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Non-Directive Supportive Therapy (NDST) for Major Depression: Is It Effective? (2024 Review)

Depression, a common yet complex mental health disorder, has various treatment options, including psychotherapies like Non-Directive Supportive Therapy (NDST).

A recent meta-analysis sheds light on the effectiveness of NDST in treating depression, comparing it with control conditions and other therapies.


  • NDST has been identified as a moderately effective treatment for depression compared to control conditions.
  • The effectiveness of NDST is somewhat less than other psychotherapies, particularly when it is used as a control group in studies.
  • The smaller effect size of NDST in comparison to other therapies may be influenced by its frequent use as a control group in research, potentially skewing results.
  • Understanding the precise mechanisms of NDST’s effectiveness remains a challenge and an area for future research.

Source: Journal of Affective Disorders (2024)

What is Non-Directive Supportive Therapy (NDST)?

Non-Directive Supportive Therapy (NDST) is a psychological approach rooted in the principles of client-centered therapy.

It emphasizes creating a supportive and empathetic environment for clients, primarily focusing on their emotional needs.

Unlike more directive therapies, NDST allows clients to lead the conversation and explore their feelings without specific guidance or intervention from the therapist.

Origin & History of NDST

NDST has its roots in the humanistic approach to psychology, particularly in the client-centered therapy developed by Carl Rogers in the 1940s and 1950s.

Rogers’ approach was revolutionary in its emphasis on the client’s innate capacity for self-healing and growth, contrasting with the more directive and therapist-driven approaches of the time.

NDST evolved from these principles, focusing on the therapeutic relationship and the power of empathy, acceptance, and genuine human connection in fostering psychological well-being.

Mechanisms & Methods of NDST in Treating Depression

NDST operates on the principle that a supportive and understanding therapeutic relationship can foster emotional healing and personal growth.

Its key mechanisms and methods include:

  • Emotional Support: Providing a safe and non-judgmental space for clients to express and explore their emotions.
  • Empathy: The therapist offers deep understanding and empathy, validating the client’s experiences and feelings.
  • Active Listening: Therapists practice active listening, reflecting on what the client shares without directing the conversation.
  • Client-Centered Approach: The therapy is guided by the client’s needs, feelings, and personal experiences, rather than a predetermined therapeutic agenda.

Why research the efficacy of NDST in depression? (Rationale)

The exploration of NDST in the context of depression treatment arises from several considerations.

Humanistic Approach: Depression is a multifaceted disorder, often requiring a more holistic, person-centered treatment approach. NDST’s emphasis on individual experience and emotional support aligns well with the need for personalized care in depression treatment.

Therapeutic Relationship: There is a growing recognition of the therapeutic relationship as a critical factor in effective mental health treatment. NDST’s focus on building a strong, empathetic connection between therapist and client is seen as a vital component in treating depression.

Alternative to Directive Therapies: While therapies like CBT are effective, they may not suit everyone. NDST offers an alternative for individuals who might benefit from a less structured, more emotionally supportive approach.

Access & Flexibility: NDST’s non-directive nature makes it potentially more accessible and adaptable to various settings and populations, including those who might feel uncomfortable with more structured therapy forms.

Efficacy of NDST for Major Depression in Adults (2024 Review)

Cuijpers et al. evaluated the effectiveness of Non-Directive Supportive Therapy (NDST) in treating adult depression based on preexisting studies.

Specifically, researchers sought to:

  • Compare NDST’s effectiveness against control conditions and other psychological therapies.
  • Determine if NDST’s effectiveness varies when used as a control group versus a standalone therapy.


  • Meta-Analysis: A comprehensive meta-analysis was conducted using an existing database of randomized trials of psychological treatments for depression.
  • Data: Trials were identified through searches in PubMed, PsycINFO, Embase, and the Cochrane Library.
  • Selection: The focus was on randomized controlled trials comparing NDST with inactive control groups (e.g., waiting list, care-as-usual) or other psychotherapies.
  • Quality Assessment: Information on study characteristics, participant demographics, and therapy types was extracted. Risk of bias was assessed using a standardized tool.


  • Effectiveness Against Control Groups: NDST showed a moderate effect size (g = 0.53) when compared with control conditions, indicating its effectiveness in reducing depressive symptoms.
  • Comparison with Other Therapies: NDST was less effective than other therapies (effect size g = −0.21), with the differential being significant in studies where NDST was used as a control group.
  • Long-term Outcomes: NDST’s effects were sustained up to 6 months but reduced at 12-month follow-up.
  • Subgroup Analysis: NDST was particularly effective in specific target groups and showed no significant difference in effectiveness compared to other therapies when not used as a control group.
  • Response Rates: NDST had a response rate of 0.33 compared to 0.41 for other therapies, indicating lower but notable effectiveness.


  • Risk of Bias: Many included trials had considerable risk of bias, potentially affecting the reliability of results.
  • Heterogeneity and Generalizability: There was considerable heterogeneity among studies, and findings might not be generalizable across different demographic and clinical settings.
  • Small Number of Trials in Certain Comparisons: The number of trials comparing NDST with control conditions was limited, leading to uncertainty in effect size estimates.
  • Unclear Description of NDST in Trials: In many trials, the description of NDST was unclear, making it difficult to ascertain if it was implemented as intended.
  • Potential Publication Bias: The analyses suggested the possibility of publication bias, which might have influenced the study outcomes.

Details of the Review Findings: NDST for Adult Depression (2024)

The meta-analysis provided nuanced insights into the effectiveness of Non-Directive Supportive Therapy (NDST) for depression.

Effect Size

Comparative Effectiveness

  • Against Control Groups: NDST demonstrated a moderate effect size of g = 0.53. This suggests a substantial improvement in depressive symptoms compared to control conditions like waitlists or usual care.
  • Against Other Therapies: When compared to other psychotherapies, NDST showed a smaller effect size of g = -0.21. This indicates that while NDST is beneficial, it may not be as potent as therapies like CBT, IPT, or BAT.

Heterogeneity & Prediction Intervals

  • The I2 statistic (51% against control groups and 43% against other therapies) revealed moderate heterogeneity, suggesting variability in the study outcomes.
  • Prediction intervals ranged from −0.02 to 1.09 against control groups and from −0.55 to 0.13 against other therapies, indicating a wide range of potential effects in different settings.

Subgroup Analysis

Control vs. Non-Control Use of NDST

  • A significant finding was that NDST’s effectiveness was comparatively lower in studies where it was used as a control group. This suggests a potential bias in these studies, possibly due to NDST being designed as an “intent-to-fail” intervention.
  • When NDST was not used as a control group, the difference in effectiveness compared to other therapies was minimal (g = -0.05), indicating comparable efficacy.

Participant Characteristics

  • NDST showed particularly positive results in specific target groups (effect size g = 0.65), suggesting its suitability for certain populations.
  • The response to NDST did not significantly differ in studies based on the diagnostic criteria for depression (mood disorder diagnosis vs. cut-off based).

Response Rates & Relative Risks

Response Rates

  • NDST had a response rate of 33%, lower than the 41% for other therapies but higher than the 24% in control conditions.
  • This differential suggests that while NDST is effective, its impact might be less pronounced than more structured therapies.

Relative Risks (RR) & Number Needed to Treat (NNT)

  • NDST vs. Control: RR of 1.48 and an NNT of 8.7, indicating that NDST is considerably more effective than no treatment.
  • NDST vs. Other Therapies: RR of 0.79 and an NNT of -11.6, showing that while effective, NDST might not be as beneficial as other therapy options.

Long-term Outcomes

NDST’s effectiveness appeared to decrease over time, with a significant effect up to 6 months but a reduced impact at 12-month follow-up.

This points to the potential need for ongoing support or booster sessions in NDST treatment plans.

What are the potential implications of the findings? (NDST in depression)

The nuanced findings from the meta-analysis of Non-Directive Supportive Therapy (NDST) for depression have several implications.

  • Therapy Selection & Personalization: NDST’s effectiveness, particularly in non-control settings, supports its viability as a treatment option, especially for individuals who might not respond to or prefer more structured therapies like CBT. The varying effectiveness based on participant characteristics suggests that NDST could be particularly beneficial for certain subgroups, underscoring the need for personalized therapy approaches in clinical settings.
  • Integration in Treatment Plans: Given NDST’s moderate success and its decline in effectiveness over time, it could be strategically integrated into longer-term treatment plans, potentially in combination with other therapies or as an initial step in a stepped-care approach.
  • Training & Supervision: The findings highlight the importance of the therapeutic relationship in NDST, suggesting that therapist training should emphasize skills in empathy, active listening, and supportive counseling.
  • Further Investigation into NDST Mechanisms: The study prompts further research into the mechanisms behind NDST’s effectiveness, particularly how it functions differently when not used as a control intervention.
  • Longitudinal Studies: The reduced effectiveness of NDST at 12-month follow-up indicates a need for longitudinal studies to understand its long-term impact and the potential need for booster sessions or ongoing support.
  • Subgroup Analysis: Research should continue to identify which specific populations or subgroups of depression patients benefit most from NDST, facilitating more targeted therapy recommendations.

Comparison: Non-Directive Supportive Therapy (NDST) vs. Cognitive Behavioral Therapy (CBT) for Depression

Depression, a multifaceted mental health disorder, is often approached with various psychotherapeutic treatments – including NDST & CBT.

These therapies, while aiming to alleviate depression, differ significantly in their methods, mechanisms, and the extent of evidence supporting their effectiveness.

NDST: A Supportive Approach

NDST centers around providing a supportive, empathetic environment for individuals.

It does not utilize structured techniques or strategies to change thought patterns or behaviors. Instead, NDST focuses on:

  • Emotional Support: Therapists offer a non-judgmental space for clients to express feelings and experiences.
  • Empathy: Therapists empathize deeply with clients, validating their emotions and experiences.
  • Client-Centered: The therapy is guided by the client’s needs and pace, without imposing direction or goals.

CBT: A Structured Technique

CBT, on the other hand, is more structured and directive.

It involves identifying and modifying dysfunctional thought patterns and behaviors that contribute to depression. Key components include:

  • Cognitive Restructuring: Identifying and challenging negative thoughts and beliefs.
  • Behavioral Techniques: Engaging in activities that can improve mood and alter behavior patterns.
  • Skills Training: Teaching skills for problem-solving and coping with depression.

Efficacy in Treatment of Depression: CBT vs. NDST

When it comes to empirical evidence, CBT has a more substantial body of research supporting its effectiveness in treating depression.

Numerous studies and meta-analyses have consistently shown that CBT is effective in reducing symptoms of depression, with benefits lasting beyond the end of treatment.

CBT is often considered the gold standard of psychotherapy for depression.

In contrast, while NDST has been found to be effective, the volume and robustness of evidence are less extensive than for CBT.

NDST has been shown to be beneficial, particularly when compared to no treatment or usual care, but it tends to have smaller effect sizes when compared to more structured therapies like CBT.

Who Might Benefit from NDST Instead of CBT?

While CBT is broadly effective and backed by extensive research, NDST might be more suitable for certain individuals or situations:

  • Preference for a Less Structured Approach: Some individuals may feel overwhelmed by the structured nature of CBT and might prefer the more fluid, empathetic approach of NDST.
  • Building Therapeutic Relationship: Those who benefit from a strong therapeutic relationship may find NDST’s focus on empathy and support more conducive to their healing.
  • Resistance to Directive Therapies: Individuals who are resistant to the directive nature of CBT might respond better to the non-directive approach of NDST.
  • Cultural Considerations: NDST’s emphasis on empathy and support without imposing specific techniques might be more aligned with certain cultural backgrounds that prioritize relational connections.
  • Complementing Other Treatments: NDST can be an excellent adjunct to other forms of therapy, including CBT, especially for those who need additional emotional support.

Takeaway: NDST for Major Depression in Adults

The study on Non-Directive Supportive Therapy (NDST) for depression highlights its potential as an effective treatment, particularly for individuals with mild to moderate symptoms.

While NDST shows a significant impact compared to no treatment, its efficacy is somewhat less robust when pitted against more structured therapies like CBT.

The sustained improvements observed at a 6-month follow-up point to the lasting benefits of NDST, although a slight decrease in efficacy at the 12-month mark suggests the need for ongoing support.

The importance of the therapeutic alliance in NDST underscores the critical role of the therapist-client relationship in treatment success.

These findings open avenues for integrating NDST into a stepped-care model for depression and underscore the need for further research to optimize its long-term effectiveness and understand its impact on different subgroups.

Overall, NDST emerges as a valuable addition to the array of therapeutic options for treating depression, meriting consideration in both clinical practice and future research.


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