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.
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.
Michael D. Yapko, PhD, is a clinical psychologist and marriage and family therapist. He's also the author of Treating Depression with Hypnosis, Hypnosis and Treating Depression, and Mindfulness and Hypnosis.
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Tags: antidepressant | anxiety and depression | clinical depression | coping with depression | curing depression | Depression & Grief | love | Michael Yapko | relationship | relationship issues | skills | trust