August 2009

Depression in Paradise

Author: Bryant Welch, J.D., Ph.D.

Jack is a 64-year-old retired corporate attorney. He and his wife, Fran, have just moved to the island from Ohio. They have raised three children who are now all adults. They have invested wisely enough that Jack will not have to work anymore. They had been coming to Hilton Head Island for many years for family vacations. Because of their interests in both tennis and boating, they felt it would be an ideal retirement spot. And they looked forward to having an opportunity to “reconnect” with one another after over three decades of work and child-rearing.

Two years after the move, things are not working out the way they had planned. Fran has become quite active through the country club. She plays tennis three times a week and has fit in well with a women’s network that plays bridge and enjoys spending time planning the next social event. New grandchildren are arriving, seemingly every year, and she enjoys extended visits, giving relief to her children as they go through the throes of young parenthood. (No small measure of her pleasure is in experiencing the newfound respect she receives from her adult children as they begin to appreciate the hard work and devotion that Fran has put into their care for over 30 years and which they had, to some degree, always taken for granted.) For Fran the retirement years are even better than she had anticipated.

For Jack, it is a different story. The first several months on Hilton Head Island, he was excited by the chance to play golf every day. While not as social as Fran, he enjoyed meeting his new club members and neighbors, which is easy to do when one first moves to the area. He also started to act on his longstanding vow to increase his exercise when he retired and had more time.

Slowly, but increasingly, however, Jack noticed there were some frayed emotional edges around his post-retirement pleasure. First, he found himself a little anxious at not being connected to his old work setting. He did not miss all the travel he once had done, and he did not miss having to dress in corporate garb every day. But he slowly noticed that he felt a little shaky and agitated because of this untethered feeling. The social milieu of the country club that Fran enjoyed felt a little foreign to him, although it was hard for Jack to put his finger on why. The relationships were not evolving into meaningful friendships. He thought that other people at the club were feeling more connected with one another than he was with them. The discussions seemed a bit forced, superficial, and contrived. He began to feel there was something missing in his social skills or even more deeply inside himself.

For the first time in their married life, Fran was socially more connected and active than Jack was. While Jack loved his wife and was happy for Fran’s happiness, her expanding involvement pulled her away from him, leaving Jack alone at home for the first time in his life. It also played into Jack’s increasing feeling that there was something wrong with him that he was unable to adapt to “Paradise.”
Fran was swept up in her new life and only gradually noticed the changes in Jack. He seemed much less excited about golf and increasingly backed out of social engagements. Whereas in the past they had each initiated dinners with friends, now it was very clear that, unless Fran initiated something, nothing would happen. Jack spent more time in front of TV or in front of his computer, monitoring their financial investments.

Jack’s interest level was not the only thing that changed. He began to take naps every afternoon, and his sleep pattern was disrupted. Sometimes he would stay up quite late at night, and on other occasions he would wake up in a very unrested state in the morning. He stopped exercising, and there were days when even his personal hygiene was neglected. His diet was heavily laden with carbohydrates and “comfort foods.”

For Fran, this had all occurred so gradually she had not quite let herself acknowledge the extent of the change. When the holidays came, the children all asked Fran what the matter was with Jack. To them he appeared withdrawn, almost sullen and morose.

Clearly, Jack was unhappy, but he was also in pain. His body motions slowed and he complained of muscle soreness, which Fran had originally attributed to the inevitable arthritis of old age. Now she felt that Jack was almost literally laboring under a heavy weight, and Fran became concerned for his health.
Jack’s reaction to all this was self-blame and a pessimism that he had just “lost his edge.” He viewed his future as one of continued decline and unworthiness that he expected to get worse with each passing month. One day he confided to Fran that he was even losing his will to live and said that, when he was driving to the grocery store, he had found himself thinking about pulling out in front of the onrushing traffic and just ending it all. But then, he thought of the innocent people in the other car and realized it would be terribly “selfish” of him.

With this Fran was frightened, very frightened. She called their family doctor, Dr. Scutaro, and asked her to meet with Jack and Fran that day if possible. She said she was very worried.

Dr. Scutaro was a well trained internist. She gave Jack a series of tests to rule out other physical problems, but from the beginning she strongly suspected that Jack was suffering from depression. While Jack and Fran were initially resistant to that notion, Dr. Scutaro was both patient and adamant, insisting that Jack needed treatment. She started Jack on anti-depressant medication and referred him to a local psychotherapist.

For a psychologist, the word “depression” is one that leads to very unfortunate semantic misunderstandings. It’s a word that is used to describe three very different things: a mild case of the blues, a painful emotional reaction to a series of life traumas or disappointments, or to a very, very painful and debilitating emotional illness with extremely real physical symptoms that require prompt medical attention.

Unfortunately there is no bright dividing line separating these categories. Yet, it is very important we all be aware of the differences, because they can have profound implications for our lives and the lives of our loved ones.

The “blues” is a very common state that we all experience from time to time. However, it should be very brief in duration, and it should not ever be of such severity that we find it hard to get on with our lives, maintain our relationships, work effectively, and feel positively about ourselves. If it is truly of short duration, treatment is generally not needed for the blues.

The second category is multi-varied, and it is probably in this area where treatment for depression is most underused. This is especially unfortunate because it is one where treatment, especially psychotherapy, can be very effective.

In this second category are people who have experienced loss such as the loss of a loved one, a job, or of good health. Loss broadly defined is inevitable, but if one does not appear to be adapting and getting over it, it is important to consult a mental health professional. The role of loss in depression has been well-documented and is generally better understood, because grief and depression have some resemblance to one another, so it is easier to see the connection.

Less understood is the connection between depression and psychological trauma. While a discussion of the connective links between traumatic events and depression is beyond the limited scope of this article, when people have experiences that shake their view of the world in a way that makes the world feel less predictable and less secure, the trauma from that experience, over time, can leave them feeling profoundly depressed. Treatment for trauma can be profoundly helpful. It generally includes psychotherapy, but increasingly medication is also used.

And, finally, many of us for reasons we are not aware of, have recurrent patterns of behavior that are self-defeating. It may be in relationships, work, or even athletic performance. In all of these areas, psychotherapy—or talk therapy—with a competent therapist can be extremely helpful. While there is a popular misconception that this treatment is a “crutch,” anyone who has been through good psychotherapy can attest it is hardly a crutch. In fact, for the most part, it involves looking at emotions and feelings that many people are uncomfortable acknowledging.

But it is the third form of depression that can be most devastating and even life threatening. It is a leading cause of suicide, causes enormous personal suffering, and, if untreated, can destroy whole families. The cost in lost productivity at work is estimated by one source to be over $45 billion dollars per year and growing, and this does not even consider the cost of physical disorders, such as heart disease, that are now shown to be heavily correlated with depression.

This depression is not “just psychological.” People who suffer from it, like Jack, are in intense pain. The best way I have been able to describe it is to compare it to walking through a very hot, very bright desert, carrying a 75-pound rock on your back while suffering from a severe case of the flu. It is about as psychological as that is. And the nature of the beast precludes any hopeful thoughts that the cavalry or even an oasis might appear. Instead, it is an endless journey which, at some point, begins to feel utterly hopeless. It is in this state that people commit suicide, not from an act of cowardice, but from a very painful and profound conclusion that their life is nothing but intolerable pain. Eventually, in the desert with no hope of rescue, one lies down and “goes to sleep.”

The good news in all of this is that we do now have treatments that work for all of the above…if people will take advantage of them. And that is the rub. Many are taking advantage of the treatments, but for many more what is actual depression is just dismissed as moral turpitude, a lack of willpower, or a sign of aging.
Aging does not in and of itself lead to depression. In fact, studies show that the older we get, the less vulnerable we are to depression, especially if certain lifestyle elements are maintained.

This leads us back to Jack and Fran. The medication Dr. Scutaro prescribed helped stabilize Jack’s sleep and appetite, and it restored some of his energy. His sense of pessimism diminished, and he was able to find pleasure in things, like golf, that had always been pleasurable before.

Equally important, in psychotherapy, Jack explored the reasons why he was feeling so estranged socially. In his work career, much of his social connection came from work-bestowed status. Relationships came from being seen as a highly competent professional person. Without that defining platform, Jack felt bereft and uncertain in a way he had not experienced since adolescence.

Jack also confronted, for the first time, his fear that Fran would not see him as “real man,” if he didn’t play the same all-important role he had always played throughout their marriage. The psychotherapist invited Fran in for a few sessions where Fran was surprised to hear of Jack’s feelings of vulnerability. Ironically, she was also able to genuinely confide that the disparity in their relationship that Jack felt was essential to feeling respected and was the one complaint Fran had about the marriage. To her, it felt like it kept her from being able to be close to Jack, to share her own most vulnerable feelings with him and to know his in return. As they began to unravel the effects of that misunderstanding for all those years, a very deep sense of tenderness became apparent in their response to one another.
Socially, Jack stopped withdrawing because of his anxiety and uncertainty. Instead, he slowly reengaged and began to see that people were interested in him independent of his old work status. Instead, they found uniqueness in him that they valued, and that ultimately made them feel less alone in the world. This was astonishing to Jack. In therapy, he was able to trace the source of this feeling that what he was, in his core, simply not good enough for other people without his badges of accomplishment.

No, Jack and Fran did not live happily ever after. They encountered the infirmities of old age and went through the painful loss of friends as many began to pass away. The difference was that they did so with a much deeper sense of connectedness to one another and with a deep sense that their community shared in their loss and could bear witness to the meaning of their lives. They were neither depressed nor full of despair.

Bryant Welch is a clinical psychologist who practices individual and couples counseling in his office at Shelter Cove. He is also the author of the recent book, State of Confusion: Political Manipulation and the Assault on the American Mind (St. Martin’s Press, 2008).

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