A Way Out of Depression
Coaxing a Loved One in Denial into Treatment Without Ruining Your Relationship
By ELIZABETH BERNSTEIN
For people suffering from depression, the advice is usually the same: Seek help.
That simple-sounding directive, however, is often difficult for those with depression to follow because one common symptom of the disease is denial or lack of awareness. This can be frustrating for well-meaning family and friends—and is one of the key ways that treating mental illness is different from treating other illnesses.
Research shows that almost 15 million American adults in any given year have a major depressive disorder. And six million Americans have another mental illness, such as schizophrenia, bipolar disorder or other psychotic disorders. Yet a full 50% of people with bipolar disorder and schizophrenia don’t believe they are ill and resist seeking help. People with clinical depression resist treatment at similar rates, experts say.
You may have seen that seemingly ubiquitous TV commercial for the anti-depressant Cymbalta that repeatedly stresses that “depression hurts”—not just the person who is sick but the people who love that person as well. (Even the dog looks sad.) It’s an ad, sure, but the sentiment is correct: People who live with a depressed person often become depressed themselves. And depression can have a terrible effect on relationships. It is a mental illness beyond just a depressed mood or situational sadness, in which a person is able to still enjoy life. Depression drains people of their interest in social connections. And it erases personality traits, taking away many of the very characteristics that made people love them in the first place.
“Depression makes a person see the world through gray-colored glasses,” says Xavier Amador, a clinical psychologist and author of “I Am Not Sick. I Don’t Need Help!” which was republished earlier this year in a 10th edition.
The challenge for a person with a depressed spouse, relative or close friend who refuses to get treatment is how to change that defiant person’s mind. Reality show-style interventions and tough love are rarely successful, experts say. But there are techniques that can help. The key is to try and avoid a debate over whether your loved one is sick and instead look for common ground.
Patricia Gallagher knows how hard this can be. Her husband, John, came home from his job as a senior financial analyst for a pharmaceutical company one day and said his boss had given him three to six months to find a new job. He was crying.
Over the next year, Ms. Gallagher, who is 59 years old and lives in Chalfont, Pa., noticed her husband became irritable, sad, and short-tempered, withdrawing from her and the kids. He lost 55 pounds, stopped sleeping and would call her numerous times each day saying he couldn’t “take it” anymore. He visited doctors dozens of times that year,
getting examined for everything from a stomach ulcer to a brain tumor. Many doctors suggested he see a psychiatrist, but he didn’t.
Ms. Gallagher tried everything she could think of to help. She urged her husband to relax or take a vacation. She begged him to see a psychologist, eventually scheduling the appointments herself, and even going alone when he refused to go, to ask advice. Eventually, he was hospitalized after becoming catatonic with anxiety, then attempted suicide by jumping out the hospital room window.
A decade later, the Gallaghers are separated. “I kept thinking, ‘You’ve wrecked everything because you didn’t go to therapy,'” she says. Mr. Gallagher, 59, a sales associate for a clothing company, says: “I didn’t understand [depression] was a chemical thing. I thought it was a physical thing.”
People who are mentally ill yet refuse or are unable to admit it or seek help may feel shame. They may feel vulnerable. Or their judgment may be impaired, keeping them from seeing that they’re depressed.
“When a loved one tells them they are depressed and should see someone, they feel they are being criticized for being a complete failure,” says Dr. Amador, director of the LEAP Institute in Taconic, NY, which trains mental-health professionals and family members how to circumvent a mentally ill person’s denial of their disease.
Getting Around Denial
Experts say there are ways to circumvent a loved one’s refusal to seek help:
BE GENTLE. Your loved one likely feels very vulnerable. “This is akin to talking to someone about his weight,” says Ken Duckworth, a psychiatrist and medical director of the National Alliance on Mental Illness, an education, support and advocacy group. Simply saying “I love you” will help.
SHARE YOUR OWN VULNERABILITY. If you’ve accepted help for anything—a problem at work, an illness, an emotional problem—tell your loved one about it. This will help reduce their shame, which is a contributing factor to denial.
STOP TRYING TO REASON. Don’t get into a debate about who is right and who is wrong. Ask questions instead. Learn what your loved one believes.
FOCUS ON THE PROBLEMS YOUR LOVED ONE CAN SEE. Suggest they get help for those. For example, if they acknowledge sleep loss or problems concentrating, ask if they will seek help for those issues. “Don’t hammer them with everything else,” says Dr. Duckworth. “Nobody wants to be pathologized.
SUGGEST YOUR LOVED ONE SEE A GENERAL PRACTITIONER. It is often far easier to persuade them to do this than to see a psychiatrist or psychologist. And this physician can diagnose depression, prescribe medicine or refer to a mental-health professional.
WORK AS A TEAM. Ask if you can attend an appointment with the doctor or mental-health professional, just once, so you can share your observations and get advice on how best to help.
ASK FOR HELP FOR YOURSELF. See a therapist to discuss how you are doing and to get help problem solving. Or contact organizations such as the National Alliance on Mental Illness to find information on caretaking or support groups.
ENLIST OTHERS. Who else loves this person and can see the changes in their behavior? Perhaps a sibling, parent, adult child or religious leader can help you break through.
LEVERAGE YOUR LOVE. Ask the person to get help for your sake. “If your loved one will not get help, you will not win on the strength of your argument,” says Xavier Amador, a clinical psychologist and director of the LEAP Institute. “You will win on the strength of your relationship.”
In addition to the psychological reasons that lead a person to deny his own mental illness, there may be a physiological one, as well. Anosognosia, an impairment of the frontal lobe of the brain, which governs self awareness, leaves a person with an inability to understand that he is sick.
Dr. Amador, who pioneered research into this syndrome 20 years ago, says it appears in about 50% of people with schizophrenia and bipolar disorder. Experts believe that similar damage sometimes occurs in people with clinical depression, although they are just beginning to research this.
At the LEAP Institute, they teach mental-health professionals and family members how to build enough trust with the mentally ill person that he will follow advice even if he won’t admit to being sick. LEAP is an acronym for listen reflectively, empathize strategically, agree on common ground and partner on shared goals.
“It’s the difference between boxing and judo, says Dr. Amador. “In boxing you throw a punch and the person blocks you. In judo, a person throws the punch and you take that punch and use their own resistance to move them where you want them.”
Sometimes loved ones are able to help. Renee Rosolino, 44, a residential appraiser in Fraser, Mich., says she is sorry she waited so long to listen to her family.
They expressed concerns about her behavior 14 years ago, when she first started showing signs of bipolar disorder. At the time, she felt judged when her husband, parents and sisters told her that her personality had changed completely in six months. She stopped eating and sleeping, cried a lot and yelled at family members, and began pulling away from everything from social activities to church.
Repeatedly, her husband tried to talk to her about her behavior, but she insisted she was fine. He even enlisted Ms. Rosolino’s sister to help. After dinner one night, they told her they were worried that she was depressed because she was sad, stressed and always on edge. Ms. Rosolino got mad and “shut down the conversation,” she says.
In addition to being angry, Ms. Rosolino says she was terrified. When she was a child, Ms. Rosolino’s father, an assistant vice president at a bank, had a mental breakdown and was taken to a psychiatric hospital in the middle of the night. “I never understood what happened to my father,” she says. “And I had it in my head that if I went to talk to someone this would happen to me, to my children. I didn’t want my kids to have those same feelings.”
Ms. Rosolino’s husband eventually broke through to her by asking her to speak to their pastor, pleading with her to do it for him and their children. “He said, ‘It’s OK. I am not going to leave you. I need you. Our kids need you,'” she says.
During her talk with the pastor, she broke down and told him about the pressures she felt as a mom—one of her children is autistic—and her irritation at feeling judged by her family. He told her that family members were worried about her and asked her to see a psychiatrist, just once, to set their minds at ease.
She agreed and started seeing the psychiatrist once a week and taking anti-depressants. Still, she has been hospitalized several times, usually, she says, when she stops taking her medication. But she has been stable for several years and says she has the people in her life to thank.
“Out of love and respect for the pastor and my family, I said I’d make the phone call,” she says. “They made me feel safe.”
—Write to Elizabeth Bernstein at email@example.com and follow her column at http://www.Facebook.com/EBernsteinWSJ