How 3 Forms of Therapy Understand and Treat Depression
Therapists take different approaches based on the theories guiding their work.
Posted January 10, 2023 | Reviewed by Ekua Hagan
- For Freud, depression is grief gone wrong, where a person internalizes aspects of those who've hurt them.
- Attachment based therapy sees depression as a byproduct of problematic ways of relating.
- According to CBT, depresssion is caused by destructive automatic thoughts.
Since so many competing forms of therapy are currently available, patients seeking treatment may not always know the differences in approach among them, or even how each school of thought understands their problem. For instance, when it comes to a common condition like depression, many treatments claim to help, but how they aim to do so varies widely.
Before deciding which kind of therapist to choose, it can be helpful to consider a few basic assumptions: What does this therapist believe depression is, and how does it originate? What causes depression to continue, and how does this therapy plan offer relief?
Psychoanalysis and Psychodynamic Therapy
Sigmund Freud invented psychoanalysis and introduced the concept of talk therapy, which characterizes all the modes of therapy discussed here. For many, psychotherapy still means Freudian analysis, though in fact, both the theory and practice have evolved extensively.
What underlies all psychodynamic therapy, and distinguishes it from other therapies, is the belief in an unconscious—that much of what influences our behavior and emotional life lies outside of our awareness. Since our unconscious fears and wishes inevitably play out in the therapeutic relationship, it becomes a place for recognizing hidden parts of ourselves, as well as implicit expectations and patterns of relating. That relationship also serves to provide new and healing relational experiences: for instance, being listened to with understanding or being able to air shameful or angry thoughts without reprisal.
Since time is required for this unique relationship to develop and take effect, treatments tend to be longer and less targeted than in CBT, for instance. Space is allotted for a more improvisational exploration of our less rational selves—through discussions of memories, dreams, dissociated (unrecognized) thoughts, feelings, and fantasies. Though not especially suited to evidence-based analysis, studies have proven the efficacy of psychodynamic work. 
So what does psychodynamic therapy have to say about depression?
For Freud, depression is a kind of grief gone wrong—where the loss of someone we both love and hate inspires us to take in their negative aspects in order to hold onto them. Put another way, we can think of depression as the negative voices or qualities of important figures—parents, siblings, etc.—internalized as our own beliefs about ourselves. Rather than be angry at a parent that makes us feel terrible, we accept that we’re terrible, so we can go on loving them; or, rather than blame the parent for being depressed, we blame ourselves for their pain and become depressed too. These early patterns create low self-esteem and cause us, throughout our lives, to attack ourselves unjustly even for others’ faults and cruelty.
For psychodynamic therapists, depression isn’t a condition that can be treated through deliberate changes in habit, as in CBT, because they believe the drivers of our behavior aren’t subject to rational access or control. For instance, there are forces that resist change that must be addressed. Only close and ongoing work with a therapist can create the kind of supportive and dynamic environment that makes change possible and lets depressed patients grieve their pains and losses, and move on.
Cognitive Behavioral Therapy
CBT emerged out of the work of Allen Beck, himself a trained psychoanalyst, who grew frustrated with Freud and wanted to create a more goal-oriented and evidence-based approach to treatment. CBT combines cognitive and behavior therapy into a structured approach that has become very popular, especially for those seeking treatment that is cost-effective and has relatively immediate and measurable results. Treatments usually range from 5-20 weeks and, since this form of therapy is suited to empirical testing, studies have shown its efficacy. 
CBT is based on the idea that destructive thinking lies at the heart of dysfunction and that we can become healthier by identifying and correcting our faulty core beliefs, as well as the day-to-day automatic thoughts that lead to our problematic behaviors. At the root of this idea is a faith in the power of conscious introspection—that we can learn to identify and change our own thinking. Unlike psychodynamic therapy, CBT isn’t so concerned with blind spots or resistance to change, nor does it emphasize the therapeutic relationship as a space of discovery and healing. The role of the CBT practitioner is to introduce transferable skills that can, in effect, make us our own therapists—so that treatment can be shorter. As part of this process, patients engage in exercises and homework—such as goal setting and identifying cognitive distortions—so as to learn to create new habits on their own.
So what does CBT have to say about depression?
CBT originated as a treatment for depression and shares with psychoanalysis the belief that distorted and negative ideas about ourselves contribute to depression. A clinician will likely take a family history, but CBT doesn’t focus on the causes of depression or past relationships, but rather on present circumstances and the self-attacking or hopeless thoughts that maintain a depressive attitude in the here and now. A cognitive behavioral therapist will likely ask a depressed patient to identify such automatic thoughts—I’m unlikable, I never get anywhere—and find replacement thoughts that will ultimately change the patient’s feeling about the situation and himself.
Depression Essential Reads
Attachment-based therapy is a treatment developed out of the theories of John Bowlby, who worked with children separated from their families during WW II. Bowlby’s central belief was that happiness and health are rooted in secure attachments to loving and reliable caretakers and that psychiatric difficulties in adults can be traced back to disruptions in early attachment.
Attachment theory organizes relational patterns into four categories: secure, avoidant, anxious (preoccupied), and disorganized. In contrast to CBT, which places less emphasis on childhood history, ABT prioritizes an exploration of early relational experiences and traumas in order to understand the coping strategies that, once necessary, are now causing difficulties and distress in current relationships and functioning.
Like psychodynamic therapy, ABT also emphasizes the importance of the connection with the therapist. It is only through the safe, empathic, and insightful presence of the therapist that the patient is able to establish the trust in human connection required to repair old trauma and become self-regulated, reflective, and find relief from symptoms. ABT is empirically supported, though with less evidence than exists for some other types of therapy. 
So what does attachment-based therapy have to say about depression?
ABT understands depression as the effect of insecure attachment and will focus on the ways of relating that contribute to a depressed mood. For instance, a depressed patient might be withdrawn or isolated, thus displaying an avoidant attachment style, or a patient with an anxious attachment style might demonstrate low self-esteem, an excessive need for approval, and difficulty regulating negative emotions, all of which manifest as depression. In this view, treatment is a matter of reestablishing trust in human connections and a more secure attachment style.
As neat as these classifications and distinctions appear here, the fact is that no two therapists practice exactly the same way, and many offer unique integrations of approaches, as influenced by their own personalities. In the end, choosing a therapist is a very personal process, but having some knowledge of the theories guiding their work can help you make an informed decision about whether they’re the right fit for you.
To find a therapist, please visit the Psychology Today Therapy Directory.
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109.
 Hofmann, SG, Asnaani, A, Vonk, IJ, et al, (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognit Ther Res, 36(5),427-440.
Diamond, G. S., Wintersteen, M. B., Brown, G. K., Diamond, G. M., Gallop, R., Shelef, K. et al. (2010). Attachment-based family therapy for adolescents with suicidal ideation: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 49(2), 122–131. doi:10.1016/j.jaac.2009.11.002.