Category Archives: Psychotherapy

Depression Often Misdiagnosed, and Untreated

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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.Depression

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 sort out 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 ABOUT DEPRESSION FINDINGS

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. If you want more information about depression, I’ve written extensively about it with a complete list of depression articles.

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

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

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

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

Here are 12 great concepts in giving feedback and criticism.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1. Anger and resentment in the relationship

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

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

2. Mediocre or boring sex

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

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

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

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

3. Issues with initiating sex

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

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

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

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

4. Failure to make sex a priority

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

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

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

5. Excessive masturbation to pornography

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

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

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

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

6. Failure to attend to personal hygiene or appearance

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

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

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

7. Failure to address sexual dysfunction

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

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

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

8. Forgetting that foreplay starts long before the bedroom.

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

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

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

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

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

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