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  • Neel Burton, MD

Psychological Treatments for Depression

Which type of talking treatment is right for you?


Key points

  • Psychological treatments for depression are safe and effective.

  • These talking treatments should be first-in-line in the management of depression.

  • The right talking treatment for a given individual depends on a number of factors.

Depression is, to varying degrees, self-remitting, but formal interventions can help to speed things up and ensure a more complete and durable recovery—and, in the meanwhile, help to keep you safe. Psychological interventions ought to be first in line in the management of depression. Very often, they offer a safer, more effective, more empowering, more individualized, and more dignified alternative to antidepressant medication.

Many people with depression prefer these “talking treatments” on the grounds that they seek to address underlying problems, rather than merely masking superficial symptoms or providing a crutch. Of course, psychological treatments and antidepressant medication are not mutually exclusive, and in some cases, as with depressive psychosis, drugs can be an essential part of recovery.

The type of talking treatment that is chosen, if any, depends on your symptoms and their origins, on your personal preferences, and, all too often, regrettably, on the available funding and human resources. If you are struggling to find a therapist or have to wait to access one, there are a growing number of apps out there that offer some of the benefits of therapy.

Supportive therapy and counseling

At its most basic, psychological treatment involves simple explanation, reassurance, and encouragement. In milder cases of depression, such “supportive therapy” is often the only intervention that is either necessary or appropriate. Counseling is similar to supportive therapy in that it involves explanation, reassurance, and encouragement. But counseling also aims at addressing life problems and is more goal-oriented than supportive therapy.

Psychodynamic psychotherapy

Exploratory psychotherapy, as the name suggests, aims to delve more deeply into your thoughts and feelings. Two important yet very different forms of exploratory psychotherapy are psychodynamic psychotherapy and cognitive behavioral therapy (CBT). Psychodynamic psychotherapy is built on the psychoanalytic theories pioneered by Sigmund Freud and others. It is similar to traditional psychoanalysis but brief (a few months rather than several years) and less intensive (once a week rather than twice or thrice).

Like psychoanalysis, psychodynamic psychotherapy aims at bringing unconscious feelings out into the open, where they can be acknowledged, experienced, and understood and thereby “dealt with.” Unlike CBT (see below), which is based on learning and cognitive theories, psychodynamic psychotherapy normally involves careful consideration of your personal history and can be particularly helpful if your problems appear to be rooted in your distant or not-so-distant past.

Cognitive-behavioral therapy (CBT)

Developed by psychiatrist Aaron Beck in the 1960s, CBT has become a mainstream treatment for non-severe depression and a number of other mental disorders. In the short term, it is at least as effective as an antidepressant treatment, and in the longer term may be more effective at preventing relapses. CBT is most often carried out on a one-to-one basis but can also be offered in small groups or online. It involves a defined number of sessions, typically between 10 and 20, although much of your progress occurs outside of sessions through “homework.” You and a trained therapist (who may be a doctor, psychologist, nurse, or counselor) develop a shared perspective on your current problems and try to understand them in terms of your thoughts (cognitions), emotions, and behaviors and how these relate to one another. This leads to the identification of realistic, time-limited goals and of cognitive and behavioral strategies for achieving them.

In depression, the main focus of CBT is usually on modifying automatic and self-perpetuating negative thoughts. These cognitive biases or “thinking errors” are considered hypotheses, which, through gentle questioning and guided discovery, can be examined, tested, and modified. Behavioral tasks might include self-monitoring, activity scheduling, graded task assignments, and assertiveness training. CBT has garnered a great deal of institutional support on the basis that it is both cheap and effective. But critics question the robustness of the research into CBT for depression and claim that it is, in fact, no more effective than other forms of talking treatment. A more profound criticism of CBT is that, by leaning so heavily on patterns of cognition, it may be mistaking the symptoms of depression for its causes while pretending that depression has little or nothing to do with real-life issues. More introspective or philosophical people can experience this rather superficial, mechanical approach as frustrating and alienating—helping to account for the high drop-out rates from CBT for depression.

Mindfulness

Some of the concerns with traditional CBT are addressed by mindfulness-based cognitive therapy (MBCT), which combines traditional CBT methods with “newer” psychological strategies, such as mindfulness and mindfulness meditation. In essence, mindfulness, which derives from Buddhist spiritual practice, aims at increasing our awareness and acceptance of incoming thoughts and feelings, and so the flexibility and fluidity of our responses, which become less like unconscious reactions and more like conscious reflections.

Mindfulness can be channeled for the treatment of recurrent depression, stress, anxiety, and addiction, among others, but it can also be used more broadly to improve our quality of life by decentring us and shifting our focus from doing to being.

Family therapy and interpersonal therapy

Family therapy involves the identification and resolution of negative aspects of couple or family dynamics that may be contributing to depression, for example, deep-seated conflict, misunderstanding, or avoidance. It usually calls upon the direct participation, and so the commitment, of each of the major actors.

Another talking treatment used in depression is interpersonal therapy (IPT), which involves a systematic and standardized treatment approach to personal relationships and life problems contributing to depression.

If you feel that your personal relationships are contributing to your distress, then you might consider the possibility of counseling, family therapy, or IPT.


Neel Burton, MD, Website, Book

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