Men and Depression: Assessment and Intervention

1. Men and Depression: Assessment and Intervention Fred Rabinowitz, Ph.D. David Shepard, Ph.D.

2. Is underlying depression the “smoking gun” for men? Why are so few men diagnosed and treated for depression? Why is the measured lifetime prevalence rate of depression in men half of the rate for women? Why are rates for alcoholism, drug dependence and abuse, violence, and antisocial personality so much higher in men than women? Why do so many more men than women commit suicide?

3. OVERT DEPRESSION SYMPTOMS • Utilizing the DSM IV Criteria –Dysphoria, thoughts of death, appetite change, sleep change, fatigue, diminished concentration, guilt, psychomotor changes and loss of interest in previous activities > 2 weeks • For men there are few differences in course of illness and symptoms for those with DSM criteria • 2:1 ration women to men holds up across studies in Western countries. • But what happens when depression is defined from a male-centric perspective?

4. Precipitating factors for male depression

5. Post-Traumatic Stress Disorder as a Precursor for Male Depression • Prior experience of an event involving actual or threatened death or serious injury, or a threat to the physical integrity of self or others • Response involved intense fear, helplessness, or horror (example: childhood physical abuse) • Men, who have experienced trauma not only battle the after effects of the traumatic situation, but also the normative male socialization that has told them to keep their emotional reactions to themselves.

7. Grief and Loss as a Precipitating Factor • Loss is inevitable • Losses accumulate over the life span • For many men, the prohibition on expressing sadness and by implication, interpersonal connection, leave them vulnerable to the unexpected impact of losses over time

8. Loss of Employment • Male identification with work • Meaning and purpose in being breadwinner • Shame about feeling like a failure • Isolation from friends and co-workers • Helplessness that comes from not being able to quickly fix the situation • Negative self-talk and depressive outlook

9. Aggression in Men as a Pathway for the Expression of Depression • Anger is often most accessible primary emotion available to a man • More socially acceptable form of behavior in for men • Hides sense of inadequacy • Keeps others at a distance • Allows for an acting out of uncomfortable negative affect

10. Addiction as Self-Medication • Central nervous system arousal from use of substance or compulsive activity • More men than women use this route to deal with depression and to numb painful affect • Attempt to control mood • Denial about its effect on others • Acting out of self-destructiveness • Can lead to recklessness and the disinhibition of negative self-statements

11. Masculinity related symptom expression • Somatic or physical complaints (back, neck) • Irritability and increases in interpersonal conflict • Difficulty with concentration • Engaging in compulsive behavior (eating, drinking, sexuality, work, television, exercise) • Withdrawal from relationships and typical activity • Wounds to self-esteem (job loss or relationship loss)

12. DEEPENING THERAPY CONFLICT ZONE ASSESSMENT • Relationship history? • History of Losses. Unresolved grief? • Conflicts between perceived cultural role demands of manhood and inner experience? • Difficulty “being” with feelings because of emphasis on “doing”? • Identify the emotional wounding that has brought him in. • Assess as you build the relationship. Rabinowitz & Cochran (2002)

13. What you see on the outside is not always what is going on on the inside. • Tough exterior takes energy and effort to maintain. • Tough exterior is a way to maintain control. • Tough exterior keeps others away. • Tough exterior protects against shameful feelings.

14. Cognitive Interventions • Confronting gender-related cognitive distortions around the following themes: winning, emotional control, risk-taking, violence, playboy, self-reliance, primacy of work, disdain for homosexuals, physical toughness • Historical review of past experience • Illogicalness of strictly following male injunction • Personal experiment Mahalik (2001)

15. Existential Interventions • Seeing life as a long journey with male client as the main character. What do you want your life to be? • Confronting the choices one has made and the anxiety that comes from the consequences of one’s actions. • Demystifying idealistic expectations and accepting reality as it is. • Accepting mortality and loss. Challenging a man to make the most of the life he has left. • Facing aloneness and learning to make meaning on one’s existence.

16. Empathy and Mirroring • Accepting what male client says as “his truth” and reflect it back to him • Unconditional positive regard • Authentic interaction with male client including relevant self-disclosure of feeling • Focus on feelings beneath the words to deepen meaning of what male client is saying

17. Psychoeducation for Alexithymia • Learn about the psychological and physiological nature of emotions • Develop a vocabulary for emotions • Learn to read the emotions of others • Keep an emotion response log related to body sensations and situations and utilize vocabulary list to pick out the word that describe emotion • Practice inside and outside of session • Levant (2001)

18. Action Oriented Interventions • Gestalt empty chair dialogue • Role playing parts of the self • Psychodrama • Art therapy (draw, sculpt, paint) • Music: play or listen to favorite songs as a way to open up to the emotional realm • Using video games as interaction vehicles, especially with boys and young men

19. Body Oriented Interventions • Hitting, pounding, and kicking • Twisting the towel • Meditation and imagery • Breathing and yoga • Exaggeration of gesture and voice quality • Use of touch

20. Men’s Groups

21. Group as an alternative and adjunct to Individual therapy • PTSD: Support around common trauma • Addiction: Confrontation of self deluding behaviors by those who know the game • Loss: Provides support system with men who are at various stages of grief process • Domestic Violence: Peer support and modeling for restructuring of thoughts and actions; accountability • Depression: Empathy, social support system, follow-up • Growth: Process life themes (aging, relationships, family, loss, disappointments, making life changes)

22. Big Issues Case Study: Jesse BACKGROUND • 54 years old, marital difficulties with second wife • 8 year old son, shared custody with ex-wife • Interested in joining men’s group • Military father, passive mother; both not alive • Only child growing up PRESENTING ISSUES: • Wants support for being a good father, personal growth UNREVEALED ISSUES: • Recovering from testicular cancer • Sexual harassment suit at work • Rigidity, irritability, and anger at home • Struggling with self-hatred • Masked depression

23. Big Issues Case Study: Leo BACKGROUND INFORMATION • 24 years old, Recently married , overweight, has bad temper, gets violent • Mandated by court to come for counseling after domestic violence charge • Works seasonally in a physical labor position. PRESENTING ISSUES • “I shouldn’t be here. My wife called the police. I only pushed her.” • “I could lose some weight and drink less beer.” • “I wish my back didn’t hurt so much. I could work more.” • “My wife doesn’t want to have sex. That’s not right.” UNREVEALED ISSUES • Parents divorced when he was 14; father was abusive to his mother; he fought off his father, protecting his siblings • Has struggled with feelings of worthlessness since he was a child • Uses alcohol and oxycontin to numb the pain • Wife also comes from an abusive family situation

24. Big Issues Case Study: Steve BACKGROUND INFORMATION • 19 years old, lives at home with mother, her boyfriend, and brother • Has never known his father • Recently was driver in a severe car accident in which two of his best friends died PRESENTING ISSUES • Sleeping 16 hours per day according to mother • Quit his job and school; staying in his room most of the day watching TV • Has lost 30 pounds since accident 4 months ago • Mother and brother came with him to first session just to make sure he arrived at the therapist’s office UNREVEALED ISSUES • Before accident, was attending college, hoping to be an accountant • Was working 40 hours per week at supermarket • Hasn’t talked to anyone about the accident • Feels extreme guilt for the death of his friends

25. Big Issues Case Study: Tim BACKGROUND INFORMATION • 35 years old, married two years, two year old son and wife pregnant • Wife told him, “Get therapy or we divorce.” • Works 60-80 hours/wk for animation studio; wife recently unemployed PRESENTING ISSUES • Stressed out by job, can’t afford to leave • Can’t sleep. • “My job is the problem. And my wife losing hers.” UNREVEALED ISSUES • Lost his temper in front of his son; deeply frightened by experience • Sister committed suicide a year ago • Parents religious fundamentalists • Believed as a child he was destined to be “great”; considers himself a failure

26. Selected Books for Men, Therapy, Depression Brooks, G. (2009) Beyond the Crisis of Masculinity. Brooks, G. & Good, G. (2001) New Handbook for Psychotherapy and Counseling with Men. Cochran, S. & Rabinowitz, F. (2000) Men and Depression. Englar-Carlson, M. & Stevens, M. (2006) In the Room with Men. Kilmartin, C. (2007) The Masculine Self (4th. ed). Pollack, W. & Levant, R. (1998) New Psychotherapy for Men. Rabinowitz, F. & Cochran, S. (2002) Deepening Psychotherapy with Men. Real, T. (1997) I Don’t Want to Talk About It: Overcoming the Legacy of Male Depression.