Chapter 1

How Does Your Loved One's Depression Affect You?

Jane, a thirty-six-year-old advertising executive, has been feeling overwhelmed with her new responsibilities. In addition to her full-time job and two children, she has recently begun to take over many of her husband's customary chores, such as paying the bills, servicing their car, and fixing things around the house. For the past several months, her husband has not been sleeping well; he feels unmotivated and tired, and complains of feeling blue. Jane knows that he is not feeling well and feels sorry for him -- but she is beginning to resent him.

Peter, a twenty-eight-year-old accountant, has not been sleeping and has been having trouble concentrating at work. Since the birth of their son four months ago, his wife has been moody and disinterested in sex. He misses the closeness with her and feels sad about the state of their marriage. He is reluctant to talk to her about his concerns because he does not want to make her more upset. Rather than express his feelings, he spends more time playing golf with his buddies.

Gail, a fifty-five-year-old homemaker, has not done any laundry or been food shopping or spent any time with her friends for several weeks. She has been preoccupied with worry about her elderly mother's worsening hopelessness and recent statement that "there is nothing left to live for." Because she is worried that her mother will harm herself, Gail travels an hour each day to visit and try to cheer her up. As a result, Gail is falling behind in her household chores, she feels that she is neglecting her friends, and her husband has begun to complain.

The specific details may be different, but Jane, Peter, and Gail all have something in common: They are affected by a loved one's depression. Jane feels overburdened and resentful. Peter is lonely and worried about his marriage. Gail's fear and guilt about her mother are taking her away from her other responsibilities. All of them want to help their loved one but are having reactions to the depression themselves. Because they are so busy caretaking, Jane, Peter, and Gall have not noticed how they too have been affected by depression.

When Peter first came to therapy to discuss his concerns about his wife, he spoke at length about her sadness and lack of energy. As a caring husband, he was understandably concerned about her adjustment to motherhood. He described all the ways in which her depressed mood had affected her personality, from her lack of interest in sex and her usual activities, to her irritability with their infant. When he was asked about how her depression had affected him, he paused and said, "I guess only in that I care about how she feels." When he was encouraged to think further about his reactions to her depression, he reluctantly revealed that he felt lonely and scared. Peter admitted that he had not been paying attention to how he was handling the situation because he was so caught up in his wife's problems. Only after he had begun to pay attention to his own reactions and feelings was he able to talk to his wife about the changes in their relationship and encourage her to seek help for her depression.

How Can Someone Else's Depression Affect You?

If you love someone who is depressed, you may be unaware of how the depression affects you. You may be so intent on helping the other person that you are blind to ways in which you are affected. Yet if you begin to reflect on your interactions with the depressed person, you may begin to recognize that indeed you do have important feelings and reactions. Perhaps you have felt frustrated with your spouse for being antisocial and overly pessimistic. Or maybe you have become annoyed or worried about your best friend who does not seem able to snap out of the blues. Our experience as therapists and the results of recent research studies have convinced us that everyone benefits when feelings and reactions to a loved one's depression are understood and acted upon constructively. In short, it is essential to your own emotional well-being and that of your depressed loved one that you pay attention to your reactions and feelings. If you recall your last interaction with the depressed person in your life, you will undoubtedly recall some feeling or reaction that you previously did not think about:

This shift in focus is a central part of our work as therapists. Experience and research have taught us that inattention to feelings and reactions is often at the root of many relationship problems people experience with a depressed loved one, and relationship problems almost always worsen a depression. In the chapters that follow, we will help you learn how to recognize the various ways in which you are affected by your loved one's depression. For some of you, it may be easier than it will be for others. For those of you who are natural caretakers, it may not be easy to think about yourself rather than focusing solely on the depressed person. However, it will be well worth your effort. It will give you the tools you need to help your relationship survive the depression.

As you read, you may discover that depression is affecting you in ways that you have not realized. But don't worry, we do not intend to leave you mired in this new knowledge without tools to do something about it. We will give you specific step-by-step guidelines as to how to use your reactions to get along better with the depressed person, to increase your sense of hopefulness, and to be a more skilled helper in the fight against the depression. Before we provide these skills, you will need to understand the various ways that depression can affect you and your relationship. We will describe in detail the most common effects of depression on relationships. After a brief review of new research on this topic we will end the chapter with a description of the four stages of adaptation to depression. In the following chapters we will teach you how to alter your passage through these stages to improve your adaptation and response to the depression.

Depression and Your Relationship

Depression is a devastating disorder for the depressed person. We all know that depression affects mood, sleep patterns, appetite, motivation, and even the will to live. But what many people do not realize is the extent to which depression affects relationships. If your partner is depressed, your marriage is nine times more likely to end in divorce than if you were married to a nondepressed person. This staggering statistic is not the only indicator of how destructive depression can be to relationships. The close relationships of depressed people are more stressful and conflictual than the relationships of nondepressed people, and arguments and misunderstandings are much more common. In this context, it comes as no surprise that depression, and sexual problems caused by depression, are the most common reasons couples seek marital counseling and that approximately 50 percent of depressed women complain of serious marital problems. The relatives of depressed people have also been found to suffer from increased worry, resentment, and exhaustion. In fact, people who live with a depressed person are more prone to depression themselves and have a higher risk for other emotional problems, such as anxiety and phobias.

Why should depression lead to such severe relationship difficulties and even harm to nondepressed family and friends? Think about it. If you are lonely and resentful because your wife has been blue for several weeks and never wants to do anything with you, you might respond to her request for help around the house by sighing and looking disgruntled. She senses your resentment and feels unsupported, more helpless, and more depressed -- reactions that feed your resentment and loneliness. Researchers have described this kind of interaction as a downward depressive spiral in which your loved one's behavior and your reactions to it can worsen the depression rather than help to alleviate it.

The early stages of this downward cycle can take many forms. One possibility is that because you feel guilty about your resentment toward your wife, you do not readily voice your feelings, and she senses that you are not telling her how you feel. As a result, the communication between the two of you begins to break down. Or you may express your anger too freely, thereby lighting your spouse's already shortened fuse and making a constructive argument virtually impossible. As we all know, when fights are too hot, they resolve nothing. But what you may not realize is that these kinds of interactions may inevitably lead to increased depression and hopelessness, for both you and your loved one. It is almost like a dance pattern that both members of the relationship get locked into, with each member's step affecting the other's step. If you and your depressed loved one are having trouble in your relationship, chances are you are already interacting in this depressive dance.

If what we have said thus far does not ring true to your experience, perhaps a brief look at the relevant research literature will convince you that your loved one's depression is affecting your relationship with her in important ways. If what we have said already fits with your experience, read on anyway. We think this research will help you to identify further the ways in which your relationship is affected. It has only been in the past decade that mental health researchers have begun paying attention to the role of significant others in the lives of depressed people. Before that, depression was considered primarily a problem for the depressed individual, separate from others in their daily lives.

Recent Research on How Depression Affects Family and Friends

Data confirming the idea that depression affects people other than the depressed person initially came from studies of the interactions between depressed persons and strangers. If you are close to someone who is depressed, it is probably not hard for you to believe that when research subjects interacted for even a short period of time with a depressed person they never had met before, they reported feeling down too. More surprising perhaps, subjects who interacted with depressed strangers also reported more anxiety, hostility, and unwillingness to spend time with them in the future than did the subjects who interacted with nondepressed strangers. Researchers concluded that something about spending time with a depressed person, even a stranger, is intrinsically difficult and alienating to others. Importantly, these results showed that the depressed person's behavior was off-putting and held people at a distance. This finding is particularly bad news for depressed people because close, supportive relationships are essential to their recovery from depression.

If you mentally review your own interactions with your loved one, you may be able to pinpoint some behaviors that have been off-putting to you. It may be that your loved one seems withdrawn, uninterested in your company, or easily irritated. In the research studies with strangers, the participants particularly complained about the depressed person's "negative attitude" or "lack of energy." We have all had the experience of interacting with someone in a foul mood and know that mood can be contagious and that a depressed person can be unpleasant to be around. But what is it that is unpleasant? And what happens in more ongoing relationships? Are the effects that are seen in interactions with strangers even more pronounced in closer relationships?

Building on the studies of strangers, researchers next looked to the interactions of college roommates. They found striking differences between the roommates of depressed and nondepressed students. The roommates of depressed students reported significantly more conflict, increased arguing, and less direct communication. In addition, they described feeling frustrated, sad, and angry themselves. When asked about their relationship with their roommate, these students said that they were much less willing to spend time with this person and tended to socialize more with other friends, preferably outside the dormitory. The conclusion from this research was that depression clearly can affect those who live with a depressed person.

If you live with someone who is depressed, you too may feel frustrated, sad, and angry. You too may have worse arguments than before the depression and much less desire to spend time with her. As you might expect, these feelings can be amplified in ongoing, closer relationships than typically exist between roommates.

Only the most recent research has examined the intimate relationships of depressed people, with results similar to, but even more striking than, the studies of strangers and roommates. Although this may seem counterintuitive at first glance -- you would think, that there should be a stronger bond in intimate relationships -- we think you will agree that these findings make a lot of sense. Marital partners, for example, spend more time together and have to resolve more daily life issues than do college roommates who may be living together for a limited period of time.

The research shows that people who are closest to a depressed person are often angry, discouraged, and strained by the depressed person's fatigue, lack of interest in a social life, hopelessness, and irritability. In addition, there is a much higher rate of anxiety and depressed mood in the spouses of depressed people than in the spouses of nondepressed people.

Both research and our clinical experience confirm that living with a depressed person frequently takes a serious toll on loved ones. Since we more or less spelled it out, it was probably clear to you that Jane, Peter, and Gall were affected by a loved one's depression. However, for all sorts of reasons, it is not always easy to recognize these same feelings and reactions in yourself. For example, when we first asked a husband of a depressed woman how her depression affected him and his relationship with her, he was surprised: "Affect me? I don't see how it affects me. She's the one who's suffering. I just want her to feel better." In the next section, we provide you with information that will make it easier for you to identify what effects the depression of your loved one is having on you and on your relationship.

Stages of Adaptation to Depression

We have found that the relationships of depressed people go through what we call the stages of adaptation to the depression (SAD). Just as an infant passes through developmental milestones, learning to crawl and then walk, so do relationships pass through stages in their response to depression. Like the infant's developmental stages, the SAD can occur at different times for different relationships, with the stages not always distinct and isolated from one another. Behaviors characteristic of a previous stage can persist into the next, just as a toddler who has learned to walk continues to crawl at times. Sometimes one can regress to an earlier stage. But the stages do progress in essentially the same sequence. At each level, decisions need to be made that can influence the course of the depression and its effect on your relationship with the depressed person. There are four stages:

1. Trouble. In this stage, one or both members in the relationship notice trouble in their interaction, some new difficulty has emerged, or an old one has intensified. The trouble can range from a change in the quantity or quality of time spent together to major arguments and communication breakdowns. For example, Jane noticed that she was assuming most of the household chores, Peter and his wife were aware that their sex life had practically disappeared, and Gall found herself spending much more time with her mother.

2. Reaction. The initial reaction to the trouble in the relationship may be conscious or unconscious -- like a reflex. Regardless of whether there is awareness, one or both members in the relationship react to the trouble, either constructively or destructively. Jane's reaction was to take up the slack and not to express her resentment. Peter's reaction was to be closed-mouthed with his wife and to spend more time with his friends in order to avoid the tension at home. Alternatively, Gail's reflex was to rush to her mother's side, spending more time with her than she really felt comfortable with.

3. Information Gathering. Information Gathering pertaining to the trouble can take the form of talking to each other or to people outside the relationship about their ideas of what the problem is. You may search your memory for similar experiences to confirm or deny ideas you have about what is causing the trouble. Depending on the idea you have about what is wrong, you might also read books like this one or seek professional advice. For example, Peter asked his friend who had a two year old if his wife had also been less interested in sex since the birth of their child. His friend told him that it was the same for them, but it eventually passed once the baby started sleeping through the night.

4. Problem Solving. Here, the information gathered is used to develop a new plan of action, which leads to a less automatic and more conscious response to the trouble. The members of the relationship may work on the problem together or separately. If the plan of action was based on the wrong problem (e.g., Peter's thinking his wife was simply exhausted), this stage will result in ineffective problem solving. If the cause of the trouble was correctly identified as depression, this stage results in an effective resolution to the trouble in the relationship. Gail eventually realized that her mother was clinically depressed and that she could not handle the situation alone. After sharing her concerns with her mother, together they decided to seek professional help.

In the chapters that follow, we will help you to identify when someone you know is depressed and even the type of depression they have. You will learn how to recognize your reactions to the "trouble" and how to build on your constructive reactions while redirecting your maladaptive efforts. We will provide you with specific guidelines to help you move through the SAD effectively. By following these guidelines, you and the depressed person you care about will learn how to interact with each other more effectively, reduce tension in the relationship, and seek appropriate treatment for the depression.

Using examples like those of Jane, Peter, and Gail, we will teach you how to use eight guidelines for your relationship with a depressed loved one:

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1. Learn all that you can.

2. Have realistic expectations.

3. Give unqualified support.

4. Keep your routine.

5. Express your feelings.

6. Don't take it personally.

7. Ask for help.

8. Work as a team.

These guidelines will be most helpful during the Information and Problem-Solving stages. By remembering these guidelines and the SAD, you will be able to influence your trip through these stages. In brief, we will teach you how to learn all that you can about depression and its treatment; how to have realistic expectations about what you and the depressed person can do about the depression; how to give and ask for unqualified support; how to keep your routine despite feelings of guilt and fear; how to express your feelings to the depressed person; how not to take the depressed person's symptoms and reactions to the illness personally; how and where to ask for help; and perhaps most importantly, how to work as a team against the depression rather than as adversaries working at odds with one another.

Learn All That You Can

Let us return briefly to the examples given at the outset of this chapter to introduce you to the first guideline: Learn all you can. Chapter 2 gives detailed information that will help you to identify the various symptoms and syndromes of depression. There is, however, another important source of information about depression that you may not have considered. We like to think of it as an early warning sign, or an alarm of sorts that you can use to check out if the trouble in the relationship is due to depression. This early warning sign consists of your feelings and reactions to the trouble in the relationship.

If someone you care about is depressed, you will likely experience a wide range of emotions and reactions -- from anger to grief, from withdrawal to critical statements like, "You just need to stop feeling sorry for yourself!" You are not alone in your thoughts and feelings about your loved one. Everyone who cares about a depressed person goes through some or all of the common feelings and reactions. They are absolutely normal and should be expected. You might be wondering whether we are saying it is normal for Gail to be angry at her elderly mother who is so depressed she wants to die. And are we suggesting that Gail should tell her mother she is angry or perhaps stop visiting? If Gail's situation were slightly different, we would not dream of suggesting she be that insensitive. Good social graces, if nothing else, require us to put aside our own needs and be sympathetic and helpful when someone is down. Indeed, if Gail's mother had been down for only a few days or even a week, then the situation would not warrant such blunt honesty. But in fact she had been feeling this way for almost a month, with no end to her suffering in sight. Because depression involves a lasting disturbance of mood, Gail and her mother were not just dealing with the everyday ups and downs that most people have. In fact, Gail normally did not feel burdened by her mother; they had a good relationship, and she loved her mother's company. The fact that she was now feeling overburdened and resentful was important information, but she was ignoring it. By not paying more attention to her feelings, Gail was slow to recognize that something unusual was going on and slow to get help for her mother and for herself.

Reactions to Watch For

Common reactions to a depressed person can run the gamut from the extreme of overfunctioning to help out to the other extreme of withdrawing and avoiding the depressed person. Gail's initial reaction was to overcompensate and travel hours each week to try and cheer up her mother. Jane was taking on some of her husband's usual responsibilities because they seemed too much for him. Peter did not want to upset his wife further, so he withdrew to avoid talking to her or initiating sex. In addition to these examples, there are a whole myriad of other common reactions. One natural reaction is to attempt to enliven the depressed person by suggesting or insisting that she be more active. One man had his depressed wife's social calendar so full that the two of them had no time to be alone or to simply unwind. He admitted that it was his way of "keeping her going." He believed that if she stayed home, she would "wallow in her sadness" and never feel better. Another typical reaction, which may seem counterintuitive at first, is to pick a fight with the depressed person. Some of us who are upset by our loved one's withdrawal and disinterest when she is depressed will find ourselves starting an argument just to get a rise out of her. So although these reactions differ widely, there is a common thread: They are all attempts, albeit often ineffective ones, to make the depressed person feel better.

Feelings to Listen To

The common feelings that trigger our reactions when someone is depressed also range from one extreme to the other. When someone first becomes depressed, you may be confused by the changes. As the depression continues, you may feel sad about the loss of the person's usual enthusiasm or interest, lonely or alienated from her, and probably helpless in your ability to make her feel better. And along with that sense of helplessness, you may feel frustrated and angry at the person for not snapping out of it, as well as guilty for having such feelings. Many family members of depressed patients tell us that they feel a whole range of feelings that can change quickly from one moment to the next. In our examples, Jane feels angry, Peter feels sad, and Gail feels worried and guilty. You may notice that your own feelings can shift very quickly, from sympathy for your loved one's sadness, to resentment that she will not join a social activity that you were looking forward to.

The feelings and reactions we described can be early warning signs of depression in a relationship. For example, Gail feels worried, and her worry propels her to drive to her mother's house each afternoon to check on her. Gail jumped to the conclusion that her mother was simply lonely and that she could help her best by keeping her company. Peter's frustration and worry account for his avoidance in talking to his wife about their relationship. He wrongly concluded that she needed to be left alone. If early on Gail had spoken to her mother about her feelings, and Peter to his wife, they could have begun a constructive dialogue resulting in recognizing that depression was at the root of the trouble in their relationship. They would have gotten the information they needed to meet each other's needs. By jumping to conclusions about what was going on and reacting without consulting with the other person in the relationship, Jane, Peter, and Gail delayed their recognition of the depression and ultimately delayed their entering into an effective Problem-Solving stage. Instead, they were stuck in the Reaction and Information-Gathering stages, assuming they knew what the trouble was about and how best to respond to it.

When Gail ultimately spoke to her mother about her resentment and worry in a constructive manner, her mother told her that she understood it was too much of a strain and that she need not bother coming anymore. Realizing that something very out of the ordinary was going on -- her mother had never told her to stay away -- she asked her mother about this statement. The two of them actually laughed together as they discussed this because the feelings and comment were so uncharacteristic of Gail's mother. Following this talk, Gail began to realize that what was happening was truly extraordinary and started her campaign to convince her mother to see a mental health professional for advice. In other words, she realized that it was unrealistic for her to expect that she could make her mother feel better by visiting more frequently. By recognizing her anger and worry and by talking to her mother about what she was feeling, Gail and her mother were able to get things pointed in the right direction. Gail realized her own limitations and in the end convinced her mother to see a psychiatrist. After three weeks on an antidepressant medication, Gail reported, with great relief, that her mother was back to her old self.

As you confront the possibility of depression in a loved one, learn all that you can to recognize it more quickly. Listen more closely to your feelings, become alert to dramatic shifts in your relationship, and be willing to discuss your feelings constructively. Because constructive communication is the key to successful negotiation of the SAD, we discuss it throughout this book and devote all of Chapter 7 to it. Of course, not all shifts or trouble in relationships are a consequence of depression. Nevertheless, certain changes can alert you to consider that depression may be responsible for the trouble. In the next chapter, we will tell you how to identify whether depression is the culprit at the root of the trouble.

Copyright © 1996 by Laura Epstein Rosen and Xavier Francisco Amador