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Men and Therapy : A Case of Masked Male Depression

Fredric E. Rabinowitz and Sam V. Cochran
Clinical Case Studies 2008 7: 575 originally published online 19 June 2008
DOI: 10.1177/1534650108319917
The online version of this article can be found at:
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Men and Therapy

A Case of Masked Male Depression

Clinical Case Studies

Volume 7 Number 6
December 2008 575-591
2008 Sage Publications
10.1177/1534650108319917
http://ccs.sagepub.com
hosted at
http://online.sagepub.com

Fredric E. Rabinowitz
University of Redlands, California

Sam V. Cochran
University of Iowa, Iowa City

Socialization influences may result in a masking of mens symptoms of depression. This

masking renders assessment a challenge for most clinicians, who are often sidetracked by
more-immediate presenting concerns (relationship or job loss, developmental transitions, or
alcohol or substance abuse). Clinicians may overlook a longer-term and more pernicious
underlying mood disorder. This case presentation describes the assessment and treatment of a
53-year-old White male in both group and individual therapy. He initially sought a mens therapy group for support for developmental transitions but was actually suffering from a more
severe underlying depression. The theoretical rationale and treatment implications for working with masked depression in men are presented.
Keywords:

men; masked depression; psychotherapy

1 Theoretical and Research Basis for Treatment

Masked Depression in Men
Clinicians who encounter men in health care settings are often confronted with the difficult task of trying to assess and treat depression in their patients. Cultural prohibitions
against displaying sadness, fear, and anxiety have frequently been described as reasons men
may be less likely to show their distress in the social environment and more likely to communicate their depressive symptoms in a nonobvious or masked manner (Cochran &
Rabinowitz, 2000). In essence, the muting of the behavioral expression of mood states
often makes it difficult for clinicians to identify clear and straightforward indications of
male depression (Cochran & Rabinowitz, 2003; Shepard, 2002).
Men who do meet the actual diagnostic criteria for depression of the Diagnostic and
Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994)
exhibit the following symptoms, in descending order of frequency: dysphoria, thoughts of
death, appetite disturbance, sleep disturbance, fatigue, diminished concentration, guilt,
psychomotor change, and loss of interest in typical activities (Weissman, Bruce, Leaf,

Authors Note: Please direct correspondence regarding this article to Fredric E. Rabinowitz, fredric_
rabinowitz@redlands.edu.

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Florio, & Holzer, 1991). This is consistent with other findings indicating that although
some small differences may be detected in clinical populations of depressed men and
women, overall symptom profiles, as well as the eventual course of a depressive episode,
tend to be similar (Coryell, Endicott, & Keller, 1992; Frank, Carpenter, & Kupfer, 1988;
Young, Scheftner, Fawcett, & Klerman, 1990).
Despite findings that depression is diagnosed in women twice as often as in men and that
women make more unsuccessful suicide attempts, epidemiological studies show that the
overall completed suicide rate among men is 3 to 4 times higher than among women
(Cochran & Rabinowitz, 2003). Given this high rate of suicide among men, researchers have
investigated nonobvious manifestations of depression in men characterized by masculinespecific modes of experiencing and expressing depression. These masculine-specific features include a tendency for depressed men to exhibit increased anger and interpersonal
conflict (Frank et al., 1988; Williamson, 1987), experience conflict between genderrole-related expectations and accomplishments (Good & Wood, 1995; Heifner, 1997),
experience work-related problems and conflicts (Vredenburg, Krames, & Flett, 1986), perceive threats to self-esteem and self-respect (Ahnlund & Frodi, 1996), exhibit antisocial
and narcissistic traits (Black, Baumgard, & Bell, 1995), and exhibit increased levels of
alcohol and other drug abuse and dependence (Grant, 1995).
These masculine-specific modes of experiencing and expressing depression often do not
match up with the criteria detailed in the DSM-IV-TR (American Psychiatric Association,
2000). Cochran and Rabinowitz (2000) have suggested that these masculine-specific features of depression can be best understood as manifestations of a masked depression that is
characterized by a masculine tendency to externalize distress into action (Gjerde, Block, &
Block, 1988; Levit, 1991); to engage in ruminative responses that may lead to alcohol abuse
(Nolen-Hoeksema & Harrell, 2002); and to express irritation, anger, and withdrawal in
reaction to narcissistic injury (Pollack, 1998). Compounding detection of this masked
depression syndrome in men is the fact that men are less likely than women to seek help
for depression (Addis & Mahalik, 2003).

Individual Therapy for Men

The National Institute of Mental Healths Treatment of Depression Collaborative
Research Program (Elkin et al., 1989) demonstrated that for mild to moderate depression
in both men and women, cognitivebehavioral approaches and interpersonal approaches
were equally effective. In addition, a meta-analysis of cognitive therapy for depression has
suggested that men are as likely to be successful in treatment as women are (Thase et al.,
1994). Although men tend to reluctantly seek psychotherapy, research suggests that it is an
effective treatment for depression.
A number of clinically salient approaches to working with men who manifest depression
or depressive symptoms have been described by several authors. Cognitivebehavioral
therapy designed specifically for men tends to focus on confronting unrealistic expectations
of the male role and distortions in thinking and behaving that lead men toward a depressed
outlook and mood (Mahalik, 2001). Interpersonal therapy emphasizes examining and
improving the ways in which the depressed individual approaches relationships and communicates needs and desires to others (Elkin et al., 1989).

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Other, innovative approaches to psychotherapy that incorporate cognitive and interpersonal

elements have also shown promise as treatments for depression in men. Pollack (1998) proposed a therapy that focuses on repairing relational trauma resulting from the abrogation of
important childhood interpersonal relationships. Cochran and Rabinowitz (1996) have
described an approach to therapy that addresses accumulation of losses at various developmental periods of life that make men more susceptible to depression. Osherson and
Krugman (1990) have emphasized, in their therapeutic approach, the role of shame in the
experience of mens depression.
Although men may not present obvious depressive symptomatology, Rabinowitz and
Cochran (2002) have outlined a deepening approach to psychotherapy with men that uses
a wide range of techniques to explore the underlying emotional trauma or wound that
brings a man to treatment. The realms of interpersonal dependence, the management of
grief and loss experiences, the shaping of masculine-specific self-structures, and a mans
preference for doing as opposed to being are major themes that are addressed throughout
the therapy process (Rabinowitz & Cochran, 2002).

Group Therapy for Men

The mens group described in this article had an overarching existentialhumanistic theoretical orientation that addressed the curative factors involved in the group process
described by Yalom (1995). He delineated these factors (instillation of hope, universality,
imparting of information, altruism, corrective recapitulation of family dynamics, socializing techniques, imitation, interpersonal learning, catharsis, and existential factors) in depth
in his seminal book The Theory and Practice of Group Psychotherapy (1995). In conjunction with curative factors, the mens therapy group combined an emphasis on gender role
awareness (Good, Gilbert, & Scher, 1990); the value of emotional expression for men
(Rabinowitz & Cochran, 2002); a psychodynamic emphasis on the significance of past
events, especially family of origin (Pollack, 1995); and a strong existential perspective on
the freedom of individuals to make choices, especially in light of potentially harmful family and societal norms around what it means to be a man (Rabinowitz, 2001).
Theorists in the field of the new psychology of men have established the need for individuals, couples, family, and group therapy to address socially constructed gender role conflict as a core element of the therapeutic process (see Brooks & Good, 2001). Researchers
have suggested that many men experience some types of gender role strain, including conflict over traditional male norms about appearing strong, self-reliant, in control, and emotionally restrained (Mahalik, Good, & Englar-Carlson, 2003). Stein (1983) and Rabinowitz
(2001) recommended that mens groups directly address mens adherence to these norms.
Instead of maintaining rigid patterns of behavior that result in avoidance of intimacy, addiction, and privately experienced distress, the mens group encouraged warmth, support, and
trust so that conflict might be dealt with in a more direct fashion. Verbal displays of affection, rather than being avoided, were used to show caring among men.
Withholding of emotional expression has been associated with increased mental health
problems, including anger control problems (Lisak, 2001) and depression (Good & Wood,
1995). Mens groups allow for the safe expression and containment of strong emotion
(Brooks, 1998a). Many men have been taught that to express strong feeling exposes too

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much personal vulnerability. Use of physical exercises, which encourage openness to feeling in the body, often led men in the group to better identify inner emotional states, including anger, frustration, sadness, and fear.
The group also encouraged men to reexplore their family-of-origin roots. Through the
process of storytelling, interpersonal encounter, and strong emotional expression, the story
of each members earlier life often could emerge with greater psychological dimension.
Memories about mother, father, siblings, friends, and others who had significant impact in
ones life were often kindled. It was not unusual for a man to recall something his father
said or did when he was a boy or to reflect on the interactions with siblings that helped
shape views on trust, masculinity, or his sense of self (Rabinowitz, 2001).
The mens therapy group also addressed some of the existential predicaments of life. In
the presence of their peers, men in the group could face their fears of the unknown. Often
group discussion centered on the willingness to take risks, based on the assumption that life
is finite and that if one is to make the most of his time here, he must be willing to risk leaving the safety of the familiar and move toward the potential unknown (Yalom, 1980). Men
have come to group intellectually ready to leave a job or let go of a dysfunctional relationship, but they were often deeply frightened of risking life change. The group uniquely
encouraged men to take the risk. The voices of the male group members often counterbalanced the internalized society, family, and work messages that said, dont change or just
be a man and suck it up. The group of men not only encouraged each man to take a risk
in his life but also provided the support necessary for him to absorb the consequences of
his actions (Rabinowitz & Cochran, 2002).
Men were screened for obvious psychopathology and psychological fit with the growthoriented goals of the group. They were asked to make a 9-month commitment to attend
once a week for a 2-hour session. If someone was accepted into the group, there was an
expectation of engaged verbal participation and a willingness to explore, in the public
realm of the group setting, ones thoughts, feelings, and behavior.
One of the main therapeutic advantages for employing a group approach for men is built
on the premise that the group situation is often a better fit than individual psychotherapy
for many men, especially those men with traditional gender role orientations (Brooks,
1998a, 1998b). Even though many men who participate in a mens group have also been in
individual therapy, they freely acknowledge that the multiple relationships that are developed in a well-run group are often better able to push them to deal with conflict, emotion,
and interpersonal connection than is an individual-therapy approach, which involves only
the relationship between therapist and client (Rabinowitz, 2001).
Our 2-hour mens group sessions involved a relatively loose structure in which the leaders briefly discussed themes and introduced exercises that encouraged the members to
respond and interact. In the early stage of the group, the exercises were more explicit. An
example of an exercise in the early stage might be, Turn to the man next to you and share
an experience in which you felt out of control. Take turns for 5 minutes. Note how you felt
before you started to share and how you feel now, after sharing. Come back to the big group
and discuss your reactions to the exercise. As the group matured, less prompting was
needed. An example at a later stage might be, What happened this week in your life in
which you felt like you betrayed a core part of yourself? Many of the themes introduced

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were generated by the leaders previous experience with mens groups and a weekly review
of the psychological issues the men in the current group had raised in previous sessions. A
sampling of the themes includes trusting other men, shame, self-medication, avoiding conflict, what it means to be a man, anger, learning from family of origin, intimate relationships,
uncomfortable emotions, sexuality, fears, projections onto others, control, interpersonal
feedback, and forgiveness (Rabinowitz, 2007).

2 Case Presentation
Jesse, a thin but youthful-looking 53-year-old White man, initially consulted the first
author to be a part of a weekly mens therapy group. He was the father of a 7-year-old boy,
with whom he shared custody with his ex-wife. He had been married to his current partner
for three years. When he consulted with me, Jesse was disturbed about conflict he was having in his current relationship, especially about the lack of time they were spending together
and his fear that his emotional dependence on her would lead to another divorce.
Jesse seemed to have a solid cognitive framework about being a father and learning to
deal with the possibility of being single again and he denied obvious depressive symptoms,
including suicidal ideation. Jesse was not taking any psychotropic medication except for
prescription pain medication on an as-needed basis. He denied the use of alcohol or drugs,
although he had been a regular user of alcohol and marijuana from his teenage years into
his mid-30s.

3 Presenting Complaints
Jesse was interested in gaining emotional support to deal with the potential separation
with his current partner and having a place to talk about being a single father. Jesses main
complaint was periods of loneliness and a sense of isolation when he did not have custody of his son and when his current wife was working long hours. With the tension he was
experiencing at home in his marriage, Jesse said he was interested in finding a place to get
some male support and potential friendship on a nonsuperficial level.
Jesse described his love for his son as the best thing that ever happened to me.
Although Jesse claimed to have come to terms with the divorce from his first wife, he
alluded to the fact that she had cheated on him. Without anger, he said, She found someone who was a better fit for her. I was surprised by his understanding attitude but attributed it to his intelligence, confidence, and self-awareness. Jesse had a masters degree in
psychology and was an administrator of a substance abuse program in town. He also talked
about having attended several male weekend mythopoetic Robert Bly retreats.
Jesses positive experiences with previous mens group retreats made him an ideal candidate for our group. His upbeat demeanor and knowledge about mens issues seemed to
suggest he would be good at making connections in the group. I was impressed with his
intellectual insight into his plight, his desire for male support, and his acknowledgment that
he needed to take care of himself during this transitional life period.

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4 History
Jesse grew up an only child in the early 1950s. His father had been a career military officer who was absent from Jesses life for long stretches of time. The family moved several
times during his childhood and teenage years, forcing Jesse to make new friends quickly.
Each time the family moved, Jesse also had to learn to let friends go. When home, his father
embraced traditional masculine ideology that seemed to be transmitted to Jesse through his
opinions and actions. His father was strong and stoic in terms of emotional expression and
intolerant of crying, whining, or expressive behavior in Jesse.
Jesses mother embraced a traditional feminine ideology, particularly in the presence of
her husband, frequently deferring to him on decision making and discipline. His mother
was a homemaker who, in the absence of her husbands domineering presence, was overly
attentive to Jesses emotional needs, perhaps to compensate for Jesses fathers harsh
parental style. Jesse, who throughout his life attached himself to women for comfort and
intimacy, felt lost when his mother died 10 years ago. He had less emotion when his father
died a few months later. Jesse claimed to have many friends, mainly women, who acted as
family but also acknowledged feeling envious of others who had extended families. Jesse
had completed a 12-step program 16 years prior to my contact with him and was proud of
being clean of illegal substances and alcohol. He was now a vegetarian and took a variety of homeopathic health supplements, as well as prescription pain medication, on an asneeded basis. Over the years, Jesse had been in individual therapy for short periods to
tweak some issues that came to light in his relationships.

5 Assessment
As is often the case with masked depression, there was little to indicate that Jesse was in
extreme psychological pain. His smooth and convincing social personality style and his
mastery of psychological language made it easy for me to see him as reflective and insightful, not a person who was in private anguish. He appeared to be an individual struggling
capably with his life circumstances rather than a person with a more serious psychological
disturbance or underlying mood disorder.
As Cochran and Rabinowitz (2003) noted, an important aspect of assessment with men
presenting with signs of depression is to evaluate suicide risk. Many authors (e.g., Bongar
et al., 1998) have presented comprehensive approaches to evaluating suicide risk, and these
approaches work well with men. Presence of ideation, plan, means, and intent are all
important topics to cover. In addition to these aspects of suicide risk assessment, the therapist should be sensitive to masculine gender rolederived risk-taking behavior and its possible relation to self-destructive behavior. Careless and risky driving practices, heavy
alcohol or substance use, extreme risk taking in leisure pursuits, and other practices that
may be sanctioned by the culture of masculinity that disdains self-care or help seeking may
actually be manifestations of a wish to die. Such considerations are important for the psychotherapist to recognize and discuss directly with the male client. Although Jesse did not
manifest any of the traditional symptoms of depression or engage in any extremes of selfdestructive behavior, I might have noted his history of alcohol and substance abuse and his

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vulnerability to abandonment-induced depressions as possible indications of a deeper or

more pernicious mood disturbance.
In addition to the clinical interview and history taking in the initial sessions, the therapist may utilize various scales to assess a male clients depression. The Beck Depression
Inventory (Beck, Steer, & Brown, 1996) is one of the most commonly used and most userfriendly assessment instruments available. It comprises 21 items that assess symptoms of
depression, to which the client answers using a scale of 0 to 3, with higher numbers indicating higher levels of depression. The Beck Depression Inventory has very impressive reliability and validity data to support its use. Other, masculine-specific scales that the
counselor may choose include the Zung Self-Rating Depression Scale (Zung, 1965) and the
Hamilton Rating Scale for Depression (Hamilton, 1967).
With hindsight, it was apparent that Jesse was adept at redirecting the conversation when
either my cotherapist or I asked him about a delicate subject. For instance, Jesse withheld
information about current health and work problems during the interview. To our surprise,
he revealed several months into the group that he had been diagnosed with colon cancer.
Jesse also did not tell us in the interview that he was the subject of an ongoing sexual
harassment investigation at his work. Moreover, after he made a suicide attempt during a
break in the groups regular meetings, my cotherapist and I were left wondering to what
extent he might have withheld his suicidal feelings and impulses at the time we screened
him for the group and during the first few months of group meetings. In public, Jesse, like
many men, played up his strengths and minimized his struggles.
I wish I had given more significance to the multiple losses he described and the feeling
of loneliness that he alluded to in talking about the problems in regard to his wife. My
cotherapist and I were also fooled by Jesses clean lifestyle. Often, men who are experiencing a male-type depression are more likely to show more externalizing symptoms, such
as anger, irritability, or drug or alcohol abuse. Perhaps one of the standardized depression
inventories might have picked up an inkling of the underlying distress.

6 Case Conceptualization
My initial impression of Jesse was of a self-aware, relatively healthy individual who was
seeking support during a period of life transition. Jesses rejection of the traditional male
socialization of his father had led him to seek comfort and support from women. He also
espoused a more humanistically oriented version of masculinity. What were initially hidden,
but became apparent during the course of treatment, were Jesses narcissistic defenses against
depression. His affable, social personality concealed painful feelings of loneliness and a sense
of brokenness about himself. Because Jesse did not reveal all of the issues weighing on him,
I did not notice the more subtle indicators of his distress until later in treatment.
The convergence of relationship abandonment, life with cancer, single parenthood, and
charges of sexual harassment at work stressed Jesses already fragile personality structure.
Losing a major relational support system rekindled abandonment from his first marriage, as
well as the loss of his mother 10 years prior and years of dealing with his fathers long
absences from his life. Jesses cancer struck at his narcissism about his youthful appearance
and attractiveness to younger women. He had married two women more than 20 years

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younger than he. The cancer took its toll on his basic defense against mortality (his belief that
he could stay young). Although Jesse loved his son, it was overwhelming for him to be in a
position of sole responsibility. Because his father did very little with him, Jesse had to work
extra hard to be emotionally present with his son. There were times when he lost his temper
and felt extremely guilty for acting like his father did with him. A big part of his interest in
mens issues was his desire to counteract the introjected attitudes of his father and the negative
feelings that often emerged in his interactions with his son and other men. Finally, the sexual
harassment suit at work had stripped Jesse of some of his sense of male power and privilege
he enjoyed in his management role. The shame and humiliation that were triggered as the
investigation moved forward reinforced his sense of being defective and unlovable.
The losses that Jesse had experienced, in what was an already vulnerable and ill-formed
containment structure for his pain and sadness, in combination with Jesses public persona
of symptom denial, produced a version of the masked depression syndrome. It was not until
he was treated following his suicide attempt during the groups holiday break that he was
fully ready to confront the underlying depression. Only after the suicide attempt could he
clearly be diagnosed with the DSM-IV version of major depression, including dysphoria,
thoughts of death, appetite disturbance, sleep disturbance, fatigue, diminished concentration, guilt, psychomotor change, and loss of interest in typical activities.

7 Course of Treatment and Assessment of Progress

Jesse started the group in October with seven other members. While the leaders facilitated early group themes around the reasons the men were in the group, Jesse stayed fairly
vague. He shared very little of what was happening with him on a more personal level. He
brought up interesting but safe stories from his past that created the aura of someone who
was self-aware and who had learned from lifes misfortunes. At one point, Jesse spoke of
being a part of the radical underground in the early 1970s, describing harrowing encounters with police and terrorists. When group members spoke about their current relationships
and past family-of-origin experiences, Jesse free-associated to their issues with articulately
woven tales from Greek and Roman mythology that mesmerized the group and made each
members life journey seem special and important.
In one group session in mid-November, the theme introduced by the leaders had to do
with what each man had taken from his own father, both positive and negative. Jesse told
in glowing terms the story of his fathers illustrious military career. When asked to share
how he felt about his father, Jesse spoke in generalities about courage and strength. One of
the men confronted him about how it must have felt for him to have his father out of his
life for long periods. I anxiously awaited Jesses response. Instead of answering the question, Jesse talked about being Telemachus, the son in Homers epic tale the Odyssey, waiting for his father, Odysseus, to return. It was a good deflection. The group ended up talking
about the significance of Homers description of the mythical fatherson relationship, and
Jesse avoided the more personal answer, which would have been a gateway to his pain.
Although I was puzzled by his avoidance of his current life, I rationalized that Jesse was
still getting comfortable with the group and building trust with other group members. In the
first 10 sessions, if anyone had asked any of the men in the group whom they found the
most charismatic or intelligent, Jesse would have been a unanimous choice.

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In early December we brought in a pile of magazines, scissors, and glue for a collage
activity. The prompt we gave the men was to create a collage of images and words that
depicted their inner emotional world. Each man spent a good half hour putting together
these intricate pieces of expression. Jesses main image was of a volcano, overflowing with
lava. He also had a cutout of Edvard Munchs famous painting The Scream superimposed
on the volcano. When asked to talk about the meaning of his collage, Jesse mentioned that
he must have eaten something bad before group and needed to excuse himself from the
room. Again, his performance was convincing, and we moved on to the collages of the
other men, who engaged in an in-depth analysis of their own work. Two of the men were
in tears as they acknowledged some of the emotional pain depicted in their artwork.
As the group moved toward Christmastime, I noticed that Jesse looked fatigued, pale,
and more contained in his body language. He told fewer stories, made fewer comments to
others in the group, and continued to reveal little of himself. Although most members of the
group had become more comfortable with each other, sharing more emotionally laden
material, Jesse seemed to be stuck in the same mode, unable to share any of his depth. I
again confronted Jesse on his quietness, but this time I was firm. I was not comfortable letting him squirm out of dealing with what seemed to be an important issue that was affecting not only him but also the group dynamics. At first he denied that anything was going
on, but after some prodding from some of the other group members, Jesse revealed that he
had been diagnosed with colon cancer. How long have you known? I asked. Jesse said he
had known since the summer, before he had even interviewed for the group.
It was at this time that I became more concerned about him, especially given how easily he
had deceived the group and me about his life. The members, who were seeking to include Jesse
in their cohesion as a group, gave him emotional support around his revelation. It seemed like
a turning point. Perhaps he was ready to deal with what was lurking beneath the surface. I met
with Jesse after the group to see whether he wanted to talk more extensively. I offered to see
him individually. He declined, telling me convincingly that it felt good to open up to the other
guys. He said he would be all right. He thanked me profusely for supporting him and helping
him share and told me this group was the best type of therapy he had ever been in. I was skeptical of his comments, but I rationalized that if it had taken him this long to trust the group with
highly emotional information, perhaps we were making progress. The delayed nature of Jesses
revelation, however, really made me question my initial assessment of Jesses relatively positive mental health. In discussing his behavior with my coleader, I began to suspect that Jesse
had been masking a more serious, underlying depression.
Jesse said he would be sharing Christmas with his son and wife and would even spend
some time with his ex-wife and her husband. We are all committed to making it a good
Christmas, he assured me. I had an uneasy feeling about the way he had been overly
praiseworthy of the group and his overly optimistic expectations for Christmas, given the
issues with which he was struggling. My own narcissistic desire to have Jesses situation
work out overrode the uneasiness. I told myself that Jesse would begin sharing more in the
second half of the year.
When Jesse did not come to the first group session after Christmas, I was concerned but
figured that he might have had an extended vacation. I rationalized that he had missed occasionally in the past. I received a call the next day from Jesses current wife, Laura. She told
me that Jesse had made a suicide attempt and was currently in the local hospital intensive
care unit.

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He had not shown up for a doctors appointment she was going to attend with him. Laura
had driven to the appointment directly from work and assumed Jesse would meet her there.
When he didnt arrive, she grew worried and came home to find him unconscious. She
immediately called 911. Jesse, who had taken an overdose of his pain medication, spent the
next week in the psychiatric ward of the local hospital. I gave my full support to Laura but
was privately overwhelmed and ashamed that I hadnt been able to pick up on the seriousness of Jesses depression or that I hadnt challenged his mask that had so effectively covered this depression.
While Jesse was slowly recovering in the hospital, Laura asked to meet with me to talk
about her reactions to Jesses suicide attempt. Since Jesse was a danger to himself, I felt
from an ethical perspective that talking with Laura might help me in understanding what
had happened and could provide me with assistance in working with Jesse if and when he
recovered. Laura was overwhelmed and needed to unload. After consulting with my cotherapist colleague, also a licensed psychologist, I decided that speaking with Laura was within
my ethical responsibilities. I did not reveal information that Jesse had shared with me in
confidence but rather focused on Lauras concerns. I also got permission from Jesse, when
he regained full consciousness, to allow me to speak with Laura. She met with me three
times during the following week to make sense for herself of what had happened and how
she might have contributed to the situation. In talking about the suicide attempt, Laura
helped me put together a more complete picture of Jesse. The hidden elements of his life
came to light. The cool and mythic Jesse that came to group was actually not the Jesse
that existed at home. Laura shared that Jesse was extremely controlling, wanting everything
from his food to the furniture to be a specific way. Jesse had recently become a fundamentalist Christian and had taken to reading the Bible 2 hours a day. She said he had become
more rigid in his beliefs about God and often spoke in a rambling but coherent manner
about the struggles of good and evil and approaching Armageddon. Laura also told me that
Jesse was much more upset about his having cancer than he had shown me. Most of the
time at home, he was irritable, edgy, and a bit paranoid. He always prided himself on staying young. In fact, Laura herself was only 29 years old. The cancer had pierced his youthful narcissism and exposed him as a middle-aged man with declining health.
Laura revealed that Jesse had been calling his ex-wife earlier in the fall and telling her what
a great mother she was to their son and that he trusted that she and her husband would continue to be excellent parents for him. Laura also said that Jesse had been having trouble at
work. One of his employees had accused him of sexual harassment, and there had been an
internal investigation, which was nearing judgment. I can only imagine the kind of shame that
this was generating in Jesse, given how he carefully managed his public persona.
Laura told me she felt incredibly guilty for abandoning Jesse. She said that she had felt
trapped in the house. All had been fine 2 years before. She thought she had married the
cool Jesse, but over the past 6 months, she had become depressed by his controlling
nature and his agitated moodiness at home. She felt like running away and had recently told
him she wanted to leave. Surprisingly, instead of getting angry, Jesse became serene and
reasonable, saying he understood. In retrospect, Laura said she was surprised by his reaction and now realized that her threatened abandonment might have sent him over the edge.
I met with Jesse when he regained consciousness in the hospital. Attached to tubes, he
looked emaciated and appeared a bit disoriented. Although he at first tried to deny the

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suicide attempt by saying he had mistakenly taken the wrong medication, I gently confronted Jesse with the events and situations that had led to his attempt. Jesse got angry and
told me that he could do whatever he wanted. If you had my life, you would want to kill
yourself too. I was taken back by his hostility. In a way, I was glad he was expressing his
anger rather than denying or sublimating it. With his defenses so effectively dismantled by
his being dependent on hospital staff and lying helpless on his back, Jesses hidden depression was suddenly much more accessible and apparent.
We met daily while he was in the hospital and twice per week after he was released from
the hospital. Now that the emotional wound had been revealed, I took a deepening psychotherapy approach to working with Jesse (Rabinowitz & Cochran, 2002). We addressed
his interpersonal dependence on women for validation, his loneliness, and his fears of abandonment. The numerous losses in his life served as a conduit to deep feelings of sadness
that I encouraged him to express directly in our sessions. We also focused on how, despite
his rejection of his fathers value system, he had unknowingly adopted many of his dads
masculine self-structures, including remaining stoic and unexpressive in the midst of a
cauldron of emotional and physical pain. Our sessions highlighted consequences of his having internalized these masculine value systems, including his avoidance of and withdrawal
from those close to him, leaving them with only his frustration, temper, and tightening
interpersonal control. We also talked about how he might better handle his stress so that
it didnt build, discussing potential physical and emotional outlets. From a cognitive
behavioral perspective, I helped Jesse identify and confront the cognitive distortions in his
thinking that had fueled his self-condemnation and adherence to destructive male gender
role norms (Mahalik, 2001). He also confronted the automatic thoughts that told him that
he was trapped and could no longer handle the demands of his life. We set up some behavioral goals that included regular physical exercise, journaling about his thoughts and feelings, and practicing a more honest approach in his personal and professional relationships.
During his hospitalization, Jesse was treated with Zoloft, a selective serotonin reuptake
inhibitor (SSRI). He regularly attended appointments with his psychiatrist, with whom I had
weekly phone contact. The psychiatrist and I consulted with each other to make sure that the
combination of medication and psychotherapy was effective. Jesses mood and energy levels
improved; however, he did complain about lower libido and delayed ejaculation, common side
effects of SSRIs (Stuart, 2000). Similar to research findings, the combination of psychotherapy and antidepressant medication seemed to help Jesse manage his self-defeating thoughts,
overwhelming feelings, and interpersonal isolation (DeRubeis et al., 2005).
Jesse returned to the mens group in mid-February. In contrast to his previous stint in the
group, Jesse acknowledged during his first session back what had happened to him, including
details of his thoughts leading up to the suicide attempt. When group members shared their
guilt about not being able to prevent him from the attempt, Jesse eloquently told individual
members of the group, You were not responsible. I am the one who did not take advantage of
the bountiful support you were extending to me. Clearly Jesse was more willing to take
responsibility for his behavior and to be more self-disclosing of his present emotions, indications of substantial progress from his previous attempts at masking his symptoms.
Over the ensuing sessions, Jesse disclosed that his wife left the house, and he spoke
about his feelings of depression, especially around losing his sense of invulnerability, as
well as his fears about being alone. What was different in these group sessions, compared

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with the sessions prior to Christmas break and his suicide attempt, was that Jesse utilized
the group as a strong support system. In contrast to his previous avoidance of social situations, Jesse initiated some social gatherings with some of the other members, outside the
regular group meetings.
Whereas earlier in group, Jesse had been a reluctant participant who avoided his own
depth work, he now was engaged in his own therapeutic process. While he still made
insightful comments in support of other group members, he was willing to engage in some
of the more advanced group activities, including gestalt work and psychodrama. For example, Jesse acted out his ambivalent feelings toward his father, using the empty chair technique (Perls, 1969). He was able to express his anger at his fathers unavailability and
judgmental nature, as well as his own deep sadness about missing him. Rather than staying
emotionally contained, Jesse showed improvement in emotional expression and interpersonal contact through the next 4 months of the group, before its summer hiatus. He also
allowed himself to get close to other men, something he had avoided much of his adult life.

8 Complicating Factors
The case was fraught with complicating issues, most important, the insidious nature of
masked depression. Because Jesse never reported any of the typical DSM-IV-R symptoms of
depression, it was difficult for us in our initial interview to determine the severity of his psychopathology. Once he had been seen in the mens group, Jesses avoidance of meaningful
here-and-now self-disclosure challenged my cotherapist and me to determine what would be
the best intervention. His skill at revealing just enough to deflect us from more-direct confrontation made working with him difficult. Jesses seemingly healthy lifestyle and desire to
stay away from the medical establishment also led us to believe that he was taking care of himself on a physical and emotional level. Both of these assumptions were erroneous. It was not
until after his suicide attempt that his acknowledgment of his emotional pain allowed me to be
more assertive in treatment and created the possibility of a team approach that included psychiatric consultation, individual therapy, and group treatment.

9 Managed Care Considerations

Because the mens therapy group described here is a cash practice and does not require
authorization by a managed care entity for reimbursement, there are no specific managed
care considerations. However, one potential managed care consideration for therapists is
the challenge of managing the tension between the managed care entitys interests in minimizing reimbursement expenditures and the time that is sometimes needed for the depression that is masked by superficial symptoms or presenting concerns to become manifest to
the therapist. Frequently, directing attention to more-contained and superficial presenting
concerns will result in the risk of missing the more pernicious mood disorder that underlies
these concerns. In this case, the presenting concerns and well-composed faade hid the
underlying pain and suffering that Jesse was clearly experiencing. In a managed care environment, pressures to quickly resolve presenting symptoms may shortcut the possible

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uncovering of these underlying mood concerns and may even exacerbate suicide risk in
some male clients.

10 Follow-Up
Jesse returned to group the following fall with renewed vitality. Over the summer, his cancer went into remission. He continued to share custody of his son with his ex-wife. He and
Laura made an attempt at reconciliation during the summer, attending six sessions of couples
therapy with another therapist. Eventually they decided to divorce. Jesse tapered off his individual sessions with me to two per month for most of the following year and continued to
attend the weekly group sessions regularly. He remained compliant with his antidepressant
medication. He also remained committed to an exercise routine that coincided with self-reports
of less frequent and prolonged depressed moods. In the summer after the suicide attempt,
Jesse found a less conservative church to attend and reported that he was focused more on the
uplifting elements of spirituality rather than on the self-condemnation and guilt.

11 Treatment Implications of the Case

In retrospect, I am struck by how normal Jesses life looked from the outside. But in
many ways, he fit the profile of a man with undiagnosed depression. His more debilitating
symptoms were often held in check in public social environments, yet privately he struggled. He was intelligent, sensitive, and superficially well-adjusted in many of his social
interactions. Internally, he battled with demons that ate away at his self-confidence and
realistic perception of himself.
Jesse had narcissistic and obsessive personality features that were exacerbated by simultaneous life stressors. Having grown up as an only child, loved by his mother and distained
by his father for his expressive tendencies, Jesse turned to alcohol and drugs in adolescence
and young adulthood to cover up feelings of rejection and abandonment. His ease in speaking with women led to gratification of his narcissistic desires to be loved and accepted.
When he did decide to settle down, he married women much younger than himself who
tended to reflect back youthful admiration and narcissistic gratification. Once in those relationships, Jesse was intolerant of too much independence in his partners, becoming
demanding about their meeting his emotional needs.
Wounded by his first wifes desire for divorce, Jesse became mildly involved with organized religion. It was not until he had been diagnosed with colon cancer that he began
attending the fundamentalist church regularly. He even considered studying to become a
minister. Jesse felt out of control, and he sincerely hoped that the structure and rules of religion might help him feel more confident in taking on lifes struggles. His involvement with
the church could also be interpreted as his seeking a buffer for his deeper fears of dying and
the emerging awareness of his mortality.
The cancer had also pierced Jesses narcissism about his own body and physical attractiveness. He had always prided himself on being able to flirt with younger women and feel
desirable. At work, he was known as a kind, funny, and informal supervisor. However, it

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turned out that one of his employees had viewed his informality and interpersonal style as
seductive and harassing, further deteriorating his self-image in the public realm.
Although he loved his son, he seemed to also begin to doubt his competency as a good
parent and father. Intellectually Jesse knew that it was important for his son to have a good
relationship with him. Unfortunately, Jesse began to believe that his sons stepfather was a
better parent. Jesses phone calls to his ex-wife were really signals that he was getting ready
to give up, checking to make sure she and her husband could take care of his son. A final
debilitating stressor seemed to be his second wifes threatened abandonment, leaving him
feeling worthless and incapable of holding onto an intimate relationship.
Jesses suicide attempt had been planned. A review of the sequence of events suggests
that he had harbored suicidal ideation most of the fall but had kept it well concealed from
the group. Jesse had hoped at the beginning that the mens group might save him from himself, but he was unable to share his emotional pain with the therapists and other members.
His disdain for traditional medicine kept him from consulting a psychiatrist for antidepressants sooner. Jesse also placed his hopes for salvation in the fundamentalist church. It
seemed that the more Jesse studied the Bible, the more distraught he became that he couldnt live up to the Christ-like ideals being emphasized. The Bibles thematic struggle
between good and evil played into his own feelings of losing the battle for his soul.
Ultimately, he felt as if he was bad and undeserving of the love of his family, friends, and
coworkers. Jesses introjection of his fathers projections of him as soft, weak, and unmanly
only reinforced this sense of being unlovable. Unable to escape the pain, Jesse plotted his
suicide to the surprise and horror of those who thought they knew him.
Jesses failing marriage, the sexual harassment suit, and the cancer overwhelmed his coping
mechanisms, intensified his shame, and finally broke his defenses. His underlying depression
became so compelling as to cause him to attempt to end his life. Through intensive individual
therapy and continued participation in the mens group after the suicide attempt, Jesse came to
realize that his means of coping with loss were actually worsening his adaptation to his current
life circumstances. He was encouraged to accept the stressors as valid, to feel the actual pain
in his life, and to reduce the self-abasement for not being as strong as he wished he could be.
Jesse reported more volatility in his emotional life but less pressure to have it all together all
the time. Once he stopped denying the impact of the potent stressors in his life, Jesse actually
gained the emotional support he had originally sought from the mens group.

12 Recommendations to Clinicians and Students

Four important lessons for clinicians can be gleaned from this case. First, when a male
client presents with precipitants of loss, trauma, chronic pain, or transition, clinicians must
be especially sensitive to any possible underlying mood disorder. Such precipitants may
activate or exacerbate a mood disorder that is not apparent at first contact. Nontraditional
symptoms of depression in men, termed masked depression in this case report, include
alcohol and substance abuse; irritability; anger management issues; interpersonal withdrawal; and preoccupations or obsessions with work, hobbies, and other distracting routines. Through careful probing and history taking, a clinician can usually detect any nascent
mood disorder that may underlie these presenting concerns.

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A second implication for clinicians is the importance of being open and receptive to the
potential depth of a male clients level of depression. The common loss experiences that
accompany normal developmental passages as well as traumatic impingements on a mans
life may result in a significant and frequently hidden depression. As noted above, careful
history taking and probing of underlying mood states will reveal the emotional consequences of these experiences for male clients.
Third, the clinician is encouraged to explore the use of various standardized scales to
assess the male clients depression. The Beck Depression Inventory (Beck et al., 1996) has
been impressive in its reliability and validity. The Zung Self-Rating Depression Scale
(Zung, 1965) and the Hamilton Rating Scale for Depression (Hamilton, 1967) may also be
useful tools in assessment.
Finally, it is important for clinicians to pay attention to their own countertransference
issues and blind spots when working with men. A sampling of the potential countertransference issues in working with men can include a suspicious approach based on negative
past experiences in relationships with men, as well as parental, competitive, and erotic
forms of relationship distortion (Rabinowitz & Cochran, 2002). In this case, the client initially presented in a way that encouraged the group leaders to empathically identify with
his plight, which distracted them from probing more deeply about possible underlying concerns that might have revealed sooner the more extensive nature of his depression.

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Fredric E. Rabinowitz, PhD, is a professor in the Psychology Department at the University of Redlands. His
research interests include the study of depression in men, as well as psychotherapy approaches with male clients.
Sam V. Cochran, PhD, is the director of the University Counseling Service and a clinical professor in the
Counseling Psychology program at the University of Iowa. His research interests include the assessment of
depression in men, psychotherapy approaches with male clients, and college student mental health.

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