Iakov Filimonov/Shutterstock
Source: Iakov Filimonov/Shutterstock

Neela* was all smiles at her best friend’s wedding. Oh sure, she shed a few tears, but they were tears of joy for her friend’s happiness.

Or were they?

On the outside, Neela looked like a bubbly and cheerful young woman. But on the inside were feelings of pain, unhappiness, and intolerable loneliness. “I’m surrounded by friends who love me, and who I love,” she said. “What’s the matter with me? Why can’t I be as happy inside as I look on the outside?”

Neela was suffering from a painful form of depression often called smiling depression.

According to Laura Coward, of the National Alliance of Mental Illness (NAMI), smiling depression involves appearing happy to others and smiling through the pain, keeping the inner turmoil hidden. It’s a major depressive disorder with atypical symptoms, and as a result, many don’t know they’re depressed or don’t seek help. People with smiling depression are often partnered or married, employed, accomplished and educated. Their public, professional, and social lives are not struggling. Their façade is well put together.

I frequently hear about this kind of contrast between how a person looks and how they feel in my work. Often clients tell me, “I have everything a person could possibly want. Why aren’t I enjoying it?”

An article in the April 2017 issue of Women’s Health describes the phenomenon, and reports on a survey of 2000 women conducted by Women’s Health and NAMI. Of the 2,000 women, 89 percent of those who said that they suffered from depression or anxiety also said that they keep their struggles hidden from friends, family, and colleagues. This number bowled me over. I knew it was not unusual for women to hide their depression — men too, in my experience — but this was more extensive than I had imagined. Like many of my clients, these women functioned well at all of their life activities, making it hard to recognize that they were depressed.

This high capacity to function is part of what makes smiling depression difficult to treat, suggests psychiatrist Ken Duckworth, medical director at NAMI. Because these women don’t appear depressed, they feel that they shouldn’t need help. Not only does that belief interfere with their seeking and using support from family, friends, and professionals, but it also adds to the negative self-image and low self-esteem that goes along with depression. Neela said what many of my clients with these symptoms have said: “I have everything. I should be happy. What’s the matter with me?” The thing is, it’s not “something” that’s the matter. It’s clinical. It’s depression, and it can be treated, but only if it’s recognized.

If you or someone you care about suffers from smiling depression, what should you do?

1. The first step in dealing with any psychological difficulty is to acknowledge its existence.

This is particularly hard for people with smiling depression. As Rita Lebeaune, a guest blogger on PsychologyToday.com, writes, “Those suffering often discount their own feelings and brush them aside. They might not even be aware of their depression, or want to acknowledge their symptoms due to a fear of being considered 'weak.'”

But ongoing feelings of sadness, loneliness, hopelessness, and even anxiety can be signs of emotional distress, not weakness. All these feelings are part of the normal range of human emotion, which we have for good reasons, one of which is that they can signal our need for contact with and support from others.

2. Talk to someone you trust.

Another difficulty for anyone with these symptoms is that they are used to keeping them to themselves. This means that if you are hurting, you may be afraid your friends or family will not understand how you feel. Or you could worry that they will be overwhelmed by your pain and not know how to help you manage it. You may simply feel that there is no one who can help you.

No one can take the feelings away from you. But sometimes simply putting the feelings into words to another person, someone you trust and feel comfortable with, is a powerful first step. Neuroscientists know this; in fact, it’s one of the reasons that talk therapy helps us feel better.

My recommendation is that you take a small step by choosing one person you trust — a friend, a relative, a professional — and telling them a little bit about what you're feeling. You might want to start and end with a statement about how you know you’re functioning well, and not falling apart, but that you just don’t always feel as happy as you look. And then remind them — and yourself — that you’re not asking them to make everything go away. You’re just checking to see if talking about this to another person helps at all.

Be prepared for the possibility that it might not help at first. If you’re not used to talking to someone else about your feelings, you’re going to feel anxious, uncomfortable, even stressed. But give yourself and the other person some time. You might be surprised at the long-term effect of just putting your feelings into words to someone else.

3. Nurture your self-esteem.

In a blog post on dealing with self-defeating behaviors, Guy Winch, author of the Emotional First Aid, reminds us that fluctuations in self-esteem are normal, but that when we are already feeling bad, we often become particularly self-critical, “essentially kicking our self-esteem when it’s already down.” He suggests that you think of your self-esteem as “an emotional immune system” and work on nurturing and strengthening it, as well as bringing it back to health. One way to do this, he suggests, is to write yourself an email expressing the same compassion and support you would offer a friend who was suffering from such self-critical feelings. Reading the email you have written as though it comes from a friend, he says, is a way of practicing the self-compassion that is sorely absent in smiling depression.

4. If you are trying to help a friend, everything in #2 applies, but in reverse.

It can be painful to hear that a friend is suffering, but here are some things you can do as you listen: Remember that you cannot take away their bad feelings. Don’t try to make things better, although it might be helpful to remind them that they are loved even if they are not the perfect person they think they have to be. And just let them talk. Listen actively — that means letting them know that you are hearing and understanding what they are saying. You can tell them that you are sorry they feel so bad, and ask if there is anything you can do.

If you feel that you have to take some kind of action after they have told you their feelings, talk it out with them first. Express your concern and compassion, and let them know what you plan to do. Listen carefully to their response.

If going to talk to a professional is part of the discussion, you can encourage them to talk to someone, especially if you have found therapy helpful. More than one client has started therapy with me on the recommendation of a friend; I have even known of friends who came along as support, going for a walk or a cup of coffee the first time their friend meets with a therapist. You don’t have to do that much, though. Just having you as moral support as they take this important step can be enough.

5. Remember that no one is perfect.

Depression, including smiling depression, can be triggered by the belief that you are not good enough, despite everything you do and are. It is great to have high standards for yourself, but it is also extremely important to remember that you have probably set the bar pretty high for yourself. Again, try to have self-compassion. In the same vein as writing yourself a caring and compassionate email as though you were writing to a friend, think about how you would talk to a friend who was not living up to his or her standards.

Depression often goes hand in hand with unrealistic demands we put on ourselves. So try to soften your demands and remind yourself that you are human — which means that you have good and bad qualities, strengths, flaws, and weaknesses. 

If you aren’t able to do these things for yourself, that’s okay; most of us can’t soothe these feelings alone. That’s what friends, family, pets, and therapists are for.

Neela began to talk to a therapist about her self-doubts and self-criticism. Her therapist said, “If I was working with a parent who said these things to their child, I would tell them that they were emotionally abusing that child. That’s actually what you’re doing to yourself.”

Once she started listening to herself from this perspective, Neela began to hear her words differently. She started trying to pay attention to things she liked about herself. “I’m not perfect,” she said, “but I’m actually not so bad as I think. I even think I have some good qualities.” Over time, with help, her depression lifted. Interestingly, she wasn’t always so good-natured or accommodating anymore. But she realized that she felt much more balanced: “I feel like a whole, real, and solid person — which I never felt before,” she said.

* Names and identifying information changed to protect privacy

Copyright @ fdbarth2017

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