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Failures in cognitive behavior therapy: The state of the art

Paul M G Emmelkamp1

  • 1Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands.

Current Opinion in Psychology
|August 5, 2025
PubMed

Insights

Cognitive Behavior Therapy (CBT) failures are underestimated by clinicians. While effective for some, factors like comorbidities and therapeutic alliance impact CBT success, necessitating careful patient selection and alliance building.

Area of Science:

  • Psychiatry and Behavioral Sciences
  • Clinical Psychology

Background:

  • Cognitive Behavior Therapy (CBT) is a widely used psychotherapy.
  • Failures in CBT are a significant concern, yet under-researched.
  • Clinicians often underestimate therapy failure rates and struggle to predict treatment outcomes.

Purpose of the Study:

  • To review the current state of research on failures in Cognitive Behavior Therapy (CBT).
  • To identify factors associated with reduced effectiveness and treatment dropout in CBT.

Main Methods:

  • Systematic literature review of studies investigating CBT failures.
  • Analysis of treatment outcomes in various clinical settings and patient populations.
  • Examination of predictors of treatment response and dropout.

Main Results:

  • CBT efficacy in outpatient settings is often lower than in randomized controlled trials.
  • Compassion-focused therapy may outperform CBT in severe eating disorders with trauma history.
  • Comorbidities (depression, personality disorders) and poor working alliance predict poorer CBT outcomes.
  • High dropout rates are observed in PTSD treatments, with some evidence favoring exposure over cognitive processing therapy.
  • Limited evidence supports enhanced CBT variants over treatment-as-usual for borderline personality disorder.

Conclusions:

  • Preventing CBT failures requires a strong therapeutic alliance and potentially integrating other therapeutic approaches.
  • Measurement-based care may help mitigate treatment failures.
  • Further research is needed to understand and address the mechanisms of CBT failure across diverse patient groups.

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