The Role of the Family in Treating the Very Depressed

In the treatment of the very depressed, the role of the family is more often defined in terms of what they ought not to do rather than what they should do.  Certainly they ought not to quarrel  with or preempt the authority of the treating psychiatrist. They ought not to interfere in treatment by suggesting that what the patient needs is a vacation, or vitamin injections, or home remedies of one sort or another, or some hard work for a change, or a good talking to. They ought not to scoff at or belittle the patient’s worries, however ridiculous they seem to be. At the other extreme, they must not themselves become so upset at the patient’s distress that they add to his/her guilt and distress.

No one should tell patients that it is absurd to feel guilty, for they will feel guilty nevertheless, but will no longer speak of it to anyone. The family should especially not argue with them about the reasons they give for their feelings, for they are not the real reasons. An elderly woman, for instance, may become depressed and attribute her melancholy to shame over some minor sexual transgression that took place when she was adolescent and that never entered her thoughts again during the intervening years. Whatever the real reason for her getting depressed, surely it is not that.

The family should not expect patients to be able to explain themselves.  Also they should not demand that they function at a level beyond their capacity. There is no point in telling them to get out into the world and work–or have some fun– if they are unable to do so. If they are given a task that is beyond them, they will fail and feel even worse. Neither, however, should they encourage them to give up entirely and take to bed. Most important of all, they should not scold or punish them for being depressed. Persons who are very depressed are not crying, complaining, clinging, and behaving helplessly, out of spite, but because they cannot help it. Whatever they may say to the contrary, their condition is not self-inflicted. They are not suffering because they have done something wrong but because they have an illness, which although it may be less tangible than a heart attack, is no less real and strikes no less forcibly.

However, the members of the family do have a positive role to play, for they are the principal actors in the life of a seriously ill person. Very little that such afflicted persons experience or accomplish takes place entirely out of their view, and whatever they have become, the person that they are, is to an extent a response to them. At times of crisis they have the most influence over the ill person in their midst, and they are his/her chief resource.

Such persons are difficult to help, however, and are often irascible and stubborn; and so family members must be patient and persistent in their determination to offer care. They cannot afford to become angry and throw up their hands in despair. When patients are depressed and withdrawn and seemingly out of reach, they may still appreciate on some level those ordinary things that people do for each other. Even wanting to withdraw, they may want someone to come after them. The family, then, should see to it that patients are not isolated. They should be treated with courtesy and forbearance and included in family planning as if they were expected to recover and remain among them rather than fade away. No one should venture to sell their possessions, such as a car, while they are in the hospital, or give up their apartment. Nor should they themselves be allowed to make such decisions while they are acutely depressed.

When patients are well enough to remain at home, no matter how irritable they may be, they should not be sequestered in a room away from their children and the rest of their family and the everyday business of the household. In all matters concerning the plans for their treatment, they should be informed at once. If it is decided they must be in a hospital, they should not be brought there under some pretext, but rather with a clear understanding of the reasons for their hospitalization. They should be told how long they are expected to remain. Once they are there, their families should communicate with them as closely as circumstances allow—by personal visit, telephone, and even letter. Living in a hospital is otherwise a very lonely experience. The family must not, however, out of their sympathy, give in to any demands they may make to be removed from the hospital prematurely and against medical advice. In general throughout this period of treatment they should encourage patients to follow strictly the advice of their doctor.

The important issues, patients should be reminded, are not in the irrevocable past, or in the unknowable future, but in the present. They must consider their days one at a time and tend to their daily needs, eating and dressing themselves properly and being with other people at least some of the time. Often they will do these simple things for their families’ sake. The application of these simple principles of nursing care something makes the difference between an illness that comes and goes like any other illness, and an illness so disruptive of life that it predisposes to invalidism and leaves behind it a permanent mark on the individual and his family.

A fifty-year-old man was significantly depressed, but not to such a degree that he needed to be in a hospital. He was treated instead as an outpatient. He was feeling badly enough, however, to stay home from work. He spent each day sitting in his room staring into space. He was sullen and irritable, which was a marked change of his personality, since he was usually effusive. In fact, he was usually so friendly and jolly that he was assigned the role of Santa Claus every Christmas. He found the role so congenial that he not infrequently dressed up in his Santa Claus suit during Easter.

Consequently his family felt terrible seeing him so out of sorts. His wife came to him frequently with sandwiches or soup or something else for him to eat, only to be turned away.  His friends came by to play cards, but he would not come of his room even to greet them. Because he enjoyed sports, his sons bought tickets for a professional basketball game and when he would not go willingly with them, they attempted to remove him to the stadium bodily, with the result that he tried to punch one of them, missed, and fell over, spraining an ankle.

He was glad he couldn’t walk, he announced to his doctor that night, for maybe finally his family would leave him alone. A month later, though, when he was better, he confided that even at those times when his family badgered him the most with their constant attention, they comforted him, for he said to himself that he could not be too awful a person if they were willing to try so hard to be nice to him.

Certainly, it is possible to go too far, as this family plainly did, in attempting to command the patient’s interest. Attending a sporting event or some other entertainment is not by itself therapeutic and is not worth fighting over. Besides, everyone in the world needs to be left alone sometimes, and a depressed person needs those moments no less than everyone else. But his family should err on the side of too much involvement with him rather than too little, for he is better off engaged too vigorously than neglected and left alone.  Excerpted from “Caring: Treatment of the Emotionally Disturbed.” (C) Fredric Neuman