In the Culture but not of the Culture: Experiences of LDS Women with Depression

1. In the Culture but not of the Culture: Experiences of LDS Women with Depression Kristine J. Doty, Ph.D., LCSW Danna Lindemann, B.S. Heather Hirsche

2. Introduction • Experiences in the ER and Clinical Practice • John and Jensen’s 2009 study • Correlation between religiosity and perfectionism in self-identified LDS students at UVU • Focus on LDS women • Research Question: What is the experience of active adult LDS women diagnosed with depression?

3. They want to be heard. “When Marybeth called me yesterday, I went ‘Oh, hallelujah!’ I have been praying for you for years! ‘Please God, let someone get into this [subject] and see that it is real, that it isn't fake, that it isn't just women who are selfish or women who are on the fringe of the church or don't have a testimony or aren't serving. Let that pain that we feel, that emptiness, let someone speak for us, finally!" Amy, 41

4. Methodology • Exploratory Qualitative Phenomenological study (N=20) • Snowball sampling / Flyers at grocery stores • Research team – • Principal Investigator – LCSW • Total of 6 student researchers (5 LDS) across various stages of the project

5. Participation Criteria • Women between 18 and 65 • Willing to be interviewed and recorded • Active in the LDS church (self-defined) • Diagnosed with depression by physician or mental health professional • Those who were self-diagnosed were not interviewed

6. Semi-Structured Interview • Six topics explored: • Religious activity • Experience with depression (diagnosis) • Current treatment • Contributing factors • Religious / Cultural influence • Coping strategies

7. The Interview • Interview length: 25 min. to 2 hrs. • PI performed all interviews with student researcher taking field notes and observations • Professionally transcribed • Pseudonyms assigned to all participants

8. Coding and Analysis • At least two readers per transcript • PI and one student researcher • Each reader coded independently with the audio files using open and axial coding methods • Used grounded theory to identify emerging themes • Met as a team to flesh out themes

9. Demographics • Self-defined level of church activity • Age: M=39 (Range: 21-63) • Ethnicity: 19 Caucasian; 1 Latina • Marital Status: • Married (13); Single (3); Divorced (3); Widowed (1) • Number of Children: M=3.3 • All residents of Utah county

10. Literature Review • Perfectionism and Depression • Ashby, Rice, & Martin (2006); DiBartolo, Li, & Frost (2008); Nepon, Flett, & Hewitt (2011). • Religion and Mental Health (LDS specific) • Edgington, Richards, Erickson, Jackson, & Hardman (2008); Williams, Belnap, & Livingston (2008).

11. Literature Review • Religious-Context Specific Perfectionism • Craddock, Church, Harrison, & Sands (2010)

12. Results • Three Emerging Themes: • Contributing Factors • Coping Strategies • Treatment

13. Contributing factors • Anniversary of death • Body image • Multiple crises • Children’s choices • Spouse’s addiction • Divorce • Self-blame • Health problems • Pressure to marry and have children • Single motherhood • Financial concerns • Postpartum • Unworthiness • Raising children with disabilities

14. Top 5 Contributing Factors • 5. Genetics (7) “Mostly it's the genetics. It really is. I'm not a ‘woe is me’ person. I can tell when I'm depressed because all of a sudden I start getting flashbacks of any dark thing that ever happened.” -Alice, 63

15. 4. Being a victim of abuse (11) • sexual, physical, spiritual, and/or emotional “When I was in the middle of my sophomore year of high school, I was molested by three boys in my ceramics class.  And that kind of tipped me over the edge and I tried to kill myself after that.  I felt like my parents kind of gave up on me.  They kind of stopped worrying so much about me and just started ignoring the fact that I was never home.  I got into some more heavy drugs and got extremely sexually active with boys and girls because now I was this person, this unclean, dirty thing.” -Megan, 21

16. 3. Family of Origin issues (12) • All 12 women mentioned issues with mother “My mom [is] very religious, too, and LDS. As a kid I never felt like I was living up to her religious expectations even though I was trying really hard to, but she struggled with … you know anything that would be contrary to the LDS church. It’s hard for me to see her point of view and it seems like nothing is ever good enough or up to her expectations religiously, so even though I know she’s happy with me I still feel like she doesn’t think I’m up to her expectations.” -Sarah, 28

17. 2. Feeling judged by others (15) “I feel like everything is judgmental. I have never seen people judge so harshly on clothing, hair, the things that [others are] doing. But that's what Utah is. I don't get it. What's wrong with me? What am I doing so wrong? For some reason, people just judge me really harshly. I don't know why. I just have come to the conclusion that it's Utah, and I hate it here.” -Traci, 26

18. “I'm not [at church] for the people that are there. I'm there because Jesus died on a cross and the gospel was restored through Joseph Smith. That has nothing to do with the fact that I had two horrible marriages, my mom's dead, and I'm dirt poor. [My circumstances have] nothing to do with the fact that I believe that the church that existed in the Bible is on the earth today. I believe that. I have to follow it. I have to do what I believe. But is it easy? No.” -Connie, 33

19. Toxic Perfectionism (15) Defined as: an otherwise healthy, strong religious commitment, and associated desire to achieve religious ideals, combined with perfectionistic concerns about “falling short” of those ideals – and the perceived personal and spiritual consequences of doing so (Craddock, Church, Harrison, & Sands, 2010).

20. “We have this idea in our mind of what we should be: to be a perfect mom or whatever. Being a stay-at-home mom is very difficult for a lot of people, myself included … then you also have these expectations of what you should be doing to be the Molly Mormon or the perfect little homemaker … I think that's a lot different in other cultures.” -Sharon, 47

21. “With reading scriptures and praying I feel like sometimes I don’t want to pray because I’m not worthy to pray, does that make sense? Like I don’t feel like I’ve lived up to what I should be doing that day and so it’s hard for me to want to pray ‘cause some days I feel like [God’s] not happy with me. “If I’m not reading my scriptures then I feel like I’m not doing what I should be doing and that I’m not keeping all of the commandments, so it makes me feel like my self-worth goes down. So even those little things make me feel lower than they should. There’s all those morals and standards that you want to live up to and want to be like, so it’s hard when you don’t live up to your expectations or others expectations.” -Sarah, 28

22. “A lot of my triggers were that I liked to be the best at everything. In high school, I was a straight-A student in school, I was in the national honor society and president of a club…In church, I wanted to be the super active one that everyone thought had it all together. “I wanted to do everything and I wanted to do everything fantastically well. I think it for sure fuels [my depression] because no one's ever going to hit that. It's like the unobtainable. No one is ever going to be perfect. Logically I know it's unobtainable, but you are still pushing for that.” -Haylee, 21

23. “When you're depressed, you just do anything to not feel it. So you think perfection is the answer. ‘So if I have the perfect body, if I had the perfect looks, if I had the perfect kids, the perfect house, the perfect whatever, the perfect spirituality, if I somehow just loved to serve and I never felt like I was being burdened by doing this, then everything would be okay and I wouldn't have depression.’ “But I think that everyone with depression kind of does that. In the LDS church it's like, ‘I feel depressed’ and it's like, ‘Oh, you must not be righteous. Maybe you should go serve somebody, and then you would be.’” -Lindsey, 32

24. Where does this perfectionistic attitude come from? “But it's just something we do to ourselves. That's not coming down from the prophet; it's not coming down from God. That's just us comparing ourselves to each other and having that perfect standard.” -Lindsey, 32

25. “[Perfectionism] is definitely a culture thing…I talk to people and I know people who live outside of Utah… and they talk about pressures, and I don't feel the same pressures. It’s a crazy phenomenon going on down here. One of the things that I have a hard time with is even general conference talks and the scriptures and the things we’re studying, they're saying, ‘Do your best and God will do the rest’. That's kind of what you hear. Then you kind of hear this cultural thing where it's super-competitive, where you need to do better than your best because everyone else is. So then you have to keep up with them and you hope God does the rest, but wouldn't it be awesome if you could just do it all yourself?” -Haylee, 21

26. Cognitive Dissonance

27. Coping strategies • Exercise (10) • Spend time with family/friends (7) • Stay busy • Sleep • Accept the situation • Work in the garden • Natural remedies • Motivational tapes • Take “me” time • Bubble bath • Watch TV or movies • Read • Write poetry • Positive self-talk • Serve others • Temple, scriptures, prayer

28. “Writing and reading, I just love literature. When I get really depressed, though, I would write about depressing things. Yeah, the poetry was great and it was beautiful and it was like ‘Wow, this is really good; I can express myself!’ “Helping other people is a huge one for me. Giving of myself to make somebody else's life better. I think that anybody, I mean, no matter how depressed you are, if you can feel like you're benefiting or contributing in some way, because everybody has something to contribute, every single person.” -Megan, 21

29. “Exercise helps quite a bit. In college that’s what I majored in and so I’d have a lot of exercise classes and I think what got me through college was exercising and just having that outlet. I think reading, or sometimes just watching a movie, or it could be taking time for myself definitely helps too…writing in my journal helps a lot, talking to a friend about anything seems to help too. I like baking as well, so that’s sometimes my outlet: if I can’t go anywhere because of the kids, I bake.” -Sarah, 28

30. “When I stay productive, that is currently the biggest contributing factor  to managing my depression. And then keeping with the faith, as it were. If I go to the temple a lot, that helps. If I study the scriptures instead of just read them, that helps. Getting enough sleep helps. When it's warm outside, it helps. Being hopeful, but not staking my happiness on chance, or the agency of other people.” -Kim, 25

31. Religious perspective • Spiritual coping strategies (prayer, scripture reading, priesthood blessing, temple attendance, fasting) used by less than a third of participants (6) • Two mentioned multiple spiritual strategies (i.e. prayer and scripture reading) • The atonement was mentioned only once

32. Role of Jesus Christ in coping or healing • Jesus Christ/Savior/Redeemer was referenced briefly and descriptively in only half of the interviews • Jesus Christ/Savior/Redeemer applied personally was discussed by only three • No one described an active use or application of the atonement

33. Treatment • 14 diagnosed by M.D. • 6 by mental health professional • Treatment options: medicationand/or therapy

34. Medication “I am on Wellbutrin, and I am on Celexa. I found out inadvertently that I really, really need the Celexa. My anxiety level went up. I have never really felt like I had anxiety. I was like, ‘okay good, let's get back on Celexa.’ It makes all the difference. But yeah, I would be just a lump of nothing without my antidepressants. I don't think I could function.” -Alice, 63

35. “I tried a bunch of different medications like Lexapro and Zoloft. I don't know, just a bunch. None of them did anything for me. They all made me kind of, just numb.” -Megan, 21

36. “I talked to my physician at the time and he said, ‘Well you’re suffering from depression.’ Right away it was, ‘Let’s put you on medication.’ There was no ‘Let’s talk to someone about talk therapy in conjunction.’ It was, ‘Let’s put you on medication.’” -Maria, 33

37. Therapy “I went and saw a psychiatrist. I don't know, I think it was probably two or three years ago. I was having a hard time with family. A really hard time… He tried to put me on different kinds of medication and it didn't work, but I think just the talking really helped more.” -Lori, 36

38. “[My doctor] didn't recommend individual therapy, he recommended group therapy. I think individual therapy helped a lot. I did marital counseling when I was married. Then I had individual therapy. I think that helped.” -Connie, 33

39. “Actually, I owe a lot of [my healing] to my therapist. We used a lot of different techniques and homework assignments. We had a lot of good challenge activities. It got to the point where it was just like, ‘I don't care what people think about me.’ “It was a matter of taking the relationship between me and everybody else and focusing on the relationship between me and God. ” -Haylee, 21

40. Social Acceptance of Medication vs. Therapy • Ward newsletter • Student in a class

41. Medication vs. Therapy • 19 used medication, 7 were on 1+ meds • 10 sought therapy • 1 saw LDS bishop for counseling • Cost and time were prohibitive factors • A few did not like it or felt it was not helpful • All 20 cited situational factors as contributing to depression; only 7 cited genetics or organic factors

42. Clinical Implications • Three Levels of Treatment • Low: medication only • Medium: medication, therapy, self-administered behavioral and spiritual interventions • High: medication as necessary, therapy, and spiritual interventions focused on the atonement

43. High level of Treatment • Focus on treatment should be 3-pronged: • Medication to return to functioning, then weaned off if possible • Therapy (necessary to reframe thoughts and reinterpret life events, particularly LDS culture myths) • Spiritual interventions and support (priesthood counsel and blessings, atonement, scripture reading “homework”)

44. Recent statement on therapy • Supported as long as interventions are evidenced based. • Therapy should be “wisely coordinated with priesthood leaders.” (Oaks, 2012)

45. Treatment Model Medication Client Therapy Spiritual support

46. In conclusion “Now when I see women who I even think are depressed, it's like, I know what to do for them. They need to be listened to, they need to be loved. They need to be validated.” - Amy, 43

47. Any questions? If you have any questions regarding our research, please contact: Dr. Kris Doty at Kris.Doty@uvu.edu or Danna Lindemann at dannalindemann@hotmail.com

48. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Ashby, J. S., Rice, K. G., & Martin, J. L. (2006). Perfection, shame, and depressive symptoms. Journal of Counseling & Development, 84,148-156. Craddock, A. E., Church, W., Fleur, Harrison, Sands, A. (2010). Family of origin qualities as predictors of religious dysfunctional perfectionism. Journal of Psychology and Theology, 38(3), 205-214. DiBartolo, P. M., Li, C. Y., & Frost, R. (2008) How do the dimensions of perfectionism relate to mental health? Cognitive Therapy Research, 32, 401-417. doi:10.1007/s10608-007-9157-7.

49. Edgington, S., Richards, P. S., Erickson, M. J., Jackson, A. P., & Hardman, R. K. (2008) Perceptions of Jesus Christ’s Atonement among Latter-day Saint women with eating disorders and perfectionism. Issues in Religion and Psychotherapy, 32, 25-39. Marshall, C., & Rossman, G. B. (2006). Designing Qualitative Research. Thousand Oaks: Sage Publication. Nepon, T., Flett, G. L., & Hewitt, P. L. (2011). Perfectionism, negative social feedback, and interpersonal rumination in depression and social anxiety. Canadian Journal of Behavioral Science, 43, 297-308. doi:10.1037/a0025032 Strauss, A. & Corbin, J. (1998). Basics of qualitative research (2nd ed.). Thousand Oaks, CA: Sage Publications. Williams, M., Belnap, W. D., & Livingstone, J. P., (2008). Matters of The Mind: Latter-day Saint Helps for Mental Illness. Salt Lake City: Deseret Book.