The “cognitive triangle” is a central concept in CBT. The triangle’s points represent thoughts, feelings, and behaviour, while the sides represent the multidirectional relationships between these elements.
Cognitive Behavioural Therapy (CBT) for depression is a powerful tool, however it comes under fire for several reasons, including for being too simplistic; too unemotional; and even culturally inappropriate (Ratnayake, 2024). We’re going to take a closer look at CBT for depression and the criticism it receives, and we’ll also explore some of the “pros” (advantages to the use of CBT for depression). The hope is that armed with an understanding of CBT and its criticisms, the reader will be best able to make their own decisions about whether CBT for depression is right for them. This blog focuses on the use of CBT for depression, but it is worth noting that CBT is also an evidence-based treatment for other common conditions, such as anxiety and insomnia. The pros and cons of CBT are similar regardless of the presenting issue, and of course, challenges such as depression, anxiety, and insomnia can be heavily related.
Depression Causes & Context
Depression can be difficult to treat. Tending to be resistant to medications and many forms of talk therapy, successes in treating depression are often modest and time limited. Depression experiences can be self-replicative (tending to “snowball”), and sufferers are prone to treatment regression/symptom relapse, even with the most intensive treatments. As a student of biomedical science, I was taught that depression is caused by “chemical imbalance” in the brain of patients, and that effective treatment involves drugs (typically SSRIs) to rectify the chemical imbalance. As a counsellor, a student of society, and a person who has experienced depression themselves, I find the usefulness and accuracy of this medicalized view to be somewhat lacking. Zooming out, borrowing context from a systems-theory perspective, we only have to look to statistics showing correlations between depression, happiness, wealth, and education: When we observe trends collectively, on a community level, we see that as levels of prosperity increase beyond what one needs to survive, there is a decrease in levels of happiness and increases in rates of depression. Many of us have been encouraged to pursue education and wealth, this encouragement imbued with a notion that these pursuits will bring happiness. This is a fallacy: It is the quality of our thoughts and relationships that inform levels of happiness, not material wealth or successes. If we look to the massively wealthy multinational companies which are the pinnacle of achievement under our economic system, one might understandably assume that fame and fortune are the most important values to pursue. This is the situation we live in: Pending environmental calamity and mass extinction; political radicalization and a fervent upswing in right-wing ideologies; ever increasing wealth inequality; the systemic abuse and enslavement of peoples and places in the global south; the manipulation and censorship of knowledge delivered through media, and seemingly exponential increases in complex social issues in developed countries, such as addiction, youth mental health, and homelessness. This is the backdrop for increasing rates of depression in the global north. We can talk about imbalanced neurotransmitters, but let’s not ignore the significance of the goings-on of the world at large. Medicine encourages treatment of the “root cause” as preferential to the treatment of individual symptoms. As we delve into how to treat depression on an individual level, let us acknowledge the need to address the bigger issues of our sick society.
“It is no measure of health to be well-adjusted to a profoundly sick society”
-Jiddu Krishnamurti (Indian philosopher, circa 1952).
History & Research Into CBT
Many common psychotherapies have been utilized in the treatment of depression (e.g. psychodynamic therapy, interpersonal therapy, existential therapy, and Rogerian therapy). CBT emerged as a fresh and unique approach for treatment, developed through the combination of two previously distinct types of therapies (cognitive therapies, and behavioural therapies). There are important and notable differences between CBT and all the therapies that came before it: CBT was simple, quick, easy to train therapists for, and decidedly manualized (meaning the techniques were replicable, universal – they lend themselves to being documented in a manual). All of these ways in which CBT was different manifested in CBT being incredibly easy to deliver. As a result, CBT is much easier, cheaper, and quicker to research than more traditional methods, and accordingly, we now have far more scientific research on CBT than on any other type of psychotherapy (David et al, 2018). This doesn’t necessarily mean that CBT is superior, however it does mean that as far as “evidenced-based” treatments go, CBT is a clear winner simply due to the sheer volume of research that has been done on it. This background can be summed up in one common overarching criticism of CBT: “It’s great in theory, but it falls short in practice”. Let’s look at some of the more specific criticisms which underlie this view.
Common Criticisms of CBT:
“It’s Too Thinking Based”
With ample use of homework, handouts, diagrams, whiteboards, and record-keeping exercises, it’s definitely true that CBT relies heavily on data and analysis. This is only helpful when a client is in a certain headspace, which isn’t a given, especially for clients enduring difficult circumstances, conflict, or those with trauma histories. Many therapists proficient in other modalities feel a lack of inherent emotional exploration involved in CBT. For example, there is no specified protocol within CBT for how to respond to crying (a physical expression of intense emotion). While most experienced therapists would feel the need to encourage emotional release and sharing when tears are shed, it’s hit or miss whether a therapist using pure CBT would pursue these aims. The bottom line: While many clients do respond well to the heavy thinking and analysis backbone of CBT, clients in acute distress, active addiction, those with strong and/or unexpressed emotions, trauma histories, and difficulty expressing themselves are unlikely to benefit from CBT alone.
“It’s Not Culturally Responsive”
Cultural responsivity is a fairly recent concept born out of efforts to improve accessibility and treatment success rates for clients from cultures other than the dominant WASP culture in many “developed” countries. A therapy is culturally responsive if it is able to adapt (to respond) to cultural needs; either to a specific non-dominant culture, or several non-dominant cultures. It is true that CBT was developed in Western countries, with predominantly white, English speaking clients. However, we find that this is true for virtually all evidence-based treatments, and the research upon which evidence depends is generally performed by well-off academics at well-off universities in well-off countries, who (at least traditionally) use university students who are traditionally well off, English speaking, and Caucasian. Participant samples also tend to be biased in that they tend to recruit more men than women, with most participants falling within the age range of 18 to 34 years of age. The bottom line? Research samples are biased, and this is a problem with research in general, rather than a problem with CBT itself. This problem affects any therapeutic modality that is being researched, but it makes sense that CBT receives the brunt of criticism around this, given that it has been the focus of so much research.
Cultural adaptation is a related concept that seeks to modify an existing modality to make it more culturally responsive. CBT does lend itself to cultural adaptation, and this has been done, quite successfully in many cases, most notably with Asian-American populations and disadvantaged caucasian populations. Cultural adaptation usually involves rewriting resources and manuals in a different language (if necessary); making use of cultural context (using the history, stories, attitudes, and metaphors of the culture), training therapists who are members of the culture in question to deliver CBT, and accounting for culturally-related barriers to treatment (such as shame and previous experiences with culturally inappropriate care).
“It Totally Ignores the Past”
CBT is considered a “here and now” approach, because compared to many other psychotherapies, its focus is largely on the present reality. CBT doesn’t typically allow for an organic unpacking of past difficult experiences. This can be a plus (e.g. if a client is feeling particularly motivated to “move forward”), but it can also rob clients of opportunities to understand and make peace with their pasts, a process which is especially important for those who’ve experienced trauma/abuse. This leaves us with a related criticism of CBT: “It’s not trauma informed”. This criticism is true, in my view, because of how manualized it is. A treatment cannot be truly trauma-informed unless it has inbuilt allowances for working with unique and personal trauma histories. Caution is advised for therapists wanting to use CBT with clients who’ve experienced trauma. Trauma-focussed CBT (TF-CBT) is an adaptation of CBT specifically designed for clients with PTSD (Allen et al., 2022). The efficacy of TF-CBT in treating other types of trauma has not been established.
Benefits of CBT for Depression:
Now that we’ve gained insight into its limitations, let’s run through the upsides for using CBT for depression. Firstly, keeping in mind that depression is often treatment resistant, and that medicalized treatments often take time to begin working and are only effective for some people, it’s easy to understand the need for alternatives. Unlike pharmaceuticals and many other forms of psychotherapy, CBT tends to deliver results fairly quickly. It’s also cost-effective, and unlike almost all other forms of psychotherapy, extensive training and experience is not required to become skilled at delivering CBT. Improvements in depression symptoms can be rapid and profound, and the symptom data collected using CBT and increased client self-awareness that results allow us to track treatment gains with much more confidence than is possible when assessing whether one feels any better a couple months into a course of antidepressant drugs. CBT is simple (a benefit to therapists and clients alike), and this fact also supports the delivery of CBT in group and online settings (Gkintoni et al., 2025). This can make CBT more accessible and affordable to those with limited resources.
As a therapist who integrates different therapies, by far the biggest benefit of CBT for depression from my perspective is that it can be easily integrated with many other therapies. Many of the shortcomings of CBT can actually be turned into benefits through selective therapeutic integration. For example, a combination of CBT and narrative therapy allows us to work on practical, present-day solutions without ignoring the significance of past experiences and traumas on a client’s identity. Similarly, a blend of CBT and Internal Family Systems therapy (a newer modality that views individuals as being composed of many distinct parts with different perspectives and intentions) supports improved coping strategies and increased self-awareness, while honouring and taking guidance from less visible, younger, and weaker parts of a client’s identity. Mindfulness-based CBT is a combination of CBT with mindfulness techniques; in this case, analytical and behavioural benefits of CBT are compounded by a focus on felt experience and acceptance of present reality. This can be an extremely powerful combination, especially for clients who are committed to building new habits and sustained recovery from depression. A skilled integrative therapist uses their finesse to determine the correct time for (and balance of) CBT interventions, and selects complementary approaches that will benefit their clients.
In summary, CBT is a versatile, simple and highly evidence-based treatment for depression. However, it is not appropriate for everyone, and like all modalities, it has some limitations. Combining CBT with other choice types of therapy can increase the efficacy of treatment overall, and gives the therapist the ability to tailor treatment to every clients’ unique needs. Therapists who value client autonomy may ask your opinion on CBT, and can provide options on the approaches they incorporate in your treatment. Don’t be afraid to ask questions. A good therapist should be able to give you a sample of CBT if you’d like to experience it before deciding if it’s right for you.
External Links:
To learn more about CBT for depression, go to: https://www.choosingtherapy.com/cbt-for-depression/
To understand CBT in greater detail, and for examples of CBT techniques, go to:
https://www.ncbi.nlm.nih.gov/books/NBK279297/
References:
Allen, B., Shenk, C. E., Dreschel, N. E., Wang, M., Bucher, A. M., Desir, M. P., … & Grabowski, S. R. (2022). Integrating animal-assisted therapy Into TF-CBT for abused youth with PTSD: A randomized controlled feasibility trial. Child maltreatment, 27(3), 466-477.
David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in psychiatry, 9, 4.
Gkintoni, E., Vassilopoulos, S. P., & Nikolaou, G. (2025). Next-Generation Cognitive-Behavioral Therapy for Depression: Integrating Digital Tools, Teletherapy, and Personalization for Enhanced Mental Health Outcomes. Medicina, 61(3), 431.
Ratnayake, S. (2024). The Decline of Psychoanalysis and the Rise of Cognitive Behavioural Therapy. Part I: Dismantling the Legend of CBT. Authorea Preprints.
Michael Indermaur, RCC, MACP, B.S.c.
Michael works with individual adults and couples. He practices integrative, interpersonal therapy, using CBT and other effective methods in the treatment of depression, anxiety, relationship troubles, life changes, and for personal growth goals.
Michael works with individual adults and couples. He practices integrative, interpersonal therapy, using CBT and other effective methods in the treatment of depression, anxiety, relationship troubles, life changes, and for personal growth goals.
