Why We Suck at Saving Money, and Suck Even Worse at Saving Time

Two recent articles in the New York Times got me thinking about why most of us really suck at saving money and more importantly why we suck at utilizing our time well. These are two separate but very connected issues. They are connected because after all we all know that time is money and money is time.

Both money and time seem like nonrenewable resources. Time actually is a nonrenewable resource. Although we don’t know exactly how much time we have, it’s a pretty good bet that most of us have between 70 and 90 years on this planet. And we each have 16 to 18 hours of conscious time each day. Just like oceanfront property, we can’t manufacture more time, we can only better utilize the time we have.

Money also seems like a nonrenewable resource for most of us. But it’s not really. In fact, thinking that money is a nonrenewable resource is probably one of the main reasons why people don’t use time better.

The first New York Times article, How to Pinch Pennies in the Right Places, gave a theoretical thought experiment. If you could save $10 on a $50 set of headphones, would you drive 30 minutes across town to get a better price at a different store? (Answer this before reading on.)

Or, if you could save $15 on a $400 television would you drive 30 minutes across town?

Research done by Daniel Kahneman and Amos Tversky in 1981 suggests that most people were more willing to drive across town to save money on the headphones than on the television. You save 20% on the headphones and only 3.75% on the television. But we don’t spend percentages, we spend dollars, and actually you’d be saving more money ($15) on the television than on the headphones ($10).

The same article discussed other research that suggested that consumers were willing to spend 20 minutes extra to save $3.75 on a $10 pen, but needed a savings of at least $278 on a $30,000 car to be willing to invest the same 20 minutes extra.

This of course is crazy! In the example of the pen people value their time at $11.25 per hour. But in the example of the car people are unwilling to make an investment of time that would pay them $834 per hour!

But we all fall prey to different versions of this. How much time do we waste surfing Amazon in order to save a few bucks on a product? Or to find a product that has 4 stars instead of 3 ½ stars?

This article also pointed out that people on the lower income level are less likely to fall prey to the percentage saved fallacy, because they care about each and every dollar. But I think the article misses a more important point – which is the real way to have more money!

Saving $10 or $15 on a purchase really doesn’t matter compared to lowering recurrent expenses. For instance, how much money do you spend each month on the following items: cell phone service, Internet service, cable or satellite TV, coffee drinks at your local café, restaurant meals, rent or mortgage, car payments? How much money did you spend on your last car? Spending $120 per month on cable TV comes out to $14,400 over 10 years. Nice late-model used cars can be had for $10,000-$15,000, yet many people drop $50,000 on a new car. Even just saving $30 on a less expensive cell phone plan means that you will save $3600 over 10 years.

(A number of years ago I looked at my recurrent expenses and realized that I was spending a lot of money on two business landlines, and on cable TV. I spent some time doing research and ended up purchasing a couple of Ooma telephone systems that when connected to the Internet provided completely free telephone service. I also put an antenna on my roof and switched to free over-the-air HDTV. The time invested was probably about 4 hours for all of the research and installation. But I saved almost $300 per month, without giving up anything I really cared about other than perhaps Monday night football (which is on cable TV only). My one-time four hour investment has paid me more than $10,000 in savings, which is roughly $2500 per hour! And I continue to save money each month.)

But the article also misses a more profound point, how to earn more money. People focus too much on saving money and not enough on earning more money, through work, entrepreneurship, education and training, and investment. In this era of the Internet there are 1 million ways to earn more money. And improving your education and training can help you earn more money in your current employment as well as well. Improving income opportunities lasts for life, while getting a good “deal” only lasts for a day! Or, if you can afford to invest money, then focusing your time on investing more successfully can yield huge benefits in total dollars. I know people that have spent the time to learn about investing in residential real estate, and who will retire with very nice incomes from the time they invested in acquiring and managing these properties.

Which brings me to the 2nd New York Times article, What Should You Choose: Time or Money? This is a fascinating and profound article. It summarizes research performed by Hal Hirschfield, Cassie Mogilner, and Uri Barnea which asked the question what do people choose, time or money? About 65% of their participants chose money over time, showing a small preference for money versus time. This in itself is not surprising or even particularly interesting. What’s more interesting is that those who chose time rather than money reported higher levels of happiness, even when the researchers controlled for participants’ amount of leisure time and income and money.

Realistically speaking, we are all in the business of balancing time against money. How we do this has significant implications in terms of our well-being and happiness. Research suggests that we should tilt in the direction of saving and valuing time rather than money if we want to maximize our happiness. There is ample research suggesting that experiences create more happiness than material possessions. And experiences take time (and sometimes money), while material purchases take money (and sometimes time.)

What can we learn from this research?

  1. When possible, tilt your decisions in favor of time rather than money. Don’t buy a cheaper house which requires you to spend many hours a week commuting. Don’t spend very much time in order to gain small savings in money.
  2. If you are going to invest time in order to save money, calculate your hourly “pay”, and only invest the time if the hourly salary is high. For instance, if it will take me 30 minutes to save 20 bucks, I’m earning $40 per hour. But if it takes me 30 minutes to save $5, then I’m earning $10 per hour. Try to be rational about these decisions and don’t pay any attention to the percentages saved, only to the dollar values and the time values.
  3. Time invested in saving money on recurrent expenses such as cable or satellite TV, car insurance, cell phone service, Internet service, etc. will always pay you a higher salary rate per hour. A few hours invested in researching less expensive alternatives and switching can save hundreds of dollars a month indefinitely which adds up to a very good return on your time invested.
  4. When you get excited about “getting a deal”, always calculate the true cost of the deal in time and in hassle. This will prevent you from driving across town to get a small savings or from spending too much time spent on the Internet looking for deals. (I am as guilty of this as most people, although I’m much more likely to spend time online rather than time in my car, even though both waste time.) Ask yourself whether on your deathbed you will be telling your grandchildren about this deal that you got. Remember that in the grand scheme of life, time is worth more than money. (See this classic parable about the poor fisherman and the entrepreneur.)
  5. Finally, remember that life is not just about time and money, it’s really about meaning and values. Spending money doesn’t really benefit you unless it ties into your core values and improves meaning in your life. That’s why even getting a multiplicity of small “deals” doesn’t really matter in the grand scheme of things. What matters more is whether you spend money to support your core values. That’s why grandparents sometimes pay for their grandchildren’s college, even though it’s an expensive proposition. And that’s why taking your family on a really fun vacation is a good investment as it leads to experiences and memories that potentially last a lifetime. (My siblings and I will always remember magical experiences from our family trips – playing telephone tag in the elevators of the Caesar’s Palace in Las Vegas, riding donkeys along a precipitous cliff in Grand Canyon, screaming “beep beep” on a narrow, twisting road in Spain when our rental car horn failed.)
  6. And even time should be evaluated in terms of meaning and values. Here in Silicon Valley a lot of people retire early. This isn’t always a good thing however. What I’ve seen is that they often end up spending time doing things that don’t really add to their happiness. For instance, they will design and build a custom house, usually quite large, which eats up several years of their life playing at general contractor and quality control inspector.
  7. Just as spending money intelligently is challenging, it’s even more challenging to spend time well. I struggle with this all the time. But I try to continually improve how I spend my time, for instance trying to focus more on writing these blog articles rather than watching television or reading a novel.

This article ended up being a lot longer than I expected, but I think these are profound and important issues for all of us to think about and to improve. Now it’s time for me to have some fun!

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Depression Often Misdiagnosed, and Untreated

The New York Times had an interesting article about how depression is often misdiagnosed in the US, and how most people who actually have depression don’t get treatment.  They reference a research study just published in the JAMA Internal Medicine.

This research study performed by Mark Olfson, Carlos Blanco, and Steven C. Marcus, looked at responses from 46,417 people on the Patient Health Questionnaire-2 (PHQ-2) which is a brief screening tool for depression. A score of over 3 indicates depression on this scale.

What did they find? They found that approximately 8.4% of all adults studied had depression, but only 28.7% had received any depression treatment in the previous year! That means 71.3% of the people who suffer depression got no treatment for this depression.

Of those who were being treated for depression, about 30% actually had depression based on the screening, and another 22% had serious psychological distress. That means that of the people in the study who were being treated for depression roughly 48% neither suffered depression nor did they suffer serious psychological distress, indicating inaccurate diagnoses by the treating professionals.

There were some interesting correlates of depression. About eighteen percent of those in the lowest income group suffered depression, while only 3.7% of those in the highest income group suffered depression. It pays to be rich!

Depression was more common in those who were separated, divorced, widowed, or who had less than a high school education. None of this is terribly surprising.

How did depression break down by age?

In the 18 to 34-year-old group 6.6% suffered depression. In the 35 to 49-year-old group 8.8% suffered depression. Ten percent of the 50 to 64-year-old group suffered depression. Of those over 65, only 8.3% suffered depression. So at least in this sample the 50 to 64-year-old group was slightly more likely to suffer depression, and contrary to what many people think, the youngest adults were somewhat less likely to suffer depression.

Of those who were married only 6.3% suffered depression. Of those who were separated, divorced, or widowed, 13.3% suffered depression. Divorce is bad for mental health, with almost a doubling of rates of depression.

Most of the patients who were treated for depression were treated by general practitioners (73%), with roughly 24% receiving treatment by psychiatrists and 13% receiving treatment by other mental health specialists. (There was some overlap, that’s why the numbers add up to more than 100%.)  This may explain the rather poor diagnosis and treatment of depression because general practitioners although competent and intelligent, are very busy and typically only have a few minutes to spend with each patient, not enough to do a good job diagnosing and treating depression.

CONCLUSIONS

What can we conclude from this research?

  1. Almost 10% of the adult population suffers from depression. Of those people who have depression less than 30% of them will get any treatment for depression.
  1. You are more likely to suffer depression if you are in the lowest income group, divorced, separated or widowed, or have no high school education. If you are married you have half the probability of being depressed.
  1. Many adults receive depression treatment even though they don’t really meet the criteria for depression. In this study, almost half of the people receiving treatment for depression were neither depressed nor were they even particularly distressed.
  1. Rates of depression by age groups were relatively equal, with the youngest age group having the least depression and the middle-aged group (50 to 64) suffering somewhat more depression. Married people are suffer half as much depression as divorced, separated, or widowed people.
  1. Most people received depression treatment from their general practitioner or internal medicine doctor, with a smaller number receiving treatment from a psychiatrist, and even a smaller number receiving treatment from psychologists. This also meant that most people who receive depression treatment were treated using medication, and very few people received psychotherapy, even though most studies comparing medication to cognitive behavioral therapy for depression have shown that therapy performs at least as well as medication and probably better over the long term, with less relapse.

Reading between the lines of this study, it suggests that many people who feel depressed would benefit from receiving an accurate diagnosis from a clinical psychologist, and might very well also benefit from receiving cognitive behavioral therapy for depression rather than medication. Even if medication is indicated, a psychologist could recommend it to the patient’s general practitioner, and then monitor more closely the results.

The study also suggests that many people receive antidepressant medication who actually are not depressed, which needlessly exposes them to side effects and also fails to provide the correct treatment for what troubles them.

And finally, since only about 30% of those who suffer depression received any treatment for it, if you feel depressed, be sure to pursue treatment for depression.. Get an accurate diagnosis and then get treatment, ideally with a psychologist or therapist who practices cognitive behavioral therapy.

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Forgiveness and Happiness Researcher Fred Luskin Says Turn Off Your Smartphone If You Want to be Happy

Earlier this year I had the good fortune to spend several morning hours listening to Stanford professor and researcher Fred Luskin talk about happiness. Dr. Luskin is a psychologist who has done groundbreaking research on forgiveness over many years. He’s the author of many books, and frequently lectures about forgiveness. I often recommend his book Forgive for Good: A Proven Prescription for Health and Happiness to clients suffering from anger and hurt.

But this morning he was discussing happiness. He came into the room with no pretense. His hair was wild and curly, partly dark and partly gray. He was wearing a puffy black down jacket, a T-shirt, running tights, and sneakers. Clearly a man comfortable with himself, and not trying to impress.

He started off by doing something quite outrageous. He asked the audience of 30 people to turn off their cell phones. Not to lower the volume, or turn off the ringers, but to actually shut down their cell phones. This clearly caused some discomfort among the audience. He explained that the reason he wanted people to turn off their cell phones is so that they would truly focus on the present and to listening to him. He cited a statistic that people check email on average 79 times a day. Each time they check their email they get a burst of adrenaline and stress. Clearly this is not conducive to genuine happiness.

He pointed out that you can’t really be happy unless you can sit still and relax. “We are all descended from anxious monkeys,” he said, and clearly most of us do not know how to sit still and relax. “Happiness is the state of ‘enough’ “, he said, “and is not consistent with wanting more.”

He pointed out that wanting what you have equals being happy. And that wanting something else than what you have equals stress.

He talked about the beginnings of his career, when clinical psychology was focused on unhappiness and problems. There was no science of happiness. Now there is a huge area of research and writing on happiness called Positive Psychology.

He shared some simple techniques for enhancing happiness. One simple technique revolved around food. When you’re eating don’t multitask. Give thanks for the food, and really focus on tasting and savoring that food. One technique I have often used is to close my eyes while I savor food, which greatly intensifies the taste.

Another simple practice is whenever you are outside, take a few moments to feel the wind or sun on your skin.

He also talked about phones and how we use them. We are completely addicted to the little bursts of dopamine and adrenaline that we get each time we check our email or we get a text. And rather than be present in most situations, we simply look at our phones. Go to any outdoor cafe and look at people who are sitting alone. Most of them are looking at their phones rather than experiencing the surroundings or interacting with other people. Even sadder, look at people who are with others, either at a cafe, or a restaurant. Much of the time they too are lost in their smartphones.

He discussed how happiness is not correlated with achievement. Nor is it correlated with money once you have an adequate amount to cover basic needs. What happiness seems to be most correlated with is relationships. If you like yourself and connect with other people you will tend to be happy.

He reviewed  the relationship between impatience, anger, frustration, judgment and happiness. He pointed out that whenever we are impatient or in a hurry all of our worst emotions tend to come out. When someone drives slowly in front of us we get annoyed. When someone takes too much time in the checkout line ahead of us, we get angry.

I really liked his discussion of grocery stores. He pointed out what an incredible miracle a modern American grocery store really is. The variety of delicious foods that we can buy for a relatively small amount of money is truly staggering. But instead of appreciating this, we focus on the slow person in the line ahead of us, or the person who has 16 items in the 15 item express line. What a shame!

He pointed out we have a choice of what we focus on, and this choice greatly influences our happiness. We all have a choice to focus on what’s wrong with our lives, or what’s right with our lives. And we have a choice of whether to focus on how other people have treated us poorly, or how other people have treated us well. These choices of focus will determine how we feel.

We also have the choice of focusing on what we already have, or focusing on what we do not have and aspire to have. For instance, let’s imagine that you are currently living in a rental apartment. The apartment is quite nice, although there are things that could be better. The kitchen could be bigger, and the tile in the bathroom could be prettier.

Perhaps you imagine owning a house, and you feel badly about renting an apartment. Rarely do we appreciate what we have. Having a place to live is clearly infinitely better than being homeless. And even a flawed apartment is still home.

All of us need to work on learning to emphasize generosity, awe, and gratitude in our lives if we want to be happy. Generosity means kindness and acceptance in contrast to anger and judgment. Awe is the ability to be astounded by the wonder and beauty in the world. Gratitude is appreciation for all the good things in your own life and in the world.

He cited one interesting study where researchers observed a traffic crosswalk. They found that the more expensive cars were less likely to stop for people in the crosswalks. Thus wealth often correlates with a lack of generosity and a higher level of hostility. Other data shows that there is very little correlation between wealth and charitable giving, with much of the charitable giving in the USA coming from those of modest means.

He also talked about secular changes in our society. He quoted a statistic that empathy is down 40% since the 1970’s. At the same time narcissism has increased by roughly 40%. This has a huge negative impact on relationships.

I was impressed by this simple but profound message of Dr. Luskin’s talk. Slow down, smell the roses, turn off your phone, focus on relationships, appreciate what you have, and become happier.

It’s a simple message, but hard to actually do.

I’m off to go for a hike in the hills, without my phone!

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Is There an Equation for Happiness?

Wouldn’t it be nice if there was a mathematical equation that could predict and explain happiness? We could tweak the numbers and get happy! Sounds pretty far-fetched, right?

Actually this equation exists. It looks like this:

Happiness-equation

 

 

A researcher named Robb Rutledge, at the Max Planck University College London Centre for Computational Psychiatry and Aging Research, developed this equation. It figures that such an equation would be developed at an institution whose name is 12 words long! Rutledge developed this equation based on outcomes from a smart phone app called The Great Brain Experiment. The data was derived from 25,189 players of the app, a pretty good sample size!

Let me explain this equation to you. I will leave out the weird Sigma symbols and the small w constants, and just explain the letters.

Basically, happiness depends on CR which stands for Certain Rewards or safe choices plus expectations associated with risky choices (EV, expected value), and the difference between the experienced outcome and the expectation which is called a reward prediction error (RPE).

So the key idea is that happiness doesn’t so much depend on how things are going, but how they are going compared to your expectations. Let’s use an example. You make plans to go to a new restaurant with your sweetie. You looked up the restaurant on various restaurant review sites, and it gets very positive reviews. You go to the restaurant and the meal is very good, but not quite as good as the reviews suggest. Your happiness decreases. Or you go to a restaurant that has mediocre reviews, and it’s actually pretty good. Your happiness goes up.

This may be why online dating is so difficult. People build up very high expectations of their potential date, based on photoshopped or out-of-date photographs, as well as email or chat communications that may represent an unrealistically positive view of the other person. When they meet the person their expectations are higher than reality, and they experience disappointment and unhappiness.

So the way to be happier is to have low expectations? Some researchers have suggested this is why Danish people are so happy. The Danes have a pretty good life, but they have lower expectations than people in many other countries, thus a higher level of happiness.

The only problem with this idea is that many choices in our life take a long time to reveal how they will work out, such as marriage and taking a new job or moving to a new city. Having higher expectations for these slow-to-reveal choices probably increases happiness, at least allows the person to hang in with the decision long enough to find out how it will work out.

In general, accurate expectations may be best. Of course the challenge is how to have accurate expectations.  Reading both negative and positive reviews of a restaurant or a product may help with this. But there’s no site that reviews your marriage or your current job so those kind of choices may be more of a challenge.

The same researchers also looked at brain scans and figured out that it appeared that dopamine levels reflect happiness changes, higher dopamine comes from increased happiness and lower dopamine comes from disappointment.

There are some practical implications from this research.

  1. For choices that have immediate feedback such as a restaurant or a movie, temper your expectations. Maybe read more negative reviews so that your expectations are lower for the event. Then you can be pleasantly surprised when the restaurant or the movie is better than expected. This also applies to online dating.
  1. For choices that you don’t get quick feedback about such as long-term decisions like marriage or a job, have reasonably high expectations., Or at least try to have realistic expectations.
  1. Lower other people’s expectations of shared choices rather than hyping the choices. For example, let’s imagine you have recently seen a movie that you loved. Don’t tell your friends it was the best movie you’ve ever seen and that it will change their lives, instead tell them it was a pretty good movie and leave out all details. Same with restaurants, cars, and other choices that we make. Downplay rather than overhype.

Now I have to go because I have reservations at that new five-star restaurant after which I’m going to that wonderful new film, and then I’m moving to Denmark! Wish me luck.

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Dealing with Conflict Over Typical Home Neatness/Cleanliness Issues: The Houzz Interview and Some Other Thoughts

I was recently interviewed for the site Houzz, which is a web site and online community about architecture, interior design and decorating, landscape design and home improvement. In an article, A Therapist’s Guide to Dealing With Conflict at HomeI was interviewed by Mitchell Parker, a writer for Houzz.

He asked me to comment on that age-old problem when people live together of neatness/sloppiness and cleanliness/messiness. How can people get along?

I suggest you read his article which really quite nicely captures my thinking about these issues. In a nutshell, it’s all about communication. It’s not the dirty dishes that create conflict, it’s the failure to communicate about the dirty dishes in ways that resolve the problem.

Most importantly, I discussed the fallacy of the moral high ground in neatness and cleanliness. I admit I might be a bit biased on this issue, living closer to the moral low ground, but the argument is that there is no moral high ground in terms of these issues. Because our culture often values neatness and cleanliness, in arguments the neat person always takes the moral high ground, “I am the one who’s right therefore you should change.” Needless to say this doesn’t usually result in any positive progress on the issue.

I prefer to think of these issues as aesthetic preferences. Just as one person might prefer abstract art on the wall, while another person might prefer realistic paintings, messiness versus neatness is really an aesthetic preference. Handling it this way usually leads to better outcomes in conflicts over these issues. If two people come at the neat/messy conflict from a position of having differing preferences as opposed to “shoulds”, it is more likely that they can come to some sort of negotiated compromise which will be workable.

And treating these differences as preferences has another advantage as well. It usually leads to much more respectful communication about these issues. If a neat person recognizes that their need for neatness is simply a preference, they will not demonize their partner who is messy, calling them a “slob” or a “pig”. In a similar way, if the messy person recognizes that their disorder is a preference, they won’t label their partner as obsessive or a “neat freak.” This makes it much easier to discuss the differences.

The key issue is to apply a sort of flowchart to these issues. The flowchart looks like this:

1.Identify what each of you wants in terms of your home environment. Recognize that these are aesthetic preferences, and not moral shoulds.

2.Identify the ideal state that you would prefer, and also identify a less than ideal but okay state. It’s the latter that you will most likely end up with.

3. Discuss the differences, and see if there is a workable compromise. Sometimes the compromise will not be a simple meeting in the middle, but will instead involve a trade-off. For instance, if one person prefers an impeccably clean house, but the other person is not willing to spend the time and effort to do this, the couple could agree that they will hire someone to come in weekly to clean the house. Or the neater person might clean the house, but the other person agrees to do other life maintenance tasks such as paying the bills, parenting tasks, gardening tasks, or house maintenance tasks. Things don’t have to be perfectly split down the middle, it’s just important that they feel fair.

4. In looking at these differences it’s also useful to see what people are able to do, and what they are willing to do. Willingness and being able to do something are completely different things. As hard as it is to believe, (for the neat person), many messy people actually do not have the ability to be ordered and neat. This seems hard to believe. After all, can’t anybody fold their clothing and put it away? Can’t anybody put a dish in the dishwasher? And of course the answer is yes, technically, but in practice, especially over time, many people lack the skills.

Think of it this way. Technically anybody should be able to exercise every single day of their life and also eat healthy. We all know how to eat healthy and how to exercise. But how many people actually succeed on a daily basis? Very few. We are willing but not very able.

5. Which brings me to my next issue that of willingness. Even if we are technically able to do something, we might not always be willing to spend the time and energy doing it. Time and energy are a zero-sum game. We only have 16 hours of conscious time each day, and actually most of us have far fewer free hours, with work, parenting, relaxation, and other priorities.

Cleaning and organizing takes time and energy, and while some people feel the time and energy is well rewarded others do not. In my interview, I suggested a market-based way of assessing willingness. Although I was speaking somewhat tongue-in-cheek, I suggested that if one partner wants the other to do something they offer to pay them. If I want my partner to wash the dishes instead of leaving them in the sink, what am I willing to pay on a daily basis? And what price would they require to be willing to do this?

This is more of a mental exercise than an actual exchange of dollars. But I know for myself if my partner asked me what it would be worth for me to keep every surface in my home perfectly cleared every single day, I would set the price very high, something like $500 a day. That is because it would take a lot of conscious work in order to keep every surface clear. And it would take perhaps an hour or two every day. My price represents my perceived value for the change.

And then my partner could decide if that was worth it. After all, we make these kinds of evaluations all the time. If our not so new car gets scratched in a parking lot, most of us choose not to spend a lot of money to have it fixed. We accept the scratches and live with them.

6. What it comes down to is very simple. If you want your partner to change some house related behavior, first try to assess their ability and willingness to do so. If they are able and willing then you can try to get them to change their behavior. This will require ongoing discussions and work, and will not be easy.

Or you can outsource the problem. If you don’t like cleaning toilets and you can’t get your partner to do that, pay someone to clean your toilets. Most of us do this in other realms without any issues. We pay car mechanics to fix our cars, we pay gardeners to cut down our trees, and we often pay tutors to help our kids learn.

Finally, you can accept the difference. Acceptance is probably the most powerful tool in dealing with these conflicts. Acceptance frees you to stop wasting energy being angry or trying to change your partner. I’m reminded of one of my favorite quotes, “Never try to teach a pig to sing, it frustrates you and annoys the pig.”

I started this post thinking I would just point to the interview that I did on house, but discovered that I wanted to elaborate on some of the concepts that I discussed during that interview.

Good luck to all of you, these can be difficult issues, and the key thing is to remember to be gentle, loving, and respectful in your communications about these differences. Nobody gets divorced over dishes in the sink, they get divorced because of the way they interact around dishes in the sink.

I’m off to straighten up, or maybe not?

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Why You Should Never Read Online Illness or Medication Forums, and Why You Should be Skeptical of Google Search Results as Well

The first thing many people seem to do when they get a diagnosis of a physical or a mental illness is to go to the internet and search on that illness. Patients who are prescribed medications do the same. Often the search results lead to internet forums. These forums consist of user-generated content that usually is not moderated or edited by any professional. Anyone can post on these forums. This seems reasonable, right? But in this article I’m going to tell you why, for the most part ,you should avoid reading these forums. And I will also tell you why you should be skeptical of Google search results regarding any illness.

When people read on forums about their illness or medication, they get scared. Many of the forum posts will say that your illness leads to awful and dire outcomes, and that the medications prescribed to you will make you depressed, addicted, or crazy.

For instance, I often treat tinnitus patients. Samplings of the forums that cover tinnitus suggest that most of the people who post on these forums are completely miserable and suffering terribly from their tinnitus.

So what’s the problem here? Isn’t this useful information? Can’t patients learn something interesting and helpful from these forums?

Unfortunately, Internet illness forums often present a distorted, grim, and negative impression of most illnesses and most medications. Why is this? The main reason is because of selection and sampling bias. The groups of people who post on illness forums are not a representative sample of people with a particular illness. Let’s use tinnitus as an example. If you read the tinnitus forums you would assume that everybody with tinnitus is anxious and depressed about it.

But actually, we know from research studies that roughly 20% to 40% of the population experience tinnitus symptoms from time to time. We also know that roughly 2% of people who have tinnitus symptoms suffer psychologically. So the data from research suggests that a small subset (2%) of people who have tinnitus symptoms suffer anxiety and depression as a result of their tinnitus. Most people (98%) with tinnitus symptoms do not suffer significantly or they have adapted over time and gotten over their suffering.

But the forums are full of posts from the people who suffer the most. People who don’t suffer don’t spend their time posting. And people who have overcome their suffering also don’t post. So reading the forums gives a tinnitus patient a distorted and scary view of the experience of tinnitus.

The other problem in reading internet information about illnesses is the way that Google Search ranks and orders search results. When you search on tinnitus, what you might not realize is that Google presents pages in order of popularity, not in order based on how accurate or scientific they are. Sites that are clicked on more frequently will rise up in the Google search results and sites that are clicked on less frequently will fall down. When you do a Google search people typically click on the most shocking and scary links. “Tinnitus caused by alien abduction” will get a lot of clicks even though it may represent a site run by a single person who claims to have been abducted by aliens. Thus the alien abduction tinnitus site will move up in the Google rankings.

Boring scientific sites fall down in the search rankings. That’s because they have scientific names that don’t encourage people to click on the links.

So how can patients get accurate information about their illness or about medication treatments?

One way is to search within scientific and medical sites. For instance, Medscape is an excellent website that offers medical articles about almost every illness. WebMD is another site more designed for lay people, which also offers good information. If you want to search scientific articles you can use the PubMed search engine which searches published research articles.

Let’s do a Google search on tinnitus. Overall, the 1st page of Google results is pretty representative of medical and scientific sites. But the 3rd listing titled “In the news”, is an article “Martin McGuinness tells of misery living with tinnitus,” from the Belfast Telegraph. Pretty grim, you think, misery!

But if you actually clicked through to the article you would get a very different impression because Martin McGuinness actually says that “it had a limited impact on day-to-day life and work and that family, friends and work colleagues were very supportive.… It does not limit me in a professional or personal capacity.” This is a much more positive view than suggested by the title and the Google link.

This is a great example of why the Internet is dangerous. The headline is what’s called click bait, a link that falsely represents the actual page, which is designed to attract people’s clicks.

Forums about medication are also problematic. Many psychiatric medications can have side effects. For most people these side effects are minimal or tolerable and are overbalanced by the benefits of the medications. For a minority of patients, the side effects are not minimal and these are the patients who are over-represented in most Internet medication forums. Also, on an Internet forum you never really know all of the medications the person is taking, the accurate dosages, as well as their underlying illness.

There is one more problem with reading about illnesses on the Internet. It’s one that particularly disturbs me. Many websites, even websites that purport to be objective, actually are selling something. They may be selling a supplement or vitamin, or an e-book or some other kind of program to treat an illness. Obviously, to increase sales, these commercial websites will paint a distorted negative picture of any illness or condition. They may also disparage other more traditional and scientifically validated treatments or drugs. In general, you should be skeptical of any information that comes from a website that sells products or services.

To review:

  1. Take Google search results with many grains of salt. Remember that Google orders search results by popularity not by accuracy.
  2. Beware of Internet illness and medication forums. By and large, they are populated with an unrepresentative sample of illness sufferers, the ones who suffer the most and cope the least well. Reading them will depress you and make you anxious.
  3. If you want to get information about your illness or potential treatments, utilize established and reputable medical and psychological information sites. An exhaustive list of best medical sites can be found at: the Consumer and Patient Health Information Site. Some of the good medical sites include MedscapeWebMD, and MayoClinic. Some of the best sites for mental health information include PsychCentral, NIMH , American Psychiatry Association, American Psychology Association .
  1. Finally, remember that a very large percentage of websites are actually selling something, and be skeptical of information from these sites.

In conclusion, suffering any illness or condition is unpleasant and sometimes scary. Don’t make it worse by consuming information on the Internet in a random way. Be skeptical and selective and remember that Google is not always your friend. Often a good physician or good psychologist can give you clear and balanced information.

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Good News! You May Be Getting More Sleep Than You Think, Especially If You Suffer Insomnia!

The Wall Street Journal today had a very interesting article about how people with insomnia tend to greatly underestimate how much sleep they get and overestimate how long it takes them to fall asleep. They also overestimate how often they wake up at night.

Roughly 30% of adults have some insomnia each year. About 10% of people have chronic insomnia which means that you have trouble sleeping three times a week or more. According to the Journal article, 42% of insomniacs who actually slept the normal amount (6 hours or more) underestimated how much they slept by more than an hour. I looked up the research article which was published in Psychosomatic Medicine. According to this research, insomniacs who slept six hours or more typically showed a profile of high depression and anxiety and low coping skills according to psychological testing.

What’s also interesting is that even though insomniacs may be sleeping six or more hours a night, there does appear to be some real differences in their brainwave activity compared to good sleepers. Even though they are asleep, their brains are more active, which may account for why they perceive their sleep to be less than it really is.

Another interesting factoid was that normal people tend to overestimate how much sleep they get. Most people when asked how much sleep they get will answer between seven and eight hours, but they are actually getting six hours. That’s why people tend to be so sleep deprived. For most people six hours is not enough sleep to feel really good.

So what’s the answer to this sleep estimating dilemma? It turns out there is a very simple answer. The two gold standards for measuring sleep are brainwave measurements and activity measurements. While brainwave measurements are difficult to come by in the home, activity measurements are very easy and inexpensive to obtain. Many of the current fitness tracker’s have a sleep tracking function. For instance, according to my Xiaomi Mi Band, which cost me the grand sum of $15, last night I was in bed for seven hours and 58 minutes, and got three hours 20 minutes of deep sleep and four hours and 38 minutes of light sleep. I was awake for one minute. (Yes, I know, please don’t hate me all you insomniacs!)

For insomniacs who worry about how much sleep they are getting, I recommend buying a fitness tracker and wearing it every night. The best ones automatically track sleep without having the requirement that you push a button to activate sleep mode. This is pretty important as most people forget to press the button. I have been pretty happy with my Xiaomi Mi Band, which you can buy directly from the company  but I’m sure there are other brands of fitness trackers which offer similar features.

Also, as I’ve written about previously here and here, cognitive behavioral therapy for insomnia (CBT-I) may also improve the quality of sleep as well as the quantity. Some studies show that CBT-I improves people’s ability to accurately estimate their sleep time, and it also may calm  the over-activity of the brain that occurs when insomniacs sleep.

So here’s the executive summary for all of you sleep-deprived folks:

1. If you are an insomniac who is anxious and depressed, then you are probably getting more sleep than you think. Buy a fitness tracker with a good sleep tracking function, and you will see how much sleep you are actually getting.

2. If you want to improve the quality of your sleep, either practice meditation or see a CBT psychologist for CBT-I, as both of these interventions seem to lower the activity of the brain during sleep, which will improve your perception of your own sleep.

3. If you consistently feel anxious or depressed, consider getting some cognitive behavioral therapy for these problems, as they may contribute to sleep difficulties.

I’m off to bed now and hope I don’t have insomnia now that I’ve written about it!

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Cognitive Behavioral Therapy for Insomnia (CBT-I) Outperforms Drugs for Insomnia

The New York Times today had an excellent article The Evidence Points to a Better Way, which summarized what I have written about before. Cognitive behavioral therapy for chronic insomnia (CBT-I) kicks the butt of drug therapy!

One study compared CBT with a common sleeping pill called Restoril and found that the CBT treatment led to larger and longer lasting improvements in sleep. Another study found that CBT treatment outperformed the drug Ambien, and that CBT alone was even better than CBT plus Ambien combined.

Even more impressive are the results of a large meta-study which was published today. This meta-study, which combined data from 20 clinical trials and involved over 1000 patients with chronic insomnia showed that CBT I resulted in these patients falling asleep 19 minutes faster and having 26 minutes less wakefulness during each night on average. The actual study is protected by a pay wall, but the summary results are here.

One might question the clinical relevance of these outcomes. Does falling asleep 19 minutes faster really make that much of a difference? Does sleeping an extra 26 minutes a night make patients feel better the next day? As a good sleeper, I don’t really know the answer to these questions.

But I suspect that the biggest impact of CBT-I is in affecting the person’s perception of control over sleep. One of the horrible things about chronic insomnia is that patients feel out of control in terms of their sleep. They worry tremendously about the impact of loss of sleep on their ability to function the next day. It is this worry cycle that actually can create insomnia.

So I suspect that even though the effects were durable but modest, that the overall treatment made a large difference in how people felt. There is a big difference between taking 45 minutes to fall sleep and 20 minutes to fall sleep. And I suspect that sleeping an extra 26 minutes a night actually does make a difference. I know that I feel much better on eight hours of sleep as opposed to 7.5 hours of sleep.

When I work with patients on CBT-I one of the things I work on is helping the patient lower their anxiety about the impact of sleep restriction. As crazy as it sounds, one of the interventions I typically use is to have the patient stay up all night and go to work the next day. Although they are typically very tired, they discover that they can focus and function, maybe not at 100% but at an adequate level, maybe 75% or so. This lowers a lot of the anxiety about insomnia, since even a bad night of insomnia typically leads to quite a bit more sleep than staying up all night.

Other than the time and energy that a patient must invest in learning CBT-I skills, there are no side effects of cognitive behavioral therapy for insomnia. All sleeping medications have significant side effects the most troubling of which involve impaired cognition and coordination during the night and the following day. This impaired coordination and cognition leads to increased falling in the elderly, and probably also leads to an increase in automobile and other accidents. Because drug companies don’t want studies done on this issue, there are relatively few studies, but one study in Norway found that there was a doubling of traffic accidents among patients who took a variety of sleeping pills. Another study that compared 10,000 sleeping pill users to 23,000 nonusers found that the sleeping pill users were five times more likely to die young than nonusers.

So what does this mean to the person suffering insomnia? It means that you should avoid taking sleeping medications, and get cognitive behavioral therapy for insomnia. This kind of therapy typically does not take very many sessions. I teach the basic skills of CBT-I in about 4 to 6 sessions, and typically the entire course of CBT-I takes less than 10 sessions. There are also options for CBT- I online and even apps that run on your phone. One such app that runs on both android and iPhone is called CBT-I Coach. This app was developed with your tax dollars as part of a large Veterans Administration insomnia treatment program, and is excellent.

It’s getting late, so rather than have to experiment with any of these treatments, I’m off to bed…

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Calming An Overactive Brain–My Day In Pacifica

Today I am taking a seminar with William Sieber calling Calming an Overactive Brain. He’s an excellent presenter, with a good sense of humor, a down to earth speaker. He’s got a nice balance of enough confidence to be a an excellent speaker without being arrogant. This is quite rare in the seminar business. Even though there’s a lot of stuff I already know I’ve learned a number of  interesting things. The seminar is on the ocean in Pacifica, and outside the windows of the meeting hall I can see the waves crashing on the sand.

One funny thing happened at lunch. I had hurried out to the next door cafe so I could get a table before the crowds hit. Dr. Sieber showed up, looking for a table. I invited him to join me at my table. We started talking and discovered some remarkable commonalities! Both of us had attended Yale for training, me for undergrad, and he for graduate school. He had worked closely with Judith Rodin and Peter Salovey while there. Judy Rodin had been my first psychology professor, and probably the one that influenced me to go into psychology. Peter I had known while teaching at the Bridge, Stanford’s peer counseling center, many years before, and in whose book I have a chapter on Listening Skills. Eventually he went on to teach at Yale, and now is Yale’s president. More surprisingly, Dr. Sieber and I both interned at the Palo Alto Veterans Hospital, in different years! We had a fun lunch reminiscing.

About the seminar. He spoke at length about sleep and it’s impacts on health and wellness. For instance, one study showed that those who got less than 6 hours of sleep were 42% more likely to get diabetes. Or that those with the most disturbed sleep were 97% more likely to die in the next 20 years. Poor sleep makes you more prone to pre-diabetes, anxiety, upsetting emotions, not to mention lowering overall mood and vitality.

Less sleep also affects appetite and eating. Leptin is the hormone that lowers our appetite, and ghrelin is the hormone that increases appetite. With sleep deprivation our leptin goes down, and our ghrelin goes up, and on average we consume 250 calories more on days after a bad night’s sleep. This doesn’t sound like much, but it adds up to about 25 pounds of extra weight per year if you chronically sleep poorly.

I also learned how to assess sleep. The key metric is “sleep efficiency”. This means what percent of the time you are in  bed trying to sleep are you actually asleep. A good number is 90-95%. This is hard.  It means if I am in bed for 8 hours a night, I am asleep 95% of the time, or all except 24 minutes. What is your sleep efficiency? He went over how to use the sleep efficiency log to diagnose sleep problems and guide treatment.

One other interesting factoid for all of you pet lovers. Fifty-three percent of pet owners have disturbed sleep due to their pets.  Maybe we should all shut the door at night and train our pets to sleep somewhere else other than in bed with us.

He discussed how to fix common sleep problems. One such pattern is mine, the delayed sleep cycle. This is the night-owl pattern, going to bed late and getting up late. To fix it, he suggested a short term use of sleep aids to shift the cycle to earlier bedtimes, combined with bright light in the mornings, and no screen light for an hour before bedtime. Cutting back on caffeine use is also helpful.

Others suffer the early phase shift, those who fall asleep too early, and get up too early. To shift these people he recommended getting bright light exposure in the early evening so the melatonin production is suppressed until later in the evening.

In the afternoon we got into discussion of moods and control. Discussing anxiety, he explained the key role that perceived control over situations plays in creating or ameliorating anxiety. Exercise turns out to be a strong treatment for anxiety. Most people with anxiety disorders do not exercise more than once a week, and those who exercise 3 or more times a week rarely have anxiety disorders.

Then he turned to relaxation training for anxiety. He made a great point—that even if you train people to relax deeply, the probability of them continuing to practice even four weeks later is very low. So instead, he shared a 20 second relaxation. Take two deep and slow belly breaths, exhaling for longer than you inhale. While doing that go somewhere relaxing in your mind, and experience that place (ie the beach) in the sensory modality of your preference—seeing, hearing, smelling, or feeling. Make up a two word description of that sensory experience, i.e. “Warm sun”. Repeat that phrase as you take your 2 deep breaths, during the exhale.

He suggested pairing this relaxation practice with something you do multiple times a day. So for instance, pair it with hitting the Send button on your email. That way you will remember to practice a quick relaxation many times a day.

He also shared James Pennebaker’s work, which I often use with patients. Pennebaker found that writing about traumatic events for just 30 minutes a day for 4 days in a row had a fairly profound impact on future emotional and physical health. Interestingly, the initial impact was negative, more anxiety and upset, and more susceptibility to illness. But after three to six months, the pattern reversed, with people showing less upset and anxiety, and better health.

Finally, he shared some info about new findings about heart rate variability (HRV). HRV is the change in the rate of your heartbeat over each beat and each several seconds. It turns out that having MORE HRV is better for both mental and physical health. People with anxiety disorders have less HRV. And it turns out the the three factors that most predict low HRV are: sedentary lifestyle, a cynical and hostile view of life, and anxiety.

Can you retrain your heart rate variability? Yes, with both breathing retraining, and with biofeedback. And it turns out that when you learn to increase your HRV, your anxiety goes down. Very interesting and cool stuff.

The final part of the workshop was about mindfulness. I won’t even try to summarize this part of the seminar, as it was very detailed, and even profound. Perhaps I’ll blog about it later.

Overall, it was a good learning experience, with a wonderful view of the ocean the whole time!

Now I need to go to sleep early….

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

SSRI Antidepressants Given in High Doses May More than Double the Risk of Suicide in Adolescents and Young Adults Under 25

So you’ve got a teenage child who’s depressed. What do you do? A new study published in the Journal JAMA Internal Medicine suggests what NOT to do. In this study, conducted at Harvard, the authors looked at 162,625 people from ages of 10 to 64 years old who took selective serotonin reuptake inhibitors (SSRIs) for depression. (These are drugs like Paxil, Prozac, Celexa, Zoloft, Lexapro, and Luvox, and their generic equivalents.)

The researchers looked at the relationship between initial starting dose and the rate of deliberate self harm and suicidal behavior. What they found was shocking. They found that for people under the age of 25 starting SSRI medication at a higher than normal dose more than doubled the risk of self harm behavior! This translated into one additional occurrence of self harm behavior for every 136 patients who were treated with high-dose SSRIs. This is a lot of additional suicide attempts!

Interestingly enough, for adults 25 to 64 years old, there was only a very small increase in self harm behavior with high-dose SSRI treatment, and the overall risk of self harm behavior was much lower.

Delving more deeply into the data is interesting. In the under 25-year-old range, 142 patients attempted suicide within one year. The rate was 14.7 suicide events per 1000 person-years for those who started SSRIs at average doses, and 31.5 suicide events per 1000 person-years in those who started at high doses. For the older adults the rates were 2.8 per 1000 person-years for average doses, and 3.2 suicide events per 1000 person-years for those who started at high doses.  These numbers translated into seven more suicide events per 1000 for patients under 25 during the first 90 days of treatment with high dose SSRIs.

Also, disturbingly, the study found that 18% of all patients were started on high initial doses of antidepressants, despite clinical guidelines that specifically recommend starting at a low dose and titrating the dose upwards slowly.  The typical doses of common antidepressants are 20 mg for Prozac, 20 mg for Paxil, 20 mg for Celexa, 50 mg for Zoloft, and 10 mg for Lexapro. For unknown reasons, almost one in five patients were started at higher doses than these.

Why were almost one in five patients started at higher doses than these? I suspect I know the answer, although it wasn’t discussed in the study. Unfortunately, the vast majority of patients are given antidepressants by their internist or family physician or pediatrician. In contrast to psychiatrists, these practitioners do not have the time or bandwidth see patients every week. So they are more likely to start the patient at a higher dose.

Most psychiatrists will start patients at subclinical doses and gradually increase the dosage to avoid side effects. It certainly has been my clinical experience that some general medicine doctors do not do a very good job of administering antidepressants. That is why with most of my patients, especially if they can afford it or have good insurance coverage, I suggest that they seek the advice of a psychopharmacologist or psychiatrist for psychoactive drugs.

The authors of this paper point out that recent research suggests that antidepressant medication is at best only slightly effective in young people and that the dosage of antidepressants are typically unrelated to their effectiveness. Given these two research findings, it certainly does not make any sense to start antidepressant treatment at a higher than average dose.

But I would go one step further. I would argue more strongly that in most cases it does not make sense to use antidepressant medications in young people at all. Why expose a young person to the heightened risk of suicide for what is at best a relatively modest improvement in mood?

This is even more relevant when you consider that there is an alternative treatment that has no side effects and has been shown to be effective. That is cognitive behavioral therapy (CBT) for depression. And there is even a specific cognitive behavioral therapy for suicide prevention that has been developed. (CBT-SP). This is a 12 week focused CBT program that in one study demonstrated that it significantly lowered the probability of a suicide event in suicidal adolescents.

If medication is going to be used, one recommendation that follows from all of this research is that it is good idea for doctors to follow the guideline of “start low and slow” when prescribing antidepressant medications to people under 25. Start at lower than typical doses, and very slowly and gradually increase the doses. While this is happening the patient should be followed on a weekly basis.

If the prescribing doctor is not a psychiatrist who sees the young person weekly, it’s a good idea to pair this with weekly psychotherapy sessions. The weekly psychotherapy session, especially when conducted by someone skilled in cognitive behavioral therapy who evaluates mood and suicidal ideation at every session, can be an essential safety measure when prescribing antidepressants to young people. Or consider treating with CBT alone,  which may very well be just as effective.

Because this is so important, I am listing some references below.

No jokes today, as suicide is not a laughing matter…

References

http://www.clinicalpsychiatrynews.com/home/article/suicide-doubles-in-young-patients-starting-high-dose-ssris/3c57e41e724244599c16d5a565ac8ce3.html

https://archinte.jamanetwork.com/article.aspx?articleid=1863925

http://www.intechopen.com/books/mental-disorders-theoretical-and-empirical-perspectives/cognitive-behavioral-therapy-approach-for-suicidal-thinking-and-behaviors-in-depression

http://www.texassuicideprevention.org/wp-content/uploads/2013/06/AdolescentSuicideAttemptersLatestResearchPromisingInterventionsCharlotteHaleyJenniferHughes.pdf  (CBT-SP)

http://www.nimh.nih.gov/news/science-news/2009/new-approach-to-reducing-suicide-attempts-among-depressed-teens.shtml

http://www.clinicalpsychiatrynews.com/home/article/suicide-doubles-in-young-patients-starting-high-dose-ssris/3c57e41e724244599c16d5a565ac8ce3.html

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How to Forgive: A Cognitive Behavioral Model for Forgiveness and Letting Go of Anger and Frustration

What is forgiveness?

Here’s what it is not. It is not for anyone else, only for you. It doesn’t imply reconciliation with the person who hurt you nor does it imply that you approve of their actions. It does not mean forgetting what happened.

What is forgiveness?

It is only for you, in order to help you feel better. As one well-known researcher said, “failing to forgive is like taking poison and waiting for the other person to die.”

Forgiveness means understanding what is causing your current distress. It is not what offended you or hurt you years ago or even a few minutes ago. The primary cause of your suffering is from your thoughts, feelings, and physical sensations in response to your thoughts about the event.

This is a subtle concept. Most of us believe the reason we are angry is because someone has done us wrong. And it’s true, that if we could erase the event, we would stop being angry. But none of us own a time machine so we can not erase the events.

What makes us suffer is each moment that we think about the offending person or event. And how we think about these events. It is as if you own a DVD collection of movies of different events in your life. If you were to choose to only watch the upsetting movies, your overall level of happiness would greatly diminish. Choosing to forgive is choosing the DVDs of your life that are positive and full of joy.

There is another component of how people think about grudges. We often have a magical belief that our anger at someone else causes them to suffer. We imagine them feeling guilty about their behavior and suffering even when we are not present. We think of ways to hurt them in return – the silent treatment, constant criticism, reminding them of their offenses. But the reality is that most people are very good at blocking out guilt and punishment. Whenever they’re not around us they tend to think about other things. And they develop good ways of avoiding our punishment. So really the one who suffers is the person who’s angry and who fails to forgive, not the offender. And if the person we take out our anger on is someone we are still in relationship with, it damages the relationship and makes it even less likely we will get what we want.

Another trigger for resentment and anger is holding onto what the anger and forgiveness researchers call “unenforceable rules”. These are what most cognitive behavioral therapists call “Shoulds”. They are the demands we make on the world and on people around us. You can’t force anyone to do something they don’t choose to do, and you can’t require people to give you things they choose not to.

For instance, you might want fidelity in your romantic partner. You certainly have every right to want that. But you can’t demand or enforce fidelity. If your partner chooses to go outside the relationship, you can’t really change it. The only options you have are how to react to this. You have choices to make about the relationship and about your future relationships.

The research on forgiveness is very interesting. It reduces blood pressure, stress, anger, depression and hurt while increasing optimism and hope. The primary researcher on forgiveness, Dr. Fred Luskin at Stanford, has even done forgiveness research with women in Northern Ireland whose husbands were murdered. Even with these extreme cases people have found the forgiveness model very helpful at easing the pain.

I’ve written about how to conquer anger using the S A P model. In this model you change your shoulds into preferences rather than demands, you place into perspective the events that have caused your anger, and you shift out of the blame model and depersonalize most events.

Forgiveness is about being happy. Living your life to its fullest is the best revenge you can take on someone who has offended you. Instead of focusing on the hurt or betrayal, focus your energy on getting what you want in your life in a different way other than through the person who has hurt or betrayed you. Take responsibility for your own happiness rather than placing it onto other people and then being disappointed when they don’t provide happiness.

Change your story. Too often we have what is called a grievance story. We tend to tell this story to many people. It always ends with us feeling stuck and angry. Change your story. Change the ending so that it ends with a powerful and strong choice to forgive.

 
So to summarize, here’s how to forgive:

1. Let yourself first feel the pain. Share the experience with a few close and trusted friends.

2. Recognize that your anger is a result of your choices about what thoughts to experience about an event. Decide to forgive so that you can move forward and feel better.

3. Recognize that you probably won’t be able to get rid of your hurt and anger by punishing the other person. All you will accomplish is to damage the relationship or make the other person suffer while you continue to suffer.

4. Recognize the role that your “unenforceable rules” or Shoulds plays in your continued hurt and anger. Change or eliminate these rules.

5. Figure out what you want in your life and how to succeed in achieving those goals even if the other person doesn’t provide the answers. Remember that happiness is the best revenge.

6. Use the S A P model to change your shoulds, eliminate exaggerated awfulizing thinking, and take away blame.

7. Rewrite your script. Tell the new story where you were hurt but recovered and forgave and moved forward. You are a hero!

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

New Hope for Procrastination: Procrastinators are Trying to Repair Their Negative Moods by Avoiding Work According to the Wall Street Journal

The Wall Street Journal has an intriguing article To Stop Procrastinating, Look to Science of Mood Repair. In the article, they discuss new research that suggests that many of the avoidant behaviors procrastinators use are actually attempts to repair low moods. Procrastinators often feel anxious or worried about the task they are attempting to accomplish, so that go to Facebook, the refrigerator, or to sleep to avoid those feelings. Learning new ways of dealing with negative feelings, and using some acceptance methods so that they can better tolerate the negative emotions are both helpful strategies for overcoming procrastination.

Highly recommended article, check it out! I’d write more, but I’m trying to get to work and stop avoiding by writing about avoidance!

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Treatment of Tinnitus using Cognitive Behavioral Therapy

Tinnitus is condition where the person hears a ringing in their ears or other sounds when none of these sounds are present. It is a very common problem, especially as people age. According to studies, up to 20% of people over the age of 55 report symptoms.

What causes tinnitus? There can be many causes. The most common cause is noise-induced hearing loss. Other causes include medication side effects, as well as withdrawal from benzodiazepines. In many cases no apparent cause can be found.

For many, tinnitus is a relatively minor problem that they tend to ignore. Almost everyone has momentary tinnitus symptoms. But for other people tinnitus creates a tremendous amount of psychological distress. This includes anxiety and depression. The person fears the loss of their hearing, and tends to focus intensely on their symptoms. They begin to avoid situations where their symptoms are more noticeable. This typically means avoiding quiet locations where there is no sound to mask the tinnitus sounds. Or it may involve avoiding situations where there are loud noises such as movie theaters due to the fear of further hearing loss.

Similar to some forms of obsessive compulsive disorder (OCD), the person may begin to engage in frequent checking behavior. This means that they consciously check the presence and volume of the ringing in their ears. They may also frequently check their hearing.

The person also suffers from constant thinking about causes of the tinnitus. They often blame themselves for exposure to loud noises in earlier life. They think about the music concerts they attended where they didn’t wear earplugs, or even recreational listening to music. They have strong feelings of regret that can blend into depressive symptoms.

Unfortunately there are no terribly effective physical treatments for tinnitus. This leaves psychological treatment as the primary modality for successful reduction of distress.

Cognitive behavioral therapy (CBT) conceptualizes tinnitus much like it conceptualizes the experience of chronic pain. Chronic pain consists of two components. The first component is the physical sensations. The second component is the bother or suffering caused by these physical sensations.

Tinnitus can be conceptualized in the same way. The subjective experience of sounds in the ears is the physical sensation. The interpretations of these sensations lead to the emotional reactions; suffering and bother.

Although CBT cannot directly change the physical sensations of tinnitus, it can change the reactions to these sensations. And changing the reactions can actually lead to a subjective experience of diminishing symptoms.

What are the components of the CBT treatment for tinnitus?

1. Psychoeducation. The first step is to educate the client about how tinnitus works. The model used is that the loss of certain frequencies in the hearing range leads the brain to fill in those frequencies with sounds. It is very much like phantom limb pain, where an amputee may experience pain in the removed extremity.

The nature of hearing loss is explained, and psychoeducation regarding tinnitus and the risk of further hearing loss is discussed. If needed, results of hearing tests can be discussed relative to the actual severity of hearing loss. Although in some cases of tinnitus hearing loss is quite significant and may actually impair functioning, in many cases the hearing loss is relatively minor and does not impair functioning in any way.

2. Cognitive therapy. Here the therapist helps the patient to identify the negative thoughts that are leading to anxiety and/or depression. Typical thoughts for anxiety are: “I can’t live my life anymore with this condition. I will lose my hearing entirely. The sounds will drive me crazy. I’m out of control. If I go into _____ situation I will be troubled by these sounds so I must avoid it. I need to constantly check my hearing to make sure it’s not diminishing. I need to constantly check the tinnitus sounds to make sure they are not getting worse. They are getting worse! They will get worse and worse until they drive me crazy.”

Typical thoughts for depression are: “Life has no meaning if I have these sounds in my ears. I can’t enjoy my life anymore. It’s hopeless. There’s nothing I can do about it. Doctors can’t help me. It will get worse and worse and slowly drive me crazy. I won’t be able to function.”

Once these thoughts are identified then the skills of challenging them and changing them are taught to the client. The client learns how to alter these thoughts to more healthy thoughts. This produces a large reduction in anxiety and depression.

3. Attentional strategies. Because much of the subjective perceived loudness of tinnitus is based on attention, with higher levels of attention leading to higher levels of perceived loudness, developing different attentional strategies will help very much. In this part of the treatment mindfulness training and attentional training is used to help the client learn how to shift their attention away from the tinnitus sounds onto other sounds or other sensations. Often a paradoxical strategy is first used, where the patient is asked to intensely focus only on their tinnitus sensations. This teaches them that attention to tinnitus symptoms increases the perceived severity, and helps motivate them to learn attentional strategies.

Another aspect of attentional retraining is to stop the constant checking of symptoms and hearing. Helpful techniques include thought stopping where the client may snap a rubber band against their wrist each time they notice themselves checking.

4. Behavioral strategies. Tinnitus sufferers typically develop an elaborate pattern of avoidance in their lives. They avoid situations where they perceive tinnitus sounds more loudly. This can include avoiding many quiet situations, including being in quiet natural places such as the woods, or even avoiding going to quiet classical music concerts. They also tend to avoid situations where they might be exposed to any loud noise. This includes movie theaters, concerts, and even noisy office situations.

The behavioral component of CBT encourages an exposure-based treatment whereby the client begins to deliberately go back into all of the avoided situations. In situations where there is actual loud noise exposure at a level potentially damaging to hearing, they are encouraged to use protective earplugs.

The purpose of the behavioral component is to help the person return to their normal life.

5. Emotional strategies. Sometimes it is necessary to help the client go through a short period of grieving for their normal hearing. This allows them to move forward and to accept the fact that they have hearing loss and tinnitus. Acceptance is a key factor in recovering psychologically. This often also includes forgiving themselves for any prior excessive loudness exposures.

Changing the thoughts about the tinnitus symptoms also produces emotional change and a reduction in anxiety and depression.

In summary, cognitive behavioral therapy of tinnitus seeks to reduce the psychological suffering caused by the sensations of tinnitus. Cognitive, emotional, behavioral, and attentional strategies are taught to the client to empower them to no longer suffer psychologically from their tinnitus symptoms. Successful treatment not only reduces the psychological suffering, but because it also changes the attentional focus and lowers the checking of symptoms, people who complete CBT for tinnitus often report that their perceived symptoms have reduced significantly.

Tips:

1. Traditional psychotherapy is typically NOT helpful for tinnitus.

2. Find a practitioner, typically a psychologist, with extensive training in Cognitive Behavioral Therapy. If they have experience treating tinnitus that is even better.

3. Give treatment a little time. You will have to work hard to learn new ways of thinking and reacting, and this won’t happen overnight. You should be doing therapy homework between sessions.

4. Medication treatment such as anti-anxiety or antidepressant medication is typically not very helpful, and in the case of anti-anxiety medications can actually worsen tinnitus especially during withdrawal. First line treatment should be CBT.

5. Get help. Although the actual symptoms of tinnitus have no easy fix, the suffering can be treated and alleviated. Especially if you are experiencing depression symptoms, is is important to seek therapy with a CBT expert.

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Two Selves: Implications for Time Management and Productivity

I’m on vacation. I’m sitting on the deck of a house overlooking Sunset Beach in Hawaii. It’s a windy day and the waves are blowing. Since I’ve been so lazy here I’ve been thinking about productivity. And the paradox of our two selves.

Here’s an interesting question:  How is it that sometimes we tell ourselves “I’m going to do such and such task” and then don’t do it?

Who is the self who is giving the orders and who is the self who is not following them?

How is this even possible? Are we a collection of multiple personalities?

It’s such a common phenomenon that we take it for granted. We are never surprised when we say to ourselves “I think I’ll skip that cake” and then we end up eating the cake. Or we say to ourselves “I think I’ll work on that project,” and then we surf the internet instead.

And yet there is something profoundly strange about all of these phenomena. It is as if there is one self who tells the other self what to do, and then that other self decides whether or not to do it. Who is driving this bus?!

How do these two selves work? There is a little bit of research about this. In his book Thinking Fast and Thinking Slow Daniel Kahneman discusses these concepts and notes that we always assume that our future self will be more disciplined and more self-controlled. Sadly, this is almost never true. Our future self is merely an extension of our current self with all of its flaws. In fact, it is our incorrect belief in the future self being more sensible that allows our current self to overeat, smoke, drink, or procrastinate doing work.

We make the dangerous assumption that we can afford these bad behaviors in the present because our future self will clean up the problem. Unfortunately, our future self is just as much of a slacker and just as self-indulgent as our present self.

So how is it possible that we have these multiple selves and cannot control our own behavior? Who is driving the bus?

I’ve been doing a lot of thinking about this issue lately and I have to admit I am somewhat puzzled by these phenomenon.

First of all, we need some terminology. Let’s call the telling-yourself-to-do-things-self the Commanding Self. And let’s call the self that actually does things The Behaving Self.

One possible explanation is that our real self is the Behaving Self, and the Commanding Self is the aspirational and illusory self. In this formulation, the reason that we don’t follow through on things is that we don’t actually really want to. Using this model we can elegantly use Occam’s razor to reduce our two selves to one self; the Behaving Self who is actually the real self. We would become behavioral reductionists, and to determine what people want we would observe what they actually do.

But then why do we spend so much time and energy having this other self who tells us what to do? And there are time when we actually do listen to the Commanding Self. What is different about those times when we listen and those times when we resist?

For instance, most of us have the experience of doing exercise, at least occasionally. And in order to do this we must listen to our Commanding Self.

Perhaps some of the current research on willpower can help us to understand the circumstances when the Commanding Self is listened to, and when it is not.

Current research on willpower suggests that it is a precious and limited commodity. It diminishes rapidly when used, and perhaps has about a 15 to 30 minutes half-life before it is exhausted. Other research suggests it is powered by our glucose metabolism so ironically the best way to resist overeating is to have a little bit of a sugary drink to restore blood sugar and thus willpower. The other factors that diminish willpower include being tired, hungry, or emotionally upset. The 12-Step people were onto something with their model of Hungry, Angry, Lonely, and Tired (HALT) which captures this concept perfectly, and predicts relapse.

So perhaps another way of conceptualizing this strange dichotomy of selves is that the Commanding Self and the Behaving Self have relatively different strengths depending on our state of being both physically and emotionally.

The Commanding Self has more relatively more strength when we are well-rested, emotionally balanced, sober, and well-fed. The Behaving Self takes over when we’re tired, emotionally upset, inebriated, or hungry.

Perhaps we should label the Behaving Self the Misbehaving Self! After all, most of the time the Behaving Self actually does misbehave. And perhaps we should label the Commanding Self as the Demanding Self.

There are many other self splits that we can look at. For instance, there clearly is a split between our short-term self and our long-term self. Many of the discrepancies in our behavior are a result of this particular split.

For instance, dieting. The short-term self wants immediate food gratification regardless of the long-term consequences on our weight or health. The short-term self wants to spend money in contradiction to the long-term self’s goal of spending less money and saving more.

So how can we integrate these multiple selves? Is it possible to create cooperation between our Commanding Self and our Behaving Self?

Can we possibly learn to show up for ourselves and actually follow through on what we say we are going to do?

Exercise: Testing the Commanding Self by Interviewing the Behaving Self

Here’s an interesting exercise. What if you means-tested each command from the Commanding Self by asking yourself “How likely is it that I will do this?” And only issuing the commands that your Behaving Self agreed with?

So if you sit down at your computer and say “I’m going to do some writing,” you would ask yourself, “Do I really want to do some writing, and will I actually follow through and do it?” If the answer was not a resounding yes, then you would not issue the command.

It would be a very interesting experiment to spend an entire day doing this. One could also experiment with lowering the expectations of the Commanding Self. For instance, rather than saying I’m going to lift weights for 30 minutes, I would say I will lift weights for 5 minutes and then decide if I feel like doing more. That way I have at least lived up to my own expectations.

Same with eating. Rather than say I’m only going to eat one chip , I would instead say I’m going to eat the entire bag. Then if I leave a little bit I have actually outperformed my expectations.

In a sense what I’m suggesting here is that we have an honest dialogue with ourselves. As we write down our to-do list each morning, we should pretend that we are a boss or a manager asking an employee if they are willing and able to do each task. “Are you willing to sit down today and write for an hour?” “I don’t really know. I’m feeling sort of tired and unmotivated today. I guess I can commit to writing for 30 minutes, but I am not sure about an hour.” “Okay, why don’t you write for 30 minutes?”

And with each item on the to-do list we would have this honest discussion. We might also have a meta-discussion about the entire to-do list. For instance, “I notice that there are a large number of items on this to-do list and you only have a few hours free today. Is it realistic to really expect to accomplish all of these items or should you be moving several to another day?”

“Yes, I see what you mean. I probably can’t achieve all of these items. I guess I have to pick one or two items and focus on those.”

“Which items would you like to select? Which are your highest priorities?”

I recently did this experiment for several days and discovered that unless my ratings of wanting to do something were in the 80 to 100 range (hundred point scale), I didn’t usually do the task. This was very consistent. I also noticed that sometimes the rating of wanting to do something didn’t get up to this critical range until the task became urgent, which of course explains procrastination.

Using the Technique of Paradoxical Agenda Setting

The technique of paradoxical agenda setting involves taking a devil’s advocate approach. Rather than trying to motivate yourself to do things by telling yourself all the good reasons why you should do those tasks, you instead ask yourself about all the reasons not to do the task?

By focusing on all the reasons not to do something you can honestly assess your motivation and even address some of these resistances more honestly. Rather than just saying to yourself “Just do it!”, you look at your resistance and troubleshoot how to eliminate it.

EXERCISES TO EXPLORE THE TWO SELVES

Exercise One: Write down all the commands you give yourself for an entire day. That includes to to-do list items that you set yourself to do, informal commands such as “I won’t eat the entire pie,” as well as any agreements you make with other people to accomplish tasks.

Write down the tasks and the commands as you issue them, not later. Otherwise you won’t remember them. At the end of the day take an inventory. Determine how many of the commands you actually accomplished. You probably want to calculate a percentage accomplished.

Take a look at this percentage. If it is over 80 percent then your two selves are very well integrated and you probably should stop reading this article right now. If it’s between 50 and 80 percent you are doing better than most people but still have plenty of room for improvement. If it’s between 30 and 50 percent then you are struggling with a split between your Commanding Self and your Behaving Self. In fact, you might just want to call it your Misbehaving Self. And if you are below 30 percent then you are probably suffering many negative consequences from your inability to integrate your multiple selves.

Exercise Two: Learning how to lower your own expectations. Write down a goal for today. Now cut it in half. Now cut it in half again. That’s the new goal. We always bite off way more than we can chew.

Exercise Three: Ownership. Write down a goal for today. Ask yourself is this is really your goal or someone else’s goal? Is it something that you want to do or is it something that you think you should do based on someone else’s opinion.?

Exercise Four: Under-promise and over-deliver. For today, practice making very small promises to yourself and overachieving on each promise. You want to be authentic and sincere in these small goals. Don’t pretend that they are actually larger goals. For instance, set a goal to walk for 10 minutes for exercise, and then walk for 15.

Exercise Five: Gradually increasing goals. If your exercise goal is to exercise 5 days a week for 30 minutes, but you only exercise once a week, then you must lower your goal first to one time a week. See if you can achieve that goal several weeks in a row. If you can, then you get to increase the goal to perhaps two times a week of exercising. Once you’ve achieved that goal you get to increase the goal to three times. But each time and each week you must reach that new goal otherwise you must go back to the previous week’s goal.

That means if you set a goal of exercising three times but you fail to meet that goal then you must roll back the goal to two times and achieve that goal that for at least two weeks in a row. This will train you to make reasonable and achievable goals and to follow through on those goals.

“Everyone wants to go to heaven but no one wants to die” : The Paradox of Goal Versus Time Management

One of the ways to explain the disparity between our multiple selves is the trade-off principal embodied by the heaven quote.

We all have many goals, but in order to achieve goals we need time. Goals are infinite, and we can add an unlimited amount of them to our to-do list. But time is the ultimate finite quantity. We can manufacture as many goals as we choose, but we can’t produce a single extra minute of time.

Hence lies one very simple explanation for the two selves paradox. The Commanding Self produces a list of goals or tasks to achieve. The other self, which we will call the Behaving Self, must perform the task of accomplishing these goals within limited time, and must balance the time to achieve one goal versus another goal. But because the Commanding Self doesn’t really consider time in it’s estimations, the Behaving Self is almost certain to fail. The problem is that the Commanding Self does not understand the trade-off principle. The Commanding Self assumes that time is infinite. Which of course is patently untrue.

So how to fix this paradox? Perhaps the Commanding Self should be required to first estimate how much time each task or goal will take. And then double or triple this time estimate. But that won’t be enough. Instead of a to-do list, perhaps the Commanding Self should only use a calendar and time schedule. If the Commanding Self wants to straighten up the house, then it should be required to put it on the time schedule. And if it doesn’t fit on a time schedule, then don’t put it on.

This gives power back to the Behaving Self. And it is the Behaving Self that actually performs tasks. So we need to take the power away from the Commanding Self, and give it back to the Behaving Self. This should resolve many of the paradoxes between the two selves.

In a sense, what I am suggesting here is for all of us to get rid of our to-do lists, and replace them with time schedules and calendars. If a task doesn’t fit in our schedule, then it doesn’t become an action item. Of course the challenge of this is that we tend to greatly underestimate the time it takes to accomplish each task, so we would have to either leave extra time, or split tasks into numerous sessions of work spread out over several days.

I am reminded of Neil Fiore’s book The Now Habit. He talks about the UnSchedule. What he suggests is that people put on their UnSchedule all of the things they have to do every day. This includes basic tasks of daily life such as showering, eating, commuting, all meetings, etc. What is left is the actual time you have to accomplish tasks. And for most people this is a very small amount of time. He then suggests that you fill in half hour blocks of work, after you accomplish that 30 minutes of work.

It is very sobering to do this. Most people realize that at best they have an hour or two per day to actually accomplish new work. Many jobs include multiple meetings which are required, leaving relatively little time in the workday to actually accomplish anything. When I did the UnSchedule I realized that after I included all of my basic tasks of daily life, exercise, returning phone calls, processing emails, and seeing clients, most days I only had an hour or two to accomplish anything else. And this hour or two could easily be used up doing a few tasks. When I realized how little time I really had during the work week, I lowered my goals and was happy accomplishing one or two significant tasks each day.

So these are some rambling thoughts from the beach about the paradoxes which make up our lives. Now my Behaving Self is saying time to go for a swim!

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

12 Techniques for Giving Criticism and Feedback so that People Can Hear It without Getting Defensive

I was recently asked a very interesting question by one of my clients. He asked, “What percentage of people can listen to feedback and criticism without getting defensive?” I responded, not really in jest, “Only the people that have taken my non-defensiveness training!”

The reality is that most people instantly get defensive when criticized or even given mildly negative feedback. Regular readers will recall that I’ve written extensively about how to respond non-defensively: see “Radical Non-Defensiveness: The Most Important Communication Skill.”

But I also wanted to write about the other side of the equation – some techniques for giving feedback and criticism that lower the probability of the other person feeling hurt or getting defensive.

Here are 12 great concepts in giving feedback and criticism.

1. Focus on behavior and not on the person. Never label the person with a pejorative label. Avoid words like “inconsiderate”, “jerk”, “slob”, “lazy”, and all other negative label words especially four letter words.

2. Be specific and concrete when you focus on behavior. Use the journalistic technique of who, what, when, where, and if appropriate, why when you describe a behavior. For instance, consider this feedback from a wife to her husband: “An hour ago, when we were talking to Herb and Lucille, in their garden, you told them about my getting fired from my job. This upset me because I have a lot of shame right now about getting fired.” Notice that this feedback includes all of the specific descriptors.

3. Whenever possible, tell the person what you want instead of what you don’t want. So instead of criticizing your partner for sitting on the couch while you clean the kitchen, instead ask them to help you clean the kitchen. If there is a specific behavior that you would like the person to stop, it’s okay to ask them to stop but usually better to also specify something else that you would prefer. Example: “I’d really like it if you wouldn’t scream at the children. Could you instead talk firmly to them? I’d really appreciate that.”

4. Recognize what people can change and cannot change, and how difficult a specific behavior will be for them to change. This is a difficult lesson, and one that most of us resist. But it’s terribly important.

I’m reminded of the famous parable of the frog and the scorpion. In the story, a scorpion and a frog meet on the bank of a stream and the scorpion asks the frog to carry him across on its back. The frog asks, “How do I know you won’t sting me?” The scorpion says, “Because if I do, I’ll drown, and I will die too.” The frog is satisfied, and they set out, but in midstream, the scorpion stings the frog. The frog feels the sting, knows he is dying, and has just enough time to gasp “Why did you sting me, now we both will die?” Replies the scorpion: “Because I am a scorpion, it’s my nature…”

Another similar saying is, “Never try to teach a pig to sing, it will frustrate you and annoy the pig.”

Some things people can change and others are more linked to their basic character and nature, and are extremely difficult if not impossible to change. There is also the issue of what people are willing to invest energy in changing.

Here are some criteria for determining whether a particular criticism even make sense.

  • Has the person had a specific behavior for most of their life? If so, what makes you think it will suddenly change?
  • Is the person genuinely interested in making the desired change? Is it within their value system to change? People can change the things that they strongly wish to change, but if they’re only changing because you asked them to, they will most likely fail.
  • How much energy would it take for the person to change the behavior? Something that takes very little energy is more likely to happen than a request which will take herculean amounts of energy.
  • Is changing this particular behavior the most important thing for you or might there be a different behavior that would yield more satisfaction for you?
  • Does the person have shame attached to the behavior you are criticizing? If so, you should carefully consider whether the criticism is worth the pain you will most likely cause.

The idea here is to avoid asking the scorpion not to sting. If someone’s been messy and disorganized for their whole life, it’s probably not reasonable to ask them to become neat and organized. That doesn’t mean you couldn’t make any requests, but a more reasonable request might be to ask the messy person to keep their mess within a specific room or rooms, and then close the door.

Always evaluate if it’s even worth giving criticism. Remember, criticism is fairly toxic to relationships. Women sometimes criticize men in the hopes that the men will change. Nobody really changes. If you feel a need to criticize your partner constantly than the problem is probably with you and your lack of tolerance and acceptance. Or maybe you need to re-evaluate whether the relationship makes sense to continue.

5. Avoid giving feedback or criticism when you are particularly angry. Very few of us have the skills to give gentle and reasonable criticism when we are really frustrated and angry. If you give criticism when you are pissed off, you will blow it. You won’t be able to follow any of the rules in this article. Your primary goal will be to hurt the other person, which never works out well.

6. Pick your time and place carefully. This should include assessing your partner’s state of mind. If they are hungry, angry, stressed out, or tired then defer your criticism for later. It will never go well if you’re not attentive to time and place and state of mind. And remember, sometimes the right time and place is never and nowhere.

7. Ask for change, don’t demand change. Most of us get really stubborn when someone demands that we change. Besides, who made you the boss?

8. Avoid spending any significant time discussing the past. Mistakes made in the past are over and done with unless you own a time machine. Giving multiple examples of past mistakes will only overwhelm the person and make them defensive. Give only one example at most. Better yet, use an example from the current time. Assume your partner isn’t stupid and can understand the specific behavior you’re asking them to change.

9. Once you’ve asked for a change don’t micromanage that change. Let the person figure out how to do it, and don’t stand over them or constantly monitor them.

10. Be very specific about your feedback and the desired outcome. Your requested outcome should be so clear to the other person that anyone would be able to determine whether the outcome had occurred or not. Use the journalistic model of who, what, when, where, and why. Use accurate language, and avoid extremes of “never” or “always”. Don’t ask your partner to never again throw their clothing on the floor. Instead, specify that you would like it to happen less frequently.

11. Use a soft start up. Give a compliment first and be gentle in the feedback you give. Point out (if true) how the criticized behavior is a departure from the person’s usual terrific behavior. This is a way of giving a compliment while giving criticism. Example: “You are usually so helpful in the kitchen. But last night you left all of the dirty dishes. I’d really appreciate if you’d clean them up this morning.”

12. Never threaten your partner or deliver ultimatums. Even if you are at the end of your rope never threaten the termination of the relationship. When people hear an ultimatum they shut off. Also it triggers resistance since none of us like to be blackmailed into action.

Also, you can only make an ultimatum once. If you make it more than once you lose all credibility. So just avoid them entirely. (Notice this applies to parenting children as well.)

So there you have 12 great techniques for giving feedback and criticism in a healthy way. Remember that it’s essential to balance criticism with lots and lots of compliments and showing appreciation. Good relationships typically have at least a 5 to 1 ratio of positive feedback to negative feedback. If your relationship has a lower ratio than this then it’s time to change. Catch your partner doing things that you like and appreciate, and let them know in a warm and genuine way. This is perhaps the most important secret of giving criticism – let it be in the context of lots of praise.

Now I have to go tell my sweetie that she is awesome!

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Power of Nurturing: How Quality of Parenting Interacts with Nature to Determine Outcomes in Life, Even in Poverty

National Public Radio (NPR) reported  recently on a very interesting study of babies. This research, performed by Elizabeth Conradt at Brown University, looked at a phenomena called baseline respiratory sinus arrhythmia. This in itself is a very interesting concept. What exactly is this? It is the difference between your heart rate when you inhale and when you exhale. It turns out that some people have a larger difference than others. Everyone has a different set point in terms of heart rate variability.

Babies that have a bigger difference tend to have greater abilities to focus on things in their environment. If you show them a new toy, they will really look at it and interact with it. Babies with low heart rate variability tend to lose interest more quickly.

So it’s better to have a baby with higher heart rate variability? It’s not that simple. Babies with a higher set point of heart rate variability are more irritable and fussy particularly when their environment is changing. On the other hand, babies with a lower set point tend to be less fussy.

Heart rate variability turns out to be a pretty good predictor of how sensitive babies are to their environment, both in good and bad ways.

Anyway, Conradt’s research looked at mothers and babies who were living in poverty. They were interested in predicting how the children would do as they aged.

So first, at five months of age, they measured heart rate variability while the babies were listening to soothing music and watching soothing video.

Roughly a year later, when the babies were around 17 months old, they came back to the lab. At this point they measured two things. First the researchers evaluated behavioral problems such as anxiety or aggression. Then they performed an interesting test that measures the quality of attachment between a mother and the baby. The researchers took the mother and child to a strange room, where the toddler played for a bit. Then, without any warning, the mother got up and left the room. In most cases this will trigger the baby being upset and crying. This is typical and normal. The baby thinks, “Where did my mom go?!”

What the researchers were really interested in was what happened three or four minutes later when the mother returned. Could the mother quickly soothe the upset child, or did the toddler pull away from the mother and continue to be upset?

The researchers made the assumption that if the mother could easily soothe the toddler then it was a marker of good attachment and a secure environment.

So here’s the very interesting part of this research. How did the initial heart rate variability set point correlate with behavioral problems? It turns out that if the baby had a high set point and insecure attachment to their mother, then they had the worst behavioral problems. But if they had a high set point and secure attachments to their mothers, then they had the lowest incidence of behavioral problems.

Children with low set points fell in the middle of the range of behavioral problems, and were not affected by the quality of their attachment with their mothers.

The amazing finding was that the children who had high set points and good quality parenting as reflected by secure attachments to their mothers tended to have less behavioral problems even than babies in middle-class and affluent families!

This is fascinating research. It shows the influence of both nature and nurture. And it shows how a biological trait such as heart rate variability can either lead to good or bad outcomes in life based on the quality of parenting. Mostly though, it demonstrates how crucial good parenting is to later outcomes in life. Good parenting can create successful, well-balanced children even in circumstances of poverty. In fact, the study showed that for the more sensitive children,  good parenting in poverty trumps bad or mediocre parenting in affluence!!!

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Guns Are Weapons of Mass Destruction: Lessons of the Newtown School Shooting

I normally don’t blog about political issues, but today is an exception. Friday’s horrific school shooting in Newtown, Connecticut shows that guns are weapons of mass destruction. It’s time for this country to get serious about regulating them.

Other types of weapons of mass destruction are banned or tightly controlled in this country. You can’t buy a rocket propelled grenade launcher. Nor can the average citizen acquire C-4 explosive. Or nerve gas. Or suitcase nukes. Why do we allow virtually anyone to acquire the weapons of mass destruction that we call guns?

The Second Amendment reads, “a well-regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed.” This was written hundreds of years ago, at a time in our history when we had just recently won our freedom from Britain after a bloody war. There was a genuine risk that England could attempt to reconquer our country, and thus maintaining an armed populace made good sense.

But today nobody is trying to invade the United States, and if they did they would be met with extreme force from our military. Our biggest danger now comes from inside, from disturbed individuals who acquire weapons of mass destruction, i.e. guns, and who kill innocent children and adults.

Imagine if instead of using guns, these school shooters built themselves suicide bomb vests. Would we not ban or tightly control any components that were necessary to build these vests? Of course we would. After the Oklahoma City bombing the government imposed controls and tagging on fertilizer components in order to reduce the possibility of future fertilizer bombs.

How many more children must be gunned down until the National Rifle Association and the Republican Party are willing to consider genuine and effective controls on guns? Do we need a school shooting every week in order to for our society to decide to make changes? Or every day? I hope not.

The Second Amendment in no way prevents strict regulation of guns, ammunition, and cartridges. Notice the emphasis on, “a well-regulated militia.” This would allow for any regulation necessary to lower the risk to innocent people. We already regulate gun ownership—screening, waiting periods, no fully-automatic machine guns, strict controls on silencers, etc.

So what are some reasonable regulations or interventions that might lower risk of mass shootings?

The first one is to re-institute the assault weapons ban. No hunter or civilian needs a semi-automatic rifle that can fire more than five or 10 bullets. Another option is to ban ammunition magazines that hold more than 10 bullets. This should apply to semi-automatic handguns as well. Again, there is no legitimate use for a civilian where they would need to fire more than 10 bullets.

There are several ways to impose these changes. One would be an outright ban, but politically this might be difficult. Another option would be regulation using taxation. Just as we have significant taxes on alcohol and cigarettes in order to lessen their use, we could have very large taxes on ammunition magazines larger than 10 bullets, and on semi-automatic rifles. If these cartridges each had a tax of $100 attached to it, and each semi-automatic rifle a tax of $1000, the sales would plummet. Manufacturers abandon production of these products.

California has already instituted many of these regulation, and the federal government should consider enacting similar rules.

Stricter legislation might be even better. If we truly are serious about eliminating these weapons of mass destruction, then we should ban not only the sale, but also the possession of large magazines. There would be an interim period during which civilians could turn in these cartridges to local law enforcement, but after that time, the possession of such large magazines would  become a felony.  Companies that manufacture these magazines could offer a trade-in program where citizens could trade in a large magazine for a legal sized magazine. This would be an incentive for both manufacturers and owners to make the swap.

Those who argue in favor of better screening for gun ownership are fooling themselves. All that our current screening procedures do is identify people who have a prior history of documented illegal behavior or disturbed behavior. There is no screening method that could identify those who will commit mass murder in the future, if they have no prior records of disturbed or illegal behavior. So tighter screening methods will not work.

And those who argue for arming schoolteachers are equally foolish. In theory it sounds great, every schoolteacher carrying a weapon and being well-trained to take out the next school shooter. In practice, it won’t work because as horrific as they are, the probability in any one classroom of a school shooter is exceedingly low. This will lead to schoolteachers leaving their guns in their desks, unloaded, and being completely unready to take on the well-prepared school shooter who will be heavily armed, wearing a bulletproof vest, and all too ready for action. Even the average police officer, armed with only a handgun, rarely takes on heavily armed perpetrators, instead leaving that task to SWAT teams who carry much more potent weaponry. And I don’t think we want to arm schoolteachers with machine guns!

In conclusion, guns are weapons of mass destruction and we should regulate them as such. As a society we should ask ourselves how many more innocent children need to die before we get serious about such regulation. We can regulate guns without banning them, and hunters, target shooters, and even people using guns for home defense will not be unduly affected. But Congress needs to hear from people, and I strongly encourage everyone who cares about the safety of children to reach out to their Congressman and their Senator and let them know that it’s time to change gun regulations to stop the mass destruction.

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

New Rapid Home Testing Kit for H.I.V. Goes on Sale, Should You Use It? (P.S., Dr. House Was Right, Everyone Lies About Sex

The New York Times reported today that there is a new rapid home testing kit for HIV that went on sale today, October 5, 2012. The kit is called OraQuick, costs $40 and takes 20 minutes to provide results. This is a major breakthrough, as it allows people to quickly determine their HIV status in the privacy of their own homes. It also opens up the potential for sexual partners to test each other before having sexual contact. I’m sure the company that makes the OraQuick test, OraSure Technologies, would love it if many people use this test before having sex. But is this a good idea?

The kit is not perfect. It is almost 100% accurate when it indicates that someone is not infected with HIV, and, in reality is not. But it is only 93% accurate when it says someone is not infected and the person actually does have the virus. This is most likely because there is a period of time after infection before the body is producing antibodies that the test detects.

Should you use this test when considering becoming sexual with a new partner? Consider some very disturbing facts based on two sexual surveys reported in this article. In the first survey, nearly 20% of infected homosexual men reported having unprotected sex with at least one partner without revealing their HIV status.

In the second study, they found that 9% of HIV-positive heterosexual men and women, and 14% of HIV-positive gay or bisexual men reported having recent unprotected sex with someone who they either knew was uninfected, without revealing their own infection! Putting this in real numbers, the authors of this survey estimated that over a year, 34,000 infected gay men and 10,000 infected heterosexual men and women had sex without telling the truth.

This really speaks to the issue of not trusting what people say about sexuality. Too often I hear experts giving the advice to ask your potential partner about their sexual history and their HIV status. Given the results of these two surveys, that seems naïve, foolish and dangerous. People lie about sex. If you are a gay male, it’s reasonable to expect that one in five infected potential partners will lie to you about their HIV status. If you’re a heterosexual, the number drops to a little below 10%. Are those the odds you want to take with your life?

What this really speaks to is the importance both of testing and of safe sex. Since the OraQuick test is only 93% accurate when the person taking it is infected, that means 7% of the time, with an infected person, the test will falsely tell you that they are not infected. So those odds aren’t very good either. So let’s calculate the probability that your new potential sexual partner might be HIV-positive, lying about it, and the OraQuick test would falsely tell you they were HIV negative.

If you are a gay man, then the probability is 20% times 7%, which equals 1.4%. If you are heterosexual the probability is 9% times 7%, which equals 0.69%. So the odds that your deceitful HIV-positive partner would not be identified by the OraQuick test are 1.4% if you are a gay male, and 0.69% if you are a heterosexual man or woman.

So even by using the OraQuick test, you can’t eliminate all risk. That’s why practicing safe sex makes so much sense. At least do so when having casual sexual contact, before you get to know the person well and can figure out whether they are trustworthy or not.

So to summarize, the new OraQuick test allows for quick at home testing of HIV status. Given the facts about how many HIV-positive gay and straight people are not honest about their HIV status, it makes sense to consider using this test. But there is still a risk, since the test is least accurate when used on HIV-positive people. The OraQuick test can improve your odds, but for ultimate safety, practice safe sex!

No joke to end this post, because this is such a serious matter.

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Understanding and Overcoming Social Anxiety: Part Two

In Part One of Understanding and Overcoming Social Anxiety, I discussed the basic core beliefs of people who suffer from social anxiety. To review, the core beliefs are:

1. Everyone is noticing me

2. Everyone is judging me, harshly

3. As a result of these judgments, I will be humiliated and rejected.

4. If people judge me negatively, I must suffer terribly.

I wrote about a simple behavioral experiment that challenged the first belief, that everyone is paying attention to you. How do we challenge the rest of these beliefs?

Let me digress for a moment into a bit of theory about change. In my opinion, there are two types of change, first-order change, and second order change. First-order change is change that occurs within a given mental system, without changing the system itself. Second order change is transformative, in that it changes the basic framework of the system.

A good example of this is the concept of a nightmare. Within the nightmare a person can do many things such as running away, fighting, screaming, etc. but they are still within a nightmare. Second order change means waking up from the nightmare.

In the case of social anxiety, first-order change would entail questioning the beliefs that people are judging you harshly. It might entail gathering evidence whether your beliefs about people judging you are accurate or not.

Although this approach would be useful, it’s not really transformative. Second-order change would be to change the belief that other people’s judgments matter. Not caring even if people are judging you negatively would be the ultimate second order change.

Now let’s come back to earth! How would we apply each of these types of change to social anxiety? To do first-order change you could check out your mind-reading perceptions. For instance, if you are worried that your boss was judging you negatively, you could sit down with your boss and ask for feedback. You could first start by asking for general feedback, such as “How do you think I’m doing?” Then you could narrow it down to your specific concerns. For instance, imagine that you are worried that you are not working fast enough. You could ask your boss, “Do you think I’m keeping up with the pace?”

With a friend or loved one you could use a similar strategy. You could tie nonverbal cues to your questioning. For instance, let’s imagine that your spouse furrows their brow at you. You imagine they are judging you negatively. You would then ask, “I noticed that you furrowed your brow at me just then, what were you thinking?”

This strategy would result in first-order change; that is, you would correct your beliefs that everyone is judging you negatively. But it wouldn’t change the power of those imagined or real judgments to upset you.

A second order change strategy for social anxiety would be to do some behavioral exposure tests that would help you overcome the fear of judgment. I do these with my patients frequently. For instance, we might walk around my office neighborhood wearing masks. Or we might put on two brightly colored socks that don’t match, roll up our pants so that the socks are fully visible, and walk around. Other tasks might include singing loudly (and off key) as we walk down the street. Another task might be on an elevator, announcing the floors as each passes.

The key concept behind all of these types of tasks is to overcome the fear of people noticing you and judging you. Clients quickly realize that the judgments of strangers really don’t matter.

There are literally hundreds of these types of anti-embarrassment tasks. (I’ve listed some good ones below.) One can create a laddered hierarchy of tasks ranging from relatively easy tasks to very scary tasks. Then the client can work their way up the hierarchy so that they get more and more comfortable being judged.

Another approach is to deliberately work on incurring some mildly negative judgments from people you are close to. For instance, I might ask a client to wear a shirt that their spouse disapproves of or doesn’t like. Or one could deliberately espouse an opinion that a friend would disagree with. The idea of this is to get comfortable with mildly negative judgments even from people you are close to.

A key concept regarding judgment that I try to teach clients is that if one has a clear sense of one’s self, including strengths and weaknesses, then it’s possible to be relatively independent of the judgments of others. You get to determine your own judgments of yourself, and when the judgments of others correlate with your own judgments, and then you can respond non-defensively. But when the judgments don’t correlate with your own judgments of yourself, you can gracefully ignore or dispute them. The key concept is that everyone has different opinions about almost everything, and you get to determine your own opinion about yourself.

In fact, one might view social anxiety through the lens of the sense of self. Those who suffer social anxiety usually have either a negative view of themselves which they project onto the judgments of others, or have an unstable view of themselves which depends on the judgments of others. In either case the core problem is the sense of self.

To walk around with a profoundly negative view of oneself would be even more painful if one was fully aware of the source of this negative view – one’s own thoughts. Because this is so painful, people with a negative self-concept will typically project this negative self-concept onto the world, and experience everyone around them as judging them negatively. The first step to overcoming this tendency to project and to mind-read is to make the assumption that virtually all of your beliefs about others judging you are actually a reflection of you judging yourself.  Then you can deal with the real problem – your own thoughts.

If you have an unstable view of yourself, and depend on the judgments of others to figure out who you are, then changing this is more challenging. I often give clients a variety of written tasks so that they can explore their beliefs about themselves. The challenge is to figure out who you really are, including both your strengths and weaknesses. And then accept both. Once you are okay with who you are, then the judgments of others don’t really matter very much.

Now I want to clarify an important point. Some judgments do matter. For instance, if you work in a company and your boss determines your bonuses and raises, then your boss’s judgment of you matters, at least in terms of your economic health. Other judgments that typically matter might include a graduate school thesis advisor, who can determine whether you can progress in your program or not. And in general the judgments of the people closest to you do matter, at least over the long run. If your wife or husband begins to have a generally negative judgment of you that persists, this may end up in divorce. But note that even in these close relationships, a momentary negative judgment doesn’t really matter. If my hair gets too long, and starts to look funny for a week or two until I get it cut, my sweetheart won’t reject me. (Of course, she may drop subtle hints about haircuts!)

So, to summarize:

1. Social anxiety is at its core a disorder of the self. People with a strong and confident sense of self don’t suffer social anxiety. One might conceptualize social anxiety as a frantic attempt to accurately determine one’s self by polling others.

2. There is first-order and second-order change regarding social anxiety. First-order change involves making more accurate determinations of the judgments of others towards you. First-order change involves challenging mind reading beliefs and testing whether others are even paying attention to your behavior.

Second-order change is more profound and more radical. It involves learning not to care, even when others judge you negatively. It also involves bringing back your attention from the outside world and the judgments of others to the inside world and your own judgments of yourself.

3. Almost everyone can benefit from tuning into their inside judgments of themselves. As Oscar Wilde once said, “To love oneself is the beginning of a life-long romance.” We are stuck with ourselves, flaws and all, and learning to love and truly accept ourselves is really the beginning and the end of internal comfort in life.

 

 

 

Appendix: Some Examples of Anti-Embarrassment Tasks

In an elevator, open your briefcase or handbag, and look inside, and ask “Got enough air in there?”

Say “Ding” at every floor.

On a bus or subway, stand up and announce each stop.

On the street, ask for directions to a store you are standing right in front of.

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Understanding and Overcoming Social Anxiety: Part One

Social anxiety is a common psychological disorder, affecting about 5 percent of the population in a strong way and up to 13 percent of the population in a weaker way.

Social anxiety is not just shyness, but a much more profound problem. People with social anxiety disorder often become intensely anxious in social and performance settings, sometimes to the point of having a full blown panic attack.

As Jerry Seinfeld once said, “According to most studies, people’s number one fear is public speaking. Number two is death. Death is number two. Does that sound right? This means to the average person, if you go to a funeral, you’re better off in the casket than doing the eulogy.”

There are several core beliefs that drive social anxiety.

The first of these beliefs is that everyone is paying a lot of attention to you and your behavior. People are noticing.

The second belief is that when people notice you, they will then judge you harshly. (Since most socially anxious people are very judgmental of other people, they assume that everyone is equally judgmental.)

The third of these beliefs is that as a result of these harsh judgments, people will reject and/or humiliate you.

And the fourth belief is that as a result of these judgments you must feel very badly, full of shame and worthless feelings.

All of these beliefs are what we in Cognitive Therapy call ANTS, or automatic negative thoughts. Let’s go through them one by one and analyze how accurate or distorted they are. Then we can talk about some behavioral experiments you can do to dispute these beliefs.

The first belief: that everyone is paying a lot of attention to you and your behavior, is simply not true. Most of the time, most people are fairly oblivious, mostly thinking about things of concern to themselves. You’re not in the spotlight unless you are a genuine celebrity.

The second belief depends on the first belief. If people don’t even notice you, then they certainly aren’t judging you harshly. The other distortion in the second belief is that people will judge you harshly. Even when people do make judgments they are typically not particularly harsh.

The third belief, that as a result of judgments people will reject or humiliate you, most likely stems from grade-school teasing and bullying. In adult life, most judgments are never acted on, and they are never expressed. After all, the modern workplace has very little tolerance for negative teasing or humiliation. People may think some judgmental thoughts about you, but unless you imagine them thinking those thoughts, they will never have any impact on you.

The final belief that you must feel badly if someone else judges you negatively is also quite distorted. It’s quite possible to know that someone is judging you negatively, and feel fine about yourself. After all, all judgments are simply another person’s opinion, not truth. If another person thinks your haircut looks funny, that’s just their opinion. You have the right to have a different opinion.

An important concept in all social anxiety is the idea of mind-reading. Most socially anxious people practice this form of cognitive distortion constantly. They assume that they can read minds, and will read into every subtle expression a negative judgment. This is of course a major cognitive distortion. Nobody can read minds. A furrowed brow can mean many different things, and can even mean the person has a mild headache, or needs a new eyeglass prescription.

Most of the time, when the socially anxious person is mind reading, they are actually projecting their own insecurities about themselves onto other people’s judgments. Let’s imagine that I am particularly self-conscious about my thinning hair. As a result of this insecurity I may imagine whenever someone looks at my head that they are actually looking at my hairline, and thinking negative thoughts about my impending baldness. This is called projection.

In almost all cases of imagined judgment, what is actually happening is projection. You can quickly figure this out by asking yourself, “Is the imagined judgment coming from the other person actually something I feel quite insecure about?” If the answer is yes, then most likely you are mind-reading and projecting.

It would be nice if just a rational discussion of these distorted beliefs created change, but in my experience as a cognitive behavioral therapist, simple discussion rarely changes beliefs completely. But there are some behavioral experiments that are very powerful in challenging these beliefs.

The first belief, that everyone is paying a lot of attention to you, can be challenged using the following behavioral experiment. Do this with a friend or a therapist. Have the friend or therapist wear something quite odd, like a mask or something equally outrageous in terms of dress. Have them walk down a busy street. Walk about 10 feet behind them so that you can observe carefully people’s reactions. Before you start, write down your prediction as to what percentage of people will notice and react to your friend or therapist looking very odd.

Walk around, and keep a running count of everyone who seems to notice, and everyone who seems oblivious. When you have collected a fair amount of data, calculate the percentage of people who even noticed your friend or therapist wearing a mask. You can also track the type of response that you notice. Do people smile or laugh, or do they frown and seem judgmental in a negative way? Compare your actual data to your predictions.

I think you will be surprised at the results of this experiment. Once you have done this experiment I recommend putting a mask on yourself and walking around and noticing people’s responses.

In Part Two of this article I will discuss some other behavioral experiments that can help you overcome social anxiety, as well as discussing some issues of deep change.

Now I’m off to give my eulogy, which is scary but better than the alternative!

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Jet Blue and Orchard Supply Hardware Customer Service: Epic Fail for JetBlue, Epic Success for Orchard Supply Hardware! (Followup: Blogging Matters, Sometimes)

In a previous post I wrote about my experience with JetBlue and Orchard Supply Hardware customer service.

Here’s a followup which shows one Epic Success, and one Even More Epic Fail!

An executive vice president from Orchard Supply Hardware called me up to discuss the situation. He was apologetic, friendly, and agreed with me that the right policy would have been to honor the coupon. We had a nice chat about customer service, and at the end of it he offered me a gift card to compensate for any inconvenience. I was impressed that a) someone at Orchard Supply Hardware cared enough to call, and b) that he appreciated my feedback. Kudos to Orchard Supply Hardware!

JetBlue on the other hand, managed to make things even worse. When I asked them to fix the miles problem, their unilateral response was to take away my JetBlue miles, and then tell me to contact American to get the miles there. At the end of all of this effort, basically what they did was to take away my JetBlue points permanently, and give me American Airline’s phone number to see if I could get miles from them! Thanks JetBlue for absolutely nothing!!!!

JetBlue turned an Epic Fail into an Even More Epic Fail. That’s a good trick.

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Gallup Survey Shows Stay-At-Home Moms Suffer More Depression

Are stay-at-home moms more depressed than working mothers? In a Gallup poll released last week, stay-at-home moms showed a 28% depression rate compared to 17% of working mothers and 17% of working women without children.

Stay-at-home mothers reported more anger, stress, sadness, and worry. They were more likely to report themselves as struggling and suffering!

This is very important data. According to Gallup, stay-at-home moms make up 37% of mothers with kids living at home.

So who are these stay-at-home moms? Contrary to the mythical model of the rich stay-at-home mom who bounces between yoga class, tennis, pilates, and home to the nanny, the reality of stay-at-home moms is much grimmer. They tend to be poorer on average, younger, Latina, less likely to have graduated from high school or college, and more likely to have been foreign-born.

Here’s some more data directly from the Gallup report, which explored the well-being of 60,000 U.S. women in 2012.

In terms of worry 41% of stay-at-home moms reported worry, compared to 34% of employed moms and 31% of employed women without children.

In terms of sadness 26% of the stay-at-home moms reported it, compared to 16% of employed moms and 16% of employed women without children.

In terms of depression, almost a third of the stay-at-home moms (28%) reported depression, while only 17% of employed moms and 17% of employed women without children reported depression.

The only negative emotion that didn’t vary very much was stress. 50% of stay-at-home moms reported stress, but 48% of employed moms and 45% of employed women without children also reported stress. So apparently stress is pretty much the same across the board for women.

In terms of anger, 19% of stay-at-home moms reported it, while 14% of employed moms and only 12% of employed women without children reported anger.

What about positive emotions? Even though Gallup makes much of the lower ratings of positive emotions for stay-at-home moms, the numbers don’t reflect very large differences. 42% of stay-at-home moms reported themselves as struggling, while 36% of employed moms and 38% of employed women without children reported themselves as struggling. Not a very large difference and probably not statistically significant. What’s interesting about this data is that so many women, regardless of their parenting status, report themselves as struggling. This is quite troubling. I’d be very curious to see comparative data on men.

This is interesting research and completely consistent with some other research that was conducted by Daniel Kahneman and associates on women’s experienced happiness performing various activities. He looked at the percentage of time that women spent in unhappy mood states. Parenting activities showed a 24% on happiness ratio as compared to 18% for housework, 12% for socializing, 12% for TV watching, and 5% for sex! Even though children are delightful, parenting is hard work, and there are many negative emotions associated with it. Working outside the home has negative emotions also, with a 27% unhappy emotion ratio, but it also has rewards and recognition that the lonely job of parenting does not have.

So what should we make of all this research? What wasn’t investigated by Gallup is the relative advantages versus disadvantages for the children of stay-at-home moms versus working moms. So we don’t know if there are significant benefits to the children, which might compensate for the higher levels of suffering reported by stay-at-home moms. I may come back to this issue in a future blog post.

In any case, it suggests that stay-at-home moms need much better support systems from our society, and that we also need to develop better ways for women split time at home and work. Currently there are few options for women who wish to work part-time at satisfying jobs. Because child care in the United States is so expensive, it is difficult for poorer women to stay in the workforce. This may lead to higher levels of depression and suffering in women.

From a clinical perspective, psychotherapists need to be alerted to be extra careful to screen stay-at-home moms for depression and anxiety disorders. I have a quick depression screening test on my website which stay-at-home moms can use to identify if they are suffering depression. If so, call someone for help. Don’t suffer in silence.

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Jet Blue and Orchard Supply Hardware Customer Service: Epic Fail! (updated)

As a psychologist, I am always amazed at how foolish companies can be in terms of customer service. I recently had two experiences which demonstrate this.

The first one was with Orchard Supply Hardware (OSH). They had published a 20% off coupon for this past weekend. It was a two-day coupon, and I didn’t look at it terribly carefully, assuming that it was good for Saturday and Sunday as most weekend coupons are. On Sunday I went over to Orchard Supply Hardware with my significant other. We were shopping for a new backyard umbrella and stand. A very nice sales clerk,  Pilar, showed us the options. We then asked her if we could apply the 20% off coupon. That’s when we found out, according to her, that the coupon was actually only for Friday and Saturday. We asked her if it was possible to have the manager override it so that we could still get the discount. We told her that we would buy an umbrella and a stand if we could get the discount. She told me it was impossible, that the computer would not allow it.

As we checked out, buying a few small items that we needed, but not an umbrella and not the stand, we saw almost everybody presenting the same coupon and being told the same thing. In several cases the person shrugged and then said well I don’t want to buy this, walking out of the store in disgust.

So here’s an example of terrible customer service. You have a large group of people who bring in a coupon one day past its unusual expiration date, asking for the coupon to be honored. All of these customers want to give you money! Rather than give your managers the ability to do this, you have a rigid computer system, and you lose sales. Anyone who has come into use that coupon on a large item most likely walks out without buying that item. Epic fail!

Another example was my  interaction today by phone with JetBlue Airlines. I recently flew round-trip from San Francisco to Boston. JetBlue has a tie-in with American Airlines such that you can choose to receive American miles rather than JetBlue miles. At the airport I had specifically given my American frequent flyer number, and requested that I receive American miles rather than JetBlue miles. When I checked my statement I discovered that I had been incorrectly credited JetBlue miles and had received no American miles.

So I called JetBlue and spoke with Monica in their True Blue frequent flyer department. I should add that first I spoke to a regular customer service person who kept me on hold for 5 min. and then transferred me to Monica. When I explained to Monica that I would like her to switch the miles over to American, she curtly told me that once the miles were credited it was not possible. Even worse, she gave me a ridiculous explanation telling me that since I had bought my ticket after logging into my True Blue account, the ticket would automatically accrue True Blue miles even if I had my American frequent flyer number in the account. Since there’s no way to buy a ticket without logging in, that was pretty ridiculous.

I then asked to speak with her supervisor, which resulted in another long hold, at which point I decided to give up since it was clear that JetBlue had no interest in fixing this problem.

Once again, epic fail. I had been really impressed with the actual flight, the comfort of the seats, the friendliness of the staff. This had been my first JetBlue flight. But I have to admit that given my poor customer service experience regarding the frequent flyer miles, it leaves a sour taste in my mouth regarding JetBlue.

The key point in the JetBlue customer service failure and the Orchard Supply Hardware Customer service failure was the inability of the front line sales person to have the authority and the power to fix the problem instantly. So many companies seem to believe that empowering front-line people to fix problems is somehow a huge mistake. This is wrong!

In summary, there are a few key points.

1. Customer loyalty and satisfaction is difficult to gain, but incredibly easy to lose. Once you betray a customer’s trust, it’s almost impossible to regain it.

2. Customers repeat bad experiences much more than good experiences. From a marketing perspective, when a customer has a bad experience it potentially drives away many other customers as that customer tells their experience to other potential customers.

3. The goal of all customer service should be to leave the customer feeling good about the interaction. The best outcome is to give the customer what they want. In this case, for Orchard Supply Hardware, it would have meant honoring the 20% coupon. In the case of JetBlue, it would’ve meant transferring the miles over to American Airlines.

4. If you can’t give the customer exactly what they want, offer something else good. For instance, Orchard Supply Hardware could have offered another type of discount, or a coupon good for future use. JetBlue could have offered me some bonus miles under their own program.

5. If, for some inexplicable reason, you cannot offer the customer something good, at least be very apologetic. Neither the clerk at Orchard Supply Hardware nor the customer service rep Monica at JetBlue said the magic words. “I really wish that I could do something more for you, but I can’t. I really apologize.”

The failure to even apologize leaves me as a customer just amazed. Epic fail! Shame on both Orchard Supply Hardware and on JetBlue Airlines!

(See my update to this story here, where JetBlue compounds their failure, and Orchard Supply Hardware makes it right, with amazing customer service.)

 

 

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How Reporters Screw up Health and Medical Reporting (and How You Can Catch Them Doing So)

I’ve written before about common mistakes in interpreting medical research in my blog post How to Read Media Coverage of Scientific Research: Sorting out the Stupid Science from Smart Science. I recently read a very interesting post by Gary Schwitzer about the most common mistakes that journalists make when reporting health and medical findings.

The three mistakes that he discusses:

 1.      Absolute versus relative risk/benefit data

“Many stories use relative risk reduction or benefit estimates without providing  the absolute data. So, in other words, a drug is said to reduce the risk of hip fracture by 50% (relative risk reduction), without ever explaining that it’s a reduction from 2 fractures in 100 untreated women down to 1 fracture in 100 treated women. Yes, that’s 50%, but in order to understand the true scope of the potential benefit, people need to know that it’s only a 1% absolute risk reduction (and that all the other 99 who didn’t benefit still had to pay and still ran the risk of side effects).

2.      Association does not equal causation

A second key observation is that journalists often fail to explain the inherent limitations in observational studies – especially that they cannot establish cause and effect. They can point to a strong statistical association but they can’t prove that A causes B, or that if you do A you’ll be protected from B. But over and over we see news stories suggesting causal links. They use active verbs in inaccurately suggesting established benefits.

3.      How we discuss screening tests

The third recurring problem I see in health news stories involves screening tests. … “Screening,” I believe, should only be used to refer to looking for problems in people who don’t have signs or symptoms or a family history. So it’s like going into Yankee Stadium filled with 50,000 people about whom you know very little and looking for disease in all of them. … I have heard women with breast cancer argue, for example, that mammograms saved their lives because they were found to have cancer just as their mothers did. I think that using “screening” in this context distorts the discussion because such a woman was obviously at higher risk because of her family history. She’s not just one of the 50,000 in the general population in the stadium. There were special reasons to look more closely in her. There may not be reasons to look more closely in the 49,999 others.”

Let’s discuss each of these in a little bit more depth. The first mistake is probably the most common one, where statistically significant findings are not put into clinical perspective. Let me explain. Suppose we are looking at a drug that prevents a rare illness. The base rate of this illness, which we will call Catachexia is 4 in 10,000 people. The drug reduces this illness to one in 10,000 people, a 75% decrease. Sounds good, right?

Not so fast. Let me add a few facts to this hypothetical case. Let’s imagine that the drug costs $10,000 a year, and also has some bad side effects. So in order to reduce the incidence from four people to one person in ten thousand, 9996 people who would never develop this rare but serious illness must be treated. The cost of doing so would be $99,960,000! Plus those 9996 people would be unnecessarily exposed to side effects.

So which headline sounds better to you?

New Drug Prevents 75% of Catachexia Cases!

Or

New Drug Lowers the Prevalence of Catachexia Cases by Three People per 10,000, at a Cost of Almost $100 Million Dollars

The first headline reflects a reporting of the relative risk reduction, without cost data, and the second headline reflects the absolute risk reduction, and the costs. The second headline is the only one that should be reported but unfortunately the first headline is much more typical in science and medical reporting.

The second error where association or correlation does not equal causation is terribly common as well. The best example of this is all of the studies looking at the health effects of coffee. Almost every week we get a different study that claims either a health benefit of coffee or a negative health impact of coffee. These findings are typically reported in the active tense such as, “drinking coffee makes you smarter.”

So which headline sounds better to you?

Drinking Coffee Makes You Smarter

Or

Smarter People Drink More Coffee

Or

Scientists Find a Relatively Weak Association between Intelligence Levels and Coffee Consumption

Of course the first headline is the one that will get reported, even though the second headline is equally inaccurate. Only the third headline accurately reports the findings.

The theoretical problem with any correlational study of two different variables is that we never know, nor can we ever know, what intervening variables might be correlated with each. Let me give you a classic example. There is a high correlation between the consumption of ice cream in Iowa and the death rate in Mumbai, India. This sounds pretty disturbing. Maybe those people in Iowa should stop eating ice cream. But of course the intervening variable here is summer heat. When the temperature goes up in Iowa people eat more ice cream. And when the temperature goes up in India, people are more likely to die.

The only way that one could actually verify a correlational finding would be to do a follow-up study where you randomly assign people to either consume or not consume the substance or food that you wish to test. The problem with this is that you would have to get coffee drinkers to agree not to drink coffee and non-coffee drinkers to agree to drink coffee, for example, which might be very difficult. But if you can do this with coffee, chocolate, broccoli, exercise, etc. then at least you could demonstrate a real causal effect. (I’ve oversimplified some of the complexity of controlled random assignment studies, but my point stands.)

The final distortion which involves confusion about screening tests is also very common, and unfortunately, incredibly complex. The main point that Schwitzer is trying to make here though is simple; screening tests are only those tests which are applied to a general population which is not at high risk for any illness. Evaluating the usefulness of screening tests must be done in the context of a low risk population, because that is how most screening tests are used. Most people don’t get colon cancer, breast cancer, or prostate cancer, even over 50. If you use a screening test only with high-risk individuals then it’s not really a screening test.

There is the whole other issue with reporting on screening tests that I’m only going to briefly mention because it’s so complicated and so controversial. It’s that many screening tests may do as much harm as good. Recently there has been a lot of discussion of screening for cancer, especially prostate and breast cancer. The dilemma with screening tests is that once you find cancer you almost always are obligated to treat it because of medical malpractice issues and psychological issues (“Get that cancer out of me!”) The problem with this automatic treatment is that current screening doesn’t distinguish between fast-growing dangerous tumors and very slow growing indolent tumors. Thus we may apply treatments which have considerable side effects or even mortality to tumors that would never harm the person.

Another problem is that screening often misses the onset of fast-growing dangerous tumors because they begin to grow between the screening tests. The bottom line is that screening for breast cancer and prostate cancer may have relatively little impact on the only statistic that counts – the cancer death rate. If we had screening tests that could distinguish between relatively harmless tumors and dangerous tumors then screening might be more helpful, but that is not where we are yet.

One more headline test. Which headline do you prefer?

Screening for Prostate Cancer Leads to Detection and Cure of Prostate Cancer

Or

Screening for Prostate Cancer Leads to Impotence and Incontinence in Many Men Who Would Never Die from Prostate Cancer

The first headline is the one that will get reported even though the second headline is scientifically more accurate.

I suggest that every time you see a health or medicine headline that you rewrite it in a more accurate way after you read the article. Remember to use absolute differences rather than relative differences, to report association instead of causation, and add in the side effects and costs of any suggested treatment or screening test. This will give you practice in reading health and medical research accurately.

Also remember the most important rule, one small study does not mean anything. It’s actually quite humorous how the media will seize upon a study, even though the study was based on 20 people and hasn’t been replicated or repeated by anybody. They also typically fail to put into context the results of one study versus other studies of the same thing. A great example is eggs and type II diabetes. The same researcher, Luc Djousse, published a study in 2008 (link) that showed a strong relationship between the consumption of eggs and the occurrence of type II diabetes, but then in 2010 published another study finding absolutely no correlation whatsoever. Always be very skeptical, and most often you will be right.

I’m off to go make a nice vegetarian omelette…

 

Copyright © 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Bad Science, Reported Badly, and Then Corrected Thanks to Your Intrepid Blogger!

I read a lot. One of my favorite online magazines is Slate.com. It is a wide-ranging online mag that covers politics, news, the arts, business, and science. I was reading the other night and noticed an article by the writer Will Saletan that was looking at some scientific research on “Gaydar”. Gaydar is the supposed ability to discern whether a person is homosexual simply by looking at them.

In the original article, Saletan quoted research by Nicholas Rule, Nalini Ambady, Reginald Adams Jr., and Neil Macrae at Tufts University. The researchers took personal ad photos from gay and straight men, and then had college students look at them to rate whether they were straight or gay. For some reason the researchers chose to use correlation coefficients or R scores to report their data. The highest R scores were 0.31, which in the original version of the article Saletan incorrectly stated was the equivalent of an accuracy rate of 65%. I’m not sure where he got the 65% number, but I immediately recognized that this was a mistake. An R score, when squared, represents the percentage of the variance being explained. So squaring an R score of 0.31 means that roughly 9% of the variance has been explained. That means that 91% of the variance in the dependent variable is still unexplained.

In the original article Saletan had called these experiments “impressive”. Given the tiny bit of variance explained by even the strongest of the experiments, I would call them less than impressive. And given the subject of the experiment, I would actually call them “oppressive”. This is a great example of taking extremely weak scientific findings and spinning them into something approaching meaningfulness. There are so many alternate explanations for why tiny findings could have happened that do not require any assumption of accurate “gaydar”.

I wrote a comment on the article explaining the mistake.   To the credit of Saletan (and Slate magazine), they noticed and read my comment on the inaccurate reporting of statistical findings, and after an e-mail correspondence with me regarding the accurate interpretation of the statistics, posted a revised version of the article. That’s honest and impressive. It also shows that it’s worth writing comments on online articles, and that writers read the comments.

I still think the original research doesn’t merit even the corrected coverage that Slate gave it, but at least the science is accurately reported. Of course, the biggest flaw in the research was that they were only looking at photos of gay men who were openly gay, and the article really is about can you tell if a man is secretly gay. So the bottom line is that even if the researchers had done better research, it still wouldn’t answer the original question of the article.

I should add that I question the use of science to pursue questions that tread dangerously close to prejudice and stereotyping. But we live in a free country, and scientists have every right to do research on any topic they choose. I’m just not sure that the National Science Foundation should be funding such research. In any case, I was glad to be able to correct misinterpretations of the statistical results of the study.

Notes:

The original version of the article is in Google’s cache,  here, at least for now. (Google updated the page, so now it’s the same as the corrected page.)

The corrected version of the article is here.

The research that the article is based on is here.

 

Copyright © 2010, 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions


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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Money and Drugs

We hear a lot these days about the drug wars in Mexico and the US. There’s another drug war being waged, the war over drugs and money. That’s the war where drug companies pay influential psychiatrists to recommend the prescriptions of potent and dangerous drugs in children, adolescents and adults. Today the little guy won a small skirmish in that war.

National Public Radio (NPR) reported today that Harvard has punished three well-known psychiatrists over failing to reveal payments from drug companies. These three doctors are accused of accepting more than $4.2 million from drug companies between 2000 and 2007 without reporting the income to Harvard, Massachusetts General Hospital, or the federal government. $4.2 million!  That is $1.4 million per Doctor!

What did they do for this money?  Supposedly they did research, but if that were true then they probably would’ve revealed these payments. One can only guess, but it’s useful to look at their positions on prescribing. Dr. Joseph Biederman is well-known for being a proponent of the off-label use of antipsychotic drugs to treat supposed  “bipolar illness” in young children. Much of his work is seen as encouraging the growth in these kinds of prescriptions, and his funding came from drug companies that make these drugs. Biederman and the other two psychiatrists accused also have published extensively on the use of drugs to treat attention deficit hyperactivity disorder, also a huge growth industry in the Psycho-Pharma business.

All three doctors have been banned from taking any industry money for one year, and will be under probation for two more years after that. Good for Harvard and Massachusetts General Hospital! But it would be better if Harvard and Massachusetts General Hospital were more open themselves about disclosing what these doctors did, who they took money from, and whether they accepted federal grant money while not disclosing industry support which would be a violation of federal guidelines.

(I should add that most psychiatrists that I know and refer to don’t get any money from drug companies. In fact, when I ran some of the data regarding drug company’s payments to psychiatrists by a friend and colleague, he jokingly said, “Wow, I wish I had known, I could be driving a much nicer car!”  It appears that the biggest offenders are psychiatrists in academic settings or large hospital settings. Maybe we should all be asking our doctors to reveal their non-clinical funding so we know their biases.)

Copyright © 2010, 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Want to Sleep Better? Get Brief CBT-I Therapy for Sleep Instead of Sleeping Pills

“To sleep–perchance to dream. Ay, there’s the rub”

The New York Times reported on a terrific study at the University of Pittsburgh, looking at ultra short treatment of insomnia in the elderly. According to the article roughly 1/4 of older adults suffer from insomnia. The researchers streamlined an approach called CBT-I, which stands for cognitive behavioral therapy of insomnia.

There were only two sessions of treatment, totaling about 90 minutes. There were also two brief follow-up phone calls, over the first month. They tested this brief treatment and 79 seniors with chronic insomnia.

So what were the results of this study? They couldn’t have been very powerful, right?

Wrong. Two thirds of the CBT-I group reported a clear improvement in sleep, compared with only 25% of the people in the control group. Even better, 55% were cured of their insomnia. And six months later the results were even better.

So what was this magic treatment and the magic rules for curing insomnia? There were only four rules.

  • Spend only seven or eight hours in bed.
  • Set your alarm and get up at the same time everyday.
  • Never go to bed until you actually feel sleepy.
  • If you are tossing and turning and can’t sleep, get out of bed and do something relaxing until you get sleepy again. Then go back to bed.

These are standard cognitive behavioral sleep hygiene rules. And they are very powerful. Although not mentioned in the study, a few other rules are also helpful.

  • Regular exercise performed no later than midday is also helpful.
  • Reducing caffeine, nicotine, and alcohol all are helpful.
  • Avoid all naps.
  • Only use your bedroom for sleep and sex. Don’t watch TV or read in bed.

So why isn’t this treatment widely available? Could it be because there isn’t a powerful drug lobby for sleeping pills pushing this very effective therapy?

What is really tragic is that most seniors end up being prescribed sleeping pills for insomnia. And this is in spite of very clear data from research that shows that modern sleeping pills such as Ambien, Lunesta, or Sonata, have very minimal effects. On average they reduced the average time to fall asleep by 12.8 minutes compared to placebo, and increased the total sleeping time by only 11.4 minutes.

Patients who took older sleeping medications like Halcion and Restoril fell asleep 10 minutes faster, and slept 32 minutes longer.

How can this be? Why is it that patients believe that sleeping pills are much more effective? The answer is very simple. All of these drugs produce a condition called anterograde amnesia. This means that you cannot form memories under the influence of these drugs. So you don’t remember tossing and turning.  If you can’t remember tossing and turning even though you may have, then you perceive your sleep has been better. The drugs also tend to reduce anxiety, so people worry less about having insomnia, and thus feel better.

The hazards of sleeping pills in older adults include cognitive impairment, poor balance, and an increased risk of falling. One study in the Journal of the American geriatrics Society found that even after being awake for two hours in the morning, elder adults who took Ambien the night before failed a simple balance test at the rate of 57% compared to 0% in the group who took placebo. This is pretty serious impairment. Interestingly enough, in the same study, even young adults who took Ambien showed impaired balance in the morning.

So what are the key messages here?

1. Even though sleeping pills give people a sense of perceived improvement in sleep, the actual improvement tends to be almost insignificant, especially with the newer and very expensive sleeping medications. The older medications increased sleep time a little better, but have more issues with addiction and tolerance. Side effects of these medications are potentially very worrisome, since they can cause cognitive impairment and increased falling which leads to injuries, especially in the elderly. Why risk these side effects for such small improvements in sleep quality?

2. Cognitive behavioral therapy for insomnia works better than sleeping pills, has no side effects, is cheaper in the long run, and has a lasting impact on sleep improvement.

3. Most people who suffer insomnia will see their physician, who will prescribe sleeping pills. This is partly because of the lack of availability of cognitive behavioral treatment for insomnia. There are relatively few cognitive behavioral practitioners, and even fewer who regularly do CBT-I. We need to improve the availability of these treatments, and should follow in the footsteps of the University of Pittsburgh researchers in learning how to streamline these treatments. Most people don’t have the patience to spend 6 to 8 weeks in cognitive behavioral therapy for insomnia. Instead we need treatments that can be administered in a single week or two with some brief follow-up.

4. CBT-I availability will always suffer from the fact that there is no powerful corporate interest backing it. There are no CBT-I sales reps going to doctors offices offering free samples of CBT-I for doctors to pass out to their patients. I don’t have a solution for this problem, but would be interested in hearing from my readers as to how we might more effectively promote effective and safe treatments such as CBT-I.

Okay, now that I’ve written this, it’s time to trundle off to bed. As Hamlet said, “To sleep — perchance to dream. Ay, there’s the rub!”

Copyright © 2010, 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

A Few Happiness Factoids from David Brooks

Listening to David Brooks on National Public Radio this morning, he mentioned two very interesting factoids related to happiness. (David Brooks is a NY Times columnist, and the author of The Social Animal: The Hidden Sources of Love, Character, and Achievement.)

He was discussing the relationship of money and happiness relative to social connection and happiness. It turns out that belonging to a club that meets once a month is the equivalent in happiness boosting to doubling your income! And that getting married increases happiness the same amount as earning $100,000 more.

Good stuff and again proves the point that most of us would be better off focusing less on work and more on socializing. He also mentioned that the two activities most associated with happiness were having sex, and dining with friends. (Not at the same time!) The activity most associated with unhappiness was commuting.

So, to maximize our happiness, we should join a club, fall in love with someone in the club and get married, have sex with our spouse as much as possible, make friends in the club that we dine with, work less, and avoid commuting by living close to work or telecommuting. Sounds simple, right?

Off to my club meeting…right after…never mind!

Copyright © 2010, 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

“Not Tonight Dear” Why Couples Stop Having Sex (and what you can do about it)

When I do couples therapy a very common complaint is that the sex is infrequent or nonexistent. Over a period of time this tends to erode a couple’s sense of connection. It also tends to breed resentment and anger.

Why do couples stop having sex, and what can you do to prevent this?

There are a number of reasons that can cause couples to stop having sex.

1. Anger and resentment in the relationship

A big reason is unresolved anger or resentment in the relationship itself. Most couples don’t want to have sex when they’re angry. (Angry sex or makeup sex seems to be relatively rare amongst most couples.) Often the anger or resentment issues are long-standing, and feel unresolvable. The couple feels distant from one another, and as a result stops being affectionate or sexual.

The solution to this problem is talking. Talking calmly and non-defensively in order to resolve problems and eliminate resentments. Clearing the air on a regular basis is essential for couples happiness. If you can’t do it yourself, get some couples counseling and learn the skills for resolving conflict.

2. Mediocre or boring sex

Another reason couples stop having sex might seem very obvious — the sex isn’t very good. Perhaps there are sexual problems such as erectile difficulties or difficulties having orgasms. Or perhaps the sex is just mediocre and routine. Perhaps sex is too much work.

The antidote to this problem is to work on improving the quality of sex and touching. There are a number of exercises that couples can do to improve their ability to please one another. One such exercise is called sensate focus. In this exercise couples take turns touching one another all over the body, while the recipient of touching give us feedback about what feels good. The purpose of this exercise is to learn where and how to touch your partner in order to give them the most pleasure.

Verbal communication is also essential for improving the quality of sex. Most couples talk about everything other than sex. It’s difficult for couples to communicate what they like and don’t like sexually. But without this communication the couple is driving blind, and the most likely outcome is going off the cliff.

If couples cannot achieve this on their own, then a few sessions of focused sex therapy can be very helpful. During these sessions the couple learns how to talk about sex comfortably, and troubleshoots issues that are preventing them from having good sex. Typically sex therapy is brief therapy — less than 10 sessions. Unless you have a fabulous sex life, a few sessions of sex therapy, learning how to communicate sexual desires, fantasies, turn-on’s, and turn-offs, is highly recommended.

3. Issues with initiating sex

Another reason couples stop having sex is issues with initiation. Initiating sex is a very delicate balance. When one person approaches the other, there is tremendous potential for hurt and rejection. If one person suggests sex, and the other turns it down, this often leads to resentment and finally avoidance.

Other initiation issues include one person doing all of the initiating, with the other partner never initiating. Or perhaps neither person is initiating sex, instead waiting for the other to initiate. If neither person initiates obviously there will be no sex.

Initiation issues are complex. One general rule of thumb is that as much as possible, partners should never reject a sexual initiation. If absolutely necessary, then the rejection should be as kind and gentle as possible, and include a rain check suggestion. Something like, “I’d really love to honey, but my stomach is killing me. Can we make love tomorrow night instead?”

The reason for this guideline is that very few people will persist after multiple sexual rejections. Couples who have a healthy sex life typically will almost always say yes to sex, even if they are tired or stressed. They may negotiate different sexual activities, or even suggest having sex the next morning or night, but they rarely say no. Saying no often usually leads an eternal no.

4. Failure to make sex a priority

Sex is a very important component of relationships, yet many couples fail to make it a priority. Couples allow work, children, exercise, socializing, television, Internet, and housework to dominate their priorities so completely that they don’t have time for sex. This is a huge mistake. Sex is one of the basic glues that hold couples together. A failure to make the romantic and sexual relationship a priority often leads to divorce.

Couples should figure out a way that they can consistently have private time in order to have sex. Perhaps this might mean even scheduling sex, which most couples resist as being unromantic, but is often essential when people are very busy. Perhaps Wednesday night is date night, and the prime focus is to connect and to make love. Sunday morning might be another time to schedule. If couples work close each other, perhaps a noontime meeting at a hotel or at home might be fun.

Turn off the TV or computer and talk, cuddle, and get close. Make having sex a priority even if it means scheduling sex. Yes scheduled sex is a little bit less romantic, but it reminds me of a famous comedian’s line, “Sex without love is an empty experience, but as empty experiences go it’s pretty good.” Paraphrasing this a bit, we get “Scheduled sex is a less romantic experience, but as less romantic experiences go it’s pretty good!”

5. Excessive masturbation to pornography

This is primarily a problem with men. Some men turn to Internet pornography and masturbation when they are not having consistent sex in their relationship. There’s nothing wrong with masturbation, but there are some serious issues that can develop. One issue is that middle aged men do not have infinite sexual potential, so if they are masturbating frequently, they will have very little left over for their wife or partner. Their libido for their partner will be low. Or when their partner wants to have sex, they will be unable to because they have just masturbated that afternoon. (Obviously this is less of an issue for young men.)

The other issue with Internet pornography is that typically the women that are depicted are young, slender, and extremely beautiful. They may be of a different race or color than the man’s actual partner. For a man with a middle-aged partner, the contrast between the perfect bodies he sees in pornography in his own partner’s less than perfect body will be jarring. This may cause loss of desire.

A similar issue is that in porn women do many sexual activities that most women have little interest in such as anal sex, threesomes, orgies, or sex in public. A man whose sexual norm calibration is based on pornagraphy will will greatly out of sync with his actual partner.

The solution to this problem is to first impose a temporary moratorium on masturbation and Internet porn. Stop for 30 days. This will allow your libido for your partner to recover. During that 30 days focus on any of the other problems with sex and address them. Schedule sex at a frequency that is comfortable for both of you. Once you are reliably and consistently having sex again, there will be less need to masturbate. Also you can schedule your masturbation sessions so that they do not interfere with scheduled partner sex.

6. Failure to attend to personal hygiene or appearance

Once couples have been together for a while they often get lazy about their hygiene or appearance. They may not brush their teeth before kissing, or showering before being close. Both partners may walk around the house wearing sweat pants and sweatshirt. Lingerie disappears out of the relationship. People put on weight and don’t maintain their fitness.

All of these things can cause problems in the bedroom. I often hear from men or women that when they married their partner they were very attractive, but they’ve let themselves go, and they are no longer so attractive. Men complain that their wives come to bed in sweats and gym socks instead of naked or in lingerie.

These are difficult issues to discuss with a partner. There is potential for very hurt feelings when one person tells the other that their weight gain has made them less attractive. Or that their breath in the morning is deadly. Or that when they walk around in their granny nighty, it’s not in the least sexy. Obviously approaching these issues with tact and sensitivity is essential. Some are obviously easier than others. It’s easy to change one’s sleep apparel. It’s fairly easy to brush one’s teeth. As all of us who are middle aged know, weight loss is more difficult.

7. Failure to address sexual dysfunction

Another issue that can get in the way of having sex is a failure to address sexual problems. Many men suffer at least intermittent erectile difficulties. Many women have difficulty having orgasms, or difficulty lubricating adequately. Shame and embarrassment about these issues often leads people to avoid having sex with their partner.

Depending on the problem, there are good solutions available. Men with erectile difficulties can often benefit from either sex therapy to address issues of anxiety and performance, or erectile disorder medications such as Cialis, Viagra, or Levitra. Of these drugs I usually recommend Cialis, as it is long-lasting (lasts up to three days), and relatively side effect free. Often a low dose of Cialis such as 5 or 10 mg can greatly improve a man’s ability to get and maintain an erection. This restores confidence, and also makes sex relatively worry free.

On the female side, difficulties in orgasm can because by issues of anxiety or inhibition, or simply issues of sexual technique and stimulation. Unfortunately there is no medication that improves female sexual functioning, but sex therapy can be very helpful. Lubrication is often an issue, and few people realize that lubrication is the female equivalent of an erection. With aging comes less lubrication, and this can often make sex painful or difficult. The solution to this problem is incredibly simple — use artificial lubrication. There are a variety of lubrication products on the market, some are water-based, and some are silicon-based. Both are good. Use lubrication liberally, and sex will feel better and be more fun.

8. Forgetting that foreplay starts long before the bedroom.

Oprah has a wonderful saying that foreplay starts early in the morning when a man unloads the dishwasher. The well-known marriage researcher John Gottman has found that men who do more housework typically get more sex. Many couples forget that foreplay starts first thing in the morning. And never stops and healthy happy sexual marriages. Showing kindness, concern, consideration, affection, respect, admiration — all are forms of foreplay. Specifically, compliments that focus on someone looking sexy or handsome or beautiful or hot get the motor running. With modern technology we can flirt even more effectively. Sending a sexy text during the workday can lead to a much more pleasant and fun evening. (Just be sure that text has some subtlety so your work phone doesn’t create problems for you with your boss.)

In similar ways, physical touching and affection can turn up the heat later in the bedroom. A quick but passionate kiss in passing. A squeeze of the bottom. Caressing and sexual touch can be normal parts of your affectionate repertoire even outside the bedroom. (Try not to scare the children or the dog!) Remember, everything can be foreplay.

So there it is — why couples stop having sex and what you can do about it. Don’t settle for a lack of sex or mediocre sex. Follow these guidelines and you can start having consistent and pleasurable lovemaking. If you need help, seek out a skilled psychologist who has specialty experience in doing sex therapy. Generalized couples therapy, although useful for other types of problems, does not usually help with sexual difficulties. Questions to ask a potential sex therapist are:

  1. What is your training in sex therapy?
  2. What is your approach to sex therapy? Can you give me an idea of the typical session?
  3. How long does sex therapy with you typically take? (If the person says a year or two then you should probably find someone else. Most sex therapy is brief therapy.)
  4. Finally, when you meet with the sex therapist, do they seem comfortable and direct talking about sex? Do they use direct language for sexual activities and sexual parts, or do they beat around the bush? If the sex therapist is not more comfortable than you are talking about sex, it is unlikely that they can be of much help.

Now I’ve got to go meet my sweetie for some crazy hot……never mind!  🙂

Copyright © 2010, 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How to Handle Mistakes–CBT Techniques for Gracefully Coping With Mistakes and Setbacks

Sometimes clients really integrate the learning about Cognitive Behavioral Therapy, and share it with family members. I was very moved when a client recently shared with me an email she wrote to her two teenage children. She gave me permission to publish it here, with a few identifying details deleted. Here it is:

To my dear children, please read this email because it will help you live life more peacefully.

I have lived my whole life worrying and I’m sick of it so I’ve spent the past months studying how to combat it. Here are some tips I’ve learned that should help you too.

As Dr. Gottlieb shared with me, here are key questions to ask yourself after making a mistake or facing something you think is devastating, in order to put the mistake into perspective

  • Did anyone die or get hurt? Remember, what doesn’t kill you makes you stronger.
  • Will I remember it in 1 or 5 years?
  • Did I lose a lot of money? (Defined as an amount that would truly change your way of life. ($100, $1000, or $10,000)
  • Is the mistake easily fixable with time or money or words?
  • What can I learn?
  • Does it really matter in the grand scheme of things?

OK, so the last point is the hardest.  Of course it always seems to totally matter and be catastrophic.  However, this brings me to the next step of Cognitive Behavior Therapy (CBT).

Sit with your thoughts. Then ask yourself what are your negative thoughts causing you to feel this way.  For instance, “I’m going to get into a horrible college, have a lousy job, be poor, get fired, be miserable, etc.”

THEN recognize these thoughts.  Are they all-or-nothing thinking?  Am I mind reading, assuming that others feel this way?  Am I being catastrophic, blowing this out of proportion?

Once you determine that this is really a distorted thought, then examine the thought in a healthier way.  You can step back and ask yourself on a scale of 0-100, how bad is this current event really?  Think of something tragic that would be a 100 (ie: parent dying, you getting cancer, etc.). Ugh.  Then compare the current event with the true 100 catastrophic event.

To help you determine the true number, ask yourself a series of “what if” statements for healthier thinking.  For instance:  “What if I don’t get an A…. I won’t get into a good college… if this is true then what if you don’t get into a good college…. I won’t get a good job…. if this is true what if you don’t get a good job…. I’ll be unemployed forever, be poor and miserable”…. Is this really true?  No.  You can think of people who didn’t attend college and are successful. You can even think of the opposite of people who DID attend a prestigious school and never worked outside of the home. You can think that there are ALL types of jobs that require all types of skills.

Then re-number your worry.  It’s probably much lower.  If not, review Dr. Gottlieb’s key points above and go through this exercise again. Most of the time the worry/event isn’t as bad as we think.

Finally, turn unproductive worry into product worry.  Unproductive worry is just thinking OMG, OMG, OMG!  That doesn’t help.  However, productive worry is problem solving.  You switch the energy into something productive and try to solve the problem.

And one last thing, remember that if you’re mind reading (believing that others will think negatively of you), no one really cares.  True, your parents and close ones do care about the important stuff, but truly no one looks at you.  Everyone is a self-centered, too busy focused on them to be concerned about you.  And if you assume that people are thinking something negatively about you, do the above steps, asking yourself to replace this with a more realistic/healthier thought and the what if exercise.  Remember, just because you may have judgmental thoughts, doesn’t mean everyone else is.  The first step is to stop judging others and be more compassionate.  Once you stop being so judgmental of others, you’ll start treating yourself nicer and have better self esteem.

I hope that you read and implement these tips so you can lead happier, more peaceful lives.  And just think, I’ve saved you hours and hours of reading, studying and discussing this stuff…  You get the Spark Notes version.  🙂

I love you both dearly.

Mom

Thanks Mom for sharing this with me, and with all of my readers….

Copyright © 2010, 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Radical Non-Defensiveness: The Most Important Communication Skill

“Jack and Jill went up the hill
To fetch a pail of water.
Jack fell down and broke his crown
And Jill came tumbling after.
Jack blamed Jill,
Jill blamed Jack,
And each vowed they would
Never come back.”

What is the secret of good couples communication? What one simple skill tremendously improves the ability of couples to discuss difficult subjects?

It is the skill of non-defensive responding. What do I mean by this?

Let me give you an example. Imagine a hypothetical couple Jack and Jill. Jack comes home from work and is tired and hungry. Jill got home from her job one hour before. She’s sitting on the couch reading the paper.

Jack says, “I can’t believe you haven’t started dinner. I’m really hungry! You’re just sitting there relaxing, while I’m starving!”

(If you were Jill, how would you react?)

A typical response that Jill might make would be something like, “You’ve got hands, why don’t you make dinner! Why do you expect me to be your slave!?”

At which point it is likely a good fight would ensue.

The non-defensive response would be something like, “It sounds like you’re really hungry and kind of annoyed that I haven’t started dinner yet. You’re absolutely right, I was really stressed out when I got home from work and I decided to relax for a while rather than start dinner. I can see how you would feel frustrated getting home from work tired and hungry and seeing me just sitting here. Why don’t you sit down and relax and I’ll get us some quick snacks, and then get dinner started.”

Notice the difference. In the first example Jill counterattacks. Jack will counterattack in return and quickly things will escalate into a full fight.

In the non-defensive example Jill acknowledges Jack’s feelings. Then she finds some truth in his statement. Next she validates his feelings. And finally, she proposes a solution.

This is an incredibly powerful skill for reducing conflict and improving communication between people. In this article I will give you some basic theoretical rationale for why non-defensive responding works so well, and then teach you — step-by-step — how respond non-defensively.

First the theory. Human ego is a delicate thing. We spend a lot of our energy defending our sense of self against attacks or criticisms. The problem with this model is that it’s impossible to defend completely against all attacks or criticisms. This is because most of us are very far from perfect — we are quite flawed — and we know it.

The problem is that we don’t accept it. We have this all or nothing model of ourselves which says either we are perfect or we are awful. So when any criticism comes along, it challenges our model of being perfect and we slip into the painful feelings of complete inadequacy.

We don’t like feeling inadequate, so we try to deny or counterattack any criticism. There are so many types of defensive responding that it’s difficult to catalog all of them. But some of the major types of defensive responding are described below. (These are based on John Gottman’s work on communication.)

Major Kinds of Defensiveness

1. Denying responsibility. This involves denying that you’re at fault no matter what your partner accuses you of. If your wife says you hurt her feelings by saying something insensitive, you reply that you didn’t do anything wrong.

2. Making excuses. This is when you acknowledge the mistake, but create a reason for why circumstances outside your control forced you to make the mistake. Classic examples of this are, “traffic made me late,” or “I just forgot to pick up the milk.”

3. Disagreeing with negative mind reading. This is when you disagree with your partner’s interpretation of your internal state or emotion.

Jack: You seemed very frustrated with me tonight.
Jill: That’s not true, I was just tense being at a work party.

4. Cross complaining. This defensive response involves meeting your partner’s complaint or criticism with an immediate complaint of your own. An example would be:

Jill: you never take me out anymore.
Jack: and you never cook me dinner anymore!

5. Rubber man/rubber woman. This is based on the old saying, “I’m rubber, you’re glue. Whatever you say bounces off me and sticks to you.” In this form of defensiveness, you immediately counterattack with a similar criticism.

Jack: You were very mean to me at the party tonight.
Jill: Well you were mean to me yesterday when we visited your mother’s house.

6. Yes-Butting.  This is where you start off agreeing, but then end up negating the agreement.

Jack: You said you would put away your work papers off the dining room      table.
Jill: Yes I did, but I was waiting for you to clear off your books first.

7. Repeating yourself. This involves repeating the criticism again and again without listening to your partner.

8. Whining. This involves the sound of your voice and the stressing of one syllable at the end of this sentence. For instance, “You always ignore me at parties.”

9. Body language. Typical body language signs of defensiveness are crossing your arms across her chest, shifting side to side, and a false smile.

Ultimately the goal of all defensiveness is to preserve the self. This is a commendable but hopeless goal, since defensiveness triggers elevated levels of criticism from the other person. As Gottman has so elegantly described, the more you defend yourself, the harsher the criticism you receive. That’s because when someone criticizes you they want you to acknowledge the validity of their feelings and thoughts. When you respond defensively you are invalidating them, so they escalate the criticism. If you can’t hear them the first time, they say it louder.

This of course leads you to become even more defensive because the criticism is now much harsher. And the two of you are off to the races! The fight escalates, gets personal, and both of you end up feeling damaged.

So what is the solution? How do we get out of this vicious cycle of defensiveness and criticism?

The answer is a radical shift in the way we think about ourselves. Radical non-defensiveness is the answer.

What is radical non-defensiveness? First it requires a shift in our core beliefs about ourselves. Remember that most of us have an all-or-nothing model of our self. We believe, “I must be perfect otherwise I am crap. If anyone points out my imperfections, they are basically saying that I am crap, and I won’t listen and I will counterattack.”

Radical non-defensiveness means that we shift our core belief about ourself to, “I am a flawed human being. I make many mistakes. I can improve on almost anything I do. But even with my flaws I am a worthwhile and valuable person.”

With this radically changed belief about the self, criticism changes as well. Instead of criticism meaning that we are worthless human being, it simply acknowledges the reality of being flawed, and helps us to improve.

If you think about it for a moment, you might realize that radical non-defensiveness is the antidote to perfectionism. Perfectionism beliefs cause much human suffering. When we feel that we need to be perfect in order to be worthwhile we are living in a glass house. The smallest pebble can crack our armor. And that pebble can be any criticism.

The radical non-defensive model is completely the opposite of perfectionism. I don’t need to be perfect to be good and worthwhile. I can shoot for an 85 rather than 100. If I make a mistake, I can acknowledge it and realize that everybody makes mistakes.

Let’s go over — step-by-step — how to respond non-defensively. (Some of this is based on some of David Burns’s work on communication.)

First let’s create another example of criticism. Back to Jack and Jill. They have finished dinner, and Jack retires to his laptop computer, where he spends the next several hours deep in Internet surfing. Jill tries to talk to him about something that happened at work, but he ignores her. Finally, she explodes, “You never listen to me!  You are always surfing on your stupid computer! You don’t care about me, and you’d rather watch YouTube videos than listen to my problems. You are an uncaring husband!”

Whew! That’s pretty intense criticism isn’t it? How can Jack respond non-defensively to this?

Let me take you through it step by step.

Step One: Paraphrase back to the person the thoughts and feelings they are expressing to you.

Jack says, “It sounds like you’re really frustrated and angry with me right now, because I was on the computer rather than focusing on you.”

Step Two: Find SOME truth in what they are saying. In this step what you try to do is select whatever reality-based truth there is, and ignore hostile names or labels. You focus on the behavior that you’ve committed rather than the nasty labels.

Jack says, “You are absolutely right. I have been spending way too much time on my computer and not enough time connecting with you.”

Step Three: Validate the emotion paraphrased in Step One, and connect it to the behavior in Step Two. This lets the person know that many people, including you, might feel the same emotion in the same situation.

Jack says, “I can see why you might feel frustrated. If I wanted to talk more with you and you were reading all the time I’d probably feel the same way. It makes perfect sense.”

Step Four: Offer possible solutions. Here there are several options. One option is a genuine apology. This is very powerful. Another option is to suggest discussing the problem in order to find solutions. This option is best when the criticism encompasses a complex problem that can’t easily be resolved. Another option is to simply fix the problem right then and there.

Jack closes his computer and says, “I’m really sorry. I do want to hear what happened at work, why don’t we sit together on the couch and talk about it.”

Step Five: Thank the other person for bringing the problem to your attention. This is probably the most alien step of all for most people. How can you thank someone for criticizing you? If you recall in the radical non-defensiveness model, you acknowledge that you can always improve, and that criticism is often what helps you to improve. So thanking the person for criticizing you is really saying thank you for caring enough about me to help me improve.

Jack says, “Thanks Jill for telling me how you feel. That allows me to be more conscious of being a better husband. Thanks again.”

One typical objection to non-defensive responding is “Won’t the the other person criticize me more if I don’t defend myself?” The truth is actually the opposite. The more you defend yourself the more criticism you receive, and the harsher the criticism becomes. Most criticism is designed to create change or to be listened to, and defensive responding achieves neither.

Another objection is, “What if the criticism is completely unfounded or unjust? How can I respond non-defensively in that case?”

Criticism is rarely completely unfounded. There is almost always SOME truth in most criticism. Even if it just factual truth, you can agree with it. Example:
Jill: You were flirting with that woman Nancy at the party. You’d like to sleep with her.
Jack: You are absolutely right, I was flirting a little. I can see how that would upset you. I don’t want to sleep with her though. What can we do at the next party so I don’t upset you?

Try using this skill at home, at work, with friends, and with family. You will be surprised at how effective it is. I’ve summarized the steps below.

Now I’ve got to go apologize to my sweetie for spending so much time writing this….

Non-Defensive Responding Step by Step
1. Empathy: respond with empathic reflection, “It sounds like you are feeling quite angry at me for forgetting your birthday.”  (Use tone matching and empathic body language). Reflect both content and feeling.

2. Find some truth in the statement, and strongly agree. “You are absolutely right. I totally forgot your birthday! What a dope I am!”

3. Validate the emotions reflected in step 1. “I can see why you are angry. I’d be angry in your situation too!”

4. Offer possible solutions, compromise, problem solving, or an apology.
“I blew it, I’m very sorry, and I’d like to make it up to you by taking you away next weekend. How does that sound?”

5. Show appreciation for the person giving you the feedback. “Thanks for letting me know how you feel. Now I can make a point of not forgetting your birthday.”

Copyright © 2010, 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How Ivan Pavlov Handled a Piece of Steak

Most psychology students recognize the name of Ivan Pavlov, one of the great minds of psychology, who developed the theory of classical conditioning (dogs salivating when he rang a bell). From the Yale Alumni magazine comes this wonderful tidbit of a story:

“In mid-August 1929, the Harvard Medical School hosted the Thirteenth International Physiological Congress, one of the largest gatherings of scientists ever convened in the United States. Pavlov, the doyen of experimental physiology at almost 80 and honored by a Nobel Prize a quarter-century earlier, was the lion of the gathering. His pioneering work on conditioned reflexes had been crucial to understanding brain function, and he was keen to see the Harvard neurosurgeon Harvey Cushing ’91 operate. The preeminent brain surgeon and father of modern neurosurgery as a field, Cushing, two decades younger than Pavlov, was at the top of his game. Performing for Pavlov in a theater at the Peter Bent Brigham Hospital, Cushing removed a large tumor of the left hemisphere from a cancer patient’s brain. The patient later recalled that Cushing introduced him to Pavlov, saying, “You are now shaking hands with the world’s greatest living physiologist.”

Pavlov was captivated by the new electrosurgical knife Cushing used in the operation, and at the end of the procedure, Cushing got a piece of beef so that the elder scientist could try his hand. After making a few incisions, Pavlov inscribed his name into the meat. “I asked him whether he wanted me to eat the meat in the hope of improving my conditional reflexes,” Cushing wrote in his journal, “or whether we could keep it in the museum, the latter we will proceed to do—’Pavlov’s beef-steak.'” A collector of old medical books and of brain tumors, when he died in 1939 Cushing bequeathed both to Yale, where his rare books would become the cornerstone for creating the Medical Historical Library.”

Anyway, I love this story, especially the concept of him eating the steak, to “improve his conditional reflexes!”

Next time I throw a barbecue party I’ll serve the Pavlov-Steak sandwich…

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Changing Thoughts May Be Better Than Changing Behavior in the Early Stage of Psychotherapy for Severe Depression

A recent study took a close look at what predicts improvement in depression in the first five sessions of cognitive behavioral therapy. They looked at the degree to which the therapists used either cognitive therapy methods, practiced structuring the sessions clearly, and how much they used behavioral methods/homework. They also examined whether the patients cooperated with these parts of cognitive behavioral therapy. They also measured the strength of the therapeutic alliance.

Sixty patients with major depression participated in the study. Their sessions were videotaped and trained raters rated how much the therapists used cognitive versus behavioral methods.

What they found was only two aspects of therapist behavior predicted improvement between sessions. Depression was measured after every session, and these measurements showed that patients felt better when therapists used cognitive techniques, but didn’t improve when the therapists focused on behavioral techniques.

Patients also showed greater improvement when they adhered to suggestions made by the therapist, which is not surprising.

The behavioral methods used were techniques such as having patients schedule their activities to become more active, and tracking how they actually spent their time. This is called behavioral activation, and previous studies have suggested it is an effective approach to treating depression. The behavioral activation model is that depressed patients tend to do very little, and this leads to further depression. Patients are encouraged to schedule activities that are fun, or activities that provide a sense of mastery or success. This leads to a lessening of depressive feelings.

The cognitive methods were techniques such as writing down what your thoughts are, and using cognitive therapy to challenge or modify distorted thinking.

So how to interpret the results of this study?

It’s only one small study and I would be cautious about taking too much from it. It does suggest that at least in the early sessions of therapy, cognitive methods may be superior to behavioral methods. This makes sense to me because early in therapy depressed patients feel a lot of pain and lethargy, and getting them to suddenly increase their activity can be very challenging and perhaps too difficult. This may lead to a sense of failure which increases depression rather than reducing it. On the other hand, using cognitive methods may lead to more immediate sense of control and relief, which would tend to reduce depression levels.

My sense is that later in therapy behavioral activation techniques are very useful. But typically in order to get patients to cooperate with these techniques there needs to be a strong alliance with the therapist. This takes some time to build.

It would have been interesting if they had continued the study beyond the first five sessions, and looked at whether over time the relative importance of the cognitive versus behavioral techniques would have shifted.

The study shows that therapist behavior in sessions does matter. This is one of my pet peeves. Many psychotherapists claim to use cognitive behavioral therapy, yet fail to actually use any cognitive behavioral techniques on a regular basis in sessions. This study shows that therapist adherence to structuring sessions and using cognitive techniques matters.

So from a consumer point of view there are a few take-home lessons.

1. If you are seeking cognitive behavioral therapy, make sure your therapist actually does cognitive behavioral therapy during sessions. This means they should structure the sessions clearly, as opposed to simply letting you talk about whatever is on your mind. It also means they should be asking you to track your self talk in written form, during sessions go over those thoughts, helping you learn to identify and correct distortions in the thoughts. If they don’t do these behaviors, and therapy feels free-form, then you’re probably not getting cognitive behavioral therapy, and you might want to look elsewhere. If you don’t regularly get homework to do between tasks, you aren’t receiving cognitive behavioral therapy.

2. At least in the early part of therapy pure cognitive therapy techniques may be more effective than behavioral techniques. You may want to focus your own homework more on identifying and changing your inner thoughts, rather than trying to increase positive behaviors. This probably will yield more relief of depression.

3. The study also confirmed that when clients cooperate and are more involved using cognitive therapy techniques, they improve faster. So even if you’re feeling skeptical, try to fully participate during sessions and in between sessions, as that provides you the best chance of more rapid relief.

Your off to analyze his thoughts psychologist,

Andrew Gottlieb, Ph.D.

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

New Study Suggests You Can Reprogram Your Brain in Less Than Five Days!

Many previous studies have shown through the use of neuroimaging that meditation can change the brain. But most of those studies have looked at medium to long-term meditators. Some looked at monks who had meditated for decades, and some looked at new meditators who had meditated daily for 6 to 8 weeks. At least this much meditation practice was thought to be necessary to create measurable changes in the brain.

But a new study at the University of North Carolina at Charlotte suggests that brain changes may happen much more quickly, in as few as four days!

Student volunteers were randomly assigned to either practice mindfulness meditation or listen to the reading of JRR Tolkien’s The Hobbit, for 20 minutes a day, for four days. The groups were tested using behavioral tests of mood, memory, visual attention, attention processing, and vigilance. The meditative practice was a simple mindfulness technique.  Participants were told to focus on their breath, and that when thoughts distracted them to notice the thought, and then refocus on the breathing.

What were the results? Both groups improved in mood, but only the meditation group improved in cognitive measures. In one challenging mental task, the meditation group did 10 times better than the reading group. It appeared that meditation improved the ability to sustain attention and vigilance.

This is an exciting study which hopefully will be replicated and expanded with their neuroimaging to see if there are functional or structural brain changes after brief meditation practice.

To summarize, it appears that a brief four-day practice of mindfulness meditation can significantly improve cognitive functioning that is related to attention and vigilance.

How lasting is this effect? Does it wear off in hours, days, etc.? What is the dose response ratio of meditation to cognitive functioning improvement? For instance, would eight days of meditation practice create even more cognitive improvement?

In any case, it’s worth practicing meditation at least briefly to see its effects on your mind and your emotions. Commit to 20 minutes a day for one week, and see what happens for you.

Now I’m off to meditate…

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How to Read Media Coverage of Scientific Research: Sorting Out the Stupid Science from Smart Science

Reading today’s headlines I saw an interesting title, “New Alzheimer’s Gene Identified.”

I was intrigued. Discovering a gene that caused late onset Alzheimer’s would be a major scientific breakthrough, perhaps leading to effective new treatments. So I read the article carefully.

To summarize the findings, a United States research team looked at the entire genome of 2269 people who had late onset Alzheimer’s and 3107 people who did not. They were looking for differences in the genome.

In the people who had late onset Alzheimer’s, 9% had a variation in the gene MTHFD1L, which lives on chromosome 6. Of those who did not have late-onset Alzheimer’s 5% had this variant.

So is this an important finding? The article suggested it was. But I think this is a prime example of bad science reporting. For instance, they went on to say that this particular gene is involved with the metabolism of folate, which influences levels of homocysteine. It’s a known fact that levels of homocysteine can affect heart disease and Alzheimer’s. So is it the gene, or is it the level of homocysteine?

The main reason why I consider this an example of stupid science reporting is that the difference is trivial. Let me give you an example of a better way to report this. The researchers could have instead reported that among people with late-onset Alzheimer’s, 91% of them had no gene changes, and then among people without late onset Alzheimer’s 95% of them had normal genes. But this doesn’t sound very impressive, and calls into question whether measurement errors would account for the differences.

So this very expensive genome test yields absolutely no predictive value in terms of who will develop Alzheimer’s and who will not. There is a known genetic variant, called APOE, which lives on chromosome 19. Forty percent of those who develop late-onset Alzheimer’s have this gene, while only 25 to 30% of the general population has it. So even this gene, which has a much stronger association with Alzheimer’s, isn’t a particularly useful clinical test.

The other reason this is an example of stupid science is that basically this is a negative finding. To scan the entire human genome looking for differences between normal elderly people and elderly people with Alzheimer’s, and discover only a subtle and tiny difference, must’ve been a huge disappointment for the researchers. If I had been the journal editor reviewing this study, I doubt I would’ve published it. Imagine a similar study of an antidepressant, which found that in the antidepressant group, 9% of people got better, and in the placebo group 5% got better. I doubt this would get published.

Interestingly enough, the study hasn’t been published yet, but is being presented as a paper at the April 14 session of the American Academy of Neurology conference in Toronto. This is another clue to reading scientific research. If it hasn’t been published in a peer-reviewed scientific journal, be very skeptical of the research. Good research usually gets published in top journals, and research that is more dubious often is presented at conferences but never published. It’s much easier to get a paper accepted for a conference than in a science journal.

It’s also important when reading media coverage of scientific research to read beyond the headlines, and to look at the actual numbers that are being reported. If they are very small numbers, or very small differences, be very skeptical of whether they mean anything at all.

As quoted in the article, “While lots of genetic variants have been singled out as possible contributors to Alzheimer’s, the findings often can’t be replicated or repeated, leaving researchers unsure if the results are a coincidence or actually important,” said Dr. Ron Petersen, director of the Mayo Alzheimer’s disease research Center in Rochester, Minnesota.

So to summarize, to be a savvy consumer of media coverage of scientific research:

1. Be skeptical of media reports of scientific research that hasn’t been published in top scientific journals. Good research gets published in peer-reviewed journals, which means that other scientists skeptically read the article before it’s published.

2. Read below the headlines and look for actual numbers that are reported, and apply common sense to these numbers. If the differences are very small in absolute numbers, it often means that the research has very little clinical usefulness. Even if the differences are large in terms of percentages, this doesn’t necessarily mean that they are useful findings.

An example would be a finding that drinking a particular type of bourbon increases a very rare type of brain tumor from one in 2,000,00 to three in 2 million. If this was reported in percentage terms the headline would say drinking this bourbon raises the risk of brain tumor by 300%, which would definitely put me and many other people off from drinking bourbon. (By the way, this is a completely fictitious example.) But if you compare the risk to something that people do every day such as driving, and revealed the driving is 1000 times more risky than drinking this type of bourbon, it paints the research in a very different light.

3. Be very skeptical of research that has not been reproduced or replicated by other scientists. There’s a long history in science of findings that cannot be reproduced or replicated by other scientists, and therefore don’t hold up as valid research findings.

4. On the web, be very skeptical of research that’s presented on sites that sell products. Unfortunately a common strategy for selling products, particularly vitamin supplements, is to present pseudoscientific research that supports the use of the supplement. In general, any site that sells a product cannot be relied on for objective information about that product. It’s much better to go to primarily information sites like Web M.D., or the Mayo Clinic site, or one can go directly to the original scientific articles (in some cases), by using PubMed.

So be a smart consumer of science, so that you can tell the difference between smart science and stupid science.

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Hacking Your Next Job Interview: The Real Secret to Getting Hired

This post is for my oldest niece, who told me she had an interview for a job, and wondered if there were any “psychological tricks” for doing well in an interview. I thought about it, and realized she wanted help with some Jobhacks™.

It turns out that there are some tricks. These are written about in a wonderful new book called 59 Seconds: Think a Little, Change a Lot by Richard Wiseman. I’ll be blogging more on the book, which is a concise, science-based set of tips for improving your life, and being happier, healthier, and more productive. I highly recommend the book. It’s a fun, easy read, full of great research and life tips.

(Full Disclosure: If you click on the link, and buy, PsychologyLounge will get a small payment, so you’ll be supporting this blog. If you don’t want to support this blog, just log into your own Amazon account, and search for the book.)

So let’s review conventional wisdom first.  Job interviews are based on academic training and work experiences, right? The candidate who gets the job is the one with the best academic credentials and the most impressive work history, correct?

That’s what most people think and they are wrong!

Chad Higgins and Timothy Judge did research looking at factors that influenced interviewers decisions about job candidates. I won’t bore you with the details of their research, but I will tell you what they found. First, they found that the qualifications and work experience of the candidate didn’t matter.

It turns out that the most important predictor of who will be offered the job was a magical and mysterious quality: the pleasantness and likability of the candidate!

So now you’re thinking: “Great, I need a personality transplant in order to become nicer and more likable. Thanks, Gottlieb, years of therapy for that one no doubt!”

No, you don’t need a personality transplant. You just need to follow a simple set of behavioral guidelines.

What were the behaviors that communicated likability? They were very simple:

1. Small talk. Talk about something that interests both you and the interviewer, even if it’s not about work. You notice a picture of them fishing, and you share fishing tales.

2. Praise. Find something you like about the organization they represent and compliment it. Or praise or compliment the interviewer in a genuine way.

3. Enthusiasm. Show your excitement about the job being offered and the company.

4. Connection. Smile and make eye contact.

5. Involvement. Show interest in the person interviewing you. Ask smart questions about the type of person they are looking for, and how the job fits into the organization.

That’s it. Do this and you will greatly increase your likability, and with it, your chance of getting a job. I suspect this would work pretty well in other interview situations too, like blind dates, but that’s more research…

P.S. Two more quick tips from 59 Seconds. If you have weaknesses that will most likely come up, bring them up early in the interview, that increases your credibility, and gives you time to use likability to your advantage. If you have a particular strength, share it later in the interview, in order to look more humble, and end on a strong note.

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Holy Cow, Psychology Lounge Got Holy Kawed!

Check it out on Alltop.com!

http://holykaw.alltop.com/depressing-effectiveness-of-anti-depressants

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

New Study Shows Antidepressant Medication Fails to Help Most Depressed Patients

A very interesting study recently published in the Journal of the American Medical Association (JAMA) demonstrated very clearly that when it comes to antidepressant medication, the Emperor is wearing few if any clothes! The researchers did what is called a meta-study or meta-analysis. They searched the research literature for all studies that were placebo-controlled studies of antidepressants when used for depression. That means the studies had to include random assignment to either a medication group or a placebo (sugar pill) group. They eliminated some studies which use a placebo washout condition. (This means the studies first gave patients a placebo, and then eliminated all patients who had a 20% or greater improvement while taking placebo.) When they eliminated all studies that didn’t meet their criteria, they were left with 6 studies of 738 people.

Based on scores on the Hamilton Depression Rating Scale (HDRS), the researchers divided the patients into mild to moderately depressed, severely depressed, and very severely depressed. This is a 17 item scale that is filled out by a psychologist or psychiatrist, and measures various aspects of depression. It is used in most studies of depression. They then analyzed the response to antidepressant medication based on how severe the initial depression was.

The two antidepressants studied were imipramine and paroxetine (Paxil). Imipramine is an older, tricyclic antidepressant, and Paxil is a more modern SSRI antidepressant.

What did they find? They were looking at the size of the difference between the medication groups and the placebo groups. Rather than do the typical thing of just looking at statistical significance, which is simply a measure of whether the difference could be explained by chance, they looked at clinical significance. They used the definition used by NICE (National Institute of Clinical Excellence in England), which was an effect size of 0.50 or a difference of 3 points on the HDRS. This is defined as a medium effect size.

What they found was very disheartening to those who use antidepressant medications in their practices. They divided the patients into three groups based on their initial HDRS scores: mild to moderate depression (HDRS 18 or less), severe depression (HDRS 19 to 22), and very severe depression (HDRS 23 or greater).

For the mild to moderately depressed patients, the effect size was d=0.11, and for severely depressed patients the effect size was d = 0.17. Both of these effect sizes are below the standard description of a small effect which is 0.20. For the patients in the very severe group, the effect size was 0.47 which is just below the accepted value of 0.50 for a medium effect size.

When they did further statistical analysis, they found that in order to meet the NICE criteria of effect size of a 3 points difference, patients had to have an initial HDRS score of 25 or above.  To meet the criteria of an effect size of .50, or medium effect size, they had to have a score of 25 or above, and to have a large effect size, 27 or above.

What does this all mean for patient care? It means that for the vast majority of clinically depressed patients who fall below the very severely depressed range, antidepressant medications most likely won’t help. The sadder news is that even for the very severely depressed, medications have a very modest effect. Looking at the scoring of the HDRS, the normal, undepressed range is 0 to 7. The very severely depressed patients had scores of 25 or above, and a medium effect size was a drop in scores of 3 or more points compared to placebo patients. Looking at the one graph in the paper that show the actual drops in HDRS scores, the medication group had a mean drop of 12 points when their initial score was 25. That means they went from 25 to 13, which is still in the depressed range, although only mildly depressed. Patients who initially were at 38 dropped by roughly 20 points, ending at 18, which is still pretty depressed. And the placebo group had only slightly worse results.

One interesting thing is how strong the placebo effects are in these studies. It seems that for depressions less serious than very severe, placebo pills work as well as antidepressant medication.  Is this because antidepressants don’t work very well, or because placebos work too well? It’s hard to know. Maybe doctors should give their patients sugar pills, and call the new drug Eliftimood!

So in summary, here are the main observations I make from this study.

  • If you are very severely depressed, antidepressants may help, and are worth trying.
  • If you are mildly, moderately, or even severely depressed, there is little evidence that antidepressants will help better than a placebo. You would be better off with CBT (Cognitive Behavioral Therapy), which has a proven track record with less severe depressions, and which has no side effects.
  • Interestingly, CBT is less effective for the most severe depressions, so for these kinds of depressions medication treatment makes a lot of sense.
  • If you are taking antidepressants and having good results, don’t change what you are doing. You may be wired in such a way that you are a good responder to antidepressants.
  • If you have been taking antidepressants for mild to severe (but not very severe) depression, and not getting very good results, this is consistent with the research, and you might want to discuss alternative treatments such as CBT with your doctor. Don’t just stop the medications, as this can produce withdrawal symptoms, work with your doctor to taper off them.
  • Even in very severely depressed patients, for whom antidepressants have some effects, they may only get the patient to a state of moderate depression, but not to “cure”. To get to an undepressed, normal state, behavioral therapy may be necessary in addition to medications.
  • How do you find out how depressed you are? Unfortunately there is no online version of the HDRS for direct comparison. You may want to see a professional psychologist or psychiatrist if you think you might be depressed, and ask them to administer the HDRS to you.  There are also online depression tests, such as here and here. If you score in the highest ranges you might want to consider trying antidepressant medications, if you score lower you might want to first try CBT.
  • The most important thing is not to ignore depression, as it tends to get worse over time. Get some help, talk to a professional.

I’m off to take my Obecalp pills now, as it’s been raining here in Northern California for more than a week, and I need a boost in my mood. (Hint: what does Obecalp spell backwards?)

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Does Money Buy Happiness? No, And The Answer Of What Does Buy Happiness May Surprise You

It is often said that money can buy happiness, and as I’ve blogged in earlier articles, this is true, but only up to a basic middle class economic status. Above that, money doesn’t seem to add much happiness. (See my posts here and here.)

So what does buy happiness? We have a surprising answer from our friends across the pond, at the University of Warwick in England. A new study published online Nov. 18 in the journal Health Economics, Policy and Law surveyed thousands of people on  their levels of happiness and correlated it with external factors such as a pay raise or winning a lottery prize, and compared this to receiving psychotherapy.  Astonishingly, even to me, a psychologist, the increase in happiness from a $1329 course of therapy was so large that to equal it people had to get a pay raise of more than $41,542! That’s a ratio of 32 times! That means a dollar spent on therapy boosts happiness 32 times more than the same dollar received in a pay raise or lottery prize.

As the study author Chris Boyce, of the University of Warwick, summarized:  “Often the importance of money for improving our well-being and bringing greater happiness is vastly over-valued in our societies. The benefits of having good mental health, on the other hand, are often not fully appreciated and people do not realize the powerful effect that psychological therapy, such as non-directive counseling, can have on improving our well-being.”

Bravo,Chris! Now when patients ask me whether therapy is worth the money, I can confidently say that research suggests it might be one of the best investments you can make in yourself and your own happiness. (And it’s okay to get a raise, as long as you spend it on therapy!)

The only problem I can see with this article being published is that it may lower MY happiness, as I might get busier, perhaps earning more money, but not having time to see my own therapist!

So to answer the original question, does money buy happiness? Money doesn’t buy happiness; it buys psychotherapy, which yields 32 times more happiness than money!

Copyright © 2009-2010 Andrew Gottlieb, Ph.D.  The Psychology Lounge/TPL Productions

Link to study: http://www.nlm.nih.gov/medlineplus/news/fullstory_92421.html

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

New Study Finds the Best Pharmacological Stop Smoking Solution: (Hint, it’s not what you’d think)

A new study at the Center for Tobacco Research and Intervention, School of Medicine and Public Health, University of Wisconsin, Madison, compared all except one of the current drug treatments that help with quitting smoking. They looked at the following treatments and combined treatments:

  • “bupropion SR (sustained release; Zyban, GlaxoSmithKline), 150 mg twice daily for 1 week before a target quit date and 8 weeks after the quit date;
  • nicotine lozenge (2 or 4 mg) for 12 weeks after the quit date;
  • nicotine patch (24-hour, 21, 14, and 7 mg titrated down during 8 weeks after quitting;
  • nicotine patch plus nicotine lozenge;
  • bupropion SR plus nicotine lozenge; or
  • placebo (1 matched to each of the 5 treatments).”

Everyone received six 10- to 20-minute individual counseling sessions, with the first 2 sessions scheduled before quitting.

What were the results?

Three treatments worked better than placebo during the immediate quit period: the patch, bupropion plus lozenge, and patch plus lozenge.

At six months, only one treatment was effective; the nicotine patch plus nicotine lozenge. The exact numbers , as confirmed by carbon monoxide tests, were: “40.1% for the patch plus lozenge, 34.4% for the patch alone, 33.5% for the lozenge alone, 33.2% for bupropion plus lozenge, 31.8% for bupropion alone, and 22.2% for placebo.”

So we see that the combined nicotine substitution therapy worked best, followed closely by either nicotine substitute alone. Zyban or Welbutrin (bupropion) was a bust, no more effective than the simple nicotine lozenge. The only advantage to Zyban would be if one prefers not to use nicotine substitutes.

Now I mentioned that they omitted one drug treatment, which is the drug Chantix (varenicline). This is probably because the drug is a nicotine receptor blocker, so wouldn’t have made sense to combine with nicotine substitutes. Also, there have been some disturbing case reports of people having severe depressive reactions to Chantrix.

Of course, there was one glaring omission that any card-carrying psychologist would spot in a moment–the lack of a behavior therapy component. Giving 6 ten minute sessions is hardly therapy. I would have liked to see true smoking cessation behavior therapy combined with the drug treatments.

So, if you’re trying to quit smoking, combine nicotine patches with nicotine lozenges, sold in any pharmacy. If you do, you have a 40 percent chance of succeeding at 6 months.

Now I am off to have a cigarette….just kidding.

Study: http://cme.medscape.com/viewarticle/712074_print

Copyright © 2009/2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Why do Most Psychologists Ignore Science Based Therapy? Evidence Based Psychotherapy and the Failure of Practicioners

A new article in Newsweek magazine titled Ignoring the Evidence documents how most psychologists ignore scientific evidence about treatments such as cognitive behavioral therapy which have been proven to be effective.

A two-year study which is going to be published in November in Psychological Science in the Public Interest, found that most psychologists “give more weight to their personal experiences then to science.”

The Newsweek article has a wonderful quote,

“Thanks to clinical trials as rigorous as those for, say, cardiology, we now know that cognitive and cognitive-behavior therapy (teaching patients to think about their thoughts in new, healthier ways and to act on those new ways of thinking) are effective against depression, panic disorder, bulimia nervosa, obsessive-compulsive disorder, and -posttraumatic-stress disorder, with multiple trials showing that these treatments-the tools of psychology-bring more durable benefits with lower relapse rates than drugs, which non-M.D. psychologists cannot prescribe. Studies have also shown that behavioral couples therapy helps alcoholics stay on the wagon, and that family therapy can help schizophrenics function. “


The article documents how most psychologists fail to provide empirically proven treatment approaches and instead use methods which are often ineffective. The truth is there is very little evidence for most of the types of therapy commonly performed in private practices by psychologists and by Masters level therapists. If you are shopping for the most effective types of therapy you need to find a practitioner who is skilled at cognitive behavioral therapy (CBT) which is one of the few psychotherapy approaches that has been proven to work on a variety of problems.

Another interesting article in Newsweek about evidence-based treatment discussed bulimia. Here’s the summary:

“On bulimia (which affects about 1 percent of women) and binge eating disorders (2 to 5 percent), the verdict is more optimistic: psychological treatment can help a lot, and cognitive behavioral therapy (CBT) is the most effective talk therapy. That’s based on 48 studies with 3,054 participants. CBT (typically, 15 to 20 sessions over five months) helps patients understand their patterns of binge eating and purging, recognize and anticipate the triggers for it, and summon the strength to resist them; it stops bingeing in just over one third of patients. Interpersonal therapy produced comparable results, but took months longer; other therapies helped no more than 22 percent of patients. If you or someone you love seeks treatment for bulimia, and is offered something other than CBT first, it’s not unreasonable to ask why. Cynthia Bulik, director of the University of North Carolina Eating Disorders Program, summarized it this way: “Bulimia nervosa is treatable; some treatment is better than no treatment; CBT is associated with the best outcome.”

So the bottom line is this:

1. Most psychologists who don’t practice Cognitive Behavioral Therapy (CBT) are just winging it, using treatments that haven’t been shown to work by scientific studies. It’s as if you went to a regular physician and got treatment with leaches!

2. Many psychologists claim to use CBT but haven’t really trained in the use of CBT, or have taken a weekend workshop. Unless they prescribe weekly homework that involves writing down thoughts, and learning skills to analyze and change your thoughts, then they aren’t really doing CBT, and I recommend you find someone else.

3. If you have an anxiety disorder, depression, bulimia, or obsessive compulsive disorder, and haven’t been offered CBT, then you are not receiving state of the art treatment.

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

A Better Voicemail Message! (warning, humor!)

Are you tired of all those multiple choice voicemail menus? Press infinity if you’d like more options. I saw this on the web, and had a giggle. Maybe I’ll change my voicemail message to it. (Kidding!)


Welcome to the Psychiatric Hotline.

  • If you are obsessive-compulsive, please press 1 repeatedly.
  • If you are co-dependent, please ask someone to press 2 for you.
  • If you have multiple personalities, please press 3, 4, 5, and 6.
  • If you are paranoid-delusional, we know who you are and what you want. Just stay on the line so we can trace the call.
  • If you are schizophrenic, listen carefully and a little voice will tell you which number to press.If you are depressed, it doesn’t matter which number you press. No one will answer.
  • If you are delusional and occasionally hallucinate, please be aware that the thing you are holding on the side of your head is alive and about to bite off your ear.
  • If you have an anger management problem, please throw the phone against the wall to select an option.

Anyway, I thought it was funny, and hope I haven’t offended anyone by posting it.

In all seriousness, the real messages that many psychiatrists have are almost as funny. You know, the one that says, “If you have a ‘true’ emergency, please go to the nearest emergency room or call 911.” I’ve always thought this is a stupid message, that is insensitive and uncaring. Like patients don’t know about 911 or the emergency room. I believe a better message is to offer a pager number or cell phone number where a patient can reach me, their psychologist, rather than an impersonal 911 operator. It doesn’t happen often, but when it does, I can usually help the client through crisis quickly and effectively.

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Overcoming Social Anxiety and Shyness

I’m often asked about social anxiety and shyness, and how to overcome them. I was lucky enough to be quoted in a Forbes Magazine article about that very topic. And here’s a link to a pdf of the article, which is easier to navigate. Enjoy!

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Which Anti-depressant Should You Take? Now We Know

Accepted wisdom for a number of years has been that all modern anti-depressants work equally well, and that drug selection depends more on the side effect profile desired. Thus a lethargic patient might benefit from an activating antidepressant like Prozac, and an anxious patient would be better off with Paxil. Often prescribing practices are based on individual doctors’ preferences and biases. But a newly published study suggests that this may be wrong. There may be antidepressants that not only work better, but are easier for patients to tolerate.

A terrific new study was recently published in the Lancet medical journal. A team of international researchers, led by Andrea Cipriani at the University of Verona in Italy, reviewed 117 studies of antidepressants which included 25928 patients, two-thirds of whom were women. These studies, done all around the world, compared various antidepressants to either placebo or other antidepressants.

The researcher compared the results of 12 new generation antidepressants in terms of efficacy and acceptabiltiy. They defined efficacy as the proportion of patients who improved at least 50% on a depression rating scale by 8 weeks of treatment. They defined acceptability as the proportion of patients who did not drop out of the study. They made an attempt to adjust for dosages, and did very sophisticated statistical analyses to compare all of the drugs. They used fluoxetine (Prozac) as the common comparison drug, since it has been on the market for the longest time.

What were the results? The winners in terms of short term effectiveness were: (drum roll) mirtazapine (Remeron), escitalopram (Lexapro), venlafaxine (Effexor), and sertraline (Zoloft). The winners in terms of acceptability were: escitalopram (Lexapro), sertraline (Zoloft), citalopram (Celexa), and bupropion (Wellbutrin) were better tolerated than other new-generation antidepressants. Note that the overall winners for effectiveness combined with tolerability were escitalopram (Lexapro) and sertraline (Zoloft). Two of the best drugs in terms of effectiveness (mirtazapine (Remeron) and venlafaxine (Effexor)) were not among the best tolerated medicines.

The losers in terms of both effectiveness and tolerability were reboxetine (Edronax), fluvoxamine (Luvox), paroxetine (Paxil), and duloxetine (Cymbalta). The worst drug of all was reboxetine (Edronax).

So what about cost? I’ve developed a spreadsheet of all of the drugs’ costs based on a 30 day supply, paying full retail price at Costco pharmacy, and using generic equivalents when available. Of the winners in terms of effectiveness and tolerability, the clear cost winner was sertraline (Zoloft), at $12 a month. The other winner, escitalopram (Lexapro), was a loser in terms of cost at $88 a month! The other winners in terms of effectiveness were quite cost effective too, with mirtazapine (Remeron) at $14 a month, and venlafaxine (Effexor) at $28 a month.

So what should doctors and patients do? For patients, the two best drugs appear to be escitalopram (Lexapro) and sertraline (Zoloft), with sertraline the clear winner if you pay much for prescription drugs. Doctors might want to consider costs as well, as this can help with overall health care inflation. If you can tolerate the side effects, consider trying mirtazapine (Remeron), or venlafaxine (Effexor).

Now there are of course a few caveats about this study. It is possible that another meta-analysis could find different results. One criticism was that the study only looked at effectiveness over 8 weeks of treatment. It is possible that some drugs work more slowly, and at 12 or 16 weeks might have different results. But most patients want results in two months or less, so this is not a major criticism.

Another issue is funding bias. Although none of the authors of this study were paid by drug companies, many of the studies they analyzed were funded by drug companies, and may have reflected some bias. But for now, this is the best information we have in terms of effectiveness and toleration of antidepressant medications.

So who’s the winner? Sertraline (Zoloft) was the clear winner by effectiveness, tolerability, and cost!

Should you change medications if you are not on one of the winners? No, of course not. If your medication is working, don’t change it. But if it’s not working, then talk with your doctor about switching.

And no, I don’t receive any funding or sponsorship from any drug companies…

 

Here’s the table of drug price comparisons.
Comparison of Antidepressant Costs for 30 Day Supply (Costco Pharmacy, Generic Equivalents if possible)
Bolded Drugs were most effective

Drug            Generic Name         Cost          Dose(mg)

Celexa             citalopram                   $3                 40
Prozac             fluoxetine                    $6                  20
Zoloft             sertraline                       $12             100
Remeron     mirtazapine                    $14               30
Luvox              fluvoxamine               $24             100
Effexor         venlafaxine                    $28                75
Welbutrin      bupropion                   $74             200
Lexapro       escitalopram                 $88                10
Paxil                paroxetine                   $91             37.5
Cymbalta       duloxetine                   $128              60

 

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Does TV Watching Increase the Risk of Depression in Teenagers?

A study published in the February 2009 issue of the Archives of General Psychiatry found that those teenagers who watched more than 9 hours a day of television where more likely to become depressed as young adults.

The researchers used data from a larger study of 4,142 adolescents who were initially not depressed. After seven years of followup, more than 7 percent had symptoms of depression.

But only 6 percent of the children who watched less than three hours a day of TV became depressed, while more than 17 percent of those who watched 9 or more hours a day became depressed.

Interestingly, there was no association with playing video games, or listening to music, or watching videos. The association of TV and depression was stronger for boys than girls, and was constant after the researchers adjusted for age, race, wealth, and educational level.

So what does this mean? First of all, it’s important to put this into context. Nine hours of TV watching is a lot!!!! It means that these kids came home from school at 3pm, and turned on the TV, and kept it on until midnight! Or it means that they spent the entire weekend watching television. So these findings are not so surprising. Basically television was their entire life, and that means that they had no hobbies, no friends, and no sports or extra-curricular activities. All these are a prescription for depression. The kids who watched less than 3 hours of television a day had lives, which is probably why fewer of them got depressed.

So the moral of the story is make sure your children have balanced lives, and limit screen time (which includes video gaming) to 2 or 3 hours a day, or less. One good way to control television time is not to have television sets in children’s bedrooms. Have a main television in the living room, and that allows you to know when and what your children are watching.

Okay, now I am off to watch no more than two hours of my favorite television shows…

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How to Deal with Teenage Depression: A New Study of Adolescent Depression and its Treatment

A new study reported in the Journal of the American Academy of Child and Adolescent Psychiatry found some interesting results of a study of teenage depression and its treatment.

This study of 439 teenage children with major depression, done at the University of Texas Southwestern Medical Center at Dallas tested anti-depressant medication (fluoxetine or Prozac), cognitive behavioral therapy (CBT), and a combination of both (COMB). They found that only 23% of the patients had their depression cured by 12 weeks of therapy. But 9 months of therapy was much more effective, with 60 percent going into remission.

The bad news though is that this means that almost half of the teenagers (40%) were still depressed after 9 months of therapy.

The good news is in terms of relapse. Of those who responded quickly to treatment, two-thirds retained the benefits of treatment over 9 months. The same was true of those who took longer to respond.

Which treatment was better? That is an interesting picture.

It depends at which time point you are looking at. At 12 weeks, the results for percentage fully remitted (cured) of depression were: combined drug and CBT therapy (37%), drug therapy only (23%), and CBT therapy only (16%). The combined therapy was significantly better than the other therapies. But note that overall, only 23% of the teenagers had recovered at 12 weeks, which means that 77% were still suffering!

But at nine months the outcomes look quite different. The combination therapy is still the best, but by less of a margin. The results for remission at at 9 months were: combination, 60%; drug, 55%; cognitive-behavioral therapy, 64%; and overall, 60%. By 24 weeks all the treatments were working well. But a full 40% of the teenagers were still depressed.

So the right answer to the question of which treatment works better is neither. Both drugs and cognitive behavioral therapy were equally effective, over the long term. But the combination of both was worked more quickly. As the researchers said, “choosing just one therapy might delay many teenagers’ recovery by 2 or 3 months.” As the saying goes, candy is dandy, but liquor is quicker, and we might conclude that drugs or CBT are dandy, but combined therapy is quicker.

So what does this mean to parents of depressed teenagers? Here are my takeaway messages:

  1. Don’t expect treatment for depression to work quickly. It may take more than 9 months of weekly treatment before your teenager responds to therapy. This means at least 40 sessions of therapy.
  2. Be patient, and set reasonable expectations for both yourself and for your child. Tell them that therapy will help, but it may take a while. Let support networks such as school counselors or trusted teachers know to be patient.
  3. Although medications and cognitive behavioral therapy were equally effective in the long run, the combination of both tended to work much more quickly. So if you can afford it, and have access to good practitioners who do cognitive behavioral therapy, use both.
  4. Be aware that in other studies, the relapse rate for medication treatment of depression was significantly higher than for cognitive behavioral therapy, once the medications are discontinued. So choosing medications only may increase the risk that your teenager will relapse into depression.
  5. Be aware that much teenage depression can be a reaction to social environments. This includes the family, the school, and peers. Be sure that your teen’s therapist is attuned to family, school, and peer issues. They should meet with the whole family at least several times.
  6. Take teenage depression seriously. It’s not just a phase. Teenage depression, when serious, can greatly increase the risk of suicide. All suspected depression should be evaluated by a professional and treated if present.

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

SOURCE: Journal of the American Academy of Child and Adolescent Psychiatry, February 2009 . And December 2006 issue too .

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Announcing iPhone (and Ipod Touch) Support for the Psychology Lounge!

I am very pleased to announce that thanks to a brilliant WordPress plugin called IWPhone The Psychology Lounge is now iPhone and Ipod Touch compatible. Nothing changes in a regular computer browser,  but if you want to read an article on your iPhone or Ipod Touch the site is now automatically formatted for those devices.  You can even leave a comment!

Enjoy!

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Terrific Web Site for Making a Font Out of Your Own Handwriting

Now for something a little different. I just tried www.yourfonts.com, which allows you to create a Windows or Mac font of your own handwriting. I highly recommend this free site. It’s quick and simple. First, print out their template. Fill in the template with your own penmanship. Next, scan it and upload it to their site. In a few minutes, you’ve got your own custom handwriting font. Download it, and install it onto your system, and you are ready to roll. I transformed a Word document into a handwritten page, and it looked remarkably as if I had handwritten it.

Highly recommended, and the price (free) is right!

Copyright © 2009 The Psychology Lounge/TPL Productions/Andrew Gottlieb

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

So Much for the Germ Theory: Scientists Demonstrate That Sleep Matters More Than Germs

More in a continuing series about one of my favorite topics, something we all do every day, and spend roughly a third of our lives doing…sleep!

Since we are in the middle of the common cold season, this post will be particularly relevant.

It turns out, grandma was right. Getting good sleep really does prevent colds. This supports a favorite belief of mine—that I don’t believe in the germ theory of illness.  Read on and you will see why I liked the referenced article.

Researchers at a variety of universities collaborated and did a clever study looking at sleep and its effects on susceptibility to the common cold. First they had their 153 subjects, healthy men and women between 21 and 55, report their sleep duration and efficiency for 2 weeks. (Efficiency is what percent of the time you are actually sleeping while in bed.) Next, these diabolical researchers sprayed cold virus up the noses of all the subjects (in quarantine), and watched what happened over the next 5 days.

The results were very interesting. Those subjects who slept less than 7 hours were almost 3 times more likely to develop a cold than those who slept 8 hours or more. In addition, those whose sleep was less than 92% efficient were 5.5 times more likely to develop a cold than those with 98% or more sleep efficiency. Interestingly, how rested subjects reported feeling after sleep was not associated with colds.  The lead author of the study concluded, “The longer you sleep, the better off you are, the less susceptible you are to colds.”

Now I promised that I would report evidence that this study bolsters my theory that germs don’t really matter that much. Remember the researchers sprayed virus up everyone’s noses. After five days, the virus had infected 135 of 153 people, or 88% of the people, but only 54 people (35%) got sick. What this suggests is that even among the people who were infected with cold virus, 60% stayed healthy, while 40% got sick. And the ones who got sick were much more likely to have reported less and lower quality sleep in the two weeks before infection. 

This is very relevant for everyday life, since much of the time we can’t really avoid exposure to common germs like colds and flu. If good sleep protects us even when infected with such germs, then it may be the key to staying healthy.

What is truly fascinating about this study is the precise immune regulation showed by those who got infected, but stayed healthy. To understand this let me digress for a moment with a short primer on the common cold. Most people think cold symptoms are caused by cold virus. This is wrong. Actually, cold symptoms are caused by our bodies’ immune reaction to the cold virus. Our bodies produce germ fighting proteins called cytokines, and when our bodies make too much, we get the congestion and runny nose symptoms. If our bodies make just the right amounts of cytokines, we fight the virus without feeling sick.

So getting 8 or more hours of sleep a night may allow your body to fine tune an immune response, and make just the perfect amount of germ fighting proteins.

Another interesting finding is the relationship of sleep efficiency and illness. Sleep efficiency was an even more powerful predictor of getting sick than total sleep. (Of course, this might reflect an overall difference in sleep quality. Those who sleep deeply may tune up their immune systems better, and they are likely to spend most of their time in bed asleep.)

But assuming that increasing sleep efficiency is useful, then those people who take a long time to fall asleep, and who sleep fitfully may benefit from spending less time in bed, and working on sleeping more of the time they are in bed. On the other hand, those who fall asleep as soon as their head hits the pillow, and who are sleep like logs, would probably benefit from spending a little more time in bed, since they are not getting enough sleep.

So there you have it. Sleep 8 hours or more, try to sleep well, and you can lower your odds of getting a cold greatly. Even if you are exposed to the virus, if you have good sleep quality, you probably won’t get sick. So much for the simple germ theory! I suspect that this applies to all infectious diseases. So getting good quality and quantity in sleep may be one of the most important health behaviors for staying well.

It’s late, and I’m off to bed now…..zzzzzzzzzzzzzzz.

Copyright © 2009 The Psychology Lounge/TPL Productions/Andrew Gottlieb

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Magic of Behavior Therapy: True Stories


Although I’ve been practicing behaviorally oriented therapy for more than 20 years, I’m still amazed and delighted by its power and effectiveness. Here are four tales of behavior therapy, from both inside and outside my office, with children, adults, and even animals!

Playing with Spiders

I recently had a very satisfying experience in the clinical practice. A client of mine asked me if she could bring her grandchildren to a session, in order to work on their spider phobia.  I told her that if they were willing, I’d be happy to work with them. We would be able to make some progress by having the children look at pictures of spiders on my computer. The kids were 10 and 13, let’s call them David and Janet.

She surprised them (and me) by announcing at the beginning of the session that she had actually brought two live spiders in jars.  This changed my plans for the session. I told the kids that we would only work with the live spiders if they were comfortable doing so. (It’s not a good idea to spring surprises during desensitization sessions.)

So we started doing what is called desensitization.  This is a process where step-by-step, in a gradated way, the client is exposed to the fearful object.  We started off by looking at pictures of spiders on the web (pun not intended).  I picked less scary pictures at first, and I asked the children to rate their anxiety.  Then I asked them to see if they could lower their anxiety numbers.  We used a hundred point scale, and when they were able to lower their anxiety from 70 or 80 to 30 or below, we moved on to the next picture.

Eventually they were looking at pictures which were quite scary looking, even for me, and I like spiders!

Next we went on to work with the actual spiders.  There were two spiders.  One of them was a small daddy long-legs spider, and the other was a relatively small but scary looking spider.  I decided to work with the daddy long-legs spider, as it was slower moving, and less scary looking.

First I had them look at the spider in the jar.  Next I had them hold the jar.  They were able to do this fairly rapidly.  The next step was to open the jar, and look into the jar with the spider walking around inside the jar. David and Janet were able to do this without very much anxiety at all.

The next step was harder. It was to allow the spider to walk around on my office floor, and to have them touch the spider.  I made this a little bit easier by having them put on surgical gloves.  First I modeled the behavior for them.  I touched the spider, and then I allowed the spider to walk over my hand.

Now it was their turn.  First one, then the other, tentatively touched the spider.  At first their anxiety rating was quite high, 70 or 80.  Then I had them do this repeatedly, until they were able to do it with relatively low anxiety ratings of about 40.

One of the advantages of working with both of them simultaneously was that they were a bit competitive.  Janet was initially a little braver, but David quickly responded to this challenge, and matched her touch for touch.

Once they were comfortable touching the spider with gloves on, it was time to take the gloves off.  Once again I modeled for them touching the spider comfortably.  In a few minutes, they were able to allow the spider to walk over the back of their hand.  After a few minutes more, they were able to have the spider walk up their arm.

By the end of the session they were very comfortable playing with this small spider.  They were actually having fun playing with Mr. Daddy Long-Legs. And this was only a 60 minute session!

Once again, I was amazed at the power of simple behavioral tools.  Modeling — where the therapist demonstrates a behavior.  Gradated exposure — gradually exposing the person to increasingly fearful stimuli.  Reinforcement — where the therapist complements and praises the client for successful exposures.  Shaping — where the client is reinforced for behaviors that gradually approximate the target behavior.

In less than 60 minutes I was able to take these two brave children from being terrified of spiders to relative comfort with spiders.  Given that most people are not comfortable having a spider crawl up their arm, by the end of the session they had actually exceeded the comfort level of the average person.

(I recently got a follow-up report on the kids. According to grandma, David now can pick up dead spiders with his fingers, without using paper, which he could not do before. While his family was recently eating dinner, they noticed a large fly buzzing around. During their meal, the fly got caught in a spider web in the corner of nearby window. After the family had eaten dinner, they inspected the web and found the spider wrapping the fly. They left the web in place, deciding that it was beneficial, and David was comfortable with the arrangement. Janet reported that was able to put her hand on a picture of a big, multi-colored ugly black tarantula in her science textbook, with her mom watching. )

Bridging the Gap

Another opportunity for using the science of behavior therapy arose on a vacation. My partner and I were visiting Vancouver Canada, and one of the attractions there is the Capilano Suspension bridge (www.capbridge.com ). The bridge is a 6 foot wide suspension bridge which is 439 feet long, and 230 feet above a river gorge. It’s like the bridge in Indiana Jones and the Temple of Doom, swaying as you walk across it.

There was only one catch, my partner is very afraid of heights. She hates any situation involving them, and doesn’t even like walking across the Golden Gate Bridge.

But I thought that this might be an opportunity for her to overcome this fear, and offered to do in vivo desensitization with her if she was willing.

So we did. First I had her approach the edge of the bridge, and once again, I had her rate her anxiety using a 100 point scale. Ninety, she said. I then asked her to use breathing and relaxation to lower the anxiety. Before long she was able to stand at the very end of the bridge.

Next I had her advance out a few feet onto the bridge, stay there as long as she needed, and then retreat to solid land. She repeated this several times, until it was more comfortable.

Then I modeled walking partly across the bridge. I went slowly and hesitantly, modeling caution and slowness rather than speed and bravado. A coping model that shows the person overcoming fear is more effective than a perfectly confident model, I have found.

She then walked 10 or so feet across the bridge, and stood on the swaying bridge. Fear spiked and then subsided.

All along, I was giving her a lot of praise and encouragement. Next she managed 15 feet, and then retreated. Then she advanced 20 feet, then 30, then 40, and so on, until she was able to walk all the way across the bridge. Once she had accomplished that success, I had her repeat the process until her comfort level increased. I even invited her to jump up and down on the bridge, to demonstrate her lowered fear levels.

By the end of our visit there, not only was she able to traverse the bridge (which I admit was scary, even for me), but she was also able to traverse another attraction, a catwalk that was built between a number of Douglas Fir trees, which at points is 100 feet off the forest floor. This required more desensitization, but was successful in the end.

By the end of the day my brave partner had successfully overcome a lifelong fear of heights, and experienced some tourist attractions that she never would have enjoyed previously. When I showed her the video of her walking across the bridge, she was amazed at what she had been able to do.

Which is what I truly love about behavioral therapy; the ability to quickly and without lengthy therapy to overcome lifelong fears and expand one’s personal horizons!

Shaping Sandy to Swim

Another technique of behavior therapy is called shaping. What is shaping? Shaping is a technique where you reinforce gradual approximations of that behavior until you achieve the full behavior.

I had an opportunity to utilize shaping last summer when we spent some time at Lake Tahoe. We were renting a house on the beach, and our next-door neighbors had an adorable golden retriever named Sandy. Sandy loved to play on the beach, and her favorite game was fetch. But she wouldn’t go in the water past her ankles, and was afraid to swim. The owner said that she had never been willing to swim, even though they came up to Lake Tahoe regularly. The dog was about three years old.

I was challenged. Could I use behavior therapy to help Sandy overcome her fear of water and start swimming? I knew one thing; that dogs instinctively know how to swim, so it wasn’t a question of skill.

I decided to utilize the technique of shaping. First I made friends with Sandy by playing fetch on the beach. Pretty soon whenever I came out to the beach Sandy would run over with a stick to play.

Next I trained Sandy to follow me with the stick. She would follow me anywhere on the beach. Then I went into the water and encouraged her to follow me a few feet in order to grab the stick. She was willing to come into the water a little bit. I would praise her, and I would play some more with her on the beach.

Next I made it a little bit more difficult. In order to grab the stick she had to follow me into the water a few feet more.

I kept repeating this, each time requiring her to follow me further out into the water. Pretty soon she was following me five or 10 feet out into the water, but she still wasn’t swimming. Her feet were still on the bottom.

Next I used a slightly different technique. This time I had her come out into the water and grab the stick with her mouth. Instead of releasing it, I held on and moved out deeper into the water. Pretty soon her feet were off the bottom and she was swimming. I would then let go and she would swim back to shore, shake off, and play with me some more. The first time I did this she seemed a little perturbed, but quickly got into the game.

Over a couple of training sessions during the same day I continued this process. She got more and more confident, and was willing to swim out to grab the stick.

Finally I had her owner call to her while swimming in the deeper part of the beach. I threw a tennis ball out to the owner, and Sandy much to everyone’s surprise, swam out to the owner, grabbed the tennis ball, and swam back to the beach!

After that, Sandy seemed comfortable swimming in order to fetch a stick or a ball, even when it required her to swim in deeper water. Shaping had allowed her to learn gradually to overcome her fear and be able to swim with comfort.

The owners were amazed, as many times they had tried to coax her into the water. All I did was apply systematic methods of behavior therapy in order to allow Sandy to succeed. I shaped Sandy to swim, and she followed her destiny as a waterdog retriever.

Finding the Right Reinforcer

I want to tell one more story about behavior therapy, this time with dogs.

Although I’m a human therapist, I am very fond of dogs, and if I had an alternate career it would be as a dog trainer.

My friends Marli and Stu have two adorable dogs.  They are Papillons, which are small cute toy dogs, who look a little bit like the gremlin "Gizmo" in the movie Gremlins .  They have the same floppy ears and big eyes. (But they don’t turn into monsters if you feed them after midnight!)
In an effort to make their lives a bit more convenient, my friends had installed a dog door into their bedroom so that the dogs could go outside without needing help.

The problem was that neither Vinnie, the older dog, nor Bowie, the younger dog, was willing to use the dog door.  They were both afraid of it.  After weeks and weeks of hoping the dogs would figure out how to use the door, they still had not. Stu and Marli kept putting the dogs through the door, but the dogs never figured out how to use the door on their own.

Enter the confident behavior therapist, who offered to solve this problem.  I was very confident that I could use food treats to entice the dogs through the door.  Once having learned how to go through the dog door, I felt that they would continue to use it without treats.

I asked my friends not to feed the dogs the day I came over so that the dogs would be hungry and more motivated by food.

To make a long story short, I failed miserably.  I was able to coax the dogs through the dog door by physically picking them up and pushing them through the door, but no amount of food treats would entice them to go through the door.  They seemed uninterested in food treats. After several hours of trying everything I could think of, I gave up.

This bothered me greatly.  Had I lost my behavior therapist powers?  Had the technology failed?  That night, as I tried to fall asleep, I found myself obsessing a lot about the problem.  Just as I was about to fall asleep I realized the solution.

Can you guess what the solution was?  I will give you a hint that it had to do with what type of reinforcements I had selected.  Let me give you one more hint.  Both of these dogs are very attached to my friend Marli.  They like Stu, but they are crazy about Marli! They follow her everywhere. When she comes home from work they go nuts wanting to play with her.

The solution was to change the reinforcement.  Instead of putting food on the other side of the dog door, I needed to put Love!  What I did was to have a Marli call her husband Stu right before she came home.  Then he would put the dogs outside.  She would come inside the house, and call to the dogs through the dog door.  The first time she did this both dogs dove through the dog door as if it wasn’t even there!

The next time she came home she came through the yard, and called to the dogs from the outside.  Once again, motivated by love, they were very willing to use the dog door to get outside.

After a few days, they no longer had to use this procedure, as the dogs were happily using the dog door on their own.  Behavior therapy had triumphed once again, but it required a more careful behavioral analysis of what these particular dogs found reinforcing.  They were more motivated by love than by food.

And that’s a key secret…sometimes the best motivators are subtle, and never forget the power of love to motivate! If reinforcement isn’t working, it’s probably because you are not using the right reinforcement.


Copyright 2008 Andrew Gottlieb, Ph.D./The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Good News and Bad News for Chocolate Lovers

There is good news and bad news today for chocolate lovers, especially those who love dark chocolate. The good news is that small amounts of dark chocolate may be very good for your heart.

A very nice study was published today that shows that a fairly small amount of dark chocolate has a powerful impact on C-reactive protein, which is a blood marker of inflammatory processes in the body. This protein is a powerful predictor of heart disease. Higher levels of C-reactive protein indicate chronic inflammation in the body which leads to more risk of cardiovascular disease.

Scientists at the Research Laboratories of the Catholic University in Campobasso, working with the national Cancer Institute of Milan conducted a large scale study of 20,000 people that examined the intake of dark chocolate and found that those people who eat moderate amounts of dark chocolate regularly have C-reactive protein levels 17% lower than those who do not consume dark chocolate. This seems like a small difference, but it correlates with a decrease in cardiovascular disease of one third in women and one fourth in men. This is actually a very significant finding.

So what’s the bad news? The bad news is the quantity of dark chocolate the researchers found optimum. The best effect was obtained by consuming an average amount of 6.7 grams of chocolate per day. Since the typical bar of dark chocolate is 100 grams that means the optimum dose of dark chocolate would be obtained by eating four small squares of chocolate per week. This means eating half a bar of chocolate per week, or roughly one small square every two days. So that’s the bad news, you have to limit your dark chocolate in order to benefit maximally. In this study they found those who ate more than this amount lost most of the benefits. So a little is good but more is not better!

By the way, the researchers adjusted for many other factors, and are confident that the dark chocolate had an impact directly. And for those who prefer milk chocolate, I am sorry, there was no benefit shown to eating milk chocolate.

As one of the lead researchers,  Giovanni de Gaetano, director of the Research Laboratories of the Catholic University of Campobasso, said, “Maybe time has come to reconsider the Mediterranean diet pyramid and take the dark chocolate off the basket of sweets considered to be bad for our health”. So that’s the good news, you can eat dark chocolate in moderation, without guilt. The bad news is that you have to stop after one small square!

I’ve got to go now, as I’ve got a lovely Le Noir Extra Amer 85% Cacao bar of Dark Bitter Chocolate waiting for me…

Copyright © 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How to Live a Long Healthy Life (for Men only)

The New York Times had an excellent article looking at a recent study that suggests that the secret to living past 90 may be found in five simple behaviors. The study, performed at Brigham and Women’s Hospital in Boston followed 2300 healthy men for 25 years. The average age at the beginning was 72. By the end of the study, 970 men had survived into their 90’s.

The key behaviors that were associated with longevity were not smoking, keeping a healthy weight, controlling blood pressure, getting regular exercise, and preventing diabetes.

The results?

“There was no less chronic illness among survivors than among those who died before 90. But after controlling for other variables, smokers had double the risk of death before 90 compared with nonsmokers, those with diabetes increased their risk of death by 86 percent, obese men by 44 percent, and those with high blood pressure by 28 percent. Compared with men who never exercised, those who did reduced their risk of death by 20 percent to 30 percent, depending on how often and how vigorously they worked out.”

So there you have it. First stop smoking, or don’t start. Second, control your weight and eating patterns to avoid Type 2 diabetes. Third, lose weight so that you are not obese. Control your blood pressure, and exercise, and you’ve got longevity nailed. What is interesting is that although smoking is a completely independent risk factor, the other four are highly related to something called Syndrome X, a metabolic syndrome that is associated with high levels of blood sugar and insulin production, which leads to weight gain, hypertension, and pre-diabetes. Exercise leads to weight loss, and independently reduces the tendency to Syndrome X.And it’s not too late. Since the study only looked at these five behaviors after age 72, even change that occurs late in life can greatly extend and improve life.

Unfortunately, since the study only included men, we can’t really generalize the results to women, but it is likely that the same principles apply.

And now, I have to go take a swim…

Copyright © 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Should the Golden Gate Bridge Have a Suicide Barrier? (Is Suicide an Act of Impulse or an Act of Premeditation?)

One of the consistent and most fascinating facts that arises out of any serious study of psychology research is how much we are influenced by external factors.  So much of our behavior is influenced by seemingly small external factors.  We eat more when served bigger portions.  We spend more when sales are in effect.  Red cars are more likely to get speeding tickets.  We are more likely to marry someone who lives or works nearby.

But what about the truly profound and serious decisions of life?  What about something as serious as suicide?  Can it be that even such a grave decision is affected by seemingly small external factors?

The New York Times Magazine recently published a fascinating article “The Urge to End It All“, which addressed this very issue.  I highly recommend you read the entire article.

First, some numbers.  (I love numbers).  The current suicide rate is 11 victims per 100,000 people, the same as it was in 1965.  In 2005, about 32,000 Americans committed suicide, which is two times the numbers who were killed by homicide.

For many years the traditional view of suicide was that it reflects mental illness — depression, bipolar illness, psychosis, schizophrenia, or other mental illnesses.  This view assumed that the method of suicide was not important; it was the underlying mental illness that mattered.

But something happened in Britain in the 1960s and 1970s that set this model on its head.  It’s called the “British Coal Gas Story” and it goes like this:

For many years people in Britain heated their homes and stoves with coal gas.  This was very cheap, but the unburned gas had very high levels of carbon monoxide, and a leak or an opened valve could kill people in just a few minutes in a closed space.  This made it a popular method of suicide — “sticking one’s head in the oven” killed 2500 Britons a year by the late 1950s — half of all suicides in Britain!

Then the government phased out the use of coal gas, replacing it with natural gas, so that by the early 1970s almost no coal gas was used.  During this time Britain’s suicide rate dropped by a third, and has remained at that level since.

How can we understand this?  If suicide is the act of an ill mind, why didn’t those who could no longer use coal gas find another means? Why did the suicide rate in Britain drop by a third when the option of coal gas was no longer available?
The answer turns conventional wisdom about suicide on its head. Conventional wisdom is that people plan out suicides carefully, and so convenience of method shouldn’t matter. But actually it appears that often suicide is an impulsive act, and when you make it less convenient, people are less likely to complete the act.

Another example of this is found in the Golden Gate Bridge.  For years this gorgeous bridge has been a popular suicide point, where nearly 2000 people have ended their lives.  There have been many debates about erecting suicide barriers on the bridge, but most opponents say “they will just find another way.”

But Richard Seiden, professor at University of California Berkeley, collected data that addresses this issue.  What he did was to get a list of all potential jumpers who were stopped from committing suicide between 1937 in 1971, 515 people in all.  He then pulled their death certificate records to see how many had gone on to kill themselves later.  What would you guess was the percentage of these people who tried to jump off the Golden Gate Bridge and who later killed themselves?  50%?  75%?  25%?

Actually it was only 6%!  Even allowing that some accidents might have been suicides, the number only went up to 10%.  Although higher than the general population, it still means that for 90% of these would-be jumpers, they got past whatever was bothering them, and went on to live full lives.

Richard Seiden got some great stories out of this study.  One of the things he found was that would-be suicides tend to get very fixated on a particular method.  They tend to only have a Plan A, with no Plan B. As he says, “At the risk of stating the obvious,” Seiden said, “people who attempt suicide aren’t thinking clearly. They might have a Plan A, but there’s no Plan B. They get fixated. They don’t say, ‘Well, I can’t jump, so now I’m going to go shoot myself.”

One example he cites was a man who was grabbed on the east side of the bridge after pedestrians noticed him looking upset.  The problem was that he had picked out a spot on the west side of the bridge that he wanted to jump from, but there were six lanes of traffic between the two sides, and he was afraid of getting hit by a car on his way over!

As Seiden said, “Crazy, huh? But he recognized it.  When he told me the story, we both laughed about it.”

Another great example is from two bridges in Northwest Washington.  The Ellington Bridge and the Taft Bridge both span Rock Creek, and both have about a 125 foot drop into the gorge below.  For some reason the Ellington has always been famous as Washington’s “suicide bridge”.  About four people on average jumped from the Ellington Bridge each year as compared to slightly less than two people from the Taft.

In 1985, after a rash of suicides from the Ellington, a suicide barrier was erected on the Ellington Bridge, but not the Taft Bridge.  Opponents countered with the same argument, that if stopped from jumping from the Ellington, people would simply jump from the Taft.

But they were wrong.  Five years after the Ellington suicide barrier went up a study showed that while all suicides were eliminated from the Ellington, the rate at the Taft barely changed, inching up from 1.7 to 2.0 deaths per year.  What’s even more interesting is that the total number of jumping suicides in Washington dropped by 50%, or the exact percentage the Ellington had previously accounted for. So people stopped from jumping from the Ellington did not jump from other locations.

Coming back to our model that small external factors can have large influences on behavior, you might wonder why the Ellington was the suicide bridge instead of the Taft.  It turns out that the height of the railing was what made the difference. The concrete railing on the Taft was chest high, while the concrete railing on the Ellington (before the barrier) was just above the belt line.  One required a bit more effort and a bit more time to get over and this tended to reduce the impulsive action of jumping.

Which brings us to guns. Although guns account for less than 1% of all American suicide attempts, because they are so lethal, they account for 54% of successful suicides.  In 2005 that meant 17,000 deaths.  It turns out there when you compare states with high rates of gun ownership to states with low rates of gun ownership; you find that there is a direct correlation between the rate of gun ownership and the rate of gun suicide.  This is not surprising.

What is more surprising is that in the states with low gun ownership, the rates of non-gun suicide are the same as those states with high gun ownership.  So the lack of availability of guns does not encourage people to find other means of harming themselves.  Studies show that the total suicide rate in high gun ownership states is double that of in low gun ownership states.  So the Supreme Court, in their recent ruling regarding Washington, D.C.’s ban on handguns, may have missed the more important data when they focused on homicide rates.  From these studies scientists conclude that a 10% reduction in firearm ownership would result in a 2.5% reduction in the overall suicide rate.

I am not anti-gun. I like shooting, and if I were a hunter, would probably own a rifle.  But this is why I don’t own a gun, and this is why I don’t recommend that most people own a gun.  All of us are potentially subject to dark moments of the soul, and the research detailed in this New York Times article suggests that the more barriers and impediments there are to impulsively harming ourselves, the less likely we are to try.  If you do own guns, at least try to create barriers and delays such as keeping the guns locked up in a gun safe, keeping ammunition separate from the guns, or even not keeping ammunition in the home where guns reside.  Not only does this protect you from those dark moments of the soul but it may also protect someone you love, your spouse, or your child.

Again, I highly recommend a careful reading of the original article, as it has much other information that is useful and interesting.

In answering the question of the title, I have to say that reading this article convinced me that we should build a suicide barrier for the Golden Gate Bridge. Yes, it would lower the beauty of this gorgeous bridge, at least for pedestrians, but I have to believe that saving another 2000 lives trumps a pretty walk across the Bay.

Copyright © 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Is “Married Sex” an Oxymoron? (and Other Myths of Sexuality)

Recently I’ve been thinking a lot about sex. (That sounds bad, doesn’t it?)

It’s not what you think. My own life in that respect is just fine, thank you! But in the couples counseling work I do, sex is a big deal. Most of the couples I work with are married, and most of them are not having much sex. Some are not having any sex. Is “married sex” an oxymoron? And why?

It is remarkable how easy it is for couples to get out of the habit of having sex. As part of my general screening/evaluation interview with new couples, I always ask, “When was the last time you two had sex?” I’m often stunned when they can’t remember, not because they are suffering memory impairment, but rather because it has been that long. It’s not uncommon that it has been more than a year, or even more than several years.

What’s surprising is that most of the couples I see are not coming to therapy for help with sexual issues. You could argue that I don’t see a representative sample of couples, and I would agree. But even amongst my friends who are married, sex is a relatively rare phenomenon.

Recently the New York Times had an interesting article called “Yes Dear. Tonight. Again” about two couples who faced a similar sexual drought in their marriages, and who had an unusual response. One couple, the Muller’s, decided to have sex 365 days in a row. The other couple, the Brown’s, went for the more reasonable 101 days (or nights). The Muller’s book is called “365 Nights”, and the Brown’s book title borrows from the famous Nike line; “Just Do It.”

I haven’t read either book. What I found interesting was that both couples reported that their overall relationship improved by having more sex. It turns out that there is a high correlation between marital satisfaction and the frequency of sex. No one really knows if more sex makes people happier, or happier couples have more sex, or both.But the couples who wrote these books add a data point to the notion that more sex makes people happier.

How often do married people have sex anyway? From the Times article: “According to a 2004 study, “American Sexual Behavior,” by the National Opinion Research Center at the University of Chicago, married couples have intercourse about 66 times a year. But that number is skewed by young marrieds, as young as 18, who couple, on average, 109 times a year.” So the youngest of couples are having sex about twice a week. And older couples are having sex quite a bit less, perhaps less than once a week. And some couples are having much less sex, such that they could count the number of times per year on two hands, without using toes!

So let’s assume that the causal relationship works in both directions—happy couples want to have more sex, and more sex makes couples happier. What can we do about this? Helping couples to be happier is outside the scope of this article, and is something that often takes couples therapy. But what about the other side of the equation, that of having more sex?

First of all, we need to consider some myths of sexuality. The first myth is that sex shouldn’t be planned and scheduled. I don’t know where people get this idea, because we plan and schedule everything else good in our life. We buy concert tickets months in advance, we make reservations at good restaurants, we plan to attend our children’s school play. We plan to go to work each day.

Imagine if we applied the same model to daily life as we use with sex: “You know, honey, I just don’t feel like driving the kids to school today. I ate too much as breakfast, and I kinda feel fat, and getting behind the wheel will make me feel bad.” “Yeah, I don’t really feel like going to work today. I’m a little tired. I think I’ll just stay home in bed and sleep all day.”

This is what I call the Myth of Spontaneity. We wait for the sun and the stars and the moon to line up for both people in the couple, and then and only then can we consider sex. If anything else then gets in the way like kids or telephone or dogs, forget it. Waiting for everything to be ideal for two people greatly lowers the odds of having sex at all.

Instead, I suggest that couples make sex dates. (Or call them pleasure dates.) Sit down and talk about how much sex you would like to be having. What’s the optimal frequency for each of you? Compromise if you have different answers. Then pull out your calendars, and figure out times when you can plan to have sex. Consider other distractions like children, pets, jobs, etc. Every couple should be able to find at least one time a week where they have some time and some privacy to get intimate.

Then make it happen. As the Browns would say, Just Do it! No excuses. If you find there is always something getting in the way, consider what the issues are. Are there other resentments that are being expressed sexually? Are there sexual issues that need to be talked about and worked on? Are there issues of appearance or hygiene that can be addressed? Sit down and talk about what’s getting in the way, and if you can’t do it alone, then see a therapist to help talk it out.

Another myth is what I call One Size Fits All. This means that couples often think of having sex in terms of a standard sexual script; a little foreplay, maybe a little oral sex, a few minutes of intercourse, and off to sleep afterwards. It is a full course meal or nothing at all. The antidote for this myth is to have a varied repertoire of sexual activities you both enjoy. Perhaps sometimes it is okay to have a quick snack, instead of the full meal, so to speak. If one person is tired, and one is feeling more amorous, maybe the tired person can be pleasured by the amorous one. Again, it helps to talk over these options. What do each of you like to do when you are not that sexually energetic? And sexy cuddling is okay too. Maybe you fool around a little, skin to skin, and no one orgasms, and that’s fine too.

Still another myth is what I call Not Tonight Dear. This is the idea that it’s fine to turn down sex whenever you don’t really feel like it, since after all, you wouldn’t want to have sex if you don’t feel like it. The problems with this belief are multiple. First of all, most people are very sensitive about being rejected sexually. A “not tonight dear” crushes them. And then they are less likely to initiate the next time. Second, if both people say “no” often, it dramatically lowers the chances that the couple will ever have sex. And both people will decrease how often they initiate, further lowering the probability of successful sexual connecting.

What is the antidote? First of all, try to limit saying “no” to the extreme examples. If you are having a massive migraine headache, food poisoning, or something similar, I think it is fine to say no. The “no” response should be rare, less than once in ten times. In the Brown’s book “Just Do It” there is a story of one time that the husband was having a vertigo episode, but they still had sex!

Second, it is okay to say yes in a limited way. For instance, let’s imagine you don’t feel very turned on. I think it is okay to say something like, “You know, I’m not feeling very sexual right now, but I’m willing to play a little and see if that changes. Is that okay with you?”

Finally if you really do need to say no, then offer a specific alternative time and place. For example, “I’m really tired tonight, honey, and I’d really rather make love tomorrow morning, is that okay?”And be affectionate and loving when you say it.

So let’s review. If you want to make sure that “married sex” is not an oxymoron in your life, then follow these guidelines:

1.Plan to have sex. Make dates to have sex, and keep the dates. Decide on your sexual goals, and then figure out the best times to schedule your “pleasure dates”.

2.Be flexible about the kinds of sexual encounters you can have. Sample from a varied menu of sexual options, and don’t be all or nothing about sex. Even sexy cuddling can be a type of sex, and is better than nothing. Not all sex needs to result in orgasm for both or even one partner.

3.Avoid turning down sex more than infrequently. To paraphrase the Brown couple, Just Say Yes. This lowers the probability of hurt in the bedroom, and keeps both partners willing to initiate because they know that rejection is infrequent.

4.Talk about your sex life, what works, and what doesn’t work. This is the only way you can improve things. And if you are too shy or inhibited to talk about it on your own, see a good couples or sex therapist, who can facilitate this dialogue.

And having said all that, now I have to go, as I have a scheduled date with my sweetie!

(Fade to black…)

Copyright © 2008 The Psychology Lounge/TPL Productions

 

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Followup on the Science of Sleep

 


It’s been a while since I wrote, and some of that is that I’ve been trying to get to bed earlier, and get a more consistent 8 hours of sleep. Since I last wrote, I saw an interesting factoid from an interview with Daniel Kripke, who is the co-director of the Scripps Clinic Sleep Center in La Jolla, California. In this interview, he talked about research he did on more than 1 million Americans that correlated sleep and mortality. There were some surprising findings, which have been corroborated by similar studies in other countries.

The results showed that those who slept between 6.5 and 7.5 hours a night lived the longest. And that those who slept more than 8 hours a night or less than 6.5 hours a night don’t live as long. This is interesting in that most previous writing I have seen suggests that sleeping more is good for you, but these data don’t support that.

Another good point he made was that when people try to get too much sleep, because they think the normal amount is 8 or 9 hours, they may unintentionally develop insomnia. Staying in bed longer than you can sleep will result in wakefulness, and anxiety about not being able to sleep. So for those of you who only can sleep 6.5 or 7 hours, just get up, it won’t hurt your health. In fact, restricting the time in bed is a more effective treatment for insomnia than sleeping pills, according to Kripke.

What we don’t know is which direction the causality runs in this association. Does the amount of sleep you get create your health status, or is it a reflection of underlying health? Do sicker people sleep too little or too much? Or does sleeping too little or too much make you sicker? No one knows for now, so I wouldn’t necessarily rush to change your sleep habits based on this study. But if you are sleeping in the 6.5 to 7.5 hour range, you can relax and not worry about it (especially late at night!)

Now I’ve got to stay up a little longer, so I don’t get too much sleep tonight…

Copyright © 2008 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Mystery of the Obesity Epidemic: Solved? (Hint: It’s simpler than you think)

 

Was Grandma Right?

It’s been too long since I last wrote, but I’ve been catching up on my sleep. Why will become relevant after you read this article.

Sleep is something we mostly take for granted as part of our daily lives, much like eating and showering. But why do we sleep? What does sleep do for our minds and our bodies? What happens if we don’t sleep, or if we don’t sleep enough?

For those of you who are interested in these questions, I’d highly recommend that you read the transcript of The Science of Sleep, an excellent piece by 60 Minutes that aired on March 16, 2008. Not only did I learn many interesting facts about sleep, I learned about my own health and how sleep affects it. More on that later.

Why do we sleep? After all, from a survival point of view, sleep is not really a good thing, in the sense that we are unconscious and helpless during sleep. So for sleep to have evolved, then it must serve some vital functions. (I should point out though, that sleep might have survival advantages, since if early humans slept in caves and other sheltered places, sleep would have kept them out of the reaches of nocturnal predators. The folks who didn’t sleep much, and who wandered around all night, probably got eaten!)

One clue of how important sleep is in studies done in the 1980’s with rats. When rats were prevented from sleeping (did they use disco music to keep them awake?) they died after 5 days! Sleep seems to be as important to rats as food.

Let me present a quick primer on sleep. When we sleep, we actually go through multiple cycles of different stages of sleep. These stages are stages 1-4 of non REM (NREM) sleep, and stage 5 which is REM (rapid eye movement) sleep. The key stages are Stage 4, or Delta Sleep, and Stage 5, REM sleep. Stage 4 Delta sleep is the deep restorative sleep where our bodies get rebuilt and restored. Stage 5 REM sleep is when we dream, and it appears that our minds get restored during REM sleep. Typically the whole cycle takes about 100 minutes, and we have 3 or 4 of them each night.

Sleep may play an important role in enhancing memory. One study found that when people learned a new skill in the afternoon, and then were tested after a night of sleep, they did 20-30 percent better than those who were tested after twelve hours, but with no sleep in between the learning and testing. This is fascinating, and jibes with a trick I learned in graduate school. When I would study statistics, I’d always review my notes right before going to sleep. The next morning, the memories of those notes were imprinted magically in my mind.

Sleep also plays a critical role in stabilizing mood. One experiment tested people who were sleep deprived by showing them disturbing images within an fMRI scanner, to look at their brain activation. They found the sleep deprived subjects had a disconnect between the brain’s emotional center (the amygdala) and the part of the brain that controls rational thought (the frontal lobe). So they couldn’t control their emotional reactions. They looked more like psychiatric patients. Of course we all know that sleep deprivation makes us cranky and short-tempered, this explains why.

Another important function of sleep is physical rejuvenation. It appears that Stage 4 sleep is essential here. In the 60 Minutes piece they show an experiment where a young man named Jonathan is deprived of only Stage 4 sleep. Each time his brain waves show Stage 4 sleep, loud sounds are played to bring him out of deep sleep. He gets a normal amount of sleep, but a reduced amount of Stage 4 sleep. After 4 nights of this regimen, this 19 year old is starting to look physically like a 70 year old. His body becomes no longer able to metabolize sugar effectively, putting him temporarily at increased risk for Type 2 diabetes.

Other studies confirm this. After just a few nights of partial sleep deprivation, young healthy people show a metabolic change that is similar to what happens as people develop Type 2 diabetes. They no longer metabolize sugar effectively. They deposit more fat. The hormone leptin, which controls appetite, seems to drop, and they want to eat more.

This is truly astonishing. If relatively short term sleep deprivation can cause such a profound shift in the body’s sugar metabolism, then this may be the key to unlock one of the great medical mysteries of the 20th century: Why obesity has increased so rapidly since 1980? Could it be that the obesity epidemic is really a sleep deprivation epidemic? Could it be so simple? Not junk food, television, lack of exercise, and all of those things that people talk about? Could grandma have been right?

Here’s the clue.

In 1960 a survey of a million Americans showed an average of 8.0 hours of sleep per night. Today similar studies show we are only getting 6.7 hours a night. That’s a drop of 16.25% in less than a generation. And teenagers are the most sleep deprived of all, since they require 9-10 hours of sleep, and most get less than 7 hours of sleep, thanks to ridiculously early school start times. Teenagers may be lacking between 22 percent and 30 percent of their needed sleep.

So we have a plausible explanation for why everyone, even children and teenagers, is getting fatter. Sleep deprivation causes shifts in metabolism, creating a pre-diabetic state, and lowering level of the satiety hormone leptin, which causes us to eat more, and store more fat. Add sugary or high carbohydrate foods, and we get even fatter. Add inactivity, and we get even fatter. The damage begins early, perhaps in early teenage years.

So if we want to lose weight, then the old saw of a healthy diet and plenty of exercise may be wrong. The proper advice is probably lots of sleep, a reasonably healthy diet, and a little exercise. Or since exercise improves sleep quality, sleep, exercise, and diet. Without adequate sleep, diet and exercise are doomed to failure, since even young people may unintentionally be turning their bodies pre-diabetic, which makes it very hard not to gain fat.

So that’s why I haven’t written. After a lifetime of staying up late, and cheating sleep, I’m starting to try to get a solid 8 hours of sleep a night. Already I’ve lost a few pounds, even though I haven’t been exercising much. The other advantage of going to bed earlier is that when you are sleeping you are not eating.

So try it. Get 8 or 8 1/2 hours of sleep a night. And make sure your teenagers get 9 or 10 hours a night. No more websurfing or TV late at night. And write me and let me know if your weight drops as a result.

Now I’ve got to stop writing and go to sleep…

Copyright © 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Neuropsychology of Long Lasting Love: Can Brain Scans Tell Us Something Useful About Staying in Love?


The Wall Street Journal today has an article called Keeping Love Alive, which documents some fascinating research looking at why a small minority of long term couples seem to maintain intense passionate loving connections.

First the grim background to these findings. Keeping love alive is no mean feat, as the research on long term relationships suggests that for most couples love is a fading affair.

From the article:

“Each year, according to surveys, the average couple loses a little spark. One sociological study of marital satisfaction at the University of Nebraska-Lincoln and Penn State University kept track of more than 2,000 married people over 17 years. Average marital happiness fell sharply in the first 10 years, then entered a slow decline.”

This is not such good news for all of us in long term relationships. What do we have to look forward to? A sharp decline in happiness for the first ten years, and then a slow erosion of whatever remaining happiness is left, until either we run out of love or time, whichever comes first? Ugggh!

But then to the rescue comes Arthur Aron, who is a social psychologist at Stony Brook University. He’s looked at those unusual couples who claim that their love is just an intense years later. It’s a strategy of research which is called examining the outliers, those people who fall outside the averages.

Aron and his students are studying these couples in an interesting way. They are taking pictures of their brain function, using magnetic resonance imaging (MRI). They have a person lie inside an MRI machine, and look at pictures of their spouse, while measuring the activity in their brain.

What have they found? It turns out that when these passionate couples look at or think about their spouses, a part of their brain called the ventral tegnmental area lights up. This is a section of the brain that is rich in the neurotransmitter dopamine, which is connected to our ability to feel pleasure and joy. The results have been duplicated in China, suggesting this is not just a western cultural phenomenon.

So what does this all mean? It’s not of much help in the challenges that I face as a marriage therapist, in helping couples repair damaged love. One of the interesting details reported in the article was that these passionate long term “in love” couples show one behavior in common. They are constantly affectionate, kissing, hugging, and holding hands. They display many PDA’s (public displays of affection).

Now that there is a brain measure of this intense love, what is more important is to study how people get there. Are these couples just more intensely in love to begin with? Perhaps it is like cognitive function, where those who start off smarter and more educated deteriorate more slowly in old age. Maybe these passionate couples simply start with more love, and show erosion, but they have such an excess that it doesn’t matter.

We might be able to answer some of these questions with a long term longitudinal study of new couples that followed them over 10 years or longer.

Is it a selection process, where better mate selection leads to better long term outcomes? Or are there behavioral differences, a set of behaviors and attitudes that preserves love? These are the key issues in answering the question of how do we go about Keeping Love Alive.

What I find deeply fascinating is that in spite of the fact that most people value love as one of the most important things in their lives, we actually know very little about what predicts success, and even less about how to help people love better. Brain scans may tell us more about the process of love and attraction, but unless we develop a “love beam” that changes the activity of the key brain regions, it won’t help us fall in love and stay in love.

…Excuse me, I’ve got to go kiss my sweetie!

Copyright © 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Secrets of How to Get Moving (Especially When You Are Stuck)

In a previous article I wrote at length and I admit, rather philosophically, about getting things done. In this article I am going to do something a little different. Clients often ask me for specific tips to help them get moving. We’ve all had the experience of being completely blocked, seemingly unable to get anything done, and struggling to get moving. Some of this is mood and energy based. When we are tired, sleep deprived, or blue, it’s hard to motivate to do anything, especially tasks that are not fun or interesting. But life demands that we function even under these circumstances, so here are 5 tips for how to get moving when you are blocked.


1. Priming the Getting Things Done Pump

The first secret is to prime your “getting things done” pump by getting something done, anything. Pick a small task that you’ve avoided or failed to do for a long time. It can be anything. It should take no more than 5 or 10 minutes to complete. The key here is that you are going to complete something, and it’s something you’ve been avoiding for a long time.

I picked a Microsoft Class Action legal settlement form that entitled me to $125 in rebates on computer products. I had sent it in a long time ago, but it had been rejected and returned on a technicality. I pulled it out, found an appropriate receipt to attach it to, and put it in an envelope, and mailed it. Time? About 8 minutes. Not only did I get something done, but I made $125 in 8 minutes, that’s $937 per hour!

The principle is to get something done, which flexes your “getting things done” muscles. By picking something you’ve avoided for a while, you get an even bigger kick.

2. The Smallest Piece Technique

You can use a related technique even for a huge and complicated tasks that we all tend to avoid starting, and thus never finish. If you have a huge task, break it down into component pieces. Then pick a very small piece, a piece that will take 5 to 10 minutes, and do it.

This breaks the ice, and gets you moving on the big task. Often once you’ve done the first small piece you can then do more pieces. Often it is best to use a pump priming strategy here. Pick the smallest piece there is, and get it done. For instance, if you want to do your taxes, you might simply set the task of pulling out your tax folders, and putting them on your desk. That’s it, you are done. (But now you want to do more, don’t you!)

This also works well for getting started with exercise. Rather than saying to yourself, “I’m going to take a 1 hour walk”, and then doing nothing, decide to take a 5 minute walk. Once you are outside and walking, you probably will find yourself walking for more than 5 minutes. The key is to set the task of walking 5 minutes every day, and then you break down your resistance.

3. The Dice Man (or Woman) Technique

The next technique is a good one if you find yourself frozen with indecision. You have a many important tasks to do, and you can’t decide which one to do first. You are like an octopus that is pulled in many different directions by each of its tentacles, and hence is frozen in place completely.

In this case, use the Diceman strategy. The The Dice Man is the title of a comedic novel published in 1971 by George Cockcroft under the pen name Luke Rhinehart, in which a psychiatrist begins to make all his life decisions using a set of dice. (It’s a wild novel, and pretty interesting.)

To use this strategy, make a short list of the some of your main tasks. Number them 1-6 or 1-12. Then throw one or two dice, and do the one that the dice indicates. Or you can throw darts at the list, or even just toss a penny onto the list, and do the task the penny falls upon.

What this does it to short-circuit the part of your brain that is trying to prioritize many equally important tasks, and gets you moving and finishing a task. Often, once you do this, it is much easier to continue picking tasks and doing them.

4. The Entertainment Strategy

What about those tasks that are just plain boring? For instance, like filing, or unloading or loading the dishwasher. The best way to do these tasks is to pair them with some other activity that is fun.

For loading or unloading the dishwasher, you could use a phone with a hands-free headset, and talk to someone you like while you take care of the dishes. The same technique is useful for straightening up the house.

For filing, this is also a good technique. Another approach is to do the boring task while watching or listening to some entertainment. I find baseball and football games on television perfect for tasks like filing. Both have many slow points, which allows me to get a lot done without missing key points. Listening to a good show on the radio also works.

5. When All Else Fails, Bribe Yourself!

Another way of getting unpleasant boring tasks done is to pair them with specific rewards. For instance, let’s say you have a big task to do like doing your taxes. This is a task that takes a couple of days. Before you start, set yourself a specific reward once you have finished. It could be that you get to buy something for yourself. Or go do an activity that you like. The key is to make sure that the reward is big enough to motivate the task. Telling yourself you get to eat a piece of pie after spending two days doing taxes won’t work. It probably will take something bigger, and not pie! I call this strategy “paying yourself to get things done.”

So there you have it. Five quick ways to explode your resistance and get something done! Good luck!

I have to go now, and pay one bill.

Copyright 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Protecting Your Brain (and Your Heart) With Fish Oil

Protecting Your Brain (and Your Heart) With Fish Oil

A fascinating idea is how to protect your brain using simple nutrients. Can we protect our brains from depression, Alzheimer’s, even stroke using simple nutrients or over the counter supplements?

The Wall Street Journal just published an interesting article about using fish oil to treat or prevent a variety of illnesses. They even summarize the findings with recommended doses of fish oil. For instance, to prevent heart disease, they recommend one gram of EPA or more per day. For optimum brain health, take one half gram of DHA or more. Even Rheumatoid arthritis may respond to 2 grams or more of fish oil.

Fish oil contains omega-3 fatty acids, of which there are two main ones; EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid). Repeat after me if you want to really impress your physician: “eye-coh-sah-pent-ah-eh-no-ick  acid” and “doh-coh-sah-hex-ah-eh-no-ick acid”. Now you see why articles always say EPA and DHA!

There is a very interesting tie in with DHA and Alzheimer’s disease, as explained by an article on medicinenet.com.  It turns out that people with Alzheimer’s disease (AD) tend to have low levels of a brain protein called LR11, and about 15% of those with AD have a gene mutation that reduces LR11. LR11 works to clear the brain of amyloid proteins, which are implicated in the production of beta-amyloid plaque that clogs the neurons of those with AD.  Scientists tested DHA in rodents and in cultures of brain cells, and found that DHA causes higher production of LR11.

So should you be taking fish oil capsules, and how many, and which brand? I’d say if you eat oily fish like salmon 3 times a week or more, don’t worry about it. But for the rest of us (all of us?) it may make sense to add fish oil capsules to our vitamin regimen. A 1999 Italian study found that adding 3 capsules a day reduces the incidence of sudden cardiac death by 45%! The subjects in this study mostly also took baby aspirin, which may work to increase the effects of fish oil.

I’d certainly talk to your doctor about it. Be sure to print out the Wall Street Journal article, which demonstrates that there were few if any side effects. Some doctors think taking fish oil will make you bleed more easily, but studies of very high doses haven’t found this. In fact, the main side effect is belching fish smells, but I have found this is dependent on the brand and type of capsules you take.

Here’s a quick rundown on what to look for in fish oil capsules. First of all, they vary as to how much of the essential ingredients they contain. Most capsules contain 1 gram of oil, but much less Omega-3 fatty acids EPA and DHA. Some contain as little as 200mg. of the Omega-3’s, which means you have to eat  a LOT of capsules to get much EPA or DHA. Often the bottles will mislead you by citing the amount per serving, and when you look more carefully you will see that one serving is 3 or 4 capsules!

So you want as high a concentration of EPA and DHA as possible. You also want fish oil that has been molecularly distilled to remove any possible contaminants such as pesticides, dioxin, etc.

Although I rarely make product recommendations, I heartily recommend Trader Joe’s Fish Oil capsules. Priced at $7.99 for a bottle of 100 capsules, these capsules are molecularly distilled, and contain 300 mg. of EPA, and 200 mg. of DHA per capsule. That means that 2 capsules make up 1 gram of Omega-3’s.  So it is easy to take 1 or 2 grams of Omega-3’s per day, at an affordable cost. These compare favorably with much more expensive brands of omega-3 capsules.  Another trick is to store these in the refrigerator, so the oil doesn’t turn, and occasionally break open a capsule and smell it. Although it may have a slightly fishy smell, it should smell rancid or strong.

So there you have it, a simple way to reduce heart disease, autoimmune disease and inflammation, and improve brain health. Cost? About $0.16  per day for 2 capsules.

As always, as I am not a physician, and certainly not your physician, talk to your doctor and do your own research before consuming more than a capsule a day of fish oil.

Copyright 2008 The Psychology Lounge/ TPL Productions 

All Rights reserved (Any web links must credit this site, and must include a link back to this site)

 

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Scientists Try to Discover the Earliest Signs of Alzheimer’s disease (Is Alzheimer’s a Lifetime Genetic Disease?)


Today’s New York Times has a fascinating article about current research in Alzheimer’s called Finding Alzheimer’s Before a Mind Fails. It is simultaneously encouraging and deeply disturbing.

The encouraging part is that researchers are discovering ways to examine patients that can find evidence of Alzheimer’s many years before the disease manifests itself in symptoms. A radioactive dye call Pittsburgh Compound B (PIB) is injected into the patient. This dye attaches itself to amyloid plaques in the brain, and then these can be seen by using a Positron Emission Tomography (PET) scan.  Studies using PIB have found the astonishing fact that amyloid plaques are found in 20-25 percent of people over 65 who appear normal! If the amyloid hypothesis is accurate, then many of these people will go on to develop Alzheimer’s disease.  Using PIB testing we could predict more accurately who will develop the disease, and perhaps develop prevention methods much like we give statins to heart patients who have plaques in their arteries. This is encouraging.

Someday in the future hopefully we will be tested for early signs of Alzheimer’s disease in our 40’s, and those who at risk given medications that will prevent it, just like we do for heart disease now. This would make aging much less scary.

Current Facts About Alzheimer’s disease

But the current facts about Alzheimer’s are less encouraging. It is the sixth more common cause of death by disease in the U.S. Five million people over 65 have Alzheimer’s disease. Estimates suggest that perhaps as many as 16 millions will have the disease by 2050, which is a staggering number that would bankrupt the health care system. (Of course, this assumes that in 43 years we have made no progress in the treatment and prevention of Alzheimer’s disease, which is absurd.)

Costs are already staggering–$148 billion dollars per year, and are increasing every year. Why? Here’s the dark truth. Alzheimer’s disease is a disease of the elderly. Almost 40 percent of those who live past 85 will eventually develop Alzheimer’s disease. The problem is that medical improvements are curing the diseases that used to kill us well before 85. One of the reasons Social Security starts at age 65 is that until recently, most people didn’t live much past the age of 65. Now as we defeat cancer and heart disease, and people stop killing themselves with diet and smoking, we are living into our 80’s and 90’s.  And getting Alzheimer’s disease.

What is Alzheimer’s disease?

Let’s talk a little more about what Alzheimer’s disease really is. Everyone worries about Alzheimer’s disease as they age. But some forgetfulness is completely normal. (We hope.) There is a old joke about Alzheimer’s disease which actually is a useful rule of thumb, it’s not a big deal if you forget where you put the car keys, as long as you can remember what keys are for. It is significant changes in memory and problem solving that are more worrisome.

When does Alzheimer’s disease begin?

This is a mystery currently. Conventional wisdom says that Alzheimer’s disease may begin a few years before symptoms appear, but some scientists question this. Because the brain has a lot of spare capacity, it may take years of deterioration before we lose enough brain function to notice. This may explain one of the common findings that the more highly educated (and probably more intelligent) develop Alzheimer’s disease as  a lower rate. They may have more spare capacity. If you start off with an IQ of 150, and lose a third of your brain functioning, you end up with an IQ of 100, and can still function. Start at IQ 100, lose 1/3, and you now are functionally retarded with an IQ of 66, and you won’t be able to live independently.

One scientist, Dr. Richard Mayeux, who is a professor at Columbia University, says, “I think there’s a very long phase where people aren’t themselves.”

If Dr. Mayeux asks family members when a patient’s memory problem began, they almost always say it started a year and a half before. If he then asks when was the last time they thought the patient’s memory was perfectly normal, many reply that the patient never really had a great memory.” (New York Times)

This is interesting and disturbing stuff. Other research finds that people who later develop Alzheimer’s disease showed lower intelligence scores even early in life, suggesting that perhaps Alzheimer’s disease is a genetic disorder that affects the brain in subtle way even early in life. If this is true, then the data on highly educated people may have been interpreted in a backwards way—instead of higher education preventing Alzheimer’s disease, it may be that Alzheimer’s disease prevents higher education!

 

Treatment of Alzheimer’s disease

Currently there are drugs that address the symptoms of Alzheimer’s disease, but no drugs that address or slow the underlying disease progress. The good news is that there are numerous studies attempting to find drugs that will actually address the underlying disease process in Alzheimer’s disease. The bad news is that no one really knows exactly what that underlying disease process is.

There are two finding from examining the brains of those with Alzheimer’s disease. The first is that they show plaques of beta amyloid between the nerve cells of the brain. The second is that the brains show tangles inside nerve cells made of a protein called tau. This damaged tau kills the nerve cells because they no longer get nutrients.  Both these are well-established facts, but no one knows what is the relationship between beta amyloid and tau, and how much each contributes to Alzheimer’s disease.

 

What Society Should Do About Alzheimer’s disease?

So what can we as a society do about Alzheimer’s disease? My grandfather used to say, “Everyone dies, so it’s just a matter of how you die.” By choosing to treat or prevent heart disease and cancer, are we choosing to die from Alzheimer’s disease?   This is a scary thought.  It’s clearly worse to outlive your mind than to outlive your body. And Alzheimer’s disease puts huge burdens on society and caretakers. Maybe we should start a campaign to encourage cigarette smoking in the elderly! (Or motorcycle riding, but this might make the roads a bit dicey.) 

More seriously, we are in the unfortunate window of time where we have successfully improved longevity without really addressing this core disease of longer life, Alzheimer’s disease.  Society desperately needs to find an Alzheimer’s disease cure or preventative treatment. Without this we will as a society incur great costs and individual suffering. I believe that this should become a top priority of private and government research spending. First we need better basic research to find out what the disease process of Alzheimer’s disease looks like. Then we can develop effective drugs to block or reverse that disease process.

In the meantime, all we can do is not worry too much, since stress may damage the brain. Eat healthy, exercise, maybe take some anti-oxidant vitamins, and hope that science can solve this puzzle so we can get old without losing our brain function.   

As for me, I aspire to these not-so famous words of the comedian Will Shriner, “I want to die in my sleep like my grandfather… Not screaming and yelling like the passengers in his car.”

 

Copyright 2007 The Psychology Lounge/ TPL Productions, All Rights Reserved

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How to Stop Anger in its Tracks: Applying the SAP™ Model in Three Easy Steps (Part 2)

In my previous article, How Anger Works: The SAP™ Model (Part 1), I wrote about the SAP™ model, which stands for Shoulds, Awfulizing, and Personalizing. In this article I want to teach you basic anger management skills that will help you to neutralize anger.

Background Concepts About Anger

I should point out a couple of important concepts about anger first. A simple way of conceptualizing anger is that it is related to the amount of difference between our expectations and reality. The larger the difference, the more anger and frustration we experience. Thus if I expect a 10 percent raise, and I only get a 5 percent raise, I will be more angry (and disappointed) than if I got a 9 percent raise.

This leads to an obvious point. To decrease anger and frustration, we need to lessen the difference between our expectations and reality. There are two ways of doing this. One is to change reality so it better conforms with our expectations. The other way is to change our expectations so they better conform with reality.

Here is where it gets tricky. Which should you try to change, reality or your expectations? It depends. When it’s possible and easy to change reality, it makes sense to do so. If you don’t like rush hour traffic you can leave earlier or later to work. Or if you have been dating someone for a few weeks and they consistently annoy you, break up with them. It’s easy, and solves the problem. Or if you have an abusive boss, and you can relatively easily transfer or find another job, do it!

But what if you are angry at your wife or husband of many years? Or at your children? Or you feel angry at the fact that Republicans have run the country for 8 years. These are much harder to change, and more costly. So in cases where you either can’t easily change reality or you don’t really want to change reality, then you need to adjust your expectations. Instead of happiness meaning getting what you want, it can mean wanting what you’ve got.

The famous Serenity Prayer summarizes these concepts elegantly: In Latin, “Deus, dona mihi serenitatem accipere res quae non possum mutare, fortitudinem mutare res quae possum, atque sapientiam differentiam cognoscere.” Or in English, “God, grant me the serenity to accept the things I cannot change; the courage to change the things I can; and the wisdom to know the difference.”

I like to use the “80 Percent Rule” in determining whether my expectations are reasonable ones or not. If 80 percent of the time, my expectation matches reality, then it is okay to hold onto that expectation. Therefore, if my friend Hugh is on time for our dinners 80 percent of the time, it is okay for me to expect that. But if he is only on time for dinner 20% of the time, then I need to change my expectation, or change friends.

Step One: Defusing Anger by Changing your Shoulds

The first step in reducing anger is to change your “shoulds”. What is a should? We tend to assume that it is a universal law, but in reality, it is simply our personal demand on the universe. If I have a should that says, “People should always treat me fairly,” this is really just a different way of thinking “I want everyone to treat me fairly all the time.”

The first step to defusing anger is to change your shoulds into preferences. Instead of thinking “My wife should not spend so much money on clothes” you would think “I would prefer she not spend so much money on clothes.” Simply doing this reduces the intensity of anger significantly. You are owning your beliefs, instead of putting them into some imaginary universal law. If they are your beliefs, then you can choose to alter them.

Try a mental experiment. Think of something that makes you mad. Identify one of your shoulds that has been violated. Say the should to yourself a number of times, and notice how angry you feel. Now transform it to a preference statement. Instead of “They should _____”, it becomes “I would prefer that they ________”. Notice what happens to the intensity of the anger.

What you will notice is that the intensity of the anger diminishes. It doesn’t disappear, but it does transform in intensity. Why doesn’t it go away entirely?

This is because even our preferences may be distorted. Let me give you an example. I live in the Bay Area, where traffic tends to be quite heavy and slow at rush hour. Let’s imagine that I have the should statement, “I should be able to drive at 65 mph on the freeway, even at 5:30pm.” This should is likely to frustrate me when I am stuck in 25mph traffic. So I turn it into a preference, “I’d prefer to be able to drive 65 mph at 5:30pm.” This doesn’t really help very much. I’m still going to be frustrated because there is a large gap between my preference and reality.

Here is where applying the “80% Rule” is helpful. I ask myself if my preference is true 80% of the time. The answer of course is no. Perhaps only 10% of the time does traffic flow well at rush hour. Thus even my preference violates the 80% rule.

So I need to change my preference. A more reasonable preference would be “I prefer that traffic moves at 25 mph during rush hour.” Now there is a better match between my preference and reality, and I will not get as frustrated.

So, to summarize Step One, first you turn your Should Statements into Preference Statements. Next, evaluate the preferences using the 80 percent rule; does reality match this preference at least 80 percent of the time? If not, change the preference. This should at least lower your anger level, if not eliminate it.

Step Two: Defusing Anger by Putting Things Into Perspective and Emphasizing Coping

The next step of the SAP™ model is Awfulizing. Here we tell ourselves, “It’s awful and terrible, and I can’t stand it.” This creates a lot of internal psychological stress, and intensifies our feelings of anger and helplessness.

How can we change these patterns of thought? We can do so by putting the problem into perspective. On a 100 point scale, how awful is it really? Imagine that a 100 represents having a leg cut off without anesthesia, or a root canal without Novocain. Then rate how terrible is it to not have your should or expectation met. So if I am stuck in a traffic jam, and no one is shooting at me, and there is no blizzard outside, how awful is it really? Maybe a 10 on the 100 point scale.

Most frustrating events are actually relatively minor in the grand scheme of things. But we lose perspective, and this creates anger and stress. Another trick is to ask yourself if you will remember this event in one month, one year, or five years. If the answer is no, then it’s really not very awful.

The other aspect of this is the second part of the awfulizing statement, which is “I can’t stand it.” How often do we say this to ourselves? I define “not standing it” as meaning that you are going insane, hallucinating, curling up in a catatonic ball, or standing on the roof of a building getting ready to jump. Anything less than that means that you are actually standing it!

So what you want to do is replace “It’s terrible and awful, and I can’t stand it,” with “It’s inconvenient, or a hassle, and I don’t like it, but I can stand it.” This will greatly alter your emotional response.

So to summarize the second step in anger management:

  1. Ask yourself “How awful is this really?” Rate the awfulness on a 100 point scale, where 100 is something truly awful, like a serious injury or death of a loved one. Put the event into perspective.
  2. Remind yourself that most events will be quickly forgotten, and that most things in life are really hassles or inconveniences, rather than genuine disasters. Substitute the phrase “It’s a hassle, and I don’t like it but I can stand it,” for the Awful-izing statement of “It’s awful and terrible and I can’t stand it!”

Step Three: Defusing Anger by Reducing Personalizing

The final step in defusing anger is to de-personalize events. Remember from the previous article, that personalizing an event greatly intensifies the anger. If I believe that someone is purposely doing something to hurt me, I will get much angrier than if I believe it is an impersonal event.

This is easy to say, not so easy to do. The trick here is to realize that most of the time, when people don’t meet your shoulds or expectations; they are not doing it to harm you. When the clerk ignores you in the store, it’s more likely that they are tired or stressed than they saw you and thought, “Gee, I think I will piss off Dr. Lounge Wizard by ignoring him as long as possible.”

But what about people we love. Don’t they purposely hurt us?

Probably not. Most of the time, when loved ones do things that we are frustrated by, it is because that’s their nature. For instance, a messy person is messy because it is their nature, and it’s not because they are trying to anger their neat spouse. (Believe me, I know.) Everyone is trying to do the best they can, and pretty much doesn’t worry about you, or plan to hurt you.

So the secret is to simply assume that most things aren’t personal, and even when they appear to be, to reframe it as the person’s nature. A critical boss is critical of everyone, in most cases. A bad driver in front of you is probably always a bad driver, even when you are not behind them!

To summarize Step Three, remember than most of the time, no one is out to get you. They are just doing their natural thing. Use compassion, and think gentle compassionate thoughts that other people are flawed, but this isn’t personal.

So there you have it; the Three Steps to Anger Management. Try it out. I suggest you keep an anger/frustration log, and write down the S.A.P’s and then write down the counter thoughts for each step.

Copyright 2007 The Psychology Lounge™/TPL Productions All rights reserved

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How Anger Works: The SAP Model ™ (Part 1)

In this article I will give you a simple cognitive behavioral explanation of how we get angry, and how you can use this knowledge to short-circuit and defuse your own anger. Anger is probably the most cognitive of all of the emotions. We can’t get angry without thinking. And most anger directly stems from our distorted thoughts.

There are three cognitive steps to getting angry. The first two are absolutely necessary for anger, and the third is like gasoline on fire, it intensifies anger. The acronym for remembering these three steps is SAP(tm), which is what anger will make you if you think these thoughts.

To help illustrate this lets consider a common situation where a person might get angry. You are driving on the freeway and a car cuts you off. You instantly react with anger. You steam all the way to work.

STEP ONE: VIOLATION OF SHOULDS or “SHOULDY THINKING”

The first step to getting angry is that you must have a set of shoulds or expectations that have been violated. Without this there is no anger. In the driving example what are your expectations? You tell yourself that the other driver shouldn’t have cut you off. He or she should have looked first and seen you. Obviously this should has been violated. This is what some cognitive therapists call “shouldy” thinking!

STEP TWO: AWFULIZING

But just having a set of shoulds or expectations is not enough to generate anger. The second step is necessary. In this step you exaggerate the negative consequences of the violation of the shoulds. You tell yourself it is awful and terrible that this event has happened. In our driving example your self talk is “Wow, the idiot could have killed me. It’s awful and terrible that they allow people like that to drive. Grrrrrr!” This step is called Awfulizing. Or Terribilizing, if you prefer. The key distortion is that you blow the event out of proportion. After all, if you are able to have these thoughts, then obviously no serious accident has ensued.

STEP THREE: PERSONALIZING

The first two steps will get you mad, but the third step of Personalizing or Blaming will make you crazy angry. If you tell yourself that the person didn’t see you, and it was an accident that they cut you off, you may still get angry. But if you tell yourself they did see you and purposely chose to cut you off anyway, then your anger spirals out of control. Blaming thoughts are like pouring gasoline on the fire of anger. They are responsible for such things as road rage.

So this how anger works. Let’s consider another example. This time we will use one closer to home. It’s early Saturday morning, and you are sleeping in after a long hard work week. Suddenly you are awoken by the loud noise of a lawn mower. It’s your neighbor George, who for some unknown reason, has decided that Saturday at 7:30am is a good time to mow his lawn. You are furious.

Let’s analyze this. What are the shoulds? Basically that your neighbor shouldn’t do noisy activities until 10 or 11 am on a weekend day. This should has been violated by George. What is the awfulizing? You are thinking that now you will be tired all day, and you’ll be cranky and irritable, and won’t have any fun. Is there a personalizing statement? Yes, you think, “George knows I work late, and knows I like to sleep in, so mowing his lawn so early is a direct insult to me!” And so you explode with anger.

So there you have it, a simple cognitive model of anger, the SAP model: Shoulds, Awfulizing, and Personalizing. Try an experiment. For a week, write down each anger incident you have by identifying the three Anger Thought Steps. This will help you to increase your awareness of how anger works, and prepare you for the next step, learning to defuse and eliminate your anger, which I will discuss in Part 2 of this article,  How to Stop Anger in its Tracks.

Copyright 2007 The Psychology Lounge/ TPL Productions All Rights Reserved

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Are Men Happier than Women?

As reported in the New York Times, several new studies suggest an interesting trend in happiness when comparing men and women over the past 35 years. These studies used an interesting methodology. Rather than ask general questions about overall happiness, they instead asked people to rate their happiness while doing various tasks and activities. The researchers give people pagers that go off at random intervals. When the pager goes off, the person writes down what they are doing, and rates the happiness level they have doing the activity. This provides very interesting data that allows us