“It might be hard to know that your therapist is as crazy as you are.” — Mike Fidler, MSW, RSW
It’s a bit of a truism in the therapeutic world that most of our compassion and no small amount of our ability to relate to our clients stems from our own personal experiences. (Not that we need overtly-relatable personal experience to BE a decent therapist, just that… it certainly helps with the perspective, even if it also risks the complication of personal experiential biases kicking in.)
So in the spirit of full disclosure, here’s a little bit of humanizing back story about Yerz Trooly:
While I have long known that I have depression, I had always thought it was mild, cyclical, and eminently manageable without significant therapeutic or pharmaceutical intervention. It wasn’t until VERY recently that I came back to a question my GP asked me over a year ago that I, to my embarrassment, discounted at the time:
“Do you think maybe you fit the label of “high-functioning depression?” she wondered.
“Yeah, maybe. Probably,” I said. “But as long as I’m functional, that’s good, right? It can’t be all that bad.”
Let me now say: It can, dear readers, be utterly, damnably, catastrophic.
“A recent survey by the British Psychological Society found that 46 percent of psychologists and psycho-therapists suffered from depression and 49.5 percent reported felt they were failures. The overall picture is one of burnout, low morale and high levels of stress (70 percent) and depression in a key workforce that is responsible for improving public mental health.
“Since American psychologists are treating the same general public with the same mental issues, it would not be surprising to find similar high rates of depression and feelings of failure. (The most recent major American survey published in 1994, found 61 percent of psychologists clinically depressed and 29 percent with suicidal thoughts.)” — William L. Mace Ph.D., for Psychology Today, Apr 27, 2016
“High-functioning depression isn’t a true medical diagnosis; you won’t find it listed in the Diagnostic and Statistical Manual of Mental Disorders, the bible of the mental health profession. But it is popping up on treatment center websites and health blogs as a way to characterize people with low mood, low energy, and anxiety, experts say.
“It’s a useful term, says Johnny Williamson, MD, medical director of the Timberline Knolls Residential Treatment Center in Lemont, Illinois, because it’s “readily understandable” and encompasses people who don’t necessarily fit neatly into traditional diagnostic categories.
“What qualifies as high-functioning depression is somewhat subjective. People often fill three or four main roles in their lives: vocation (meaning work or school); intimate partner or spouse; parent; and friend or community member, explains Michael Thase, MD, professor of psychiatry at the University of Pennsylvania Perelman School of Medicine and co-author of Beating the Blues: New Approaches to Overcoming Dysthymia and Chronic Mild Depression. Assessing how active you are in your roles can help a mental health professional gauge high-functioning depression, he says. “You may notice that there’s a hole in this person’s extracurricular life.”
“Steven Huprich, PhD, professor of psychology at University of Detroit Mercy, says there may be something in a person’s nature–“a particular type of negative self-image”–fueling his or her chronic unhappiness. “If somebody came to me and said, ‘I think I have high-functioning depression,’ chances are not only would I hear about mood symptoms, but I’d probably hear something about being kind of perfectionistic, feeling guilty a lot, feeling self-critical,” he says.” — Karen Pallarito, for Health, February 07, 2018
“High-functioning depression, or dysthymia, may be harder to detect than major depressive disorder (MDD) because the people living with it are often high achievers who make you think everything is all right all the time.” […]
“For people with high-functioning depression, the “invisible illness” aspect of the mental state can feel particularly searing. A few years ago, after shoulder surgery, my arm was in a sling. People fell over themselves to cluck with sympathy at my pain—socially sanctioned pain. It felt good to be the object of so much caring.
But on the days when listening to the sorrows of others exacerbates my own and I feel spent, I typically stay silent, not wanting to advertise my own vulnerability. Why is it so much easier to let others in on pain when it’s physical?” — Sherry Amatenstein, LCSW, for PSYCOM, Sep 11, 2018
The problem with the high-function aspect of High-functioning Depression is that it doesn’t look like the debilitating kinds of behaviours most people associate with depression. Or in some cases (like mine) there are physical health conditions (like perimenopause) with symptomology that masks the impact of depression, or makes it impossible to tell the difference between PM symptoms and HFD symptoms. When the health issues mask the psychological ones, especially if the health issues are perceived to be transient, the narrative EASILY slides into one of, “Just ride it out, this is just a temporary thing.” The unfortunate result is a misatribution of cause, and therefore a failure to effectively diagnose and treat the more devastating issue. Eventually, the lack of cope that is the key component of the high-functioning script fails utterly, and in ways that are even more difficult to recover from, than if the depressive aspect had been caught and dealt with from the get-go.
Therapists, really anyone working in the mental health field, are hamstrung in very particular ways by this high-functioning aspect. The staggering numbers of therapists in therapy themselves for depression tells a haunting story if we consider those are just the REPORTED cases. I am my own best example of therapists who are late to the party, in terms of recognizing, acknowledging, and bending to the need for treatment, of their own depression. We are often the WORST people for believing we have to buy into the myth of “having our shit together” to be the support our clients need, and to model more effective mental health practices (individually or within our relationships) for friends and family around us. In short, we buy into our own PR, and we suffer for it in significant numbers.
Imposter Syndrome is another factor that I suspect (based on nothing more than purely observational, anecdotal “evidence”) figures strongly into HFD. Imposter Syndrome occurs across all professions and all walks of life, specifically affecting those in positions of increased or increasing responsibility and authority. The greater the sense of responsibility and authority, the more likely it is that the individual in question will feel anxious about being “found out” or discovered to be less able than others believe them to be. This fear of discovery often drives us (yes, I include myself in this august and populous group) to do everything we can to “be worthy”, to meet the standards we feel are expected of us by those who look to us to perform in our roles… even if we don’t know or haven’t validated what those expectations actually entail. But because we strive so hard to meet that worthiness, we tell ourselves that we cannot fail, we are not ALLOWED to fail, that failure will lead to discovery of our own incompetence… and voila, we’re binding ourselves into the script of “must be high-functioning OR ELSE”, often at the cost of our own equilibrium and mental health.
So what leads to the breaking points? How does someone caught up in the whirlwind of staying functional-at-all-costs finally get around that cycle? As with a lot of depression disorders, there are many things that can pull a sufferer out of the darkness, including, simply time. For me, the epiphany came as the result of a LONG period of draining demands that built inexorably over time well beyond the tolerance point, yet still sustained. There was a singular, precipitating incident that triggered a realization that something that SHOULD have been exceptionally terrifying and upsetting wasn’t producing really any kind of emotional response. I had flatlined, emotionally. More importantly, looking backward, I realized I had been flatlining for a while–able to function in caretaking roles in other relationships (personal and professional), but ultimately seeing those as ways of distracting myself from my own eroding state of health–and doubling-down on the “Just Ride It Out” script. I knew there was a problem, but I didn’t do my own homework to separate out the dogpile, so I didn’t have to admit there was something IN the dogpile that needed to be addressed differently.
In short, it took recognizing that I was NOT responding to stimuli at all (let alone “appropriately”) that forced me to realize just how disconnected I had become, and how much was being locked in a box buried deep below the surface, just so I could function from one day to the next. Like the flipping of a switch, I very clearly had one thought that hit me like a sledgehammer: “Holy shit. I am really VERY NOT OKAY.”
And admitting that was the crucial turning point. (Of course, by the time Pandora realizes what’s in the box, it’s too late to close the lid on that shit, and now we have to actually, y’know, DEAL with it.)
“While “high-functioning depression” isn’t an official term for any of them, and has even been debated on social media, it’s what many like Judge use to describe their condition. Part of the reason is that they don’t fit the stereotypical image of a depressed person, the one put forward in antidepressant ads and TV dramas. They may not be skipping work, withdrawing from social activities, feeling hopeless or crying all the time. In fact, they may be honors students in college, business executives, physicians, journalists, startup employees, or any of a variety of seemingly confident, successful individuals. […]
“On the surface, high-functioning depression may seem like it’s easier to deal with, but it can persist for years, leading to more functional impairment over time than acute episodes of major depression, Craske says. Research has shown that the low self-esteem, lack of energy, irritability, and decrease in productivity that accompanies persistent depression is associated with significant long-term social dysfunction, psychiatric hospitalizations, and high rates of suicide attempts. And, ironically, persistent depression also puts people at a higher risk for major depressive episodes with more severe symptoms.” — Knvul Sheikh, for Tonic, Oct 16 2017
“Because high functioning depression so often flies under the radar, many people either don’t seek help until their condition has progressed to a severe state or their clinician doesn’t recognize the severity of their illness, leading to inadequate treatment. If this is your experience, residential treatment can provide the best path toward recovery.” — Elisabet Kvarnstrom, for Bridges to Recovery, June 6, 2017
Because residential programs are a luxury many of us can’t afford–not just in terms of expense, but also many of us can’t afford to be not working for the length of time any kind of residential or in-patient program demands–we have to consider what intensive treatment options ARE affordable. It might involve revisiting discussions about, or changing up existing prescriptions for, anti-depressant medications. It almost certainly involves getting in with a good therapist. Yes, even therapists have therapists of our own (and yes, sometimes even therapists don’t want to call their own therapists to admit there’s maybe a wee problem and could we please come in at their first available opportunity… I’m pretty sure I’m not alone in that regard. *looks around the room shiftily*). It also seems extremely important to consider one of the comments above, about looking for the “hole in this person’s extracurricular life”, to see what’s missing. High-functioning individuals, whether driven by Imposter Syndrome or not, often lack balance across their various roles. The gaps and places where they are ignoring, subsuming, deflecting, or otherwise compartmentalizing their needs then becomes a place to explore, to consider why those absences have been permitted to occur.
Because HFD is not clinically differentiated from any other depressive disorders, the treatment modalities are likely to be the same. Medication as determined in consultation with medical or psychiatric professionals, psychotherapy, lifestyle shifts if necessary. None of which is going to be easy for those of us who have taken so long to get to the point of even admitting there’s a problem in the first place. This comic comes up as hugely relevant, and highly descriptive, a lot for many of us, frankly:
So be gentle with those of us who are hitting this point, or starting our way back from where we’ve wandered into the weeds. It’s hard enough to make the admission that we’re not healthy, let alone reach out to ask for help with what we’re realizing. People struggling with depression are already likely overwhelmed with where they’re at, and sorting out what feelings need what assistance is just “altogether too much”. When the depressed individual is able to articulate what they can, hopefully they will (Note to Self: take my own damned advice), and maybe they will be able to ask for something specific.
And always consider that just because someone is BEHAVING like they have all their shit together, their internal truth may be very, very different.