We invite our clinicians to post on-line articles for us, discussing either a current mental health issue or something in their particular area of expertise.  The following article is from Michael Eatmon, LCSW.  Michael finds himself enjoying the work and therapy he does with men and midlife issues.  Michael is a thoughtful and insightful therapist and we are pleased to feature his work.
Men's Depression: Pathology, Problem, or Portal?

In a dark time the eye begins to see.

And I meet my shadow in the deepening shade…

What is madness but nobility of soul

At odds with circumstance?

The days on fire And I know the purity of pure despair

My shadow pinned against the sweating wall.

That place among the rocks

Is it a cave or a winding path?

In a dark time

The edge is what we have.

- Theodore Roethki

Many men have the quiet experience of being somehow "edgy" without really knowing why. It is a mystery to them and a closely guarded secret. It feels somehow dangerous to get too close to this "edginess"… it has vapors emanating from it that smell uneasily like despair. But after a time it becomes clear to his wife, life-partner, children, co-workers, family and friends (though, curiously, not necessarily to himself) the "edge is what he has".

In the dark times of a man’s life, or in the dark time that is a man’s life, current culture and thought provides few dignified places to put a man’s pain. Men know this. Whether his dark time is situational or "seasonal" to his stage of life development or a chronic state of being that feels like a fate that cannot be escaped from, modern man’s "nobility of soul at odds with circumstance" has increasingly been reduced to malfunctioning neural synapses and adjustment/adaptation problems. Hence, medication and counseling will combine to maximize a man’s "current level of functioning". But the wife, life-partner, children, co-workers, family and friends all know his functioning is not the dilemma…the edginess he has about him is as is the various ways he distracts from this edge in his life.

Pathology (as something "wrong" in the physical body or brain) and Problem (as something "wrong" in the situational/life adjustment that interventionist or problem-solving therapies will solve in brief time) are the predominant modes of clinical thought. The most available "containers", if you will, that we have in which to place a man’s pain…his dark time.

In my work with men over the last twenty-four years I have found they echo the protest to these two containers put in poetic form by D.H. Lawrence:

HEALING

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 to the soul 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.

D. H. LAWRENCE

The poems by Roethki and Lawrence point to a much older container to hold a man’s pain with full dignity of human _expression and genuiness of person. It is older in the sense that this container flows from time tested wisdom. We often forget the human animal we know has been around some 30,000 to 40,000 years while the modern containers of Pathology and Problem are both just under 100 years old (modern psychiatry and psychological approaches I take as beginning with Freud, Jung, and Adler). Through this long season of human history there were "scientists" who observed, studied, tested, re-searched, and practiced healing just as meticulously and with equal genius as the modern lab-coated healer.

This older container (i.e. approach or paradigm) of which the poets point to holds that a man’s "pathos" (i.e., his "suffering") is simultaneously the dilemma of his life and the portal to a more vivified, full ranged, and personally genuine life. The ancient Greeks had a phrase for this that baffles the modern: "the disease is the cure". As "portal" a man’s pain is envisioned as a kind of crossing through to a new life that is insisted upon by the man’s own psychology. I find in my practice experience this crossing through is very often misunderstood and hence resisted by the man, his family and the social group around him. The result is the required change initiated by and insisted upon by the man’s own psychology must intensify its efforts to bring about that change. The method used by his psychology to intensify its efforts to bring about the change it requires is intensification of the symptom that first presented itself at the diagnostic interview.

It is in this sense that I have often encouraged the men I work with to view their presenting symptom as a guide. In the increasingly lost language of depth psychology this was referred to as a "psychopomp" who was to be followed, learned from, and negotiated with. A poet from the ancient world captures this "guide/teacher to follower/student" procession through the portal of a man’s suffering:

ON RESURRECTION DAY

On Resurrection Day your body testifies against you.
Your hand says, "I stole money."
Your lips, "I said meanness."
Your feet, "I went where I shouldn’t."
Your genitals, "Me too."

They will make your praying sound hypocritical.
Let the body’s doings speak openly now,
without your saying a word,
as a student’s walking behind a teacher
says, "This one knows more clearly
than I the way."

- RUMI

This process and procession through the "symptom-body" as a portal requires what James Hillman has called "psychological faith": an inherent belief that one’s own psychological life is not against you nor somehow out to get you by presenting this symptom and initiating this process in your life. That is to say, your own psychology knows what is needed in your life and knows precisely what it is doing. The question then becomes: is the man paying attention to what the symptom is doing or wants? Attention in the sense of tending to and noticing the details the symptom itself presents and then carrying, being with and negotiating with those details as they are not as you would wish or judge they should be. Otherwise you can fall into all manner of delusions and denial about what the "problem" is and what can be done about it. This process requires the same efforts of time and tending by the practitioner who must continually be "in consultation" with the symptom and psychology of the man being worked with.

The question and concern I always keep in mind regarding the Pathology and Problem paradigms is how these help or hinder what the symptom is doing and what the man’s psychology wants (i.e., not just what the "ego-complex" wants). In the admirable goal of healing suffering I have seen these approaches abort the process of transformation the symptom has initiated. Aborted through drugs that numb the "felt-sense impact" (i.e., the "symptom-body") the symptom carries with it to get the man’s attention to tend to, carry, and be with the symptom. Thereby furthering his passage through the portal of changes required by his own psychology in order to reach the more vivified, full ranged, and genuine personal life intended by his own psychology.

In the Problem paradigm the process may well be aborted as the practitioner "intervenes" with cognitive-behaviorally based or problem-solving methods to "enhance adjustment and improve current level of functioning". I imagine this scene as the practitioner and client discussing and implementing intervention strategies while the symptom (who probably doesn’t want to be intervened upon nor strategized about, seeing these as intrusions upon what it is doing based upon its own wisdom) sits in a corner of the consulting room ignored and already knowing precisely how the symptom will be re-presented to the man’s life. It is a rule in psychology…get the message or get worse. If ones approach is to in fact declare war on the symptom by seeking to eliminate it then you may well have the endlessly returning client who needs yet another "medication adjustment" or another therapist.

* * *

Men’s depression was offered two dignified containers in which to place and view the pain associated with its pathos in the last two decades. Both emphasized the notion of "descent"…of depression in a man being the downward movement initiated by a man’s own psychology to get him to attend to the stagnating/threatening/ withholding/limiting/ingenuine aspects of his life that keep him from a full ranged and vivid experience of life as it truly is as he truly is. In other words, to hide, repress, or deny any truth/genuine aspect of himself as he is or of his actual experience as it is will summon the required symptom/pathos perfectly suited to initiate the transformation process…then the journey on "the road of ashes" and through "the dark night of the soul" begins.

The first and most impactful container offered was the Mytho-Poetic Men’s Movement of the 1980’s and 1990’s. Robert Bly (an insightful and award winning poet), James Hillman (a second generation Jungian analyst and leading founder of the "Archetypal Psychology" mode of thought), and Michael Meade (a mythologist and master story-teller) put together several men’s gatherings that gave men alternatives to exploring the grief under their depression (which in turn was hiding under the task-oriented/achievement style of their lives) other than the "sickness requiring treatment and cure" approach of the medical model ruling the healing professions. How can men identify with "sickness" when, though suffering secretly, they function or excel in the task-oriented (nowadays the "multi-tasking") world which remains the cultural standard of measurement for men? The corollary of this is the man who isn’t functioning in the task-oriented world is shamed. He then experiences help offered as further shaming as he is now "sick" or "maladjusted". No wonder men don’t come to therapists save coercion or last resort.

Bly, Hillman, and Meade pointed to the experience of suffering, with its symptoms and pathologizings, as a portal descending through "…that place among the rocks…a winding path" that Roethki’s poem so beautifully touches on. Further, they pointed to the experience as universally masculine though with idiosyncratic manifestations of intensity and type depending upon a man’s individual psychology and its requirements. They in effect were saying: this suffering path is an essential part of a man’s journey throughout life not a path of being "sick", "maladjusted", "abnormal". The path is quite "normal" though with varied or even bizarre/phantasmagoric manifestations.

In order to provide the largest container possible to hold the myriad expressions of men’s depression, rage, and grief these three men returned to story, poem, and song opening men to that mysterious and far ranging fullness of the deep masculine hidden in the dark wood or lying in the deep pond of their bodies. As Rumi suggests in his poem a man’s body has its own wisdom and is his true self…without a body he would neither exist nor be. These experiential and expressive methods, used for thousands of years, evoke a felt-sense connection with a man’s body, with other men and with men who have gone before them (i.e., the time honored idea of masculine ancestry furthering men’s sense of being a man rather than an oddity outside the norm, sick, shamed, and alone).

* * *

A second container offered for men’s depression is best represented by Terence Real in his book "I Don’t Want to Talk About It", though his container is not as immense and comes dangerously close to returning the dark night of the soul back to the Pathology and Problem containers of the medical model rather than the universalizing and welcoming of a men’s work community. His excellent contribution is his idea of "covert’ vs. "overt" depression in men. He details covert depression as a common experience among men with plenty of men’s personal stories to carry the common experience forward by allowing the reader to identify with the actual experiences of other men. This, as the stories in the Mytho-Poetic Men’s Movement, carries a man into community rather than isolate him as a "case history". In other words, stories, whether ancient or personal and immediate, grant men the entry point into the dilemmas of their lives and the community of men.

Overt depression is the classic diagnostic category of clinical depression that is typically seen in the practitioner’s consulting room (i.e., poor appetite, disturbed sleep, poor concentration, blue mood, feelings of hopelessness and non-motivation, etc.). Covert depression is "the hidden" depression in men. The idea is a man’s life enactments, his apparently functional or even excellent routines are in fact symptoms designed to carry him into and through the portal of transformation. They are suffering points for he and his family though not seen or noticed as such (i.e., he is unconscious/unaware). One frequently seen example is the successful professional with advanced degrees, on the board of you name it, meeting life’s obligations, admired in the community, and generally enacting a compulsive work life. When he shaves he has bizarre fantasies, episodically, of cutting his own throat and is shocked by this intrusive thought and shakes it off. His kids have no personal relationship with him and his wife develops a compulsive spending life to keep her distracted from the loneliness she feels in the marriage. He may rely on alcohol and, perhaps, sex to keep him…just so. But he wouldn’t "see it that way". Our man suffers from what is humorously dismissed as "work-a-holism" with a strong dose of compulsive "heroic" achievement.

Compulsive "cover-ups" enact themselves while the person suffering from them doesn’t notice the details of the symptom nor what it is doing in his actual life. He doesn’t see life as it truly is as he truly is. He is covertly depressed working his way toward a bottom…what I call the portal of the "down and out" road into a new life which is symptomatically working just under the surface of his "up and up" road he over identifies with to avoid his depression, grief, and rage.

This "up and up" road has been referred to as "ascenscionism" and is the dominant unconscious symptom operative not only in modern men’s psychology but in the collective psychology of the culture. And, as in a man’s life, the change required in the collective psychology of the culture by the symptom of "ascending" (e.g., higher profits, religions of transcendence, medicines of getting better, thrill seeking forms of "extreme" entertainment, etc.,) will be "descending" toward a fuller ranged experience of what life is. Yeats, the poet, saw this one coming:

THE SECOND COMING

Turning and turning on the widening gyre,
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world.
The blood-dimmed tide is loosed, and everywhere
The best lack all conviction, while the worst
Are full of passionate intensity.

Surely some revelation is at hand;
Surely the Second Coming is at hand.
The Second Coming! Hardly are those words out
When a vast image out of
Spiritus Mundi
Troubles my sight: Somewhere in the sands of the desert
A shape with a lion body and the head of a man,
A gaze blank and pitiless as the sun,
Is moving its slow thighs, while all about it
Reel shadows of the indignant desert birds.
The darkness drops again, but now I know
That twenty centuries of stony sleep
Were vexed to nightmare by a rocking cradle,
And what rough beast, its hour come round at at last,
Slouches towards Bethlehem to be born?

WILLIAM BUTLER YEATS

Compulsive work, drinking, drugging, sexing, thinking, relating, religioning, eating, entertainment seeking, aggressing (to name just a few) are highlighted by Real as symptoms that can point toward the portal of required and necessary change if tended to and heeded. If not, these continue in their de-structuring aspect by gradually intensifying both the suffering the symptoms cause and the man’s inability to see these as they truly are in his life (in the field of addictions this is referred to as "denial"; in the mental health field, "repression"; while in biblical language it is most famously captured in the phrase "hardening of Pharaoh’s heart"). Remember the rule…get the message or get worse.

* * *

In Real’s presentation the life experiences not seen nor tended to that are being pointed to by the symptom of compulsive cover-ups are trauma events in the man’s life and his reaction to those events in the form of unconscious conclusions/decisions about himself and his life world. Trauma events are described as the "too much" or "not enough" experiences in a man’s life. "Too much" experiences are events like physical abuse, sexual abuse, or emotional abuse:

o Too much closeness with a parent to prop up a parent’s pained life.

o Too much expectation and judgment vs. acceptance and interest in the child as he is.

o Getting angry enough to hit the child but phrase it as discipline for the child.

o Showing interest in taking time with a child only to seduce him into a sexual encounter.

"Not enough" experiences are a type of "violent lack" of something needed:

o Lack of face-to-face time with a father (I’ve worked with countless men who only received 2-5 minutes of face-to-face direct interaction time on an average day with their fathers growing up…and that time was usually spent being questioned or corrected rather than being personal).

o Lack of active and genuine guidance usually in the form of "deprivation teachings" (groundings, removal of privileges and personal possessions, taking away a boy’s personal say to the point he no longer has one, go to your room, be quiet, sit still, don’t bother me, etc.).

o Lack of nurturing touch by a father (many men’s only experience of touching or being touched by a father is hitting or being hit).

o Lack of personal boundaries being respected (as when a mother cannot meet her own emotional needs and over bonds with her son as "surrogate spouse"; also known a "Psychic incest").

Reactions to such trauma events are at least as impactful as the traumas themselves. These reactions are described as survival based strategies that are a boy’s best attempts to make sense of and get through the shadowy life of the family. In very general terms it basically works this way:

o A boy suffers a "too much"/"not enough" trauma or ongoing series of these, which is most often the case.

o He gets through these experiences by coming up with a series of decisions and conclusions about himself and his world that are made and registered far below the level of consciousness.

o These decisions and conclusions make the trauma "about him" (it is his fault dad hits him, it is his fault mom isn’t happy, it is his fault he doesn’t measure up to expectations, etc.).

o This saves him from realizing (i.e., making real) the unsafe and dangerous place his parent and family world actually is and how powerless he is to control for his safety needs in such a place.

o At the same time these decisions/conclusions provide the illusion of control. If it is all his fault then he has the power to change it all. When he changes his "faults" enough then he will be safe in a safe world (when he is good enough, smart enough, performs enough, helps out enough, is violent enough, drunk enough, busy enough, sexy enough, religious enough, eats enough, is out of the way enough, sensitive to women’s needs enough, etc., etc., ad nauseum).

This control-for-safety is what I call "the deal made" based upon the decisions and conclusions the boy reaches in response to the traumas he has suffered. In adulthood these deals are re-enacted as compulsive activities that seek to keep a man from the awareness and felt-sense of what is true and genuine about himself as he is and his life experience as it is (i.e., wounded, unsafe, and out of control). This is what D.H. Lawrence pointed to that needed healing in the phrase "…a realization of life’s mistake and the endless repetition of that mistake…". These compulsive/repetitive "deals" are what must be "realized" (i.e., noticed and tended to) in a man’s healing process as much as, if not more than, the original trauma.

* * *

One of the most insidious yet culturally reinforced survival based strategies that is compulsively re-enacted by men is what is humorously referred to as "work-a-holism". The humor allows us to, tongue in cheek, both look at and "blow-off" a painful realization pressing upward into awareness. Much like boys whistling to themselves as they go through a graveyard.

In my experiences with men compulsive work isn’t limited to spending time at the office, factory, or job site. The heart of this compulsion is activity (or "doing") and, oddly enough, inactivity (or "not doing"). A man works, comes home and goes out to the garage, basement, den, upstairs to work on a ceiling fan…tinkering but never really "finishing". He never sits still to be available for face-to-face genuine encounters with family or himself.

If he isn’t "on" this mode he is "off". I do mean "off". "Out" in the chair, lost with the channel changer and TV or napping. Or he is "off" on the motorcycle, fishing, golfing, softballing, baseballing… those activities of the shoulder-to-shoulder world of men that is truly wondrous but doesn’t hold experiences of sufficient depth that could further a man’s life. These too, then, become an avoidance of intimacy with self and others.

The overall felt-sense about this man, whether "on", "off", or "out", is he really isn’t present to the moment, himself, or others. You just know you are receiving a well-worn routine persona. Men are particularly adept at seeing this absence in a man’s eyes…but not in their own.

Because he is active and functioning or "resting and recreating" he is not seen as depressed. Hence the genius of Real’s formulation: COVERT depression. Men live whole lives like this and then begin to notice how truly unhappy they are with the results without knowing why. This happens vaguely at first but with more urgency as time goes on. Needless to say, this noticing process, once started, is very confusing to the man:

WHO MAKES THESE CHAGES?

Who makes these changes?
I shoot an arrow right.
It lands left.
I ride after a deer and find myself
chased by a hog.
I plot to get what I want
and end up in prison.

I dig pits to trap others
and fall in.

I should be suspicious
of what I want.

- RUMI

So the symptom, the workaholism and its consequences slowly pushes a man toward realizing what is true about him and his experience while simultaneously protecting and shielding him from what is true about him and his experience. While this process is confusing to go through one thing is clear…a man’s nemesis is his guide.

Real’s covert depression as compulsive re-enactments that may look "functional" from the outside is a great breakthrough concept for working with men’s issues. Equating these symptoms as manifestations of portals through a wounded life that is the common experience of manhood holds the promise of easing the shame men feel about the suffering in their lives and getting help. It dignifies a man’s pain by emphasizing he is every man…he is hu-MAN

--Michael Eatmon, LCSW

 

 

 

The following is an archived article written by Dr. Bambenek concerning the issue of mental health services in Evansville.

Crisis? What Crisis?

Recently, there has been much commotion in the media concerning problems with the lack of psychiatric services in the Evansville area.  It is true that our community has suffered the loss of at least 6 psychiatrists in the last 2 years, but by my assessment we have also gained 4 new psychiatrists in that same time span.  Our Yellow Pages list 13 practicing psychiatrists that still have offices in Evansville.  In addition, Southwest Indiana Mental Health employs 8 psychiatrists, Deaconness Cross Pointe employs 4 psychiatrists and Mulberry Center has a full time psychiatrist devoted exclusively to inpatient care.  Without even considering the psychiatrists that work at the State Hospital, that gives us a total of 26 practicing psychiatrists.  If you compare the ratio of psychiatrists to the population of the Evansville community, you can see that this is a reasonable number of doctors for an area of this size.  If you contrast these numbers with those from similar metropolitan areas, I believe Evansville compares quite favorably.

What is the real problem then?  Patients are having unacceptably long waiting periods for new appointments and in fact some patients are unable to even obtain an appointment.  I would suggest that these problems have much more to do with the insurance/managed care industry in our area, and what types of health insurance these individuals have.  With the onslaught of managed care's restrictive treatment options, unfairly low reimbursement rates and draconian approval and payment processes, many psychiatrists have had to learn, oftentimes the hard way, that to even survive they must carefully consider what plans they can accept.  This process involves careful examination of what each plan pays, what type of therapy the plan will "allow," scrutiny of the plan's "pre-approval" processes, evaluation of how much paperwork and staff time the plan will require and if the plans even pay at all.  One company that is prevalent in our area is famous for it's delayed payments.  This company needs legal threats to pay their already abysmal claims that are over a year old!  They will approve a visit at one rate and when they do pay, the rate is lower.  Many doctors are also reluctant to accept Medicare and Medicaid not only because of the minimal reimbursements, but because of the bureaucratic requirements and fear of the consequences, both financial and criminal, if even an unintentional paperwork error is made.    

I believe if you were to speak with individuals who are having difficulty obtaining mental health appointments, they may well fall into one of the above categories.  Southwest Indiana Mental Health is mandated by our state to care for indigent patients as well as Medicaid clients, however they accept some private insurance patients as well.  With this they are obviously very busy, and the wait for a new appointment can be long.

As for others in need:  I would urge you to carefully examine the mental health benefits in the policy that you are paying for.  Sadly, there are short-sighted policies that do not even cover mental health needs.  Call and see what approved psychiatrists your policy allows.  If their list is short, ask your insurance company why they do not have more local doctors on their panel.  It may be that individual doctors have quit them, or the insurance plan may just be very restrictive about letting well qualified physicans on their panels because this saves the company money.  There are some excellent local health insurance policies with fair rates and reasonable paperwork procedures, and I suspect that people with these policies are not having much difficulty finding appointments.  If you are having difficulty locating a psychiatrist or other mental health professional, please call us.

                                                                John C. Bambenek III, MD