After all these years, what have we learned about the most effective treatments for depression?
Michael Yapko: Just as there are many pathways into depression, there are many treatments that can provide pathways out of it. The most effective treatments have certain common denominators. We’ve learned that approaches that emphasize skill-building do better than those that don’t. Treatments that require the client to be active in the therapy process, as well as those that emphasize present and future orientation, rather than the past, also seem to get better outcomes. But the real skill in providing therapy is in knowing what approaches are going to be best for a given individual. In that respect, there’s no one-size-fits-all formula.
Overall, one of the most useful ways of understanding depression is the stress generation model. It’s based on the idea that depressed people need better skills and resources for managing life challenges so that they don’t wind up feeling trapped and victimized in their own lives. A major goal in therapy is helping depressed people learn to make better concrete choices, determining when to do this versus doing that in trying to manage their problems. The focus is on making more helpful distinctions or discriminations. Given the typical helplessness of depression, important discrimination questions to ask are “Is this hurtful situation in your control or isn’t it? How do you tell?” Given the tendency to withdraw and isolate, another important discrimination is: “Should you say something, or should you just keep quiet? How do you decide?”
When people come to see me in therapy, I start by asking what they want help with. Invariably, as they’re telling me about their negative past experiences, I learn about the discriminations they didn’t make that have made matters worse. That typically leads to my asking a series of questions that begin with the word how. I’m not looking to interpret the meaning of people’s depression: I’m trying to understand the way my client is thinking that limits their perspective, rather than analyzing why they think that way.
Many, or even most, depressed people think with a global cognitive style. They see the forest, but not the trees, in the situations where they’re feeling stuck, overwhelmed, depressed, or anxious. They know in a global way they “want to be happy,” but have no idea where to begin, or what specific steps to take to attain their goals. So they do whatever reflexively occurs to them, often making matters worse. When I ask depressed clients, “How did you decide to do what you did?” they often reply, “I don’t know” or, worse, “I just followed my gut feeling.”
So I begin by focusing on learning the person’s strategies: what they know and what they don’t know. If a depressed client tells me an ambiguous story about someone he thinks is upset with him, I’m likely to ask, “How do you know that she’s upset with you?” If his answer is “Because that’s how I’d feel if I were in her shoes,” that instantly tells me he’s relying too much on his own frame of reference to understand somebody else’s response to him. That’s usually a mistake, especially for depressed people, because so often they may care about things other people don’t care about. Or they don’t care about things that matter deeply to other people. It’s a common characteristic of depression called internal orientation, in which people use their own feelings as their prime reference point.
Here’s an example of the over-general thinking that gives rise to overreactions or misdirected actions that can keep a depressed client stuck. Anna was wounded deeply when her boyfriend cheated on her. She broke up with him, felt depressed, and vowed never to be vulnerable again, convinced that men just can’t be trusted. She then went through a period of being angry and edgy around men, often sarcastic and even rude. Although she finally met a nice guy, who gently lured her out of her self-imposed prison, she still often snapped at him and remained vigilant for the inevitable betrayal she “knew” would come.
Anna’s approach to men was so general and superficial that she failed to make important distinctions between different kinds of men, essentially treating them as if they’re all much the same. This was easy to detect in the opening statement of why she came for therapy when she said, “I don’t trust men. Every time I’ve been in a relationship, the guy used me, cheated on me, hurt me. Aren’t there any good guys out there?”
My first question involved the question how: “When you start dating someone, how do you assess a man in order to know what sort of man he is and what he’s capable of?”
There was a long pause and a confused look on her face before she asked in a puzzled voice, “Assess?”
“Yes. How do you determine whether a guy is a good fit for you?”
“What do you mean?”
I asked a third time, in a different way, “How do you decide whether this is a guy you want to go out and develop a deeper relationship with?”
She paused again and finally replied, “If he makes me feel special.”
What Anna feels is not a statement about the guy—what kind of a person he is, what his deeper values are, how trustworthy or manipulative he might be, or anything meaningful about him. After all, a true sociopath can make you feel great, right before he steals everything you own and moves on to exploit his next sucker. So not even five minutes into the therapy session, it’s already clear what skills Anna will need to learn if she stands any chance of eventually having a good relationship in her life.
Anna doesn’t assess men. If she sees them as essentially all the same, then why would she notice anything beyond the superficial differences between them? Her only criterion for choosing whom to date is whether she feels good because she globally senses some “chemistry” between them. Her strategy of focusing internally on her feelings while enjoying some man’s attention prevents her from making the key external discriminations she needs to make about him. You can’t be a good observer and a good partner if you’re too wrapped up inside yourself.
From a clinical perspective, we didn’t need to spend valuable therapy time analyzing her previous failed relationships, and we certainly didn’t need to analyze her relationship with her father or her attachment history. She needed to learn how to discriminate between the good and bad guys in her life in order to make an informed choice and be comfortable in a new relationship.
I began therapy with Anna by emphasizing that it was her responsibility to assess men, and that this was a crucial first step in any relationship that had been missing. She understood and accepted this point, and through this new awareness learned to develop impulse control and set the desperation and fear related to men aside. Second, she needed to learn how to meet a man and assess him. She needed to learn to consider questions like: What values does he profess to hold? How insightful does he seem to be? Is he able to demonstrate kindness and a respectful acceptance of their inevitable differences? How well does he take responsibility for his own actions? We went through what can be observed and understood and what remains hidden, what’s consistent and what’s inconsistent, what’s a minor flaw and what’s a deal breaker for her. She learned that when she was on a lunch date and heard or observed certain things indicating a poor prognosis with a guy, she didn’t have to finish her sandwich. She could just get up and politely go.
After a few sessions, Anna was empowered to face dating with a new set of skills. These inevitably fostered greater self-awareness. She learned how to discriminate between men, so she could choose more wisely—and she did. Anna has been married more than 11 years now, and she still writes to me on occasion to share the latest happy life event with me.
You seem to have a different way of understanding some of the common symptoms of depression. For example, from the viewpoint of discrimination strategies, why is excessive or inappropriate guilt such a common characteristic of depressed clients?
Yapko: Many depressed clients don’t have a discrimination strategy to determine what they are and aren’t responsible for. If I ask, “How do you decide whether you’re responsible for something?” and the depressed person says, “I’m responsible for everything that happens in my life, aren’t I?” I know why he’s not getting anywhere. He’s a victim of a global style of thinking, which misses the fact that some events just happen and some choices may yield hurtful consequences. For instance, someone might say, “I disappointed my dad by deciding to become a musician instead of a lawyer.” It doesn’t mean it was the wrong decision and a basis for painful guilt. Instead of feeling burdened and responsible for everything, this person needs to develop a discrimination strategy for distinguishing what he is and isn’t responsible for. Can you imagine how difficult life must be for someone who can’t make that distinction?
You’ve been critical of some popular therapy approaches that you believe can make the problem worse. Where do therapists commonly go wrong with depressed clients?
Yapko: Therapy can unintentionally hurt people when it teaches global philosophies, rather than specific skills in critical thinking. When clients come in and present global complaints, like “Life is so unfair,” it doesn’t serve them to have a therapist who provides global solutions, like “All you need to do is identify and correct your cognitive distortions” or “All you need to do is focus on your breathing.” These are unhelpful pieces of advice because they don’t teach the specific discrimination strategies clients need.
Take the common mindfulness intervention of acceptance. How do therapists make the distinction whether to help clients strive for acceptance or for transformation? When is acceptance a better approach? When is striving to change things a better approach? These are questions therapists would need to ask themselves before they dole out a prescription such as “acceptance is the solution.” A global belief will end up hurting people in situations where it doesn’t apply or is counterproductive.
Without having a template for how to make these kinds of discriminations, people are going to react only on the basis of their feelings. And when you make decisions solely according to your feelings, especially when you’re depressed, you’re at risk for making very bad decisions. There’s a relatively new field called affective neuroscience, which studies the relationship between mood states and cognitive functions and has shown that people in bad moods make decisions quite different than people in good moods. Similarly, someone who’s anxious will make more conservative decisions, whereas someone who’s angry will make more reckless decisions. Treating someone who’s depressed necessarily needs to address how this person makes decisions. When people aren’t empowered to make decisions wisely, they can make bad decisions, which often make their depression worse.
I often ask depressed clients discrimination questions such as “How do you know when it’s selfish and when it’s taking care of yourself?” or “How do you know whether the goal you set is realistic or unrealistic?” or “How do you know when to listen to your feelings and when to override them?” Their answers help me identify their experiential deficit in order to know what to target in therapy. Also, I’m trying to make them aware that they’re lacking a vital piece of information that’ll profoundly influence the direction their lives take, for better or worse. They begin to make progress when they realize that they’re trying to make decisions without having a reasonable way of making the decision or have a certain outcome without knowing if it’s realistic.
One of the distinctive things about your approach is the way you combine your cognitive orientation with hypnosis. Hypnosis is still an approach that makes many therapists uneasy. Why do you consider it such an important tool in working with people suffering depression?
Yapko: There’s a popular mythology that hypnosis involves a loss of control. My work draws people’s attention to the opposite truth: hypnosis is a great way of teaching self-regulation and helping clients focus their attention on self-defined goals. Depressed people may be the most disempowered people out there, so hypnosis is a particularly effective method to use with them.
One aspect of hypnosis that makes it especially well-suited to working with depressed clients is its ability to instill thoughts of a positive nature to counter automatic negative thoughts. It’s a phenomenon called automaticity: how can we introduce positive ideas in ways that allow them to become more nonvolitional, more reflexive for the person? To me, one of the primary values of hypnosis is introducing helpful images, feelings, behaviors, and thoughts that will just bubble up automatically in the appropriate contexts.
A central process in hypnosis involves a quality called dissociation, which most people have studied only in the pathological sense. They’ve learned about dissociative identity disorder or psychogenic fugue states and so forth. But dissociation is a far more common psychological process, defined as the ability to break global experiences into their separate components. Let’s take something as simple as mindfulness and the emphasis on breathing. If you’re going to suggest to clients that they just focus on the breath, you’re indirectly suggesting dissociation, directing their attention to their breathing and letting everything else recede into the background. If you’re going to suggest that clients step away from the thoughts or feelings (e.g., “picture your thoughts as if clouds in the sky”) in order to examine them and even correct them, that ability to step outside your thinking involves dissociation. These are critical components of cognitive behavioral therapies, interpersonal therapies, dialectical therapies, emotion-focused therapies, and many others.
Homework is a central element in cognitive therapy and in your approach in particular. Why do you think it’s so useful?
Yapko: As a therapist, I’m always trying to move the problem from being abstract and undefined, and therefore seemingly hopeless, to something that’s concrete and defined. I’m trying to take global, seemingly unchangeable problems and break them into treatable issues. It’s one of the most valuable lessons I learned from Jay Haley: always define problems in solvable terms. Telling people their problem is biochemical or genetic or the product of trauma is the antithesis of that teaching. Homework is a great way to show people how to take concrete actions with the problems they bring to therapy.
One of the most common homework assignments I use is called A Flow of Steps. It’s meant to help clients break down an issue typically presented in global, unsolvable terms into a more specific or linear cognitive and/or behavioral process. Since you can’t solve a problem globally, you need specific steps. How do you help people go from a global understanding or a global goal to a much more specific one? First, I’ll ask clients to make a flowchart for some behavior that they engage in that they know they do well, something simple. I’ll tell them, “I want you to pretend for a moment that it’s your job to instruct someone who’s never taken a shower before. You need to create a sequence they can follow that guarantees their success in being able to do that. Go home and write down the sequence step by step for how to take a shower so that somebody else can follow that exact sequence and be guaranteed success.”
Clients come back a week later and they present their sequence of steps to me. Inevitably, their first step is something like “turn on the shower.” Then I’ll stop them and say, “Wait a second. How do I find out where the shower is? How do I even know what room to go to?” I’ll start picking apart their incomplete sequence and make them aware of how many steps they’ve missed. They leave out things like “Turn on the hot water. Turn on the cold water. Flick the switch from tub to shower.” Usually, they only have three steps: get wet, soap up, rinse off. So they discover their sequence would have led to failure, not success, if someone else followed it. I have to add in the other dozens of steps for how to successfully take a shower.
Then I can turn to them and say, “Okay, now you’ve got the sequence for how to successfully take a shower. Now I want you to do the sequence for how to be happy.” That’s usually the first time that they realize they have no idea. It’s not because of any pathology or biochemical imbalances. It’s because they just don’t know how to do certain things. If you don’t know how to ask someone out, or how to resolve a conflict, or how to stop the reflex of taking things personally that aren’t really personal, you’re going to keep making the same mistakes in life over and over.
By all indications, the incidence of depression is increasing around the world. What role can therapists play in addressing that problem?
Yapko: A dozen years ago, the World Health Organization predicted that depression would rise to become the second greatest cause of human suffering and disability by the year 2020. We reached that disastrous mark in late 2013. I believe too much emphasis has been placed on exclusively biological solutions when the evidence is clear that social factors are even more powerful in shaping the onset and course of depression. We need to change our focus if we’re going to slow the rising tide of depression and do much, much more to educate people regarding the fact that a pill a day won’t keep the depression away. People need the skills to manage life’s challenges with insight and foresight, and no drug alone can help people do that. I’m hopeful that the mental health profession will grow to be less fragmented in how it sees and treats depression, and that far more attention will be paid to issues of prevention. We can prevent depression, as many studies affirm. We just haven’t made it the priority—at least, not yet.
Photo © Cultura RM / Maria Schriber RM / Getty Images
Michael D. Yapko, PhD, is a clinical psychologist and marriage and family therapist and internationally recognized for his work in depression and outcome-focused psychotherapy, routinely teaching to professional audiences all over the world. Dr. Yapko has a special interest which spans more than three decades in the intricacies of brief therapy, the clinical applications of directive and experiential methods, and proactively treating the disorder of major depression. He is the author of a dozen books and editor of three others, and numerous book chapters and articles on these subjects. These include his books Mindfulness and Hypnosis and Depression is Contagious: How the Most Common Mood Disorder is Spreading Around the World and How to Stop It, as well as Hand-Me-Down Blues: How to Stop Depression from Spreading in Families, Treating Depression with Hypnosis, and Breaking the Patterns of Depression.