Michael Yapko on Psychotherapy and Hypnosis for Depression

Michael Yapko on Psychotherapy and Hypnosis for Depression

by Rafal Mietkiewicz
Michael Yapko discusses the keys of successful psychotherapy and treatment for depression, including the use of metaphors and hypnosis.


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Understanding Depression

Rafal Mietkiewicz: Welcome, Dr. Yapko. I am delighted to have the opportunity to talk with you today. Let't start off with the question of how do you understand depression? Where does depression come from?
Michael Yapko: Depression comes from many different places. There isn't a single cause for it; there are many contributing factors. And in a general way, the factors are grouped into three areas. There are biological factors that contribute: genetic contributions, biochemical contributions. There are psychological factors: your individual temperament, your coping style, your attributional style, your personal history, all those kinds of things and more. And then there's the social realm: the social factors that contribute to depression, the quality of your relationships, the culture in which you live. Those are all three contributive domains. Consequently, the predominant model in the field is called the bio-psycho-social model and simply acknowledges that there are many, many different factors that contribute. And it's because depression is a complex phenomenon, and the fact that there are so many different factors. When I started studying depression 30 years ago, we knew of only two risk factors—one was gender and the other was family history. Now we know there are dozens and dozens and dozens of risk factors, factors that increase your vulnerability to depression. And so we've learned a lot over the last 30 years.

RM: What is the role of childhood, including the first experiences of the child, along with family history?
MY: Childhood obviously is a time when socialization forces are the most intense. And so the quality of your attachments, the modeling that you learn from your family about how to cope with stress and adversity, the way that you are taught as a child to explain the meaning of life events are all factors that can make you quite vulnerable to depression. And so the childhood is important, but I think one of the things that we've learned quite well is that depression isn't about events that happen in people's lives. It's more about ongoing processes of how the person uses information, how the person forms relationships, how the person interprets the meaning of things that happen to them.
RM: Isn't the way in which a person formulates interpretations determined by his own phenomenology, his own life history?
MY: It's partly determined by that, but socialization goes on your entire life. It doesn't stop when you're five years old; it doesn't stop when you're eight years old.
RM: Some people could say that these are the most crucial years, and that making any changes later is very hard.
MY: People could say that.
RM: Do you agree?
MY: Not entirely. If you look at the fact that some of the most successful therapies for depression never examine childhood, that should tell you something. You look at the three therapies that have the highest treatment success rate—cognitive therapy, behavioral therapy, interpersonal therapy—and right behind it, behavioral activation—none of those treatments focus on childhood.
RM: So, you're saying you can cure people from depression without taking care of events that happened long ago in the past, without dealing with the big traumas?
MY: Clearly. It's not an opinion—look at the research. In fact, cognitive-behavioral therapy is the most widely researched treatment there is. And this is an approach that has no interest in the past. Now, people will come in and they will naturally talk about the past—"Here's what happened to me when I was eight years old." But a cognitive therapist is not going to sit around and talk about that in great detail, but rather will ask, "So what does that lead you to think, and how does it lead you to behave, and how can we change what you think and how can we change how you behave?" And guess what? It has the best treatment success. And when you look at the analytic approach, it comes in almost at the bottom of treatment success studies—for a reason. See, the problem is, it's a treatment model that you use with everybody, as if everybody's the same, as if everybody has the same pathway into depression. But in fact each person has their own individual pathway into depression. For one person, it's about failed relationships. For another person, it's about trauma as a child. For another person, it's about the surgery they just had and all the drugs they're on. And for somebody else, it's about the hormonal imbalance, and for somebody else it's because their diet is so terrible and they never exercise. There's no blueprint. The model of depression that came out of the analytic world was that depression was anger turned inwards.
RM: Yes...
MY: That was disproved 30 years ago.
RM: However, it's still considered as something important and valid for many people...
MY: Well, that's wrong. You know, I rarely make a statement that's that flat. Usually there's an element of truth in something, and maybe the truth gets exaggerated, but the idea of depression as anger turned inwards has been disproved. It's an old, outdated concept that doesn't work in the face of modern research. And consider the fact, how many people get out of depression and stay out of depression without addressing anger and without addressing trauma and without addressing childhood. It's always interesting to me that when somebody says, "Well, I think exploring your past is vitally important." Okay. You think it's vitally important. That doesn't mean it is. You want to believe that? You can believe that. You're allowed. You can think whatever you want. But if we go into the realm of research and we compare different treatments and which ones have higher treatment success rates and which ones have lower treatment success rates, such as psychoanalysis—I don't mean to bash psychoanalysis in a global way—but if we ask the question, "Are there some treatments for depression that work better than others?" the answer is yes. It's not as if all treatments are the same. And when we look at which treatments are better, they're the ones that teach people specific skills, whether it's skills in how to use information, how to make decisions intelligently, how to form relationships in a way that's healthy, how to manage yourself and be self-efficacious, and learning skills of emotional self-regulation. And if you look at things that go on in analysis, they actually work against people getting better in two very specific ways. Part of the problem with people who suffer depression is they make meaning out of events and their style of making-meaning hurts them. So to give you a simple example, I call you. You're not home. I leave a message for you. I say, "Call me back."
RM: And I don't.
MY: And you don't call me back. Now, if I'm a depressed person, how do I interpret that?
RM: Probably like "I'm not worthy..."
MY: "I'm not worthy, you don't like me."
RM: Yes...
MY: "You don't think I'm important. What's wrong with me? How come nobody ever likes me?" It's facing an uncertain or ambiguous situation and projecting negative meanings into it. Analysis is filled with making negative interpretations, negative projections in the face of uncertainty. "What does this dream mean? What does this symbol mean? What does this image mean?" And so much of what happens in analysis is teaching a person to make interpretations that are the same as the analyst. That doesn't help the person learn how to think and use information more critically. And then the second thing that happens in analysis, when we look at coping styles there's a particular style of coping called rumination: spinning things around and analyzing them and analyzing them and analyzing them, at the expense of taking effective action. And when you look at the people who ruminate, they have higher levels of anxious symptoms, more severe depressive symptoms. Ruminating, analyzing, works against getting better. Action is what helps people get better. And when you look again at the therapies that have the highest treatment success rates, it's not a coincidence that every single one of them gives homework. Every single one of them gives tasks to do in between sessions. Every single one of them emphasizes teaching specific skills, whether it's relationship skills, thinking skills, behavioral skills—but the emphasis is on movement, not analysis. That's why people in the other domains call it the analysis paralysis: instead of encouraging people to take effective action, instead, they spend more time thinking and analyzing and miss opportunities to do things that would help themselves.

Nobody Wants to be Depressed

RM: It sounds refreshing and optimistic, but I'm just wondering, if patients are willing to change their behaviors, learn new skills right away, are they ready for it-- especially, when we consider secondary benefits from depression.
MY: Who said there are secondary benefits? You said that. I didn't say that. I don't believe that.
RM: You don't believe the idea of secondary benefits from depression is true?
MY: No.
RM: Why not?
MY: Everything you experience has consequences. Everything. Going to a conference for five days has consequences. It means you're away from your family. Does that mean you want to be away from your family? You make choices. But to suggest that the consequences drive the pattern to me is so offensive because it blames the depressed person. Depressed people don't want to be depressed. What makes it look like secondary gain or secondary benefit is when you see depressed people who don't lift a finger to help themselves, the easiest conclusion is they must not want to change. They must be getting benefits from being depressed. And that is a fundamental misunderstanding that I wish people would let go of already. Nobody wants to be depressed. But the basis of depression is helplessness, hopelessness. Most depressed people don't go for help not because they want to be depressed, but because they don't think help will make a difference. Why would I go see a therapist if I believe that it's never going to help me? That's why depression has so few people who seek treatment. Only about 20 to 25 percent of depression sufferers seek help because they don't believe it's going to make a difference.
RM: So it sounds like you don't really believe in the unconscious?
MY: You're going off in an entirely different direction now. Of course there are unconscious processes.
RM: I am not blaming a person for being depressed, or saying that it is the choice a person makes; however, there are many benefits of being depressed I could think of...
MY: But by saying it that way, you're suggesting that there is a motivation to stay depressed.
RM: Unconscious ones...
MY: And I'm suggesting that is incorrect. It's damaging. It's unfair to the patient. And it delays getting effective treatment. It's not a useful concept. And again, when you look at the therapies that work, none of them explore that domain because it is theoretically interesting but it isn't really what the nature of depression is about. And it's one of the things that every analyst needs to do, is be able to distinguish between their interest in a particular theory versus what the client's actual experience is. Instead of fitting the patient to the theory, how about if we learn something about how this person generates depression? It's a very different question—how does this person generate depression, instead of why. As soon as you ask why, you're now inviting theorizing.
RM: That is true to some extent.
MY: And what I'm interested in is, "Here's how this person does this. How can I interrupt that sequence so that instead of going from here to here to here to depression, can I introduce some new possibilities that move them in a new direction?"
RM: I see.
MY: That's the problem with when people make theories and then they actually believe themselves.
RM: What you are telling us is that you're very concentrated on the individual, rather than generalized theories.
MY: Every person's different. And that's the point--
you have to generate a new theory for each person, instead of fitting the person to some preexisting idea.
you have to generate a new theory for each person, instead of fitting the person to some preexisting idea. And that's the problem with any approach that adapts the person to the theory instead of the reverse. And that's the danger for any model. You know, I wouldn't want a cognitive therapist to only read cognitive literature. I wouldn't want a behavioral therapist to only read behavior literature.
RM: The more you know the better for the patient?
MY: Yeah, when I said there are so many factors that have been proven to contribute to depression, it means that each practitioner needs to know something about genetics, needs to know something about epigenetics, needs to know something about biochemistry, needs to know something about social depression and the cultural contributions to depression, needs to know something about cognition, needs to know something about diet and exercise. You know, exercise has a treatment success rate that matches antidepressant medications and has a lower relapse rate. Now, that without ever saying a word to somebody. Doesn't that complicate the picture a little bit when you ask, "Well, how does somebody get better exercising if they never deal with their unconscious and they never deal with their traumas?" That's an important question.
RM: Good point!
MY: And that's where you would hope the people reading this would be curious enough to ask, "What is it that cognitive therapists have learned that have made the treatment so successful without doing any of the things that the people who are loyal to analysis think you should do?" And then, of course, part of the model is to dismiss it as superficial. "Well, that's not really therapy if they're only seeing people for six sessions." Well, you can take that position. It's a very arrogant position to take to say that you know what the right way is, other people are doing it the wrong way, when the other people actually have the data to show that it works better and lasts longer and prevents more episodes than any other approach.

Diagnosing and Treating Depression

RM: How long does it actually take you to cure someone from depression?
MY: When you look at the literature, you look at the science of what the studies have shown us, they're usually around 12 to 16 sessions.
RM: And these sessions are structured?
MY: They're structured and they're educational. There's a lot of teaching—what's called psychoeducation—that goes into the process of teaching people how to think and how to use information, how to think clearly. And the same is true with interpersonal approaches. Interpersonal psychotherapy has a treatment success rate that is even slightly higher than cognitive-behavioral. And it teaches relationship skills, social skills. And when you think about the skills that go into good relationships, and we've known for half a century that people who are in good relationships have lower ratings of depression. Why? And what are those skills that go into good relationships? And what about now, when we're seeing depression on the rise and relationships on the decline? So it's such a complicated picture, but spending more time thinking of depression as only in the person, only in the person's unconscious, misses that there are big cultural differences. There are big differences within demographic groups within one culture. And when you look, then, at how do families increase or decrease vulnerability to depression; how do marriages increase or decrease vulnerability; why is the child of a depressed parent so much more likely to suffer depression than a child of a non-depressed parent now that we know that the main reason is not genetic?
RM: Could you give some hints for beginning therapists on how to recognize a depressed client? It is pretty easy with major depression, but how to recognize the signs of it in ongoing therapy with a client who is experiencing moderate depression or dysthymia? And the second question is about masked depression: do you believe it exists and, if so, how do you recognize it?
MY: It's so interesting how your questions all contain the analytic viewpoint.
RM: Really?
MY: Where it's really hard for you to get outside that long enough to even ask the questions differently. But let's take the first...
RM: I wasn't aware of this. Maybe that was my unconscious...
MY: Well, "masked depression"—nobody uses that phrase anymore.
RM: I'm sure I've heard it many times in Europe, where I live and practice.
MY: I understand, I understand. Well, there are people in New York who would probably use the same language—New York being one of the main centers where analysis is still practiced in the United States.

The first question was, "How do you recognize depression?" Depression takes many different forms, so there are many different ways to answer this. If you look at the DSM IV, which is our diagnostic system, there are 227 different symptom combinations that could all yield a correct diagnosis of depression. So depression is a soft diagnosis. It's not an easy diagnosis to make because of all these different combinations.. The United States government has been pushing physicians for almost 10 years now to recognize depression more frequently. When I said earlier that only 20 to 25 percent of depression sufferers seek help from a mental health professional, more than 90 percent of them have seen a physician within the last year, presented the symptoms of depression, and many physicians miss it. So the government's been asking physicians to just ask two questions. One question is about mood; "Have you been feeling down, sad, blue, or depressed for the last month or more?" And the second question is about anhedonia, or the loss of pleasure; "Have you lost interest in the things that usually interest you, or have you stopped deriving pleasure from the things that normally give you pleasure?" Now, if somebody says yes to one or both of those questions, it doesn't automatically mean they're depressed, but it leads you to take a closer look.

Sleep disturbance is the single most common symptom of depression, and the most common form of insomnia is early morning awakening, what's called terminal insomnia because it interrupts the terminal phase of sleep. But there are other symptoms as well. People who are depressed are most often suffering a coexisting condition. Anxiety disorder is the most common coexisting condition, but there are others including substance abuse problems—alcohol especially—medical problems, and personality disorders. So that complicates the diagnosis. But when you're talking with somebody who is feeling hopeless and helpless—the two biggest characteristics of depression—it leads you to look more closely.

Now, the second question was about so-called "masked depression." And the reality is that moods fluctuate. Depressed people aren't in the same level of depression every hour of every day. Typically there fluctuations, times when they feel a little worse—early morning, for example—times when they feel a little better, times when today they're feeling optimistic, and tomorrow they feel rotten again. Today they can barely get out of bed; yesterday they had a good day. So what is a masked depression? The assumption is that the depression is being hidden by some other symptom or some other behavioral pattern. And a good diagnostician, someone who understands what depression looks like in all of its different forms, would simply say instead of "masked depression" that this person has a comorbid condition. They have another coexisting issue, whether it's an anxiety disorder or alcohol abuse or something like that.
RM: It's obvious for me right now that you don't deal with the matter of transference and countertransference, but let me ask you about the role of the relationship between you and the patient.
MY: There are over 400 different forms of psychotherapy, and every single one of them emphasizes the importance of the relationship. If you don't have the connection with the person, then how do you attain the level of influence that it takes to teach them new skills, to motivate them to follow homework assignments, to share your sense of optimism that their life can be different if they do some things different and learn some things differently and approach some things differently? So for me, and I think any therapist would say this, the relationship is critically important.

Learning from People's Strengths

RM: Let's move to the area of core techniques. You write about so many different techniques that are useful with working with depressed persons. I'm wondering what are your favorite techniques.
MY: Well, my favorite technique is the one that works.
RM: You're not attached to techniques.
MY: For me, what defines the work that I do is I respond to these questions. First question: "What is the goal? What does this person want?" And secondly, "What are the resources they're going to need to do it? What specific skills will this person need in order to be able to do this?" You know, I think one of my unique contributions to the field has been in asking how people do things well. Studying how somebody becomes depressed, asking the question, "Why does somebody become depressed?" Okay, that's interesting....
RM: But it's half-baked?
MY: Yes. What I'm really interested in is people who have faced adversity and didn't become depressed. Why didn't they become depressed ? What's different about the way they think about it? How do they cope differently? For somebody who had a difficult family life or had traumas as a child but didn't become depressed, why not? And you can do one of two things. If you are prone to pathologizing people, then you would say, "Oh, they're in denial and they have great defense mechanisms." And if you're more focused on the strengths of people the way I am, then you say, "Okay, how do I understand these strengths so that I can teach the same strengths to other people?"
I'm focused on what's right with people rather than what's wrong.
I'm focused on what's right with people rather than what's wrong.

So when I encounter somebody who's been through a terrible set of experiences and they're strong and they're motivated and they're positive and they're happy, I don't look at that as a defense. I look at that as health. I want to know how they did that so I can teach it to somebody else. So that's where the techniques that I've developed come from: studying people who cope well in the face of adversity, the people who manage intense stress well, who have lost people and then managed to love again instead of saying, "I'll never love again." The people who fall down and get back up again. And I think there's much, much, much more to learn from them than there is from analyzing people and talking everyday about how bad they feel and how crummy their childhood was. What a waste of time! It's like putting 10 people together in a group who all have airplane phobias. Now you have the blind leading the blind. You're not going to learn anything about how to get on an airplane comfortably by sitting in a room with nine other people who have the same fear you do.
RM: From your point of view the most they could do is just share similar experiences?
MY: There's so much that goes on in the name of therapy that's simply silly. So my focus is, "Okay, here's somebody who has a particular skill that helps them. This person could learn that skill and benefit from it." The techniques that I put in the books are about, "How have I found ways to teach somebody that skill?" Life is filled with uncertainties. The example that I used earlier: I call you, you didn't call me back--it's unclear why you didn't call me back. It is a skill to prevent myself from interpreting it negatively and saying, "He must not like me," because then I'll feel rejected and I'll feel hurt. But for all I know, you had an emergency, and simply forgot to call me back, or somebody else took the message off the answering machine and never gave it to you. But for me to interpret that it's evidence that you don't like me is a big jump, and one of the most important skills you can learn in life is to be able to recognize and tolerate uncertainty.
RM: Changing thinking and the way we make attributions will also affect our feelings or emotions?
MY: That's certainly a big part of it. Well, think about it. You apply for a job. You don't get the job. What does it mean? Well, if you're sensitive about your age, you'll say, "Well, it's because of my age." and if you're sensitive about your gender, you'll say, "Well, it's because of my gender." But you don't know that. You're never going to know that they hired the boss's nephew. You're never going to know that. So to form these explanations that hurt you is what depressed people do very, very well. So one of the skills is knowing when to analyze something and when not to. To be able to make a distinction, what question is answerable and what question can I ask that no amount of research is ever going to generate an answer to? When this woman is depressed because her two-year-old son died from leukemia, and she says, "Why did this happen?" Is there any answer you can give her that's going to make her feel okay?
RM: I guess not.
MY: What can you say? It's a tragedy. And the last thing that you want to do is say, "It happened because you had a drink when you were four months pregnant." We don't know that. Now, can she still find meaning in it that helps her? Can she say, "I want to start a support group for other mothers who have lost young children"? That would be a great thing to do. But it's different than asking, "Why did this happen to me?" It's a very different question than "What can I do about this that will enhance my life?"

Using Metaphors and Hypnosis in Therapy

RM: Let's talk a while about metaphors.
MY: Okay.
RM: Do you like using metaphors? Do they just pop right into your head or is it hard work to make a metaphor?
MY: I wouldn't say it's hard work. The metaphors are all around us all the time. But let me back up a second. I like the use of metaphor, but not for everybody. And again, techniques don't have any value by themselves. What gives them value is the client. It's not the technique that works. It's the relationship between the technique and the person. No technique is worth anything if the relationship doesn't support it. There are people who will listen to the story and they'll be entertained by it; they'll find it interesting, but they won't learn anything from it.
There are some people who don't value deep thought; they're much more interested in who's going to win the big game this week.
There are some people who don't value deep thought; they're much more interested in who's going to win the big game this week. And then there are other people who listen to the story and they see a deeper meaning in it. What drives metaphor, what makes metaphor valuable, is when you have somebody who engages in what's called a search for relevance. They're willing to actively engage with the metaphor and ask themselves, "How does this apply to me? What can I learn from this? What can I learn from this other person's experience or from this situation?" But not everybody does that. There are some people that the metaphor goes in one ear and out the other, and they just don't think about it.

But the point about the use of metaphor—it has become so basic in the practice of hypnosis to be able to absorb people in a story and encourage multiple-level processing. The conscious understanding, and then stimulating the unconscious processes of the person to build new understandings, build new associations. I'm obviously a big fan of hypnosis. Many of my books are about hypnosis. And hypnosis is such an extraordinarily powerful context for teaching people things and helping people get focused on and absorbed in new ideas and new possibilities. And it helps to understand that hypnosis cures nothing. It's what happens during hypnosis that has the potential to be therapeutic—the new understandings the person develops, the new associations they form in their mind, the new perspectives that evolve for this person as they go through the hypnotic experience. So the hypnosis itself, where metaphor is most commonly used, simply provides a context in which this person can learn things in a much more concentrated way.
RM: You said during your lecture that the viewpoint that hypnosis cannot be used with psychotic patients is wrong...
MY: Somebody asked me that question. My answer was, "Of course it can."
RM: Yes. How so?
MY: There's a distinction that I make between formal hypnosis and informal hypnosis. Formal hypnosis, where you identify this procedure as hypnosis—"Now we're going to do hypnosis. Sit back, close your eyes, focus." But you don't need the announcement for hypnosis to occur. Every time you immerse someone in memory, you're doing age regression. Every time you say to somebody, "I want you to stay focused right here, right now, as you remember," you're doing dissociation. Every time that you focus someone on their feelings, you're focusing them. Every time that you offer interpretation, you're giving a suggestion. And the use of suggestion and how to use suggestion skillfully is what the study of hypnosis is about. But there's no form of treatment—especially analysis, which is a highly suggestive approach—where you're not using suggestions routinely. So the question is how much deliberate focus you create.

I worked in an acute care psychiatric hospital for three years, working with very psychotic patients, very chronic patients. Now with some of them, they could focus long enough, five minutes, ten minutes to actually, "Sit back, close your eyes, let's do an exercise here." And then there are others where it was just being very deliberate about getting their attention for a moment to say something in a way that would focus them and introduce another possibility. Now, that's not formal hypnosis, but it's using the same patterns, the same principles of hypnosis. And so that's what I was talking about.
RM: It seems like everyone can benefit from this form of treatment, this approach.
MY: Yes. What I'm really saying is, I don't know how to separate psychotherapy from hypnosis. They're so merged together because, you know, if you give me a transcript of one of your analytic sessions, I promise you I can highlight suggestion after suggestion and tell you what kind of response that suggestion was trying to create.
RM: So every psychotherapy is partly hypnosis.
MY: Involves suggestion, yes. And what hypnosis involves is the focused use of suggestion. For example, the most empirically supported application of hypnosis is in the realm of behavioral medicine, using hypnosis for pain management. Now, the idea that you can do hypnosis to create anesthesia with someone through language, and this person can now go into an operating room, have their body cut open, and have surgery—that's remarkable. But that's what I do, and that's what many people who practice hypnosis do. Here in the United States, I don't think there's a behavioral medicine program in the country that doesn't have people doing hypnosis, because it is so effective in helping people manage pain with reduced or no medication, to prepare people for surgery so they have better and faster recoveries, and fewer postsurgical complications.

And hypnosis now is such an obvious contributor to our understanding of the brain, and the relationship between brain and mind, because it's an obvious research question: "What changes in a brain when someone is able to go into hypnosis, generate an anesthesia, and have a surgery?" Using fMRI scanning techniques, PET scans, SPECT scans, the person has a scan, then they go through hypnosis and some procedure and then they have another scan, and you literally watch how their brain changes. We're learning about how brains change in psychotherapy or through suggestive procedures, whether it's cognitive therapy or some kind of hypnotic protocol. But the fact that hypnosis is now at the heart of the new neuroscience, this is how fields advance.

No form of therapy that I'm aware of doesn't include suggestion as a basic part of its procedures.
No form of therapy that I'm aware of doesn't include suggestion as a basic part of its procedures. Even the suggestion, "If you lie on the couch, you'll feel better. If you talk about your dreams, you'll feel better. If you feel your deep, innermost thoughts, you'll feel better." That's a suggestion. That "if you come here four times a week and talk about these things, you'll get better in a couple years"—that's a suggestion. And to say to somebody, "It'll take you a couple years to do this," is a very powerful suggestion. Because what you're now telling the person is, "You really shouldn't start to feel any better any sooner than that."
RM: That's a strong statement.
MY: "And if you do start to feel better sooner than that, then that's a problem. That's a defense. That's a flight to health." It's an unusual way of framing it. But the point is, how is it that somebody can practice a form of therapy and not understand the role they play in how the therapy proceeds? That it's not just uncovering what's in the person. There are two people in the room; you're influencing this person whether you realize it or not. And the danger for me is when people are influencing someone and they don't realize it. It's like the big controversy we had here in the United States 15 years ago, about false memories.
RM: Oh, yes.
MY: You had therapists who didn't know that by digging for the memories, they could actually create them. They thought they were just uncovering memories. They didn't know that they were influencing what kind of memories came up and what the quality of those memories were. That's what's dangerous. That's when therapy goes badly--when people don't recognize they are a fundamental, unavoidable part of the process.
RM: It seems obvious that every therapy approach would benefit from learning something about hypnosis and suggestions...
MY: I certainly feel that way, yes.
RM: Can this approach be combined with any other therapeutic approaches?
MY: Well, it isn't a therapy, so the answer is yes. It is routinely incorporated by practitioners who use hypnosis in different ways. There is one form of hypnosis called hypnoanalysis, where therapists use hypnosis to enhance the processes of psychoanalysis. There are others who do cognitive-behavioral hypnotherapy, and they're doing hypnosis from a cognitive-behavioral framework. You name it and there are people who are doing it. So hypnosis isn't really a therapy.
RM: It isn't an approach either.
MY: It's a tool. It's a way of organizing ideas, it's a way of delivering information, it's a way of creating a context where this person can listen to what you have to say and can talk about what they need to say. So how any one therapist would use the principles of hypnosis—that's going to be up to them. It's the equivalent of learning a language, and then each person expresses themselves in their own way. So some people will use hypnosis to give commands to someone: "You will do this, you will do this, you will do this." Personally, that's not my style, and I don't particularly care for that style. There are other people who simply introduce possibilities: "You might want to think about this."
RM: And this is your style.
MY: It's closer to my style.. The reason why I think people should study hypnosis is because hypnosis has studied the quality of communication between a therapist and client. It studies whether your approach should be more direct or more indirect, whether you should be more positive or more negative, whether you should give more detail or less detail, whether you should be more directive or less directive. It teaches you flexibility in how to adjust your style to the patient's need—"How does this person process information so that I can present information to them in a way that fits?"—as opposed to fitting the client to, "This is my theory, this is what I do. And if you don't benefit from it, it's because you're really sick."

Surprising Origins, Unexpected Discoveries

RM: All right. Let's finish with the question that is usually asked at the beginning of an interview. What stirred your interest in depression, and how did your understanding and ways of treating patients evolve during that time?
MY: When I was studying and getting my degrees, it might interest you to know that I spent my first four years studying psychoanalysis and learning to speak that language fluently. I understand psychoanalysis. I've studied it at one of the finest academic institutions in the United States, the University of Michigan, which was at the time a very heavily psychoanalytic school.
RM: So it's not like you're rejecting some ideas that you've just heard about, but you're rejecting ideas that you know profoundly well.
MY: I do definitely, profoundly. Some of the most distinguished analysts in the United States were my professors. But I was moved by the fact that depression was and still is the most common mood disorder in United States--indeed in the world. And there were no good treatments for it. A depressed person is never going to go into analysis anyway—they don't have the frustration tolerance, they don't have the ability to feel bad day after day after day for years waiting for the therapist to say something helpful—the problem doesn't fit the solution. Analysis isn't going to be valuable for most depressed people. They want an answer and they want it now. They want to feel better now. And it's part of the pattern of depression to want it now—it's called low frustration tolerance. Do we say, "Well, that's part of the problem and we shouldn't have to change what we do to fit their problem?" To me that is the opposite response I have, which is, "How do I help this person from within their own framework, instead of expecting them to somehow magically come to my framework?"

At that time, cognitive therapy was in its absolute infancy. It wasn't well developed yet. There were no good therapies, and there were no good drugs. And so to watch people suffer in depression, and to know that nobody's doing anything that really makes a difference, for me it was a challenge. "Can I make a contribution here? Here's the most common problem, and I want to be able to do something about it."
RM: You wanted to have some influence. You wanted to be able to help these people.
MY: I wanted to be able to help. I wanted to be a true clinician and help as many people as quickly as possible. And so the idea of developing short-term interventions was obvious in importance. It's how people use therapy. It's interesting that when you look at the studies of people in therapy, the average number of sessions is between six and seven. The most common number of sessions is one. Can you really do therapy in one session? You saw a video of my work, with 10-year follow-up.
RM: Yeah, it was pretty amazing.
MY: So what does that do to the psychoanalytic viewpoint? It challenges it. And that's the point--you can either dismiss it, or you can say, "There's something here worth studying," depending on how open and how flexible you are. If you're rigid, you pathologize it. If you're open, you say, "There's something there worth studying." And so I was very interested in studying people who have recovered from depression, and asking "What made the difference? What helped you overcome all the helplessness and hopelessness and all of that? What changed for you? How did you cope? How did you learn? How did you relate? How did you, how did you, how did you?" What I realized very quickly when I got into clinical practice was that
everything that I had been studying for the last four years was irrelevant in the real world.
everything that I had been studying for the last four years was irrelevant in the real world.
RM: I think you had a lot of courage to make such a statement.
MY: To me it didn't seem like courage. It just seemed like common sense, that one of two things is going to happen: I'm either going to build my own little world and try to bring people to it, or I'm going to go out into the world and talk to people in terms of the way they think and the way they do things. So to me it didn't seem like courage—it seemed like common sense. And it took me years to unlearn everything I learned.
RM: Everything? Or is there anything left?
MY: If you ask me today, is there one thing that I learned then that I still use? I can't think of a single thing. It took me a long time to unlearn that because I had been intensely trained to continually look for symbolism, to continually look for deeper meaning, to continually speculate about unconscious needs and wishes. And those were all things that got in my way of actually helping desperate people who needed help now.
RM: Thank you very much for this very inspiring conversation. I hope our readers will enjoy reading it as much as I enjoyed talking with you.
MY: Well, predictably, readers are going to react in one of two ways. They're either going to get angry and conclude I don't know what I'm talking about, or hopefully they'll say, "Maybe now would be a good time to start to explore what other people have to say about dealing with these same problems," because then the question becomes "What is the most effective way to treat depression?" And there's no single answer for that.

But it's certainly interesting that, of the many different therapies that have good treatment success rate, it's interesting that none of them analyze childhood. None of them focus on symbolic meanings of things. All of them teach skills. All of them have an orientation towards the future that help the client come to understand how the future can be different in very specific ways. So instead of saying that the goal is insight, saying that the goal is change--that poses a direct challenge. And typically when people are challenged, they either get angry or they get open. I'm hoping at least some of the readers will get curious enough to see what else is going on that might inspire them to change some of what they do in ways that they feel good about.
RM: Any concluding remarks that you want to share with the therapists who might read this interview?
MY: You know, I am a clinician. I am treating the same kinds of patients, maybe even more severe patients than the average clinician treats. And I have a great deal of respect and appreciation for people who make psychotherapy their profession. It's almost as if it's a calling. You want to do something to reduce human suffering, and you are forced to make decisions about how you're going to practice and what the goals of practice are. Is the goal to be loyal to a theory, or is the goal to make a difference? Is the goal to continually filter things in life through your preexisting beliefs, or is the goal to be open and curious about what other people are doing to see if what they're doing works better? And for me, everything that I've learned has come from studying people who do things well, recognizing that they have abilities and strengths—even the people I treat who are severely depressed. Okay, they're depressed; it doesn't mean they're stupid. They have great wisdom, they have a great many skills, and we can learn from those. And especially from the people who handle things well, what can we learn from them? So if somebody recovers well from a loss, instead of saying they're in denial, why aren't we studying how they did that? When somebody bounces back from an adversity, why are we saying that's a defense mechanism instead of an asset? I firmly believe that what you notice and what you focus on, you amplify. And if you focus on pathology, you'll find it. And if you focus on strengths, you'll find them. So I would simply encourage therapists to look for what's right. I think they'll be better clinicians for it.
RM: You've raised some mind-opening questions at the end of our conversation. Thank you very much. It was a huge pleasure.
MY: Thank you. It was my pleasure.

Copyright © 2010 Psychotherapy.net. All rights reserved. Published February 2010.
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Michael Yapko

Michael D. Yapko, PhD, is a clinical psychologist, author, and internationally known expert in the areas of treating depression, strategic short-term psychotherapy, and clinical applications of hypnosis. He routinely teaches to professional audiences all over the world. To date, he has been invited to present his ideas and methods to colleagues in 29 countries across six continents, and all over the United States.

Dr. Yapko is the author of numerous books, book chapters, and articles on the subjects of hypnosis, depression, and the use of strategic psychotherapies. These include the popular (now in its twelfth printing) Breaking the Patterns of Depression, Trancework: An Introduction to the Practice of Clinical Hypnosis (3rd edition), Treating Depression With Hypnosis: Integrating Cognitive-Behavioral and Strategic Approaches, Hand-Me-Down Blues: How to Stop Depression from Spreading in Families, Essentials of Hypnosis, and Hypnosis and the Treatment of Depressions.

He is a recipient of The Milton H. Erickson Lifetime Achievement Award (2007), twice a recipient of the Arthur Shapiro Award for the "best book of the year on hypnosis" from the Society for Clinical and Experimental Hypnosis for Treating Depression with Hypnosis (2001) and Hypnosis and Treating Depression (2006), and the 2003 Pierre Janet Award for Clinical Excellence from the International Society of Hypnosis, a lifetime achievement award honoring his many contributions to the field.

Rafal Mietkiewicz, PhD is a clinical psychologist working in private practice in Gdynia, Poland. He is trained as a Gestalt psychotherapist, and includes an existential approach in his work. Apart from classical psychological knowledge, he takes a lot of inspiration from literature, art and philosophy. If you`d like to contact him, please visit his website www.psychoterapeuci.net.

CE credits: 2

Learning Objectives:

  • Describe Michael Yapko's approach to treating depression
  • List the differences between psychoanalytic and cognitive-behavioral approaches to depression
  • Discuss the differences between psychoanalytic and cognitive-behavioral approaches to treating depression

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here