CBT provides a powerful set of interventions for the treatment of patients suffering from substance use disorders (Beck, Wright, Newman, & Liese, 1993; Newman, 2008), and works in a complementary fashion with 12-step approaches that provide patients with valuable social support and a methodology for change (Ouimette, Finney, & Moos, 1997). At times our patients pose questions about the compatibility of lessons they learn in their 12-step meetings with the principles of self-help they are learning in CBT. While it is important to acknowledge that there are differences between the two approaches, these differences can be bridged so that patients can avail themselves of both sets of methods without an undue sense of confusion or conflict.
The Concept of “Powerlessness”
In 12-step philosophy, persons must admit that they are “powerless” in the face of their addictions, and that their lives have become unmanageable. Patients sometimes ask us, “How can I take part in CBT self-help if I have to admit to being powerless?” Our answer is that the “powerlessness” which they are acknowledging has to do with their prior behavioral and cognitive habits that were maintaining their problems with substances. Indeed, when patients are actively involved in using their chemical(s) of choice, it is folly for them to continue to enact the same behavioral habits and to manifest the same problematic beliefs and yet expect to recover, and/or to have their lives improve. By utilizing CBT self-help skills, patients are trying something new that gives them a chance at positive change, whereas reverting to old patterns will disempower them and make their lives less manageable.
Absolute Abstinence Versus “Harm Reduction”
Patients sometimes enter therapy in a “stage of change” (see Prochaska & Norcross, 2002) in which they do not wish to become abstinent from drinking or using other psychoactive drugs. Instead, they profess to wish to reduce or “control” their drinking and/or using, but not to discontinue altogether. They may avoid 12-step meetings based on the expectation that they can attend only if they agree to an absolute cessation of drinking or using. Such patients may view CBT as a more user-friendly venue, especially if they have read about the concept of “harm reduction” (e.g., Roberts & Marlatt, 1999). These patients may jump to the conclusion that “a little bit” of drinking and/or using is “allowed” in CBT. In response to this assumption, we as CBT practitioners can make it clear that while we generally eschew “all-or-none” thinking, and while we believe it is better to make improvements in stages (via the behavioral concept of “shaping”) rather than make no changes at all, we also recognize that abstinence is indeed the safest outcome. Nevertheless, gaining “admittance” into outpatient CBT typically is not contingent upon a commitment to total abstinence, as it is important for practitioners to positively reinforce any attempts by patients to take part in treatment. Further, it is our intention that by teaching patients skills such as self-monitoring, tolerating unpleasant emotions, minimizing exposure to high-risk situations, postponing acting on cravings, and modifying addiction-related beliefs, they will gradually move closer to the goal of abstinence (something which may never happen if we insist on abstinence from the start).
We also do not want our patients to respond to a lapse by believing that this is as bad as a full relapse, lest they conclude erroneously that they “might as well relapse all the way” by drinking and using as much as they want (now that they’ve broken their abstinence). An important part of utilizing CBT is recognizing how to “nip a lapse in the bud” by re-doubling efforts to apply self-help skills, reaching out for social support, contacting the therapist to schedule a CBT appointment as soon as possible, and perhaps going to a 12-step meeting. For good measure, CBT therapists point out the all-or-none thinking that patients engage in when they state that they cannot go to a 12-step meeting if they are drinking or using. Not infrequently, 12-step groups will accept such participants, provided that they are honest in their self-disclosures and show genuine motivation to “work the steps.”
Is Pharmacotherapy for a Comorbid Disorder Just Another “Chemical Dependency?”
The treatment of comorbid substance use disorders with other psychiatric disorders (e.g., unipolar depression, bipolar disorder) often includes appropriate pharmacotherapy. Unfortunately, some patients misconstrue taking medications (such as mood stabilizers) as being synonymous with chemical dependency. In response, CBT therapists provide psycho-education, explaining that while some medications (such as anxiolytics) that are quick-acting, have a short half-life, and can induce an immediately noticeable “altered state” are often contraindicated in patients with chemical addictions, there are other medications that do not pose such a risk. Slow-acting medications (e.g., anti-depressants, mood stabilizers, anti-psychotic medications) that do not create a “buzz” do not pose a risk to the person with substance use disorders. We add that a clinically significant “chemical dependency” refers to the habitual use of chemical(s) that impair the user’s ability to function well in their life roles as family member, friend, student, employee, employer, and citizen. By contrast, taking a properly prescribed and monitored medication that improves and sustains a person’s ability to function well in their important life roles is not a problematic chemical dependency to be avoided. To be fair, it seems that most people who take part in 12-step groups see it this way, too.
This is one area where CBT and 12-step principles agree entirely. A person’s thinking style is a very important part of their overall psychological functioning and recovery goals. The ability to look at oneself and one’s life with greater objectivity, openness to new facts, and a systematic (non-impulsive) process is central to making good decisions, improving self-efficacy, and maximizing healthy, favorable outcomes. Participants in both CBT and 12-step groups (as well as their therapists and sponsors) watch out for such faulty thinking as:
- Permission-giving beliefs: Also known as “rationalizations,” these are beliefs in which people spuriously justify their drinking and/or using. An example is, “I haven’t used cocaine for three months, so I think I’ve earned the right to use this weekend.”
- Magnification of craving: Here, people who are considering or trying to be abstinent dwell on the idea that their cravings will continue to increase unabated until they either “go nuts” or give in and use. They do not consider a third option – that the cravings are manageable and will naturally subside — and they will neither “go nuts” nor necessarily have to use.
- Apparently irrelevant decisions: This type of thinking pertains to how people set themselves up for lapses and relapses by unnecessarily choosing to put themselves in vulnerable positions, “reasoning” to themselves that they didn’t see the harm. An example is a person in recovery who drives his friend to a bar (“just to drop him off”) rather than explain (to himself and the friend) that this would be too risky to his own sobriety.
- Hopelessness: This kind of thinking is dangerous to a person’s sobriety, and perhaps to his or her life as well. Hopelessness invites someone to give up, to stop all attempts at coping, and to “not care” what happens. It runs completely counter to “working a program.”
Therapists providing CBT to their patients with substance misuse problems can support the patients’ involvement in 12-steps groups without having to be concerned that the two approaches are incompatible. When patients demonstrate sufficient motivation to take part in both individual CBT and group 12-step meetings, it is important to support them, while at the same time being ready to explain some of the apparent differences in the tenets of the two approaches. Some straightforward reframing (as described above) is typically enough to reduce confusion, and in some areas (e.g., “stinking thinking”) the points of convergence speak for themselves.
Learn more at our CBT for Substance Use Disorders workshop.
Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York: Guilford Press.
Newman, C. F. (2008). Substance abuse. In M. A. Whisman (Ed.), Adapting cognitive therapy for depression (pp. 233-254). New York: Guilford Press.
Ouimette, P. C., Finney, J. W., & Moos, R. H. (1997). Twelve-Step and cognitive-behavioral treatment for substance abuse: A comparison of treatment
effectiveness. Journal of Consulting and Clinical Psychology, 65, 230-240.
Prochaska, J. O., & Norcross, J. C. (2002). Stages of change. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 303-313). New York: Oxford University Press.
Roberts, L. J., & Marlatt, G. A. (1999). Harm reduction. In P.J. Ott, R.E. Tarter, & Ammerman, R.T. (Eds.), Sourcebook on substance abuse: Etiology, epidemiology, assessment, and treatment (pp. 389-398). Needham Heights, MA: Allyn & Bacon.
Depressed clients often isolate themselves from others and withdraw from life. A depressed client of mine I’ll call Adam did exactly this. He began feeling depressed after his marriage ended. He stopped responding to calls and social invitations from friends and family members. He also stopped going to the gym and gave up his favorite hobby, golfing. When clients withdraw from life, they give up any chance of meaningful or pleasurable experiences, so their depression is more likely to continue and become more intense.
To counter the isolation and withdrawal common to depression, therapists can introduce behavioral activation. This strategy entails getting clients more active and involved in life by scheduling activities that have the potential to improve their mood. Research suggests that behavioral activation alone is an evidence-based treatment for depression, and may be particularly well-suited for chronically depressed clients (Sturmey, 2009). The following tip from the Beck Institute therapists can help make behavioral activation even more effective.
It’s important to focus on valued or meaningful activities instead of, or in addition to pleasurable activities as part of behavioral activation. Many depressed clients (especially those with chronic or severe depression) state that there aren’t any activities that give them a sense of pleasure. They may also come to the following session feeling frustrated and hopeless because they didn’t enjoy the activities as much as they had before they became depressed, or they didn’t enjoy them at all. While emotions and moods are temporary, values tend to be more stable and can serve as a guide for behavioral activation. We can obtain the client’s values by listing different value categories and then asking the client to rate the strength of each category from 0 (not valuing it at all) to 10 (the most they can value something). The categories we include are work, self-education/learning, volunteering, intimacy, family, friendship, religion/spirituality, entertainment/recreation, and health/fitness. Adam’s most valued categories were friendship (10), family (9), recreation/entertainment (8), and health/fitness (8).
The client’s value ratings indicate the best place to begin with behavioral activation. Start with the highest value rating, which, for Adam, was friendship. We ask our clients, “Why is [the value] important to you?” Adam responded that friendship was important to him because it provided mutual support and shared experiences. We then ask the client to list specific, concrete activities that make up the value category. For friendship, Adam’s list of activities included: poker night, golfing, watching sports together, going out to dinner, and regular phone calls. We then repeat these steps for the remaining high value categories. Typically, we won’t ask about a category if the client rated it below a 5 out of 10.
Finally, we help the client decide which valued activities to engage in. Instead of telling the client what to do, we collaboratively ask the client which activities they want to schedule. In his friendship category, Adam decided to call his friend, Matt, to inform him that he would be attending their weekly poker night on Wednesday. During poker night, Adam decided to seek support from his friends by talking about having a difficult time after his divorce and making additional plans for the weekend with whoever was available. He agreed to suggest they play a round of golf on Sunday.
Sturmey, P. (2009). Behavioral activation is an evidence-based treatment for depression. Behavior Modification, 33, 818-829.
Learn more about treating depression at the CBT for Depression and Suicide workshop.
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