Depression doesn’t go away for everyone. For most people, depression is temporary and passes naturally or once the person has expressed the feelings and resolved the thoughts causing the depression. But there is a small percentage of people who can talk about their issues, express their feelings, take very good care of themselves emotionally, even take medication and have a great life, and still be depressed throughout their lives. They may have periods of feeling good, periods of feeling less bad, and periods of feeling horrible—for these people, the depression never goes away permanently.

Major depressive disorder is the medical term for repeated episodes of a very intense, deep depression that is disabling and enormously painful. People who are bipolar experience similar disabling depression during their depressive phases. Often, between episodes, people return to a functional, happy state. Sometimes people can also have a milder depression, even between episodes of major depression but the feeling of depression stays.

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What is “Atypical” Depression?

There are also people with “atypical” depression who can be in a deep depressive episode and yet appear to come out of it long enough to laugh or enjoy something briefly before sinking back in, or can act normal for short periods. This can be confusing to both the depressed person and to other people. This isn’t an indication that the person is any less depressed or any less in danger than someone in a major depressive episode who doesn’t have those brief breaks. It’s just a different form. Atypical depression is also characterized by feeling emotionally paralyzed, physically leaden—barely able to move or engage in any activity, and often overeating, oversleeping, and experiencing sensitivity to rejection.

It’s difficult for most people to understand any kind of deep depression if they haven’t experienced it. What people see with illnesses or injuries is a runny nose, blood, expressions of acute physical pain, or an x-ray of what hurts. What people see when someone is seriously depressed is a person who isn’t doing anything; this person may be crying or snapping at them or sounding insecure and hopeless. These are behaviors we associate with personality and moral character—we think these are choices people are making, not an illness that has taken over their personality. Most people wonder why the unrelentingly depressed person doesn’t just get over it and may even wonder if it’s a manipulation or if the person is just lazy, weak, or giving in to something he or she could fight. It is difficult for the person who experiences it to describe because it is intensely painful, but not in any particular part of the body. It can be totally debilitating and sometimes even fatal.

Chronic, Servere Depression

People with chronic, severe depression are not indulging themselves, lazy, giving in, manipulating, or exaggerating their pain and dysfunction. Taking this view is often destructive to them and the situation. While this kind of depression can be described as an illness, compared to other debilitating, painful, potentially fatal illnesses, it is pretty unique in the affect it has on people’s minds, behavior, personality, and thought processes. When the mind is part of the illness, other people may not recognize the ill one as the person they love, and that makes it more difficult to be patient, to take care of the person, and to remember what they loved about the person, much like when a loved one has Alzheimer’s.

Of course, this is all true for someone who has one episode of major depression, but it becomes much more complicated when it is recurring and takes over a person’s life. We know that, statistically, every major depressive episode someone has makes additional episodes more likely. So once a person has had two or three such episodes, it’s pretty clear that more of them will happen, and likely with increasing frequency. It’s also likely that during significant hormonal events, such as menstruation, pregnancy, childbirth, perimenopause, and menopause, women with recurring major depressive episodes will be especially vulnerable to having another episode.

How does a person live with a chronic disability that can’t be effectively described to those around them? How do people function? How do loved ones take care of them long-term? How do relationships survive? Can depression last forever?

References:

1. Depression In-Depth Report. (n.d.). The New York Times. Retrieved from http://www.nytimes.com/health/guides/symptoms/depression/print.html
2. Women and Depression: Discovering Hope. (n.d.). National Institute of Mental Health. Retrieved from http://www.nimh.nih.gov/health/publications/women-and-depression-discovering-hope/index.shtml

People think of depression as really bad sadness, but it’s actually much more complicated. To be diagnosed with depression, a person has to have several (but not all) of the symptoms from a diagnostic list outlined in the Diagnostic and Statistical Manual (DSM). Sadness is one of these symptoms, but it is possible to have enough other symptoms on the list to be depressed and yet not feel sad.

The list of depression symptoms includes:

• Lack of interest or pleasure in anything
• Significant increase or decrease in eating
• Insomnia or over-sleeping
• Restlessness or being slowed down physically
• Fatigue or low energy
• Feelings of worthlessness or excessive guilt
• Inability to think, concentrate, or make decisions
• Suicidal thoughts or attempts
• Lack of enjoyment or interest in previously enjoyed activities
• Feeling hopeless, empty, or pessimistic

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Most people who are depressed feel sad, but there are several reasons some people can be depressed without feeling sad. These reasons may include:

• Numbness: One scenario that causes people to feel depressed without feeling sad is when depression causes them to feel primarily numb. They don’t feel sad, angry, joyful, or really anything at all. They may feel an amorphous misery, but no specific emotion. They may go through the motions of living without the feelings that motivate and satisfy people. This numbness can be experienced as suffering, but in such an ill-defined way that it isn’t identified as sadness.
• Addictions: Another reason people may not feel sad when they are depressed is the influence of addictions or chemical dependency which prevent them from feeling sad. If a depressed person frequently and compulsively uses alcohol, drugs, other chemicals, sugar, sex, gambling, work, or anything else, he or she may get temporary relief from sadness or even feel euphoric. The person may not realize there is an underlying sadness being suppressed. He or she may feel ups and downs with the chemical variations in the brain, while the chemicals mask the person’s sadness, depression, or whatever else is going on underneath.
• Anger: Sometimes even without external substances or compulsive activities, people can internally turn sadness into other forms, not recognized as sadness. One of those forms is any other emotion. Anger, especially, is often a transformation of another feeling. When people are more comfortable with anger than they are with sadness (or fear or hurt), they may not even experience sadness before it’s converted to anger.
• Obsessing: Similarly, people transform sadness into obsessive (compulsively repetitive) thoughts. For example, people think obsessively about someone they have a crush on, something they regret, or whether their stove is turned off. These or any obsessive thought processes turn off the experience of sadness.
• Somatizing: Another way people transform sadness into another form is through somatizing. Physical pain or illness, such as migraines, digestive problems, or virtually any physical symptoms, can sometimes be a physical experience of sadness that isn’t recognized as sadness. For example, if Nancy’s husband dies and she’s not comfortable or supported in grieving, her back may go into spasm and she may be in such physical pain that she can’t feel sad in a recognizable way—she just feels back pain. In this case, her back pain may be sadness expressed in another form.
• Illness: Another reason people may be depressed without feeling sad is when they have a physical illness, such as thyroid problems, multiple sclerosis, brain injury or tumor, or inflammatory illnesses. Other than the disease itself, there may be nothing sad in the person’s life, but in some physical way we don’t understand, the illness may create symptoms of depression.
• Fluctuations: Even people who feel sad, empty, or hopeless when they get depressed may not feel it constantly. Some people get depressed in a way that is not constant. A minority of depressed people can be distracted from their depression for short periods. These people might feel relatively normal during these periods, even if they feel depression with sadness the rest of the time.

Differences between Sadness and Depression

Another important twist is that people can feel sad, even intensely sad, without depression being involved. When people experience a loss, they usually feel sad, but don’t necessarily feel depressed. Sadness and depression have similarities, but they have some important differences.

When people are sad and express their sadness, they feel better, whereas when people are depressed, crying and expressing their pain may not give them relief. Sadness doesn’t involve mean thoughts about oneself, or hopeless or suicidal thoughts, but depression often does. Sadness doesn’t involve distortion in perception, or loss of perspective, whereas depression usually does. Finally, sadness doesn’t interfere with feeling other emotions, while depression often prevents a range of specific emotions.

In my experience, most people who are depressed have some sense that something is wrong, and if they don’t, people around them usually do. It really doesn’t matter whether suffering fits neatly into the DSM diagnosis for depression or not.

It’s not necessary to diagnose yourself or your loved ones. If you or someone you love is suffering, get professional help to assess what is causing the suffering and what would help relieve it.

Even the most honest people are faced with lying when they are depressed. This is yet another indignity adding to the suffering of depression. The most obvious and pervasive example is the frequent, daily question, “How are you?” It is a social convention to greet friends, strangers, and acquaintances with this question. Frankly, most of us lie in response to this question, or at least shade or limit the truth, because people generally don’t want to hear the true answer when they ask. Convention tells us to answer, “I’m fine, thanks; how are you?” For most people most of the time, this isn’t a big deal. It’s just a formality that facilitates greeting people, and is understood as a friendly hello. It’s not generally a problem because mostly people are fine, and don’t need to tell someone about the rash on their butt or the dog poo they stepped in.

But for a depressed person, the lies required for social convention are constant, and they create more and more isolation and separateness from other people. They reinforce a sense of having a shameful secret that no one wants to know or help them resolve. It reinforces a sense of being a burden or unlovable. All of these thoughts are common in depression, and to have them reinforced all day long by multiple people is crushing. Many people deal with it by isolating themselves from others if they can.

Of course, we all expect to lie to store clerks and other strangers, or even coworkers or neighbors, when they ask how we are and the truthful answer is too personal. But what about when a doctor asks—or clergy, someone we’re dating, our parents, our children, or our friends? What if what we are thinking is, “I hate myself,” “I’m disgusting,” “I’m a failure,” “Everyone would be better off if I were dead,” “I can’t stand the emotional pain anymore,” or even “Day after day I can barely get out of bed, and when I do, I can’t do anything—I’m neglecting my children and spouse, doing a terrible job at work, and have no interest or joy in anything”?

[fat_widget_left]If people say these thoughts aloud, they are likely to get an upsetting response. Some will tell them they don’t really feel that way, or shouldn’t feel that way. Some will try to cheer them up. Others will shame or blame them for how they suffer. Many will get scared; some may laugh. Some will distance themselves. Even some inexperienced therapists may get distracted by their fear of suicide and shift focus to keeping the person alive rather than addressing the pain. Good friends may listen and care, but if the condition is chronic, they get tired of listening to the same scary, depressing point of view that is their friend’s experience.

Here’s an example of the kind of conversation depressed people have all the time, in this case between friends. The italics indicate unspoken thoughts.

Friend: “Hi, how are you?”

Depressed person: I feel like crap, but if I say that, she’ll think I’m being negative and tease me about being Eeyore. I don’t want to alienate her or make her depressed, and I also don’t want to answer a lot of questions to explain or justify how I feel. I’d better act like I’m OK. Maybe she won’t notice. “I’m fine, how are you?”

Friend: She doesn’t look good, but I don’t want to pry, and I don’t know what to do if I find out she’s not OK, so I’ll just wait for her to tell me what’s wrong. Exercise would probably help her—maybe I can inspire her. “I’m good—just had a great workout.”

Depressed person: Oh, god, she thinks I’m a fat slug. I don’t have the energy to brush my teeth, much less work out. I’m a worthless piece of crap. I’ll never be a normal person like her. Everyone else just goes on with their lives, and everything would go on the same way without me. I’m really not a participant in life; I’m just dead weight. “Wow, that’s awesome. I have to get back to the gym, too. How’re the kids?”

Friend: If I entertain her with stories, maybe it will cheer her up …

Depressed person (tuning in and out of stories): I’ve told her how crappy I felt—or some of it—both times I’ve seen her recently. If she knows I’m still depressed, she’ll probably be bored and overwhelmed and won’t want to see me again until I feel better. Maybe I can just talk about one problem. “Yeah, I really worry about my kids. Henry punched a kid at school the other day …”

The depressed person walks away from the visit feeling alone in her secret life and drained from keeping the secret.

This is one of the most important reasons to find an experienced, qualified depression therapist when depression lasts longer than a few weeks. It’s essential to be able to tell someone the whole truth about how much you’re suffering, without concern that the person will discount you, disbelieve, judge, get distracted by fear about what you are saying, or respond with boredom, irritation, or impatience. As obvious as that may sound, not many people can do this for others.

I see many people who struggle with self-esteem issues. In fact, self-esteem issues and depression almost always occur together. Which one causes the other is not always clear, but the majority of people seem to have the self-esteem issues first.

People often tell me they want to die—because they “shouldn’t exist,” were “never wanted,” never “fit in,” are a “burden,” “don’t deserve anything,” or even have the feeling they “did something horrible” but don’t know what.

Generally, this viewpoint comes from something that happened when the person was very young. We now know that even embryos traveling down the fallopian tube are being affected by their environment in ways that have implications for physical and emotional health throughout the rest of their lives.

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To work with this, sometimes I ask people if they deserved to live (or die) when they were an embryo, then a fetus, then a newborn, etc. Most people see themselves as innocent and deserving to live at some point. Going through this exercise helps them see that there was a time they could have compassion for themselves, rather than blame or condemnation. For others, as we advance in age, we come to a place where they can no longer say they were innocent and deserved to live. That can lead us to the origin of the issue. If they can’t say they were good anymore after age 2, 4, 10, or whatever, then we look for what happened at that age to change that. Almost always, it was some kind of abuse or trauma.

For example, I saw a woman who wanted to die and believed she didn’t deserve to live, despite the fact she was a kind, giving, loving person. She was severely depressed and obsessed about suicide. She told me if therapy didn’t work, she was going to kill herself. One of the things I did was to take her through this exercise. She reluctantly conceded that she was innocent as an embryo, fetus, and newborn. When we got to 2, she said she deserved to die at that point. When we explored it, she said something happened then to change this, but she didn’t know what. Few people have conscious memories from that age, so early memories can be challenging to resolve.

But then she said she had an image, but she was sure it didn’t happen—”it couldn’t have happened.” The image was of a sexual assault from a family member. It was very specific and unusual. We processed the image as if it was a memory with EMDR, and she felt enormous relief. She no longer thought she was so bad that she didn’t deserve to live. She finally saw that she had done nothing wrong and the shame wasn’t hers. It belonged to the adult perpetrator.

Others blame themselves for their parents’ divorce, or for their parents’ lost lives after marrying each other only because of the pregnancy. People blame themselves for being the gender the parent didn’t want, for their mother dying in childbirth, or for their parent’s depression. When children try to make sense of something that feels terrible in their world, and no one helps them, they tend to think they caused the problem. So many innocent children grow up feeling guilt, shame, and self-hatred because of this. Sometimes, they don’t even remember why. Once they can connect their adult perspective with their child beliefs, they see that it’s unreasonable to punish themselves the rest of their lives because when they were too young to be responsible, their parents made the choices they did.

So if you think you are bad, disgusting, undeserving, unlovable, or inadequate, were you so as an embryo? A fetus? A newborn? An infant? A crawling baby? A walking toddler? A talking toddler? When did you become unforgivable, and why?

Those of you who’ve read my chapter in the anthology Goddess Shift: Women Leading for a Change know that I have had plenty of personal experience with depression, and that I have a unique relationship with it. I believe this has been an enormous help to me in helping others with depression. So I thought it might be useful to share some of what I do when I get depressed.

What resolves depression is grieving losses and traumas, changing brain chemistry, changing life circumstances, and time. What I have written below is more about what I do to cope during the process of resolution. This is not a complete list, by any means, but it is key for me and I hope you find it useful for you or someone you know.

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1. Stay in bed, and give in to the exhaustion and lack of motivation.

This is a tricky call because spending time in bed, sleeping, isolating, crying, etc., can sometimes be the worst thing for depression, and can exacerbate and prolong it. Sometimes the best thing I can do to cope with depression is to keep busy. My mother used to tell me when I was growing up that when she got depressed, she’d clean out a closet. Many of us have noticed that when we have to keep functioning—keep parenting, working, or whatever—we actually get through the depression better. When busy is what helps, I try to accomplish something satisfying.

On the other hand, depression can be a sign that we need rest. Though giving up and not functioning can be the exact opposite of what’s helpful at times, other times it can be exactly what is needed for my brain to begin to heal. If I have the time the sense that I need a break from life, I will try this. It doesn’t necessarily make me feel better, and may even make me more aware of the pain I’m in. But I use the time to rest, think, write in a journal, and express my feelings, and within a few hours or days I am usually more ready to join life. Sometimes I’m ready because I feel better, and sometimes just because I’m bored with lying around. If it doesn’t go that way, I force myself to get up and join life and try to heal another way. The call on whether to rest or get busy has to come from experience with yourself, intuition, and experimenting.

2. Force myself to exercise.

Exercise is one of the hardest things to do when I’m depressed, and yet it is one of the absolute proven ways to feel better. Few people when they’re depressed love getting up and exercising, but most people feel better after they do it. You probably already know it does all the right things for brain chemistry, and can be as effective as medication. The trick is not to think about it. As soon as I start to think about it, I talk myself out of it. I have to “just do it” without thinking about it. The form or exercise should be rewarding in itself—walking amid nature, in interesting parts of the city, or with a friend, dancing, Zumba (if that’s your thing; it’s not mine), or cycling—whatever involves movement and increased heart rate for a sustained period of time.

3. Fantasize about something so amazing that it might give me pleasure.

My mind is my best friend. It can comfort me, figure out solutions to problems, entertain me, and take me traveling anywhere in the world or anywhere I can imagine, even if it doesn’t exist. I can virtually travel to the ocean, listen to the waves wash rhythmically to the shore, and feel the blue, salty water lap at my feet, the sand squishing between my toes. I can take care of dying people in India, go canyoning in France, raft in Idaho, live in an RV, go to Sundance, live on a farm, study painting at a retreat in Vermont … OK, these are random things and maybe not what you want to fantasize about, but something might give you a little pleasure or relief, and if you let your mind explore, you might find what it is for you. It’s free; you can do it anytime, and your mind responds to what you imagine the same way it does to what you see.

4. Look for pleasure through my senses.

Pleasure is incompatible with depression. Anywhere I can find pleasure, as long as it doesn’t hurt me or anyone else, it’s a good thing. The gift of being alive is our bodies, and that means our senses and our emotions. I remind myself of that and consider what would feel good: a hot bath, gently scratching my head, walking, smelling cinnamon, stroking my cat, tasting something delicious, hugging someone I love, lying on pine needles, putting my hand over my heart and feeling the warmth and protection from that, singing to music I love … whatever harmlessly gives me pleasure—even a little—I go toward that.

5. Talk to someone about whatever I need to complain about.

This is one of the most important options for me, but also one of the harder ones to arrange. People have to be available, capable, and in the mood. Fortunately, I cultivate people who can and want to do this well when I need it, including my own therapist.

I would love to hear from you about what helps you when you are depressed.

Surprisingly, studies show that some of the seemingly less dramatic kinds of experiences, such as neglect, in childhood actually do more harm than overt abuse such as physical violence. Neglect isn’t talked about as much as physical, sexual, or even verbal abuse, and depressed adults who experienced neglect in their childhoods often wonder why they’re depressed.

Even when people think about neglect, they picture parents who are too drunk or high to take care of their children, who prioritize adult sexual relationships over their children, or who don’t care about their children and thus don’t bother to feed them or provide clothes and other necessities. They may imagine parents who are irresponsible and who forget or don’t know how to take care of their children’s needs. All of this happens, but it can happen without such extreme dysfunction.

Sometimes neglect can happen even when parents are trying to be responsible, when they simply don’t have the resources to parent fully. For example, when one parent leaves and the other has to work two jobs to provide food and shelter, they may have to leave the kids to fend for themselves or let the older ones to do the best they can to parent the younger ones. I’ve had clients from families in which this happened when the older one was as young as 3, taking care of a baby or two.

But neglect can also happen in families in which one or both parents are depressed, have demanding jobs, or have so many children that there isn’t time to meet all of their needs. It can happen when one of the parents, siblings, or grandparents is chronically or gravely ill or dealing with mental issues. Often this requires the rest of the family to put most of their time, energy, and attention into that person. It can even happen in families that value individuality and independence. Thinking they are teaching these values to their capable children, parents may overlook concrete and emotional needs even capable children have.

Neglect can cause children to miss learning the skills they need to be fully functional adults. When kids have to teach themselves how to handle life, they often don’t learn the best ways. Neglect can cause children to feel profoundly lonely and empty. It can make it more difficult for them to form friendships, causing them to feel even lonelier and preventing opportunities to develop social skills. They may feel like they don’t fit in anywhere, and learn to cope alone. Perhaps most insidiously, neglected children often conclude they aren’t worth parental attention and care, or that their needs aren’t important or just aren’t ever going to get met. These beliefs, carried into adulthood, undermine the ability to develop loving, respectful, equally powerful relationships.

Not through parents’ intention or direct action or message, but through lack of action, children can turn in on themselves—blaming themselves for how bad they feel. They can grow up with these invisible wounds, not even associating them with their parents, who may be loving, well-intentioned people.

Clearly, there is a huge range of severity of neglect, depending on factors such as how young the child is when it begins, how extensive it is, whether there’s a basic foundation of love and respect from parents, whether there are other adults who provide at least some of what the child needs when parents don’t, what other abuse is involved, and whether other resources are available.

How people cope with neglect also varies, just as it does with abuse and trauma. Neglected children may cope by clinging and being dependent; by giving up and lacking motivation or hope; by withdrawing and resisting human contact; or by acting out with crime, dangerous sex, etc. They may experience depression, anxiety, self-attacks, eating issues, or addictions. Any or all of these results of the neglect can follow the child into adulthood.

If you don’t understand why you’re depressed and think you had good parents and no trauma, consider what you might not have had. Did you struggle with anything your parents didn’t protect you from or help you with—even things like unrealistic standards for yourself? Did you have to take care of yourself more than your friends had to take care of themselves, or that you would expect of your children, nieces, nephews, or godchildren? Did your parents show no interest in things that were important to you? Did you have to work at getting your parents’ attention? Did you get physically or emotionally hurt because your parents weren’t paying attention? Do you feel like your needs aren’t important? Do you not expect to have them met? Check in with yourself, your journal, your therapist, and maybe your siblings to see if you can find ways your parents weren’t there for you that others are for their kids … and look at how it affected you.

While not everyone’s experience is the same, when people have a major depressive episode, generally the world looks, feels, and is understood completely differently than before and after the episode. During a major depressive episode, the world can literally seem like a dark place. What was beautiful may look ugly, flat, or even sinister. The depressed person may believe loved ones, even their own children, are better off without them. Nothing seems comforting, pleasurable, or worth living for. There’s no apparent hope for things ever feeling better, and history is rewritten and experienced as confirmation that everything has always been miserable, and always will be.

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When this reality shift happens, it’s difficult to remember or believe what seemed normal before the episode. What the person believes during the episode seems absolutely real, and anything that conflicts with it is as unbelievable as a memory or message telling him or her that the sky is purple. For example, if the person is unable to feel love for a spouse, and someone reminds the person that he or she used to feel that love, the person may firmly believe he or she had been pretending to himself/herself and others—though at the time he or she really felt it. The person can’t remember feeling the love, and can’t feel it during the episode, and thus concludes he or she never felt it. The same process happens with happiness and pleasure. Attempts to tell the person that he or she used to be happy, and will feel happy again, can cause the person to feel more misunderstood and isolated because he or she is convinced it’s not true.

Even if nothing was wrong before the episode, everything seems wrong when it descends. Suddenly, no one seems loving or lovable. Everything is irritating. Work is boring and unbearable. Any activity takes many times more effort, as if every movement requires displacing quicksand to make it. What was challenging feels overwhelming; what was sad feels unbearable; what felt joyful feels pleasureless—or, at best, a fleeting drop of pleasure in an ocean of pain.

Major depression feels like intense pain that can’t be identified in any particular part of the body. The most (normally) pleasant and comforting touch can feel painful to the point of tears. People seem far away—on the other side of a glass bubble. No one seems to understand or care, and people seem insincere. Depression is utterly isolating.

There is terrible shame about the actions depression dictates, such as not accomplishing anything or snapping at people. Everything seems meaningless, including previous accomplishments and what had given life meaning. Anything that had given the person a sense of value or self-esteem vanishes. These assets or accomplishments no longer matter, no longer seem genuine, or are overshadowed by negative self-images. Anything that ever caused the person to feel shame, guilt, or regret grows to take up most of his or her psychic space. That and being in this state causes the person to feel irredeemably unlovable, and sure everyone has abandoned or will abandon him or her.

It’s difficult to describe all of this in a way that someone who’s never experienced it can make sense of it. I can’t emphasize enough that when this happens, what I am describing is absolutely the depressed person’s reality. When people try to get the person to look on the bright side, be grateful, change his or her thoughts, or meditate, or they minimize or try to disprove the person’s reality, they are very unlikely to succeed. Instead, they and the depressed person are likely to feel frustrated and alienated from one another. I do believe cognitive therapy has an important place, but generally not in the throes of a major depressive episode.

Support for People with Depression

So what does a person whose reality has shifted in this way need? Please keep in mind that I am talking about a major depressive episode—severe depression that has lasted more than two weeks. I would take a different approach for someone with milder depression, or one that is a response to a terrible loss.

For some people in a major depression, psychotropic medication works and is the only thing that works. The same could be said for electroshock treatment, though it’s not for everyone. Many people will emerge from major depression in time, though episodes seem to make more episodes more likely, so if medication works to end the episode, it’s usually prudent to take it. Nutrition, acupuncture, and other body-based treatments as well as therapy can help without the side effects of medication.

What Loved Ones Can Do

Loved ones can gently hold and show love and commitment to the depressed person, try not to take on the person’s reality, but also not argue with him or her about it. They can also gently remind the person that depression causes his or her perspective on everything to change, and he or she is unable to think outside of depression mode at the moment. It is a time for the person to avoid making decisions, or avoid doing anything significant that requires a nondepressed perspective. If this is a repeated experience for this person, it can be helpful to discuss all of this between episodes so he or she is more prepared when caught in the quicksand.

As someone who loves a person with depression, it can be emotionally difficult or stressful at times to support that person. It can be beneficial to focus on your own needs and self-care, and to reach out for help if you need it such as seeking the support of a counselor or therapist.

You may know someone who is depressed and not know they’re depressed. People expect someone who is depressed to cry a lot, stay in bed all day, mope, or sound like Eeyore from Winnie the Pooh. But depression isn’t always this obvious.

Some people can totally fake it. They can smile and laugh; they can act like everyone else, even while they are in excruciating emotional pain. Occasionally people who can do this end up killing themselves, and no one can believe it. People who are depressed but act like they are fine may not confide in anyone. Usually they find a way to spend time alone crying or letting down the facade and then go back to acting when they have to be with people. I’ve had clients who lived with their families and only found time to cry after everyone went to sleep, and only in the bathroom. The rest of the time they were acting like someone who wasn’t in pain. On top of the pain they already feel, acting happy is emotionally exhausting, and having this secret is isolating. So, faking it can even increase the depression.

Others funnel their pain into anger and people see them rage, abuse, shame, or react with annoyance or irritation to whatever happens around them. They may or may not themselves know they’re depressed, but others often don’t guess how much devastating emotional pain they are in. People may fear them, despise them, or dismiss them as mean. It is very difficult to feel sympathy for someone who is hurting people, and it is difficult to see their vulnerability, so their depression goes unnoticed.

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Still others are addicted to something, and the depression is obscured by the addiction. People with addictions spend most of their time and energy relating to the addiction. They plan to do it, anticipate doing it—these phases excite them and elevate their mood temporarily. Then they use whatever they are addicted to and it boosts their mood. But the thrill wears off, and they are depleted by the effects of the addiction and may also feel remorse or shame, so the depression descends on them, pulling them down like a cement jacket. They begin the cycle again to try to feel better; they plan and anticipate. Their whole life is about running from depression, but it becomes centered around the more dramatic force of addiction, and the depression can be unrecognized. I am not saying that all addicts are driven by depression—depression can also be caused by addiction. But addiction can be a form depression takes that is not easy to identify as depression. I include eating disorders in this category. I also include people who work most of their waking hours.

Depression isolates people. Whether they are hiding from the world in bed, preoccupied with an addiction, pushing people away with anger, or keeping their real thoughts and feelings inside while pretending to be okay, people with depression usually feel very alone.

Depression isolates people. Whether they are hiding from the world in bed, preoccupied with an addiction, pushing people away with anger, or keeping their real thoughts and feelings inside while pretending to be okay, people with depression usually feel very alone. Depression also has a built-in isolating fog quality that makes it very difficult to feel connected to people. Even when people feel safe to express exactly how they feel, it is very difficult for people who haven’t experienced a deep depression to understand how that feels. How can anyone who hasn’t experienced it understand a pain that is as intense as any open-heart surgery without anesthesia, with no cuts or bruises to show? How can anyone who hasn’t experienced it understand the complexity of pain that is not only unbearably intense itself but also complicated by many painful factors like the stigma of mental illness and the confusion of the fact that unlike other illnesses, depression causes behavior changes. People attribute behavior to the moral character of the person, rather than to the illness.

The pain is also complicated by the fact that depression attacks a person’s thoughts and feelings, rather than liver or lungs. Depression can cause a person to think she hates herself or is unhappy in her relationships. It can cause someone to believe everyone would be better off without him, or even that others would be better off dead. It can cause people to feel sad, angry, guilty, numb, or rageful, even when none of this is how they feel when they aren’t depressed.

So what can you do to help people you love who are depressed, if you can’t tell they’re depressed? Ask questions very kindly and listen to the answers very carefully. Empathize with their emotional pain—even if you have to guess at what it might be. Let them know you are there to listen and understand for as long as it takes, and you aren’t taking no for an answer. Of course if you aren’t trustworthy—if you judge them, or talk to others about what they tell you, or interrupt, get impatient, or misunderstand them, then it is better for them to talk to someone who can really listen without any of this. Being a reliable, trustworthy, patient, nonjudgmental listener is the best thing you can do in most cases with someone who is depressed.

A couple of caveats: I am talking about adults—children and teens require some variations. Also, addictions cloud the picture of depression and require their own, very different intervention. Nonjudgmental listening is still essential but may need to be combined with some firm boundary-setting and professional treatment for the addiction.

Never underestimate the power of talking with someone who really listens.

Our culture doesn’t encourage people to talk about their emotional pain. Our culture teaches people to suppress their feelings. People tell each other not to “whine” about problems or not to “dwell” on them. People are told to “get over it” and to “be strong,” meaning “don’t feel anything—and if you do, don’t talk about it or show it.”

One example of this is when only certain emotions are deemed “appropriate.” Anger, especially for men, is more acceptable than sadness or anything vulnerable. So, for many men, emotions like sadness, loneliness, disappointment, anxiety, guilt, and shame get funneled into expressions that look like anger. Unhealthy coping mechanisms—such as using alcohol, other substances, or addictive activities—are taken up in order to push the genuine feelings down. These provide some temporary relief but, ultimately, undermine a person’s strength, health, and functionality.

Most people, when they feel upset, benefit by talking to someone who listens patiently, nonjudgmentally, empathically, and who shows that he/she understands at a deep level. There is something basic in the way human beings react when receiving this simple, but skillful, response to talking about their emotional pain.

Depression is no different from any other emotional pain, in this sense. [fat_widget_right]If everyone who felt depressed was comfortable talking about it to a good listener, we would have far fewer depressed people—possibly even fewer people on antidepressants.

Recently, a psychiatrist who was treating a friend of mine said that few people truly have a chemical imbalance causing their depression. Maybe this is why some research shows that antidepressants work about as well as placebos. Maybe the placebo works because the patients get some caring human contact before taking the pill. Human contact goes hand-in-hand with talking. We all need to see people smile at us, be warm toward us, perhaps even touch us in a friendly, appropriate way. Warm, caring human contact is essential for us to live and thrive.

Ideally, we would all have this in our lives without having to pay someone to get it. We would all have friends, relatives, spiritual leaders, mentors, teachers, or healers around to listen and care when we are upset. Yet our culture no longer supports this basic need. We are too busy. Many of us come from families who have abused us, or from whom we are separated. We often live alone, or have only our immediate family around. We are not connected to a church or community where this kind of talking may have been more available in the past. Instead we put value on the rational, over the emotional, to the extreme. As a result, many people end up trying to hide their tears and vulnerability, thus creating more alienation and isolation. Ironically, suppressing our feelings and being deprived of warm contact actually makes us more susceptible to depression, making people think they have even more to hide.

So if you are feeling depressed or in emotional pain, try to find someone you can talk to—someone who will listen deeply and without judgement. Talk to him/her about everything that’s seriously bothering you, and keep talking until you feel relief (even if you have to go through several people to have as much time talking as you need). If there’s no one in your life like this, and you don’t think you can find anyone, find a good therapist. It will help to do your talking with a highly trained, skilled, and naturally intuitive professional. You owe it to yourself to do whatever it takes to prevent depression, or deeper depression. It’s really so simple (though not always easy), yet so important.

Without the tools to manage it, recurring and intense depression often breaks up relationships. The truth is, depression is hard to handle. One way to help make it through depressive episodes is by preparing a depression plan when the partner who experiences depression is not depressed. The aim of the plan should be to create a shared understanding about the changes in thoughts and behavior that depression causes, as well as a commitment to “stretch” to get through the difficult period of depression.

Separating the Person from the Depression
It takes a great deal of effort, on the part of both the depressed person and their partner, to separate the person from the depression. Yet doing this can be very important to maintaining the relationship. Try thinking of “Depression” as a third party in the relationship: an entity with its own unique thoughts and actions that it expresses through your loved one’s body. One way to do this is to establish the difference between how the depressed person acts when they are depressed and how they act when they aren’t.

For example, during an episode of depression, the depressed person may get much more sensitive to criticism. If both people know that, it can help them to remember that that behavior is the depression, not the person. The partner may want to be more careful not to be critical, or to not react to the depressed person’s overly sensitive reaction to criticism. “That is Depression speaking (yelling, crying, acting insecure, calling me names), not my loved one,” can be a useful mantra.

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This doesn’t mean the partner should take abuse. Partners still need to set limits—calmly, firmly and before accumulating resentment—about anything the depressed person does that doesn’t feel respectful. This may sound something like, “I know you’re in a lot of pain right now, but I won’t allow you to call me names under any circumstances. I’m going out now; let me know when you are confident you can treat me respectfully and I’ll come back.”

For the depressed person, it can also be helpful to remember that no matter what terrible things the depression is telling them (she doesn’t love me, she thinks I’m disgusting…), those thoughts are the depression interpreting what the partner says and does through a filter that turns everything to the worst possible scenario. If the depressed person can identify that this is the way Depression causes them to think before the depression happens, it can help them to remember that those feelings are likely distortions of reality, even though they may continue to seem real in the moment.

The depressed person can also prevent damage to the relationship by attempting to translate what they want to say (“You’re a skank”) into their own fears and sad thoughts (“I’m scared you’re going to leave me”) before saying it out loud.

Identifying Depressed Belief Patterns
Try making a list of messages that Depression gives, in general and/or for the specific person, in order to be able to look at it when depression hits. If every time the depressed person gets depressed, they become certain that their partner is having an affair, put that on the list. A list can be written from the point of view of the depressed person or the partner, or each can have their own. An example from the depressed person’s point of view could look like this:

“When depression hits, I see things differently and characteristically believe:

• My partner is having an affair
• I am ugly and undesirable
• I will never feel better
• I am a burden to everyone and would be better off dead
• I am inadequate in any number of ways
• I fail at everything I do
• My life is cursed
• Nobody loves me, or even likes me

“When I’m not depressed, all of this looks different. When I am depressed, I believe the depressed point of view is reality and the nondepressed point of view was distorted. This is not true and not helpful to my desire to feel good.”

Setting Boundaries for Caretaking
While it can be helpful for the depressed person and loved ones to define reality, loved ones can get burned out on reassuring the depressed person. They should do it only as much as it is possible to do so without resentment. They may need to pace themselves—can they do it once a day? Once a week? Give what support is possible without getting burned out or resentful, or starting to agree with the distortions (maybe I don’t love him, maybe he is disgusting). The rest of the time, the depressed person needs to do their own work: some alone, some in therapy, and some with other friends and people they feel comfortable talking to in order to soften the distortions.

Many years ago, a mentor of mine talked about how she coped with taking care of her partner who was dying of cancer. She wanted to be there, but not to feel resentful and burned out. She told her partner that she expected her to do everything she could possibly do on her own, and then my mentor would do the rest. So if her partner could get up and get a magazine for herself but didn’t feel like it, my mentor wouldn’t get it for her. This left her available for the kind of caretaking that her partner absolutely needed and allowed her to sustain her energy over a long period of time even as her partner’s needs increased. I thought this was a brilliant way of thinking about caretaking for loved ones. It’s so easy to want to rush in and do everything in the beginning and then burn out. Pacing oneself and seeing the other person take as much responsibility as they can helps the caretaker so much.

It is important for the depressed person to commit to “stretch” as far and do as much as they possibly can—as much as they would be able to do if they were alone. Then, if the partner is willing to act in a caretaking role, they can do what the depressed person absolutely can’t do. With depression, this can be tricky to identify. Only the depressed person knows where that line is, and it can be difficult for even them to establish. It also may change from day to day or minute to minute. A depressed person may have to spend a whole day psyching themselves up to get up and take a shower or to make a phone call—but then they may be able to do it, whereas earlier in the day they absolutely couldn’t.

It is also important for the depressed partner to “stretch” by giving expressions of love and gratitude to the caretaking partner. It may be very difficult for the depressed person to do this, but it is usually possible if the depressed person commits ahead of time and the caretaker reminds them that the relationship needs it.

Caretakers need to consciously keep their own life going as much as possible. If they can’t expect to be emotionally nourished by their partner when they’re depressed, they need to be sure to be “fed” by other family and friends, activities they enjoy, work, or whatever is available. They might consider going to Co-Dependents Anonymous for support with keeping boundaries and not giving too much. This can, ironically, free people up to be more available to the person who needs their care.

Maintaining Balance
Most depressive episodes do pass, and the person who experiences depression returns to their nondepressed personality and functioning. Both depressed people and loved ones have to try to remember this fact as they do everything possible to get through and resolve periods of depression. The most important thing to remember is that neither person should make big decisions about their relationship, or judgments about how things will be, until the episode is over.