Failures in cognitive behavior therapy: The state of the art

The aim of this review is to evaluate the state of the art of studies investigating failures in cognitive behavior therapy (CBT). The last couple of years relatively few studies have specifically focused on failures in CBT. Generally, clinicians underestimate the number of therapies that fail and therapists are no better than chance at predicting effectiveness classification. In patients treated in outpatient clinics, effects of therapy were lower than effects of therapy in disorder-specific CBT efficacy randomized controlled trials. In eating disorders, results of CBT are moderate with high remission rates. In severe eating disorders compassion focused therapy was more effective than CBT at one year follow-up among patients with a history of childhood trauma. Co-morbid personality disorders and depression were significant negative predictors of treatment response in CBT. Few studies have investigated which processes are associated with failure of CBT in patients with PTSD. Drop-out rates for treatments for adult PTSD are rather high. One study reported significantly more drop-outs in cognitive processing therapy compared with exposure therapy. There is only limited evidence that CBT including dialectical behavior therapy and schema therapy are more effective than treatment as usual especially with patients with borderline personality disorder. To prevent failures in CBT, a good working alliance is of high importance. Engagement in measurement-based care may help to prevent treatment failures as well.