There’s a lot of evidence showing that cognitive-behavioral therapy (CBT) works if by “works,” you mean it provides statistically significantly more symptom relief than is provided by doing nothing (Shedler, 2015, 2025). The catch is that statistical significance can mean almost no relief at all, the difference of a couple of points on a 45-point scale. It’s like saying a weight-loss program works if the average participant goes from 100 pounds overweight to 97 pounds overweight. With enough participants, that will be a statistically significant difference.

What matters, of course, is clinical significance. With CBT, most depressed people are still depressed at the end of treatment. The same holds for PTSD, anxiety disorders, and so on.

CBT makes so much sense on its surface that it seems worthwhile to explore why it doesn’t work so well in practice. Shedler (2025) points out that it doesn’t typically last long enough, especially in the versions studied by researchers, to work. CBT makes sense because we often change our behavior when we change our beliefs. For example, if you are looking for the mustard at the grocery store among the salad dressings, it may be said that you believe the mustard is in Aisle 4. When someone tells you the mustard is in Aisle 7 with the condiments, this change in your belief is followed by a change in your behavior.

But that analogy is false, because you are not attached to your belief about Aisle 4 the way you are to core beliefs about who you are, how you are seen, and what the world is like. A set of beliefs can be analogized to a map of reality. A lot of our beliefs are formed in childhood, and the maps we use to navigate reality have our family’s imprimatur. I can easily question my Rand-McNally map of the world that still has Yugoslavia on it, but it’s a lot harder to question a Rand-McNally map if you yourself are a Rand or a McNally.

More importantly, the beliefs associated with problematic behavior are more like articles of faith than they are like ideas about where the mustard is located. An article of faith is held so closely and so fiercely that contradictory evidence actually strengthens the belief. The evidence causes cognitive dissonance and the dissonance is resolved by doubling down on the belief.

Imagine you’re at a dinner party where you are interested in keeping things light, a business event, for example, or Thanksgiving dinner with the family. You already know not to discuss politics or religion. People say all sorts of silly things that you disagree with, but for the sake of the dinner, you smile and let them go. But then someone says something that you can’t let go. You feel it would be a betrayal of yourself and what you stand for to let it go. That pressure, that heat, is a sign that the belief being questioned is an article of faith. It’s the way we feel about the beliefs associated with our problematic behavior.

In my experience, many (but not all) CBT practitioners expect patients to be engaged participants in the questioning of their beliefs. And certainly, the sense of collaboration is central to effective psychotherapy. But not so many CBT practitioners know to interpret their patients’ willing participation as a sign that they are not discussing the right belief. If they were, the patient would not be so sanguine about questioning the belief. Further, not so many CBT practitioners recognize how their efforts to change core beliefs through direct methods harden those beliefs.

Take the common example of a depression associated with a patient’s belief in his own worthlessness. As I blogged here, the therapy would immediately get closer to discussing the right belief if “worthlessness” were defined as an image of the patient from a specific memory or dream, and also if “I am worthless” were reframed as “You are worthless,” since we talk to ourselves in the second person, not in the first person. Noting the second person also introduces the character of the part of the self that is saying bad things, not just the part of the self that bad things are being said about.

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Adducing evidence and challenging poor logic treats the core belief as rational error when, in reality, it is closer to a talisman or incantation that wards off evil. Challenging its value, as noted, increases the person’s attachment to it. Good therapists, instead, comment on its function. “I notice that when we get close to considering a different course of action, you fill your head with the mantra of how worthless you are.” This kind of indirect approach, among many others, induces circumspection and eventually changes sacred cows into regular animals.

References

Shedler J. (2015). Where is the evidence for “evidence-based” therapy? Journal of Psychological Therapies in Primary Care, 4:47–59.