Much obviously remains to be learned (and a great deal will doubtless continue to be a mystery, owing to the disease’s idiopathic nature, its constant interchangeability of factors), but certainly one psychological element has been established beyond reasonable doubt, and that is the concept of loss. Loss in all of its manifestations is the touchstone of depression — in the progress of the disease and, most likely, in its origin.

William Styron

Many men may not exhibit classical symptoms of depression as directly as women. Unlike men, women are afforded culturally sanctioned permission to express emotional pain overtly. For many men, an insidious and covert depressive syndrome may exist that is much less apparent to the outside observer but may have significant deleterious effects. Depressive syndromes that are not manifest through the classic constellation of depressive symptomatology have been variously described as a “depressive equivalent” or “masked depression”. This syndrome is thought to manifest itself in a variety of behaviors that seem incompatible with depression, including alcohol abuse, delinquency, reckless behavior, anger, and somatic complaints. Might men express their depression through these outlets, many of which are more culturally acceptable?

While the Diagnostic and Statistical Manual of Mental Disorders distinguishes major depression from uncomplicated bereavement, in which there has been a tangible loss to the individual, the overlap and timing of these two conditions has not been fully specified. Early psychoanalysts noted the close relationship between bereavement and melancholia or depression. Personal and cultural variability in the mourning process makes it difficult to connect depressive symptomology to loss.

For many men, there may appear little correlation between experiences of trauma, loss, and the onset of depressive symptomology. Men are less likely than women to show obvious symptoms of depression initially following a traumatic loss experience. In studies comparing the grief response of widows and widowers, males were significantly more depressed than their female counterparts after two to four years. This finding was especially prominent when comparing widows and widowers living alone. Men who did not address their grief in therapy following the death of a spouse tended to be more depressed later in their bereavement than were widowers who took this action. Recently bereaved men were more likely to be diagnosed with an alcohol problem than an affective disorder and more likely to develop a serious physical illness, commit suicide, or die prematurely when compared to bereaved women. Taken together, these studies suggest that men tend to have difficulty expressing their grief directly and may be more prone to long-term mental and physical health problems as a consequence of their culturally derived tendency to truncate normative grief processes. Men who have experienced both active and passive trauma may be susceptible to delayed or covert grief reactions, and these delayed or covert reactions often include significant depressive components.

Instead of overtly expressing the emotional impact of loss, men are prone to outwardly diminish its significance in order to maintain some semblance of control over their lives. Men are more likely to rely on externalization-based defenses and coping styles that often serve to detach them from their emotions. Traditional male cultural training has stressed emotional stoicism, control, denial of weakness, and logical thinking in the face of emotional chaos. While this may be an effective short-term strategy, it is a poor long-term one for most men. The losses of life that accumulate for many men may result in unforeseen consequences, such as unexplained depression, identity crises, and bouts of severe anxiety at middle age. For older men who have relied solely on a spouse or significant other to buffer them against the effects of life’s tragedies, the loss of this person multiplies their exposure to psychological and physical health risks.

In this chapter, the interplay of depression with loss, trauma, and grief that men experience at various points across the life span will be explored. We will see that men are vulnerable to loss and grief in distinctly masculine ways. How does this vulnerability relate to depression in men? Loss will be defined as the separation or dissolution of a man’s way of self-identification. Trauma will be defined as active and passive experiences of physical or psychological pain originating from outside the person. Bereavement will be defined as the permanent loss of a significant other. Grief is the affective state accompanying bereavement and loss. Attention will be paid to the unique ways that men experience these emotionally charged states.

Clinician Query — “I just want to get back to work.” Adam sought consultation after having been arrested for “creating a disturbance” at his ex-girlfriend’s apartment one night. He was home by himself, had drunk a number of beers, began feeling sad and lonely, and decided to visit her in hopes of renewing their long-term relationship that she had abruptly ended two days ago. He arrived at the apartment and began pounding on the door, pleading that she let him in so they could talk. She responded by informing him that if he didn’t leave she would call the police. He continued to pound away, and she called the police. Before they arrived, he broke a fire-extinguisher container in the corridor and cut himself in a number of places on his arms. When the police arrived, he was transported to the emergency room. There, the attending physician determined that he was intoxicated but at minimal risk for serious harm to himself or to his ex-girlfriend. He was arrested and transported to jail.

The following day, he visited a therapist for consultation. His attorney advised him that this might help in his efforts to obtain a deferred sentence since he had no other criminal record or history of this kind of behavior. He was composed and articulate, and appeared embarrassed at his behavior as he discussed the previous evening. His appearance did not seem consistent with the story that preceded him. He was short and slightly overweight, with a roly-poly appearance, a sheepish grin, and an easygoing, self-effacing demeanor. He presented himself as polite and easy going.

“I just couldn’t believe she really meant it. I still can’t believe it’s over,” he lamented in response to a question about what had happened the previous evening. Then, he quickly changed the topic of conversation. “I have a lot of accounts to work up and a lot of territory to cover. I just need to get myself focused on my work. That will make things better. I just want to get back to work.”

“You seemed pretty bent on creating quite a scene,” his therapist queried in an effort to direct Adam’s attention back to the problems that had brought them together. “What with the emergency room visit and winding up in jail. Quite an evening of it, I would say, wouldn’t you?”

“I was just at the end of my rope. I didn’t know what to do. Why would I do such a thing? I’ve never acted like this before! I feel so embarrassed and ashamed of myself,” Adam responded with sincerity.

“That’s a good question. Why would you do such a thing? What do you think? Do you have any theories?” his therapist probed.

“The breakup, and the way Angie has been behaving towards me, have just been too much for me to handle, I guess,” Adam replied.

“Too much to handle? In what way?”

“I’ve been really depressed, just not myself. I’m way off my pace at work, I just don’t feel like doing anything. It’s only been a couple of days, but I feel like I can’t live without her. And she has just cut me off. She won’t talk to me or answer my phone calls. It’s really frustrating. I just get really fed up with the whole situation. I just can’t handle it.”

•  To what extent is male depression related to vulnerability to emotional abandonment and relationship dissolution?

•   How do men behave when faced with the challenge of coping with feelings of abandonment, loss, and shame when a close relationship ends?

Normative Loss Across The Life Span

Trauma And Depression

Grief and Depression

Manifestations of covert depression in men

Summary

Our understanding of the way men are socialized informs us that male depression is often a result of the combined effects of biological predisposition, early childhood loss and trauma, gender-role restrictions in behavior, life disappointments, unresolved grief, poor social support, and a growing awareness of mortality. Theory and research suggest that depression is often manifest differently in men and women. With little tolerance for overt emotional expression of trauma, loss, and grief, men may find it more acceptable to act out their feelings through more socially acceptable, although often covert, channels. While depressive symptoms may be hidden to others, subtle behavioral and somatic indicators can be seen through the empathic lens of a male psychology that transcends the blinders of the traditional male gender role. From this perspective, men are appreciated for their strengths, while recognition is given to areas of functioning that are limited by gender socialization.

Masking of male depression may occur through somatization or psychophysiological disorders, addictions, and aggressive behavior outbursts. Many of these hypothesized oudets for male depression are categories in which men are proportionally overrepresented compared with women. For example, men are three to five times as likely to suffer from alcohol abuse and dependency as women. Given the documented connection between depression and these various conditions that could serve as covert outlets for depression in men, could this be where men find expression of their psychic pain? Are these outlets not socially sanctioned for men, thus making men more inclined to express depressive affect through such socially acceptable channels as addiction, aggression, and avoidance?

A number of psychoanalytically informed theorists,have pointed out the gender-bifurcated impact of our culture’s child-rearing practices. In these conceptualizations, little boys must traverse an emotionally challenging and problematic developmental trajectory. This trajectory requires them to prematurely seek connection outside the maternal emotional holding environment in order to conform to our culture’s prevailing conceptions of masculinity. For little girls, this cultural script is played out developmentally via connection to the mother, who is experienced “like me.” In our maternally based child-rearing culture, identity and relatedness become fundamentally connected for little girls. Little boys, on the other hand, must negotiate their construction of gender in a process that is based on separation and distancing from the mother as well as the culturally sanctioned push away from the mother’s relational holding environment. In this process, a little boy’s conception of himself becomes intertwined with separation from others and autonomous emotional functioning.

Greenson (1968), Tyson (1982, 1986), and PoUack (1995a) identify this breaking away from the maternal bond early in life as an important one in male development. Pollack (1995b) has speculated that disruption of this early bond produces a gender-specific vulnerability resulting from a “traumatic abrogation of the early holding environment” in little boys’ development. This abrogation creates a dynamic foundation that has a profound impact on the boy’s later experience of relationships with both other boys and girls. One hypothesized outcome of this developmental process is a defensive firming of interpersonal boundaries, a tendency toward distancing and self-protectiveness in the face of what is ultimately experienced as a pull toward intimacy and connection with others.

A second experience of normative loss in little boys, especially those born prior to and including the post-World War II “baby boomers,” is the relative absence of the father, both physically and psychologically. In our Western culture, in which there is value and honor in a man’s providing for his family, such provisioning often takes the father from the home and away from those he loves most. A number of authors address this key relationship, often focusing on the positive aspects of the father in facilitating the little boy’s separation and identity development . However, with a father away at work, how can a little boy experience the full benefit of this relationship? Osherson (1986) has proposed that for many men, facing the grief and pain over the absence of their father is a critical dimension of men’s psychological development. The absence of a stable and enduring relational bond with the father, as well as the grief and pain that is experienced by many men in relation to this absence, further compounds the experience of grief and loss to which boys are subjected in their push from maternal connection.

While, in many cases, the father can be a positive role model for the young boy’s separation and identity development, he often is a poor role model in the realm of interpersonal relating. Many boys are left to fend for themselves, superficially imitating their father’s independent style but having little substantive guidance on how to manage feelings of hurt, sadness, or grief. Unlike girls, who are more relationally oriented, boys have little experience managing the grief of making attachments and then separating from them. Instead, many boys learn to avoid the emotional signals that might point toward their grief or confusion and instead develop a more extroverted, activity-oriented lifestyle.

A recapitulation of these earlier interpersonal loss experiences often occurs at adolescence for boys. After a period of years in which they may be growing physically and on the sports field, boys are faced with the demands of interpersonal relationships with the advent of adolescence. These relational challenges often resonate with the confusion and defensiveness that was experienced in conjunction with the dislocation from the emotional holding environment of earlier years. With the onset of adolescence, sex differences in the prevalence of depression become manifest, with girls beginning to lead boys in both symptoms and diagnosis of depression. Before adolescence, little boys are generally diagnosed at least as frequently with depression as little girls. It is at adolescence that the female preponderance of depressive disorders first begins to emerge.

Young men have been found to exhibit externalizing patterns of defenses and behaviors such as projection, anger, and antagonism and are perceived as disagreeable, aggressive, and antagonistic by others. Consistent with this externalizing, activity-oriented style, successful male adaptation in our culture is defined by  achievement, intellectual  capacity, and  competence. As Gjerde (1995) has found, lack of competence and the presence of allocentric behaviors (self-centered, narcissistic behavioral patterns) in boys as adolescents were related to depression in young men. It is not surprising to find young men channeling their emotional intensity into strivings for success via their careers and the pursuit of “the dream” of success. During this pursuit, many men also seek out a mate who will support them and help them raise a family. Like his father before him, a man is often better equipped to work than to connect in his relationships. A romantic partner may find a man’s energy and activity focus attractive from a provider standpoint. It is often not until a man is faced with the demands of work and family that he is confronted with his poor relational skills. Some men repeat the pattern of their fathers, working hard, but distancing themselves from their spouses and children. Others choose to focus on family but pay the price in the competitive work environment for not being fully on task. Some men find the pressures too great and leave the family totally, retreating to a less complicated and less emotionally demanding relationship situation.

Unfortunately, many men are not well prepared to deal with the limitations of their lives. Taught from an early age to achieve, accomplish, and win, there is no real training in how to psychologically accept one’s strengths and weaknesses in a healthy and nonshaming way. Believing that they have more control than they actually do, many men find that when life events do not go their way, they are good at compensating behaviorally but poorly equipped emotionally to absorb the blow. This is especially the case at midlife, where many men are faced with the foreclosure of their occupational and social dreams.

Men often pursue identity through achievement in the workplace. Attaining achievement in the workplace is one of the primary ways that a man can erect defenses against other types of threats to his ego. When a man is skipped over for a promotion, downsized out of a job, or told that his skills are no longer needed, he is faced with a loss that cuts deeper than the job itself. It is as if he has been devalued as a man, raising questions about his self-definition. While he may outwardly deny the importance of his work to others, he will experience an internal sense of shame that may dominate his consciousness. A man may find that this shame cuts across his life, coaxing him to question his role as a provider, mate, father, or human being. While some psychologists see this as an opportunity to redefine oneself, most men will struggle to recapture that which they have lost in order to avoid the full brunt of the emotional pain. Often, a man feels he has no choice but to fight back in some way and re-prove his masculinity, even if he feels defeated internally.

Another tragic event for a number of men is the loss of a partner or spouse during midlife to divorce. Divorce is quite common and usually involves a couple’s miscommunicating, losing interest in each other, or growing in different directions. Data suggests that marriage serves to protect many men against depression and other mood disturbances. While extramarital affairs may contribute to marital discord, it is usually more a symptom of a problem in the relationship. Traditionally, communication in relationships is in the domain of the female partner, who tolerates a man’s less emotionally expressive style as long as her needs are being met. Often, when there are problems in the relationship, men tend to try to problem-solve while women try to work out the problem through talking . When a couple finds it can no longer function, one of the partners registers the dissatisfaction and often expects the other to change in response. Fortunate couples who go to therapy often can remedy problems through self-awareness, blame sharing, and mutual problem-solving. Many couples, who do not take this route, conclude the other is to blame. Such a blaming stance on the part of either partner results in a high probability of separation and divorce.

For many men, divorce is not only personally shaming but often involves the loss of regular contact with their children. Most men enter marriage with the intention of being a lifelong partner in a relationship. Choosing monogamy is a very large decision for men, considering that it means limiting one’s sexual partner to one individual. Whether caused by death or by divorce, the loss of a long-term relationship or marriage is a painful and devastating experience for many men. Attachment theory suggests that one’s connection with another is not easily broken, and severing relational bonds typically results in separation anxiety and depression. The pain of relationship loss for men is often exacerbated by earlier experiences of dislocation from the maternal holding environment compounded by the accrual of painful loss experiences through adolescence and early adulthood .

Another loss for men at midlife is that of losing regular contact with children through divorce or when they grow up and leave home. Most men identify in a proud and positive way with being a father. Much time and energy is involved in raising children. While statistics show that mothers are more involved in the daily lives of children, fathers are still considered extremely important to a child’s welfare. Fathers act as role models for young boys and are considered extremely important contributors to the self-esteem of girls, especially as they navigate adolescence. The role of father is an important element of the stage of generativity in Erikson’s (1980) scheme of psychosocial development. Deprived of the opportunity to fulfill this important role, many men face a crisis of meaning and purpose during the later stages of the life span.

Until midlife, it is unlikely that the average man will show many of the symptoms that define major depression. Rates of depression increase as men grow into middle age, and peak in the 35 — 45 age group. Men may erect defenses against depression by betting that achievement in the external world can substitute for experiences of abandonment and loss absorbed since childhood. It is typically when a man has met his goals or has discovered the limits of his expansion in the world that he begins to doubt, question, or redefine his identity. With an awareness of his mortality, he is thrown face to face with the meaning of his life. The impact of losses experienced in midlife is magnified. Perhaps he is overwhelmed by an accumulation of avoidant coping choices made beginning in boyhood. Maybe he is tired of partitioning his emotions from the instrumental areas of his life in the spirit of the traditional male gender role. Either way, many men are forced to confront aspects of their emotional selves as they traverse midlife and beyond.

As men grow older, the impact of life’s slings and arrows begins to chip away at what some have characterized as a narcissistic armor or character structure. This accrual of loss experiences and the ensuing narcissistic wounding may help explain the increase in rates of depression as men grow older. It may also help to understand the alarming rates of suicide in men, especially elderly men. The eventual breakdown of culturally sanctioned defenses against pain and grief leaves middle-aged and elderly men vulnerable to a breakthrough of depressive mood states. Although these states may not rise to the level of a full-blown depressive episode at any given point in time, this underlying shading of mood is common in many men who eventually make their way to a therapist’s office for assistance at these later stages in their lives.

In midlife and beyond, men navigate the final two stages of life that Erikson (1963) termed generativity versus stagnation and ego integrity versus despair. A process of reflection on life and a review of accomplishments and failures often serves as an impetus for emotional engagement for many men. For those men fortunate enough to have successfully navigated the earlier developmental milestones of their life journey, this reflection can be a richly rewarding and gratifying process. For other men who have been less successful in their journeys, late adulthood can be a time of crushing despair and depression. In light of our culture’s emphasis on achievement and competence, it is not surprising that those men who are faced with looking back on a life path strewn with failures in relationships and work endeavors may be catapulted into depression. The dramatic increase in suicide rates as men grow older may be partly function of such an impact.

Clinician’s Query — “I feel really uncomfortable. Like I’m some sort of freak”

Jason, an overweight 27-year-old married man, had been referred for psychotherapy by his family physician, who had been treating him for depression and anxiety. Jason, who had been taking buproprion for the past six months, complained to his physician that he was still having trouble sleeping and that he often had intrusive thoughts that were interfering with his relationship with his wife as well as with his coworkers at the manufacturing company where he was employed as a shipping clerk.

“I feel spacey. Sometimes, I miss periods of time, like I have been somewhere else,” he described some of his discomfort to his therapist.

While initially hesitant about contacting a therapist, Jason made an appointment at the insistence of his wife. In the first two sessions, Jason spoke about not really knowing his real father, who left his mother when Jason was a baby. His mother had a series of boyfriends during his childhood, eventually marrying one of them when Jason was in high school. Jason revealed little feeling, speaking mainly in a monotone. When asked about his feelings, Jason often replied “I don’t know what I am feeling.”

He told the therapist that he and his wife had not been having sex for the past year. “It’s my fault. She’s been trying to get me interested, but my desire just hasn’t been there. I just don’t feel like it. I don’t know what I’m going to do about it, either.”

During the third session, Jason responded tentatively to a question from the therapist about anything that stood out from his childhood that he actually did have feelings about. It was at this point that he revealed that he had been sexually molested by one of his mother’s boyfriends when he was 10 years old.

“Do you think that after all these years what happened to me then could make me depressed now?” Jason wondered.

“It’s possible. How often did it occur?” his therapist asked.

“It happened several times when my mother was out. The bad thing is that I really liked this guy. He listened to me. He seemed to genuinely take an active interest in who I was. He would be really friendly,” Jason replied with some animation. Then looking down, his voice slowed. “He’d find a way to touch my penis, like after a bath or shower. He told me he was making sure it was clean or dried off.”

“You perceived this as uncomfortable?” his therapist asked.

“Sure. It was weird. I felt kind of creepy and dirty when he did this. Sometimes, my penis would get hard and it felt good. I didn’t know what to think. I think it scared me, really.”

“So on one hand, it felt really great to get some attention from a father figure, but there was also something disturbing and scary about it.”

“During those times, I just kind of blanked out. I pretended like it hadn’t happened so I could still enjoy what this guy had to offer me. I wasn’t used to having a receptive older guy around the house.”

“Did you ever tell anyone about it?” his therapist inquired.

“No. I didn’t want to worry my mom. She had enough to worry about. Like I said, I just erased it from my mind so I didn’t have to deal with it. I rationalized that he just was being helpful to me at bath time.”

“Jason, do you think that your intrusive thoughts are at all related to these incidents?”

“Maybe. The images come and go and when I become aware of where I am, it’s like a dream that I can’t remember. This whole memory thing is pretty overwhelming to me right now,” Jason stated with a look of fear on his face.

“That’s understandable. You look afraid.”

“I know it happened. But it seems unreal. I’ve never told anyone about it before today. I don’t really know what to make of it or what to do with it. I can feel myself shaking.”

“It’s o.k. to let yourself feel here. You’ve put a lot of energy into trying to fight off those feelings.”

“I feel really uncomfortable. Like I’m some sort of freak.”

•  How are childhood sexual abuse and depression related in men?

•  How does the traditional male gender role, with its emphasis on strength, stoicism, and avoidance of vulnerability, interfere with the healing process for men who have had traumatic sexual experiences in childhood?

Trauma involves a severe disturbance of an individual’s mental and emotional life through a painfully inflicted experience or series of experiences from outside of oneself. Psychologists have used the term “trauma” to describe the impact of child abuse, sexual abuse, combat, violence, and physical accidents, among other life events. Although a number of scientists believe that early traumatic experiences are likely to contribute to depression in later life, experimental findings are somewhat inconclusive. Severe trauma may result in physiological damage to the brain, especially areas in the hippocampus where memory is processed. Biondi and Picardi (1996) speculate that trauma in the form of irreparable loss experiences results in increased adrenocortical activity and suppressed immune function in humans. Stressful life events may activate certain neuroendocrine processes that may result in the development of depression. Such activation, which may contribute to irreversible changes in the neurotransmitter systems of the central nervous system, contributes to the emergence and exacerbation of depressive symptoms.

Real (1997) has made a distinction between active trauma and passive trauma. Active trauma involves obvious and dramatic violations of trust, such as child sexual abuse, witnessing or being the victim of physical violence, or the death of one or both parents. Passive trauma situations involve subtle breaches of trust, such as a parent not meeting a child’s need to be loved, seen, or valued. Although not as obvious, passive trauma can have a profound effect, since its source may not be found in conscious memory. A man may be left with an unexplained feeling of loss, pain, or emptiness following an interpersonal slight and not have a rationale for its existence.

Men who have experienced active trauma, including childhood sexual abuse, often keep this information to themselves in conformity with the traditional male gender role.To admit weakness or share emotional vulnerability is to place oneself in a precarious position, especially among other men, who are often perceived as competitors, ready to take advantage of each other. Masculinity is defined partially by one’s ability to overcome tragic circumstances without complaining or assuming a victim stance. It is no wonder that, until recently, there has been little information gathered about boys’ childhood sexual abuse. Only after investigators were willing to sit down for extended confidential interview sessions and ask questions in non-shame-inducing ways were men who had been abused able to speak honestly about traumatic experiences and their impact.

Active trauma impacts an individual in a number of psychological and emotional ways. The traumatic experience itself is often recalled with vividness, producing feelings of anxiety and shame. For most men, these feelings alone are shameful and lead to conscious and unconscious coping methods. Many men swear, at some point, that they will do everything in their power not to be affected by the memories of trauma. The traditional male gender role, with its emphasis on overcoming pain and achieving success, provides many men with an outlet for their energy and focus. It is extremely manly to be tough, competitive, and not to let anyone interfere with one’s goals.

The severity of the abuse and the number of abuse situations endured will have an influence on how an individual is psychologically impacted. In autobiographical interviews of male survivors of sexual abuse, researchers found that several themes emerged in these men’s lives. These included feelings of anger, betrayal, fear, helplessness, isolation, loss, shame, humiliation, self-blame, and guilt. They also included themes related to questioning one’s masculinity, concerns about sexuality and homosexuality, questions about the legitimacy of one’s abuse experience, negative childhood peer relations, and negative schemas about oneself and others. Many of these feelings and concerns lie at the core of the depression for men who suffered through sexual abuse episodes.

While active traumas like parental abandonment and sexual abuse have obvious impact, passive traumas often go unnoticed in many men’s lives. Something as small as an unfulfilled need to be noticed or recognized can have damaging implications on male personality structure. Winnicott (1960/1965) and Kohut (1977) describe the subtly wounded self. Kohut suggests that the developing child has three major needs to be fulfilled. These include the need to be mirrored, the need to idealize, and the need to be like others. The need to be mirrored is best understood as the way that a child develops self-acceptance by having a significant adult validate (mirror) his or her best qualities. Parents often, through subde gestures and verbalizations, make a child feel as if he is special, important, and desired. When parental mirroring fails, a child who has had significant parental support learns to create his own mirror. This process, called transmuting internalization, allows an individual to gradually create a self-structure, based on the accrual of mirroring experiences, that is stable and relatively positive. If a child does not get enough positive mirroring, he will have difficulty sustaining stable self-esteem. This failure of an internalized sense of positive mirroring results in feelings of low self worth and is defended against by grandiosity. In the normal child, grandiose needs are eventually fulfilled from resources drawn from within. In the child lacking adequate self structure, the need to be seen and validated becomes so strong that it may completely overwhelm the ego structure. This leads to inappropriate exhibitionism to gain attention and only minimal gratification from external sources. Even for men who have not been physically or sexually abused, a lack of mirroring can be a subtle but significant passive trauma that results in an inner hollowness and an overcompensated persona. For a man who has lacked adequate mirroring, a narcissistic setback such as a job loss or relationship breakup can precipitate strong feelings of emptiness and depression, since these setbacks often activate the pain of prior wounding of an already embattled self.

The frustration of the need to idealize a parent can also be damaging to the male self structure. A boy’s idealization of his mother and father provide him with hope for the future. By looking up to his parents, a boy can identify and one day imagine himself as a competent and successful adult. If a parent betrays his trust and frustrates his idealization, the growing boy is left with little in which to believe. In child abuse, the violation is obvious and overt. The damage sustained from the trauma makes it difficult for the boy to believe that his own future will be positive. Even subtle betrayals by parents can inflict passive trauma that, if not repaired, can lead to a sense of pessimism or negativity, the source of which is not consciously recalled. Pessimism, negativity, and loss of hope are some of the hallmarks of depression.

Kohut’s (1977) final aspect of self is based on the concept of twinship. This is the need to have a double or a playmate who is one’s equal to validate each other’s feelings, thoughts, and interests. This often occurs in childhood and can lead to a strong sense of belonging. If there has been active trauma, such as child abuse, shame, doubt, and secrecy may replace the openness needed for peer intimacy For boys, the traditional male code suggests that shameful events not be shared for fear of appearing weak. For many boys, trauma leads to social isolation or exaggerated nonintimate ways of acting, such as bullying, fighting, or exhibitionism. Passive trauma can also lead to internalized negative feelings about the self, which may keep a boy from sharing personal information with friends or interacting in a spontaneous and uninhibited manner.

Lack of twinship is often reinforced by the male role that pits men against each other in adulthood, in competition for jobs and sexual partners. These restrictive and oppressive norms are transmitted in our child-rearing practices and socialization processes to little boys, who find it difficult to overcome these restrictive aspects of the “boy code”. As a result, many boys emerge into adolescence and young adulthood isolated and disconnected from these important peer relationships that are viewed as so important to the development of a healthy sense of self. Isolation from other men is a common complaint of men who experience depressive symptoms.

Few men seem to reach adulthood without suffering subtle trauma. Rejection, betrayal, competitive antagonism, and avoidance are part and parcel of life for most boys and men. The male gender-role code makes displays of the painful consequence of these experiences taboo by forbidding crying, emotional displays other than anger, and physical comforting by other males. This leaves men few outlets to express or emotionally soothe themselves in an authentic way. A real man will overcome his traumatic losses through stoicism, strength, and will power. Efforts to distract from or externalize depressed and sad affect may provide relief in the short run, but are ultimately self-defeating strategies. The ineffectiveness of such attempts is reflected in high rates of drug abuse, alcoholism, and other addictions, as well as in higher suicide and accident rates and a shorter life span. While effective in the short run to hide weakness and pain, the traditional male way of handling trauma is deadly in the long term.

Throughout the life span, boys and men are subjected to active and passive trauma that is, in part, a consequence of restrictive and dysfunctional gender-role socialization. Gender-role training forces boys and men to utilize maladaptive coping strategies, interferes with effective management of trauma-related depression, and prolongs or derails natural healing processes that repair the impact of traumatic events. Many boys and men experience strong conflict between experiencing and coping with trauma and the externally imposed gender-role norms of our culture. Such conflict often, sadly, results in boys and men erecting defenses against an ever increasing reservoir of unspeakable pain, grief, and sadness, that leaves many men vulnerable to depressive states at various stress-points throughout the life span.

Clinician Query — “It just doesn’t get any worse than this.” Paul was an unemployed 38-year-old man who had been laid off from his job as a mechanic at a local automobile repair shop. He contacted a psychotherapist at the insistence of his spouse, who had become concerned about how he was behaving after the layoff. Paul had not had any previous psychological or psychiatric treatment when the first met with his therapist. At this first meeting, he was dressed casually in jeans and a popular sport shirt. He was of medium height and athletic in build. He had short hair and a ruddy, deep complexion. He used a strong grip as he shook hands and introduced himself to the therapist. They entered the consulting room and the therapist asked Paul to just start wherever he would like, and review what had happened that had brought him in to the office that day.

“Well, you know that commercial, vit doesn’t get any better than this?’Well, as far as I’m concerned, it doesn’t get any worse that this,” was Paul’s response to this opening question. He continued, “Ever since Jamie died, two years ago now, things have just gone downhill. Ugh. It’s just too hard to think about.”

Paul glanced out the window.

“You mentioned that on the phone when you made the appointment. What happened?” Paul’s therapist inquired, inviting more details about the background and circumstances that had brought Paul to therapy.

“Well, he was diagnosed with leukemia when he was 8 years old. The doctors thought they could beat it, but…” He gazed out the window again. “I remember that day in the hospital when he died. It’s so clear to me. I just play it over and over in my head about every day. We were just sitting there, just me and him. He was pretty much out of it, with drugs and all. But I think he was aware enough to open his eyes and hear me talk.” Paul paused and struggled to continue. “It was unreal. Here I was, sitting there with my son, my only son, dying, right in front of me. Only 10 years old.” Paul paused and was clearly trying to restrain himself from being overcome with grief. His Up quivered as he took a deep breath and continued.

“Well, after he died, I just tried to forget about it. But I guess that’s easier said than done. It wasn’t too bad, with all the activity around putting on a wake and with relatives visiting, a guy keeps pretty busy. Then, a couple of months after the funeral and everything, my boss comes in and says he’s going to have to let me go. Just temporary, he says, until there is more work. We were having the usual winter slowdown, but I just can’t help but think he noticed I just wasn’t up to par. Well, that was just what I needed. A double whammy!” Paul paused again. “I just haven’t been able to pull myself out of it since then. That was over a year ago now. I’ve been depressed, but what can a guy do? I’m still alive, still eating and sleeping. I guess. Julie thought I should come in and talk. She thought it would help me feel better. Maybe it will, I don’t know.”

“I’m glad you came in, Paul. I’m just overwhelmed by what you have just said. That’s a really sad story about your son, and I’m so sorry it ended the way it did. And to top it off, to lose your job, too. You know, it’s not too surprising you would be feeling some depression. I think anyone would after what you’ve been through. You said you haven’t been able to pull yourself out of it? What do you mean?” the therapist continued.

“Well, I just can’t get going. I just don’t have any get-up-and-go. I’m just stuck. It’s like I weigh 600 pounds and can’t move myself,” Paul described his physical heaviness and inertia. “And I just want to hide. A guy loses his son, and then his job. What’s next?”

•  How does the traditional male gender role inhibit the expression of grief in men?

•  What relationship is there between grief and depression in men?

Grief is defined as the physical and emotional state and the behaviors that accompany the permanent loss of a significant other. Much of the research literature on men and grief has focused on men who have recently become widowed or friends and partners of men who have died from the AIDS epidemic. For men raised in American culture, there is little sanction to outwardly grieve losses with tears or overt emotional expression of sadness. American heroes such as the characters that John Wayne, Clint Eastwood, and Steven Segal portray in film are more likely to show a stiff upper lip and a stoic expression following the deaths of companions. The deaths will likely be avenged in a violent manner, reinforcing a stereotype of men who channel emotional pain into anger.

Freud (1917/1957), in his paper “Mourning and Melancholia,” suggested that depression is an affective state related to object loss through death or separation. Through the process of introjection, the lost object or person is retained as an emotionally charged intrapsychic representation incorporated into the self. Identification occurs when the individual modifies his self-image in accordance with certain characteristics of the lost object.This process serves to internally recapture the lost person. Subsequent ego psychologists speculated that the experience of depression is actually an identification with the depressive affect of the lost object. Abraham (1911/1948) and Freud (1917/1957) both believed that the lost object is often ambivalently loved. While the individual introjects the good and bad characteristics of the person into his own ego, he is also extremely angry at the lost love object for abandoning him. Anger aimed at the object of loss is directed inward in a punitive manner, resulting in self-condemnation, a wish to die, and in dramatic situations, an active suicide attempt. Klein (1959/1975) suggested that all children go through a phase of extreme rage toward their parents for not meeting their needs, resulting in what she called the “depressive position.” The depressive position is a mood state resulting from feelings of guilt following the child’s angry outbursts. The child fears that these outbursts have damaged his real relationships resulting in abandonment and a vulnerable state.

For men at midlife, the death of a parent typically precedes a period of personal turmoil, transition, and a deeply felt sense of one’s mortality. For aging men, the loss of one’s lifetime partner is perhaps the most stressful life event. This loss has been found to result in a significant decline in a man’s psychological and physical health. Changes in life routines, decision-making processes, and social support add stress to a man already shocked by the death of his companion. The death may also complicate adjustment to the occupational role change of retirement. Deaths other than that of a spouse or partner have also been found to be as devastating to an aging man’s health. Although the research literature is limited, the death of a parent, child, sibling, or close friend also has a severely destabilizing impact on the psychological health of the older man. The main factor found to mediate the impact of grief for an older man is social support. Those men who have more friends and social networks are less likely to be as psychologically and physically impaired. For gay men whose partners and friends died during the AIDS epidemic, research suggests that the number of losses, as well as one’s HIV status, are predictors of psychological distress, depression, anxiety, and substance abuse.

For many men who have adopted the traditional male gender role, grief is extremely uncomfortable. There is a sense of impotence, frustration, and self-blame that accompanies loss. Women in western culture are more comfortable with the depressive position, perhaps viewing it as a natural consequence of emotional attachment. Men prefer to avoid or suppress the depressive affect that accompanies separation and loss since it exposes vulnerability and perceived weakness. A common strategy employed by many men experiencing loss and grief is to split off this affect and focus on external activities that are rational, practical, or goal directed. This masculine way of grieving serves to bolster those socially sanctioned behaviors, values, and norms that comprise traditional masculine coping styles and afford men a sense of control. While most practitioners encourage men in grief to find social support and safe places to tell their stories and express feelings, most men are uncomfortable seeking help, even in this situation . Sadly, grief for many men remains an unspoken, hidden experience.

Clinician Query — “A bunch of twisted demons inside.”

Lyle, a 51-year-old divorced man, arrived for psychotherapy at the urging of his sister, with whom he lives. Lyle, who is 5 feet 10 inches tall and weighs 325 pounds, has not worked in five years because of physical ailments that have rendered him disabled. Lyle had been a successful attorney for 20 years, specializing in product liability issues for a large law firm. Seven years ago, his wife of 15 years left him for another man. He was involved in a serious car accident approximately two months after she left. This accident left him with chronic back pain and migraine headaches. Lyle had been arrested two times for assault after getting into fights at a local tavern that he frequents. Although he did not serve time in jail, he was put on probation and is still under the jurisdiction of the court.

Lyle was severely beaten by his stepfather as a child, but has tended to diminish the significance of this. “What’s done is done. My father was an alcoholic who didn’t know what he was doing. It just made me tough,” he commented. Both of Lyle’s children are adults who live out of state and have no contact with their father.

“I wish he would just lay off me. That probation officer I have to report to is such a weenie. I think he believes I’m just a common criminal. He doesn’t seem to believe that at one time I earned five times his puny salary,” Lyle complained in an early therapy session.

“You feel like he doesn’t really understand you,” paraphrased his therapist.

“I find very few, if any, people in this world who do understand me,” Lyle replied.

“I wonder if you feel like I understand you.”

“You’re paid to understand me.You are a bit like a whore, but I forgive you,” Lyle joked, laughing to himself.

“Seriously. I sense that you don’t trust me with most feelings other than anger,” his therapist persisted.

“That’s pretty accurate, doc. No one gets inside here, not even me most of the time,” he said, pointing at his large belly.

“What do you think I might find if I did get in there?” queried his therapist.

“A bunch of twisted demons, I reckon,” Lyle responded.

“Twisted demons?”

“Oh, yeah. They would just torture you with their threats and confuse the hell out of you with their logic,” Lyle replied, his eyes going cold, his face rigid.

“Where do the demons come from?” asked his therapist.

“They probably were born some time during one of my fathers beatings, I guess. He used to beat the shit out of me for no good reason. Maybe I deserved it, who knows?”

“You really believe that you deserved to get the shit beat out of you?”

“Damn right, partner. If I didn’t show him the respect he asked for, I took the blows. Problem was, I didn’t always know what kind of respect he was looking for. The bastard, he was drunk most of the time I interacted with him,” he replied with an empty laugh.

“You seem like you are proud of yourself for how much pain you could take.”

“Right again. There is no way for you to know how much I can take. I oudasted him. He’s under ground and I’m still here,” Lyle gloated.

“I guess I’m confused. If you’re so strong, why are you here with me?” his therapist asked, confronting Lyle’s grandiosity.

“I told you before. It’s the damn demons. I want to care about people, my kids, my sister. But I get so disheartened. Everyone doesn’t want to see how screwed up this culture is. Why can’t an intelligent man like me find some use for myself out there? It’s enough to make you want to give up. What’s the point? You let me know that and we can end this therapy.”

“Lyle, you seem strong on the outside, but the demons are eating you up right now. What do you say we take a good, hard look at those demons and see if we can find a way to beat them?”

“Good luck.”

•  What role does childhood physical abuse have in the manifestation of depression in adult men?

•  What clues of depression are present in this case and in other cases in which anger is a prominent affective state?

Biopsychosocial models of depression emphasize a complex interplay of biological and genetic vulnerability, psychological mechanisms, and behavioral tendencies shaped by social and cultural norms. Within this framework, many have speculated that mood disorders are frequently masked by various physical and behavioral phenomena. Alexithymia, literally, “without words,” is thought to be related to the masking of mood difficulties that are unable to be expressed via language. Such masking, termed “masked depression,” “depressive equivalent,” or “covert depression,” can be defined using an exclusive or inclusive approach. The exclusive approach seeks to discover depression underlying only vegetative, somatic, or physical complaints. The inclusive approach considers a wider spectrum of problems, including alcohol and substance abuse, delinquency, anger and aggressive behavior, accidental injuries, and self-injurious behavior. In comparison to women, men are more likely to be perceived and identified as less verbally expressive, less psychologically oriented, and less willing to acknowledge emotional distress.The masking of depressed mood may be a “face-saving” strategy for many men, who are less skilled at emotional expression and more bound to societal expectations of masculinity.

Empirical support for the construct of masked depression is mixed, owing to difficulty operationalizing this construct and to its exclusion from formal diagnostic and research categories. Case reports in the literature have indicated success in treatment of anger associated with depression and of alexithymia associated with depression in a Holocaust survivor. In a study of 46 boys manifesting antisocial behavior, 39 were found to report significant depressive symptomatology, lower self-esteem, higher levels of guilt, and greater cognitive problems compared with those who did not manifest an underlying depression. Stoudemire, Kahn,Brown, Linfors, and Houpt (1985) found that of 212 patients in a combined medical — psychiatric unit, 17% were diagnosed as depressed on admission, while over 50% received a diagnosis of depression after a thorough psychiatric evaluation. The depression in these patients was manifest at time of admission mainly by somatic complaints that were not expressed directly through verbal means. Other conditions hypothesized to have complex depressive — vegetative components include insomnia, heart disease, and chronic pain. Such findings, on the other hand, raise questions concerning the validity of this construct. Nevertheless, cultural conditioning and internal psychological prohibitions that result in men’s suppression of painful, sad, or guilt-laden emotional states suggest that depressed mood may be masked by men in many situations and circumstances. The construct of masked depression is, thus, useful in fully understanding the phenomenon of male depression in all its various manifestations.

Overtly avoiding or repressing feelings of loss, guilt, and depression may lead to indirect behavioral or somatic manifestations of the denied emotional states. Cumulative effects of loss, trauma, and grief impact even the healthiest of men. It is still considered taboo in many circles of our society for men to acknowledge their inner pain. Men who follow traditional male gender-role norms have been found to experience higher levels of emotional distress but a decreased likelihood for seeking psychological help, in general, as well as for depression in particular. While men have a tendency to avoid primary healthcare settings, it is sometimes more acceptable for a man to seek help for physical pain than psychological pain. Approximately 12-35% of individuals seeking relief in a primary care medical setting for somatic complaints are thought to be significantly depressed. An empirical study utilizing depression questionnaires showed that physicians missed more than 95% of the cases of depression when depression is not self-reported. Many men who are depressed may seek help from primary care physicians for physical problems.

One study of two groups of individuals who had equal levels of anxiety, identified either as somatizers or psychologically minded, found that the somatizers were less likely to report feelings of depression than were those with a more psychological orientation. The authors suggest that somatization functions as a defense against personal responsibility for life predicaments. Those who somaticize can project their troubles onto something physical or outside of themselves and avoid internal self-blame. This process functions similarly to the male gender-role socialization pattern, whereby men disavow psychological weakness in order to appear in control and avoid shame. Such a process makes it extremely probable that men will detach, disassociate, and displace emotional distress, resulting in what a number of authors have termed depressive equivalents or masked depression .

Somatization functions as an equivalent outlet for the recognition and expression of emotion. However, without the mental awareness of what is bothering him, a man will find that his body repeats its outlet of expression, resulting in his noticing a somatic area of anxiety or pain (i.e.. racing heart rate, migraine headaches, lower back pain). Even for men conscious of their bodies, it is not unusual for a man to engage in some sort of physical activity that leads to injury or negative consequences during a period of stress, worry, or loss. Several theorists have suggested that the body and mind could not be separated, that all somatized symptoms, injuries, and diseases were connected to both external and intrapsychic events.

In addition to these speculations on the vicissitudes of repressed emotion, a common theme from the psychoanalytic literature on somatization is the connection between loss and depression. Winnicott (1936/1978) found that many of the children he treated for eating disorders were experiencing anxiety and depression from the earliest days of life. A syndrome identified as anaclitic depression was found to emerge within four to six months after a child separated from his or her mother or caregivers. Symptoms of anaclitic depression included withdrawal, sadness, lack of physical growth, anorexia, weight loss, insomnia, and psychomotor retardation. Spitz (1951) suggested that the psyche and somatic systems are actually merged as one and form an ego structure that allows for psychic discharges through the body.

Winnicott (1960/1965) hypothesized that persons who had to adapt to inconsistent or abusive parenting were forced to split emotional experiences from their bodies and create a false self that complied outwardly with parental wishes and demands. For a man with this experience, the body may speak an emotional truth that is nothing like the reality to which he has adapted. Somatization may be his only way of self-expression, revealed to himself and others as a physical symptom such as overeating, high blood pressure, excessive sleeping, chronic back pain, or difficulty concentrating.

The Kleinian object-relations focus on the depressive position may offer an understanding of why men may have a difficult time tolerating depression. Most men have been able to tolerate depression as children. However, the male gender role reminds boys and men that they are not to show weakness or vulnerability, characterized by the longing and sadness of the depressive position. The forgotten trauma of separation from mother makes boys and men unconsciously sensitive to depressive affect.

For some men, the acting out of aggression, one of the few acceptable forms of emotional release, may be conceptualized as a cathartic expression of sadness, grief, or depression. While a man may feel some sense of relief following an aggressive action, there are few places where this behavior is acceptable. The exceptions for this emotional outlet are aggressive sports and physically active forms of psychotherapy. Unfortunately, the recipient of a socially inappropriate aggressive act is typically a person the individual knows or with whom he is intimate. Although there may be immediate relief, the likely overriding emotional response for the sensitive man will be self-blame, self-hatred, and a repetition of the cycle. Thus, for men who grieve through aggression, there is likely to be a further internalization of self-criticism and a propensity toward withholding any type of emotional reactivity until the internal pain is again unbearable. Is it possible that certain types of aggressive actions in men may be disguised loss or grief reactions? Other men who have more fully disconnected from their empathic connection to others may find that aggression is an adaptive way of life that allows them to meet basic needs and externalize their huge reservoir of pain, betrayal, loss, and humiliation.

Another form of masking depressive mood states is mood alteration through alcohol, drugs, or other addictive activities. We know that men suffer from alcohol and drug abuse in significantly greater numbers than women. Could the dramatically higher rates of alcohol and other drug abuse and dependence in men represent this masking on a large scale? In order to calm feelings of impotence, anger, and self-reproach brought on by trauma or loss, biochemically adjusting mood in a predictable manner allows a man to regain an illusion of control and power in his emotional life. At the first sign of discomfort, a man can change his body’s biochemistry in a direction he finds desirable at the time. Such activity is consistent with the traditional male gender role that emphasizes strength, power, and control. In the short run, this may relieve his pain and provide a false sense of wholeness. However, most men keep the long-term consequences of this lifestyle out of conscious thought. The man who reaches for a cigarette is not worried about his unconscious self-destruction nor is the man who drinks beer to anesthetize negative feelings aware of how he is avoiding the sources of his frustrations. With more potent narcotics such as heroin or cocaine, men are even more removed from their internal psychological reality, masking impotence with an illusion of power. More socially acceptable addictions, such as work, gambling, or sex, also serve the same function for many men as drugs, altering body chemistry, diverting thoughts and feelings about inner conflict, and minimizing awareness of the effects on others. It is no wonder that some men unconsciously choose various types of addictions to avoid shameful and depressing feelings.While the addiction may have originated as a means to cope with depression and reduce anxiety, it often tends to exacerbate the condition, leading to more severe cycling of depressive affect when not engaged in the addictive behavior.

Researchers have focused specifically on the quality of the marital and romantic relationships of depressed individuals to better understand the role of interpersonal factors in the onset, maintenance, and recurrence of depressive symptoms. This focus is warranted for several reasons. First, there is converging evidence for a robust cross-sectional association of marital distress and depression across different populations (e.g., clinical and subthreshold depression) and different assessment methods (e.g., self-report vs. interview). There is also evidence suggesting that depressed individuals’ interpersonal problems and difficulties are most likely to manifest in their interactions with significant others. Furthermore, living with a depressed spouse has been associated with negative outcomes for the non-depressed spouse.

The strong association between depression and marital distress has prompted researchers to investigate whether the two variables are causally related. Efforts to elucidate the longitudinal association between depression and marital dysfunction should be informed by epidemiological data on the prevalence and course of depression and marital dysfunction. Notably, epidemiological findings suggest that age of onset of depression is decreasing, whereas the age of first marriage is increasing. Thus, for most depressed individuals, their first episode of depression will precede their marriage, suggesting that most of the research on the longitudinal association between depression and marital distress is appropriately conceptualized in terms of the link between marital dysfunction and depression maintenance and recurrence, rather than incident (first episode) depression. With respect to understanding how marital variables influence the course of clinical depression, evidence suggests that depressed individuals in unhappy marriages recover less quickly from a depressive episode and are more likely to experience a relapse in their depressive symptoms. Thus, overall, disruptions in the marital relationship appear to maintain, exacerbate, and lead to a recurrence of depressive symptoms.

Although there is empirical support for the position that marital distress adversely effects the course of a depressive episode, there is also evidence that depression temporally precedes declines in marital quality. Thus, studies examining the prospective, longitudinal association between depression and marital distress have produced inconclusive results. One potential reason for the discrepant findings is the methodological difference across the studies. However, other theorists have argued that determining the temporal primacy of depression or marital dysfunction is not the most relevant or fruitful line of inquiry. Rather, it is possible that marital dysfunction and depression exert bidirectional, reciprocal influences with changes in one variable both preceding and following changes in the other variable. To explore this possibility, more recent longitudinal studies have used multiwave designs, as opposed to a two-wave design, and have employed statistical tools that are designed to measure within-couple changes over time. These studies have found support for such a doubly developmental perspective.

The association between marital distress and depression does not inform us about the mechanisms by which marital dysfunction leads to depression, and vice versa. To answer this question, an important line of research has compared the interpersonal behaviors of couples with a depressed partner to couples where neither partner is depressed. Across numerous studies, the evidence suggests that marital interactions of couples with a depressed partner are reliably more negative than the marital interactions of non-depressed couples. However, it is unclear whether these findings are specific to depression or whether the observed behaviors are nonspecific markers of a troubled interpersonal milieu. More promising results have emerged from research that has used interpersonal theories of depression to focus on theoretically derived, depression-relevant behaviors. For example, consistent with Coyne’s (1976) interactional theory of depression, Joiner and colleagues found evidence that a dependent interpersonal style, characterized by excessive reassurance-seeking from others in the social environment about one’s value and worth, represents a specific vulnerability factor for future depressive symptoms. Joiner and colleagues have further integrated Coyne’s interactional model with Swan’s self-verification model, which posits that individuals seek to maintain their self-concepts and, to do so, solicit feedback that is consistent with their self-views, even if their self-views are negative. By using an integrative framework that combined key elements from both of these perspectives, Joiner and colleagues have found that depressed individuals simultaneously solicit reassurance from others about their worth, while engaging in behaviors that confirm their negative self-views, thereby generating interpersonal processes that frustrate others and contribute to their own ongoing distress. In a similar vein, empirical tests of Hammen’s (1991) stress generation model of depression demonstrate that depressed individuals can unwittingly play an active role in the chronicity of their symptoms through their interpersonal interactions.

Increasingly, theorists are developing models that integrate different interpersonal perspectives on depression as well as models that integrate interpersonal and cognitive perspectives. This focus acknowledges the complexity and heterogeneity of depressive disorders by recognizing that it is unlikely that one level of analysis — be it intrapersonal or interpersonal — is sufficient to explain the progression of depressive illness. Furthermore, within the interpersonal level of analysis, marital dysfunction is only one, though a vital, pathway to consider.

As knowledge of the marital context of depression has evolved, the clinical implications of the high comorbidity between depression and marital dysfunction have also been investigated. A number of well-controlled clinical trials have compared the efficacy of marital therapy versus individual therapy when both depression and marital distress are present. Based on their review of all relevant outcome studies, Beach, Fincham, and Katz (1998) conclude that the current evidence suggests that when depression occurs in the context of marital dysfunction, marital therapy may be preferred over individual treatment, as it has been demonstrated both to improve symptoms of depression and to improve marital quality, whereas individual depression treatment has been found only to improve symptoms of depression. The authors caution, however, that marital therapy may be most appropriate for those couples who view marital problem as preceding the onset of depression and who report significant marital difficulties.

Conclusions

Depression occurs within an interpersonal context, substantially alters that context, and is, in turn, altered by it. There has been a burgeoning of research examining marriage and depression, beginning with seminal studies demonstrating that depression and marital dysfunction are strongly associated. More recent work sheds light on the nature of this link. The quality of depressed individuals’ romantic relationships influence the course of their depressive symptoms, with individuals in distressed relationships recovering less quickly from an episode of depression and more likely to relapse than those in nondistressed relationships.

See also

Interpersonal Model of Depression

Marital Therapy

Stress Generation

Childhood maltreatment, including physical abuse, emotional maltreatment, sexual abuse, and neglect, has long been implicated in the development of depression in children, adolescents, and adults. Child maltreatment places individuals at markedly elevated risk for the development of major depressive disorder, depressive symptomatology, and dysthymia. Child maltreatment has also been related to higher likelihood of a relapse after an initial remission of depression. Studies have consistently found high prevalence rates of depression among individuals with histories of child maltreatment. For instance, one study found that, among non-clinically referred samples of protective services cases, 18% of preadolescents and 40% of adolescents with histories of child maltreatment met the diagnostic criteria for major depressive disorder. In general, compared to their nonmaltreated counterparts, individuals with histories of childhood sexual abuse or physical abuse exhibit more symptoms of depression and anxiety, higher attempted suicide rates, and earlier onset and more chronic levels of depression.

Various mechanisms have been proposed to explain the association between maltreatment and depression, including the following: (a) quality of the mother-child attachment relationship, (b) low social support in the context of highly stressful life events, (c) attributional styles, (d) social competence, (e) self-esteem, and (f) neuroendocrine and neurotransmitter dysregulation. These factors can be broadly categorized as psycho-social and neurobiological mechanisms by which childhood maltreatment leads to depression. One of the predominant perspectives in describing the psychosocial mechanism is that children who experienced maltreatment are likely to develop negative representational models of attachment figures, self, and self in relationship to significant others. Maltreated children often show insecure attachment relationships and negative self-images, which lead to the emergence of depressive symptoms. The effects of maltreatment on depression also appear to be mediated through social support and stress. Individuals with maltreatment histories tend to have smaller support networks, to be less satisfied with their supportive networks, and/or to perceive their relationships as less supportive. Perhaps this is because maltreatment affects children’s cognition regarding themselves and others. It may also be the case that maltreated children have smaller actual support networks due to dysfunctional family environments. Besides having impaired social support, individuals with maltreatment histories are more susceptible to daily stressors and report more stress compared to their nonmaltreated counterparts. They may perceive life events as more stressful because of a predisposition to a sense of helplessness. A lack of coping skills may also contribute to this process.

The growing interest in the neurobiological effects of childhood maltreatment on later adjustment adds significant insight into the neurobiological processes in the association between maltreatment and the development of depression. Currently, the effects of maltreatment on depression are believed to be mediated by the central nervous system. Childhood maltreatment experiences may cause long-term changes in the brain regions that mediate stress and emotion regulation, leading to altered emotional processing and heightened responsiveness to stress, which may be associated with psychiatric disorders such as depression (Heim et al., 2004). Recent research has shown evidence that the higher vulnerability for depression among maltreated children may be closely related to stress-responsive neurobiological systems. One major stress-response system that has been closely examined in depression is the hypothalamic-pituitary-adrenal (HPA) axis. Several brain pathways modulate HPA-axis activity, and disruptions in these neural circuits stemming from maltreatment may lead to altered stress reactivity and to the emotional, cognitive, and vegetative changes often found in depression.

Additional factors have been proposed to moderate the effects of maltreatment on depression. Differential effects of specific subtypes of maltreatment on depression have been observed. Some researchers have argued that childhood emotional abuse, compared to physical or sexual abuse, has a stronger association with hopelessness depression among young adults. Other researchers have argued that psychological abuse, compared to physical abuse, sexual abuse, physical neglect, and exposure to family violence, is the most prominent predictor of adolescents’ internalizing problems. However, it is important to note that most maltreated children experience more than one form of abuse and neglect, though the effects of such multitype maltreatment on depression have not been well studied.

Another important factor in the association between maltreatment and depression is gender. Some researchers have suggested that, compared to their male counterparts, women with maltreatment histories are more vulnerable to the development of depression. However, little is known about gender differences in the mechanisms of risk and protection. Besides gender, factors such as genetic variations, family environment, and ongoing stress have all been shown to influence the effects of maltreatment on the development of depression.

The high frequency of depression in maltreated individuals suggests that depression screening should be part of any standardized assessment protocol in this population, with follow-up treatment and monitoring for those who appear to be manifesting depressive symptoms. Similarly, individuals being treated for depression should be evaluated for prior maltreatment as a possible etiological factor, with maltreatment being addressed in the context of psychotherapy as needed.

See also

Early Adversity

Parenting

Stressful Life Events

The notion that painful life experience is critically linked with depressive illness is in no way new. On the one hand within orthodox psychiatry, well before World War II, despite acknowledgment that many depressions were endogenous (and thus presumed biological), there was also the accepted notion that just as many were reactive to circumstances. On the other hand, Freud’s insights in his “Mourning and Melancholia” (1971) show how the experience of loss as a candidate to explain depression was also already current on the other side of the ideological divide, in psychoanalytic circles. By the 1960s the notion of hopelessness and/or helplessness as central to the depressive experience had gained prominence in many schools of thought. The founder of cognitive behavioral therapy had embodied it in his famous cognitive triad — that the self seems worthless, the world seems pointless, and the future hopeless; animal research had charted the process of “learning helplessness” through entrapping experiences; and it was but a step for those with a psychoanalytic background to highlight the link between these feelings and loss.

Around this time Brown and Harris were developing an approach to the measurement of stressful life events that aimed to capture the “meaning” of these experiences. Following the insights of Schutz about verstehen, they elaborated rules for greater understanding of each event by taking account of its context. Thus the meaning of discovering a pregnancy will vary according to whether the woman has planned it, whether she already has children, whether her financial and housing circumstances are adequate, whether she will have good marital and other family support, and whether she has a health history of difficult pregnancies. In a study in Camberwell, South London, Brown and Harris compared depressed psychiatric patients at the local hospital with a representative sample of the general population (published later in 1978). Seventeen percent of this community was found to be suffering depression at a severity comparable to outpatients (a threshold later verified as close to the major depression of the American Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association, 1994]). Those with depressive onset reported significantly more severe events or events judged likely to be experienced as highly distressing by others in similar biographical circumstances. Over ensuing decades these probabilistic standards of severity have been embodied in detailed manuals of anchoring examples collected from over 100 studies in varying cultures, with consequent high interrater reliability. But it was this early study that already revealed that the events preceding depression particularly involved loss, either of person, role, object, or cherished idea, such as the idea of one’s child’s honesty or spouse’s fidelity. While it is easy to appreciate that a loss of income consequent upon unemployment may be as devastating as a bereavement, particularly if the respondent also loses his key role as provider for the family, the notion of lost cherished ideas gave a new slant on the meaning of depressogenic events. Other examples have involved a respondent discovering he was adopted and that his parents had thus lied about his birth origins, discovering a brother had sexually abused a sister, finding a son was a transvestite. The exploration of these narratives revealed types of loss that differed from the context of simple bereavement and mourning, or loss of role, because of the overtone of secrets and lies, that the self was not only left behind or abandoned, but somehow devalued, if not positively rejected. It was, however, only after another decade of work on prior vulnerability to depressogenic events, and in particular on low self-esteem, that Brown and Harris introduced ratings of humiliation as a refinement to the concept of loss.

Humiliation or Entrapment and Depressive Onset

Reworking qualitative data on individuals’ experiences of stress in the light of the threefold greater vulnerability to depression of those with initial negative self-evaluation brought new insights. First it emerged that after losses of close relationships due to separation, onset of depression was more than 4 times more common if the separation was initiated by the other person than if the respondent had been the source of the breakup. It became clear that the loss of the other person was not per se the crucial element: rather some implication about the acceptability of the self implied by whether or not one had the separation forced upon oneself. Later refinement identified experiences of humiliation or entrapment as particularly prominent before depressive onset among the losses of cherished idea. Apart from deaths, those losses that did not involve humiliation — for example redundancy and temporary unemployment as a result of a large firm going bankrupt, a loss for which

the interviewee would therefore not be held to blame — were followed by a much lower rate of depressive onset (13% as compared with 31%). The match between the shamefulness of such events and the shame felt by people with low self-esteem, whose vulnerability to depression was already acknowledged, encouraged a perspective akin to that of Gilbert’s insights about shame and depression and akin to evolutionary theory, with its challenging notions that depression has proved a condition of great functional benefit for the survival of the human species.

Regaining Lost Hope: Fresh Start Experiences and Remission From Depression

A final insight about loss comes from the investigation of the meaning of those fresh start experiences that, more often than not, preceded depressive remission. Although all this data was collected retrospectively, the time order between these and remission, and the high proportion of such events that were independent of the subject’s agency, lent plausibility to this being the effect of the environment on pathology. It seemed fresh starts were the mirror image of those producing the generalized hopelessness of Beck’s depressive cognitive triad. They either involved events such as starting a new job after months unemployed, starting a course after years as a housewife, establishing a regular relationship with a new boyfriend or girlfriend after many months single, or the reduction of a severe difficulty, usually with interpersonal relationships, housing, or finance. They seemed to embody the promise of new hope against a background of deprivation. It was notable that even for women who continued to experience difficulties of a depressogenic severity in one life domain such as marriage, a fresh start in another life domain — starting an access course — often seemed to tip the balance and set them on course for remission.

Conclusions

It is important to emphasize that this work on the losses preceding depression has been done in parallel with explorations of people’s vulnerability to their impact. Low self-esteem has already been mentioned in this connection, but work on the protective effect of emotional support from a close other in coping with the loss, and on increased vulnerability stemming from childhood experiences of abuse and neglect — themselves prime examples of loss and humiliation — substantiate the perspective that central to depression is the sense of a depleted self.

See also

Bereavement

Interpersonal Model of Depression

Interpersonal Psychotherapy

Many patients with depression, like those with posttraumatic stress disorder (PTSD), experience unwanted memories of one or more significant events in their lives that intrude frequently into their minds. These memories are vivid, distressing, absorbing, and associated with intense negative emotions. Most research has concerned unipolar depression, but recent research suggests intrusive memories are also a feature of bipolar disorder. In studies to date, the proportion of depressed unipolar patients reporting intrusive memories has varied from 44% to 87%. Typically, frequency of intrusions (and the amount of effort put into blocking them out) is related to depression severity, so that intrusions are more likely to be a feature of severe depression.

The first systematic study of intrusive memories focused on memories of child abuse in depressed female patients. Intrusions were more likely when the abuse had been more severe. Typical features of depressive cognition such as lower self-esteem, a more negative attributional style, and the use of avoidant coping were strongly related to the amount memories of this abuse intruded. In contrast they were much less strongly related to the simple fact of whether or not abuse had occurred. This suggests that a lot of depressive thinking may be fuelled by the presence in the consciousness of repeated reminders of sad, frustrating, or humiliating events, rather than by depressed mood itself. Consistent with this idea, high levels of intrusive memories were found to be associated with low self-esteem regardless of how depressed patients were.

Kuyken and Brewin (1995) also found that greater attempts to avoid intrusive memories of abuse were related to overgeneral memory recall on the Autobiographical Memory Test (AMT). Overgeneral memory is another well-established feature of depressive thinking whereby the depressed struggle to recall specific autobiographical events in response to cue words such as happy or lonely. This finding of a link between intrusive memories and overgeneral recall has since been replicated a number of times. One possible explanation is that the effort involved in avoiding intrusions reduces the available capacity to perform the Autobiographical Memory Test. Another is that overgeneral memory recall is a defensive strategy designed to prevent the retrieval of upsetting personal memories. Both these explanations have been discussed in detail by Williams and colleagues (2007).

Subsequent research has investigated whether intrusive memories are really a product of depression or simply of being exposed to a large number of upsetting events. It has been shown that intrusive memories are much more frequent in people who are depressed than in individuals exposed to a similar number or type of stressors. Further, the intrusions are not a permanent feature of vulnerable individuals but begin with or are exacerbated by an episode of depression. Critically, the presence of frequent intrusive memories has been found to predict the course of the disorder even when initial symptoms are controlled for. These findings suggest not just that intrusive memories are centrally involved in the experience of depression, but that they can be an important maintaining factor.

Since then we have learned that whereas intrusive memories of personal illness, injury, or assault are somewhat more common in posttraumatic stress disorder, memories of death, illness, or injury to family members, and memories of interpersonal problems, are more common in depression. Although intrusive memories tend to be somewhat less common and less intense in depression than in posttraumatic stress disorder, when they do occur they are equally distressing, and there are few qualitative differences between them. For example, both groups tend to report some degree of reliving past experiences, as well as accompanying physical sensations. Whereas intrusions in depression are usually experienced as ordinary autobiographical memories that belong in the past, in posttraumatic stress disorder they are more likely to have a “here and now” quality (“flashbacks”) and be linked to an out-of-body experience. These differences are probably due to the fact that, compared with depressed patients, posttraumatic stress disorder patients experience higher levels of dissociation, resulting in distortions of time and place that are reflected in their intrusive memories.

Recent evidence suggests that intrusive memories in depression are often part of a network of related representations. In Patel and colleagues’ (2007) study, just over half the patients in the sample who received psychological treatment reported experiencing additional intrusive memories, as their original, main intrusion began to subside. The number of new memories ranged between two and three, with the thematic component being similar to the dominant intrusion. For example, two patients reported childhood sexual abuse as their main intrusion. During treatment both patients reported experiencing additional intrusive memories of incidents of teenage and/or adult sexual abuse, intrusions that had not been present during the original assessment. This emphasizes that single assessments may not capture all aspects of a memory network associated with a depressive episode.

The observations concerning intrusive memories in depression are consistent with the claims of many social psychologists that knowledge about the self does not just exist in a generalized, semantic form (cf., trait knowledge about the worthlessness of the self), but in the form of episodic memories of specific autobiographical events. Such events (e.g., a child being told by a parent that he or she was not wanted) may form “turning points” that help to define or provide evidence for the conclusions about the self at which depressed patients may have arrived. Thus, asking about intrusive memories can furnish important clues about how the person’s history is related to current depressive symptoms and negative styles of thinking.

Apart from their theoretical importance in understanding the nature of negative self-representations in depression, the presence of intrusive memories suggests that novel forms of therapy such as imagery rescripting may be relevant to a subset of depressed patients. Imagery rescripting involves having patients focus on the contents of their intrusive memory and imagine an alternative, more positive outcome that they have previously generated and rehearsed with their therapist. Typically this involves a strong sense of mastery or compassion that replaces feelings of helplessness or shame associated with the memories. In contrast to standard cognitive-behavioral methods, rescripting can be implemented purely through imagery and without any cognitive challenging of negative beliefs or behavioral experiments. A recent article describes two patients with major depressive disorder who were successfully treated with a short course of imagery rescripting and remained well at 1 year follow-up. Rescripting produced a rapid and powerful experience of increased positive affect that arguably would have been difficult to achieve using traditional methods.

See also

Memory Processes

Posttraumatic Stress Disorder

Interpersonal Psychotherapy (IPT) is a time-limited psychotherapy specified in a manual and tested in numerous clinical trials that have established its efficacy. Initially developed for adult patients with depression, it has been adapted for adolescents and the elderly with depression, medical patients, and pregnant and postpartum depressed women, and for dysthymia and bipolar depression. It has been tested as acute and as maintenance treatment for depression. The most exciting recent work has been the successful adaptation and testing in Uganda for adults and adolescents with depression. Interpersonal Psychotherapy has been translated into French, German, Italian, and Spanish. International training and studies are ongoing in China, Japan, Goa, Thailand, United Kingdom, Spain, Sweden, Ethiopia, and numerous other countries. There is an International Society of Interpersonal Psychotherapy (www.interpersonalpsychotherapy.org/). Designed for administration by experienced and trained mental health professionals including physicians, psychologists, social workers, and nurses, it can also be taught to less-trained persons. Interpersonal Psychotherapy has been used with and without medication. The primary example of Interpersonal Psychotherapy presented here illustrates the treatment of patients with major depressive disorder because that is its best-established and most widely employed use.

Interpersonal Psychotherapy is built on the idea that the symptoms of depression have multiple causes, genetic and environmental, but the symptoms do not arise in a vacuum. Depressive symptoms are usually associated with something going on in the patient’s current personal life, usually in association with people they feel close to.

Some common events include the following:

• A marriage breaks up.

• A dispute threatens an important relationship.

• A spouse has an affair.

• A job is lost or in jeopardy.

• A move to a new neighborhood is made.

• A loved one dies.

• A promotion or demotion occurs.

• A person retires.

• A medical illness is diagnosed.

Understanding the social and interpersonal context of the development of the depression may help to unravel the immediate reasons for the symptoms. This can be the first step in helping the patient to understand depression as an illness and to develop new ways of dealing with people and situations. Developing these new social skills may help treat the current episode and reduce future vulnerability.

The IPT therapist views depression as having three parts:

1. Symptoms. The emotional, cognitive, and physical symptoms of depression include depressed and anxious mood, difficulty concentrating, indecisiveness, pessimistic outlook, guilt, sleeping and eating disturbances, loss of interest and pleasure in life, fatigue, and suicidality.

2. Social and Interpersonal Life. The ability to get along with other important people in the patient’s life (e.g., family, friends, work associates). Social supports protect against depression, whereas social stressors increase vulnerability for depression.

3. Personality. There are enduring patterns with which people deal with life: how they assert themselves, express their angers, maintain their self-esteem, and whether they are shy, aggressive, inhibited, or suspicious. These interpersonal patterns may contribute to developing or maintaining depression.

Some therapists begin by trying to treat a person’s personality difficulties and see personality as the underlying cause of depression. The IPT therapist does not try to treat personality and, in fact, recognizes that many behaviors that appear enduring and lifelong may be a reflection of the depression itself. Patients may seem dependent, self-preoccupied, and irritable while depressed, yet when the depression lifts, these supposedly lasting traits also disappear or recede.

The thrust of Interpersonal Psychotherapy is to try to understand the interpersonal context in which depressive symptoms arose and how the symptoms relate to the current social and personal context. The IPT therapist looks for what is currently happening in the patient’s life (“here and now” problems) rather than problems in childhood or the past.

Progress in genetics and the neurosciences has made psychotherapy an even more important therapeutic tool in psychiatry. Psychiatric disorders are genetically complex syndromes, comparable to diabetes and hypertension, in which genes and environment are both important and interact. The genotype, influenced by the environment, is expressed in the phenotype (the clinical picture).

For psychiatric disorders, the most important environment consists of close personal attachments. These connections, their availability, and their disruption (or threat of disruption) can powerfully influence the emergence of symptoms (phenotype expression), especially in genetically vulnerable individuals. Situations in which these disruptions can be found and where symptoms may erupt have been defined as the focal problem areas in Interpersonal Psychotherapy:

• Grief (complicated bereavement)

• Interpersonal role disputes

• Interpersonal role transitions

• Interpersonal deficits (paucity of attachments)

Interpersonal Psychotherapy is used with patients who develop symptoms in association with these situations. Genetic vulnerability cannot be readily altered, but the environment can. Symptoms can improve with the clarification, understanding, and — especially — handling of these interpersonal situations associated with symptom onset. Psychotherapy can be crucial to this change. Evidence has shown that this paradigm works for major depression in patients of all ages.

A Brief Outline of Interpersonal Psychotherapy

Initial Sessions

Throughout these sessions, the therapist simultaneously works to establish a positive treatment alliance: listening carefully, eliciting affect, helping the patient to feel understood by identifying and normalizing feelings, and providing support, encouragement, and psychoeducation about depression.

Diagnosing Depression

Review the depressive symptoms or syndrome. Assist the patient’s symptoms and their severity. Use the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994) to help the patient understand the diagnosis. Use a scale such as the Hamilton Depression Rating Scale or the Beck Depression Inventory to help the patient understand the severity and the nature of his or her symptoms. Explain what the score means, and alert the patient that you will be using the scale regularly to see how treatment is progressing.

Give the syndrome a name: “You are suffering from major depression.”

Explain depression as a medical illness, and explain its treatment. Depression is a treatable illness, and not the patient’s fault. Despite its symptom of hopelessness, depression has a good prognosis.

Interpersonal Psychotherapy is a time-limited treatment that focuses on the relationship between interactions with other people and how the patient is feeling. The patient will be meeting for X weekly sessions (define the number), and the patient has a good chance of feeling better soon.

Give the patient the “sick role”: “If there are things you can’t do because you’re feeling depressed, that’s not your fault: You’re ill.” However, the patient has a responsibility to work as a patient to get better.

Evaluate the Patient’s Need for Medication

Relate depression to an interpersonal context by reviewing with the patient his or her current and past interpersonal relationships. Explain their connection to the current depressive symptoms. Determine with the patient the “interpersonal inventory,” which includes the following:

• Nature of interaction with significant persons

• Expectations of the patient and significant persons (differentiate them from one another and discuss whether these were fulfilled)

• Satisfying and unsatisfying aspects of the relationships

• Changes the patient wants in the relationships

Identify a focal problem area: grief, role disputes, role transitions, or interpersonal deficits.

• Determine the problem area related to current depression, and set the treatment goals.

• Determine which relationship or aspect of a relationship is related to the depression and what might change in it.

Explain the IPT concepts and contract. Outline your understanding of the problem, linking illness to a life situation in a formulation: “You’re suffering from depression, and that seems to have something to do with what’s going on in your life. We call that (complicated bereavement, a role dispute, etc.). I suggest that we spend the next X weeks working on solving that difficult life crisis. If you can solve that problem, your depression is likely to lift as well.”

Agree on treatment goals and determine which problem area will be the focus. Obtain the patient’s explicit agreement on the focus.

Describe the procedures of Interpersonal Psychotherapy. Focus on current issues and the need for the patient to discuss important concerns, review the patient’s current interpersonal relations, discuss the practical aspects of the treatment (length, frequency, times, fees, policy for missed appointments).

Intermediate Sessions: The Problem Areas

With the patient’s agreement to your formulation, you will enter the middle phase of treatment and spend all but the final few sessions working on one of the four IPT problem areas: grief, role dispute, transitions, or deficits. During this time do the following:

• Maintain a supportive treatment alliance: listen and sympathize.

• Keep the treatment centered on the focus, as your treatment contract specified you would.

• Provide psychoeducation about depression, where appropriate, to excuse the patient for low energy, guilt, and so on.

• Explore for affect.

• Focus on interpersonal encounters and how the patient handled them:

• What the patient felt.

• What the patient said.

• If things went well, congratulate the patient, and reinforce adaptive social functioning.

• If things went badly, sympathize and explore other options.

• In either case, link the patient’s mood to the interpersonal outcome.

• Role play interpersonal options.

• Summarize the sessions at their end.

• Regularly (e.g., every 3-4 weeks) repeat the depression measure to assess symptom severity.

Termination

The third phase of Interpersonal Psychotherapy is the termination phase, in which the progress of the previous sessions is reviewed. Discuss with the patient what has been accomplished and what remains to be considered. Address termination several weeks before it is actually scheduled. If the patient remains symptomatic, consider another course of treatment, such as maintenance Interpersonal Psychotherapy, the addition of medication, a different medication, or a different kind of psychotherapy.

For further description of this adaptation for different populations, disorders, and format, see Weissman and colleagues. For training opportunities, consult the International Society of IPT Web site.

See also

Bereavement

Cognitive Behavioral Therapy

Interpersonal Model of Depression