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Wednesday, March 11, 1998 - Page updated at 12:00 AM

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Male Depression: The Hidden Monster -- Terrence Real Wants To Help Men Find The Covert Source Of Their Troubles - And Treat It

Seattle Times Staff Reporter

Are men as depressed as women?

Yes they are, answers psychotherapist Terrence Real in his book, "I Don't Want to Talk About It: Overcoming the Secret Legacy of Male Depression" (Fireside, $13).

Real depicts male depression as an epidemic rooted in a societal cacophony pressuring boys to bury their feelings in order to fit in.

"The whole point of boyhood is disconnection, severing them from their mothers, severing them from their feelings," Real explained during an eight-city book-tour stop in Seattle yesterday. "The very phrase `Be a man,' means, `Don't feel it.' "

Controversial? Somewhat. His conclusions contradict health statistics that clearly show twice as many women feel the pain and sadness of depression. Real's premise, however, expands the definition of depression to include both pain felt internally, as women are socialized to express it, and pain lashed out externally, the male-dominant expression.

"Depressed women tend to have pain; depressed men tend to have trouble," Real said. "These are two different manifestations of depression. It isn't that women are more depressed than men; it is that women are more overtly depressed than men."

Men, Real concludes, are more likely to self-medicate depression with actions ultimately destructive to themselves and / or their families, many unaware that depression lurks behind and fuels their behavior. Real calls this hidden depression "covert." Statistics show at least twice as many men as women abuse alcohol or drugs or engage in antisocial personality disorders such as domestic violence. When incidents of covert and overt depression are averaged, the total splits evenly between men and women.

Real says these are the symptoms of the covert epidemic of depression in men. Men do get depressed.

In his book, Real uses case studies and his own childhood emotional and physical abuse to describe how alcohol and drug abuse - as well as other behaviors such as domestic violence, sexual addictions, workaholism, excessive TV viewing - are how men, collectively socialized not to feel, externalize depression.

"We tend not to recognize depression in men because the disorder itself is seen as unmanly," Real wrote in the first chapter. "Depression carries, to many, a double stain - the stigma of mental illness and also the stigma of `feminine' emotionality . . . Hidden depression drives several of the problems we think of as typically male: physical illness, alcohol and drug abuse, domestic violence, failures in intimacy, self-sabotage in careers."

The struggle and triumph over severe depression acknowledged by the likes of television journalist Mike Wallace, novelist William Styron and Tony Dow, who played Wally Cleaver on "Leave it to Beaver," lessen the stigma, Real said. But he cautions men to seek treatment before depression becomes suicidally acute.

Real employs a storyteller's flair for drama - complete with dialogue - to demonstrate how covert depression can hurt men and their families, and how treatment can heal. The 383-page, abundantly annotated book combines theory, statistics and anecdotes drawn from cases he has treated during his 20 years as a clinical psychologist - successful men alienated from their children and cheating on their wives; strong, silent types lashing out because they are unable to talk it out. Real does not excuse these behaviors. But he urges men who exhibit them to get help. Depression is very treatable.

"With a combination of psychotherapy and medication, between 80 and 90 percent of depressed patients can get relief - if they ask for it," Real wrote. "And yet the condition goes mostly undiagnosed. Somewhere between 60 and 80 percent of people with depression never get help."

Explanations and reenacted client / therapist dialogues show the reader how Real helps men move along the continuum from covert to overt depression, to finally feeling and working through the grief.

"My focus in treating depressed men is relational," Real wrote. "What kind of relationship does a depressed man have with others? I ask, followed by: What kind of relationship does he have with himself? The answer to both these questions is often: a bad one."

Until recently, rarely did Real see covertly depressed men in individual therapy. Not until the alcoholism, workaholism, withdrawal or violence threatened to tear their relationships asunder did men seek help, usually in family therapy. Once the men are coaxed to stop the behavior for the sake of the family, the classic symptoms of overt depression flood their consciousness. These include sadness, fatigue, feelings of worthlessness or guilt, too little or too much sleep, weight loss or gain, difficulty making decisions or forgetfulness, preoccupation with death or suicide. Real says since the book was released in hard cover last year, men who read it and recognize their condition have begun to seek treatment.

Real comes across as the Billy Crystal of psychotherapy. With mesmerizing interpersonal skills, he's genuine, quick-witted, charmingly confrontational, understanding because he's walked out of the same darkness - but not about to excuse the destruction men wreak in the throes of covert depression.

In the book, he steps out from his therapist persona and tells about his abusive, withdrawn and covertly depressed father, and his own substance abuse and reckless behavior. The approach also reflects his belief in the 12-step method used by Alcoholics Anonymous and other addiction-cessation programs.

Real has a family, a wife who is also a psychotherapist and two sons. He sought professional help and peer support to ultimately let go of his addictions, face the pain behind his depression and feel.

"Part of my decision to tell my story, my father's story, my sons' stories was to put my body on the line to let men see men can be depressed and also let men see they can get better and what better looks like," Real said. "I am better. I don't feel the kind of emptiness and bleakness I felt for decades. They are gone. If I can do it you can do it."

Real, now a senior faculty member at the Family Institute of Cambridge, is also co-director of the Harvard University Gender Research Project. His passion to challenge rigid gender-role constructs forms the core of his research.

Gender socialization splits girls and boys, Real says, discouraging girls from realizing their full assertive potential and boys from feeling the full range of emotions. Real is convinced the violence and covert depression predominant among men is rooted in these dynamics.

"It is clear that the stable ratio of women in therapy and men in prison has something to teach us about the ways in which each sex is taught by our culture to handle pain," Real wrote. "Men make up close to 93 percent of the prison population, leading one `Men's Movement' leader to quip that the largest men's gathering in the United States is San Quentin."

An impromptu support group followed Real's reading at The Elliott Bay Book Company in Pioneer Square early yesterday evening. The 35 people who attended eagerly delved into the topic. Though the audience was evenly split between men and women from a gamut of ages and a smattering of races, most of the discussion was by and about men.

One young man asked Real for advice on honing the discipline to feel emotions responsibly instead of reacting with rage, violence or withdrawal. An older man praised the younger man's concern and recounted his own difficulty with expressing emotion. These are the discussions Real wants men to have more often.

"There are tens of thousands of men across the country who are sick of being straitjacketed in the male role and they want out," Real said. "It's about reaching into a guy's heart and saying, `What are you running from? What happened to you? Why are you in so much pain?' "

------------------------------ The signs of hidden depression ------------------------------

If you engage in any of these behaviors to alleviate bad feelings or mask an empty anxiousness, they may be a signal of covert depression. Ask your physician for a referral to a mental-health professional or call the Crisis Center community-information line for an appropriate support group: 206-461-3200.

Self-medication

-- Excessive alcohol or drug use.

-- Sex addiction.

-- Workaholism.

-- Excessive television viewing.

-- Overspending.

-- Food binging.

Withdrawal

-- Hiding from life.

Lashing out

-- Ranging from increased irritability to domestic abuse.

------------------------------------- An expanded definition of depression: -------------------------------------

Statistics show twice as many women as men suffer episodes of depression. However, when psychotherapist Terrence Real includes alcohol and drug dependence and violent or other antisocial behaviors - associated twice as often with men - in his expanded definition of depression, the percentage of men versus women suffering from this expanded set of disorders is the same.

Lifetime incidents of mental disorders

(as percentage of population)

-----------------------------------------------------------------

Affective disorders Men Women Both

Major depressive episode 12.7 21.3 17.1

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Manic Episode 1.6 1.7 6.4

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Dysthymia (mild depression) 4.8 8.0 6.4

-----------------------------------------------------------------

Anxiety disorders

Panic disorder 2.0 5.0 3.5

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Agorophobia 3.5 7.0 5.3

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Social phobia 11.1 15.5 13.3

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Simple phobia 6.7 15.7 11.3

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Generalized anxiety 3.6 6.6 5.1

-----------------------------------------------------------------

Substance abuse disorders

Alcohol abuse 12.5 6.4 9.4

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Alcohol dependence 20.1 8.2 14.1

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Drug abuse 5.4 3.5 4.4

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Drug dependence 9.2 5.9 7.5

-----------------------------------------------------------------

Other disorders

Antisocial personality 5.8 1.2 3.5

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Nonaffective psychosis 0.6 0.6 0.7

-----------------------------------------------------------------

Totals 48.7 47.3 48

-----------------------------------------------------------------

Source: Archives of General Psychiatry, January 1994.

Copyright (c) 1998 Seattle Times Company, All Rights Reserved.

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