Integrating 12-Step and Cognitive Behavioral Principles
Integrating 12-Step and Cognitive Behavioral Principles
Mark S. Carlson, PhD, LP
October 28, 2010, MARRCH Conference, St. Paul, MN
Checking on background of participants:
Primarily mental health or chemical health?
Familiarity with IDDT, 12 Steps and DBT?
Personal Background:
Psychologist who has worked with lots of folks with dual disorders
Over the years strove to make productive use of AA concepts
For many years I was a supervisor of a Day Treatment with a MI/CD track
and facilitated groups within that program.
Currently a faculty member at Argosy University—Twin Cities
The central organizing principle that has emerged in my practice and my experience with Al-Anon is the dialectic between acceptance and change.
State/National Backdrop: The Rise of Evidence-Based Practices
Six in all: Integrated Dual Disorder Treatment (IDDT)
Key Concepts in IDDT
(based on the “purple Bible”: Integrated Treatment for Dual Disorders
By Kim T. Mueser et al)
Stage-Wise Case Management
The Payoff Matrix: allows for discussion of conflicting motivations
Motivational Interviewing: accepts ambivalence as a point of departure
Cognitive Behavioral Based Treatment Plans
Harm Reduction
IDDT acknowledges AA as a support but doesn’t focus a lot on its
principles.
Two disciplines: need to find common language and common ground
Why is this so critical?
A lot of wisdom in both traditions.
With the majority of our folks dual-disordered, we need to be able to talk to each other for the sake of our clients.
Most therapists clients who have chemical issues, are familiar with and/or
embrace AA concepts and so it only makes sense to tap into and perhaps expand upon an existing worldview.
12-step groups are the primary available support group available
If SAMHSA and insurance companies increasingly endorse CBT over AA principles it is harder to effectively use 12-Step Principles without being able to translate concepts.
Relatedly, helps in writing behaviorally-oriented notes
Helps redefine one of the more controversial aspects of AA philosophy
i.e., powerlessness
And I fully believe that by trying to translate CBT and AA concepts into the language of the other, wider perspectives and novel applications emerge.
It certainly has been the case for me, in any case.
The folk wisdom of AA, looked at from a contemporary perspective, melds aspects of Zen, cognitive behavioral therapy (CBT) and Judeo-Christian belief. This parallels Marsha Linnehan’s self-conscious amalgamation of principles in DBT.
Key Concepts in 12-Step Philosophy that readily can be understood in CBT terms
The Serenity Principle: a dialectic of change and acceptance tasks
One Day at a Time: mindfulness
Powerlessness
Fearless Inventory
Making Amends
AA maxims are in essence cognitive modification
Discussion: Solicit most helpful AA sayings from group.
Can We Reconcile Evidence-Based and Spiritually-Based Practices?
Differing traditions in chemical health and mental health treatment
regarding the “separation of church and state”
The 12 Steps are “articles of faith” and can’t change as in an EBP
but our interpretation of them can (and must)
I lean in the direction of minimizing focus on higher power in my work
AA treatment wisdom can still be utilized
AA concepts can be fleshed out with EBP principles
I want to start with talking about DBT, which is a form of CBT and
HOW KEY CONCEPTS of DBT RELATE to the 12-STEP MODEL
(Dialectical Behavior Therapy concepts from Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan)
The dialectic: two contradictory things can be true at once
Acceptance and Change tasks embody the core of DBT as they do the Serenity Prayer.
Four dimensions to DBT Skills training
1. Mindfulness skills
Emotional Mind/Reasonable Mind/Wise Mind
Wise Mind combines the wisdom of the head and the heart.
DBT tasks parallel to the Serenity Prayer
Accept the Feeling
Change the Self-Talk or Behavior
The combination of both is Wise mind
Wisdom in the Serenity Prayer
Mindfulness “What” Skills: observe, describe and participate
Mindfulness “How” Skills: non-judgmental stance, one thing at a time,
focus on what works
Powerful exercise in therapy, especially when feeling stuck:
“I want you to close your eyes and take a deep breath. Hold it, hold it, and let it go. And one more time. Take a deep breath and hold it and hold it let it go. Now I want you to go to that quiet place that knows things, where you can get at the wisdom of the head and the wisdom of the heart. We’ll pose the question most on your mind right now and then let whatever thoughts or feelings surface come to mind without judgment. And after a minute or so, I’ll ask you to open your eyes and we can talk about what came up. And the question is… (State question. After a minute) All right you can open your eyes. What came up? (After client describes ask) So what do you feel your Wise Mind is telling you?
About 80% of the time a useful and emotionally grounded insight emerges. In some senses, the Wise Mind parallels Higher Power as this task has many similarities in structure to prayer.
2. Interpersonal effectiveness skills
Consider priorities, capability (what’s possible) and timeliness (does no harm)
3. Emotion regulation skills
Understand emotions
Looks at prompting events (triggers), interpretations that prompt those feelings (stinking thinking), how one experiences and acts on those feelings, and the after-effects of same.
Reduce emotional vulnerability
Build mastery, build positive experience, be mindful of positive
experiences (an attitude of gratitude)
Decrease emotional suffering
Letting go of emotional suffering (let go, let God)
Changing emotions by acting
Repair the transgression (making amends)
4. Distress tolerance skills
Distracting Self-soothe (healthily)
Improve the moment with imagery, meaning, prayer, relaxation, one thing in the moment (does one day at a time one better), vacation (20 minutes), encouragement
Radical acceptance
contact information: mcarlson@argosy.edu or 651-286-7970
Radical acceptance as an operational definition of powerless
and accepting what you cannot change
Try reading Marsha Linnehan’s definitions of “radical acceptance” in a chemical dependency/12-step context (pp. 176-77 of her book)
Discussion: How have you utilized mindfulness and other DBT concepts in working with your clients?
ADMITTING POWERLESSNESS
Probably the single biggest block to mutual understanding between AA and CBT.
CBT is all about empowering individuals through teaching them techniques
modify their feelings by modifying their thoughts.
Of course, we all know powerlessness is a complicated concept.
Talk about a dialectic!
we’re powerless over the influence that alcohol has over our lives AND we’re encouraging people to make major changes.
Original basis for powerlessness notion: counter to false arrogance.
Does powerlessness work as well as a notion for women who often need to be
empowered? Example of woman whose Higher Power was clearly Him.
Discussion: How do you handle the concept of powerlessness with clients for whom the concept is confusing—not the false confidence of someone who says they’ve still got a handle on their substance use—but rather the people who honestly say, I don’t like it or I don’t get it.
How could we operationally define powerlessness in life in general?
Put in other Serenity Prayer terms: what do we have power over (i.e., can change) and what things are we powerless over (i.e., need to accept)
I’ve broken down this into four cognitions (people often take exception):
We are powerless to change the past or the future.
“If only” thinking feeds depression and regret.
“What if” thinking feeds anxiety.
We do have power to take action in the present.
We are powerless to change other people’s behavior.
We do have power to change our selves.
We are powerless to change our initial reaction to events.
We do have power what we do with that initial reaction.
For example: do we decide to feed negative feelings.
My maxim: Feel the feeling, but don’t feed the feeling. We are powerless over perfection being beyond our grasp.
We can strive to do better.
When we think we can control what we can’t, that constitutes dysfunctional thinking in CBT terms.
Specifically regarding substances, I add:
We are powerless over how and when the urge to use a substance occurs to us and how strong that initial urge is.
We do have power over how we respond to that urge.
People who already like the Serenity Prayer, feel this frame helps them deepen its application. It is respectful of both CBT and AA.
In essence this discussion in therapy embodies Discernment.
That is to say, “the wisdom to know the difference.”
Working with our clients on how they define their power and powerlessness, seen in these terms, is a highly cognitive behavioral task.
CBT psychologists may also need to pay attention to the profound shift in perspective and meaning admitting powerlessness entails.
It is truly a paradigm shift.
In narrative psychotherapy terms, it is the second stage in a re-storying
process.
For folks who are only contemplating change, how can we help them
achieve this cognitive shift? Motivational interviewing is obviously part of the answer. Not sure it always captures the full implications of the shift.
Schema oriented CBT may be part of the answer.
Definition of schemas—as defined by Jeffrey Young.
Training therapists in how to navigate the complex ball of thoughts,
feelings and behaviors related to addiction.
Some questions/tasks for CBT therapists and CD counselors to consider:
Further explicating the Serenity Prayer principles of courage to change and the serenity to accept. Courage is not the same as being unafraid.
Serenity is not a key CBT concept. I think it should be.
Further, how do we best tolerate our fearfulness to still take helpful action?
Do powerlessness and acceptance take different shapes when dealing with mental illness vs. chemical dependency? With men vs. women?
STAGE TALK and the AA MODEL
Stages of change: precontemplation, contemplation, preparation, action, maintenance
Do we need more thought on what constitutes attitudes towards using at different stages, such as glorifying past use? Other examples?
The dry drunk reflects positions on the continuum is neither static, unidirectional or monolithic—ex: of abstaining young man & using friends
Belief (#2), Decision (step #3) and Readiness (step #6)
All intimately relate to Stage of Change theory.
contact information: mcarlson@argosy.edu or 651-286-7970
Three types of groups: persuasion, active treatment, relapse prevention
I think it’s positive that there are now considering change groups.
Are harm reduction, DBT and AA more appropriate at some stages than others?
We need to better answer in more sophisticated terms than motivational interviewing captures what helps individuals move to a new stage or solidify their commitment to the stage they’re at?
What makes it more difficult to decide or keep a commitment to change?
I want to return to the concepts of acceptance, change and powerless, as they amplify the critical concepts of
MAKING AMENDS and FORGIVENESS
Because we can’t change the past (past wrongs) all we can do is act in the present (make amends). Example of the depressed woman and the parakeet
Fearless Inventory and Making Amends thus become cognitive tasks.
A cognitive behavioral equivalent, I would argue, is the chain analysis.
How do things routinely go wrong in our lives?
How do we define “defects in character” in CBT terms?
STEPS in RELATIONSHIP RESTORATION
Neil Jacobson’s Integrative Cognitive Therapy approach for Couples
Initially focused on change tasks: learning communication and problem-solving skills. But there was the human tendency for couples to backslide
Acceptance tasks added to stability of couple gains.
“Every relationship has at least one unsolvable problem.”
Recurring Dialectic of Acceptance and Change
Making amends and forgiveness tasks take center stage.
The biggest obstacle to the aggrieved partner forgiving is bitterness.
Forgiveness research suggests this is a skill that has multiple steps not always intuitively obvious.
From Mary Hayes Grieco, The Freedom of Forgiveness: Eight Steps to Freedom
1. State your will to make a change in attitude and move on.
2. Express your emotions about what happened.
3. Release the expectations you are holding in your mind. Acknowledge reality. Open up to getting your needs met in a different way. Visualize letting go.
4. Give others responsibility for their actions and take yours.
5. Open to receiving healing energy.
6. Send unconditional love.
7. See the good in the person or situation.
8. Notice the physical change inside you and take the time to gently integrate it as your new way of being.
Discussion: What are the similarities you see between these eight steps and the twelve steps of AA?
BITTERNESS
Bitterness is anger that has solidified and taken root. Unlike anger, a feeling which can come and go rather quickly, bitterness tends to linger. It begins to feel less like a feeling, and more like a part of our personality. People who are bitter often say things like, "I wasn't always like this", as if their bitterness had become a part of who they are.
While anger is usually about a particular behavior or event, bitterness is usually about a relationship or a prolonged situation in our lives. It often has an aspect of helplessness or resignation to it. People who feel angry often feel moved to take action to correct the injustices in their life. People who feel bitter often sit and wait for the next injustice to come their way, because their life has begun to feel like an unending string of unfair treatment and they have largely lost hope of it ever being any different.
One of the ironies about bitterness is that once it has taken over, it becomes harder and harder to obtain any sense of relief. Even if the person we are angry at makes a positive change or does something nice, we greet the positive behavior with skepticism.
The self-talk of bitterness
Here are just a few things that people feeling bitter think to themselves when confronted by positive actions or events:
It won't last.
Too little, too late.
What kind of fool do they take me for?
Do they really think that makes up for everything?
What are they up to?
Why couldn't you have said/done that five years ago?
I'd like to trust it, but I can't bear to be hurt again.
If I accept this kind gesture, they'll think I've forgiven them for all the unkind things
they've done.
Each person has their own list of things they say to themselves that discourages hope and accepting the good things that happen, however rare they may be.
It is important to say that none of the above is meant to pass judgment on the person who has become bitter. People who fell bitter are often generous people who may well have been taken advantage of or treated poorly. They often are people who are slow to really let another person know how much their behavior is hurting them. By the time the increasingly bitter person finally convinces the other person how upset they really are, it is often late in the game. By this time, the person with bitterness may be so angry, the anger having become so solidified and intractable, that any movements in the right direction are met with more anger. The question becomes: how can a person consumed by bitter feelings regain a sense of hope, power and joy?
c 2010 Mark S. Carlson, PhD, LP
contact information: mcarlson@argosy.edu or 651-286-7970
STEPS TO TAKE IN OVERCOMING BITTERNESS
1) Recognize the feeling for what is.
Bitterness is not about specific behaviors or events. Every time someone or something disappoints us, we react not just to the current situation but to a perceived pattern of behavior or events. In short, we typically become more upset over what we see as a personality trait rather than a single behavior. Thus, when a spouse comes home late, we are bitter over their insensitivity and for all the times they have done similar things that have hurt or disappointed us. That's a normal reaction to have, but it is important to realize that the anger we feel is out of proportion to the particular act of coming home late. While it is not possible to stop feeling bitter over these disappointments, just by wishing we could, it is possible to start basing what we say on individual positive and negative events.
2) Accept that there is no way anyone can undo the past.
There is no way a spouse or a friend can make up for past wrongs, no way they can even the ledger, especially if we feel we have been wronged for years. To accept this, does not mean we have to be happy about our past, or even that we forgive the person or persons that have hurt us. What it does mean is that there is very little power for change in this area of our emotional lives.
3) Identify what you want in the present. Find a way to express those wants with as little anger as possible. Look at what makes it hard to express those wants.
Take a look at your needs in a variety of areas: what you need to hear, what specific help you need on various taks, what you need to have done to feel more loved, what you need to be doing to have more fun, what you need to help make time for you to have some rest and recovery time. Then look at what makes it tough to ask for these things: fear of disappointment, desire to be independent, fear of vulnerability, not wishing to put a burden on someone else.
4) Pay attention to whether you are able to take in the things you've asked for. Look at what makes it hard to receive them.
Sometimes, after it feels like your needs have gone unmet for so long, it is hard to accept them with a positive spirit. You may feel bitterness over why this good thing didn't happen years before, you may distrustful over your partner's motives, or may feel very skeptical whether this new behavior will last.
5) Identify what, if anything, you are willing or able to do to overcome these blocks.
Accept your feeling of distrust and skepticism as normal, but try not to express them to your partner in a bitter tone. Saying thank you doesn't mean you are forgiving or forgetting all past wrongs, or that you're saying the slate is washed clean or that the ledger is balanced. All it means is that you appreciate the intent behind that single action. If you need to express your mixed feelings about this new "good" behavior, express it as an "I" statement. Try saying, "Thank you for that. I'm having a hard time taking it in just now. I still feel angry," rather than reminding that person of there past shortcomings.
6) Interrupt dwelling on bitterness with a recognition of the feelings behind it. Then ask yourself the question, what can I do for myself today?
When you catch yourself thinking bitter thoughts, and you will, try and stop the ruminating, the endless replay of past wrongs and disappointments. Try to identify the feelings underneath your bitterness. Hurt? Frustration? Loneliness? Despair? Then ask yourself what you can try do to help meet the needs those feelings suggest to you. It may mean speaking to your partner, or calling a friend. It may mean distracting yourself. In any case, try to take action that helps you feel better, regardless of what the other person in your life does (or doesn't) do.
7) Cultivate patience and a healthy assertiveness.
The bitter person often feels they have already been too patient. And perhaps they have. Yet this may be the first time in a while that you are trying to work on this problem in a new way. Progress in overcoming bitterness will be slow. Bitter feelings will only fade gradually, as people get a sense that their needs and feelings actually can be met and acknowledged. But the bitter person must be able to acknowledge positive actions when they do occur. They need to do this both so their own hurt feelings can gradually be soothed and so their partner is reinforced in keeping up their new behavior. If both things happen, positive change and an acknowledgement of that change, bitterness will slowly fade. But patience and a healthy assertiveness will both be necessary.
None of this is easy. Nor is it really fair that you have to be doing this hard work in changing the way you respond to your world. But doing what is necessary for peace of mind when dealing with life’s hardships is often not fair.
Remember that you are doing this for yourself and to improve the quality of your emotional life. If it results in an improvement in your relationship, that is secondary.
You may overcome your bitterness and still decide that ending the relationship is what’s best for you. Either way, you will be making decisions based on what is good for you and not out of place of hardened anger.
c 2010 Mark S. Carlson
Contact information:
mcarlson@argosy.edu or 651-286-7970
WHEN YOU’VE MADE SOME BAD MISTAKES
Often in relationships there’s one person who has made some major mistakes that have left the other person feeling angry, bitter or betrayed. (Sometimes all three!) These mistakes can include infidelity, prolonged chemical abuse, financial irresponsibility, problematic jealousy or physical abuse. The person who has made these mistakes usually feels bad and is seeking forgiveness. They often have begun to make genuine efforts at changing their behavior and acting more like the loving person they want to be and that the wronged party has always asked them to be. The person who is trying to make amends to the wronged party is often distressed and frustrated when their partner often rejects or is unable to accept their efforts.
The self-talk of the prodigal partner
Here are some of the thoughts people have who are trying to make amends to partners who seem unable to forgive them:
• What’s the point of trying? They treat me the same whether I’m being good or bad.
• I said I’m sorry. How long are they going to punish me for this?
• Why do they have to dwell on the past?
• Why can’t we try to do something constructive about the problems we have now?
• I know I screwed up but there’s no way I can make up for it.
• I’m doing what they always asked for. Why can’t they accept it?
• They don’t ever give me credit for the changes I’m making.
• Will I have to be one down and them one up forever?
These feelings are understandable and are not wrong. However, they are not based on what is realistic to expect from a person whom you have let down or disappointed sometimes for many years.
People who are changing destructive patterns need to make their peace with the fact that doing the right thing won’t necessarily bring on applause in the parties who’ve been wronged. Work on doing the right thing because it is the right thing to do, not for the approval it will bring.
Winning back the love of a long-wronged partner or spouse will require five things above all else:
1. Patience.
2. Endurance.
3. Tolerating being unpopular (for at least a good while).
4. Developing specific insights into what prompted bad behavior in the past, and identifying your plan to combat that behavior.
5. Ongoing evidence of new behavior.
Romantic declarations of love and earnest declarations of good intentions are typically not enough, especially if they haven’t been backed up by action in the past. Actions will be what wins the day, if the day can still be won, and even then only over time.
c 2010 Mark S. Carlson, PhD, LP
contact information: mcarlson@argosy.edu or 651-286-7970
WHEN YOU’VE MADE SOME BAD MISTAKES (THE PLAN)
Reestablishing trust and acknowledging ongoing anger
The thing the person trying to make amends must remember is this. Even if their partner makes a sincere effort at forgiving them, fundamental trust has been violated.
Reestablishing trust is a very long process. It may be helpful to think of trust as a bank account. A few weeks or even a few months of good behavior will not get the trust account into the black after years of bad behavior. But those first few weeks are helpful. They just need to be followed up by a few months more.
If you’re serious about saving your relationship, make a commitment to persist in your new and better behavior for at least six months without expecting much recognition. Even if you see little sign of appreciation, you need to know that in many cases each week of good behavior is slowly moving your partner’s trust account towards the black. Find a supportive family member or friend who will support you and affirm you in your efforts to keep on track. Don’t expect your partner to do this for you, at least at first.
In the meantime, your partner’s anger will continue to surface. Anger is not something that can just be dealt with once and be done with. It comes in irregular and erratic waves. Acknowledge their anger when it comes. You don’t need to defend yourself or do something remarkable at that moment. Simply say, “Of course you’re still angry. I understand.” Or words to that effect. What is important is affirming their feeling. This is not about beating your self up, or humbling yourself before them.
Remember—their anger is not bad, it just is. Also remember—just because they’re angry at you, doesn’t make you a jerk. Honoring their feeling of anger is about honoring them as an important person in your eyes. It is about letting them feel heard and understood. Providing rationales or explanations for your bad behavior typically interferes with this key process. Provide explanations or rationales for your bad behavior rarely and only after you’ve asked if they want to hear it. And then after you’ve spent several paragraphs of good, solid listening.
To simply and non-defensively honor another person’s anger is not saying you’re worthless or totally to blame. If you have shameful feelings about past behaviors, this is for you to work on overcoming. It is not the job of the wronged party to help you feel better about your past bad behavior. Just as your partner will need to work at managing their anger as best they can.
Be patient. Your partner was patient for a long time before they became as angry as they currently are. The two of you fell in love for a reason. With perseverance and a little luck, that love can often be resurrected, though occasional flashes of anger and wounded trust may still resurface.
c 2010 Mark Carlson, PhD, LP
Contact information:
mcarlson@argosy.edu or 651-286-7970
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