No pain, no gain: Depressed clients' experiences of cognitive behavioural therapy


  • This article is published with the permission of the Controller of HMSO/Queen's Printer for Scotland and the NIHR.



Cognitive behavioural therapy (CBT) is an effective treatment for depression, but many clients do not complete therapy. What clients find difficult about CBT is poorly understood. This study explored clients' views and experiences of face-to-face CBT.


A mixed methods design was used to collect data as part of the CoBalT trial.


Participants randomized to CBT indicated their reasons for never starting or stopping therapy on the follow-up questionnaires. In-depth qualitative interviews took place with a purposive sample (n = 26) of those randomized to CBT. Framework analysis was used to analyse across the data.


Seventy-four participants withdrew from therapy or were discharged for non-adherence. A total of 54 (73%) gave reasons for not starting or stopping CBT; mostly the time/location was inconvenient or they had other commitments.

Interviews identified that clients could struggle in, and between, CBT sessions. This was true for those who did and did not complete therapy. CBT homework was the biggest challenge and was often associated with negative school homework experiences. Although clients may have disliked aspects of CBT, those who attended more than one session felt that they had gained insight into managing their depression.


Highlighting the possible barriers to adherence in CBT can help clinicians to better prepare clients in making an informed choice about therapy. Exploring these issues during therapy may also help with engagement. Despite the challenges, clients can still benefit from CBT by learning strategies that enable them to effectively deal with their depression.

Practitioner points

  • Talking to participants about the challenges of CBT – such as homework – can help clinicians better prepare clients in making an informed choice about therapy.
  • Exploration of possible barriers during therapy may also help with engagement and completion of therapy.
  • Despite the challenges, clients report benefiting from CBT; in particular learning strategies which help identify negative thought patterns and enable them to deal more effectively with their depression.