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

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

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

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

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

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

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

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

In summary, there are a few key points.

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

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

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

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

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

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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 three mistakes that he discusses:

 1.      Absolute versus relative risk/benefit data

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

2.      Association does not equal causation

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

3.      How we discuss screening tests

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

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

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

So which headline sounds better to you?

New Drug Prevents 75% of Catachexia Cases!

Or

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

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

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

So which headline sounds better to you?

Drinking Coffee Makes You Smarter

Or

Smarter People Drink More Coffee

Or

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

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

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

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

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

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

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

One more headline test. Which headline do you prefer?

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

Or

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

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

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

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

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

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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.

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

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

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

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

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

Notes:

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

The corrected version of the article is here.

The research that the article is based on is here.

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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.

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

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

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

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

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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 New York Times reported on a terrific study at the University of Pittsburgh, looking at ultra short treatment of insomnia in the elderly. According to the article roughly 1/4 of older adults suffer from insomnia. The researchers streamlined an approach called CBT-I, which stands for cognitive behavioral therapy of insomnia.

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

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

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

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

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

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

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

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

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

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

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

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

So what are the key messages here?

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

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

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

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

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

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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.

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

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

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

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

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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 couples stop having sex, and what can you do to prevent this?

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

1. Anger and resentment in the relationship

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

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

2. Mediocre or boring sex

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

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

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

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

3. Issues with initiating sex

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

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

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

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

4. Failure to make sex a priority

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

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

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

5. Excessive masturbation to pornography

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

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

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

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

6. Failure to attend to personal hygiene or appearance

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

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

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

7. Failure to address sexual dysfunction

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

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

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

8. Forgetting that foreplay starts long before the bedroom.

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

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

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

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

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

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

I love you both dearly.

Mom

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

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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 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 knowledge 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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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.

“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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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.

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

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

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

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

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

So how to interpret the results of this study?

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

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

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

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

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

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

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

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

Your off to analyze his thoughts psychologist,

Andrew Gottlieb, Ph.D.

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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.

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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.

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

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

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

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

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

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

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

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

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

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

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

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

4. Connection. Smile and make eye contact.

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

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

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

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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.

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

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

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, 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.