The Effects Of Depression On The Family: A Cultural Perspective By Dr. Amin Azimi Jan.-March 1999 Lemar-Aftaab We all feel sad from time to time, sometimes without really knowing why. Some people seem to have a regular pattern of this which can be called a "valley." This means they are down every few weeks or months. But for a few people these valleys grow into what can be called "bottomless pits." They appear completely overwhelmed by the sadness and futility of life. They become passive, refuse to leave their beds; often being faced with suicidal tendencies. Depression can be triggered by the loss of a job, the death of a loved one, or by some other traumatic event, such as the loss of a country, being forced to leave one's homeland, living in an unfamiliar culture, and consequent loss of status. For example: Mr. F, a middle-aged educated Afghan came to the U.S as a refugee with his wife and three children fifteen years ago. Mr. F's depression started when his oldest son disappeared while attending Kabul University. He spent two years searching for his son. Finally Mr.F and his family left Kabul, and after a few years came to America. Mr. F developed the habit of drinking alcohol excessively despite having numerous physical problems. He was warned by his physician about the danger of alcohol, but he continued to drink. Mr. F's family life is such that he has no close relationship with his other three children or his wife. Mr. F cannot hold stable employment, though he held a high position in Afghanistan. The reality is Mr. F suffers from depression. He has lost the capacity to experience joy; when family or friends invite him for dinner, this previously witty man can barely manage to engage in small talk. His depression started when his son disappeared. He never ceased to blame himself for the loss of his son, and for years he refused to talk about his feelings, even to his wife. Mr. F cut himself off emotionally from the pain of his loss. He stopped grieving, and he never let go of the reality that his son was gone forever. He continuously denies depression, despite being confronted by his family, as well as his physician. Mr. F repeatedly refuses to get help. He uses alcohol to self-medicate himself. As every Afghan believes, admission of having mental difficulties is a sign of weakness in the culture. In contrast to Mr. F, many people experience severe depression without any obvious triggering event. Others endure more moderate episodes which may evolve into a relatively permanent condition. For most of us, sadness lifts after a time and does not become severe. But for the individual who suffers from depression, life essentially comes to a halt. There is clear evidence that the children of depressed parents are at significant risk of developing depression themselves as well as other psychopathologies. The classic symptoms of depression have a profound effect on the adult sufferer as well as all the people involved in his or her life. The onset is often gradual and lacking in dramatics, so that the individual may be less aware of the changes than are those with whom the person regularly interacts. In many cases, depression is initially experienced in physical terms, usually characterized by a sense of running out of energy or extreme tiredness or overwhelming fatigue. This is commonly associated with cognitive changes such as loss of concentration, difficulty with short-term memory, and forgetfulness. Sleep, appetite, sex drive and general level of interest are usually disrupted, and ordinary human interactions become a dreaded burden. The person may appear sad, cranky or even lazy, and eventually feel that even getting out of bed is too big a demand. Feelings of guilt, shame, and worthlessness often lead to despair, suicidal thoughts, and even suicidal attempts. Families are profoundly affected by the presence of a member with major depression. Marriages of depressed couples are problematic, and have a higher divorce rate than the normal population. Depressed people often refuse or postpone getting help. A common outcome for the rest of the family is the development of simmering, chronic resentment toward the depressed person. Another unhealthy posture involves resignation, accepting the depressed person's condition as permanent. Children of depressed parents are at increased risk of major depression, drug and alcohol problems, and other psychological problems, especially anxiety disorders, and behavioral problems. There is a direct relationship between the severity of parental depression and the degree of psychological problems and poor adaptive functioning in their children. Depressed mothers are less satisfied with a child's development and feel powerless over influencing the outcome of their child-rearing. Out of a sense of responsibility, the parent tries to interact with the child, but lacks the emotional stamina to be convincing at simulating approval and pleasure. Children, being sensitive and perceptive, tend to personalize this emotional unavailability. The child concludes that Dad or Mom doesn't love them or approve of them, and feels it must be because he or she is not good enough. The cumulative effect of these experiences can be chronic poor self-esteem that persists into adulthood. Children of parents with depression are affected at all ages of development, but they are particularly vulnerable during infancy and adolescence. From a cultural perspective, family members vary in the extent to which they retain their heritage, though clearly the impact of the past diminishes as families have new experiences. The language of the country of origin will help to preserve its culture. Often family members vary in the rate at which they learn English. It is important to stress the value of the native language to children while they are growing up. Recently, I received an E-mail from a 22 year old Afghan male who was experiencing depression, anger and emotional instability. Mr. N reported that his family had come to the U.S. when he was five years old. He stated that his parent's native language is Pushtu, his mother is uneducated and she has been a homemaker since their arrival in the U.S. She speaks English with difficulty. His father learned to speak English, though he is not fluent. His sister is married and his two older brothers, because of employment opportunities, moved far away after a couple of years from the rest of the family. His neighbors were English speaking people and he spent most of his time playing with kids his own age. He spoke to his parents on a superficial level of language exchange. When Mr. N entered school, he gradually lost fluency in speaking Pushtoo. His parents were content that he was doing well at school and didn't mind that he was less talkative, and was not able to write in Pushtu. His parents placed all of their hopes on their son who had done very well academically. Mr. N confided that some time ago he read the article "Ethnicity, the Foundation of Identity," and came to terms with himself that his depression is related to his relationship with his parents. He feels a deep void inside due to not being able to communicate with his parents, especially with his mother. He feels personally isolated and can't get in touch with the wealth of his family's heritage. He feels a tremendous sadness that the language barrier has prevented him from making emotional contact with his mother over the years and realizes how much that has influenced his sense of identity, despite having the outward trappings of academic success in a top university. Ethnicity interacts with the family life cycle at every stage. Migration is so disruptive in itself, that one could say that it adds an entire extra stage to the life cycle for those families who must face it. The readjustment to a new culture is by no means a single event; it is a prolonged developmental process of adjustment, which will affect family members differently, depending on the life cycle phase they are in at the time of the transition. When family members come into the young adult phase, they may have the greatest potential for adapting to the new culture in terms of career and marital choice. However, they are perhaps the most vulnerable to loss of heritage, as a result, leaving themselves vulnerable to disconnection at later phases of the life cycle. For example: Mr. B, a 58 year old Afghan came to the U.S as a student when he was 25 years old. His parents, an older brother and two younger sisters lived in a remote province in Afghanistan. He completed his education, married an American and fathered two children. As time progressed, the frequency of contact with his family in Afghanistan gradually declined. He became involved in the American lifestyle and gradually lost contact with Afghan traditions. Twelve years later he learned that both his parents had died in the same year. He wrote to his siblings, but he never allowed himself to grieve. Mr. B's children completed high school, attended college, and after graduation, they established their life in another part of the country. Two years ago, his wife informed him that she was divorcing him because she would no longer put up with his alcohol consumption. Mr. B's alcohol use had reached the point that one morning he was found unconscious and hospitalized for a week. He then started counseling. Mr. B acknowledges that he has been depressed for many years, but has never known the reason for his sadness. He began to talk about the shame, guilt, and grief that he experienced by cutting himself off from his family of origin and his cultural heritage. He felt emptiness, and a void for the lost years. He began to grieve the loss of his parents after two decades. He viewed himself a man with no country and no identity. The fact is, his wife's decision to leave finally opened the gate of emotion that he had kept shut for over 30 years. Some time ago, Mr. B along with one of his sons visited his brother, and sisters and their families who are now living as refugees in another foreign land. Mr. B attends therapy and no longer drinks. He realizes that it will take him a long time to resolve the feelings that he had buried all those years. Afghan families that came to the U.S. with young children are perhaps strengthened by having each other, but they are vulnerable to the parental reversal of hierarchies. If the family came with small children, there is likelihood that the parents acculturated more slowly than their children, creating a problematic power reversal in the family. If the children must take on the task of interpreting the new culture for the parents, parental leadership may be so threatened that children are left without effective adult authority to support them and without the positive identification with their ethnic background to ease their struggle with life in this new culture. If the parents have no support in cultural adjustment, depression may gradually begin to develop. An individual may be aware of feeling anxious, but not realize that, in fact, anxiety is a common symptom of depression. The depressed adolescent may or may not resemble the adult counterpart. Some teenagers exhibit the "classic" symptoms, while others, especially boys, may "act out" their depression through antisocial behavior, drug and alcohol problems, sexual promiscuity, truancy, and running away. A third group consists of obsessive, perfectionists who set high and often unattainable goals, becoming anxious and isolating themselves. Feelings of restlessness, grouchiness, aggression, reluctance to cooperate in family ventures, withdrawal from social activities, and a desire to leave home are all common in adolescent depression. School difficulties are also likely. There may be inattention to personal appearance and increased emotionality, with particular sensitivity to rejection in love relationships. These kids lack a frame of reference and therefore assume that they are inadequate failures. It is also easy to see the powerful lure of alcohol and drugs to these depressed teens. All children in the same family are not affected equally, however, and temperament plays an important role. Kids who have an easy temperament are less prone to become the target of parental irritation. The presence of one healthy, well adjusted parent or surrogate can also exercise a protective effect by shielding the youngster and providing some accurate reality testing. Children who weather the storm growing up have considerable understanding of themselves and their parents' illness, and consequently have healthier peer relationships. According to one theory, depression is a learned response to stressful events. When we are continually hit with problems that appears to be extremely difficult to resolve, we may eventually give up and become depressed. Our failures are most likely to depress us if we attribute their cause to our own weakness or to unchangeable conditions in our environment. This assumption clearly explains the depression of Mr. F. If we can attribute failure to temporary conditions, such as fatigue or bad luck, our disappointment is less likely to cause depression. So, while environmental events produce depression, the way we interpret those events also affects our mood. Depressed people have a negative interpretation of the world. They hold constantly negative views of themselves and their surroundings, as well as a pessimistic view of the future. Further, they maintain these views by exaggerating bad experiences and overlooking or minimizing good ones. A vicious circle of self-defeating thoughts produces depression and then perpetuates it. Depression is truly a family problem, and the family's whose loved one is depressed, can become hidden victims, if the impact on their lives is overlooked or underestimated. Making the family an ally in treatment helps the family and the individual, and increases the probability that depression in other members of the family will be recognized and dealt with in a timely manner. This long-term alliance also allows for rapid and effective intervention if there are recurrences in the future. When depressed individuals fail to talk about what bothers them, they tend to live with it, and ruminate about it in an exaggerated and unresolvable manner. Perhaps the younger Afghan generation can be helpful to their parents, since they have a more flexible view of life, by encouraging their parents to ventilate their feelings and by making them understand that psychological difficulties are not a sign of weakness, but rather the same as physical difficulties. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Dr. Amin Azimi is a licensed psychologist and licensed marriage and family therapist in Nashville, Tennessee. For sugguestion and comments, please e-mail at kabul@bellsouth.net - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Other Works by Dr. Amim Azimi: Culture, Family, School: Where Does East Meets West?An Edu.Model (article) Oct-Dec.1998 yaar-e dourang (poem) Oct-Dec.1998 Family, Culture, and the Generation Gap: A Communication Model (article) July-Sept. 1998 tofaan-e shab (poem) July-Sept. 1998 yaar-o-bahaar (poem) April-June 1998 goft ba khod(poem) April-June 1998 Ethnicity: The Foundation of Identity (article) Jan.-Dec. 1998 The Poetry of Dr. Amin Azimi (English)July-Aug. 1997 Copyright © 1999 Aftaabzad Publications. All Rights Reserved. May not be duplicated or distributed in any form without permission.