Episode 81 Transcript: Supporting a Partner with Depression

Title:  Supporting a Partner with Depression

Guest:  Dr. David Dozois, PhD

 

Yeah, I'm very excited. We have Dr. Dozois today. Dr. David Dozois is a professor of psychology and psychiatry at the University of Western Ontario and Canada. His work focuses on cognitive behavioral therapy and helping individuals and couples navigate the challenges that depression brings to relationships in everyday life. He’s published more than 200 scientific articles, books, and chapters over the course of his career. Today he leads the Mood Research Lab at Western University, known as “Breaking Sad”, where his team continues studying the causes, treatment, and prevention of depression.

 

Dr. Dozois is a fellow of the Canadian Psychological Association, the Academy of Cognitive and Behavioral Therapies, and the International Association of Applied Psychology. He's also served twice as president of the Canadian Psychological Association and was a Beck Institute Scholar at the Beck Institute for Cognitive Therapy and Research. His latest book, What to Do When Your Partner is Depressed, is a practical guide for supporting a loved one through depression while also taking care of yourself. We’re excited to talk with Dr. Dozois about his decades of work, understanding depression, its impact on relationships, what partners can do to support the people they love while also caring for themselves. So, hey, welcome. Thanks so much for joining us.

 

Yeah, thanks for having me.

 

This is a huge and exciting topic for us to talk about because I think both as a provider, as someone who's had people in my life who've gone through mental illness, I just don't think there's a ton out there for what you do to support. I mean, of course there is. There's Al and other places, but I'm so excited for a practical resource to be able to provide.

 

Yeah, it's long coming. When I first started as faculty, various places, you know, I did a lot of teaching. And often when medical students come to you or residents, that's the question they come with. It’s so-and-so, my loved one, my wife, my mother, father, someone has a mental illness,  now I know stuff being in training. What do I do?

 

Yes.

 

And you know, frankly, I kind of wish I had that book back then when I was like dealing with that.

 

Rvery time I fly, you know, you get in a conversation with someone and they ask you what you do, and invariably you hear that my wife, my brother, my sister, my friend suffers from depression. It's so prevalent and it's such a common, common problem.

 

So, you know, you've really built this career. It spans research on cognitive vulnerability to depression, CBT, and practice education. Can you tell us just a little about yourself, how the career developed, and what kind of drew you to studying depression?

 

Sure. Interestingly, I think, early on in life, I never predicted I'd ever go to university. In fact, I remember in high school, I was told by my principal that I skipped 87% of high school, and if I skipped one more class, I would be kicked out.

 

And what in the world were you doing? Maybe it's not my business.

 

I was doing nothing nefarious, just skipping. I wasn't interested for some reason. And I think part of it was I didn't find my passion, but part of it was perhaps some self-doubt. You know, can I do this? And you know, I started after high school, I was a garbage collector for about a year and a half, and it was a really good motivator to go to school, and so I did. I went into a smaller sort of liberal arts college in Calgary, Alberta, Canada, and did my first year there, just taking a bunch of different courses. When I took psychology, it was just this aha experience for me. I really felt like wow, this is what really fits for me. And I was really motivated and passionate for it. And so in that course of training, I then transferred to the University of Calgary and you know, just took more courses and got excited about it. And the way I got into depression was a bit strange. You know, I've never had a history of depression. My family members, fortunately, haven't either. And I think it was really when I was in my last year of undergraduate, I was doing my honors degree, and I was very interested at the time in stress and coping. Some of the work of Lazarus, Richard Lazarus and Susan Folkman, and that kind of stuff really turned me on. And in that research, I was looking at predicting unemployment status in people who had low back pain. And I realized that what a huge variable it was –depression. And so I got interested in depression, ended up working with Keith Dobson, who is a well-known depression researcher and cognitive behavioral therapist, and the rest is history. And so I moved into depression quickly and fell in love with that field.

 

Wow.

 

Can I say something only just slightly off topic for a moment? I worked with, when I was a professor, I was working obviously with undergrads, but I work with young adults a lot as a clinician. So it's still with college-aged people. And the amount of people I've heard that, in their college years, feel like I have to know exactly what I'm interested in and exactly where I'm going. In like sophomore year. I always tell them, I always say, you know, go listen to our podcast. Go listen to our podcast because nearly everybody, we ask this question to… nearly everybody, and almost everybody says, you know, these incredible experts. Like, let's be honest, Dr. Dozois, you're an incredible expert on this. Like your resume is remarkable. And your story is, you know, I kind of stumbled into it. I got interested through these ways. I figured it out along the way. And that is just so common among so many experts in our field, that it wasn't like they knew by age 10 they were going to do this. And they pursued it with relentlessness.

 

As long as we're getting off topic and then we're going to maybe let our guests speak. Absolutely it is  one of my common rants that I was going to keep to myself, but since you started this… is that we live in an area where there's no longer the phenomenon of crappy summer jobs. Everyone now, when a kid is like home from college, they're doing preparatory work or research or something to help them either get into college or to get into graduate school or something like that.

 

Isn't that true?

 

Right. Whereas when I was home, I worked in a factory. And like you said, if I ever like doubted whether I wanted to continue my studies and work ahead, I would just think about a typical day working at that factory. I know, did you have jobs like that?

 

I actually worked at a place called Papa Murphy's, and I only very recently connected that I named my child Murphy. Oh my god. And I thought, I wonder if that's like a weird consciousness.

 

Okay, so unfortunately, I think that's a lost thing, but at any rate, we should move on.

 

I just really like your story, and I'm appreciating even that high school wasn't really your thing, and I think that's an important thing for people to hear because you are clearly such an accomplished person in the field.

 

Thank you.

 

Back to it though. You know, so much of your work really has been to help understand what creates vulnerability for depression. I even think that the early example you said of unemployment and lower back pain and seeing the moderating effect of depression in there. Mediating effect, moderating effect, one of those two, I imagine. But really looking at what puts people in this vulnerability for depression. And yeah, I'm curious what led up to in your experience of treating and understanding depression to getting to your interest, the interest in people's partners experience. I wonder if you felt like there was something missing from the literature from kind of clinical experience?

 

Yeah, I think in my career, it was for years I had studied cognitive vulnerability to depression and cognitive behavioral therapy, and more specifically, an interest in self-schemas, core beliefs people have about themselves and how those beliefs are organized and how that impacts depression and the course of depression and how it can be treated and so on. And during the course of that work, I increasingly realized that it wasn't just self-schemas, it was largely interpersonal negative schemas that were driving a lot of depression and that seemed to be stable over time. So even though someone improves from an episode of depression, there's their negative, well-organized structures that seem to be stable, which suggests that it's there still, it's dormant, but it's there. And so often in the literature, you used to find that when people improve from an episode of depression, while they're depressed, they have attentional biases and memory biases and negative thoughts. But once they improve, those seem to lift. And it didn't make sense in a way because according to Beck's model of depression, the people should have this schema that's there, that's latent and ready to be activated. And so I wanted to look at what that process looked like and started to look at the organization of people's beliefs and memories and thoughts and how that the research was showing that it was stable over time. So even though people improved from an episode of depression, that negative structure was still there. And attention biases and memory biases improved, but that was still there, suggesting that it keeps them vulnerable potentially to future risk of relapse. And as I was doing this, I realized it was largely the interpersonal negative. And then over time, you know, I got into a bit of work on excessive reassurance seeking and depression and things like that but really realized that we're missing a lot of the interpersonal piece in cognitive therapy, I think. We touch on it as clinicians, but not as much as academics. And so with one of my now doctoral level psychologists, but at the time my graduate student, we worked together on developing this model called the Dietic Partner Schema model, in which we're looking not just at self-schemas, but also partner schemas, beliefs we have about our closest partners and how that can impact the attributions we make. You know, for example, they don't respond to a text one day. And if you have a positive, well-connected partner schema, you might think, well, maybe they forgot or they're having a rough day. And if you have a negative, well-organized partner schema, you're thinking that they're always forgetting. And how could they be so rude? And so that impacts the attributions we make, which impacts the behaviors in the moment, which affect how you feel about the relationship and your own depression, which then feeds back again into the partner schema and starts to consolidate that over time.

 

That has a lot of overlap with mentalizing theory and sort of how the mentalizing folks would talk about how we experience others. I am fascinated with this. With that theory though…the dyadic partner schema.

 

Yeah.

 

I said it wrong. Can you say it one more time?

 

Yeah, the dyadic partner schema model of relationship to stress and depression.

 

And based on what you're saying, I think I have a sense that this would be something that would transition even between different partners. It wouldn't be an internal schema that would just be for one partner, correct?

 

Oh, I didn't take that. Is that true?

 

Yeah, no, it's a dyadic, it's a dyadic thing. So my research more recently, we've been trying to look more at dyads in our research, which is a new thing for me. But no, it very much is a dyadic process because it's almost like I have a filter and my partner has a filter, and what they're relaying to me gets filtered through my partner schema of them, and it affects how I respond and what I think and how I behave, which then feeds back and is filtered through their own system.

 

So this is specific. It's okay. So I did get that wrong. This is specific. So it'd be like me and my husband, because we are married and we've been together, we're developing this schema together of what I expect from him and how he knows me and how that ends up playing a role. That's really interesting. That does feel super important and relevant to how people function and the stuff that actually ends up impacting their life.

 

Yeah. Although I think it's generalizable. I think we develop schemas for lots of different relationships. And I think that maybe that's where you were going. I think we have beliefs, we have schemas about our parents, we have schemas about our friends. I mean, I think the closer we are to people, the more well developed those are.

 

Yeah.

 

But they do impact that. And I think, you know, I think largely they're based on, I think there's a lot of parallel between cognitive behavioral therapy and attachment work in terms of that notion of an internal working model that we develop based on what we grew up with in relationship. And so it impacts what we expect in relationships, how we expect people to respond to us. Will they be there for us? Will they provide this secure base? Or will they not? And so that can, you know, I think an internal working model more of a broader kind of schema, if you will, of others in relation. But I think we developed specific schemas about particular people in ongoing interactions with them.

 

That's super helpful as a way to think about it.

 

And that ties in well with your work with partners …a person has a partner who's depressed. And how do you approach that? I mean, obviously people feel responsible and they feel like there's something they should be doing, even though, perhaps they can't be their therapist or be the one to treat them. How do you approach that?

 

Well, you know, it's difficult. I think that's partly what the genesis of the book was, because when you look out there, I mean, I think in the years I've been an academic,  almost 30 years, I guess 27 at Western University. And during that time I've had a private practice as well. And so I've often heard, as you mentioned as well, Bob, you've got people who are asking, what can I do? I think they have a partner with depression, and they feel like they're looking down at the top into a pit where their partner is, and they don't understand what I can do. I  feel paralyzed, I don't have any resources or skills to know how to deal with that. And so that in large part was why I wrote the book. But the other piece was trying to think through, you know, oftentimes the partner themself is forgotten. And so they're going through this process of trying to help, and they want to love, they might love their partner, they might want to support them, but there's a mix of conflicting emotions, and they feel like love and care on one hand and resentment and anger on the other. It's like “I didn't sign up for this. Like, holy smokes, why am I carrying the burden of responsibility in this relationship?” And so the second part of the book really focuses on strategies for the partner. How do I get through this unscathed myself? And then the third is to focus on sort of tips for the relationship. You know, we know depression and relationship distress go hand in hand. Some of the work of Mark Weissman at the University of Colorado and others have looked at,  it's causal. I mean, relationship distress causes depression and vice versa. And so I think providing good evidence-based strategies for how do you keep your relationship going during this difficult time? And it is difficult because, as you mentioned, there's so many mixed feelings, but also a lack of tools to deal with them.

 

Sure. And I was just saying you make a distinction between healthy support versus sort of trying to take on a more directive role. I don't know if you could say more about that.

 

Yeah, the goal is not for you, a partner, to be the therapist. They don't have the resources or the knowledge. And in fact, you know, in some ways I think the relationship would become too enmeshed if you were serving in that role. And I so I think the idea is to be an ideal ally. And in terms of helping your partner understand, not the cause of their own depression, but what are some ways out of it and learning about effective treatments, learning about what are some strategies that we might be able to work on together, or not, depending on where they're at, you know? Just some tools that will arm them, like a toolbox, really, so that you have a set of resources that you can use with your partner, not to replace therapy. In fact, if depression is severe, I think someone should see a psychologist or other regulated health provider. They maybe should see their physician for medication and so on, but to really be able to serve as an ally, as a coach, as a partner, to be able to help them through this, to support them in the way they need to be supported without overdoing it, but providing tips and strategies that you can work on potentially together.

 

It's good empathy to me, you know, that it's a willingness to step into the mess with the person and be with them and to say, I'm going to, again, I'm not going to get enmeshed, but I'm going to hold your hand and be with you as we walk through it. It's reminding me of, you know, like several times in my marriage, my husband and I both had different health issues where then one of us needed to go on a specific, awful, obnoxious diet. And the other person always did it too. Cause it was like, this was a kind of allied thing of like, all right, you have to, you know, I was pregnant, I had to be in a certain diet. All right, then we're going to do it together. I really feel like that's very good empathy. One thing I'm thinking as you're talking, though, and maybe then before getting into some of those strategies, this is so common in family systems where there's a person who's going through a mental illness, is that there can feel like this false binary that there's the person with the mental illness, and then everybody else is healthy. And so the everybody else, these you know, partners, other family members, they are totally without their own struggles or even their own vulnerabilities to how they think about things. And that has significantly rarely been the case in my experience. And so, because so often with partners or parents, what I see when they have a depressed loved one is these really unhelpful ideas, they just need to snap out of it. They just need to look at what they have to be grateful for. They need to be grateful and then they wouldn't be depressed. We just got to get them on an ADHD medication, and then they'll be good and they can do work and they'll get out of this motivation slump. There's this sort of either misinformation or a lot of times what comes from a place of simplifying for the sake of control. And so I imagine part of this, like even early steps, is we need to help people understand depression, what it is, what it isn't.

 

Absolutely.

 

So that some of that early stuff can get out of the way.

 

Yes. And those are great points to not just tell someone, you know, snap out of it, or…  you just need X, Y, or Z …get up, get out of the way.

 

Yeah.

 

Yeah. But to help understand the symptomatology so that you're not personalizing it as much, too. You know, I give an example in the book of …you're kind of lighting candles and playing Ed Sheeran romantic music and hoping to have a night of intimacy… and your partner kind of comes in and shuts away in the bedroom and wants to be alone. You know, understanding that depression is related to fatigue and to low motivation and anhedonia, the lack of pleasure, that may not take the total sting away, but it helps you to personalize it a bit less and have some understanding about it. But it's interesting what you raised as well in terms of not just them snapping out of it, but I think instead of treating it as an  “I'm not depressed… you are,”  I think as you work together, it can become what some dyadic researchers call a “we disease” or a “we problem,” right? It's something we're working on together. That's not just you know, it's not just your problem, it's our problem because we're a unit.

 

You know, I work with adolescents a lot, and this is where it's not partners, but parents. They're like, yes, okay, our kid's the sick one…and we're good. And it's like, let's think about this all together, not to say that you're sick, but that, you know, this is all happening together.

 

That's from a family systems point of view, which you pointed out, it you know, it's the identified patient, if I quote, right? Right. But there's a lot more to the system that's going on, and everyone is participating in various ways.

 

 Yes.

 

Yeah, I mean, one of the pieces of advice you give people is to connect first rather than jumping into solutions, which is frankly, the opposite of what most of us do, I think. Yes, naturally. And you know, why do you think that is? I mean obviously we want to help, people want to be helpful. They kind of keep coming up with ways to do that and stuff. And can you talk a bit about the importance of the connection?

 

Yeah, I think for all of us as human beings, social support is huge. We all want to feel loved and needed and supported and cared for.  And there's different ways to give support. We can give instrumental support, we can give informational support, we can give cognitive support. Emotional support seems to be what partners are really after. And there's some interesting work by Lara Kammrath, who I heard at a conference a couple years ago, who did some work on this notion of connect first, where your partner is dealing with whatever it is, it doesn't even need to be depression. And what we want to do often is we want to help fix it for them or give them information or give them advice. And what her research has found is when we connect first, when we validate, we're there for someone, we're just caring and letting them know we're there, about 81% of people feel supported. Whereas if we jump to change and help them, you know, you might want to think about this… and you might want to try this… only about 41% feel supported. And so that work is really interesting. And the kind of rule is to connect first. And I think we engage in the wanting to fix it because of what, you know, William Miller and Steve Rollnick, who developed motivational interviewing, called “the fix it reflex.”  It's this notion that we just… I think we do it as therapists, but we also do it just as human beings. When we see someone suffering, it's logical to want to problem solve and figure out what I can do to help fix it, right? And when we do that, we're missing the boat more times than not, because what we need to do is step back and kind of restrain that fix it reflex to connect first, validate, be there, understand, and then check in with your partner. Okay, is there anything I can do? Is there anything you want me to do in addition to that? And that's sort of a good strategy.

 

 I think it’s interesting. And I like that you consider it almost like a reflex because you know, we've probably all been told at some point:  “stop trying to fix it. I just want to tell you how I'm feeling,” and yet we continue to do it. So, it's not something we don't know. And I've certainly explained to my wife that I much prefer, sometimes, you know, cursing the darkness rather than lighting a candle.

 

But exactly though. It is, I feel like it's a human reaction, especially for people we love. We want to be there. I think a lot of ways I tend to try to talk to loved ones about it, is that they don't need you to be a therapist. They need their therapist to be a therapist, they need you to be their partner, or they need you to be their parent. And that role is actually so important for someone in recovery and they're going through a mental illness, is that they know they have their loved one, they have their partner to be there in that. Yes. and I also can't help but think about, and I wonder if you have thoughts about this, that the fix it reflex, I imagine in so many ways it must worsen depression because it's probably stuff that the person is either not able to do without support, or there's some reason, right? Like because if they could just get up off the couch and go run and feel better and exercise, they would, right? So there's something happening where they're going to need more support than that. So oftentimes the suggestions don't work, which then probably reiterates to the depressed person you're worthless, you're no good, you're lazy, you can't even do this thing your wife wants you to do, so on and so forth. And so, I imagine the fix it reflex is total fodder for worsening depression and then ongoing resentment.

 

It must be very invalidating. Yeah, the person really doesn't understand where you're at or they wouldn't be saying this.

 

Yes, exactly. There’s this exercise I do in my grad class when I'm teaching different psychotherapy approaches. When we talk about motivational interviewing, I have them split up into pairs, and one student is deciding what they want, what they're considering about change, whether it's quitting smoking or changing their diet or drinking less or whatever it is. And the other student's role is to try to be the persuader and keep pushing them to change, right? And all the good reasons… here are the reasons why changing is so important, and here's what you can do. And I asked students after that exercise, you know, how when you were the person trying to consider making a change, how did you feel? And like you said, Bob, they felt invalidated, defeated, immoral, demoralized, even anger, like there's a lot of emotions there. And instead, if you approach it as in a motivational interviewing sort of way, with the spirit of curiosity and understanding and empathy…those basic Carl Rogers sort of unconditional positive regard and genuineness and empathy, then it's perceived very differently, and people are much more willing to engage in change.

 

And putting in a shameless plug that if you're interested in hearing more about motivational interviewing, we had the delight of interviewing Dr. Bill Miller about motivational interviewing on our podcast. Go listen. He also has a new book now, if I'm not mistaken.

 

You know one part of your book that struck me, and I think it's probably kind of a… I don't know if scary is the right word… but it's probably kind of an unnerving part of it, which is like, when do you know if you've reached the limits of being in the relationship with the depressed person? And that's a tough question, right? How a partner can dissect and think about and consider …can we keep changing? Are we moving forward? What just needs to be accepted? And, you know, I can accept this and I can just appreciate this, might be part of my relationship forever. And then when is it kind of time to call it? I just wonder if you could speak a little bit to that and how you help partners think about making those complex decisions.

 

It really is a complex decision, and it's one for which there is not empirical data to back up, okay. If X, then do Y. You know, it's not an easy solution.

 

A good flowchart of just like decision making.

 

Exactly. It's not there. And so what I tried to do in that was wrestle with the reader on that and recognize that there's no right answer, but to think through, you know, what was the relationship like before the depression hit? If it was a relationship that was really doing well and then depression hit and things changed, you can maybe get some of that back. And you've not lost the person, right? Underneath the depression. And I think there are many effective treatments available that can help someone out of depression. And so part of it is to be patient and make sure you're not making a hasty decision, but also to think through, you know, what originally attracted you to them and to try to reflect on some of those core values or characteristics that you really thought were important in the relationship and important to you in terms of fundamentals. But then you know, there's a point where perhaps your partner's not engaging in treatment, they're not working hard enough, perhaps, change isn’t being made, it seems you know, it's endless slogging. And I was trying to also bring in the notion that your needs matter too. And to not feel guilty about it. It's easy to feel guilty because you're the one with the resources and they're the one suffering. How dare you leave a relationship? It's almost like someone leaving when a partner has cancer or something. I mean, how awful is that, right? But I think depression is a dyadic, it affects the diad, it affects the partner and the relationship. And so there comes a point where you need to ask yourself, have I consulted with others? Have we seen a couple’s therapist? Have we done what we can do and done the work and given it enough time and patience and care to ensure that this is not going to turn around or that the relationship isn't going to improve. It's a tough decision, though. It's one that one has to make on their own, and there are no easy answers.

 

As an author and as a thinker, that was an incredibly brave part of the book to wade through because of that complexity. And I think some of the balance between what it might feel like as a partner to want to support the person they love through depression but also hold their needs and how to find that balance. I think that is something that is very hard to talk about and put words to. And I imagine many people will find that very comforting and validating to their experience. Gosh, I really think people are going to find this book to be an incredible resource because, again, I think it pays homage, if you will, to the complexity of depression, the hope that there's good treatment and that people need to be getting good treatment and that partners are allies in treatment, not treatment itself. And yeah, that there are these complex questions to attend to. I wonder as we begin to wrap up, if you have anything else that you'd really like to highlight from this work, you know, anything that you'd like to leave our listeners with who predominantly are mental health providers. But yeah, any kind of final thoughts on this work?

 

Yeah, it is interesting. And I think there's maybe two messages if the listeners are mainly mental health providers.  One is I think this is worth considering for people your clients are seeing for their partners to help through that process. Because I think involving a partner in treatment, there's not good evidence on this, but I think it can deepen the understanding and it can deepen empathy. And if someone can learn some of the skills that are being taught in psychotherapy, some of which are outlined in this book… as ways to help work through, like how to change your thinking, how to engage in behavioral activation, how to do communication and problem solving. Those kinds of strategies I think are helpful and can be useful for a clinician to almost work alongside. It's almost like using Greenberger and Pedesky's mind over mood in therapy. You know, it's a good complement, I think. And especially when a partner often feels paralyzed and not able to be involved in that process as much. So, I think it can be a really helpful sort of guide that way. And then I guess the other thing is the message, to me, is that, just like good cognitive behavioral therapy, whenever something we're experiencing is a negative emotion, whether it's in our relationship or whatever it is, stop and ask yourself, “okay, what am I thinking? And are my thoughts aligned with facts?” And if they are and there's still an issue, then you start to engage in problem solving, which is also outlined in the book. You know, how do you figure out how to solve this? But then the third, another part of the book talks about acceptance strategies. There are times when we're hitting our head against the wall and we're not making change and we're not able to problem solve our way through this or just change our thinking. And that's where some of Steve Hayes' work in terms of acceptance and needing to, it's not resignation, but it's coming to an acceptance of this is where things are at. He gives a great example of the unwanted guests in one of his books. This person comes in and you've sent out an invitation to the community, and who shows up but this unwelcome guest? And this is someone who double dips and swears, and you know, you're worried about them stealing stuff and so on. And so you have a choice. You can either follow them into every room and ensure they're not going to offend people or steal your stuff, or you can say, you know what, I don't like that they're here, but I'm I need to accept that. And then you can get on with the party. And I think similarly with a partner with depression, there's some things you're not going to change in any relationship. And I think it's really helpful to stop and just kind of allow yourself to accept those things which can't change.

 

And think about that to let go of some of the control. Yeah, get on with your life in some ways.

 

Exactly.

 

Exactly. Well thanks. Thanks very much. We've been discussing the book: What to Do When Your Partner is Depressed. It's by Dr. David Dozois, who's a professor of psychology and psychiatry at the University of Western Ontario in Canada. Dr. Dozois, thanks so much for coming on and talking with us today. It's been fascinating.

 

This is such an important topic. And I I actually maybe have a third thing for people listening to think about…is that if there's people interested in doing that research, finding more good clinical evidence for how you involve partner-based work in the treatment of depression. We need that out there next. That's next, very sure.

 

That is a beautiful call to research. We do definitely need that.

 

Well, you've been listening to the Mind Dive podcast. I'm your host, Kerry Horrell.

 

And I'm Bob Boland.