultures the threshold into ‘manhood’ isrecognised, consciously organised, and celebrated. The crossing over is more structured, often more ritualised. But in our culture it’s obscure and unspoken. We start conforming to these rules but without being able to acknowledge and reflect on them for what they are, and what they may be doing to us.

DP: Is it just a stereotype that girls from a very early age are more interested in feelings and tend to talk to one another about them? There issome research to confirm this. Whereas boys are more likely to fixate on objects like sticks and guns. There is intense and quite politicised debate over whether this is nature or nurture. Probably both, while we live in a culture of blue onesies for boy babies and pink for girls; offer them different toys; talk to them differently.

DR: It’s the socialisation men undergo. Ordinarily, we think that masculinity is something owned by men, but actually it’s owned and reinforcedby society through messages coming from society, a society invested in certain assumptions about masculinity, rather than in what men are or might authentically be. All societies have have their own stories about masculinity and what it should look like, and whether or not we know it, we all have an investment in these stories, and they shape our expectations. For example, some men when they’ve experienced being vulnerable in a relationship, say they feel they’ve been ridiculed or looked down upon by their partner, or by others. It’s as if they feel that men letting their emotional guard down means they lose face or status as men. If this kind of reinforcing of men’s insecurity is something real. Instead of blaming men for their inauthenticity and associated problems, it’s the whole social system and its dynamics that we need to focus on when we talk of masculinity.

DP: So we shouldn’t blame men for the downsides of masculinity?

DR: Well, we are all responsible for our behaviours. But perhaps we need to be more understanding. Men are understandable, arent they? Infact, at some level, men know they are playing the ‘masculinity game’. They can reflect on what they are doing, if you give them a safe space to do so.

DP: And our culture apparently values most those aspects of masculinity to do with competitiveness and warriorhood and strength.

DR: Sometimes I wonder if that’s because we are still largely a militaristic society, that still needs men to prepare for war; that socialises men tocut off from their feelings, in a society that cuts off from men. Think about the disproportionate levels of male suicide. This ought to be a much bigger issue for public debate than it is. CALM does great work in raising awareness, but still too few people have empathised with the unspoken anguish men go through, and what it is that stops them seeking help, and drives them to take their own lives. And though suicide is the biggest killer of young men we still don’t treat the effects of these problems seriously enough, let alone their root causes.

DP: Nowadays it’s a major killer of middle-aged men too. So what’s going on, do you think? Why do men kill themselves in larger numbers thanwomen do?

DR: Good question. In medical school we were told it’s because men find more violent and effective ways to kill themselves. But I feel it’s morecomplicated than the official explanation; that it’s to do with the kinds of complex socialisation we are talking about; a mix of internal and societal self-reinforcing and damaging messages about masculinity. The struggle for authenticity. The shame men feel in being vulnerable. It’s not just about means. Men are implicitly trained not to talk about being upset. So these unacceptable feeling can get to become very big in their minds. Problems that might have been resolved by sharing them, by realising that others (especially other men) also experience the same things – for example despair, failure, weakness – become insurmountable when left to fester. This distorted and toxic way of thinking takes over, and suicide comes to look like a solution.

DP: Yet to talk about feelings, and especially dark feelings, you need a language. And if you have little experience of sharing your emotional life, it won’t be easy to articulate what is happening, and so seek help until it’s too late.

DR: I think so, but sometimes I worry that we oversimplify it. I think for people to be more aware of male suicide and talk more openly about it is really important. And for men to feel encouraged to talk about distress is a truly important message. And I think the message is getting through because for whatever reason, in the latest statistics male suicide has decreased somewhat. Perhaps this is because men are beginning to feel they have more permission to be open and to be listened to. Historically, the research shows that men are also changing; younger generations of men are much more touchy-feely (Anderson and McCormack, 2014). But the other side of the equation is that the quality of the listening to men is also important. For example, if someone wants to talk about their distress, but the person they turn to is unable or unwilling to listen, then there is a problem for men. Of course it’s obviously very uncomfortable for someone to talk about pain and suicide, but hearing about these feelings is also bound to stir up really uncomfortable feelings in the person hearing about it. Even some helping professionals are uncomfortable with a man who is crying or otherwise in distress, let alone friends.

DP: So just talking about feelings of despair and anxiety or rage with a friend may not be so easy if, after all, friends aren’t necessarily ready forthat kind of conversation?

DR: Nor may family be. And it’s understandable that people will have an investment, even an agenda, in a relationship as they have known it,and this kind of shift in the relationship can feel threatening, and this is likely to get in the way of just listening. So we need to talk about distressed men, and promote quality listening and the empathy it calls for. This is probably the next phase of suicide prevention. I think we’ve been successful in promoting the idea that people should be able to talk about their distress; that the days of stiff upper lips are over. It’s a great thing that the young royals have been so very vocal about this, and open about their own struggles. But the corollary of greater emotional openess is to begin growing the necessary receptiveness, and to enable the quality of these conversations and the skill of being open to hearing really uncomfortable material. I think that’s probably where we need to focus more efforts in the future.

DP: For instance the kind of training the Samaritans provide? The way they train their amazing volunteers to listen, and not to try to fix. Thesevolunteers are taught to sit and listen to some truly harrowing stuff. And it’s being heard, isn’t it, that seems to make a difference?

DR: I think so. So, for example, a listener may feel compelled to rush in with solutions, because it’s so very human to want to lessen pain. But forthe person who just needs to get something off their chest it is not helpful if the other feels compelled to advise, or in some magical way try to fix ‘the problem’. It takes some effort or even training to realise that it’s OK just to listen; that this is what will help. Also, to show empathy but not by saying ‘oh I know what you’re going through’. That’s not empathy. Empathy might be more like acknowledging your authentic feelings as a listener: ‘I can’t imagine what it must be like for you right now, but I can try to understand if you give me a chance’. These skills can be learned and it’s possible to teach people simply to be there and to listen. Just a three-minute look at the YouTube clip by Brené Brown can help people better grasp the concept of empathy.

DP: I fear that is verging on being counter-cultural in the current NHS, where counselling/psychotherapy is turning into cognitive behaviouraltherapy (CBT). Which, if you’re in deep distress may be very far from what you need in order to unload dark and difficult to articulate thoughts and feelings.

DR: Yes, for some people CBT can be helpful of course. But for people – particularly men I think – with problems that have built up from earlylife, and which they have never been able to speak about, will that kind of six-week approach meet their (perhaps unspoken but deep) need to connect and relate to another? Nor is it going to be fixed in six sessions. I understand that the NHS has limited resources, but relationships are largely the cause of our emotional problems, and relationships are an important key to resolving them. So we need approaches other than CBT to be available.

DP: Approaches other than traditional counselling too, of course. That’s why we set up the Atlas men’s project as an NHS service in the Victoria Medical Centre. This was piloting a new model for a more man-friendly approach.

DR: Men in distress often present to GPs with physical symptoms – sleep problems, tension, so we offered men the choice of counselling and/or acupuncture. But actually many chose the counselling option or moved on to counselling after they had begun talking more openly with the acupuncturist. And they could have up to 12 treatments; potentially even a few more if needed. It was a very successful pilot but it had to stop when funding ended two years ago (Cheshire, Peters and Ridge, 2016). Now the GPs are starting it up again because they found it so useful and it proved so popular with men. There’s a need for an ‘Atlas Two’ model, because men want to choose what suits them, not just CBT nor necessarily even the kind of counselling that so many GP practices used to have in-house.

DP: What is a GP who is faced with an upset man to do? He isn’t necessarily acutely depressed or overtly suicidal, but he’s having difficult with hurtful feelings he doesn’t know how to share. He possibly feels shame and guilt about these feelings. The GP listens but doesn’t know quite where to turn to get this man appropriate help. What do they have to offer: anti-depressants, CBT, referal to a psychiatrist?

DR: Of course, the NHS is an increasingly resource-limited system and this man doesn’t necessarily need anti-depressants, nor perhaps to be told how to get his thoughts and feelings fixed with CBT. He might turn to a friend or a partner or a colleague, but they may feel that hearing his distress made them uncomfortable themselves. These situations are difficult knots in communication especially if the relationship with the partner or friend or family or work colleagues is in some way part of the problem. Anyone who is going to listen would first have to notice that this was a difficult conversation to be having.

DP: It would help if they were able to be aware of their own reactions and knew how to calm down their own emotion systems. Which I suppose is one way of describing what a good psychotherapist trains to do.

DR: Agreed. So you might have to notice your own discomfort and hold your tongue. And just to try and convey back you are hearing, and caring about what’s being said; expressing empathy just by reflecting back their underlying feeling, rather than focusing on the detail: ‘… what you’re going through sounds really tough’ or ‘….it sounds like you are so frustrated’ or ‘…it sounds like you are in such despair right now’. Or whatever you feel they’re trying to convey, but absolutely without trying to offer a solution.

DP: Do we professionalise caring and medicalise discomfort and suffering too much? The fact is human beings do get into very unhappy places and always have. Which is why evolution has hard-wired us for empathy with other human beings. The men of our species survived not simply through strength but at least as much because they were able to tend and befriend others; perhaps other men especially. Empathy is part of our nature; it’s why we so easily pick up on another person’s emotions. And that is something important to know. And so rather than find ourselves caught up in a negative way by the distress someone is expressing, we could all learn better ways of being there for our fellow man and woman.

DR: I think so. And fortunately, this is something that can be learnt.

DP: I don’t see our upbringing as giving us a language or a context for talking about emotion though. If men were more able to sit with one another’s feelings I think that would be, on many levels, a revolutionary shift.

DR: Interiority…the last frontier! Men together exploring their inner space.

DP: To boldly go…

DR: Well, it is courageous, isn’t it? And no wonder men are confused when society at large is messaging us not to show vulnerability, while the ‘new man’ on the other hand is expected to be sensitive. We need to be finding ways to incorporate a different notion of sensitivity and strength into our notions of masculinity. ‘What doesn’t kill you will make you stronger’ is a cliché but there is much truth to it when it comes to being vulnerable.

DP: It does imply deeper and different kinds of strength though.

DR: Just being able to accept the presence of unpleasant feelings can be helpful in itself. On its own this can lead to change and transformation. Feeling bad isn’t wrong and the tortuous tactics we use to avoid feeling bad just invite more suffering in the end. But as you can’t know this without going there, it’s a real leap of faith for men to take. Male psychotherapy clients may not be willing to go there initially at least. And of course it’s a lot to take on when you’re already feeling feeling rubbish about yourself.

DP: Most men, if they go anywhere to be heard, will turn to their GP.

DR: Yes, the GP is often a crucial first port of call. And some GPs will be more receptive to men’s mental health issues than others (and we know from our research that quite a few will be struggling with their own depression or burnout) (Cheshire et al, 2017). From a psychotherapist’s perspective, a man who is depressed is likely to be highly self-critical, his anger turned inward, and if the encounter doesn’t work he may blame himself, or he may feel abandoned. So being heard in a way that is not critical is vital for men, as (hidden) hypersensitivity is the other side of more traditional masculinity. If the professional can supply and model a more nurturing voice that will be a fine start, whether or not they have particular skills to help a man reframe his experiences in a less critical way.

DP: It would be a wise and experienced GP who would be able to do that.

DR: Some people do have wise friends, mates that they can turn to, particularly mates who have experienced distress of their own and come through it. At work, a man might find a colleague or a boss who under-stands because they’ve been through something similar. So for example in some research we’ve done, we found that men will talk about anti-depressants with colleagues who have also taken them. Talking about anti-depressants can be a less threatening way for men to start talking more openly about distress. After all, nowadays so many people have taken anti-depressants or are on them. So this can be a way of getting real about depression, of being honest about how we feel. But depression isn’t always seen as being legitimate: the ‘pull your socks up’ attitude is still very much around. It is difficult to talk about one’s depression if there is a whiff of cynicism about the condition.

DP: But as it’s such a widespread problem, finding ways to be honest about it in the workplace – perhaps through people who’ve been through it – would be an important step.

DR: And if friends can’t help, people can go online and find support. There’s a CALM webchat area where men don’t even have to talk to someone, they can just type into a forum. Or they can talk to somebody on a phone helpline. There are lots of online support groups that people can turn to these days. So a man who wants to maintain anonymity can still talk about his problems that way. And, although these days there seem to be far fewer counsellors available in primary care, we shouldn’t dismiss CBT for some people. Obviously it can help, particularly for men who are solution-focused and want something that appeals to their rationality.

DP: I know from my involvement with counselling and counsellors (my wife is one!), that the majority by far of people who train as counsellors are women. And I think most of their clients are women. I know two men who trained as counsellors and in both cases they had been the only men in their course. I think a bare majority of GPs are now women. So with women being so prominent in family medicine and counselling services, a man in distress is more likely to end up talking to a woman than with another man. Do you have any thoughts about that?

DR: It depends on their preference: some men want to see women, but some men are going to have problems with relating to women, aren’t they? So you do need to have a mixture, which is what we provided in Atlas; people had a choice of male or female acupuncturists and counsellors. And if we are serious about designing more man-friendly mental health services we ought to ask whether there may be things that only another man can understand experientially. Obviously, for instance, some men might be embarrassed to talk about sexual issues with a woman, and might feel more comfortable with a man. On the other hand, some men might feel competitive or threatened by having to talk to another man. So I think the choice has to be there. Even here in our psychology department, most of the students coming in are women, so we’re asking ourselves how can we make psychology more appealing to men? Do we, for example, need to go out to schools and encourage men to come and do psychology degrees? Do we need to have a module on male psychology?

DP: Is that yet another indicator that the mind and the emotions are viewed as feminine territory? I know you and I feel this blinkered approach to their inner life is at the heart of men’s emotional difficulties. I certainly suspect that men’s inability to tolerate emotions such as sadness or anger is what leads them into acting them out as violence and addiction. But whether it really matters if men are saddled with this assumption remains an under-researched question. Yet if we are right then what’s to be done about redeeming this stunted view of masculinity? How indeed to rehabilitate emotions so that men may come to see them as something valuable? I’m very interested in finding new ways for men to talk to other men about them, because my own experience has convinced me that men’s groups properly held and led with care have a huge amount to offer; and not just to individual men, but potentially to the culture as a whole.

DR: Yes, you and I have thought about reworking the Atlas model so that some of the men who benefit from a programme could be trained as facilitators, and become the seed for peer-led groups. Apart from any other considerations this could (as long as group leaders and participants were well-selected) be acceptable to men and potentially cost-effective too.

DP: That’s right, but without these circles having to be typical talk therapy groups; perhaps drawing instead more on the many lessons learned in different corners of the ‘men’s movement’: the work with military veterans, young offenders, and in prison workshops especially in the US. But I know there’s good work being done over here too in some tough estates by the Band of Brothers that grew out of the Mankind Project (https://mankindproject.co.uk). I believe their group structure draws on traditional Native American tribal circles. That’s not as whacky as it might sound if, as many suspect, some indigenous cultures have held on to practical ways of dealing with the male psyche’s obvious problems. Another significant driver for a new story is Robert Bly’s narrative about men’s emotion-life – that side-by-side (rather than in the female face-to-face fashion) – men can explore their vulnerability and allow themselves to tolerate emotions like sadness and despair. This reframes the journey into emotional intelligence as something courageous, heroic even!

References

• Anderson E, McCormack M (2015) Cuddling and spooning: heteromasculinity and homosocial tactility among student-athletes. Men and Masculinities 18(2): 214–230.
• Cheshire A, Peters D, Ridge D (2016) How do we improve men’s mental health via primary care? An evaluation of the Atlas Men’s Well-being Pilot Programme for stressed/distressed men. BMC Family Practice 17(1):1–11.
• Cheshire A, Ridge D, Hughes J, Peters D, Panagioti M, Simon C, Lewith G (2017) Influences on GP coping and resilience: a qualitative study in primary care. British Journal of General Practice 67(659): e428–e436
• Ridge D, Emslie C, and White A (2011) Understanding how men experience, express and cope with mental distress: Where to next? Sociology of Health & Illness 33(1):145–59.
• Ridge D, Kokanovic R, Broom A, Kirkpatrick S, Anderson C, Tanner C (2015) ‘My dirty little habit’: Patient constructions of antidepressant use and the “crisis” of legitimacy. Social Science & Medicine 146:53–61.
• Ridge D, Ziebland S (2006) ‘The old me could never have done that’: how people give meaning to recovery following depression. Qual Health Res 16(8):1038–53.