macscotland presents focusing on enhancing well-being: depression and health beyond the medical...

MacScotland presents

Focusing on Enhancing Well-Being:Depression and Health Beyond the Medical

Model

withMichael D. Yapko, Ph.D.

August 23, 2015Glasgow, Scotland

1copyright 2015 by Michael D. Yapko, Ph.D. www.yapko.com

Part 1:Reframing Depression and

The Power of Focus


What causes depression?


How you answer this question is the single most important

determinant of how you will deliver treatment… and how you will relate

to all I will discuss today


Is Depression Caused By: Genetics? A biochemical imbalance in the brain? Systemic inflammation? Psychosocial stressors? Cognitive distortions ? A lack of environmental and social rewards? Social inequities? Cultural and/or familial influences? Mishandling key vulnerable situations? Dietary issues? A lack of physical exercise?


Major Depression is a Heterogeneous Condition…

…and a variety of biological, psychological and social theories have been formulated to describe its development


The Biopsychosocial Model Of Depression

• Depression has a biological component (genes and biochemistry, diseases,drugs)

• Depression has a psychological component (cognitive distortions, history)

• Depression exists in a social context (social disturbances, distress, cultural influences)


One of the most powerful social forces operating today is the push to

comply with a biological interpretation of depression


In a triumph of marketing over science, the biology of depression

has been greatly overstated…

Depression is about much more than “it’s all in your genes” or “you have a biochemical

imbalance in your brain”


GENETIC EVIDENCEThe genetic variance for depression is

consistently placed at between .3 and .4

Genetic contributions are relatively mild and largely mediated by environmental

factors, including social ones


“The strongest predictor of major depression is still your life experience.

There aren’t genes that make you depressed. There are genes that make you

vulnerable to depression.”Kenneth Kendler, M.D.Professor of Psychiatry and Genetics

Medical College of Virginia


EPIGENETIC EVIDENCE• Epigenetics refers to the processes that lead from a

genotype to its final product…• In an excellent summary article published in September,

2009, the author wrote, “…how genes are expressed is invariably influenced by the milieu in which they function…recent research is beginning to identify environmental factors that lead to these changes…(for example) early parenting has been shown to change these epigenetic patterns, and thereby genetic expression.”

Masterpasqua, F. (September, 2009). “Psychology and Epigenetics.” Review of General Psychology, 13(3), 194-201.


Psychotherapy and Epigenetics

• “Insofar as psychotherapy or counseling is effective and produces long-term changes in behavior, it presumably does so through learning, by producing changes in gene expression that alter the strength of synaptic connections and structural changes that alter the anatomical pattern of interconnections between nerve cells of the brain.”

Eric Kandel, M.D.Geneticist, Nobel prize winner in 2000


Suggesting a drug will cure depression misses the

inescapable point…

…Depression is more a social than medical problem.


No Amount of Medication Can Teach Your Client:

• More effective coping skills• More realistic explanatory styles• Healthier relationship styles• More flexible and discriminative cognitive skills• Sophisticated problem-solving skills• More effective decision-making strategies• How to build and maintain a support network• How to transcend an adverse personal history• How to build a realistic and motivating future


Drug treatment alone has many different problems associated with it (see the article “Treating

Depression with Antidepressants: Drug-Placebo Efficacy Debates Limit Broader

Considerations” posted on my website –www.yapko.com - for a detailed

summary of these)

Perhaps the biggest problem is in the unfortunate message, “You don’t have to change anything in

your life… you just have to take your drug and wait for it to work”


Depression is a disorder that is built on a foundation of passivity

The last thing we want to do as clinicians is reinforce it


The more we learn about the biology of depression, the more we discover the power of human relationships to

either increase or decrease one’s vulnerability to depression


The Social Context of Depression


Through the process of socialization, you evolve your individual patterns for responding to the challenges of life


Depression Intensifies From One Generation to the Next

The first such study following 3 generations of high-risk families and has taken more than 2 decades to complete showed most of the prepubescent grandchildren with a 2 generation history of depression developed anxiety disorders that developed into depression as they aged into adolescence.

Weissman et. al, Archives of General Psychiatry, January, 2005


How often are other people at the heart of one’s depression?

Rejection, loss, betrayal, humiliation, abuse, and abandonment are all common points of

depression’s origin- and they are all social phenomena


And, how often is it our misperceptions about others that lie

at the base of depression?

Seeing rejection where there was none? Feeling left out despite invitations to join?

Missing social cues and misinterpreting others’ motives?


The quality of your relationships is a significant predictor of your risk for

depression

What about social skills training as a preventive opportunity?


Stress Generation Patterns

• The presence of depression and/or anxiety seriously compromises these individuals’ stress coping resources. Minor aggravations become major problems.

• Poor problem solving skills lead to poor choices, which aggravate negative circumstances.

Hammen, Journal of Abnormal Psychology, 1991Harkness & Luther, Journal of Abnormal Psychology,2001


Let’s Shift Our Focus to the Hypnotic Side of the Equation


The primary purpose of hypnosis and related approaches such as mindfulness is to absorb the person in a frame of mind that is consistent with the therapeutic

objectives

Using experiential approaches to teach empowering strategies is a core part of

that process


Why Hypnosis for Depression?

• Helps people focus• Facilitates the acquisition of new skills• Encourages people to define themselves as

resourceful• Eases the transfer of information across contexts• Intensifies useful subjective associations• Provides experiential learning• Defines people as active managers of themselves


Part 2:Group hypnosis; Expectancy


“Deeds are the offspring of hope and expectancy.”

Milton H. Erickson


Stable Style Predicts Whether the Client Will be Prone to :

seek treatmentprogress quickly or slowlyactively participate in treatmentexperience a partial or complete

recovery relapse

copyright 2015 by Michael D. Yapko, Ph.D. www.yapko.com 31

The first task in treatment is to shift the person from a stable to unstable

attributional style

Co-create Vision of What is Possible:Realistic Hopefulness is Crucial!


Discovering and Creating Client Possibilities

• Identifying exceptions in the pattern• Identifying possible solutions• Identifying alternative framings• Identifying dissociated client resources• Encouraging experimentation• Avoiding labeling• Using presuppositions


Building Expectancy:Basic Structure

• Induction- focusing process• Response set re: future possibilities (e.g., what will change

in the future)• Defining steps toward the goal (e.g., linear sequence) and

acknowledging one’s salient resources (e.g., persistence, creativity)

• Dissociating feelings from action steps (e.g., follow the plan, not your feelings)

• Post-hypnotic suggestions for integration• Closure and disengagement


Part 3:The Case of Mike


The Inner Critic

Having an inner critic is normal. Believing it is negotiable.


All the things one would say to be helpful to someone can, of course,

be said without hypnosis…

But hypnosis makes for a focused experience of multi-dimensional

experiential learning


Goals for My Session with Mike

1. Establish rapport and a therapeutic alliance2. Deframe his viewpoint (“It’s my past”) and reframe the

salient issue (“It’s the need for an effective strategy to deal with negativity”)

3. Encourage the development of a discrimination strategy (“What is worth listening to?”)

4. At times of uncertainty, help Mike shift his focus to future possibilities rather than past abuse to guide his choices.


Goals for My Session with Mike (continued)

5. Re-associate Mike to his family, relating to them positively and with an absorption in them as a source of optimism and pride.

6. Introduce hypnosis/focusing techniques and encourage their development as skills for symptom management and empowerment

7. Reinforce critical thinking by addressing his global and dichotomous thinking and personalization of his parents’ limitations


• You can develop the skills to cope• The past doesn’t predict the future• You’re more than your history• You’re more than your symptoms• You have more resources than you

realize and you can learn how to use them effectively


Did You Notice?

• The change in Mike’s face and demeanor• Mike went from “I can’t” to “I can!”• Mike’s internal locus of control (“I have to be

the one to close the windows and doors”)• Mike’s revised association to his wife and

children


Why Hypnosis for Depression?Because it Empowers People

• Helps people focus• Facilitates the acquisition of new skills• Encourages people to define themselves as

resourceful• Eases the transfer of information across contexts• Intensifies useful subjective associations• Provides experiential learning• Defines people as active managers of themselves


Part 4:Global thinking, ambiguity


Global Cognitive Style as a Key Factor

When you can’t see the trees for the forest…


Examples of Global Style in Client Self-Reports

• “I just want to be happy”

• “I just want to feel normal”• “I am my depression” (anxiety, history,or

diagnosis)• “I’m just so overwhelmed”

• “I get so bad I just can’t think”

• “The symptom just happens to me”


“I always wanted to be someone. Now I think I should have been

more specific.”

Comedian Lily Tomlin


Examples of Global Therapeutic Truisms

• “Trust your guts” (inner sage, unconscious)• “Life is what happens to you when you had

other plans”• “Just let go…no need to try to control it”• “Be fully present in the moment”• “It’s a disease…it’s not your fault”• “Everyone is entitled to good self-esteem”


Global Thinking in the Symptom Context Virtually Precludes the

Ability to:

• Compartmentalize (e.g., contain anxiety)

• Think linearly, sequentially• Maintain good boundaries• Make key discriminations


“Overgenerality Bias” and the Global Cognitive Style in Depression

Depressed individuals suffer from an overgenerality bias in retrieving personal memories of past emotional experiences as well as in imagining possible future experiences. For instance, when asked to recall experiences of anger, depressed individuals tend to report overgeneral events (e.g., “When I am with my girlfriend”) rather than a specific event (e.g., “last Sunday, I had an argument with my neighbor whose dog was endlessly barking”). (p. 560)

Philippot et al., Emotion, Nov., 2006, Vol. 6, No. 4, 560-571.


A discrimination strategy is an ability to skillfully distinguish between two

or more available options in a specific context


Controllability as an ambiguous stimulus


Extreme Perceptions Regarding Controllability

Learned Helplessness: Learned expectations that one’s efforts will have no effect on the outcome

Illusion of control: Learned expectations that one’s efforts are the sole determinant of the outcome


Depressed and Anxious Individuals Tend to Underestimate Their Personal Power…

Thus, passivity seems like a reasonable response


Exercise in Assessing Controllability

Task: Attach a specific numerical percentage of perceived controllability to the following vignettes, ranging from zero (no control) to

100 (total control).


Ambiguity is a Risk Factor

• People strive to understand and make “meaning”

• Ambiguity raises, while certainty lowers, anxiety; projection as a coping device

• Cognitive distortions represent efforts to reduce, eliminate ambiguity

• A therapeutic goal is to learn to both RECOGNIZE and TOLERATE ambiguity


Hypnotically Tolerating Ambiguity

Key messages:•It’s natural to make up stories to explain things… but

you don’t have to believe them!•It’s okay, sometimes even desirable, not to know

•Some questions simply aren’t answerable


• Orient client to hypnosis• Induction process• Build a response set regarding uncertainty (“You don’t

know what I’m going to say…”)• Introduce the process of inference (“We all make guesses

about the meanings of things we observe or experience”)• Suggestions/metaphors regarding inferences (“When you

were told the classic stories, did you wonder what they meant?”)


• Introduce the value of knowing (“It can inspire confidence to know you made a good decision based on the facts”)

• Suggestions/metaphors regarding “knowing” (“I wanted to buy a car with really good gas mileage so I read studies comparing models…”)

• Introduce the value of not knowing (“There are some questions we cannot answer, fortunately…”)

• Suggestions/metaphors regarding “not knowing” (“When I began college and I didn’t know what I wanted to do with my life, it allowed me an openness…”)


• Reframing and reinforcing “not knowing” as desirable in some contexts; the merits of saying “I don’t know”

-Cues for identifying when “not knowing’ is desirable (e.g., there is no way to know)

• Post-hypnotic suggestions for integration (“So when you find yourself making an interpretation about the meaning of some event, you can remind yourself…”)

• Closure• Disengagement


I want to advance an awareness for the value of experiential learning in general, the value of

hypnosis in particular, and how focusing--using methods like mindfulness and hypnosis-- makes a difference, especially when applied in a multi-

dimensional framework


The greatest potential for prevention is in teaching people how to step

outside their own thinking


Prevention Opportunities

• Expanding diagnostic opportunities• Addressing sleep• Encouraging exercise• Working with couples and families• Screening for postpartum depression• Identifying children at risk• Teaching social and problem solving skills• Practicing foresight


An Excellent Review of the Current Depression Prevention Literature

• See “Major Depression Can be Prevented” by Ricardo Muñoz, William Beardslee, and Yan Leykin in the May-June, 2012, issue of American Psychologist (Vol. 67, No. 4, 285-295).

• Meta-analyses suggest that 22-38% of major depressive episodes could be prevented with currently available methods.


HIGHLY RECOMMENDED SELF-HELP RESOURCES

Depression is Contagious (Yapko)Breaking the Patterns of Depression(Yapko)Hand-Me-Down Blues (Yapko)Focusing on Feeling Good CD Program(Yapko)Calm Down! CD Program (Yapko)Learned Optimism (Seligman)Emotional Intelligence (Goleman)The Optimistic Child (Seligman)Feeling Good (Burns)


I’ll be providing a 3 day intermediate level hypnosis training (not for

beginners) in Nottingham in February

Please visit the ITC Consultancy website www.taking-control.co.uk

Or email [email protected] for details

I hope you’ll join me!

Please visit my website (www.yapko.com) to join my electronic mail list in order to

receive my newsletter


Thank you for coming!

Michael D. Yapko, Ph.D.

E-mail: [email protected]: www.yapko.com

Address: P.O. Box 487 Fallbrook, CA.

92088-0487USA

67copyright 2015 by Michael D. Yapko, Ph.D.

www.yapko.com

macscotland presents focusing on enhancing well-being: depression and health beyond the medical...

Documents

history depression

biology of depression

reframing depression

causes depression

social inequities

social rewards

social ones

social theories