Which psychotherapy helps with depression — and why the name of the method tells you less than you think

“Can you just tell me straight which therapy is best for depression? Online it says cognitive behavioural. My friend went to a psychoanalyst and says he saved her life. And my sister says it’s all just talking.”

The question is completely reasonable. When depression has been holding you under water for months, you have no energy to try out five different approaches. You want to know where to go so that it will help. And online you find answers that seem to contradict each other: every school claims that its own is the right one.

In this post I will try to answer as honestly as I can. The answer from research is surprising — and for most people actually good news. Then I will say what really seems to matter when choosing, where the limits of psychotherapy lie, and where I stand in all this.

What the research shows

Psychotherapy for depression is one of the most thoroughly researched areas in all of psychology. Over the past twenty years, the Dutch researcher Pim Cuijpers and his colleagues have gathered and compared hundreds of randomised trials. In 2008 his group published a meta-analysis that directly compared seven common forms of psychotherapy for depression in adults: cognitive behavioural therapy, interpersonal therapy, psychodynamic therapy, behavioural activation, problem-solving therapy, non-directive supportive therapy and social skills training.

The finding was that they are very similar in their effects. The differences between them were small and mostly not significant — only supportive therapy proved somewhat less effective in places, and interpersonal therapy somewhat more. Five years later, a group led by Jürgen Barth carried out an even more detailed network meta-analysis of the same seven approaches and reached a similar conclusion: all were more effective than waiting for therapy, and they differed little from one another.

What does this mean for you? That there is no single “right” therapy for depression that you would miss by choosing another. There are several well-researched paths that lead to a similar place.

Four common paths

To make it clearer what lies behind the names, here is a short description of the four you are most likely to come across.

Cognitive behavioural therapy (CBT) works with the thoughts and behaviours that keep depression going. Together with the therapist you observe automatic thoughts such as “nothing I do works”, test how true they are, and gradually change your behaviour. It is structured, often with homework. You can find a short explanation in the knowledge base under cognitive behavioural therapy.

Interpersonal therapy starts from the observation that depression often begins or deepens with changes in relationships: loss, conflict, a change of role, loneliness. The therapy focuses on one or two such relationships and on how you can change them.

Psychodynamic therapy explores how early experiences and unconscious patterns shape how you experience things today. It is less structured and gives more time to what emerges in the conversation and in the relationship with the therapist.

Behavioural activation is the simplest of the four: a gradual return to activities that have meaning for you or bring satisfaction, whether or not you feel like doing them. I described it in more detail in Behavioural activation: how to move when there is no motivation, and the post Exercise and depression is related to it too.

Besides these four, you will come across others: mindfulness-based cognitive therapy, developed mainly to prevent relapse; systemic and family approaches that bring loved ones into the work; and integrative therapists who combine several schools. In Slovenia the choice is often more practical than theoretical: how long you will have to wait, whether you can afford the sessions, whether the therapist is close enough or also works online. These are perfectly legitimate criteria too.

Why they are so similar

When researchers first noticed that different therapies achieve similar outcomes, they borrowed a scene from Alice in Wonderland, where the Dodo announces after a race: “Everybody has won, and all must have prizes.” The American psychologist Saul Rosenzweig used this image as early as 1936. Since then the field has continued a debate that Bruce Wampold later described in detail: do therapies work because of their specific techniques, or because of what they have in common?

The answer is probably both, but the common factors matter more than you might think. Every good therapy offers a relationship in which you feel heard. It offers an explanation of why you are suffering that makes sense to you. It sets a goal you both agree on. And it offers something you do differently — in your thoughts, your behaviour or your relationships. The techniques are different languages in which these things are said.

This does not mean it doesn’t matter what the therapist does. But it does mean that for the outcome, how well a therapy suits you is often more important than what it is called.

The relationship you cannot skip

Of the common factors, the most researched is the therapeutic relationship — professionally often called the working alliance. In a 2018 meta-analysis of almost three hundred studies with more than 30,000 clients, Christoph Flückiger and colleagues showed that the quality of the relationship between therapist and client is reliably linked with the outcome of therapy. The link is not huge, but it is one of the most stable findings in psychotherapy research — and it holds regardless of the school.

With depression this is especially important. Depression often convinces a person that they are a burden to others, that no one understands them, or that nothing can help them anyway. A relationship in which someone accepts you as you are, and stays even when you have nothing to say, is in itself an experience that contradicts these beliefs. You can find a short explanation in the knowledge base under the therapeutic relationship.

So I suggest that after the first few sessions you ask yourself not only “is this the right method?”, but also “do I feel safe enough with this person to tell them even the things I’m ashamed of?”.

Psychotherapy and medication

I am often asked whether psychotherapy is “instead of” antidepressants. In mild depression, psychotherapy alone is often enough. In moderate and severe depression, however, research shows something different. In a large network meta-analysis in 2020, Cuijpers and colleagues found that combining psychotherapy and medication is more effective than either on its own. Medication can raise the floor enough for a person to be able to work in therapy at all; therapy offers tools and understanding that remain after treatment ends.

A study led by Steven Hollon (2005) showed that people with moderate to severe depression who had received cognitive therapy had fewer relapses after the end of treatment than those who stopped taking medication. This is one of the reasons psychotherapy also has an important place in preventing depression from returning. I wrote about why a recurrence is not a failure in When depression comes back: why a recurrence is not a failure.

Decisions about medication are always a matter for a doctor or psychiatrist. I explained in more detail how medication and therapy complement each other in Antidepressants and therapy are not rivals: what the research says about combining them.

Where I stand

It is only fair to say where I stand. I am a therapist in training under supervision in marriage and family therapy, and I am training in relational family therapy at the Franciscan Family Institute in Ljubljana. This approach, developed by Christian Gostečnik, looks at depression in the context of relationships — those a person grew up in and those they live in today. We are interested in how old emotional patterns repeat in present relationships and how they can begin to change within a safe relationship.

I will not claim that my approach is better than others. The research I have described does not support that for any school. Relational family therapy is less researched than CBT or interpersonal therapy, but its idea fits well with what we know about depression: that it is often born in relationships and that it also finds its way out through them. When depression affects a partnership or a family, it can be useful to involve loved ones too — this is the subject of Depression in a relationship: what happens to the couple, and what you can do.

And because I am in training, I work under regular supervision. This means that I discuss my work, of course without personal details, with a more experienced therapist who helps me see what I might otherwise miss.

What a first session can sound like

People are often afraid that in the first session they will have to tell everything or that they will immediately be given a “diagnosis”. Usually it is different. This is how the beginning might sound (a composite, not a real person):

“I don’t know if I’m in the right place. Maybe I’m just exaggerating.”
“Tell me what brought you here right now.”
“For a few months I haven’t been able to get up in the morning without a struggle. At home I try not to let anyone notice.”
“You try hard so that no one notices. That sounds exhausting.”
“It is. I think I’m more tired from hiding than from anything else.”
“Then here, to begin with, you can stop hiding. And we’ll look at what’s underneath.”

The first sessions are for getting to know each other, for the therapist to understand what brought you, and for agreeing together on what you will work on. In the profession this is called the therapeutic goal. If after a few sessions you don’t feel you are moving anywhere, it is completely fine to say so.

Exercise: prepare for your first session

If you are thinking about therapy but don’t know where to start, a short preparation can help. It takes fifteen minutes.

1. Write down when you noticed that things were no longer right. It doesn’t have to be precise. “Sometime since spring” is enough.
2. List three things you can no longer do the way you used to. Getting up, work, seeing people, enjoying something. This will make it easier to describe to the therapist how things are, even if you are tired or embarrassed in the session.
3. Write down what you have already tried. What helped at least a little, what didn’t. That is valuable information too.
4. Choose one or two questions from the list above to ask in your first session.
5. After the session, write one sentence: how you felt with this person. Don’t rate the method, rate the feeling. After three sessions, read all three sentences together.

Where psychotherapy is not enough

It would be dishonest of me to claim that psychotherapy helps everyone, always. Research shows that even with the best approaches, quite a few people do not reach full recovery. This is not a sign that they are “incurable”, but that they need something different or something more.

Severe depression needs a doctor. When a person cannot get up, is not eating, not sleeping or is thinking about death, therapy alone is not enough. The first step is the family doctor, who can refer you to a psychiatrist. A psychotherapist is not a substitute for a psychiatric assessment.

Some conditions need specific treatment. If periods of depression alternate with periods of unusually elevated mood, or if perceptions and beliefs appear that others do not share, this needs to be assessed by a psychiatrist, as the treatment is different.

Sometimes it is not the wrong method but the wrong moment. Someone in the middle of a severe crisis sometimes first needs stabilisation, sleep and safety, and only then deeper work.

Sometimes it is not the right therapist. That is not a failure, neither yours nor theirs. Changing therapist is a legitimate decision, and a good therapist will support it.

If you are having thoughts that it would be better if you weren’t here, don’t wait for a free slot with a therapist. In Slovenia, call the crisis line Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am) or the Samaritans helpline on 116 123 (24 hours a day). In an emergency, call 112.

And one more thing: depression is not just intense sadness that needs to be “worked through”. I described the difference in Depression is not sadness: how to tell them apart and why it matters, and you can find a short explanation of the term in the knowledge base under depression.

What to remember

• Research by Pim Cuijpers and others shows that different forms of psychotherapy for depression are very similar in their effects.
• A large part of the effect is explained by common factors: the relationship, an explanation that makes sense and an agreed goal.
• The therapeutic relationship is one of the most stable predictors of success — ask yourself whether you feel safe with your therapist.
• In moderate and severe depression, combining therapy with medication is often more effective than either alone.
• Psychotherapy is not a substitute for seeing a doctor or psychiatrist when depression is severe.