Fixing Men: The Trouble With Men -- Full-Length Expert's Interview

Ivanhoe Broadcast News Transcript with
Terrence Real, Psychiatric Social Worker,
Family Institute of Cambridge, Massachusetts,
TOPIC: Fixing Men: The Trouble With Men

We always hear that twice as many women get depression than men. What would be your guess of what the true statistic is?

Real: I think that it is probably closer to even. As I say in the book, people are beginning to understand men and women express depression differently. If you add in alcohol addiction, and acting out behaviors like violence and domestic violence, then the numbers come to be about exactly even between the two sexes.

In your book, you say there are two types of male depression. Can you explain those two types?

Real: There are two different manifestations of male depression. One is the classic depression that looks just like a woman's. The men just do not talk about it, but what they are experiencing is exactly the same. The other type I call hidden or covert depression. In this type of depression, the men are desperately running from feelings of depression through withdrawal, acting out, and self-medication with drugs, work, gambling, sex or alcohol. Research tells us when most women are in pain, they internalize it. They feel bad, they know they feel bad, and they reach out for help. When men are in pain they tend to externalize it. They look for some way to get out of it, and some of those ways of getting out of it are fairly constructive. They may get into work and exercise, but a lot of them are not so constructive, and none of them will deal with the actual issue.

What are the signs of overt depression?

Real: Signs of overt depression are the same in men and women. You look for the person to be feeling sad and blue for a couple for weeks or more. You look for changes in sleep. The person is either sleeping all the time or has trouble sleeping. Look for changes in food. He loses his appetite or eats a lot. Sometimes he exhibits a sense of guilt or hopelessness, difficulty concentrating, increased irritability, and a lack of pleasure in one's life. He is feeling pretty sad and blue, and the world turns very gray. Not every depressed person has all of these, but if he has more then three or four and it goes on for more then a couple of weeks, he should start thinking about being evaluated.

What are signs of covert depression?

Real: There is self-medication, which could be alcohol or drugs or it could be a process like gambling, risk taking, or spending. I have treated men, for example, who have a gambling addiction, but they do not know that is what it is because they are just playing the stock market but with very high risk investments. Men have lost millions of dollars. Another self-medication is radical withdrawal. Obviously, more then normal retirement from life and from relationships. The third is acting pout, which runs the gamut from increased irritability all the way up to anger, domestic violence, and even murder.

In covert depression, you do not see the depression itself, but you see the footprints that the depression has made on the man. What you see are the ways in which the man is trying to ward off the depression.

Is a man going to recognize these, or do you think it is going to come from somebody else recognizing them?

Real: Overtly depressed men have pain. Covertly depressed men have troubles. With covertly depressed men, often times they are not in pain, but the people around them are in pain. If you have a guy who is self-medicating, irritable, suddenly very distant, but thinks he is fine, you can ask his wife and kids how he is doing. Then, you'll get quite a different story. People around a covertly depressed man will probably recognize the issue better than the man.

Why do you think men do not seek treatment?

Real: I say that most guys are about as likely to get help for depression as they are to ask for directions and for much the same reason. It is unmanly to be vulnerable. It is unmanly to need help. We do not like men to be too emotional or vulnerable, and a depressed man is both. A depressed man has literally been overwhelmed by his feelings. This sets up what I call double shame. The guy gets depressed about being depressed. He gets ashamed about feeling shame, and he goes into hiding. Sometimes he hides it from others, and in covert depression, he hides it so well he almost succeeds in hiding it from himself.

If you recognize these things in the man in your life, how would you recommend getting the man into therapy?

Real: To deal with depression in men, you need to get help. Depression is one of psychiatry's great success stories. About 90 percent of people who get help for depression report substantial relief, but fewer then one in five ever gets helps. That is really a tragic story because we are not just talking about the guy, we are talking about the marriage and the children who are also dealing with all of this. There is really a great deal of damage that could be avoided if men would get help. If you live with this person as a spouse or an older kid, you have the right to insist on health in your family. If you confront the guy with what he is doing, that leaves you to think that there may be an untreated depression. So get your husband and say: "Look, this is what I notice: I notice you have been drinking about twice as heavily as you used to. I noticed you are really irritable with the kids and yelling. I noticed you are not sleeping. Here let me show you in this book. It says these are symptoms of depression. I think that you could get some help and things could be better for you and the family." If the guy says yes, then you know you are a winner. If the guy says no, I tell that women to say, "Look, you may not think that this is an individual issue and you may not go to therapy on your own, but then I am going to call it a couples issue. I booked an appointment next Thursday at 9 p.m. with a couples therapist. I am going with or without you, but I expect you to come with me." By hook or crook get that guy in front of a mental health professional and put it on the table.

Can you anticipate that there will be a lot of anger directed toward the person trying to get help for the man?

Real: There is a lot of anger at you. They are thinking, 'Who are you to be telling me?' On the other hand, a lot women feel that confronting a man about his depression is almost cruel. They think, 'Oh god, he is already feeling fragile. I better not push him, but what women have to understand is if you do not treat this disorder, it is not going to get better. There are going to be ups and downs, but it is not going to get better, and neither you nor your family has to live like that.

There is a study that says the rates of depression in Amish country are almost equal between men and women. One of the theories for this is that Amish men do not have the things that you described, the gambling, the drinking, and the womanizing, to cover the depression. What do you think of that hypothesis?

Real: I think it is also cultural. I think it is more permissible for Amish men to admit to some of their difficulties. The other group that has equal rates of depression between men and women is elementary school teachers. These are men who are out of the traditional masculine mode, and I think for very different reasons, these are men that are not ruled by the need to hide what is going on with them. Once you remove that stigmatism, then the depression rate is pretty equal.

What is the hardest part of treatting depression -- the acknowledgment or the actual treatment?

Real: Acknowledgment is the hardest part in the sense that if you do not get through that gate, you do not get any treatment. One of the things people, including clinicians, need to understand is that covert depression demands a two-step process. First, you have to deal with what the man is doing to get him away from it. Depending on how bad it is, he may need treatment for addiction or anger management in addition to getting at the underlying depression. In fact, it is the other way around. You will not get at the underlying depression until these things settle down. One of the things I say is that the cure for covert depression is overt depression. Once these defenses settle down, then the depression that the man has been running from will come up. Then you can treat it pretty much the way you treat any other depression with medication and talk.

Do you think we as a culture might be getting better at understanding the great unknown of therapy? I wonder if things like seeing Tony in "The Sopranos" has demystified depression?

Real: I do think that today it is slightly more permissible for men to be in therapy. I know that most identify with Tony Soprano. I think more then that people like Mike Wallace and William Stirin coming forward and talking about serious depression has been a great help. I also think that it is a work in progress. Men are starting to get the message that depression is a biological disease. It is just like diabetes, and you are an idiot if you do not get help. I think some men think we are talking about the near-suicidal depression, the can-hardly-get-out-of-bed form of depression, but in reality, depression runs along the whole spectrum from the very severe to relatively short-lived episodes to a more chronic kind of depression where you just feel gray and unhappy and are living under a cloud. It is not a gray thunderstorm, it is just a gray cloud, but it is a gray cloud you live with your whole life. That does not have to be there. I think men are beginning to get the message that in the very extreme kind of depression, they can get help. A lot men, however, still feel like it is a moral issue. They feel they should be able to tough it out because getting help for something like a bad mood is being a wimp. These men are simply wrong. You do not have to live like that.

The statistic that still strikes me is that although women are two-times more likely to be depressed, men commit suicide at four-times the rate?

Real: A man is four-times more likely to commit suicide then a woman and infinitely more likely to succeed at a suicide attempt. When men try to commit suicide they do it like guys. They are very efficient, they are very violent, and they usually get the job done.

How did you get involved in this type of work?

Real: My dad was a depressed man who did not know he was depressed, and he was very difficult to live with. His father was a depressed angry man, and I vowed that my two boys were not going to say that about me. I have had bouts with depression and also with acting out. I have gone through a pretty extensive amount of work to fix that. So, this is all very personal to me. I say that depression in men runs through generations like a fire in the woods from father to son to father to son to father to son until somebody turns around and faces it. I do not think it is just an issue for that man. I say that man is a hero who brings peace to the men before him and spares the children that come after him. This is not just about you, it is about you and your father and your children.

How do you get men to work on themselves?

Real: I teach therapists to ask a very simple round of questions to the man: What kind of father did you have? What kind of father do you want to be? What is the legacy that you want to pass on to your kid? Will you let me help you? And a lot of men who will not do this work for their own sake will do it for the sake of not damaging their children.

Is it frustrating for you to know the huge success rate of therapy and then to see all of these undiagnosed cases of depression in men?

Real: I know the depression is creating havoc not just for them, but for the people around them. You know the problem is that the same forces that start up depression in men set men up to not be willing to get help for it. What sets up depression in men, along with biology, is the code of masculinity. The stoicism that says be alone, be tough, do not feel anything, and do not reach out for help with anything sets so many men up to be so easily triggered to feel like failures and losers. They feel like their life is not getting where they think it ought to be. Those same forces that set a guy up to be vulnerable to depression also whisper in his ear that it is unmanly to reach out and get some help for it. One of my patients said, "First, you get your legs cut off, and then you get your arms cut off so that you can not ask for any help." It is sad.

When I deal with a depressed woman, the issue is almost always about feeling disempowered and losing their voice, and the work is about empowering them. When I am dealing with a depressed man, it is about being cutoff from other people and his own emotions. The healing work is about reconnecting them, but since the wound is about disconnection it is very hard to reach out and connect with somebody who can help you.

Do you think we are turning a corner on treating depression in men yet?

Real: I think that we are definitely turning a corner for the more clearly biological forms of depression. I think that it is very important to begin to get the message out to men who have the “milder” version of depression. It is starting to be taught that this is just not a matter of attitude or moral strength, but it really is a clinical disorder that can be treated. So, I think we are doing better at the sledgehammer forms of depression, but I think there is more work to be done with the less-obvious forms.

What advice to do you have for women who think the man in their life is depressed?

Real: I think women are one of the greatest unrecognized forces in men's health. Most of the men who come to see me are brought by women. They are what I call wife-mandated referrals. My message to women is to stand up to this disorder. It is no favor to anybody to let a man continue on in this much pain and therefore reek this much havoc on other people. You have the right to do that, and yes, it may be rocky getting him there, but once he is there and properly treated everybody's life will be better including yours. So, step up to the plate and help.

Is there a particular type of therapist you would recommend for this situation? Would it be a family therapist?

Real: You want a therapist who knows how to work with men. One of the things about therapists who know how to work with men is that they are much more active then traditional therapists. You know men do not respond all that well to, "Yes. Uh-huh, tell me more about it. That is too bad." Men want an action plan. They want to know what is going on. They want to know what steps to take to alleviate the depression. If you are going to interview therapists for your guy, which I really recommend, you would want to use words like active. Also ask how much experience they have with men and if they adjust the therapy when they are working with guys. The answer should be, "Yes. I work with guys differently then I work with women."

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END OF INTERVIEW

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc., or any medical professional interviewed. Ivanhoe Broadcast News, Inc., assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors in different ways; always consult your physician on medical matters.

If you would like more information, please contact:

Terrence Real
http://www.terryreal.com