Withan estimated 17 million Americans suffering from a depressive illness (Sheffield, 1998), it is safe to say that mental illness is one of the most painful and persistenttrials that a family will face (Morrison, 2005). The American MedicalAssociation considers it the most incapacitating of chronic conditions inrelation to social functioning (Sheffield, 2003). More than one in ten peoplewill suffer a serious depression at some point in their life; however, nearlytwo-thirds do not get the help they need (Morrison, 2003; Sheffield, 1998).
Suchan illness impacts the home, specifically a marriage where one spouse issuffering from depression. Both partners benefit from understanding depression.
Althoughthis illness impacts so many lives, it is apparent form the number ofindividuals who actually seek help that few victims and family members areequipped with the information they need to understand mental illness. This isunfortunate because depression is the number one psychiatric disability of ourtime and takes place within relationships, often having harmful effects on them(Papp, 2003; Kung, 2000; Jeglic, 2005).
Everyonefeels sad from time to time. However, it is important to distinguish betweenmajor depression and life's transient sadness (Morrison, 2003). The term mentalillness does not refer to the normal wear and tear of life that comes as aresult of social and emotional concerns (Morrison, 2005). Rather, mentalillness is described as abnormality in an individual's mood or a brain disordercausing mild to severe disturbances in an individual's understanding, thinking,and behaviors (McKenry, 2005; Morrison, 2005). Depression consists of negativebehaviors such as lower motivation, and increased self-focus and irritability, whichleads to strains in the depressive's relationships (Papp, 2003). In his book, Valleyof Sorrow: A Layman's Guide to Understanding Mental Illness, AlexanderMorrison described the affects of mental illness in the following manner,
It will have become apparent that emotional,spiritual, and physical toll from mental disease is horrendous. It exceeds theability of words to describe. The tsunami of suffering extends outward from thevictim to engulf family members, friends, Church associates, and fellowworkers. All involved struggle to try to make sense out of what is going on. Dreamsare discarded, hopes dashed. Panic, sorrow, and a sense of hopelessness canpervade every waking moment. (p. 115)
Whendisturbances are severe and last long enough they can affect the victim'sability to function normally as an individual or productive member of society (Morrison,2005). Serious depression takes on a life of its own, all encompassing andunlimited (Morrison, 2003). Even serious depression may disappear of its ownaccord but usually some sort of treatment will be necessary, and it isrecurrent and may occur again (Morrison, 2003).
Likeother infirmities such as cancer or heart disease, mental illness appears inmultiple forms with different characteristics requiring different treatments(Morrison, 2003; Sheffield, 1998). Although certain characteristics will turnup consistently, it is impossible to predict with complete accuracy how anygiven depression will manifest itself; for example, some people areconsistently depressed for years at a time while others will experience cyclesof depression and remission (Sheffield, 1998).
Depressionis an "internalizing" disorder, meaning it involves major disturbances in moodsand emotions (McKenry, 2005). An understanding and an ability to interpretsymptoms will give clues to a correct diagnosis of depression (Sheffield, 1998).
Asmentioned above, type and severity of symptoms will vary and will lookdifferent for each individual. Those who suffer from a mild and untreateddepression may be able to function well enough to fool those around them, butit is when depression goes beyond a mild form that it can wreak havoc in theindividual's life (Sheffield, 2003).
Depressionand the Family
Researchershave found that depression tends to run in families (Sheffield, 1998). Andwhile it is known that depression has a genetic connection, researchers haveyet to discover exactly how (Morrison, 2003).
Familieswith predispositions for mental illness face many challenges. For example thereare reports of victims who have records of past hospitalizations facing reducedcareer opportunities, receiving limited insurance coverage, and even beingdenied coverage from insurance companies (Morrison, 2005). In addition manyfamilies will face social stigmas about depression. Victims may encounter fearsof being shunned, whispered, or laughed about (Morrison, 2005). Also thosesuffering from depression may believe that spouses, friends, children, and evenemployers may abandon them (Morrison, 2005).
Thesocial costs of depression are not limited to the depressed individual butinclude family members (Benazon, 2000). In sum, a large part of the burden forvictims and their family members will be "the prejudice, ignorance, misunderstandingand social stigma which characterize the attitudes of many in society towardsthe mentally ill" (Morrison, 2005, p. 289).
TheFacts About Depression and Marriage
Depressionand marital problems have reached epidemic proportions in today's society(Gordon, 2005). For example, depression affects 10%-25% of the population and one-halfto two-thirds of all marriages are likely to be affected by a separation ordivorce or both (Gordon, 2005). This does not, however, mean that divorce andseparation always lead to depression. But it should be kept in mind that whenindividuals do seek help from a mental health facility, marital problems anddepression are among the most prevalent problems for which treatment is sought(Heene, 2005). Some researchers suggest that 50 percent of all distressedcouples have at least one member who is clinically depressed (Gordon, 2005). Furthermoreresearch done on depression and the marital relationship indicates that one ofthe most consistent predictors of difficulties in relationships is negativeaffect (depression, etc.) in one partner (Papp, 2003). And indeed couples inwhich one spouse is depressed report more uncomfortable feelings and negativewell-being when compared to nondespressed couples (Jeglic, 2005).
Researchhas found that the stress of taking care of someone who is mentally ill cantrigger depression (Sheffield, 2003). This is crucial information when tiedwith other findings. For example more than 50 percent of depressed individualsreport marital problems and depression has been found to precede maritalproblems which in turn results in an increase of the one-year likelihood ofdivorce by a startling 70 percent (Johnson, 2000; Benazon, 2000). This is a lotof information and another way to understand this information is to realizethat marital problems and depression form a detrimental cycle. Depression leadsto marital problems and marital problems in turn lead to depression.
Maritalproblems and depression take on a cyclical relationship as shown by additionalevidence suggesting that marital problems influence the onset, maintenance, andtreatment of depressive episodes (Kung, 2000; Johnson, 2000). For exampledifficulties in marriage such as arguments are most frequently reported as theevents prior to the onset of depression (Kung, 2000). On the other handresearch also indicates that depression may induce poor interpersonal relationswhich cause additional stress resulting in increased levels of depression(Gordon, 2005). In sum, research has found the relationship between depressionand marital conflict to be reciprocal (Papp, 2003).
Whileit is certainly not depression alone that breaks up relationships a growingnumber of experts believe that depression is often the cause rather than the resultof a divorce (Sheffield, 2003). For example two ways in which the functioningof a marriage were affected by depression were first the way the couplescommunicated when fighting and second how the individuals in the couplementally represented their relationship and its functioning (Heene, 2005).
TheSpouse as Caregiver
Tobe a spouse and also the caregiver of a depressed person can have a strongimpact on the individual (Wittmund, 2002). In fact patients' partners have beenfound to be at high risk of developing depression themselves, and report anincrease in depressive symptoms (Wittmund, 2002, Jeglic, 2005). Research alsoshows that living with a depressed spouse places a considerable psychologicalburden for the caregiving spouse (Benazon, 2000). It is no surprise thatspouses as caregivers are the most at risk because they have the most investedin the relationship (Jeglic, 2005).
Inorder to understand how depression reeks such havoc on the spouse of depressedindividual it is important to have a picture of a loving and healthyrelationship to compare. Individuals who come together to form a couple bringwith them individual beliefs about love, marriage, intimacy, gender roles, etc(Papp, 2003). Once a couple is formed there are attributes that act to help a relationshipor marriage function in a healthy way. For example there are conscious effortsto develop emotional closeness and show love (Duncan, 2000). Individuals instrong relationships take time to communicate and really listen to each other'shopes, dreams, feelings and concerns (Duncan, 2000). Strong marriages willinclude individuals who solve problems together, do family work together, andare based on equality in the marriage relationship (Duncan, 2000).
TheFamily: a Proclamation to the World declares that a "Husband and wife have asolemn responsibility to love and care for each other..." (¶ 6). Marriagecontributes significantly to an individual's self-esteem (Kung, 2000). It is nowonder that when such an influential role is threatened or when an individualperceives they have failed in marriage, a sense of failure may permeate allaspects of life (Kung, 2000).
Spousesof depressed individuals are like anyone else entering a relationship. Theycome with expectations, dreams and hopes. As a result when they examine theirlives after becoming a caretaker they see multiple limitations and lossesparticularly concerning the partnership (Wittmund, 2002). It is no surprisethat living with a depressed spouse acts as a source of strain and emotionaldistress for spouses (Benazon, 2000). Caretaker spouses not only experiencelimitations in their personal relationships but problems may affect theircareer, social acceptance and limit their leisure activities and life style(Wittmund, 2002). Spouses of depressed individuals who were interviewedreported restrictions in their social and leisure activities, a fall in thefamily income, and a strain in the marital relationship (Benazon, 2000).
Notonly do spouses of depressed individuals deal with life's daily hassles theyalso have to deal with the symptoms of their partner's depression and inabilityto help or participate in the relationship. Often the caretaker spouse is leftwith an increased work load and a decreased support system (Wittmund, 2002). Forexample in a relationship where one spouse is depressed, the caretaker spouseoften have more responsibility for maintaining family functioning and thewell-being of any children (Benazon, 2000). This lack of spousal support is onereason caretaker spouses may have an increased risk of depression (Kung, 2000).Spouses may be unable to ask friends or neighbors for help with day-to-daytasks due to shame or fear and this can lead to a general avoidance of socialsituations in an attempt to avoid uncomfortable questions (Wittmund, 2002).
Sheffield(1998) gives words to the emotions caretaker spouses experience in her book HowYou Can Survive When They're Dressed when she says, "[caretaker spouses]wonder why no one understands that another's depression directs and colors ourlives, our thoughts, our feelings, just as surely as it does those of thedepressive" (p. 1). For a caretaker spouse living with a depressive who viewsthe world through despair is disheartening and leads to many of the samefeelings, such as worthlessness, that the depressive feels themselves (Sheffield, 1998).
Theproblems for the caretaker spouse begin out of the public view and within theprivate marital relationship where the caretaker spouse is an eye-witness astheir friend and lover transforms into someone they don't recognize (Sheffield,1998). The despair only increases when the caretaker spouse realizes that nomatter how much love or sympathy they show they are not able to help theirspouse and as a result they begin to lose themselves as well (Sheffield, 1998).
Thecaretaker spouse often finds that their life with a depressed partner is verydifferent from how they had imagined it would be (Wittmund, 2002). Often theywill have negative attitudes toward their depressed spouse (Benazon, 2000). Sometimescaretakers may even see their depressed partner as a burden (Jeglic, 2005). Manycaretakers will talk about their depressed partner as though they were anotherchild to be taken care of rather than a spouse (Wittmund, 2002). Ironicallythese feelings can lead to the same feelings that the depressive experiencessuch as self-doubt, demoralization, anger, and a desire to escape the source ofdistress (Sheffield, 1998).
Asa result both members in the partnership where one member is depressed viewtheir partner as more "negative, hostile, mistrusting, and detached and lessagreeable, [and] nurturing" (Kung, 2000). With such feelings it is no wonderthat hurtful acts such as name calling, ridiculing, or intentional negativesocial comparisons occur that are damaging to the relationship (Roby et al,2000). This lack of mutual respect and courtesy between spouses can lead topsychological abuse between the partners (Roby et al, 2000). Such abuse betweenpartners is especially painful because it occurs between two individuals whohave promised to each other and the law to nurture and cherish each other (Robyet al, 2000).
Undersuch circumstances what can be done for the depressed, the caretaker spouse andthe relationship?
LearningTo Live with Depression
Muchadvice is written as though the process of diagnosis and treatment ofdepression is easy or occurs in a perfect world (Sheffield, 1998). However,those in the role of caretaker spouse they know that it is much harder then itseems. Sheffield (2003) describes the position of a caretaker spouse well whenshe says, "Loving someone who is depressed brews confusion frustration,resentment, and pain" (p. xxii). But it is important to remember that familymembers are vital to helping those with mental illness (Morrison, 2005).
Theconnection between depression and marital distress is influenced principallythrough the way individuals explain the negative behavior of their partner(Gordon, 2005). Individual's personal explanations of negative martial eventsgreatly impacts marital satisfaction and their emotional state (Gordon, 2005).
Tryingto attribute blame to someone is pointless and results in unnecessary sufferingfor the depressed and the caretaker spouse. Searching for a source to blamewastes energy that would be better spent in learning more about the illness andpossible treatments (Morrison, 2005). Those who suffer from depression don'tchoose to and are not simply lacking willpower, "they cannot, through anyexercise of will, get out of the predicament they are in" (Morrison, 2005).
Byunderstanding that depression is not intentional caretaker spouses may be ableto change they way they think of their spouses. For example caretaker spousesmy see their spouses as a victim rather than a saboteur of the marriage (Sheffield, 1998).
Abetter use of time and energy would be to search for understanding andincreased capabilities for compassion and patience (Morrison, 2005). Developingpatience through increased understanding is one of the best tools a caretakerspouse can acquire. Patience will be especially beneficial when dealing withthe continuous ups and downs of depression and even the constant care neededfor patients who may be in danger of suicide (Morrison, 2005).
Caretakerspouses can provide encouragement and realistically remind the depressed ofGod's love, and the love of family members (Morrison, 2005). It will beimportant not to lose patience and to avoid saying things such as "just snapout of it" or "get a little backbone" (Morrison, 2005). The importance ofavoiding such phrases is exemplified through this quote from Helping andHealing Our Families:
Anyone who has ever witnessed the almostunbearable pain and uncontrollable weeping of a severe panic attack, or theindescribable sadness of severely depressed person who cries all day andretreats in hopeless apathy, would never think for a moment that mental illnessis just a matter of willpower (Morrison, 2005 p. 292).
Recognizingthat depression and not the spouse is the villain is a huge step in the battle.However while patience, compassion, and love provide support and are crucialfor learning to live with depression within a marriage they are not a cure forthe illness therefore it is important to seek knowledge of the illness and oftreatment options (Sheffield, 1998).
Understandingdepression as an illness and the biological process can help caretaker spousesto take an active role in treatment (Morrison, 2005). Caretaker spouses whohave little understanding of depression may try to control the ill person andtheir behavior as if the depressed spouse were a child (Sheffield, 1998). Havingknowledge of the illness and where it comes from will help and enable caretakerspouses to better cope and communicate with health care professionals (Sheffield, 1998). This includes understanding the length of time medication can take tobecome active and learning behavioral techniques that are crucial to the healingprocess (Morrison, 2005). Sheffield (2003) put the importance of knowledge intoperspective when she said,
Knowledge is power; choices should beinformed by an appreciation of the advantages and limitations of any treatment.Asking the right questions of the professionals reduces uncertainty and stress,and will help both partners assess progress, or lack of it, more accurately.(p. 108)
Encouragingthe depressed to get treatment is not always easy and may require more thangentle assertiveness (Sheffield, 1998). Caretaker spouses may even experiencestrong resistance to the idea of seeking help (Sheffield, 1998). Sheffield (1998) points out that the better informed a caretaker spouse is the better theywill be able to help the depressive overcome resistance and seek appropriatetreatment.
Howeverit is important to seek help and treatment promptly (Morrison, 2005). Quickerand better results can be expected from cases that received professional helpearly before the illness became deep-seated and therefore less easily treated (Morrison,2005).
Thereare many forms of treatment and it can be daunting to try and understand whatthe doctors are talking about (Sheffield, 1998). The type of treatment that isprescribed will be determined by the form of depression that the victim suffersfrom (Morrison, 2003). For the caretaker spouse, knowing what is medically thematter with their spouse is essential to their wellbeing and can provide afoundation for the future (Sheffield, 1998). It is invaluable to the caretakerspouse to learn about depression and how to deal with it (Morrison, 2005). Thisis especially true since depressed individuals may not be good questioners orlisteners, may distort information based on their moods, and are often not thebest judges of their progress (Sheffield, 2003).
Manyvictims of depression will find their suffering greatly reduced with propertreatment (Morrison, 2005). An absence of necessary treatment increases thepotential for depressed individuals to harm themselves and others (Morrison,2005).
Professionalcare providers often use a three-pronged treatment approach that includes thesocial, biological and psychological aspects of depression (Morrison, 2003). Manysufferers, in fact just under half, seek help from primary care physiciansrather then specialist such as psychiatrists and psychologists (Sheffield, 2003).
Herbaland other remedies are not subject to the Food and Drug Administrationrequirements for safety and efficacy trials (Sheffield, 2003). While theseremedies may have been tested or researched the studies have been poorlydesigned and have been tested against placebos and not against antidepressants(Sheffield, 2003). Nonprescription remedies can be risky and have not beenfound to be the best remedy (Sheffield, 2003).
Currentantidepressants, if used well, have been found to provide help to 60 to 70percent of all those suffering from depression (Sheffield, 2003). One studyfound antidepressants to be helpful in alleviating most severe symptoms of depressionand enabling sufferers to face life's problems although they did not alleviatethe problems (Papp, 2003). Medication can reverse bizarre behavior and assistin healing the brain and improving effectiveness of psychotherapy (Morrison,2005). The influence of an optimal dose of medication can occasionally be feltwithin ten days, however for most sufferers a more gradual change, possiblytaking up to twelve weeks, is more normal (Sheffield, 2003).
Caretakerspouses should be aware that patients may start skipping pills and evendiscontinue them because they may not be able to discriminate between their preand post-medicated self (Sheffield, 2003). In the minds of the depressed,behavior changes as a result of medication may not be noticed and this can leadto discouragement and the eventual stopping of medication (Sheffield, 2003).
Knowledgeabout medication(s) a depressed partner is taking is only the beginning (Sheffield, 2003). A caretaker spouse should maintain good communication with the careprovider as they can provide good input as a close observer of the depressed (Sheffield, 2003).
Withall the responsibilities and weight that caretaker spouses face it is importantthat they take time out for themselves. As a caretaker spouse individuals spendmuch time supporting not only the depressed but children and outside roles suchas employee as well. Caretaker spouses will also bear the brunt of depressedmoods of their spouse which can lead to personal demoralization (Sheffield, 2003).
Asa result it is important that caretaker spouses maintain a life of their own. Notonly is this beneficial for the caretaker spouse but it will allow them to beof most help to their depressed spouse. It is important that caretaker spousesfind time each day, even if it's only a few minutes, to recharge themselves (Morrison,2005). Some suggestions for recharging include: reading a good book, talking toa trusted friend, or calling a family member (Morrison, 2005). The method isnot as important as realizing that nurturing the self is vital to the health ofthe relationship (Morrison, 2005).
Depression is an illness that can greatlyimpact a marriage if it goes untreated. Not only does the depressed individuallive with the symptoms of the illness but the caretaker spouse also is subjectto similar symptoms and increased responsibility with less support.
Moreinformation on mental illness is available for the general public online at:
Toaccompany her books Anne Sheffield has created a website that includes a freediscussion board that may be helpful for some individuals. Follow the link tothe main page and then click on message board:
Written by Jaelynn R. Jenkins,Research Assistant, edited by Alan Springer, Ph.D., Marriage and Family Therapist,and Stephen F. Duncan, Professor, School of Family Life, Brigham Young University.
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