In her 2019 book, clinical psychologist Margaret Rutherford talks about the signs and effects of a serious and underreported issue: perfectly hidden depression.
Natalie always had a smile on her face, even when discussing painful topics. She was highly successful, worked hard, and was an involved, loving mother. In addition to her full-time job, 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, PhD, when she found Natalie lying still in her bed with empty vodka and pill bottles by her side. Natalie’s husband, who was out of town, had asked Rutherford to check on her.
Rutherford was helping Natalie work through her anxiety over juggling so many responsibilities. At the same time, Natalie would tell her therapist, “I shouldn’t complain. I have it easy compared with most people.”
Natalie’s depression doesn’t resemble what we typically think of as depression: a heavy force that siphons your energy and prevents you from getting out of bed.
And yet hidden depression is just as serious, exhausting, and devastating.
Rutherford, an Arkansas-based clinical psychologist, recounts Natalie’s poignant story (and others’ similar stories) in her 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 her book, Rutherford notes that people with PHD rarely see their challenges 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 has 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 is 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.”
Sometimes it’s a conscious decision to deny your depression, 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 had addiction, you likely 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 overachiever 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 by those around you.
According to Rutherford, the 10 specific signs of PHD are that you:
- are highly perfectionistic with a constant, critical inner voice of intense shame
- have an excessive sense of responsibility
- have difficulty accepting and expressing painful emotions
- worry a great deal, and avoid situations where you cannot be in control
- intensely focus on tasks, using accomplishment as a way to feel valuable
- have a sincere concern about others’ well-being but don’t let anyone (or only a few) into your inner world
- discount or dismiss hurt or abuse from the past or the present
- have accompanying mental health issues involving control or escape from anxiety
- hold a strong belief in “counting your blessings” as the foundation of well-being
- have difficulty navigating personal relationships but demonstrate significant professional success
If you think you have PHD, you may benefit from seeking professional help.
Rutherford suggested starting with this script when talking with a 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 can be terrifying, she said.
Plus, remember that people 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 past sexual abuse and a persistent inner critic.
Natalie 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.”