Loneliness and suicide in men are increasing — what can mental health professionals do about it?
In the U.K. in 2020, there were 5,224 suicides, and 75.1% of these were men (ONS, 2020). Many causal factors lead to suicide, but this article will focus on addressing male loneliness to help prevent suicide. This article is not an attempt to argue that men are lonelier than women. The focus of the article is on the problems faced by men in Western society and what can be done to help. We will consider how culture, the media, and a lack of spirituality may be contributing to this problem. We will also consider how traditional psychotherapy may be unsuitable for men and how it can be made more useful. We may need to look away from traditional forms of 'talk therapy' to incorporate approaches that do not solely focus on the intellect, like the body, the field, spirituality, breathwork, and psychedelic therapy.
(Caveat, this article takes a very traditional binary approach to men and women. I can only apologize that I am not more informed on mental health issues for those who do not identify as man or woman.)
Research demonstrates a direct correlation between loneliness and depression (Alpass & Neville, 2003). In addition to this, clear links have been shown between suicide and depression, with 90% of the people who die by suicide having an existing mental illness or substance abuse problem at the time of their death (Suicide Awareness Voices of Education, 2019).
What is confusing to see is that the number of men diagnosed with depression is about half that of women (Hrustic, 2016). It is likely that the reasons for this are that men are less likely to seek help for mental health issues due to unhelpful masculine norms such as the age-old 'boys don't cry' trope. Additionally, mental health problems manifest differently between the sexes, with men likely to turn to addictive behaviors. For example, in 2019 66% of Americans diagnosed with opiate addictions were male (KFF, 2019).
As depression and suicides have risen over the last few decades, it is no surprise to find statistical proof of loneliness growing along with it. Researchers investigating loneliness conducted a study that asked how many people someone could call in a crisis. In 1985 the most common answer was 3. In 2006 the most common response was zero (McPherson et al., 2006).
Loneliness causes depression because it is much more than just a problematic emotion; it causes physiological damage. Eisenberger (2003) has shown that the regions of the brain that respond to physical harm light up in the same way in response to social ostracism. Loneliness itself raises cortisol levels as much as a physical attack (Cacioppo, 2010). Loneliness is so damaging because separation could mean death when we were living in tribes. Loneliness is accompanied by anxiety because our biology tells us we must find our tribe (Junger, 2016). This idea is supported by Carl Jung, who saw mental illness not as a pathology but as a positive force trying to motivate change in the individual (Corbett, 2013). Causes of loneliness can be attributed to the individual, but another significant part of the problem is how our society creates loneliness.
Two main changes in societal structures have hugely affected our sense of connectedness. The first was the agricultural revolution, and the second was the industrial revolution. In part, the adverse changes are caused, due to the accumulation of personal property, allowing people to live more and more individualistic lives and diminish group efforts towards a common goal. It is now common for a person living in a city or suburb to go an entire day encountering strangers. They are surrounded by others but feel entirely alone (Junger, 2016). It takes around 25,000 years for a genetic adaptation to appear in humans, and so the enormous changes brought about by the agricultural revolution that took place in the last 10,000 years will not be seen in humans yet (Junger, 2016).
Counter to what we might expect; affluence does not buffer people from depression; it creates it. Sebastian Junger (2016, p265), in his research on tribal living, states that "as affluence and urbanization rise in a society, rates of depression and suicide tend to go up rather than down." According to a global survey by the World Health Organization, people in wealthy countries suffer depression as much as eight times their rate in developing countries. The problem is even more severe in countries with high-income disparities between the rich and poor, like the United Kingdom and the United States. (Junger, 2016).
Suicide is very much a problem of the affluent modern society. According to Margaret Batten (2015), researchers could not find any incidences of suicide in American Indians rooted in psychological issues. For Junger (2016, p264), the mechanism is quite simple: "poor people are forced to share their time and resources more than wealthy people are, and as a result, they live in closer communities." When researchers discovered that children raised in urban environments were twice as likely to suffer from depression than those raised in rural environments, they wondered why. What they found was that the urban areas with the least social cohesion had the highest amounts of mental health problems (Duke University, 2016).
Why don’t men get help?
One of the reasons for the high rates of male suicide may be that men do not seek therapy when depressed. 90% of people who seek out counseling are women (Gray, 2017).
One issue that may be keeping men away from seeking help is how the media portrays mental health issues. Researchers have shown that the media still links depression to madness (Nairn, 2007). Additionally, masculine norms of stoicism and avoidance of emotional displays are still portrayed positively in the press (Scholz et al., 2014). Brownhill et al. (2005) believe that this is why men deal with depression by numbing it, escaping it, self-harming, avoiding it, and suicide rather than seeking therapy.
The medicalization of therapy may be why men do not seek therapy. Bohart (2000) believes that therapy should be a learning opportunity rather than a medical intervention. By learning how to master one's problems, a client is more able to deal with the issues they face in their life. Bohart asks us to consider the difference between saying 'I am being treated for a depression' versus saying that 'I am coming to therapy to learn how to deal with my depression.’ There is a big difference in how empowering each statement is.
Another reason men are not seeking therapy could be the weak evidence supporting the standard treatments offered. Antidepressant use in men has increased by 69% since 1992, with 1 in 10 men in the U.S. now taking these medications (Hrustic, 2017). However, a meta-analysis on SSRI antidepressants conducted in 2010 showed that they only "had a small, nonsignificant benefit over placebo in mild and moderate depression" (Mandal, 2019). Additionally, a study by The University of Michigan (2019) has shown that "spending an hour in talk therapy with a trained counselor costs much more, and takes more time, than swallowing an inexpensive antidepressant pill." This is a damning indictment of both talk therapy and antidepressants.
This study on the ineffectiveness of psychotherapy leads to several questions. An obvious issue is that the therapy used in the study was Cognitive Behavioural Therapy (CBT). CBT is limited to working with the mind of the client. The study's message could have been that CBT is not an effective therapy, but the headline misleads one to believe that all psychotherapy is ineffective.
There is a reason to believe that up to 100% of the healing power of antidepressants is a placebo effect (Kirsch & Lynn, 1999). It may be that the reason why CBT and antidepressant pills were equally ineffective in this study was that both were only working as a placebo. While at first, it may be demoralizing to believe that antidepressants worked for you only as a placebo, it could also be a reason for encouragement. You felt better all by yourself, and you don’t need to give the power to heal to an external source.
Three of the most influential therapist have independently come to the same conclusions about what factors makes therapy effective. These three are Bessel Van der Kolk, Carl Jung, and Irvine Yalon, and their focus is on the depth of the therapeutic relationship. Van der Kolk (2014, p58) is an expert in trauma and states that "trauma almost invariably involves not being seen, not being mirrored and not being taken into account." This sounds very much like what it is to be lonely. Yalom (2001, 08:56:30- 08:56:40) supports Van der Kolk's idea with his observations that "overwhelming, research evidence shows that good outcomes depend on the intensity, the warmth, the genuineness [and] the empathy of the therapeutic relationship." Further to this, a therapeutic encounter that enables 'relational depth' can be extremely powerful. Although therapy is usually just one hour a week, the effect of this type of encounter can engender hope in the client. Psychological distress is not just about what someone is experiencing, it is also about what one expects to experience. If someone expects more loneliness, then their distress will continue or increase (Mearns & Thorne, 2000).
Gray (2017) believes that the reason men are not attracted to talk therapy is that talking about emotions lowers a man's testosterone and raises his estrogen levels. In the past, high testosterone levels have been mistakenly linked to expressions of anger. Actually, the reverse is true. Men need high levels of testosterone to ensure the stress hormone cortisol does not rise too high. High estrogen levels in men lead to defensiveness and anger.
Women, being more estrogen dominant, find therapy more useful because talking boosts estrogen levels, and is, therefore, more useful to keep their hormones in balance. Gray (2017) believes that for men to lower their stress levels, they need to participate in activities that increase testosterone while lowering estrogen and cortisol. He gives examples of playing or watching sports, spending time alone in nature, meditation, driving, or hobbies that make them feel that they are good at something.
Gray (2017) also attributes the higher suicide rate in men to hormonal differences between the sexes. Women's estrogen dominance leads them to want to talk to lower stress, while men's testosterone dominance leads them to take immediate action. Rather than seeking therapy to lower their stress levels, they act by taking their lives and ending their pain. If this is the case, then we should not be trying to find ways to convince men to seek therapy, we should be finding therapeutic activities that appeal to men. This is probably why you will find a high concentration of men utilizing tools such as breathwork, ice baths, and ayahuasca ceremonies. None of these techniques involve a focus on talking.
People's sense of belonging has eroded at the same rate as religious affiliation and attendance in Britain (Voas, 2005). Unsurprisingly, research has found that women participate in religious and spiritual activities by as much as 80% more than men (Simpson, 2008; Woodlead, 2007). Another study revealed that those scoring higher on the measure of spiritual health displayed better outcomes on many psychosocial measures, including loneliness (Hammermeister and Peterson, 2001). This research is useful for highlighting the power of spirituality. However, it is not to say that all problems are spiritual in nature but that a spiritual dimension needs to be addressed as part of psychotherapeutic healing (Elkins, 2001).
Traditional 'talk-therapy' has also come under attack from the likes of Wilhelm Reich and Dr. Stanislav Grof. Reich went so far as to say that human language was getting in the way of healing as it could be a defense against feeling the biological core. He stated that psychoanalysis had "become stuck in a pathological use of language" (Reich, 1933, p67). While psychoanalyst Grof's (2018), the founder of Holotropic breathwork stated that his "clients could give you lectures in their problems, but the problems don't change". It was only with the help of breathwork that Grof's clients were able to do the deep processing of emotions that lead to changes in their lives.
If we believe that talking through problems is ineffective, then other paths towards healing need to be explored. Gendlin believed that the path should be through the body. Gendlin's (2003) 'Focusing' technique is useful in addition to the 'core conditions' that Carl Roger's (1961) insists upon. Roger's approach was similar to Yalom and Kolk's in his emphasis on creating a healing relationship rather than diagnosing the problems of the client. By adding the 'Focusing' technique to the therapeutic relationship, Gendlin believed that an extra dimension of therapy could emerge. Focusing is about articulating responses that are difficult to express with words. It may be a gateway to areas of healing that the mind cannot or will not go. This type of work has been built upon by the likes of Peter Levine and his technique of Somatic Experiencing that has become very popular for trauma healing.
Field theory may be particularly useful for a client suffering from loneliness because of the unique form of human contact that one can experience. This theory encourages a therapist to observe the relationship with the client as a whole. The therapist's interventions and awareness are thought of as functions of the field. They do not exist independently but emerge out of the field itself (Roubal, 2012). Day (2016, p90) says, "to work with field sensitivity is thus to recognize that there are not separate selves meeting across empty space." Actually what is happening is there is a shared, mutually influencing loop that both participants can affect and be affected by.
Siegal (2010) suggests that a therapeutic interaction activates neural circuitry that allows the client to 'feel felt' by the therapist. Although the client may not be attuned to this feeling, whatever is taken in through the senses sits within the awareness. The therapist can incorporate a mindful-awareness approach to this where they direct the client's attention to this feeling of being 'felt' by the other. Robertson (2018) states that "given a supportive environment and neuroplasticity, new neural pathways and prosocial qualities and behavior can grow throughout our lifespan." This method may be of particular use because it requires less intellectual effort and less of a focus on emotional expression and vulnerability that men struggle to face.
Some suggest that the argument over the effectiveness of different techniques is irrelevant. Asay and Lambert (1999, pp. 39–40) propose that "for those convinced of the singular abilities of their models and related interventions, the results have been disappointing". "Typically, there is little or no difference between therapies and techniques". They believe that the client is the most crucial variable in the outcomes of therapy, not the therapist or the model of therapy that they provide. This conclusion is very threatening to psychotherapy. Bergin and Garfield (1994, p. 822) suggest that any protestations against this are mere:
“rationalisations that attempt to preserve the role of special theories, the status of leaders of such approaches, the technical training programs for therapists, the professional legitimacy of psychotherapy, and the rewards that come to those having supposedly curative powers.”
A worrying amount of people are turning to Instagram and charismatic social media influencers, life coaches, and celebrities for their mental health advice. Very few of them have the required training or experience, passed any sort of exam, or have the ethical integrity to be talking about such delicate topics.
Another argument dismissing the importance of different theories suggests that it is the personality of the therapist that is the determining factor in the outcome (Brown et al., 1999; Luborsky et al., 1985). Instead of looking for the best therapeutic technique, we should be asking how we can improve the personalities of psychotherapists. Of course, this approach would bring about its own obstacles, as deciding upon the definition of an 'improved personality' would be highly subjective. Perhaps, further research could be done to determine what kind of personality traits elicits the most desired outcomes from clients.
While there are plenty of arguments for and against different theories, we should also be looking at other cultures to discover if there are tools useful to psychotherapy. Johann Hari (2018) researched the healing power of community in other cultures as an alternative to talk therapy and antidepressants. He gave an example of a Cambodian rice farmer who lost his leg to a land mine explosion. While this man had a new leg fitted, he became depressed and anxious. The response of his neighbors was to gather together with the local doctor, listen to his issues and then buy him a cow. The physical pain brought about by having to walk on his artificial leg to tend his rice paddies caused his depression. The locals realized it would be much easier for him to become a dairy farmer. To the Cambodians, Hari (2018, p159) says, "an antidepressant was not about changing brain chemistry…it was about community, together, empowering the depressed person to change his life".
Maté (2010) and Grof (2018) are advocates of psychedelic-assisted psychotherapies like those used in the Amazonian cultures. Of particular interest to the therapist in the U.K. may be psilocybin mushrooms which have just been categorized as a 'breakthrough therapy' for treating depression. MDMA is another similar treatment that is now prescribed for sufferers of PTSD in the USA. Research from Palhano-Fontes et al. (2019) showed the rapid reduction of symptoms in those with treatment-resistant depression after ceremonies utilizing ayahuasca. More and more research is being conducted in this area. More cities, like Denver and Oakland in the U.S., are decriminalizing psilocybin. Soon there will be a more extensive choice of tools for the psychotherapist.
The power of psychedelic-assisted-psychotherapies may lie in their ability to create a spiritual or mystical experience. A recent study (Roseman, 2018) suggested that the quality of the mystical experience encountered in a psychedelic-assisted therapy session was a key predictor of recovery rates from depression. The researchers even went so far as to suggest that there is a need to find ways to increase the power of mystical experiences to ensure higher recovery rates in patients.
There are more factors to loneliness than just the ones addressed in this essay. A new study from the University of Arizona (2019) has demonstrated that a person's reliance on his or her smartphone predicts greater loneliness and depressive symptoms, rather than the other way around. The suggestion is that social media use negatively impacts a person's ability to feel empathy. A lack of empathy can lead to social ostracism, and from there, the cascade of adverse events begins.
As we invent more barriers to connection like smartphones and income disparities, we will need to create more tools to help with the adverse effects for future generations. It can sometimes feel like we are out at sea in a storm, with waves flooding the boat and the only tool we have is a small bucket to throw the water over the sides. We need to find ways to reduce the intensity of the storm by creating societies that foster connection as well as finding bigger buckets for therapists to increase the effectiveness of their tools. Psychotherapy may need to embrace new and old methods like breathwork psychedelics, spiritual connection, and body-focused therapies to help people cope with the rising problems of loneliness.
When life is difficult, Samaritans are there in the U.K.— day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
In the USA you can call 800–273–8255 to speak to the National Suicide Prevention Hotline.
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