Author Archives: Elisa Brennecke

 About Elisa Brennecke

Elisa Brennecke is a licensed therapist and founder of Marra, a multi-niche trauma based practice in Chicago. Elisa has spent the majority of her career working with clients experiencing childhood attachment injuries and how that impacts their intimate relationships as adults.

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PTSD vs. Complex PTSD: What Is the Difference?

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A lot of people come across the term complex PTSD late at night, on their phone, and feel a jolt of recognition. Something about the description fits in a way the usual picture of PTSD never did.

If that was you, I want to walk you through what each term means, where they overlap, and where they part ways. Not so you can diagnose yourself, but so the words stop feeling like a locked room.

What PTSD is

Post traumatic stress disorder usually grows out of a specific event, or a few of them. A car accident. An assault. Combat. A medical emergency. A sudden, frightening loss.

It tends to show up in three ways. Reliving it, through flashbacks, nightmares or memories that arrive uninvited. Avoiding it, by steering around the places, people, conversations or thoughts that bring it close. And a sense of threat that has not switched off, so you stay on edge, startle easily and struggle to sleep.

Most people go through some of this after something terrible happens. It becomes PTSD when it holds on for weeks or months and starts getting in the way of your life.

What complex PTSD adds

Complex PTSD, often shortened to CPTSD, includes those same three patterns. What it adds is a set of changes in how you relate to yourself and to other people.

It most often follows trauma that was prolonged or repeated, and hard or impossible to escape. That is frequently trauma that happened inside relationships: growing up with a parent who was frightening or unpredictable, years of neglect, a long abusive relationship. When the danger is the place you live, or the person you depend on, your nervous system adapts to it as the normal state of things.

The additions tend to look like this. Emotions that feel either too big to manage or shut off entirely. A deep, persistent sense of being worthless, defective or to blame. And real difficulty in relationships: trusting people, staying close, or believing that closeness is safe.

Those are not deficiencies.They are what a person learns when they have to survive something for a long time with no way out.

Why you may hear the terms used differently

The World Health Organization’s diagnostic manual, the ICD-11, recognizes complex PTSD as its own diagnosis. The DSM-5-TR, which many clinicians in the United States use, does not list it separately and folds much of it under PTSD.

So if one professional uses the term and another does not, they are not necessarily disagreeing about you. They may just be working from different manuals.

You do not need the label to start

I say this often, and I mean it: you do not need a diagnosis to begin trauma therapy, and you do not need to know which term fits.

Some people find a name enormously relieving, because it tells them they are not imagining things. Others never need one at all. Your therapist will help you understand what you are dealing with as you go, and the work can begin before anyone has decided what to call it.

How treatment can differ

Both start in the same place: safety. Before anyone goes near the hardest memories, the first job is to help your body and your days feel steadier.

For PTSD tied to a specific event, approaches like EMDR and trauma focused CBT have strong research behind them and are often part of the plan.

Complex PTSD usually asks for more time on the foundations. Building skills for big emotions. Untangling the beliefs about yourself that formed early. And often, relational work, where the relationship with your therapist becomes part of how trust gets rebuilt. If what happened to you happened in relationship, a lot of the repair tends to happen there too.

Neither one is a race. A good trauma therapist will move at a pace your nervous system can actually follow.

A word about recognizing yourself

If you read the section on complex PTSD and something in you went quiet, that recognition matters. It does not mean you are broken. It means you adapted to something that was asking too much of you, and adaptations can be updated, slowly, with the right support.

If you are ready to talk

At Marra, several of our therapists focus on trauma, PTSD and complex trauma, using approaches like EMDR, ACT and relational therapy. You can read more on our trauma therapy page. The first step is a free 15 minute consultation with our intake team, who will help match you with the right person. You do not have to tell the story to start.

If you are having thoughts of harming yourself, please contact the 988 Suicide and Crisis Lifeline by calling or texting 988. It is free, confidential, and available 24 hours a day.

Founder Burnout Is Rarely About the Workload

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I want to talk about something I have watched happen in founders and business owners for years, and that I still catch happening in myself.

The hard day usually does not announce itself as a hard day. On paper it is fine. Someone gives you feedback. Someone decides to leave. A number lands differently than you expected it to. And you tell yourself, honestly, that it is going to be okay, and you actually believe it.

Then you notice the knot at the base of your throat. The pressure across your chest. That particular alertness that is just adrenaline and cortisol moving through a body which has decided something important is happening.

Your head is fine. Your body did not get the memo.

I have come to think this gap is the whole story. We talk about founder burnout like it is a math problem, too many hours divided by not enough sleep. In my experience that is rarely what breaks people. Sixty hours building something you love does not break you. Ten hours carrying a conversation you cannot put down will.

It is not the work, it is what the work is touching

Here is the part nobody warns you about when you start something.

If you build a business that matters to you, you have handed it something. Your judgment is in it. Your taste is in it. Often your name is on it. So when it wobbles, it does not land on your calendar. It lands somewhere much older and much softer.

Someone on your team gives you feedback in a review and you hear it as a verdict on whether you are good. Someone resigns and some part of you files it under rejection before your reasonable mind can get there with context. You have built something people depend on, and for one unguarded minute you feel like the one who was not chosen.

That minute is not a failure of professionalism. It is a younger version of you walking into a meeting she was not invited to, because the room finally feels important enough for her to show up in.

And here is what I want to say clearly, because I think founders get this wrong in a way that costs them: it does not mean you are unaware. It does not mean you have not done the work. Awareness is not a fence. The parts of us that formed early are not watching for whether we have read the right books. They are watching for whether the stakes are high, and they show up most reliably in the places we care about most. That is not a flaw in the system. That is the system working exactly as designed, at an inconvenient moment.

Almost everything that feels like a verdict is actually data

Someone leaving is one of the cleanest examples of this.

A resignation feels like a referendum. It almost never is one. People are running their own lives, with their own timelines and their own families and their own things they are trying to outrun or move toward, and most of the time they are doing their best inside circumstances you can only partly see. Their exit is information about fit, or timing, or money, or a season of their life. It is not a measurement of your worth as a leader, even on the days it arrives looking exactly like one.

The same is true of hard feedback. Feedback is someone’s experience of you, delivered imperfectly, usually late, usually with the kindest version sanded off by nerves. It is worth taking in. It is worth taking seriously. It is not worth taking as a sentence handed down.

What I try to ask now, once the first wave passes, is simply this: what did I just learn? Sometimes the answer is nothing, and that is allowed. More often there is something real in there. A leak in a system I had not noticed. A conversation I avoided for six months that would have taken twenty minutes at the start. A role I never fully defined and then quietly resented someone for not performing.

I am not going to tell you the hard thing was secretly a gift. That is the kind of thing people say when they want you to stop talking about it. But I have yet to go through a bitter situation that did not hand me at least one usable piece of information, and I have learned to go looking for it on purpose instead of waiting for it to reveal itself in hindsight.

Your feelings are telling the truth. The story around them might not be.

This distinction has done more for me than almost anything else.

The feeling is accurate. The knot in your throat is real, the heaviness is real, the sense of something at stake is real, and your body is not making it up. When people tell you that you are overreacting, they are almost always wrong about the feeling.

The story is the part that needs checking. The feeling says this matters and it hurts. The story says this means I am not good at this, or everyone will leave eventually, or I have been fooling people the whole time. Those are not emotions. Those are conclusions, written in a hurry, by a part of you that is scared and in no condition to be drafting policy.

So the move is not to argue with the feeling. It is to let the feeling be entirely true and then look hard at the sentence you attached to it. Does the evidence actually support this. Would I say this about anyone else in my position. Is this a fact about my business or a fact about my fear.

Capacity is real, and it is not built the way we were told

Most of us were handed a bad definition of resilience. Mine was something close to: feel less, and feel it later.

For a long time what I called being tough was mostly just getting good at not feeling things until a more convenient time. That works, right up until it does not, and the bill it eventually sends is not itemized. It arrives as exhaustion you cannot sleep off, or a flatness around work you used to love, or a reaction five times larger than the thing that caused it.

What has actually grown my capacity is boring and much slower.

Naming what is happening while it is happening. Not analyzing it. Just naming it, in plain language, the way you would describe weather. My chest is tight. I feel dismissed. I am scared this means something about me.

Then letting the sentence be incomplete. You do not have to solve this today. One of the real skills of running something is the ability to hold an unfinished problem without needing to resolve it by bedtime. Almost every decision is better in the morning than it is at eleven at night.

Then reframing, which I want to be careful about, because reframing has been ruined by people who use it to mean looking on the bright side. That is not what I mean. I mean asking an honest question with an uncertain answer. What else could be true here. What would I need to find out to know. That is not optimism. That is just refusing to let the first interpretation be the only one you consider.

The question I come back to

When something is genuinely at risk, I eventually get to this one.

If the worst case happened, would I survive it?

The answer is almost always yes. Not a cheerful yes. A real one. You would figure it out, because you have figured out harder things with fewer resources and less experience than you have right now.

And then I make myself finish the question, because the second half matters just as much. Would it be uncomfortable? Absolutely. Possibly awful for a while. I am not interested in the version of this where we skip that part, because minimizing is just numbing wearing a nicer outfit.

Both halves together is where the ground actually is. I would not want this. I would also live through it. That is usually enough to put something down for the night.

Sorting what is yours now from what is older

This is the one I want to leave you with, because it is the work that keeps paying.

When something lands hard, there are usually two things in it. There is the adult problem, which is real and solvable and belongs to the leader you are now. We are short a person. The schedule needs rebuilding. I need to have a conversation I have been avoiding.

And then there is the older thing, which belongs to a much younger version of you, and which is not actually about this at all. The part that felt unwanted. The part that learned somewhere along the way that people leave, or that being chosen was conditional on performance, or that an unhappy person in the room was her responsibility to fix.

If you treat all of it as the adult problem, you will over-solve. You will offer a raise to someone who was never leaving over money, or restructure an entire team to settle a feeling. If you treat all of it as the old wound, you will under-solve, and the actual operational gap will still be sitting there weeks later.

Sorting them is not something most of us can do alone in the car. It is quieter work, and it usually needs a witness.

What it looks like when this is going well

You will not stop feeling it. I have been doing this a long time and I still feel it, which I have stopped treating as evidence that I am bad at this and started treating as evidence that I still care.

What changes is recovery time. The feeling arrives and you know what it is within an hour instead of a week. You stop needing the person who left to be wrong in order for you to be fine. You can hold two things at once: this hurt, and it was a reasonable decision for them to make. You can take feedback without rebuilding your self-image around it, and still change the thing that needed changing.

And the noise drops. That is the real prize. Not calm exactly, but a lot less static between you and the decision in front of you, which is the thing the business actually needed from you all along.

Four questions to sit with

When the next hard day comes, these will do more for you than rereading the email.

What am I actually feeling, in plain words? Not what I think about it. What it is.

Which part of this is a problem to solve, and which part is a feeling to feel? They need completely different things from you, and giving the wrong one the wrong treatment is most of why this gets exhausting.

If the worst case happened, would I survive it, and what would it cost me? Answer both halves honestly.

What did this just teach me about my business? There is usually something, and finding it on purpose beats finding it in hindsight.

If you want help with this

Some of this you can do on your own, with an honest question and enough quiet to hear the answer. Some of it is harder to see from the inside, particularly the part where an old wound and a current business problem arrive wearing the same coat.

I recommend therapy to founders and leaders more often than I recommend almost anything else, and not because something is wrong with them. Running something is a role with a very specific kind of pressure and very few places to put it down. Having one hour a week where you are not the person everyone is depending on is not an indulgence. It is maintenance on the instrument you are using to make every decision.

At Marra, the first step is a free 15 minute consultation with our intake team. You tell them what is going on, and they help figure out which of our therapists is the right fit for it. If nobody here is right for you, we will tell you that and point you somewhere better. Sessions are 55 minutes. We are in River West and we see clients online anywhere in Illinois, and you can meet our therapists before you commit to anything at all.

You do not need to be in crisis to deserve this. A knot in your throat you have been arguing with for months is plenty.

If you are having thoughts of harming yourself, please contact the 988 Suicide and Crisis Lifeline by calling or texting 988. It is free, confidential, and available 24 hours a day.

I’m Just Protecting My Peace

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You said it in the group chat and three people liked it.

You are not going to the thing. You muted the thread. You are not doing the school committee this year and you are not explaining why. You are protecting your peace.

And sometimes that is exactly the right call, and you should keep doing it. There is a version of this where you are a woman with too much on her and not enough hours, who has finally learned to say no, and every one of those nos is load-bearing. If that is you, nothing in this article is an argument against it.

But there is another version, and I want to describe it carefully, because it looks identical from the outside and it does not feel the same on the inside.

The thing with the clinical name

In anxiety treatment there is a term for the small moves we make to get through something frightening: safety behaviors.

A safety behavior is anything you do to make the anxiety survivable. Leaving the party by nine because you always have a reason to leave by nine. Reading the email a ninth time before you send it. Arriving twenty minutes early so you are never the one walking in. Rehearsing the conversation in the shower until you have the wording right. Asking a friend one more time whether it sounded okay. Sitting where you can see the door.

And, most invisibly, not going at all.

Why they are so hard to spot in yourself

Most of yours look like being good at your life.

Nobody has ever pulled you aside to say you prepare too thoroughly. You get praised for it. You are the one who is never caught out, never unready, never the person who said the wrong thing in the meeting. The behavior and the competence are the same behavior.

Which means the thing most likely to be maintaining your anxiety is the thing you are proudest of.

“Protecting my peace” is the strongest version of all of them, because the culture handed you the words. It is the only safety behavior that comes with applause.

The mechanism, which is the part worth knowing

Here is why this matters more than it sounds like it should.

Anxiety is a prediction. Something bad will happen, and you will not be able to handle it. The only thing that ever updates that prediction is evidence. You go, the bad thing does not happen, and some part of your nervous system quietly files that away.

A safety behavior stops the evidence from arriving.

You go to the party and you leave at nine, and the evening is fine. Now, what did your brain learn? Not that you can handle a party. It learned that you can handle a party if you leave at nine. You send the email after the ninth read and nobody is upset, so the ninth read stays. The credit goes to the behavior, every single time.

And when you skip the thing entirely, there is no evidence at all. Just a quiet, relieved certainty that you made the right call, which is the feeling anxiety produces when it has won.

So the anxiety does not shrink. It narrows the world instead, one reasonable decision at a time, and every one of those decisions was defensible on the day you made it.

Telling a boundary from avoidance

This is the part I get asked about, and I want to give you something usable rather than a judgment.

A boundary protects something you are moving toward. Avoidance protects you from something you are afraid of. Both produce a no. They do not feel the same afterwards.

A boundary tends to leave you settled. You said no to the committee because your Tuesdays belong to your kid, and that is still true an hour later.

Avoidance tends to leave you relieved first, and slightly smaller after. There is often a little argument running in your head about it later in the evening. You notice yourself building the case for it to someone who has not challenged you.

One more test, and it is the cleanest one. Would you still be saying no to this if you were not anxious about it? If the honest answer is that you would love to go and you are not going, that is worth looking at. If the honest answer is that you would not go either way, you are fine, and you can stop reading this paragraph.

What to do with one of them this week

Not all of them. One, and a small one.

Pick the lowest-stakes safety behavior you have, and drop it once on purpose. Send the email after two reads instead of nine. Stay until nine twenty. Go without the friend you always bring. Do not send the text asking whether it was okay.

Then pay attention to what happens, because that is the whole point. You are not testing your willpower. You are collecting the one piece of evidence your brain has never been allowed to have, which is that it was fine and you did not do the thing that usually makes it fine.

It will feel worse while you do it. That is not a sign it is going badly, it is the feeling of your nervous system noticing the handrail is gone. It passes, and the second time is easier, because nothing happened the first time.

That handles the small ones. The bigger question, why being unprepared feels genuinely dangerous to you, usually has a history attached, and that part is where a therapist comes in.

If you want to look at it with someone

At Marra, the first step is a free consultation, and this is ordinary work for us. Anxiety treatment with real evidence behind it spends a lot less time talking you out of your worries than people expect, and a lot more time helping you find out, carefully and on purpose, what you can actually handle. If we are not the right fit, we will tell you and point you somewhere better.

And if you read all this and decide your no was a real no, good. That is the correct outcome for a lot of women reading this.

I was not protecting my peace. I was protecting myself from finding out I would have been fine.

I’m Fine. I Just Need Help Communicating.

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A man standing outdoors in low evening sun, holding his phone, looking straight ahead with a neutral expression

That is close to word for word how a lot of men get in touch with us.

Not “I think something is wrong.” Something cleaner than that. Work is good, the marriage is mostly good, I just want to get better at the conversations. Give me the tools, I am a quick study.

And it is a fair request. You probably are bad at those conversations, and there are real skills in there worth having.

But here is what tends to happen. Six or eight weeks in, we are almost never working on communication.

What turns up instead

It comes out sideways, usually.

You mention you have not slept properly since spring. You say you have been having two drinks on a Tuesday instead of none, and then you bring it up again the following week, which means it is bothering you. You describe snapping at your kid over something that did not warrant it, and your face changes while you are describing it.

And somewhere in there you say a version of this: I used to bounce back from this stuff faster.

Nobody in the room says the word depression, because it would land wrong and it would not be useful yet. But that is what we are looking at.

The kind that does not look like it

Terrence Real wrote a book about this in the nineties called I Don’t Want to Talk About It, and the distinction he draws is the most useful one I know on this subject.

He separates overt from covert depression. Overt is the version everyone can picture. A man goes down. He cannot get up for work, he is visibly not okay, and eventually somebody notices.

Covert depression is the one that never gets named, because the man is outrunning it. He is working more than he ever has. Drinking a bit more than he used to. He is sharper with people, quicker to be right, quicker to find the flaw in whatever someone just said. From the outside he can look like he is doing well. Sometimes he is doing the best work of his life.

Real’s argument is that the depression is underneath the whole time, and the running is the symptom. None of that presentation looks like sadness. That is exactly why it goes on for years.

Why you would not call it depression

Because you are not sad. You would know if you were sad.

What you are is tired in a way sleep does not fix. Irritable at a level that embarrasses you a few hours later. A little bit done with everyone. Short with people over things that do not matter, and harder on yourself than you would ever say out loud.

The thing you would notice first, if anyone asked you properly, is that this used to pass and now it does not.

Depression in the brochure is sadness. Depression in a lot of men is irritation, distance, and a quiet low opinion of nearly everything.

What the screening questions actually ask

Here is something worth knowing, and it surprises most people.

The questionnaire clinicians use for this is called the PHQ. It is eight items, it is free, it is not ours, and it has been used in primary care for decades. Two of those eight ask about mood.

The other six ask whether you are sleeping badly or sleeping too much. Whether your energy is gone. What has happened to your appetite. Whether you can concentrate well enough to read something or watch something through. Whether you are moving and speaking more slowly than usual, or the opposite, restless enough that you cannot sit still. Whether you have been feeling like a failure, or like you have let the people around you down.

Read that list again as a man who says he is not depressed.

Most of it is the stuff you have been filing under being busy, or getting older, or a rough stretch at work. That is not an accident. It is what the condition actually looks like in a body, and sadness is only a small part of it.

The quiz is on our site if you want it. Nine questions, two minutes, nobody sees the result except you. It is a screening tool, not a diagnosis, and it cannot tell you anything a conversation with a good clinician could not tell you better. What it can do is give you a number. A number is easier to argue with than a feeling, which may be exactly why it is useful to you.

Why a skills problem is the easier one to have

A communication problem is a respectable problem. It is a gap in technique. It is external, it is fixable, and it says nothing at all about you. You can hire someone to close a skills gap the same way you would hire someone to fix the furnace, and you stay exactly who you were on the way out.

Depression is not that. Depression sounds like something being wrong with you, which is a much worse thing to carry into a first appointment.

Real’s whole framework turns on shame. His argument is that when a man gets near something shameful, he does not sit down in it. He goes up. He gets competent, gets busy, gets right, gets a little contemptuous of whoever is in front of him.

So “I just need some tools” is not a dodge you invented. It is the most natural move available to you, and it keeps you one-up, which is the only position that has ever felt safe.

Where this starts

Real’s view is that none of this is a personal failing, and I think he is right about that.

Most boys learn early which parts of themselves cause problems. Not usually through anything dramatic. Through a few thousand small moments where showing something soft cost you something, and being capable paid. By twelve the sorting is automatic. By forty, someone asks how you are doing and the honest answer is that you do not actually know, because the equipment for checking got put away a long time ago.

That is not you being closed off on purpose. It is a skill you were taught, and it worked for years, which is the reason it is still running.

What slowing down can feel like

If the running has been keeping it down, then slowing down can feel worse before it feels better. That is not a sign the treatment is failing. It is the thing you have been outpacing finally sitting still long enough for someone to work on it.

Better to know that going in than to hit it in week nine and decide the whole thing is not working.

And if it gets darker than you can manage on your own at any point, that is the thing to say out loud to someone that day. Your doctor, a friend, someone here, or the 988 line, which you can call or text.

Something to try this week

The next time someone who loves you asks what is wrong and you say nothing, you are often telling the truth. You do not have an answer. Nothing is the closest word you have got.

So answer a smaller question instead. Not what is wrong. What was the worst ten minutes of my day.

That one has an answer. The call at two. The email you read four times. The twenty minutes you sat in the car outside the house before you came in. You can say any of that out loud without having to name a feeling, and it is real information, which is considerably more than nothing was.

Do it once. The bar is lower than it sounds and it usually goes better than men expect.

That handles this week. Why the bigger question is so hard to answer is where a therapist comes in.

And if you read all of this and it is not you, fine. Some men asking for communication tools need communication tools, and that is a perfectly good thing to go and get.

I said I was fine for years. The part I cannot get past is that I was not lying.

When Reassurance Stops Helping: Loving Someone With Moral OCD

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It is eleven at night and she asks you again.

Was I rude to her. Did that sound bad. Do you think she took it the wrong way. And you say what you have said forty times, which is no, you were fine, honestly, you were kind. She breathes out. For about twenty minutes you have her back.

Then it comes again, slightly rearranged. But you were only in the room for part of it. You didn’t hear how I said it.

If you have started to dread the question, and then felt like a bad partner for dreading it, I want to tell you what is actually going on, because almost nobody explains this part to the person on your side of it. Reassurance seeking in OCD is one of the hardest things to live beside, and it is almost never explained to the person being asked.

Why reassurance seeking in OCD gets worse when you answer

What you are describing is usually the reassurance loop in moral OCD. The question she is asking is not really a question. It is a compulsion, the same way checking a lock is a compulsion, and you have become the lock.

Clinicians call this family accommodation. It means the people who love someone with OCD get pulled into the rituals: answering, checking, reviewing, going over it one more time. It happens in almost every household where OCD lives, and it is done entirely out of love. It is also consistently linked to more severe symptoms, and when accommodation comes down over the course of treatment, outcomes tend to improve.

So I want to be clear about something before we go further. You did not cause this and you have not been doing it wrong. Comforting a distressed person you love is the right move almost everywhere else in life. This is the one situation where the kind answer makes the next question louder.

Here is why. Reassurance settles a worry. It feeds an obsession. Every answer teaches her brain that the discomfort only ends when someone resolves it, so the doubt comes back sooner and hungrier. You have been handing over relief that gets shorter each time, and you have probably noticed that yourself.

What you are actually withholding

This is the part worth getting straight before you change anything, because it will feel wrong in your body.

You are not withholding comfort. You are not withholding love or presence or tenderness. You are declining to answer one specific question, and you are staying right there while she is uncomfortable. Those two things can happen at the same time, and in the beginning they will feel identical to her, which is why you say it out loud.

The conversation to have when nothing is happening

Not at eleven at night mid spiral. On a Saturday, when it is quiet.

“I’ve noticed that when I answer, it helps for a few minutes and then it comes back worse. I don’t want to keep feeding something that is hurting you. Can we figure out together what I should say instead?”

That sentence does three things. It tells her you noticed, which is not the same as being fed up. It puts the two of you on the same side of it. And it asks her permission, which matters, because this works best as a plan you both agreed to rather than a wall that appeared one Tuesday with no warning.

If she is already working with a therapist, this belongs in that room too. Accommodation is usually reduced gradually, in an order the two of you choose, with her clinician’s help. Pulling all of it at once tends to go badly.

The sentences to use in the moment

Say these warmly. Tone is doing as much work here as the words.

When the question comes. “I love you, and I’m not going to answer that one.”

When she asks what you mean. “I can’t give you certainty about this. Nobody can. What I can do is sit here with you while it’s loud.”

When she rephrases it, which she will. “That’s the same question wearing a different coat. I’m still here and I’m still not answering it.”

When she escalates, or cries, or tells you that you don’t care. “I know this is awful right now. I’m not leaving. I’m just not going to do the thing that makes it worse.”

When you want to say something true. Say something about her that is not an answer to the question. “You are the most careful person I know about other people’s feelings.” That is not a verdict on the specific incident, so it does not close the loop, and it is true.

One useful rule of thumb: answering once is a normal thing couples do. The second time the same question arrives, that is the ritual, and that is where the line goes.

What not to say

Not “you’re being irrational.” She knows. Being told does not help and it adds shame to a pile that is already high.

Not “we’ve been through this.” True, and it lands as impatience.

And, surprisingly, not “you’re a good person.” I know you mean it. That is the exact reassurance the loop runs on, and it is the most comfortable version of it, which makes it the stickiest.

What this costs you, and what you are allowed to say about it

Partners of people with OCD get almost no attention, and they are often tired in a way they cannot describe to anyone. You have been managing someone else’s nervous system at bedtime for months. You are allowed to find that hard. You are allowed to say so, kindly, to her, and you are allowed to have your own support for it. That is not disloyalty and it is not a betrayal of her.

What I would steer you away from is becoming her therapist. Do not start tracking her compulsions, quizzing her about whether she did a ritual, or running the treatment. You are the person who loves her. That is a bigger job and it is the one nobody else can do.

If you want help with this

At Marra, our concierge matches people with a therapist based on what is actually going on, and the first step is a free consultation. Some of our therapists who work with OCD are trained in ERP, and many ERP clinicians will bring a partner into part of the work, which is often where the accommodation piece gets sorted out properly. If we are not the right fit, we will tell you and help you find someone who is.

You cannot answer the question. You can refuse to leave the room while it is being asked, and that turns out to be the thing she will remember.

Sources

International OCD Foundation, Moral Scrupulosity

Strauss, Hale and Stobie, 2015, a meta-analytic review of the relationship between family accommodation and OCD symptom severity, Journal of Anxiety Disorders

Lebowitz and colleagues, family accommodation in OCD and anxiety disorders

Moral OCD: When Your Mind Keeps Asking If You’re a Good Person

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A mint green bicycle with a white wicker basket full of white lilacs, parked beside a flowering lilac bush in warm evening light

It usually starts with something small

You told your manager the deck was basically done, and it was about seventy percent done. You laughed at a joke you didn’t find funny. You forgot to mention to your partner that you had lunch with an old friend. Ordinary things. The kind of thing most people forget by dinner.

Except you don’t forget it. By 11pm you’re replaying it. Was that a lie? Did I do it on purpose? What does it say about me that it came so easily?

Then the thought widens, the way these thoughts do. Maybe I’m manipulative and I’ve just never noticed. Maybe people like me because they don’t know who I really am. Maybe I’m not a good person at all, just a good performer.

So you do something to make it stop. You reread the email thread. You text a friend to ask whether you came across as rude. You tell your partner about the lunch, and they look at you, a little confused, and say it’s fine. For a minute, it is fine. Then the doubt finds a gap in the answer, and you’re back where you started, only more tired.

If that loop sounds familiar, I want to give it a name, because the name matters. What I’m describing is often moral OCD, sometimes called moral scrupulosity. It is one of the most painful forms of OCD I’ve seen, and one of the least recognized, partly because from the outside it looks like conscientiousness, and from the inside it feels like the truth.

So let me say this before anything else. Having these thoughts is not evidence that you’re a bad person. It’s evidence of how much being good matters to you.

What moral OCD actually is

OCD is not about liking your spice rack alphabetized. It’s a pattern of obsessions, meaning unwanted thoughts, images or doubts that push their way in, and compulsions, meaning whatever you do, out loud or in your head, to make the distress go away.

Moral OCD isn’t a separate diagnosis. It’s OCD that has latched onto your ethics: honesty, kindness, fairness, whether you hurt someone, whether you meant to. Its cousin, religious scrupulosity, fixates on sin and faith. Moral scrupulosity doesn’t need a religion. It works from your own moral compass, which is exactly what makes it so convincing.

The International OCD Foundation makes a point I come back to again and again: OCD tends to go after the things a person values most. Someone who doesn’t care about honesty doesn’t get stuck on whether they lied. You get stuck because you care.

It can look like a lot of things. The fear that you did something wrong on purpose and are hiding it from yourself. The fear that you’re deceiving the people around you, and that if they saw who you really are, they’d leave. Replaying meetings for anything that might have been misleading. Over-explaining so nothing you say could possibly be untrue. Apologizing for things nobody noticed. Confessing small things to your partner, not because they need to know, but because you can’t stand carrying it alone. Googling “am I a narcissist” at 1am and taking the quiz twice.

Why the thoughts feel so real

Here’s something that surprises almost everyone I share it with. In a study led by Adam Radomsky at Concordia University, across thirteen countries and six continents, about 94 percent of people said they’d had unwanted, intrusive thoughts in the previous three months. Thoughts of doing something wrong, hurting someone, saying something awful. Nearly everyone has them.

The difference with OCD isn’t the thoughts. It’s the relationship to them. Most people have the thought, find it strange, and move on. When OCD is involved, the thought lands like a verdict that has to be appealed, right now, or it will mean something terrible about you.

Sometimes there’s an obvious trigger, like the email or the joke. Sometimes there isn’t. The thought just arrives, on the train, in the shower, halfway through a good day. That’s one of the more disorienting parts. You didn’t go looking for it, and you can’t make it leave on command.

Clinicians call these thoughts ego dystonic, which is a formal way of saying they go against who you are and what you believe. That’s precisely why they hurt. Someone who is genuinely at ease deceiving people rarely lies awake wondering whether they might be.

Why arguing with it doesn’t work

When a thought says you might be a bad person, the most natural thing in the world is to try to prove it wrong. Gather the evidence. Review what happened. Ask someone you trust. Reach a conclusion.

With moral OCD, that’s the trap. Every answer opens a new question. You prove you didn’t lie, and the doubt shifts: fine, but did you want to? Your partner reassures you, and it shifts again: they’re just being kind, they don’t know the whole story.

The doubt isn’t looking for an answer. It’s looking for certainty, and certainty about your own goodness isn’t available to any human being. Not to you, not to me, not to anyone you admire. That’s why it feels circular and tangential at the same time. You circle the same question, and every lap it grows a new branch.

So I want to be honest with you about this article too. If part of you is reading it hoping I’ll settle it, that I’ll tell you once and for all that you’re good, notice that. It’s the same pull. I’m not going to try to win the argument for you, because the argument is the problem.

Is it OCD, or something else?

Not every hard thought about yourself is OCD. Low self-esteem can sound like “I’m not good enough.” Depression can sound like “I’m a burden, I ruin things.” Real guilt, about a real thing you did, can keep you up too. All of those deserve care, and they often show up alongside OCD.

Here’s the distinction I use. First, notice whether the thought feels intrusive, like it pushed in uninvited and doesn’t sound like your considered view of yourself. Then notice what comes next. If there’s something you feel you have to do to make it stop, check, confess, reread, ask, review, and the relief never lasts, that pattern points toward OCD.

Real guilt tends to point somewhere. You apologize, you repair, and it settles. OCD guilt doesn’t settle, no matter how many times you repair. Depression often feels like a heavy conclusion you already believe. Moral OCD feels more like a question demanding an answer right now.

You don’t have to sort this out on your own, and honestly, you shouldn’t have to. Telling these apart is exactly what a good clinician is trained to help with.

Who it shows up in, and where autism fits

In my years of clinical work, I’ve seen moral OCD show up a lot in women. Often she’s the reliable one, the one who holds things together at work and at home, the one who was praised her whole life for being good and easy and responsible. I don’t think that causes OCD. I do think it can shape which doubts feel the most dangerous.

I want to be careful here, because that’s my clinical observation, not a research finding. The studies don’t show moral OCD belonging to one gender, and men live with it too. If you’re a man reading this and recognizing yourself, this is for you just as much.

I’ve also seen it overlap with autism, sometimes in adults who weren’t recognized as autistic until later in life. OCD and autism do show up together more often than you’d expect by chance, and from the outside they can look alike: the deep focus, the need to get something exactly right, the thought that won’t let go.

The difference is in how it feels from the inside. Autistic hyperfocus or a deep interest usually feels good, absorbing, yours. An OCD obsession feels unwanted and distressing, and it comes with an urge to neutralize it. Plenty of people have both. Moral OCD also happens entirely on its own, with no neurodivergence in the picture at all.

This matters for treatment. A clinician who understands both will know not to treat your natural ways of focusing or settling yourself as symptoms, and to aim the work at the part that’s actually causing you pain.

What actually helps

Here’s the good news, and I mean it: OCD is very treatable. It’s also one of the conditions where the type of therapy matters a great deal.

The gold standard is a form of cognitive behavioral therapy called exposure and response prevention, or ERP. The idea is simple, even if doing it isn’t easy. With your therapist, you gradually and deliberately come into contact with the doubt, and then you practice not doing the compulsion. You send the email without rereading it four times. You let “maybe I was misleading, maybe I wasn’t” stand without confessing. You notice the urge to ask your friend if you were rude, and you don’t ask.

At first that feels awful, because every part of you believes the compulsion is what keeps you safe. Over time you learn something you can’t learn by arguing: that you can carry uncertainty and still be okay. The thought loses its urgency. It doesn’t have to disappear for you to be free of it.

People sometimes hear this and picture white-knuckling. It’s not that. It’s closer to learning to let a thought sit in the room without obeying it. Some therapists also draw on acceptance and commitment therapy (ACT) or inference-based CBT, and for many people medication is part of the picture too.

Most people who get the right treatment improve in a meaningful way. It takes practice and it’s rarely a straight line. But it can change a great deal about how you live with your own mind.

A few things to try this week

None of this replaces treatment. Think of it as a way to start noticing.

Name it instead of answering it. When the question shows up, try “there’s the doubt again,” or “I’m having the thought that I lied,” instead of going back through the evidence.

Put a little space before the ritual. If you usually reread, confess or ask right away, see whether you can wait ten minutes. You’re not trying to win. You’re noticing that the urge rises and, if you let it, falls.

Let “maybe” be an answer. Maybe I was misleading. Maybe I wasn’t. I’m going to go make dinner. It will feel unfinished, and sitting with that unfinished feeling is the practice.

And go easy on yourself when the thoughts come back. They will. What changes is how much of your evening they get to take.

If your therapist doesn’t know OCD

This happens more than you’d think, and it’s nobody’s fault. OCD often goes a long time without being recognized. The International OCD Foundation estimates it takes 14 to 17 years, on average, between when symptoms start and when someone gets effective treatment. Part of that is misdiagnosis. Part of it is that a lot of therapy, even very good therapy, isn’t built for OCD.

Here’s how that can backfire. A warm therapist who tells you, week after week, that you’re clearly a good person is offering real care. With moral OCD, that same kindness can quietly become the most comfortable reassurance ritual of your week.

So it’s always okay to ask. You can ask your therapist directly whether they’re trained in ERP and how often they treat OCD. If the answer isn’t what you need, it’s okay to ask to work with someone who has more expertise. A good therapist won’t be hurt by that. They’ll want you to get the right care. I would.

If you want help with this

At Marra, our concierge personally matches you with a therapist based on what you’re going through, and a free 15 minute consultation makes sure the match is right. Some of our therapists are trained in ERP and work with OCD, and you can meet the therapists who work with OCD before you commit to anything. If we’re not the right fit for you, we’ll say so and help you find someone who is.

Our studio is on Green Street, near River North and West Town, and we also see clients online anywhere in Illinois.

You’re not flawed. You have a mind that got very good at protecting something you care about, and it can learn a gentler way to do that.

Book a Consultation

If you’re having thoughts of harming yourself, please contact the 988 Suicide and Crisis Lifeline by calling or texting 988. It’s free, confidential and available 24 hours a day.

Sources

Depression in Women: Signs, Causes, and What Helps

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Depression in Women

If you’ve been exhausted for longer than any explanation covers, you’re not alone. And if you’ve been told more than once that it’s probably just hormones, there’s likely more going on than that phrase allows for.

Women are diagnosed with depression at roughly twice the rate of men. CDC data covering 2013 to 2016 found that 10.4 percent of women had depression in a given two-week period, against 5.5 percent of men. Hormonal transitions across the reproductive years play a well-documented part in that gap. So does the caregiving load and the invisible daily work that comes with it, which is a real contributing factor and not a softer version of one.

This is different from postpartum depression specifically, which is tied to a defined window after birth. And whatever combination of things is driving it, depression responds well to treatment.

Here’s why depression affects women differently, and the signs, grouped by how they tend to show up. You’ll also find the load that never gets counted, how to tell a hormonal mood shift from a depressive episode, and what treatment should look like.

Why Does Depression Affect Women Differently?

Two kinds of factors combine here: hormonal transitions and social load.

The hormonal side is well documented. NIMH identifies three life stages where hormonal change is specifically implicated. The first is premenstrual dysphoric disorder, a more intense form of premenstrual syndrome that shows up in the weeks before your period. The second is perinatal depression, during pregnancy or after childbirth. The third is perimenopausal depression, during the transition to menopause, which NIMH describes as involving irritability, anxiety, sadness, or loss of enjoyment.

The social side gets named less often in a clinical setting, and it isn’t smaller. Caregiving still falls disproportionately on women, for children and increasingly for aging parents, often alongside a full-time job. So does the invisible administrative work of running a household. Then add the well-documented tendency for women’s physical symptoms to be taken less seriously in medical settings. What you get is a pattern where exhaustion gets chalked up to circumstance for years before anyone asks whether it’s depression.

Neither factor makes depression less treatable. Both change what a good clinician should be watching for.

What Are the Signs of Depression in Women?

Emotional and Cognitive Signs

Low mood or emptiness that doesn’t lift when things improve. What sets it apart is how stuck it feels. A good day happens, and it doesn’t touch it.

Guilt that attaches to everything. A diffuse sense of falling short as a mother, a partner, a daughter, a colleague, often across several of those at once. It’s one of the most consistently reported features, and one of the most exhausting.

Rumination. Replaying conversations, going back over old decisions, running the same loop at two in the morning. Rumination shows up more often in women, and it’s easy to mistake for problem-solving. It isn’t.

Trouble concentrating and making decisions. This usually gets written off as being scattered or overloaded. It’s also a cognitive symptom of depression.

Physical Signs

Fatigue that rest doesn’t touch. Given how many women are short on sleep for structural reasons, this is the easiest symptom of all to explain away, and it can run for years while everyone blames the schedule.

Changes in appetite and weight in either direction, sometimes with a specific pull toward carbohydrates.

Sleep disruption, either insomnia or sleeping much more and still waking with nothing.

Physical pain with no clear cause: headaches, digestive trouble, general aching. These overlap heavily with premenstrual and perimenopausal symptoms, which is exactly why they get filed under hormones and never looked at again.

Signs Tied to Hormonal Life Stages

A reliable, severe mood shift in the week or two before your period, well beyond ordinary premenstrual symptoms and getting in the way of work or relationships. This may be premenstrual dysphoric disorder, a more intense form of PMS, and it’s treatable. You don’t have to ride it out every month.

Depression during pregnancy or in the first year after birth. Perinatal and postpartum depression are common. Onset can happen at any point in that first year.

Mood changes during the transition to menopause, often arriving before any obvious change in your cycle and often mistaken for stress, burnout, or a personality shift. Perimenopausal depression is recognized and treatable, and it’s one of the most under-diagnosed forms of depression on this list.

Mood changes after a switch in hormonal contraception, or after fertility treatment or pregnancy loss. Bring these up with a clinician. You don’t have to carry them alone. Any decision about medication or contraception belongs with a prescriber who knows your history.

Social and Relational Signs

Pulling back from friendships, usually by drift rather than decision. Replies get slower, plans get declined, and the friendships that needed upkeep quietly fade.

Caregiver burnout. Resentment toward people you love, then immediate guilt about the resentment, then working harder to make up for it. The cycle feeds itself, and it’s one of the more common routes into depression for women in their thirties and forties.

Trouble asking for help, or not being able to name what help you’d even want. If you’ve spent years as the person who organizes everyone else, the habit of being on the receiving end usually isn’t there.

If you’d like something more structured than a list, our depression check-in takes about two minutes and uses the PHQ-8, the same screening questions a clinician would open with. It’s an inventory, not a diagnosis, and it isn’t a substitute for talking to someone. It gives you a starting point, not the whole picture.

What About the Load That Never Appears on the Chart?

There’s a category of work that doesn’t show up in any account of how you spend your week, and it’s often the thing sitting underneath everything else.

It’s the remembering. Which child needs what on which day, when the prescription runs out, that your mother’s appointment needs rescheduling, whose birthday is coming, what’s left in the fridge. No single one of these is large. What wears you down is that the noticing never stops. It runs underneath everything else, all the time.

This load is still shared unevenly, and it has two features that make it especially corrosive. It’s invisible, so nobody thanks you for it, and it’s hard to even describe. And it has no end point. You can finish every task on the list, and the monitoring keeps going.

Constant demand with no finish line and no recognition is a known route into exhaustion and low mood in any setting. It goes unexamined here because it gets called being organized, when what it actually is is a genuine stressor.

If you’re trying to work out why you’re this tired when nothing obviously terrible is happening, this is a real answer. And any treatment that only works on your thinking about the load, without touching the load itself, will keep hitting the same wall.

Why Does It Get Missed for So Long?

Because the low mood gets noticed right away and then gets attributed to something else, and that’s where the questions stop.

It’s nearly the opposite of what happens with men, whose depression gets missed because the symptoms don’t look like depression at all. Here it’s hormones, or the kids, or the stage of life, or the job. Each explanation is plausible, each is often a genuine contributing factor, and each one can absorb years.

The perimenopausal version does the most damage. Mood changes can start well before any obvious change in your cycle, sometimes years before, and they get routinely put down to stress, aging, or personality. Women in their forties get told with a lot of confidence that this is just what forty is like.

Physical symptoms reported by women are also, on average, taken less seriously and investigated less thoroughly in medical settings. If you’ve raised persistent exhaustion more than once and left feeling like you were being slightly dramatic, that experience is common. It isn’t a reason to stop raising it.

The useful correction is to stop treating an explanation as a fix. Knowing why you’re depressed doesn’t treat it. Plenty of people can account for their depression in complete detail and stay thoroughly depressed.

How Is Depression in Women Different From Depression in Men?

How it shows up and how often it’s diagnosed differ. Treatment largely doesn’t.

Depression in women more often looks the way the condition is popularly described: sadness, tearfulness, guilt, and rumination. That’s one reason it gets recognized sooner. Depression in men more often surfaces as irritability, anger, risk-taking, and substance use, which is a big part of why it goes unidentified for years.

There’s a trap in each direction. Women’s symptoms are more likely to be recognized as depression, and also more likely to be put down to hormones and left there. Men’s are more likely to be missed entirely. Different failures, and the cost is the same.

When Do Hormonal Shifts Cross Into Depression?

When they get in the way of your life, stop resolving, or start bringing hopelessness with them. This is the hardest line to draw, and the one most often drawn wrong, usually in the direction of not getting help.

Three questions do most of the work.

Does it interfere? Expected hormonal mood changes are unpleasant and you keep functioning. When work suffers, when you’re canceling repeatedly, or when relationships are strained, you’re past the threshold, whatever is driving it.

Does it resolve? Premenstrual mood shifts lift once your period starts. If the low mood no longer clears, or the good stretches in between keep getting shorter, the pattern has turned into something else.

How severe is it? Hopelessness, not being able to feel pleasure at all, or any thought that you’d be better off not here sits outside the ordinary hormonal range. Those call for a conversation today.

Hormonal changes and depression aren’t two separate things to sort between. Hormonal transitions are a well-documented trigger for real depressive episodes. The more useful question is whether what you’re experiencing meets the threshold for treatment. Often the answer is yes, and the hormonal trigger becomes part of what gets treated.

What Does Treatment for Depression in Women Look Like?

The same evidence-based approaches used for depression generally: cognitive behavioral therapy, dialectical behavior therapy, acceptance and commitment therapy, and psychodynamic work, sometimes alongside medication.

Look for a clinician who takes the hormonal and structural context seriously and works with it rather than around it. Someone who asks where you are in your cycle or your menopausal transition. Someone who doesn’t treat perimenopausal mood change as something to wait out, and who understands that a caregiving load is a clinical factor in its own right. When hormonal transitions are clearly involved, treatment sometimes works best alongside a physician managing that side, like an OB-GYN or a menopause specialist. Therapy doesn’t replace that, and a good therapist will tell you so.

Whatever the approach, it has to make room for the actual circumstances. So much of this attaches to role transitions and relationships. Becoming a mother, caring for a parent, a marriage changing shape, an identity shifting at midlife. It’s also fair to want a therapist who has worked with a lot of women at your stage, and to ask about that directly on a first call.

One practical note deserves more attention than it gets. If the reason you haven’t started is that there’s no room in the schedule, online sessions take out the travel and most of the childcare problem, and they work just as well as in-person care for depression. The logistics are often the actual obstacle, more than any hesitation about therapy itself.

Treatment also doesn’t ask for what people assume it asks for. You don’t have to cut back your commitments before you’re allowed to start. You don’t have to have already made the changes you suspect you need to make. People routinely put therapy off until they’ve sorted out the job, the marriage, or the schedule, which puts treatment behind exactly the decisions it would help with.

How Is This Different From Postpartum Depression?

Postpartum depression is one specific form of depression in women, tied to a defined window and a defined trigger.

What sets it apart is timing and context. It happens during pregnancy or in the first year after birth, alongside a physiological event of enormous scale. It comes with its own screening tools and its own treatment considerations, including questions about breastfeeding that don’t come up anywhere else.

It also carries a particular kind of guilt. Depression at any life stage tends to come with a sense of falling short. Depression around a new baby adds something else: the conviction that you’re failing at something that’s supposed to be instinctive, and that saying so out loud would confirm it. That belief keeps more new parents out of treatment than any practical barrier.

What If It’s Someone You Know?

Describe specific things you’ve noticed. Then take one specific task off her plate.

“You haven’t been sleeping, you haven’t seen anyone in months, and you seem to be running on empty” is easier to answer directly than “I think you’re depressed,” which tends to produce automatic reassurance.

Someone already carrying an unbounded mental load doesn’t need the extra task of working out what to hand off and then asking for it. Take something specific and take it completely. Skip “let me know what I can do.” Try “I’m collecting them on Thursdays from now on.”

Expect the first response to be that she’s fine and other people have it worse. That answer is close to automatic for anyone who has spent years as the person who copes, and it isn’t reliable.

If what she describes is a mood pattern tied to her cycle, to a recent birth, or to perimenopause, take it as seriously as you would any other symptom. Don’t let it become an explanation that closes the subject. Being told it’s probably just hormones is one of the more common reasons women stop mentioning it.

One thing overrides everything else here. If she’s said anything about not wanting to be here, ask her directly if she’s thinking about suicide. It doesn’t plant the idea, and it’s often a relief to be asked plainly. Get help today.

What Progress Actually Looks Like

The first thing that usually shifts isn’t mood. It’s the guilt loosening slightly, so that a sentence like “I can’t do that this week” stops costing you three days of second-guessing. The rumination gets shorter before it stops. You catch yourself doing it at two in the morning and put it down sooner than you used to.

Then some room comes back. You notice you wanted something, and you notice it in time to act on it. None of that arrives as happiness showing up one morning. It looks more like capacity returning, and it’s usually slower than you want and steadier than you expect.

Book a Consult With Marra Therapy

If you’ve spent a long time managing everyone else, the idea of an hour a week that exists only for you can feel a little indulgent. It isn’t. It’s the least indulgent thing available, because the alternative is carrying on at this level until something gives.

Our therapy for women in Chicago covers this territory, including how hormonal changes affect mood, and our team spans a range of approaches and specialties.

A free consultation is just a 15-minute call. You describe what’s been going on, and we’ll tell you honestly which of our clinicians fits.

We see clients in person minutes from West Loop, Wicker Park, and Bucktown, or online anywhere in Illinois, and we’re in network with Blue Cross Blue Shield, Cigna, Aetna, and UnitedHealthcare.

You don’t have to have worked out whether it’s hormones, circumstances, or something with a name. Sorting that out is the clinical work, not a prerequisite for booking.

If you’re having thoughts of harming yourself, please contact the 988 Suicide and Crisis Lifeline by calling or texting 988. It’s free, confidential, and available 24 hours a day.

When Everyone Around You Is Shrinking

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A woman in a white eyelet dress holds a ceramic bowl of red cherries and green plums close to her body

I want to talk about something I’ve been noticing, first in my own life and then in almost every conversation I have with women right now.

It starts small. A friend at brunch who takes three bites and says she’s just not that hungry anymore. A mom at school pickup whose jeans are suddenly hanging off her. The group chat where someone mentions, half joking, that she “started a little something.” Then one day you look around the room and realize that nearly everyone you know is getting smaller. Some of them so small that their bodies start to look like they belong to someone much younger than the life they’re living.

Nobody said anything to you. Nobody told you that you needed to change. But you catch your reflection in the car window on the way home, and something in you has quietly shifted. You don’t feel fit enough. You don’t feel attractive enough. You’re doing math about your own body that you never agreed to start doing.

If that’s you, I want you to know two things before we go any further. You are not shallow for feeling this. And you are not stuck with it.

Is this a suburbs thing, an American thing, or something bigger?

It’s the question I keep hearing, and one I’ve asked myself: is this just where we live?

The honest answer is that it’s bigger than any one zip code, and it follows money more than it follows a map.

The numbers have moved fast. In late 2025, KFF found that about one in eight American adults were currently taking a GLP-1 medication like Ozempic, Wegovy or Zepbound, double the share from a year and a half earlier, and women were more likely than men to be on one. Many of those people take them for exactly what they were designed for: diabetes, heart health, obesity. I want to be really clear that this piece is not about them. A medication your doctor prescribed for your health is not a character question.

What’s newer is who else is using them. A large study of US medical records in the journal Obesity found that prescriptions to adults with no apparent approved reason grew more than thirteenfold between 2021 and 2025, and about a third of those people had a BMI in the normal range. The pattern leaned toward people who are more financially comfortable and privately insured.

It isn’t only an American story, either. In the UK, an analysis of more than 110,000 private prescriptions found that roughly four in five went to women, uptake peaked between ages 30 and 49, and use was higher in wealthier areas even though those areas have less obesity. Researchers in Brazil have written that using these drugs for slimness is quietly redefining what a “responsible” body looks like, and they warn against shaming the people who use them, because the pressure is cultural, not personal.

So if it feels like the suburbs, that’s not your imagination. Suburbs gather people of similar income and similar life stage into the same rooms: the same school gym, the same Pilates studio, the same Saturday sidelines. When a trend follows money, it shows up there first and all at once. But what you’re seeing is a cultural shift, not a local quirk. We spent a decade hearing that every body was welcome, and in about two years, thin quietly became something you could order.

Why it gets under your skin, even when you know better

Here’s what I find reassuring about the research, strange as that sounds: the way you’re reacting is exactly how humans are built.

Back in the 1950s, the psychologist Leon Festinger described our deep drive to size ourselves up against the people around us, a drive that gets stronger when we feel unsure of where we stand. Decades later, a meta-analysis of 156 studies found that comparing our appearance to others is reliably linked to feeling worse about our bodies, and that the link is stronger for women than for men.

And here’s the part that explains why this moment stings so much. In one study of university women, comparing themselves to peers they actually knew was tied to more body dissatisfaction than comparing themselves to models or celebrities. We’ve gotten pretty good at rolling our eyes at a magazine cover. It’s much harder to roll your eyes at your best friend, your sister in law, or the woman next to you at spin class.

The younger part of you who is watching

Sometimes the reaction is bigger than the moment. You notice a friend’s new collarbones and suddenly you’re thirteen again, in a dressing room, or at a family dinner where someone commented on your plate.

That’s not you being dramatic. In therapy we often talk about parts: the younger versions of us who learned, a long time ago, that love or safety or belonging depended on how we looked. When everyone around you is shrinking, that younger part gets loud. She’s scanning the room the way she learned to, asking the questions she has always asked. Am I still okay? Will I still belong?

If that’s what’s happening for you, that’s okay. She isn’t the problem. She’s just been left in charge of a decision that belongs to the adult you.

Coming back to your adult self

I’ll be honest with you, because I’d want you to be honest with me. I’ve felt the pull too. Watching women around me change, I caught myself wondering whether I should be doing the same. What brought me back was a simple, stubborn truth about my own life: a strong body is what serves me best. I want a body that can carry what my days ask of it, stay present through long hours with the people who count on me, and keep moving for a long time. That’s the body I’m choosing to build.

That’s what coming back to your adult self looks like in real life. Not shaming the younger part for being scared. Turning toward her the way you would with a child who’s upset, and telling her: I see you. I know why you’re worried. I’ve got this now. You’re safe, and you don’t have to earn your place by getting smaller.

The adult you gets to ask better questions than the younger one can. Not “how do I look next to her?” but “what do I want my body to be able to do in ten years? What does taking care of myself actually look like, for me?”

Sometimes the answer includes a real conversation with your doctor about your health, and that’s a grown up decision that belongs to you. What I want for you is that the choice gets made by the woman you are now, with good information and a lot of care, and not by the thirteen year old in the dressing room.

Pride in the body that carries you

There’s a small, lovely line of research I come back to often. Psychologist Jessica Alleva and her colleagues created a writing program called Expand Your Horizon. Women who were unhappy with their bodies spent three short sessions, about fifteen minutes each, writing about what their bodies can do and why that matters to them. Nothing about how they look. Afterward, they felt better about their bodies, including their appearance, and saw themselves less as something to be judged. The shift held a month later.

That tells me something hopeful. You don’t have to love how your body looks this week to start feeling proud of it. You can begin with what it does.

So tonight, or this weekend, try this. Grab a notebook and write for fifteen minutes about everything your body did for you this week. It carried you through a hard meeting. It held someone you love. It walked you home in the cold. It healed a cut you already forgot about. It woke up, again. Write it like a thank you note, not a report card.

A few other things help too. Notice when your chest tightens while you scroll, and give yourself permission to mute accounts, even ones that belong to people you like. You can love someone without needing a daily view of their body. When the comparison comes up with a friend, try getting curious instead of going quiet: most women are feeling some version of this, and saying it out loud tends to shrink the shame instead of you. And move your body for how it feels, not how it looks. Strength, breath, the walk that clears your head.

If you want help with this

Some of this you can do on your own, with a notebook and a little honesty. Some of it needs company, especially when that younger part has been running things for a long time.

At Marra, the first step is a free 15 minute consultation with our intake team. You tell them what’s going on, and they help you find the therapist here who fits. If nobody here is right for you, we’ll tell you that and point you somewhere better. We’re in River West and see clients online anywhere in Illinois, and you can meet our therapists before you commit to anything at all. When you’re ready, Book a Consultation.

You don’t need a crisis to deserve support. Feeling a little less at home in your own body lately is plenty.

If thoughts about food, weight or your body have started taking over your days, you deserve specialized care, and the National Alliance for Eating Disorders helpline at (866) 662-1235 is a good place to start. If you’re having thoughts of harming yourself, please contact the 988 Suicide and Crisis Lifeline by calling or texting 988. It’s free, confidential, and available 24 hours a day.

Five things your dog already knows about mental health

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Let me say the obvious part first: your dog is not your therapist. I would never tell you otherwise, and anyone who does is selling something. But I have spent a lot of years sitting across from people who are working very hard at feeling better, and I have noticed that the things we struggle to do are often the things a dog does without thinking. So here is a short list. Read it, then go find your dog.

1. Go outside every day.

Your dog does not check the weather and decide today is not a good day for it. She just goes. Ten minutes counts. Daylight on your face and a slow lap around the block do more for a heavy mood than most of us give them credit for, and you do not have to feel like it first. The wanting usually shows up somewhere around the corner.

2. Nap without apologizing.

Rest is not something you earn by finishing the list. Your dog has never once felt guilty about lying down in a patch of sun, and it seems to be going well for her. If you are the kind of person who narrates your own laziness while you rest, try this: lie down, and let that be the whole activity.

3. Greet the people you love like you mean it.

You know the greeting I mean. Connection is a daily practice, not a reserve you draw on in an emergency. Say hello to the people who come home to you like you are glad they came home, because you are, and because it turns out that saying so out loud changes the room.

4. Ask plainly for what you need.

A dog with a ball does not hint. She brings you the ball. Most of us could stand to be a little more direct about what we want and a little less worried about how it lands. Wanting something is not a character flaw, and the people who love you would usually rather know.

5. Shake it off, then actually move on.

After something stressful, a dog shakes out her whole body and goes back to her day. She does not replay it at 2 a.m. You have a version of the shake, too: a long exhale, a stretch, a walk to the end of the street and back. It will not fix everything. It will let your body know the moment has passed, and that is worth more than it sounds.

That is the list. None of it is complicated, and all of it is easier said than done, which is exactly why the dog is winning.

Want the occasional note from me?

I write about the ordinary hard parts of a full life: breakups, new babies, aging parents, burnout, the week where nothing goes right. A few notes a year, nothing more, and you can leave whenever you like.

And if you are looking for a therapist

MARRA is my therapy studio in Chicago. When you reach out, a real person on our team matches you to a therapist based on what you need, and the first conversation is free so we can make sure the match is right. We see people in person at 700 N Green and online anywhere in Illinois, and every therapist is in network with BCBS PPO, Aetna, Cigna and United.

Book a Consultation

If today is not that day, that is fine too. Go give your dog a scratch from me.

Depression in Men: The Signs That Often Go Unnoticed

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Depression in Men

Maybe you’re here because something has felt off in you for a while. Maybe you’re here because you’re worried about someone else, a husband, a brother, a friend. Either way, the picture of depression most of us carry around probably doesn’t match what’s happening underneath.

He isn’t sad. That’s the part everyone keeps getting wrong.

He’s short-tempered in a way he never used to be. He’s exhausted and sleeping badly. He’s drinking more than he was a year ago, working later than the job needs, and he’s drifted away from the people he used to see. Ask him how he is and he’ll say fine, and he’ll mean it. Sadness is what he’s been told depression is, and he doesn’t feel sad.

So it looks like anger. Or exhaustion. Or pulling away. And because none of that matches the picture, it goes undiagnosed for years, by doctors, by families, and by the man himself.

It also tends to arrive attached to something that looks ordinary from the outside. A role changing. A long stretch of stress with no break in it. Anxiety that’s run so long it reads as personality now. None of that changes what helps. Treatment works the same way no matter how the symptoms show up.

Here’s why male depression goes unrecognized, 15 signs grouped by how they tend to show up, what causes it, why anger and depression sit so close together, what to do if it’s someone you know, and what treatment looks like.

Why is Depression in Men So Often Missed?

Three things combine here, and none of them is about men feeling less.

The first is that the symptoms look different. NIMH notes that men and women can develop the same conditions but may experience different symptoms, and it lists anger, irritability, high-risk activities, and substance misuse among the ones more common in men. Every one of those gets read as a personality trait. Every one of those is a symptom.

The second is what boys learn early about which feelings are allowed. Sadness, fear, and need get discouraged long before anyone can describe it happening. Anger and tiredness usually survive, because both are acceptable and neither asks you to be vulnerable. So distress travels down the routes that are still open. That has nothing to do with emotional intelligence and everything to do with which exits are left.

The third is what happens at the doctor’s office. A man who describes back pain, insomnia, and low energy is likely to have all three investigated as physical problems, because that’s how he framed them. Nobody asks about depression. He leaves thinking whatever this is doesn’t have a name.

You can see it in the numbers. NIMH states plainly that men are less likely to have received mental health treatment than women in the past year. CDC data covering 2013 to 2016 found 5.5 percent of men had depression in a given two-week period, against 10.4 percent of women. That gap reflects who gets identified and diagnosed as much as who’s affected.

What Are the Signs of Depression in Men?

These are grouped by how they tend to show up, because the grouping is the point. If you only read the emotional ones, you’ll miss most of them.

Emotional Signs That Don’t Look Like Sadness

Ongoing irritability or anger. A short fuse over things that never used to register, like traffic, a slow website, or a question asked twice. The anger is usually followed by self-criticism nobody else sees. Irritability is one of the most reliable markers of depression in men, and one of the least likely to be read as one.

Flatness where you’d expect sadness. Things that should land don’t. Good news barely registers. A lot of men describe it as watching their own life through glass.

Getting stung by criticism that wouldn’t have touched you before. A note in a meeting, a joke from a friend. What shows on the outside is defensiveness or withdrawal, with no sign at all of the hurt underneath it.

A harsh running commentary in your head that never stops. It’s not spoken out loud, so nobody else knows it’s there. It’s the constant assessment that you’re falling short, that you’re a burden, that you’re getting away with something and someone will notice eventually.

Behavioral Signs

Drinking more, or using more of something else. It usually starts as taking the edge off in the evening and becomes routine without anyone deciding it should. The drinking gets treated as the problem when it’s often the thing holding the problem down.

Risk-taking that’s out of character. Driving faster, spending impulsively, gambling, or physical risks that would have seemed pointless a year ago. The pull is usually about feeling something, more than about the outcome, which is why from the outside it can look like recklessness or a midlife crisis.

Pulling back from friendships. It’s rarely a decision and almost always a drift. Fewer replies, more declined invitations, no longer being the one who organizes anything. Male friendships are often built around doing something together rather than talking, so when the energy for the activity goes, the friendship goes with it.

Conflict at home. Shorter with a partner, less patient with the kids, then guilt afterward, then more withdrawal to avoid doing it again. This cycle is often what finally prompts a call. It usually gets framed as a relationship problem when a mood problem is what’s underneath it.

Physical Signs

Exhaustion that sleep doesn’t fix. Eight hours and no energy. This is one of the most common ways depression shows up physically and one of the most likely to get investigated as something else.

Broken sleep. Waking at four and not getting back off, or sleeping far more than usual and waking with nothing. Early-morning waking in particular is a classic depression pattern, and it usually gets put down to stress or age.

Pain with no clear cause: headaches, back pain, digestive problems, muscle tension. If you’ve had tests that came back clear and the symptoms are still there, that’s worth raising with a clinician as a possible expression of emotional strain rather than dropping.

Changes in appetite or weight in either direction, and a loss of interest in sex, which is common in depression and almost never brought up.

Signs at Work or Under Stress

Working longer without producing more. The hours go up, the output doesn’t, and the extra time is spent doing something other than work. It’s filling the space where thinking might otherwise happen. Because it gets rewarded, it can run for years.

Trouble concentrating and making decisions. Reading the same paragraph four times. Small choices taking forever. Both are cognitive symptoms of depression, and both get read as being tired or losing your edge.

A shorter temper with colleagues than the situation calls for, followed by a private conviction that you’re turning into someone you don’t like.

The One Sign That Overrides Everything Else

If there are thoughts of not wanting to be here, of others being better off without you, or of not existing, that isn’t something to monitor for a few more weeks. That’s a reason to talk to someone today. Men account for a disproportionate share of suicide deaths, and the gap between how someone appears and what they’re carrying can be very wide.

What Causes Depression in Men?

Depression rarely has one cause, and in men it often arrives attached to something that looks from the outside like an ordinary life event.

Role transitions are a big one. A layoff, retirement, a demotion, a business failing, becoming a father, kids leaving home, a relationship ending. What they share is a change in what you’re for. If your identity is built around providing or performing, that shift leaves you exposed.

Long stress with no recovery is another, and it’s often the one people are proudest of surviving. Sustained pressure with no let-up wears down mood regulation no matter how well you’re handling it.

Then there are the ordinary contributors: grief, chronic pain or illness, money strain, sleep deprivation, family history, and untreated anxiety that’s been mistaken for personality. Alcohol deserves its own mention, because it’s both a common consequence and a real driver, and the loop between the two gets tighter over time.

Loneliness belongs here too, and it’s the one men are least likely to name. Male friendships tend to be organized around doing things together rather than talking, which works fine until the activity stops. A lot of men reach their forties with a wide social circle and nobody they’d call at eleven at night.

How Depression in Men Can Affect Relationships

Depression can show up in a relationship long before anyone calls it depression. Irritability with a partner, emotional distance, less talking, losing interest in shared activities or sex, more time spent at work or alone. All common.

Any one of them has plenty of other explanations, so a single bad week doesn’t mean much. What’s worth paying attention to is the pattern over time, not one isolated behavior.

It’s also common for a partner to read withdrawal or numbness as a loss of love or interest, when what’s actually happening is depression narrowing what someone has left to offer. That difference matters, because the two call for very different conversations.

Why Are Anger and Depression So Closely Linked?

Because pain has to go somewhere, and anger is often the only channel still open.

If sadness, fear, and need were discouraged for most of your life and anger wasn’t, anger becomes the available exit. It isn’t fake, and it isn’t a disguise. It’s just the route with the door open, so a lot of traffic goes down it.

There’s a second thing happening too. Depression drains the reserve that normally absorbs friction. Everyone has a buffer between an irritation and a reaction, and depression burns through it. That’s why the anger runs out of proportion, and why it’s so often followed by real confusion at your own reaction.

This changes what treatment should aim at. If anger is what you’re presenting with, anger management on its own usually isn’t the answer, because managing the output while ignoring what drives it rarely holds. Treat the depression and a lot of the irritability tends to settle without being addressed directly.

What If It’s Someone You Know?

Describe specific things you’ve noticed. That lands better than naming a conclusion. Most people reading this aren’t reading it about themselves. They’re reading it about a husband, a father, a brother, or a friend who hasn’t been right for a while.

“You haven’t been sleeping, you’ve been snapping at everyone, and I’ve noticed you haven’t seen anyone in months” is much harder to deflect than “I think you’re depressed,” which invites a straight denial.

Pick a moment with no eye contact and no audience. Driving, walking, doing something with your hands. Sitting a man down across from you and announcing a serious conversation triggers exactly the defenses you’re trying to get past.

Expect the first attempt to go nowhere, and don’t treat that as your answer. It’s common for someone to brush it off entirely and come back to it days or weeks later. You’re opening a door. The fact that it got mentioned once and nothing terrible happened is what makes the second conversation possible.

A concrete offer works better than encouragement on its own. Sending a link, sitting with him while he makes the call, booking the consultation yourself if he asks you to. All of that beats telling him he should talk to someone. And don’t build the whole approach around the word depression if that word is going to end the conversation. Sleep, exhaustion, and stress are all legitimate reasons to see someone.

One exception overrides all of this. If he’s said anything about not wanting to be here, or you believe he may be at risk, don’t manage that gently over several weeks. Ask him directly if he’s thinking about suicide. This doesn’t plant the idea, and it frequently comes as a relief. Get help the same day.

Why Are Men Less Likely to Seek Help?

The usual explanation is stigma, which is true and too vague to be useful. Get more specific and four reasons show up.

A lot of men have no framework for what they’re experiencing. Depression was described to them as sadness; they don’t feel sad, so the word never seems to apply. A lot of men also picture therapy as an open-ended commitment to discussing their childhood with no endpoint in sight, which sounds like signing up for something with no exit. For others, the whole sense of self is built around being the one who copes. Asking for help doesn’t feel like a practical step. It feels like becoming a different kind of person. And some tried it once, got a bad fit with a therapist, and decided the whole thing wasn’t for them.

What’s changing is less about attitudes and more about format. Sessions online, in the evening, from your own house remove several barriers at once. Structured approaches with a clear ending point answer the worry about open-ended commitment directly.

If it helps to think of this as problem-solving rather than emotional disclosure, that’s a fair description of it. A lot of therapy for depression is practical. Work out what’s happening, work out what keeps it going, change those things, then check whether it worked.

Is Depression in Men Different From Depression in Women?

How it shows up differs more than the condition does, and treatment barely differs at all.

Depression in women more often looks the way the condition is popularly described: sadness, tearfulness, guilt, and rumination. That’s part of why it gets recognized sooner. Depression in men more often surfaces as irritability, anger, risk-taking, and substance use, which is a big part of why it goes unidentified for years. We cover the other side of this in our companion article on depression in women.

There’s a trap in each direction. Women’s symptoms are more likely to be recognized as depression, and also more likely to be put down to hormones and left there. Men’s are more likely to be missed entirely, including by the man himself. Different failures, and the cost is the same.

What doesn’t really change is what works. The approaches with the best evidence apply regardless of sex, and a good clinician mostly adjusts how the conversation opens.

What Does Treatment for Male Depression Look Like?

Treatment itself isn’t different for men. The approaches with the best evidence are the same regardless of who’s in the chair: cognitive behavioral therapy, behavioral activation, acceptance and commitment therapy, psychodynamic work, and sometimes medication alongside.

What does adapt is the conversation. A good therapist working with someone who’s spent decades not discussing any of this won’t open by asking how that makes you feel, because the honest answer is probably that he doesn’t know.

It usually starts somewhere more concrete. What does a bad week look like? When did you last feel like yourself? What is the drinking doing for you? Emotional vocabulary comes later, and it’s a skill you can learn at any age.

Expect a structure and a checkpoint. Weekly to begin with, a real review at around eight to twelve sessions, and a plan you can describe back to yourself. If knowing there’s a review point makes starting easier, ask for it on the first call. Our guide to the types of therapy used for depression sets out how the main approaches differ, and we offer therapy for men in Chicago specifically.

Frequently Asked Questions

Is depression in men different from depression in women?

How it shows up differs more than the condition itself. Depression in men more often presents as irritability, anger, and withdrawal, while depression in women more often matches the classic picture of sadness and rumination. Treatment approaches barely differ between the two.

Why do men hide depression?

Often because it doesn’t register as depression to them in the first place. They were taught to associate the condition with a sadness they don’t feel. Stigma plays a part too, along with a sense that asking for help doesn’t fit with being the one who copes.

Is therapy or medication better for men?

Neither is universally better, and the evidence doesn’t point to a difference by gender. For moderate to severe depression, therapy combined with medication tends to outperform either alone. Plenty of men start with therapy and add medication later if they need it, or the other way around.

How can I help a husband or partner with depression?

Describe specific things you’ve noticed rather than naming a diagnosis. It’s easier to hear and harder to deflect. Pick a low-pressure moment, like a drive, instead of a formal sit-down. If he mentions not wanting to be here, ask directly about suicide and get help the same day.

What Progress Actually Looks Like

The first thing to shift usually isn’t mood. It’s the fuse getting a little longer. You notice you didn’t snap at something that would have set you off last month, and you notice it a day later rather than in the moment. Sleep tends to move early too, before anything feels different in your head.

After that it’s the small stuff coming back. You answer the text. You go to the thing. Something is actually funny again. It’s slower than most men want and steadier than they expect, and you’ll usually see it before anyone around you does.

Take the Quiz or Book a Consult

If booking a call is a bigger step than you’re ready for, start smaller.

Our depression assessment takes about two minutes and uses the PHQ-8, the same screening questions a clinician would open with. It’s an inventory, not a diagnosis, and it isn’t a substitute for talking to someone. It gives you a starting point, not the whole picture. For a lot of men it’s the first time the thing has a shape and a name instead of a vague sense that something’s been off for a while.

It also gets around the sadness problem, because it asks about energy, sleep, concentration, and interest rather than only about mood.

Two routes, and either is a reasonable first move. Take the check-in if you want something concrete before involving anyone, or book a free consultation if you’d rather just talk to someone. Fifteen minutes, no cost, and we’ll tell you honestly which of our clinicians is the right fit.

We see clients in person minutes from West Loop, Wicker Park, and Bucktown, or online anywhere in Illinois, including evenings, and we’re in network with Blue Cross Blue Shield, Cigna, Aetna, and UnitedHealthcare.

You don’t need to arrive with the right words. “I’m angry all the time and I don’t know why” is a completely adequate place to start, and it’s roughly how a lot of these conversations begin.

If you’re having thoughts of harming yourself, please contact the 988 Suicide and Crisis Lifeline by calling or texting 988. It’s free, confidential, and available 24 hours a day.

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