By Philip Chanin, Ed.D, ABPP, CGP

Board Certified Clinical Psychologist

Assistant Clinical Professor, Department of Psychiatry

Vanderbilt University Medical Center

www.drphilchanin.com

philchanin@gmail.com

“Like Dante and Virgil, standing together on the broad plain of Hell, looking down into the concentric circles of the Inferno, Jeffrey Robinson and I perch on the rim of his personal wasteland.  We speak, almost abstractly, like two merchants weighing an object for purchase, of the pros and cons of his possible descent, the hardest work of his life.  Jeffrey and I are at one of the critical junctures in healing the depressed man’s relationship to himself—the moment he decides to stop his flight and face his own condition.  Once a man resolves to take up his hero’s journey, real therapy can begin.  Our descent occurs in three phases.  First, the addictive defenses must stop.  Then, the dysfunctional patterns in the man’s relationship to himself must be attended to.  Finally, buried early trauma must reemerge and, as much as possible, be released.” (pp. 269-270)

“Depression is not really a feeling; it is a condition of numbness, of nonfeeling.  In my work with depressed men, I differentiate between states and feelings.  States are global, diffuse, impersonal.   One’s relationship to a state is passive, disembodied.  A state of depression just drops over someone, like bad weather…Feelings, in contrast to states, are specific, anchored in the body of one’s experience.  Depression is a state.  Sadness and anger are feelings.  Anxiety is a state.  Fear is a feeling.  Intoxication is a state.  Happiness is a feeling.  One feels about something.  Feelings are embedded in relationships; thus, when one feels something about a relationship, one can take relieving action.  Emotions are signals that emerge from the context of our interactions.  The cure for states is feelings…unlike states, which tend to congeal, feelings will run their course in due time…Feelings are not endless, but our numbing attempts to avoid them can last a lifetime.” (pp. 285-286)

“In our society, most males have difficulty not just in expressing, but even in identifying their feelings.  The psychiatric term for this impairment is alexithymia, and psychologist Ron Levant estimates that close to eighty percent of men in our society have a mild to severe form of it.” (p. 146)

“Depression is an obsessive disorder.  A depressed person is endlessly caught in the chains of his rehearsed inadequacies.” (p. 225)

“Treating covert depression is like peeling back the layers of an onion.  Underneath the covertly depressed man’s addictive defenses lies the pain of a faulty relationship to himself.  And at the core of this self-disorder lies the unresolved pain of childhood trauma.  Healing from depression unpeels these three layers in three phases: sobriety, the practice of relational maturity, and trauma release.” (p. 279)

I am as compelled by this book today as I was when I first read it 25 years ago.  And I have witnessed the profound impact it has had on probably hundreds of male patients (and many of their partners) to whom I have introduced it, in the years since then.  Terry Real’s concepts, such as “covert depression,” “performance-based self-esteem” and “relational heroism” have been immensely important in my work with men and with couples.

A number of years ago I offered a men’s therapy group with the title “I Don’t Want to Talk About It:  Addiction, Depression, and the Loss of the Relational in Men’s Lives.”  I began my flyer for the group with the following quote from this book: “…for many depressed men, recovery is linked to opposing the force of disconnection, and reentering the world of the relational—often kicking and screaming.  A man cannot recover from…depression and remain simultaneously numb at the same time; he cannot be related and walled off simultaneously; he cannot be intimate with others before establishing intimate terms with his own heart. (pp 158-159)

Terry Real makes a clear distinction between overt and covert depression.  He writes: “While many of the men I treat report the classic symptoms of overt depression–feelings of hopelessness, helplessness, and despair–many more experience depression as a state of numbness…This experience of depression is not about feeling bad so much as about losing the capacity to feel at all.” (p. 55).  He says that depression in men is likely to be “mild, elusive, and chronic.” (p. 33)

Real has done work with Carol Gilligan at Harvard into the profound role that typical male socialization has upon men and men’s relationships.  He writes “Hidden depression drives several of the problems we think of as typically male: physical illness, alcohol and drug abuse, domestic violence, failures in intimacy, self-sabotage in business.” (p. 22). He adds, “Men die early because they do not take care of themselves.  Men wait longer to acknowledge they are sick, take longer to get help, and once they get treatment do not comply with it as well as women do.” (p. 37)

Real takes a tremendously helpful stance on the distinctions between “healthy self-esteem” and the “performance-based self-esteem” upon which most men depend.  He adds, “Covert depression is at its core a disorder of self-esteem.  Healthy self-esteem is essentially internal.  It is the capacity to cherish oneself in the face of one’s own imperfections, not because of what one has or what one does.” (p. 44).  Real continues, “What we offer boys in our culture is highly conditional, performance-based esteem, not an essential sense of worth that comes from within.  One cannot earn healthy self-esteem.  One has it.  Performance-based esteem augments an insufficient, internal sense of worth by the measuring of one’s accomplishments against those of others and coming out on top.” (p. 182)   He says, “It is hard for many successful men…to see the harmful effects of compulsive work until the relational bill comes due.” (p. 47)

Real, like Alice Miller in her book The Drama of the Gifted Child, explores the profound interplay of shame and grandiosity.  Real writes, “A common compensation for shame, of feeling less than, is a subtle or flagrant flight into grandiosity, of feeling better than…The ‘narcissistic defense’ of using grandiosity to ward off shame.” (p. 55). He adds, “Grandiose behavior is a defense against images of the self as worthless and inferior…The flight from shame to grandiosity lies at the heart of covert male depression.” (p. 56)

I have found Terry Reals words and concepts so helpful that I often reach for this book during a psychotherapy session and share these ideas with my patients.  I have read several passages in this book so many times that I have memorized them and can quote them without even opening the book!  Here is one of those concepts:

“Whenever a man turns to an external prop for self-esteem regulation, he is involved in the defensive structures of covert depression.  Narcissus at the well (transfixed by his image) is an addict.  For simplicity’s sake, I label dependency on any self-esteem ‘dialysis machine’ as addictive dependency…Just about anything can be used as an addictive defense—spending, food, work, achievement, exercise, computer games…The cure for the addictive defenses is simple in theory, miserable to experience.  All one need do to stop such defenses is decide to stop them—then, with ample support, withstand the withdrawal.” (pp. 270-271)

Real draws upon the work of others in the field of addictions, including “Edward Khantzian, the father of the self-medication hypothesis, (who) speaks of addictions as attempts to ‘correct’ for flaws in the user’s ego capacities…Khantzian and others currently writing on the psychology of addiction speak of substance abuse as a desperate strategy for dealing with self “dysregulation.’  Khantzian’s research on both alcoholics and drug abusers led him to focus on four cardinal areas of dysregulation:  difficulty in maintaining healthy self-esteem; difficulty in regulating one’s feelings; difficulty in exercising self-care; and difficulty in sustaining connection to others…The damage to self that Khantzian describes can be summed up as damage in relatedness.” (p. 276)

One of Terry Real’s most useful concepts in my work with men and with couples is “relational heroism.”  He writes, “Relational heroism occurs when every muscle and nerve in one’s body pulls one toward reenacting one’s usual dysfunctional pattern, but through sheer force of discipline or grace, one lifts oneself off the well-worn track toward behaviors that are more vulnerable, more cherishing, more mature…Each time Jeffrey Robinson feels the physical flood of agitation, depression, and shame sweep over his body, but does not run…he has learned to give himself the functional parenting he never received.  Such moments lie at the heart of the recovery process.  Jeffrey once teased me that our therapy felt like couples counseling between himself and himself.” (p.277)

As you have probably experienced in these quotations from Terry Real, he is an extraordinary writer who gives powerful vignettes of the exchanges that take place between him and the men that he works with in psychotherapy.  In his writing, he also draws upon relevant literature as well.  The poem “Healing,” by D.H. Lawrence is one example:

I am not a mechanism, an assembly of various sections.

And it is not because the mechanism is working wrongly, that I am ill.

I am ill because of wounds to the soul, to the deep emotional self

and the wounds take a long, long time, only time can help

and patience, and a certain difficult repentance,

long, difficult repentance, realization of life’s mistake, and the freeing oneself

from the endless repetition of the mistake

which mankind at large has chosen to sanctify.”(p. 226-227)

Real closes this particular chapter in the book saying, “A man who is willing to drop down as far and work as hard as young Billy did is after bigger game than relief from an illness.  A man willing to permanently alter the terms of his internal dialogue—to transmute the dynamic of wounded boy and harsh boy, feminine and masculine, shame and grandiosity, inside himself—seeks nothing less than a transformation in the way that he lives, the values he lives by.  Such a journey goes beyond recovery.  It is alchemy.  It is a quest.” (p. 227)

Connect with Dr. Phil Chanin, a psychologist for male depression in Nashville, TN.