If you are considering couples counseling but are unsure about whether it will be worth your effort, you are not alone. Perhaps you have heard about the lack of success reported by a friend or tried it already yourself without much benefit. Here I will provide answers to some common questions I frequently hear from those who are wondering about whether it works, and for whom it works. 

Why are so many skeptical about couples counseling?
It is understandable that many people are skeptical about the effectiveness of couples' counseling. Prior to the 1980's, the most common methods used in couples' work had limited success. The average success rate for most couples was about 50 percent. Useful skills were learned, including how to listen to each other and to appreciate the other's point of view. Attributions (explanations we give ourselves for the other persons behavior) were transformed from negative, to positive or neutral. The research of John Gottman helped to identify critical behaviors to avoid if you wanted to remain together "happily ever after" . These included cutting out the sarcasms and the contemptuous comments, while building the friendship as well as romance. This was all well and good, but not enough for lasting and profound changes in relationships. Even when couples reported less distress at the conclusion of therapy, the new habits tended to drop off over subsequent months and old problems returned. 

How effective is couples therapy?
The good news is that couples counseling as it is currently practiced using Emotionally-Focused Therapy (EFT) is now roughly 75 percent effective. This is true according to the American Psychological Association and is based on over 25 years of research. Outcome studies have included couples therapy for high-stress clients such as military couples, veterans with PTSD, parents of chronically ill children, and infertile couples. Results are also positive and substantial across different cultural groups. 

How do we measure effectiveness?
The most common outcome measure has been self-report using a particular questionnaire called the Dyadic Adjustment Scale (DAS). This measure has been used since 1976 and provides a good comparison of success rates now versus those from past decades. The major positive outcome is the reduction of complaints between partners. Post-treatment scores are compared to pre-treatment scores for the same couple, and also to the scores of couples who have been wait-listed for treatment. The positive results have consistently been found to continue for at least two years after the conclusion of treatment. 

Who tends to be in the 25 percent failure group?
Couples who are in abusive relationships should not expect improvement in therapy until the abusive behavior stops. Separate therapy is often each recommended for each partner in order to work toward self control or to maintain safety, depending on the individual's needs. Likewise, EFT is not recommended for couples in the process of separating. The process of separating is contrary to the goals of EFT. Substance abuse in the absence of physical or emotional abuse does not preclude couples therapy as long as the addicted person is actively working to manage the addiction.

How does it work?
To briefly summarize, EFT is a systematic approach to changing the constricted patterns of interaction between distressed couples and thereby changing the emotional responses to each other. Unlike prior therapies which were directed at changing behaviors and thoughts, EFT leads to changes in emotional responses in a way that strengthens the emotional bond. The goal is to establish a more secure attachment. In my experience, it requires a minimum six-month commitment. Many couples require more time, depending upon other circumstances in their lives and the frequency of sessions. 

How can one maximize the chances of a positive outcome?
Positive outcomes are most likely when the couple beginning therapy have a willingness to learn some basic skills and to become more self-aware as well as emotionally vulnerable to each other. Only very basic communication skills are necessary, such as using “feeling” words. Many people have difficulty distinguishing feelings from thoughts, usually because they were never taught to identify feelings as children. However, this skill can be learned, and it is encouraged during the therapy process. A second important characteristic of successful couples is the ability to stop seeing each other as the opponent but rather as a team member, working to improve mutual contentment. Seeing yourselves as being “on the same team” increases cooperation and also each person’s willingness to be emotionally vulnerable. Thirdly, the ability to feel empathy for the partner is a critical part of the work in EFT. Each person needs to have compassion for the other’s feelings of vulnerability and past emotional traumas. Lastly, a pre-requisite for success in couples’ work is the willingness of each person to own their part in the problems as well as the process of bringing about positive change. Many individuals come to couples therapy with a list of complaints about the other person and a desire for the therapist to validate the complaints and then change the behavior of the other person. Although there are often valid complaints, nothing is resolved unless both individuals are open to change some aspect of their own behavior.

You might hear the words anxiety attack and panic attack used interchangeably as if they mean the same thing. In fact, panic and anxiety have different features, and behavioral health professionals use the terms for specific symptoms and disorders. Panic attacks are often associated with sudden fear and anxiety with high-stress levels or excessive worrying. Some of the symptoms are similar, including rapid heart beat, shortness of breath, and dizziness. Each also has other symptoms that are unique. Everyone can experience panic attacks and anxiety, they are apart of the emotional and protective response hardwired into the human body. It's when either occurs frequently that there is cause for concern. No matter which you experience, it's important to understand their definitions, symptoms, and treatments. 

Clinical Differences:
Professionals who treat mental health conditions base diagnosis on definitions found in the "Diagnostic and Statistic Manual of Mental Disorders, 5th edition," known as the DSM-5. Though anxiety and panic attacks may feel the same at times, the subtle differences outlined in this handbook help identify each. The DSM-5 uses the term panic attack to describe the hallmark features associated with the condition known as panic disorder. However, panic attacks may occur in other psychiatric disorders and it is possible to have a panic attack with no disorder. The term "anxiety attack" is not defined in the DSM-5. Rather, "anxiety" is used to describe a core feature of several illnesses identified under the headings of anxiety disorders, obsessive-compulsive disorder, and trauma- and stressor-related disorders. Some of the most common disorders under these three headings include:

• Panic disorder
  
• Agoraphobia without history of panic disorder
  
• Specific phobia
  
• Social anxiety disorder
  
• Separation anxiety disorder
  
• Obsessive-Compulsive Disorder (OCD)
  
• Post-traumatic stress disorder (PTSD)
  
• Generalized anxiety disorder (GAD)
  

The differences between panic and anxiety are best described in terms of the intensity of the symptoms and length of time the main symptoms occur. The in-depth guide in the DSM-5 guide your health provider to make a diagnosis and classify your condition. 

Panic Attacks:
A panic attack is a sudden and intense feeling of fear, terror, nervousness, or apprehension. The symptoms are often so extreme that they cause a severe disruption during your day. Panic attacks usually occur out of the blue without an obvious, immediate trigger. In some cases, they are "expected" because the fear is caused by a known stressor such as a phobia. Panic attack symptoms peak within 10 minutes and then they subside. However, some panic attacks may last longer or may occur in succession, making it difficult to determine when on attack ends and the other begins. Following an attack, it is not unusual to feel stressed, worried, out-of-sorts, or "keyed up" for the remainder of the day. According to the DSM-5, a panic attack is characterized by four or more of the following symptoms:

• Heart palpitations, pounding heart, accelerated heart rate
• Excessive sweating
  
• Trembling or shaking
  
• Sensations of shortness of breath, difficulty breathing
  
• Feeling of choking
  
• Chest pain or discomfort
  
• Nausea or abdominal distress
  
• Feeling dizzy, unsteady, light headed, or faint
  
• Feelings of unreality; or being detached from oneself 
  
• Fear of losing control or going crazy
  
• Fear of dying
  
• Numbness or tingling sensation
  
• Chills or hot flashes
  

Anxiety:
In contrast, anxiety generally intensifies over a period of time and is highly correlated with excessive "worry" about some potential danger- whether real or perceived. If the anticipation of something builds up and the high amount of stress reaches a level where it becomes overwhelming, it may feel like an "attack". The symptoms of anxiety may include:

• Muscle tension
• Disturbed sleep
  
• Difficulty concentrating
  
• Fatigue
  
• Restlessness
  
• Irritability
  
• Increased startle response
  
• Increased heart rate
  
• Shortness of breath
  
• Dizziness 

Depression (major depressive disorder or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how you think, feel, and handle daily activities, such as sleeping, eating, or working. To be diagnosed with depression, the symptoms must be present for at least two weeks. Some forms of depression are slightly different, or they may develop under unique circumstances, such as: 

• Persistent depressive disorder (also called dysthymia) is a depressed mood that lasts for at least two years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for two years to be considered persistent depressive disorder.  
• Postpartum depression is much more serious than the "baby blues" (relatively mild depressive and anxiety symptoms that typically clear within two weeks of delivery) that many women experience after giving birth. Woman with postpartum depression experience full-blown major depression during pregnancy or after delivery (postpartum depression). The feelings of extreme sadness, anxiety, and exhaustion that accompany postpartum depression may make it difficult for these new mothers to complete daily care activities for themselves and/or for their babies. 
• Psychotic depression occurs when a person has severe depression plus some form of psychosis, such as having disturbing false fixed beliefs (delusions) or hearing or seeing upsetting things that that others cannot hear or see (hallucinations). The psychotic symptoms typically have a depressive "theme", such as delusions of guilt, poverty, or illness. 
• Seasonal affective disorder is characterized by the onset of depression during winter months, when there is less natural sunlight. This depression generally lifts during the spring and summer. Winter depression, typically accompanied by social withdrawal, increased sleep, and weight gain, predictably returns every year in seasonal affective disorder. 
• Bipolar disorder is different from depression, but it is included in the list because someone with bipolar disorder experiences episodes of extremely low moods that meet the criteria for major depression (called "bipolar depression"). But a person with bipolar disorder also experiences extreme high- euphoric or irritable - moods called "mania" or a less severe form called "hypomania". 

Examples of other types of depressive disorders newly added to the diagnostic classification of DSM-5 include disruptive mood dysregulation disorder (diagnosed in children and adolescents) and premenstrual dysphoric disorder. 
Signs & Symptoms:
If you have been experiencing some of the following signs and symptoms most of the day, nearly every day, for at least two weeks, you may be suffering from depression:

• Persistent sad, anxious, or "empty" mood
• Feelings of hopelessness, or pessimism
• Irritability
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in hobbies and activities
• Decreased energy or fatigue
• Moving or talking more slowly
• Feeling restlessness or having trouble sitting still
• Difficulty concentrating, remembering, or making decisions
• Difficulty sleeping, early-morning awakening, or oversleeping
• Appetite and/or weight changes
• Thoughts of death or suicide; or suicide attempts
• Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment

Not everyone who is depressed experiences every symptom. Some people experience only a few symptoms while others may experience many. Several persistent symptoms in addition to low mood are required for a diagnosis of major depression, but people with only a few - but distressing - symptoms may benefit from treatment of their "subsyndromal" depression. The severity and frequency of symptoms and how long they last will vary depending on the individual and his or her particular illness. Symptoms may also vary depending on the stage of the illness.
Risk Factors:
Depression is one of the most common mental disorders in the U.S. Current research suggests that depression is caused by a combination of genetic, biological, environmental, and psychological factors. Depression can happen at any age, but often begins in adulthood. Depression is now recognized as occurring in children and adolescents, although it sometimes presents with more prominent irritability than low mood. Many chronic mood and anxiety disorders in adults begin as high levels of anxiety in children. Depression, especially in midlife or older adults, can co-occur with other serious medical illnesses, such as diabetes, cancer, heart disease, and Parkinson's disease. These conditions are often worse when depression is present. Sometimes medications taken for these physical illnesses may cause side effects that contribute to depression. A doctor experienced in treating these complicated illnesses can help work out the best treatment strategy. 
Risk Factors Include:

• Personal or family history of depression
• Major life changes, trauma, or stress
• Certain physical illnesses and medications

Treatment and Therapies
Depression, even in the most severe cases, can be treated. The earlier that treatment can begin, the more effective it is. Depression is usually treated with medications, psychotherapy, or a combination of the two. If these treatments do not reduce symptoms, electroconvulsive therapy (ECT) and other brain simulation therapies may be options to explore. 
Medications
Antidepressants are medications that treat depression. They may help improve the way your brain uses certain chemicals that control mood or stress. You may need to try several different antidepressant medications before finding the one that improves your symptoms and has manageable side effects. A medication that has helped your or a close family member in the past will often be considered. Antidepressants take time - usually 2 to 4 weeks- to work, and often, symptoms such as sleep, appetite, and concentration problems improve before mood lifts, so it is important to give the medication a chance before reaching a conclusion about its effectiveness. If you being taking antidepressants, do not stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and then stop taking the medication on their own, and the depression returns. When you and your doctor have decided it is time to stop the medication, usually after a course of 6 to 12 months, the doctor will help you slowly and safely decrease your dose. Stopping them abruptly can cause withdrawal symptoms. You may have heard about an herbal medication called St. John's wort. Although it is a top selling botanical product, the FDA has not approved its use as an over-the-counter or prescription medicine for depression, and there are serious concerns about its safety (it should never be combined with a prescription antidepressant) and effectiveness. Do not use St. John's wort before talking to your health care provider. Other natural products such as dietary supplements, including omega-3 fatty acids and S-adenosylmethionine (SAMe), remain under study but have not yet been proven safe and effective for routine use. For more information on herbal and other complementary approaches and current research, please visit the National Center For Complementary and Integrative Health website. 
Psychotherapies
Several types of psychotherapy (also called "talk therapy", or in a less specific form, counseling) can help people with depression. Examples of evidence based approaches specific to the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy. More information about psychotherapy is available on the NIMH website and in the NIMH publication Depression: What You Need To Know. 
Brain Stimulation Therapies
If medication does not reduce the symptoms of depression, electroconvulsive therapy (ECT) may be an option to explore. Based on the latest research:

• ECT can provide relief for people with severe depression who have not been able to feel better with other forms of treatment.
• ECT can be an affective treatment for depression. In some severe cases where a rapid response is necessary or medications cannot be used safely, ECT can even be a first line intervention.
• Once strictly an inpatient procedure, today ECT is often performed on an outpatient basis. The treatment consists of a series of sessions, typically three times a week, for two to four weeks.
  
• ECT may cause some side effects, including confusions, disorientation, and memory loss. Usually these side-effects are short term, but sometimes memory problems can linger, especially for the months around the time of the treatment course. Advances in ECT devices and methods have made modern ECT safe and effective for the vast majority of patients. Talk to your doctor and make sure you understand the potential benefits and risks of the treatment before giving your informed consent to under go ECT.
  
• ECT is not painful, and you cannot feel the electrical impulses. Before ECT begins, a patient is put under brief anesthesia and given  a muscle relaxant. Within one hour after the treatment session, which takes only a few minutes, the patient is awake and alert.
  

 Other more recently introduced types of brain simulation therapies used to treat medicine-resistant depression include repetitive transcranial magnetic stiumlation (rTMS) and vague nerve stimulation (VNS). Other types of brain stimulation treatments are under study. You can learn more about these therapies on the NIMH Brain Stimulation Therapies webpage. If you think you may have depression, start making an appointment to see your doctor or health care provider. This could be your primary care practitioner or a health provider who specializes in diagnosing and treating mental health conditions. Visit the NIMH Find Help for Mental Illnesses if you are unsure of where to start. 
Beyond Treatment: Things You Can Do
Here are other tips to help you or a loved one during treatment for depression:

• Try to be active and exercise
• Set realistic goals for yourself
• Try to spend time with other people and confide in a trusted friend or relative
• Try not to isolate yourself, and let others help you
• Expect your mood to improve gradually, not immediately
• Postpone important decisions, such as getting married or divorced, or changing jobs until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
• Continue to educate yourself about depression

Stress , in everyday terms, is a feeling that people have when they are overloaded and struggling to cope with demands. These demands can be related to finances, work, relationships, and other situations, but anything that poses a real or perceived threat or challenge to a person's well-being can cause stress.

Stress can be a motivator. It can be essential to survive. The "Fight or Flight" mechanism can tell us when and how to respond to danger. However, if this mechanism is triggered to easily, or when there are to many stressors at one time, it can undermine a persons mental and physical health and become harmful. According to the annual stress survey conducted by the American Psychological Association (APA), average stress levels in the US rose from 4.9 to 5.1 on a scale from 1 to 10 in 2015. The main reasons given were employment and money.

Fast Facts on Stress:
1. Stress helps the body to prepare to face danger.
2. The symptoms can be both physical and psychological.
3. Short-term stress can be helpful, but long-term stress is linked to various health conditions.
4. We can prepare for stress by learning some self-management tips.

What is Stress?
Stress is the body's natural defense against predators and danger. It flushes the body with hormones to prepare systems to evade or confront danger. This is known as the "Fight or Flight" mechanism.  When we are faced with a challenge, part of our response is physical. The body activates resources to protect us by preparing us either to stay and fight or get away as fast as possible. 

The body produces large quantities of the chemical cortisol, adrenaline, and nor-adrenaline. These trigger and increased heart rate, heightened muscle preparedness, sweating, and alertness. All these factors improve the ability to respond to a hazardous or challenging situation. Factors of the environment that trigger this reaction are called stressors. Examples include noises, aggressive behavior, a speeding car, scary moments in movies, or even going out on a first date. The more stressors we experience, the more stressed we tend to feel.

Changes to the Body
Stress slows normal bodily function, such as digestive and immune systems. All resources can then be focused on rapid breathing, blood flow, alertness, and muscle use. The body changes the following ways during stress:
1. Blood pressure and pulse rate rise
2. Breathing is faster
3. Digestive system slows down
4. Immune activity decreases
5. Muscles become tense
6. Heightened state of alertness prevents sleep

How we react to a difficult situation will affect how stress affects us and our health. A person who feels they do not have enough resources to cope will be more likely to have a stronger reaction, and one that can trigger health problems. Stressors affect individuals in different ways. Some experiences that are generally considered positive can lead to stress, such as having a baby, going on a trip, moving to a nicer house, and being promoted. 

This is because they often involve a major change, extra effort, new responsibilities, and a need for adaptation. They are also steps into the unknown. The person wonders if they will cope. A persistently negative response to challenges can have a detrimental effect on health and happiness. However, being aware of how you react to stressors can help reduce the negative feeling and effects of stress, and to manage it more effectively. The APA recognizes three different types of stress that require different levels of management.

Acute Stress
This type of stress is short-term and is the most common way that stress occurs. Acute Stress is often caused by thinking about the pressures of events that have recently occurred, or up coming demands in the near future.  For example, if you have recently been involved in an argument that has caused upset or have an up coming deadline, you may feel stress about these triggers. However, the stress will be removed or reduced once these are resolved.

It does not cause the same amount of damage as long-term, chronic stress. Short-term effects include tension headaches and an upset stomach, as well as a moderate amount of distress. However, repeated instances of acute stress over a longer period of time can become chronic and harmful.

Episodic Acute Stress
People who frequently experience acute stress, or whose lives present frequent triggers of stress, have Episodic Acute stress. A person with too many commitments and poor organization can find themselves displaying Episodic Acute stress symptoms. These include a tendency to be irritable and tense, and this irritability can affect relationships. Individuals that worry too much on a constant basis can also find themselves facing this type of stress. This type of stress can also lead to high blood pressure and heart diseases. 

Chronic Stress
This is the most harmful type of stress and grinds away after a long period of time. Ongoing poverty, dysfunctional family, or an unhappy marriage can cause Chronic stress. It occurs when the person never sees an escape from the stress and stops seeking solutions. Sometimes, it can be cause by a traumatic experience early in life. 

Chronic stress can continue unnoticed, as people can become used to it, unlike Acute stress that it's new and often has an immediate solution. It can become apart of an individual's personality, making them constantly prone to the effects of stress regardless of the scenarios they come up against.  People with Chronic stress are likely to have a final breakdown that can lead to suicide, violent actions, heart attacks, and strokes.

Causes
We all react differently to stressful situations. What is stressful to one person may not be stressful to another. Almost anything can cause stress. For some people, just thinking about things or several small things can cause stress. Common major life events that can trigger stress include:
1. Job issues or retirement
2. Lack of time or money
3. Bereavement
4. Family problems
5. Illness
6. Moving home
7.  Relationships, marriage, divorce