Getting started on this path means first recognizing depression as an illness and getting the treatment you need, then staying with that treatment, often for a long time. Naturally, getting started is a time of self-doubt, of asking questions like "Will my child be all right?" and "Will my marriage survive?" But the more fundamental question to ask is "Am I ready to change? Am I ready to think about talking to my family in a new way?"

This new way of communicating means confronting straight-on fears about having harmed your child. Of course, it also means entertaining the possibility that you have not harmed your child. It even means recognizing that children can be strengthened against the possibility of harm. That strengthening, which we call developing resilience, is the fundamental promise of this book. Developing resilience is one of the many ways in which breaking the silence means gradually rediscovering hope.

Families begin at different places on this road to understanding. Some, the veterans of many treatments, start already knowing a great deal about depression; others, even those who've suffered for many years, are just becoming aware of depression as an illness. Some are reeling from a series of losses, while others are emerging from personal depths unrelated to life events. Wherever a family starts, the more fully it can articulate what its worries are and where it needs help, the better these can be addressed.

Regardless of where it begins, change comes slowly and in uncertain fits and starts, and the way ahead often seems very unclear. Once families have recognized the illness and begun treatment, though, they generally make sense of depression by moving through the following six steps:

1. Sharing a history together

2. Bringing knowledge about depression and resilience to bear on their own unique circumstances

3. Addressing the needs of the children

4. Planning how to talk to the children

5. Breaking the silence together as a family

6. Continuing the family dialogue

These stages can vary and sometimes they are not obvious. Still, I offer this basic sequence of events as a framework for getting started. It's the sequence we've used in working with many, many families. As you'll discover in the pages ahead, I've also used this same six-step framework to guide you through the first half of this book.

These stages first became apparent to me as I observed the journey of Katherine and Dan Petrocelli and their children. They came to us for help with their children having heard of our new program from the therapist treating Katherine, and they were among the very first families I worked with. From the beginning, I made certain to work collaboratively with those caring for Katherine's depression to coordinate our care for the family.

Every family's story has unique characteristics, but the Petrocellis' story is unusual in that her depression was closely tied in Katherine's mind to a specific and terrible family secret. Their story is also unusual in the depth of the depression she suffered. Even so, there are aspects that are typical: not just the gradual progression of stages, but the profound and deep uncertainty, the gnawing doubts that families live through and are able to get beyond.

Katherine and Dan Petrocelli first came to see me one December when Katherine was in the throes of an acute depression. Her face was etched with suffering, gaunt and drawn, and she lived with daily thoughts of suicide. When she talked about herself and her recent hospitalizations, her speech was painfully slow, as if each word were wrung from her at great cost. But when Katherine spoke of her three children, her face lit up with pleasure.

Katherine was determined to make a family Christmas as wonderful as the ones she remembered from the early years of her marriage, when her children were young and when she had felt better. Katherine was determined "this time" to stay out of the hospital, against her psychiatrist's advice. She revealed the stubborn will and determination that often led her into struggles with her caregivers but that also kept her reaching out for and holding on fiercely to her husband and children.

So strong was her desire to make things better for her family that in spite of her pain, Katherine insisted we plan a family meeting. Katherine's commitment to being the best parent possible despite the ravages of her illness was a source of enormous strength for the family. The same was true of her husband, Dan. He stepped in repeatedly when Katherine wasn't able to function or care for their children, chauffeuring the kids, preparing meals, supporting her even when she stayed in bed, unable to face the demands and darkness of winter.

Katherine recalled her first recognized episode of depression, which had occurred two and a half years before our first meeting. Her youngest daughter had just been stung by a bee at the beach and had broken out all over, and Katherine was driving her to the hospital. The trauma of her daughter's pain, combined with her awareness of salt breezes and of sand squeaking under the tires, stirred memories. She saw herself riding with her grandfather down the same beach roads many years earlier, but it was not a pleasant recollection. What it brought to mind was the fact that she'd been molested. Not only had Katherine been violated by her grandfather that day long ago, she had felt obligated to keep silent about it, and had done so for years at terrible cost.

In talking both to me and to her therapist, sometimes as often as three times a week, Katherine began to explore how painful that silence had been. She also became aware that there had been several other times when she'd been depressed: following the births of her two older children, and once when she'd been hospitalized for a bladder infection.

Katherine's illness was shaped by her experience with her wealthy and powerful family. Just as this family seemed to tower haughtily over the rest of the community — a town fading away after the loss of a once-thriving fishing industry — so the family looked down on her. She had been labeled the "family problem." Despite being the oldest, and despite laboring constantly to win the family's love, she felt herself to be her mother's least-favorite child, blamed for everything but expected to wait on the other members of the family hand and foot.

In many ways, Katherine's brothers and sisters repeatedly undermined her attempts to get better, particularly during periods of acute depression. She told me about one example: "Dan was out, and I felt really terrible, really scared. So did the kids. Scared enough that I called my brother and told him I was afraid to be alone. Two hours went by before he turned up, and when he did, he paraded around the house in front of the kids, proclaiming himself my savior. He talked about me to the children and to Dan. 'Will she be safe going upstairs by herself?' as though I were invisible, or stupid. My kids freaked out seeing him take control that way." She felt her brothers had tried to take charge of her treatment and hadn't helped her recover from the devastation of sexual abuse, and the kids were right in the middle of it.

When I began with the Petrocellis, Katherine did not yet understand the reason for her feelings about her place in the family, and she struggled with them. When Katherine became depressed, she lost all her energy, all her concentration, and all interest in the world around her. She couldn't sleep. She couldn't manage. A nurse by profession, she blamed herself for not being able to cure her own illness. She even thought of suicide, which was the reason for her first and a subsequent psychiatric hospitalization during the previous two and a half years. Katherine, Dan, and I agreed early on that I should keep in touch with her doctors. It was especially important that I work closely with Katherine's psychotherapist and psychopharmacologist in light of the potential for a suicide attempt or for more hospitalizations.

Although Katherine was a medical professional, she and Dan still had some misconceptions about her disease. We talked about how depression was no one's fault, no more than any other biological illness such as a heart attack or chronic condition such as diabetes. After all, I pointed out, if no one expects a person who's had a heart attack to jump right back into full swing, then why should a depressed person be expected to? Katherine laughed grimly. "So depression's legitimate, like a heart attack. You should tell my parents that."

When the discussion turned to their children, Katherine and Dan spoke with warmth, humor, and great enthusiasm about each child. Their oldest, Thomas, was nineteen, hard-driving, pragmatic, and athletic. Thirteen-year-old Lisa was a nonstop talker with a "ton of friends." The youngest child, eight-year-old Mary, was quiet and shy but sometimes exploded into anger. After she once screamed at her parents that she wished she were dead, Katherine and Dan worried that Mary might be depressed. But I could hear no major symptoms of depression in their descriptions of the three children. In fact, the family continued to function remarkably well in the face of Katherine's illness. The kids felt close to one another and carried on at school as they had always done. They were even able to eat meals together on occasion. The vital patterns of their lives had been preserved.

Having listened to Katherine and Dan describe their children, I began to introduce the general idea of resilience. This notion — that in the midst of the family's devastation, the children could be strong — was completely new to Katherine and Dan. Dan and Katherine supported my meeting individually with each child. My goals for the conversations with Thomas, Lisa, and Mary were to evaluate their general state of mind, their potential risk for childhood depression, and signs of their resilience. I also wanted to give them the opportunity to have their questions answered and to help them speak up for themselves.

We've found that parents who've learned how depression affects children are more open to having someone outside the family meet with their kids, though they may do so with great anxiety. Before reaching this point, parents may be afraid that a clinician will prove them bad parents. They also worry that the children will tell a woeful tale of a family without hope. Their willingness to let children speak, and to ask them about what's going well and whether they have worries or concerns, represents a significant first step in resolving the dilemma of depression in families.

I met first with nineteen-year-old Thomas — forceful, clearthinking, and laconic. I came to this meeting prepared for a dramatic encounter full of meaningful, if unpracticed, discussion of family events. Thomas, however, immediately made it clear that he'd much rather have been with his friends than talking with his parents' well-meaning doctor. On the one hand, Thomas denied that he was worried about his mother's illness and seemed to minimize the situation. "Mom went in the hospital," he said. "She told us it was because she was depressed. Mom thought her mother didn't like her or something. I don't see why she can't just pull herself together if she really wants to." On the other hand, Thomas was concerned about how hard things had been on his father, and he feared that his parents might get divorced.

I next met with Lisa, who was obviously more comfortable talking about her mother's illness and its impact on her and the rest of the family. Right away, she told me of the time she'd found what seemed to be a suicide note written by her mother. Katherine drove long distances along the shore to see her therapist and sometimes stopped the car by the side of the road, overcome by thoughts that everyone would be better off without her. Lisa had found the note stuffed under the car seat. She had confronted her mother, who then confessed that she couldn't promise she wouldn't carry out the suicide. After this episode, Lisa had desperately wanted to talk to her mother about her fears, but she was afraid that the conversation itself might trigger a suicide attempt. Lisa told me that she was constantly worried that the holiday season would be too much for her mother. Lisa, more than anyone else in her family, remembered that it had been the stress of Christmas a few years earlier that had brought on signs of depression, including irritability, sleeplessness, and fatigue.

In spite of the pain her mother's illness caused everyone in the family, Lisa found many positives in her life, including her friendships and activities — being captain of the ice hockey team, cheerleading, and jazz dancing. There was even a lot to appreciate within the family, she told me, especially when her mother wasn't feeling so irritable and unhappy. In fact, Lisa's version of family life corresponded closely to the way Katherine and Dan told the story. Eight-year-old Mary didn't ask as many questions as her two older and more sophisticated siblings. But she made it clear that she was frightened and wanted her mother to be better. Did I learn anything awful about the family? Not at all. I felt comfortable that none of the children was depressed. The patterns of their lives — the rhythms of going to school, hanging out with other kids, drawing, dancing, playing sports — were intact. Yet, despite the children's apparent ability to "get on with their lives," they clearly misunderstood their mother's illness and were very disturbed by it. They were baffled by Katherine's disruptive actions toward them, her erratic behavior, including sudden departures or bursts of temper interspersed with periods of calm.

Although each child spoke about different things, their comments were consistent enough to affirm that they shared a common experience of their mother's depression. Each recognized the depression in terms of Katherine's hospitalizations, her irritability, and her withdrawal. I hoped that because of their common perceptions, eventually they would be able to talk about the experience.

Our original plan for the family meeting coincided with the Christmas holidays, but by that time Katherine's depression had worsened. The family decided that the meeting was so important they wanted to delay it until Katherine felt ready. I agreed with them, and I had a long conversation with her psychotherapist, who also agreed.

During the following months, with Dan's support and with her therapist's help, Katherine came to a new understanding of herself and her illness. This self-understanding became the bedrock on which the Petrocellis would build a different way of being a family.

It represented both her coming to grips with the dark specters of how she had been raised and her own fears that she was repeating it. As she tried to think about a new way to talk to her children, Katherine began to reach through the shame and the depression to reexamine the sexual abuse and her troubled relationship with her family, especially her mother. She began to see how her self-blaming and perfectionism were a legacy from her mother, for whom Katherine could never do anything right. Her mother was obsessively neat, and Katherine, who had picked up this trait, worried that she might be perpetuating her past. "I remember my mother viciously dumping my clothes all over the floor because I hadn't cleaned up my room properly. I was so miserable, but the awful thing is that I've done the same thing to my own children. I once saw Mary standing in the driveway, so bewildered and forlorn. I saw myself as a child in her. I would have done anything for my mother, anything at all. I would have swept the garage floor with my own body if it would have pleased her. I'm so afraid that my children will have a childhood like mine and think of me as the ogre."

As she recalled more details from her childhood, Katherine began to wonder if her own mother had struggled with depression. Then again, she began to see the ways in which she was very different from her mother. Likewise, she recognized that the childhood experiences of Thomas, Lisa, and Mary were very different from hers. Katherine began to separate her past from her present, to accept her childhood, and to feel new confidence in herself. She put it this way: "I know my kids have gone through some rough times. And I used to think that they'd completely stopped respecting me as a parent and as a person. I was so sure that they couldn't possibly love me anymore. I guess I just can't jump to that conclusion anymore." Katherine also needed to make another journey, reliving the great difficulties she had had when, after one of her hospitalizations, she tried to talk about her abuse with her family. No sooner had she shared her story with her brothers and sisters than they picked up the phone and repeated the story to their mother, whose response was, "I'll take it to my grave that this disgusting thing ever happened." Imagine, then, Katherine's courage in seeking another family conversation with her own children.

Katherine, Dan, and I now began to plan for the family meeting. What should Katherine tell her children about her grandfather's abuse? About her thoughts of suicide? About her unhappy relationship with their grandmother, who lived only ten miles away? What did the children need to know? Katherine and Dan wanted to make sure that whatever they said would make things better for the family, not worse.

At first, we decided together that they needed to discuss what the children had actually witnessed and were worried about. These included Katherine's outbursts and her thoughts of suicide, but not things that had happened long ago.

For the Petrocellis, then, there was clear agreement to talk about Katherine's depression and the family dynamics around her symptoms, such as irritability, unpredictable behavior, and withdrawal. Katherine was willing to talk about her thoughts of suicide but feared that talking about the abuse would ruin her children's relationship with their grandparents, aunts, and uncles. Dan wanted to talk about the sexual abuse lest the children someday hear about it from someone in Katherine's family. Eventually, after much discussion, Katherine and Dan chose together to talk about the abuse.

We decided to meet in the Petrocelli home, so the children would feel comfortable and see that their parents — rather than their parents' doctor — were leading the way. It was a beautiful early spring day when Thomas, Lisa, and Mary filed into the living room, each clearly wishing to be somewhere else.

This meeting represented months of planning on Katherine and Dan's part. It had been a long journey to understanding before she was ready to talk with her loved ones about her hospitalization and what they'd been through together, the many arguments and the daily agony of not being able to regain who she'd been earlier in her life. But through it all, as we will see time and again, her paramount concern was to be able to take care of her children.

Katherine spoke first, reassuring them that she was all right, that she could handle the meeting without getting upset. Dan joined in, supporting her, letting the kids know that everyone would get a chance to speak, then and in future conversations. I shared with the whole family how much respect I had for their courage and willingness to talk.

Hesitant but composed, Katherine looked directly into the faces of her children and began to address one of the most painful aspects of her depression — her thoughts of suicide. "Weren't you really concerned?" she asked them. "What about the time I left at night? Did you think I was never going to come back?" Thomas responded boldly, voicing what so many family members feel. "Why are you asking that? All you're doing is refreshing the memory of what happened. I just don't understand why you're doing it."

Then her youngest daughter, hoping to smooth things over, said, "You're doing so well. Why risk talking about this in this meeting? There are no problems."

Dan calmly insisted that this had to be done and that they were going to do it together.

Softly, Katherine responded, "I feel comfortable enough about the way things are going that I don't feel talking will make things worse. I think it's another step forward. I love you very much. I'm going to tell you something I have thought about for a long time. Because you're my children, I'm going to share it with you. I want you to understand it and to know it so you're not going to be afraid of it and think it could happen to you. I think it's going to clarify a whole lot of things."

Since this information had been helpful to the two of them, Katherine and Dan had asked me to talk first to the whole family about the basic facts of depression. We started by addressing some of the children's misconceptions. Thomas told us that he thought Katherine's depression was caused by how she'd been treated as a child. Katherine gently replied, "There's a lot more to it than just that. Really bad things happened to me when I was a little child. In those days, we just didn't talk about bad things, but if you don't talk about things, they come back to haunt you. I kept things inside for too long. And I'd like to change that now."

The room was tense; the children's frightened eyes fixed on Katherine as she told them about how she came to recall her grandfather's abuse. She told them about her unhappy place in her family. She also made it clear that she had begun to accept these events. She couldn't change the past, but perhaps she could learn to deal with her feelings.

Katherine began a frank discussion about her treatment, including the setbacks and problems she'd experienced over the years. Often, Dan would step in with a comment or question, showing a comfortable and loving rapport with his wife. Dan described the onset of Katherine's depression as he'd heard it from a doctor: "It's like what you've heard about Vietnam veterans and posttraumatic stress. Years later, the stress and pain come back to them." Thomas began to cry when he heard Dan's explanation. He no longer had trouble understanding why his mother just couldn't will herself back to health.

Katherine reiterated how important it was that their family try to talk about things openly from now on. Even Thomas eventually agreed. Katherine continued, "I'm sorry that we have to talk about all these sad things. I'm sorry, but I know it's the right thing for your father and me and especially for you children. I love you so much. My love for you leads me to tell you so you'll understand for yourselves. Maybe you'll be able to understand how bad I've sometimes felt, how sometimes I've wondered if it would be easier if I just went away. I know that I would hurt you much more by leaving. Even when I thought about leaving, during the worst days of my illness, it never was to leave you forever. I really wanted to see if I could leave myself, if I could run away from myself for a while. But I love you so much I don't want you to be afraid for me or for yourselves. And I know you'll be okay, yourselves. You didn't have my childhood, so you won't have to go through what I've gone through with depression. I love you so much."

The family talked on and on, clearly shaken by Katherine's story, but also somewhat relieved.

When I met Katherine and Dan a week later, they were glad to have held the session. All of us had been quite concerned about Thomas: his anger and his wish to deny his mother's illness. But the family had continued to talk even in the few days since I'd met with them, and he and the rest of the family were fine.

We made plans that I would be available to them whenever they needed it and that they would keep talking to one another. We set a time when I would see them again. We kept that date, and I stayed in touch with them throughout the years that followed.

In later chapters, I will come back to the idea of a family meeting and explore it from other perspectives. But having provided this overview of the six steps, I now need to back up and, just as we do with the families in our care, discuss in greater depth the basic information families need, providing a more detailed view of the essential facts of depression and resilience.