Section 3 – Cognitive Behavioral Therapy and Social Interest
In this section of our workbook, we are going to teach you a tool that will not only help to reduce your risk of relapse but will also teach you to manage the negative thoughts and feelings that lead to many unhealthy behaviors. Unlike some skills you will develop through workbook exercises that you learn and move on, Cognitive Behavioral Therapy (CBT) is a skill that you develop through practice.
CBT is far from new. In fact, as best we can tell its origin is over 2,000 years old when the Greek philosopher Epictetus said: “Man is not troubled by things, but by the view he takes of them.” In the early 1900s theorist Alfred Adler gave us the concept of “Mistaken Beliefs” and “Private Logic.” These essentially amount to a system of values and beliefs that we may learn as children and accept to be true, whether they are true in reality or not. When we carry these ideals into adulthood, and encounter views and cultures that differ from ours, they can make us uncomfortable if not neurotic. Many theorists have followed in Adler’s path over the years with similar theories such as Reality Therapy and Solution Focused Therapy. However, CBT was probably most popularized by Albert Ellis in his development of Rational Emotive-Cognitive Behavioral Therapy that provides the foundation for the model I have been teaching for over 30 years. The model I have adopted, the “STEP” model, is slightly different than the traditional “ABC” model that Ellis taught. The truth is I didn’t invent the “STEP” model of Cognitive Behavioral Therapy, but I’ve been teaching it for the last 3+ decades. I’d like to give credit to a Dr. Charles Stark, whose video I watched as a grad student at the University of Georgia, but in research, I have never been able to find him or the video to thank him for this life changing approach.
The model is simple enough to understand in theory, but embracing it requires much practice. Implementing it once is easy, turning into a lifestyle requires frequent challenging of our thoughts, values, and priorities. The first concept that is essential to understand is that you have a thinking problem every bit as much as you have a drinking or drug use problem. Whether you know it or not, outside of biological functions, we think about everything!
This is such an important concept to grasp. Our thoughts, conscious or unconscious are developed over time and help to create our value and priority system in the brain. We make choices based on our values and priorities, and (are you ready for this provocative statement?) we always act in accordance with our values and priorities. There are positive and negative consequences associated with the choices that we make (performance or behavior) based on those values and priorities. Before I confuse you any further, let me provide some examples, because I know the cynic in you is thinking right now, I’ve made a lot of choices that weren’t based on my values and priorities, so let me provide some illustrations before we lay out the model more fully.
Dan is a diabetic on a diet. He has been on this diet for 6 months and has done fabulously. He has lost 20 pounds and lowered his blood sugar to within normal range. He goes to a dinner party, and he sees the most delicious cake. Dan knows this is not a part of his diet. He has a decision to make. Give in to the temptation of eating a piece of cake or rigidly stick to his diet. If Dan chooses to eat the cake, he is doing so based on his values and priorities in the moment. He values eating that cake, and is willing to put his diet aside, at least for the moment, to enjoy a piece of cake. Once he eats that cake a new set of thoughts, values and priorities emerge. Does Dan hop right back on the horse and return to his diet, or like many, is this the beginning of the end of Dan’s diet. Dan can also value and prioritize his diet over the piece of cake, and not have a slice. This too opens up a menu of thoughts, values, and priorities. If Dan feels like bad about not eating the cake and feels he denied himself the pleasure, it may lead to him giving up the diet a short time later. On the other hand, Dan can pat himself on the back and be proud of himself for not giving in, providing further fuel for him to continue his diet. All this over a piece of cake! And yet, this is a process that we encounter with virtually every situation every day.
Everything in life is a (S) situation. Depending on the situation we have (T) thoughts about that situation. Depending on what we tell ourselves about the situation, we create (E) emotions about the situation. My only new contribution to this model lies here in our emotions. So let me add to the previous sentence about emotions. Depending on what we tell ourselves about the situation, we create emotions, and it’s the intensity of these emotions on a scale of 1-10 that determines our (P) performance or behavior when faced with that situation. If Dan feels denied by not having that piece of cake on scale of 1-10, a 2, then it may be a blip on the diet radar. If, however, his level of feeling deprived is an 8, he may later on give up on the diet. Starting to make sense?
Let me provide another personal example of mistaken beliefs and private logic gone awry. When I was growing up, we played a game at the dinner table every night. Only I didn’t know it was a game, it was simply how we ate dinner. Mom would make dinner. There were four of us at the table, and 6 pieces of chicken. Each of us would take a piece of chicken, eat it and then the game began. Mom would pick up her plate and go to the kitchen. She was out of the game. Now there were 3 of us left and 2 pieces of chicken. The next part of the game was the visual/audio part. My father, brother and I would look at each other to determine if we were all still in the game. When that was confirmed, we would begin talking to each other. “Do you want a piece, I want a piece, do you want a piece… we’ll split it, you get this, I’ll take that.” That was my entire life at dinner, and I thought that’s how dinner is eaten all around the world.
I went off to college in rural Virginia. I was invited to a friend’s house for the weekend, and we sat down to the table for dinner. Plates were passed around, and I took the appropriate portion, ensuring that there was more than enough to go around the table, when everyone stopped and looked at me. “Don’t you like our food?” I replied, “I like it just fine, I just figured I’d take a portion and pass it around and if there was enough, I’d ask for more.” I was informed that this was not how they ate dinner there. You take what you want and that’s what you get. I was shocked. I was confronted with the fact that they didn’t play the game- that everyone didn’t play the game that seemed part of my DNA.
Now this didn’t scar me for life, but it may have been the first time I could recall a challenge to my values and priorities. I could have had an outburst and told them that they were eating wrong, but it didn’t bother me enough, and I quickly adapted. I was presented with a situation, I had thoughts and feelings about that situation, and my behavior matched the way I was feeling at the time, and I was able to move on from there.
So, lets introduce you to the STEP model, which we will be discussing in further detail later.
S-ituation
T-houghts
E-motions (1-10)
P-erformance/Behavior
From the time you open your eyes in the morning, until you close them at night, everything in between is a situation. Situations in and of themselves are meaningless until we give them meaning. This is incredibly empowering, but it also makes us responsible for almost everything. It means that we have the power to be our own best friends or our own worst enemies, and your participation in this program may be indicative that you have been your own worst enemy for a while now.
Many years ago, I had a meeting in New York City. As I was approaching a traffic light, I spotted a rare parking spot on the street just past the light. The light had turned yellow, but I was determined to get that spot. So rather than lose the parking spot, I charged through the light that had already turned red, and I got to the parking spot. Victory was mine! Before I got out of the car, a rock had fallen from the building above and made a large dent in my car. That’s just bad luck, right? It doesn’t have anything to do with my thinking or values and priorities, correct? Well, when I say we think about everything from sunup to sundown, I find a way to be responsible for this occurrence. It’s not that others wouldn’t have done the same thing. But when I replay the tape, I realize that if I hadn’t coveted the parking spot so much, and if I valued following the law and not running a red light, the rock would have fallen before my car ever got to the spot. I valued the parking spot above all else, and the consequence was a big dent in my car.
Imagine you are walking down the street, and someone calls you the worst name you can think of. What do you do? Some would keep walking, others might say something back, and some might get into a physical altercation. If the behavior you choose to engage in is something of a multiple choice, then we lose the excuse, “I didn’t have a choice.” What we choose to do in this situation is based on our values, priorities, and emotions.
Now let’s say for a moment that you get into a physical altercation, and as a result, you get arrested, and end up in front of a judge in court. The judge looks at you and the case and determines that you while you could go to jail for your actions, you are instead getting 2 years of probation. On one hand you are glad that you are not going to jail, but you aren’t happy that you got two years’ probation. As you walk out of the courthouse, you encounter the same person, who says the exact same thing to you that you engage in the physical altercation in the first place. If you hold onto the same values and priorities “Nobody does that to me and gets away with it,” we are likely to conjure up the same intensity of negative emotions, and get into another physical altercation, and you may be dragged right back into custody. On the other hand, you could change your thoughts, values and priorities and tell yourself, “I’d like to hit that person, but it’s not worth going to jail over.” This change in thinking doesn’t eliminate anger but reduces the intensity of the anger to the point that we are able to walk away. You see the situation doesn’t change. You are still called exactly the same name, but how you think about it may change, empowering you to not experience the consequences of your thinking.
The more we practice, the more quickly we can process information, but it does not mean we do things without thinking. Take a look at this example that demonstrates our ability to think and process information in a flash. Let’s say you are driving a car and have someone that you care about sitting next to you. A deer runs out in front of you, you slam on the brakes and most people do something else. Many people hold out their arms to provide some safety to their loved ones. Now let’s change that situation slightly. You are driving a car, and a deer jumps out in front of you, but this time you are driving alone. Do you behave any differently? Many people would grip the steering wheel more tightly, rather than hold their hand out for protection. This is an example of literally split-second decisions that we make depending on how we think about the situation.
S-ituation- Driving, Deer jumps out S-ituation- Driving, Deer jumps out
T- I want to avoid hitting the deer, T-hought- I want to avoid hitting the deer
I want to protect my loved one
E-motion- Scared, Nervous, Protective (10) E-motion- Scared, Nervous (10)
P- erformanace- Hold out arm, slam on brakes P-erformance- Grip wheel, slam on brakes
Let’s move on to some crazy words and phrases that we use in our daily lives that are often untrue and create negative emotions which lead to substance use or other negative behaviors.
The first group consists of axiomatic (all or nothing) statements:
“Must, Have to, Need, Always, Never, Can’t”
The first concept to understand about these words is that there is only one thing we “Need” to do in life or “can’t” avoid. That is death. Everything else in life is a choice that we make based on our values and priorities. In addiction we often use these words to disown responsibility for the things we think we want but deceive and deny ourselves our wants by telling ourselves we need it. For example: “I want to drink but I need to be sober.” Nonsense. We don’t need to be sober. Many of you have told yourself this statement, only to drink or drug again proving the following: I really want to use, but I am denying myself using by staying sober. Thinking this way will ultimately lead to use. It’s a form of a lie and self-deception. Of course, we can use again. We are capable of using again, but we use when we want to, and we stay clean when we don’t want to. We do whatever it is that we want to in life.
We can start taking responsibility for these axiomatic statements by inserting the word “if” into them. See the difference from the statement above: “I need to stay sober, if I don’t want to experience the consequences of using.” This is a true statement that highlights our values and priorities. This more accurate statement speaks to what it is that we truly want. If I don’t want to experience the consequences of use, then what I really want to do is stay sober- it’s no longer about needs but wants. If I become willing to risk the possibility of those consequences, then I will use again, and I am valuing, and prioritizing use more than I am staying sober. Similarly, we might say, “I must make a 12-step meeting.” Again, nonsense. Many people miss meetings. You go when you want to and miss when we want to. We say, “I can’t stay sober unless my family forgives me and lets me back into their lives.” Of course, we can stay sober despite family not being ready to forgive us. When we come to realize that this statement is untrue, and if we want and are willing to stay sober, despite our family’s unwillingness to forgive, then we are in control of our wants, and may be more likely to rebuild family relationships because we are demonstrating that we are getting sober because we want to. Do you think families can tell the difference in you, when you are doing something because you tell yourself you “need to” vs. “want to?”
One of the most common axiomatic statements we hear is “I can’t ever use again.” As stated before, we can use anytime we want to. It is our hope that even if you are using this statement now, that you at some point realize that you are doing this because you want to. Things we tell ourselves we “must”, “need”, “have to”, “can’t” do- we may be able to do for short periods of time, but it doesn’t last for long. When we are doing things that we want to do, we have a better ability to sustain it.
We see this all the time in other forms of life. For example, quitting smoking. The price of cigarettes goes up, and we tell ourselves that we need to quit smoking. We try to quit, but we are doing so reluctantly, not because we want to quit, but because the price has gone up. Many make these types of promises, but ultimately go back to smoking because that is what we truly want to do despite the cost. When we come to the realization that we want to quit, we become more capable of not just quitting, but staying tobacco free.
The next set of words also create levels of discomfort within us. They frequently go together. They are “should” and “it’s not fair.” A working definition of “should” is “expectations unmet in self and others.” When we tell ourselves what we think we “should” or “shouldn’t” do, or “should” or “shouldn’t” have done. Many make statements like: “I should have gotten sober a long time ago.” If that statement is true, then it begs the question why didn’t we? The truth is that we didn’t get sober a long time ago, because we didn’t want to. If we wanted to, based on our values and priorities at that time, we would have. However, by making this statement now, can you see how we are robbing ourselves of the gratitude for the opportunity in front of us? These untrue negative thoughts yield feelings and behaviors that are unhealthy. If I stay stuck in what I should have done in the past, can you see how it interferes with our efforts for what we have the ability to accomplish today?
Now we defined “should” as expectations unmet in self and others. What about the use of “should” with others? How upsetting is it when we put expectations on others that they don’t meet? “My husband should forgive me for the things I have done, because I am getting sober now.” Rather than accepting the fact that you have broken trust as a result of your use, we put expectations on how others should be thinking, feeling, and behaving. This creates negative thought, feelings, and emotions in ourselves.
There is a relationship between how many “shoulds” we have in our lives, and how miserable we tend to be. We are best served when we challenge our “shoulds,” and work towards eliminating how we think we or others “should” be.
On to “It’s not fair.” Often times people who say, “It’s not fair” are not looking for life to be fair, but rather are looking for life to be “more than fair.” Think about some of the things that you have done while using. Did you drive while under the influence? Did you steal? Did you break the law in other ways? Did you manipulate others? I’ve worked with people who have had multiple DWI’s, and stated that, “it’s not fair that I have to be in treatment.” However, if life were fair, then it would make more sense that that person be in jail. But in this instance, we are not looking for life to be fair, but “more than fair.” The person wants to be able to commit a crime and not have to experience any consequences for their behavior. Fairness of life tends to work more like this: Sometimes you are the windshield, and sometimes you are the bug. Sometimes life is fair, sometimes it is not. We become more troubled when we seek for life to be fair all of the time or fail to recognize the balance of fairness in life. Is there someone in your life that has asked you to participate in the Sober at Home program? Have you told them that it’s not fair, you don’t have a problem, or you don’t need any help, because you don’t have a problem? Given your history, isn’t it fair that you give the program a try?
The final set of words we will explain now also identify how we suffer needlessly with our internal set of thoughts, values, and priorities. They are “perfectionism” and “rating oneself with one’s behaviors.” In 12-step programs a commonly used phrase is “progress not perfection.” Perfectionism is not attainable. Perfectionism is, in a sense an axiomatic all or nothing concept, and all but guarantees misery. There is a lot of perfectionism in addiction. Many remain stuck in the lifestyle of use, because they are afraid that they will not be successful in efforts to get clean and sober. So, they continue the unhealthy lifestyle of addiction out of fear of failing at sobriety. In their minds they are better off in the misery they know, then to try something new and different and failing at it.
Failure to live up to our own perfectionistic tendencies is damaging enough, but perfectionists also become troubled with having to live life with others that don’t meet their perfectionistic ideals. How troubled we become when others don’t see things the way that they should in our eyes. It is our perfectionism that troubles us, when often the people that aren’t living up to our expectations go on simply living their lives.
Rating oneself with one’s behaviors is also a breeding ground for misery. Those of you who struggle with these types of thoughts, you find yourself undeserving of a better, sober life because you have engaged in behaviors you regret, and now falsely believe that you do not deserve anything good in life, like sobriety because of the things you have done. This is not only untrue, but selfish. If you are someone who has driven while intoxicated, and hurt someone, you may tell yourself that because you have hurt someone, you don’t deserve anything good in life like sobriety. You therefore stay engaged in the lifestyle of use because of the “bad” things you have done. But in doing so, you continue drinking (and driving), and therefore continue to hurt yourself and potentially others. It is appropriate to feel bad, even guilty, for the things you have done. This, however, doesn’t mean that you don’t deserve better things in life. Quite the opposite- when you get better, the whole world benefits from your sobriety, because you place yourself in a position not to hurt others. You are deserving of a better life despite transgressions of your past. When you start to embrace this concept, you become well positioned for change.
This concludes a brief overview of cognitive behavioral therapy. While the use of CBT is old, the use of the “STEP” model is new. There will be several worksheets that follow, that will hopefully further your understanding and help you to embrace this model. There are also blank STEP model worksheets for you to use, so that you can have a tool in your toolbox at your disposal to utilize when troublesome situations arise. Take this section of the workbook seriously, and you will reap the rewards.