You’ve Done Years of CBT and You Still Believe You’re Not Enough
I meet a particular kind of person fairly often in this practice. They are usually competent, often accomplished, and they have done the work.
They have a therapist, or they’ve had several. They can name their cognitive distortions. They’ve filled out thought records. They can explain, accurately and without prompting, that catastrophizing is a distortion and that their evidence for “I’m a fraud” is thin.
And they still believe it.
Not intellectually. Intellectually they’ll grant you every point. But somewhere below the level where arguments reach, the belief sits there intact, and it has outlasted every reasonable thing anyone has said to it — including everything they’ve said to themselves.
If that’s you, I want to say something that I hope lands: this is not a failure of effort, and it probably isn’t a failure of your therapist either.
CBT works. That’s not the issue.
I want to be careful here, because there is a genre of writing that builds up one treatment by knocking down another, and it’s usually dishonest.
Cognitive behavioural therapy is one of the most thoroughly researched psychotherapies in existence. It helps enormous numbers of people. If it has helped you, keep it. That is the goal of therapy after all: to find a method that works for you.
But the research on what happens after CBT for depression is worth knowing about. A systematic review and meta-analysis of thirteen studies, following more than twelve hundred patients, found relapse and recurrence rates after acute-phase CBT ranging from 18.5% to 46.5%, with an average of 33.4% across follow-up periods extending to three years (Wojnarowski et al., 2019).
The same analysis identified what most strongly predicted who relapsed. It wasn’t how severe the original episode was. The strongest predictor was residual symptoms — the part that didn’t fully resolve.
That finding matches what I see clinically. People finish a course of CBT genuinely better. The sleep improves, the rumination quiets, the functioning returns. And underneath, something hasn’t moved. It’s quieter, but it’s the same thing it always was.
Why some beliefs don’t respond to argument
Here is the distinction I’d want you to take from this.
There is a difference between a thought and a belief that is stored as if it were a memory.
A thought is something you’re having. It responds to evidence. If you think it might rain and then look outside, the thought updates.
The beliefs I’m describing don’t behave that way. I’m not enough. If they really knew me. I’m fundamentally a disappointment. These don’t feel like opinions you’re holding. They feel like facts you’ve noticed about yourself.
That’s because they weren’t formed by reasoning. They were formed by experience — usually early, usually repeatedly, usually in circumstances where that conclusion was a sensible thing for a child to arrive at. A belief installed by experience tends not to be removed by argument, which is why the thought record keeps producing a correct answer that changes nothing.
The clinical literature describes these as early maladaptive schemas, and the research on treating them directly is encouraging. A multicentre randomized controlled trial of 323 patients across twelve Dutch institutions found that schema-focused treatment produced significantly greater recovery than treatment as usual at three-year follow-up (Bamelis et al., 2014).
The point isn’t that you need schema therapy specifically. The point is that beliefs of this kind have to be approached at the level where they actually live — which is not the level of reasoning.
Where EMDR comes into it
This is the gap I work in most often.
EMDR was developed for trauma, and that’s still its main evidence base. A systematic review and meta-analysis of eighteen randomized clinical trials found EMDR produced significant improvements in post-traumatic stress, depressive and anxiety symptoms post-treatment, though the authors described the effects as small and were explicitly cautious about the long-term picture (Rasines-Laudes & Serrano-Pintado, 2023).
I’d rather give you that number honestly than a better one. EMDR is a good treatment. It is not magic, and anyone who tells you otherwise is selling something.
What makes it relevant here is structural. The standard EMDR protocol doesn’t target thoughts — it targets a memory, the belief attached to it, and the physical sensation that comes with it, all at once. You identify the negative belief (for example, “I’m not enough”), locate the experiences it came from, and reprocess those rather than debating the conclusion.
The mechanism is still genuinely debated. A meta-analysis of twenty-six studies found that the eye movements themselves contributed a moderate effect in clinical trials and a large effect in laboratory studies, with particularly strong effects on how vivid a memory felt (Lee & Cuijpers, 2013). Researchers continue to argue about why that is. I don’t think clinicians should pretend the question is settled. But I can tell you honestly, I see it work, patient and patient. In the room (in office or virtually), the thing people notice is this: the belief stops feeling true before they’ve been persuaded it’s false.
What I’d actually suggest
Don’t throw out what worked. The skills you built in CBT are real. Keep them. And they will work even better after EMDR.
Get specific about what’s left. “I’m still depressed” is hard to work with. “I believe I’m fundamentally a disappointment to my parents and I’ve believed it since I was nine” is a target.
Ask where it came from. Not to assign blame. Beliefs like these usually have a history, and that history is the thing with the charge in it.
Be honest with whoever you’re working with. “I’ve done the thought records and it hasn’t shifted the core of it” is clinically useful information, not a complaint. Any therapist worth seeing will want to know.
If you’re in the DMV
I work with clients across Washington DC, Maryland and Virginia by secure video, and I’m independently licensed in all three — which in this region matters more than it should, because a great many people live in one jurisdiction and work in another.
A disproportionate number of the people I see here are, by any external measure, doing well. That’s partly the nature of the place. It’s also, I think, why this particular problem shows up so often: a belief that you’re not enough is remarkably compatible with a career built on proving otherwise. It doesn’t interfere with achievement. It just means none of it ever counts.
If you’ve done years of good work and the floor underneath it hasn’t moved, that’s worth another look.
Please reach out for a consultation and see if EMDR may be a good fit. I’ll be straight-forward if I think its not. I look forward to speaking with you.
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References
Bamelis, L. L. M., Evers, S. M. A. A., Spinhoven, P., & Arntz, A. (2014). Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. American Journal of Psychiatry, 171(3), 305–322. https://doi.org/10.1176/appi.ajp.2013.12040518
Lee, C. W., & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44(2), 231–239. https://doi.org/10.1016/j.jbtep.2012.11.001
Rasines-Laudes, P., & Serrano-Pintado, I. (2023). Efficacy of EMDR in post-traumatic stress disorder: A systematic review and meta-analysis of randomized clinical trials. Psicothema, 35(4), 385–396. https://doi.org/10.7334/psicothema2022.309
Wojnarowski, C., Firth, N., Finegan, M., & Delgadillo, J. (2019). Predictors of depression relapse and recurrence after cognitive behavioural therapy: A systematic review and meta-analysis. Behavioural and Cognitive Psychotherapy, 47(5), 514–529. https://doi.org/10.1017/S1352465819000080
