Natalie always had a smile on her face, even when discussing painful topics. She was a highly successful, hard worker and an involved, loving mother. In addition to her full-time job as an accountant, Natalie volunteered at her children’s school and in her community.
Her house was immaculate. Every item had a place, everything was neatly labeled, and every appliance gleamed.
So it was quite a shock to her therapist, Margaret Robinson Rutherford, Ph.D, when she found Natalie lying still in her bed with empty vodka and pill bottles by her side.
Rutherford was helping Natalie work through her anxiety over juggling so many responsibilities. At the same time, she’d tell Rutherford, “I shouldn’t complain. I have it easy compared with most people.”
That morning, Natalie’s husband, who was out of town, asked Rutherford to check on her.
Natalie’s depression doesn’t resemble what we typically think of depression: a heavy, chilling darkness that siphons a person’s energy and prevents them from getting out of bed. And yet it’s just as serious, exhausting, and devastating.
Rutherford, an Arkansas-based clinical psychologist, recounts Natalie’s poignant story (and others’ similar stories) in her new book Perfectly Hidden Depression: How to Break Free from the Perfectionism That Masks Your Depression.
As Rutherford told Psych Central, perfectly hidden depression (PHD) isn’t a diagnosis. It’s a syndrome that consists of a group of behaviors and beliefs.
In the book, Rutherford notes that people with PHD rarely see their struggles as depression—and others usually don’t either. “No one suspects anything is wrong,” she writes. Because what people see and what you project is a person who’s handled immense pressures and losses and come out unscathed. You’re a great parent, helper, and worker. You’re highly efficient, organized, and upbeat.
But beneath that perky, productive, perfect exterior lies pain, loneliness, and despair.
Rutherford’s clients have told her that when they entered her office, “while avidly denying depression, they had plans to die by suicide.”
Why do people deny their depression?
Sometimes, it’s a conscious decision, and sometimes, it’s not.
Rutherford stated that “the need to repress, to hide, to become invisible or to look perfect to others primarily evolves in childhood.” She shared these examples: Living with parents who struggled with addiction, you grew up quickly to care for your siblings. So, taking responsibility for everything and everyone while neglecting your own needs comes naturally to you.
Or you grew up with a parent who only paid attention to the tasks you did well—“that’s when you felt most loved.” So, you become an over-achiever who prioritizes perfection and ignores their deepest desires.
Hiding your depression can also stem from cultural beliefs and norms. Maybe discussing your emotions or mental health in general has always been discouraged or downright forbidden. Maybe seeing a therapist is seen as weak and shameful.
Signs and Symptoms
According to Rutherford, there are 10 specific signs of PHD:
- You are highly perfectionistic with a constant, critical inner voice of intense shame.
- You have an excessive sense of responsibility.
- You have difficulty accepting and expressing painful emotions.
- You worry a great deal, and avoid situations where control isn’t possible.
- You intensely focus on tasks, using accomplishment as a way to feel valuable.
- You have a sincere concern about others’ well-being, but don’t let anyone (or only a few) into your inner world.
- You discount or dismiss hurt or abuse from the past, or the present.
- You have accompanying mental health issues, involving control or escape from anxiety.
- You hold a strong belief in “counting your blessings” as the foundation of well-being.
- You have difficulty navigating personal relationships but demonstrate significant professional success.
If you think you have PHD, please seek professional help. Rutherford suggested starting with this script when talking to the doctor or clinician: “I’ve read something that makes a lot of sense to me. And the first thing I need you to know is that I haven’t told you everything about my life. And I probably can’t today either. But I want to begin. I know you can’t help me unless I’m totally honest. But I have fears about being open that go way back.”
If you notice the above signs in a loved one, Rutherford emphasized focusing on what you’ve observed and how that’s affecting you, such as: “I’m sad that you are…” or “I feel helpless when I see you…”
She also suggested being indirect and giving the person some information on PHD. After all, getting defensive is a typical reaction for anyone and change is terrifying, she said. Plus, remember that individuals with PHD “have a strong investment in hiding; it’s protected them and in a way, ‘worked’ for them for years.”
Thankfully, Natalie survived her suicide attempt and went to rehab. Afterward, she continued working with Rutherford. She began sharing her real struggles with her husband and processing her past, including her sexual abuse and persistent inner critic. She worked on her sobriety, set clear-cut boundaries with her mother, relinquished her perfectionism, and explored who she wanted to be.
“Her smiles were real, her joy infectious,” Rutherford writes. And “she was glad to be alive.”