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.