November 2022 – Depression and the Illness of Loved Ones
As with last month, I’m going to answer another question from the list that folks have sent me, with this being about depression in relation to the long-term illness of a loved one. Although the article below is specific to this question, the thoughts are relevant to any “slow-motion” loss we are experiencing, whether that of a loved one, or loss of a career, or a medical situation of our own.
As we move into winter, I hope you are staying warm, literally and internally, but also enjoying the transitions in whatever way you can.
The experience of depression and the long-term illness of a loved one.
A reader posed this question recently: “What about depression around the long-term illness of a loved one?” Essentially, this is a companion to last month’s article about beloveds (link), except that here we are talking about our loved ones not as cultural abstractions, but as real people we are bonded to.
Anyone we consider a “loved one” is, by definition, someone to whom we are attached. Technically, to be “attached” to a person is to have internalized a version (a model or representation) of them which is meaningful in some way, and in the case of a “loved one” their meaningfulness to us is as a “loved other.” Admittedly, this is a pretty dry way of phrasing it, but it is important to understand what a “loved one” actually is, in psychological terms, to understand why depression often attends to their illness.
Loss: fast and slow
When a loved one dies suddenly, we experience the shock of their loss in a moment. Our subjective world, which is built with that person as an integrated piece, ruptures. We do not know the objective world directly but through our models of it (however accurate or inaccurate those might be), and it is our models that break when an integral part of them like a loved one dies. Initially it is shock that we feel, a surreal sense in which we know that the objective reality has changed while at the same time our internal model of it still refers to a world now gone. If we do not freeze indefinitely, we will go through a grieving process which often includes a phase of depression, which in grief is not a resistance to reality but a “slump of clear recognition” which presages acceptance.
In contrast to sudden loss, grief in the long-term illness of a loved one is spread out over time, without definitive markers. It is a slow-motion grieving, what is sometimes called “anticipatory grief.” Loss is happening slowly, in blurred stages of decline (especially in cases of dementia) where changes are in increments, rather than all at once. Nonetheless, the losses are objective and experienced as such. The conversations we used to be able to have with our loved one now are inconsistent or incoherent. The walks we had together are now slow or impossible. The parent that we used to lean on for support and strength now needs to lean on us.
Loss and depression
If we humans were built to orient to the world only through direct experience, then we would be able to simply hold the “world” as it was showing up in the moment, including the changes from what we used to know. But because we create and privilege models of reality over direct experience of reality itself, these slow losses are progressive chips in our modeled “world,” as well as a slow education in the impermanence of these models, however they may be constituted. That is, the loss of a loved one is both the loss of that person, as well as often the loss in the conviction in our modeling of reality itself. If, without realizing it, I thought my father would be permanently here and yet now I am losing him to the erosion of aging, then what does that say about anything else I thought was permanent?
To deal with this stack of loss (the relative and existential), depression essentially gives a complex defense against loss that we cannot tolerate. If we could tolerate loss, we then experience the movements of grief rather than the frozenness and deactivation of depression. But if we can’t tolerate it, because the particular loss of a loved one (and all of the small losses with one who is chronically ill) is also the loss of the “world” within which we live our lives, then our systems freeze out the changes in that world with depression. It is a kind of protective response against the loss of the “world” on which we stand, without which we feel that we will fall into the Void, the space of disconnection and dislocation (see here for more on the Void). We depend on the structures of our world-model to have a sense of meaning in life, to know how to connect to others, and to believe that we can actually connect and be relevantly connected. The threat of losing that connection, and more deeply the belief that connection is possible, is what depression guards against.
The example of Sara
Here’s an example to illustrate what I’m talking about here, with “Sara” being an amalgam of folks that I have worked with over the years.
Sara is a 35-year-old woman who lost her mother as an 8-year-old, and was raised by her grandmother Fran. Sara is happily married and has a five-year-old boy, and her life as a CPA is going well as she climbs the professional ladder at her job. She has maintained a very positive relationship with Fran, who lives in the next town over. Fran was a widow when she took on the raising of Sara, never remarried, and has been retired for years.
Two years ago, Fran was diagnosed with a degenerative disorder without cure, but whose progress could be slowed through medical management. Her exact prognosis is uncertain, but in general people with her condition die within five years of diagnosis.
Sara’s initial response to the news was a combination of shock at the inevitable death of her beloved grandmother, and relief that she would have years left with her. What she did not realize was what the experience of seeing Fran lose capacity over time would feel like. Initially, there were little symptoms except for the physical one that led to the diagnosis. But within the first year, Fran began to become more frail, unable to play tennis with Sara, a game they both loved and had bonded around all their lives. In the second year, Fran’s normally sharp wit and intellect began eroding, such that the flowing banter the two used to share became halting and broken.
Sara understood intellectually the facts of her grandmother’s diagnosis, having listened to the doctors and done the research. She knew that there was no miracle coming, and that Fran was dying. Emotionally, in the first few years, she was able to feel some of the grief and share that with her husband, and talk about it with Fran who was open about her process. But towards the end of the second year, the cognitive changes began to become glaringly obvious, and Sara began noticing that she was feeling less emotion about her grandmother, and more of a general malaise and lack of motivation. She continued to visit and care for Fran, but with a greater mechanicalness. As she became aware of this increasing numbness, she realized she was slipping into depression.
So, what was happening with Sara?
Sara was someone who centered her sense of herself in the world around her grandmother, which was especially strong since her grandmother stepped in to fill the role of Sara’s lost mother and helped Sara guard against that early trauma. Initially in her grandmother’s illness, when Fran was still very much herself with minimal compromise, Sara could know the situation cognitively, but her worldview was not yet exposed to the loss of one of its central pillars. She knew she was losing her grandmother, but the fact of that was not yet so experientially obvious that her worldview had to start shifting.
However, when Fran’s illness crossed a threshold then the person that Sara knew was recognized as irreversibly changed. This meant that the support that Sara had taken for granted, as well as the sense of identity and validation that Fran gave her shifted irrevocably. That is, Sara’s model of her self-in-the-world began to fracture without any sense or delusion that it could be restored. Sara had not realized how dependent she was on the Fran that she had always known, and so was not prepared for this change. Fran, in a sense, had been the bedrock that Sara stood on, preventing both a fall into the relative void of her trauma around the loss of her mother, as well as some deeper Void of experiencing the fragility of this human life. This, then, is the terrain of depression, which heard its call to protect against disaster, and began proactively covering Sara with numbness.
Although of course there is nuance, this is essentially what happens in the relation of depression to the experience of the long-term illness of a loved one. The small progressive losses can accumulate weight such that, at some indistinct point, they cross a threshold and start implying the loss of the “world” that we built around our loved one. The depth of that connection is usually unbeknownst to us, such that we are unprepared for that deep loss.
As with everything about depression, knowing what is going on is a big part of the cure. The other big part is the opening to the grieving of the loss of our “world.” This allows us to seek appropriate supports—from loved ones, spiritual guides, and professional counseling—to help with this transition between worlds.