CBT Effective for Mental Health, But Not for All

Imagine seeking help for anxiety, only to find that your treatment makes you feel worse. This is a concern for some people who undergo cognitive behavioural therapy (CBT).

CBT is one of the most revolutionary approaches to treating mental health problems. It is a widely used and effective treatment for many mental health conditions, including anxiety and stress-related disorders.

For many patients, the therapy leads to significant improvements in mental health. But evidence also suggests it may worsen some patients' symptoms.

CBT focuses on changing negative thought patterns and behaviours. This is done by helping patients identify and challenge distorted or unhelpful thoughts and beliefs, replacing them with more realistic and positive ones.

Additionally, CBT involves practising new behaviours and coping strategies in real-life situations to reinforce positive change and reduce symptoms of anxiety, depression, or other mental health issues.

In England and Wales, medical guidelines from the government's National Institute for Health and Care Excellence recommend CBT for a wide range of psychological and long-term physical conditions, from anxiety and depression to chronic pain, irritable bowel syndrome, and tinnitus (ringing in the ears).

This wide range of uses makes it seem like CBT could fix just about anything. As a clinical psychologist using CBT with my patients, I can attest to its efficacy. But I've also seen that it doesn't work for everyone.

So, why and when might this happen?

Expertise is everything

CBT is a structured therapy that relies heavily on the expertise of the therapist to guide the patient through the process. If the therapist lacks experience or is not well matched with the patient, the therapy may not be as effective. Worse still, it could lead to misunderstandings and frustration, potentially exacerbating the patient's condition.

There is an important difference, though, between negative or unwanted effects caused by poorly delivered therapy on the one hand, and side-effects, which can occur even when therapy is done correctly, on the other.

For instance, a 2018 study found that 100 CBT therapists reported 372 unwanted effects in 98 patients, and side-effects in 43 patients. In the case of unwanted effects, inadequate practice of CBT might lead to no improvement or even psychological harm.

For some therapists, recognising that their work might have negative consequences for their patients might be difficult to accept. This may lead to hesitancy in acknowledging when it happens, potentially attributing the fault to the patient instead. But, even in cases when CBT is conducted correctly, side-effects such as worsening of symptoms and increased distress are sometimes reported by both patients and therapists.

One possible reason is that CBT requires patients to confront their negative thoughts and feelings head on. This can be challenging and, in some cases, overwhelming. Consider people who have experienced complex trauma, for example. Simply modifying thought patterns does not tackle the deep-seated emotional pain and relational issues that underpin their symptoms, which are often rooted in early childhood.

In fact, some CBT strategies, such as exposure therapy through imagery - recalling painful thoughts in a controlled manner to lessen their present impact - can occasionally magnify these symptoms.

Also, some patients report that CBT can feel invalidating. The therapy's focus on rational thinking and evidence based beliefs can seem to dismiss their emotions.

For example, among people who are grieving or experiencing life-changing trauma, a critique of CBT by some patients is that it may mislabel the distress caused by traumatic events as "maladaptive". This refers to behaviour or emotional responses that are counterproductive to coping effectively with stress or trauma.

They can potentially diminish the legitimacy of patients' emotional reactions. In such cases, other approaches, such as acceptance and commitment therapy (ACT), might be more appropriate.

ACT, a type of talking therapy, focuses on accepting difficult emotions rather than challenging them, emphasising mindfulness and committed action in line with personal values. Mindfulness techniques, often used in ACT and other therapies, help patients observe and accept their thoughts and feelings without judgment, fostering a sense of calm and presence.

Not suitable for everyone

The cognitive aspect of CBT has faced further criticism, especially regarding its potential to induce rumination. This tendency to overthink painful past events is a known feature of depression, and focusing intensively on why one's thinking might be maladaptive could exacerbate this issue.

Research suggests that CBT may, in some cases, intensify worries and low mood by promoting rumination, particularly in people with obsessive traits.

CBT interventions generally require robust cognitive resources, including memory, attention and the ability to form abstract concepts. Elderly patients, those suffering from dementia, people dealing with anxiety after a stroke or traumatic brain injury, or patients with lower intellectual functioning may find CBT challenging. Research suggests that intact cognitive functions, as measured on psychological assessments, can significantly influence the efficacy of CBT.

Despite all these issues, it's important to recognise how effective CBT is in many cases. Even in instances where there is an initial increase in distress, these effects are usually temporary rather than permanent. Research has shown that long-term significant improvements in mental health are observed after a course of CBT - even among those who initially report worsening symptoms.

Strategies including screening for CBT appropriateness, educating patients about CBT before therapy begins, adapting the approach to individual needs, and ensuring adequate training and supervision of therapists, are likely to minimise side-effects and maximise the benefits of CBT.

Elena Makovac does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.