At a recent training session I was asked whether the bereavement counsellor using a pluralistic approach to the work, should take gender into account.
I would argue that within the caveats of gender stereotyping, a case can be made. Whilst women are often comfortable with an emotion-focused approach to counselling, men are often happier with a problem-solving focus.
There is a case for giving all clients a choice as to the style and focus of your work together.
This essay may be helpful
Bereaved men: are they disadvantaged in grief?
Are there workable solutions to overcome this?
John Wilson PhD
In this essay, I will explore the evidence that men, compared to women, are disadvantaged in grief following the loss of a partner. After considering the important caveats which could lead to gender stereotyping (Martin and Doka, 2000), I will review the published evidence of the heightened risk of mortality in men and reflect on how that is matched by my personal and professional experience. I will consider the ways in which workable solutions could be put in place to mitigate the effects of gender disadvantage, and critically reflect on the possible limitations of the research I have cited.
Might one issue be due to the ways in which men typically grieve? Evidence suggests that we need to take care in making this assumption. Martin and Doka (2000) noted a tendency for grieving styles to be gender stereotyped in Western society. Men are expected to have a cognitive focus, to be concerned with practical solutions to ameliorate their grief, including avoidance and distraction, whereas women are likely to be more emotionally focused, including tearfully meeting their grief head on. While for many people these differences may be true, problems arise when, due to societal pressure, a man or a woman attempts to grieve in a way that befits their gender, but not their needs. As the authors say, “These people are truly at war with themselves” (ibid, p 58). As a practitioner I have met men secretly grieving in the ‘female’ style, whilst hiding this from the friends, family, and colleagues around them. In our roles of supporting others to remain physically healthy in their grief , it is important that we validate our clients in the grieving style that that naturally and intuitively choose.
Research into the relationship between bereavement and health is not new. Young et al, (1963) found that widowers had a 40% increased risk of mortality than married men. In a landmark metanalysis of previous research, Stroebe et al (2007) suggested potential reasons for such findings. A bereaved person, male or female, may neglect their health, including not keeping GP appointments, forgetting to take medication, inadequate exercise, skipping meals, not preparing proper meals. Mental health may suffer, increasing suicide ideation and risk. Stress can affect the circulatory system, increasing the likelihood of stroke, heart attack etc. Changes to the immune system, can lower resistance to disease or result in autoimmune disorders. Alcohol abuse is a significant factor in excess deaths when compared to control groups of non-bereaved people. The implication is that widowers may be less likely to care for themselves without the support and encouragement of a wife.
“For widowers, the increased risk will probably be associated with alcohol consumption and the loss of their sole confidante, who would have overseen her husband’s health status.” (Stroebe et al., 2007 p.1962).
Sullivan & Fenelon, (2014) concurred. Their research discovered that men whose wives died unexpectedly, are at a nearly 70% higher risk of dying than men whose wives’ deaths were expected. They suggested that this “may reflect the fact that men receive a greater social support benefit from marriage than do women and may thus have more difficulty adapting to new conditions” (p.60).
Apart from the meta-analysis by Stroebe et al (2007), and in a later review paper, Ennis and Majid (2021), both of whom concluded that there was a higher mortality risk for men when compared to women, there have been several more detailed studies. Schaefer et al (1995) examined a cohort of 12,522 spouse pairs in Northern California. Both spouses completed a questionnaire between 1964 and 1973, and they were tracked until one of them died. The study was completed in 1987. Over the 23 years of the study, 1,453 men (12%) were bereaved, compared to 3,294 women (26%). During the follow-up, 440 bereaved men (30%) and 510 women (15%) died. Whereas previous studies have found the risk decreasing after 6 months, this study found that the highest relative risks (of mortality) occurred 7–12 months following bereavement.
From the wealth of research spanning almost 60 years, we can reasonably conclude that men are at significantly greater risk of grief related death than are women, although the actual proportion of deaths is small. Around 5% of widowers over 55 years old die in the first 6 months after spousal bereavement. This compares with 3% of married men in the same age category, and the risk diminishes over time. (Stroebe et al., 2007 p.1962). Nevertheless, given the number of married women who die each year, if only two in every hundred bereaved husbands soon follow them, it is still a concern if such deaths are avoidable, not to mention those who survive, yet show a deterioration in their health and fitness. What are the conditions and diseases that bring this widower effect? Elwert & Christakis, (2008) analysed the US Medicare records of 373189 married couples for 17 causes of death. For men, spousal death increased the risk of mortality by more than 20% for chronic obstructive pulmonary disease, diabetes, accidents or serious fractures, infections or sepsis, lung cancer, and unknown causes of death; 10% for colon cancer, heart disease, heart failure, kidney disease, stroke, vascular diseases, and other cancers. For women, spousal loss increases the risk for mortality by more than 20% for chronic obstructive pulmonary disease, colon cancer, accidents or serious fractures, lung cancer, and unknown causes; 10% for infections, flu, kidney disease, diabetes, vascular diseases, and heart failure. They noted a particularly strong effects on death from causes that were either acute health events (e.g., infections or sepsis, accidents) or chronic diseases that require careful patient management to treat or prevent (e.g., diabetes, COPD, colon cancer). They suggested that this could be explained by a loss of social support and social integration following the death of a spouse. Of course, when researchers investigate the morbidity and mortality of an elderly population, it is likely that many individuals in their sample will have life-limiting health conditions which predate the bereavement. Einiö et al, (2017) discovered that widowers who died from ischemic heart diseases following the death of their spouse, were already vulnerable to cardiac disease. Does this mean that the age of bereaved husband is a factor? Whilst some research suggests a greater mortality risk for younger than for older people bereaved of their spouse (Stroebe et al, 2007, Ennis and Majid, 2021), the Schaefer et al (1995) study cited above, found no difference in the mortality of younger, compared to older widows.
If, as a society, we are to prevent unnecessary deaths and protect the physical and emotional health of widowers, we need to be aware of the factors, proven and inferred, which may be employed to ameliorate the grief of spousally bereaved men. The picture is complex, and protective factors are inter-related (Ennis & Majid, 2021). These include engaging with physical activity and maintaining a healthy diet, taking personal responsibility for maintaining physical health with professional support, accepting social support, and interacting positively with others. This could be through the direct care of the individual, as well as via community and national initiatives. Wise policy-makers reach decisions based on what can be gleaned from the evidence of empirical studies. It has been shown, for example, rather surprisingly, that widowers with at least five pre-existing medical conditions, do better, and are more likely to survive, than widowers with no previously diagnosed conditions (Schaefer et al, 1995). This suggests that the very act of being seen regularly in a caring medical environment is, in itself, protective, and that regular, post-loss contact with people who care, should be extended to bereaved male spouses, whatever their diagnosed health status. Furthermore, a proactive approach could be even more effective. Einiö et al., (2017) suggested that proactive medical interventions and health counselling, could be offered to husbands of terminally ill wives, so as improve their health over the transition to widowhood. I would argue, based on my own professional experience, that professionals need to be sensitive to the individual’s personality and culture in facilitating appropriate intervention which maximises choice and appropriately addresses individual needs (Cooper and Norcross, 2021). As professionals we should recognise what are normal grief reactions and be slow to medicalise or label our client as a having a ‘disorder’ (Wilson, 2014). We should collaborate with the client’s expert knowledge of their bereavement story, their identified needs, and their knowledge of their own physical and mental health. This involves actively listening to them in recognition that any narrative of the client’s grief constructed in the therapeutic dyad will be co-authored:
“As Bohart and Tallman (1999, p.224) put it, ‘a mutual, equal, active collaboration between two intelligences in which two streams of expertise enrich one another and blend’. This is not about ‘empowering’ clients, but respecting, recognizing and responding to the power they already have.” (Cooper and McLeod, 2011, p. 35)
This means collaborating with the bereaved husband on plans to adapt to loss together, monitoring depressive symptoms, diet, exercise, and taking time out from grief (Stroebe & Schut, 1999)
When supporting individual men, we must be sensitive to their gendered needs. Typical models of therapy, be they one to one or support group, may not suit all men. My own professional experience is that far fewer men than women sign up to one-to-one bereavement support, therapeutic support groups, or social media support groups. Men are known to respond differently to counselling services when compared with women, often preferring a problem focused rather than an emotionally focused approach (Jordan and Neimeyer, 2002). For example, Murphy et al (1998) offered emotionally focused support for parents who had lost a child in violent circumstances. Although mothers with severe symptoms improved, those with initially moderate distressing symptoms got worse from the intervention. Fathers did not appear to benefit at all. At a community level, men who would be reluctant to approach psychologically informed services, may participate in group activities such as the Men in Sheds (Fischer et al 2018). Male bereaved spouses appear to benefit from contact with other widowers. Subramanian et al (2008) found that the presence of other widowed individuals in the neighbourhood protected men more than women from the widowhood effect. Groups which address the loneliness and isolation of bereaved men can mitigate their grief. I know from professional experience, that the loneliness of widowers often lasts beyond the most painful phases of grief, and that men who find interests involving company with others, do better than isolated men.
At a national, sociopolitical level, poverty and social deprivation is known to affect the health of widowers.Education and wealth differences between widows and the married explains around one third of the increased risk of morbidity and mortality (Sullivan & Fenelon, 2014). Government initiatives to manage the health and social care of men bereaved of a spouse and to target men who have a wife with a life-limiting diagnosis, would go a significant way to reducing the negative health and wellbeing consequences of widowhood.
Based on my own experience, I suggest that the outcomes of the research I have cited, is credible. However, some of the work has been carried out with comparatively small populations which may be atypical of larger cohorts, may under-represent sections of the wider community, and disguise health disparities between white and black patients (Wilson & O’Connor, 2022). Even if this is taken into account, the data from other nations may not always translate to the UK population.
In conclusion, there is convincing evidence that the health outcomes of bereaved men are significantly worse than their female counterparts. There are workable solutions that could help overcome this disadvantage. Any measures put in place require a collaborative approach encompassing the medical, social care and mental health sectors at an individual, community and national level, including the voluntary sector, and the facilitation of self-help possibilities. Most importantly, available strategies need to be culturally sensitive, community-based, and designed to maximise the choices available to this disadvantaged group. with the aim of helping grieving men back into good mental health and a fulfilling life.
References
Bohart, A. C., & Tallman, K. (1999). How Clients Make Therapy Work: The Process of Active Self-healing. American Psychological Association.
Cooper, M., & McLeod, J. (2011). Pluralistic Counselling and Psychotherapy. Sage.
Einiö, E., Moustgaard, H., Martikainen, P., & Leinonen, T. (2017). Does the risk of hospitalisation for ischaemic heart disease rise already before widowhood? J Epidemiol Community Health, 71(6), 599-605.
Elwert, F., & Christakis, N. A. (2008). The Effect of Widowhood on Mortality by the Causes of Death of Both Spouses. American Journal of Public Health, 98(11), 2092-2099
Ennis, J., & Majid, U. (2021). “Death from a broken heart”: A systematic review of the relationship between spousal bereavement and physical and physiological health outcomes. Death Studies, 45(7), 538-551.
Fisher, J., Lawthom, R., Hartley, S., Koivunen, E., & Yeowell, G. (2018). Evaluation of men in sheds for Age UK Cheshire final report July 2018.
Jordan, J. R., & Neimeyer, R. A. (2003). Does grief counseling work? Death Studies, 27(9), 765-786.
Martin, T. L., & Doka, K. J. (2000). Men don’t cry…women do: Transcending gender stereotypes of grief. Taylor and Francis.
Murphy, S. A., Johnson, C., Cain, K. C., Das, G. A., Dimond, M., Lohan, J., & Baugher, R. (1998). Broad-spectrum group treatment for parents bereaved by the violent deaths of their 12- to 28-year-old children: a randomized controlled trial. Death Studies, 22(3), 209-235.
Norcross, J. C., & Cooper, M. (2021). Personalizing Psychotherapy: Assessing and Accommodating Patient Preferences. American Psychological Association.
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Wilson, J. (2014). Supporting People through Loss and Grief: An Introduction for Counsellors and other Caring Practitioners. Jessica Kingsley.
Wilson, D. M. T., & O’Connor, M. F. (2022). From Grief to Grievance: Combined Axes of Personal and Collective Grief Among Black Americans. Frontiers in Psychiatry, 828.
Young, M., Benjamin, B., & Wallis, C. (1963). The Mortality of Widows. Lancet, 2(7395), 454 to 456.