Strangely, perhaps, I want to start this article with a quote from Robert Louis Stevenson, an inveterate traveller: ‘There is no foreign land,’ he wrote; ‘it is the traveller only that is foreign.’
Working for an NHS counselling service some years ago, I was asked if I might like to get involved in developing and piloting psycho-educational workshops for families affected by perinatal depression (PND). Up until that time, I had never really considered PND to be part of my life experience; it was like some foreign land I had heard of but never visited. However, the stories my mother told me about my first months returned to me with renewed meaning: ‘I would creep up to your cot as you slept and startle you awake… just so I could cuddle you when you cried.’ Her father died shortly before I was born, and so, on reflection, I wonder who was actually comforting whom during those dark winter days when she was alone, grieving, and my father was at work? Maybe it wasn’t such a foreign country after all, I told myself. As a male counsellor, this felt like a unique opportunity to explore the needs of the mother’s partner – often, but not always, a man – in the context of supporting their family system.1
This article describes my own experience as a foreigner in a world that is, more than most others, exclusively female.
I was standing in for a male colleague who had withdrawn for reasons unknown, leaving his female colleagues metaphorically ‘holding the baby’. I was aware that I was a foreigner in this land, and was viewed sceptically by my new colleagues. Expectations were low; as a female colleague remarked, ‘What do you know about PND? You’re a man.’ My experience perhaps paralleled that of men living with PND. Giving birth and adapting to the new mother role is without question a unique and specific experience; unfortunately the experience can trigger the onset of depression in some women who are already predisposed to this, and can exacerbate recurrent low mood in others. Situational factors such as bereavement, birth complications and temperamentally difficult infants are other risk factors. Women with PND often feel their partner is not offering adequate practical and emotional support.2
The structure and content of the workshops were adapted from a CBT-based model developed by Milgrom and colleagues.3 Eight day-time sessions were offered to mothers, and three shorter evening sessions were organised for their partners, supporters and other family members. Through feedback, I quickly learnt that these ‘partner workshops’ weren’t meeting participants’ needs. Some practical changes made an immediate improvement to their experience. These included providing more and longer sessions on a Saturday morning, and a crèche. But in addition to these practical changes, I gave some careful thought to the nature of masculinity itself, and to what the literature tells us about men’s experiences of PND,4 with the aim to ensure that the workshops more accurately met participants’ needs.
Working with men
Research tells us that men seek help, including psychiatric and counselling services, less often than do women.5 In the past it was assumed that women accessed help for emotional distress more often simply because they were more vulnerable to depression.6 The higher rates of suicide among men in almost every culture suggest that a more sophisticated analysis of the relationship between gender and help-seeking is required.
Boys are taught to avoid revealing our emotional vulnerability – our basic need for human connection – because it may threaten our socially-constructed sense of identity. For men, help-seeking for an emotional problem can conflict with the multiple messages we are given about what it is to be masculine – the emphasis on physical toughness; the preoccupation with power and competition, self-reliance and emotional control; the fear of intimacy; homophobia. To me, and to many others, gender is more usefully understood not simply as a property of individuals but as nested layers of highly situated and contested social practices, where we are taught to ‘do this’ and ‘not to do that’.7 For example, through the cultural influence of being married to an Italian, I am much more likely to greet another man with a kiss when I am in Italy than when I’m in the UK.
Normalising the problem
Given the dynamic nature of gender, it became clear that I would better serve my clients by meeting them where they were, rather than where I wished they could be. Bringing this awareness to bear on the PND workshops meant that I could use gendered social cues that made sense to men, enabling them to more readily engage their usual behaviours to support their partners with PND.
Below, I outline the recurring themes that evolved from my research with men whose partners were experiencing PND, through focus groups, research interviews and, of course, through my own clinical experience. Their words are communicated here through fictionalised narratives.
For men to manage the knock to our self-esteem when we encounter a problem we find perplexing, it seems particularly important for us to establish whether or not our problem is ‘normal’. This process of normalising is often best facilitated through sharing with others who have experienced similar situations. Belonging to a network where others are willing to share experiences, and sometimes vulnerabilities, helps mitigate the negative effects of isolation. As Harry explained: ‘For me, it was about hearing “Many go through it and survive… you’ll be OK”… that was the turning point… meeting other guys who have been through it and survived. At the time I got no support at all; as a man… I was quite literally on my own. It wasn’t something I talked about with my mates at work. And even if I could talk to somebody, what would I say…? “My wife’s gone loopy”? Men would make a joke about it in the way they joke about PMT.’ And in one of the most severe cases of PND I encountered, Mark described how, ‘I was so desperate that when they came to section her, I asked the ambulance guy: “Do you want to go for a curry after?”’
Accessing networks through which men caring for their partners can feel understood and be reassured about the future is a crucial step towards normalisation, along with clear signposting to information about depression and its causes. Charities that support people affected by PND, such as Bristol-based Bluebell, recognise the importance of reducing the barriers to men’s help-seeking by creating readily accessible online resources (see, for example, the videos at dropbox.com), which aim to help normalise men’s experiences.
Reframing a technical problem
Roy quickly seized on the practical things he could do to help his partner: ‘I read on the internet that ginger biscuits and ginger beer were helpful for morning sickness, so I went out in the middle of the night to find those things for her.’ But the ‘up and down’ of his partner’s mood reflected the unpredictability and loss of control that PND introduces.
Communication becomes almost non-existent and, like many men in his position, Roy felt exasperated when his offers of practical help were received unsympathetically: ‘It’s like walking on eggshells… almost everything I did was wrong… and that included trying to help with the baby.’ He struggled to understand his partner’s depression: ‘You can’t say or do anything right… it’s all wrong… no end of reassurance or comforting works… there isn’t the logical response to it that you would normally expect… it’s so irrational… nothing gets through.’ It was, he said, ‘much harder for a man to empathise with.’
Roy framed depression as an external experience: ‘You just take pills for it.’ This approach is consistent with a more masculine understanding of the condition.8 He explained: ‘I dreaded coming home from work to find her crying… day after day… having to cope with her… and our son… I found it really depressing.’9 He wasn’t going to take pills himself though: ‘I had different options… I just got on with it… went to the gym… kept busy.’
Roy recognised that this was his way of trying to ‘take control’ of a situation over which he felt completely powerless. He preferred to socialise with friends who didn’t have children: ‘They were easier to get hold of, and the conversation wasn’t about kids… Friends with kids saw hardship and sleep deprivation almost as a badge of honour… as if the greater the suffering endured… the better the parent you were.’10
Roy ultimately recognised that, by relinquishing elements of his masculine sense of autonomy and competence, he could play an important part in his partner’s recovery: ‘At one point, Maria and the baby moved back home to be with her parents… I wondered whether she would come back.’ Reflecting upon his role as a carer, he recalled wondering: ‘Have I failed? Was I good enough to look after my own wife? In some respects, you know… I wasn’t. I failed at a practical level… because I just couldn’t provide the support.’
Toby re-framed his technical problem and adapted: ‘I suspect my mum had PND so it wasn’t unfamiliar to me… I changed my role at work so that I could spend two or three days a week at home caring for them both... I didn’t expect my boss to be so brilliant… Molly’s parents were often down to share the care… and they would also spend a week or so with her parents so that she could have 24/7 support.’ Toby had respite when the care was shared with Molly’s parents: ‘That’s when I had a break… I played sport… and even with Molly here I managed a bit of me time… it’s really important and not so difficult to find.’
Toby managed to create an environment in which Molly could concentrate wholly on her recovery by:
- being open about the mood disorder
- accessing a supportive network of friends, family and professionals
- taking on much of the child care, and all of the day-to-day tasks of running the home, and
- attending to self-care.
As a result, Molly emerged from depression within about six months.
In my experience of facilitating PND groups for partners, I found men were more likely to come to the group believing that some technical problem lay with their partner. And that’s fine; it’s the first step; in this way, men feel they are taking emotional control without there being an immediate threat to their self-esteem. Ultimately, however, a process of re-framing the issue may be required, during which they recognise that some of their masculine norms require renegotiation. I’ve witnessed many times the inspirational transformation that occurs during groupwork as men begin to gently challenge each other’s gendered perspectives and develop more adaptive solutions, as was the case for Toby.
Reciprocity and indebtedness
Men are much more likely to seek help when they perceive there is also an opportunity to help others. Masculine ideals of strength and competence can be preserved when they don’t feel indebted to anyone else. This is a surprisingly strong drive. For example, one cold, dark winter evening I found myself preferring to struggle on trying to repair a puncture rather than accept the offer of help from a fellow cyclist! The masculine norms of self-reliance and the avoidance of dependence help maintain a man’s sense of power and control. However, in PND groupwork, as soon as men notice that they are able to empathise with others who are experiencing something similar, they become more available to offering their perspectives and support to their peers. I have been often moved and humbled by the levels of disclosure and intimacy that unfold in groupwork as men wander away from their more usual masculine identities. As Chris explained: ‘I’m happy to help other guys... the key for me is to forget the nurses in uniform and all that kind of stuff… and give guys the opportunity to talk to those who have been through it… From a selfish perspective, it’s really good for me too.’
Simply loving… and willing
In short, I noticed how it seemed important for men to normalise their experiences, re-frame technical problems into adaptive ones, and engage in peer-to-peer support. I incorporated these elements into a variety of activities in the workshops. Single-gender (and later whole-group) work offers an accessible means for men to renegotiate masculine norms. Single-gender groups are congruent with the work of reciprocity and reframing. The male counsellor may safely challenge norms here, and even find himself nominated to voice the anxieties of the sub-group, conveying the male partners’ perspectives that were previously unvoiced for fear of appearing disloyal (I was affectionately termed ‘the nominated bastard’). Whole-group and couple work offer men the opportunity to support each other, as well as access their partner’s experiences of depression, hone communication skills, and develop deeper empathy.
PND seems a particularly gender-specific issue, and it isn’t uncommon to overlook the positive role men can play. Austerity has meant that NHS trusts are now less able to reach out and engage men in wrestling with their social conditioning, and help them overcome their barriers to help-seeking and support their partners and families through PND. I have been inspired by the support, compassion and understanding offered by men during these PND partner workshops, not because they are men but because they model positive qualities for all human beings. As Sam, a valued co-facilitator who herself experienced PND, put it: ‘Feeling like a traveller in a foreign land mirrors our own role as counsellors… We don’t need to experience what our clients do in order to be helpful and supportive… If men are simply loving and willing, they can help a great deal.’
James Costello is a registered MBACP (accredited) counsellor, who also teaches counselling in the Department of Psychology, University of the West of England, Bristol. He specialises in workplace relations and wellbeing, advocacy and conflict resolution. Elements of this work were presented at the 18th Annual BACP Research Conference in Edinburgh, 2012.
James is happy to share the resources he developed for the psycho-education workshops. They are available to download for free from people.uwe.ac.uk (type ‘Costello’ into the search box).
1. Fletcher R. Promoting infant well-being in the context of maternal depression by supporting the father. Infant Mental Health Journal 2009; 30(1): 95–102.
2. O’Hara M. Social support, life events and depression during pregnancy and the puerperium. Archives of General Psychiatry 1986; 43: 569–573.
3. Milgrom J, Martin PR, Negri LM. Treating postnatal depression: a psychological approach for health care practitioners. Chichester: John Wiley & Sons; 1999.
4. Muchena G. Men’s experiences of partner’s postnatal mental illness. Nursing Times 2007; 103: 32–33.
5. Addis ME, Mahalik JR. Men, masculinity, and the contexts of help seeking. American Psychologist 2003; 58(1): 5–14.
6. Weissman MM, Klerman GL. Sex differences and the epidemiology of depression. Archives of General Psychiatry 1977; 34: 98–111.
7. Addis ME, Mansfield AK, Syzdek MR. Is ‘masculinity’ a problem? Framing the effects of gendered social learning in men. Psychology of Men & Masculinity 2010; 11(2): 77–90.
8. Danielsson U, Bengs C, Lehti A, Hammarström A, Johansson E. Struck by lightning or slowly suffocating – gendered trajectories into depression. BMC Family Practice 2009; 10: 56.
9. Ramchandani PG, Stein A, O’Connor TG, Evans J, Heron J, Murray L, Evans J. Depression in men in the postnatal period and later child psychopathology: a population cohort study. Journal of the American Academy of Child and Adolescent Psychiatry 2008; 47(4): 390–398.
10. Rotkirch A. Maternal guilt. Evolutionary Psychology 2009; 8(1): 90–106.