AN ANALYSIS OF THE 12 STEP RECOVERY PROCESSES FROM A COGNITIVE-BEHAVIOURAL POINT OF VIEW: COMPARING AND CONTRASTING HOW THOUGHTS AND BELIEFS ARE MODIFIED AND NEW BEHAVIOUR IS ADOPTED IN AA/NA WITH HOW THIS IS ATTEMPTED IN COGNITIVE THERAPY.
INTRODUCTION: The above question is interesting in that once an understanding of AA’s 12 Step recovery process is gained, it can be seen that cognitive-behavioural interventions are inherent within its therapeutic framework. Indeed, by the end of the second part of this essay, after comparing and contrasting the two approaches, I hope to be able to show that there is not a lot of difference between them; and that both approaches can be integrated in a ‘combined approach to substance abuse’. (Waller and Rumball, 2004, p. 83-84.) Incidentally, 12-Step facilitation (TSF) – the model utilised by the Welsh Council on Alcohol and Other Drugs (WCAOD) - which is an independent treatment based on the 12 step philosophy of Alcoholics Anonymous (AA, 1976).is not addressed in this essay but can be accessed under the heading The Central Ideas in the Philosophy of the 12-Step Programme.
First of all, to answer the question, it will be useful to give a brief overview of the AA 12 Step process as a change mechanism to induce a healing/recovery state for addiction that is ‘transcendental and non-positivist by its nature’. (Flores, 1988.) (See also appendix 1.)
Prior to analysing the 12 Step recovery process from a Cognitive-Behavioural point of view (CBA), however, I will briefly define CBA as a collaborative coaching and teaching model which examines the thoughts and beliefs connected to our ‘moods, behaviours, physical experience, and to the events in our lives - and challenges our perception of those thoughts and beliefs’.(Greenberger and Padesky, 1995.) Thus, a conditioned response, if the stimulus is overridden using CBA, can become de-conditioned - and new healthier habits substituted for old injurious, maladaptive ones (Waller and Rumball, 2004).
THE COGNITIVE-BEHAVIOURAL APPROACH “AT WORK” IN THE 12 STEP RECOVERY PROCESS: Let’s first of all look at some of the 12 Steps:
Step 1 says ‘We admitted we were powerless over alcohol - that our lives had become unmanageable’ (AA, 1976). Step1, from a Cognitive-behavioural approach, challenges the member’s ‘core belief’ that ‘he is in control’ of his thoughts, behaviour, using/drinking, etc – that he has choices and that he is powerful. In a CBT way it looks at the evidence and asks in a ‘Socratic’ way, ‘What is the evidence for that belief?” (Beck et al., 1993.) In an AA meeting, the member will ‘share his experience, strength, and hope’ with the group. Invariable, ‘his experience’ will amount to proof-positive that his core belief is maladaptive – he’ll refer to countless examples where ‘loss of control’ occurred and damage resulted to himself and significant others. Additionally, he will listen to others “share” in AA meetings how they were powerless over alcohol; and the fact that his marriage might be in difficulty; that his finances are in a mess; or that he is unemployable, reinforces the ‘thought replacement’ that “he is powerless over alcohol, and that his life is unmanageable”
To further reinforce Step 1, a CBT counsellor, if he were trying to achieve the same outcome, might issue the AA member with a ‘Thought Record’ to help limit his drinking and achieve abstinence (which is a goal and a ‘prerequisite’ for recovery in AA), and to monitor how an internal or external ‘high-risk stimuli triggers an automatic thought, e.g. “Life isn’t worth living, but I can make it better if I have just one drink”. The member would be instructed how to complete the Record, and how to rate the emotion that arises from the automatic thought, and how to counter it with a Rational Response, e.g. “I’ll end up in a mess again if I take that one drink, ‘[I] know that no real alcoholic ever recovers control’ (AA, 1976).
Step 2 ‘Came to believe that a power greater than ourselves could restore us to sanity’ (AA, 1976). The member’s core belief here might be, “I am sane” (i.e. not suffering from a compulsive obsession). Again, CBT would challenge that thought and ask him to look at the evidence. “What went though his head when he picked up that drink?” (Beck et al., 1993.) And the answer, usually, is that he has been doing ‘the same thing over and over again’ hoping to get different results. “This time I thought I might be able to control my drinking” he says, but that ability to control his drinking never materialised – ‘All of us felt at times that we were regaining control, but such intervals – usually brief – were invariably followed by still less control, which led in time to pitiful and incomprehensible demoralization’ (AA, 1976. P.30). Step 2, says you haven’t been sane, and need to be restored to sanity; and if you need any further proof, just ask any long-term member in AA or read ‘The Doctor’s Opinion’ and ‘More about Alcoholisms’ in the Big Book. (AA, 1976, p.xxiii/30.) Step 2 is a restructuring/reframing process. (Beck et al., 1993.)
Step 3 ‘Made a decision to turn our will and our lives over to the care of God as we understood him. (AA, 1976.) The ‘core belief’ here might be “I can’t trust anyone else to help me; I have to do it by myself’. However, if the member looks at the evidence, as CBT invites him to do, he finds that he cannot ‘do it alone’ and needs to find a power which is extrinsic (other than self). ‘Lack of power - that was our dilemma. We had to find a power by which we could live, and it had to be a Power greater than ourselves’. (AA, 1976.) CBT is about challenging that core belief in order to affect feelings - which changes the way the member behaves. (Waller and Rumball, 2004.) The first three steps are ‘conclusions of the mind’ – no action is yet needed; they are ‘thinking interventions’ and part of a larger restructuring/reframing process. They merely tell the alcoholic what the problem is.
The ‘action’, that the alcoholic hopes will resolve his problem and change his thinking and feeling (AA’s refers to them as “altered attitudes”), begins in Steps 4 through to 12. As the Big Book of AA says, ‘Next we launched out on a course of vigorous action – the first step of which is a personal housecleaning which many of us had never attempted.’ (AA, 1976, p.63-64.) This is pure CBT as I shall now demonstrate:
Step 4 ‘Made a searching and fearless moral inventory of ourselves.’ (AA, 1976.) The purpose of this step is to discover, within the individual’s character, the hindrances to sobriety by overcoming self-defeating attitudes, beliefs and emotions that put him at risk of relapsing. For example, the AA member might have a great fear of financial insecurity. The CB approach would challenge his negative automatic thoughts around this fear “I will be made bankrupt; I will loose everything” using, possibly, the ‘three question technique’: ‘What is the evidence for that belief? How else can you interpret that? If your belief is true what are the implications?’ Or, alternatively, the member can be helped to “decatastrophise” using the ‘downward arrow technique’ which would re-evaluate and modify his maladaptive, negative thoughts. (Beck et al,. 1993.) And so on, by ‘thought replacement’ and ‘reconditioning his thinking’, the alcoholic can address other issues such as ‘anger’ ‘unresolved grief’ and ‘depression’. A ‘Daily Thought Record’, whereby the alcoholic is able to examine a maladaptive belief about drinking in a ‘more systematic’, detached way is also an invaluable technique. (Beck et al., 1993.) However, Step 4, is about dealing with ‘resentment’ which, according to AA, is the “number one” offender.
AA suggests writing them on paper (a ‘formal homework assignment, which is a component part of the CT therapy session), and listing any resentments against ‘people, institutions or principles with whom we were angry’ (AA, 1976. p. 64.) For example, in the first column under the heading I’m resentful at: the AA member might write ‘My father’; under the next column headed The cause: he might write ‘He didn’t love me’. And that is as far, usually, as the alcoholic ever gets – blaming and criticising (AA,1976, p.66). But, AA, from a CBT point of view, asks him to check out the evidence for that thought, and, by doing so, he confronts a ‘core belief’ that he has never before challenged its veracity: “I’m not lovable.”/“I’m worthless.” But hang on, that’s not all – AA, again in a CBT way, is now asking the alcoholic to view this resentment from ‘an entirely different angle’ - because in the third column he is asked to write down how he allowed the resentment against his father to Affects his: ‘self-esteem (personal relationships/companionships), his security (personal, emotional and financial), his ambitions (personal and social), and his personal, or (hidden) sex relations? (AA, 1976, p.65). And now, a perfect piece of Reality Therapy concludes the inventory and the restructuring process - because the alcoholic, would you believe it, is now being asked in the fourth column to Look at his own mistakes! ‘Where had he been selfish, dishonest, self-seeking and frightened?’ Reality Therapy, incidentally, operates in the ‘here-an-now’ and is a ‘behavioural’ component of CBT - and, as in this case, is about a sense of ‘resolution or commitment’ that powers the decision-making process, ‘which is felt in the musculature’ (Beck et al., 1993, p.35.) The Advantage-Disadvantage Analysis could also, theoretically, be used here to gauge the benefits or otherwise of ‘Holding on to the resentment’/’Not holding on to the resentment’.
The alcoholic, whose locus of control has hitherto been extrinsic (relying on ‘people places and things’ to satisfy his needs), is being offered a ‘restructuring exercise’ - through Reality Therapy, which asks “How has your behaviour helped you to get your needs met?”, and through the four columns of the Step 4 process - in order to help him see that his needs cannot be satisfied extrinsically. If AA is to be successful, the member needs to transfer to an intrinsic locus of control – that is the purpose of the 12 Steps, because AA believes that ‘only a spiritual experience would conquer alcoholism’, and ‘only God could and would relieve it.’ (AA, 1976, p.60.) In CBT parlance, incidentally, ‘intrinsic’ means helping the alcoholic to ‘reattribute responsibility’ for his drinking to himself so that he can take the initiative to modify his alcoholic behaviour.
OTHER ASPECTS OF THE AA RECOVERY PROCESS FROM THE POINT OF VIEW OF THE ‘BEHAVIOURAL’ COMPONENT OF CBT: Self-efficacy is an integral part of the social learning cognitive framework, and is defined as ‘a perception or judgment of one’s capability to execute a particular course of action required to deal with an impending situation’ (Thombs, 1999.) In AA, alcoholism is seen as an ‘ongoing’ crisis whereby the recovered alcoholic has only ‘a daily remission contingent on keeping in fit spiritual condition’ (AA, 1976, p.85) – and, as such, his ‘ongoing’ crisis qualifies as an ‘impending situation’. Self-efficacy has two components – ‘outcome expectations’ and efficacy expectations’ (Thombs (1999, p.150) – both of which are adequately provided for in AA. For example the practice of celebrating AA birthdays with a birthday cake, or giving chips or key-rings as rewards for staying sober, demonstrates to the newcomer that a specific course of action (not drinking and working the steps to the best of his ability) will lead to a similar outcome for himself. Additionally, seeing somebody else who, by his own admission in his ‘birthday share’ earlier that same evening, admitted to once feeling just “as hopeless and inadequate”, reinforces the newcomer’s belief (or ‘efficacy expectation’ ) that he too can carry out the necessary course of action to obtain a similar outcome.
In CBT, one way of helping client’s reduce the arousal cravings which can lead to relapse, is to use Flashcards, because generating ‘coping statements’ can help the client through such critical periods. In AA, this method is used to reinforce behavioural skills which help sustain continued abstinence, e.g. “One day at a time”/”Keep it simple”/“Let go let God”, etc. This way, the AA member also learnt about the ‘dysfunctional’ beliefs and maladaptive behaviours which are the antithesis of the ones the slogans positively reinforce. (Beck et al., 1993.)
Using an AA sponsor; attending regular AA meetings, and meeting new, sober friends for coffee, etc are all part of the ongoing social restructuring that the newcomer undertakes to stay sober (they also act as a reinforcement of irrational behaviours and thinking through identification of shared experience.) In CBT, the process would be described as ‘Graded Task Assignments’ – whereby the alcoholic would be encouraged to engage in ‘approximations’ of whatever behaviour is desired in order to ‘build’ towards the desired goal, e.g. ‘instead of mixing with old friends who are heavy drinkers, the newcomer would be encouraged to meet a sober member of AA (his sponsor possibly) for a ‘chat over coffee’. The practice of attending ‘ninety meetings in ninety days’ or practicing the acronym HALT - don’t get Hungry, Angry, Lonely or Tired, which are ‘triggers’ to relapse – is, likewise, effective behavioural reprogramming.
I could, if space allowed, continue analysing the AA’s recovery process from a CBT point of view – notably referring to Steps 6, 7, 8 & 9, and the 10th Step, in particular, which is “pure” CBT - in that it satisfies all the criteria according to the definition of CBT which I included as part of the introduction to this essay.
COMPARE AND CONTRAST HOW THOUGHTS AND BELIEFS ARE MODIFIED AND NEW BEHAVIOUR IS ADOPTED IN AA WITH HOW THIS IS ATTEMPTED IN COGNITIVE THERAPY.
A common ‘brand’ of CBA is Aaron T. Beck’s Cognitive Therapy (CT) of Substance Abuse (Beck et al., 1993) – a therapy which he adapted from his ‘Cognitive therapy of depression’ (1979). (For more detail of how CT works see appendix 2.) One major difference between CBT and CT, however, is that CT does not deal with the root causes (or maladaptive ‘core beliefs’), which trigger the ‘automatic thoughts’ that lead to relapse and/or continued abusive drinking – rather, it deals with the “symptoms” – which are a combination of the ‘automatic thoughts’ and ‘permission-giving beliefs’. (Beck, et al., 1993.)
AA differs from CT with the assumption that peer support is fundamental to recovery, and is therefore commonly undertaken in group settings; it is referred to, incidentally, as ‘a programme for life’. (Nowinski, 2003.) CT, on the other hand, is facilitated collaboratively by a specialist in short term, one-to-one coaching/teaching methods whereby the alcoholic learns about the relationship between ‘situations, cognitions, affect, craving, behaviour, and abusive drinking’. (Beck et al., 1993, p. 112.) AA is a natural, highly structured, social method to achieve and sustain abstinence which involves a belief system rather than a specific intervention (Waller and Rumball, 2004). No one in AA is saying “Look, today you’ll be doing so and so”; instead the alcoholic learns through listening to others attending the programme. Not even a sponsor (a “buddy” who is abstinent and working the steps in his daily living) counsels. AA believes in stopping the behaviour (drinking) to change the thinking; whereas CT changes the thinking to stop the behaviour. Abstinence is needed, therefore, in order for the AA programme to work successfully - it is not the primary concern, however, of CT, which can relieve psychological harm and ‘aid the process of recovery before abstinence has been achieved’. (Waller and Rumball, 2004. p. 24.) CT views ‘remission’ or relapse as a characteristic of substance abuse – and a major goal is that the clients ‘learn from whatever setbacks in long-term abstinence goals they may have’ (Beck et al., 1993. p.292.)
CBT has been extensively evaluated - and in particular, its derivative, CT, which has undergone rigorous clinical trials, as has Twelve-Step Facilitation (TSF), a programme of recovery based on the 12 Step approach of AA, and usually utilised in Tier 4 specialised alcohol treatment settings: – both their effectiveness has been shown empirically (NIAAA, 2005). This is important because it is a requirement these days by government and funding agencies (Gossop, 2006).
AA believes that alcoholism is an illness, as does the ‘Traditional Medical Model’ suggested by E.M. Jellinek (1960) and others, who viewed it as a medical disorder where there is a biological disposition towards addiction, and a biological vulnerability expressed as ‘loss of control’. AA describes the illness as ‘being beyond [the alcoholic’s] mental control’, and as a progressive illness - ‘over a considerable period we get worse, never better’.(AA,1976. p.3.) From AA’s perspective, therefore, the experience is ‘truly one of losing control - rather than one of not deciding to exercise control’, as in CT which views alcoholism ‘as a set of learned behaviours that are acquired through experience’ (Marlatt and Donovan, 2005, p.65).
CONCLUSION: AA believes that ‘only a spiritual experience would conquer alcoholism’ – an experience, which is defined in the Big Book of Alcoholics Anonymous (AA,1976. p.569), as ‘an immediate and overwhelming “God consciousness” followed at once by a vast change in feeling and outlook’. AA is deep; it’s spiritual; and the alcoholic has to find his own language to express that spirituality (Doe, 1957). And it is this spirituality more than anything else, I believe, that is the biggest contrast between the AA approach and CBT. Otherwise, both recovery approaches are perfectly compatible, as I’ve demonstrated, I hope, during the course of this essay; they both just use a different set of jargon, that is all (as do all other treatment approaches: Motivational Interviewing. Group Psychotherapy; Person-Centred Counselling, etc). In the end, however, they are all doing the same thing: changing maladaptive behaviour. I trust the reader will agree with my contention that both 12 Step and CBT approaches can be integrated in a ‘combined approach to substance abuse’ (Waller and Rumball, 2004, p. 83-84) – and that there is, fundamentally, not a lot of difference, therefore, between CBT and the AA 12 Step recovery process.
************* APPENDIX 1 AA’S 12 STEP RECOVERY PROCESS: ‘Addiction must be viewed as a process that is progressive. Addiction must be seen as an illness - in AA it is described as a three-fold illness: physical, mental/emotional and spiritual; and unless there is ‘adjustment of personality’ on all three levels, there will be no permanent sobriety; additionally, it is an illness that undergoes continuous development from a definite, though often unclear, beginning towards an end point.” (Nakken,1988, p.4.) Simply stated, recovery in AA and its relatives (Narcotics Anonymous (NA), The Minnesota Model, Overeaters Anonymous (OA), etc) involves reaching a personal ‘rock bottom’ whereby the alcoholic or addict become motivated enough to stop. (Waller and Rumball, 2004.) Recovery, AA believes, is made possible through a realisation that ‘only a spiritual experience can conquer alcoholism’ (Flores, 1988) and involves moving from an external locus of control to an internal one – an experience which is actuated through practise of the 12 Step “suggested” programme of recovery, and which involves: 1) Self examination – alcoholics have to admit defeat, 2) Acknowledgment of faults – they also need to take stock of themselves and confess any defects to another person in confidence, 3) Restitution of wrongs done – they need to make amends for harm done to others and, above all, 4) Constant work with others – they need to practice the kind of giving that has ‘no price tag on it’, the giving of themselves to somebody’ (Flores, 1988). AA advocates abstinence and believes, from collective experience, that the illness is characterised by a loss of control. It is the first drink that does the damage by setting off a compulsive need for more. Alcoholics (and addicts in NA) do not say they’ll never drink (or use) again. They stay sober or clean ‘One day at a time’. The 12 Step AA/NA approach is structured, specific, solution-focused, goal-oriented and manual-driven, and is based on behavioural, spiritual, and cognitive principles. (Perkinson, 2002.) It is, as AA itself admits, ‘a programme for living’ – and, as such, is a ‘way of life’ for the lifetime of the recovered alcoholic or addict. (AA, 1976.)
APPENDIX 2 COGNITIVE THERAPY – A BRIEF OVERVIEW OF HOW IT WORKS: A common ‘brand’ of CBA is Aaron T. Beck’s Cognitive Therapy (CT) of Substance Abuse (Beck et al., 1993) – a therapy which he adapted from his ‘Cognitive therapy of depression’ (1979). Beck believes that relapse or ongoing abusive drinking is triggered, initially, by a high-risk stimuli which can be 1) internal e.g. a bout of depression or a feeling of isolation, or 2) external e.g. an argument with the wife, or the arrival in the post of a tax demand, which then activates ‘basic drug-related beliefs’ or ‘positive expectancy’ around drinking; and these can be: 1) Pleasure oriented – “It will be fun to get legless” 2) Performance oriented – “I will function better and become better at doing what I’m doing” and 3) Relief oriented – “I need a drink to get me out of the emotional pain I’m experiencing at this moment”; these then elicit ‘automatic thoughts’ which provoke and maintain painful or difficult emotional states e.g. “I am helpless” or “I am unlovable”, etc.; urges and cravings then occur; and these are followed by ‘permission-giving beliefs and thoughts’, which tend to: a) justify the client’s use of alcohol – “Nobody will know”, etc; b) encourage risk taking – “It’s OK I can handle it”, etc.; and c) provide entitlement – “I’ve worked hard so I deserve this drink”, etc. The alcoholic then focuses on finding the next drink – and relapse ensues, or the drinking bout continues. This cycle is repeated unless the ‘automatic thought’ and/or ‘facilitating beliefs’ are challenged. CT is intended to do just that by overriding these with ‘control beliefs’: e.g. “This stuff is poisoning me”. This model, incidentally, does not deal with the root causes (or maladaptive ‘core beliefs’), which trigger the ‘automatic thoughts’ – rather, they deals with the “symptoms” – which are a combination of the ‘automatic thoughts’ and ‘permission-giving beliefs’. (Beck, et al., 1993.)
BIBLIOGRAPHY: Alcoholics Anonymous. (1976). 3rd ed. New York: Alcoholics Anonymous World Services, Inc.
BECK, A. T., RUSH, A. J., SHAW, B. F., & EMERY, G., (1979) Cognitive therapy of depression. New York: The Guilford Press.
BECK, A. T., WRIGHT, F. D., NEWMAN, C. F., LIESE, B. S., (1993). Cognitive Therapy of Substance Abuse. New York: The Guilford Press.
DOE, J., PFAU, R., (1957). Sobriety without End. Minnesota: Hazelden.
FLORES, P. J., (1988). Group Psychotherapy with Addicted Population. New York: The Haworth Press.
GOSSOP, M., (2006). Treating drug misuse problems: evidence of effectiveness. London: NTA Publication.
GREENBERGER, D., PADESKY, C. A., (1995). Mind Over Mood – Change how you feel by changing the way you think. New York: The Guilford Press.
JELLINECK, E. M., (1960). The disease concept of alcoholism. New Haven:, CT: College and University Press.
MARLATT, G. A., DONOVAN, D. M., ed., (2005). 2nd ed. Relapse Prevention. New York: The Guilford Press.
NATIONAL INSTITUTE ON ALCOHOL ABUSE (NIAAA). (2005). NIH News [online]. Available from: www.niaaa.nih.gov/NewsEvents/NewsReleases/match.htm
[Accessed 15 Dec 2007].
NAKKEN, C., (1988). 2nd ed. The Addictive Personality – understanding the addictive process and compulsive behaviour. Minnesota: Hazelden.
NOWINSKI, J., (2003). Twelve-Step Facilitation. National Institute on Drug Abuse. [online]. Available from: www.nida.nih.gov/ADAC/ADAC10.html [Accessed 14 Dec 2007].
PERKINSON, R. R., (2002). 2nd ed. Chemical Dependency Counselling – A Practical Guide. California: Sage Publications.
THOMBS, D. L., (1999). 2nd ed. Introduction to Addictive Behaviours New York: The Guilford Press.
WALLER, T., RUMBALL, D., (2004). Treating Drinkers & Drug Users in the Community. Kundli: Blackwell Publishing