Can Therapy Work If Prior Therapy Failed?

I recently enjoyed celebrating the successful completion of treatment with several clients for whom prior therapy failed. In this post, I describe what I do differently when a client comes to me after prior therapy failed. I divide this into two types of therapy a client might have experienced before: Cognitive Behavioral Therapy (CBT) and Psychodynamic Psychotherapy. I also discuss what I do when both CBT and Psychodynamic Therapy failed before.

What If Cognitive Behavioral Prior Therapy Failed?

Cognitive Behavioral Therapy (CBT) is the treatment of preference for many psychological disorders. The research evidence for CBT’s efficacy is very strong for many disorders, including depression. (Cuijpers et al., 2023). CBT involves gathering data on symptoms and triggers, making changes in thoughts and behaviors to reduce symptoms, and systematically overcoming those symptoms with an individually developed set of responses. Because CBT can be easily manualized for treating different disorders, it lends itself well to scientific study.

When prior therapy failed using CBT, I need to find out why. In my experience, there are three common reasons CBT treatment may have failed:

1. The client didn’t do the homework.
2. The prior therapist didn’t follow through on the homework.
3. There was a poor fit between CBT and the client’s needs.

Prior Therapy Failed Because the Client Didn’t Do the Homework

If prior therapy failed because the client didn’t do the homework, I need to find out why. Sometimes the client lacked confidence in the treatment’s effectiveness. In those cases, I help the client build confidence in CBT’s efficacy. I also identify specific fears about what it would mean if CBT didn’t work again.

For example, I reassure the client that while CBT is the preferred treatment for many disorders, other options exist if it fails. CBT is often my first choice because it is effective in a short period of time. But it is not the only path.

Sometimes the client was discouraged when the homework wasn’t 100% effective right away. Initial failures are a normal part of CBT treatment. When a tool fails, that information helps us understand which other tools may be more appropriate.

Sometimes, more personal reasons explain why the client didn’t do the homework. For example, a client might avoid eliminating anxiety if that anxiety has made them successful at work. In those cases, I determine how treatment can preserve what the client values about their symptoms while eliminating the unwanted aspects.

Prior Therapy Failed Because the Therapist Didn’t Follow Through

If prior therapy failed because the prior therapist didn’t follow through on the homework, I explain to the client that the problem isn’t CBT itself. CBT requires constant attention to data and homework. Without that follow-through, it is unlikely to be effective.

I help the client build confidence in my ability to follow that protocol. I also ensure the client understands my expectations about homework completion from the start. Not that they must do it, but that we will talk about it, even if they didn’t do it.

Prior Therapy Failed Because CBT Wasn’t the Right Treatment

If prior therapy failed due to a mismatch between CBT and the client, I figure out exactly what that mismatch is. The three most common mismatches I see are:

1. The client has a clinical inability to follow through on homework (e.g., a client with ADHD).
2. The presenting issue is not a problem but a developmental process (e.g., a midlife crisis).
3. The presenting issue is not a problem but a meaning-making challenge (e.g., grieving a death).

If a client has difficulty following through on homework, we address that challenge before trying CBT again. If the client is in a developmental process, a more psychodynamic approach may help them synthesize their history and develop their identity. If the client is in a meaning-making process, we explore past values and life meanings, identify how the current stressor challenges those meanings, and encourage the development of new ones.

What If Psychodynamic Prior Therapy Failed?

Psychodynamic Psychotherapy involves paying attention to the client’s present life, their relationship with the therapist, and their biographical history. The goal is to understand how the past shapes the present — and to use that understanding to create a new experience of self and life.

Research evidence for psychodynamic therapy’s efficacy is not as abundant as that for CBT, but meta-analytic reviews confirm its effectiveness including for depression (Driessen et al., 2015) young adults (Trotta et al., 2024). One reason it is studied less often is that it cannot be manualized as easily. There are too many variables to study it well as a treatment for a specific disorder. Yet psychodynamic psychotherapy is effective, and evidence suggests its results may be long-lasting.

When prior therapy failed using a psychodynamic approach, the most common reasons clients report are:

1. Poor fit with the therapist.
2. Too little attention to outcomes during treatment.
3. A poor fit between the presenting issue and a psychodynamic approach.

Prior Therapy Failed Because the Therapist Wasn’t a Good Fit

Psychodynamic therapy requires a strong bond between therapist and client. If prior therapy failed, I try to learn about the client’s relationship with their previous therapist. This helps me anticipate their needs and prepare for similar challenges in our work together.

Sometimes, psychodynamic therapy reaches a challenging moment for an intentional reason. For example, a therapist might invite the client to notice that, despite their fears, the therapist actually cares. This kind of moment can strain the therapy and cause the client to leave treatment prematurely.

When I suspect such a moment may have occurred in a prior episode of treatment, I talk with the client about how we would handle a similar moment between us. This preparation helps us navigate challenges that ended the prior treatment. When possible, I also try to speak with the previous therapist to gain additional context.

Prior Therapy Failed Because There Was Too Little Attention to Outcomes

Psychodynamic psychotherapy is a slow process. It can be challenging to track the broad arc of therapy and ensure the client is experiencing real change. For example, a client may come in with a relationship pattern rooted in childhood. Many sessions may focus on making conscious connections between past and present. If the therapist doesn’t attend to how the client applies those insights, the client may become frustrated by a lack of visible progress.

My collaborative treatment-planning process and regular check-ins about the client’s satisfaction help prevent this from happening again.

Prior Therapy Failed Because Psychodynamic Therapy Wasn’t the Right Treatment

When prior therapy failed due to a mismatch between the approach and the presenting need, the two most common examples I see are:

1. The client is experiencing an acute condition, like panic attacks or PTSD.
2. The client doesn’t need to understand why. They need to answer a yes-or-no question.

For acute conditions, CBT methods are more effective because they focus on building skills to reduce immediate suffering. After that suffering is relieved, insight-oriented work can be valuable.

If the client needs to answer a “whether” question — “Should I leave my spouse?” or “Should I change careers?” — these questions require attention to present values and meaning more than to past history. A psychodynamic perspective helps clients understand the origins of their behavior. But it doesn’t always focus clients on their capacity, regardless of history, to build the life they choose today.

Our individual agency to shape the future is not limitless. But it is an awesome power nonetheless. Forks in the road can paralyze us, we need a sense of clarity to cut through the enormity of the moment.

What If Both CBT and Psychodynamic Prior Therapy Failed?

When prior therapy failed using both CBT and psychodynamic approaches, I am most inclined to try an Existential-Humanistic approach. I have been alluding to this framework throughout this post without naming it.

Existential-Humanistic psychotherapy emphasizes humanistic responses to four existential truths:

• I will die.
• I am free to make my own choices — and that’s terrifying.
• I am alone. No one else is inside of me. The ongoing unfolding of my experience is unknowable to others.
• Life appears meaningless. The right answers to life’s toughest choices aren’t clear, and we’ll never know if we did it right or wrong.

In my clinical experience, when clients are grieving, existentially disoriented, or uncertain about their place in life, they often need to attend to these truths directly. Many people need to face the enormity of life and death, of suffering and evil — and only then do they find they can rest more peacefully in the present moment. Research supports the effectiveness of existential therapy for clients experiencing this kind of distress (Vos, 2023).

The picture above shows how humanism softens the hard edge of these existential truths and gives us agency to face a harsh world.

Conclusion

I don’t use Existential-Humanistic methods often because they aren’t usually the appropriate tool. However, I find the work very satisfying. My exposure to Existential-Humanistic methods has shaped how I practice CBT and psychodynamic psychotherapy.

In my experience, psychodynamic training can sometimes lead therapists to assume they know best. CBT can sometimes assume that the tools are sufficient — that if the client learns and applies the skills, they will improve. My Existential-Humanistic background brings a degree of humility to both approaches.

I may have ideas about the psychodynamic cause of a client’s relationship pattern. Whether that insight resonates with the client determines its value. I have tools to help clients overcome anxiety. It is the client’s decision whether to use them. This tends to make me less reactive when clients resist my efforts to help. In those moments of “resistance,” I pause and consider my own values and the meaning I am giving to the interaction — rather than blaming the client for what is happening.

If you liked this post, you may also be interested in When Prior Couples Therapy Failed.

If you are interested in working with a therapist who takes a different approach to help you achieve better results in your next treatment episode, please contact me.

References

Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Ebert, D., & Karyotaki, E. (2023). Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients. World Psychiatry, 22(1), 105–115. https://doi.org/10.1002/wps.21069

Driessen, E., Hegelmaier, L. M., Abbass, A. A., Barber, J. P., Dekker, J. J., Van, H. L., Jansma, E. P., & Cuijpers, P. (2015). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update. Clinical Psychology Review, 42, 1–15. https://doi.org/10.1016/j.cpr.2015.07.004

Trotta, A., Gerber, A. J., Rost, F., Robertson, S., Shmueli, A., & Perelberg, R. J. (2024). The efficacy of psychodynamic psychotherapy for young adults: a systematic review and meta-analysis. Frontiers in psychology, 15, 1366032. https://doi.org/10.3389/fpsyg.2024.1366032

Vos, J. (2023). Existential psychological therapies: An overview of empirical research. Pratiques Psychologiques, 29(4), 211-229. [Read an English summary]
https://doi.org/10.1016/j.prps.2023.06.001