The millennial generation seems to be doing something in our culture that other generations have stigmatized. What is that? They’re seeking therapy in much greater numbers. There are multiple reasons why. They’re stressed-out, anxious about reaching even the same or better markers that their parents reached in their 20’s and 30’s, and fearing they’re not going to make a right choice. Sociologist Jean Twenge has great concerns about this generation, so heavily influenced by the latest recession, the constant stimulation of cell phones, social media and the resultant immediacy of communication and knowledge. They share strengths for sure. But they’re also more isolated and more depressed, and suicide rates are rising dramatically.

But they’re not just going to therapy. A few are fighting back against the expectation of the perfect-looking facade – the “I’ve got this down” attitude. Specific challenges are happening on some of our major elite college campuses, in protest of the marked increase in student suicides. The students themselves are confronting the unspoken message that you’re not supposed to struggle, appear lost or frustrated, or reveal that your studies are actually very difficult for you. After all, you’re a student at Stanford, or Penn. You’re above all that. You were smart enough to get in. It should be no sweat.

How are they challenging this myth? They’re putting a name to this kind of pressure. And they’re getting out the word to students who may be struggling.

Enter the Stanford Duck Syndrome and the Penn face. A member of the Stanford student news writes, “Everyone on campus appears to be gliding effortlessly across this Lake College. But below the surface, our little duck feet are paddling furiously, working our feathered little tails off.” A Penn student journalist writes, “The Penn Face is the pressure to always present yourself as if you have all of the pieces of your life in order. It’s the pressure to say you’re OK and act OK even when you don’t feel OK. Everyone reacts to the Penn Face differently – some adapt to it naturally, some spend all of finals week in their rooms to avoid it, and for many, it takes a serious toll on their mental health, stability and ability to cope.”

One such Penn Face was Maddy Holleran, track star and adored friend. Her life and suicide were the subject of the recent New York Times bestseller, “What Made Maddy Run?’ by Kate Fagan, as the author chronicled the pressure of collegiate sports, what Maddy showed the world, and what was the inner despair loved ones could piece together after her death. I’ve heard more stories than I’d like that mimic this tragedy. One was about Ryan, a high school senior who seemed to have everything in place for his future but confided in a friend about secret thoughts of suicide. She emailed the high school. So, he was called to the office by the high school counselor who questioned him briefly, and then let him go. His parents were never alerted. Ryan hung himself a month later.

Perfectly Hidden Depression is written for these students, as well as for the men and women who daily shroud their real selves in what might seem perfect to others. It’s a book for parents who may have buried their perfect-looking children and are searching for answers. It’s a book for doctors, teachers, counselors and therapists who need to raise their awareness that perfect seeming can be far from perfect.

The Link Between Perfectionism and Suicide

Although well-researched, it’s not widely recognized that perfectionism is strongly linked to depression and even suicidal thoughts. While doing interviews with volunteers who came forward to talk about this very painful relationship in their own lives, Jennifer’s incredibly poignant story stood out.

“Five years ago, just before my 39th birthday, I was seconds away from driving my car into the path of a tractor trailer. The only thing that stopped me was seeing the driver’s face. I realized he would think he killed me, and my pain would simply be transferred to him. I couldn’t be responsible for that. The next day I went to my doctor and, for the first time ever, spoke freely about what I learned later was anxiety and depression. I’d been seeing my doctor for over fifteen years. I remember the pain in her eyes as she said, ‘I had no idea. Why didn’t you say anything?’”

My term for this connection is perfectly hidden depression. You’ve created a perfect-looking, very successful, very engaged life. You love your children and your friends. Your career is going great guns. Underneath, however, lie secrets and pain long discounted and suppressed, and shame that is slowly eating away at your will to live. Jennifer and many others came forward because they don’t want anyone to come as close to suicide as they did.

Yet when you’re a perfectionist, when you’ve woven an intricate façade of the perfect-looking life, it can be terrifying to reveal more of who you really “are.” There are multiple mental and emotional hurdles; the perceived stakes can be very high; the strategy can be conscious or largely unconscious; the predicted loss of status or control can be frightening. Yet there are those who decide to risk the revelation of early trauma or childhood struggles, realizing if they do not, the lives that they’d fought so hard to create might end by their own hand.

Perfectly Hidden Depression spells out a detailed healing process for those who, sadly, would never go to a workshop on learning to be vulnerable, but might, in the quiet of their own homes, begin to listen to the very small voice that tells them something’s wrong. And pick up a book.

Here are the five not-so-easy steps.

  • Consciousness: Growing more self-aware of the risks of perfectionism
  • Commitment: Recognizing and working through the multiple ways to sabotage the work
  • Confrontation: Revisiting and replacing the rigid rules and beliefs that currently govern
  • your life
  • Connection: Through a trauma timeline, risking vulnerability and developing self-
  • compassion, allowing long suppressed emotions and experiences to surface
  • Change: Individually moving toward greater freedom and openness while also inviting
  • movement and change in your relationships with others

It’s vital to understand that, for those seeking refuge from their lives on perfectionism steroids, change must start one small step at a time. Or the risk is too great; revealing and connecting with their trauma takes time. As you let go of your defenses, the emotions that you’ve been masking are there, waiting for you. They ask to be accepted. Understood. Worked through.

For healing is a process, not a destination. And moving toward self-acceptance is the goal that leads to an amazing freedom. It’s more than a decision to be vulnerable. It’s confronting

Perfectly Hidden Depression Vs. Depression

If you watch television for more than an hour these days, you’ll see a parade of anti-depressant commercials, with classic depictions of depression. A despairing woman sitting on the bathroom floor, head in her hands. A man whose dog is patiently waiting to play, whose lethargy is overwhelming. That’s how we think of depression. Its two major symptoms are depressed mood and not enjoying things that you’ve previously enjoyed. Other symptoms can be tricky. Perhaps you aren’t sleeping well, or you want to sleep all the time. You may lose your appetite or overeat. You may get angry or sad for no apparent reason.

Trying to explain the core of classic depression, Andrew Solomon, author of The Noonday Demon: An Atlas of Depression states, “The opposite of depression is not happiness but vitality…”. You can develop a complete or near-complete lack of engagement with the basics of living.  

When I watch a patient emerge from this kind of depression, it can feel as if I’m getting to know someone new. Their eyes twinkle a bit; they’re laughing at their own jokes. They notice things in the room that they’ve never seen, no longer consumed by their own internal chaos. They walk a bit straighter as they journey out of mental fog into clarity. 

Yet the traits of perfectly hidden depression don’t meet classic depression’s criteria. Your depression can’t be seen in the way you overtly live your life. Your anxiety may be increasing but there’s not a marked change in you. You remain bright, smiling and caring. You may not be sleeping well but you push through your fatigue. No one’s giving you feedback that you don’t seem “yourself.” If you sought a doctor’s help, you’d more than likely answer their questions with, “I haven’t had any changes really. I’ve always been a worrier.” Or, “I’m not sleeping as well as I normally do. But my energy is good.” 

Perfectly hidden depression is a group of behaviors and beliefs that are found together, sort of like salt and pepper. Or red hair and freckles. I’ve termed it a syndrome which has ten commonly shared traits. 

What are they? Perfectionism that is fueled by an inner voice of shame, being uber-responsible, worry and a need to feel in control, being a fantastic friend and worker but not allowing anyone to know the real you, discounting or denying hurt or abuse from the past, struggling to express painful emotion, intensely focusing on tasks to feel accomplished, fervently believing in counting your blessings, being highly successful professionally but struggling with intimacy in relationships, and perhaps experiencing an actual mental health issue having to do with control (anxiety, eating disorders, or addictions for example). 

But why is it called depression? Because underneath all those traits lie memories and painful experiences that hold the same destructive strength as those that trigger classic depression. You can either be very conscious of what you are doing (and that’s similar to what’s called “smiling” or “high-functioning” depression). Or quite dangerously, you might not be aware at all of how you learned to hide as you emotionally survived and protected yourself long ago. You simply did it. You handled what came at you as a child by becoming the star, or feeling like you had to prove your worth, or taking on adult responsibility. The reasons for beginning to perfectly hide are diverse. But they all can lead to a similar syndrome – perfectly hidden depression. 

Therapy is very different with these two presentations of depression. With the first, the goal is to reengage with life, to reenergize, to challenge thinking that’s irrational and inhibiting, to work through and let go of sadness, apathy, despair, or anger that’s been far too overwhelming. 

With perfectly hidden depression, therapy is much more about diving inward, learning how to express emotional pain safely and openly, discovering calm, challenging the rigid beliefs that have pushed and prodded your need to look perfect. It’s about allowing vulnerability and ultimately, about self-acceptance. 

So, what do I see happen when someone who’s been masking pain gets better? I see the same twinkle, but it’s because you experienced the freedom of spontaneously opening up about something that had hurt you. I hear relief from the immense pressure of your past life, as you’ve given yourself permission to care about your own welfare. I feel your joy in the recognition that you don’t have to lose your drive or ambition, but ultimate control is no longer the goal. I hear, more often than anyone might realize, “I was so incredibly lonely. I might not have been alive now if I hadn’t done this work.” 

Perfectly hidden depression is real. What seems is not always what is. 

But you don’t have to hide. 

Why mental health professionals need to think outside the diagnostic box

What is the first thing that happens after a tornado rips through a town and lives are lost? The city council rushes to find funds to build a better warning system. After a massive hurricane floods an entire city, engineers are called in to assess the existing dam system and why it didn’t function properly.

We grieve and try to determine how tragedy could’ve been prevented.

It’s no different when the tragedy is suicide.

Especially after a teenager or a celebrity dies by suicide, news agencies and mental health advocates are quick to stream the classic signs of depression – and how they might appear in your loved one’s life. Isolating, losing interest in something they’ve loved, irritability and reacting negatively to interference or perceived criticism, talking about suicide or writing poems about dying – all of these and others are vital to notice.

But what if your child or your husband or your friend killed themselves — and none of these symptoms existed? Instead, each appeared as if they had the world by the tail — happy, confident, and engaged. One grieving mom told me, “I’d talked to my son the last night he was alive. He asked me to bring his warmer winter coat when we visited the next weekend. I don’t understand.” What’s going on that people we love, who look incredibly successful, with smiling selfies and a full slate of activities on their calendars, can keep secret this most destructive torment?

The answer is far from simple. But suicide rates are on the rise, as is perfectionism. It would seem that the loneliness and pressure of living a perfect-looking life can grow unbearable. Let’s look at a couple of examples of what I term perfectly hidden depression (PHD), a syndrome of behaviors and beliefs that can act to mask a silent depression.

Shana, a single mom, doesn’t know that her beautiful seventeen-year-old gymnast-daughter Carrie, hears a shameful inner voice that mocks her, viciously whispering that she’ll never make the championship team, although earning trophy after trophy and a college scholarship. Her coach pushes her relentlessly as well. But Carrie can’t quit. Her dad left when she was eight, and her mother gave up everything for her, sacrificing financially and emotionally. They’ve been a team all her life. Her mom recognizes that she’s not eating, but Carrie explains it away. Still her mom brings her to your office. Carrie smiles brightly and says she’s fine. But the teenager’s foot is constantly moving. ‘I’m here because I want to make sure I make finals. But mom worries too much.” And she looks away.

Mark, an accountant and father of three, divorced twice but “a phenomenal dad,” may not tell his girlfriend, Andrea, about the intense emptiness that he can’t remember not feeling. Neither ex-wife had been allowed to know him on a deeper, more vulnerable level, so his marriages were great-looking on the outside but lacked any kind of intimacy. He escapes through rock-climbing, but only he knows how many times he’s considered letting go. Thoughts of his children stop him. But Andrea does know that he drinks a lot on the weekends when he doesn’t have his kids. She urges him to go to therapy so, to appease her, he makes an appointment. He’s jovial, saying

he’s taking everything in stride. When you ask what happened in his marriages, he blames himself. “I was a really lousy husband.” When asked about his upbringing, he sighs and says, “Oh, you probably don’t want to hear about all that.” And he laughs. When asked about suicidality, he’ll stop. “No, I’m not suicidal. I have my kids.”

So, what are some of the traits of PHD?

Perfectionism with a constant critical shaming voice. Taking on massive responsibility. Caring sincerely for others but not allowing anyone into your inner world. Rigid compartmentalization of past trauma and conflict. Worry and a need for control. Those are five of the ten. These are highly functioning, highly successful, very well-liked people who look as if they’re dealing well with the pressure of their lives. But inwardly, shame and loneliness are mounting. The current system of diagnosing depression will, in most cases, cause this silent presentation of depression to be overlooked. The basic criteria of depressed mood and/or anhedonia aren’t met. Even if a depression inventory is given, these people will likely breeze through with flying colors.

We as doctors, clinicians, mental health advocates, parents and friends need to realize that, although we’re not mind readers, awareness of this syndrome is vital. By writing PerfectlyHidden Depression, I’m not offering the absolute, never-has-been-considered-by-anyone-else warning signal for depression or suicide. Perfectionism has been known to be correlated with depression. Yet an awareness of the presence of perfectionism might lead to different questions being asked. Instead of, “Do you feel hopeless,” the question becomes, “If you ever felt hopeless, would you tell anyone?”

Researcher and inspirational speaker Brené Brown states that the path to what she calls “whole- hearted” living requires recognizing the power of personal vulnerability. I couldn’t agree with her more.

Yet if you’re one of these perfect-looking people, you struggle even more than others to allow that process to happen. You’re wary of a loss of status or others’ confidence. You’re convinced that the analytical “stay in my head” strategy that seems to have kept you safe should remain irrevocable.

I’m challenging mental health professionals to think outside the classic diagnostic box. Just as we know that depression can present as melancholy or anger and agitation, a potent contender for another presentation needs to be the virtual absence of spontaneous expression of any emotion but positivity. Worry may be expressed; anxiety is given voice. But not sadness. Not grief. And certainly not vulnerability.

Perfect-looking is perfect-seeming. But seeming isn’t being.

With your professional help, what “seems” can finally become… what is.

Click here to purchase Perfectly Hidden Depression: How to Break Free from the Perfectionism that Masks Your Depression by Dr. Margaret Robinson Rutherford.