Depression can be a crippling disease, and its pain is only worsened when our loved ones discard our illness as laziness or drama. This is why this happens.
Depression can be a crippling disease, and its pain is only worsened when our loved ones discard our illness as laziness or drama. This is why this happens.
Many of those struggling with depression don’t get the support they’d expect from family and friends throughout the course of the illness. For those unfamiliar with the disease, it can be difficult to empathize with a condition that shares similarities with normal daily struggles. By understanding these barriers, we can better educate our loved ones and better prepare ourselves to be empathetic supporters of those with depression.
10 Barriers to Empathizing with Depression:
- Many have not experienced Major Depressive Disorder and/or question if it really exists.
For example: “You’re just overthinking things. Everything will be okay.”
Empathy is all about listening to the individual, trying to form an understanding of the thoughts and feelings churning inside of him/her, and finally, communicating this understanding back to the person. The point of listening is not to problem-solve, but rather to allow the person to fully flesh out and communicate whatever he or she is thinking and feeling. Much of our ability to empathize comes from relating to our personal experience, so it is understandable that those without a history of depression struggle to empathize with MDD. For those who aren’t convinced that depression really exists, they often attribute a persistently sad mood to things like “negative thinking” or “overthinking things” (as in the above example). With good intent, they’ll tend to offer easy, superficial encouragement like “Think positively; everything will be okay”. While well-intentioned, such simplistic explanations and encouragements fail to acknowledge the validity and severity of the person’s experience. Instead of being curious, humbling oneself to uncover the experience of the person with depression, such responses allow the advice-giver to avoid encountering the depressed person’s internal reality. MDD does exist, and although we may not have experienced it before, we should make our best attempt to uncover what it must feel like to have persistent emotional suffering.
- Most are able to recover from sadness. Why can’t people with MDD do the same?
For example: “C’mon, lighten up! Go work out. Whenever I do that, I feel better.”
While each of us has recovered from sadness at least once in our lives, we tend to confuse our sadness cures for depression cures. Sadness, unlike depression, is a transient emotion. It’s like a different, bad path in the snow which your sled rarely goes down. Since you hardly use the path, it’s easier for your sled to depart from its boundaries. While MDD can include a sad mood, the person’s sled is stuck in a path which it has trudged down thousands of times - the path is slippery and icy and the edges are high; there’s no easy escape. Simple suggestions like “get out of bed” or “go work out” suggest the person has the energy and motivation that we (still) possessed when we felt sad. Our sled may be nimble and free to travel wherever, while the sled of the person with MDD is entrenched. Such simple suggestions, while intended to be helpful, completely disregard how ‘stuck’ the person with MDD really feels. MDD is distinct from sadness, and the very nature of the disease makes it difficult to gain the energy and motivation necessary to emerge from the disease on our own.
- Being lazy, whiny, and negative is common, and many aren’t sure how this differs from MDD.
For example: “You just whine and complain about everything. Get over it!”
While this statement is negative and critical, it is natural for loved ones to become frustrated by our depression. We must be understanding of this frustration; it can be difficult to coexist with someone who feels down or depressed all the time. However, for the frustrated loved one, it is important to recognize that there is a difference between an acute mental illness and one’s personality. While it is possible to develop a personality that minimizes effort (“lazy”), commonly voices unfavorable thoughts (“whiny”) or has a persistent bad mood (“negative”), personality is a consistent, long-lasting set of characteristics which evolves on the scale of years or decades, not weeks. MDD and many other mental illnesses, in contrast, develop on the scale of weeks or months. Many well-intentioned loved ones will try to correct our negative thoughts, feelings, and behaviors out of fear that they are shaping our personality, but such efforts may leave a treatable mental illness unaddressed. Instead, noticing abrupt changes in our thoughts, feelings, and behaviors should alert ourselves and loved ones that we may be suffering from a mental illness and should seek evaluation. An acute mental illness is distinct from a longstanding personality; we shouldn’t withhold empathy due to a concern of creating a problematic personality.
- Depression often takes a while to improve.
For example: “Enough! Just snap out of it!”
While a few of the treatments for MDD work relatively quickly, most of the medications and therapies require a few weeks or months until they demonstrate significant improvement. If a loved one is experiencing depression, it can be quite frustrating and defeating for him or her to demonstrate no improvement after several weeks on medications and several visits with doctors and therapists. In many cases, more time is needed before significant improvement can be seen. However, in other instances, patients will require months of several different medication trials or new therapist consultations until they find a combination that is effective. Such an extensive course of trial-and-error can lead one to think the patient is doing something wrong. It is important to remember that, as a chronic disease with no one-size-fits-all cure, depression may take a while to improve, so we must practice patience.
- Depression can come and go.
For example: “I thought we were done with this when we got you on meds!”
Let’s imagine what it’s like to care deeply about somebody, make time in our schedule to take them to the doctor several times, see a glimmer of hope as they start to recover, and then suddenly watch them fall into another depressive episode. Wouldn’t that be incredibly frustrating? Wouldn’t you feel like the person is wasting your time? Wouldn’t you wish there were some way to magically cure the person of his or her depression? Of course; we would all feel this way. While this frustrating, lingering nature of depression can be difficult to process, it is important to remember that MDD is a chronic disease. It is hardly ever cured in hours or days, but rather improves and, perhaps, goes into remission on the scale of months. Just as a cancer can produce multiple tumors, disappear with chemotherapy and radiation, and return out-of-the-blue, so too, can depression disappear and return when we least expect it. We mustn’t lose hope when depression returns. It, too, is a relapsing and remitting disease - it can come and go. Just as we would consult our doctor and continue treatment if our cancer relapsed, we should consult our doctor and continue treatments (like medications and therapy) if our depression relapses. We must remain persistent. Healing and freedom are the fruits of consistency and persistence. Depression can come and go, so we must do our best to provide empathy in times when we feel frustrated by the disease’s return.
- Mental illness can interfere with family responsibilities, work, or group projects, forcing others to pick up the slack.
For example: “So, you’re feeling too depressed to come to work? The deadline is Friday. I’ll have to pull all-nighters without your help!”
It can feel frustrating to pull more weight than our teammates, especially if they sleep while we continue to work despite our sleep deprivation, frustration, or exhaustion. When we see our teammate lying in bed all day because he or she is depressed, one can think “Gee, sure would be nice to go lay in bed. Too bad someone needs to help get the kids ready for school!” Feeling this inequality of effort can lead us to criticize or despise the person with MDD, and our words can make someone with depression feel even more guilty, worthless, or suicidal. Extreme guilt can be dangerous when combined with suicidal thoughts; we must really watch our words in these moments of frustration. Once we know that everything possible is being done to treat his or her depression, we must focus our frustration toward the disease and not the person. Just as we wouldn’t bat an eye at someone missing work, a project, or house chores because they developed a bad diabetic foot infection or chest pains from heart disease, so too should we allow those suffering from severe mental illness to get treatment and heal. Mental illness may require our teammates to pick up the slack; this is an unfortunate consequence of disease of the brain as well as disease of any other organ.
- There is no easily identifiable cause of the depression:
For example: “What’s wrong with you? Answer me! Why are you being like this?”
“What’s wrong?” is perhaps the most common first question that is asked to somebody with depression. “I don’t know” is perhaps the most common response. As emotional beings, humans are conditioned to identify a singular cause of our sadness: “I’m sad because I got laid off”, “I’m sad because I got dumped”, or “I’m sad because grandma died”. In depression, abnormalities in brain circuits and/or neurotransmitters can make someone feel sad without a clear good reason. This can be difficult for loved ones to understand. Instead of incessantly asking for a cause of someone’s sadness, the best way to empathize is to listen, try to understand and communicate what the person may be feeling, and accompany her as she seeks treatment. When there are no clear patterns of thoughts, feelings, or behaviors, it is possible that some clarity will emerge once medications or stimulations begin to raise the person’s mental fog. Conversely, a talented therapist can sometimes help untangle a complex web of thoughts, feelings, and behaviors to provide more clarity for a question like this. Regardless, it is normal for there to be no easily identifiable single cause of one’s depression, and that is okay. More clarity will come by moving forward with treatment.
- The reason why the person is depressed seems ridiculous.
For example: “Oh, you feel bad because your Porsche needs repairs? I feel so bad for you [*eye roll*]. A lot of people have it worse than you.”
While it’s frustrating when someone may not have a clear cause of his or her depression, people with seemingly ridiculous causes of their depression may be the most difficult to understand. The confusion arises from focusing on one’s worldly experience instead of their neurological experience. Losing one’s Porsche for repairs is not what it appears to the world - neuropsychologically, it’s a difficult loss event like any other. Depending on the person’s history of loss events, their history of depression, and their individual depression triggers, a seemingly superficial loss event like this can send someone into a depressive episode. People with depression have a big, slippery, well-defined path in the snow that their sled may be able to avoid for days, weeks, months, or years at a time. However, even the most trivial or silly event can nudge them back into their depression path. While people may be confused (or even disgusted) by the wealthy man who became depressed because his Porsche was in repair, it is important to remember that our neuropsychological processes make no distinction between the cause of the nudge. Neuropsychologically, a 15-minute flight delay can produce just as aggressive of a cascade of thoughts, feelings, and emotions as hearing you’ve been diagnosed with cancer. Losing a purse can be neuropsychologically equivalent to losing a child in a car accident. Having no ice cream in the freezer can be neuropsychologically equivalent to having no food, clothes, or shelter in real life. All it takes is a nudge to send the sled of somebody with MDD down a well-defined, depressive neuropsychological path. The brain (often) makes no distinction, but onlookers may be disgusted by our complaints, knowing there are people who have it much worse: cancer diagnoses, death of a child, or extreme poverty. If we have a slippery depression path in our brain, even the most trivial disturbance can push our sled back towards the same path. Even though the stimulus may be trivial, the severity of the psychological experience is the same.
- People with MDD often have other mental or medical illnesses, making them seem high-maintenance or demanding.
For example: “So, you’re depressed and you have irritable bowel syndrome, insomnia, chronic back pain, and eczema? You’re so demanding of our time and resources!”
There is strong evidence of a link between depression, anxiety, and many medical illnesses. Some of the most common include irritable bowel syndrome, chronic back pain, eczema, and other autoimmune diseases. The human body was created to strive towards rewards and run away from threats. Thoughts like “I’m going to be late!” can produce the same threat avoidance cascade as physical threats like a hungry lion running toward you. Have you ever noticed that your bowel movements change when you’re traveling? This is because increased anxiety and activation of our sympathetic nervous system (our fight-or-flight response) slows down our intestines. Very slight elevations in our stress level can have major impacts on the rest of the body. As our brain perceives a possible threat, it raises its sensitivity to pain and signals the release of cortisol and adrenaline from our adrenal glands. These hormones prepare us for “fight or flight”, shifting our blood away from our gut and towards our muscles so we can run or fight. Microscopically, our immune systems are also primed to fight invaders, sometimes mistakenly attacking our own bodies. In a state of constant fear or anxiety, which is common in depression, our bodies aren’t allowed to “rest and digest” and are instead stuck in “fight or flight” mode. As a result, our bowels don’t move as regularly, our muscles are tense, our immune systems become overactive, and our sense of pain is heightened. Also, since our bodies are sensitized to pain and our emotional pain is processed in a similar way to physical pain, sufferers of chronic pain feel a ‘double whammy’ of pain during depression; their experience of physical pain is compounded with emotional pain Due to all of these reasons, there is a strong link between depression and many medical illnesses. While frustrating and overwhelming to some, those with MDD may require more medical care and resources than the general population. By understanding the mind-body connection, we can have greater empathy for the mental and physical suffering that those with MDD often experience.
- There is a false belief that those with mental illness can “pull themselves up by their bootstraps”.
For example: “Well, you did this to yourself. Only you can help yourself.”
While hardly ever applied to any other area of medicine, in the United States, we often ascribe a ‘pull yourself up by your bootstraps’ attitude to mental illness. While our thoughts, feelings, and behaviors can lead us into a major depressive episode, many assume that we can pull ourselves out of the episode by our own effort. Nevertheless, the reality is that MDD robs us of the energy, motivation, and concentration necessary to do the problem-solving actions that are necessary for healing. Indeed, without outside support, MDD often follows a reliable sequence of worsening depression, sleep disturbances, changes in movements and appetite, intense feelings of guilt and worthlessness, and for many, suicide. The advice to “pull yourself up by your bootstraps” is just as terrible and deadly as the “fix yourself” said to someone suffering a heart attack. Both are legitimate medical illnesses which require the outside support of medical providers in order to heal and recover. We can have greater empathy for the sufferer of a mental illness once we recognize the foolishness of expecting anyone ill to pull him or herself up by the bootstraps.
Those are ten of the most common barriers to empathizing with those who have MDD. The next time that you’re feeling critical of yourself or a loved one with MDD, ask yourself whether you’re still operating under any of these flawed frameworks. As you’ll see, it can be difficult to rid ourselves of these patterns, and that is okay; we’ll get better with practice. The one underlying pattern is this: recognize MDD as a disease like any other and channel all anger and frustration toward the disease - not the person.
Another way to gain empathy is by attempting to imagine the reality of the sufferer. As we try to ‘put ourselves in their shoes’, we can gain insight by further examining our own experience with sadness. Even though we may not have a mental illness, we have all experienced a range of emotions and can better understand MDD by focusing on our reality in these most extreme moments. We all know what it feels like to simply feel “down” or “sad”. We know those rainy days when we just want to stay in bed, listen to sad music, and forget about life for a while. Sometimes our gloominess gets our sleep out-of-whack; we sleep during the day, toss and turn at night, but feel no energy to get out of bed.
Some of us know what it feels like to suddenly not care about things that mattered to us before (like certain friends, clubs, sports, or other activities). Some of us may be able to recognize strong feelings of guilt for sulking and being ineffective for a period of time. We may have wondered “what’s the point of it all?”, feeling ‘checked out’, ‘spacing out’, and feeling incapable of focusing on the task at hand. In these moments, loved ones may have noticed, saying “You look tired” or asking, “Why are you talking and moving so slowly?”
Some of us may have even lost our interest in food for a few days, losing a few pounds, or conversely, turning to food as our only comfort and gaining weight. In feeling so guilty about our lives, mistakes, and ‘laziness’, some of us may have wondered whether the world would be better off without us.
The above characteristics, when combined and brought to their most extreme, encompass the primary features of major depressive disorder. As we imagine our own periods of sadness, it can be difficult to empathize with MDD because we were able to recover on our own. We may have felt sad until a friend stopped by the house to cheer us up. We may have felt low energy until we decided to start exercising and felt renewed and invigorated. We may have felt guilty for sulking until we, one day, landed a new job and became suddenly inspired. We recovered. The inability to recover is, in one way, the very nature of MDD. However, for those who are able to recover, it’s difficult to understand those who cannot. As described before, it is easier to depart from a snow path when it is shallow and less traveled. However, as our sled passes through the same path again and again, the sides of the path become more like walls, locking us in to a way of thinking, feeling, and behaving which is more and more inescapable. This is the “stuckness” of depression that many of us have not experienced and have difficulty conceptualizing.
Certainly, we’ve all had moments where we felt we were wrestling with one or more of these other features of depression in our own lives. Let’s imagine what it would feel like to have our own sad or depressed experience feel ten times or a hundred times as severe, discouraging, or crippling. Let’s imagine feeling totally stuck in that way of thinking, feeling, and behaving. That severe experience of depression is felt by people around the world. Our experience was merely the bottom or middle of a spectrum, and imagining the intensity of these features at their most extreme should engender an intense respect for those with MDD.
We must begin to treat mental illness with the same respect as physical illness. By further respecting the suffering of those with MDD, we can provide more authentic empathy and provide the resources and time necessary to heal. We don’t tell the construction worker with the broken hand to “suck it up and get back to work” because we know it’s a crippling injury, and avoidance of the issue will only produce further problems down the line. So too, we must realize that there is a crippling injury behind depression and that avoidance of treatment will only produce more problems in the future. Effective treatments exist; we must not hold anyone back from healing.
Empathy is the critical first piece in our response to MDD, and yet, barriers to empathy have become deeply ingrained in our society. By learning about the misinformation behind the common barriers to empathy, we can better identify our own misunderstandings and begin to take a different approach to mental illness in ourselves and loved ones. Knowledge is power, and the more we know about MDD, the better we can advocate for ourselves and loved ones. A better understanding of MDD will help to defeat the stigma of mental illness; that is why this book was written. Now is the time to understand major depressive disorder, share our knowledge with our loved ones, conquer the stigma of mental illness, and move forward with recovery.
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