"On Healing" October 2002

Posted on Mon, Oct. 21, 2002
Too much depression stays hidden
By Dan Gottlieb

When Sally first came to treatment several years ago, she was a 35-year-old lawyer who, by all appearances, was an accomplished, successful woman.

She gave her father credit as a role model for her professional success. But she was angry with her mother, whom she described as "weak" or "lazy." Her mother, I learned, had spent a good deal of time in her own room, feeling unable to prepare meals and socializing very little. Sally's father carried the family.

Sally reluctantly agreed to bring her parents in. I soon saw her mother wasn't weak or lazy. She was clinically depressed.

Once she came to grips with her mother's diagnosis, Sally said: "I thought that was just Mom - a weak and fragile person. I never thought she might have an illness causing this."

In fact, most depression is unrecognized and unacknowledged. Twenty percent of Americans will experience clinical depression sometime in their lives. That figure does not include the additional millions of people who experience various other forms of depression, such as dysthymia - a low-grade chronic depression. And the numbers have been climbing. Worldwide, depression is the fourth most common cause of impairment, and many expect it to become the single most debilitating illness over the next 20 years.

Yet despite advances in treatment, the vast majority of those with this illness never get it. Sally's family is typical: Many with depression tend to hide or deny it, feeling that it is a sign of weakness.

Depression can take many forms. A patient named Elliot told me his father was constantly irritable, angry and judgmental. After I evaluated his 75-year-old father and suggested that he might have a treatable depression, his wife, who had been living with his anger for 50 years, wept with relief.

Although the father refused psychotherapy, he did agree to medication. Six months later, Elliot said: "Well, he is not Dr. Dolittle, but he is much more relaxed than I ever remember. I can have a reasonable conversation with him and I even saw him smile!" Depression can take other forms as well, with symptoms from lifelong cynicism to hopelessness, social withdrawal or chronic fatigue.

But listing the symptoms - sad mood, sleep, appetite and sexual disturbances, increased risk of suicide - doesn't begin to address the suffering. I know. After a serious automobile accident, I suffered a clinical depression for three years. Living with quadriplegia, although quite difficult, is not nearly as difficult as living with depression. It is like an invisible, 1,000-pound weight you carry around every day. It affects judgment, making it difficult to see your own worth. Most people with depression look forward to the end of the day when they can go to bed and get respite. Yet sleep can be elusive, and the depressive thoughts and emotions of the day get worse. Many feel as though they don't deserve to be loved or even to live. So although people with this illness may have friends and family, they still feel alone and misunderstood. That is how I felt, anyway.

Like most illness, depression affects more than one person. Witness Sally's and Elliot's experiences over years and years.

Over the summer, William Beardsley was a guest on my Voices in the Family radio show. He is professor of psychiatry at Harvard and the author of Out of the Darkened Room. He researches the impact of parental depression on kids. After studying 275 families, he found that some children were greatly affected and some were quite resilient.

He found that the most severe impact on children was in families where depression was not talked about. He said those children tended to be sad or confused and that they were at increased risk for becoming depressed themselves. "Because depressed people have low self-esteem, they tend to feel guilty and blame themselves for all of the family problems," he said. "But when the depression is unspoken, the children also blame themselves - that puts the children at increased risk for their own depression."

Realizing that openness was a critical factor in childhood resilience, Beardsley's research team began what they call "Family Conversations." These took place when children were old enough to understand what depression was - generally around 7 or 8 years old. He said two things were made clear in these meetings: (1) Depression can be treated, and (2) Many children with depressed parents do quite well and demonstrate remarkable resilience.

Beardsley emphasized that when children know what their parents are struggling with, and that they are getting treatment, they are much less likely to feel the effects of the depression. After all, we have known for years that children can sense when there is something wrong. In the absence of real knowledge, they will tend to blame themselves and take on responsibility for helping their parents.

When children learn that a parent has an illness called depression and that he or she is getting treated, they are freer to resume the role of being a child. Just acknowledging a depression and seeking treatment can contribute significantly to protecting children from its harmful effects.

Beardsley also found that the children who demonstrated resilience had three characteristics in common: "They were very committed to relationships, they were very good in activities outside of the home (in school, neighborhood and church), and they understood their parents had an illness. Therefore they were able to say, 'I am not to blame for this, I am not guilty for it, and it is OK to go on with my own life.' Those are the three characteristics of resilience that showed through like a beacon."

Silence in a family can cause terrible injury. Truth rarely does.

Posted on Mon, Oct. 07, 2002
Beyond hue and cry, consider the real story
By Dan Gottlieb

I am angry.

Lately the news has been filled with awful stories of child abuse, neglect, abduction, a videotape of a mother beating her child. There was the story of a Pennsylvania teenager allegedly sent away by his family and starved, and another about an 11-year-old boy who said his parents forced him to sell drugs.

It was on this last one that I received a telephone call from a local news station asking whether I would consent to an interview for their story. "What do you want to talk about?" I asked. They wanted me to explain the psychological impact of selling drugs on this 11-year-old. I told them they did not need a psychologist to tell them that - anyone could explain that, and I declined.

That's when I got angry.

I know how these stories go: Understanding mental health professional talks about horrible things these parents may have done to this child... he explains that the boy could be scarred for life because those he trusted put him in harm's way... in the background, pictures of this child alternate with footage of his parents being booked... invoking viewers' feelings of kindness for the boy and hatred for his evil parents, perhaps wishing for them a quick and long imprisonment, or worse.

Watching this story, we first feel outraged and indignant. Eventually, we see that justice will be served. We feel relief.

Don't get me wrong; if accurate, this is a horrible story. Yes, this poor child may well be scarred (although most kids, in the proper environment, show remarkable resilience). What his parents allegedly did was horrible and such behavior probably would deserve a swift and severe punishment.

But that's the TV story - not the whole story. The whole story did not begin with this supposed episode of child abuse and would not end with a prison term.

The whole story - my story - begins with the question: "Who are these people?" I have never met a person who said that when they grow up they want to have children so they can have someone to beat, neglect or force to sell drugs. Nobody I have treated enjoys being a drug addict or having no control over violent impulses. Dare we look at these people? Whether they are in prison or not, dare we look in their eyes, open ours and listen to their story? We have all seen their dark sides, but dare we see their humanity as well?

So here is the whole of my story. It is not based on the specific people in the news. It is based on hundreds of people I have met and interviewed, worked with and listened to, all of whom have done terrible things to someone.

Most were once children who grew up in homes that were unstable - even dangerous. Children who usually were raised by one parent who was deprived, depleted, confused and often addicted to drugs. Many of these children are left to raise themselves, pretending to be strong and competent. Usually they are neither.

These are children who feel scared, lonely, and two steps behind everyone else. They are children who feel scared, lonely and alienated, feelings that fester and eventually give birth to desperation or hopelessness. To compound matters, frequently these are children who inherit some unhealthy genes that put them at risk for impulse disorders, depression, violence or substance abuse. Many of these children are born addicted, which has them beginning life with two strikes.

Poet Franklin Abbott once wrote: "As sure as a flower is drawn to the sun, it is the entropy of the human spirit to seek wholeness." And that's what the vast majority of these children are doing - pursuing life. Some are so desperate for love or security that they do terrible things to find it. Those children who feel out of control may do anything to find a semblance of control in their lives - including using drugs or acting out violently.

And because of the world in which we live, most of these children grow up without getting the help they need. Still feeling alone, desperate, out of control or just empty.

And what do they do? They do what the rest of us do. They look for a partner to make them feel whole. It fails. And inevitably, things get worse. These children simply turn into disturbed people making disturbed decisions with disturbing consequences.

People who feel alienated, desperate and hopeless give birth to children who eventually feel the same. In the wake of this cycle, people get addicted, wounded, arrested and sometimes murdered.

My story continues beyond the prison sentence. In my story, they do get punished. But our involvement in their lives does not end with their release. In this community, we look beyond horrible behavior with horrible consequences, and we look in the eyes of both parents and children. And we keep looking until we see their hearts, their alienation and suffering.

And then? Once we realize that this is a story of human suffering, not good and evil, then we realize that this story is repeated in thousands of homes in Philadelphia alone. (And quite a few in the suburbs as well.)

In my story, we go beyond pointing fingers at parents and social-service agencies, and we begin to volunteer. In my story, the Department of Human Services is flooded with people who want to do whatever they can to help these thousands of children and their parents before someone else gets hurt.

Anyway, that's my story. It's not as clear as the news story. Nor does it conclude with a sense of justice. It leaves us feeling a little overwhelmed, frustrated and helpless. Don't worry, though, the next time this happens, you will again see the same story. And when you do, think about the other story - the one you would find if you could look in their eyes and see what's in their hearts.

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