How to Support People with Depression

This I wrote as a Facebook Note which does not easily embed into WordPress, so I have copied and pasted it.  Here is a link to the original post.

My experience with depression

The diagnoses

I’ve been dealing with depression since 2000 (at the time of writing, 16 years) and anxiety since 2002 (at the latest). The severity of the depression has varied vastly, but it is always there to some degree. In 2009, I finally broke down and agreed to see a psychiatrist and to be put on some meds. Since then, I’ve tried about twenty different meds. Some of them helped some; some helped a lot but their effect wore off shortly after; some made me more depressed; some had no discernible effect.

My anxiety, when I first realized something was wrong in spring 2002, presented as a tic—a twitch of the neck or arm, or a hard, involuntary blink—that would occur whenever I remembered or imagined something supremely discomforting or embarrassing. Over the years it’s evolved, sometimes into my whole body convulsing, sometimes yelling, “STOP,” or screaming in the car, and most recently, into spouting of curse words like someone with Tourette syndrome. Now, along with these tic-like symptoms, depending on the severity, I’ll experience an anxiety attack: my mind will completely shut down, I’m incapable of making even the simplest of decisions, and all I want to do is run away from everyone and do nothing.

About a year ago, April or May 2015, I was diagnosed with OCD, the type that causes me to compulsively think a thought over and over again. My ritual is to count out syllables on my fingers, always attempting to phrase sentences in multiples of five syllables. After being diagnosed, I’ve realized upon reflection that this ritual began around third or fourth grade, 1995-96ish, with the sentence, “I want to go home,” which I would repeat in my head regardless of whether I was home. At the time I found it really odd, but now it makes a lot more sense. When my psychiatrist diagnosed me, she said that my OCD has been marinating in depression for the better part of two decades. So, the vast majority of my repeating thoughts are self-loathing or suicidal in nature. Generally, the thoughts aren’t true—when I think “I just want to die,” while I am in pain, in actuality, I don’t usually want to die—they’re more like a song or chant stuck in my head with tiresome lyrics and no melody. Still, when I hear myself think “I just want to die” a few hundred times a day (no exaggeration), it really starts to wear me down, and eventually, when things are bad enough, the mantra rings true.

The crash

In June of 2015, my wife left me, wanted to reconcile in October, and left me again in December. We both suffer from severe depression, anxiety, and OCD (plus each of our own unshared mental illnesses), and the combined strain of trying to support each other while each combating our own mental health was more than the relationship could handle. Regardless of the rationale and need to separate, divorce is never easy and has greatly contributed to my anxiety, suppressed anger, and depression.

The next month, January 2016, my high school best friend very unexpectedly committed suicide. Since late 2011 when I had to quit my dream job at Microsoft because I was underperforming, my anxiety has steadily gotten worse, to the point that in February, I stopped being able to work. I fell behind on my bills, increasing my anxiety even more, to the extent that I could no longer even open my mailbox. In March, I admitted myself to a psych ward for six days, which helped immensely!… until thirty-six hours after discharge, at which point I dropped even lower, as my sudden glimmer of hope snuffed out. About four weeks later, I admitted myself again for another four-day stay, and three weeks after that, knowing that I could not just continue the cycle, going in and out of the hospital, moved in with my mom and stepfather while I complete a partial hospitalization program.

I can say with complete honesty that the number of days in the last ten years that I would have agreed with the statement, I want to live, total less than a month.

My intention here is not to gain your pity, but to demonstrate my intimate understanding of my depression, anxiety, and OCD. I can only speak from my experience, and my suggestions will not work universally. That said, I hope I can give you some insight into how depression makes its victims think and feel, and in turn, allow you to better empathize with and support your loved ones suffering from depression. With better understanding, you will be more successful at coming up with creative solutions to support your family and friends with this struggle.

In particular, I will focus on how to talk to someone who’s in the midst of depression.

The struggle with support

The odds are, if you’re inexperienced with supporting people with depression, your instincts are wrong. That’s not your fault, and it’s not the depressed person’s fault—they can’t help how they interpret your actions—it’s just the nature of the beast.

I have a good dozen friends and family members supporting me through my recovery. For this, I trust that when I’m thinking clearly, I will be eternally grateful. Unfortunately, right now, it makes me feel helpless, worthless, incompetent, and burdensome. It is support that I recognize that I need, but it is very hard to accept. It is humbling at a time when my self esteem is already at an all-time low.

On top of this, my supporters who haven’t experienced severe depression themselves really have no idea how to help. It would be unreasonable to expect them to know how to help, because they can’t intuitively understand how I think and view the world; a rational mind cannot be expected to think irrationally. Things that would make most people feel thankful, instead worsen my mood. Suggestions on how I could help myself feel better, instead tear me apart and wrack me with guilt. This, in turn, understandably frustrates my supporters, once more compounding my depression.

Patience

The hardest thing you will have to learn in order to support someone with depression is patience. I guaranty that eventually you will lose your patience—anyone would, and that’s okay—but people suffering from depression are fragile and cannot handle their supporters blowing up at them, no matter how unreasonable the depressed person may be acting. If you feel you are running out of patience, it is far better to take a time out, leave the person alone (if safe to do so—I’ll cover this), and go regroup. If you have it within you, let them know before leaving that your need to step back and pick the conversation up later is not their fault (assuming the issue trying your patience is a symptom of their depression), that you love them, and that you will come back.

Anhedonia

A symptom of severe depression is anhedonia, the inability to feel pleasure. Even my favorite things—activities, TV shows, discussion subjects, even foods—when I’m depressed, at best feel neutral. This makes it extremely difficult to get out of the pit. Further, the realization that my favorite things aren’t enjoyable anymore is even more disheartening. In my experience, anhedonia comes in waves, and I just have to wait it out.

Suicidal thoughts

I won’t go into too much detail, but just to have suicidal thoughts or to “be suicidal” is not the same thing as being ready to jump off a building. Taylor Jones wrote an excellent (and mercifully shorter) article entitled When You’re in the Gray Area of Being Suicidal describing what it means to be “suicidal”, and I highly encourage you to read it. Suffice it to say, here, that when someone with depression expresses suicidal feelings, it is not necessarily time to call the police or drive them to a hospital. Ask them to rate their suicidal thoughts on a scale of 0-10, where 0 is no desire at all, and 10 is about to pull the trigger. For me, anything below an 8, while varying levels of painful and frustrating, is a level at which I can still keep myself safe. At 8, I start to make plans; at 9, seriously consider or research the feasibility of those plans; and at 10, am actively making preparations.

One of my biggest struggles when it comes to my OCD/depression combo is that so much of my time is spent ruminating on suicidal thoughts, and because I’ve learned that to discuss them incites panic in whomever I’ve chosen to confide, I feel alone. I feel trapped.

If you are particularly close to a person who suffers with depression, if you’re a trusted confidant, it is a good idea to extract a promise from them to notify you if their suicidal rating reaches a certain point (if you aren’t that person, it’s a good idea to make sure they have such a person). For me that’s 8 or 9; for others it may be different. In the mental health world, this is called contracting for safety. If the person is unwilling to make that promise, then it is time to get them professional help. Though I don’t personally struggle with self-harm, many people with depression, OCD, and other mental illnesses do, and it’s a good idea to use the same kind of scale and contracting for safety for those temptations.

Don’t rely on logic

Depression isn’t logical. It exaggerates the bad and diminishes the good. Just because you can see fifty positive things going on in a person’s life for every negative thing, it doesn’t mean I will be able to see it that way; the good things simply don’t matter, and pointing out that I have so much going for me makes me feel selfish and guilty for being unable to see it. Sometimes logic will work—for example, if you can present an alternative view of my circumstance that I can accept—but often it won’t.

How to help (and what help actually hurts)

Sympathize; don’t advise

Frequently when someone talks to you about how they’re feeling sad, your natural instinct is probably to figure out how to fix the problem. After all, you care about the person; you want them to feel better as soon as possible! Suggestions roll off the tongue, all things that work for you. Eat something healthy. Drink plenty of liquids. Go for a walk. Hang out with friends. Think about things you’re thankful for. Read a good book. Just get out the door, and your anxiety will be fine when you arrive at work. The thing is, I know all of those things. And I know that either they won’t work right now, or that I’m not emotionally capable of doing those things; otherwise I would have already. When I hear these suggestions, what I’m really hearing is, “It is your fault you are feeling depressed. Why don’t you take better care of yourself? If you just pulled yourself up by your bootstraps and conjured the willpower to do these simple things, you’d feel fine. Get over yourself.”

When I talk to someone while I’m depressed, I am never seeking advice. I’m looking for someone to listen, for someone to comfort me, for someone to understand what I’m feeling. In a sense, I’m acting stereotypically like a woman, and for some reason, depression especially elicits the reaction of a stereotypical man: to fix the problem. I’m looking to not feel alone in my struggle. In the rare case I do want advice, I ask for it. If it really feels like the person is inviting advice, but not explicitly requesting it, it’s safest merely to ask them what it is they need right now.

Validate; don’t minimize

Most of the time, even when feeling particularly depressed, part of me can still think rationally enough to know, intellectually, that the intensity of my feelings does not match the magnitude of my circumstances. I feel pathetic for overreacting, and not being able to handle something as common as going to the grocery store because the fridge is empty or my meds are running low.

When someone tries to point out that I’m strong enough to do something because the task is so small, it confirms my negative belief that I shouldn’t feel as bad as I do. I don’t feel any more capable of doing it, but now I feel worse about my limitations.

Similarly, pointing out that other people have it worse only makes me feel guilty for having feelings. Frankly, I’m not sure how this is supposed to help anybody, let alone depressed people.

What I need is to be reminded that feelings are natural and involuntary. Overreactions are natural for people with depression (though I would avoid the use of the word overreaction). The emotions are real; they’re legitimate even if they seem disproportionate. Feeling my emotions is not something I can control, nor should I. I need someone to sympathize with me, to take on some of the weight of those emotions, to have compassion, to feel alongside me. I don’t need “oh, you poor thing”—I don’t want pity—I just need to know that I’m not crazy, and that I’m not weak for being unable to handle things people ordinarily can, even things I was able to handle previously.

Similarly, I need to know that my feelings matter, regardless of the overreaction. It’s easy to think, I’m feeling bad, but because I know I’m depressed right now, my feelings are not important. It’s easy to feel dismissed. Women, you know how this feels when someone says, “Oh, you’re just PMSing.”

Despite knowing, intellectually, that depression is real, it often doesn’t feel real. It feels like I’m making it up. I need to be reminded that I’m not, and that it has a real effect that I’m not responsible for. I need to know that the people supporting me acknowledge this handicap as real, even if they don’t fully understand it. I need to know they don’t think that I’m just seeking attention or that I’m lazy.

With depression, overreactions are involuntary, and so to overreact needs to be okay. Imagine that you believed that you shouldn’t need to breathe, and that to succumb to this need was weakness and worthy of guilt. You do your best to hold your breath, to tell yourself that air doesn’t matter, that you’re strong enough to get over the burning in your lungs, but in the end, of course, you take in a breath. Now you feel weak, guilty, and a failure for feeling and acting in a way that we know is natural. It is similar with depression and trying not to let negative feelings overwhelm you, to act as if you’re not depressed and make it through the day. Everyone, depressed or not, tries to put on their best face around other people, to pretend that everything is okay. Depression makes this significantly harder, and it is embarrassing, shameful, and false-guilt-inducing, when the mask breaks. I need to know that when this happens, people, especially those I care about, aren’t thinking any less of me, aren’t seeing me as a failure.

Sometimes life really sucks, and when it does, it’s natural to feel bad about it. With depression, it’s natural to feel really bad about it, and to feel bad about everything even when only one thing is going wrong. This is not their fault and that needs to be affirmed, because it really feels like it is. Before you can affirm it, you must first believe it, really believe it.

Guilt and shame

I’ve heard dozens of times that suicide is the most selfish act there is. The feeling and the thoughts are always there, against my own will, and to be reminded of how selfish I’m being by considering suicide only appends additional shame, making me want to end it even more, to get out from under the guilt and shame of being suicidal, something I can’t control.

Likewise, it hurts so much when someone says, “Do you know how much pain it would cause me if you killed yourself? I would never recover.” I can’t speak for every depressed person out there, but I know this already. It is what has kept me from killing myself this long. Reminding me only heaps on yet another enormous portion of guilt and shame, worsening my mood and heightening the appeal of ending it all.

Instead, use positive language. Tell me why I’m important to you, how, despite my depression, I’m still a positive asset in your life. Be specific. It may seem like I’m just fishing for compliments, but when I am in a state where I believe only negative things about myself, compliments, specifically those I can’t argue with, such as how I make you feel or what you appreciate about me, make a world of difference.

Things won’t necessarily all work out

Currently there is no cure for depression. There are meds that might help most of the time. There are techniques for managing it. There are habits that reduce the frequency and strength of the depression. But there is no cure.

You don’t know the future. The situation might—even probably will—work out, or the depressive episode will likely eventually abate, but there’s no guaranty. Platitudes offend me; they trivialize a complex situation or set of feelings to the size of something dismissible. (At least, that’s how I see it.) Plus, when you’ve been depressed for well into your second straight decade, there’s not an abundance of evidence to support the notion that things will eventually work out. Things might get better, but I’ve seen them get worse again every time.

What helps me is when someone tells me they hope and believe—are even confident that—life will get better to the extent that I’ll want to live on a regular basis, but that they are not sure. However, regardless of whether life improves or not, it helps to be assured that no matter how bad things get, they’ll stick with me, to listen and to support. I need reassurance, sometimes constant reassurance, that as long as I’m doing my best and continually trying to learn how to manage the depression in ways that work for me, I’m still a success in life. Hopefully if I’m told this enough times, I’ll eventually accept it as true.

Assure them they are worth helping

One of my biggest struggles regarding my depression is how much I have to rely on other people to make it through the day. My sister has graciously taken over handling my finances. My mom, dad, and grandpa have all provided money to handle my bills while I’m doing the partial hospitalization program and am only working a few hours a week. Dozens of people have helped me in the past year.

And it makes me feel like a burden.

It’s very, very easy to believe that I am so screwed up, that I’m not worth the time, effort, and money of so many people, when I don’t trust that I’ll ever get better. It would be better to cut everyone’s losses now, than to let people keep helping me until I ultimately fail later.

This is one I’m not sure what you can do to help, aside from consistent reassurance, both that I am worth helping, and that I am not a burden. If you really want to sell it, and you can say this sincerely, tell me that even if I do eventually commit suicide, the help, effort, and money spent to keep me alive as long as I did was worth it.

When there’s nothing left to say

Even at my longest winded, I eventually deplete my store of new ways to express my depressed feelings and fall silent. It is only after this point, after I’ve felt heard, recognized, and validated, that I really am able to move onto something that could make me feel better.

Now you can shift the discussion to something the depressed person finds enjoyable. Even better, if possible, suggest an engaging activity you both enjoy doing, and then do it together. Don’t tell them to focus on something positive—no positive thought feels authentic—instead provide that positive focus. Don’t just suggest a list of positive things, but actually start discussing one. For example, relive a pleasant shared memory with them. Walk them through it, so they can remember it with minimal effort. Tell them a story from your own life of a struggle that resonates with their own.

Establish and respect boundaries

It’s difficult to watch someone just lie in bed all day. It’s tempting to say, “This isn’t good for you,” and force them to do something. You might even succeed at rousing them from bed, but at the expense of demoralizing, angering, and dehumanizing them. Ultimately, it is still the depressed person’s responsibility to get better. You can only help them while they work at it.

Final thoughts

I hope you have found this helpful or at least insightful. Depression is not a battle that can be fought alone. Unfortunately, it is also very easy to inadvertently make someone feel worse while trying to help them. When talking to someone who is feeling depressed, remember that no matter how absurdly exaggerated their feelings may seem, they’re real to the person, and need to be validated and respected. It is always safer to listen than to speak. Encouragement and sympathy trump suggestions. The more you understand how the person is feeling and what they need (not what you think they need), the better you will be able to help. Conversely, the less you invest in understanding, the more counterproductive your attempts to help will be. Above all, remember that though the person may be fragile, they are still human, and more than anything else, desire unconditional connection, affirmation, validation, and comfort.

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