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.

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.

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Understanding and Overcoming Social Anxiety: Part Two

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

1. Everyone is noticing me

2. Everyone is judging me, harshly

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So, to summarize:

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

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

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

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

 

 

 

Appendix: Some Examples of Anti-Embarrassment Tasks

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

Say “Ding” at every floor.

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

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

 

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

Understanding and Overcoming Social Anxiety: Part One

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

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

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

There are several core beliefs that drive social anxiety.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

 

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

Radical Non-Defensiveness: The Most Important Communication Skill

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Major Kinds of Defensiveness

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Let me take you through it step by step.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How Ivan Pavlov Handled a Piece of Steak

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Now I’m off to meditate…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Newsweek article has a wonderful quote,

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


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

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

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

So the bottom line is this:

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

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

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

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

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

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

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

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

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

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

Which treatment was better? That is an interesting picture.

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

But at nine months the outcomes look quite different. The combination therapy is still the best, but by less of a margin. The results for remission at at 9 months were: combination, 60%; drug, 55%; cognitive-behavioral therapy, 64%; and overall, 60%. By 24 weeks all the treatments were working well. But a full 40% of the teenagers were still depressed.

So the right answer to the question of which treatment works better is neither. Both drugs and cognitive behavioral therapy were equally effective, over the long term. But the combination of both was worked more quickly. As the researchers said, “choosing just one therapy might delay many teenagers’ recovery by 2 or 3 months.” As the saying goes, candy is dandy, but liquor is quicker, and we might conclude that drugs or CBT are dandy, but combined therapy is quicker.

So what does this mean to parents of depressed teenagers? Here are my takeaway messages:

  1. Don’t expect treatment for depression to work quickly. It may take more than 9 months of weekly treatment before your teenager responds to therapy. This means at least 40 sessions of therapy.
  2. Be patient, and set reasonable expectations for both yourself and for your child. Tell them that therapy will help, but it may take a while. Let support networks such as school counselors or trusted teachers know to be patient.
  3. Although medications and cognitive behavioral therapy were equally effective in the long run, the combination of both tended to work much more quickly. So if you can afford it, and have access to good practitioners who do cognitive behavioral therapy, use both.
  4. Be aware that in other studies, the relapse rate for medication treatment of depression was significantly higher than for cognitive behavioral therapy, once the medications are discontinued. So choosing medications only may increase the risk that your teenager will relapse into depression.
  5. Be aware that much teenage depression can be a reaction to social environments. This includes the family, the school, and peers. Be sure that your teen’s therapist is attuned to family, school, and peer issues. They should meet with the whole family at least several times.
  6. Take teenage depression seriously. It’s not just a phase. Teenage depression, when serious, can greatly increase the risk of suicide. All suspected depression should be evaluated by a professional and treated if present.

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

SOURCE: Journal of the American Academy of Child and Adolescent Psychiatry, February 2009 . And December 2006 issue too .

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

The Magic of Behavior Therapy: True Stories


Although I’ve been practicing behaviorally oriented therapy for more than 20 years, I’m still amazed and delighted by its power and effectiveness. Here are four tales of behavior therapy, from both inside and outside my office, with children, adults, and even animals!

Playing with Spiders

I recently had a very satisfying experience in the clinical practice. A client of mine asked me if she could bring her grandchildren to a session, in order to work on their spider phobia.  I told her that if they were willing, I’d be happy to work with them. We would be able to make some progress by having the children look at pictures of spiders on my computer. The kids were 10 and 13, let’s call them David and Janet.

She surprised them (and me) by announcing at the beginning of the session that she had actually brought two live spiders in jars.  This changed my plans for the session. I told the kids that we would only work with the live spiders if they were comfortable doing so. (It’s not a good idea to spring surprises during desensitization sessions.)

So we started doing what is called desensitization.  This is a process where step-by-step, in a gradated way, the client is exposed to the fearful object.  We started off by looking at pictures of spiders on the web (pun not intended).  I picked less scary pictures at first, and I asked the children to rate their anxiety.  Then I asked them to see if they could lower their anxiety numbers.  We used a hundred point scale, and when they were able to lower their anxiety from 70 or 80 to 30 or below, we moved on to the next picture.

Eventually they were looking at pictures which were quite scary looking, even for me, and I like spiders!

Next we went on to work with the actual spiders.  There were two spiders.  One of them was a small daddy long-legs spider, and the other was a relatively small but scary looking spider.  I decided to work with the daddy long-legs spider, as it was slower moving, and less scary looking.

First I had them look at the spider in the jar.  Next I had them hold the jar.  They were able to do this fairly rapidly.  The next step was to open the jar, and look into the jar with the spider walking around inside the jar. David and Janet were able to do this without very much anxiety at all.

The next step was harder. It was to allow the spider to walk around on my office floor, and to have them touch the spider.  I made this a little bit easier by having them put on surgical gloves.  First I modeled the behavior for them.  I touched the spider, and then I allowed the spider to walk over my hand.

Now it was their turn.  First one, then the other, tentatively touched the spider.  At first their anxiety rating was quite high, 70 or 80.  Then I had them do this repeatedly, until they were able to do it with relatively low anxiety ratings of about 40.

One of the advantages of working with both of them simultaneously was that they were a bit competitive.  Janet was initially a little braver, but David quickly responded to this challenge, and matched her touch for touch.

Once they were comfortable touching the spider with gloves on, it was time to take the gloves off.  Once again I modeled for them touching the spider comfortably.  In a few minutes, they were able to allow the spider to walk over the back of their hand.  After a few minutes more, they were able to have the spider walk up their arm.

By the end of the session they were very comfortable playing with this small spider.  They were actually having fun playing with Mr. Daddy Long-Legs. And this was only a 60 minute session!

Once again, I was amazed at the power of simple behavioral tools.  Modeling — where the therapist demonstrates a behavior.  Gradated exposure — gradually exposing the person to increasingly fearful stimuli.  Reinforcement — where the therapist complements and praises the client for successful exposures.  Shaping — where the client is reinforced for behaviors that gradually approximate the target behavior.

In less than 60 minutes I was able to take these two brave children from being terrified of spiders to relative comfort with spiders.  Given that most people are not comfortable having a spider crawl up their arm, by the end of the session they had actually exceeded the comfort level of the average person.

(I recently got a follow-up report on the kids. According to grandma, David now can pick up dead spiders with his fingers, without using paper, which he could not do before. While his family was recently eating dinner, they noticed a large fly buzzing around. During their meal, the fly got caught in a spider web in the corner of nearby window. After the family had eaten dinner, they inspected the web and found the spider wrapping the fly. They left the web in place, deciding that it was beneficial, and David was comfortable with the arrangement. Janet reported that was able to put her hand on a picture of a big, multi-colored ugly black tarantula in her science textbook, with her mom watching. )

Bridging the Gap

Another opportunity for using the science of behavior therapy arose on a vacation. My partner and I were visiting Vancouver Canada, and one of the attractions there is the Capilano Suspension bridge (www.capbridge.com ). The bridge is a 6 foot wide suspension bridge which is 439 feet long, and 230 feet above a river gorge. It’s like the bridge in Indiana Jones and the Temple of Doom, swaying as you walk across it.

There was only one catch, my partner is very afraid of heights. She hates any situation involving them, and doesn’t even like walking across the Golden Gate Bridge.

But I thought that this might be an opportunity for her to overcome this fear, and offered to do in vivo desensitization with her if she was willing.

So we did. First I had her approach the edge of the bridge, and once again, I had her rate her anxiety using a 100 point scale. Ninety, she said. I then asked her to use breathing and relaxation to lower the anxiety. Before long she was able to stand at the very end of the bridge.

Next I had her advance out a few feet onto the bridge, stay there as long as she needed, and then retreat to solid land. She repeated this several times, until it was more comfortable.

Then I modeled walking partly across the bridge. I went slowly and hesitantly, modeling caution and slowness rather than speed and bravado. A coping model that shows the person overcoming fear is more effective than a perfectly confident model, I have found.

She then walked 10 or so feet across the bridge, and stood on the swaying bridge. Fear spiked and then subsided.

All along, I was giving her a lot of praise and encouragement. Next she managed 15 feet, and then retreated. Then she advanced 20 feet, then 30, then 40, and so on, until she was able to walk all the way across the bridge. Once she had accomplished that success, I had her repeat the process until her comfort level increased. I even invited her to jump up and down on the bridge, to demonstrate her lowered fear levels.

By the end of our visit there, not only was she able to traverse the bridge (which I admit was scary, even for me), but she was also able to traverse another attraction, a catwalk that was built between a number of Douglas Fir trees, which at points is 100 feet off the forest floor. This required more desensitization, but was successful in the end.

By the end of the day my brave partner had successfully overcome a lifelong fear of heights, and experienced some tourist attractions that she never would have enjoyed previously. When I showed her the video of her walking across the bridge, she was amazed at what she had been able to do.

Which is what I truly love about behavioral therapy; the ability to quickly and without lengthy therapy to overcome lifelong fears and expand one’s personal horizons!

Shaping Sandy to Swim

Another technique of behavior therapy is called shaping. What is shaping? Shaping is a technique where you reinforce gradual approximations of that behavior until you achieve the full behavior.

I had an opportunity to utilize shaping last summer when we spent some time at Lake Tahoe. We were renting a house on the beach, and our next-door neighbors had an adorable golden retriever named Sandy. Sandy loved to play on the beach, and her favorite game was fetch. But she wouldn’t go in the water past her ankles, and was afraid to swim. The owner said that she had never been willing to swim, even though they came up to Lake Tahoe regularly. The dog was about three years old.

I was challenged. Could I use behavior therapy to help Sandy overcome her fear of water and start swimming? I knew one thing; that dogs instinctively know how to swim, so it wasn’t a question of skill.

I decided to utilize the technique of shaping. First I made friends with Sandy by playing fetch on the beach. Pretty soon whenever I came out to the beach Sandy would run over with a stick to play.

Next I trained Sandy to follow me with the stick. She would follow me anywhere on the beach. Then I went into the water and encouraged her to follow me a few feet in order to grab the stick. She was willing to come into the water a little bit. I would praise her, and I would play some more with her on the beach.

Next I made it a little bit more difficult. In order to grab the stick she had to follow me into the water a few feet more.

I kept repeating this, each time requiring her to follow me further out into the water. Pretty soon she was following me five or 10 feet out into the water, but she still wasn’t swimming. Her feet were still on the bottom.

Next I used a slightly different technique. This time I had her come out into the water and grab the stick with her mouth. Instead of releasing it, I held on and moved out deeper into the water. Pretty soon her feet were off the bottom and she was swimming. I would then let go and she would swim back to shore, shake off, and play with me some more. The first time I did this she seemed a little perturbed, but quickly got into the game.

Over a couple of training sessions during the same day I continued this process. She got more and more confident, and was willing to swim out to grab the stick.

Finally I had her owner call to her while swimming in the deeper part of the beach. I threw a tennis ball out to the owner, and Sandy much to everyone’s surprise, swam out to the owner, grabbed the tennis ball, and swam back to the beach!

After that, Sandy seemed comfortable swimming in order to fetch a stick or a ball, even when it required her to swim in deeper water. Shaping had allowed her to learn gradually to overcome her fear and be able to swim with comfort.

The owners were amazed, as many times they had tried to coax her into the water. All I did was apply systematic methods of behavior therapy in order to allow Sandy to succeed. I shaped Sandy to swim, and she followed her destiny as a waterdog retriever.

Finding the Right Reinforcer

I want to tell one more story about behavior therapy, this time with dogs.

Although I’m a human therapist, I am very fond of dogs, and if I had an alternate career it would be as a dog trainer.

My friends Marli and Stu have two adorable dogs.  They are Papillons, which are small cute toy dogs, who look a little bit like the gremlin "Gizmo" in the movie Gremlins .  They have the same floppy ears and big eyes. (But they don’t turn into monsters if you feed them after midnight!)
In an effort to make their lives a bit more convenient, my friends had installed a dog door into their bedroom so that the dogs could go outside without needing help.

The problem was that neither Vinnie, the older dog, nor Bowie, the younger dog, was willing to use the dog door.  They were both afraid of it.  After weeks and weeks of hoping the dogs would figure out how to use the door, they still had not. Stu and Marli kept putting the dogs through the door, but the dogs never figured out how to use the door on their own.

Enter the confident behavior therapist, who offered to solve this problem.  I was very confident that I could use food treats to entice the dogs through the door.  Once having learned how to go through the dog door, I felt that they would continue to use it without treats.

I asked my friends not to feed the dogs the day I came over so that the dogs would be hungry and more motivated by food.

To make a long story short, I failed miserably.  I was able to coax the dogs through the dog door by physically picking them up and pushing them through the door, but no amount of food treats would entice them to go through the door.  They seemed uninterested in food treats. After several hours of trying everything I could think of, I gave up.

This bothered me greatly.  Had I lost my behavior therapist powers?  Had the technology failed?  That night, as I tried to fall asleep, I found myself obsessing a lot about the problem.  Just as I was about to fall asleep I realized the solution.

Can you guess what the solution was?  I will give you a hint that it had to do with what type of reinforcements I had selected.  Let me give you one more hint.  Both of these dogs are very attached to my friend Marli.  They like Stu, but they are crazy about Marli! They follow her everywhere. When she comes home from work they go nuts wanting to play with her.

The solution was to change the reinforcement.  Instead of putting food on the other side of the dog door, I needed to put Love!  What I did was to have a Marli call her husband Stu right before she came home.  Then he would put the dogs outside.  She would come inside the house, and call to the dogs through the dog door.  The first time she did this both dogs dove through the dog door as if it wasn’t even there!

The next time she came home she came through the yard, and called to the dogs from the outside.  Once again, motivated by love, they were very willing to use the dog door to get outside.

After a few days, they no longer had to use this procedure, as the dogs were happily using the dog door on their own.  Behavior therapy had triumphed once again, but it required a more careful behavioral analysis of what these particular dogs found reinforcing.  They were more motivated by love than by food.

And that’s a key secret…sometimes the best motivators are subtle, and never forget the power of love to motivate! If reinforcement isn’t working, it’s probably because you are not using the right reinforcement.


Copyright 2008 Andrew Gottlieb, Ph.D./The Psychology Lounge/TPL Productions

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

Should the Golden Gate Bridge Have a Suicide Barrier? (Is Suicide an Act of Impulse or an Act of Premeditation?)

One of the consistent and most fascinating facts that arises out of any serious study of psychology research is how much we are influenced by external factors.  So much of our behavior is influenced by seemingly small external factors.  We eat more when served bigger portions.  We spend more when sales are in effect.  Red cars are more likely to get speeding tickets.  We are more likely to marry someone who lives or works nearby.

But what about the truly profound and serious decisions of life?  What about something as serious as suicide?  Can it be that even such a grave decision is affected by seemingly small external factors?

The New York Times Magazine recently published a fascinating article “The Urge to End It All“, which addressed this very issue.  I highly recommend you read the entire article.

First, some numbers.  (I love numbers).  The current suicide rate is 11 victims per 100,000 people, the same as it was in 1965.  In 2005, about 32,000 Americans committed suicide, which is two times the numbers who were killed by homicide.

For many years the traditional view of suicide was that it reflects mental illness — depression, bipolar illness, psychosis, schizophrenia, or other mental illnesses.  This view assumed that the method of suicide was not important; it was the underlying mental illness that mattered.

But something happened in Britain in the 1960s and 1970s that set this model on its head.  It’s called the “British Coal Gas Story” and it goes like this:

For many years people in Britain heated their homes and stoves with coal gas.  This was very cheap, but the unburned gas had very high levels of carbon monoxide, and a leak or an opened valve could kill people in just a few minutes in a closed space.  This made it a popular method of suicide — “sticking one’s head in the oven” killed 2500 Britons a year by the late 1950s — half of all suicides in Britain!

Then the government phased out the use of coal gas, replacing it with natural gas, so that by the early 1970s almost no coal gas was used.  During this time Britain’s suicide rate dropped by a third, and has remained at that level since.

How can we understand this?  If suicide is the act of an ill mind, why didn’t those who could no longer use coal gas find another means? Why did the suicide rate in Britain drop by a third when the option of coal gas was no longer available?
The answer turns conventional wisdom about suicide on its head. Conventional wisdom is that people plan out suicides carefully, and so convenience of method shouldn’t matter. But actually it appears that often suicide is an impulsive act, and when you make it less convenient, people are less likely to complete the act.

Another example of this is found in the Golden Gate Bridge.  For years this gorgeous bridge has been a popular suicide point, where nearly 2000 people have ended their lives.  There have been many debates about erecting suicide barriers on the bridge, but most opponents say “they will just find another way.”

But Richard Seiden, professor at University of California Berkeley, collected data that addresses this issue.  What he did was to get a list of all potential jumpers who were stopped from committing suicide between 1937 in 1971, 515 people in all.  He then pulled their death certificate records to see how many had gone on to kill themselves later.  What would you guess was the percentage of these people who tried to jump off the Golden Gate Bridge and who later killed themselves?  50%?  75%?  25%?

Actually it was only 6%!  Even allowing that some accidents might have been suicides, the number only went up to 10%.  Although higher than the general population, it still means that for 90% of these would-be jumpers, they got past whatever was bothering them, and went on to live full lives.

Richard Seiden got some great stories out of this study.  One of the things he found was that would-be suicides tend to get very fixated on a particular method.  They tend to only have a Plan A, with no Plan B. As he says, “At the risk of stating the obvious,” Seiden said, “people who attempt suicide aren’t thinking clearly. They might have a Plan A, but there’s no Plan B. They get fixated. They don’t say, ‘Well, I can’t jump, so now I’m going to go shoot myself.”

One example he cites was a man who was grabbed on the east side of the bridge after pedestrians noticed him looking upset.  The problem was that he had picked out a spot on the west side of the bridge that he wanted to jump from, but there were six lanes of traffic between the two sides, and he was afraid of getting hit by a car on his way over!

As Seiden said, “Crazy, huh? But he recognized it.  When he told me the story, we both laughed about it.”

Another great example is from two bridges in Northwest Washington.  The Ellington Bridge and the Taft Bridge both span Rock Creek, and both have about a 125 foot drop into the gorge below.  For some reason the Ellington has always been famous as Washington’s “suicide bridge”.  About four people on average jumped from the Ellington Bridge each year as compared to slightly less than two people from the Taft.

In 1985, after a rash of suicides from the Ellington, a suicide barrier was erected on the Ellington Bridge, but not the Taft Bridge.  Opponents countered with the same argument, that if stopped from jumping from the Ellington, people would simply jump from the Taft.

But they were wrong.  Five years after the Ellington suicide barrier went up a study showed that while all suicides were eliminated from the Ellington, the rate at the Taft barely changed, inching up from 1.7 to 2.0 deaths per year.  What’s even more interesting is that the total number of jumping suicides in Washington dropped by 50%, or the exact percentage the Ellington had previously accounted for. So people stopped from jumping from the Ellington did not jump from other locations.

Coming back to our model that small external factors can have large influences on behavior, you might wonder why the Ellington was the suicide bridge instead of the Taft.  It turns out that the height of the railing was what made the difference. The concrete railing on the Taft was chest high, while the concrete railing on the Ellington (before the barrier) was just above the belt line.  One required a bit more effort and a bit more time to get over and this tended to reduce the impulsive action of jumping.

Which brings us to guns. Although guns account for less than 1% of all American suicide attempts, because they are so lethal, they account for 54% of successful suicides.  In 2005 that meant 17,000 deaths.  It turns out there when you compare states with high rates of gun ownership to states with low rates of gun ownership; you find that there is a direct correlation between the rate of gun ownership and the rate of gun suicide.  This is not surprising.

What is more surprising is that in the states with low gun ownership, the rates of non-gun suicide are the same as those states with high gun ownership.  So the lack of availability of guns does not encourage people to find other means of harming themselves.  Studies show that the total suicide rate in high gun ownership states is double that of in low gun ownership states.  So the Supreme Court, in their recent ruling regarding Washington, D.C.’s ban on handguns, may have missed the more important data when they focused on homicide rates.  From these studies scientists conclude that a 10% reduction in firearm ownership would result in a 2.5% reduction in the overall suicide rate.

I am not anti-gun. I like shooting, and if I were a hunter, would probably own a rifle.  But this is why I don’t own a gun, and this is why I don’t recommend that most people own a gun.  All of us are potentially subject to dark moments of the soul, and the research detailed in this New York Times article suggests that the more barriers and impediments there are to impulsively harming ourselves, the less likely we are to try.  If you do own guns, at least try to create barriers and delays such as keeping the guns locked up in a gun safe, keeping ammunition separate from the guns, or even not keeping ammunition in the home where guns reside.  Not only does this protect you from those dark moments of the soul but it may also protect someone you love, your spouse, or your child.

Again, I highly recommend a careful reading of the original article, as it has much other information that is useful and interesting.

In answering the question of the title, I have to say that reading this article convinced me that we should build a suicide barrier for the Golden Gate Bridge. Yes, it would lower the beauty of this gorgeous bridge, at least for pedestrians, but I have to believe that saving another 2000 lives trumps a pretty walk across the Bay.

Copyright © 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

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

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

Is “Married Sex” an Oxymoron? (and Other Myths of Sexuality)

Recently I’ve been thinking a lot about sex. (That sounds bad, doesn’t it?)

It’s not what you think. My own life in that respect is just fine, thank you! But in the couples counseling work I do, sex is a big deal. Most of the couples I work with are married, and most of them are not having much sex. Some are not having any sex. Is “married sex” an oxymoron? And why?

It is remarkable how easy it is for couples to get out of the habit of having sex. As part of my general screening/evaluation interview with new couples, I always ask, “When was the last time you two had sex?” I’m often stunned when they can’t remember, not because they are suffering memory impairment, but rather because it has been that long. It’s not uncommon that it has been more than a year, or even more than several years.

What’s surprising is that most of the couples I see are not coming to therapy for help with sexual issues. You could argue that I don’t see a representative sample of couples, and I would agree. But even amongst my friends who are married, sex is a relatively rare phenomenon.

Recently the New York Times had an interesting article called “Yes Dear. Tonight. Again” about two couples who faced a similar sexual drought in their marriages, and who had an unusual response. One couple, the Muller’s, decided to have sex 365 days in a row. The other couple, the Brown’s, went for the more reasonable 101 days (or nights). The Muller’s book is called “365 Nights”, and the Brown’s book title borrows from the famous Nike line; “Just Do It.”

I haven’t read either book. What I found interesting was that both couples reported that their overall relationship improved by having more sex. It turns out that there is a high correlation between marital satisfaction and the frequency of sex. No one really knows if more sex makes people happier, or happier couples have more sex, or both.But the couples who wrote these books add a data point to the notion that more sex makes people happier.

How often do married people have sex anyway? From the Times article: “According to a 2004 study, “American Sexual Behavior,” by the National Opinion Research Center at the University of Chicago, married couples have intercourse about 66 times a year. But that number is skewed by young marrieds, as young as 18, who couple, on average, 109 times a year.” So the youngest of couples are having sex about twice a week. And older couples are having sex quite a bit less, perhaps less than once a week. And some couples are having much less sex, such that they could count the number of times per year on two hands, without using toes!

So let’s assume that the causal relationship works in both directions—happy couples want to have more sex, and more sex makes couples happier. What can we do about this? Helping couples to be happier is outside the scope of this article, and is something that often takes couples therapy. But what about the other side of the equation, that of having more sex?

First of all, we need to consider some myths of sexuality. The first myth is that sex shouldn’t be planned and scheduled. I don’t know where people get this idea, because we plan and schedule everything else good in our life. We buy concert tickets months in advance, we make reservations at good restaurants, we plan to attend our children’s school play. We plan to go to work each day.

Imagine if we applied the same model to daily life as we use with sex: “You know, honey, I just don’t feel like driving the kids to school today. I ate too much as breakfast, and I kinda feel fat, and getting behind the wheel will make me feel bad.” “Yeah, I don’t really feel like going to work today. I’m a little tired. I think I’ll just stay home in bed and sleep all day.”

This is what I call the Myth of Spontaneity. We wait for the sun and the stars and the moon to line up for both people in the couple, and then and only then can we consider sex. If anything else then gets in the way like kids or telephone or dogs, forget it. Waiting for everything to be ideal for two people greatly lowers the odds of having sex at all.

Instead, I suggest that couples make sex dates. (Or call them pleasure dates.) Sit down and talk about how much sex you would like to be having. What’s the optimal frequency for each of you? Compromise if you have different answers. Then pull out your calendars, and figure out times when you can plan to have sex. Consider other distractions like children, pets, jobs, etc. Every couple should be able to find at least one time a week where they have some time and some privacy to get intimate.

Then make it happen. As the Browns would say, Just Do it! No excuses. If you find there is always something getting in the way, consider what the issues are. Are there other resentments that are being expressed sexually? Are there sexual issues that need to be talked about and worked on? Are there issues of appearance or hygiene that can be addressed? Sit down and talk about what’s getting in the way, and if you can’t do it alone, then see a therapist to help talk it out.

Another myth is what I call One Size Fits All. This means that couples often think of having sex in terms of a standard sexual script; a little foreplay, maybe a little oral sex, a few minutes of intercourse, and off to sleep afterwards. It is a full course meal or nothing at all. The antidote for this myth is to have a varied repertoire of sexual activities you both enjoy. Perhaps sometimes it is okay to have a quick snack, instead of the full meal, so to speak. If one person is tired, and one is feeling more amorous, maybe the tired person can be pleasured by the amorous one. Again, it helps to talk over these options. What do each of you like to do when you are not that sexually energetic? And sexy cuddling is okay too. Maybe you fool around a little, skin to skin, and no one orgasms, and that’s fine too.

Still another myth is what I call Not Tonight Dear. This is the idea that it’s fine to turn down sex whenever you don’t really feel like it, since after all, you wouldn’t want to have sex if you don’t feel like it. The problems with this belief are multiple. First of all, most people are very sensitive about being rejected sexually. A “not tonight dear” crushes them. And then they are less likely to initiate the next time. Second, if both people say “no” often, it dramatically lowers the chances that the couple will ever have sex. And both people will decrease how often they initiate, further lowering the probability of successful sexual connecting.

What is the antidote? First of all, try to limit saying “no” to the extreme examples. If you are having a massive migraine headache, food poisoning, or something similar, I think it is fine to say no. The “no” response should be rare, less than once in ten times. In the Brown’s book “Just Do It” there is a story of one time that the husband was having a vertigo episode, but they still had sex!

Second, it is okay to say yes in a limited way. For instance, let’s imagine you don’t feel very turned on. I think it is okay to say something like, “You know, I’m not feeling very sexual right now, but I’m willing to play a little and see if that changes. Is that okay with you?”

Finally if you really do need to say no, then offer a specific alternative time and place. For example, “I’m really tired tonight, honey, and I’d really rather make love tomorrow morning, is that okay?”And be affectionate and loving when you say it.

So let’s review. If you want to make sure that “married sex” is not an oxymoron in your life, then follow these guidelines:

1.Plan to have sex. Make dates to have sex, and keep the dates. Decide on your sexual goals, and then figure out the best times to schedule your “pleasure dates”.

2.Be flexible about the kinds of sexual encounters you can have. Sample from a varied menu of sexual options, and don’t be all or nothing about sex. Even sexy cuddling can be a type of sex, and is better than nothing. Not all sex needs to result in orgasm for both or even one partner.

3.Avoid turning down sex more than infrequently. To paraphrase the Brown couple, Just Say Yes. This lowers the probability of hurt in the bedroom, and keeps both partners willing to initiate because they know that rejection is infrequent.

4.Talk about your sex life, what works, and what doesn’t work. This is the only way you can improve things. And if you are too shy or inhibited to talk about it on your own, see a good couples or sex therapist, who can facilitate this dialogue.

And having said all that, now I have to go, as I have a scheduled date with my sweetie!

(Fade to black…)

Copyright © 2008 The Psychology Lounge/TPL Productions

 

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

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

The Mystery of the Obesity Epidemic: Solved? (Hint: It’s simpler than you think)

 

Was Grandma Right?

It’s been too long since I last wrote, but I’ve been catching up on my sleep. Why will become relevant after you read this article.

Sleep is something we mostly take for granted as part of our daily lives, much like eating and showering. But why do we sleep? What does sleep do for our minds and our bodies? What happens if we don’t sleep, or if we don’t sleep enough?

For those of you who are interested in these questions, I’d highly recommend that you read the transcript of The Science of Sleep, an excellent piece by 60 Minutes that aired on March 16, 2008. Not only did I learn many interesting facts about sleep, I learned about my own health and how sleep affects it. More on that later.

Why do we sleep? After all, from a survival point of view, sleep is not really a good thing, in the sense that we are unconscious and helpless during sleep. So for sleep to have evolved, then it must serve some vital functions. (I should point out though, that sleep might have survival advantages, since if early humans slept in caves and other sheltered places, sleep would have kept them out of the reaches of nocturnal predators. The folks who didn’t sleep much, and who wandered around all night, probably got eaten!)

One clue of how important sleep is in studies done in the 1980’s with rats. When rats were prevented from sleeping (did they use disco music to keep them awake?) they died after 5 days! Sleep seems to be as important to rats as food.

Let me present a quick primer on sleep. When we sleep, we actually go through multiple cycles of different stages of sleep. These stages are stages 1-4 of non REM (NREM) sleep, and stage 5 which is REM (rapid eye movement) sleep. The key stages are Stage 4, or Delta Sleep, and Stage 5, REM sleep. Stage 4 Delta sleep is the deep restorative sleep where our bodies get rebuilt and restored. Stage 5 REM sleep is when we dream, and it appears that our minds get restored during REM sleep. Typically the whole cycle takes about 100 minutes, and we have 3 or 4 of them each night.

Sleep may play an important role in enhancing memory. One study found that when people learned a new skill in the afternoon, and then were tested after a night of sleep, they did 20-30 percent better than those who were tested after twelve hours, but with no sleep in between the learning and testing. This is fascinating, and jibes with a trick I learned in graduate school. When I would study statistics, I’d always review my notes right before going to sleep. The next morning, the memories of those notes were imprinted magically in my mind.

Sleep also plays a critical role in stabilizing mood. One experiment tested people who were sleep deprived by showing them disturbing images within an fMRI scanner, to look at their brain activation. They found the sleep deprived subjects had a disconnect between the brain’s emotional center (the amygdala) and the part of the brain that controls rational thought (the frontal lobe). So they couldn’t control their emotional reactions. They looked more like psychiatric patients. Of course we all know that sleep deprivation makes us cranky and short-tempered, this explains why.

Another important function of sleep is physical rejuvenation. It appears that Stage 4 sleep is essential here. In the 60 Minutes piece they show an experiment where a young man named Jonathan is deprived of only Stage 4 sleep. Each time his brain waves show Stage 4 sleep, loud sounds are played to bring him out of deep sleep. He gets a normal amount of sleep, but a reduced amount of Stage 4 sleep. After 4 nights of this regimen, this 19 year old is starting to look physically like a 70 year old. His body becomes no longer able to metabolize sugar effectively, putting him temporarily at increased risk for Type 2 diabetes.

Other studies confirm this. After just a few nights of partial sleep deprivation, young healthy people show a metabolic change that is similar to what happens as people develop Type 2 diabetes. They no longer metabolize sugar effectively. They deposit more fat. The hormone leptin, which controls appetite, seems to drop, and they want to eat more.

This is truly astonishing. If relatively short term sleep deprivation can cause such a profound shift in the body’s sugar metabolism, then this may be the key to unlock one of the great medical mysteries of the 20th century: Why obesity has increased so rapidly since 1980? Could it be that the obesity epidemic is really a sleep deprivation epidemic? Could it be so simple? Not junk food, television, lack of exercise, and all of those things that people talk about? Could grandma have been right?

Here’s the clue.

In 1960 a survey of a million Americans showed an average of 8.0 hours of sleep per night. Today similar studies show we are only getting 6.7 hours a night. That’s a drop of 16.25% in less than a generation. And teenagers are the most sleep deprived of all, since they require 9-10 hours of sleep, and most get less than 7 hours of sleep, thanks to ridiculously early school start times. Teenagers may be lacking between 22 percent and 30 percent of their needed sleep.

So we have a plausible explanation for why everyone, even children and teenagers, is getting fatter. Sleep deprivation causes shifts in metabolism, creating a pre-diabetic state, and lowering level of the satiety hormone leptin, which causes us to eat more, and store more fat. Add sugary or high carbohydrate foods, and we get even fatter. Add inactivity, and we get even fatter. The damage begins early, perhaps in early teenage years.

So if we want to lose weight, then the old saw of a healthy diet and plenty of exercise may be wrong. The proper advice is probably lots of sleep, a reasonably healthy diet, and a little exercise. Or since exercise improves sleep quality, sleep, exercise, and diet. Without adequate sleep, diet and exercise are doomed to failure, since even young people may unintentionally be turning their bodies pre-diabetic, which makes it very hard not to gain fat.

So that’s why I haven’t written. After a lifetime of staying up late, and cheating sleep, I’m starting to try to get a solid 8 hours of sleep a night. Already I’ve lost a few pounds, even though I haven’t been exercising much. The other advantage of going to bed earlier is that when you are sleeping you are not eating.

So try it. Get 8 or 8 1/2 hours of sleep a night. And make sure your teenagers get 9 or 10 hours a night. No more websurfing or TV late at night. And write me and let me know if your weight drops as a result.

Now I’ve got to stop writing and go to sleep…

Copyright © 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

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

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

The Neuropsychology of Long Lasting Love: Can Brain Scans Tell Us Something Useful About Staying in Love?


The Wall Street Journal today has an article called Keeping Love Alive, which documents some fascinating research looking at why a small minority of long term couples seem to maintain intense passionate loving connections.

First the grim background to these findings. Keeping love alive is no mean feat, as the research on long term relationships suggests that for most couples love is a fading affair.

From the article:

“Each year, according to surveys, the average couple loses a little spark. One sociological study of marital satisfaction at the University of Nebraska-Lincoln and Penn State University kept track of more than 2,000 married people over 17 years. Average marital happiness fell sharply in the first 10 years, then entered a slow decline.”

This is not such good news for all of us in long term relationships. What do we have to look forward to? A sharp decline in happiness for the first ten years, and then a slow erosion of whatever remaining happiness is left, until either we run out of love or time, whichever comes first? Ugggh!

But then to the rescue comes Arthur Aron, who is a social psychologist at Stony Brook University. He’s looked at those unusual couples who claim that their love is just an intense years later. It’s a strategy of research which is called examining the outliers, those people who fall outside the averages.

Aron and his students are studying these couples in an interesting way. They are taking pictures of their brain function, using magnetic resonance imaging (MRI). They have a person lie inside an MRI machine, and look at pictures of their spouse, while measuring the activity in their brain.

What have they found? It turns out that when these passionate couples look at or think about their spouses, a part of their brain called the ventral tegnmental area lights up. This is a section of the brain that is rich in the neurotransmitter dopamine, which is connected to our ability to feel pleasure and joy. The results have been duplicated in China, suggesting this is not just a western cultural phenomenon.

So what does this all mean? It’s not of much help in the challenges that I face as a marriage therapist, in helping couples repair damaged love. One of the interesting details reported in the article was that these passionate long term “in love” couples show one behavior in common. They are constantly affectionate, kissing, hugging, and holding hands. They display many PDA’s (public displays of affection).

Now that there is a brain measure of this intense love, what is more important is to study how people get there. Are these couples just more intensely in love to begin with? Perhaps it is like cognitive function, where those who start off smarter and more educated deteriorate more slowly in old age. Maybe these passionate couples simply start with more love, and show erosion, but they have such an excess that it doesn’t matter.

We might be able to answer some of these questions with a long term longitudinal study of new couples that followed them over 10 years or longer.

Is it a selection process, where better mate selection leads to better long term outcomes? Or are there behavioral differences, a set of behaviors and attitudes that preserves love? These are the key issues in answering the question of how do we go about Keeping Love Alive.

What I find deeply fascinating is that in spite of the fact that most people value love as one of the most important things in their lives, we actually know very little about what predicts success, and even less about how to help people love better. Brain scans may tell us more about the process of love and attraction, but unless we develop a “love beam” that changes the activity of the key brain regions, it won’t help us fall in love and stay in love.

…Excuse me, I’ve got to go kiss my sweetie!

Copyright © 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

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

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

Secrets of How to Get Moving (Especially When You Are Stuck)

In a previous article I wrote at length and I admit, rather philosophically, about getting things done. In this article I am going to do something a little different. Clients often ask me for specific tips to help them get moving. We’ve all had the experience of being completely blocked, seemingly unable to get anything done, and struggling to get moving. Some of this is mood and energy based. When we are tired, sleep deprived, or blue, it’s hard to motivate to do anything, especially tasks that are not fun or interesting. But life demands that we function even under these circumstances, so here are 5 tips for how to get moving when you are blocked.


1. Priming the Getting Things Done Pump

The first secret is to prime your “getting things done” pump by getting something done, anything. Pick a small task that you’ve avoided or failed to do for a long time. It can be anything. It should take no more than 5 or 10 minutes to complete. The key here is that you are going to complete something, and it’s something you’ve been avoiding for a long time.

I picked a Microsoft Class Action legal settlement form that entitled me to $125 in rebates on computer products. I had sent it in a long time ago, but it had been rejected and returned on a technicality. I pulled it out, found an appropriate receipt to attach it to, and put it in an envelope, and mailed it. Time? About 8 minutes. Not only did I get something done, but I made $125 in 8 minutes, that’s $937 per hour!

The principle is to get something done, which flexes your “getting things done” muscles. By picking something you’ve avoided for a while, you get an even bigger kick.

2. The Smallest Piece Technique

You can use a related technique even for a huge and complicated tasks that we all tend to avoid starting, and thus never finish. If you have a huge task, break it down into component pieces. Then pick a very small piece, a piece that will take 5 to 10 minutes, and do it.

This breaks the ice, and gets you moving on the big task. Often once you’ve done the first small piece you can then do more pieces. Often it is best to use a pump priming strategy here. Pick the smallest piece there is, and get it done. For instance, if you want to do your taxes, you might simply set the task of pulling out your tax folders, and putting them on your desk. That’s it, you are done. (But now you want to do more, don’t you!)

This also works well for getting started with exercise. Rather than saying to yourself, “I’m going to take a 1 hour walk”, and then doing nothing, decide to take a 5 minute walk. Once you are outside and walking, you probably will find yourself walking for more than 5 minutes. The key is to set the task of walking 5 minutes every day, and then you break down your resistance.

3. The Dice Man (or Woman) Technique

The next technique is a good one if you find yourself frozen with indecision. You have a many important tasks to do, and you can’t decide which one to do first. You are like an octopus that is pulled in many different directions by each of its tentacles, and hence is frozen in place completely.

In this case, use the Diceman strategy. The The Dice Man is the title of a comedic novel published in 1971 by George Cockcroft under the pen name Luke Rhinehart, in which a psychiatrist begins to make all his life decisions using a set of dice. (It’s a wild novel, and pretty interesting.)

To use this strategy, make a short list of the some of your main tasks. Number them 1-6 or 1-12. Then throw one or two dice, and do the one that the dice indicates. Or you can throw darts at the list, or even just toss a penny onto the list, and do the task the penny falls upon.

What this does it to short-circuit the part of your brain that is trying to prioritize many equally important tasks, and gets you moving and finishing a task. Often, once you do this, it is much easier to continue picking tasks and doing them.

4. The Entertainment Strategy

What about those tasks that are just plain boring? For instance, like filing, or unloading or loading the dishwasher. The best way to do these tasks is to pair them with some other activity that is fun.

For loading or unloading the dishwasher, you could use a phone with a hands-free headset, and talk to someone you like while you take care of the dishes. The same technique is useful for straightening up the house.

For filing, this is also a good technique. Another approach is to do the boring task while watching or listening to some entertainment. I find baseball and football games on television perfect for tasks like filing. Both have many slow points, which allows me to get a lot done without missing key points. Listening to a good show on the radio also works.

5. When All Else Fails, Bribe Yourself!

Another way of getting unpleasant boring tasks done is to pair them with specific rewards. For instance, let’s say you have a big task to do like doing your taxes. This is a task that takes a couple of days. Before you start, set yourself a specific reward once you have finished. It could be that you get to buy something for yourself. Or go do an activity that you like. The key is to make sure that the reward is big enough to motivate the task. Telling yourself you get to eat a piece of pie after spending two days doing taxes won’t work. It probably will take something bigger, and not pie! I call this strategy “paying yourself to get things done.”

So there you have it. Five quick ways to explode your resistance and get something done! Good luck!

I have to go now, and pay one bill.

Copyright 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

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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.

Scientists Try to Discover the Earliest Signs of Alzheimer’s disease (Is Alzheimer’s a Lifetime Genetic Disease?)


Today’s New York Times has a fascinating article about current research in Alzheimer’s called Finding Alzheimer’s Before a Mind Fails. It is simultaneously encouraging and deeply disturbing.

The encouraging part is that researchers are discovering ways to examine patients that can find evidence of Alzheimer’s many years before the disease manifests itself in symptoms. A radioactive dye call Pittsburgh Compound B (PIB) is injected into the patient. This dye attaches itself to amyloid plaques in the brain, and then these can be seen by using a Positron Emission Tomography (PET) scan.  Studies using PIB have found the astonishing fact that amyloid plaques are found in 20-25 percent of people over 65 who appear normal! If the amyloid hypothesis is accurate, then many of these people will go on to develop Alzheimer’s disease.  Using PIB testing we could predict more accurately who will develop the disease, and perhaps develop prevention methods much like we give statins to heart patients who have plaques in their arteries. This is encouraging.

Someday in the future hopefully we will be tested for early signs of Alzheimer’s disease in our 40’s, and those who at risk given medications that will prevent it, just like we do for heart disease now. This would make aging much less scary.

Current Facts About Alzheimer’s disease

But the current facts about Alzheimer’s are less encouraging. It is the sixth more common cause of death by disease in the U.S. Five million people over 65 have Alzheimer’s disease. Estimates suggest that perhaps as many as 16 millions will have the disease by 2050, which is a staggering number that would bankrupt the health care system. (Of course, this assumes that in 43 years we have made no progress in the treatment and prevention of Alzheimer’s disease, which is absurd.)

Costs are already staggering–$148 billion dollars per year, and are increasing every year. Why? Here’s the dark truth. Alzheimer’s disease is a disease of the elderly. Almost 40 percent of those who live past 85 will eventually develop Alzheimer’s disease. The problem is that medical improvements are curing the diseases that used to kill us well before 85. One of the reasons Social Security starts at age 65 is that until recently, most people didn’t live much past the age of 65. Now as we defeat cancer and heart disease, and people stop killing themselves with diet and smoking, we are living into our 80’s and 90’s.  And getting Alzheimer’s disease.

What is Alzheimer’s disease?

Let’s talk a little more about what Alzheimer’s disease really is. Everyone worries about Alzheimer’s disease as they age. But some forgetfulness is completely normal. (We hope.) There is a old joke about Alzheimer’s disease which actually is a useful rule of thumb, it’s not a big deal if you forget where you put the car keys, as long as you can remember what keys are for. It is significant changes in memory and problem solving that are more worrisome.

When does Alzheimer’s disease begin?

This is a mystery currently. Conventional wisdom says that Alzheimer’s disease may begin a few years before symptoms appear, but some scientists question this. Because the brain has a lot of spare capacity, it may take years of deterioration before we lose enough brain function to notice. This may explain one of the common findings that the more highly educated (and probably more intelligent) develop Alzheimer’s disease as  a lower rate. They may have more spare capacity. If you start off with an IQ of 150, and lose a third of your brain functioning, you end up with an IQ of 100, and can still function. Start at IQ 100, lose 1/3, and you now are functionally retarded with an IQ of 66, and you won’t be able to live independently.

One scientist, Dr. Richard Mayeux, who is a professor at Columbia University, says, “I think there’s a very long phase where people aren’t themselves.”

If Dr. Mayeux asks family members when a patient’s memory problem began, they almost always say it started a year and a half before. If he then asks when was the last time they thought the patient’s memory was perfectly normal, many reply that the patient never really had a great memory.” (New York Times)

This is interesting and disturbing stuff. Other research finds that people who later develop Alzheimer’s disease showed lower intelligence scores even early in life, suggesting that perhaps Alzheimer’s disease is a genetic disorder that affects the brain in subtle way even early in life. If this is true, then the data on highly educated people may have been interpreted in a backwards way—instead of higher education preventing Alzheimer’s disease, it may be that Alzheimer’s disease prevents higher education!

 

Treatment of Alzheimer’s disease

Currently there are drugs that address the symptoms of Alzheimer’s disease, but no drugs that address or slow the underlying disease progress. The good news is that there are numerous studies attempting to find drugs that will actually address the underlying disease process in Alzheimer’s disease. The bad news is that no one really knows exactly what that underlying disease process is.

There are two finding from examining the brains of those with Alzheimer’s disease. The first is that they show plaques of beta amyloid between the nerve cells of the brain. The second is that the brains show tangles inside nerve cells made of a protein called tau. This damaged tau kills the nerve cells because they no longer get nutrients.  Both these are well-established facts, but no one knows what is the relationship between beta amyloid and tau, and how much each contributes to Alzheimer’s disease.

 

What Society Should Do About Alzheimer’s disease?

So what can we as a society do about Alzheimer’s disease? My grandfather used to say, “Everyone dies, so it’s just a matter of how you die.” By choosing to treat or prevent heart disease and cancer, are we choosing to die from Alzheimer’s disease?   This is a scary thought.  It’s clearly worse to outlive your mind than to outlive your body. And Alzheimer’s disease puts huge burdens on society and caretakers. Maybe we should start a campaign to encourage cigarette smoking in the elderly! (Or motorcycle riding, but this might make the roads a bit dicey.) 

More seriously, we are in the unfortunate window of time where we have successfully improved longevity without really addressing this core disease of longer life, Alzheimer’s disease.  Society desperately needs to find an Alzheimer’s disease cure or preventative treatment. Without this we will as a society incur great costs and individual suffering. I believe that this should become a top priority of private and government research spending. First we need better basic research to find out what the disease process of Alzheimer’s disease looks like. Then we can develop effective drugs to block or reverse that disease process.

In the meantime, all we can do is not worry too much, since stress may damage the brain. Eat healthy, exercise, maybe take some anti-oxidant vitamins, and hope that science can solve this puzzle so we can get old without losing our brain function.   

As for me, I aspire to these not-so famous words of the comedian Will Shriner, “I want to die in my sleep like my grandfather… Not screaming and yelling like the passengers in his car.”

 

Copyright 2007 The Psychology Lounge/ TPL Productions, All Rights Reserved

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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 Stop Anger in its Tracks: Applying the SAP™ Model in Three Easy Steps (Part 2)

In my previous article, How Anger Works: The SAP™ Model (Part 1), I wrote about the SAP™ model, which stands for Shoulds, Awfulizing, and Personalizing. In this article I want to teach you basic anger management skills that will help you to neutralize anger.

Background Concepts About Anger

I should point out a couple of important concepts about anger first. A simple way of conceptualizing anger is that it is related to the amount of difference between our expectations and reality. The larger the difference, the more anger and frustration we experience. Thus if I expect a 10 percent raise, and I only get a 5 percent raise, I will be more angry (and disappointed) than if I got a 9 percent raise.

This leads to an obvious point. To decrease anger and frustration, we need to lessen the difference between our expectations and reality. There are two ways of doing this. One is to change reality so it better conforms with our expectations. The other way is to change our expectations so they better conform with reality.

Here is where it gets tricky. Which should you try to change, reality or your expectations? It depends. When it’s possible and easy to change reality, it makes sense to do so. If you don’t like rush hour traffic you can leave earlier or later to work. Or if you have been dating someone for a few weeks and they consistently annoy you, break up with them. It’s easy, and solves the problem. Or if you have an abusive boss, and you can relatively easily transfer or find another job, do it!

But what if you are angry at your wife or husband of many years? Or at your children? Or you feel angry at the fact that Republicans have run the country for 8 years. These are much harder to change, and more costly. So in cases where you either can’t easily change reality or you don’t really want to change reality, then you need to adjust your expectations. Instead of happiness meaning getting what you want, it can mean wanting what you’ve got.

The famous Serenity Prayer summarizes these concepts elegantly: In Latin, “Deus, dona mihi serenitatem accipere res quae non possum mutare, fortitudinem mutare res quae possum, atque sapientiam differentiam cognoscere.” Or in English, “God, grant me the serenity to accept the things I cannot change; the courage to change the things I can; and the wisdom to know the difference.”

I like to use the “80 Percent Rule” in determining whether my expectations are reasonable ones or not. If 80 percent of the time, my expectation matches reality, then it is okay to hold onto that expectation. Therefore, if my friend Hugh is on time for our dinners 80 percent of the time, it is okay for me to expect that. But if he is only on time for dinner 20% of the time, then I need to change my expectation, or change friends.

Step One: Defusing Anger by Changing your Shoulds

The first step in reducing anger is to change your “shoulds”. What is a should? We tend to assume that it is a universal law, but in reality, it is simply our personal demand on the universe. If I have a should that says, “People should always treat me fairly,” this is really just a different way of thinking “I want everyone to treat me fairly all the time.”

The first step to defusing anger is to change your shoulds into preferences. Instead of thinking “My wife should not spend so much money on clothes” you would think “I would prefer she not spend so much money on clothes.” Simply doing this reduces the intensity of anger significantly. You are owning your beliefs, instead of putting them into some imaginary universal law. If they are your beliefs, then you can choose to alter them.

Try a mental experiment. Think of something that makes you mad. Identify one of your shoulds that has been violated. Say the should to yourself a number of times, and notice how angry you feel. Now transform it to a preference statement. Instead of “They should _____”, it becomes “I would prefer that they ________”. Notice what happens to the intensity of the anger.

What you will notice is that the intensity of the anger diminishes. It doesn’t disappear, but it does transform in intensity. Why doesn’t it go away entirely?

This is because even our preferences may be distorted. Let me give you an example. I live in the Bay Area, where traffic tends to be quite heavy and slow at rush hour. Let’s imagine that I have the should statement, “I should be able to drive at 65 mph on the freeway, even at 5:30pm.” This should is likely to frustrate me when I am stuck in 25mph traffic. So I turn it into a preference, “I’d prefer to be able to drive 65 mph at 5:30pm.” This doesn’t really help very much. I’m still going to be frustrated because there is a large gap between my preference and reality.

Here is where applying the “80% Rule” is helpful. I ask myself if my preference is true 80% of the time. The answer of course is no. Perhaps only 10% of the time does traffic flow well at rush hour. Thus even my preference violates the 80% rule.

So I need to change my preference. A more reasonable preference would be “I prefer that traffic moves at 25 mph during rush hour.” Now there is a better match between my preference and reality, and I will not get as frustrated.

So, to summarize Step One, first you turn your Should Statements into Preference Statements. Next, evaluate the preferences using the 80 percent rule; does reality match this preference at least 80 percent of the time? If not, change the preference. This should at least lower your anger level, if not eliminate it.

Step Two: Defusing Anger by Putting Things Into Perspective and Emphasizing Coping

The next step of the SAP™ model is Awfulizing. Here we tell ourselves, “It’s awful and terrible, and I can’t stand it.” This creates a lot of internal psychological stress, and intensifies our feelings of anger and helplessness.

How can we change these patterns of thought? We can do so by putting the problem into perspective. On a 100 point scale, how awful is it really? Imagine that a 100 represents having a leg cut off without anesthesia, or a root canal without Novocain. Then rate how terrible is it to not have your should or expectation met. So if I am stuck in a traffic jam, and no one is shooting at me, and there is no blizzard outside, how awful is it really? Maybe a 10 on the 100 point scale.

Most frustrating events are actually relatively minor in the grand scheme of things. But we lose perspective, and this creates anger and stress. Another trick is to ask yourself if you will remember this event in one month, one year, or five years. If the answer is no, then it’s really not very awful.

The other aspect of this is the second part of the awfulizing statement, which is “I can’t stand it.” How often do we say this to ourselves? I define “not standing it” as meaning that you are going insane, hallucinating, curling up in a catatonic ball, or standing on the roof of a building getting ready to jump. Anything less than that means that you are actually standing it!

So what you want to do is replace “It’s terrible and awful, and I can’t stand it,” with “It’s inconvenient, or a hassle, and I don’t like it, but I can stand it.” This will greatly alter your emotional response.

So to summarize the second step in anger management:

  1. Ask yourself “How awful is this really?” Rate the awfulness on a 100 point scale, where 100 is something truly awful, like a serious injury or death of a loved one. Put the event into perspective.
  2. Remind yourself that most events will be quickly forgotten, and that most things in life are really hassles or inconveniences, rather than genuine disasters. Substitute the phrase “It’s a hassle, and I don’t like it but I can stand it,” for the Awful-izing statement of “It’s awful and terrible and I can’t stand it!”

Step Three: Defusing Anger by Reducing Personalizing

The final step in defusing anger is to de-personalize events. Remember from the previous article, that personalizing an event greatly intensifies the anger. If I believe that someone is purposely doing something to hurt me, I will get much angrier than if I believe it is an impersonal event.

This is easy to say, not so easy to do. The trick here is to realize that most of the time, when people don’t meet your shoulds or expectations; they are not doing it to harm you. When the clerk ignores you in the store, it’s more likely that they are tired or stressed than they saw you and thought, “Gee, I think I will piss off Dr. Lounge Wizard by ignoring him as long as possible.”

But what about people we love. Don’t they purposely hurt us?

Probably not. Most of the time, when loved ones do things that we are frustrated by, it is because that’s their nature. For instance, a messy person is messy because it is their nature, and it’s not because they are trying to anger their neat spouse. (Believe me, I know.) Everyone is trying to do the best they can, and pretty much doesn’t worry about you, or plan to hurt you.

So the secret is to simply assume that most things aren’t personal, and even when they appear to be, to reframe it as the person’s nature. A critical boss is critical of everyone, in most cases. A bad driver in front of you is probably always a bad driver, even when you are not behind them!

To summarize Step Three, remember than most of the time, no one is out to get you. They are just doing their natural thing. Use compassion, and think gentle compassionate thoughts that other people are flawed, but this isn’t personal.

So there you have it; the Three Steps to Anger Management. Try it out. I suggest you keep an anger/frustration log, and write down the S.A.P’s and then write down the counter thoughts for each step.

Copyright 2007 The Psychology Lounge™/TPL Productions All rights reserved

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

How Anger Works: The SAP Model ™ (Part 1)

In this article I will give you a simple cognitive behavioral explanation of how we get angry, and how you can use this knowledge to short-circuit and defuse your own anger. Anger is probably the most cognitive of all of the emotions. We can’t get angry without thinking. And most anger directly stems from our distorted thoughts.

There are three cognitive steps to getting angry. The first two are absolutely necessary for anger, and the third is like gasoline on fire, it intensifies anger. The acronym for remembering these three steps is SAP(tm), which is what anger will make you if you think these thoughts.

To help illustrate this lets consider a common situation where a person might get angry. You are driving on the freeway and a car cuts you off. You instantly react with anger. You steam all the way to work.

STEP ONE: VIOLATION OF SHOULDS or “SHOULDY THINKING”

The first step to getting angry is that you must have a set of shoulds or expectations that have been violated. Without this there is no anger. In the driving example what are your expectations? You tell yourself that the other driver shouldn’t have cut you off. He or she should have looked first and seen you. Obviously this should has been violated. This is what some cognitive therapists call “shouldy” thinking!

STEP TWO: AWFULIZING

But just having a set of shoulds or expectations is not enough to generate anger. The second step is necessary. In this step you exaggerate the negative consequences of the violation of the shoulds. You tell yourself it is awful and terrible that this event has happened. In our driving example your self talk is “Wow, the idiot could have killed me. It’s awful and terrible that they allow people like that to drive. Grrrrrr!” This step is called Awfulizing. Or Terribilizing, if you prefer. The key distortion is that you blow the event out of proportion. After all, if you are able to have these thoughts, then obviously no serious accident has ensued.

STEP THREE: PERSONALIZING

The first two steps will get you mad, but the third step of Personalizing or Blaming will make you crazy angry. If you tell yourself that the person didn’t see you, and it was an accident that they cut you off, you may still get angry. But if you tell yourself they did see you and purposely chose to cut you off anyway, then your anger spirals out of control. Blaming thoughts are like pouring gasoline on the fire of anger. They are responsible for such things as road rage.

So this how anger works. Let’s consider another example. This time we will use one closer to home. It’s early Saturday morning, and you are sleeping in after a long hard work week. Suddenly you are awoken by the loud noise of a lawn mower. It’s your neighbor George, who for some unknown reason, has decided that Saturday at 7:30am is a good time to mow his lawn. You are furious.

Let’s analyze this. What are the shoulds? Basically that your neighbor shouldn’t do noisy activities until 10 or 11 am on a weekend day. This should has been violated by George. What is the awfulizing? You are thinking that now you will be tired all day, and you’ll be cranky and irritable, and won’t have any fun. Is there a personalizing statement? Yes, you think, “George knows I work late, and knows I like to sleep in, so mowing his lawn so early is a direct insult to me!” And so you explode with anger.

So there you have it, a simple cognitive model of anger, the SAP model: Shoulds, Awfulizing, and Personalizing. Try an experiment. For a week, write down each anger incident you have by identifying the three Anger Thought Steps. This will help you to increase your awareness of how anger works, and prepare you for the next step, learning to defuse and eliminate your anger, which I will discuss in Part 2 of this article,  How to Stop Anger in its Tracks.

Copyright 2007 The Psychology Lounge/ TPL Productions All Rights Reserved

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

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

Sadder but Not Necessarily Wiser (and not quite as sad as expected)

Here is some more evidence that we poorly predict happiness and unhappiness.

A recent article in the Journal of Experimental Social Psychology again shows how poor we are at predicting our future states of happiness or unhappiness. As I wrote about in previous posts on happiness, we seem to be quite poor at predicting how we will feel in the future.

Eli Finkel and Paul Eastwick at Northwestern University studied young lovers to see if their predictions of unhappiness after a breakup matched their actual suffering when the breakup occurred.

They looked at college students who had been dating for at least two months and had them fill out multiple questionnaires. Twenty six of the students broke up during the first six months of the study and these students predictions of distress were examined. The students at rated how painful a breakup would be on average two weeks before the breakup.

On average people overestimated the pain of a breakup. There was some correlation between how much people were in love and how much pain they suffered after the breakup, but everyone recovered more quickly than they had predicted. Looking at the actual study it appears that people were able to predict somewhat accurately their suffering in the first two weeks after the breakup. The correlation between their prediction and the actual distress was about 0.60 which means that they were able to predict about 36% of their suffering. But between weeks six and 10, the correlations dropped to about 0.30, which means that they were only able to predict about 10% of the variation in their suffering.

This is interesting in terms of the habituation process that I wrote about earlier. We habituate to both good and bad events. And we underestimate our ability to adapt to both types of events.

Now we shouldn’t make too much of this study. Remember this is a study of college students who had been dating for at least two months. This isn’t exactly a study of deep connection and commitment. It would be interesting, but much more difficult, to look at the same data for married couples who later break up.

Copyright 2007 The Psychology Lounge ™ /TPL Productions , All Rights Reserved

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

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

Shyness Plus Rejection Plus Anger = School Shooters? News from APA Conference

Ah the joy of summer conferences! American Psychological Association had their annual conference in my lovely city of San Francisco this weekend, and one of the more interesting studies discussed was a study of kids who shoot other kids in school in mass murder attacks. They looked at eight teen shooters and rated them on what they call “cynical shyness.” Cynical shyness is a subset of normal shyness that involves anger and hostility towards others, especially when they are rejected.

Bernardo Carducci, lead author of the study and director of the Shyness Research Institute at Indiana University Southeast in New Albany explained:

“In addition to feelings of anxiety about social situations, cynically shy people, who are a small subclass of shy people, also have feelings of anger and hostility toward others and that comes from this sense of disconnect. Shyness has more in common with extroversion than with introversion. Shy people truly want to be with others, so they make the effort, but when they are rejected or ostracized, they disconnect. Once you disconnect, it’s very easy to start being angry and hate other people. It’s you against them, and they become what I call a cult of one. Once you start thinking ‘it’s me versus them,’ then it becomes easy to start hurting these people.”

Rating the eight teen shooters, they found that four of them had scores of 10 (on a 10 point scale) of cynical shyness, three had scores of 8, and one had a score of 6. Both of the Columbine shooters had scores of 10.

Now it should be pointed out that shyness per se is not dangerous. It is only this angry, cynical form of shyness, mainly found in teenage boys, that may be associated with dangerousness. And one weakness of the study is that they only looked at shooters. There may be many teens who score high on cynical shyness that do not escalate into violence. In fact this would be a good study, to identify what allows other cynically shy students NOT to become dangerous.

But shyness in pre-teens and adolescents is a serious disorder, as it can create intense misery in young people. Shy people desperately want to connect, they just don’t know how. Classes and workshops and group therapy approaches may be helpful in helping teens overcome this serious disorder.

Copyright 2007  The Psychology Lounge ™, All rights reserved

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

Getting Things Done: The Inner Game

How We Don’t Get Things Done

Today I am going to write about a topic that simultaneously seems ridiculously simple and yet is deeply complex. This isn’t based on any article or book, only my own musings, so you have only me to blame if this makes no sense. The question is: “Why can’t we accomplish our goals? Why can’t we get things done that we tell ourselves we want to do? Why is getting things done so hard?”

After all, think about it this way. If you want to raise your right hand and touch your chin, you will have no difficulty in doing so. You think, “Move your right hand to your chin,” and your hand moves completely predictably and reliably. You don’t forget to do it. You don’t struggle to do it. It is easy, almost effortless.

There are so many other examples where we get things done without apparent effort. You go to a restaurant, order food, and eat. No struggle, no difficulty. You don’t have to make a list of what to do. You don’t make a list; “1. Order food, 2. Eat food, 3. Pay bill.” You don’t check off anything. It all happens without drama or hassle.

So why is it so hard to do things like paying bills, cleaning up the kitchen, or doing financial planning? Why is it so hard to exercise? Who exactly is running the show? Which self says, “You should exercise.” Which self refuses to do so? How many selves do we have?

This is a deep mystery of the self. It’s almost like we have multiple warring selves, some of whom want to accomplish tasks and be productive citizens and some of whom want to sleep all day, or go to the beach, or eat crackers in bed.

How can we make sense of this? I’m going to propose a model for understanding this. It will develop as I write, so hang onto your hats.


WHAT DO WE REALLY WANT?

The first Big Question we need to examine is What Do We Really Want? Perhaps the problem is that we tell ourselves to do many tasks that we really don’t have any interest or intention of doing.

Why would we do this? Mainly because of social pressure, which we internalize. We are told you should clean up, pay bills, exercise, call your mother…and so on, and we end up internalizing these demands. But do we really want to do any of these things?

So when I tell myself, “You should pay the bills now,” do I really want to do this? I would argue that the behavior that follows answers the question. If I immediately sit down and pay the bills, then I wanted to pay them. But if I struggle, avoid, and don’t pay them without a lot of internal mental friction, then the answer is I didn’t want to pay them. I can force myself to do things that I don’t really want to do, but it’s hard, and takes extra time and effort. I want the bills to be paid, but I don’t want to pay them. That’s a common dilemma—we want the outcomes of an action, but we don’t want to do the action itself.

I am reminded of two stories that shed light on this dilemma. The first is a famous Zen story. A young monk visits the old Zen Master, telling the old master that he wishes to study with him to gain enlightenment. He goes on and on about how great it would be to study with the old master. The old Zen master says “walk with me.” They walk up a hillside, through a forest, and then come to a lake. The old Zen master walks out into the lake. Figuring that this is what Zen masters do, the young monk follows him out into the water. Soon the water is up to their necks. Calmly, the old master reaches out, forces the young monk under water, and holds him there with remarkable strength. The young monk struggles, and just when his lungs are bursting, he fights to the surface, and takes a huge breath. He looks with horror at the old Zen master, who simply smiles calmly and says, “Come back when you want enlightenment as much as you wanted that breath of air.”

Clearly we have no difficulty getting things done when we want those things done as much as the monk wanted that breath of air.

The second story is something I learned from a friend of mine who is a large animal veterinarian. I was always curious about the psychology of large animals like horses and cows. Carol worked with those, but also with more exotic beasts like buffalo. One time she mentioned a “buffalo bridle.” I was curious about what kind of bridle could be strong enough to control a buffalo, and asked her about it.

She looked at me with a sly smile, as if to say, “What a city slicker you are!” Then she explained that the buffalo bridle was not a thing, but rather something you know. Falling for it, I asked the obvious question: what do you need to know to control buffalo?

She said, “You only need to know two things.”

“What are they?” I asked.

“The first thing is that you can make a buffalo go anywhere you want…

as long as the buffalo wants to go there.”

“And let me guess the second principle,” I said. “You can keep a buffalo out of anywhere you want…. as long as they don’t want to go there.”

“Exactly!” she said.

So that’s another clue. We are a lot like buffalo. We get lots of things done, mainly the things we want to. And we are really good at not doing the things we don’t want to do.

So there you have it, a simple theory of why we get things done or don’t get things done. The things we get done easily are the things we wanted to do, and the rest is just a bunch of internalized “shoulds” that we never really wanted to do in the first place. In this radical notion there is nothing wrong with our “getting things done” mechanism. We simply have to stop fooling ourselves that we want to get all these things done. Accept our limited ambitions, and be done with it!

But there is a problem with this elegant and simple model. If this model is right, then what do we do? How can we get things done? It wouldn’t really work very well if everyone stopped doing the things they don’t want to do, like paying bills, cleaning the dishes, taking out the garbage, going to meetings, and so on. Unfortunately, sometimes we really need to do the things we don’t particularly want to do, like working at job, for an example.

Yet there is a simple allure to this model. And maybe we can use it to sort out the genuine wants from shoulds in our lives. Here’s an exercise. Take out a piece of paper right now. Make four columns vertically. In the first column list all of the tasks you find hard to get done. You can stop after 10 or so.

Next, label the second column “Want Rating.” In this column I want you to rate the degree to which you want to do each thing. This is your genuine desire to do the task, not the degree to which you think you should do it. Use a 0-10 scale where 10 is intense wanting.

In the next column rate the degree of should that you feel about the task. Again use a 0-10 scale.

Now look over the tasks where the rating for want is low, and should is high. In the last column write down what would happen if you never did the task. What would be the consequences?

This exercise can help sort out the wheat from the chaff, and help us eliminate thankless tasks or at least outsource them. For instance, I hate mowing the lawn, and can’t think of anything I’d rather not do instead. So I pay a gardener to do it. And I hate paying bills, so I don’t. Instead, I have most of my bills automatically deducted from my checking account or Visa card. If we analyzed all of our lives this way, perhaps we could spend more time doing our wants, and less time doing shoulds, and thus find happiness.

But let’s continue on our journey into the land of getting things done. Another question we need to ask is how can we want to do certain tasks? How do we increase our wanting? How do we become like that monk who desperately wants that next breath of air?

A Brief Digression into the Language of Wanting

But before I discuss that I want to take a slight detour through the intellectual forest, and talk about how we figure out what we want and perhaps more important, what we don’t want.

People often talk about doing things in terms of “having to.” “I have to go to work today. I have to take out the garbage, I have to pay the bills, I have to exercise, I have to take the kids to school.” Then there are other things that we don’t use this language about. No one really says, “I have to do the crossword puzzle, or I have to watch TV, or I have to kiss you.” But the truth is that the words “have to” don’t mean what they say. I don’t really have to go to work today. I don’t have to pay the bills. I can let the kids stay home and watch television. I can even let the garbage rot in the pail.

But we choose to do these things, mainly because we don’t want the negative consequences of not doing them. I don’t like the smell of rotting garbage, nor do I like bill collectors or truant officers banging on the door. The reason we don’t use the “have to” formulation for doing crossword puzzles, or watching television is because we enjoy them, and there are no negative consequences for not doing them.

Another difference is between process and outcome. Tasks that are easy are usually fun during the process of doing them, and have a good outcome. So watching a good show on television is fun during the watching, and leads to a satisfying outcome, assuming you are not watching the cliffhanger “24.” But paying bills is a mostly thankless process, and the only outcome is that you are poorer.

Another distinction is that easy tasks lead to some reward in the outcome, while hard tasks often the outcome is simply the lack of any negative outcome. When I pay bills, at the end I am a little poorer, and my creditors richer. All I have accomplished is to avert financial disaster.

So what happens if we change the inner and outer language we use? What happens if instead of saying “I have to _____” we instead say, “I choose to do_____” or even “I choose not to do _____?”

What is interesting is that saying “I choose not to do ____” is very powerful. It forces one to confront one’s actions as a conscious choice, rather than pretending that forces beyond your control are determining your actions.

And sometimes, when we say, “I choose not to do ____” we discover that that is just fine. For instance, my garage is a mess, but this weekend I choose not to clean it up. Instead I will take a bike ride.

Capitalism is to some extent based on altering what people choose to do. Forbes recently had a survey of the highest paying jobs in the United States. Almost all of them were medical jobs. Surgeons, anesthesiologists, dentists, and oral surgeons were all on the list. CEO’s were actually a little lower on the list.

Let’s think about this. We tend to think of these as good jobs. But let’s get real. Surgeons stick their hands inside the bloody guts of sick people. Anesthesiologist watch people sleep and try not to fall asleep themselves. Dentist and oral surgeons poke around people’s smelly mouths with small sharp tools. In order to get people to take on high stress, bloody, and often disgusting jobs, we pay them really well. Imagine if these jobs paid $40,000 a year. No one would do them. Most jobs that pay well require either lots of training, high stress, or great talent, and people are willing to work towards these jobs because they pay well. Salary is one way we get people to want to do things more than they would otherwise want to do them.

I often do a mental experiment with clients. When they are struggling to get something done, I ask them if they could do it if, upon completion, I wrote them a one million dollar check (and the check wouldn’t bounce.) Invariably, they say they would have no problem. So this tells us that one of the challenges of getting things done is that hard tasks have inadequate rewards. Or the rewards are too far off in the future to matter much. If I tell them instead of giving them a million dollars on completion, I will pay them 30 years later, then my offer loses most of its appeal.

How to Alter What We Want

So if my simple model is correct and we fail to accomplish things because we don’t want them enough, how do we change our wanting?

It seems that the key is to understand the basic principles that make us want to do things. Those things we do easily either are pleasant and fun during the actual process of doing them, or they have powerful rewards that follow their completion.

So understanding this we can begin to think about modifying tasks so that we can get them done. The first step is to improve the actual process of doing the task. For many boring, repetitive tasks, the easiest way to do this is to add another activity you do simultaneously. For instance, I usually clean the kitchen while on my headset phone talking with my mom or my brother long distance. This makes the experience almost painless, and I also benefit from staying in touch with people I love.

Or I will watch a baseball or football game on TV while sorting and filing papers. I have a rolling filing cabinet which I roll out into the living room, and this makes filing fairly painless.

Or I will listen to a podcast while grocery shopping.

Almost any task can be improved by adding good music, or an audiobook to the background.

The other strategy for lowering the aversiveness of tasks is time. If instead of trying to do an hour or two of boring paperwork, I instead break it down into 5 or 10 minute pieces, I can tolerate that much more easily. Some tasks are just too annoying to tolerate for very long, so breaking them down into smaller pieces makes good sense.

Another strategy is to change the reward structure. Let’s say you have 4 hours of filing to do. Although your papers will be filed at the end of the day, this is too small a reward to really motivate. You could break it down into 10 minute pieces, but this would mean you’d be still filing in 2050! The best strategy here is to create an artificial reward structure. Establish a reward you get when finished. Maybe you get to buy that Ipod Shuffle ™ you didn’t really need. I like to think in terms of an hourly rate of pay, even for nonwork tasks. I’ve set mine at $30 per hour, so after a four hour task I get to spend $120. Yours might be higher or lower, just be sure it’s high enough so that you are motivated. Pay yourself well for scut work!

This is the end of Part 1. In the next Part I will talk about the perils of prediction, the limitations of memory, and I’ll comment on the official Getting Things Done system.

Copyright 2007 The Psychology Lounge/TPL Productions

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

The Physiological Mechanism for How Stress Affects the Brain


For those readers curious about the mechanisms by which emotional stress affects brain function, I found an interesting piece of research about the physical mechanisms for how chronic stress can induce brain changes that could lead to cognitive impairment.

Scientists at Salk Institute for Biological Studies subjected mice to mild chronic stress for two weeks. What they found was fascinating. First some background on the physiology of Alzheimer’s disease. As the article explains:

“Alzheimer’s disease is defined by the accumulation of amyloid plaques and neurofibrillary tangles. While plaques accumulate outside of brain cells, tangles litter the inside of neurons. They consist of a modified form of the tau protein, which–in its unmodified form–helps to stabilize the intracellular network of microtubules. In Alzheimer’s disease, as well as various other neurodegenerative conditions, phosphate groups are attached to tau. As a result, tau looses its grip on the microtubules, and starts to collapse into insoluble protein fibers, which ultimately cause cell death.”

So basically, when phosphate attaches the the tau molecules, it causes them to change from helpful molecules to damaging the neurons.

The mice research found that the brain-damaging effects of negative emotions are relayed through the two known corticotropin-releasing factor receptors, CRFR1 and CRFR2, which are part of the body’s central stress mediation system.

So what does this all mean? It suggests that we have to protect our brains from stress, particularly chronic stress. Occasional stress doesn’t cause problems, but daily chronic stress does. The mice only showed permanent brain changes after 2 weeks of daily stress.

So stress management through cognitive behavioral therapy (CBT) or other means is not just a nice comfort option, but may be essential if you want your brain to last. Emotional pain doesn’t just cause emotional damage, it also damages the brain.

Perhaps scientists will be able to develop drugs that change CRF1 and CRF2 levels, but in the meantime, better take up that yoga, meditation, relaxation exercise, or CBT stress management program!

Copyright 2007 The Psychology Lounge/TPL Productions

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

Your Brain Wants You to Be Mellow: New Evidence Shows Chronic Emotional Stress Can Increase the Risk of Mild Cognitive Impairment in Later Life

So you’ve been putting off getting therapy, even though most of the time you feel anxious and upset? Well, a new study suggests that you may be putting your brain in danger.

Researchers at Rush University Medical Center in Chicago, Illinois, followed more than 1200 men and women who were 65 and older, average age of about 76. At the beginning of the study they made sure that none of them had mild cognitive impairment (MCI), and measured their emotional distress using a simple 6 item scale of neuroticism. Items such as 1) “Are you the type of person whose feelings are easily hurt?”; 2) “Are you the type of person who is rather nervous?”; and 3) “Are you the type of person who is a worrier?” make up this scale.

At the beginning of the study the average score was about 15 on this emotional distress scale. Patients were followed up for up to 12 years. About 38% developed MCI during the study. Those in the top 10% of emotional distress at the beginning of the study were about 40% more likely to develop MCI.

What is interesting is this relationship held even after researchers statistically removed the effects of depressive symptoms at the beginning of the study. So the results were from emotional distress, not from depression. The risk for MCI increased by 2% for every 1 point increase on the distress scale. This is a pretty strong correlation.

So what does this mean? I think what it means is that chronic emotional upset is hard on the brain. It makes sense, since emotional stress raises stress hormones such as cortisol, which we know can damage the brain, especially the hippocampus, which controls memory. What we don’t know is whether this study was picking up some early brain changes in the elderly, changes which correlate with both emotional distress AND a tendency to develop MCI. A better study would look at younger people, and see if emotional distress in those aged 40 or 50 leads to the development of MCI in later life.

Since about a third of those with MCI will develop Alzheimer’s Disease, any reductions in the prevalence of MCI would be tremendously beneficial to society. Perhaps psychotherapy should be mandatory for all those over 65!

What can you do to lower your brain risk? First of all, honestly evaluate whether you suffer chronic emotional stress. Ask yourself if most of the time you feel calm and happy, or upset and worried and stressed. Also ask your close friends and/or family what they think. If you are someone who suffers chronic stress, then get help. A cognitive behavioral psychologist can teach you good stress management skills, and may help break lifelong patterns of emotional stress. Another good option is to learn mindfulness meditation and yoga and practice them daily. These are known to reduce psychological distress.

Whatever you do, don’t take it lightly if you are in long term distress. Your brain wants you to be mellow!

Copyright 2007 The Psychology Lounge/TPL Productions

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

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

Can Cognitive Behavioral Therapy Make a Baby? How Psychological and Behavioral Factors Can Reduce Infertility

An article in the May 7 edition of U.S. News and World Report titled “Success at Last: Couples Fighting Infertility Might Have More Control Than They Think” shows how health psychology can impact even something as basic as making a baby. This fascinating article shows that behavioral and psychological factors may play a big and controllable role in producing the infertility that 1 in 8 couples suffer. It turns out, that the body may be smarter than we gave it credit for. Woman’s bodies may recognize certain states as not ideal for childbearing, and therefore prevent or lower fertility. Two examples are being overweight or underweight. Overweight risks pregnancy complications such as diabetes, high blood pressure, so the extra estrogen produced by body fat interferes with ovulation. Underweight women may not have enough body fat to sustain a baby, so the pituitary gland releases less of key ovulation hormones. Other behaviors strongly influence fertility. Take smoking for example. Multiple studies show that smoking can delay getting pregnant by a year or more. And one study at

Columbia University found smokers entered menopause 3 years earlier on average. Or diet. Trans fats, a key component in such unhealthy foods as donuts, cakes, etc. may raise testosterone, which suppresses the ovaries. Research shows that as little as 4.5 grams, which is the amount found in one donut, can have this effect. Even positive behaviors can negatively affect fertility. One study found woman who exercised four or more hours a week were 40 percent less likely to conceive after their first IVF (In vitro Fertility) treatment than women who didn’t exercise. Once again, it may be that the body interprets hard exercise as danger and stress, and shuts down the fertility system.

Even pure psychological stress can affect fertility. Here’s the biological mechanism. A few hours before ovulation, the pituitary gland sends out luteinizing hormone (LH), which tells the ovaries to release an egg. But if you are experiencing psychological stress such as a fight with your husband, or a dressing down from your boss, or a kid having a tantrum, then your LH will be suppressed, disrupting ovulation.

Even mild stress may have a big effect. One study of monkeys found that moving monkeys to a new cage, combined with a little less food and 1 hour on treadmill caused 70 percent of the monkeys to have irregular menstruation! So don’t skip that meal and take a long run when stressed, or you’ll greatly lower you odds of getting pregnant.

What’s worse is that IVF treatment itself may lead to large amounts of psychological stress. One fertility expert found that 40 percent of women in infertility treatment had all of the symptoms of an anxiety disorder or depression: sleep disturbances, difficulty concentrating, and irritability. So if stress lowers fertility, and fertility treatment increases stress, then fertility treatment may actually harm fertility!

But cognitive behavioral therapy may improve the situation. Alice Domar and colleagues at Harvard found that a 10 week cognitive behavioral group therapy program improved the success of fertility treatment from 20 percent to 55 percent in the women who participated in the group therapy. So what can we learn from this research?

  1. A woman’s body is wise. It will respond to behavioral and psychological stressors by lowering fertility. Anything that resembles stress, even hard exercise, will trigger physical responses that lower fertility.
  2. At critical points such as several hours before ovulation, even normal stressors can disrupt the ovulation process. And in stress-prone or perfectionist or angry women, the likelihood of experiencing stress during these critical hours is very high. Thus for women who are experiencing difficulty getting pregnant and who by personality are “stressy” (you know who you are!) cognitive behavioral therapy (CBT) will be helpful in learning to manage and lower stress.
  3. Infertility treatment is by its nature stressful, and this leads to a paradox; infertility treatment may lower fertility if it increases stress. It may be helpful to evaluate stress levels in women undergoing IVF and if stress is high, intervene with CBT group or individual therapy.
  4. The ultimate in infertility treatment may be what I recommended to my friend Jill, who had tried many cycles of IVF to no avail. I told her, “You’re young, why don’t you and your husband stop trying to get pregnant, and just have sex for fun, and enjoy life for a few years. If nothing happens then you can adopt.” She was pregnant within the year, and now has two lovely children. A good long relaxing vacation with no schedule, no hard exercise, healthy food, and no stress may be the best fertility treatment available, and even if it doesn’t work, at least you’ve gotten a great vacation!
  5. Finally, what this research shows us is how linked our minds and bodies are. Changing thoughts and feelings and behaviors changes our bodies, and fertility is just one example of this.

Copyright 2007 The Psychology Lounge/TPL Productions

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

Is Your Shrink Being Paid to Give You Drugs? The Secret Link Between Psychiatrists and the Drug Industry

Regular readers of this blog will remember my earlier article on Rebecca Riley, the young girl whose overtreatment with powerful psychiatric drugs may have led to her death.

Now it turns out that some psychiatrists may actually be getting paid by the drug industry to give kids powerful drugs! And this is in spite of an almost complete lack of evidence that these drugs work or are safe for children.

The New York Times has an article called Psychiatrists, Children, and Drug Industry’s Role, and this scary article documents the secretive practice of paying psychiatrists to prescribe certain drugs.

The article documents that more than half a million children are now receiving atypical antipsychotics such as Risperdal, Seroquel, Zyprexa, Abilify, and Geodon. These drugs have never been tested on or approved for use in children!

In Minnesota alone, the only state that requires such reporting, from 2000 to 2005 payments from pharmaceutical companies to psychiatrists soared by six times, to $1.6 million, and the rates of prescribing antipsychotics to children went up by nine times.

And the Times found that the money worked. Those psychiatrists who received more than $5000 from the drug companies wrote 3 times as many prescriptions for atypical antipsychotics than those doctors who got less or no money. Other interesting figures are that the average payment to psychiatrists was $1750, with a maximum of $689,000. (Nice work if you can get it!)

I should point out that atypical antipsychotics are not benign drugs. Side effects can include rapid weight gain that leads to diabetes, and movement disorders such as tics and dystonia, which can lead to a lifelong muscle disorder.

The Times describes one unfortunate girl, Anya Bailey, who was given Risperdal for an eating disorder by her psychiatrist George Realmuto, who had received more than $7000 from Johnson and Johnson, the maker of Risperdal.

Although the drug helped her gain weight, she also developed a painful and permanent dystonia in her neck that now causes her chronic pain and a movement disorder, even after stopping the drug.

And she was never given any counseling for her problems, only drugs!

So what can we learn from this article? First of all, the practice of paying psychiatrists to prescribe certain medications is widespread, but only Minnesota requires full disclosure. We should pressure our legislatures to mandate full disclosure in every state. Write to your state and federal congress and senate and ask them to either ban this practice or to require full disclosure, on the web, by name of doctors, of how much money is given by each drug company.

Secondly, when you take your child to a psychiatrist, you should ask them for a full written disclosure of any money they received in the last few years from drug companies for speaking, or for research. Payments to psychiatrists (and other M.D.’s) are disguised as speaking honorariums or research payments, but when a doctor receives $5000 for giving one or two talks, it is safe to say that they are being paid for something else. If the psychiatrist admits to receiving money, then you should probably find another psychiatrist, as this creates a bias to prescribe that I do not think can be overcome.

Third, you should be dubious about any suggestion to give your child an antipsychotic medication for any diagnosis other than true psychosis. This means that unless your child is actively hallucinating, and delusional, i.e. “crazy” there is no evidence that antipsychotics will help them. For instance, there was only one well controlled study of the use of atypical antipsychotics in bipolar illness in children, and it found little or no difference between using the antipsychotic and not using it. And most of the children in the group receiving the antipsychotic dropped out of the study due to side effects. A second study by the same researchers found no advantage to using antipsychotics.

Fourth, consider taking your child to a psychologist or counselor rather than a psychiatrist. Psychologists don’t receive money to influence their treatment decisions, and use behavioral approaches that don’t have side effects. And there is much more research evidence that supports the use of these behavioral approaches in childhood disorders. Dangerous medications should be reserved as second or third line treatments only. Remember the old saying that to a young boy with a hammer everything becomes a nail, similarly to a doctor whose specialty is giving drugs, all problems become biochemical.

Finally, let’s put pressure on our legislators to outlaw this thinly disguised bribery, which threatens the health of children and adults. Shame on the pharmaceutical industry! And even more shame on psychiatrists, who of all people should be trustworthy and not willing to accept such bribes. I make the perhaps radical suggestion that patients boycott psychiatrists who accept money from drug manufacturers. If doctors can’t earn a decent living without taking payments from drug companies that often have the appearance of bribes, then perhaps they need a new profession. I realize that there are decent, honest psychiatrists who either don’t take drug company money or don’t let it influence them, but I suggest that it may be hard to tell the difference, unless psychiatrists employ full disclosure.


Copyright 2007 The Psychology Lounge/TPL Productions

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

My Afternoon With the Dalai Lama: Lessons and Insights

I sat a mere thirty feet from his Holiness the Dalai Lama yesterday for 90 minutes. The day April 29, 2007 will always be special to me. It was very magical. Not because of what he said, standard but true Buddhism 101, but his character and his energy. There is a magic about this man, who more than anyone else seems to be completely in his own skin, and truly comfortable in that skin. He laughs, and he smiles, and he just seems unflappable. No pretense. When asked about parenting tips to raise a compassionate child, he laughs, and says, “I am monk. What do I know about raising children?” but then he continues, “Maximum care, maximum affection, and more time is the key.”

His basic message was about happiness. Happiness is mental, not based on people’s situations. Does this sound familiar? Basic cognitive therapy 101, happiness depends on how you think about things. Someone poor and homeless could be happier than someone wealthy and accomplished, depending on their respective expectations.

In the Dalai Lama’s view, happiness also comes from good companionship—friends, lovers, children, and a calm mind. Again, the Buddhists knew something 5000 years ago that modern social scientists are merely rediscovering—the critical importance of social support in mental health. For instance, 40 percent of married people describe themselves as “very happy” versus just 24 percent of single people. Those with 5 or more close friends are more likely to describe themselves as happy.

The fascinating thing about seeing the Dalai Lama is that once I settled down into a calm and meditative state listening to him, something transformative happened. I started to write down some ideas for creative projects, and suddenly words were flowing out of my pen. Anything was possible. I found myself having one of those magical moments that scientists describe as “Flow”. My confidence soared, and I had some important insights into life.

One of these insights was about watching television. I realized that watching television is about having nothing better to do at the moment. Even good television pales if there are wonderful social opportunities or creative ones. We watch TV because we are tired and a little bored. (Of course, even the Dalai Lama watches a little TV in the evenings, as he writes in the Art of Happiness—mostly nature documentaries, and not episodes of “24!” )

Another insight was about purpose. What is your purpose on this planet? What is the main thing you want to accomplish? So much of our striving and actions have no central purpose focus. We just sleepwalk through life. We just fill time. Some of us do it with work, some do it with relationships, some do it with reading, some with television, but all addictions have the same basic theme—how do I fill the time between being born and dying? If we know our purpose, then time fills itself.

The day after seeing the Dalai Lama, I awoke to a strange sense of emptiness. I felt like somehow it was gone: that quiet feeling of confidence, of knowing, of lack of worry. Was it all just a contact high? Later that same day, with meditation, contemplation, and writing I felt like I could get some of it back, so I knew then that my afternoon with the Dalai Lama had led to something real.

Namaste.

Copyright 2007 The Psychology Lounge/TPL Productions

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

Shopping for Happiness ™

I’ve been working on a book length project on how to apply the current happiness research to everyday life, and this is an excerpt from that book.

It is said that money can’t buy happiness. This is mostly true. Like most generalizations, though, there are exceptions. What I hope to do in this chapter is to use the happiness research to teach you how to be better at shopping for happiness.

The happiness research teaches us several things. One basic principle is that of habituation, or getting used to things. This unfortunately robs us of joy from new and shiny possessions.

Thus using your hard–earned money to buy that shiny sports car will most likely not result in as much happiness as you anticipated. This is disappointing. After all, what is the point of making money if spending it doesn’t bring happiness?

The happiness research also shows us what tends to make people happy are experiences. This gives us some clues how to spend money to maximize happiness. Instead of buying things, which fade remarkably rapidly in their ability to please us, it makes more sense to use your spending to purchase items that allow you to have experiences you will enjoy. Or to directly purchase experiences that you will enjoy such as exotic trips, unique experiences, or thrills and chills like a parachute jump or bungee cord drop.

Let me give you some do’s and don’ts of shopping for happiness.

In many financial magazines and journals you will see little articles about how much money you can save by skipping the latte at your local café. They run the numbers, calculating one latte per day investing for umpteen million years, invested at 10% interest, becomes some ridiculous number by the time you are 93, perhaps even several hundred thousand dollars. It certainly would be nice to have a spare $200,000 by the time you are 93, assuming you make it that far.

The problem with all these articles is that they ignore what science has discovered about happiness. It really depends how you spend the $3 on your latte. If you spend $3 on a latte just so you can rush in and out of your local Starsucks, jump in your car, and spend your morning commute more caffeinated, then the articles are right. You’d be better off making coffee at home, putting it in a go cup, and investing that money for the long term.

However, if the way you enjoy your latte is by sitting at your local café where you know people, chatting with your table neighbor, reading the New York Times or Wall Street Journal or the local paper, and in general, relaxing and socializing, then this is a $3 very well spent indeed! What you done is to purchase a pleasant and social experience. If you do this daily, you will form a community of sorts, which always increases happiness.

Spending money in order to have satisfying experiences leaves you with memories of those experiences, which linger, and raise your happiness level.

Let me give another example. Someone close to me was living with a woman and he was struggling to find athletic activities he could share with his partner. She didn’t like hiking,  and would complain bitterly when they climbed hills.

Biking was even worse. She was a slow and unconfident rider. He was resentful at how slowly she rode, as it prevented him from enjoying a workout. He also constantly worried about her in traffic, as she had little experience riding, and often would dart out into traffic. She would get mad at him when he rode ahead of her. It was no fun for either of them.

This was a problem. What was the solution? I suggested to them that they spend some money to solve this. What did I suggest? I told him to buy a tandem bicycle. I had seen one on EBay, a recumbent tandem, for about $1800 shipped.

He bought it, and they started to ride together. She would ride on the back of the bike where all she had to do was peddle, and he would steer the bike from the front position. He got a great workout, even if she didn’t peddle very hard, and she was guaranteed to keep up.

It became a very enjoyable activity for them, riding almost every weekend, talking while they rode, and enjoying a pleasant and athletic activity together.

What did my friend purchase? It seemed like he purchased an expensive tandem bike. But in actuality, he purchased a “ticket to ride” or a ticket to a recurring pleasant experience for him and his wife.

Similar examples would be buying backpacking equipment, golf equipment, scuba gear, running shoes, and so on. But it should be something you use regularly. Buying a pair of skis and boots that you only use 3 days a year will not have a significant impact on your happiness level, in fact, in many of these cases it’s better to rent.

For instance, I enjoy scuba. But other than a mask and fins, I own no scuba equipment. The main reason is that I only scuba dive a few days each year, and thus the hassle of buying and owning and maintaining the equipment is not worth the small increment in happiness that my own gear would bring. If I dove frequently I would own my own equipment. 

This brings me to another useful principle in shopping for happiness. I didn’t invent this one, my friend Dan came up with this principle. Dan taught me one simple principle for purchasing things. He told me that one should buy the very best in things that you interact with every day.

Again, if I scuba dive daily, I should buy the best equipment I can afford. Or if I am a bicyclist, and I ride daily or almost daily, then it makes sense to spend three, four, or even five thousand dollars on a great bike if I can afford that.

As a result of Dan’s law, I am writing this on my very sleek three-pound IBM Laptop computer, which I use almost daily for writing and web-surfing in cafes. At home I write on a dual monitor workstation, with two 20 inch monitors side-by-side. This is a delicious luxury which I use for many hours each day. As an avid computer user, I think one of the best investments one can make is to buy large flat screen monitors for all of your computers. Especially if you are over 40, and developing presbyopia.

How does this apply to buying cars? Cars are tricky because there are at least three different issues that are relevant: status, function, and add-ons.

The most obvious issue is status. Unfortunately, this is the one that has the smallest and most fleeting impact on happiness. If you buy your car to impress others, they will be less impressed than you expect, even if you buy an outrageous car like a Ferrari or Lamborghini. Secondly, their being impressed will actually give you less happiness than you expected, and you will get used to the oooh’s and aaaah’s all too quickly. Finally, the hassles and owning and insuring and driving a supercar will soon outweigh the relatively small happiness that status brings you. So rule # 1 is don’t buy things for status.

(The same applies for kitchens, bathrooms, televisions, or any other product where you might be torn between shopping for status versus function. If you are buying granite countertops because you like chopping food on granite, that makes sense. If you are buying them so your friends will say “Ooooooh and Aaaaaah” when they come into your kitchen, then your happiness dividends will be much less than you expect. After all, your friends will habituate to your new kitchen, and will stop marveling at its wonders after a few visits. And long before that, you too will have grown used to the “new normal” and lost your initial joy in it.)

Going back to the example of a car, you should be thinking about function. Therein lies the rub. Most expensive cars are not very different in function from less expensive cars. All cars have four wheels, a motor, brakes, and a radio. Heresy! You are thinking. Of course expensive cars are different. But not very much. Once you get into the $20,000 to $30,000 range for a car, you are getting a fast, quiet, and comfortable car that takes you where you wish to go. Above this amount, you are primarily paying for status or for features you can’t use much. Case in point, many expensive cars go very fast. A Ferrari can do a top speed of 155 mile per hour. Cool, right? There’s only one catch. It’s hard to get up to this speed on your morning or evening commute. In fact, you are lucky if you even get up to 45 mph.

So buying features you can’t use won’t increase happiness much, and may even frustrate you. Trying driving a six-speed manual transmission Ferrari in bumper to bumper traffic on the freeway sometime, if you don’t believe me.

Remember I said there were three factors. The first was status which I hope that I have demonstrated has relatively little lasting impact on happiness. The second is function. Function matters somewhat, but what really matters is the basic functions of a car, the ability to drive at reasonable speeds with reasonable comfort and quiet. That’s why convertibles rarely bring people as much happiness as they expect. Convertibles are really fun about one or two weeks a year. But much of the time it is too hot, too cold, or too rainy to benefit. And convertibles are not very pleasant cars with the tops rolled up. So it makes more sense to rent a convertible for a week or two a year, and enjoy it. Most mid-range cars function very well, and expensive luxury cars have only a few additional functions, and sometimes these functions are more trouble than they are worth. As an example, the BMW 5 series, which has something called an I-drive ™ which is like a joystick that controls the car’s functions. Many reviewers have complained that this feature is confusing and difficult to use, and requires constant reading of the car’s manual.

The third principle of shopping for happiness with cars is the add-on principle. Instead of buying an expensive car, and having no money left over, buy a cheaper car and invest the money you save by customizing and improving the car in ways that will actually increase your happiness while driving.

An example is two items that can have a big impact on happiness. The first is a GPS unit. If you are like my friend’s girlfriend, who is directionally impaired, and who constantly is getting lost and arriving late to every destination, then buying a GPS unit will have a huge impact on your happiness level while driving. She has told me numerous times that buying a GPS was the best thing she ever bought for her car. It eliminated a constant annoyance in her life, for an investment of only about $300.

The other investment in a car that makes sense is a good sound system for your car. Now if you only drive 5 minutes a day, skip this paragraph. But if you are like most Americans, and you commute a significant distance each day, then it makes good sense to spend some money on adding a great sound system to your car, if it doesn’t have one already.

You will definitely want a way to play all of your favorite music. It doesn’t matter whether that is a way to plug in your Ipod, a CD changer, or some other device. You may also want to consider a satellite radio unit, especially if you like commercial free radio and you like talk radio without commercials. (No one has ever demonstrated that commercials add to happiness levels.) So for the mere $15 a month that it costs, satellite radio may be an excellent investment in happiness.

Once again, neither a GPS nor a satellite radio is very expensive, and they can be just as easily installed in a $15,000 car as a $100,000 car.

I practiced this with older cars for many years. When my Nissan Maxima passed its 15th year, I decided to give it a birthday party, and to improve the car. I replaced the sound system, put new shocks in the front, and added an anti-sway bar to improve its cornering ability. This greatly improved both the driving quality and the experience of being inside the car, and was much cheaper than buying a new car.

In a similar way, you could utilize the add-on principle for a house. Instead of buying a new house, you might focus on improving several areas of your current house, focusing on function rather than status.

I was speaking with a client recently, who loves cooking. She was contemplating a kitchen remodel. She was talking about granite countertops.

 

I asked her, “Can you cut food on granite?”

 

“No, of course not,” she said.

 

“Can you prepare food on granite?” I asked.

 

“You can,” she said, “but it’s not a good idea. The food can stain the granite.”

 

“How is a granite countertop going to make your cooking experience more enjoyable? “ I asked.

 

She thought about it for a moment, and then said quietly, “Well, it probably won’t make it more fun, but it will look nice.”

 

So I asked her how much the granite countertop would cost. She told me $12,000. I asked her if her budget was unlimited. She said no. Then I said, “Are there any functional items that would make your life easier as a cook? Are there any things you would rather spend your $12,000 on?”

 

She thought about it, and then she mentioned a special European dishwasher that had two drawers, so that you never had to unload it. And a special type of oven that was costly but worked better.

 

In the end, she decided to keep her tile countertops, and instead spent the money on high- end incredible appliances that she uses every day.

 

This was a great example of shopping for happiness. She spent her money on things that would bring her direct joy every day. In general, if you want to spend money on making your kitchen “look impressive”, you’d be better off spending the money on a beautiful painting, or on functional items that you can enjoy every day. Very few people spend time sitting in their kitchen, simply staring at and admiring the granite counters!

 

Let’s talk about more shopping decisions, and other ways to shop for happiness.

Travel is a great example where shopping for happiness principles are useful. First of all, travel in general enhances happiness. This is because even trips that aren’t that great tend to improve in memory, especially as we tell and retell the stories. Some of the biggest disasters on trips end up making the most memorable stories.

 

I’m reminded of an infamous bus trip I took while in graduate school, on a hippy bus line from Seattle to Baja Mexico. My then girlfriend and I decided it would be a lark to spend three weeks traveling around Baja on this hippie bus, and off we went. Many disasters ensued, including a middle of the night near head-on crash with another bus which took off the side mirrors on both buses, a trailered boat breaking an axle, falling off the bus, and taking a short and tragic trip across the chaparral, ending up in pieces, multiple encounters with Mexicans who were baffled by this group of Americans, getting off the bus when it became apparent that it was dangerous to stay on the bus, hiking to a deserted beach in the desert, and waking up in the morning to a beautiful experience of homemade fruit salad and skinny dipping, which resulted in every local bee attacking for hours, hiking out from the beach in a hurry as a result, and getting lost in the desert when I proudly said I knew exactly where we were, waking up in the middle of the night in a cheap hotel room only to discover 6 inch roaches trying to drag our food bags away, and then sleeping fully dressed, with blindfolds and the lights on for the rest of a very fearful night!

 

And these are just the highlights!

 

This is the stuff of legend, and I have to admit it was one of the best trips of my life. It also brought us closer because we had to cope with all of these disasters.

 

There are principles of shopping for happiness in travel which many people ignore. For instance, many people will pay more money to upgrade to business or first class when flying. This is generally not a good investment in happiness. (Unless work pays for it, then why not?)

 

(I should add at this point that these comments apply to people who do not have unlimited financial resources. If you are a Bill Gates or Steve Jobs, you have a completely different set of problems in terms of shopping for happiness, which I will talk about later in a section called Shopping for Happiness Tips for the Billionaire.)

 

This is not to say that business class and first class are not pleasant experiences. In comparison to coach, they are. The reason why they do not deliver a proportionately higher level of happiness, relative to their cost, is that most airline rides are short. If you are flying 2 to 5 hours, the difference is not very significant. It’s especially less significant if you tend to nap on cross country flights. If I close my eyes, and nap for half of my cross country flight, then I am looking at a 2.5 hour experience in First Class, for a cost of an extra thousand or more dollars. Spending $500 an hour to have a slightly wider seat, better food, and a few free drinks seems like a bad investment in happiness.

 

The same principle applies to hotels. Many people like to stay in four of five star class hotels, probably because they like the status of doing so. In general this is not a wise investment of travel money, especially if you tend not to spend a lot of time in your hotel room.

 

If you mainly use the hotel to sleep, then a five star hotel offers very little that a two star hotel does not. As long as the bed is comfortable, and the room is quiet at night, nothing else really matters. A big TV is not important, as you can watch TV at home. A gorgeous swimming pool is also not so important, as you can use the five star hotel’s swimming pool even if you are staying across the street in the two star hotel. Or you can go to the beach, which is free.

 

There is one exception, though, which is if you plan on never leaving your hotel during your stay. In that case it may make sense to pay more for a luxurious hotel room, as you will get to experience that luxury 24/7. This may have a small impact on increasing your happiness level.

 

The better way to spend money on travel is to use the happiness research which tells us that status items do not bring much happiness, and that experiences are what we remember fondly. An example of this would be to skip the five star hotel in Hawaii which costs $300 or $500 a night, and to instead stay at the $150 three star hotel. Then invest the difference in buying great experiences.

 

One day you might spend $200 on renting a pair of jet skis, and have a very exhilarating experience zooming around the coast. Another day you could spend that $200 taking surfing lessons, and renting surfboards. Whether you surf successfully or not, you will have a memorable experience. The next night you treat yourselves to a dinner in the best restaurant in Honolulu, where you run into Barack Obama, who is having dinner with his family at the next table. (True story from 2006.)

 

Think about travel stories you have told or listened to. Was it very memorable that the hotel room was large or luxurious? No. What was memorable is when you left the hotel and had exciting experiences.

 

To be continued…

 

Copyright 2006-2007 The Psychology Lounge/TPL Productions/Andrew Gottlieb, Ph.D.

Shopping for Happiness ™ is a trademarked term. Trademark 2006, Andrew Gottlieb.

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

The Mind-Body Connection: Depression and Its Effects On Physical Health

I will return to the theme of happiness in a few more days, but today we will continue with our series about depression, based on Peter Cramer’s book Against Depression, which I heartily recommend to anyone who wants to learn more about depression.

Depression is not just a psychological disease. It impacts the whole body, and especially impacts the cardiovascular system. Depression is one of the strongest predictors of cardiac disease. Even minor depression increase the risk of cardiac disease by 50 percent. Major depression increases risk by 3 to 4 times. For those with pre-existing coronary artery disease, risk is increased 5 times!

You might be thinking that this is no surprise. Perhaps depressed people smoke more, exercise less, eat more bacon, etc. What is surprising is that the numbers in the preceding paragraph are after adjusting for lifestyle and behavior! The raw numbers are even higher!

Why is this? What is the mechanism by which depression reeks havoc with the cardiovascular system?

There are several possible mechanisms. One is through the impact on blood clotting.

Blood clotting is controlled by cells in the blood called platelets. The stickier the platelets are, the more likely you are to develop blood clots, which can lead to stroke or heart attack. Depressed patients have stickier platelets.

Another mechanism is stress. Depressed patients are under constant physiological stress, with excess stress chemicals circulating in their blood. This may raise blood pressure and cause other changes that affect the cardiovascular system.

So what happens if you treat depression? Does this reduce risk of cardiovascular disease?

Studies of antidepressants given after heart attack show a 30 to 40 percent reduction in subsequent heart attacks and deaths.

Antidepressants improve the outcomes after stroke as well. When stroke patients were given either antidepressants or placebo, 66 percent of the antidepressant group survived 2 years, but only 35 percent of placebo group.

Other physical triggers like treatment with interferon for hepatic C and melanoma can also cause depression. In fact, 50 percent of patients who receive interferon will get seriously depressed. Depression in these cases is serious because it can cause the person to stop taking a potentially life-saving treatment.

Antidepressants help even in these cases of drug induced depression. One study found that treatment with Paxil, an antidepressant, reduced depression from 45 percent to 11 percent.

What are the implications of these finding?

  1. All patients who have had a heart attack or a stroke should probably take an antidepressant.
  2. All patients taking long-term interferon treatment should begin taking an antidepressant several weeks before starting the interferon.
  3. Probably most seriously ill cancer patients should take an antidepressant as well.
  4. Counseling that focuses on evaluating and treating depression should be part of any seriously ill medical patient’s treatment regimen.

Copyright 2007 The Psychology Lounge/TPL Productions

All Rights Reserved


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

Your Junk is My Treasure! The Psychology of Compulsive Hoarding


Today I am going to write about a very different type of psychological problem, called compulsive hoarding. The Boston Globe had a very interesting article about hoarding. Researchers Gail Steketee and Randy Carlson have a new book, called “Buried in Treasures,” which documents their new approach to treating this disorder.

First of all, what is compulsive hoarding? It’s when you can’t get rid of anything, and can’t put in order what you have, so much so that you end up having difficulties using the spaces you live or work in.

Are you a hoarder? Of course not! But Steketee and her colleagues developed a simple photo test for hoarding . Take a look at these photos, and pick out the one that looks the most like your bedroom. If it is number 4 or higher, then you probably have a problem with hoarding. (Hoarders, it turns out, are very accurate at identifying the level of chaos in their spaces.)

Your official Lounge Wizard, Dr. Psychology took the test, and scored a 2 or 3, which puts him in the normal range, but right on the borderline of hoarding. So this article is close to his heart.

What causes hoarding? It’s not what most non-hoarders think; laziness, messiness, or even depression. Although many hoarders have some elements of depression or anxiety, the core of hoarding is that they have strong attachments to things. They are sentimental about possessions, and often have very intense feelings about them. They tend to be creative, and can think of many uses for objects.

Most hoarders function fairly well outside their homes. They have jobs, friends, and active involvements. Where hoarding seems to impact them is in romantic relationships. The hoarders I know tend to not have long term romantic relationships, which isn’t surprising, as girlfriends and boyfriends tend to want to come over to your house, and for a hoarder than is a painful experience. “Why do you have all of this stuff? Why don’t you get rid of all this junk? I can’t believe you live this way!” are all typical comments they may hear. Needless to say, there are no more invitations after that. Steketee finds that at least 50% of hoarders are single.

So is there any hope for hoarding? One thing that doesn’t seem to work very well is traditional medicines for depression like antidepressants. Although these medicines work well for regular obsessive compulsive disorder (OCD) they don’t appear to do much for hoarding. Traditional psychotherapy doesn’t work either.

Steketee and colleagues have developed a very nice cognitive behavioral model for treating hoarding. They find that hoarders have similar cognitive models. For instance, hoarders have four common fears: 1) missing important information or opportunities, 2) forgetting something important, 3) experiencing loss, and 4) being wasteful. They tend to focus on lost opportunity, so getting rid of a newspaper entails a possibility of losing some opportunity that was in the newspaper. In general, all of their possessions get elevated in value.

Another common issue is needing to keep things in sight. This is tied into the need to not forget anything. “Out of sight, out of mind,” is the hoarder’s mantra. This causes the visual chaos that creates many of the problems of hoarding, since if one just had many possessions, but they were well organized and stored, hoarding would not be a big problem.

So it is not surprising that Steketee’s treatment plan focuses on helping hoarders learn to organize their space, rather than focusing on getting rid of stuff. This is more palatable goal for most hoarders, who know that their space is poorly organized.

The treatment also focuses on helping hoarders overcome the need to acquire things. The rules for acquisition are: 1) immediate need for the object (this week), 2) time enough to acquire and use the object, 3) money to buy it, and 4) an appropriate space for the object. This nips the problem in the bud.

The treatment works, but it’s not a miracle. According to Steketee, it’s not unusual for someone to move from 7 to 3 on a 9 point scale where 1 is neat and organized, and 9 is total mess. But relapse is always a danger, as there is something very compelling about hoarding.

So what is the core of hoarding? Even Steketee and her colleagues are a little baffled about this. As a borderline hoarder who closest friends include some hoarders, I can give some intriguing answers.

Hoarding is about possibility. The thought “I could use this item someday,” is central to the decision to hold onto something. For instance, I have a box of scrap pieces of wood and plastic, which I keep because I might have a use someday. Every once in a while, I use a piece from my scrap box. And that reinforces keeping it.

Or papers. I used to clip articles from papers, thinking I would write about the topic someday. I had many files of articles on travel, psychology, and technology. The technology innovation that has changed that is computers, and more specifically, the email program Gmail. Instead of printing out articles, now I email them to myself. Since Gmail can hold thousands of articles, and with a simple search I can find any of them, I’ve tossed out my article files.

One of the beauties of computers is that even massive hoarding of articles or writing takes very little space on a hard drive. I can hold every email I’ve ever written in my life on a single USB memory stick. So if you are a hoarder of articles, or papers, consider buying a scanner, and using computer technology to hoard more effectively.

Another aspect of hoarding is sentiment. I hate throwing out something that reminds me of a good time in my life, or almost anything that has significant meaning. So I’d never throw away a photograph or a letter from someone I care about. I will throw out cards, though, unless they have a significant written message inside.

And some of hoarding is simply about difficulty in making decisions. For instance, I have too many books. But it is hard to figure out which books to toss. Some rules are easy. A bad paperback novel is easy to toss. But a good novel is tougher; maybe I will want to reread it sometime.

And reference books are still arder. Will I need the information in this book sometime? I try to ask myself realistically if the info is something I’ll need in the foreseeable future, and especially if the information is still even relevant. Thus old computer books are easy to toss, since in the computer world things date quickly.

One trick I’ve used successfully in de-hoarding is to remind myself that one of the advantages of getting rid of things is that you can get new things! For instance, if you go through one’s clothes closet and toss all the clothing that doesn’t fit and doesn’t look good, then you get to buy some cool new threads! The same is true with books. The key is to replace less than you toss.

Conquering hoarding is about psychological growth. Central to the process of growth is letting go of the old in order to make room for the new. New things, new people, and new experiences. Another aspect of de-hoarding is traveling through life less encumbered. That gives you more flexibility to move, and change. The irony of hoarding is that the biggest hoarders I know love to travel. And when they travel, they leave almost all of their stuff behind. And they are perfectly happy living out of a suitcase or backpack, and don’t miss their stuff at all.

Maybe this is really a metaphor for our psychological baggage. Travel light, and leave the junk behind. Throw out old stuff, and organize what you keep. Let go of things, and make room for new things.

Copyright 2007 The Psychology Lounge/TPL Productions

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

Forbes Magazine Endorses Cognitive Behavioral Therapy! In a Faceoff between Cognitive Behavioral Therapy and Antidepressant drugs, Therapy Wins!


As regular readers know, your editor is a big fan of a type of psychotherapy called Cognitive Behavioral Therapy (CBT). Cognitive therapy is a modern non-drug therapy that teaches clients new ways of thinking and feeling. The basic concept is that it is our distorted thinking that creates psychological problems of anxiety, depression, panic, etc. The cognitive therapist combines teaching cognitive skills with behavioral techniques that allow the client to overcome their difficulties.

And much to his surprise, this week Forbes Magazine put CBT on their cover! The Forbes article about Cognitive Behavioral Therapy was very positive. They summarize 30 years of research, including studies that show that CBT works well for insomnia, hypochondria, anxiety, depression, bulimia, obsessive compulsive disorder, preventing suicide, and even matches surgery for low back pain. Here is a video demonstration of exposure treatment for an elevator phobia.

They also compare the effectiveness of CBT to antidepressant medication. Although both work, in the long run CBT is more cost effective, and leads to less relapse. In one study comparing Paxil to CBT, only 31% of the CBT group relapsed within one year of completing treatment, compared to 76% of the Paxil group! This is a very big difference. The skills that clients learn seem to have a lasting impact on preventing future depressions.

Even in terms of cost, CBT beats antidepressant medications, at least with the assumptions the Forbes editors made. After three months of treatment, they estimate the costs of cognitive therapy at $1200 and the costs of medication treatment with Effexor at $502, which includes one psychiatrist visit at $200, and $302 in drug costs. At one year, they estimate the costs of cognitive therapy at $2000, and drug treatment at $2009, which includes $800 for four psychiatrist visits at $200 each, and $1209 for the Effexor.

As much as I like the comparison, it is based on faulty assumptions. First of all, it’s not clear how many sessions of cognitive therapy they are estimating. The $2000 would pay for 20 sessions at $100, but only 13 at $150. It’s probably optimistic to believe that a good outcome would come out of only 13 sessions. And because the primary group of professionals who perform cognitive therapy are psychologists, who typically charge more than masters level therapists, $100 is probably too low.

So let’s fix the numbers. Let’s assume 25 sessions of cognitive therapy, at $150 per session, which comes out to $3750. That’s probably a fairer assumption.

Now let’s look at the other assumptions. Effexor is an expensive, non-generic anti-depressant, which costs $100 a month, or even more. But the generic version of Prozac, called fluoxetine, can cost as little as $10 a month. And four psychiatrist visits in a year is also too optimistic. In my experience, patients need every two week visits initially to get the medication adjusted, and after 6 or 8 weeks, can graduate to once a month, and after another 3 visits, can be seen every three months. Also, psychiatrists typically charge at least $300 for the initial evaluation, and less than $200 for the follow-up visits which tend to be shorter visits.

So by these assumptions, the psychiatrist visits would cost $1380 at least. This brings the total cost of one year of treatment with Effexor to $2589. Of course, if fluoxetine was substituted then the total costs would only come to $1500!

So drug treatment costs less than cognitive therapy, right? It either costs a lot less ($1500 compared to $3750) or somewhat less ($2589 compared to $3750).

But there is still a glitch in the assumptions. We are only looking at the first year costs. Remember the statistics mentioned above, that up to 76% of patients who stop taking antidepressants relapse back into depression. Those are pretty bad odds. If a patient stayed on Effexor for 5 more years, their total cost of treatment would skyrocket to $6756, assuming psychiatrist visits 4 times a year. Compared to this cognitive therapy looks good!

There is another, unmentioned advantage to cognitive therapy, which is incredibly important, and which too often is left out of this debate. Here’s the dirty little secret the drug companies don’t want you to know—most antidepressants ruin your sex life! With really just a few exceptions (Wellbutrin, and Emsam) almost all of the major antidepressants make it much harder to have an orgasm for both men and women, and for men may make it difficult or impossible to get or maintain an erection. Antidepressants should really be called anti-sex drugs! (Caveat: not everyone will have the sexual side effects, but most will.) Here is a good article about the sexual side effects of antidepressants.

And this leaves out all of the other side effects of antidepressants. Here’s a link to common side effects of antidepressant medication Dry mouth, dry eyes, blurred vision, nausea, insomnia, headaches, the list goes on and on. How do you place a value on the costs of side effects?

Cognitive therapy obviously has no sexual side effects, or any other side effects. So for this reason, and for the advantage in preventing relapse, I believe cognitive therapy should be the first choice therapy for those patients suffering depression, providing they can afford therapy or have good insurance coverage for therapy. If not, then having your regular doctor prescribe and monitor a generic antidepressant such as fluoxetine (Prozac), sertraline (Zoloft), or bupropion (Wellbutrin) is the best option, with the downside being that you will most likely need to take the medications long-term to avoid relapse, and that you will most likely have physical side effects. Thus it may be worth taking a loan from your credit card in the form of a cash advance, or simply using a credit card to pay for cognitive therapy. After all, that’s how most people pay for their next car, or flat screen television set.

So here’s the executive summary. Cognitive therapy works for a large variety of common psychological problems, and even a few physical problems. Although initially it costs a little more, the effects are longer lasting than medication treatment. And in the long run, it can end up saving money. Best of all, other than working a little bit on therapy homework, there are no side effects of therapy! Conclusion: If you are depressed, anxious, having insomnia, obsessive compulsive disorder, hypochondriasis, phobias, or relationship problems, your first move should be to find a psychologist who specializes in cognitive therapy. Borrow the money if you don’t have it, or put it onto your credit card, but don’t miss out on this effective treatment out of some false sense of economizing.

Copyright 2007 The Psychology Lounge/TPL Productions

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

Cheer Up! It Gets Worse, Then Better (Depending On Your Age)

 

This week I am starting a series of articles on that magical quality we call happiness. I’ve been studying the scientific literature on happiness for a while now, and it’s not all just common sense. There is some gold in the ore. In fact, much of what science has discovered about happiness goes against what we commonly believe. For instance, it turns out that money does buy happiness, but only if you have almost no money. Once you acquire the basics, food, shelter, a car, more money has relatively little impact on happiness. Or take having children. Everyone assumes that having children brings joy. But the research doesn’t support this very strongly. Marriages suffer when children enter the scene, and parenting is rated relatively low in the grand scheme of activities. In fact, what the science of happiness suggests is that we are remarkably bad at predicting what will make us happy. Hence the high rates of job change, house selling and rebuying, and of course, divorce.

But I will write more on these matters later. For today I want to talk about an interesting new study that looks at happiness over the course of a lifetime. This latest study, performed by economists David Blanchflower of Dartmouth and Andrew Oswald of Warwick, looks at how happiness changes as people age. Using data from about 45,000 Americans, and 400,000 Europeans, they looked at the average ratings of happiness by age.

What they discovered is very interesting. Basically happiness is high when people are young adults, early in their 20s. This is not surprising, as the early 20s are that magical point where one is freed from parental constraints, but doesn’t have a lot of other new constraints. Unfortunately, it’s all downhill from there. Happiness sinks gradually over the next 20 something years, and reaches in nadir on average around age 45. Depressing news for young people, eh?

But the news gets better. After age 45, happiness increases steadily on into old age. Wow! This isn’t what we’d expect at all. Elderly people happier than people in their 30s!

The European and American data were fairly similar, except that the Europeans reached their lowest happiness levels a few years earlier than the Americans.

So happiness is a U-shaped curve. Why? The research doesn’t answer the question. But they did rule out one explanation, the generational one. People born earlier still show the U-shaped happiness pattern.

The authors also looked at the influence of income on happiness. This data is fascinating! They found that the wealthier you are the happier you are on average, which is not surprising. But the decline is happiness from young adulthood to middle age is the equivalent to a 50% reduction in income, and the increase in happiness from age 45 to old age is equivalent to a doubling of income!

Finally, the authors found over the last hundred years, Americans have gotten much less happy. The difference in happiness between the generations born in the 1960s and the 1920s is the same as a tenfold change in income. So someone born in 1962 would need 10 times the income to be equally as happy as their grandfather who was born in 1922. This is a disturbing finding. Why are we so unhappy? I have some ideas, but I will come back to them in a future article.

One clue may exist in the differences in the European data. The generations that were born in Europe since 1950 have gotten steadily happier. Shorter work weeks, longer vacations, more social welfare and security, all may be part of the mystery, especially when compared to the opposite trends in the United States.

So cheer up. Adulthood brings with it a steady decline in happiness, but just when it’s looking pretty grim, things improve. And even though we all are going to get old and infirm, we can at least look forward to getting steadily happier.

Copyright 2007 The Psychology Lounge/TPL Productions

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

On Perfectionism and How to Overcome It

Today I am writing about perfectionism, that deadly trait that infects so many people, causing low self-esteem, depression, anxiety, and procrastination. Perfectionism is really about having unreasonable standards for your own or others’ performance. When you are a perfectionist, it means you never can live up to your internal standards. This causes unhappiness and depression. It may also cause anxiety.

Closely linked to perfectionism is all-or-nothing thinking. Although the real world is an analog world, we often think of it in binary terms. Our job is “good” or it is “bad.” A vacation is “wonderful” or “horrible.” People are “interesting” or “boring.” What makes all-or-nothing thinking part of perfectionism is that it makes your standards rigid and inflexible. There’s no grading on a curve with binary thinking. Your performance is an “A” or an “F.”

So what’s wrong with perfectionism anyway? Doesn’t it make one perform better?

The answer is no. Perfectionism actually leads to lower performance. When you have unreasonably high standards you are more likely to get disappointed when you fail to meet that standard. And disappointment makes people try less hard. It saps the will and depresses the spirit.

So you might be wondering how do I change my perfectionism? (And how do I do it instantly!) 🙂 The key to altering perfectionist tendencies is to do several things:

1. Set reasonable and flexible standards for your performance and others.

2. Reserve higher standards only for those tasks that truly require them.

3. Test out your standards. See if it’s necessary to actually be so perfect. Try doing things less well, and see if the sky falls.

4. Remember life is not just about performance. It is also about enjoyment, fun, and relaxation.

5. Think in terms of a continuum or grey scale. Instead of using all-or-nothing terms like “good” or “bad” instead use a 10 point rating scale. The dinner was a “6.” The movie was a “2.” This gets you thinking along a continuum, which is healthier and less stressful.

6. Always ask yourself before you decide on standards whether the task is actually worth doing at all. If something is not worth doing, then it is not worth doing perfectly. So for instance, when you purchase some small item that doesn’t work out, perhaps it makes sense to toss it out, or give it away, rather than gathering up the packing materials, driving 30 minutes, and returning it. Not perfect, but perhaps a better choice.

7.

The End (Notice the slight imperfection.)

Copyright 2007 The Psychology Lounge/TPL Productions

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

Let’s Not Kill Any More Rebecca Riley’s! Debate Over the Use of Psychiatric Drugs for Young Children

 

The New York Times reported that Rebecca Riley, a four year old girl from near Boston, was found dead on the morning of December 13, a victim of an apparent overdose of the psychiatric drugs Seroquel, an antipsychotic drug; Depakote, a powerful anti-seizure medicine used for mood control, and Clonidine, a blood pressure drug often prescribed to calm children. Rebecca had been diagnosed at having bipolar disorder at the age of two! So some overzealous psychiatrist had diagnosed her as been manic depressive at age 2.

Now this is pretty crazy. A child at two is a work in progress, and if is virtually impossible to diagnose anything at that age. The only exceptions are the developmental disorders, such as autism. Probably Rebecca was a difficult child, prone to moodiness and maybe even tantrums. So her parents, with a willing psychiatrist, gave her mind-numbing drugs to calm her, rather than learning better parenting skills. From the article: “A relative of her mother, Carolyn Riley, 32, told the police that Rebecca seemed “sleepy and drugged” most days, according to the charging documents. One preschool teacher said that at about 2 p.m. every day the girl came to life, “as if the medication Rebecca was on was wearing off,” according to the documents.”

This is more than sad, it is pitiful. How many other, nondrug interventions were tried before using medication? Was there parenting training? Was there a home visit, to see how Rebecca and her parents were interacting? The article does not say, but I’m guessing that none of these things were done. There’s an old saying, “Give a young boy a hammer, and everything becomes a nail.” In much the same way, bringing a child to a psychiatrist means that they are likely to get drugs. That’s why the first stop for children, especially young children, should be to a child psychologist, a psychologist who specializes in treating children and their families.

It should also be noted that most psychiatric medications are not and have never been approved for use in young children. There are no studies of using these drugs on toddlers. Although it might be occasionally reasonable to use drugs meant for adults on older teenagers, who are at least biologically similar to adults, it is irresponsible at best to use these drugs with young children.

The problem is that giving kids drugs is too easy. From the New York Times article, “Paraphrasing H. L. Mencken, Dr. Carlson added, ‘Every serious problem has an easy solution that is usually wrong.’” Behavioral problems in children can be very serious, and the behavioral interventions take time and commitment. Learning good parenting techniques, such as the proper use of time-outs and other interventions, takes dedication and a competent psychologist’s help.

As with adults, medications should always be reserved for after all other interventions have failed. And with children, only medications that have been tested on children, and used for years should be tried. If psychiatrists want to prescribe these medications for children, let them first run the research trials required by the FDA to test safety and effectiveness. Let’s not kill anymore Rebecca Riley’s!

PermaLink to article

Copyright 2007 The Psychology Lounge/TPL Productions

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

Thoughts about Online Dating: Why you should go offline if you want to find a partner!


Scientific American recently had a terrific article about the reality behind online dating, which shows scientifically what psychologists have known for a long time. Online dating doesn’t work very well.

The data is fascinating. The biggest problem is deception. Twenty percent of online daters admit openly to deception, but the real numbers are probably closer to 90%, since that’s the number most online daters say fits the other daters online.

Everyone, male and female, adds about 1 inch of height. Everyone is attractive, in a strange sort of Lake Woebegone world, only 1% of online daters say they are less than average attractive. Wow! A world of movie stars and models. If only!

Women lie a lot about their weight. In their 20’s they lower their real weight by an average of five pounds, in their 30’s this “error” goes up to 17 pounds, and in their 40’s they are deceptively reporting their weight as an average of 19 lbs. under their real weight!

Everyone lies about their age. Men will say they are 36 rather than 37-41. Women say they are 29 rather than 30-34. They also like the ages of 35 and 44 rather than their real ages.

All this would be fine if the services worked. But they don’t. There is a terrific White Paper written by Philip Zimbardo , Mark Thompson, and Glenn Hutchinson: CONSUMERS ARE HAVING SECOND THOUGHTS ABOUT ONLINE DATING.

In it Zimbardo, a former president of the American Psychological Association, concludes about one popular service, “When eHarmony recommends someone as a compatible match, there is a 1 in 500 chance that you’ll marry this person…. Given that eHarmony delivers about 1.5 matches a month, if you went on a date with all of them, it would take 346 dates and 19 years to reach [a] 50% chance of getting married.”

Other services overpromise and undeliver too. Match.com claims 15 million members, but only 1 million are paying members, which means that only 1 in 15 “member” can even reply to emails. This sets users up for rejection when they contact a user who is not able to respond.

In general, there are probably far fewer Americans than advertised using online dating services, and surveys suggest that less than 25% of them are satisfied.

There is also the “click” problem. This is where singles, thinking there is an infinite supply of available singles, will click away the instant they detect any flaws or problems. And most only allow for one date with potential mates, since why spend time getting to know someone when there is probably someone better over the online horizon.

So, online dating promises deception about appearance, age, income, and other things, and sets you up for disappointment and rejection. And yet it has become the way that many tech savvy singles use to meet people.

Why? I think it’s because we’ve gotten too timid and afraid of the real world. There are a million opportunities to meet people in the offline world. But it takes a little courage and chutzpah to meet them.

The real world offers some real advantages. In the real world you get to see people and there is no deception in terms of appearance (other than good lighting or makeup or elevator shoes). Age you can evaluate by appearance, and personality you can quickly ascertain. Let me give you some suggestions for how to meet people in the real world.

Women, start by getting over your fear of flirting. Men are eager to approach you and talk with you, you just have to show them with smiles and eye contact that they won’t be rejected if they do. If you see a guy you think is cute, smile at him. Go up to him and ask him any question, it doesn’t matter. Start a conversation with him. This could be in a café, bar, restaurant, or bookstore. It doesn’t matter. If he is interested he will talk with you, and if you hit it off, he may ask you for your phone number. But if he is timid, he may chicken out, so if you like him, don’t let him get away. Suggest that you exchange cell phone numbers or email addresses so you can “get a cup of coffee sometime.” This will overcome the fear of most men, and if he demurs, then it’s probably because he is either not interested or not available. (You might want to look him in the eye, and ask him point blank, “do you have a girlfriend or a wife?”)

Men, you too must get over your fear of flirting and rejection. Start by talking to women more. Talk in line at the post office, at your favorite café, in the store, at work, etc. Learn how to make women laugh, that’s the thing most women like in a man. And don’t be afraid to ask a woman for her phone number or email address. What’s the worst thing that will happen? She might say no. Big deal!

If you really want to make it easy, start by looking around your workplace for attractive potential partners. Or join a biking or hiking club, and get to know its members. The main thing is to get out of your apartment or house, and go places where people hang out, and start to talk with them, flirt with them, and get comfortable asking them to coffee, drinks, lunch, or dinner. The offline world is full of exciting, attractive people, all you have to do is put down your mouse, close your laptop computer, and go out into the real world!

Copyright 2007 The Psychology Lounge/TPL Productions

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

Mild Depression, A Mild Problem?

 

More from Peter Cramer’s book Against Depression, which I heartily recommend to anyone who wants to learn more about depression.

We talked about the full blown diagnosis of depression. For a diagnosis of major depression you need 5 or more symptoms for at least 2 weeks. What if a patient has only 2 or 3 symptoms for 2 weeks? Is that a problem?

First of all these mild depressions can be the precursor or follow-up to major depression. So they are important for that reason.

But even if there is no major depression, mild depression looks like major depression. Mild depression runs in families where major depression is prevalent. Low level depression causes disability, absenteeism, more medical visits.

Another type of mild depression is dysthymia. Dysthymia means being sad at least 50% of the time, for 2 years or more. And dysthymia is not the same as unhappiness. Dysthymics suffer the same relentless internal stress, the hopelessness, sadness, and low self-esteem of the depressed. The fact that they may function well, or eat and sleep well, is of small comfort to them.

The problem with dysthymia and mild depression is that medications may be less effective with these conditions, and some types of psychotherapy, more effective. Although no one exactly knows, the general consensus is that dysthymia is less responsive to antidepressants than is major depression. But it may be more responsive to cognitive behavioral therapy.

In summary, even mild depression has serious impacts on people. Mild depression can be effectively treated with cognitive behavioral therapy, and responds well to it.


Copyright 2006 The Psychology Lounge/TPL Productions

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

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

The Natural History of Depression

I’m still reading Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good as Listening to Prozac. I continue to be impressed by his scholarship and ability to pull interesting research together. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression.

What is the natural history of depression? That is, what happens later in life if you get depressed now? Do you recover, or do you have more depressions?

We have good data on this issue from some studies funded by the National Institute of Mental Health. These studies followed depressed patients over many years. The findings are astounding, at least to me.

They show that if you are diagnosed as being depressed today, there is a 20 percent chance you will still be depressed 2 years later, and a 7 percent chance you will still be depressed ten years later, and a 6 percent chance you will be depressed 15 years later!

Even if you recovered, your probability of relapse is high. In these studies, most patients had subsequent depressions: 40 percent at two years, 60 percent at five years, 75 percent at ten years, and 87 percent at 15 years.

And with each episode of depression the prognosis worsens. After the second episode of depression, the 2 year recurrence rate soars to 75 percent!

One likely explanation for this effect is called kindling. The kindling model was first developed to explain how epilepsy works. In epilepsy, each seizure you have makes you more likely to have more seizures. This is because the seizure damages the brain.

We now think that each major depression may alter the brain as well. Particularly it may cause a shrinking of cells in several important areas of the brain. One of these is the hippocampus, which governs the formation of short term memory. Another is the prefrontal cortex, which has many functions in reasoning.

And how many patients got treatment? Only 3 percent of the patients who were diagnosed with depression had ever received even a single one month trial of anti-depressant medication! This is shameful in a country that claims to have good health care.

So what do we learn from these studies?

  1. Depression is a chronic disease, and relapse is very high.
  2. Each relapse makes you more susceptible to future depressions. Each depression erodes the resilience of the brain.
  3. A small but substantial percentage of depressed patients remain depressed for years on end.
  4. Prevention of initial depressions, early treatment of major depression, and prevention of future depressions can change the natural history of depression, and prevent a lifetime of depression.


The other important thing to realize about these studies is that they only looked at major depression. That is, at depression with many serious symptoms. Later studies that have looked at milder versions of depression have found that even mild depressions predict future major depressions. A future post will talk about minor depression, or dysthymia.

Copyright 2006 The Psychology Lounge/TPL Productions

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

Depression: No Big Problem? Right? Wrong!

Here is some more good stuff from Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good as Listening to Prozac. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression. Much of what follows is inspired by this book.

How big a problem is depression compared to other illnesses? Other health problems such as AIDS, arthritis, heart disease, diabetes, and cancer are much bigger problems, right?

Wrong. If you look at the impact of depression on disability, very interesting facts emerge. Let me explain how these figures are calculated. Imagine a 20 year old woman develops chronic depression that causes her to be 1/3 disabled for the next 60 years. That means she loses the equivalent of 20 years of life, which is the same as if a healthy woman died at age 60 instead of the normal lifespan of 80.

When disability from depression is calculated this way, the figures are astounding. The World Health Organization looked at this data from around the world. They found that by the year 2020 depression will be the largest cause of disability with the sole exception of heart disease. Even in 1990, depression was already the number one cause of disability within the major chronic diseases of midlife. Major depression accounted for almost 20 percent of disability-adjusted life years lost for women in the developed countries. This was more than three times the amount caused by the next illness.

Other studies looked at the impact of depression in the workplace. In the United States this cost is estimated at over 40 billion dollars, which is almost 3% of the total economy. Being depressed on the job is estimated as the equivalent of calling in sick half a day per week.

Just how common is depression? There are many studies and they often disagree, but the best studies suggest that about 16 percent of Americans will suffer a major depression over their lifetime. That is almost 1 in 6 Americans. Look around at your friends and family and co-workers, 1 in 6 of them will suffer a major depression. In any given year, between 6-7 percent suffer major depression.

And depression has major health implications. Studies that look at elderly people find that depression increases the risk of death very significantly, independent of suicide. One study found that elderly people who were depressed were 40 percent more likely to die than those who were undepressed. When they analyzed the data to see what the cause was, they found that even when you controlled for all other health behaviors and other factors, depression still accounted for 24 percent increase in deaths. This was the equivalent of high blood pressure, smoking, stroke, or congestive heart failure.

So depression is no big deal? Not unless you consider major disability, huge workplace effects, and shortened life a big deal. In reality, depression is one of the most devastating diseases that human beings suffer.

Copyright 2006 The Psychology Lounge/TPL Productions

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

Depression in Middle Age and Beyond

Here is some more fascinating stuff from Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good or better than Listening to Prozac. I continue to be impressed by his scholarship and ability to pull interesting research together. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression.

What about those people who have their first depression later in life? Are they similar or different to those who get depressed earlier in life?

What is interesting is that there may be a type of depression in older adults that is physically triggered. Let me tell you a story about how this was discovered.

Much of this research was conducted by K. Ranga Ram Krishnan and his group at Duke University. In the 1980’s they got their first MRI machines. These machines let you take detailed pictures of the brain without using radiation (they use magnetic resonance imagery instead.)

His group didn’t really know what to do with these new machines. So they decided to take a look at the brains of elderly depressed patients. What they found was fascinating. In 70% of the patients who had suffered late in life depressions, they found small white patches in various areas of the brain. When they autopsied some of the these patients who later died, they found that these were lesions in the brain that ranged from tiny pinpoint lesions up to rather large (2 inches in diameter) lesions. These were where silent strokes had occurred, killing the brain tissue.

Silent strokes are those strokes that happen in a part of the brain that does not control sensation or motion, so you often are unaware you even had the stroke.

This led to the realization that these people were suffering from vascular depression, that is, depression caused by damage to the brain from a silent stroke.

The main area of the brain where Krishnan found these lesions was the prefrontal cortex, or more specifically the orbitofrontal cortex, right behind the eyes.

These depressions were very similar to regular depression, with the main difference being that this group generally hadn’t suffered depression earlier in life.

The good news is that these depressions respond well to antidepressant medications, and the patients tend to get well just like regular depressions.

In summary, if you or a relative suffers a sudden depression later in life, suspect a vascular depression. And get treatment. (Also, if your elderly relative suffers a vascular depression, they may also show pseudo-dementia, which is a type of cognitive impairment which is caused by serious depression. It can look like they have suddenly developed Alzheimer’s or some other dementing disorder, but it actually is a side effect of the depression. Treating the depression will often resolve the pseudo-dementia. )

Most important, if a doctor or psychologist tells you that your older relative is depressed because they are old and sick, don’t accept this. There is no reason for the elderly to be more depressed, in spite of age or infirmity.

Copyright 2006 The Psychology Lounge/TPL Productions

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

New Research into the Causes of Depression

 

Lately I’ve been reading Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good as Listening to Prozac. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression. Much of what follows is inspired by this book.

Today I want to talk about the new and exciting research on depression done by Kenneth Kendler at the Virginia Commonwealth University.

Dr. Kendler has looked at the causes of major depression. His research finds that there are three pathways to depression. That means there are a number of different triggers that cause people to become depressed.

The first is what he calls the internal pathway. This includes two variables that predict depression–childhood onset anxiety disorders (before age 18) and neuroticism (a general trait of psychological disorder). This means that if you have an anxiety disorder as a child, or if you are generally neurotic, you are more likely to become depressed later in life.

The second is the external pathway. This path includes two variables: conduct disorder and substance abuse. (Conduct disorder means getting into trouble with the law.) So if you abused alcohol as a teenager, and got arrested, you are more likely to get depressed later in life.

The third path is not surprisingly, through adversity in life. And this pathway is the most complex. It starts in childhood with a disturbed family environment, childhood sexual abuse, and the loss of a parent. It continues with low educational achievement, lifetime trauma, low social support, and the likelihood of divorce. Finally, it ends with current stressors such as marital problems, life difficulties, and stressful events in the last year before depression starts. Kendler believes that much of the adversity that people experience are actually interpersonal difficulties.

What is worse is that the factors are related to one another. If you have adversity in childhood, you are more likely to develop conduct disorder and substance abuse, and these disorders make it more likely you will get into a bad marriage, lose your job, etc.

This complex model was able to account for 52 percent of the likelihood of depression in a one year period.

So far none of this is really that surprising or interesting. After all, most people would predict that a lousy childhood, getting into trouble, and being anxious might lead to depression.

The really interesting part of his research is how these factors influence one another, and how the genetic component influences all of them. Genetic factors influence all three of the major factors. If you are genetically prone to depression, you are more likely to have a lousy childhood, get into trouble and abuse substances, and be anxious and neurotic! How does this work?

Kendler isn’t sure, but suspects that if you are prone to depression, your parents might have been also, and this impaired their ability to parent well. Or perhaps, it is harder to parent an anxious, depressed, neurotic child. Or perhaps both are true; depressed parents have a harder time parenting, and their children tend to be moodier and harder to deal with. The genetic propensity to depression may also be connected to substance abuse directly or as an attempt to self-medicate the depression.

Other findings from his research. He found that if you have an anxiety disorder before age 18, this is a strong and independent predictor of depression.

So what can we learn from this research?

There appears to be a tragic path to depression. The depressed person is born with a genetic tendency to depression which in turn is correlated with the likelihood of a bad childhood. Then they do worse in school, get in trouble more, turn to substance abuse, and then aas adults pick bad relationships, have more conflict in jobs and family, and are more likely to be traumatized. Basically their whole life goes poorly. Chaos and conflict and loss and low social support leads to depression. A single depression leads to future depressions.

It is all pretty depressing! But what it shows is also the pathway to healing. For instance, therapy in childhood may help prevent some of this. Treating early anxiety disorders or substance abuse may prevent some of the later chaos.

It also shows why therapy is so important in the treatment of adult depression. Although anti-depressant medications may help with the biological problems in depression, therapy is necessary to help clients learn new ways to relate to people and how to make better interpersonal decisions. A supportive therapist may also help buffer the effects of adversity and loss and make depression a less likely outcome.

This research also suggests that depression is not just a mood state, but is an illness that affects many aspects of a person’s life (and in a negative direction.) We need to be aggressive in treating this serious and debilitating illness.

Copyright 2006 The Psychology Lounge/TPL Productions

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

What is Depression? Is It the Same as Being Sad?

What is depression, anyway? Is it the same as feeling sad? No. Depression is not just feeling down for a day or two. The diagnosis of depression is based on having certain symptoms.

Two key symptoms are depressed mood, which is feeling sad or blue, and difficulty experiencing pleasure or joy, which is sometimes called anhedonia.

Other symptoms of depression are problems sleeping, changes in appetite (more or less), feelings of worthlessness or guilt, problems concentrating, fatigue or low energy, mental/physical agitation or chronic worry or slowing, and having thoughts about suicide.

To have major depression, you need to have at least five of these symptoms, including one of the first two, depressed mood and anhedonia. And the symptoms have to last at least two weeks, and cause you some discomfort and impairment in your functioning.

The exception is mourning or bereavement, which can cause the same symptoms, but doesn’t count as depression. So if your mother has died and you have these symptoms, don’t worry.

Depression Screening Checklist

Instructions: Check any symptoms that you have been troubled by and that has lasted for the past two weeks.

Category A

___ I have felt sad or blue or depressed

___ I have had a hard time feeling joy or pleasure, even while doing activities that typically bring me joy or pleasure. I feel “flat”.

Category B

___I have had a hard time concentrating.

___I have felt tired or low energy.

___I have had difficulty sleeping (sleeping too little or too much)

___I have had changes in my appetite (eating too little, or too much).

___I have felt mental/physical agitation or slowing down.

___ I have felt worthless or guilty or lowered self-esteem.

___I have had thoughts about death or suicide or hurting myself.

Scoring:

Count the number of checks in Category A. Write that here:____

Count the number of checks in Category B. Write that here: ____.

Add up the number of checks in Category A and Category B, and write that here: _____.

If A is 1 or 2, and the sum of A and B is 5 or more, you have major depression, and should seek help from your doctor or from a psychologist. If A is 1 or 2, and the sum of A and B is 3 or 4, you may have mild depression, and should probably seek help as well.

IMPORTANT: If you are having any thoughts about hurting yourself or killing yourself, you should seek help immediately, calling your local suicide prevention line (listed in the front of your phonebook), or calling 911, or seeing your doctor or a psychologist right away.

Copyright 2006 The Psychology Lounge/TPL Productions

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

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

Welcome to the Psychology Lounge!

Welcome to the Psychology Lounge. The purpose of this blog is to educate and amuse, or maybe amuse and educate. About psychology. And about things related to psychology, like health, medicine, and technology. I’ll be writing about my current events in these fields, and updating older issues like depression, anxiety, and how people find meaning. I will also write about the new science of studying happiness, and how to affect it. There will be posts about relationship therapy, and tips and tricks for improving your relationships.

Who am I? My name is Andrew Gottlieb, and I’m a practicing clinical psychologist in Silicon Valley, in the heart of technoland, where the living is stressful but interesting. My private practice is full of interesting people struggling with their own issues of meaning and happiness. In my spare time, I write about psychology, and enjoy hiking and biking in the beautiful Bay Area.

Copyright 2006 The Psychology Lounge/TPL Productions

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

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