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“Dulling the edges” : young men’s use of alcohol to deal with grief following the death of a male friend Creighton, Genevieve; Oliffe, John Lindsay; Matthews, Jennifer; Saewyc, Elizabeth Marie Feb 1, 2016

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1       “Dulling the edges”: young men’s use of alcohol to deal with grief following the death of a male friend      Genevieve Creighton1     John Oliffe1     Jennifer Matthews2     Elizabeth Saewyc1      1University of British Columbia, Vancouver, British Columbia, Canada     2BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada    Author’s prepublication copy      2  Abstract  Background: The death of a male friend can be challenging for men because expressions of grief can be governed and restrained by dominant ideals of masculinity. It is common for young men to engage in health risk practices, such as alcohol overuse, to deal with feelings of sadness. Objective: This qualitative study investigated the ways that young men use alcohol in the process of grieving the accidental death of a male friend. Methods: Participants included 35 men 19- 25 years old, and 22 men, ages 26-35 who participated in individual semi-structured interviews between 2010-2012. Results: Methodology informed by grounded theory and narrative analysis was used to analyse and interpret the transcribed interviews, focusing on the ways that men used alcohol in the grief process. Through data analysis we inductively derived three themes: 1) Using Alcohol to Dull the Pain and 2) Using Alcohol to Purge Sadness, and 3) Troubled Drinking. Conclusions: This study provides evidence to show that men’s binge drinking following tragic loss is a means to express emotion and connect with others. Health interventions for young men who have lost a male peer need to be sensitive to gendered norms that inform grief practices and work with them to discern pathways toward recovery that promote long term wellness.  Keywords young men, bereavement, alcohol use, masculinity     3  While unintentional injuries are the leading cause of mortality among young men (Statistics Canada, 2012), little is known about the grieving processes that men go through following the sudden death of a friend. Literature suggests that grief can be challenging for men because expressions of sadness and vulnerability are governed and restrained by dominant ideals of masculinity (Creighton, Oliffe, Butterwick, & Saewyc, 2013; Creighton & Oliffe, 2010). Because these masculine ideals include practices of stoicism and rationality, men who grieve in other ways can feel judged and alienated (Martin & Doka, 2000; Shamir & Travis, 2002). While not all men feel compelled to align with masculine norms  (see Creighton et al, 2013 for broader discussion on men and grief identities), some men may engaged in risk-taking, including  alcohol overuse to mask, control or justify their grief related  emotions (Martin & Doka, 2000; Oliffe & Phillips, 2008). As such, drinking to be intoxicated can be a way for men to engage in the processes of grief but it also can also be disruptive to health.   Men and Alcohol Use Alcohol overuse has long been considered a serious health issue for young men. Forty-four percent of young Canadian men report drinking heavily (more than five drinks on one occasion) more than once per month (Statistics Canada, 2011). Binge drinking is a common social practice for both young men and women, but men tend to drink more heavily and with greater frequency - 12.5 binging episodes per year compared to women’s 2.7 episodes (Naimi et al., 2003; Nolen-Hoeksema, 2004). In addition, men have high rates of alcohol related deaths, injuries and episodes of violence and aggression (Center for Disease Control, 2010; Nolen-Hoeksema, 2004). Eighty percent of deaths from alcohol related motor vehicle accidents (MVA) 4  are men, two-thirds of these being the driver of the car (Collin, 2006). Men engage in heavier drinking practices than women do and cause greater harm to themselves and others. Evidence suggests that men’s alcohol overuse can be seen as a gendered practice, taken up to demonstrate alignment with dominant ideals of masculinity such as competitiveness, risk taking, fearlessness and strength. As Connell and Messerschmidt (2005) suggest, hegemonic masculinities are patterns of patriarchal gender relations that exalt dominant forms of masculinity and subjugates femininity and alternate forms of masculinity. While not all men embody or align  with hegemonic masculinities, Connell (1995) argues that men  position each other and  themselves within masculine hierarchies in response to these gendered discourses..  Men may drink to demonstrate  strength, power, and disregard for danger, and provide assurances of their masculinity (Capraro, 2000; Connell, 1995; Kimmel, 1997). Colloquially deemed “liquid courage,” men who may ordinarily be quiet and gentle can become extroverted and aggressive when intoxicated (Capraro, 2000; DeVisser, 2009; Peralta, 2007; Young, Morales, McCabe, Boyd, & D’Arcy, 2005).  Young men can also drink to express more vulnerable emotions that are inconsistent with the dominant masculine ideals (DeVisser, 2009; DeVisser, 2012; Harris, 2008). Peralta (2008) suggests, being drunk can allow men to commit “gender blunders” and without compromising their alignment to and embodiment of  stoicism and toughness. In this regard alcohol use can be tightly tied to sustaining or transgressing dominant masculine ideals.      The aim of this qualitative study is to better understand the way that young men use alcohol in the process of grieving the accidental death of a male friend as a means to inform the strategies of grief counselors and others involved in supporting young men.  5  Method Data Collection Participants: Following University ethics approval, participants were recruited using posters, flyers, online advertising and word of mouth. Information was also distributed to staff of local youth service organizations to direct study information to potential participants. Potential participants could request more information or volunteer for the study by contacting researchers by telephone, text or e-mail. A total of 57 participants were recruited from Vancouver, British Columbia, a large urban center on the West Coast of Canada, and from Whistler, a nearby mountain resort town. Participant inclusion criteria  was that their male friend’s death must have been linked to a risky activity such as operating a motor vehicle while intoxicated, snow sports in avalanche conditions or illicit drug use (see Table 1).  There were two cohorts: younger men (19-25, mean age 21 years) who had a male friend who had died accidentally within the past three years, and older men (26-35) who had a male friend die accidentally when they were a young adult (Table 1). The two cohorts provided longitudinal perspectives about grief and the death of a male peer. Integral to our approach was attention to participants’ alcohol use in the context of losing a male friend to a risky activity.  Procedures: Participants were guided through a consent process with an opportunity to ask questions about the study procedures.  Cohort 1 (age 19-25 at interview) constituted the focus demographic for this study. Participants were interviewed individually on two separate occasions using a semi-structured interview guide and photo elicitation methods. Each interview lasted approximately one hour. In the first interview, participants were invited to tell the story of their friendship and how the death occurred (Creighton et al., 2013). The second interview 6  focused on issues of loss, grief, risk and masculinity, with questions designed to elicit the details of how participants coped immediately after the death and in weeks and months that followed. Participants were asked about formal and informal support systems that were salient to their process of grieving.     Cohort 2 participants (age 26-35 at interview) were each interviewed once as a means to provide a retrospective account of losing a male friend influenced their life in the ensuring years. Interview questions focused on what participants remembered about the time immediately following their loss, and their reflections on grief and masculinities as older men with temporal distance from the event.  Data were collected between 2010 and 2012. Interviews were conducted by three female researchers, and participants received $20 honoraria following each interview. Participants were provided with contact information for professional grief and crisis intervention services.   Qualitative Analysis: Interviews were digitally recorded and transcribed. Transcribed interviews were uploaded into a qualitative data software program (Atlas.ti6™). . We drew from grounded theory informed methods (Charmaz, 2006) and narrative analytic strategies (Elliot, 2005) to conduct  thematic analyses by constantly comparing  the meaning that each participant made of their alcohol use following the loss (Morse, 2008). Within this inductive approach, we coded the data based on assigning excerpts from the interviews such as “I got drunk so I wouldn’t feel” and  “got hammered at the wake”. Phrases were grouped based on similar meanings and themes were defined from the coded data (Bong, 2002; Corbin & Strauss, 2008). Once initial themes were defined, we compared across participant interviews to further refine the themes. Our exploration of the relationships and patterns across themes led to an integration of data 7  or sense making which allowed us to describe   prevailing similarities  across  the two participant cohorts (Elliot, 2005). Cohort 1 & 2 interviews were analyzed in two separate groups (reflecting the different questions asked of each group). In comparing the two cohorts, we looked specifically at what prevailed and differed across time. Though this longitudinal approach did not permit us to assess how individual viewpoints may have shifted across time, we were able to note the ways in which reflections about a similar experience evolved with age and temporal distance, and how they related to alcohol use. Connell’s (1995) hegemonic and multiple masculinities framework was used to theorize the  study findings. We focused on the ways that men constructed gendered identities both by drawing on and purposefully transgressing masculine norms in the aftermath of such a loss. Results Early on in the analysis, it was evident that references to alcohol were common in both cohorts’ stories. While some participants spoke of using drugs in addition to alcohol, alcohol use predominated, and therefore became the focus of our analyses. In analyzing these data in the wider context of the participant interviews, we inductively derived two themes distilling the men’s primary practices around alcohol:  1) Using Alcohol to Dull the Pain and 2) Using Alcohol to Purge Sadness. We found a third theme, Troubled Drinking, in Cohort 2 which related to persistent, frequent and intense use of alcohol to cope with their loss. This third theme was found among participants who recognized their problematic drinking and questioned the utility of alcohol use as a long term remedy. As shown in Table 2. the first and second themes were  present in most participant  interviews  across the two cohorts. The third theme prevailed among older men (cohort 2) who identified as single at the time of their interview.   8  [Table 2. placed here] Using Alcohol to Dull the Pain   As illustrated in Table 2, the majority of participants from both cohorts spoke about drinking to become drunk immediately after hearing about their friend’s death in order to anaesthetize the pain of the loss. Many men spoke about their sense that they would be unable to cope with feelings of sadness and used alcohol as a means to dull the pain of their intense emotion.   Stephan, now 24, was 23 when his friend died as a result of a drug overdose. Stephan and his friend were part of a group of young, urban Aboriginals. They acted as mentors for youth in the inner city, building relationships and helping to foster resiliency among their peers. Stephan found out about the death from a close friend: “I was at my house. I had just got home. I didn‘t really take it very well. I kind of slipped up and did a bunch of MDMA [Methylenedioxy-methamphetamine] and got drunk for like three days straight.”  While Stephan had struggled with drugs and alcohol, he had been clean and sober for eight months prior to the death of his friend. Yet, when he heard about his friend’s death, he felt as though he could not cope without the help of drugs and alcohol. As Stephan eloquently summated, “I just wanted to dull the edges… but I really did go too far that time.” Though his relapse was limited to one grief-induced binge, Stephan’s alcohol and drug use reflected the experiences of other men in the sample illustrating some men’s limited options for coping with significant emotions.  Jose, age 19, was 18 years-old when he lost a friend to a drug overdose, the one person he felt truly understood him. An immigrant from El Salvador, Jose had been in and out of foster care, living on the street when he didn’t have a stable home. Jose described his recent life as 9  “evening out,” and had considered his friend an asset in his newfound balance. “He was just one of those people who would like you for who you were… and not try to use you or anything.” Jose was devastated by the death. “As soon as I heard about his passing, I went to a bar that we hung out at. I kind of just went and got really drunk.” He used alcohol, not only as a way to reduce his sadness but as a means to assuage his pain and regret at having lost a friendship that had garnered positive change in his life. Participants also identified becoming drunk within these contexts as having purchase on a strong masculinity. In essence, alcohol helped them dampen the pain associated with their loss, so that they could maintain an image of strength and solidity. Nathan, a 22-year-old Jamaican-Canadian, explained that his friend was stabbed in a fight outside of a bar, and recalled finding out about the death through an online memorial that was circulating on Facebooktm. He too recounted going out and getting drunk immediately after discovering his friend had died. He discussed how difficult it is for men to express grief.  It‘s harder for us… because we look like—excuse my French—like a bitch if you don‘t try and deal with it on your own. If a whole bunch of people go through a tragedy together, then you kind of lean on each other, but eventually have to fight through it all on your own.   As Nathan pointed out, many men submit to being strong and stoic in the face of grief, and while it is acceptable to “lean on each other” temporarily, dealing with emotions is ultimately a solitary task. Even in the face of such traumatic loss, crying or talking to others about their grief was feminized and devalued as unmasculine wherein  men who were perceived as being unable to  manage their grief  labeled  as weak.  10  Masculinity is often defined by what it is not – feminine (Mahalik, Burns, & Sysdek, 2007). Within the context of alcohol dulling the pain it was clear that to be emotionally vulnerable marked a significant departure from the manly control and restraint linked to western masculine ideals. Countering this is the opportunity to align with what men do – drink their ‘feelings’ away. The masculine script condoning, and at time celebrating alcohol overuse afforded some legitimacy in the context of the men’s grief wherein the familiar path to drinking was much less confronting than being seen as unable to deal with one’s emotions.  Using Alcohol to Purge Sadness   Paradoxically, while becoming intoxicated was a means to gain control over an emotional loss, it also facilitated or excused expressions of sadness that might be considered outside masculine norms. As Peralta (2008) suggests, men described using alcohol to grieve because it lower inhibitions and allowed them to freely express themselves, but also because others would temporarily accept some  non-masculine behaviours as being caused by their drunkenness.      Sheldon, a 28-year-old of Euro-Canadian descent, was 24 when his friend died in a skiing accident. On that afternoon, after a few runs, Sheldon and the rest of the group had called it a day, but his friend decided to go for one more run, was trapped in an avalanche, and died from his injuries. Sheldon attended his friend’s wake, describing the event as an opportunity that men used to work through their feelings about the death: But I don't think that anybody is like, ‘Well, I'm going to go get hammered for [my friend’s] wake because I want to be able to express my emotions and whatnot.’ It's like, ‘Oh, I'm going to go celebrate [my friend’s] life and get hammered with all the boys.’  11   Along with other participants, Sheldon spoke of the way that, outside of being drunk, his male friends were restrained in their grieving. They spoke about the death in distanced and detached terms amid avoiding its emotional impact. They were able to couch the act of becoming intoxicated as “celebrating [his] life” while letting loose feelings of despair and sadness at the same time.   Andrew, a 28 year old Anglo-Canadian, was 26 and working at a bar when a young fellow employee died from an overdose on MDMA. He also described alcohol use as a vehicle for the expression of sadness and grief. Andrew told the story of how the bar management held a gathering afterwards to provide other employees, mostly a tightly-knit group of young men, an opportunity to talk about the death and celebrate the life of their friend. He described the way the young men got increasingly intoxicated:  I mean they just came in and it was just Jack Daniels, all of them just got as boozy as possible and they got rough.  They were breaking chairs and screaming and being really barbaric, something that guys would do as opposed to females.   Andrew questioned the appropriateness of this alcohol-soaked memorial, as the event shifted from a memorial gathering where men could support each other to a drunken brawl. However, he also spoke about how intoxication allowed the men to connect on an emotional level: “[There was] lots of hugging and touching and stuff like that.  I think [the memorial] became really important for them.”  In contrast to this peer led memorial, Andrew described how a different attempt by trained professionals to get the young men to process the grief backfired. Because the death was an overdose, the police brought in the victim support worker team to provide critical incident 12  response. However, Andrew argued that this only added to their trauma; the workers gathered the group together inviting them to talk about their feelings regards the very recent death of their friend. Andrew felt that the setting was cold and unwelcoming, and did not help, but rather inhibited the young men. Comparing it to the memorial at the bar initiated by friends and family, Andrew explained that the more relaxed environment was more appropriate for young men. “That's how we cope. That's what we want, you know? Probably just want to sit down, have a beer, and talk with your friends amongst each other. You don't want a cup of tea or a glass of water.”    Both Andrew and Sheldon maintained that, rather than serving to prevent or delay feelings associated with grief, alcohol helped men connect with their emotions. Men were able to be close, affectionate and support each other in ways that were unacceptable when they were sober.  Troubled Drinking   Moderate alcohol use in young adulthood has been linked to some benefits, such as building social connections and relationships, and improving psychological functioning and adjustment (Schulenberg, O’Malley, Bachman, Wadsworth, & Johnson, 1996; Tan, 2012). Many of the older cohort participants confirmed that, in the short term, the positive effects of alcohol use outweighed the negative. Participants also acknowledged that prolonged alcohol use could become negative, particularly when it led to patterns of risk taking, addiction and alcoholism.  Eleven participants in the older group explained that, while they initially drank in order to numb their grief and bond with other survivors, over time their drinking had become problematic. Some participants spoke about how they had begun using alcohol as a means to dull 13  an array of feelings or pain but that this drinking had become a solitary activity done, not just to grieve, but to cope day to day. Adrian, a 31-year-old Anglo Canadian, remembered losing his friend in a car accident when he was 23. He explained that his difficulties with alcohol started after the death of his friend, fueled by a ritual he referred to as “drink fests,” wherein a group of friends drank, retelling stories about their friend and the meaning of his life. After a while, Adrian recalled, the gatherings became less frequent while his heavy drinking continued:   I drank quite a bit after, a few months after his death, and like, well not every day, but it was just like every time I’d like go out, I’d be like pounding beers, you know?  Where I used to be a mellow drinker who eventually gets drunk but then I’m getting like, focusing on being wasted and that I didn’t care, I was just like, ‘I don’t fucking care’.  Adrian described his feelings of being “left behind” by his friends and the profound isolation that accompanied his loneliness. His drinking evolved from a purposeful group activity to a solitary engagement that made him ever more depressed.  Randy, a 35-year-old South Asian- Canadian, experienced the death of his childhood friend from a cocaine overdose 10 years prior to the interview. He also spoke about the way that his drinking went from light and sporadic to heavy and regular. Unlike Adrian and other men who recounted memorial gatherings, Randy highlighted the absence of a communal grieving experience to honor his friend which he thought may have been due to shame about the circumstances of the death. Because Randy and his friends did not have an opportunity to talk about the death of their friend, they tried to find other ways to cope. He said his drinking went from an “occasional night out or brief bender,” to heavy drinking on a daily basis: “When one beer didn’t make me feel any better, it would turn into seven.” 14  Mike, a 27-year-old Anglo-Canadian, was 22-years-old when his friend and mentor was killed in a car accident.  Mike and his friend sailed on the university team together and his friend died en-route to a regatta when the driver fell asleep and rolled the car into a ditch.  Mike’s friend and his friend’s girlfriend were killed instantly while the driver suffered a permanent brain injury:  Emotionally I felt really fragile so I was drinking, I started definitely drinking a lot.  I withdrew and I think I did certainly for a few weeks, not really wanting to talk to anybody but you almost want people to know that you are angry, you want people to feel your pain or feel that same way, that sense of loss because you do feel that there is some injustice that has been committed…but in the long-term, I definitely drank and smoked marijuana and all that peripheral stuff that you kind of do to manage your…self medicate your blues away.   Mike remembered using alcohol and drugs to express his emotions publicly. He framed his drinking as both a “cry for help” and a long term strategy to deal with his enduring pain. It wasn’t until his addiction “spiraled out of control” that he sought help from his parents and a professional counselor.   Josh, a 35-year-old of East Indian descent, was 17 when a high school friend was killed in a motorbike accident. He recalled coping with the loss by drinking heavily, sometimes with other friends from school and other times in his basement alone. “Drinking was not strange in my family. My dad was a regular drunk…a hardcore drinker and I’m pretty sure my mom had a few too many every weekend.” While he described himself as “troubled” for the year following the death of his friend, he began drinking less and becoming more and more capable of holding a 15  job. However, when he turned 22, Josh suffered a setback when another friend died in a motorcycle crash:  [The next few years] were a total blur. I got jobs because I could turn on the charm but sooner or later I’d blow it by coming into work drunk or making some fatal error or mistake or whatever. I was working in the non-profits, funnily enough, you know, with drunks in recovery. I kind of started to get a bad name.  Josh’s account illustrates how multiple traumas can fuel one’s problematic patterns of alcohol use. While heavy drinking to cope might taper off, drinking to manage a series of losses may trigger psychological and physiological dependency and disrupt employment and social relationships. Threaded through these men’s narratives were the early drinking patterns spiraling toward dependency and dysfunction in other areas of their life. Ironically, the use of alcohol as a short term remedy and means to connecting with others threatened to isolate men in the longer term.  Discussion In describing young men’s experiences following the death of a male peer, the current study examines the ways alcohol is used in the aftermath of loss. Our findings demonstrate alcohol use constitutes a masculine practice in the context of grief for young men, both to suppress and express feelings of sadness, vulnerability and loss.  The health and wellness outcomes of alcohol use within grief appear mixed in our study. Alcohol use was not an entirely negative experience for participants; instead, it was implicitly and often explicitly located as therapeutic, in helping men cope with the sudden loss of a male friend. However, as research shows, alcohol use can also increase other health risks, such as 16  driving while under the influence, engaging in activities beyond one’s ability and capacity, and alcohol-induced fighting (Center for Disease Control, 2010; Collin, 2006; Nolen-Hoeksema, 2004; Tryggvesson, 2004). Becoming drunk in order to prove a strong masculine identity while avoiding help-seeking or supports can also place men at risk for depression and suicide (Courtenay, 2000b; Courtenay, 2011). By providing a short term pain management solution and a means through which to sustain a performance of strong masculinity, alcohol use can slow, prevent recovery, or worse still result in complicated grief.  Most participants spoke about using alcohol to facilitate their own grief process. Participants who saw their drinking as problematic, compared to participants who did not report life disruptions from their alcohol use, had other risk factors. Specifically, the  11 participants featured in Troubled Drinking identified as single,  and had experienced multiple tragedies, feelings of isolation, relationship breakdowns, and limited psychological resources for coping with loss. As well, those who reported repeated episodes of extremely heavy drinking and long term, systematic use of alcohol to numb feelings were most likely to have alcohol dependency issues. For some of these young men, their associated job loss, relationship break downs and health issues led to more drinking, to quell the upheaval from such outcomes. These participants may have started drinking as a means to counter or express grief with other survivors, but they continued on alone, no longer using alcohol as a way of bonding with other men (and gaining support) but as a way of getting through each day. Since excessive alcohol use can be central to men’s risk taking, the dangers are often overlooked as part of ‘being a guy’. The challenge for those responding to young men in grief is to pay attention to problematic drinking as a sign of unacknowledged pain, rather than just masculine recklessness. 17  The current study is limited in what it can reasonably say about  women, both in relation to men’s drinking and in terms of gender comparisons.  Women, as well as men, use alcohol as a means to express or not express difficult emotions, and research indicates some  women  drink to perform masculinity and to garner respect from male peers (McCabe, 2002; Young et al., 2005). Future research might usefully include mixed samples to distil the difference and similarities within and between men and women to understand and address grief in gender sensitive ways.  This study has some other limitations that should be considered. Because Cohort 2 was asked to reflect on a loss that took place years ago, the issue of recall bias should be taken into account. The study took place in both a major urban center and resort town on the west coast of Canada; to the extent young men in other contexts experience similar forms of loss, and similar masculine norms, these findings may be transferable. Likewise, although the study participants were from a variety of ethnic and socioeconomic backgrounds, they reflect the diversity of western Canada, rather than the USA or elsewhere. In terms of methodology, we wondered about the effect of urban, female interviewers on the data that were elicited. With the notion that gender is constructed in interaction (West & Zimmerman, 2009) we speculated about the potential for men to perform in hyper alignment with idealized public masculinities. While these and other gender dynamics may have also played out with male interviewers we suspect that female interviewers facilitated openness given that  many men are  accustomed to discussing issues of health and well-being with the women in their lives ( Oliffe, 2010; Oliffe & Mroz, 2005).  There are a variety of implications that emerge from the current study. First, when assessing problem drinking among young men, it may be useful to further screen for recent loss, given the possibility young men will experience the accidental death of a friend just prior to or 18  during their early adult years. Interventions in health or counseling services that support men to learn other coping skills may help prevent problematic drinking for some young men, and could be part of either individual clinical interventions or group education programs. While not explicit in the findings reported on in this article, adults or respected peers who model positive ways to express grief, or who help organize non-substance using rituals, may offer legitimized alternatives to alcohol-aided grieving (Creighton, 2012). While health care practitioners should be cautious about the timing and setting of any groups they might refer to and/or help organize, ensuring the setting is relevant to and welcoming for young men is key. 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