Fatigue. Feelings of worthlessness. Loss of interest. We recognize these as classic signs of depression.
But according to Terry Real, MSW, LICSW, these symptoms aren’t always the way men experience depression.
So how do we help clients when their depression doesn’t necessarily look like depression?
In this short video, Terry shares a two-pronged approach to help his clients find relief.
Click here for full transcript
Please leave a comment below and tell us how you plan to use this in your work.
I agree wholeheartedly
Elaine
I find helpful, that Terry described two types of depression. I wish those mens come with partner to emotionally focused therapy. To help them make secure bond with their partner, they will not need anymore to cope with depression alone and in unhealthy way. (depression is for me a sign of broken bond with attachment figure).
My way of coping is to imagine myself hugging tightly a tree (mother of life) and crying into tears “don’t leave me” I would tell it in tears. And referring to this every time I feel pain of losing someone makes me feel empowered because the tree is strong – as a caring – never left . It is very helpful and soothing technics
It’s great to understand the differences and to also know the mask one places on ..
I think that this can also happen to women ..only a small percentage..
Thankyou
Mixed feelings re gender split. I’m a first born female and was raised, primarily by my father, to be best “son”. My brother talked about feeling useless and diminished when he reflected on our history because I was always given the “boy” slots. Took work before I could allow myself to be my true self. My point is that some women fit this description quite well, so I’m thinking overt/covert is not gender based. It’s all in the story. I work w/women in the military and this is often true. Some of the women I meet have been leads in their families due to mom’s absence, for whatever the reason and taken on so called masculine coping attributes, depending on culture and support. I’m thinking this is more about listening well to the client as we sort tx choices and language. I tend to use “grief” and “unresolved anger” if I think “depression” will be rejected. Those two seem to be ok for most. I’m rarely asked what my diagnosis is. I’m usually asked “so what’s wrong w/me?”
Would you consider pornography to be a unhealthy coping strategy for male depression?
My son was a self medicated and depressed individual. Whenever the substances were eliminated, he would face intense guilt and depression. Then it would start over again. He OD d in a sober house after broken arm surgery when they gave him oxycodon. He was in and out of therapy and rehabs and hospitals. He was only beginning to talk about it when we lost him.
This is the first time I have visited this website. After viewing the video, all I can say is Why is this “news?” I have been aware of what you call “overt” and “covert” depression in both myself and others for literally decades. I never separated the two and cannot imagine being treated for, or treating, simply “overt” depression. There is always a denial, a defense, in most (not all) men and the opposite in most (not all) women. One of the reasons anti-depressant drugs don’t work reliably is because they don’t treat the cause of depression–which lies deeper than the emotion of depression itself. Some anti-depressants even cause depression as a side effect.
Why not go directly for the root cause, trauma?
The overt depression is often the symptom of the covert past trauma.
Terry is very clear with the method to care well for male covert depression by allowing the client to go into his overt depression in order to deal with the masked or unwanted painful symptoms and to begin to move away from harmful self-treatment. There is always a better way that involves healthy choices and the discipline to find a way out with being honest and true to yourself and your pain. Sticking with your client in healthy disciplines; eating well, exercise, sleep management (with an aide is ok), alternative and interesting activities and faith-based prayer or meditation in a group setting are some ways to step away from self-harm in the lie of covertness.
Sometimes women, wives and girlfriends, partners are not compassionate with men who are depressed because of sexism. They are repulsed by men’s depressive feelings and don’t want to see it or shame them.
I am really moved by the messages that have appeared here. In fact, we often forget that men as strong as they may seem may have weaknesses, that women do not “forgive” them. But the heart has its reasons, for this the absence of affection and love from their loved ones, they turn away from relationships and feel defeated and in failure. What a powerful feeling to miss. Terry role was therefore that of being a good mentor and for me to understand my father and my brothers and sisters who have a passive-aggressive response towards others by pride and fear of being used or abused, he played a important role. I am really touched by the fact that Terry invest an invaluable effort to work on oneself and to understand oneself in order to easily bond with others. A job very well done. Thank you.
As a couple therapist, whose preference is to use EFT with couple, the m ostt succsessful clients I have are the one who have decided to take on the courage to find the answer without consulting significants others or close friends. A woman expecting twins came to me and divulgue that she has strong feelings and can’t tell me all the reasons. I intuitively guess that it is intimately related to her current pregnancy and life with her husband. But she denied. Then, the next session when she showed up, it looks like she was relief about her worries, that she couldn’t share with me (which made me feel very mad at that time). Then I realized that a good friend of her, saw her with her boyfriend in a coffee shop and started to spread the news to the village. Then the rumors whihc wasn’t really one became something she felt she didn’t have to deal with anymore since it is known as true and no one business to come and ask. Then, in her session, she talked about which life she is going to chose for herself and never mentionned about her husband. Now she is almost due, her life has been taken a ninety degree turn around. I understood that gender differences is an issue that one has to go through if we want to get to the deeper work.
I work in a substance rehabilitation residence for males where length of stay is often 90 days. While I am certainly no expert, I have noticed that some substance use specialists often report seeing depressive and/or anxiety-like symptoms in this time-frame. We do dual-diagnose where we think appropriate, but exercise caution.
I liked the way Terry differentiated between the two types of depression, will be helpful in my work.
Appreciate the explanation and the explanation between covert and overt behavior. Some men are taught this great mask of indifference, taught by role modeling learned in early childhood.
We have a more important danger than diagnosing these men. The state of what is going on in society regarding critical judgment, blaming mental health field for all the world ills is terrifying. If this occurs any longer, these men who we help will not even be coming into treatment where there is hope now, I see it as a real danger to society.
These men need to understand their covert behavior with a partner. They do such great work when they finally can find the many parts of their masculinity.
Nurturing missed in the family of origin needs to be reparented by them for themselves and a great avenue if they have children.
So wish you would all speak to ways to defeat this ongoing damage done to men who will now fear going into counseling due to the trash we hear regarding our profession daily.
Realize this is somewhat off track from the excellent presentation, but we will need to assure this counseling we do is honored by society instead of disregarded in the news by sheer ignorance regarding the scope of the help you all provide. The word “mental” is being used as a weapon against working on self improvement and emotional regulation, common in all men and women.
I would like to add here that sometimes it is not just from one partner. Recently, a distressed couple came to see me. They are in their forties and saw each other sparingly and continued their lives and lost contact. Their business continued without their partner knowing they suspected it. The distance between them only adds to the attachment problems and the multiple ties that their husbands have with other wives. They finally decided that by following their own path and putting their lives back on in order to decide on a more sedentary, healthier and more lively life, they realize that this does not suit them well. I am devoid of solutions for my clients because as a clinician and social worker, I approve of their choice, but I do not think less that I help them. I am retired from my career and volunteer for a family agency, but in the past I have mostly worked with OD. Meds would not do what therapy could do but I do completely agree that it plays a big part in this.
Very true and insightful. It often takes time to break through the defenses in order to treat the underlying pain.
I will use this awareness to help me determine if any of the men I see are depressed without having the overt symptoms.
Curious, I was sure when I started watching that this would be about trauma symptoms intermingling with depressive symptoms (anger, irritability, outbursts, negative emotional state), but that was not the case. Regardless, making the covert overt begins with awareness and then acceptance. Simply telling a client that depression often looks like anger can be a first step. Addressing shame and embarrassment with mindfulness practices (and a mindful clinician), observing without judgement, is relevant. Then skill building, behavioral activation, and possibly EMDR can be effective. Making the covert overt is about facing rather than denying reality. It takes courage. Many of our clients, male or female, are frightened. First, they need a safe environment rooted in a trusting relationship.
Kevin – Great suggestion. I would consider this. Thank you.
I fully agree with your idea. I doubt that the secret n / is always a secret because too familiar for people, by being more sure of these choices we can only have more choices in the ability to act and act freely without depending opinions of others. Relations expert John Gray wrote the book “Beyond Mars and Venus” speaks very well of relational skills for today’s complex world “I recommend this book or even these memoirs but very concise readings on these differences on The mini conference seems endless, but its brevity makes it very enjoyable.
This brought a question to mind…could that avoidance of depression come out in behaviors that appear healthy to others, i.e., extreme exercise, which is, then, followed by normal symptoms of depression that are explained away by “exhaustion” ? I have seen this before and wondered if depression was underlying.
I find this distinction helpful, and I wonder how a man’s experience of trauma/abuse complicates this. Trauma may underly the depression. I’m struck how the psyche is layered. Thank you.
I agree with this observation, although I don’t think it is gender specific, but certainly gender weighted (often according to background/culture/age.) My observations are that anger can often accompany depression, and that behaviours such as substance abuse and violence are perhaps a means to deal with that emotion. Men seem to be more willing or able to act out from anger (social conditioning perhaps?) I have wondered if anger is actually a natural psychological defense mechanism that rises to stimulate the sufferer out of the grip of the paralysis of a more acute depression? It certainly seems to be a commonly felt emotion when in mild to moderate depressive states.
I’ve just begun seeing a couple where the man, who has been sober for 2 years, has been unable to find therapist (and this is why I’m commenting) who – at least from his perspective – didn’t get ‘stuck’ on his alcoholism as the only thing to treat, and no one has helped him to get below that to deal with what is surely lifelong depression. It took his partner to decide enough was enough and search elsewhere for therapy together. His mother was alcoholic and committed suicide (under the influence, so perhaps accidental) when he was 18. She’d left his birth father when she learned she was pregnant, and he grew up with a stepdad who was controlling and abusive. How could he not be depressed? But for decades alcohol was the recourse – the “footprint” to use Terry word.
I write because I believe when there is a ‘dual diagnosis’ of, say, substance abuse and depression, there may be too frequent a tendency to treat these things sequentially instead of starting at the outset to address the underlying depression as well.
And shame is surely the deep-seated emotion under the depression. A prison study many years ago had a rather serendipitous ‘controlled study’ population of men whose criminal convictions had involved substance abuse in roughly equal numbers to those who had not been substance-abusing. The large study finding was that deep-seated shame (unlike guilt) was significantly correlated with substance abuse, and plausibly causal.
Depression is curable … but there is no specific “cure”. Thanks for the video.
My teens boys are in their phase when the peer pressure is remarkable. They are under the impression that they have to be reliable and to compete for their friends and their own gain. It is very depressing to see them spend so much time into this game, and it may not affect them directly or academically but I am trying to stop this abuse as a way to intervene that nothing similar would happen to them.
Yes we see this frequently. Sadly the men dont always seek help. They try to solve it on their own. I often ask women describing relationship issues, especially alchol abuse, if their partner might be depressed and they say yes. The women can recognize the dual diagnosis. Men are also often impacted by early trauma.
Helpful info, I provide onsite services in a major corporation with engineers and other professional males. I saw this recently with someone using alcohol to deal with his separation from his family. Once he addressed the alcohol use he allowed himself to recognize depression and begin antidepressant meds. Now 6 weeks later he is no longer angry, demonstrates productive thinking processes and positive thoughts towards his contribution to the downfall of his marriage. Thanks for the terms overt and covert to apply to his experiences.
I was married to my X for 23 years. I realized something was wrong and I suspected he was depressed. He was withdrawn, had to drink beer every day, would not even talk to me his spouse. Over the years he never spoke about childhood memories unless pressed to do so. He only had 2 memories he would share with me and they were both negative. I’m convinced now he was depressed. Thanks! This was very interesting.
Agree with the principle and would look for this in any individual. I really struggle with this “gendered” approach to mental health. It feels very archaic and assumes static archetypes of “manly” and “womanly”…time to update thinking about individuals as unique and move beyond this binary approach. Good concept but the application is broader!
i ve never seen it as “binary” but as part of who we are
Thank you! There’s already so much stigma surrounding mental health issues that we as a society are yet to overcome and to see so many comments from those that work in this field to not see this.. is unfortunately not surprising but definitely disappointing. Using gender stereotypes, terms like “typical f/male behaviour” , comments like (not all but most) cause they think it makes them sound inclusive…. FYI, it does not! Mental health issues do not fit neatly into carefully packaged and labelled boxes just waiting to be placed in the right spot, never have, never will! So until the “experts” figure that out…. I think most of us (not all) are probably better off without them.
I’ve suffered with depression for decades now, swinging from covert to overt as I taught myself to become mentally stronger and educating myself. I had too, noone else knew how to help this angry little girl who was raging at the world! Unfortunately due to this exact gender stigma described in the video, I went through years of tremendous hardship. As a teen I was basically rejected by society for being an angry female who was obviously struggling and quite literally screaming for help while I watched boys my age doing the same thing get inundated with help from every possible avenue. It broke me even more. I fell into the most horrific nightmare of deafening silence you could imagine and drowned in front of everyone’s eyes… all because I didn’t act accordingly to my gender. Its taken me over 20 yrs to recover. So again, thank you for having the presence of mind (and reading my slightly triggered rant haha) to know that people need to be treated and helped, not boxed into specific categories. The world needs more people like you in it.
Superb, simple, yet making the complexity visible!! AND, I would add that in the current world of ‘super-women’ the overt vs covert issues is something of which I’ll be more aware. Thanks!
Thank you. Helpful information to properly treat men with depression.
Trained by James Bugental Phd. I have tried in my practice to ‘work close to the resisitance.’ I am now adding mindfulness at a deeper level to help my clients feel that which they resist. When working with substance abusers I try to address the issue of self medication in the 1st or 2nd session to prepare to address co-morbidity.
Thank you, especially for using “overt” and “covert” as describing words. Very helpful. I try to look beyond specific behaviors to ask what said behavior indicates. This information expands the indications.
Thank you. Beautifully explained. Clear, concise and accurate.
Awareness the key I think
Superb. I wished Terry Real gives away a specific situation of how he has used this to help his client. Insightful enough about covert and overt behavior.
Utilize tests to detect covert depression. Conversations had before testing may unravel such behaviours you mentioned in the video.
Good point. I have often associated anger, violence and alcohol/drugs with anxiety, but this clip has made me more aware of possible depression when working with these clients.
Thanks very much for these videos
Canberra, Australia
Depression is so often covered up with a smile. We don’t like other people to think of us as somehow damaged or mentally handicapped. It can mean the difference between getting a job, a new client or even getting an unwanted reputation if you live in a small town. We’re not
supposed to care what other people think, but when a person is depressed it can be difficult to think rationally. Loneliness is a major problem and we don’t want to repel people by coming across as sad and depressed. I personally live happy people and try and surround myself with them :). QED
Does going on with drugs may be a covert depression?
I am currently a student and the hidden depression in men is what I am being taught. I appreciate the terms covert and overt depression.
When depression presents and it is not due to diet, endocrine system, toxins (not a chemical imbalance in brain either – that has long been disproven yet ignored in favor of pharmaceutical industry). When life is overwhelming and seems to suck, it gets named depression, (among other damaging diagnoses including PTSD). It isn’t borderline personality, as someone suggests below, as parts of self are formed to deal with different levels of trauma, overwhelm et al… STOP PATHOLOGIZING PAIN! Depression is normal. This is what is wrong with psychiatry and the way therapists are trained – all that is taught is to diagnose symptoms, not the cause – great therapists get to the root, and in my practice whether men or women, depression is unmitigated stress and trauma. Most people cannot feel why they are depressed because they are so numbed and are lead to believe it is in their brain, but an exceptional therapist shines a light on the root cause, and brings forth clarity and an individuals inner wisdom so they can focus on healing; they as well have positive expectancy for them, and join with their client so that they can heal.
Thank you, I agree.
I have been told by family that depression runs in our family. Paternal grandmother died from alcoholism and her two sons were alcoholics. One committed suicide. A psychologist once told me she thought I had been depressed since my teens.
I recently discovered the idea of childhood emotional neglect and now I wonder if my depression is more nurture than nature. It doesn’t help the symptoms to know either way.
I appreciate your response here. Get to the cause…and treat THAT, with kind expectency, encouragement and empathy, first and foremost.
Reinforces the view I had of hidden male depression and will continue to use it with confidence in my work
I saw this often in my practise. The self medication was there but there was this sense of anger. Difficult for men to describe what they felt or acknowledge but once they could give it a name it often helped. At times the feeling was pretty profound.
Is this what we call a classic “midlife crisis”? Acting out in order to defend from deeper inner pain.
Yes, withdrawal definitely. Not only from partner/spouse but from children too. There are men who don’t talk to their kids for half a decade.
Another area which is common and wasn’t mentioned is workaholism. “I’m not depressed or withdrawing from my family, I’m just really busy.”
This is an approach to which I had not given a lot of thought. I found it to be insightful and enlighten.
Is this a form of depression? Dreadfully low physical energy for no obvious reason, wanting to close the eyes whenever possible and not look at the world, closing the eyes when listening on the telephone, sense of sinking into “darkness” at some deep level, personal interpretation that one is slowly dying.
Sounds like one symptom of Depression
Sounds like low thyroid.
Some of the behaviors he labels as defensive could also be borderline behaviors; the compulsive acting out, rages, splurge spending, etc……. been thinking lately though how borderline issues can so easily exist with depression and or bipolar stuff. Not so sure if he’s right about the differences in shame in how men and women experience depression. While it may be more socially acceptable for women to express their feelings, because this culture is so “happiness” focused, whenever I feel lousy, I also feel a sense of shame, that I “should” be able to control my emotions and “choose” happiness.
Very helpful and informative video! I see this a lot in clients addicted to pornography.
Nice short overview. For whatever reason NICABM has left out the historical context. The intro & video are presented as something new, a new concept or intervention. In fact, covert depression has been standard in graduate school teaching and in practice since Terry Real popularized it 20+ years ago.
Thanks! Wondersfull conceptualzation about why it is harder for men to acknowledge their depression! These defense patterns seem to fit perfectly within the framework of experiential avoidance, as it is conceptualized in ACT or dysfunctional emotion regulation in DBT. So I’ll integrate these insights within such frameworks. Another form of “covert” depresssion is the anxious depression as in comorbid GAD and MDD (Dysthymia). These are depressed people who never stay over in bed and who will complain about other anxiety disorders, insomnia, sexual disorders, irritability, interpersonal conflicts and so on, but never about being or feeling depressed. Happy new year!!
Thanks! Wondersfull conceptualzation about why it is harder for men to acknowledge their depression! These defense patterns seem to fit perfectly within the framework of experiential avoidance, as it is conceptualized in ACT or dysfunctional emotion regulation in DBT. So I’ll integrate these insights within such frameworks. Another form of “covert” depresssion is the anxious depression as in comorbid GAD and MDD (Dysthymia). These are depressed people who never stay over in bed and who will complain of other anxiety disorders, insomnia, sexual disorders, irritability, interpersonal conflicts and so on, but never about being or feeling depressed. Happy new year!!
Amazingly perfectly right! This is something that I have similarly found recently. Happy new year!
Ignacio – “Thanks! Wondersfull conceptualization about why it is harder for men to acknowledge their depression! These defense patterns seem to fit perfectly within the framework of experiential avoidance” – great observation, and adding to this, I would say the emulated behaviors among men that are the aggressive reactions to their own distress can’t justify the fact that they are themselves resisting to receive help. This is a taunting and misfortunate depressive cycle due to anxiety in itself.
Very nice insight and formulation and with intervention strategy. I believe men are prone to be embarrassed about depression.
Thank you for bringing this forward. I’ve been recommending Terry Real’s book “I don’t want to talk about it” for several years. Men who are highly resistant to accepting that depression is a real issue for them, I ask them to either buy the book or to listen to it in audio format. I often find they are more resistant to reading it than listening to it. It has turned lives around. I’m currently working with a 32 year old man who came in because his mother was pleading with him to stop alcohol, cocaine, womanizing, and overspending. He was labelled with ADHD in school when he was young, and struggles to read. He was resentful of his mother’s interference, and determined there was NOTHING wrong with him. I told him he might see it that way, but if he could just listen to this book, before we close his file. He got the audiobook and is changing his life around. He has a long way to go (only 30 days sober/abstinent), but at least now he is starting to have better self awareness, and recognizes his childhood and most of his life has been difficult. It’s so rewarding to see him turn this corner!