Why psychotherapy may fail

While psychotherapy can be incredibly helpful for many people with depression, it doesn’t always work (or solve all issues) for everyone.

Patients often cite unprofessionalism, incompetence, mismatch, and the counselor’s negative traits as reasons for failure.

1. Depression is complex and diverse

Depression isn’t one-size-fits-all since it can be caused by a mix of genetic, biological, psychological, and environmental factors.

Some have more biologically driven depression (like atypical or melancholic depression), while others struggle due to chronic stress, trauma, or unhelpful thinking patterns.

Psychotherapy may not address every underlying cause.

For example, someone with strong biological predispositions might need pharmacological support in addition to therapy.

For me, a combination of antidepressants and CBT seems to work best.

2. The type of therapy matters

Different therapies work for different people.

Cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and psychodynamic therapy are all evidence-based, but none work for everyone.

• • Some people may not respond to CBT if their thinking isn’t the main issue.

• • Psychodynamic therapy may not be as helpful if someone struggles to engage with introspective work.

• • IPT may not help if the person’s depression is more internal than socially driven.

Meta-analyses show that while psychotherapy is generally effective, the effect sizes vary, with 30–40% of people often seeing little to no improvement.

I think that cognitive behavioral therapy is helpful for most because it deals with both the mental part and with unhelpful actions.

3. Therapeutic alliance isn’t always strong

The relationship between the client and the therapist (therapeutic alliance) plays a huge role in outcomes.

That’s because therapy is less likely to help if the person doesn’t feel heard, safe, or respected.

The therapeutic alliance accounts for as much outcome variance as the specific techniques used.

As a practicing occupational therapist, I can say that I can get a whole lot more done from the clients who trust and like me than those who don’t, leading to better treatment outcomes.

4. Timing and readiness

Sometimes people start therapy before they’re ready to engage with it. For instance:

• • They may be in survival mode.

• • They might not fully believe therapy can help.

• • They’re pressured into it by someone else.

Therapy works best when someone is at least somewhat motivated and open to the process, even if they’re skeptical.

5. Comorbid conditions

Conditions like anxiety, PTSD, ADHD, personality disorders, or substance use can interfere with the success of standard depression-focused therapy.

Progress can be limited if these aren’t recognized or treated alongside the depression.

I had to manage my anxiety in addition to my depression because both were unhelpful and negatively impacted each other.

6. Therapist skills and fit

Not all therapists are equally trained, experienced, or skilled.

A poor counselor fit (either in personality or competence) can make therapy futile or even harmful in some instances.

It’s known that therapist competence and adherence to evidence-based protocols are major predictors of success.

7. External factors

If someone is living in a harmful environment like ongoing abuse, severe poverty, or isolation, therapy can only do so much.

You can’t “talk” someone out of real-world, ongoing distress since that requires action.

Social determinants of mental health, like housing, employment, and social connection, strongly impact depression outcomes.

8. Unrealistic expectations

Therapy isn’t a quick fix.

Some people expect fast results or complete symptom relief, and when that doesn’t happen, they give up too early.

It often takes weeks to months before meaningful (and noticeable) change happens, and progress is rarely linear.

I knew that some of my issues would take a long time to resolve, meaning I had to persevere before things got substantially better.

9. Misdiagnosis or incorrect focus

Sometimes what looks like depression might actually be:

• • Bipolar disorder (especially bipolar II).

• • Complex PTSD.

• • Chronic fatigue or other medical conditions.

• • A personality disorder.

Therapy won’t help much if it’s aimed at the wrong issue.

Misdiagnosis is a known barrier to effective treatment.

10. Therapy concentrates more on insight than action (or vice versa)

Some therapeutic approaches prioritize insight (e.g., understanding childhood trauma), while others aim at behavioral change (e.g., CBT or behavioral activation).

If there’s a mismatch between what the client needs and what the therapy provides, progress may stall.

For instance, someone in a serious depressive slump might need action-oriented support before they’re ready for greater self-reflection.

11. Therapy doesn’t always target the nervous system

Depression often involves dysregulation in the nervous system, causing hyperarousal (like anxiety) or hypoarousal (like emotional numbness or fatigue).

Traditional talk therapy doesn’t always deal with this somatic level.

Modalities like somatic experiencing or EMDR may be more useful for some people, particularly those with trauma-related depression.

12. Lack of cultural sensitivity or representation

Many therapeutic models were developed in Western, individualistic cultures.

Some may feel misunderstood or invalidated in therapy if someone comes from a collectivist, marginalized, or non-Western background.

Culturally adapted psychotherapies yield significantly better outcomes for ethnic minority clients.

13. Cognitive impairments due to depression

Severe depression can impair concentration, memory, and executive function.

This can make it hard to engage in therapy, remember insights, or apply coping strategies.

Cognitive dysfunction affects up to 95% of people with major depressive disorder, notably during acute phases.

While it didn’t affect my therapy too much, I did notice that I processed information a lot more slowly while having more trouble concentrating than usual.

14. Stigma or shame around therapy

Some may hold back, mask their symptoms, or resist the process if they feel ashamed for needing therapy in cultures or families where mental illness is taboo.

This emotional conflict can unconsciously block progress, even if people show up regularly.

15. Logistical barriers

Even when therapy is available, certain factors can lower effectiveness.

For instance:

• • Session length (often too short).

• • Infrequent appointments (such as every 2–3 weeks).

• • Inconsistent attendance due to life stress.

Therapy thrives on continuity and consistency, which isn’t always possible for people under pressure.

16. Therapy can sometimes re-traumatize

Diving into painful memories too early can crush someone and worsen symptoms if trauma isn’t handled carefully.

This can lead clients to shut down, avoid sessions, or drop out altogether.

This is why trauma-informed care is crucial, even in non-trauma-focused therapy.

17. Financial and time constraints

Therapy often requires long-term commitment.

If someone can’t afford consistent sessions, or if therapy ends too early (due to insurance or therapist turnover), they might not get the full benefit.

18. Emotional numbing or alexithymia

Some people with depression have difficulty identifying or expressing emotions (alexithymia), making it hard to engage in emotional work.

This creates a barrier in therapy for approaches that rely on emotional exploration.

Studies suggest alexithymia is common in people with depression and is linked to poorer therapy outcomes.

I experienced a lot of emotional numbing during my major depressive disorder, but fortunately didn’t change my treatment trajectory too much since my therapist mainly used CBT techniques instead of emotion-based approaches.

19. Overemphasis on pathology

Some therapeutic models focus heavily on what’s wrong, which can reinforce a client’s hopelessness or sense of brokenness.

People could benefit more from approaches that build strengths, hope, and meaning (like positive psychology or ACT).

I can confidently say that my patients are glad and feel a lot better when I treat them as “normal” people and when we’re not fixating on what they can’t do and what’s wrong.

20. The window of tolerance is too narrow

If someone is constantly outside their “window of tolerance” by being either too anxious or too shut down, they won’t be able to process therapy sessions efficiently.

Even good therapy can fall flat on its face without the proper grounding and regulation skills.

21. Therapy may reinforce over-intellectualization

Some individuals living with depression tend to overthink and analyze, often as a coping mechanism.

Therapy can unintentionally feed that pattern in these cases by keeping them “stuck in their head” without managing emotions or expressing them.

This is sometimes called “cognitive bypassing,” understanding the problem intellectually but not feeling emotional shifts or behavioral change.

22. Mismatch between client’s expectations and therapist’s approach

Some clients might feel like nothing is happening, even if slow progress is occurring, if their therapist takes a non-directive or open-ended stance, while someone expects psychotherapy to offer direct advice, structured tools, or fast results.

Disillusionment with the process can lead to dropout or lack of engagement.

As a therapist myself, a good counselor will attempt to adjust their approach to fit with your expectations. But perhaps more importantly, we will talk things through so we can set realistic expectations in the first place.

23. Clients may not disclose the full picture

Some individuals don’t share key aspects of their life, like suicidal ideation, substance use, relationship issues, or trauma, out of fear, shame, or mistrust.

Without this info, the counselor may not target the root causes of depression.

Therapy is only as effective as the honesty and openness allowed in the room.

24. Depression is sometimes protective

Depression can serve a function such as numbing unbearable pain, avoiding risk, or protecting against overwhelming anxiety or grief.

The client may resist improvement on an unconscious level if therapy tries to “remove” the depression without understanding what it’s protecting.

Psychodynamic and internal family systems (IFS) therapy often explores this idea of symptoms being adaptive, not just pathological.

25. Unresolved grief or existential crisis

Typical therapeutic techniques may not be intense enough when depression is rooted in loss or a lack of meaning.

People in existential despair may feel alienated by symptom-focused treatments because they need approaches that validate the big questions, such as “What’s the point?” “Why go on?”

Existential therapy or meaning-focused therapies (like Viktor Frankl’s logotherapy) may be more appropriate in such cases.

26. Too much focus on the individual instead of the system

Standard therapy tends to individualize distress.

But someone might be depressed because of systemic oppression, discrimination, or intergenerational trauma.

If therapy ignores these realities and treats the person as “the problem,” it can invalidate and alienate them.

Liberation psychology and community-based mental health approaches challenge this individualized aim.

27. Neurodivergence that’s misunderstood or missed

Many autistic people, ADHDers, or those with sensory processing differences go through chronic burnout and depression, but are often misdiagnosed.

If the therapy doesn’t recognize these neurotypes, it may pathologize normal responses to a neurodivergent life experience.

Late-diagnosed neurodivergent adults often report feeling gaslit or unseen in traditional therapy settings.

28. Emotional avoidance or fear of change

Even when therapy starts to work, the idea of feeling better can be terrifying.

That’s because depression is familiar, even if it is painful.

Joy, hope, or self-worth might feel foreign or unsafe.

This can trigger sabotage of progress, even if often unconsciously.

29. Secondary gains of depression

Depression can bring indirect benefits at times, such as getting care, avoiding vast responsibilities, or protecting against failure.

These “secondary gains” aren’t manipulative since they’re often unconscious and rooted in coping strategies, even if unhelpful and maladaptive in the long run.

30. Lack of holistic integration

Therapy may be missing essential drivers of mood when it doesn’t acknowledge body, sleep, nutrition, movement, sunlight, and nervous system regulation.

Depression is a whole-body experience, and treatment works best when it’s integrated.

Therapies that combine psychoeducation with lifestyle and mind-body interventions (like behavioral activation + movement + diet) show promising outcomes.

Final note

Psychotherapy is incredibly valuable, but it’s not magic.

It’s a relationship-based, human process that needs the right conditions to work.

When it doesn’t, it’s not always because the person has failed. It’s more often because the therapy wasn’t aligned with their needs, context, biology, or life circumstances.

Therapy often works best when combined with medication, social support, and lifestyle changes like exercise, sleep hygiene, and dealing with social needs.

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