Men's Masked Depression
Marcus, 36, firefighter
Fictional teaching case
Compare the formulations ↓Presentation
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.'
Read the full case history and clinical context
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.
Compare how approaches understand this case
Two approaches to begin with; change them below. These are starting examples, not a clinical ranking.
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Showing 2 of 8 formulations.
ACT
Marcus is fused with a masculine identity that equates emotion with weakness and self-sufficiency with health. Experiential avoidance is massive: the drinking, overworking, and anger are all avoidance of grief, fear, and vulnerability. His values (family, connection) are being sacrificed.
Creative hopelessness: is the 'toughing it out' strategy working? Defusion from the 'real men don't feel' narrative. Contact with values about fatherhood. Willingness to feel what he's been avoiding.
"The strategy of powering through has worked for you in a lot of ways: you're a firefighter, you took care of your siblings. But is that same strategy working in your marriage? In your body?"
CBT
Male-socialized depression often presents as irritability, somatic complaints, substance use, and overwork rather than sadness. Cognitive distortions: 'Asking for help is weak,' 'I should be able to handle this,' 'Emotions are dangerous.' His sources of reward have narrowed to two, work and alcohol, and both now cost more than they return.
Psychoeducation about male-pattern depression (externalizing, somatic, behavioral). Behavioral activation beyond work. Cognitive restructuring of masculine role beliefs. Sleep hygiene. Graded alcohol reduction.
"A lot of guys who come in here describe exactly what you're describing: not feeling sad, but the sleep's gone, the fuse is short, the drinking creeps up. That's actually what depression looks like for a lot of men. Not weakness. A signal."
Compassion-Focused Therapy
Massive threat-system activation (anger, hypervigilance) and drive-system dominance (overwork) with the soothing system completely offline. Self-criticism masked as toughness. Shame about needing help activates more threat, creating a vicious cycle.
Psychoeducation about three emotion systems in male-accessible language. Normalize the threat response. Build compassionate self-correction. Breathing and soothing rhythm work framed as 'nervous system regulation' (not 'self-compassion,' since that language may trigger resistance).
"Your nervous system is stuck in firefighter mode. Even when you're home. That's not weakness, that's training. But your body can't sustain this. What if we worked on giving your system a way to stand down?"
Existential Psychotherapy
Marcus's father's death at 58 is the unspoken center of gravity. He is living his father's life: working himself to death, emotionally unavailable, 'tough but fair.' The anger and insomnia are death anxiety breaking through a lifestyle designed to avoid confronting mortality and vulnerability.
Gently explore the parallel with his father. What does he fear if he stops? Death awareness. Authenticity vs. role performance. What would it mean to live differently than his father did?
"Your dad was tough, worked hard, and died at 58. You're tough, you work hard, and you're 36 with high blood pressure. I'm not trying to scare you. I'm wondering if you've noticed that."
IFS
A Manager part, the tough guy who takes the overtime and handles everything, has been running the show since he was 14. It's protecting Exiles carrying grief (mother's cancer, father's emotional absence, close calls on the job) and fear (of being vulnerable, of losing control). The anger and the nightly beers are Firefighter parts: reactive, fast, arriving whenever an Exile gets near the surface.
Build a relationship with the Manager from Marcus's Self rather than from another part, and honor what it has done. Understand what it's afraid would happen if he showed vulnerability. Only with its permission, and slowly, approach the exile underneath: the 14-year-old who became the family's strong one.
"The part of you that says 'I'm fine' has been doing its job for a long time. Since you were about 14, I'd guess. Can you appreciate what it's been protecting you from?"
Interpersonal Process Group Therapy
The group is a social microcosm: whatever Marcus does in relationships he will eventually do in the room, and the group will react to it roughly the way his wife does. Emotional avoidance, caretaking, and anger as the only permitted emotion are not reported here, they are performed here, and can be worked in the moment. Universality does the rest, since hearing other men name fear is much harder to dismiss than hearing a therapist name it.
All-male or mixed therapy group. Marcus's role in the group will likely mirror his family role (caretaker, tough one). Feedback from peers about the impact of his emotional distance. Modeling vulnerability.
"[After another group member shares something vulnerable] Marcus, I noticed something shifted in your face just now when David talked about his dad. What happened for you?"
Motivational Interviewing
Marcus is precontemplative: he doesn't see a problem. Confrontation will produce reactance. The therapeutic task is to develop discrepancy between his values (family, being a good husband/father) and current behavior (drinking, overworking, emotional unavailability), without telling him what to do.
Develop rapport through respect for autonomy. Express empathy for the position he's in. Explore values: what kind of husband and father does he want to be? Roll with resistance. Develop discrepancy gently.
"You're here because your wife asked you to come. I respect that. It takes guts. I'm not here to tell you something's wrong. I'm curious what matters to you about your family."
Narrative Therapy
Marcus is living inside a dominant story of masculinity: 'the strong one,' 'the provider,' 'the one who doesn't break.' This story was written by his family of origin and reinforced by fire service culture. It's totalizing, leaving no room for grief, tenderness, or help-seeking.
Externalize the dominant masculinity narrative. Map its influence on his marriage, health, and inner life. Search for unique outcomes: moments when he was tender, vulnerable, or asked for help. Re-author.
"This story that you have to be the strong one. When did it first recruit you? And has there ever been a time when you stepped outside it, even for a moment?"
Where Approaches Genuinely Disagree
Psychoeducation about male depression helps normalize the experience. Name it so it can be treated.
Naming it is a confrontation he did not ask for, and confrontation produces reactance. Start where he starts, with the sleep and the marriage, and let the discrepancy surface in his own words.
Philosophical Lenses
These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.
Marcus is not thinking. He is functioning: performing the routines of masculinity (work, toughness, irritability-as-strength) without examining them. Arendt's concept of thoughtlessness applies: not stupidity but the absence of the inner dialogue that constitutes genuine selfhood. His insistence that he's 'fine' and the problem is 'everyone else' is a refusal to stop and examine: what Arendt called the banality of unreflected life. The blood pressure and insomnia are the body's protest against a life lived on autopilot. The therapeutic task is not behavior change but the restoration of thinking: the capacity to stop, examine one's actions, and recognize oneself as a moral agent rather than a role.
Marcus's masked depression is patriarchy doing what it does to men: severing them from emotional life and then punishing them when the body revolts. hooks would see his anger not as the 'real' emotion beneath the depression but as the only emotion the patriarchal script permits. He is not 'too sensitive'; he is trapped in a masculinity that equates vulnerability with weakness and connection with dependency. His wife's threat to leave is a crisis of love, and hooks would insist that love requires the will to nurture one's own and another's spiritual growth, which Marcus's gender training has made nearly impossible. Individual therapy without a critique of patriarchal masculinity treats the symptom.
Sources & Method
This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.