A Secret Sadness: Interview with Dr. Valerie Whiffen

For information about my book, A Secret Sadness, listen to my podcast interview with psychologists, Dr. Brian Macdonald and Dr. Guiseppe Spezzano.  The interview is published in two parts.  In the first part, we talk about patterns in parent-child relationships that may promote the development of depression later in life.  In the second part, I describe how women’s romantic relationships can lead them to become depressed.  For reviews and other information about my book, please visit www.secretsadness.com.

Those of you who are interested in family relationships and parenting will find lots of valuable information and interviews with other writers and researchers at the website hosted by Drs. Macdonald and Spezzano.

 

The Six Myths of Postpartum Depression

Myth # 1: Having a Baby Causes Postpartum Depression

The name says it all: “postpartum” depression is brought on by having a baby.  It’s true that women are more likely to be depressed during and following pregnancy than at other times in their lives.  Surveys of women who recently had babies show that about 13% are depressed which is higher than the normal rate for women in their childbearing years.  However, this finding doesn’t mean that they became depressed after giving birth.  Studies that follow women from pregnancy through the postpartum period show that up to 40% of the women who are depressed after childbirth also were depressed while they were pregnant.  At this time, we don’t know how many of these women were depressed before becoming pregnant or what role the pregnancy played in their depression.  At least some of these women will be depressed for reasons unrelated to their pregnancy, such as the death of a family member.

Myth #2: Postpartum Depression is caused by Hormones

Myth #2 follows from Myth #1.  If having a baby causes postpartum depression then postpartum depression must be caused by hormones.  You read it in magazines; you hear it from your doctor.  This is the most persistent – and the least substantiated – of the six myths.  For 50 years researchers have tried to find a link between hormones and postpartum depression.  They’ve looked at the levels of estrogen and progesterone, both in isolation and together.  They’ve looked at the rate at which these hormones return to normal.  They’ve found nothing.  There is not a single piece of evidence to support the myth that hormones cause postpartum depression.

However, the persistence of this myth is impressive.  I’ve had the experience of sitting in my office with a postpartum depressed woman and telling her what I’ve just written only to have her say, “Well, yeah, but I’m feeling really hormonal.”

Myth # 3: Postpartum Depression isn’t the same as Regular Depression

This myth follows from Myth #2.  We know that reproductive hormones don’t cause depression if a woman hasn’t recently been pregnant.  So if postpartum depression is caused by hormones, it must be a different kind of depression.  Some people argue that the symptoms are different; others believe that postpartum depressed women want to hurt their babies.  The media are particularly keen to link postpartum depression and killing one’s baby.

What does the evidence say?  When postpartum depressed women are compared to depressed women who haven’t just had a baby, there are very few differences.  One is that the postpartum women tend to be less severely depressed.  However, the types of symptoms they report and how long their depression lasts are the same.

Another issue is the predictors of postpartum depression.  If this is a different kind of depression then it should be predicted by different factors.  However, the predictors of postpartum depression are identical to the predictors of regular depression: life stress, a lack of social support and a difficult marriage.

In all the ways researchers have thought to look, postpartum depression looks the same as regular depression.

Myth #4: Postpartum Depression doesn’t need to be treated

This myth also follows from Myth #2.  If postpartum depression is due to hormones then the woman just has to wait for her hormones to come back to normal.  Physicians will often assure postpartum depressed women that their depression will get better as time goes on.

This myth is dangerous.  It may be one of the reasons that postpartum depressed women typically don’t receive any form of treatment.  But they should.  Women who are depressed during or after pregnancy are at risk for more depressive episodes, both after the birth of later children and at other times in their lives.  For many women, the postpartum episode is just the first of many.  This finding makes it an important episode to treat because the research shows that every time a woman gets depressed she increases her risk for another depression.

Depression at this point in a woman’s life also can have enduring consequences for her baby and her marriage.  When a new mom is depressed, her baby develops more slowly, cries more often and is less likely to form a secure attachment to her, which can create problems for the child later in life.  Women who experience postpartum depression also are less happily married 5 years later than women who didn’t become depressed.

Myth #5:  Postpartum depression occurs out of the blue to emotionally healthy women

This myth certainly reflects what many women tell me.  However, the impression that they were okay before the baby simply isn’t borne out by the research.  The majority of women who develop postpartum depression have sought help for emotional problems in the past.  The strongest predictors of an episode of postpartum depression are: 1. A previous history of depression and 2. Feeling depressed during pregnancy.

Myth #6: Only women experience Postpartum Depression

Again, this myth follows from Myth #2.  If postpartum depression is due to hormones then there’s no reason to think new fathers will become depressed.  In fact, having a baby is even more disruptive for fathers than it is for mothers, and on average more distressing.  Up to 10% of new dads experience significant levels of anxiety and/or depression.  This rate is 1 in 4 if their wives are depressed.

So what is Postpartum Depression?

If it’s not what the myths say it is, what is it?  The causes of postpartum depression are just as varied as the causes of regular depression.  A woman can become depressed because one of her parents dies, because she loses her job in a bad economy, because she’s all alone in a foreign country.  There are just as many causes of depression as there are individual’s life stories.

That being said, the research does suggest certain patterns.  The typical woman who experiences postpartum depression is unhappy in her romantic relationship and may fear that her partner does not love her.  She feels unsupported by him.  Perhaps her partner does not help out around the house or with taking care of other children.  Outsiders may see her partner as indifferent to her.  These factors induce depression at any point in a woman’s life.  When women are unable to have close and harmonious relationships with the people who are most important to them, they feel bad.  I believe this is especially true when a woman is pregnant or has just had a child because the baby is a tangible sign of her commitment to her partner, and she is sensitive to any indication that this commitment is not shared.

There is a reason that women who’ve just had babies are more likely than other women to experience depression – it just has nothing to do with hormones.

Two years for two lives: How the justice system fails sexually abused children

Recently, former hockey coach Graham James was sentenced to two years in prison for the sexual abuse of two young hockey players.  A third charge was dropped as part of the plea bargain.  The man whose charge was dropped wrote a victim impact statement for the purposes of sentencing.  The story he tells is one that I’ve heard repeatedly as a therapist working with adults who were sexually abused as children.  It’s well worth reading if you want to understand the impact that sexual abuse has on children or if you were sexually abused as a child and you feel alone in your struggle.

If Graham James had murdered his victims, he would have received a life sentence.  Because he abused them, they’re the ones serving the life sentences.

 

The Diagnosis of Depression: What your Physician doesn’t know

A recent article in Canada’s Globe and Mail newspaper reported that doctors misdiagnose about 20% of their patients’ illnesses. Wow. If physicians misdiagnose this many physical illnesses, I wondered how accurate they can be when it comes to emotional problems like depression.

As it turns out: not very.

In 2007, a physician named Cepolu looked at the results of 36 studies that had examined physicians’ diagnoses of patients who mental health professionals agreed were depressed. 75% of the physicians were family doctors, while the rest worked in hospitals where they might encounter depression, such as emergency rooms and internal medicine. The results of the single studies were compiled in what statisticians call a “meta-analysis.” The results of the meta-analysis showed that the physicians accurately detected depression 42% of the time. Although the detection rate has improved over the past 15 years, more recent studies show that only 1 in 2 depressed patients is accurately identified.

Physician misdiagnosis is a problem because the first person people normally talk to when they feel bad is their family doctor.

Why is physicians’ diagnosis of depression inaccurate? Patients are partly responsible: they tend to report physical symptoms of depression, such as insomnia, rather than the emotional symptoms, such as feelings of sadness. The way patients present the problem may lead their physician to look for physical causes rather than emotional ones. Even physicians who are knowledgeable about depression may be reluctant to ask about emotional symptoms for fear of upsetting their patients or getting a defensive reaction.

Physicians also tend to think of depression as a purely biological problem, which leads them to be poorly informed about the social causes of depression, which I discuss in my book A Secret Sadness. For instance, life stress is strongly associated with the onset of an episode of depression. Most individuals who experience depression had something very bad happen to them within the month prior to the onset of their depression, particularly a loss, such as the end of a relationship. If a physician is knowledgeable about the social context in which depression occurs, they will take this information into account when considering diagnoses. For example, insomnia in a patient who also tells the physician that his marriage has just ended should be more indicative of depression than insomnia that occurs in the absence of major life stress.

Similarly, a person who had a difficult childhood or who has recently experienced a traumatic event is at increased risk for depression.  If physicians don’t know about the connection between depression and negative life events, both contemporary and historical, they’re unlikely to take these risk factors into account when making a diagnosis.

Another strong predictor of depression is past history. A woman who has been depressed previously is at 40 times the risk of another episode when she experiences life stress.  If a physician doesn’t know the patient’s history of depression, she or he may be unlikely to consider this diagnosis when a woman reports physical symptoms of depression.

The advice in the Globe and Mail article is clear: when you’re trying to get an accurate diagnosis, you’re your own best advocate. If you think you’re depressed, read as much as you can about the symptoms of depression. Then if you strongly suspect you are depressed, read as much as you can about treatments. Many people – and most physicians – think the most effective treatment for depression is antidepressants, but their effectiveness may be due to a placebo effect, as described in a recent 60 Minutes report.  A placebo effect means that the act of taking the medication makes people feel better, not the drug itself.  Both psychological treatments and regular, aerobic exercise have been shown by research to be just as effective as antidepressants. While antidepressants only work as long as you take them, psychotherapy teaches you new life skills and exercise gets you in shape.

In Canada, if you think you’re depressed, the only reason to consult a physician is to get a prescription for an antidepressant. You don’t need a physician’s referral to see a psychologist or counsellor unless your extended health care plan requires a referral to reimburse your treatment.

If you think you’re depressed and you want to try antidepressants, tell your family physician about the specific symptoms you know may indicate you’re depressed. If he or she doesn’t raise depression as a possible diagnosis, ask questions: What else could be causing my insomnia? Is it possible I’m depressed?

To help get you started, here are 14 symptoms of depression:

• Feeling sad or crying easily
• Feeling numb or flat
• Feeling angry or easily irritated
• Feeling you no longer enjoy things as much as you once did

AND

• Not wanting to see people, even friends and family
• Feeling that everything is an effort or lacking motivation
• Feeling tired all the time or having to nap to get through the day
• Sleep problems; either you sleep too much or you wake up after a few hours and can’t get back to sleep
• Appetite problems, either you want to eat all the time or you’re never hungry
• Difficulty concentrating or making decisions
• Feeling critical of yourself for your faults or weaknesses
• Blaming yourself, even for things you know rationally aren’t your fault
• Feeling pessimistic about the future
• Feeling that you’ve failed or are a loser

If you feel any of the first 4 symptoms on a regular basis, that is, at least a few days a week, and 3 or more of the remaining symptoms, you may be depressed. If you consult a physician, don’t forget to talk about the emotional symptoms as well as the physical ones. A licensed psychologist also is qualified to diagnose depression.

© 2012 Valerie Whiffen

The Dance of Marital Distress

Like many people, most of what I know about the private lives of celebrities comes from the covers of the magazines at the supermarket checkout.  Most of this information makes a fleeting impression (Whatever happened to those twins Jen was carrying?)  But occasionally a story catches my eye because it feels heartbreakingly familiar. 

A few years ago I read that Demi Moore’s name on twitter was “mrskutcher.”  I was taken by surprise because in films she gravitates toward parts where she is strong, independent, even witchy.  I was struck that a woman who projects such a strong image would invest her identity in her relationship with her husband.  Of course, women do this all the time.  Even when we’re highly successful, we often think of ourselves as wives and mothers first. As a therapist, though, another possibility presented itself: sometimes women who project a strong image are longing for a romantic relationship in which they can feel safe. 

Last fall, as the Kutchers’ marriage unravelled, Demi Moore gave an interview to Harper’s Bazaar in which she confessed to feeling “unlovable.”  “Unlovable” is a big word to a therapist.  We can all feel unloved at times, by a specific person or in a particular context, but the word unlovable suggests that not being loved is part of who she is, not an aspect of her marriage.  Why would a successful woman, a rich and beautiful woman, think she wasn’t worthy of love?  It’s in the past, Demi explained.  Although she didn’t say what had happened, her past has left her feeling “unsafe” whenever she isn’t in control.  When people feel unlovable and unsafe in relationships, they’ve often grown up in families where they felt rejected or were abandoned. They enter new relationships afraid there’s something fundamentally wrong with them and terrified they’ll experience rejection again. And, as it did to Demi, the outcome that is most feared is the one that often happens: Ashton had an affair.

A couple of months later, an alcohol and drug-fueled meltdown landed Demi in a mental health facility for treatment of her “addictions and eating disorder.”  When relationships end, it’s often the person who felt most insecure who is devastated.  She can feel that she’s failed and become depressed; she can use drugs and/or alcohol to numb the pain; she can hold tenaciously to the belief that if she was just more beautiful, or 10 pounds thinner, the relationship wouldn’t have ended.

Meanwhile, Ashton was photographed partying in Brazil with a clutch of lovely young women.  He returned to LAX the day after his wife’s hospitalization, stony-faced and silent.  Implicitly, the media accused him of indifference.  In his defense, unnamed sources claimed Demi was no longer the woman he’d married, that she’d become “needy” and insecure. 

This pattern – an insecure, needy and emotionally distressed woman and her apparently indifferent husband — is so common when couples are unhappy that it has a name: the academic-sounding “demand-withdraw interaction pattern.”  80% of the couples I work with show this pattern.  One partner demands, pleads and cries, or is angry, controlling and critical, while the other retreats, is defensive and withdrawn, and passively refuses to do what the demander wants. Around the world, and regardless of sexual orientation, couples that show a demand-withdraw pattern are unhappy.

Like the Kutchers, the majority of demanders are women, while the majority of withdrawers are men.  In my practice, three-quarters of the demand-withdraw couples are woman-demand and man-withdraw.  The combination of a demanding wife and a withdrawn husband is particularly toxic, and these marriages frequently end in divorce.

Over time the partners become increasingly polarized: the demander gets more distraught, needy and controlling, while the withdrawer becomes even more distant and shut down emotionally.  The problem gets worse because demand-withdraw is a dance in which each partner’s behaviour escalates the problem.  The demander says she wants communication, but she often shows so much anger toward the withdrawer that he can only respond with silence.  His silence communicates that the demander’s concerns aren’t valid or important. 

It’s easier for partners to see what the other person is doing to create problems than to see their own contribution.  One demander that I worked with micro-managed her husband to the point that she advised him about the correct way to walk their dog.  But when her husband told her she was “controlling,” she was astonished.  She was the one who was controlled by him, she said, because he made all the major decisions in their life.  Similarly, he was so afraid of his wife’s emotions that when she cried and told him how uncared for she felt, he told her she was “over-reacting.”  When she replied that he had just “shut her down,” he also expressed surprise. Really?  She was the one who was always telling him what to think. Both partners feel misunderstood.  Both are highly emotional, and, as a result, neither is capable of co-operative discussions that might lead to solving their problems.  Once the dance starts, it’s extremely difficult for either partner to leave the floor, and so they go round and round, arguing about the same topics, over and over again, without resolution.

Some researchers believe that the person who wants change in the relationship is the demander, while the one who wants to keep things the way they are is the withdrawer.  This is what researchers find when they watch couples discuss their problems.  In our culture, wives usually want more change than their husbands do, which would lead to more female demanders. 

Other researchers argue that gender is less important than power. The person who feels less powerful in the relationship is the demander.  Anyone who wants her partner to change is in a low power position from the get go because she has to rely on him to give her what she wants.  On average, husbands have more power than their wives.  They usually make more money and have more influence over big decisions, like how money is spent or where the couple lives. 

On the face of it, the power explanation seems to fit the Kutchers.  She feels unlovable.  She’s more than a decade older than him and on the brink of physical changes that no amount of exercise or diet will stave off.  Her career is well past its peak.  She’s reduced to bit parts, while he recently joined a popular TV show as the hot new guy on the block.  Ashton appears to have more power than Demi.

In my clinical experience, however, it’s difficult to judge who has the power in a couple, even when you know them well.  When I work with couples, often both partners feel powerless.  The demander may feel helpless to have an impact on her partner.  She may feel he doesn’t hear or value her concerns.  But the withdrawer often feels inadequate.  No matter how hard he tries to please his wife, he can never get it right, which leaves him feeling helpless. 

In therapy the couples who are most stuck are those for whom the demand-withdraw pattern touches old and deep wounds.  A woman feels scared of rejection and unsafe unless she can control every aspect of her husband’s life.  She can’t talk about these shameful feelings, so he doesn’t know that vulnerability lies behind her criticism and control.  He starts to shut down emotionally, which makes it easy for him to have an affair and tell himself it means nothing.  His affair tells his wife that, at least for a time, someone else was more desirable than her, which, with the logic of the heart, makes the other woman more lovable.  And in that moment he has confirmed her worst fear about herself.

That’s the dance of distress. 

© 2012 Valerie Whiffen