When Evidence-Based Methods Don’t Seem to Fit: An Example During Cognitive Restructuring 

Disclaimer: Nothing in this document should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care.

I attended an introductory training focused on cognitive restructuring.  Attending was nostalgic, humorous and odd for me because I received such focused and intense education and training on cognitive restructuring during graduate school within a department grounded in radical behaviorism.  And I’ve used cognitive restructuring for decades. 

In this work I’ll discuss a role play that was done later in the training.  I’ll show how that role play demonstrated the limits of applicability inherent in cognitive restructuring.  And I’ll contrast those limits with methods from Depth Psychology that the reader can at least begin to consider. 

Rather than dismiss anything from Depth Psychology as not being “evidence-based”, consider that for something to be evidence-based it had to exist, and not be evidence-based yet, and put to the test of enough research studies that it later is called “evidence-based”.  As you read along, consider how the role play shows the limits of applicability inherent in one particular evidence-based method.  And ask yourself what lessons we can gain from that reality.   

The Role Play

The unscripted scenario was the death of a child via a tragic accident. The patient role was that of someone who had investigated the accidental death and was disturbed and in counseling as a result.  That patient role was played by an attendee of the training. 

The trainer role-played the counselor and the purpose of the role play was to model fidelity to the cognitive restructuring protocol. During the non-scripted demonstration, the trainer while playing the “counselor” experienced the “patient” coming to a stuck point of sorts.  In fact, the “patient” came to this same stuck point a number of times.  And the stuck point seemed irreconcilable by use of the cognitive restructuring protocol being taught.   

What was the stuck point? 

The patient was struck by the rather mundane nature of the accident that led to the child’s death, and the completely average and typical family within which this accident happened. “If this can happen to this family, it can happen to any family.”  

As the restructuring proceeded, the content eventually moved from surface-level thought content about the event toward an inward experience. That experience was something like a consolidation of existential guilt, annihilation anxiety, and a complete reconsidering of what can happen in life, and of what life even means.  And remember, the role being played was that of someone who had investigated the death, not one of the family members involved in the circumstances of the accident. 

After significant (but still only partial) progress in the restructuring was made, the process of the manualized cognitive restructuring method was halted by the trainer, and the stuck point was discussed with the attendees.  After that discussion, the process returned to the stepwise restructuring protocol.  That is to say, fidelity to the sequence was resumed. 

This sequence of the stuck point emerging, stopping the restructuring, discussing the process, and then restarting, eventually happened a number of times during the role play. 

The patient being role-played kept linking the death of the child to something they could not quite identify or articulate.  The feelings were hard for the patient to name, the cognitions were not clear even to themselves, and during the role play these cognitions and affects were not really verbalized much at all.  At other times the patient would exit the content of the overt situation and begin to discuss their awe and horror at the meaning of the event, and of life itself.  In this, the patient could not find sufficient words.  But it was palpable, nonetheless.

During the role play, as this juncture re-appeared a number of times, it occurred to me that the restructuring method had entered the domain of the “pre-symbolized” the “non-observable”, and the “non-discursive”. 

Comments Upon Reflection

These are three of the domains I identified some years back and wrote about in my Depth Psychology Applied to Addiction Counseling monograph¹.  I’ll outline them here as follows:

• Pre-symbolized:  a thought that’s not yet formed, or represented, but is nonetheless there.
• Non-observable:  mental content that is not manifest in any version of any behavior. 
• Non-discursive:  content not formulated in speech. 

At one point during the role play the trainer paused, looked at the audience, and said, “It seems like something odd is going on with this patient’s relationship with this topic”.

To me that was the presenter’s intuition working clearly and accurately.  By contrast, in radical behaviorism we observe and use observation as our method for determining what’s going on.  And we do not intuit, or give things names or labels.  We stay objective, external, measurable, and descriptive. 

But then the trainer/clinician returned to the CBT protocol.

The trainer had side-stepped the “odd” content/topic/barrier and its related voids and affects.  These “unrepresented” areas² of the mind were set aside by the trainer.    

Meditating on this has continued for me since attending the training.  During my process of considering this I found a quote I had kept for further consideration.  Check it out.  And as you read it, think about its possible relevance to the content represented by the patient’s stuckness and the trainer’s struggle. 

Attention is “neither an association of ideas (empiricism) nor the return to itself of a thought that is already the master of its objects (intellectualism); rather, attention is the active constitution of a new object that develops and thematizes what was until then only offered as an indeterminate horizon.”  (Maurice Merleau-Ponty, Phenomenology of Perception)³

That quote is a bit difficult, perhaps.  Read it over and over again, until you “get” it. 

To me the quote nails the phenomenology of the trainer’s struggle.  And the fit of the quote is interesting and instructive to me on multiple levels. 

The trainer was bound in empiricism and intellectualism, and thus had no tools other than cognitive restructuring.  I’m all too familiar with those bounds, and those limits, given my academic upbringing in radical behaviorism and strict cognitive-behavioral psychology.   

In the role play, the trainer did recognize they had found the location of the limit of the CBT protocol they were teaching us.  That’s why they paused and processed it with the audience of learners.  But the trainer didn’t explicitly say CBT had reached its limit.  Rather they processed the “odd” nature of the patient’s relationship with the topic, and then resumed the protocol. 

And to me, considering the quote above, that limit was the limit of empiricism + intellectualism as described in that difficult quotation.  To me, each time the trainer came up to this limit during the role play, it was clear they were then at the door of Depth Psychology.  But each time they reached that edge and that door, they walked away from that location and returned to both empiricism and intellectualism – by returning to the cognitive restructuring protocol regardless. 

Instead of returning to the protocol, the trainer could have given themself permission to think.  And permission to experience themself while also experiencing the patient.  And they could have trusted and followed their own intuition toward the constitution of a new object (the patient’s relationship with this grief and their struggle with meaning).  And in doing so the trainer could have been guided by the developed theme of oddness that they identified – the very theme they rightly intuited to be present – but that was still without adequate words or any name. 

The activity and language in the role play showed some of the limits of CBT.  And it revealed the horizon over which the presenter, as a clinician, trainer, and person, refused to look. 

How fascinating. 

Watching that unfold was almost like watching a purposefully pre-planned training that used CBT as a failed starting point for a well-planned introduction to the topic of Depth Psychology and its relevance.  A training where the content shown by the patient was a well-framed emptiness with content that was nameless, wordless, could only be partly described, and yet continued to emerge time and again.  

The attendees of the training were SUD counselors.  And the protocol was evidence-based.  So, consider the following: 

• The patient was fully motivated (so MI had no relevance).
• The patient was attending all sessions and doing all the homework (so Stages of Change had no relevance). 
• The patient was not triggered to return to use in a way they or the clinician could identify (so relapse prevention therapy had no use). 
• The patient was compliant with all suggestions (so contingency management had no relevance).
• And here, CBT itself seemed to not apply after a certain point, and not be a person-centered “fit” for this kind of material.
• Third-wave CBT methods such as Acceptance and Commitment Therapy (ACT) might have successfully ventured a bit further into this material.  On the other hand, it might have delayed the clarification of the presence and nature of the stuckness by creating and prolonging the appearance of pseudo-relevance to the content. 

Can We Do Better?

I am left to wonder if addiction counseling will one day develop an evidence-based method in the arena of Depth Psychology. 

Has this kind of development been done before?  Absolutely.  Follow this lineage.⁴ 

1. The psychoanalyst Otto Rank emphasized the conscious, present, and willed (as opposed to Freud who emphasized the unconscious, past, and wished).  Rank formed and named the “here and now” principle.  And decided that empathy was the primary active ingredient in therapy (as opposed to Freud who thought it was the “truth” as delivered in interpretations given to the analysand by the analyst).  He broke from Freud who had hoped Rank would be his successor. 
2. The humanistic psychotherapists, existential psychologists, and others, used Rank as a fundamental starting point. 
3. Rank was the psychoanalyst for a patient named Carl Rogers.  Rogers also attended a number of public lectures given by Rank on his model of psychoanalysis.
4. Rogers spent a career length developing content and methods centered in empathy, the here and now principle, and so forth.
5. Bill Miller used that material as a base, extended it, and built his method called Motivational Interviewing upon it.

But for now, I am only left to wonder if addiction counseling will someday make systematic use of some particular psychodynamic methods to improve outcomes when facing scenarios such as the one I saw unfold in that training.  And wonder when treatment matching methods will select for them instead of always selecting against them. And no longer rest the rationale for rejecting them on a list of evidence-based methods from which we are required to choose, and forbid us to go beyond. And no longer train us accordingly.

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References

¹ Coon, B.  (2024).  Depth Psychology Monograph. 

² Howard Levine

³ Phenomenology of Perception 

⁴ Stillpoint. The History of Psychoanalysis. Lecture 4: Psychoanalysis as a Developmental Theory. 

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Resources

Bollas, C.  (1987).  The Shadow of the Object:  Psychoanalysis of the Unthought Known.  New York:  Columbia University Press. 

Coon, B.  (2021).  Recovery: What Is It Good For? – Recovery Review