Chris DeLine

Cedar Rapids, IA

CBT and the 12 Steps (Terminally Unique, Pt. 15/21)

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I’ve heard it said that the best diet is the one you’re actually willing to do. In recovery terms, there is no single best way to get or stay sober, there’s only the plan for recovery you’re willing to try. A decade or so ago I had tried maybe two or three different Alcoholics Anonymous groups before determining the whole of it wasn’t for me. At that point in time, the only professional therapeutic interaction I’d had was with a psychiatrist I saw once in 2008, who prescribed me Lexapro shortly before I attempted to end my life, and with the staff at the court-appointed rehab and outpatient treatment which followed. A.A. uses the phrase “contempt prior to investigation,” but I don’t even know if that truly speaks to the mindset I was in then; it was closer to a presumption of expertise or a denial of value prior to investigation. A decade ago, when writing Believed to Be Seen, I referenced cognitive behavioral therapy (CBT) numerous times without a well informed understanding of what it actually was, aside from generally recognizing that it focused on “behavioral reconditioning.” What I missed at the time was a deeper understanding of CBT’s principles, how they can actually help and support recovery, and also how they reconcile with numerous other avenues people take when trying to get sober. This includes A.A.

The requirements of my Master’s program in clinical mental health counseling included two semester-long internships and a practicum (which is essentially a mini-internship). The purpose of all three of these placements was to start working in the field, utilizing the information and skills from the classroom and putting it all to work with clients in a real life counseling setting. Through my internship work I landed placement at two offices on vastly different ends of the competency spectrum: One, which I’ll discuss more later, and the other an incredibly professional, well-structured, and welcoming clinic that specializes in obsessive-compulsive disorder (OCD) and anxiety-based disorders. I genuinely had little understanding for what OCD was prior to connecting with the clinic, but by the time I left, I not only benefited from their experience and the opportunity to work hands-on with clients who were struggling with the disorder, but I came away with an unintended understanding of how the principles that guide treatment for it also apply to addiction and recovery.

I don’t want to make this too much about OCD, but the disorder itself is really interesting when considering it through the same lens as addiction: OCD is a learned disorder, but also a biological disorder; sometimes it’s a big issue for those dealing with it, while at others it doesn’t impact life much whatsoever; it begins at different ages for different people and shows up in wildly different ways in people’s lives; behavioral modification is used as a primary means of treatment; and medication can help treat it, but never really “cure” anyone of their OCD. So, what is OCD? One factor of the disorder includes unwanted obsessions, which are sometimes referred to as intrusive thoughts, that can also come in the form of mental images or impulsive urges. Compulsions, also referred to as rituals, are behaviors that someone engages in to relieve the distress or discomfort of those obsessions. Everyone has thoughts. Everyone does things to help make themselves feel better. What makes OCD so different is the vicious cycle that develops out of the ritualistic nature of satisfying the obsession with a compulsion. Over time, wiring between those obsessions, urges (or intrusive thoughts), and the compulsions that follow create something of a habit loop, to put it in simple terms. Anyone who’s heard of Pavlov’s Dog might start to see a connection to the concept of conditioning here.

Addiction OCD Symptom Map

Imagine with me a picture of a circle, and on that loop there are four distinct stations: one at the top, one to the right, one at the bottom, and one to the left. There is one more station that’s outside of the loop, however, and that’s what we’ll call a “trigger.” When a trigger occurs, it sets the cycle in motion. For those with a form of OCD that revolves around checking compulsions (take, for example, someone who needs to check to make sure their front door has been locked a specific number of times before leaving the house), the trigger could be merely a thought of having to walk out the door for work in the morning. For those with a contamination-focused OCD, it could be something like seeing another person cough or blow their nose around them. The list of what can trigger people struggling with different forms of OCD is endless, but the point is that something serves as the trigger, which then leads to a mental obsession. “Obsession” is a relative term here, obviously, and the levels of distress caused by the obsession vary considerably based on the trigger and context of the situation, but what’s common at this first station at the top of the loop is some form of rumination, worry, or concern associated with some level of distress, influenced by the trigger.

Obsession leads to the next station on the loop, which focuses on anxiety symptoms that stem from the obsession. For some, this can be a low hum of uneasiness, while for others it can show up in the form of sweating, racing heart, hyperventilating, dizziness, or a variety of other body-focused symptoms. To combat, or sometimes help prevent the symptoms from potentially escalating, the loop follows into the bottom (or third) station which is referred to as a compulsion or “safety behavior.” In the example of the person leaving for work in the morning, that compulsion might be to go through their kitchen and touch all the knobs on the stove to make sure they’re not turned on. The person triggered by someone coughing near them could hold their breath for a specific number of seconds they deem to be valid. The examples here are less important than the point, which is that the compulsion affects a person in a way that leads to the fourth and final station on the loop: temporary relief. To summarize: Something triggers a person, sparking an obsession, leading to anxiety symptoms, which are combated by some form of safety behavior which, when utilized, results in temporary relief. The good thing is, use of a safety behavior usually helps the person suffering with OCD reduce their symptoms in the short run. The problem is, every time those specific compulsions are used to offset anxiety symptoms, they also reinforce the loop, teaching the mind that the most efficient way of escaping anxiety is to perform said compulsions. (A secondary result comes with the increased anxiety produced when the safety behavior cannot be performed, or cannot be performed as desired.)

“Few things are more useful to recovering alcoholics than discovering the reasons why they drank excessively,” writes Charles Bufe in Alcoholics Anonymous: Cult or Cure. “For once they’ve discovered those reasons, especially the irrational beliefs which made drinking seem unattractive, they can deal with them.” I don’t disagree, but experience also tells me that the “why” doesn’t always matter much. To quote one of the leading voices in the field of OCD, psychologist Jonathan Grayson says “the conditions that start a problem are not the ones that maintain it.” Understanding the source of an impulse does little to help control or resolve it in the heat of the moment. To frame this dilemma in another way, as I once heard in an A.A. meeting: I don’t care how the donkey got in the ditch, what we need is to get it out! A.A.’s first step reads, “We admitted we were powerless over alcohol—that our lives had become unmanageable.” The message of this step aligns as it promotes a desire to acknowledge that there is a problem and that quality of life is being sacrificed because of it. For alcoholism, that problem is one of drinking, for OCD it’s ritualistic behavior. Obstacles such as trauma can have a significant impact on the success of treatment in both OCD and alcohol or substance use disorders, but bringing the problem into the here and now of the moment in either case is to say that any chance of change is to begin with a desire to change and willingness to take action at this exact moment.

I’m going to be up front with my position surrounding any overlap between 12 Step principles and CBT. Parallels do exist, but it’s often a stretch to find a direct connection between the two when using the language of A.A.’s text, itself, opposed to the tools that are promoted through meetings, sponsorship, and its fellowship. Take, for example, A.A.’s second and third steps. They read that members “Came to believe that a Power greater than ourselves could restore us to sanity” and “Made a decision to turn our will and our lives over to the care of God as we understood Him.” There isn’t much direct connection between cognitive behavioral therapy and turning one’s will and life over to the care of God, but there is a connection when exploring the underlying goal. A.A.’s second step is a process of awakening to an honest desire to enhance quality of life, or personal well-being, while the third encourages individuals to experiment with new methodologies or approaches for recovery: methodologies, or guidance, which exists outside the mind of the person seeking help in the first place, I’ll add. God-language aside, this essentially advocates for something Albert Einstein said, when he remarked that “No problem can be solved from the same level of consciousness that created it.” As for whether it’s a higher power that needs to be sought after to resolve the dilemma, I don’t know. But at the very least it’s a different power, and that counts for something. Asking for help is hard for a lot of people, myself included, and having some level of faith in that external support can be hugely impactful on the results. As was true with my experience, I gained far more from the tools provided to me from meetings, conversation, and step work with my sponsor than I did from the Big Book or the steps as they’re written. Using this anecdotal evidence, along with how little of a direct line between A.A.’s steps and CBT principles there appear to be, I’m going to jump around a little in terms outlining my points.

An interesting connection I noticed between OCD and addiction is an onset of anxiety that develops in the presence of uncertainty among those struggling with either. For OCD, compulsions or safety behaviors tend to support some sense of control on behalf of the individual taking the action; control, I’ll add, that serves to decrease that individual’s feeling of uncertainty. Without getting deep into it, what’s considered the “gold standard” of treatment for OCD is a technique called exposure and response prevention therapy (ERP). There’s so much more to it than this, but the part of it relevant to this discussion comes with purposefully manufacturing exposure to an anxiety-inducing stimulus or situation, and preventing or delaying a ritualistic behavior in response to the trigger. The last part of that is an important component because of the re-wiring (or “reconditioning”) that takes place, nurtured by repetition, to strengthen a different set of connections in the brain and influence feelings, thoughts, and emotions that arise in similar circumstances. Essentially, the more times you can delay or prevent yourself from responding to a certain feeling in a compulsive manner, the less likely you are to respond to it in that way in the future.

There’s also a component of this that relates to neuroplasticity, which is the brain’s ability to adapt and change in both structure and function as a response to personal experience. When talking of addiction, one could say that responding to triggers with addictive behaviors makes the addictive behaviors stronger, while responding to triggers with life-affirming actions makes life-affirming actions stronger. The way I was able to understand it is to think of the brain as a giant mountain, and the brain’s pathways as ski-slope trails. At first, atop a thick dusting fresh snow, it’s very difficult to carve out a new trail. With that obstacle of resistance in the way, the path of least resistance is to literally proceed down the pre-existing trails. In this case, those pre-existing trails include habits, addictive behaviors, and safety behaviors. But with persistence, repeated attempts to carve a trail into the untouched snow helps create a more defined pathway; one which becomes easier and easier to navigate, before it eventually offers no resistance. This new path can become the default option.

Cognitive behavioral therapy helps support the development of new pathways by following a similar line of thinking as that promoted by Alcoholics Anonymous, particularly in A.A.’s use of the Serenity Prayer. It reads, “God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” The wisdom to know the difference, as CBT might suggest, is the ability to recognize the difference between that which is not under one’s own control (thoughts and feelings) and that which is (behaviors). Think of CBT as a triangle, with each corner occupied by either thoughts, feelings/emotions, and behaviors. It doesn’t matter where they land on the triangle, because each influences the other; there’s a bi-lateral relationship between all three, such that emotions influence thoughts and behaviors, thoughts influence emotions and behaviors, and behaviors influence emotions and thoughts.

CBT Triangle Thoughts Feelings Behaviors

It’s regularly recommended in A.A. to attend 90 meetings in 90 days when first getting sober. From the position of an A.A. cynic, this could easily be interpreted as a militaristic approach to indoctrination, but there are some practical aspects of following the advice. Beyond utilizing accountability surrounding actually showing up somewhere in support of one’s own recovery, this works to strengthen the muscle of taking a specific action, regardless of whether or not you feel like doing it. It’s regularly said in A.A. that you can’t think your way into right action, but that you have to act your way into right thinking. This is pure CBT, recognizing how behaviors influence feelings, and when repeated can also influence thoughts. The more often you do something, like getting up off the couch, getting your keys, getting in the car, and driving to an A.A. meeting when you don’t feel like it, the more you’re helping create a new trail on the ski slope; this is an act in support of changing the behaviors in you’re life that you can control.

The same line of thinking is behind such commonly used suggestions as making your bed in the morning, or reaching out and calling another person who’s in recovery on the phone every day. Both have surface level benefits, but the activity also promotes a behavior that serves to break old habits and develop new ones. This also helps to normalize feelings and thoughts that would otherwise drive unproductive or damaging behaviors, providing evidence that feeling a certain way doesn’t necessarily have to result in behaving a certain way. This is sometimes referred to as distress tolerance, and the function of developing it as a muscle is a game-changer in recovery as it aids in the development of a mindset that recognizes the discomfort of anxiety but responds by acknowledging that the anxiety doesn’t have to lead to a specific behavior. Feelings and emotions will pass, in time, if you let them.

Within the context of CBT, “behaviors” aren’t purely physical actions, but they can also sometimes relate to our thoughts and how we interact with them. A.A.’s fourth step reads that members “Made a searching and fearless moral inventory of ourselves.” This step is vague on the surface, but at its core the exercise helps promote an awareness around internal responses, core beliefs, and negative-self talk. CBT isn’t purely a technique to promote action in the face of friction-producing thoughts and emotions, but it also serves to help change one’s own relationship with their thoughts. In A.A. I’ve heard the suggestion, “Don’t believe everything you think,” and while it seems obvious on the surface, it can be seriously damaging to believe everything you think. In some regard, we are thought processing machines, with our minds serving up tens of thousands of thoughts a day. Each conscious thought sounds like us, arising from our own mind, so, why then, wouldn’t we give our own thoughts the benefit of the doubt and assume they’re true? As Oliver Burkeman relates in his book, The Antidote: Happiness for People Who Can’t Stand Positive Thinking, he writes,

“It is when we identify with this inner chatter, Eckert Tolle suggests⁠—when we come to think of it as us⁠—that thinking becomes compulsive. We do it all the time, ceaselessly, and the idea that we might ever enjoy a respite from thinking never occurs to us. […] The way out of this trap is not to stop thinking⁠—thinking, Tolle agrees, is exceedingly useful⁠—but to disidentify from thoughts: to stop taking your thoughts to be you, to realize, in the words of The Power of Now, that ‘you are not your mind’. We should start using the mind as a tool, he argues, instead of letting the mind use us, which is the normal state of affairs.”

“Cognitive fusion” occurs when there is no space between the thought and the reaction to our interpretation of it. In shifting to a perspective that thoughts are not facts, that they’re only just thoughts, such awareness can help crack open a little bit of space between oneself and that inner dialog, where thoughts can then be challenged. There are numerous helpful techniques and approaches available for anyone struggling to create this “cognitive defusion,” each of which contribute to developing awareness around which internal red flags to look out for, particularly as it relates to recognizing the automatic nature our thoughts and how false beliefs and insecurities can promote misguided thinking and destructive behaviors. When those red flags, mental traps, and problematic patterns start showing up we can choose to let them exist unchallenged, or we can attempt to challenge them.

A.A. uses the term “resentments” when discussing lingering feelings toward people, places, and things that continue to sit with its members long after they’ve outlived their usefulness. Not entirely dissimilar to its approach with the fourth step, A.A.’s eighth step reads that members “Made a list of all persons we had harmed, and became willing to make amends to them all.” A portion of this step is set in place to encourage ownership of problematic behavior, but also to change the behavioral response to problematic thinking. I want to bring back around the complicated nature of those who are struggling with addiction, and the “terminally unique” mindset which I detailed several chapters back, because of how it can further complicate the outlook of individuals seeking sobriety.

As Chandler McMillin and Ronald L. Rogers write in Under Your Own Power: A Secular Approach to Twelve Step Programs, “After months or years of manipulating others in order to gain access to drugs or protect [themselves] from the consequences of drug use, the addict may assume that everyone else’s motives are as self-serving as [their] own.” While hardly a “unique” phenomenon, it’s difficult to characterize the distorted thinking that develops within the addicted mind for those who haven’t experienced it first-hand; it embodies the spirit of personal exceptionalism, amplifying pre-existing patterns of thinking. I’ll refer to those patterns of thinking here as “cognitive distortions” because of how they can warp and distort reality. Here are several common cognitive distortions which are commonly experienced by those with addiction issues:

  • “All or nothing thinking,” which is a cousin of the perfectionistic thinking I’ve previously outlined, showing up as thinking in terms of “always” or “never.”
  • “Catastrophizing,” which is seeing the worst possible outcome of a situation.
  • “Magnification” or “Minimization,” which is exaggerating or downplaying the importance of events.
  • “Personalization,” which is believing you’re personally responsible for events outside your control, or that other people’s otherwise unrelated actions somehow have something to do with you.
  • “Jumping to conclusions,” which is interpreting meaning of a situation without adequate evidence.
  • “Mind reading,” which is projecting motivation of others’ actions, or interpreting another person’s thoughts or beliefs without asking for clarity.
  • And “Should statements.” This was best described to me by a past therapist of my own, who once said, “Be careful of using ‘should’ or you’re likely to should all over yourself.” This is a belief that things should be a certain way and nothing else will do.

These are thought traps we all deal with at some point in time, but they’re also warning signs for those with histories of addiction to watch out for because of what tends to follow.

Through the aforementioned step work, A.A. calls out an individual’s misguided thinking, and the tenth step adds that members, “Continued to take personal inventory and when we were wrong promptly admitted it.” Framed within the context of CBT, this attempts to encourage maintained awareness surrounding cognitive distortions or problematic behavior. A.A. recommends taking a daily inventory, in essence reflecting on what went right and what went wrong each day, to support course correction before thoughts or behavior get out of hand. It also promotes an idea akin to outsourcing one’s own thinking when cognitive distortions are taking over, which is accomplished by calling one’s sponsor or another A.A. member to help identify errors in their thought process. I’ve repeated it numerous times already in this series, but it can’t be said enough: If you have to go into your own mind, sometimes it’s best not to go alone.

If there is a point to this chapter, it’s to emphasize the importance of overcoming any urge to find faults with any particular system or methodology when first getting sober. As an example, take the perspective which was used at the rehab I went to in 2008, which promotes a three step approach to curbing addictive behaviors. This is achieved by recognizing: “1) Our thoughts shape our experiences, guiding how we view the world; 2) Personal consciousness is what makes our thoughts appear real; and 3) The mind is the source of both consciousness (the ability to become aware of your life) and thought (the power to think, and thus the ability to create reality).” They called this “health realization,” but it certainly does sound a lot like cognitive behavioral therapy. Earlier, I briefly mentioned a teaching from Eckert Tolle’s focused on mindfulness. There is certainly some overlap between mindfulness and CBT, as well, but also with cognitive defusion, and A.A.’s own recommendation of using meditation as a tool to help promote clarity of mind. Different schools of thought use different language and bear different perspectives which might speak to people in different ways, but if you’re open to seeing the commonalities between them they certainly do exist. There isn’t one best way to get sober or pursue recovery, and I’ll bring this back around full-circle to how I began this chapter by clarifying that the best plan for recovery is the one you’re willing to try. Not picking a starting point is every bit as much of a choice as diving in and seeing where the path can lead.

Terminally Unique - Alcoholism - AA - Addiction

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[The track opening and closing the episode is called “styles.”]