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CBT and the 12 Steps Have a Lot in Common

It turns out that cognitive-behavioral therapy and the 12 Steps share plenty of DNA. A therapist and a sober Fix staffer compare and contrast, one step at a time.

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Spot the difference! Art: Danny Jock

By Alexis Stein and Hunter R. Slaton

04/19/13

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Beautiful Boy author David Sheff’s important new book, Clean, takes AA to task for the failings of some of its adherents and its undue influence on US addiction treatment. Yet he acknowledges that the program started by a soused stockbroker has saved millions of lives.

Why is that? Sheff—whom The Fix will host in a special event in Newport Beach on May 9writes, “researchers discovered that Bill Wilson unwittingly designed and implemented contingency-management, CBT, and group therapies that would prove to be valid evidence-based treatments.”

We wanted to find out more about how working the Steps is similar to cognitive-behavioral therapy (CBT), which focuses on helping someone change his or her dysfunctional emotions, behaviors or thoughts through goal-oriented, specific exercises. CBT is used primarily to treat patients struggling with mood disorders, depression, anxiety, substance abuse and personality disorders.

With that in mind, one of The Fix's sober staffers wrote up his experience of working each of the 12 Steps and shared it with Alexis Stein, LCSW, a New York City–based therapist with experience working with addicted people. Here’s what Stein had to say about where CBT and the Steps meet—and where they diverge.

AA’s First Step speaks to CBT's focus on the here and now. In both methods, it’s essential to first identify behavior patterns you want to change.

Step 1. We admitted we were powerless over alcohol—that our lives had become unmanageable.

Hunter Slaton: As “homework” for my First Step, my sponsor told me to make a list of 10 ways in which drinking and drugs had made my life unmanageable, as well as 10 ways in which I demonstrated my own powerlessness over drugs and alcohol.

Alexis Stein: AA’s First Step speaks to a main principle of CBT, which is a focus on the here and now. In both methods, it’s essential to first identify behavior patterns you want to change. This focus on recent displays of chaos and its consequences can serve as a motivator for curbing the behavior.

Step 2. Came to believe that a Power greater than ourselves could restore us to sanity.

HS: Step Two is one of the more ruminative steps. As such, I didn’t really “do” anything for this step other than read the relevant literature in the Big Book and the “12 & 12,” and let my sponsor know when I felt like I was ready. Furthermore, I was obviously already demonstrating my “belief” in this department in that I had started going to AA meetings.

AS: Some people struggle with the 12 Steps’ concept of a higher power. CBT places more of an emphasis on the individual and his empowerment—and yet, one of the most frequent symptoms of an active addict is resistance towards accepting help and letting others in. I often counsel my clients that they do not necessarily have to believe in the traditional idea of a higher power, but that they must have faith in something bigger or better than their current active addict self, which can include a more actualized version of oneself.

Step 3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

HS: For this step, my sponsor and I sat on a bench outside the church where one of my regular meetings met, and, again, read the relevant portions of the Big Book—including the so-called “Third-Step prayer.” As I read this prayer—out loud—from the Big Book, my sponsor and I actually clasped hands, sitting side by side on that bench. It felt a little weird, but it really did underline the importance of that moment.

AS: One goal of CBT is to instill that a person can gain control of how they interpret and deal with things in their environment, even if they cannot control everything in it—similar to the Serenity Prayer. When one commits to CBT, a part of them has to have faith in their therapist to guide them through the process. And connecting to someone—as with holding a sponsor’s hand and praying together—creates the sort of therapeutic alliance that is central to CBT.

That said, the divergence of CBT and the 12 Steps on this point of personal empowerment vs. turning over one’s will is one reason why most therapists feel that therapy is a necessary component of fighting addiction—albeit one that AA can complement.

Step 4. Made a searching and fearless moral inventory of ourselves.

HS: First, down the left-hand side of a yellow legal pad, I made a column list of all the people, institutions, or principles with whom I was angry, and why. Later, I went back and noted “What part of [my] self was hurt or threatened?” and “Where was I to blame?” Next, I listed all of my fears and why I had them.

AS: Making columns is much like using “thought records” in CBT. These are guided, often written exercises that are used to keep track of behaviors you want to address and to create awareness surrounding your emotional and cognitive responses. This also can give insight into the origins of our trauma, as well as core beliefs about ourselves and negative cognitions and negative self-talk. 

Step 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

HS: I met with my sponsor—for several hours, sitting on a jetty in Jersey City—and talked through everything I’d written down during my Fourth Step. He mostly listened, without judgment, interjecting at points where he saw a pattern appearing, or casually noting similarities to his own story.

AS: Step Five is equivalent to bringing your CBT worksheets/homework to the therapist to review. It facilitates mindfulness—a.k.a. attention and awareness towards your experiences, cued into your feelings and thoughts—which is an important concept in CBT. In this case, the sponsor behaved as a CBT therapist might: he engaged you and interjected his insights to help you notice your feelings and behaviors. CBT says that, by becoming more aware of ourselves, we acquire more awareness in moments of choice. This ideally helps us to avoid our more automatic negative thoughts or behaviors.

Step 6. Were entirely ready to have God remove all these defects of character.

HS: For this step, my sponsor told me to make two lists: one of my “small” character defects, and one of my “large.” Into the first I put things like, “lack of physical exercise,” while into the second I put stuff like “envy at friends and acquaintances’ success in their careers.”

AS: This step is reminiscent of the part of CBT in which the client and therapist create goal awareness and engage in goal rehearsal. A therapist will help a client identify situations where an undesirable behavior was demonstrated and decide how the client would prefer to react or behave. The therapist will often then use imagery exercises, encouraging the client to imagine himself in those situations and play out the situation using the desired responses and behaviors. The more practice, the more the client is desensitized to undesired emotions that the situation used to evoke.

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