The night shift in a medical facility possesses a specific quality of quiet that you never entirely forget once you leave it behind. For ten years I walked the corridors of a palliative care unit in South London where the hours between midnight and dawn felt separate from the rest of human time. We would hear the low hum of oxygen concentrators or the squeak of a nurse's rubber shoe on the linoleum. We would hear the erratic breathing of patients entering their final stages of life. Mostly we heard the silence of the relatives sitting beside them. I remember a man named Arthur who sat next to his wife's bed for four consecutive nights without speaking a word to any of the staff. He wore a heavy wool sweater and kept his hands resting on his knees. When his adult children visited during the day he was completely composed. He made sure they had enough change for the tea machine in the family room. He asked the doctors highly technical questions about pain management dosages. He gave the appearance of a man managing a complex logistical project rather than a man watching his spouse of forty years slip away.
People look at a man like Arthur and they form rapid conclusions about his internal state. When the funeral happens and the husband stands straight backed at the front of the church shaking hands with the attendees there is a collective judgment made by society. We tell ourselves he is being strong for the family. We might whisper to each other that he is perhaps a bit cold or that the reality of the situation has not caught up with him yet. The expectation is that grief requires a very specific type of performance. We expect tears. We expect verbal processing. We expect a person to sit in a room and speak eloquently about the pain expanding inside their chest. If a man does not do these things we assume he is failing at grief or repressing his emotions to a dangerous degree. The man who returns to his desk on Monday morning and answers his emails is viewed with a mixture of admiration and intense clinical suspicion.
This suspicion is rooted in a very narrow understanding of how human beings process loss. In my current practice as a bereavement counselor I spend a significant amount of my week sitting with men who have been told by their partners or their doctors that they are grieving incorrectly. These men arrive in my office looking defensive. They sit heavily in the chair and wait for me to pass judgment on their lack of visible despair. The therapeutic profession has a heavy bias toward what researchers Terry Martin and Kenneth Doka categorized as intuitive grieving. This is the style of grief most commonly represented in television shows and self-help literature. The intuitive griever experiences loss primarily as waves of heavy emotion and they process that emotion by expressing it outward. They cry. They talk to friends. They join support groups where feelings are laid bare in the center of a circle. Our society has elevated the intuitive style as the gold standard of healthy mourning.
The doing of grief
Martin and Doka proposed that there is another point on the continuum of mourning which they called instrumental grieving. Men fall quite frequently into this category. The instrumental griever experiences loss cognitively or physically rather than in waves of pure sorrow. They process the death of a loved one by doing things. When a man loses his brother and immediately signs up to run a seventy mile ultramarathon he is not necessarily running away from his feelings. The training schedule and the physical exhaustion become the language he uses to make sense of the absence. Every mile logged on the pavement is a physical expression of a sorrow he cannot articulate with words. When Arthur sat in the hospice asking the junior doctors about the milligram increments of his wife's morphine drip he was enacting his grief through the gathering of data. We do a massive disservice to men when we look at these actions and label them as denial.
Robert Neimeyer writes extensively about grief as a process of meaning reconstruction. When someone we love dies the entire narrative of our life is severed. The story we were telling ourselves about who we are and what our future looks like suddenly stops making sense. A man who has spent two decades identifying as a provider and a protector wakes up one morning and finds there is nobody left to protect. He has to figure out how to rebuild an entirely shattered sense of self. Many men attempt this reconstruction using the physical materials of the world around them. They will take a week off work to completely gut and renovate a bathroom. They will spend sixteen hours a day sorting through a chaotic garage until every rusty nail and loose screw is categorized in plastic containers. They are trying to restore order to a universe that has just demonstrated extreme cruelty and randomness.
I once worked with a client named David who lost his teenage son in a traffic collision. David was a mechanic who rarely spoke more than three sentences at a time during our initial sessions. His wife had insisted he come to therapy because she was worried about his absolute refusal to cry. During our third meeting I asked David what he had been doing with his evenings since the funeral. He told me he was rebuilding the engine of an old motorcycle his son had bought a year prior. He spent fifty minutes explaining the intricate mechanical problems involved in sourcing parts for this specific engine. A traditional therapist might have interrupted David to ask how he felt about the motorcycle. They might have gently pushed him to connect the broken engine to his broken heart. I employed a strictly person-centered approach instead and simply listened to his monologue about spark plugs and carburettors. I recognized that the act of fixing that motorcycle was the only way David could currently tolerate being alive. He was pouring all of his fatherly devotion into cold metal because the boy he wanted to pour it into was gone.
A counselor must offer immense unconditional positive regard to the man who grieves with his hands. Carl Rogers taught us that clients have the capacity to find their own way forward if we simply provide a therapeutic environment free of judgment. If I sit in my chair and secretly wish for the instrumental griever to break down in tears I am failing him. I am imposing my own theoretical bias onto his reality. There is a deep therapeutic value in allowing a man to mourn through action without pathologizing him for it. We have to learn to interpret the spreadsheets and the sudden obsession with lawn care as legitimate expressions of mourning. When we validate this style of grieving we often see the client relax. The defensive posture softens. They realize they do not have to perform for the therapist and they do not have to pretend to be someone they are not.
When the tasks run out
The tragedy of the instrumental style is that the world eventually runs out of urgent tasks. The immediate aftermath of a death is highly bureaucratic. There are death certificates to secure and bank accounts to freeze. There are relatives to call and caterers to hire for the wake. The modern workplace might offer three to five days of bereavement leave to deal with these logistics. The instrumental griever excels during this period. He manages the crisis with efficiency. He returns to the office and throws himself into quarterly reports or client meetings. His colleagues are relieved because they do not have to deal with awkward emotional outbursts in the break room. The society around him applauds his resilience and rapidly moves on with its own concerns. The protective bubble of early grief dissipates entirely.
Six or seven months later the probate is finally settled. The thank you notes for the floral arrangements were mailed out a long time ago. The motorcycle engine is completely rebuilt and runs perfectly. This is the exact moment when the delayed crash typically occurs. The doing stops because there is nothing left to do. The silence of the house can no longer be drowned out by the noise of constant productivity. I see a surge of men entering counseling around the six month mark. They do not come in saying they are sad. They come in reporting physical ailments. They complain of severe lower back pain or horrible insomnia. They describe sudden flashes of intense rage that frighten them. A man will tell me he screamed at a young cashier in a supermarket because she scanned an item twice. He will look profoundly ashamed of himself as he recounts the story. He thinks he is losing his mind.
This is what masked grief looks like when the physical energy required to sustain it finally depletes. The human nervous system can only operate in a state of high alert for so long before it mandates a shutdown. The anger at the cashier is rarely about the cashier. It is the overflow of unexpressed pain looking for a safe target. The problem for men at this stage is that their social support network has long since scattered. During the first two weeks after the death there were casseroles left on the porch and text messages asking how he was holding up. Six months later people assume he is fine because he looked completely fine in week two. He is now falling apart in a terrifying vacuum. His friends might invite him out for a pint but they absolutely do not want to discuss the deceased. They want to talk about football or interest rates.
In the counseling room my job at this juncture is to sit with the anger and the physical exhaustion. The men who crash at six months are intensely critical of themselves. They believe they have failed some arbitrary test of endurance. I use these sessions to carefully deconstruct the expectations they have absorbed from the world. We look at the reality of their exhaustion. I will often ask a client how much sleep he has averaged over the last half year. The answer is usually grim. We discuss the physiological toll of carrying unresolved stress in the muscles of the jaw and the shoulders. By moving the conversation away from abstract emotional concepts and focusing on the concrete reality of his physical state the client begins to feel seen. We build a bridge from the physical experience of grief to the emotional core of it. We do this very slowly.
The line between moving and running away
There is a necessary distinction to be made here. Counseling is not entirely about validating everything a client does. We have to be honest about the precarious edge where instrumental grieving slips quietly into destructive avoidance. It is a very thin border. Building a memorial garden for a deceased spouse is an act of continuing bonds. It keeps the connection alive through physical labor and creation. Working ninety hours a week at a corporate law firm until your remaining family forgets what you look like is not instrumental grief. That is a frantic attempt to outrun the silence. We have to examine the function of the behavior rather than just the behavior itself. If the action brings the person closer to an understanding of their loss it is healthy. If the action is a desperate mechanism to blot out conscious thought it will eventually cause immense collateral damage.
I watch for the signs of genuine avoidance. The most common indicator is an increasing reliance on alcohol or prescription medication to manage the transition between daytime activity and nighttime stillness. A man might be highly productive until eight in the evening. He might then require half a bottle of whiskey to endure the hours before sleep. The alcohol forces a blunt shutdown of the nervous system. As a counselor I must address this without stripping the client of his dignity. We explore what happens in those quiet evening hours. We look at the specific thoughts that arise when the television is turned off. I do not demand that he stop his coping mechanisms immediately. I merely ask him to observe what the mechanisms are attempting to hide. We bring a mild curiosity to the avoidance.
It takes a great deal of patience to wait for a man to drop the mask on his own terms. You cannot pry it off him with clever therapeutic techniques. You certainly cannot shame him into emoting. I think often of those nights in the hospice sitting at the nurses station with the low lights. There were times when a man like Arthur would get up from his wife's bedside at two in the morning to fetch a glass of water from the kitchen. He would stand by the sink in the semi darkness. Thinking he was alone he would let his shoulders drop. The rigid posture would collapse completely. He would place both hands on the edge of the counter and bow his head while his chest heaved with silent, ragged breaths. He would allow the sorrow to physically inhabit him for exactly two minutes. Then he would wash his face with cold water. He would straighten his spine. He would walk back into the dimly lit room and resume his vigil.
That private moment by the sink was his grief. It was as valid as a hundred hours of weeping. My role as a counselor is to create a room safe enough for him to let the shoulders drop if he chooses to. I do not force the collapse and I do not judge the rigidity. I am simply there to witness whichever state he brings through the door. Men will grieve exactly as they must. They will build sheds and run marathons and fix broken machines to survive the unsurvivable. We just need to stop telling them they are doing it wrong long enough for them to heal.
