Psychiatric nurses who work at inpatient mental health facilities interact with many different types of clients. Some may be relatively subdued and withdrawn while others may be more outgoing. Facilities designed to address the needs of the severely mentally incapacitated treat individuals with extreme cognitive and behavioral problems, and constant supervision and precaution are necessary to ensure the safety of both the clinicians and the clients. Nursing stations within these facilities are designed to provide maximum accessibility and supervision while also providing safety and security to the staff members. Some stations are designed with glass barriers and locked doors and others are built with no walls or windows, allowing both the staff members and clients open access.

Kelly Southard, the Quality Outcomes Coordinator at the Cone Behavioral Health Hospital in Greensboro, North Carolina, recently conducted a study to determine how each type of nursing station design affected therapeutic outcomes. For her study, Southard assessed 25 nurses and 81 clients in an acute psychiatric unit of a hospital before the nursing station was renovated and after. Prior to renovation, the nursing station was closed and had window and door barriers. The nursing station was only modestly renovated with new paint and countertops and removal of the window and door.

Southard found no significant differences in the perceptions of the ward environment after the renovation compared to before the renovation. The staff members and the clients did not report an increase in therapeutic ambiance as a result of having an open nursing station. However, many clients did comment that they felt that that the nurses were more accessible in the open station. Another interesting finding and one that is of concern to staff members charged with the care of high-risk clients was that the open station did not increase the level of aggression or violence on the ward. In contrast, the staff members discovered that the clients actually exhibited less aggression and anger after the renovations. Southard added, “Although more research is needed, these desired trends could be related to nursing staff being more readily available to better meet patients’ needs.”

Reference:
Southard, K., Jarrell, A., Shattell, M. M., McCoy, T. P., Bartlett, R. (2012). Enclosed versus open nursing stations in adult acute care psychiatric settings: Does the design affect the therapeutic milieu? Journal of Psychosocial Nursing & Mental Health Services, 50.5, 28-34.

If you are reading this article, then you probably have completed Codependency Workbook Exercise Two by creating a list of your troubled relationships. Congratulations for completing this. Generally, in codependent relationships there is some pain and emotional abuse. They tend to be rather lopsided, with you doing most if not all of the giving. When you realize this, you may get angry and feel as though others are using you. You may wonder why this is. It is because when they meet you, they sense that you are a caretaker who will want to help them. When you do this, it is because you care about them and believe that you can love and care some of their problems away. Most of the time this cannot be done. Often, by giving to them, you are actually making it easier for them to continue their maladaptive behavior.

If your loved one gets a DWI, you may rush out and hire a good lawyer who may get him or her off. Had this person suffered the consequences of the DWI, he or she might have been ordered to complete substance abuse treatment, which might have ended or at least interfered with the drinking. So if you are in a relationship with a person with an alcohol or drug problem, can you think of a boundary that you could set that would be good for you and, in the long run, him or her? For example, you might tell this person that if he or she has another legal problem related to substances, that you will no longer help. The person will be on his own. Of course, he or she may not like this and try to push your guilt buttons. Remind yourself that you are not only doing what is best for yourself but also for the other person. You might take your boundary a step further and tell the person that effective immediately, you will no longer undo any of the consequences of his or her using. I suggest you only set the boundary when you are ready. The hard part will come when you have to stick to the boundary. You will need some support from a therapist, your sponsor, or a friend to hold to it. Once you maintain a boundary you will find that it is easier to stick to the next one.

What are some other boundaries that you might set? Maybe you have a friend who borrows money from you and has never paid it back. The next time the friend asks to borrow money, you might tell him or her that you are unwilling to loan any more money until the person repays you the funds already owed. Maybe you have someone who always asks you for rides but never offers to pay for your gasoline. You might decide to tell this person that you cannot afford to continue giving him or her rides. Make a list of all the boundaries that you need to set to take care of yourself. While you are identifying them, do not worry about actually setting them. Try to take one step at a time. I know that the thought of setting them is very scary. You may also be scared about what will happen to your friend if you set them. If your friend is dysfunctional, something will happen to this person no matter what you do. Once you get the hang of doing this, you are going to feel an enormous sense of relief. You will realize you are not responsible for everybody, nor do you have to help someone just because that person needs it.

If you are like some people, you may fear that if you stand up for yourself, you will be abandoned by your friend. I believe that if this happens, then that person was not really a friend to begin with. Can you imagine treating someone that you care about like that? I am sure that you cannot. Now you will have more energy to direct toward taking care of yourself. You will no longer feel so angry at others. The next time you feel like a victim, you may need to check and see if you need to set another boundary.

Despite decades of research and several new classes of antidepressant medications, successful treatment of depression is still an elusive goal. In particular, people with major depressive disorder (MDD) often fail to respond to the first line of treatment or relapse after a short period of recovery. The search for new therapies and combinations of therapies is ongoing. Recently, the antipsychotic medication Abilify (aripiprazole) has been prescribed as a secondary treatment for MDD patients, often with positive outcomes.

Originally designed as a treatment for symptoms of schizophrenia and other psychotic disorders, Abilify’s usage has expanded widely in just a few years. Now, doctors are prescribing this medication for conditions ranging from bipolar disorder to certain forms of autism. Like all psychotropic medications, Abilify works by altering the balance of chemicals in the brain called neurotransmitters. Several of these neurotransmitters, including serotonin and dopamine, are largely responsible for a person’s emotional state. Abilify has demonstrated great potential to stabilize emotional states for a wide variety of patients. This includes the capacity to reduce anger and aggressive outbursts, which is why its original usage was for psychotic patients.

In 2007, the Food and Drug Administration approved Abilify as a supplementary treatment option for patients with MDD who were already following a course of traditional antidepressants. Several clinical trials and controlled experiments have demonstrated that Abilify may offer a “boost” to the mood stabilizing attributes of antidepressants. At the same time, Abilify may work to offset some of the more unpleasant side effects of these drugs, such as sexual dysfunction.

In addition to its effectiveness as a supplementary therapy, clinical trials and tests indicated that Abilify is a relatively safe and well-tolerated medication in depressed patients. The most commonly reported side effect associated with the medication was restlessness. Rarely was this side effect bothersome enough to cause the patient to discontinue taking Abilify.

Millions of people experience the debilitating symptoms of depression every day. Nevertheless, a reliable cure or even a more effective treatment for depression is likely still many years away. Because the brain is the body’s most sophisticated organ, understanding how best to restore the proper neurochemical balance is difficult. Discovering the most successful early treatment options is therefore important in reducing relapse and improving long-term outcomes.

References

1. PubMed Health [Internet]. (n.d.). Bethesda (MD): National Library of Medicine. Major depression. Retrieved February 20, 2012. Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001941/
2. Pae, C., Forbes, A., & Patkar, A. A. (2011). Aripiprazole as adjunctive therapy for patients with major depressive disorder. CNS Drugs, 25(2), 109-127.

Racism and prejudice are issues that are at the forefront of social concern today. Ethnic differences are causing riots, uprisings, and loss of life in nations throughout the world, including our own. Classic conditioning is a theory that suggests that individuals learn racism and prejudice through exposure to events by either experiencing them personally or observing them. Once a perspective is formed, it can be reinforced through continual verbal, visual, or actual cues. For instance, a person who has a fearful encounter with someone from another race may later see others exhibit fear, thus reinforcing their opinion and prejudice of that race. Likewise, this effect can be reversed if this same person goes on to experience positive situations with people of the other race. Either way, discrimination and prejudice are learned at a very young age and unless it is reversed, can lead to significant stress and anxiety. People who are discriminated against based on their religion, race, or sexual preference often face obstacles in many areas of their lives. Finding a career, a job, or school can be a challenging experience for people who are faced with prejudice and discrimination.

To identify how different ethnic groups learn racism and how it is perceived across different races, David Rollock, Associate Professor of the Department of Psychological Sciences at Purdue University, recently conducted a study involving participants who were African American, White, Asian, and Hispanic. The 282 participants ranged in age from 17 to 61 years old and responded to a questionnaire that asked them about their experiences with prejudice. They were instructed to report their emotional responses to various interracial encounters, positive and negative.

Rollock discovered that the White participants had the strongest negative emotions as a result of bad interracial experiences, while other races experienced lower levels of negativity. The findings also showed that Whites reported fear as the most common response to negative interracial experiences, regardless of whether they were verbal, observed, or physically experienced. Whites and African Americans had similar levels of anxiety, but these levels were much lower than levels found in the Asian and Hispanic participants.

Although all the participants exhibited anger as a result of interracial experiences, it was minimal. Rollock also found that some of the participants had positive interracial experiences that decreased their prejudice, but the effect was minimal. Rollock added, “Interestingly, people from different ethnic and sex groups did not appear to ‘learn’ their adverse race-elicited emotions in different ways, suggesting that strategies that build or reduce adverse race-elicited emotion for members of one group should be similarly effective with other groups.” This finding could help clinicians who are dealing with victims and perpetrators of racial intolerance. By understanding that the mechanism that leads to prejudice and racism is similar across all races, mental health professionals should be able to help most people overcome these obstacles, regardless of their ethnicity.

Reference:
Conger, A. J., Dygdon, J. A., Rollock, D. (2012). Conditioned emotional responses in racial prejudice. Ethnic & Racial Studies 35.2, 298-319.

If you want to make God laugh, tell him your plans.
-Woody Allen

No matter who you are, things will happen that throw you off-kilter. Life intrudes on inner peace with an uncanny regularity. It may be your boss, spouse or partner, children, house, parents, finances, health, or even a freaky weather event, but life has its own trajectory, and no one can know what new challenge awaits.

Luckily, there are many ways to regain equilibrium. Trial and error, plumbing your depths to see what really works for you, and discerning the differences between various situations that trigger your sympathetic nervous system—your fight or flight reaction—are all very helpful in developing an emotional first aid kit.

When you find you have strayed from your center, allow the imbalance. Just notice what is going on emotionally, physically, and mentally. What are you telling yourself about this experience? Are you ready to regroup, or do you need a bit more time to explore what is happening? Sometimes, the hardest thing is allowing yourself to totter emotionally, to grieve or feel angry, overwhelmed, or exhausted. Whatever is happening, it won’t last.

Ten Tips For Emergency Emotional First Aid

Since it is easy to get thrown off-kilter when you are shocked or surprised by unwelcome news, you may want to try these techniques as first responses:

1. Take slow, deep breaths, and allow a little extra time to exhale.
2. Remind yourself that this, too, shall pass.
3. Allow space for all of your feelings.
4. Have faith in yourself. The truth is that you can handle more than you might believe at this particular moment. You can use prayer or meditation for added support and to access your belief in a greater power.
5. Don’t take anything personally.
6. Try to stick with your routine, even if you are feeling dazed or numb. Having a routine will anchor you.
7. Eat, sleep, and get some fresh air.
8. Picture your 6-year-old self, and lovingly embrace that child. Gently reassure the frightened little being inside.
9. Connect with someone, such as a friend or family member, a therapist or neighbor, even a stranger on a local hot line.
10. Understand that you are here for everything, good and bad. Visualize yourself as a river of experiences, and let life flow without judgment.

Reading this list takes only a few minutes, but actually working through each item builds resiliency and will help you keep going, one second at a time. Sometimes, just existing during a traumatic experience is the best you can do and remembering that as time passes, your perspective will change. For now, it is best to accept the present, do what you can, and choose to believe everything is happening for your highest good.

If or when you are ready to re-center, reach out to a trusted friend, relative, clergy person, or therapist. Speak honestly and openly. Being heard and understood is one of the most bonding, loving, and freeing experiences you can have, but you have to ask for help. If this has been hard for you in the past, break out of your old rut of being super-independent and pick up the phone. Find a therapist in my area.

If company doesn’t fit the bill, try some solitude. Silence can be soothing and afford you the opportunity to integrate what you have experienced. If that feels overwhelming, try a guided meditation. There are numerous free podcasts on iTunes, like Meditation Oasis, A Quiet Mind, or The Meditation Podcast. If you have the time, try a soothing Yoga Nidra practice—this is a guided practice of yogic sleep, where you are in the liminal space between waking and sleeping, and involves no knowledge of yoga postures. (My favorite is available free from iTunes through Elsie’s Yoga Podcast, episode #62.)

Take a bath with Epsom salts and lavender oil. The magnesium sulfate in the salts will quiet any muscle tension, and the essential oil—about six to eight drops—will calm your mind and act as a pain reliever.

Read something inspirational. Try some poetry, or escape with a novel. Reading is both relaxing and engaging. If audio books work better for you, check some out from the library and download them to your iTunes so you’ll have a ready supply.

Music really can soothe the savage breast, as the playwright William Congreve suggested in the late 17th century. Find something that works for you: it may be hard rock, or hemi-synch. Sanskrit chants can be remarkably helpful, as they bathe you in mantras designed to calm your nervous system. Chanting them yourself will bring even greater benefits, as making the sounds activates different parts of the mouth that correspond to different areas in your brain. The simplest one is om, a sound that is said to embody all sounds.

Moving your body takes the kinks out emotionally, too. Even if the last thing you feel like doing is dancing, yoga, or taking a walk, just do something for five minutes as an experiment. If you feel better, do another five minutes.

Allow nature to work its magic. Dr. Samuel Hahnemann, the father of homeopathic medicine, wrote that eating well, sleeping enough, and getting fresh air are essential to good health, mentally and physically. Don’t underestimate their value.

Rebalance with a favorite ritual, like making yourself a cup of tea and sipping it slowly.

When parents use children as pawns in their divorce, the psychological consequences can be devastating. Parental alienation (PA) is the act of deliberately alienating a child from a targeted parent (TP) by an alienating parent (AP) and can cause a psychological condition referred to as parental alienation syndrome (PAS). Although this term is relatively new, the damage this type of behavior inflicts is not. When one parent denies a child access to the TP, the child struggles with feelings of hatred and fear towards the TP. These children often live in an environment riddled with malicious and derogatory remarks about the TP, and as they age, maintain guilt over harboring these feelings toward their parent.

Research on children of divorce has shown that this pattern of behavior can cause children to have social impairments that negatively impact their quality of life as adults. But until now, no study has looked specifically at PAS and its effect on key factors of development. To address this issue, Naomi Ben-Ami of Yeshiva University in New York evaluated 118 adult children of divorce and compared the children who experienced PAS to those who did not. She assessed several areas of social and psychological well-being, including depression, trust, self-hatred/esteem, anger, guilt, marital status, and achievement and identity problems.

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Ben-Ami found that the PA participants had substantially lower levels of achievement than the non-PA group, which was demonstrated by fewer college degrees, less overall employment, lower college enrollment, and more economic hardship. They also exhibited attachment issues, impaired relationships, and decreased self-esteem, possibly as a result of the lack of attention they received from their APs. The controlling behavior of an AP was also shown to increase feelings of anger and guilt in the PA participants. These emotions, coupled with diminished self-sufficiency, elevated the risk for depression in the children who were exposed to PAS. Ben-Ami believes these findings support previous research that shows the destructive and long-term consequences that a child must bear when he or she becomes entangled in a parent’s highly fueled emotions arising from a divorce or separation. This type of evidence, if made available to parents and involved psychological and legal experts, could help prevent this type of activity and maintain the integrity of relationships, present and future. Ben-Ami added, “Ideally, the trajectory can be interrupted successfully to allow children to maintain healthy relationships with both parents, to be loved by them and loving with them.”

Reference:
Ben-Ami, N., Baker, A. J. L. The long-term correlates of childhood exposure to parental alienation on adult self-sufficiency and well-being. American Journal of Family Therapy 40.2 (2012): 169-83.

If you have completed Codependency Workbook Exercise One, congratulations to you. Please take a moment to pat yourself on the back. You deserve it, because it must have taken a great deal of courage to write about your family history. Most people shed some tears in our therapy session when they share it with me. Then they feel very relieved.

Many people are not ready to share the letter with their family of origin right away. If you have a therapist available or a sponsor, discuss it with that person. If not, review it with a supportive, nonjudgmental friend. Before sharing this with your family, it is important that you be ready to deal with their reactions. Unless they are in recovery, most families will not be able to validate your experience. However, it is very therapeutic to put your family history on paper and share it with another person.

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Now we are ready to begin the next workbook exercise, which concerns relationships. Please make a list of the most important people in your life. This may include friends, lovers, a spouse, family members, coworkers, or a boss. Spend a few minutes thinking about each relationship. How many people on your list do you believe are dysfunctional? How many are addicts, have untreated mental illness, refuse to work, even if they are able, or have other major issues? Are you taking care of some of the people on your list? Are some of the relationships lopsided, where you do most of the giving?

You may wonder why some of your relationships are lopsided. Dysfunctional people can sense that you are a caretaker and are drawn to you. It is almost as though they can smell you. You may find yourself drawn to them as well.

Last night, I saw a married couple where the wife was unsuccessfully trying to stop her alcoholic husband from drinking. She was anxious, frustrated, and very angry. Of course she would be frustrated. She was trying to control something that she had no control over. The facts are that we are powerless over other people, places, and things. Realizing this is helpful to codependents because they can learn to let go and relax. Trying to fix others is impossible, and just upsets the fixer. It also is not helpful to the dysfunctional person. Normally addicts only get help because of the consequences of their using. If the caretaker undoes the consequences, they caretaker unknowingly helps enable the dysfunctional person to remain sick.

Since caretaking may make you miserable and help your loved one stay sick, maybe we can work on not doing it. How? You can begin to learn to set boundaries. For example, you might tell the loved one that you will no longer bail him or her out if he is arrested. You may tell him that you will no longer call in sick if he is too hung over to work. You may tell her that you will only talk with her when she is sober.

I suggest that you put your list away for at least 24 hours. Then pick the relationship that causes you the most stress. Think about a boundary that you may set and write it down. Practice telling your loved one about the boundary. He or she will probably not like it, but in the long run it will be good for both of you. Be sure that you are prepared to maintain the boundary before you set it. The first time you do this, you are taking a major step in your recovery. Be sure to spend some time with someone who will support you setting a boundary.

“I’ve been suffering for years,” Marcelle said. “When I tell Andrew that he’s hurt my feelings, he gets angry. Can you imagine that? What kind of human being gets angry when he sees his wife crying?”

This is a good question, and one that I get asked often. The answer is that a person like Andrew, who gets angry at being told that he has—once again—done it wrong, is a human who has never heard a word of praise and experienced more criticism in his life than he knows what to do with.

Such a person—often, but not always, a man—is highly conflicted. In moments when he does not feel put on the defensive, he cares deeply for his wife, loves her, and doesn’t want her to hurt. On the other hand, when he thinks he’s being attacked, he reflexively circles the wagons to protect himself.

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“So finally, I got good and angry myself,” Marcelle went on. “How much of this can I take? I get mistreated and I can’t even express myself. That’s not right! That’s not fair! I deserve better, so I told him a thing or two. I let him have it. And, frankly, I felt much better after that.”

That’s a typical pattern—and highly destructive.

The Elusive Satisfaction of Retaliation
Marcelle has every justification in the world to feel hurt. It is also human for her to be angry at the cause of that hurt when he is so unsympathetic. But her reaction in this scenario is wrong. For one thing, she’s hurting herself more by lowering herself to his level. If she acknowledges that his anger is hurtful, then her anger is hurtful too. If she acknowledges that anger displays a lack of humanity on his part, then it displays a lack of humanity on hers as well.

Later, alone with her feelings, Marcelle will confide that the good feeling of “giving it back” was short lived. Over time, the idea that she had betrayed herself by stooping to his level gnawed at her innermost being. She had always liked herself for her own kindness and goodness. “Now who am I?” she wondered. Not only did she reduce herself to a level that she did not respect, but in doing so, she also became alienated from herself.

Many victims of mistreatment feel this way. They feel estranged from the person they thought they were, they don’t like the person they’ve become, and they’re still depressed over the way they were treated. They add depression to depression. Being mean and striking back is completely self-defeating.

How Retaliation Makes Bad Behavior Worse
There’s another, even worse problem with Marcelle’s reaction: it ensures that Andrew’s behavior will also get worse. Now that’s bad.

Andrew doesn’t want to be the bad guy that he is, but he has no clue how to make the awful feelings go away when he is repeatedly reminded of his failings. When he hears what comes across to him as a criticism, he is thrown into a pit of despair. After all, if he knew how to handle the problem in the first place, he would not have created it. Growing up in a home in which such things as compassion, sharing, consideration, and respect were not taught or modeled, he is unaware of how to deal with situations which call for these traits. How can he fix a problem he’s clueless about?

But Andrew does know the one thing he learned very well growing up: how to defend himself, strike back, or tune out. It’s only natural that when he feels attacked, he’s going to do what it takes to prevent those old feelings from rushing in. What better smokescreen than for him to attack back?

Will he feel better? No, just as Marcelle didn’t feel better when she retaliated. Will the marriage improve this way? Obviously not. What should be done?

Alternatives to Retaliation
Marcelle has to switch her approach from telling Andrew what he did wrong to what she wants him to do. It means changing a negative sentence to a positive one. This might not seem hard to do, but listen to what Marcelle has to say about it: “What about my feelings? Are you telling me to stifle my feelings? He’s my husband; shouldn’t I be able to tell my own husband that he hurt my feelings?”

Marcelle has a point. She should not have to stifle her feelings; she should be able to express them to her own husband. But we are not operating in a fair and just world. Her husband simply cannot hear this until he has healed from his past pain.

So Marcelle’s real job is to deal with her “shoulds.” Theoretically, she should be free to express herself, and in reality, she shoots herself in the foot when she does. What are Marcelle’s options?

• Marcelle has to make a list for herself of healthy ways to self-soothe such as doing affirmations, practicing relaxation and deep breathing, getting sufficient sleep and exercise, and deriving pleasure from her work and daily tasks. She can also journal or talk to a marriage counselor who is pro-marriage. All of these serve both as channels for her bad feelings and as ways to empower herself to feel good, despite the tough hand that she was dealt.

• Marcelle should learn to assertively ask for what she wants in very specific terms, such as, “When I come home with groceries, please help me with them, and please smile at me when you do.” She herself should be pleasant and smiling when making these requests. Andrew did not have the benefit of learning how to handle interpersonal relationships growing up, so part of his attraction to Marcelle was that she was so skilled at them. He is actually looking to her for a way out of the labyrinth. Furthermore, by being pleasant in her request, she is also modeling the very behavior she wants—and putting in a teaspoon of sugar to make the medicine go down.

Retaliation is not one of Marcelle’s options, but she will find that if she follows the options above, she will be empowered and happier, even before Andrew has started to “get it.” Eventually, he will “get it” and then they will both be happier.

Autism is the general term for a spectrum of developmental disorders that begin in early childhood. People with this disorder may have difficulty socializing, understanding emotional cues, or functioning in daily life. People with autism are not, as was once thought, intellectually impaired. In fact, many children and adults with autistic disorder show remarkably high intelligence in a variety of areas. Despite years of research, scientists are still not able to explain what causes autism, much less develop preventative measures or cures. The best approaches we have for helping those with autism are therapy and behavioral counseling. The goal of such therapy is to keep behavioral symptoms under control and improve the overall quality of life.

Children with autism show different signs and symptoms. Some are completely withdrawn, seemingly trapped in their own consciousness. Others are very outgoing but oblivious to the social or emotional needs of those around them. Among all behavioral symptoms, aggression towards oneself and others is the most troubling. In two controlled trials, the antipsychotic medication Abilify (aripiprazole) was shown to significantly reduce aggressive outbursts and mood variability in children aged 6 to 17 years.

In most instances, Abilify represents a good choice for modifying aggressive behavior. Adverse side effects reported from the trials included sedation, fatigue, and vomiting. These side effects typically occurred in the first week or two of taking the medication and faded with time. About 10% of patients in the trials discontinued Abilify because of adverse effects, compared with 7% for placebo. In the long term, the most commonly observed side effect was weight gain, which also plateaued after several weeks. Physical activity and a well-managed diet may offset some of this weight gain. In a 52-week trial, the effectiveness of Abilify at reducing irritability appeared unchanged. This finding is encouraging, as the benefits of some psychotropic drugs have been shown to diminish after prolonged use.

Stabilizing the emotional states of children with autism is an important goal for therapists and parents. When the child is calm and responsive, talk therapy and other interactive activities can be more meaningful and effective. Aggressive outbursts and irritability lead to a poor quality of life for the child with autism. Although a cure may still be a long way off, Abilify has proven that it can help improve quality of life for autistic children who exhibit anger and aggression toward themselves and others.

References
Curran, M. P. (2011). Aripiprazole in the treatment of irritability associated with autistic disorder in pediatric patients. Pediatric Drugs, 13 (3), 197-204.

This article is part of a series that explores the ways specific “clusters” of depression symptoms manifest to create different experiences of depression. The previous article in this series discussed the hopeless experience.

The irritable or angry experience of depression is often not recognized as depression, either by the person who experiences it or by those around then. For the person experiencing this kind of depression, the people around them may seem disappointing, irritating, or intolerable, and the depressed person may feel as emotionally uncomfortable as someone with severe poison oak feels physically. They may feel very frustrated that they can’t get the people who seem to be causing their suffering to change. People around the angry or irritable depressed person may see them as mean, angry, or a bully. It may not even occur to onlookers that this person could be depressed.

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Irritability and Anger in Men and Women

I believe men and women may express this experience differently. Many men feel a great deal of pressure not to cry or express vulnerability, so when they get depressed, anger can be a more acceptable way to experience the emotional pain they’re feeling. Men may also feel more pressure to not feel anything, and so turn to drugs and alcohol when they’re in emotional pain to try to numb themselves. So while we associate crying with depression, men may not cry and yet be just as depressed as those who do. I believe this is the main reason women are diagnosed with depression nearly twice as often as men are: many men who are depressed aren’t getting the help they need.

When men are depressed and express it as anger, violence, or addiction, the consequences may further distract from getting the help they need. These consequences can be extreme, like jail or chasing a high, but they may also take the form of loneliness and isolation after alienating people. Self-hate may grow inside as depression festers, and the consequences of anger create more and more to hate.

Women are certainly not immune to experiencing depression as anger. Often in women it comes out as irritability, particularly with their children. This too may go undetected because sometimes, only their children see it, and children rarely call a therapist for their mother.

How Anger Manifests

There are two types of anger:

1. One is a response to something hurtful or unfair happening to or around the person who feels angry.
2. The other is a protection against feeling something more vulnerable.

When someone has been abused or traumatized, they certainly have reason to be angry and often don’t have a chance to express it when the trauma occurs. So anger may linger as a symptom of posttraumatic stress or may become incorporated into a person’s personality over time. When that happens, people feel angry a great deal of the time, and the anger isn’t just anger anymore—it becomes a way of life. It’s probable the anger develops this way in order to protect the person from further abuse and from the painful feelings of sadness, hurt, and fear that were also a part of the traumatic experience.

Classic examples of depression expressed as anger include veterans who come home from combat with the experiences of terror of imminent death, sadness from losing friends who were killed, and systematic emotional training to channel all these feelings into anger, revenge, and warfare. Coming home with all of this, it’s not hard to understand why a veteran would be depressed, or why they would express it through domestic violence, picking fights, or even just caustic cynicism. Police officers can have a similar experience, as can people who grow up with angry or sadistic parents who repeatedly abuse them. Even people whose parents used them for their own needs, without concern for their child’s emotional needs, may carry chronic anger that covers the hurt, sadness, and fear.

The Roots of Anger and Depression

In fact, anger almost always covers or is accompanied by hurt, sadness, or fear. When anger is helpfully expressed and begins to resolve, it almost always dissolves into tears and more vulnerable feelings. Usually, as long as a person sticks with the anger, they are stuck in the depression.

One way to look at this is that “frozen” feelings are often at the root of depression. Someone who feels and/or expresses only anger probably has frozen hurt, fear, shame, guilt, or sadness. Someone who never feels or expresses anger may have frozen anger. In either case, the person may be depressed and suffering and probably will continue to suffer until their frozen feelings are safely unlocked, expressed, and resolved.

While feelings of anger caused by depression can feel overwhelming, the support of a therapist helps many people work through these feelings and address their depression in a healthy way. Start here to find a therapist near you who can help.

Steroid use is believed to cause rage, commonly referred to as “Roid Rage.” But a new study suggests that the anger resulting from increased levels of testosterone may actually merely be a means to an end. “The link between aggression and testosterone has sparked the interest of many kinds of people, from a fan wondering whether anabolic steroids might be responsible for his favorite athlete’s wild antics to the scientist hypothesizing about the biological processes involved in violence,” said Carly K. Peterson and Eddie Harmon-Jones, researchers from Texas A&M University and authors of the study. “Instead, researchers now believe that testosterone plays a role in a broader picture involving power and dominance as opposed to aggression per se. That is, testosterone may facilitate behaviors aimed at obtaining and maintaining power and dominance. It is possible testosterone relates to aggression only because aggression can be one of many ways that people attempt to exert control over others.”

The researchers enlisted 43 students for their study and took saliva samples at the beginning of the study to measure cortisol and testosterone levels. The students were given a neutral activity for 5 minutes, followed by a stressful, competitive virtual game. They were led to believe they were competing with other people and the game was designed so that the students were included during the play for half of the game, and completely ostracized for the other half, causing them to experience heightened emotional arousal. At the end of the game, the students measured their emotions. Within fifteen minutes of the game ending, the team collected a second saliva sample. The results revealed that anger was the only emotion that was linked to increases in testosterone. The team believes that the participants needed to be included and dominate the game as a result of higher levels of testosterone. They added, “Although we believe that a motivation to regain control may assist in explaining the observed correlation between self-reported anger and testosterone, future research is necessary to elucidate the precise mechanisms underlying the link between anger and testosterone.”

Reference:
Peterson, C. K., & Harmon-Jones, E. (2011, September 12). Anger and Testosterone: Evidence That Situationally-Induced Anger Relates to Situationally-Induced Testosterone. Emotion. Advance online publication. doi: 10.1037/a0025300

I recently stumbled across a new blog called Infinite Daze where the author poignantly writes about her daily struggles with Fibromyalgia and Chronic Fatigue Syndrome (CFS).  In a recent post titled Should I Stay or Should I Go Now, she has this to say about her marriage:

“I had a revelation today. During my son’s graduation ceremony at his high school, my husband came up to me and squatted down next to my wheelchair to share a story with me. Without thinking I ran my hand over his hair and down his arm. I’m still in love with this guy. He can be very nice. He can be very sweet. I married him because of this. This is why I find his behavior so baffling. I’ve known this guy just shy of 25 years. That is a long time. The meanness, the temper tantrums, the spitefulness is all new. I’ve never seen this in him before. Living with someone for 25 years means this isn’t behavior that has been hidden away. It is brand spanking new. It is why I’ve been blindsided with it. I so didn’t see this coming. It also makes the whole idea of divorce so messy. If he was always nasty this would be a no-brainer. I would up and leave in a heartbeat. But he swings hot and cold. One day he is super nice to me; takes good care of me and even gives me hugs. The next day he is slamming doors and telling me he wants out. I am so very confused.”

Ever feel like you’re living with Dr. Jekyll and Mr. Hyde? Your partner is warm, loving and compassionate one moment and angry, silent or indifferent the next.  What’s up with that? You’ve most likely rubbed your partner’s “raw spot.”

We all struggle with vulnerable feelings in love whether we want to admit it or not. It’s inevitable that we will hurt each other with careless words or selfish actions. While these occasions sting, the pain is often fleeting and we get over it quickly. But according to Dr. Sue Johnson, founder of Emotionally Focused Therapy, almost all of us have at least one hypersensitivity – a raw spot in our emotional skin– that is tender to the touch, easily rubbed, and deeply painful.  When this spot gets rubbed often enough, it can bleed all over our relationship.

For those of us in chronic marriages, this hypersensitivity can emerge seemingly out of nowhere at the onset of our illness when the need for support from our partner is particularly intense, but it doesn’t come. When our need for attachment and connection is repeatedly neglected, ignored or dismissed, it results in two potential raw spots: feeling emotionally deprived or deserted/abandoned.

I know my raw spot rather well. When I hear a tone of impatience in my husband’s voice (chronic illness-related or not), I get angry and defensive. It sends me back to days when my father would dismiss me as not being important or worthy enough of his time. My father’s impatience was his way of disconnecting from the relationship. This experience made me hypersensitive – impatience signals emotional abandonment to me.

Many of us have no idea what our own raw spots are, let alone our partners’.  We simply get caught up in the same old vicious cycle of petty squabbles and conflicts when in actuality they are symptoms of a raw and tender spot on our emotional skin.

So how do you identify your raw spot?

Think about a time in your marriage when you got suddenly thrown off balance, when a small response or lack of response suddenly seemed to change your sense of safety or connection with your spouse, or when you got totally caught up in reacting in a way that you knew would spiral you into your usual dysfunctional pattern of relating. Maybe you are aware of a moment when you found yourself reacting very angrily or numbing out.

Let’s unpack this incident:

• What was happening in the relationship?  What was the trigger that created a sense of emotional disconnection for you?  What was your general feeling in the split second before you reacted and got mad or numb?  What did your spouse specifically do or say that sparked this response?
• As you think of a moment when your own raw spot is rubbed, what happens to your body?  You might feel spacey, detached, hot, breathless, tight in the chest, very small, empty, shaky, tearful, cold, on fire.
• What does your brain decide about the meaning of all this?  What do you say to yourself when this happens?
• What did you do then?  How do you move into action?
• See if you can tie in all these elements together by filling in the blanks below:

In this incident, the trigger for my raw feeling was _________.  On the surface, I probably showed _____________.  But deep down, I just felt (pick one of the basic negative emotions, sadness, anger, shame, fear).  What I longed for was ___________.  The main message I got about our bond, about me or my love was _________________.

Here are some common scenarios:

You experience a flare-up and it’s worse than usual. You are really struggling and looking for support and empathy from your husband.  He begins to suggest ways you can get your flare-up under control. You hear his suggestions as him lecturing you. In your head you say to yourself, “He’s judging me.  He’s not with me in this. I have to do this all on my own. My need for support doesn’t matter. This is scary”.  What happens next? You start yelling and tell him he’s a jerk and you don’t need his help anyway.

Or how about this scenario?

Your husband asks you to watch a movie with him on the couch after dinner. Your head is pounding from a migraine and you tell him you’re tired and going to bed. The next morning you ask him if a certain outfit looks good on you. He says “it’s OK but since when does my opinion really make a difference here? Wear what you want. What I want is irrelevant.” Still stuck in feelings of rejection from the previous night, his sadness over lack of connection with you force him into withdrawal and giving you the silent treatment.

In both scenarios, rage and withdrawal mask the emotions that are central in vulnerability: sadness, shame, and most of all, fear.

If you find yourself continually stuck in an unhealthy pattern of relating with your spouse, you can bet it is being sparked by attempts to deal with the pain of a sore spot, or more likely, sore spots in both of you. And unfortunately, your raw spots almost inevitably rub against your spouse’s. Rub one in your spouse, and his or her reaction often irritates one in you.

What’s the dead giveaway that tells you your raw spot or your spouse’s raw spot has been hit?

First, there is a sudden and radical shift in the emotional tone of the conversation. You and your spouse were joking just a minute ago, but now one of you is upset or angry, or, conversely, aloof and cold. You are thrown off balance. It’s as if the rules changed and no one told you.

Second, your spouse’s reaction to a perceived offense seems way out of proportion.

These signs are all about attachment needs and fears popping up. They are all about our deepest and most powerful emotions suddenly taking over. We get set to move in a particular way, toward, away from, or against our spouse. This readiness to act is wired into every emotion. Anger tells us to approach and fight. Shame tells us to withdraw and hide.  Fear tells us to flee or freeze, or in real extremes to turn back and attack back. Sadness tells us to grieve and let go.

All this happens in a nanosecond.

Stopping these destructive patterns depends not only on identifying and stopping our unhealthy ways of relating but also on finding and soothing our raw spots and helping our spouse to do the same.

Here’s how you do just that:

1. Stop the Game – one or both of you has to say “Can we stop this?  This is the place we always go.  We get trapped here and we end up totally exhausted and defeated.”
2. Claim Your Own Moves – together come up with a short summary of your moves.  e.g. you lose it while your spouse pretends not to be affected; you get louder and threaten; your spouse sees you as impossible and withdraws.
3. Claim Your Own Feelings – talk about your own feelings rather than focusing on your spouse and blaming everything on him/her.
4. Own How You Shape Your Partner’s Feelings – Recognize how your usual way of dealing with your emotions pulls your spouse off balance and turns on deeper attachment fears.
5. Ask About Your Partner’s Deeper Emotions – Look at the big picture and slow down a little.  Begin to be curious about your spouse’s softer, underlying emotions, rather than just listening to your own hurts and fears and assuming the worst about your spouse.
6. Share Your Own Deeper, Softer Emotions – Although voicing your deepest emotions, especially fears around not being connected or attached to your spouse, may be the most difficult step for you, it is also the most rewarding.  Let your spouse see what’s really at stake when you argue.
7. Stand Together – Take the above steps and forge a renewed and true partnership.  You now have a common ground and cause.  You no longer see each other as enemies but allies.  You can take control of escalating negative conversations that feed your insecurities and face those insecurities together.

Content for this article has been adapted from the book Hold Me Tight by Dr. Sue Johnson.