The CBT Gap: What Therapists Think Matters vs. What Clients Actually Value
New research reveals surprising disconnects between professional priorities and lived experience in depression therapy—and what it means for practice.
Have you ever worked with a client who tells you, “I know the techniques help, but what really mattered was feeling understood”? Or perhaps another who insists that homework assignments felt overwhelming, even though you saw them as essential?
These moments capture a tension many CBT therapists recognise: the gap between what we emphasise in treatment and what clients actually find most meaningful.
Depression continues to be one of the most common and debilitating mental health conditions worldwide. Despite advances in neuroscience, psychology, and public awareness, depression still disrupts millions of lives and creates immense challenges for health systems.
Among available treatments, cognitive behavioural therapy (CBT) remains one of the most widely researched and recommended psychological approaches. It is often positioned as a first-line treatment, supported by decades of evidence demonstrating its effectiveness in reducing depressive symptoms and preventing relapse [1,4].
However, research trials and clinical manuals only tell part of the story. The real-world experience of receiving CBT does not always align neatly with what therapists emphasise or what treatment guidelines prescribe. This tension between evidence-based priorities and lived experience has been increasingly recognised in recent years.
A new study by Yarwood and colleagues (2025) brings fresh insight by directly comparing what therapists and people with lived experience of CBT for depression identify as the most important components of therapy [5]. Their findings highlight important areas of agreement, but also notable gaps that deserve careful attention.
What the Yarwood Study Found
Yarwood et al. (2025) conducted a Delphi study involving two groups: experienced CBT therapists and people who had received CBT for depression. Both groups were asked to rate the importance of different therapy components and qualities.
✅ Consensus areas:
Therapist qualities: Both groups placed strong emphasis on qualities such as being trustworthy, non-judgmental, empathetic, and knowledgeable. These were seen as essential foundations of therapy.
Cognitive restructuring: There was widespread agreement on the importance of helping people identify and reframe unhelpful thoughts. This reinforced its role as a central pillar of CBT for depression.
❌ Divergence areas:
Behavioural activation and homework: Therapists prioritised these techniques more than patients did. While therapists saw them as core interventions, people with lived experience often described them as less central or more burdensome.
Psychoeducation and behavioural experiments: Therapists rated these highly, but patients placed less emphasis on them.
Process factors: Patients highlighted the importance of session pacing, length, and flexibility. Therapists, by contrast, did not prioritise these aspects to the same degree.
Mindfulness: Both groups showed mixed opinions, with no clear consensus. Some saw it as a valuable addition, while others considered it optional or unrelated to core CBT.
➡️ In practice, this highlights where our training aligns with what clients value, and where the gaps in understanding can leave them feeling less engaged.
Comparing with Broader Research
The Yarwood study builds on a growing body of work examining what makes CBT effective. For example, Taylor et al. (2019) established expert consensus on the most effective components of CBT for adults with depression.
Key elements included a strong therapeutic alliance, clear rationale for treatment, structured activity monitoring, relapse prevention, homework, therapist competence, and flexibility in scheduling [3].
While this study focused on depression, similar components, particularly alliance, cognitive restructuring, and exposure, are consistently highlighted in the anxiety treatment literature, though often through reviews and clinical guidelines rather than formal consensus studies.
This aligns with some of Yarwood’s findings, especially the emphasis on the alliance and structured techniques, but also shows that different populations may value components differently.
Meta-analyses further reinforce the picture of complexity. Angelakis et al. (2022) found that both simple and complex CBT protocols reduce depression, but more comprehensive approaches lead to stronger long-term outcomes [4].
Here’s the dilemma: clients often want something simpler and more flexible, but as therapists we know that keeping certain structured elements is what really protects against relapse.
Taken together, the research suggests that while CBT has robust evidence for its effectiveness, how it is experienced can differ depending on whether the perspective is professional or personal.
Practical Reflections For Therapists
The study by Yarwood et al. (2025) offers several important lessons for how CBT is delivered in practice.
1. Therapist qualities remain the cornerstone.
Regardless of technique, people consistently value trust, empathy, and collaboration. No manualised method can replace the sense of safety and understanding that comes from a strong therapeutic relationship. This reminds us that relational skills deserve as much training focus as technical competence.
2. Cognitive restructuring is essential, but requires flexibility.
Helping individuals challenge unhelpful thoughts remains a powerful tool. But not everyone responds well to structured worksheets or thought records. Some may prefer more conversational approaches or imagery-based techniques. Therapists may need to adapt formats so that the process feels less mechanical and more personally meaningful [1,5].
3. Behavioural activation needs reframing, not discarding.
While patients rated it lower, behavioural activation has decades of evidence supporting its effectiveness [4]. The challenge lies in presentation. Instead of framing it as a prescribed “task,” it may resonate more when described as a way to reconnect with enjoyable or meaningful activities, to rediscover mastery, or to test out beliefs in daily life. This reframing could increase engagement and reduce resistance.
4. Process factors deserve greater attention.
Patients emphasised aspects such as pacing, flexibility, and session length. These factors may not always feature prominently in manuals but can make or break engagement. Asking simple check-in questions such as, “Is the pace working for you?” or “Would a shorter or longer session be more useful?” can improve the therapy experience [5].
5. Mindfulness is best offered as optional.
While mindfulness-based cognitive therapy has proven benefits, particularly for relapse prevention, it does not resonate with everyone [4]. Offering it as an optional tool, rather than a mandatory component, respects individual differences while still keeping it available for those who are open to it.
6. Homework and psychoeducation need purpose and clarity.
Patients often see homework as an added burden rather than a helpful practice. Clarifying its role as a way to strengthen skills between sessions can shift perceptions. Similarly, psychoeducation is most effective when brief, directly relevant, and linked to a person’s goals [5].
Moving Forward
The most important message from Yarwood et al. (2025) is that CBT must remain responsive to the people receiving it. Evidence-based methods are crucial, but therapy also needs to reflect client priorities. Several steps could help move practice and research in this direction:
Co-designed research: Involving patients in shaping therapy protocols and outcome measures can ensure that lived experience is built into the design from the start.
Training emphasis: Professional training programmes should balance teaching technical CBT skills with relational skills and responsiveness to process factors.
Routine feedback: Building structured feedback into therapy (e.g., brief check-ins at the end of sessions) can help therapists identify when pacing, delivery, or techniques need adjustment.
System-level flexibility: Services could consider offering different formats , such as shorter, more frequent sessions, or blended digital and in-person approaches , to reflect diverse needs.
In the end, the work asks us to remain humble, listening as much as guiding, and to adapt so therapy feels collaborative, not prescriptive. What therapists prioritise and what patients value do not always match. Aligning these perspectives does not mean discarding evidence-based techniques, but rather integrating them in ways that feel accessible and meaningful.
By listening more closely to lived experience, adapting delivery styles, and maintaining flexibility, CBT can continue to evolve as both an effective and a human therapy. In this way, the future of CBT lies not only in scientific validation but also in the everyday realities of those who experience it.
How do you approach this balance in your own practice? Do you find yourself leaning more toward evidence-based fidelity, or tailoring interventions to client preferences, even if that means adjusting the “textbook” CBT approach?
Share your experiences and reflections below, we would love to hear how you navigate this challenge in your therapy rooms.
Author: Kavya Suresh Kumar