Addiction Treatment: Cognitive Behavioural Therapy vs the Twelve Step Programme

Which type of addiction treatment is right for me, or my loved one? There are a number of different approaches, and this question can be confusing to those seeking a solution for a substance or behavioural addiction problem.

Many treatment centres are focused on the 12-Step programme which is essentially the Alcoholics Anonymous paradigm, some have strong faith-based approaches and others focus more on medical and therapeutic interventions.

Addiction affects all walks of life, and some of us are drawn to faith-based approaches, but many of us are looking for something more empirical, with as much scientific evidence as possible. This is where Cognitive Behavioural Therapy (CBT) and related approaches are appealing to many seeking treatment for substance use disorders as well as behavioural addictions.

There is a growing awareness amongst professionals, that addiction is a much more complex intersection of biological, psychological and social issues, what is known as the “biopsychosocial” model, and that focussing on just one aspect with a reductionist approach is less helpful than looking at it holistically. So the trend in recent years is towards more integrated programmes and many treatment facilities, like The Cedars, are using integrated techniques derived from approaches like CBT, DBT, Motivational Enhancement therapy all structured around the core 12-Step format. In fact, the 12-Step programme is the key focus of The Cedars’ programme, and as we explore in this article, it has relevance to the use of CBT in treating addiction.

What is CBT?

CBT is simply defined as a talking therapy that can help manage psychological problems by changing the way we think and behave. It is based on the principals that psychological problems are due at least in part to faulty or unhelpful ways of thinking, learned patterns of unhelpful behaviour and that people suffering from these problems can change these patterns to relieve symptoms and become more effective in their lives.

There have been continuing evidence-based advances in the development of CBT as well as Dialectical Behaviour Therapy (DBT) which is considered to be a particular mode of CBT, and numerous research studies have shown that CBT leads to significant improvement in functioning and quality of life. Strategies include learning to recognise distortions in thinking, gaining an understanding of behaviour and its motivation, a greater sense of confidence (often involving facing fears instead of avoiding them) and learning to calm the mind and relax the body. These combine to form the basis of what is known as Relapse Prevention, which is an important element of lasting recovery.

Is CBT compatible with the 12-Step programme?

The 12-Step programme and CBT are often seen as opposing approaches, but it is argued that upon close examination they are found to have many similarities and are much closer and more in line than previously thought. In his 2018 book Twelve Step Recovery and Cognitive Behavioral Therapy, John Elford says:

“Both approaches work by changing people’s attitudes and their behavior by focusing on the thoughts, images, beliefs, and attitudes that influence their behavior and lead them to self-destructive actions. The two approaches within CBT that really resonate with Twelve-Step recovery are the behavioral and the cognitive.”

He argues that in 12-Step meetings people learn not to react to the first things that pop into their heads. They read and hear slogans like ‘one day at a time’, ‘keep it simple’, ‘live and let live’, and ‘don’t pick up the first drink and you can’t get drunk’. All these new ways of thinking help to reduce the internal voices that can keep a person repeating old behaviours – exactly the aim of CBT. Sponsors will often work closely with newcomers to work out new patterns of behaviour, from the route taken to get home, to what one does when one wakes up, giving rise to new behaviours and avoidance of trigger situations.

It’s interesting to note that many more empirically minded sufferers (and professionals) are put off by the 12-Step use of such words as “God”, “higher power” and “spiritual awakening”. Similarly, those with more instinctive or faith-based views are concerned by words and phrases such as “disputational methods”, “collaborative empiricism” and “ego deflation”. The use of a combined approach gives more people an easier “way-in” to a holistic road to recovery and is one of the reasons why we use an integrated programme with a focus on the 12-Step programme at The Cedars.

It is interesting to note that DBT has as a fundamental principal the promoting of two opposing goals for patients: change and acceptance and how this echoes the Serenity Prayer which is used to open 12-Step meetings:

God, grant me the serenity to accept the things I cannot change,courage to change the things I can,and wisdom to know the difference

But where does CBT leave spirituality?

Spirituality is a very broad term and means many different things to different people. It is more common in recent times to see the idea of spirituality being increasingly disconnected from theistic religion, although many people are able to access spirituality through a traditional religious lens. Spirituality is often discussed in terms of the internal, subjective experience of “self” and the search for authenticity or the true nature of “self”. In treatment, many of us found it as something of a revelation that our identity is not actually defined by our thoughts and beliefs. The techniques of CBT led to self-enquiry around our thoughts and behaviours that can result in a detachment of “self” from “thought”. We would argue that the self-awareness that one can access with CBT and other similar techniques, is both extremely useful for long term recovery, and a perfect “way-in” to more spiritual thinking.

Whichever direction you choose to go in seeking recovery from addiction, we invite you to consider the biopsychosocial as well as spiritual nature of the condition. People can and do achieve a measure of success by focussing on the key aspects that are directly relevant to their experience, but more often than not the complexity of the biological, psychological and social interactions is such that they all need to be addressed to achieve lasting recovery. It is our experience and the belief of a growing number of professionals that many more people are finding lasting solutions with an integrated approach.

At The Cedars we have found that a 12-Step focus yields the best long-term results, and we augment this by integrating a number of therapeutic models into our one-on-one and group therapy, in addition to medication-assisted treatment specifically with reference to detox requirements.