Meeting Number 1752

4:00 P.M.

November 15, 2007

The Nature of Male Depression

Fredric E. Rabinowitz Ph.D.

Fredric E. Rabinowitz, Ph.D.

Summary

While depression has been recognized throughout history, its assessment and treatment has proved problematic for men in our society. Because of traditional male gender role socialization with its emphasis on independence, stoicism, and toughness, many men perceive emotional distress, particularly depression, as a sign of weakness and vulnerabilty. The hidden dangers of not seeking help include an increased risk of premature death and suicide. New anti-depressant medications that impact neurotransmitter sites in the brain combined with psychotherapy sensitive to male socialization is providing hope for men suffering from depression.

Just 35 years ago in 1972, Vice-Presidential candidate, Missouri Senator Thomas Eagleton, was forced to withdraw from the Democratic Party ticket because he had acknowledged that he suffered from depression. The 42 year old Navy veteran and Harvard law school graduate admitted to having gone to counseling and receiving electroconvulsive treatments for his depression. At the time, any type of acknowledgement by a man of having received psychiatric or psychological help was greeted with derision and shame. For many men in our current era, the stigmatization of mental health struggles continues to make it difficult to seek help for problems they might be having. Admitting to any type of vulnerability, especially a psychological one, is believed by many to be an anathema to what it means to be a "real man." This paper will explore the implications traditional male gender role socialization has on the way many men experience, express, and treat their private battles with depression. Newer psychiatric and psychological treatments will be addressed.

Depression has long been noted in historical records. During much of ancient history, demonic possession or punishment from the gods was thought to be the cause of depression. At various junctures in time however, those experiencing depression were diagnosed and treated more compassionately. Hippocrates, the Greek physician of the 5 th century B.C., and Rhazes, a prominent 9 th century Baghdad physician, both noted that melancholy was a serious psychological and biological complex that required rest, exercise, talk, and even frequent bathing in hot springs (Nemade, Reiss, & Domback, 2007).

Today, depression is known as a psychiatric disorder with several different forms and variations. Major depression, at its extreme, is characterized by a subjective sense of several of the following: depressed mood, diminished interest in most activities that previously provided pleasure, insomnia or hypersomnia, feelings of worthlessness, tearful and sad demeanor, diminished ability to think and concentrate, periods of emotional upset, guilt, and recurrent thoughts of death and suicide that cause impairment in social and occupational functioning for a minimum of two straight weeks (American Psychiatric Association, 2000). On the other side of the depression continuum is a less intense, more long term condition called dysthymia, which often includes low energy, low self-esteem, poor concentration, insomnia or hypersomnia, poor appetite or overeating, and subjective feelings of hopelessness (American Psychiatric Association, 2000). Bi-polar disorder is another form of depression that involves the symptoms of major depression punctuated by shorter periods of manic-like symptoms, including high energy level, inflated self-esteem, racing thoughts, distractibility, little if any sleep, and engagement in high pleasure activities without regard for consequences (American Psychiatric Association, 2000). When there has been an obvious psychological stressor such as a major relationship loss, job loss, or death, a person may have the symptoms of major depression and/or dysthymia, but psychiatric professionals consider this to be a normal grief reaction and tend to label it as “uncomplicated bereavement” or “adjustment disorder with depressed mood” (American Psychiatric Association, 2000). Seasonal Affective Disorder, a recently distinguished disorder, involves depressive symptoms manifested during the winter months, when there is less sunlight, and more indoor confinement.

Research suggests that major depression and bipolar depression are disorders with a strong genetic component, with higher than expected rates for children of a depressed parent and in monozygotic twins (McGuffin, Katz, Watkins, & Rutherford, 1996; Weissman, Gammon, John, Merikangas, Warner, Prusoff, & Sholomskas, 1987). Those with genetic predispositions may be most susceptible to depression when faced with adverse life conditions, interpersonal problems, or a particularly strong environmental stressor (Hammen, 1997). This paper will not focus on bipolar depression, but rather on the dysthymia-major depression spectrum.

The heterogeneity of depressive symptomology makes it difficult to identify the exact mechanisms in the brain that are responsible for the disorder. Since the 1950’s, one of the most researched areas in the field has been the monoamine neurotransmitters, which regulate emotion and motivation in the limbic system in the brain (Schildkraut, 1965). Neurotransmitters are chemical messengers that connect the various areas of the brain through electrical and chemical processes. The neurotransmitters serotonin and norepinephrine have been implicated in understanding depression, with lower levels associated with depressive symptomology (Hammen, 1997). Research findings related to the effectiveness of anti-depressant medication has made the case for this relationship, with drugs that increase serotonin and norepinephrine, resulting in the amelioration of symptoms over time (Schildkraut, 1965). More recent findings suggest that the relationship is more complex, since many anti-depressant medications that increase amounts of these neurotransmitters in the limbic system do not result in immediate mood shifting and work effectively in only 50-60 % of those who take them (Schatzberg & Kramer, 2000). Anti-depressant medication will be addressed in the treatment section of this paper.

Another major area of study that adds to the complexity of understanding depression has been with the brain’s endocrine system, which includes the hypothalamus, pituitary, and adrenal glands. The release of hormones from these glands is triggered by the actions of the neurotransmitters norepinephrine and serotonin, which are first responder’s to perceived stress (Lewis, Amini, & Lannon, 2000). During stressful situations, the release of the hormone cortisol into the bloodstream, mobilizes the body to cope with danger. In a short-term stress event, cortisol levels return to normal relatively quickly. However, if the stressor is long lasting, or of high magnitude, cortisol can have damaging effects (Ledoux, 2002). It is believed that excessive cortisol begins to destroy portions of the hippocampus, the brain center responsible for integrating new experiences into more long term memory, leading to problems with new memory formation. The individual in this circumstance is likely to experience a loss of interest in previously engaging activities, dulled perception, and an agitated, negative mood state. The stress reaction theory is bolstered by the robust findings that depressed individuals often have higher levels of cortisol in their bloodstream than those not depressed (LeDoux, 2002).

What is perhaps one of the more interesting scientific findings related to the prevalence of depression, is that in many epidemiological studies, women are typically found to have double the depression rate of men (Nolen-Hoeksema, 1990). While early data was derived from studying admission rates to psychiatric hospitals, more recent findings have come from large-scale studies. In one such study, looking at samples from five population areas in the United States, sponsored by the National Institute of Mental Health, interviewers trained to detect the signs and symptoms of mental illness had in-depth interviews with 19,182 persons in New Haven, Connecticut; Baltimore, Maryland; Raleigh-Durham, North Carolina; St. Louis, Missouri; and Los Angeles, California (Robins & Reiger, 1991). The findings replicated in another large epidemiological survey, found women to have a 30% lifetime prevalence rate of major depressive disorder/dysthymia and men to have a 17.5% lifetime prevalence rate.

How might this discrepancy be explained? Perhaps women are under more stress than men. Or perhaps women experience more stress in response to similar stimuli. Interestingly, men were overrepresented in the categories of alcohol and drug abuse and dependence by a margin of 35% to 17% for women. One of the hypotheses suggested by these findings is that perhaps men are masking the symptoms of their depression by self-medicating the condition with alcohol and mood altering substances (Cochran & Rabinowitz, 2000; Pollack, 1998).

Support for this interpretation comes from studies of cultural groups in which alcohol and illicit drug use is minimal, in which there are no significant differences in the rates of depression between men and women (Cochran & Rabinowitz, 2000). This was true in a study of the Amish in Lancaster County, Pennsylvania (Egeland & Hostetter, 1983) and in a study of an Orthodox Jewish community in London, England (Lowenthal, Goldblatt, Gorton, Lubitsch, Bickness, Fellowes, and Sowden, 1995). Non-acculturated Chinese American living in Los Angeles were found to have no sex differences in depression rates, but those who were acculturated did show the normal 2:1 female to male prevalence rate of depression (Takeuchi, Chung, Lin, Shen, Kurasake, Chun, and Sue (1998). Finally in two studies of elderly populations, it was found that depression rates were actually slightly greater for men than women (Bebbington, Dunn, Jenkins, Lewis, Brigha, Farrell, and Leltzer, 1998; Girling, Barkley, Paykel, Gehlhaar, Brayne, Gill, Mathewson, and Huppert, 1995). These findings taken together suggest that cultural practices, as well as developmental stage of life, may have an impact on the gender normative way that depressive symptoms are expressed and/or suppressed.

Traditional western culture gender role norms encourage a diminutive emotional response to many life events for men. Men are taught to not cry, to be strong in the face of adversity, and solve problems independently. Showing emotional pain is thought to signify weakness and vulnerability. Taking control, maintaining one’s cool, and demonstrating one’s dominance through flashes of anger are more accepted social norms when facing difficult life circumstances (Rabinowitz & Cochran, 1994). It is not surprising that when most men are asked how they are feeling they often reply with a single word, “Fine” regardless of their inner emotional state. Implied in this response, is that as a man “I don’t need any help.” It is shameful to feel needy, overwhelmed, unsure, or not in control of one’s life (Cochran & Rabinowitz, 2000). The consequences of not asking for help are often dire. Men are less likely to seek timely healthcare for medical and emotional problems, are less likely to share important information about their physical and mental health when they do make contact with a health care professional, have higher death rates than women for all 15 leading causes of death, and will die nearly seven years younger than women (Courtney, 2000).

It is not surprising that some men raised in a culture that values the suppression of distressing emotion may actually express depressive symptoms in a way that varies from traditional diagnostic observations. Termed masculine-specific depression, these symptoms are often mistaken as normative male behaviors (Cochran, 2001; Pollack, 1998). While some of the traditional DSM symptoms of depression might be present, masculine-specific symptoms can include: irritability, increased interpersonal conflict, increased alcohol, food, or drug (illicit or legal) intake, somatic complaints, a desire to be alone, work-related complaints, and difficulty with concentration and motivation (Cochran & Rabinowitz, 2000). Perhaps the most powerful evidence for the expression of male-specific depression is the high suicide rate for men when compared to women. For example, suicide rates of men between age 15-24 and for men over 80 are seven to fifteen times the rate of women of the same age. Across ages, men kill themselves at four times the rate of women (Buda & Tsuang, 1990). This data supports the assumption that because fewer men seek treatment for underlying depression, they are at a higher risk for their mental condition worsening and resulting in self-inflicted death (Cochran, 2001). In contrast, men who maintain strong social networks throughout their lives are less likely to experience severe episodes of depression in their lifetime, even when facing loss (Cochran & Rabinowitz, 2000).

Depressive symptomology is thought to be maintained by a process of rumination about events and circumstances that cause emotional distress (Nolen-Hoeksema, 1990). Addis (in press) suggests that the lower rate of depression in men may actually be understood more generally as a coping reaction to distress. He suggests that how any individual responds to negative affect in general, not just depression, may predispose some to become depressed and others to not. In a culture that encourages men to avoid negative feelings by distracting themselves with mood altering activities, and encourages women to ruminate about distressing moods, it is not surprising to find that men are less likely to report depressive symptoms. While effective in the short term, it still leaves open the question about whether this is a good long term strategy. The high male suicide rate suggests that unsuccessful attempts at distraction and avoidance, may result in a worsening of the underlying depressive conditions for some men.

The treatment of depression in men

Psychopharmacology therapy

It is a dilemma for many men to seek treatment for any kind of health concern, let alone something as serious and shame provoking as their mental health. Men are often told to "man up" when faced with life problems. Cultural norms around self-reliance, emotional control, and power compromise self-initiated help seeking in men (Addis & Mahalik, 2003). While some men find relief in physical workouts like running or weight lifting, feelings of doubt, shame, and depression are not so easily resolved in this manner. Often it is someone other than the man himself who initiates the possibility of psychiatric or psychological treatment; a concerned partner, family member, co-worker, or even a legal sanction. It is not uncommon for a man to first seek out his primary care physician with an accompanying tangible complaint like sleep problems, sexual performance concerns, headaches, or pain in the back, neck, or gut. Physicians who do not probe deeply about a man's psychological state may find themselves prescribing pain medication, sleeping pills, and erectile dysfunction drugs when a man is really experiencing depression. Depression must sometimes be inferred from the configuration of symptoms, since men are often less than forthcoming about describing the depth of their mood disturbance. As stated earlier in the paper, masculine-specific symptoms can include manifestations that might be misdiagnosed as being typical male reactions to stress, like eating and drinking too much, irritability, tiredness, lack of sex drive, watching too much television, or difficulty with concentration (Cochran & Rabinowitz, 2000). When depression is diagnosed, medication is often a first step treatment. Many men feel more comfortable with a medical model approach that emphasizes their condition being a biochemical abnormality that needs a biochemical treatment.

In recent years, there has been a proliferation of anti-depressant medications introduced that are effective in altering the amounts of neurotransmitter substances in the brain. The first real anti-depressant, iproniazid, was developed in the 1950’s from hydrazine, a compound originally used as rocket fuel by the German army in World War II (LeDoux, 2002). Although researchers didn’t initially understand the mechanism of its effectiveness, this drug was found to work at as a monoamine oxidase (MAO) inhibitor. MAO inhibitors allow the neurotransmitters dopamine, norepinephrine and serotonin to remain at the synapse of the individual neurons longer, resulting in more to be available, and a subjective lifting of the depression (LeDoux, 2002). Unfortunately, one of the side effects of this drug is the breakdown of the amino acid tyramine, leading to life threatening high blood pressure when certain fermenting foods are digested, like wine, beer, and cheeses. The other drug that was developed around the same time was called imipramine with brand names Tofranil and Elavil, also known as a tricyclic anti-depressant (LeDoux, 2002). Imipramine also increased norepinephrine and serotonin at the receptor sites by blocking the transportation of the substances back into the releasing neuron’s terminal. The side effects were less severe, but still included dry mouth, constipation, urinary retention, and sometimes confusion (Preston & Johnson, 2005). These anti-depressants took four to six weeks to become effective, suggesting that biochemical changes at the synapses needed extended time to develop.

An anti-depressant revolution occurred in the late 1980’s with the advent of the selective serotonin reuptake inhibitors (SSRIs) (Kramer, 1993). With significantly fewer side effects, this class of drug selectively targeted either serotonin or norepinephrine receptor sites, leading to the alleviation of depressed mood. Most of these drugs take 4-6 weeks of continuous use to become fully effective. For men, the main side effects of these medications has been found to be sexual dysfunction in the form of lower libido and delayed ejaculation (Stuart, 2000). The promotion of SSRI’s by the pharmaceutical companies promised a way for those with even mild mood disturbances to live happier lives. Drugs marketed under the names of Prozac, Paxil, Celexa, and Lexipro, for example, made this class of antidepressants the most prescribed medication in history (LeDoux, 2002).

While in the past psychiatrists primarily prescribed psychiatric drugs, today SSRI’s are often prescribed by physicians with little psychiatric training. As a result, many individuals taking these drugs are not being referred for psychotherapy in conjunction with the medication. This diminishes the possibility of changing cognitive beliefs that might be psychologically maintaining an individual’s depressive outlook. Clinical trials pitting psychotherapy against anti-depressant medication as well as combinations of the two suggest that cognitive psychotherapy is as effective as medication and that a combination of the two may be the best long-term strategy for recovery from depression ( DeRubeis, Hollon, Amsterdam, Shelton, Young, Salomon, O’Reardon, Lovett, Gladis, Brown, & Gallop, 2005; Jacobson & Hollon, 1996 ).

Electroconvulsive treatment (ECT) for depression, also popularly known as shock treatment, involves inducing an epileptic-like seizure in an individual. This treatment, which takes place over several consecutive days, is used on a limited basis for individuals with the most severe catatonic forms of the depressive disorder, who have been resistant to other interventions. ECT, which has been found to increase short-term memory loss and cause some confusion, has also been found to be effective in alleviating severe depressive symptomology for several months at a time. The mechanism for its effectiveness is thought to be a resetting of the neurotransmitters serotonin, norepinephrine, and dopamine, but is still not fully understood ( Mayo Clinic, 2007).

Psychotherapy with Men

Even though only one third of all visits to psychotherapists are made by men (Vessey & Howard, 1993), those who do attend treatment have a success rate equal to women (Cochran & Rabinowitz, 2000). Often it is at the urging of a concerned partner, who observes that even with SSRI medication and some alleviation of the depressed mood, that a man’s negative thinking and strained interpersonal style may persist. Some men seek help for other male-specific symptoms that the medication doesn’t address or may exacerbate like overeating, sexual dysfunction, difficulty finding pleasure in life activities, alcohol or drug abuse, addiction to pornography, or outbursts of anger (Cochran & Rabinowitz, 2003).

The National Institute of Mental Health’s Treatment of Depression Collaborative Research Program demonstrated that for mild to moderate depression, both cognitive –behavioral and interpersonal approaches were equally effective (Elkin, Shea, Watkins, Imber, Sotsky, Collins, et.al., 1989). Cognitive-behavioral therapy for men focuses on confronting unrealistic expectations of the male role and distortions in thinking and behaving that lead men toward a depressed outlook and mood (Mahalik, 2001). Interpersonal therapy emphasizes examining and improving how the depressed individual approaches relationships and communicates needs and desires to others (Elkin, et. al, 1989).

Recently, more innovative approaches to psychotherapy have shown promise as treatment for depression. Pollack (1998) has proposed a therapy that focuses on repairing childhood relational trauma, which has resulted from the abrogation of important interpersonal relationships. Cochran and Rabinowitz (1996) have described therapy that addresses the accumulation of losses at various developmental periods of life that make men more susceptible to depression. Osherson and Krugman (1990) emphasize in their therapeutic approach, the role of shame in the experience of men’s depression. All three of these approaches have shown that vulnerability to male depression has a strong interpersonal component that should be addressed in treatment.

Those who have never had the experience often misunderstand the process of psychotherapy. The next section of this paper integrates the various therapeutic approaches to describe in some detail what is likely to occur in this type of relational treatment with a male patient and how symptoms of depression might be addressed.

In the initial consultation, the psychotherapist has two major tasks. The first is to investigate through history taking, the intensity of the depression, how it is expressed, its likely causal nature, previous depressive episodes, and current medications. Also assessed are current coping mechanisms, suicidal thinking, planning, and impulses (Cochran & Rabinowitz, 2000). The second task is to create a therapeutic alliance based on explicit empathy for the man's experience (Pollack, 1990). Although an initial awkwardness is to be expected, it is the psychotherapist's job to make the creation of a relationship a less threatening process. Starting with the present symptoms rather than quickly delving into the past can facilitate this. Some small talk, humor, and humanizing self-disclosure by the therapist can also reduce the shame-based intensity of the encounter (Rabinowitz & Cochran, 2002).

By carefully listening to the story the male client weaves, the therapist can combine in his responses empathy for the losses and traumas expressed, as well as relevant questions about history and suicide that don't change the context or flow of the story being told. Most men seem more receptive to revealing themselves when their experience is framed by the psychotherapist as a rich revelation of their life journey, rather than a clinical retelling of their psychohistory (Rabinowitz & Cochran, 2002).

Tentative self-disclosures will become more substantive as a man’s trust level increases in the therapy sessions. For many men, the shameful element of having to seek help for life issues remains present in the early encounters with the psychotherapist but eventually diminishes over time (Osherson & Krugman, 1990). Although it might feel frustrating and non-productive for the therapist to have to pry information from a hesitant patient or go over similar ground from session to session and not feel especially valued, the male client's defense system is actually using these interactions to perceive rejection and seek verification of his worth. The patient may even be overtly asking for a cure to his depression to see how hard the therapist will work to help him. In a sense, these initial sessions are unconscious tests by the client to see if the psychotherapist will really be there in a caring and consistent way (Goldstein, 1991).

Paradoxically, the depressed male patient seems to want the therapist to have the energy to help him and at the same time, feel as depressed as he does. Exhausted by enough "yes buts,” the eager psychotherapist cannot help but to descend into the client's depressed emotional state. The energy drain that depressed clients seem to have on the therapist is a reminder to the clinician that he or she must be willing to enter into the "low psychic space" of the client. It is only from this space, that the clinician can truly empathize with the patient's experience and offer an existential kinship with life's downside (Yalom, 1980). This willingness by the therapist to be with a man experiencing negativity in his life, often gives the male patient hope and a sense that he is understood. In group therapy, this function can be shared among supportive group members (Rabinowitz, 2001).

For the depressed man, engaging the contemptuous and shame-inducing "critical parent" or “internal judge” is often a crucial piece of the work that must be faced in psychotherapy. This introjected self, which often has the voice of a parent, carries much power and when turned against the self has the capacity to immobilize the individual with anxiety and depression. Often this is projected onto the therapist. For instance, a man in therapy may feel like he is not living up to the expectations of the therapist, despite the therapist’s judgmental neutrality and emotional support. He might state to the clinician, “You must think I am such a loser. I can’t even imagine how you could stand to listen to me talk about this crap. Some kind of man I am. Good thing you are getting paid for this.” Drawing out the projection onto the psychotherapist allows these negative messages to be said aloud and confronted. Often a man does not realize how much impact these ideas have on his self-esteem and behavior. Assumptions about what it means to be a man, including being a son, father, partner, or worker, may be a big part of the unrealistic thinking in which a depressed man might engage (Mahalik, 2001). This can be seen in the following exchange:

Male client: “I never seem to be satisfied with anything I do. It is never enough.” Therapist: “Sounds like someone in your life may have told you these words and you bought them hook, line, and sinker.”

Male client: “Damn right I did and now I can’t shut down the voice.”

Therapist: “Whose voice is it?”

Male client: “Beside mom, dad, my wife, and every boss I’ve ever had?”

Therapist: “Didn’t realize you had a whole team cheering you on.”

Male client: “It often feels more like an army.”

Therapist: “How does it feel just saying this to me now?”

Male client: “Like when I was a kid and I picked up a big rock and all the bugs and maggots scattered: freaky at first, then kind of interesting.”

Therapist: “Interesting?”

Male client: “Not so scary when I let myself see what they were doing and try not take it all to heart.”

Therapist: “Maybe it has more to do with them than you.”

Male client: “I don’t have to own all of their expectations.”

Therapist (smiling), “No you don’t. Maybe, we are making some progress.”

Held up to the light, depressive thinking is less convincing. Distortions, generalizations, exaggerations, and all or nothing thinking can be confronted (Beck, 1976). A man who can articulate the thoughts that go along with his depression is more open to changing them and replacing them with less harsh, more positive ideation (Vodde & Randall, 1994). A man who is frozen by his depression, can be gently motivated by a therapist’s sense of humor, appropriate self-disclosure, patience, mild confrontation, and encouragement to break through self-imposed self-devaluation (Rabinowitz & Cochran, 2002).

Often the emotional retelling of hopes, triumphs, mistakes, and failures opens a man to see connections and patterns that he had never before noticed. It is not uncommon for a man to realize that his pursuit of a particular career or woman had its roots in both intrapsychic conflicts and male gender role socialization (Cochran & Rabinowitz, 1996).

With reflections of meaning and feeling by the therapist, an isolated series of life events can be transformed into an intricately organized web of pictures, emotions, and connections. The therapy relationship itself serves as a model of relationships in which a man can be less than perfect, emotionally open, while still being valued by another adult. By fully investing in the therapeutic relationship, it is possible for a man to have breakthrough feelings of anger, deep sadness, joy, and laughter. Coming at this later point in the therapy process, the sharing of emotion feels less alien and much more congruent and meaningful than when he first came to therapy. Although it is rarely what he thought he was looking for, a man who can feel and express a range of emotion perceives himself less broken, and more whole. By learning how to disarm the shame brought on by his own harsh self-criticism and society's script for him as a male, he opens himself up to the world of connection and emotional aliveness. The outcome of therapy is not necessarily a permanent removal of depressing feelings but rather an acceptance of the emotional spectrum that comes with living life authentically.

Conclusion

Life is often stressful. Extended periods of coping with conflictual, painful, or traumatic situations leads to changes in brain chemistry, which manifest as emotional states like fear, anger, and depression. These are the body’s natural way of letting an individual know that something is wrong and to respond to it. Unfortunately in our culture, we send messages to boys and men that they should strong enough to be able to tough out any type of pain and adversity. While no one can argue with the benefit of mental toughness in particularly harsh situations, one can argue that not asking for help, ignoring one’s emotions, not communicating clearly, distracting oneself from painful life situations, and taking unnecessary risks equate more with stupidity than strength. What following these traditionally masculine behaviors is more likely to do, is lead to poorer health, a higher probability of addiction, strained interpersonal relationships, private suffering from emotional disorders that might otherwise be treated, and earlier death.

There is hope for reaching men who might not otherwise be open to seeking help. Prominent national figures like writer William Styron, ex-professional quarterback and NFL commentator Terry Bradshaw, and longtime news commentator Mike Wallace have all acknowledged publicly their struggles with depression in public. The National Institute of Mental Health, as well as a group of psychologists and psychiatrists has collaborated on a campaign called, “Real Men, Real Depression” that has targeted men suffering silently from depression. By using brochures and commercials featuring strong, tough-looking men who acknowledge living with depression and seeking treatment, they are hoping that increasing social norms around help seeking will lead to men being more proactive in this area. This initiative is one example of expanding the perceived parameters of what is acceptable male behavior and of breaking down the stereotype about real men not asking for help (Rochlen, McKelly, & Pituch, 2006).

We live in an era of unprecedented research on the brain, the body, and human behavior. Medications continue to be fine-tuned to alter specific neurotransmitters, including those that target the symptoms of depression. Cutting edge psychotherapy practice has become more male-friendly and social norms are beginning to shift toward a more holistic acceptance of what it means to be a man. By integrating our knowledge base of brain functioning, psychotherapy, and the power to change masculine norms, it is possible to imagine a time in the near future when men will seek mental health check ups for their emotional life in much the same way they are willing to get periodic service for their cars and trucks.

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Fredric E. Rabinowitz, Ph.D. was born and raised in Philadelphia, Pennsylvania. He earned his B.A. at Ithaca College, his M.A. at Loyola College, and his Ph.D. in Counseling Psychology at the University of Missouri. Since 1984, he has been a Professor of Psychology at the University of Redlands and a private practice psychologist in Redlands, CA specializing in individual and group psychotherapy with men. Dr. Rabinowitz has been the Psychology Department Chair; Salzburg, Austria Program Director; Interim Johnston College Director, and is currently the Assistant Dean of the College of Arts and Sciences, in addition to his faculty role. He was the Clinical Director of the Redlands-Yucaipa Guidance Clinic from 1994-1997 and has been co-leading therapeutic men’s groups in Redlands since 1987. Dr. Rabinowitz has authored and co-authored numerous articles and three books: Deepening Psychotherapy with Men (2002); Men and Depression: Clinical and Empirical Perspectives (2000); and Man Alive: A Primer of Men’s Issues (1994). Dr. Rabinowitz has earned Outstanding Faculty Teaching and Research awards in 1995, 1996, 2001, and 2002. He was elected as a Fellow to the American Psychological Association in 2004 and is the past President of the Society for the Psychological Study of Men and Masculinity, a division of the American Psychological Association. Dr. Rabinowitz is a father of two children, Jared and Karina and a husband to Janet Rabinowitz since 1989. He is an avid reader, writer, skier, and golfer.