Referred by physician after elevated blood pressure and insomnia. Wife says he's 'angry all the time' and threatened to leave. Marcus says he's 'fine' — the problem is everyone else being 'too sensitive.' Drinks 3-4 beers nightly. Works overtime constantly. Hasn't cried in years. Says: 'I don't need therapy. I just need people to stop telling me something's wrong with me.'
History
Father was 'tough but fair' — never showed emotion, worked himself to death (MI at 58). Marcus was the family's strong one, caretaker of younger siblings after mother's cancer diagnosis at 14. Two close calls on the job he minimizes. Came to session only because wife made an ultimatum.
Clinical note: Male-socialized depression is systematically underdiagnosed because standard screening instruments (PHQ-9, BDI) were normed on presentations skewing toward female-typical symptoms — sadness, crying, guilt (Addis, 2008; Cochran & Rabinowitz, 2000). The Male Depression Risk Scale (Rice et al., 2013) captures externalizing symptoms: irritability, anger, risk-taking, substance use, emotional suppression. When male-typical symptoms are included, the gender gap in depression prevalence largely disappears (Martin et al., 2013). Derek's presentation — anger, overwork, drinking, somatic complaints — is textbook male-pattern depression that would score low on the PHQ-9 despite severe impairment. The clinical challenge is engagement: men attend therapy at roughly half the rate of women, and male-socialized clients often frame distress in instrumental terms ('I need to fix my sleep') rather than emotional ones. Seidler et al. (2018) found that male-adapted protocols using action-oriented language, addressing help-seeking barriers, and normalizing masculine emotional experience show better engagement. The formulations above illustrate how different modalities approach the same underlying depression through dramatically different entry points — and how the therapist's ability to meet Derek in his language, not clinical language, determines whether he returns for session two.
Where Approaches Genuinely Disagree
Name the depression or work around it?
CBT
Psychoeducation about male depression helps normalize the experience. Name it so it can be treated.
vs.
ACT
Don't fight the client's frame. If he comes in talking about anger and work stress, start there.