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.
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 9—writes, “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.
Step 7. Humbly asked Him to remove our shortcomings.
HS: The first time I did this step, my sponsor just told to me pray regularly to have my “character defects” removed. The second time, though, my sponsor (a new one) told me to pick one thing from my “small” list and one from my “large,” and to focus and pray about these items regularly, and also try to take action on them “in the real world.”
AS: A common CBT practice is to have a client create a dysfunctional thought record, which consists of writing about a situation and the emotions it precipitated. Then the client takes note of his automatic thoughts about the situation and the evidence that supports those thoughts; notes the evidence that challenges those automatic thoughts; and finally arrives at a new, alternative and more balanced thought. Praying about one’s character defects could have a similar effect, and repetition of an exercise like this should only increase its positive results.
Similar to a 10th Step, many CBT clients write daily thought records, or mood logs.
Step 8. Made a list of all persons we had harmed, and became willing to make amends to them all.
HS: Back to the pen and yellow legal pad: I made a list of all the people I’d hurt or offended over the years, whether directly because of drinking- and using-related behavior or otherwise, and listed the particulars of each case. I “became willing,” again, by just praying and thinking about making amends to these people.
AS: Identifying problematic behavior would be among the first things a client and therapist would discuss in CBT. This would include identifying damaged relationships. Volition is a necessity when it comes to therapy, as success will be limited if the client is unwilling.
Step 9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
HS: With my sponsor I went through the list I’d made in Step Eight, and started getting in touch with a handful of people at a time, telling them I wanted to meet up and talk to them about something. The first one I did was an old boss of mine. I met him at a coffee shop and laid out how my behavior had been lacking, and asked if there was anything I could do to make it right. He said that wasn’t necessary, and everything went fine. Other amends I made followed roughly the same script. I felt good when I finished each one, like I had straightened up something in my past that had gotten out of whack.
AS: CBT focuses on curbing problematic behavior in future situations, but that doesn’t mean there’s no room for addressing past consequences. In fact, doing so can bring validation and support of a client’s new, rational way of thinking. An addict doing the 12 Steps, like a client in CBT, might imagine that trying to make amends would result in hateful words or drama, but instead it is usually a validating and liberating experience.
Step 10. Continued to take personal inventory, and when we were wrong, promptly admitted it.
HS: My sponsor recommended that at the end of each day I write briefly about what happened that day, including anything I didn’t feel great about, as well as stuff I did well—and, if I needed to say to someone, “Hey, I’m sorry for X thing,” doing it right away.
AS: Many CBT clients do daily thought records, or mood logs. Daily “homework” in CBT helps the therapist gain insight into the client’s motivation to change, coping abilities and areas of dysfunction. For the client, it creates and maintains awareness of their thought and behavior patterns, and it puts the work done in session into practice in daily life.
Step 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
HS: Even though I am an atheist, I pray on a regular basis. (I’m not much one for meditation.) When pray, I think, “God, help me to stay sober today, help me to stay calm, and help me to be generous toward my fellows.” If something in particular is going on in my life that I’m having trouble with—work, say, or a relationship—I’ll often add that into my prayer. I think of prayer as a tuning fork for my mind, that will hopefully direct my attention toward what I want to work on or get better at on any particular day.
AS: Spirituality is not part of CBT, but mindfulness is—and prayer and meditation can lead to the sort of mindfulness that is one of the ultimate goals of CBT. Meditation also can be central to CBT, especially when dealing with generalized anxiety disorder. Relaxation techniques—including more guided imagery (“happy place”), breathing exercises and progressive muscle relaxation—are used to reduce anxiety.
Step 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.
HS: My sponsor told me to practice the 12th Step it by taking new guys through the Steps, and participating in AA meetings, by talking to newcomers and doing service. When I guide sponsees through the Steps, I feel like it really reinforces my own “stepwork.”
AS: CBT generally is a short-term therapy, focusing on specific life issues. While CBT clients do not, in turn, become therapists by virtue of their experience, many continue to have therapeutic maintenance sessions to continue addressing target behaviors. As with the 12 Steps, the hope is that, after completing CBT, one will possess the tools to cope with any related situations and address similar target behaviors that may arise in the future.
Alexis Stein, LCSW, is a psychotherapist with years of experience in the field of addiction. She specializes in individual, couples and group therapy in her Manhattan private practice. Hunter Slaton is The Fix's Rehab Review editor.