Cognitive–Behavioral Treatment of Depression in Men

Abstract

Depression is a significant public health issue and many researchers have suggested that modifications to conventional cognitive–behavioral therapy (CBT) are required to address infrequent help-seeking in men and counter negative effects of traditional masculinity on therapeutic engagement. This narrative review summarizes recommended alterations to CBT in the areas of therapeutic setting, process, and content. Key themes from this literature include a focus on behavioural interventions, and harmful cognitions that orginate from the traditional male gender stereotype. This literature is marked by limited empirical support for many of the recommended treatment modifications, and several options for future research are outlined.

Depression is a major public health issue with lifetime prevalence rates of over 16% (Kessler et al., 2003). Cognitive–behavioral therapy (CBT) is a well-validated psychological intervention available to treat this problem (Beck, 2005; Butler, Chapman, Forman, & Beck, 2006; Cuijpers et al., 2013). Despite this, it is well-established that males hold less favorable attitudes toward help-seeking and utilize formal assistance less frequently than females for depression and other psychological problems (Chan & Hayashi, 2010; Curtis, 2010; Moller-Leimkuhler, 2002). Several researchers have highlighted the role played by gender socialization in these findings. For example, an inverse relationship has been identified between adherence to traditional masculine norms and help-seeking attitudes (Berger, Addis, Green, Mackowiak, & Goldberg, 2012; Berger, Levant, McMillan, Kelleher, & Sellers, 2005). There is also a negative relationship between endorsement of traditional masculine norms and likelihood of presenting for CBT (Primack, Addis, Syzdek, & Miller, 2010).

Once attending therapy, the traditional masculine stereotype can also contribute to difficulties with therapeutic engagement and process. The reluctance of some men to seek and effectively engage with treatment appears to reflect an incongruence between traditional gender norms, depression, and the process of psychotherapy. Men with a history of low mood experience discomfort when talking about depression because this problem embodies characteristics perceived as incompatible with the traditional masculine stereotype (Rochlen et al., 2010). Other men have been reported to view psychotherapy itself as antimasculine (Englar-Carlson, 2006). For instance, men (portrayed in vignettes) who seek help for depressive symptoms are rated as more feminine compared to those who do not seek assistance (McCusker & Galupo, 2011).

The above findings suggest that male-specific considerations and modifications to psychological treatments such as CBT may be needed in order to improve treatment engagement and address the negative effects of traditional masculinity. While several researchers have made recommendations to this end, there is limited integration and synthesis of this literature. The current narrative review attempts to addresses this gap in a way that both informs current practice and identifies future research directions. The current review focuses on the following questions: What is the rationale for favoring CBT as a treatment model in men’s depression? What gender-relevant theoretical work can be integrated with this model? What specific process and content issues have been identified in men’s depression treatment? While there are various forms of masculinity (Connell & Messerschmidt, 2005; Englar-Carlson, 2006), a full review is beyond the scope of the current review. The current review instead focuses on hegemonic or traditional masculinity because it is widely discussed and has been associated with various negative outcomes in men (Courtenay, 2003).

Method

To address the review questions, an electronic search was conducted of PsychINFO, PubMed, MEDLINE, and Google Scholar for relevant English-language peer reviewed journals published between 1990 and 2013. An initial list of publications was generated via a database search using the keyword terms “men,” “males,” “masculinity,” “gender stereotypes,” “depressi*,” “treatment,” “therapy,” “psychotherapy,” and “treatment.” A secondary search was conducted by manually reviewing reference sections of works returned from the initial database search. Also, a hand search was conducted for articles in relevant peer-review academic journals including Journal of Men’s Health and Gender, Psychology of Men & Masculinities, International Journal of Men’s Health, and American Journal of Men’s Health.

What Is the Rationale for CBT in Men’s Depression?

Perhaps the clearest case for a specific therapeutic modality for use with men exists with CBT (e.g., Brooks, 2010; Primack et al., 2010). CBT is the most well-validated psychological intervention for unipolar depression among both men and women (Butler et al., 2006; Driessen & Hollon, 2010; Gould, Coulson, & Howard, 2012). However, we are as yet unable to provide a definitive response to the question of which psychological treatment overall is most effective in treating men’s depression. This is on account of the lack of empirical data with which to make gender comparisons between treatments. While several meta-analytic studies of psychotherapy outcome for depression are available, the exclusion of analysis with potential moderator variables such as gender has been identified as a limitation of this literature (Butler et al., 2006). Furthermore, many treatment models have been recommended for use with depressed men, but there is often unclear and/or limited rationale provided for adopting a specific treatment approach. In the absence of additional outcome data by gender across various treatment modalities, Tolin’s (2010) argument that CBT should be the treatment of choice is prudent.

Aside from treatment efficacy data, the focus on cognitive restructuring has been identified as a key reason for using CBT with men (Brooks, 2010; Primack et al., 2010). Primack et al. further suggest that cognitive rigidity around gender roles contributes to poor engagement and retention in psychotherapy, and that increased flexibility may yield improved treatment outcomes for men. For instance, men who hold traditional gender identities are less open to disclosure in psychotherapy (Pattee & Farber, 2008). Lorber and Garcia (2010) also reported that high levels of traditional masculinity lead to ambivalence and early termination of therapy. These findings suggest that an inflexible cognitive style can interfere with therapeutic process and engagement. Addressing cognitive rigidity through CBT techniques may improve therapeutic process and outcomes. This approach would also be consistent with a recent emphasis on the benefits of psychological flexibility for overall well-being (e.g., Kashdan & Rottenberg, 2010). Close adherence to traditional masculine identity has also been associated with negative mental health outcomes (Alston & Kent, 2009; Courtenay, 2003).

While other features of CBT have been promoted as “male-friendly,” these tend to be based on opinion, rather than a clear theoretical and empirical platform. For example, the argument has also been made that CBT is suited to men because of a practical focus on behavior and relative de-emphasis (compared with other treatment models) on emotion/affect (Brooks, 2010). While such arguments may be relevant, they are in need of further empirical support. In sum, CBT for men’s depression appears to be a treatment model with an identified empirical and theoretical rational. The main reasons for this include the strong extant evidence base and the utility of cognitive restructuring techniques in addressing inflexible and rigid forms of masculinity. Other claims have been made around the suitability of CBT in men’s depression, but further research is required to validate these claims. Because of these arguments and the frequent reference to CBT in the literature on men’s depression, this therapeutic model is emphasized in the remainder of this review.

Gender Role Theory and the CBT Model

The general CBT model does not make specific reference to or predictions with respect to gender socialization. While several models could potentially be applied to men’s depression, those with a strong cognitive and behavioral focus may be particularly compatible with the general CBT model. Bem (1981), via her gender role schema theory, hypothesized that cultural influences shape an individual’s model of masculinity and femininity. These schemas are highly pervasive across all domains of life guiding what is considered “acceptable” and “unacceptable” enactments of gender. The concept of a gender model also relates to work conducted by Joseph Pleck (1995) who argued that gender roles lack consistency and coherence thereby leading to “gender role strain.” O’Neil, Good, and Holmes, (1995) have extended Pleck’s work with “gender role conflict.” They argue that gender role conflict occurs when “rigid, sexist, or restrictive gender roles result in personal restriction, devaluation, or violation of others or self.” (pp. 166-167). While social constructionist and socialization theories have different epistemological foundations, Addis (2008) argues that research should consider different models of gender as no one theory of men’s depression can fully encapsulate this phenomenon.

These models can be incorporated within the general CBT model to help practitioners and clients understand gender-related mechanisms that lead to mental health problems such as depression. For example, deviating from the prevailing gender schema/role is predicted to cause distress (according to the gender-role strain framework) and could be viewed as a “critical incident” (stressful life events such as loss of employment, bereavement, physical illness) where dysfunctional beliefs and assumptions are activated (Westbrook, Kennerley, & Kirk, 2011). Alternatively, failure to live up to stereotypical masculinity may result in stress and maladaptive compensatory behaviors; both of which may contribute to the development and maintenance of depression.

The aforementioned gender-related theories are helpful in that, in the context of a general CBT model, they can be used to draw out gender-specific cognitive and behavioral contributors to the development and maintenance of depression. What currently lacks is the formal integration and testing of gender-specific theories within the general CBT model. There are also at least two important caveats when applying theoretical work to men’s depression. Mahalik (2008) states that there must be an emphasis on a broad (biopsychosocial) framework to conceptualize men’s depression in order to avoid an overemphasis on gender socialization. The second caveat concerns the concept of “multiple masculinities.” Englar-Carlson (2006), among others, argues that multiple forms of masculinity exist and that it is therefore important to guard against being overly influenced by hegemonic masculinity.

Identified Process Issues and Therapeutic Setting

The impact of masculine stereotypes on therapeutic engagement and process has been discussed by several authors. Because help-seeking and engagement in psychotherapy is seen as feminizing through the lens of traditional masculinity (Mahalik, Good, & Englar-Carlson, 2003; Rochlen et al., 2010), the possible use of compensatory strategies has been suggested. While there have been limited attempts to identify specific strategies used by men, research cited above suggests that, particularly for gender traditional men, phenomena such as limited disclosure and ambivalence may maifest. Englar-Carlson (2006) suggests that therapy-interfering processes have multiple causes including, for example, fear of being stigmatized (for attending treatment) and fear of being coerced into particular treatment strategies (experiencing a loss of power). Courtenay (2000) argued that, like other behaviors, health behaviors are an opportunity for men to “demonstrate masculinity.” Therefore, it is possible that men may engage in unhelpful responses to maintain or restore a perceived departure from an idealized model of masculinity.

In light of the potential role of unhelpful process issues, some researchers have attempted to suggest specific strategies that may counteract their negative effects. The following recommendations come from Englar-Carlson (2006) and Mahalik, Good, Tager, Levant, and Mackowiak (2012):

1. Normalize ambivalence about therapy and acknowledge differences between psychotherapy and masculinity. ¹

2. Emphasize collaboration or a “power sharing” model of treatment including the use of regular therapist self-disclosure.

3. Use nonclinical language where possible (e.g., call sessions “coaching” rather than therapy).

4. Consider being physically active during sessions (e.g., getting out of chairs, walking around).

5. Make the physical treatment environment “male-friendly” (e.g., supplying newspapers).

Working in Groups

A case has been made by some researchers for using a group treatment format for men’s depression. Kiselica and Englar-Carlson (2010) argue that males have an affinity for working together in groups and a long history of interacting in this way. James Mahalik and colleagues (Mahalik, 2008; Mahalik et al., 2012) have also argued that perceptions of how other men exhibit and respond to depression can be therapeutically used witinin a social learning model. Thus, a group therapy format may be useful in that it allows men to observe other men adopting adaptive mood management strategies, thereby encouraging a less rigid model of masculinity (Kiselica & Englar-Carlson, 2010). This also raises a potential indirect (behavioral) means of countering cognitive rigidity and may be more acceptable to clients who do not engage well with a cognitive restructuring/reality testing approach. Other potential advantages of treating men’s depression in a group format include an opportunity to strengthen social support networks and the generalization of treatment strategies. Social support has been previously reported as a predictor of treatment effectiveness in group CBT (Hoberman, Lewinsohn, & Tilson, 1988). However, it is currently unclear whether group intervention is more effective than individual treatment for either gender, let alone for men specifically. While Cuijpers, van Straten, and Warmerdam (2008) reported a small effect size in favor of individual over group treatment in their meta-analysis, clinical significance was questioned, differences were not evident at follow-up (1 and 6 months) and findings were based on a small sample.

To summarize, a number of suggestions have been made to make the therapeutic environment conducive to positive engagement with men. However, further work is needed to test the validity of these recommendations. A case has also been made for conducting treatment with men in group settings, but further empirical research is similarly required to assess the relative efficacy of group versus individual treatment.

Identified Content Issues

A number of authors have made recommendations regarding how best to modify conventional CBT to be more male-friendly. However, there are a limited number of examples of CBT protocols explicitly adapted for men. An exception is Primack et al. (2010) who describe a “Men’s Stress workshop” (so called in order to avoid references to depression). The Men’s Stress Workshop is a program that incorporates conventional CBT elements (stress and relaxation, psychoeducation, identifying negative thought patterns, challenging negative thought patterns, experience mapping) along with coverage of masculine gender-role socialization in an 8-week program. These authors state that the program was structured to appeal more strongly to clients endorsing traditional gender roles. Efficacy data has only been reported with a small sample (N = 5) despite positive change in depression scores. Clearly, further evaluation is required to establish efficacy of a modified program prior to any trials comparing conventional and modified CBT protocols.

The remainder of the section summarizes the recommendations made for working with men in the areas of psychoeducation, cognitive interventions, behavioral interventions, affective interventions, and interpersonal interventions and socialization.

Psychoeducation

A key component of many treatment models including CBT is the provision of psychoeducation. In addition to presenting conventional educational topics (e.g., presenting a psychological model of depression), the literature presented above would suggest that psychoeducation with men needs to include an overview of the potential role played by rigid adherence to traditional masculinity. Oliffe et al. (2010), for example, argue that depression is perceived by some men as a barrier to enacting masculine stereotypes. Cochran and Rabinowitz (2003) suggest that emphasis should be placed on the potentially depressenogenic effects of perceiving oneself as not adhering to stereotypical norms. As already indicated, practitioners need to guard against an overemphasis on gender socialization (Safford, 2008), but this material may represent a useful addition to a conventional educational package.

Cognitive Interventions

The content of depressenogenic cognitions is an important focus in CBT. For instance, the identification and modification of “cognitive biases” (e.g., dichotomous thinking, catastrophization) is an often-used technique (Westbrook et al., 2011). Emslie, Ridge, and Hunt (2006) and Mahalik (1999) have attempted to consolidate masculine-specific cognitive distortions into several thematic areas. These include themes of success (e.g., “I must win against others to be worthwhile”), power (e.g., “I must be powerful or I am worthless”), emotional control (e.g., “I cannot express my feelings because others will see me as weak”), fearlessness (e.g., “People will think I am a wimp if they know I’m scared”), and self-reliance (e.g., “Asking for help is a sign of weakness”). These authors have recommended the use of conventional cognitive–therapy strategies in working with these distortions (e.g., self-monitoring of thoughts, helping clients to recognize the thought–behavior link).

In terms of information processing issues, cognitive inflexibility around masculine schemas has been argued as an important treatment focus as indicated above. A conventional reality testing approach incorporating behavioral experiments has been advocated to address these cognitions (Cochran & Rabinowitz, 2003). In focus group discussions, some male participants have reported using the concept of multiple masculinities as a way to adaptively adjust to the experience of depression and hegemonic masculinity (Oliffie & Phillips, 2008). Such efforts may tap more fundamental cognitive change (akin to Beckian core belief concept) and may be a useful way to help men develop more cognitive flexibility without inadvertently conveying the message that an existing view of (traditional) masculinity is “wrong.” Skarsater, Dencker, Haggstrom, and Fridlund (2003) used the term restoring one’s health in referring to an adaptive reprioritizing activities/demands to manage mood disturbance. These authors also reference participants who endeavored to find meaning in their experiences of depression and accepting those circumstances. Such examples could be used therapeutically with men to demonstrate and model adaptive changes in thinking.

While masculine norms can lead to damaging outcomes (e.g., excessive risk-taking, self-destructive behaviors, negative help-seeking attitudes; Englar-Carlson, 2006), some argue that features of traditional masculinity can be cognitively reframed for therapeutic benefit. Kilmartin (2005), for example, highlights the concept of courage being seen to represent taking risk by going against the gender stereotype and seeking help. Alternatively, treatment seeking can be seen to demonstrate independence (e.g., not “following the crowd”) and leadership (e.g., being a model to others for adaptive responding to psychological distress). Strengths-based treatment models are widely reported in the literature (e.g., strengths-based cognitive–behavioral therapy; Padesky & Mooney, 2012), and the increased focus on the clinical applications of the burgeoning field of positive psychology has also been considered (Wood & Tarrier, 2010). Kiselica and Englar-Carlson (2010) have presented a positive psychology/masculinity framework and argue that a strength-based approach should be central to therapeutic work with males.

Behavioral Interventions

Brooks (2010) has argued that behavioral therapeutic strategies may be particularly suited to men due to their practical and tangible nature. This is consistent with recommendations made by Englar-Carlson (2006) who suggests that sessions with men should be practically focused through the use of tangible session goals/outcomes and an emphasis on “fixing” problems.

Avoidant coping has been associated with higher levels of depression in men (Iwamoto, Liao, & Liu, 2010). Avoidance in men has been viewed as a negative coping strategy that can come in both cognitive (e.g., denying, minimizing) and behavioral forms (e.g., substance use, gambling; Carvalho & Hopko, 2011). Of these behavioral manifestations, drug use and active symptom concealment have been specifically cited strategies among men. Therefore, the role of substance use in men’s management of depression is likely to be an important treatment topic. For example, Mahalik and Rochlen (2006) reported that the strategy “Have a few drinks” was commonly employed by men and significant correlated with conformity to masculine norms (r = 0.27, p < .01). In their thematic analysis, Oliffie, Galdas, Han, and Kelly (2013) described the “risk-reliant” man who uses alcohol and drugs to self-manage and avoid professional help. Avoidance has been hypothesized to contribute to depression through various mechanisms including reduced positive experiences and reinforcement, promotion of information processing biases, and repetition of attempts to achieve unattainable goals (Trew, 2011).

Some studies have reported men deploying adaptive behavioral strategies. One of these is aimed at maintaining or restoring valued social and occupational roles. In a qualitative study by Chuick et al. (2009), some participants reported an increased or renewed focus on one’s occupational life. Supporting men to maintain or reestablish engagement with valued social/occupational roles could be an important treatment strategy provided this is not primarily used as a distraction strategy. Other adaptive behavioral strategies have also been reported including behavioral activation (Skarsater et al., 2003) and physical exercise (Mahalik & Rochlen, 2006) as examples. However, it is again important for the therapist to draw out the intended functions of behaviors. Mahalik and Rochlen (2006) indicated that exercise correlated significantly with the Conformity to Masculine Norms Inventory (r = 0.22, p < .01; Mahalik & Rochlen, 2006). This may suggest that some men see functional value in exercise in terms of compensating for the anti-masculine nature of depression, rather than as an adaptive symptom management strategy.

Interpersonal Interventions and Socialization

There has been limited research looking at interpersonal factors that maintain men’s depression; however, therapy focused on interpersonal relationships may be particularly useful given that relationship disruptions can result in more adverse consequences for men compared with women (Cochran & Rabinowitz, 2003). Lay coping strategies have been identified in the literature as a set of approach behaviors that appear to represent efforts to promote functioning through social engagement and preservation of existing social roles. For example, Jensen, Munk, and Madsen (2010) reported that some men look to increase their frequency of social engagement in response to depression. Oliffe, Orgrodniczuk, Bottorff, Johnson, & Hoyak (2012) described a similar process as “countering by connection” in which men reported (N = 38) using existing social supports and/or spiritual/moral guidance along with engaging in masculine roles (father role). While there are few specific recommendations made in this area for men’s depression, the above literature suggests that therapeutic activity scheduling may need to account for some men’s wish to build social support networks and/or promote valued social roles. Again the potential value of conducting treatment in group settings may be relevant here especially with regard to building social support.

The role of significant others in the maintenance of depression via cognitive and behavioral mechanisms has also been discussed. For example, Mahalik (1999) has argued that many women internalize some masculine-related cognitive distortions (e.g., I must be Superwoman). Accordingly, therapists may need to be aware of cognitive distortions may be maintained in men, in part, by endorsement of such distortions by other people. Alternatively, Oliffe, Han, Ogrodniczuk, Phillips, and Ro (2011) have suggested at least two mechanisms by which couples attempt to manage men’s depression: (a) “trading places” occurs where couples assume atypical gender stereotypical roles to cope with depression effects and (b) a “business as usual” approach is taken whereby reinforcement of masculine gender roles is promoted (to manage and conceal problems resulting from depression). These authors further suggest that “edgy tensions” can result when disparate gender expectations create tensions within a relationship. This may create additional pressure for a depressed man to maintain unhelpful cognitive distortions and/or roles. While much more research is required in this area, the above studies suggest it may be important for the therapist to consider the potential role of interpersonal factors in maintaining depression via change in social roles.

Use of Psychometrics

Recent developments in the psychometric assessment of men’s depression and key gender role constructs have been useful not only in the research context, but have the potential to be advantageous in clinical settings. Clinical instruments such as these are important, among other reasons, for monitoring therapeutic progress. There is an ongoing debate regarding the potentially gendered phenomenology of depression that is beyond the scope of the present review. However, the rationale for developing gender specific screening instruments is that men experience atytpical symptoms of depression such as anger, substance use, and risk taking (Martin, Neighbors, & Griffith, 2013), and instruments are needed that capture these symptoms. Instruments developed in this area include the Gotland Male Depression Scale (Rutz, 1999) and the Masculine Depression Scale (Magovcevic & Addis, 2008). For the Gotland Male Depression Scale, good internal consistency (Cronbach α = .86) and adequate external validity (correlation with the Major Depression Inventory = .77) have been reported (Zierau, Bille, Rutz, & Beck, 2002). Good internal consistency (.95) has been reported with the Masculine Depression Scale and significant correlations have been reported between its two scale factors and the Beck Depression Inventory (.80, .36).

Psychometric instruments have also been developed that relate to some of the clinical issues discussed above. Regarding gender stereotyping and gender role conflict, The Conformity to Male Norms Inventory (CMNI) can be used to examine how conformity can be associated with both benefits and costs (Mahalik & Rochlen, 2006). General guidelines for using the CMNI in clinical settings have been discussed by Mahalik, Talmadge, Locke, and Scott (2005). Internal consistency (alpha coefficient) of .94 has been reported for scale total score (Mahalik et al., 2003). The CMNI is correlated with the Gender Role Conflict Scale (O’Neil, Helms, Gable, David, & Wrightsman, 1986). For alexithymia, psychometrics include the Toronto Alexithymia Scale (Bagby, Parker, & Taylor, 1994) and the Normative Male Alexithymia Scale (Levant et al., 2006).

Summary and Future Research Directions

Depression is an important mental health issue for men and the current review has synthesized previously identified treatment issues and recommendations within a CBT framework. This treatment modality is currently the recommended model in men’s depression due to the existing evidence base, the availability of cognitive restructuring techniques to address traditional masculine-related thought content, and an emphasis on a practical skills-based approach. Key gender role/schema models such as Bem’s (1981) gender role schema and O’Neil et al.’s (1995) gender role conflict appear to compliment the general theoretical framework of CBT. Thus, these models can be used to enhance therapist and client understanding of the potentially depressenogenic role played by stringent behavioral expectations placed on some men.

The potential for rigid masculine beliefs to impair the development of a therapeutic relationship is the fundamental concern of several researchers. In response, a number of recommendations have also been made in the delivery of psychological treatment. These cover modifications and/or emphasis on specific issues within conventional CBT and range from modifications to conventional psychoeducation content to identifying and addressing specific behavioral issues. While several recommendations have been made to effectively modify conventional CBT to a more male-friendly format, many of these remain empirically untested.

A number of recommendations for future research can be made in the treatment of men’s depression. As already suggested there is a need for integration and testing of gender-relevant models within the general CBT model in a way that helps explain the mechanisms by which hegemonic masculinity impacts on therapeutic process and the development of depression.

There has been limited testing of CBT treatment protocols modified for use with men. The current review has identified a number of ways in which gender-neutral treatment programs could be tailored to men. These modifications require testing to determine their efficacy. Given the difficulties associated with conducting clinical trials (e.g., resource intensiveness, recruitment), researchers could initially focus on testing the therapeutic utility of individual components. For instance, one priority would be to empirically examine the relationships between cognitive inflexibility (as applied to the masculine stereotype) and depressive symptoms. Given the emphasis on increasing psychological flexibility in men, future investigations may also focus on the therapeutic benefits of increases in overall psychological flexibility on a wide spectrum of maladaptive cognitive and noncognitive responses to low mood (e.g., high-risk behaviors, experiential avoidance of affect). In this vein, the efficacy of third-wave approaches such as Acceptance and Commitment Therapy may be a useful focus of intervention studies in the future.

Several lines of enquiry could be pursued where men’s subjective experience of psychotherapy could be evaluated further. Because engagement and therapeutic rapport represent key issues in treatment with men, participant evaluations of “what works” could help build the evidence base of how to effectively engage with men in therapy. For instance, men could be asked about preferences for and barriers to participation in specific CBT techniques (e.g., reality testing, behavioral experiments). Another important area may be in testing whether men express a preference for group over individual treatment settings.

The current review highlighted concerns regarding the potentially negative impact of traditional masculine socialization on therapeutic process. One potentially useful avenue of enquiry would be the identification of specific “therapy interfering” behaviors that may occur during therapy. These are not currently well-validated empirically but this knowledge could provide useful information to practitioners in their work with men.

While not directly discussed in the current review, the issue of help seeking is an important one for men’s depression. Future research that helps clarify what gets men through the therapeutic “front-door” is needed. Clearly, effective treatments are largely irrelevant if no clients come forward to receive it. Aside from public education campaigns (e.g., the Real Men. Real Depression. initiative by the National Institute of Mental Health), Syzdek, Addis, Green, Whorley, & Berger (2013) have reported a one-session gender-based motivational interviewing study (N = 23). Results were not statistically significant but noted a trend toward increased help seeking from informal sources. Further work around such pretreatment interventions may increase help seeking and also assist men to come to treatment better prepared to engage.