Hypnosis and Treating Depression

Applications in Clinical Practice

Michael D. Yapko

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135442316
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Michael Yapko's seminal 1992 book, Hypnosis and the Treatment of Depressions, was the first book ever written on the subject of applying hypnosis in the treatment of depressed individuals. Since its publication, Yapko's work has not only withstood the test of colleagues previously dismissive of the merits of hypnosis as a tool of treatment, but has thrived in the face of it.

Hypnosis and Treating Depression diversifies the range of topics to consider and increases the number of knowledgeable contributors on the subject of treating depression with hypnosis. The book features chapter contributions by highly experienced and well-known experts on using hypnosis to treat specific forms of depression, with assessment and intervention strategies as well as sample transcripts of the use of hypnosis in therapy sessions. It discusses both broad and targeted applications of hypnosis in treatment, the treatment of depression with hypnosis in special populations, as well as special considerations regarding hypnotic treatment. As a practical guidebook for clinicians looking to add to their treatment protocols, Hypnosis and Treating Depression: Applications in Clinical Practice provides an updated and comprehensive volume on therapeutic uses of hypnosis in the treatment of depression.

Section III

TREATING DEPRESSION WITH HYPNOSIS IN SPECIAL POPULATIONS

8

Using Hypnosis and Metaphor in the Treatment of Comorbid Depression and Eating Disorders

NORMA BARRETTA
AND PHILIP F. BARRETTA

OVERVIEW

Disruptions in normal eating habits have a long and even celebrated history. The Egyptians endured long periods of fasting, often in “sleep temples.” The Romans had vomitoriums, places to purge themselves in order to accommodate their gluttonous feasting. Christ fasted for 40 days in the desert for a “spiritual cleansing” of sorts, and many early Christian martyrs engaged in fasting for similar reasons. Gandhi changed the political structure of his country by fasting, using his refusal of food as a means of reining in extremists and building a consensus.

Relatively few people engage in such extreme behaviors in regard to their eating habits. As with any behavior deemed extreme, eventually such behaviors came to be considered evidence of a psychological disorder, particularly when they either became life-threatening or interfered with the person’s ability to function. There are a number of eating disorders included in the DSM-IV-R (American Psychiatric Association [APA], 1999). Most common among these are anorexia nervosa and bulimia, two serious disorders featuring dangerous self-starvation in the former and repetitive patterns of bingeing and purging in the latter. The two disorders may merge in a disorder called bulimia nervosa that features bingeing and purging behavior followed by periods of self-starvation (Bulik, Sullivan, & Fear, 1997).

Epidemiological evidence shows that the incidence of both depression and bulimia is on the rise (Kendler et al., 1991; Maser, Weise, & Gwirtsman, 1995). Currently, approximately 20 to 23 million Americans are thought to suffer from major depression, and these numbers are expected to continue to rise (Gardner, 2004; World Health Organization, 2002). Similarly, there had already been a significant increase documented in the reported incidence of bulimia from 1988 to 2000 (Hay, 2005). Although these disorders can occur independently of each other, there is a high incidence of comorbidity between eating disorders and major depressive disorder (Kuehnel, 1998). The co-occurrence of depression and eating disorders is not precisely known, but there have been estimates ranging from 36 to 68% of eating disordered patients also suffering comorbid depression (Maser et al., 1995). The relationship between depression and eating disorders is a strong one, and often the treatment of one will necessitate treating the other as well.

In this chapter, we will explore the relationship between depression, suicidality, and eating disorders. We will describe a conceptual framework for treating such patients, and we will especially emphasize the potential role hypnosis can play in the treatment process. We will describe some of the ways a hypnotic framework for understanding the mechanisms of eating disorders can be helpful in formulating interventions, and we will provide an illustrative case example.

HYPNOSIS AND TREATING COMORBID DEPRESSION AND EATING DISORDERS: A RATIONALE

Working hypnotically with depressed patients who are also experiencing eating disorders would, on first consideration, certainly seems to be appropriate and potentially useful. After all, one could reasonably argue that hypnosis, depression, and anorexia and/or bulimia all involve a common denominator of some form of altered state. All require some degree of focus and an absorption in a frame of mind that includes some awarenesses and excludes others. In fact, some hypnosis experts have made the distinction between therapeutic hypnosis and symptomatic hypnosis, suggesting that the direction of focus may differ between therapeutic and symptomatic conditions, but not necessarily the quality of the focus (Araoz, 1985, Gilligan, 1987). As Yapko (2003) described, the so-called classical hypnotic phenomena are the “building blocks” of experience, whether positive or negative. Thus, it has seemed logical to us to consider how hypnosis has played a role in the onset of these comorbid conditions and, more important, how we can sensibly use hypnosis to help the comorbid patient overcome his or her difficulties. The issue in treatment, as we see it, is how to eliminate the self-injurious patterns by initiating a very different and positively focused altered state with a definitive shift in the resulting behavior.

Arriving at this rationale for employing a hypnotic framework for problem conceptualization and treatment has been a circuitous path. After all, in our training as clinicians, we were encouraged to help people with creative applications of hypnosis, but we were also instructed not to challenge established protocols. This represented a “double bind” of sorts for us, in other words, seemingly a “no-win” situation in which a person must choose between equally unsatisfactory alternatives.

Patients come to us for treatment with any number of complex, psychological roadblocks that often result from double-binds they face. But, what if it is the therapist, rather than the patient, who is caught up in such a dilemma? How should a therapist proceed when hoping to employ a therapeutic strategy that is both encouraged and admonished by the scientific community of fellow researchers and clinicians? We have faced this dilemma many times, and later in this chapter we present one such episode involving a case requiring innovation in methodology. Julia (not her real name) was referred for treatment because she was severely depressed, threatening suicide, and suffering from a severe case of bulimia nervosa. She regularly engaged in bingeing and purging, a pattern that was interrupted every few months by a week or more of stringent fasting and drinking only water.

To work hypnotically with Julia, or not? The literature on the use of hypnosis with depressed individuals has ranged from warning therapists to “never” hypnotize a depressed individual, to the opposite position, which promotes hypnosis as an integral part of depression’s treatment. With suicidal patients in particular, hypnosis has traditionally been considered “forbidden.” We were told directly and unambiguously from an acknowledged authority in hypnosis, Dr. William Kroger (personal communications, December 1976 and January 1977), that we should “NEVER hypnotize someone who is suicidal.” (The issues associated with employing hypnosis in the treatment of depression will be described more fully in the next section.) On the other hand, for the treatment of eating disorders, hypnosis has generally been considered an effective and useful tool (Barabasz & Watkins, 2005; Lynn, Rhue, Kvaal, & Mare, 1993; Nash & Baker, 1993). Clearly, when someone is depressed and suicidal, and suffers a comorbid eating disorder, the confusing messages about what constitutes reasonable interventions can make treatment planning more difficult. We hope to provide clinical experience as well recent literature citations that can help the reader to resolve conflicting viewpoints and comfortably integrate hypnosis into the treatments of such patients.

HYPNOSIS IN THE TREATMENT OF DEPRESSION

Depression is a complex, multidimensional disorder that affects tens of millions of Americans, directly or indirectly (Kessler et al., 2003). Worldwide, it is considered one of the leading causes of human disability (World Health Organization, 2002). Inarguably, depression is a serious disorder that requires effective treatment. Can hypnosis be a viable component of effective treatment?

Past Perspectives Delayed Evolving More Realistic Perspectives

In the past, hypnosis was viewed as a contraindicated treatment for depression for a variety of reasons: Some thought that hypnosis with depressed patients might further erode their already inadequate defenses, thereby increasing the potential for suicide (Burrows, 1980). Some claimed that hypnosis was, at best, merely a method of symptom substitution and that the substituted symptoms may worsen depression (Crasilneck & Hall, 1985). Herbert and David Spiegel (1978) claimed hypnosis was likely to be harmful simply because it was unlikely to be effective with depressed clients. They were presumed to be unhypnotizable. The Spiegels suggested that clients suffering from depression cannot attend to input signals because they may be so narcissistically withdrawn and deficient of energy. André Weitzenhoffer, the co-creator of the Stanford Hypnotic Susceptibility Scales, also generally advised against the use of hypnosis with more severely depressed patients. He did, however, state that hypnosis may be useful when treating milder depressive neurosis (Weitzenhoffer, 2000), a diagnostic terminology no longer in use. Burrows (1980) and Watkins (1987) also concluded that hypnosis is not a suitable treatment for depression. Their psychoanalytic framework addresses the most destructive intrapsychic aspects of depression, such as anger and/or guilt. They believe that because the techniques of hypnosis move faster than regular psychotherapy into transference situations, hypnosis may be dangerous for a depressed patient with deeply repressed anger. They fear that such patients may become overreactive to the words or actions of the therapist as the new transference representation, thus resulting in the desire to punish the therapist for an imagined lack of care (Burrows, 1980). The anger, if turned inward as was presumed to be the case in the psychodynamics of depression, might then result in suicide. Finally, it was also believed that by employing hypnosis, there might be an overwhelming amplification of emotions that might lead to serious psychosomatic disorders or even death (Milechnin, 1967).

With direct threats of suicidality, ego fragmentation, emotional overload, and even death considered possible if hypnosis was employed with depressed patients, it is no wonder that this topic is so terribly underdeveloped in the literature (Yapko, 1992, 2001b). The older literature is full of anecdotal accounts of bad outcomes using hypnosis for depression, but meaningful controlled research is virtually absent.

In considering the underdeveloped role of hypnosis in the treatment of depression, it is useful to understand what researchers have found to be so dangerous about it, as described above. We agree with Yapko’s statement (1992), made in response to the fear-mongering of others:

It is my contention that virtually every hazard associated with hypnosis, not only in the treatment of depression, but in the treatment of any disorder, is a function not of hypnosis itself, but of the manner in which it is applied. (p. 20)

Over time, as depression was seen less as a psychodynamically motivated phenomenon and more as an outgrowth of multiple risk factors interacting with environmental conditions, views on the use of hypnosis for depression also changed. Many highly respected teachers and clinicians (such as those whose work is included in this text) have recently come to believe that hypnosis is a highly efficient therapeutic tool that can be used in addressing underlying dynamic issues, social and psychological risk factors, as well as the resultant symptoms of depression. Previous beliefs are continuously being dispelled as more insights about and cases of successful applications of hypnosis in treating depression accumulate.

Hypnotic Approaches to Treatment

It is important to note that hypnosis is not generally regarded as a therapy in itself, but as a valuable therapeutic tool to be used in conjunction with other established therapies (APA, Division of Psychological Hypnosis, 1999, pp. 4–5). Yapko (2001a) advocates not for hypnosis to resolve depression in a global sense, but rather for it to address specific patterns and risk factors known to exacerbate depression. Along these lines, several hypnotic approaches have been used successfully in the treatment of depression. Age regression and age progression have been employed in the treatment of psychotic and neurotic depression, embedded within hypnoanalytic methodology. This technique orients the patient to the future rather than the past in terms of a guided or directed fantasy of a future event (Sexton & Maddock, 1979). Because of the already existent ego suspension in the psychotic state and the reduced observing ego, age regression and age progression can be carried out without the necessity of formal hypnosis or trance induction, thus allowing for more expression of the experiencing ego (Sexton & Maddock, 1979).

Some have used cognitive therapy in conjunction with other behavioral techniques including hypnosis to allow for more flexibility and utility in counseling and psychotherapy (Gilliland & James, 1983). Hypnosis is a kind of social interaction in which various changes in experience and behavior are suggested, and it provides a context in which the effects of cognitive-behavioral interventions can be potentiated for some clients (Kirsch, 1993). For example, the hypnotic context permits the therapist to repeat statements over and over that would ordinarily seem strange outside of the hypnotic context (Kirsch, 1993). The innovative psychiatrist, Milton Erickson, described an approach to removing depressive symptoms in which he would restructure pessimistic and dysfunctional cognitions by the suggested generation of a physical symptom and then a post-hypnotic suggestion that it would subside (Haley, 1973). This was done with the hope that symptom reduction would be generalized to the experience of depression (Alexander, 1982). A more straightforward approach involves the therapist suggesting that the patient visualize a more preferable way to live. While affirming the positive potentials, the therapist can also challenge the legitimacy of the patient’s negative self-concepts and offer encouragement that his or her pessimistic life views will be replaced with more positive ones (Deltito & Baer, 1986). Finally, anxiety is often found as a comorbid condition in depressed persons (see Chapter 4 in this volume, by Steve Lynn, Abigail Matthews, Steven Fraioli, Judith Rhue, and David Mellinger, for more on comorbid depression and anxiety), and hypnosis can be useful as a relaxation tool to help better manage anxiety. It has been found that exposure to relaxation techniques frequently decreases both anxiety and depression symptoms in these comorbid patients (Rachman, Hodgson, & Marks, 1971). The approaches above have been relatively weak applications of hypnosis yet have still generated meaningful results. However, there are even better reasons and more effective ways to use hypnosis.

Yapko (1993) identified several compelling reasons for using hypnosis in the treatment of depressed patients: (a) hypnosis makes active and experiential learning possible, (b) hypnosis brings about faster integration of germane learning, (c) hypnosis establishes therapeutic associations in a more concerted manner, (d) hypnosis disrupts one’s habitual experience of oneself that augments developing an unstable attributional style, and (e) hypnosis models flexibility by inspiring experiences beyond one’s usual constraints. Depression is highly treatable, and with the integration of hypnosis into the therapy process aimed at salient targets (i.e., risk factors and symptom patterns), there is a high chance of recovery as well as a reduced rate of relapses (Yapko, 1993, 2001b).

Hypnosis and Suicidal Patients

Suicidality has been a major factor contributing to the fear of using hypnosis for depression and other related disorders. As mentioned above, it was believed that hypnosis somehow strips the client of defenses, leading to an increased potential for suicide (Yapko, 1992). This line of thinking is similar to previous erroneous beliefs that a direct discussion of suicide would be heard by the depressed patient as a suggestion to carry it out. This myth has been dispelled by recent and substantial evidence that talking about suicide does not encourage...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Foreword
• About the Editor
• Contributors
• Acknowledgments
• A Poetic Beginning
• Introduction
• Section I Broad Applications of Hypnosis in Treatment
• Section II Targeted Applications of Hypnosis in Treatment
• Section III Treating Depression with Hypnosis in Special Populations
• Section IV Special Considerations Regarding Hypnotic Treatment
• Appendix: Websites of Note
• Name Index
• Subject Index