Cognitive restructuring

Let's begin with some of the cognitive restructuring that occurs every day among people staying sober in AA. As we learned from Albert Ellis, Aaron Beck, and others, we can change how we feel by changing how we think. For many clients, this concept seems unreal, academic, or simply semantic hocus-pocus. But it works—and clients are better able to embrace the idea when we point to the ever-popular “one day at a time” adage from the AA tradition.

We humans don't instinctively think in terms of “one day at a time.” We learn to focus on today—giving less energy to yesterday and tomorrow. “One day at a time” offers a good example of cognitive restructuring. It is a learned skill and something that gets easier over time.

“This too shall pass” constitutes another example of changing how we think. It moves us away from “catastrophizing” and toward acceptance—the foundation of AA's serenity prayer.

Mind-set adjustments such as these require neither a high IQ nor complex training. All that is required is a willingness to choose consciously to think in a new way. Going to AA meetings reminds the alcoholic to embrace new ways of thinking.

Table 1 lists some phrases commonly heard in AA meetings. Notice that they encourage the participant to challenge his/her worldview—the old way of dealing with life. Some of these phrases also belong in the behavioral category, but they are good examples of the cognitive restructuring that goes on in the minds of recovering people.

Behavior modification

Simply put, classical conditioning (Pavlov) and operant learning (Skinner) are the foundations for how we help people to change their behaviors. Focusing on the cravings caused by certain triggers (classical conditioning) and on the rewards or consequences associated with using or not using (operant learning), clients are able to create behavioral options for themselves.

Table 1. Changing how we think—common phrases at AA meetings

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Table 2. Changing our behaviors—common phrases at AA meetings

But if cognitive restructuring sounds like hocus-pocus to the average client, the concept of “Fake it ‘til you make it” can be even more foreign. Substance abusers, particularly those in early recovery, are too wrapped up in emotional chaos to make wise choices.

It is for this reason that AA's “Just keep coming” mantra is so important. It says to the newcomer, “You don't have to understand why; you just have to show up.” Other important messages to the newcomer include: “Knowing how to stay sober won't keep you sober. It's not what you know—it's what you do.” Table 2 lists some of the phrases commonly heard at AA and NA meetings that reinforce the importance of changing one's behaviors.

But what about the client still in the precontemplation stage, not ready to admit that change is needed? Clinicians using Motivational Interviewing techniques, for example, help clients find the willingness to change from within. Similarly, 12-Step recovery programs rely on attraction, not promotion. AA is not for people who need it—it's for people who want it. If a client maintains even a marginally open mind and attends enough AA meetings, he might come to want the serenity that many AA members seem to possess. He might become willing to change his way of thinking and/or his way of behaving. He might admit that, for some reason, people in the group seem to be doing what they were unable to do on their own.

We wouldn't be so naive to suggest that AA negates the need for individual or group therapy. For a million reasons, it doesn't. But AA and other similar programs employ some compelling cognitive and behavioral interventions. So let's not compare AA with CBT. AA is CBT.