Ask Alex

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I’ve chosen three questions from readers to discuss in this week’s post.  To those who sent me these questions, please recognize my answers are by necessity general as I obviously don’t know you personally nor the details of the situations you wrote about.  I do hope my answers can provide you new ways to think about the problems you’re facing as well as provide other readers useful perspectives on similar situations they may be facing in their own lives, but please don’t mistake any of the following for my professional medical advice.


M. writes that her husband is depressed and has told her he’s not sure he wants to be married to her any more.  She’s suggested they seek therapy together, but he agrees only to seek therapy on an individual basis, not together as a couple.  And he states he’s willing to do that only because she’s requesting it, which makes M. believe his heart isn’t really in it.  She wants to know if she should wait until he “finds an answer” but is terrified he’ll discover he really doesn’t want to be married to her any more and that he no longer loves her.

This question provides a sharp reminder that depression never occurs in isolation.  When we’re depressed, it affects everyone we know and contact, those closest to us most intensely, but even perfect strangers we encounter only briefly to some degree.  Unfortunately, depression severely telescopes our thinking, leaving room in our minds only for our own pain almost exclusively, significantly handicapping our ability to feel empathy or even pause to consider what others may be feeling.

One key point to keep in mind is that when a person is depressed, all their thinking and feeling reflects that state more than it necessarily does the truth.  Ideas people consider seriously when depressed (“I don’t love her any more,” “I’m a total failure,” “I’ll never be happy again”) are often revealed as complete chimeras once their depression lifts.  I always counsel depressed patients not to make any major life decisions while depressed as such decisions tend to represent more a reaction to their own pain than a wise plan for the future.  Depression cuts off many if not most joyful feelings we have and can convince us not only that we don’t feel them but that we never even did feel them.

As I wrote in a previous post, The True Cause Of Depression, many things can trigger depression, but in my view the underlying common cause of almost all forms is a belief that we’re powerless to solve some problem.  Once such a belief is powerfully triggered and depression results, depression itself then reinforces our belief we’re powerless.

But we’re not.  We may be powerless to solve our problems the way we want, but that doesn’t mean our problems can’t be solved.  People suffering from depression are sometimes able to put their finger on the cause, but if the depression is moderate to severe (in contrast to the blues we all feel from time to time) they’re often off the mark.  Their thinking is just often too distorted to provide accurate insight.

What can a spouse do in a situation where their relationship is being threatened by their partner’s emotional state?  Everything in their power to get their spouse the professional help they need.  No rational discussion about the future of the relationship can take place until the depression improves.

Unfortunately, not every depression is easily treatable.  It’s not unreasonable, after months or even years go by without improvement, that the non-depressed spouse begin considering the effect being in an intimate relationship with a depressed partner is having on their own mental health and well-being.  We must always be careful not to blame someone for being depressed—depression isn’t something people can simply think their way out of, no matter what it’s proximal cause.  But that fact doesn’t obligate us to stay in an intimate relationship with a depressed person indefinitely.  Sometimes you do have to detach with love.  But only you can decide if that’s the right thing for you to do.


Patti writes that a female loved one close to her has been making decisions that lead to consequences that frustrate her but for which she refuses to take responsibility.  Instead, Patti reports, she takes her anger out on family.  Patti is finding it increasingly difficult to accept her behavior, which causes pain for others, and even finds herself struggling to continue loving her.  How does one continue to love and accept people whose behavior continues to be hurtful?

I wrestle with this one myself:  how do we love a person for their potential when their present behavior is abominable?  How do we think about our relationship with them?  How do we behave toward them?

I think we must always speak out against injustice.  Bad behavior that harms others can’t be tolerated.  But when we speak out, especially if it’s to a loved one, we must do so both pragmatically (with the intent to have a real beneficial effect) and with love.  If we’re angry with them, we must master ourselves enough to speak with genuine concern about the person (or people) they’re hurting as well as for them.  What helps me with this is remembering that everyone wants to be happy, and that inappropriate or cruel behavior really only arises out of that intent gone terribly awry.

People can almost smell our true intentions, accurately assessing whether we’re coming to them in the spirit of genuine compassion or out of annoyance (however legitimate that annoyance may be).  I try not to give feedback until I’ve worked myself into a frame of mind in which I can do so in the spirit of the former.  I try to remind myself that no one challenges us to enlarge our compassion as much as people to whom we’re tied by blood, and that, in one sense, when we have difficulty embracing a loved one whose behavior we find unacceptable, it represents an opportunity for us to grow even more than them.

Whether or not we continue to maintain close ties to friends or family whose behavior we find objectionable is an entirely different matter.  Sometimes the best means to protect our own well-being is to distance ourselves from a loved one or even break off all contact.  You never can predict the future, however:  perhaps such a response is just what’s required to shock the person from whom you’re disconnecting into seeing the truth about themselves.  For this reason, even if you do choose the dramatic step of cutting off all contact, always reserve a place in your heart for them to return.


Lynda asks, “Why do you think people often get better when they start hospice care?”

I find this question interesting because its underlying assumption flies in the face of my own experience:  rarely have I seen patients improve after entering hospice care.  I presume from Lynda’s question, however, that she has, and more than once.  Because I think it will help highlight important aspects of the hospice experience, I’ll try to speculate why Lynda (and perhaps others) may have had the experience she describes.

First, studies have shown physicians are notoriously poor at predicting patients’ lifespans, even patients with terminal illnesses.  To qualify for hospice, patients must have a life expectancy less than six months.  I’ve seen many, many terminal patients surpass this.  But doctors often want terminal patients in hospice even if they think their life expectancy is greater than six months because such patients often need the support hospice care brings.  The perception that patients “get better” in hospice may at least partly be only that—a perception.

On the other hand, patients generally feel happier when in familiar environments, like their homes (rather than hospitals).  Paradoxically, they may actually fare better there, too (which perhaps explains to some degree Lynda’s observation).  The risk of harm from being in a health care setting shouldn’t be underestimated.  Studies have suggested more care results often in worse care, principally because of increased numbers of complications.  Knowing when doing nothing is doing something requires great wisdom and restraint.  We all want to help and though inaction is a kind of action too, it rarely feels like it.  But just because we can do something doesn’t mean we should, and the unintended consequences of any medical intervention are sometimes more severe than anyone could have imagined.

Thanks again to all who wrote.

Next weekThe Therapeutic Application Of Denial

10 comments to Ask Alex

  • M.C

    This is different and I love it! You give amazing pearls of wisdom, Alex. I hope you do this again soon.

    M.C.: Glad you liked it.


  • I enjoyed reading your thoughtful and practical responses to all three questions. With the proviso that I’m not a therapist, I’d like to add something to your response to the first question. M. said that her husband is depressed and that, although he’s not willing to go to couples therapy, he is willing to seek therapy on his own. You said that you think that what underlies depression is a belief that we’re powerless to solve a problem. I always think that some movement in the direction of possibly solving a problem is better than no movement and so I would suggest to M. that she take her husband up on his offer to seek individual therapy. If you think this is not good advice on my part, Alex, please say so!

    Toni: I think it’s excellent advice. The impression I got from M.’s question was that though her husband was willing to go into individual counseling at her request, he would be doing so reluctantly, and M. was worried about how effective such therapy would be if his heart wasn’t in it.


  • As a hospice nurse, I would like to respond, if I may, to the hospice care question. Many times, patients do in fact “get better.” Depending on the diagnosis, some actually come off of hospice. That is usually an elderly patient that has the generalized diagnosis of “debility.” With the team approach that we employ, we can deliver modalities like physical therapy, occupational therapy, a nutritionist, an RN with frequent visits, an HHA to assist with ADLs and a social worker to assist the patient with special community services they may need. We also provide support from volunteers and our chaplain. Socialization is important. These patients are many times isolated and lonely. Also, we often find that after discontinuing unnecessary medications that have been interacting with other medications and ordering only appropriate treatment, they are relieved of side effects that may have been making them confused and tired. It is unfortunate that the hospice benefit under medicare is so rich. It should be like this for all patients. We would see many less hospitalizations, further reducing complications and further reducing costs.

    As for the “real” hospice patient, who may have a true life-ending illness such as cancer, we employ all the same treatment as described above, with the addition of aggressive pain management, including some alternative therapies such as massage. Getting pain better managed is the key to everything. The patient eats better, sleeps better and ultimately, feels better. They do end up dying from their disease, but they have a much better journey getting there, with many good days in between.

    That at least is our goal.

    Janice: Thank you for this wonderfully informative comment.


  • Rob

    If I can just tag on to Toni’s comment. I understand that M’s concern was that her husband’s heart might not be in it with therapy. But the possibility that he might *start* therapy reluctantly and then, after a few sessions, open up to the process and start to benefit is enough, I think, for her to encourage him to begin. Her other options (suffering the status quo or walking out on a spouse who is suffering and whom she loves) are certainly not appealing. Also, many marriage counselors recommend that individual therapy happen first. Joint therapy when underlying individual issues have not been addressed is likely to fail.

  • M.C

    I was thinking the exact same thing. That’s all it takes sometimes to get things moving and start the healing process.There might be too much fighting and taking things to personally if they go in to together right away.

  • mariann poirier

    M.’s husband might not be depressed but exhibiting guilt. Spouses who are having serious affairs try to ease out of a marriage without causing too much pain by claiming that they are feeling depressed, unfulfilled and “need time” to sort themselves out. Sometimes they need their own “space” too. They go along with the suggestion of counseling, but solo because repairing the marriage is not the real goal. They don’t want a scene or to shock their mate with the news that they’ve found someone else. I know of several such instances, so when I hear someone voice M.’s concerns—I say “cherchez la femme” or man. Especially in a longer marriage.

  • KAO

    Wow—Alex I love to read your blogs! I can always gain something from them. Just wanted to add a comment on the depressed husband…after 11 difficult years of supporting and going to counseling with a husband having depression issues, Mariann’s post is exactly what was going on…. affairs. Thankfully, I continued in my individual counseling and even though presently I am going through an ugly divorce; it is what I learned in counseling that has helped me survive and grow stronger. I have my “down” days where I wonder how I can do this, but my husband robbed all of us who supported him through his “midlife crisis” and periods of depression. Counseling is so wonderful IF one is willing to be totally honest and open.

  • revathi

    This was different and enjoyable!

  • Alex,

    I found your Q & A interesting to read. As always, you demonstrate an ability for insightful and compassionate answers.

    Have a wonderful week.

    (P.S. last paragraph, third sentence—typo, should be “there”) 🙂

    Angelina: Ugh. I hate making those kinds of mistakes. Thanks for catching it.


  • anne

    The responses to the question by M. about her husband, that he might be having an affair, make sense. But I would also like to add, as someone who has been very depressed, that it means a lot to be asked by your significant other to have counseling. When you’re that depressed you can get into a state of mind where you feel you’re not “worth” counseling (and you might even fight the idea for that reason). So, being asked (insistently) can be the deciding factor in getting it. Also, you might even resist counseling together as a couple because you are afraid to reveal something to your spouse/partner that you consider horrifyingly shameful, that is at the root of your depression.

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