Ep #166: Perfectly Hidden Depression: An Interview with Dr. Margaret Robinson Rutherford

Welcome to The Widowed Mom Podcast, episode 166, Perfectly Hidden Depression: An Interview with Dr. Margaret Robinson Rutherford.

Welcome to The Widowed Mom Podcast, the only podcast that offers a proven process to help you work through your grief, to grow, evolve, and create a future you can truly look forward to. Here’s your host, Master Certified life coach, grief expert, widow, and mom, Krista St. Germain.

Hey there, welcome to another episode of the podcast. This is one I didn’t see coming, I’ll have to be honest with you. I had never even heard the term ‘perfectly hidden depression’ until not very long ago when a client told me that her husband who died by suicide was told or she was told later that he had perfectly hidden depression. New term for me and at the exact same time I came across the work of Margaret Robinson Rutherford who is my guest on today’s podcast.

I really think this is going to be valuable for you and I want you to listen to it in three ways. If you are a widow who has lost her person from suicide I want you to listen through that lens to see if possibly you can understand more about what your person may have been going through. And if you’re putting pressure on yourself and guilting yourself for having missed signs, I want you to consider what she has to say.

If you are the mother of a child which of course you all are because you’re listening to this podcast episode, pay attention to how this could be impacting your child and preventing you from seeing what’s really going on for them. And then also I want you to consider, do you relate to this idea of perfectly hidden depression? Are you someone who is suffering from perfectionism who is suffering from a lack of self-acceptance? And what is there for you to gain from this episode? Alright.

And then on another note before we get into it, as you’re listening to this podcast episode it is August 1^st, 2022 which means it is six years since my beloved Hugo died. And I just want to say that I know we all have the inclination to believe that time heals. I believe that time is necessary most often but time alone does not heal. But at the same time, I also want to tell you that looking back over the last six years of my own life I am in such a different place. And that said I still miss him and that’s okay.

I still love him and that’s okay. And I want to make sure that you are setting yourself up for success using the and statement. Instead of if I want to love my life then I have to be past missing my spouse. I can’t miss them anymore or I can’t cry anymore. I want you to give yourself permission to use an and statement because the truth for me and for most of the women that I work with is that we miss them and we figured out how to love life again. We’re sometimes still sad and we figured out how to love live again.

That’s part of loving life is experiencing all of the emotions, not telling yourself that there’s some false binary, that there’s some either or that you have to get to but making space for all of it. You can miss them, you can cry, you can still have grief grenades whatever is happening and you can still love your life. And that’s what I want to offer to you is possible. So, with that, let’s jump into my interview with Dr. Margaret.

                                                                                                                    

Krista: Alright, welcome Dr. Margaret: to the podcast. I’m excited to have you.

Margaret: It’s just great to be here, thank you.

Krista: It’s so fascinating to me because I think sometimes just the universe is just sending you the exact thing that you need when you need it. I had never heard the term ‘perfectly hidden depression’ until very shortly before we connected, literally had never heard the term, and a client brought it to me, lost her husband to suicide. And she was the first time I had ever heard that term so I’m really grateful that it’s something that I now have in my lexicon, I have read your book and I cannot wait for my listeners to learn about perfectly hidden depression and your work.

So, if you wouldn’t mind, just tell us a little bit about you, introduce yourself and we’ll take it from there.

Margaret: Sure. Well, I’m a psychologist. I’ve been a psychologist for now almost 30 years. I actually was a jingle singer in my 20s. I sang radio and television commercials.

Krista: How cool is that?

Margaret: Yeah, it was a very interesting career and then sang some jazz at night and that kind of thing. And then I got unhappy with the lifestyle and got a degree in music therapy which led me to clinical psychology. I didn’t get a PhD until I was 38 years old so it took me a while. But I have loved this career and after my son left, I was lucky enough to have a son, and after he left I [inaudible] for college, I figured that I had some time and I was really unhappy with so much of what was going on about mental health and the stigma surrounding it.

And I thought, well, maybe if I write about things and it is clearcut as I can and I can do some good. And that started in 2012 and then that led me to podcasting in 2016.

Krista: That’s really early for podcasting.

Margaret: Yeah. And I definitely was the oldest person taking the course to figure out how to do it. I remember but I go, okay, great, I can do this. And I thought, now, what are you doing on the laptop? I can do this. But it’s called The Self-Work Podcast.

And as far as perfectly hidden depression is concerned. I was literally out in my sunroom writing what was going to be my weekly blog post and I started thinking about these people that I had seen through the years that when they walked in my door would never have said they were depressed. In fact, they probably would have vehemently denied it. But what was the thread, the common thread in all of them was this complete, almost complete inability to express painful emotions.

They would tell me about something that would normally be considered traumatic in their lives and they would sort of be smiling and dismissed it, or discounting it, or I feel funny talking about it or it’s not that big a deal, it happened a long time ago and everybody has problems and blah, blah, blah. So, I wrote about these people and of course anonymously. And the post went viral, I never had a post go viral before. And then it was called The Perfectly Hidden Depressed Person, Are You one? Are you one? Are you one?

And then the HuffPost I was writing for them at the time and they put it on the HuffPost and I literally got hundreds of emails from people, how do you know about this? It’s like you’re in my head. Where can I learn more? So, I got curious. And I found Brené Brown’s work which, I must have been living under a rock to not have found her work. But I guess I’d been busy rearing a child.

And I found a wonderful book that’s still great, it’s by Terrence Real, it’s called I Don’t Want to Talk About It. And it’s about men. And he was trying to make the point that there is a difference between women’s depression and men’s depression which was kind of debunked but he thought that men had more covert depression than women did. So anyway, that’s also a wonderful book.

And so, I started researching and I realized that the academic literature had a growing body of a research that showed that actual destructive perfectionism which not all perfectionism is bad. There is constructive perfectionism but that destructive perfectionism, especially a certain kind can lead to suicide. And that there’s growing evidence that this is getting to be a worse and worse problem internationally actually.

And it certainly fit with my clinical experience of these people that I was seeing because when we got down to brass tacks and they finally trusted me enough to open up, I would find out that, yes, I have thoughts about hurting myself and that kind of thing. So even Brené Brown, Krista, did not make the connection. She stopped. She talked about perfectionism and depression but she didn’t go so far as to say, “This is a tremendously difficult problem and it’s difficult, and we need to protect people but we also need to educate the mental health profession.”

Because the mental health profession is getting out the diagnostic manual and going down the criteria and these people are not going to fit that criteria. Their lives look great, they have lots of energy. They’re very responsible. They will tell you they’re happy. They will say they don’t cry much and they’re sleeping fine, and they’re maybe a little too busy, maybe they would admit being a control freak. But very few of the symptoms though. And so, they’d say, “You’re not depressed.”

So, I decided to write a book. I’m a believer in if it doesn’t exist and you think it should then create it. And sure, enough I, with the help of a wonderful agent, I was able to find a publisher. It was turned down by a lot of people because they said, “You’re a therapist from Arkansas, you’re not on the Harvard faculty or [inaudible] faculty. Nobody knows who you are.” And so, they took a risk on me. By that time, I had started the podcast and so that was growing in popularity.

And I’ve just been so blessed that the book has done fairly well. It’s been translated into eight different languages at this point because it is an international problem. And so, this kind of these people who don’t look despairing at all, but are underneath. I mean there’s some famous examples of that, Andrew – oh gosh, his last name has escaped, Woodham and Kate Spade are celebrity examples of that.

Although I think Kate Spade was in treatment for some sort of mood disorder, so that may not be as apt but certainly her life looked great on the outside. But I have been contacted by so many people who have lost children who had perfect looking lives, who’d lost spouses, who have lost good friends, best friends. I had a very traumatic example and when I first told the story I would tear up.

I had some friends from Florida contact me and they had just buried a really good friend who looked like her life was going gangbusters and nobody knew why or had any inkling that this could happen. And her husband came up to them and said, “I found this book on her.” Her name was Patricia, “And it was my book, I found this book on her nightstand.” I just, oh my gosh, I thought, I’ve got to work harder.

I’ve got to try to get this message out and so that’s why I so appreciate being on your podcast because I think it is such an important message and I mean I guess every writer thinks the message of their book is important. But this, I will hope literally saves lives.

Krista: Yeah. Obviously I’m in full agreement with you and even more than that. So, for my listenership, I’m thinking of it in kind of three ways. So, I’m thinking of the woman who lost her spouse who did not know that there was depression happening. I want you to talk to her so she knows why she didn’t see it. I’m thinking of the woman who’s listening to the podcast who is experiencing this for herself and hasn’t identified it.

And I’m also thinking about it in terms of being a parent and to your point about suicide loss and thinking of one of my clients specifically who lost her niece, Zoe, and no one saw that coming. And I’ve seen how painful that has been on her and on her family. And so, I want you to help my listeners know what to look for and know what might hold them back from seeing the truth of what’s really there. So maybe before we get into that because a lot of my listeners probably could use some help understanding.

What’s the difference between classic depression as determined by the DSM, or what even is the DSM? Let’s roll back that.

Margaret: Diagnostical and Statistical Manual of mental health disorders. And it was devised years ago not like it’s being used now, it was devised as we need a common language. It was created to create a common international language for when we say someone’s depressed and what are we talking about? What are we talking about from Guam, to Mexico, to France, to Arkansas? I mean what is it that we’re talking about? But now it’s used as criteria. You must fit these criteria in order to be diagnosed with this.

And that was never the original intention but it has morphed into that probably as egos got involved or whatever. So that’s what the DSM is. And we all study it. If you go to graduate school, or a coaching program, or some kind of marriage and family program then you’re going to get handed a copy of the DSM and you’re supposed to look at it and know exactly everything that’s in it which is near nigh impossible.

Krista: It’s a big book.

Margaret: It’s a big book. But what I would tell listeners is, first I’m going to tell a story about myself. It’s the first story in the book. There was a woman who’d come to see me, she was in her early 30s, two kids, happy marriage but she had had some issues growing up that had caused her, she felt like she was anxious all the time. And she’d gotten into a profession that she really didn’t like which she talked a lot about. Well, I can’t say what she was. Let’s caller her a CPA.

Krista: Okay, hard to protect confidentiality sometimes, yeah.

Margaret: Yeah. But a very, you know, dealing with figures, not dealing in any kind of intimate emotional way with people. So, I was treating her for anxiety, that’s what I diagnosed her with. Well, her husband called me back when we had pagers, he contacted me and said, “I’m concerned about her and I don’t know what’s wrong, it just is something in my gut.” And he was out of town and he was still three or four hours away. And he said, “Would you go over to the house and just check on her?” I said, “I feel kind of funny doing that.” No, I’ve never done that before.

And basically, I’ve never done it again. But something in my gut was responding to his. And I knew where they lived. And so, he told me how to get in and sure enough she wasn’t out in the yard doing anything. She had asked him to pick up the kids and then come home by himself which was a very strange request. So, I let myself in the house feeling very burglar ish and the house was quiet, there were dishes drying, all the toys were picked up.

I’ll never forget, I have a picture of it in my head and I went back, I saw a hall that I assumed maybe that was the master bedroom hall and I was calling her name. I didn’t want to scare her. Well, she had taken a bottle of pills and had drunk about a half a bottle of vodka. And she was trying to kill herself. So, I called 911 etc. And then they came and got her and her life was saved. And I remember standing there and just thinking, I missed this. I missed it. Suicide had never come up, it had never occurred to me.

And I walked out of that, and in a Disney story that would have changed my life forever. I do know that it turned on some awareness that I needed to not believe just what people were telling me, which of course seems like such a simple thing for a therapist to figure out. But she was definitely in my mind all the time as I interviewed people, but I wrote the book. So, to that mother or to that spouse who doesn’t know, these people are masters. They have had years of experience of what’s called rigidly compartmentalizing their painful emotions.

They are frightened, they are scared to let anyone know about their vulnerabilities. They shoved them away so hard, so long ago, that actually if you asked them, “Did it bother you that your father died?” “No, it was just the way my life was.” They have minimized, and ignored, and avoided. I’ve talked with many spouses whose partners have killed themselves.

And I remember one lady saying, “Gosh, the only thing I can think of that I noticed that he did was in order to handle emotions he would have to have a couple of drinks. He didn’t know, cold sober he could not talk about being angry. He had to have something to let down some of his filters.” And so, people have rifled through whatever that term is, their memories. And adults can get very, very good at not acknowledging this. And then it may be that they chose you because you also struggle to do that.

It may be that you’re all attracted to one another because they are an over-functioner and they’ve just took the lead and you follow. I get plenty of emails from people who say, “I’ve been married to my wife for 12 years and I’ve never seen her cry.” And this may be her. So, it is very difficult to see. And again, this isn’t high functioning depression or what’s called smiling depression where someone knows they’re depressed. And they’re even classically depressed.

Classic depression is a depressed mood that lasts for a certain amount of time and is a noticeable change of behavior.

Krista: Yeah. So, if they actually looked at the criteria for depression they would know they fit it and then they would hide it?

Margaret: Friends are coming up to them and saying, “What’s going on? What’s wrong?” But they themselves go, “I’m just not myself.” The second thing is what’s called anhedonia which is a lack of pleasure in previously pleasurable activities. Meaning that if you used to love to crochet, or you used to love to go hunting, or you used to love to create a podcast, you can’t whomp up the energy to do that anymore. It just seems like, I don’t know why I liked that so much, it seems stupid now. You isolate. You can have feelings of helpless and hopelessness.

Your mind is foggy, you can be indecisive, you can have suicidal ideation, maybe you cry but also maybe you get agitated or anxious a lot. So, these are things, they’re physical symptoms, you feel fatigued and like your body’s heavy. Or maybe you’re just really agitated. But those are changes in you that you notice or that others notice.

Krista: Yes, others notice.

Margaret: So that’s classic depression. And people who have high functioning depression actually know that’s going on and they’re on medicine, or they’re exercising a lot, or they’re in therapy. But their depression is manageable enough to where they can put on a front and not let people know really what’s going on with them. People like that will probably get something out of the book and even feel like they are hiding their depression. People, well, just say desperately, but really want to.

Krista: Yeah, feel they need to be reached for sure.

Margaret: Yes. When they hear the term, perfectly hidden depression they go, “Oh, maybe.” Something in their gut kind of goes, “Listen, listen.” It’s also another term I’ve been using with it is called trauma based perfectionism that they have a trauma that they have again, shamed themselves for, they’ve got a constant critical shaming voice in their head but they’ve pushed all that away. And they’ve stowed it, compartmentalization is actually a skill that we all have.

If I had this interview with you this morning, if my dog had died this morning I would need to compartmentalize that. I would need to think, I’ve got to grieve that afterwards. I can’t go on her show and be sobbing. So, it’s a skill that all of us need, the point is that people with perfectly hidden depression use it far too much. Does that help?

Krista: It does, and it’s funny, there’s the coach in me who wants to use this information to help other people. And then there’s the coach in me to tell them about it so they can help themselves. In my mind I’m going back through and thinking about all the times I have been looking for the classic signs of depression and wondering what I have missed. And then also there’s another part of me that has this huge desire to connect you to every other coach I know who also needs this information.

Margaret: I’m actually teaching clinicians now and it’s really exciting because they’ll say things to me like you just said. And I don’t remember anybody ever talking about perfectionism in graduate school ever. They just expected us to [crosstalk]. But if you think about cardiology, I’m going to give a very pedestrian view of this thing because I’m sure it’s more complicated.

But if I had gone 30 years ago to a cardiologist and had had certain heart symptoms as a woman, and he’d said or she’d said, probably he, “You don’t have any signs of a heart attack.” Because they were doing research only with men.

Krista: On men, yeah.

Margaret: And so, women were having heart attacks but they were going undetected because they might present but then the physician following the criteria would say, “No.” Then they began doing research on women and all of a sudden cardiology’s rubric changed what was going to be on their list of things to check for. And all of a sudden it wasn’t that women were having more heart attacks, it’s that women were being identified as, you know, that’s what we need to do in mental health. We need to expand. I’m not against the symptoms of classic depression, I’m not that narcissistic.

I’m just trying to say, we need to expand the definition to realize that those symptoms are not going to describe everyone. I did a podcast with a therapist and she had read the book, and I so appreciate you all reading the book by the way. And she said, “I did exactly what you said to do in the book with a patient of mine.” And I got chill bumps when she said that because we ask the question, “Do you ever feel hopeless?” No, that’s what someone with perfectly hidden depression would say. No, no, not hopeless. If you felt hopeless, would you tell anyone?

Krista: Would you tell me? Yeah.

Margaret: No, would also be the answer. There’s a window that pops up right then when you say, “Well, what would get in your way of telling someone?” All of a sudden you started a conversation that you realize, wait a minute, wait, wait, wait, there’s some things here that I don’t understand that aren’t evident.

There’s a Scottish psychiatrist, Rebecca Lawrence who wrote this very open article about the fact in psychiatry that when someone walks in and they’re smiling, they immediately go, “Not depressed.” They’re fine, maybe anxious. What else can I look toward? That there is an overdependence on physical cues. So, you really have to begin assessing things differently and understand that there’s more to depression than meets the eye. To parents there’s a wonderful book that I would recommend to them called What Made Maddy Run and it’s by Kate Fagan.

Krista: So, we’re going to link to, anything she says we’re going to link it in the show notes. So, all you’re going to have to do is go to the show notes.

Margaret: Okay. So, I read the book obviously because it touched on exactly what I was talking about. Maddy Holleran was a track star in one of the Pennsylvanian universities, I don’t know if it was Penn State or UPenn. And she was an up and coming, she’d always wanted to go and do college track. She told her parents that’s what her whole life was about and she seemed relatively happy. Her Instagram looked great. But she killed herself. And she actually ran off a parking garage to her death.

She had presents for all of her loved ones stacked in a parking garage. And I’ve heard about other young people doing this kind of thing, that have gifts, and notes and all that kind of thing. All her family knew was that she was trying to decide whether the program made it too rigorous for her. It was just being in track or being a college sports athlete is just so tough. You hardly have any personal life. But her parents kept saying, “But you love it, you love it.” And they thought maybe she was just struggling with not doing as well as she wanted to do.

So, they very bravely let Kate Fagan tell her story. And I think what they would say would be, never assume that there’s not something going on in your child’s mind that they’re not being open with you about. Because I would say the best thing you can do with your children is to talk about your own vulnerabilities.

Krista: Wait. I don’t think that can be underestimated. I think a lot of women that come to me believe the exact opposite is true. And they think that they don’t want to burden their children. Their children have already had a major loss and they’re afraid that if they share about their own emotional experience of that loss that they will be burdening their child even further. That if they don’t present as doing well, that their children will somehow prosper less.

Margaret: They’ve got to be the rock.

Krista: Yeah, they’ve got to be the rock. And then couple that with what we’re taught about grief and feelings a lot of us growing up. If you’ve got something to cry about, go to your room. So, what you just said was, don’t hide it, essentially.

Margaret: Age appropriately talk about it.

Krista: Age appropriately.

Margaret: You don’t want to make your children your therapist. But you can say, “Let’s all talk about what we’re struggling with. This is what I’m struggling with. I miss this.” I wonder if I could have done anything, if it was a suicide or even if it was an accidental murder or something, an accidental death. And so, if you set up a household where people are open about their vulnerabilities, I remember, I think my son wouldn’t mind me telling this story.

In college he called me, I had a really chaotic decade, the jingle singer decade was fun but there was a lot of emotional chaos as well and I made a lot of mistakes. And he called me when he was in college and he was so upset. He goes, “Mom, I’ve done x, y or z.” And I had at first a mom reaction which is, “Damn, my gosh.” And then he said, he stopped and he goes, “Mom, I called you because you’ve told me that you struggled with this too.” And all of a sudden I realized, wait a minute, I’m getting exactly what I’ve tried to foster for my son.

And so, I need to say, “Yeah, I had, I did, I’ve made this mistake. Let me be there for you.” And I don’t say, “I was such a perfect mother.” I was far from a perfect mother but in this particular case because I had shared with him that I had struggled then he felt okay about sharing with me.

Krista: Yeah. And to present an illusion as though you were somehow perfect or not struggling would have been in complete disservice.

Margaret: Right. So, it is scary, suicide is if not the first, it is the second cause of death in I think 18 to 25 year old’s and is growing from 11 to 18. Of course, that is tremendously frightening. And I’ll tell you somebody else who writes about this is Jean Twenge T-W-E-N-G-E. She’s a sociologist and she talks about in her book, I-Gen, it’s got a real complicated subtitle. So, I never remember the subtitle. But it’s about how social media and being online is depressing, is creating depression in our kids.

So, my best recommendation for you is to be open and to do what you can to limit social media and to try to have real relationships with your kids and then to recognize if you do have someone that you have loved and cared about to recognize that anybody can keep a secret, anybody. And these people are expert at it. And so, if reading the book or the concept itself begins to raise awareness of, I really, especially I need to look at my friend who is very successful, or my spouse, or whomever I care about.

And maybe there’s something underneath that that I need to at least ask the question. “If you felt helpless would you tell anybody? If you felt sad would you share that with anybody?”

Krista: Yeah. And so, since it’s so easily hidden, I mean obviously it’s in the name, what are some of the things you might actually see as a parent?

Margaret: What I did, I’m not a researcher, so none of this is ‘empirically validated’. And so, I want to make sure that people realize that I used my own experience. I did have another source. As I was writing about this and trying to figure out what I was writing about, because back then I was just blogging about it. I actually did a series of articles, trying to formulate my ideas. And I said at the bottom of those articles, “If you identify with this would you please email me?” And I did that for about three months.

I got about 90 people who volunteered, again, they were from all over the world. I culled it down to about 60 interviews. And I spent two hours talking to every one of those people, hour and a half, two hours. And I took voluminous notes about how they’d gotten there, what life circumstance it created for them, did they grow up in a family where feelings were never discussed or allowed? Painful feelings, were they only celebrated for their accomplishment, were they abused, were they neglected? What exactly was it that created this need in them or this habit?

But the 10 traits are this, now, I’ve already said they’re highly perfectionistic and have a constant critical and shaming inner voice. And what I mean by that, again, constructive perfectionism is one thing. But destructive perfectionism, constructive perfectionism which I think I’m one of those people is typically fueled by generosity, or creativity, or drive, or a sense of wellbeing. I’ve been given a lot, I want to give a lot.

But destructive perfectionism is fueled by shame and fear. I must do well or I’ll be seen as a failure. I must do well. I must be better than everybody else or people will see into me and that scares me. They’re also very responsible people. They are constantly volunteering and a lot of that is distraction. They keep their lives very, very busy so that they don’t go anywhere near feelings. They’re the people that you go up to and you go, “How do you get done everything you get done? I couldn’t do it.”

And sometimes, not all the time but sometimes that could be a part of this perfectly hidden depression.

Krista: Makes sense. I see that a lot in grief too by the way.

Margaret: I bet you do.

Krista: Yeah. Where we’re just, we’re so afraid if we slow down that the feelings are going to catch up with us. We keep trying to outrun them.

Margaret: That makes all the sense in the world. The third one is, these folks would much prefer staying in their heads, they again don’t do emotions very well. They will look at you and say – now they’re empathic with you but they don’t reveal themselves. They worry but they don’t want to be seen as a worrier, that would be too vulnerable so they just take control of everything.

Say an example I’ve used in the past is let’s say your mother’s going into assisted living. And so, you live three hours away and your brother lives 30 minutes away but you still say, “No, I’ll go check on mom.” Because you would worry that your brother wasn’t doing it right. And so, you take control of it so you don’t worry but then you get resentful because your brother isn’t doing it. Resentment shows so you worry about that. So, it can be this huge cycle.

Krista: But the person is not experiencing that as a boiling pot of increasing pressure. They’re just so good at not feeling it.

Margaret: Exactly. It’s something else to compartmentalize, perfectly said, perfectly said.  They use accomplishment to feel valuable. I had a woman say, “I’m a duman, not a human”, one time. She doesn’t feel she has any value unless she does things.

Krista: And I think that too, our culture has, we live in a culture that values productivity. And a lot of people think their productivity determines their value.

Margaret: Exactly.

Krista: What’s the difference do you think?

Margaret: It feels good to produce. It feels good to do something well and to get a raise, or just to be told you are doing well, or you care about this non-profit and you helped to make a lot of money and you celebrate. But the problem is these folks don’t take time to appreciate the kudos of what they have done. They’re onto the next thing.

Krista: Yeah. Or what happens when they stop doing or for some reason can’t do?

Margaret: Right, exactly, they don’t know what to do.

Krista: Yeah, totally makes sense.

Margaret: They do focus on the wellbeing of others, don’t let anyone else in their inner world. These people, if I say, “What’s self-compassion?” Most of them would say, “That’s feeling sorry for yourself.” They don’t have a sense of tenderness toward themselves, or kindness towards themselves. And again, you don’t have to fit all these criteria but they believe strongly in counting their blessings, is the foundation.

You and I were talking about this tyranny of positivity and it can be very toxic. It’s like you’re not being grateful enough if you stop and say, “This hurts, or that did hurt, or that was hard.” They’re usually professionally successful unless their perfectionism is also accompanied by procrastination. But again, that kind of person is probably not as successful as these folks typically are but they lack a lot of emotional intimacy.

So, I was working with a woman as I was writing the book and she had identified with this and had come in. And she was very successful at what she did. And she said to me one time, she said, “When I’m on the phone with my supervisor, I always have to stay one step ahead of him and answer the question that he’s going to ask me next before he asks it.” So obviously these people look like they’re onboard and they are. Then she said, “And then I would hang up the phone and my husband would say, “Well, how was that call?” “Oh, it was just fine.””

There’s no sense of sharing with their partner about who they are or what they’re struggling with.

Krista: Probably first and foremost though because they aren’t even experiencing it as a struggle.

Margaret: Exactly. Until they start it and that can be overwhelming. The last one, I mean I’ve had some people who have identified with this, come in as patients and they’ve said, “I’m so scared to touch this. I think my whole life will disintegrate if I do.” And so, I said, “So we go slowly and you’re in charge. You’re in charge.”

The last trait is one I had to put in as a clinician because I don’t want anyone to walk away from this conversation or any other thinking I have perfectly hidden depression, that’s what’s wrong with me because there could be other things that are actual clinical diagnostic features like panic disorder, generalized anxiety disorder, obsessive compulsive disorder. Eating disorders are very common, exercise disorders, orthorexia.

And some problems with substances can be a problem too because it’s a secret but you’re in your garage sipping on something so that you can go to sleep or something. So those kinds of issues can be there too.

Krista: Yeah, okay. And in your book I also love that you have not only this criteria but you also actually have a quiz that people can take to kind of assess. Do you want to talk a little bit about that?

Margaret: Again, not empirically validated, but the experience of taking it I think is very helpful because a lot of the things that people will check, yes, I do this, yes, I do this, are considered positive traits. It’s when there are too many of them, when you fall so far on the spectrum of perfection, or appearing perfect, or appearing totally in control that that can be a danger. And again I’m [inaudible].  So, it can be an eye opener, it’s a very easy little questionnaire to take.

Krista: Yeah. The way I’m thinking of it is it’s not the behaviors one at a time, it’s the overall net impact of those behaviors or patterns on a person.

Margaret: Exactly.

Krista: Okay. In your book you also talk about five stages of healing. And I know that’s probably a lot to cover in a podcast but maybe can you kind of touch on them briefly?

Margaret: I have to tell you a funny story. Okay. So, I thought this book I would just be describing this phenomenon and that would be it. So, this publisher who did end up publishing the book said, “Well, we’re very interested but you have to give us a healing strategy and you have two weeks.” I said, “Two weeks.” So, what I did basically was I looked back to see, okay, what do I do with almost everybody and just plug perfectionism into that. And what would that look like with a destructive perfectionist?

The first one is you have to see there’s a problem. Perfectionism is something most of us would go, “Well, yeah, I like being perfectionistic, I like it’s ramifications in my life. It’s part of my success.” But you have to begin seeing it as a problem like you were just saying, that you’re so far on that side of the issue and you’ve got this critical voice in your head all the time that you have to not deny that it’s governing your life. It’s not something you use when you need it, it’s governing your life, that need to control. And I call that stage, consciousness.

The second stage, it’s about hurdles, commitment, it’s about hurdles that are specifically really difficult for people with perfectionism because they will do things, not to intentionally sabotage themselves in treatment. I had a woman one time say, “Well.” Because there’s 60 reflections in the book. There’s 60 exercises. And she said, “Well, I’ve been in therapy before. And I’ve done a lot of the exercises so I just jumped to the last chapter and did the trauma timeline.”

Krista: And so, she skipped everything else?

Margaret: Yeah. She goes, “Oh, it was too hard. I couldn’t do it.” And I said, “But that’s because there are 40 other exercises before that that are taking you in very small steps to get there to where you have the psychological emotional stamina to do, or the bandwidth”, would be a popular term, “To do that and you skipped all of it.” So, there’s some specific hurdles to working with a perfectionist that the clinicians need to know and the perfectionists themselves needs to know.

The third one is basically confrontation, basically confrontation which is pretty classic cognitive behavioral theory, to look at the rules for following. And the beliefs underneath those rules, not just, I can’t ever say I’m angry. But what’s the belief in saying you’re angry? The belief is I will be rejected if I’m angry and my friendship will end if I’m saying I’m disappointed. You have a belief about that, I won’t be safe. And where did that belief come from? So that’s the work of confrontation.

Then quickly connection is all about emotional connection and it’s about learning how to begin to actually feel those emotions that you have compartmentalized. I don’t know about you but sometimes when I clean out my closet which is about every five years, not very much. And I’ll just pull everything out and then put it back piece by piece which is probably not the best way to do it. But that’s what people are scared of. “You mean everything’s going to come out all at once?” And so, what you have to do is kind of like a game of Jinga.

I can take this piece out and look at it and the whole structure’s not going to tumble. And gradually you do that, obviously if you have severe trauma in your background you need to do that with a therapist. And so, you begin to do a trauma timeline which is going back and thinking, what are the good things that happened to me when I was two, four, seven, 11, 14? I had a great teacher, or I was bullied, or I was raped or whatever it was. And you look and you begin to see how all that happened with compassion and acknowledgement, not blame.

And then the fifth thing, so that’s very tough for most people. And again, having a therapist can be very helpful for that. The last one is change and I don’t know about you, Krista, but I think insight is wonderful. I’ve seen a lot of people have aha moments of, now I get it, I never realized that what my mother said to me about what was appropriate that I’m still following that rule and now I don’t have to follow that rule. That’s kind of that cognitive behavioral stuff. Aha, I get it.

But where you get help from is not inside, it’s from behavior change, or thought change, feelings change. When you see yourself feeling, doing things differently than you’ve ever done before, then you can feel hopeful and that is what is so important because the antidote, this is going to sound kind of – I don’t know, but maybe trite. But it’s one of the deeper things I have to say in the book, is that really self-acceptance is the antidote for perfectly hidden depression.

And my working definition of self-acceptance is that knowing that you have strengths and you have vulnerabilities but neither one defines you any more than the other one does.

Krista: One of my favorite things that you wrote was you wrote if classic depression is lack of vitality then perfect hidden depression is lack of self-acceptance. And yeah, I think it’s such a beautiful takeaway and I love your definition of self-acceptance.

Margaret: The example I use is that I have three letters after my name, I’m very proud of PhD, it gives me a license to do what I do.

Krista: I’ve just made that connection.

Margaret: Yeah. Isn’t that an interesting connection?

Krista: Yeah.

Margaret: I appreciate those letters, I work hard with those letters. I also have been married three times. Now, for the last one it’s been 32 years, but the first two as I’ve already previously – already previously, I don’t need to say [inaudible], I’m not proud of that. In fact, I worked through lots of shame about that. Neither one of those things defines me. That doesn’t mean that if somebody found out that I’d been married three times they might go, “I don’t know if I want to go to her.”

But I can’t do anything about that but I can accept that that was a part of my life and that so are the things that I’m proud of. And neither one of those things defines me completely.

Krista: Yeah. I could not agree with you more. Yeah, the way I see it is we’re 100% worthy, it was given to us at birth. There’s nothing we can do to destroy that, there’s nothing we can do to improve upon it. And none of it defines who we are because who we are is so much bigger than what we think, how we feel, what we do, any of it.

Margaret: I agree with you.

Krista: Yeah, so good.

Margaret: Thank you so much.

Krista: I’m just so glad to bring this to my audience. Okay, so here’s what I’m a little bit worried about and you kind of touched on it earlier, everybody’s going to hear this. And they’re going to think, eek, this is me, I have this problem. And then they’re not going to know what to do next. So, if somebody is experiencing that, maybe you’re just intrigued enough that you’re going to go buy the book, in which case I think the steps are in the book, or at least the resources are there available to you.

But let’s say somebody’s just not listening to the podcast, and they have kind of got themselves into a little bit of a tizzy about it, what say you?

Margaret: I’ve had a lot of people in my office who have said, “Well, I can talk to you about this because I know that you can’t tell anybody. But I cannot even imagine telling anybody else any of these things.” And I’ll listen to that for a couple of sessions if not longer.

But eventually when I think that some of the work is ongoing I will say to them, “I bet there’s one person in your world, an old high school friend, an aunt, someone who would welcome you saying to them and would understand you saying to them, “I’m just finding out about something about myself that I’m really scared to talk about and I don’t even think I can talk about it right now. But when I’m ready would you be willing to listen?” And I bet they’d say, “Of course.” Now, they might get curious and go, “What are you talking about?””

And you go, “You know what? That’s the point, I’m not quite ready to talk about it yet.” But if you begin to knock on the door of letting someone know what you really deal with at those moments when you are at your most quiet and at the moments when you’re taking your shower, or when all the distractions are over, that at least for the day. There’s someone you know, it can start with a therapist, that’s fine. But there is someone who would be eager to know you. And as you are ready to reveal, of course I appreciate people getting the book.

Again, it is a small step by small step kind of hopefully guide on how to do this. I will say, Krista, and I’m not being critical, there are a lot of workbooks on perfectionism. But when I look at them I don’t see that they are trying to unearth the why. How did you become this way? Why did you become this way? What exists in your background or your history that caused this to be something that would be your go to and would become unconscious? You’ve done it for so long you don’t even realize you’re doing it anymore.

And so, I think that we all have at least one person, and if you don’t then maybe a therapist is your best option.

Krista: Okay, yeah. And I will just add that the book is very readable. It’s full of stories, it is not clinical. It is very readable. And sometimes I think people shy away from topics they believe will be heavy because they don’t think they’ll either understand it, or it’ll be too much, or it’s just full of clinical terms and it’s not that way at all.

Margaret: No. I’m a real shoot from the hip kind of therapist and person. And so, I didn’t want to make it a jargonistic kind of thing. And there are lots of stories and what people have told me is that that part of the book really meant a lot to them because they could find themselves in one story or another.

Krista: Yes. That doesn’t surprise me at all. So, okay, a little bit about your podcast because obviously my listeners are podcast listeners so they would probably like to hear about your podcast.

Margaret: It’s called The Self-Work Podcast. And it is basically about two-thirds to three-quarters of the time I will take a topic that either has been suggested to me by a reader, or a listener, or one that has come up in my own clinical practice. I’ll research it so you’ll know what other people think about it and I’ll talk about that. And then I give my own two bits about it typically. And a phrase I use on the podcast a lot is, “But what can you do about it?”

I hesitate to use the word ‘solutions’, but there’s certain things you can control and so we’re going to look at those things and what you can do about this problem. And then I also have guests about once a month. And the podcast is, we are 20,000 downloads away from four million.

Krista: Yes, that’s a huge impact, oh my gosh.

Margaret: [Crosstalk] end of this month I think. So yeah, it’s all over the world and it has been absolutely wonderful to do. I hear from so many people and it’s great. And it’s about 25 minutes long so it’s very doable on a ride to work, or when you’re doing the dishes, or whatever you’re doing. In fact, people have said they like my voice and it puts them to sleep.

Krista: That’s I feel like thank you, I don’t know, is that a compliment?

Margaret: Yeah, I’m not real sure.

Krista: I get that too actually, it’s funny, yeah. And so, they can listen to the podcast. How else if people want to learn more about you? And there’s nothing in it for me to recommend this book to you. I just think it’s a good book and I think it’s an important topic. So, Perfectly Hidden Depression is your book. And then how else can people get in touch with you if they’d like to?

Margaret: My website is drmargaretrutherford.com, very creative name and my blog posts are there. And then also I am on a journey within the next three or four years to do more speaking. So, you have an organization that you think needs to hear this message about perfectly hidden depression, I’ll be right there. I’ll come to you. I’ve done a lot of virtual seminars obviously over the last two years but beginning to do more in person. So, I would love to do that.

Krista: Okay. Well, when we pause this recording or stop it, we’re going to talk about other people I know that I want to connect you with because I think this work really matters. So, thank you so much for coming on the podcast, Dr. Margaret.

Margaret: Thank you, Krista.

Krista: Yeah, so amazing. Alright, take care.

                                                                                                                    

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