Imagine trying to get help for your anxiety, but the treatment you try actually makes you feel worse. This isn’t unusual for some people who go through cognitive behavioral therapy (CBT), even though it’s known as a great way to help with mental health. CBT is popular because it’s supposed to help people with all kinds of issues, like anxiety and stress. While it really works well for many, some people end up feeling worse. The goal of CBT is to help people change negative thoughts and behaviors. It teaches them to notice and challenge unhelpful thoughts, replacing them with better ones. It also encourages trying new ways of coping in real-life situations to help with anxiety, depression, or other mental health struggles.
In England and Wales, CBT is recommended for many conditions, like anxiety, depression, chronic pain, and even things like IBS (irritable bowel syndrome) and tinnitus (ringing in the ears). This makes it seem like CBT works for almost everything. As a psychologist who uses CBT with my patients, I’ve seen it help many people, but I’ve also seen it not work for others. So, what makes it work for some but not for others?
CBT is structured, and its success often depends on how well the therapist can connect with and guide the patient. If the therapist isn’t very experienced or doesn’t work well with the patient, the therapy might not go as planned. This can lead to frustration and even make the person feel worse. However, it’s important to know that a bad experience with CBT might be due to how it was done rather than the therapy itself.
For example, a 2018 study found that out of 100 therapists, 372 unwanted effects were reported in 98 patients, with 43 of them experiencing some negative side effects. If CBT isn’t done properly, it might not help or could even make things worse. Some therapists might find it hard to admit their methods are affecting a patient negatively, so sometimes they blame the patient. However, even when CBT is done correctly, some patients still experience side effects, like worsening symptoms and increased stress.
One reason for this could be that CBT requires people to confront their negative thoughts and feelings, which can feel overwhelming or too intense. For people dealing with complex trauma, just trying to change their thoughts might not be enough to handle deeper emotional pain that might come from difficult childhood experiences. Some techniques in CBT, like exposure therapy (where you think about painful memories in a safe space), can actually make symptoms worse. Also, some patients feel like CBT’s focus on “thinking rationally” doesn’t always respect their emotions.
People who have gone through grief or serious trauma may feel that CBT labels their pain as “maladaptive,” which can feel like being told their emotions aren’t useful for coping. Another therapy called acceptance and commitment therapy (ACT) may feel more suitable for some. Instead of focusing on changing thoughts, ACT is about accepting tough emotions. ACT encourages mindfulness—staying present and calm—and helps people accept their thoughts and feelings without judgment, aligning them with their values.
Some researchers worry about CBT’s focus on thinking patterns, especially for people who tend to ruminate (dwell on painful memories or thoughts), which is common in depression. Trying to change “unhelpful” thoughts could make people ruminate even more. Research has shown that CBT can sometimes increase anxiety and low mood by making people think too much, especially if they have obsessive traits.
CBT can also be challenging for people who need a lot of cognitive support, like memory or attention. This can be hard for older patients, people with dementia, people with anxiety after a stroke or brain injury, or those with lower intellectual abilities. Studies show that cognitive abilities are important for how well CBT works.
Despite these challenges, CBT has shown great results. Even though it can increase stress at first, these effects are usually temporary. Over time, studies have found that mental health often improves a lot with CBT, even for people who initially felt worse.