Full Show Notes
We know our teenagers better than anybody else, so we’d definitely know when they were feeling depressed…right? The basic symptoms of a depressed person are recognizable—withdrawing from social activities, no longer participating in things they used to enjoy, changes in dress and diet. If we saw that our teen exhibited these symptoms or noticed that they seemed anxious or unenthusiastic about life, we’d definitely know something was up.
But what about a teen who’s depression isn’t quite so easily spotted? What if your teen seemed to be doing perfectly–class president, varsity soccer team, prom queen–but deep down, they were hiding a seriously crippling mental health crisis? Teenagers like this exist, and in fact this kind of depression is a lot more common than you might think.
To shed some light on this subject, we’re sitting down with Dr. Margaret Rutherford, author of Perfectly Hidden Depression: How to Break Free From the Perfectionism that Masks your Depression. The book is all about how some people experience depression in a way we may not think of as “traditional” or” conventional”. These people seem as though they’ve got everything together on the surface, but inside, a deep depression is stirring.
Dr. Rutherford began to notice this kind of depression in patients in her 25+ years as a therapist. Patients would come in for other conditions, like eating disorders or insomnia, and were surprised at the suggestion that perhaps they may be suffering from depression. These patients would insist that their life was going well, when it was time to discuss the serious traumas they’ve faced, they smiled through it as though there was no pain at all.
That’s when Margaret realized that perhaps these patients were experiencing depression in a way she hadn’t quite considered before. She coined the term “Perfectly Hidden Depression”, to describe people who’s sadness was so well hidden that even they themselves didn’t realize it was there. They don’t look depressed, don’t act depressed, have an active life with plenty of friends, but then are suddenly discovered attempting suicide or checking themselves into psych hospitals.
In order to help you better understand how this could be possible, Dr. Rutherford dives into the definition of Perfectly Hidden Depression and explains it’s symptoms and signs. In the episode, she describes common habits of people with this condition, which can serve as warning signs that your teen might be experiencing a mental health issue that they can’t or won’t talk about.
10 Signs of Perfectly Hidden Depression
If you’re worried that the description of Perfectly Hidden Depression might sound like your teen, don’t fret. Margaret and I discuss in depth ten common symptoms of people with this condition, so that you can develop a deeper understanding of how it works and how it may be affecting your teen.
Dr. Rutherford explains that one thing people with this kind of depression tend to do is focus intensely on outward accomplishments in order to feel valuable. This may occur as a result of feeling an excessive pressure from family or society to achieve highly. They might feel as though they aren’t valid or worthy of love when they aren’t winning awards or getting promotions. Margaret emphasizes that while ambition is a wonderful attribute, this need to fulfill external measures of success can become irrational or cause intense self criticism, leading to a dangerous decline in mental health.
This leads to another common habit of those with Perfectly Hidden Depression–the tendency to compartmentalize their feelings. While those who are struggling with these feelings may sense that something is off within them, these folks are likely to put this feeling in a box in their mind and pretend it doesn’t exist, or believe it is simply the result of a bad day. Margaret shares a tragic example of an individual who exhibited some depressive behaviors, who, when a worried friend showed concern, insisted it was only a fleeting feeling. Sadly, a few weeks later, he committed suicide.
Oftentimes, people with Perfectly Hidden Depression don’t feel like they can share their negative feelings, or may even suppress them to the point where they don’t let themselves really experience sadness. Dr. Rutherford says that this often occurs because these individuals have a harsh inner critic which might cause them to feel shame over these negative emotions. They’re also often perfectionists, and don’t like to cry, complain, or show that their life is anything less than smooth sailing.
In the episode, Margaret discusses all ten common habits of those with Perfectly Hidden Depression and explains how to spot them. Once we’ve defined the syndrome a little further, we dive into what parents might be doing to worsen this condition in teens, and how they can prevent this condition from developing in their kids.
How Parents Can Hurt And Help
Dr. Rutherford knows that parents would never want to cause their children grief, but she points out some ways parents may be contributing to or worsening the development of Perfectly Hidden Depression in their teens. Oftentimes, the pressure from parents to achieve and perform, whether that’s in school, sports, or other extracurriculars, can be a major contributor to this problem. In the episode, Margaret talks about how we can continue to encourage kids in a healthy way, allowing them to reach their full potential while also allowing them to remain emotionally stable.
In many cases, parents might see their kid performing extremely well, and take this to mean that this kid is happy and thriving. This is not a bad assumption–and it is certainly true in some cases. Margaret suggests, however, checking in with your teenager and making sure they are maintaining healthy habits and considering their own mental well-being. In the episode, she explores this idea further and gives tips for what to do if you suspect your teen might be struggling with Perfectly Hidden Depression.
When it comes to prevention, Dr. Rutherford stresses the importance of being vulnerable with your kid. She stresses how important it is to model emotional vulnerability to allow teens to grow into individuals who know how to handle all of life’s ups and downs. If parents make it seem as though expressing sadness, anger and fear is unacceptable, kids may not learn how to let their feelings out.
This means it’s ok to share your disappointments about losing out on a job, your sadness about the death of a loved one. It’s ok to show your teenager that life doesn’t always go as planned. Now of course, it’s not a teenager’s job to help you fix the problem or to be your therapist, but letting them see that failure and negative emotions are a part of life can do wonders for their own emotional health.
In The Episode…
When it comes to Perfectly Hidden Depression, there’s a lot to learn! Dr. Rutherford and I also cover:
- How to spot symptoms of Perfectly Hidden Depression
- Why praising perfectionism can be dangerous
- What is appropriate to share with kids and what is not
- The five stages of overcoming perfectly hidden depression
Dr. Rutherford had intriguing insights into this type of hidden depression and I’m excited to share it with you! If you enjoy the interview, share it with someone you think would like it and don’t forget to subscribe. See you next week!
Word-for-word examples of what to say to your teen
1. Express vulnerability, without treating your teen like a therapist:
“Well, that felt crummy. I’m kind of mad. I’m hurt. I don’t know what’s wrong. I’m confused about what to do. If you get into this situation, I just want you to know it’s okay to feel these things.”-Margaret Rutherford
2. Try vulnerability during your divorce:(Members Only)
3. When you get passed over on a job or promotion, open up to your teen with:(Members Only)
4. Help your teen reframe the concept of vulnerability:(Members Only)
5. Prepare your teen for the inevitability that not everyone will live up to their expectations:(Members Only)
6. Let your teen know that some people will not like when they change:(Members Only)
Complete Interview Transcript
Andy: Okay. Can you just give us the low down here on what is Perfectly Hidden Depression? How did this come about in your life, and how did you become so interested in this topic?
Margaret: You know, Andy, I’d never wanted to write a book. I love being a therapist. I’ve been a therapist for, gosh, 28 years now. And so, I wasn’t looking for a subject to write about. But, this subject found me.
Margaret: I had started blogging back in 2012, and then in April of 2014, I was just sitting around thinking about some of the people I’ve treated over the years, who, when they walked in my office, they certainly didn’t talk about being depressed. In fact, if I asked them if they were depressed, they said, oh no, no. I’ve got too many blessings in my life. I’m doing great. They’d come in for eating disorders, or they realized they had to take a Klonopin every night to go to sleep and that bothered them, or maybe they were having some anxiety.
Margaret: What I did notice was that the people in front of me, when I would ask them historical questions, would talk about something really bad happening to them, and they’d be smiling at me. I remember saying to one of them, “If I turned down the audio, I would think that you were talking to me about what you’d had for dinner last night.” There was just no emotional connection with rapes, or being bullied, or moving multiple times, or parents being alcoholics or something. It was kind of shrugged off like, oh, well I didn’t have it as bad as a lot of people, or something like that.
Margaret: So, I wrote a blog post about those folks, and I just picked a term out of the air and I said, “Let’s call it the perfectly hidden depressed person. Are you one?” Well, sure enough, the post went viral. And at the time, I was writing for the Huffington Post and they put it on their site, and I got hundreds of emails.
Margaret: Like, how did you know this was happening? It’s like you’re inside my head. How did you figure this out? What is this?
Margaret: So, I got curious, and I started looking in the popular literature for what was out there about perfectionism and depression. And, I found Brene Brown’s completely wonderful work about shame and vulnerability and perfectionism. But, she didn’t make a link with depression. Then there was another book I found by Terrence Real, I Don’t Want To Talk About It, which was an incredibly good book about covert depression in men, but he didn’t talk about perfectionism.
Margaret: So, I thought, well, there doesn’t look to be a popular book out there about it. And so, with the encouragement of some author friends of mine, they said, “Well, you can write a book.” I went, “Woo.” But, I gave it a whirl and I found a wonderful publisher who just did a fantastic job with their editing. And, lo and behold, November of 2019, Perfectly Hidden Depression was published.
Andy: And so, was it hard to pull everything you knew about it and had learned about it into a book, or did it come together pretty easy?
Margaret: My family doctor tells me, he thinks this book almost killed me. I had every known malady to man, practically. No, it was not easy. Actually what I had done, after I wrote that blog post, I started just trying to think more about these people, like, well, what do they have in common?
Margaret: I think it was a year later that I wrote another blog post called, The 10 Characteristics of Perfectly Hidden Depression. And, as I was sort of formulating my own ideas, by the time I did the book, some of those ideas were really pretty solid, in my mind at least. And the important part of this to hear, especially if your listeners are teenagers and their parents, which I know they are, what is happening, Andy, is that this is a presentation of depression. But, these people will fall through the cracks because they don’t fit the criteria for depression. They don’t look depressed. They don’t tell you they’re depressed. They’re very engaged and active and busy and successful, and have lots of friends.
Margaret: What’s kind of scary about this, what’s very scary about this, is that clinicians and doctors and teachers and parents don’t realize that their perfect looking friend, or their perfect looking daughter or son, or they’re perfect looking spouse, there could be something wrong. The pressure is just gotten to be too great. And that’s why I’m trying to sound the alarm so strongly for this, because I know. I’ve talked to people now, hundreds of people, who said, “I either tried to die by suicide.” Or, “I went to a doctor and they said I wasn’t depressed. And yet, three weeks later I was in a psych hospital.” So, it’s really something we need to pay attention to.
Andy: You talked about the 10 characteristics of PHD. What are some of those, or what are the important ones to be aware of?
Margaret: Sure. Well again, let me point out that perfectly hidden depression, as I think about it, is not a diagnosis. It’s a syndrome. What a syndrome is, is a group of behaviors and beliefs that are often found together, like salt and pepper, or something like that. You usually, when you find one, you find the other.
Margaret: But, the ones that I have talked about in the book are being highly perfectionistic with a constant, critical, inner voice of intense shame. This is not striving for excellence. These are people who are trying to prove who they are and prove their value, because they’ve got these, not like hallucinatory voices, but they’ve got this self-criticism and self-loathing, probably born in their families or born from the pressure they feel from their families. They must succeed. They must achieve. And so, they’re trying to fight off those voices.
Margaret: Number two is, you demonstrate a heightened or excessive sense of responsibility. These are the people that are president of the senior class, or are getting scholarships out the wazoo, or they’ve got their hands up in the air. I’ll do it. I’ll do it. I’ll do it. But, they also have difficulty accepting and expressing painful emotions. That’s what I was talking about before. They can identify that they might feel sad or something, but they can’t connect with it. You very rarely see them cry, or even maybe get angry unless the anger is about control, which is the fourth thing we’re going to talk about.
Margaret: These are warriors and they avoid situations where control isn’t possible. Now, these people won’t look like they’re worried. They’re not known to their friends as, ah, he worries all the time. This is an inner worry.
Margaret: Yes. And so, your mind’s on a treadmill all the time, but you can’t let anybody know. And so, you don’t want anything to interrupt your control of things. So, guess what? If you’re going to be involved, you’re going to be in charge.
Margaret: Then, the fifth one is somewhat close to the second one, but you intensely focus on tasks using accomplishment as a way to feel valuable. For example, a guy comes to mind who said to me, “My mother loved me, but what she loved about me was what I could do and what I could accomplish. I didn’t even like the piano, but she wanted me to be a piano player.” So, by gosh, by his senior year in high school, he even did a piano recital. He had to please her. Well, guess what? The rest of his life, he was a pleaser. And then, other people might have been told they were never going to amount to anything by parents, and so they also are trying to live down that voice.
Margaret: Number six is you have an active and sincere concern about the well-being of others while allowing few, if any, into your inner world. And what that means is, these are people who, I mean, they show up. One of their friends gets in trouble and they’re the first person there, and really helping, and really caring. This isn’t put on. This isn’t put on. It’s real sincere empathy, but no one knows what’s really going on with them.
Margaret: There was a case. That’s not a case, it’s a young man died. But, he had told one friend that he had at camp that he was considering dying, killing himself. The friend called his high school counselor, told him, or texted him, or emailed him, or something. And, the counselor called this young man in and said, “Listen, I’ve got this contact, and she said you’re really struggling.” He said, “But, I see you in the cafeteria and you always look great. You’re always surrounded by people. What’s going on?” And he goes, “Oh, that was a weird moment. No, I’m fine. I was just having a down day.” But, actually, that young man hung himself three weeks later.
Margaret: So, these things that they don’t allow anyone to see, that’s what’s so scary, because parents will say, well, how am I supposed to see it?
Andy: They’re just going to say everything is fine, and that makes it pretty hard.
Margaret: Right. Right. We’ll talk more about that in a minute. You discount or dismiss hurt or abuse from the past or even the present. These are people who will say, “I shouldn’t even be in therapy because there’s so many people out there that are struggling more than I am.” Or, they’re the teenager who says, “I’d never go to therapy because my life’s great.” When it’s really, maybe they’ve got an alcoholic parent, or something has happened to them. And so, how they do that is they rigidly over compartmentalize. Meaning, if something bad does happen, they have this box they put it in, and they lock it in the box, and then they put it in some sort of emotional vault they have in their mind, and it just goes away, and it never comes back. These are people who, if that’s a good skill to have, we all need to compartmentalize. If something bad had happened to you or me this morning, we have this to do this afternoon. We can’t stay there. We need to put it away.
Andy: Yeah. Set it aside.
Margaret: Right. Set it aside.
Andy: Say, “I’ll come back to you later.”
Margaret: But, these people don’t take it back out. They don’t take it out. Yeah. Number eight. I really felt like was important because as a clinician, I didn’t want people to say, oh yes, I identify with perfectly hidden depression, and then stop there. Also, you certainly can have simultaneous clinical conditions like OCD, like generalized anxiety, like panic attacks, like eating disorders, like addictions even. And so, it’s important to realize that those things may actually need attention before the perfectly hidden depression does.
Margaret: Number nine. These people want to count their blessings. They are just a foundation of their well-being, and what they don’t realize is that for every blessing, you have a great podcast, and I’m sure you love doing it, and it’s an honor. But at the same time, you have to find guests, and you have to work on it. And, it’s not something that just happens easily. So, even if something’s a blessing, sometimes the underbelly of it can be really difficult.
Margaret: And then, the very last one is, these people don’t do emotional intimacy. They usually are very successful professionally. We reward perfectionism. We reward people who get things done ahead of time and it’s perfect. We want those people to be our brain surgeons, and our CPAs, and all that kind of stuff. But, they don’t know how to do emotional intimacy. Often they’re drawn to people who either don’t know how to do it either, or want an over-functioner, or somebody who’s going to take all the responsibility. It’s just sometimes they’re partnered up with someone who goes, you know, I’ve been with you for 10 years, or I’ve been your friend for 12 years, and I’ve never seen you cry about anything. I’ve never seen you look ruffled. I’ve never seen you complain. What’s going on? It’s, these people are sort of, use a fancy word, enigmatic to people who are around them, because it may be that their friend or their partner is really yearning to have a closer experience with them. They don’t know how to do it.
Andy: That’s a lot, I guess.
Margaret: It could have been 12!
Andy: But, I see how they all go together. So then, this is both things to look out for in yourself and your partner, and also in your kids?
Margaret: Yes. A lot of times if a teenager or a young adult kills themselves and it’s local news or something, quite appropriately, the local news pulls out the classic signs of depression. And some of them are different with teenagers and young adults. Sometimes you’ll see a change in hygiene with a teenager, or you’ll see a change of friends, or all of a sudden they dress differently. Or, in adults, you see more they give away things, or they isolate, or they seem to be saying goodbye to people. Sometimes it’s overt, but sometimes it’s very subtle. Classic signs of depression being things like, not enjoying things you used to enjoy, or being by yourself too much, or something like that.
Margaret: And sometimes I’m just so frustrated when I think about this particular kind of depression, because even if the person who killed themselves, there were no signs, they don’t talk about vulnerability, Andy. And I think, if you grow up in a home where anger, or sadness, or fear, or disappointment, isn’t being allowed to be expressed, that’s a huge problem, because for you to be vulnerable, your parents have had to model vulnerability for you. You have to know that they’re not going to judge you for that.
Margaret: A great phone call that happened between me and my son, when he was in college, he knew I’d done something really stupid in college and sure enough, he did the same thing. But, I talked about it openly. And so, he called me and told me, and I first had that mother reaction of, “Oh no, I can’t believe you did this.” And then he said, “Mom, I called you because I knew you’d been through this.” I settled down. I said, “You’re right. Let’s just talk about this.”
Margaret: But, the fact that he said, “I called you because I knew you’d been through this.” I was vulnerable also with him, and then he could be vulnerable with me. That phone call meant so much to me. And we worked through it together. But, I think if there are parents listening, and you don’t talk about your disappointment, or your sadness, or your fears, or your struggles, with your children in an age appropriate way, obviously, they’re not going to know that it’s okay to talk about theirs. Now, that may seem an overly simplistic answer, and maybe in some ways it is a little bit, but that’s what you’ve got control over is what do you model for your kids?
Andy: So then, how do you do that? Or, how do you know where the line is of what to share?
Margaret: Well, you don’t want to share necessarily, let’s say you’re divorced and you don’t want to share some kind of struggle you’re having with their father or mother. But, you can say things like, “I’m disappointed in myself that I couldn’t make this marriage work. I tried and I failed at some things, and I’m sorry it’s affected you.” And you talk about the stuff that … Or, let’s say you’re going for a job and you don’t get it. You talk about, “Gosh, I really wanted that job, and I’m disappointed. I’m a little embarrassed.” You’re just vulnerable.
Margaret: Let’s say you start dating somebody as an adult, and they ghost you. You talk about that with your kids. And, “Well, that felt crummy. I’m kind of mad. I’m hurt. I don’t know what’s wrong. I’m confused about what to do.” Again, just not in a way that then it becomes their responsibility to help you fix the problem. But, in a way where you say, “If you get into this situation, I just want you to know it’s okay to feel these things.” You’re just modeling for them, rather than leaning on them to listen to you like they’re your therapist. That’s inappropriate.
Andy: Right. Or, looking for them to tell you it’s okay or something.
Andy: What’s the difference between what you actually do, or how you actually treat between classic depression or perfectly hidden depression?
Margaret: It’s very different. The work in classic depression, depression in and of itself, classic depression, is kind of an implosion of the self. It means that it’s almost inherently self-centered, and I don’t mean that in a bad way. I mean that it’s just, you can’t get engaged with thinking about other people. It’s very hard for you to do that. It’s hard for you to care about the things you used to care about. In fact, sometimes it can seem almost impossible, depending upon how severe your depression is.
Margaret: So, what you’re trying to help someone do who’s classically depressed is, one, of course, understand how they got there. But also, begin that very tricky dynamic of helping them get re-engaged with themselves, with their world, with their friends, with their work, with what they used to care about, so that the effort is to go outward with them.
Margaret: With perfectly hidden depression, it’s quite the opposite. These people look great on the outside. They don’t have the energy going inward. Sometimes they don’t even know how to do it, Andy. They’ll look at me and go, “I don’t know what you feel. You want me to get in touch with my sadness, what sadness? I don’t have any sadness.” They have really not ever learned how to connect with that.
Margaret: And so, you can provide them with experiences to help them begin to feel more. You can give them permission to feel things they’ve never felt. You can start pointing out how all these traits are combined in them. Perfectionism is kind of a hard thing, because we often think of it as a strength. In fact, excellence is a strength. It’s a character trait that’s really good, most people would think. But, when it goes south on you, when it begins to darken your rational thinking, when you have to be perfect, rather than you’re choosing to really try your best, then your ability to go inward and to check out, am I tired? Am I sad? Am I disappointed? Am I afraid? You don’t pay attention to any of that stuff. And so, therapy is about getting them to turn inward and realize that they have this vast inner emotional life that’s viable and important to connect with.
About Margaret Rutherford, PhD
Dr. Margaret Rutherford is a practicing psychologist and writer. Over the course of her 25-year career, Margaret noticed a trend among certain patients who had attempted to take their own lives, but denied having depression. She identified this phenomenon as “perfectly hidden depression. After five years of intense research, her first book, Perfectly Hidden Depression, came out in 2019.
Dr. Rutherford’s expertise ad writing has been featured in HuffPost, Psychology Today, The Mighty, Psych Central, The Gottman Blog, Psychologies, StigmaFighters, The Good Men Project, This Is My Brave, and others since she began writing back in 2012. She currently runs a podcast titled The SelfWork Podcast with over 200 episodes to date.
Dr. Margaret lives, works, and podcasts from Arkansas.