Being a supermom can be very stressful. Here are strategies to help mothers manage stress.

Mothers are the world's best jugglers: family, work, money—they seem to do it all. However, all that responsibility can often leave moms feeling overstretched and stressed out. According to a 2006 survey by the American Psychological Association (APA), women are more affected by stress than men and report engaging in unhealthy behaviors such as comfort eating, poor diet choices, smoking, and inactivity to help deal with stress. The same survey showed women report feeling the effects of stress on their physical health more than men. With Mother's Day fast approaching, it's a good time for moms and their families to recognize the importance of addressing stress and managing it in healthy ways.

"How a mother manages stress is often a model for the rest of the family," says APA psychologist Lynn Bufka, Ph.D. "Other family members will imitate her unhealthy behavior."

Women are also more likely to take on the high-anxiety role of health care manager for the family. APA 2006 survey results indicate that stress is higher among family health care decision makers—17 percent of people who report being the primary health care decision-makers are very concerned about stress versus 11 percent of those whose spouse or partner takes care of these matters—and that women disproportionately serve that role for their families (73 percent versus 40 percent of men).

"It's particularly stressful to be the family's health manager, making health care decisions for yourself, your children, and possibly aging parents," says Bufka. "People who handle stress in unhealthy ways may alleviate symptoms of stress in the short term, but end up creating significant health problems over time, and, ironically, more stress."

APA offers these strategies to help mothers manage stress:

• Understand how you experience stress — Everyone experiences stress differently. How do you know when you are stressed? How are your thoughts or behaviors different from times when you do not feel stressed?
• Identify stressors — What events or situations trigger stressful feelings? Are they related to your children, family health, financial decisions, work, relationships or something else
• Recognize how you deal with stress —Determine if you are using unhealthy behaviors to cope with the stress of motherhood. Is this a routine behavior, or is it specific to certain events or situations? Do you make unhealthy choices as a result of feeling rushed and overwhelmed, such as stopping for fast food while running errands or picking up your kids? Put things in perspective—make time for what's really important. Prioritize and delegate responsibilities. Identify ways your family and friends can lessen your load so that you can take a break. Delay or say no to less important tasks.
• Find healthy ways to manage stress — Consider healthy, stress-reducing activities—taking a short walk, exercising, or talking things out with friends or family. Keep in mind that unhealthy behaviors develop over time and can be difficult to change. Don't take on too much at once. Focus on changing only one behavior at a time.
• Ask for professional support — Accepting help from supportive friends and family can improve your ability to persevere during stressful times. If you continue to feel overwhelmed by stress, you may want to talk to a psychologist who can help you manage stress and change unhealthy behaviors.

"Mothers often put their family needs first and neglect their own," says Bufka. "It's okay to relax your standards—don't put a lot of pressure on yourself to have the "perfect" house or be the "perfect" mother. No one expects you to be Superwoman."

Source: American Psychological Association

I'm one of those people who cut. A self-injury cutter.

I started cutting myself, self-injury cutting, when I was 9 years old. It was the beginning of fifth grade for me. It should have been a good year. I got to wear a new uniform, a skirt and blouse instead of a childish jumper. I was one of the upperclassmen in the small school, and one step closer to 8th grade when I would graduate, get out of there and move on to high school. But that year, in September, my grandmother was killed by a drunk driver. I had a special relationship with her that's hard to explain. I always knew that she understood me better than anyone, even my parents. When my mother wanted me to have more friends or different friends or to be more social, my grandmother told her that she would have to accept me the way that I was because I was never going to be like the other kids. She told my mom that as long as I was happy, there was nothing to worry about. My parents were good about a lot of things, but somehow Mommom always understood me better. When she died, it seemed like I lost more than just a grandmother. I lost a friend, a confidant and a mentor.

My dad woke me up the morning after she died. It was early, before my alarm clock had gone off. I remember his exact words.

"Lauren," he said. "You have to get up now. Mommom's dead. It's okay to cry." Just like that. Bang. Reality check. A hard thing for a father to have to tell his child, I'm sure. I believed him, but it didn't seem real, not when I went to the viewings or to the funeral or when my parents went to court to testify against the drunk driver. I knew what dead was, but I couldn't apply it to my Mommom. Then, one day, I realized dead meant that no one would ever understand me ever again. At least that's how it felt.

How I Became "One of Those People Who Cut"

That night, I sat in the basement, in front of the TV, took my good old Swiss Army knife out of my pocket and cut myself, a diagonal cut on the back of my left arm. I don't know what made me do it, or why I thought that it would make me feel better, but it did. It made me feel strong and it made me forget my sadness. I didn't know exactly what I had done or the potential ramifications, but I knew that I couldn't tell my parents. They had other things to worry about.

I didn't cut myself again until high school. I cut myself twice in the 4 years that I was in high school, and I don't remember being particularly upset or emotional at the time. I just needed to know that I could still do it, that I was still strong enough. I remember friends talking about eraser burns on their hands, but I didn't consider it the same as what I did. I didn't think that I was doing anything at all, certainly not anything that had a name or that was potentially addicting. I know differently now, of course.

Cutting Made Me Feel Strong, In Control

When I went away to college, it got much worse. I was becoming a full-fledged self-injury cutter. I don't know if it was just the stress of trying to adapt to being away from home, or always feeling like I wanted to cry, or not having anyone to talk to that made me feel so weak and vulnerable. But I knew that cutting made me feel strong and in control and in some ways worthwhile. Late at night, alone in my room, it would make me feel better, stronger than the girl who was afraid of so much, who always wanted to cry. I'd cut a slash into an arm or leg or wrist, cut until I'd forget about everything but the cut. The pain didn't bother me; the blood didn't bother me. Surely this meant that I was strong. I would do the same the next day and the next, cutting in the same place. As I felt better about myself, I would let the cut heal a day and then cut it open again, then maybe wait two days until I cut it open again. Slowly it would heal, until the next time I felt like my emotions and my fear were getting the best of me. Because of this, I don't have a lot of scars, but the self-harm scars that I do have are fairly obvious.

A Self Injury Cutter. Explain That!

I lived in a dorm on campus for 2 years. I guess it was inevitable that one of my roommates would find out about it. I mean, how many boxes of bandaids and gauze pads can a normal person use anyway? Near the end of my sophomore year, my roommate found out I was a self-injury cutter. I didn't particularly like her anyway, so she was the last person that I wanted to know. But she took a picture of me one day. She just knocked on the door and as soon as I opened it, she snapped the picture. A lovely picture of me with a very startled look on my face, and my right hand holding open the door, wrist facing the camera, cuts for all to see. It was careless of me, and I can't help but smile sarcastically as I'm thinking about it now. I should have known better than to wear short sleeves in my own room. So she confronted me about it later and when she showed me the picture, I admitted it. Yes, I was a self-injury cutter.

I tried to explain as calmly as I could, even though I was frantic with worry. People finding out has always been one of my worst fears. I told her that yes, sometimes I cut myself. I am very careful. I have never been suicidal. I don't want anyone to know. And I looked at my watch and realized that I was going to be late for an English class. I told her not to do anything, that I'd talk to her more after my class.

I wish I had read something about how to talk to someone about self-injury. I think that maybe it would have turned out better if I had skipped the class, because, of course, she panicked and told the Resident Assistant (who is just a graduate student that gets free room and board for living in the dorm and keeping the rest of us in line). The RA called me into her office that evening and told me that I would have to get counseling at the university counseling center or I would be kicked out of the dorm and be put on behavioral probation until I either graduated or complied. It may not seem like much of a threat, but I was terrified. I couldn't get kicked out of the dorm. How would I explain that to my parents? And behavioral probation - I was a good student in class and in the dorm. I followed the rules to the letter. I didn't want that on my record.

So I went to the counselor, an older man with long bushy grey hair and wire-rimmed glasses. It wasn't as bad as I expected, but it wasn't very good either. I signed a paper insisting that the only information that could be released if anyone asked was that I was there, so that was one less thing to worry about. And once I managed to convince him that I wasn't suicidal, he spent the rest of the hour pretty much telling me stuff that I already knew. He told me that I could be institutionalized for doing what I was doing, which is certainly incentive to at least pretend to recover in a hurry. Basically, he said that I should stop self-injuring because there are better and healthier ways of dealing with things. So I went for a few months until he decided that I wasn't being helped and that since I wasn't going to kill myself, I was okay. I have to admit that I didn't put forth my best effort either. I didn't want to be there, and I made sure that everyone knew it. My roommate moved out not long after she found out about my little secret, and the next year I moved into a one-room apartment off campus, one of the best decisions that I've ever made.

People Who Cut Need Understanding, Support

That roommate was only one of several people that have known about my self-injury. A few I told willingly. Others found out on their own. Of all the people that have known, Angela and Kelly by far handled it the best. They were my best friends in college and they probably know more about me than anyone, second only to my boyfriend. When I told them that I cut myself, they didn't panic or refuse to see me again. Instead, they went to the library and printed out as much information as they could get off of the internet. This was when I realized that I didn't have to deal with it all alone. Not only did other people have the same problem, but I had friends that were willing to learn about it by my side. (see Reactions to Self-Harm Disclosure Important)

Self-Injury Cutter, Why?

in her own words

Why do I self-harm? I cut because cutting makes me feel strong and in control when emotions make me feel weak and vulnerable. It's a way to punish myself for getting emotional. It's a way to distract myself from things. It's a way to prove to myself that I am strong when things make me feel weak and vulnerable. I think that if pain and blood don't bother me, then that makes me strong, and I want to be strong more than anything else. It's a way of getting myself accustomed to the pain. It may hurt, but I need to know that I can take it, because I want to be tough and self-sufficient and in control. Those are all reasons that I self injure. I don't want people to know that I cut myself intentionally; that's the last thing that I want people to know about me, but sometimes I want people to see the cuts, to see the scars. It makes me think that that's how I can show people how strong I am. And that makes me feel guilty, because that's asking for attention in a way, and I shouldn't have to do that. Also along the lines of people seeing the results of my self-injury, sometimes I want people to notice so that they'll worry.

Before you start thinking that I'm nothing but a manipulative self-centered attention-seeker, lemme finish. I hate guilt, and nothing makes me feel guiltier than knowing that someone is worried about me, especially if its someone that I love and care about. I don't want people to worry about me. How am I? I'm fine. I'm always fine, but there's a part of me way in the back of my mind somewhere that equates worrying with caring. Logically, I know that the two don't have to go hand-in-hand. You can care without worrying, but I can't tell someone that I'm not fine, because then I'll feel bad for whining and complaining. But if I cut myself, let's call it an accident because as far as anyone is concerned that's what it is, then people can see that something is wrong without me telling them anything. It's not what's really wrong. It's not what I want them to worry about, but at least if they notice, and say something, then I know that they care. It's a twisted way of thinking, I realize that, but I don't know quite how to change it.

And I guess I cut sometimes because I hate myself, or I hate the way I feel and act.

Self-injury is an addiction, and like other addictions, sometimes I do it for no good reason at all. There's no specific trigger, I just want to and I can't think about anything else until I do. More and more often, I can't pinpoint my reasons for cutting except to say that I felt like I had to do it. This is scariest for me because its more random, less in control, less easy to explain.

Ed. Note: If you're wondering why you self-harm, this self-injury test may help. And if you're thinking of telling a friend, parent or loved one, this article on how to tell someone you self-injure may help.

I think it is very simple. The answer is not complicated at all. What I call "the masters of marriage" are individuals who are being kind to one another. They may raise difficult issues, but they also soften them in a very considerate way. They frequently express appreciation. They communicate respect and love every day in numerous small ways. There are so many more positive exchanges in these relationships than those that are heading for divorce.

These individuals show more affection for each other, and they communicate greater interest in one another, and use more humor. They scan their environment, looking for opportunities to say "thank you" rather than searching for mistakes the other person has made. They look at their partner through a different filter. It is a much more positive one. That turns out to have very powerful implications.

The other thing they are doing, is they are very mindful of people trying to reach out and connect with them (i.e., what I call "making bids"). The couples in our laboratory that turn out to have long happy marriages are responding to 96% of their partners' bids for attention, by turning toward them with attention. That is a huge amount.

In contrast, couples headed for divorce are responding only 30% of the time. Robinson and Price found the same thing when they studied positive interaction in couples. Unhappily married couples were not noticing 50% of the positive things their partner was doing. The observers could see the positive behavior, but the spouses were not seeing it. What this means is, that for a lot of unhappy couples you do not have to change their behavior at all; you just have to get them to see what is actually going on.

To make marriages work is really quite simple. Explained in my book, The Seven Principles for Making a Marriage Work (co-author Nan Silver, Crown Publishers, 1999).

In addition, the following components are also important to successful long term relationships for couples.

1. They are gentle with each other.
2. They spend time in and enjoy conversation with each other.
3. They allow for influence by their partner.
4. They do keep score by remembering the good things their partner does for them.
5. Each partner knows themselves reasonably well.
6. Each partner honors the other's dreams.
7. There is a positive sense of humor in the relationship.
8. There are shared goals and a sense of teamwork in the relationship.
9. There are good conflict resolution skills in the relationship. (Sometimes this means doing something, and sometimes it means lettings things take care of themselves.)
10. There is a sense of continued romance in the relationship.
11. Contempt, for the partner, in all its forms, will more than anything else bring the relationship down. It needs to be avoided or worked through.

Depression is perhaps the most widely studied psychiatric complication of any medical illness, including HIV. Many people, doctors and patients alike, think of depression as a natural consequence of having a chronic or terminal illness. Yet being depressed is not part and parcel of being ill or facing an illness. In fact, people meet the emotional challenges and adjustments of illness in a myriad of ways. Major depression is a potentially severe complication of HIV. This article reviews what major depression is, how to recognize it, and various forms of treatment.

What is Major Depressive Disorder?

Major depression, also called major depressive disorder (MDD), is a clinical illness far more serious than daily parlance would suggest. Everyone's said or heard someone say, "I'm depressed today." This is usually not major depression, but rather a temporary feeling of sadness, discouragement, or grief, which everyone has from time to time. These mild versions of depressive symptoms are familiar to most people and make up the experiences of everyday life. Most everyone has felt sad, grumpy, or irritable, been distracted or disinterested, not felt like eating, or indulged in excessive eating or sleeping as a reaction to bad news or events. Major depression includes these symptoms and a subjective experience of being sad, unhappy, or dissatisfied, but these feelings are magnified, persistent, and nearly unremitting. They are not passing feelings, but instead they seep into every area of life and rob the individual of the ability to experience pleasure and joy, of desires and motivations. The perspective of the person who suffers major depression is so distorted that the proverbial glass is not only half-empty, but will never be full and may even be broken and dangerous.

Major depressive disorder as a clinical disorder is defined in the Diagnostic and Statistical Manual (DSM-IV). The DSM-IV identifies different clinical entities comprised of groups of symptoms that are statistically validated and reproducible. This system was developed for use by researchers to provide consistency in nomenclature. Thus, when one research describes major depression, other researchers know that this involves certain symptoms and, for the most part, implies certain generally agreed upon potential biological and psychological etiologies, family history profiles, prognosis and response to certain treatments. The DSM-IV is the reference most commonly used to make a psychiatric diagnosis.

Diagnosis of MDD

The diagnosis of major depressive disorder generally must be made by a trained medical professional and requires the presence of at least five of nine symptoms occurring together, most of the time for a period of at least two weeks. The person must experience depressed mood and/or markedly diminished interest or pleasure in activities; and three or four (for a total of five symptoms) of the following:

• Significant unintentional weight loss or gain
• Sleep disturbance including insomnia or hypersomnia
• Psychomotor retardation (a slowing in thinking or movement) or agitation
• Loss of energy or fatigue
• Feelings of worthlessness or excessive or inappropriate guilt
• Decreased concentration
• Recurrent thoughts of death or suicide

Thoughts of death and suicide alarm many people. Most people who are diagnosed with a chronic and potentially life-threatening illness have increased thoughts of death during the course of their adjustment, or repeated adjustment, to their illness or diagnosis. It is often a natural part of facing one's mortality. If these thoughts are pervasive, unrelenting, intrusive, or even particularly bothersome, then it is wise to seek mental-health consultation and treatment. Thoughts of suicide can reflect an individual's desire to gain control in the face of loss of control because of illness. These thoughts, however, may be a sign of a more severe depression and also merit professional evaluation. If the thoughts are accompanied by a plan and intent to act on them, a severe depression is more likely and urgent psychiatric evaluation is indicated. Researchers have studied suicide and the desire for death in people with HIV and they have concluded that in the overwhelming majority of cases, these thoughts and feelings change when the person is treated for depression.

Physical symptoms of major depression

It is important to note that the symptoms of MDD include not only mood- and emotion-related symptoms, but also cognitive and somatic, or physical, symptoms. Indeed, diagnosing major depression in the context of a medical illness like HIV disease can be complicated by the presence of physical symptoms. Thus, when making the diagnosis of major depression in a person with HIV, it is important that the doctor be very familiar with the physical manifestations of HIV disease as well as with the manifestations of depression.

The diagnosis of MDD in the context of a medical illness is the subject of a fair amount of study among consultation-liaison (C-L) psychiatrists (psychiatrists who specialize in working with people with medical illnesses). Clearly, physical symptoms from an illness can be mistaken for physical symptoms from depression. There are several ways of approaching this problem. The symptoms that can be attributed to a medical illness can be included in the diagnosis, thus leading to overdiagnosis of depression, or they can be excluded, thus risking underdiagnosis. A third approach to control for over- or underdiagnosis is to substitute other signs for symptoms that can be attributed to the underlying illness. For example, a tearful or depressed appearance can be substituted for appetite or weight change. Specific substitutions, known as the Endicott Substitution Criteria, have been researched but are not standardized like the DSM-IV criteria. In studies of the various approaches to diagnosis, it seems that the most important factor is that the physician or mental health provider is very familiar with the physical, neuropsychiatric, and psychological manifestations of the illness

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HIV-related illnesses that mimic symptoms of major depression

Because major depression has so many physical manifestations, there are, in fact, certain physical conditions that mimic major depression. Common culprits in HIV disease include anemia (significantly low red blood cell count or hemoglobin) and, in men, hypogonadism (significantly low testosterone). When there are concomitant affective (mood) symptoms that resolve with treatment of the underlying condition (such as getting a transfusion for anemia), then the person is generally considered to have a mood disorder secondary to a general medical condition and not major depression. HIV itself does not cause MDD, but complications, such as a very high viral load, often contribute to illness feelings that may mimic MDD.

Under these circumstances, how is the person with HIV supposed to know if he or she has major depression? In its severe forms, MDD is usually easy to identify. But often issues like stigma and prejudice, and even simply lack of information serve as obstacles to identifying the problem. Frequently, behaviors that reflect low self-esteem, shame, and guilt often increase the chances of high-risk activities. These activities, such as drug and alcohol use, and unsafe and high-risk sex, may be attempts to ward off or defend against the unpleasant feelings of depression. Many people seek an emotional escape or a feeling of disinhibition through drugs, alcohol, and sex. An honest, but often difficult, appraisal of the role these behaviors have in your life may reveal an underlying depressive disorder.

Seeking Help and Getting Treatment

Where is the person with MDD to seek help? Remember that MDD is a clinical disorder and not a natural consequence of illness or diagnosis, but it will complicate your ability to get and adhere to treatment. Thus, when seeking information or help, a consultation with your primary care provider is a good place to start. Providing information and asking a healthcare professional for his opinion is part of your job as a patient. He can help begin an evaluation that may lead to more specialized care from a mental health professional. Most primary care providers are comfortable referring their patients to a small number of mental health professionals who they know and recommend. Feel free to ask for a recommendation. Of course, seeking treatment directly from an individual therapist or a mental health clinic is a good alternative. It is quite reasonable to seek out a consultation, as opposed to committing to treatment, from a mental health professional who can help determine if you are experiencing major depression and what treatment or combination of treatments might be right for you.

If you are suffering from severe major depression, you may need medications to break the downward cycle and to recover from this illness. There are, however, other potential treatments if you really don't want to take medications or you try them and can't tolerate them. Psychotherapy, where you discuss your problems and potential solutions, is an excellent treatment for depression, particularly in its mild to moderate forms. Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are two types of psychotherapy that have been studied in people with HIV or AIDS and have been shown to be effective.

Finding a therapist When looking for a therapist, many people feel intimidated and don't know where to begin. In addition to the referral sources mentioned above, be creative. Ask your friends or family, if you're comfortable with sharing your need with them, or ask some of the services available at many community-based organizations (CBOs) such as Gay Men's Health Crisis (GHMC) or the Gay and Lesbian Community Center. There are resources available for all types of people. You may be concerned about whether or not their mental health professional will be familiar with the issues associated with HIV. At this point in the epidemic, there are mental health professionals who sub-specialize in treating people with HIV, so it is possible, but not essential, to find such a therapist. While a specialist in HIV-related depression is not absolutely essential, it is extremely important to seek a therapist at least somewhat familiar with, if not an expert in, the physical and emotional complications of HIV, and also familiar with the environments and cultures which comprise high-risk populations. Often, those at risk for HIV are more vulnerable to issues of stigma and thus more reluctant to seek mental healthcare. Many potential patients or clients are concerned that, in seeking therapy or a consultation, they will be confronted with some of the traditional, but antiquated, prejudices of the mental health profession, such as prejudices against homosexuality. It is definitely outside the mainstream of accepted clinical practice to view homosexuality pathological or to try to change and individual's sexual orientation. Doing so is counter-therapeutic and often leads to worsening of depressive symptoms.

When consulting with a mental health professional, it is important to consider several factors. Foremost, you should feel that the person is a good listener. If your therapist doesn't hear you, you'll get nowhere. You should feel comfortable being with the therapist. That person should be able to answer your questions, be open to your theories and ideas, ask good questions that stimulate your thinking and self-reflection and be someone with whom you feel you can work and can trust. Therapy is a collaborative effort. It is reasonable to interview several candidates to be your therapist. Note, however, that it's probably your issue if, after more than a small handful of candidates, you can't find anyone to work with.

Antidepressants

Combining psychotherapy with medication is generally considered the optimal treatment for depression. Quite often, medication is the most readily accessible treatment for most people with HIV and a depressive disorder. Many of the currently available antidepressants have been studied in people with HIV or AIDS and all have been shown to be safe and effective. A primary care provider can often initiate treatment with an antidepressant. Ongoing treatment should, however, be supervised by a psychiatrist familiar with HIV treatments and potential pharmacologic interactions. Only people with a medical degree, an MD, can prescribe medications. If you're working with a psychologist (PhD) or social work therapist (LCSW), that person should have a working relationship with a psychiatrist who is available to you for medication consultation.

The decision to seek medication treatment should be collaborative, but it's not unusual for the HIV-positive individual in psychotherapy to resist taking steps that could lead to going on yet another medication. Consider your initial consultation with a psychiatrist as information gathering. Get her opinions about your problems and how medications may be helpful. Feel open about discussing this information with your regular therapist. Because so many people with HIV are on some form of antidepressant, many people prefer to work with a psychiatrist, as opposed to a psychologist, as a way of minimizing their number of providers. Most psychiatrists also do psychotherapy and are quite interested in providing this service in combination with medication management.

Conclusion

Major depression is a serious clinical disorder. It is not part of having HIV, but in mild forms, some of its signs and symptoms may reflect a natural adjustment to HIV as a diagnosis or illness. As with many illnesses, early detection usually leads to more rapid and complete treatment. In the end, getting treatment is your choice. The mode or combination of treatments you choose is also your choice. If your are uncertain about your feelings, changes in emotions, energy, or interests, having thoughts of death or suicide, open up to your healthcare provider. Listen to your friends and family when they say, "Maybe you should seek treatment." The information and help you get may greatly add to your quality of life or even save your life.

A board-certified psychiatrist, Dr. David Goldenberg is a staff psychiatrist at the Center for Special Studies (CSS), the HIV/AIDS clinic at the New York Presbyterian Hospital of Cornell University. He specializes in the psychiatric and psychological complications of HIV and cancer.

Dads are facing more stress than ever which can lead to mental health and health problems. Here are some strategies to help fathers manage stress.

Parenting is difficult in today's fast-paced and demanding world, and it can take a toll on one's physical and emotional well-being. With equal sharing of parenting duties increasingly becoming the norm, many men (as well as women) are experiencing the pressure of being both a breadwinner and an active care giver. Father's Day is right around the corner—it is important to recognize the challenges dads face and figure out how dads can deal with the resulting stress.

According to a 2006 APA survey, forty-three percent of men are concerned about stress. Balancing both work and family life can leave many men feeling as if they're drowning in a sea of work, bills, and the responsibilities of being a father. "Men in particular respond to stress by feeling irritable, angry, and having trouble sleeping," says psychologist Ron Palomares, Ph.D. "This stress is, unfortunately, often dealt with in unhealthy ways, such as by smoking, drinking, and overeating."

Moreover, since fathers and mothers serve as role models for children, it is important to set a good example. "Children mold their behavior after that of their parents," says Palomares. "Thus, developing healthy responses to stress will be good for you, and, ultimately, good for your children."

APA offers these few strategies to help fathers manage stress:

• Identify — How do you know when you are stressed? What events or situations trigger stressful feelings? Are they related to your children, family health, financial decisions, work, relationships, or something else?
• Recognize — Determine if you are using unhealthy behaviors to cope with work or life stress. Are you a restless sleeper or do you become easily upset and annoyed over trivial things? Is this a routine behavior, or is it specific to certain events or situations?
• Manage — Unhealthy reactions to stress are like taking the easy way out: consider healthy, stress-reducing activities like exercising or playing sports. Focus on the quality of time spent, not the quantity. Keep in mind that unhealthy behaviors develop over time and can be difficult to change. Put everything in perspective, think before you act or speak, and make time for what's really important.
• Support — Accepting help from supportive friends and family can improve your ability to persevere during stressful times. If you continue to feel overwhelmed by stress, you may want to talk to a psychologist who can help you manage stress and change entrenched, unproductive behaviors.

"No one expects you to be the perfect father. It is essential to maintain balance among what is "Superdad" fantasy and what are realistic and attainable aspects of fatherhood," Palomares asserts. "Stress management is not a race to the finish line—don't take on more than you can handle. Instead, set goals and focus on changing one behavior at a time."

Source: American Psychological Association

In many ways, a divorce is similar to dealing with any loss. There are stages we all go through to make peace with ourselves.

When there is a death of a partner in a marriage, it is considered tragic by friends and family, and they gather round in support and reassurance and understanding, responding to the mourning and grief of the survivor. This seems a natural and humane part of our culture.

Strangely divorce (which could be likened to the death of a marriage) does not receive the same response from friends and family. Family members are often disapproving, shamed, embarrassed, or perhaps take an "I told you so" stance. Friends are often made uneasy or uncomfortable by your action. Your divorce in some strange way may threaten their marriages. So that they may feel very awkward around you, having difficulty finding "safe" topics of conversation. Your church may be condemning and punitive, rather than supportive and understanding. On the other hand, others may see you as light-hearted and happy, fortunate to have rid yourself of a burden. None of these reactions to your state gives you a chance to grieve. There is grief and sadness on the part of both the "leaver" and the "left", even though each may see the other as having the best part of things.

Elizabeth Kubler-Ross, in her book On Death and Dying, lists five stages which a dying person goes through in his recognition of his / her mortality - as well as his /her family going through the same steps in dealing with this loss.

These steps seem particularly fitting in thinking of the death of a marriage. These steps need to be recognized and worked through in order to be able to readjust and move toward a new and different life.

1. The denial and isolation: involves the refusal to recognize the situation and the difficulty of not being able to talk about the situation to anyone. There is a feeling of being alone in your struggle.
2. Anger: involves the need to punish, to get even, to make him /her hurt as much as you do, all of the punitive kinds of reactions are present.
3. Bargaining: involves all the ways in which we try to keep things as they were. Common thoughts include "I'll do anything to please if only you will try again, "please don't leave", and "I can't live without you" (which holds its own threat).
4. Depression: is the stage where things feel as if "all is lost", when the feelings of loss and gain are confused. The past looks good and the future cannot be tolerated. The hurt is intolerable so that the world looks lonely and desolate. There seems to be nothing to look forward to and common thoughts include "I will never have anything" and "I will always be alone". This is a bleak stage indeed, but it is a stage.
5. Acceptance: involves facing the reality of the situation, being willing to deal with this reality, moving on to the future, and making new relationships.

One of the feelings not mentioned here is guilt, which so often interferes with the readjustment and forward-looking movement which follows "healthy" mourning. Perhaps one reason for this is the difficulty in looking at oneself and the reluctance to accept one's own responsibility in the relationship. One vital reason for looking at oneself and being able to accept the role I played in the disintegration of the marriage is to not ruin future relationships.

To say "I am doomed to failure" (as is often heard in the depressive stage) is to say I have no responsibility. It should be mentioned that there is a great difference in accepting one's own responsibility in the relationship and compulsively blaming yourself for it all. This can be as non-productive or and as destructive as putting all the blame on your partner. You must be willing to want to change before any change takes place. It is important to be willing to look at oneself, say "this is what I did wrong in this relationship", and accept one's own weaknesses and strengths so that the future will indeed be different from the past.

The failure to go through the stages and the failure to somehow make peace with yourself and move on from there may indeed cause a repetition of past errors.

Sometimes it is most difficult to find a place to mourn or to find someone who will listen, much less understand the things you may be going through. Regardless of the worries you may have of wondering what others will think, it is important to find a place or persons who can give you support.

Note: This document is based on an audio tape script developed by the University of Texas, Austin. With their permission, it was revised and edited into its current format.

Learn how to help a friend and the importance of boundaries; how far you should go in helping a friend.

Helping another person involves listening, understanding, caring and planning together. The following are some guidelines that you might consider as you assume a helping role.

First Step in Helping A Friend

The key to all helping is listening, which may be more difficult than it might appear. Listening means focusing our attention on the thoughts, words and feelings of another person. Listening involves considering another person's concerns from his or her point of view. We aren't listening well if we are busy trying to think of what to say in return or if we are thinking about our own problems. Often we are tempted to give advice and solutions. Indeed our advice is given with the sincere desire to help the person feel better. Yet much advice is useless or unhelpful, especially when it is given before the other person has had the opportunity to talk about the problem and to express her or his feelings fully.

Listening may seem passive, like we are not doing anything. However, effective listening requires that we communicate our attentiveness to the person who is speaking. That might involve looking at the person directly, asking them clarify things you don't understand, touching them physically in a reassuring way, trying to summarize what they are saying to be sure you and they know that you understand, or asking questions to help them take a closer look at what they are saying. If you find the person rejecting what you have to say, or arguing with you, you may want to ask yourself if you are listening carefully. You may have slipped over into an advice-giving mode or you may have begun to talk about your own or other people's problems rather than the ones your friend is presenting.

Second Step in Helping A Friend

The second most important part of helping is the creation of an atmosphere in which the other person can express feelings of sadness, frustration, anger or despair. Often, we are tempted to cut off feelings by making reassuring statements that everything will be all right. As we experience the discomfort of someone we care about, our first reaction is often to do or say something that might help him or her feel better. If we move too quickly to do this, though, the people will feel that they haven't completely expressed their feelings. They may even feel like their feelings should be held back because the feelings are too "bad."

Before people can begin to deal with their feelings fully, they need to be able to express them fully. Questions like, "How did you feel about what happened?" can help people get in touch with their feelings about the situation. Often you will find that people have a variety of feelings, some of which seem conflicting to the person. Just sitting with someone while they express their various feelings about what is going on can be very helpful. Your understanding and supportive presence while they are trying to sort out their various thoughts and feelings is often more important and effective than any advice you may give to try to solve the problem.

Third Step in Helping A Friend

The third important aspect of helping is the generation of alternatives and options and the careful consideration of each of the alternatives and options. While it may not seem so to the person in distress, there are usually several possible options in any problem situation. Some of the options may be ones the person doesn't want to think about and some may be options that have never occurred to her or him. For example, the person who has failed an exam has several options: to get tutoring in the course material, to develop new study habits, to rearrange schedules to create more study time, to talk with the professor, to change majors, or to drop out of school. Some of these may, of course, be unrealistic options if they clash with other goals and objectives, but even initially unrealistic options might become desirable as the person evaluates his or her position more objectively.

Final Step in Helping A Friend

The final step is to determine a specific plan of action. Although we, as friends, can be helpful in defining the alternatives and clarifying the consequences of each option, the final decision needs to remain with the other person. At times it is tempting to encourage a particular solution that makes sense to us. It is important that the person make a plan of action that makes sense to them because, unless the person can commit him- or herself to a specific plan of action, nothing is likely to happen and the problem will remain unresolved.

Other Things to Consider

It is not always necessary that you need to go through all four steps with your friends in order to help them. Often you only need to be a good listener. What they may need at the time in not a specific solution to a particular problem, but just a chance to express what they are feeling and someone to listen to them.

We also need to be aware that a person may not always feel "better" after having talked with us. They may still feel bad about their situation or their loss. This is especially true if they have lost a significant and meaningful relationship. They may need to grieve that loss over a period of days, weeks or months. We can be helpful by accepting and communicating our awareness of the appropriateness of the grieving. Our support, acceptance and understanding over a period of time can be helpful to our friend to move on to other meaningful relationships and/or resume a more normal, active life.

Friends who we just can't seem to help.

You may find yourself in the helping role with a friend who cannot define specific concerns, who cannot take the initiative to carry out any defined options, who constantly comes to you to talk about the same problem, or who continues to be upset without taking steps to resolve the problem. In such cases, you may want to suggest that the person seek professional counseling. You might say something like: "We have been talking about this same problem for weeks and nothing seems to be changing for you. I know this has been a difficult time for you but I just don't know what to do to help you and I think you need to talk with someone who is trained to help people with their problems."

If they are on a college campus, you might suggest they go to their counseling or mental health center. Most communities also have local mental health personnel available in public agencies or in private practice. If your friend resists seeking help, you may want to consult with some of these practitioners to get assistance with your own feelings about dealing with your friend under these stressful conditions.

Note: This document is based on an audio tape script developed by the University of Texas, Austin. With their permission, it was revised and edited into its current form by the staff of the University of Florida Counseling Center.

General Definition

Sexual Arousal Disorder is the inability to attain or maintain adequate genital lubrication, swelling or other somatic responses, such as nipple sensitivity. The disorder can include:

• Lack of vaginal lubrication

• Decreased clitoral and labial sensation (e.g. lack of tingling/ warmth, or "asleep feelings in the genitals")

• Decreased clitoral and labial engorgement

• Lack of vaginal lengthening, dilation and arousal

Potential Causes

• Psychological/emotional factors: e.g. depression, anxiety, stress

• Relationship Factors: e.g. conflict, anger, lack of trust

• Medical factors: low testosterone, low estrogen, diminished vaginal or clitoral blood flow, nerve damage.

What Can You Do?

First, consider whether there are indeed emotional or relationship variables contributing to your problem. It helps to be evaluated by a trained sex therapist who can help you sort this out. Not only do traumatic pasts, relationship issues, and general emotional conflicts impact on sexual arousal, but unrealistic expectations about sexuality or stress around sexual situations can impact on your sexual response as well. It will also be important to rule out medical factors, both testosterone (connected to genital sensation) and estrogen (connected to lubrication). This way you can talk to your doctor about replacement if your levels are low. Also, diminished blood flow to the genital area, either as a result of aging, or some kind of pelvic injury or pelvic surgery can impact on response. Nerve damage can occur in the same way and impact on sexual arousal as well. If your hormones are where they should be, you may want to consider talking to your doctor about trying a blood flow enhancing medication (like ) or device (like the EROS-CTD).

Grace was a happily married woman with a family and a career. After more than 20 years of marriage, her husband left her. After her divorce, she began dating George, a close family friend she had known for years. They became lovers. Because she was beyond childbearing years, she wasn't worried about getting pregnant and didn't think about using condoms. And because she had known George for years, it didn't occur to her to ask about his sexual history or if he had been tested for HIV.

At age 55 she had a routine medical checkup. Her blood tested positive for HIV. George had infected her. She will spend the rest of her life worrying that the virus would develop into life-threatening AIDS -- that any cough, sneeze, rash, or flu would, in fact, indicate AIDS and perhaps the beginning of the end of her life.

What Are HIV and AIDS?

HIV (short for human immunodeficiency virus) is a virus that kills cells in your immune system, the system that fights diseases. Once your immune system is weakened to the point where you get certain types of life-threatening diseases, infections, and cancers, you have what is called AIDS (short for acquired immunodeficiency syndrome). AIDS is the most advanced stage of HIV infection. If there's any chance that you might be infected with HIV, you should be tested, because now there are drugs you can take to help your body keep the HIV in check and fight off AIDS.

Many people do not have any symptoms when they are first infected with HIV. It can take as little as a few weeks for minor flu-like symptoms to show up or as long as 10 years or more for more serious symptoms. Symptoms can include headache, chronic cough, diarrhea, swollen glands, lack of energy, loss of appetite and weight loss, frequent fevers and sweats, frequent yeast infections, skin rashes, pelvic and abdominal cramps, sores on certain parts of your body, and short-term memory loss. People age 50 and older may not recognize HIV symptoms in themselves because they think what they are feeling and experiencing is part of normal aging.

How Do People Get HIV/AIDS?

ANYONE can get HIV and AIDS. Regardless of your age, and especially if you are 50 or older, you may be at risk for HIV if any of the following is true:

If you are sexually active and don't use a male latex condom. You can get HIV/AIDS from having sex with someone who is infected with the HIV virus. The virus passes from the infected person to another through the exchange of body fluids such as blood, semen, and vaginal fluid. HIV can get into your body during sex through any opening, such as a tear or cut in the lining of the vagina, vulva, penis, rectum, or mouth.

If you don't know your partner's sexual and drug history. Has your partner been tested for HIV/AIDS? Has he or she had a number of different sex partners? Does your partner inject drugs?

If you inject drugs and share needles or syringes with other people. Drug users are not the only people who might share needles. People with diabetes, for example, who inject insulin or draw blood to test glucose levels, might share needles. If you have shared needles for any reason or if you have had sex with someone who has, you should be tested for HIV/AIDS.

If you had a blood transfusion between 1978 and 1985, or a blood transfusion or operation in a developing country at any time.

If any one of the above is true, you should be tested for HIV/AIDS. Check your local phone directory for the number of a hospital or health center where you can get a list of test sites. In most states the tests can be confidential (you give your name) or anonymous (you don't give your name).

There are many myths about HIV/AIDS. The examples below are FACTS:

• You cannot get HIV through casual contact such as shaking hands or hugging a person with HIV/AIDS.

• You cannot get HIV from using a public telephone, drinking fountain, restroom, swimming pool, Jacuzzi, or hot tub.

• You cannot get HIV from sharing a drink or being coughed or sneezed on by a person with HIV/AIDS.

• You cannot get HIV from donating blood.

• You cannot get HIV from a mosquito bite.

Is HIV/AIDS Different in Older People?

The number of older people with HIV/AIDS is on the rise. About 10% of all people diagnosed with AIDS in the U.S. -- some 75,000 Americans - are age 50 and older. Because older people don't get tested for HIV/AIDS on a regular basis, there may be even more cases than we know. How has this happened?

Because older Americans know less about HIV/AIDS than younger age groups: how it is spread; the importance of using condoms and not sharing needles; the importance of getting tested; the importance of talking to their doctor.

Because healthcare workers and educators have neglected the middle-age and older population in terms of HIV/AIDS education and prevention.

Because older people are less likely than younger people to talk about their sex lives or drug use with their doctors.

Because doctors don't tend to ask their older patients about sex or drug use. It is harder for doctors to recognize the symptoms of HIV/AIDS in older people. Doctors need to talk to their patients about the specific behaviors that put them at risk for HIV/AIDS.

Older people often mistake HIV/AIDS symptoms for the aches and pains of normal aging, so they are less likely than younger people to get tested for HIV/AIDS. They may be embarrassed, ashamed, and fearful of being tested for HIV/AIDS, a disease connected with having sex and injecting drugs. People age 50 and over may have had the virus for years before being tested. By the time they are diagnosed with HIV/AIDS, the virus may be in its most advanced stages.

Older people diagnosed with HIV/AIDS do not live as long as younger people who have the virus. It is important to get tested early. The earlier you begin medical treatment, the better your chances for living longer.

Many older people who have HIV/AIDS live in isolation because they are afraid to tell family and friends about their illness. They may have more severe depression than younger people. Older people are less likely to join support groups. Older people with HIV/AIDS need help coping both emotionally and physically with the disease. As the infection progresses, they will need help getting around and caring for themselves. Older people with AIDS need support and understanding from their doctors, family, friends, and community.

HIV/AIDS affects older people in yet another way. Many younger people with HIV/AIDS turn to their parents and grandparents for financial support and nursing care. Many older people have cared for their own children with HIV/AIDS and then for their orphaned and sometimes HIV-infected grandchildren. Taking care of others can be mentally, physically, and financially draining. This is particularly true for older caregivers. Taking care of someone with HIV/AIDS can be very hard and stressful.

---

HIV/AIDS, People of Color, and Women

Of all the people age 50 and over with AIDS, more than half (52%) are black and Hispanic. Of all men age 50 and over with AIDS, 49% are black and Hispanic. Of all women age 50 and over with AIDS, 70% are black and Hispanic. The number of HIV/AIDS cases continues to rise in communities of color. Educators, healthcare workers, and community leaders need to inform and warn people about HIV -- the dangers of having sex without a condom, the dangers of injecting drugs and using infected needles, and the importance of getting tested. The number of older women with HIV/AIDS, regardless of race, is also on the rise. Over a recent five-year period, the number of new AIDS cases in women age 50 and older increased by 40%. Two-thirds of the women got the virus because they had sex with infected partners. Nearly one-third of the women got HIV because they shared needles.

There may be a connection between HIV/AIDS and women in menopause. Women who are no longer worried about getting pregnant may be less likely to use a condom and practice safe sex. Some menopausal women have vaginal dryness and thinning. This means they are more likely to have small tears and abrasions during sex. This can put women at greater risk for HIV. Because women may live longer than men and because of the rising rate of divorce, there are a large number of widowed, divorced, or separated women starting to date. Because many of these women do not understand how HIV/AIDS is spread, they may be at risk.

Treatment and Prevention

There is no cure for HIV/AIDS. Once you are infected, there are a number of medical treatments available to help keep the HIV virus in check and to help guard against AIDS. If there's any chance you might be infected, get tested. Early medical treatment is important, especially for middle-aged and older people. Your doctor or medical provider can give you information about the kinds of treatments available. Doctors and medical providers should talk to patients about the risk of HIV/AIDS, get the patient's sex and drug histories, and encourage HIV testing if there is any chance that the patient has been infected.

Remember, HIV/AIDS is all about behaviors. By practicing all the following behaviors, you can greatly reduce your risk of getting HIV/AIDS:

• If you are having sex, make sure your partner is HIV negative.

• Use male or female condoms (latex or polyurethane) during sex.

• Do not share needles or any other drug-use paraphernalia.

• If you or your partner had a blood transfusion between 1978 and 1985, or an operation or blood transfusion in a developing country at any time, get tested.

Resources

Health agencies in most cities offer HIV testing. The following national organizations have information about HIV/AIDS:

AARP
601 E Street, NW
Washington, DC 20049
202-434-2260
http://www.aarp.org/griefandloss

AARP has information on HIV/AIDS and its impact on mid-life and older adults. Ask about "It Can Happen to Me," a 28-minute videotape and discussion guide (available for loan or sale) for older adults or healthcare professionals.

Center for AIDS Prevention Studies at The University of California, San Francisco
74 New Montgomery Street Suite 600
San Francisco, CA 94105
415-597-9100
http://www.caps.ucsf.edu

Centers for Disease Control and Prevention (CDC) National AIDS Hotline
1-800-342-AIDS
1-800-344-7432 for Spanish
1-800-243-7889 (TTY)
http://www.cdc.gov/hiv/hivinfo/nah.htm

The hotline operates 24 hours a day, 7 days a week. It offers general information and referrals to resources in your area.

CDC National Prevention Information Network
PO Box 6003
Rockville, MD 20849
1-800-458-5231
1-800-243-7012 (TTY)
info@cdc.npin.org

This clearinghouse offers free government publications and information.

National Institute of Allergy and Infectious Diseases (NIAID)
Office of Communications Building 31, Room 7A32
Bethesda, MD 220892
http://www.niaid.nih.gov

Part of the National Institutes of Health, the NIAID provides information about AIDS research and clinical trials.

Senior Action in a Gay Environment (SAGE)
305 7th Avenue, 16th Floor New York, NY 10001
212-741-2247
http://www.sageusa.org

SAGE provides HIV/AIDS information and referrals for people age 50 and over.

Social Security Administration
Call your local office or:
1-800-SSA-1213

Social Security has disability benefit programs that provide financial assistance to eligible AIDS patients.

"The National Institute on Aging of The National Institutes of Health. National Institute on Aging Age Page: HIV, AIDS, and Older Adults. 1994. Last updated March 11, 1999. (Online)

The end of a relationship is experienced as a loss. Loss can occur when:

• someone important to us dies;
• a pet dies;
• we move households;
• a dream is shattered;
• a relationship is over.

Loss is not a feeling. It is an event that may induce positive or negative feelings - or both.

The negative: rejection, confusion, frustration, anger, rage, fury, regret, shame, hurt, remorse, sadness, depression, melancholy, desperation, anxiety, fear, betrayal, humiliation, bitterness, alienation, insecurity, loneliness, self-blame, grief.

The positive: relief, contentment, lightness, refreshment, aliveness, hopefulness, optimism, peace.

Recovery is a Process, Not an Event

Loss will descend on you like a wave then recede until next time. Each wave will pass and each wave helps diminish the pain.

If what you are doing feels wrong or right it probably is. Even though you still feel terrible, persist in what seems right and reconsider what seems wrong. It takes time.

The process is made smoother if you:

1. Accept pain is normal ... Do not waste energy denying it or fighting it.
2. Accept that recovery will take time ...

Task 1 - Help Yourself

• Make an active decision to do something - as reluctant as you might feel (e.g. read a book on loss). Learn how have others dealt with this. You feel crazy. Is that normal? Browse the bookstores till you find something that seems to talk to you. Or, better yet because it is free, go to the library.
• Try to continue some of your normal routines. Go through the motions if necessary but avoid withdrawing entirely from the world.
• Distractions are okay if they do not become avoidance of the pain.
• Spend time alone and use it to go over the loss. You will not be drowned by the grief even though you feel like once you start you won't be able to stop.

Task 2 - Make a Conscious Decision to Say Enough IS Enough

Caught on a merry-go-round? Feel like you are going nowhere? Nothing is changing? You are as depressed as the first day? Then you have to make an active decision to do something?

• "It is time to move on - time to say Goodbye."
• "It is time to let go."
• "I am letting this destroy my life. I will not let it do that."
• "I am losing what is left. It is time to get on."
• "That chapter is over. I need to start a new one. I deserve to start afresh."

You must want to let go. Do not pretend.

This is not easy but sometimes its easier to act your way into positive feelings than it is to feel your way into acting positively. Do what feels right to you.

Warning! Beginning a new relationship before healing after the end of an old one can often lead to even more remorse and pain. Temporary distractions are fine - you do have to move on - but be careful about using other people to avoid your pain. Try to see being single as an opportunity, not a life sentence.

Task 3 - Acknowledge the Hurt ... Confront It

By doing this, you are beginning to assume control - not being controlled. You might choose to:

• Talk about what is going on with a close friend, with a counselor, with yourself.
• Spend time alone - Important: This is a positive, active choice not to be done when you are utterly depressed (that is when you should seek out someone to talk to).
• Meditate - focus on your physical feelings - identify your emotions.
• Go into the country or walk on the beach. Spend an hour with yourself.
• Rituals - using symbols in rituals can be a powerful way to let go. Rituals can mark the last stage of recovery and the first step forward.

1. Gather together items that represent something about your relationship (letters, photos, jewelry, a book, a record.

° When it is time to let go, burn the item, throw it into the ocean, bury it, send it to someone needy.

2. Write a "Goodbye Letter" - write to your ex and express all that you feel now. Remember the good as well the bad. Do not send the letter right away. Wait for some time to pass. If you still feel it would be helpful to send it, do so. Preferably burn it or bury it as part of your ritual closure.

3. Visit a place of significance to your relationship to mentally say "Goodbye."

Task 4 - Moving On and Rediscovering Life

Loss leaves a huge vacuum in your life. You need to replace the emptiness with positive experiences. Emptiness reminds you of the loss - go walking, jogging, walking, surfing, try cooking classes, meet with friends, catch a movie, go to the museum, join a drama group. Stick with it for six weeks.

Remember the Things You Enjoy

Slowly start returning to some things you have probably neglected for a while. At first, you will not feel anything - persist. Eventually, you might discover you are looking forward to the future and not running from the past.

The Role of Counseling

Counseling is not an essential part of recovery. Try to help yourself first. However, if you are stuck or feeling destructive, if you think your friends have heard enough, if you have no close friends or do not want to bother them with your worries, a counselor may be able to give you the support you need.

Sometimes loss can trigger emotions that seem way out of proportion to the event. That is because traumas can accumulate until you have no more capacity to deal with the next one. Hidden memories can tumble out and feelings become confused and frightening. Issues which arise out of relationships often revolve around self-esteem, dependency, submissiveness, self-blaming, fear of rejection, feelings of worthlessness.