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1 CBT Manual for Group Sessions - PCRC - FOURTH DRAFT

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                                   Group Therapy:
                 Objectives for Training in 12 Step Recovery and CBT

The objectives of this training are presented in two parts. The first part of the training is
an introduction to group therapy. It consist of four general stages of group counseling.
This material comes from a course on group counseling that I taught at Ohio University
and follows Gerald Corey’s text “Groups, Process and Practice.” The second part of the
training consist of a 12-16 week Twelve Step CBT Group covering relevant topics with
handouts.

PART 1: Introduction to Group Therapy
Characteristics of an effective group counselor.

Four Stages of Group Process
1. Initial Stage of a Group:
        - Group characteristics at the initial stage.
        - Creating trust: Leader and Member Roles.
        - Identifying and clarifying goals.
        - Group process concepts at the initial stage.
        - Helping clients get the most from the group experience.
        - Leader Issues at the Initial Stage.
        - Initial Stage: Summary

2. Transition Stage of a Group:
       - Group Characteristics of the transition stage:
       - Problem Behaviors and difficult group members.
       - Interventions for dealing with resistance therapeutically.
       - Transition Stage: Summary

3. Working Stage of a Group.
      - Progressing from the transition stage to the working stage.
      - Characteristics of the working stage.
      - Group norms and behavior
      - Contrasts between a working group and a nonworking group
      - Therapeutic factors that operate in groups
      - Working Stage: Summary

4. Ending a Group:
      - Tasks of the Final: Consolidation of Learning.
      - Termination of the Group Experience.
      - Evaluation of the group experience.
      - Final Stage: Summary.
                                                                   2


PART 2:

Topic 1 – Introduction to 12 Step Recovery and CBT.
Topic 2 – The CBT Model of Addiction.
Topic 3 – Identifying Your Triggers (focused on the “B” of CBT)
Topic 4 – Coping with Craving (focused on the “B” of CBT)
Topic 5 – Refusal Skills (focused on the “B” of CBT)
Topic 6 – Managing Your Mood.
Topic 7 – Changing Your Thinking (focused on the “C” of CBT)
Topic 8 – Changing Your Core Beliefs (focused on the “C” of CBT)
Topic 9. – Managing Anger (focused on the “C” of CBT)
Topic 10 – Developing an All Purpose Coping Plan
Topic 11 – Relapse Prevention
Topic 12 – Step Review.
                                                                                              3




                             Introduction to Group Therapy.


                     Characteristics of an effective group counselor.

Spirituality is an essential quality of an effective group counselor. Since spirituality is the
foundation of recovery it is important for group leaders to make progress in their own
spiritual life. You cannot give what you do not have.

Courage is demonstrated through your willingness to …
      - be vulnerable at times, admit mistakes and imperfections.
      - confront others by to stay “with” them through the confrontation.
      - act on your beliefs and hunches (which are based on your clinical judgment).
      - be emotionally touched by others and to identify with others.
      - examine your own life.
      - be direct and honest.
      - express your fears and expectations about the group process.

Willingness to model is one of the best ways to teach desired behaviors.
       The effective group counselor models …
       - behavior.
       - attitudes.
       - openness.
       - seriousness of purpose.
       - acceptance of others.
       - the willingness to take risks.

Presence is the ability to be emotionally present with group members. It involves being
touched by others’ pain, struggles, and joys.

Goodwill and caring is demonstrated by showing sincere interest in the welfare of others.
It implies that you will not exploit or use group members to enhance your own ego. Your
main job is to help members achieve their goals.

Belief in the group process is essential. Effective group counselors have a deep
confidence in the value of group process. Faith in the group process leads to constructive
outcomes.

Openness with yourself and others is a fundamental quality of an effective group
counselor. Openness does not mean that you reveal everything you have experienced.
Self-disclosure must be use judiciously. Openness means that you are open to group
members, open to new experiences, and open to values that differ from your own.
                                                                                           4


Becoming aware of your own culture enables you to understand yourself and others.
Knowing how you own culture influences your decisions and daily behaviors provides a
frame of reference for understanding the worldview of those who differ from you.

Non-defensiveness in coping with attacks allows you to deal with criticism. You cannot
afford to have a fragile ego. Group leaders who are insecure, easily threatened, overly
sensitive to negative feedback and who depend on group approval will encounter major
problems.

Stamina refers to your ability to endure. Leading recovery groups can be taxing and
draining. You need physical and psychological stamina and the ability to withstand
pressure to remain vitalized throughout the process of group.

Self awareness is a central characteristic for an effective group leader. You need an
awareness of self including your identity, cultural perspectives, goals, motivations, needs,
limitations, strengths, values, feelings and problems.

Sense of humor is important because, at times, humor can facilitate insight and growth. It
also enables clients to enjoy the process and gain new perspectives.

Creativity is the capacity to be spontaneous, inventive and fresh. Using your creative can
facilitate growth in yourself and your clients.

Personal dedication and commitment to improve your clinical skills in leading group is
an essential for every group leader. Leaders are learners. They are dedicated and
committed to improving their skills.
                                                                                                 5




                           Necessary Group Leadership Skills


Empathic listening involves listening to the content and feeling of what is being said.
Seek first to understand then to be understood. Most people do not listen with the intent
to understand. They listen with the intent to reply. So most of their energy is channeled
into talking, not listening. Below are five levels of listening.

       -   ignoring.
       -   pretend listening.
       -   selective listening.
       -   active listening.
       -   empathic listening.

Reflecting is a skill that is dependent on empathic listening. It is the ability to convey the
essence of what a client has communicated so that the client feels understood.

Clarifying is a skill that enables you to help the client sort out the exact meaning of what
he or she is trying to communicate. It is also used to help clients understand the meaning
of what you are communicating.

Summarizing is a skill that is used to condense concepts or material in a clear and concise
manner. This can sometimes be accomplished by listing two or three main points.

Facilitating encourages and enhances the group process. The group dynamic is not one
way or two-way communication. The process of group is multidimensional and dynamic
among group members.

Interpreting enables the group leader to offer possible explanations for certain behaviors
and symptoms.

Questioning is useful if it is not overused. Interrogation seldom leads to productive
outcomes. It is best to use Socratic questions that are relevant, thought provoking and
meaningful.

Linking is a skill that requires insight. Effective group leaders find ways of relating
various topics to a theme.

Confronting group members is sometimes necessary and helpful because it challenges
specific behaviors to be examined and modified.

Supporting is appropriate when clients are facing a crisis or when they venture into
frightening territory. Supporting clients in the group can lead to constructive outcomes.
                                                                                                 6


Blocking is a skill that refers to the responsibility clinicians have to block certain
activities of group members such as questioning, probing, gossiping, invasion of
another’s privacy, breaking confidence, and so forth.

Diagnostic skills involve more than labeling behavior, identifying symptoms, and
figuring out what category a client falls into. It involves the ability to educate the client,
appraise certain behavior problems and choose appropriate interventions.

Modeling is an essential method of demonstrating attitudes, abilities and techniques
which relate to positive outcomes.

Suggesting options and alternatives can help group members develop an alternative
course of action.

Evaluating is a crucial skill that helps measure progress toward treatment objectives.

Terminating the group refers to a clinician’s ability to …
      - helping clients transfer what they have learned to their own world.
      - preparing clients for the problems they may face after the group.
      - arranging aftercare.
      - maintaining treatment gains.
                                                                                                  7




                                 Initial Stage of a Group:


Group characteristics at the initial stage.

       Initial resistance

       -   Some attitudes that relate to initial resistance include …
              o I don’t really belong here.
              o I’m not as bad off as these people.
              o I’m not going to learn anything.
              o I’ve been hurt in groups like this before.
              o I’m only here because the court ordered it.

       -   Some common questions clients may have are …
              o Will I be accepted or rejected?
              o Can I really say what I feel?
              o Will other people judge me?
              o Am I like other people in here?
              o Will I look stupid?
              o What if I’m asked to do something I don’t want to do?

       Self focus versus focus on others.

       -   Some examples of focusing on others rather than working on self include …
              o Talking about others outside the group.
              o Telling stories about particular situations that don’t relate.

Creating trust: Leader and Member Roles.

       Establishing trust is a central task in the initial stage of a group. It is not possible
       to overemphasize the significance of the leader’s modeling and the attitudes
       expressed through the leader’s behavior in these early sessions.

       -   The importance of modeling. Ask yourself these questions:
              o Do I feel energetic?
              o Do I feel enthusiastic about this group?
              o Do I trust myself to lead?
              o Do I inspire confidence in the group process?
              o Do I understand the concepts I’m teaching?
              o Do I know how to use the techniques I’m encouraging others to use?
              o To what degree do I trust the group members to work effectively with
                 one another?
                                                                                  8


       -   Attitudes and actions leading to trust.
               o Attending and listening.
               o Interest.
               o Curiosity.
               o Understanding nonverbal behavior.
               o Empathy.
               o Genuineness.
               o Judicious use of self-disclosure.
               o Respect.
               o Caring confrontations.

Identifying and clarifying goals.

       -   Some general goals for group members may include …

              o   To work the 12 steps.
              o   To instill hope through the promises of AA.
              o   To maintain sobriety.
              o   To learn refusal skills.
              o   To change dysfunctional thoughts and behavior.
              o   To manage moods.
              o   To improve skills in conflict resolution.
              o   To comply with court orders.
              o   To improve relationships.
              o   To grow spiritually.
              o   To cope with craving.
              o   To improve decision making skills.
              o   To learn to trust self and others.
              o   To increase self-esteem.
              o   To encourage service work.
              o   To improve communication skills.
              o   To prevent relapse.
              o   To support and challenge others.
              o   To become independent and interdependent.
              o   To increase the capacity for empathy.
              o   To confront others with care and concern.
              o   To learn how to ask for what you need or want.
              o   To learn cooperation.
              o   To be linked to a support network e.g., AA.
              o   To improve social skills for career.
              o   To stop domestic violence and improve relationships.
              o   To become more sensitive to the needs and feelings of others.
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Group process concepts at the initial stage.

Group norms – refer to standards of behavior. The following are examples of standards
of behavior that are common in many groups.

       -   Members are expected to attend regularly and show up on time.
       -   Members are expected to be personal and share meaningful aspects of
           themselves through active participation in the group process.
       -   Members are expected to give feedback to one another.
       -   Members are expected to focus on feelings and express them, rather than
           talking about problems in a detached and intellectual manner.
       -   Members are expected to focus on the here-and-now interactions in group.
       -   Members are expected to bring into the group personal problems and concerns
           that relate to recovery and be willing to discuss them openly.
       -   Members are expected to provide therapeutic support to other members.
       -   Members will accept challenges and examine their own thoughts, behaviors
           and feelings with the goal toward constructive change.
       -   Members are expected to follow the norm of listening to understand, rather
           than thinking of a quick rebuttal and without becoming overly defensive.


Group cohesion – refers to a true sense of community or a feeling of belonging. Genuine
cohesion typically comes after groups have struggled with conflict, have shared pain, and
have committed themselves to taking significant risks. But the foundation of cohesion
can begin to take shape during the initial stage. Below are some suggestions for
enhancing group cohesion.

       -   Build trust by creating a climate of respect.
       -   Fulfill the purpose of the group.
       -   Expect disruptions and deal with them creatively.
       -   Encourage group members to share meaningful aspects of themselves as it
           relates to recovery.
       -   Deal with needs as they emerge. Don’t feel obligated to stay strictly with the
           agenda.
       -   Avoid too much teaching.
       -   Avoid the misuse of psychological jargon.
       -   Invite all members to become active participants, not merely observers.
       -   Cohesion can be built by sharing the leadership role with the group.
       -   Express persistent feelings of boredom, anger, or disappointment with the
           group.
       -   Deal with conflict openly and work toward a resolution.
       -   Encourage and praise group when progress toward goals is made.
       -   Be willing to work before and after group.
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Initial Stage: Summary

Stage characteristics. The early phase of a group is a time for orientation. At this stage:

       -   Clients test the atmosphere and get acquainted.
       -   They learn what to expect.
       -   Group cohesion and trust is gradually established.
       -   Clients are concerned about whether they will be included or feel excluded.
       -   A central issue is trust versus mistrust.
       -   There are periods of silence and awkwardness which the group leader deals
           with constructively by allowing the group process to work.
       -   Members are learning the basic attitudes of respect, acceptance, caring,
           listening and responding – all attitudes that facilitated building trust.


Member functions. Early in the course of the group specific member roles and tasks are
critical to shaping the group.

       -   Taking active steps to create a trusting climate.
       -   Learning to express feelings and thoughts.
       -   Being willing to express fears, hopes, concerns, reservations, and expectations
           about the group.
       -   Establishing goals.
       -   Learning the basics of group process.
       -   Being involved to the creation of group norms.


Leader functions. The major tasks of group leaders during the initial stage of orientation
are:

       -   Teaching general guidelines.
       -   Developing ground rules.
       -   Setting norms.
       -   Assisting group members in expressing their fears and expectations.
       -   Modeling the facilitative dimensions of therapeutic behavior.
       -   Helping the group establish goals.
       -   Providing a flexible structure for the group.
       -   Assessing the needs of the group and leading in such a way that these needs
           are met.
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                              Transition Stage of a Group.


Characteristics of the transition stage:

Anxiety may arise within individuals or the group itself.

Defensiveness and resistance is natural during this stage. Group members need to test the
leader and other group members before the group can move from the transition stage to
the working stage. Some factors that influence defensiveness and resistance are …

               o   The fear of making a fool of oneself.
               o   The fear of rejection.
               o   The fear of causing more trouble for oneself.
               o   The fear of emptiness and loneliness.
               o   The fear of losing control.
               o   The fear of self-disclosure.

       -   Once members overcome defensiveness and resistance they can develop
           mature ways of relating in group such as …

               o   Making emotional connections with each other.
               o   Talk is simple and direct.
               o   Hidden agendas are not present.
               o   Openly taking risk.
               o   Feelings are acknowledged and expressed.

The struggle for control is common during the transition stage. Some characteristic group
behaviors include
       - Competition.
       - Rivalry.
       - Jockeying for position.
       - Jealousy.
       - “One-upmanship”.
       - Challenges to the leadership.
       - Passive-aggressive behavior.
       - “You can’t make me” or “I will do it my way” attitudes.
       - Attention seeking behavior.

Conflict at the transition stage is common. It is the avoidance of conflict that makes it
destructive. Cohesion within a group typically increases after conflict and anger are
recognized, expressed and resolved. Venting feelings is one way of testing the freedom
and trustworthiness of the group.
                                                                                         12


Confrontation involves both challenge and support. Below are some guidelines for
appropriate and responsible confrontation.

       -   Members and leaders should know why they are confronting.
       -   Confrontations should not be dogmatic statements concerning who or what a
           person is.
       -   Don’t brand or label group members with a name.
       -   Instead of making global generalizations about a person, focus on specific,
           observable behaviors.
       -   Show genuine concern.
       -   It is useful for the person doing the confronting to imagine being the recipient
           of what is being said.
       -   Ask yourself if you are willing to do what you’re asking others to do.

The leader‟s reaction to resistance may help or hinder the group. Below are some
suggestions for leaders on how to deal with resistance.

       -   Do not dismiss the client as a “problem”.
       -   Express their annoyance and anger without denigrating their character.
       -   Avoid making sarcastic remarks
       -   Educated the members how the group works.
       -   Explain that resistances is sometimes the necessary prerequisite to cohesion.
       -   Be honest with members rather than mystifying the process.
       -   State observations and hunches in a tentative way, as opposed to being
           dogmatic.
       -   Avoid stereotyping.
       -   Be sensitive and respectful of cultural differences.
       -   Avoid using intimidation.
       -   Avoid retreating when conflict arises.
       -   Do not meet their need or want at the expense of other clients.
       -   Do not take things too personal.
       -   Facilitate a more focused and objective exploration of the problem.
       -   Invite group members to state how they are personally affected by the
           problematic behaviors of other members while blocking judgments and harsh
           evaluations.

Problem Behaviors from difficult group members may include …

       -   Silence and lack of participation.
       -   Monopolistic behavior.
       -   Storytelling.
       -   Questioning.
       -   Giving advice.
       -   Band-aiding.
       -   Hostile Behavior.
       -   Dependency.
                                                                                      13


       -   Acting superior.
       -   Socializing.
       -   Intellectualizing.
       -   Emotionalizing.


Transition Stage: Summary

Transition Stage characteristics: During the transition stage group members are
typically:

       -   Concerned about what others think.
       -   Testing the leader and other members to determine how safe the environment
           is.
       -   Struggling between wanting to play it safe and wanting to risk getting
           involved.
       -   Experiencing some struggle for control and power and some conflict with
           other members or the leader.
       -   Observing the leader to determine if she or he is trustworthy.
       -   Learning how to express themselves so that others will listen.

Member functions: During the transition stage group member functions include …

       -   Recognizing and expressing any negative reactions.
       -   Respecting one’s own resistances but working with them.
       -   Moving from dependence to independence to interdependence.
       -   Learning how to confront others in a constructive manner.
       -   Being willing to work through conflicts, rather than avoid them.

Leader functions. During the transition stage group leader functions include …

       -   Teaching members to the value of recognizing and dealing fully with conflict
           situations.
       -   Assisting group members to recognize their own patterns of defensiveness.
       -   Teaching members to respect resistance and to work constructively with the
           many forms it takes.
       -   Providing a model for members by dealing directly and tactfully with conflict.
       -   Avoiding labeling members but learning to understand certain problem
           behaviors.
       -   Assisting members to become independent and interdependent.
       -   Encouraging members to express reactions that pertain to here-and-now
           happenings in the group sessions.
                                                                                           14




                                Working Stage of Group


Progressing from the transition stage to the working stage.

       -   There are no arbitrary dividing lines between the phases of a group.
       -   In actual practice there may be considerable overlap.
       -   Some groups never evolve to a working level.

Characteristics of the working stage.

Group norms and behavior

       -   Members are provided with both support and challenge.
       -   They are reinforce for making behavioral changes.
       -   The leader is free to employ a variety therapeutic strategies.
       -   Members increasingly interact with each other in more direct ways.
       -   Members are less dependent on the leader for direction and there is less eye
           contact with the leader and more with the members.
       -   Members learn how to deal with control issues, power struggles, and
           interpersonal conflicts on a deeper level and are able to transfer these skills to
           other environments outside the group.
       -   A healing capacity develops within the group as members increasingly
           experience acceptance of who they are.


Contrasts between a working group and a nonworking group

               Working Group                                Nonworking Group
Members trust other members and the             Mistrust is evidenced by an undercurrent of
leaders, or at least they openly express any    unexpressed hostility. Members withhold
lack of trust. There is a willingness to take   themselves, refusing to express feelings
risks by sharing meaningful here-and-now        and thoughts.
reactions.
Goals are clear and specific and are            Goals are fuzzy, abstract, and general.
determined jointly by the members and the       Members have unclear personal goals or no
leader. There is a willingness to direct        goals at all.
group behavior toward realizing these
goals.
Most members feel a sense of inclusion and      Many members feel excluded or cannot
excluded members are invited to become          identify with other members. Cliques are
more active. Communication among most           formed that tend to lead to fragmentation.
members is open and involves accurate           There is a fear of expressing feelings of
expression of what is being experienced.        being left out.
                                                                                            15


There is a focus on the here and now; and        Clients tend to focus on others and not
participants talk directly to one another        themselves. Storytelling is typical. There is
about what they are experiencing.                a resistance to dealing with reactions to one
                                                 another.
The leadership functions are shared by the       Members lean on the leader for all
group; people feel free to initiate activities   direction. There are power conflicts among
or to suggest exploring particular areas.        members as well as between members and
                                                 the leader.
There is a willingness to risk disclosing        Clients hold back and are not open.
threatening material; people become              Disclosure is at a minimum.
known.
Cohesion is high; there is a close emotional     Division exists; people feel distant from
bond among group members.                        each other.
Conflict among members or with the leader        Conflicts and negative feelings are ignored,
is recognized, discussed, and often              denied, or avoided.
resolved.
Members accept responsibility for deciding       Members blame others for their personal
what action they will take to solve              difficulties and aren’t willing to talk action
problems.                                        to change.
Feedback is given freely and accepted            What little feedback is given is rejected
without defensiveness. There is a                defensively. Feedback is given without care
willingness to seriously reflect on the          or compassion.
accuracy of feedback.
Members fell hopeful; they feel that             Members feel hopeless. They despair
constructive change is possible.                 because they feel that change is not
                                                 possible.
Confrontation is accepted as a challenge to      Confrontation is done in a hostile attacking
examine one’s behavior and not as an             way; the confronted one feels judged and
uncaring attack.                                 rejected. At times the members gang up on
                                                 a member, using this person as a scapegoat.
Communication is clear and direct.               Communication is unclear and indirect.
Group members use one another as a               Group members are interested only in
resource and show interest in one another.       themselves.
There is an awareness of group process,          There is an indifference or lack of
and members know what makes the group            awareness of what is going on within the
productive and nonproductive.                    group, and group dynamics are rarely
                                                 discussed.
Diversity is encouraged, and there is a          Conformity is prized, and individual and
respect for individual and cultural              cultural differences are devalued.
differences.
Group norms are developed cooperatively          Norms are merely imposed by the leader.
by members and the leader. Norms are             They may not be clear.
clear and designed to help the members
attain their goals.
Group members use out-of-group time to           Group members think about group activity
work on problems raised in group.                very little when they are outside of group.
                                                                                      16


Therapeutic factors that operate in groups
      - Self-disclosure.
      - Confrontation.
      - Feedback.
      - Cohesion and universality.
      - Hope.
      - Willingness to risk and trust.
      - Caring and acceptance.
      - Power.
      - Catharsis.
      - The cognitive component.
      - Commitment to change.
      - Freedom to experiment.
      - Humor.

Working Stage: Summary

Stage characteristics.
       - High level of trust and cohesion.
       - Communication is open and involves an accurate expression of what is being
          experienced.
       - Leadership functions are shared by group members.
       - There is a willingness to risk discussing threatening material.
       - Conflict is recognized, dealt with directly and effectively.
       - Feedback is given freely and considered nondefensively.
       - Confrontation occurs in a way in which those doing the challenging avoid
          slapping judgmental labels on others.
       - Members are willing to work outside the group to achieve behavioral change.
       - Clients feel supported by the group and are willing to risk new behavior.
       - Members feel hopeful that they can change if they are willing to take action.

Member functions.
     - Being willing to engage.
     - Offering feedback
     - Being open to feedback from others.
     - Practicing new skills in daily life.
     - Offering challenge and support to other members.

Leader functions.
       - Continuing to model appropriate behavior, especially caring confrontation,
          and disclosing ongoing reactions to the group.
       - Providing a balance between support and confrontation.
       - Supporting the members’ willingness to take risks and assisting them in
          carrying this into daily living.
       - Interpreting the meaning of behavior patterns at the appropriate times.
       - Translating insight into action.
                                                       17


-   Encouraging members to practice new skills.
-   Promoting behaviors that enhance group cohesion.
-   Further develop group norms.
                                                                                       18




                                    Ending a Group


Tasks of the Final: Consolidation of Learning.

During the final stage of a group, members need to be asking certain questions like:
“What has this experience meant to you?” “How can you use what you’ve learned in
daily living?” “Where do we go from here?”

Termination of the Group Experience.
      - Dealing with feelings of separation.
      - Dealing with unfinished business.
      - Reviewing the group experience.
      - Practice of behavioral change.
      - Ways of carrying learning further.

Giving and receiving feedback. Below are some questions that can be used for giving
and receiving feedback during the final stage of the group. Members can ask and answer
these questions during group.

       -   My hope for you is …
       -   My greatest fear for you is …
       -   I hope that you will seriously consider …
       -   I see you blocking your strengths by …
       -   Some things I hope you will think about doing for yourself are …
       -   Some ways I hope you’d be different with others are …
       -   Some ways for you to stay in recovery are …

Final Stage: Summary.

Stage characteristics.
       - Members may express their hopes optimistically.
       - There may be some sadness.
       - There may be some anxiety and fear over the reality of separation.
       - Members may be deciding what course to take.
       - They may feel a sense of accomplishment.
       - There will be planning about follow-up.

Member functions.
     - Dealing with their feelings about separation and termination.
     - Preparing for generalizing their learning for everyday life.
     - Expressing appreciation and gratitude for the support they have received from
         group members and leader.
     - Making decisions and plans for the future.
                                                                                  19


Leader functions.
       - Assisting members as they deal with feelings about separation and
          termination.
       - Preparing members for generalizing their learning for everyday life.
       - Expressing appreciation and gratitude the growth they have seen in the
          members.
       - Evaluating progress.
       - Helping members make decisions and plans for the future.
       - Linking members to AA and/or aftercare.
                                                                                         20



                Topic 1 – Introduction to 12 Step Recovery and CBT.




                                     The 12 Steps


   1. We admitted we were powerless over alcohol - that our lives had become
       unmanageable.
   2. Came to believe that a power greater than ourselves could restore us to sanity.
   3. Made a decision to turn our will and our lives over to the care of God as we
       understood Him.
   4. Made a searching and fearless moral inventory of ourselves.
   5. Admitted to God, to ourselves, and to another human being the exact nature of our
       wrongs.
   6. Were entirely ready to have God remove all these defects of character.
   7. Humbly asked Him to remove our shortcomings.
   8. Made a list of all persons we had harmed, and became willing to make amends to
       them all.
   9. Made direct amends to such people wherever possible, except when to do so
       would injure them or others.
   10. Continued to take personal inventory and when we were wrong, promptly
       admitted it.
   11. Sought though prayer and meditation to improve our conscious contact with God
       as we understood Him, praying only for knowledge of His will for us and the
       power to carry that out.
   12. Having had a spiritual awakening as the result of these steps, we tried to carry this
       message to alcoholics and to practice these principles in all our affairs.


Discussion:
Discuss how these steps can be incorporated into group and individual counseling.
You may also read the 12 traditions and process them in group.

Possible Discussion Questions
Why are these steps read at the beginning of each AA meeting?
What role do the 12 steps play in recovery?
Why do you have to work each step one at a time?
What is a sponsor’s role in relation to the 12 steps?
How do you get a sponsor? (Role play asking someone to be a sponsor).
How do you feel about asking someone to sponsor you?
What should you expect from your sponsor?
Why is it important to read the Big Book?
Why is it important to attend meetings?
What should you expect when you go to meetings?
                                                                         21




                                    Goals Worksheet
                  Reviewing your goals can strengthen your motivation.
The changes I want to make during the next ________ weeks are:




The most important reasons why I want to make those changes are:




The steps I plan to take in changing are:




The ways other people can help me are:




Some things that might interfere with my plan are:
                                                                                        22



                        Topic 2 – The CBT Model of Addiction.

                             The CBT Model of Addiction

We think ten times faster than we talk. On the average we talk about 150 words a minute
but we think about 1500 words a minute. This inner dialogue is continuous (you are
doing it right now). We process information through words, images and memories.

There are five components: thoughts, feelings, behavior, physiological reactions, and
environment (situation). Each of the five components affects and interacts with the
others. Small changes in any one area can lead to changes in the other areas.




                                         Thoughts

               Environment




                                         Addiction                     Feelings
             Physical
             Reaction




                                         Behavior
                                                                                          23


                              The CBT Model of Addiction




                                           Thoughts

              Environment




                                          Addiction                       Feelings
            Behavior




                                           Physical
                                           Reaction




              Conceptualizing the Client Who Is Seeking Treatment

Environment            Several family members and friends abuse alcohol and drugs. Legal
                       trouble. Financial trouble. Divorce and parent-child problems.
                       Problems at work.
Thoughts               I’m a failure. I am worthless. My life is hopeless. I am rejected. I
                       will never get sober. I may as well be dead.
Feelings               Depressed, Anxious.
Physical Reaction      Great deal of time spent in using alcohol and drugs, or recovering
                       from hangovers. Sweating, rapid pulse, insomnia, nausea or
                       vomiting, physical agitation
Behavior               Great deal of time spent thinking about, acquiring and using alcohol
                       and drugs. Difficulty working; isolating self, crying, anger outburst,
                       suicide attempts
                                                                          24


                            The CBT Model of Addiction




                                      Thoughts

              Environment




                                     _________                 Feelings
            Behavior




                                      Physical
                                      Reaction




                         Understanding My Problems
                       Describe the five areas listed below.


Environment


Thoughts


Feelings


Physical Reaction


Behavior
                                             25


            The Belief Hierarchy




Situation                          Emotion




Situation    Automatic
                                   Emotion
             Thoughts
                                                26


               The Belief Hierarchy




Situation       Automatic
                                      Emotion
                Thoughts


            Intermediate Beliefs




Situation       Automatic
                                      Emotion
                Thoughts


            Intermediate Beliefs


                Core Beliefs
                                                                             27




                   The Belief Hierarchy




     Core Belief -                 I am inadequate




     Core Belief -                 I am inadequate


Intermediate 1. Attitude             It’s terrible to be inadequate
Beliefs      2. Assumption (positive)If I work extra hard, I can do OK
                  (negative)         If I don’t work hard, I fail
             3. Rules:               I should always do my best
                                     I should be great at everything I try
                                                                             28



                   The Belief Hierarchy




     Core Belief -                 I am inadequate


Intermediate 1. Attitude             It’s terrible to be inadequate
Beliefs      2. Assumption (positive)If I work extra hard, I can do OK
                  (negative)         If I don’t work hard, I fail
             3. Rules:               I should always do my best
                                     I should be great at everything I try




Automatic Thoughts                     I can’t do this
when depressed                         This is too hard
                                       I’ll never learn this
                                       I always fail
                                                                                        29



          Topic 3 – Identifying Your Triggers (focused on the “B” of CBT)

The therapist may begin with a questions like: “How many group members have ever
heard of Pavlov‟s dogs? What do you know about his experiment? What does it mean to
you?” Then give a simple explanation like “Pavlov demonstrated that, over time,
repeated pairings of one stimulus (e.g., a bell ringing) with another (e.g., the
presentation of food) could elicit a reliable response (e.g., a dog salivating).”

Use the diagram below to illustrate. You may want to draw the diagram on the board as
you teach this concept.




                                 The “B” of CBT.

                      Food                            Salivation



                     Bell with
                      Food                            Salivation




                       Bell                            Salivation




Check for understanding. Then ask, “How could Pavlov‟s experiment possibly relate to
addictive behaviors?” Give them a chance to answer. Then give a simple explanation like
“Over time, addictive behavior can become paired with things like money or
paraphernalia, particular places (bars, places to buy drugs), particular people (drug-
using associates, dealers), times of day or week (after work, weekends), feeling states
(lonely, bored), and so on. Eventually, exposure to those cues (or triggers) alone is
sufficient to elicit very intense cravings or urges that are often followed by substance
abuse.”
                                                                                      30




                                   Craving          Substance
                    People
                                                      Abuse


                                   Craving          Substance
                     Places
                                                      Abuse



                                   Craving          Substance
                    Things
                                                      Abuse



                                    Craving         Substance
                    Feelings
                                                      Abuse


                                                     Substance
                     Time           Craving            Abuse




After group members understand these basic concepts ask them to identify their triggers.

Identify your “triggers”

What people are paired with your addiction? ________________________________

What places are paired with your addiction? ________________________________

What things are paired with your addiction? ________________________________

What feelings are paired with your addiction? ________________________________

What times are paired with your addiction? ________________________________
                                                                                           31



                      How is addictive behavior reinforced?

Instructions for Therapist:

The therapist may begin with a questions like: “How is addictive behavior reinforced?
Why do you keep using? What are the desired effects?” Give group members a chance to
respond. Encourage group discussion among group members. Then give a simple
explanation like: “Drug use is reinforcing because it changes the way a person feels
(e.g., powerful, energetic, euphoric, stimulated, less depressed), thinks (I can do
anything, I can only get through this if I am high), and behaves (less inhibited, more
confident).”

Therapist should process the diagram below with the group. Help clients personalize the
concept by filling in the blanks in the diagram. The therapist can invite group
participation by saying: “This diagram illustrates how addictive behaviors are
reinforced. Please help me fill in the blanks. Think of the first blank as the „trigger‟ and
the second blank as the „desired effect‟.




                                           _______




                 Negative                                           Substance
               Consequences                                           Abuse




                                          _______




If the group becomes stuck in this process you may give them an example.
Depressed  Substance abuse  Euphoria  Negative consequences
Anger  Substance abuse  Carefree Negative consequences
Tired Substance abuse  Stimulated  Negative consequences
Timid  Substance abuse  Confident  Negative consequences
Anxious  Substance abuse  Calm  Negative consequences
                                                   32


INSERT FUNCTIONAL ANALYSIS WORKSHEET (LANDSCAPE)
                                                                                          33




                                Identify Your Triggers


This worksheet will help you identify your triggers. Please reflect each major area
(Social, environmental, mental, emotional, and spiritual) as you record your answers in
writing. Then share your written responses with the group.

Social Triggers:

Do you typically use alcohol or other drugs when you are alone or with other people?
____________________________________________________________________

Environmental Triggers:

Where do you typically use alcohol or other drugs? What situations or circumstances
trigger your use? ________________________________________________________

______________________________________________________________________

Mental Triggers:

What thoughts typically trigger your use of alcohol or other drugs? ________________

______________________________________________________________________

Emotional Triggers:

What feelings typically trigger your use of alcohol or other drugs? ________________

______________________________________________________________________

Spiritual Triggers:

How would you describe your spiritual life when you are triggered to use? ___________

______________________________________________________________________


Other relevant questions:
What is your pattern of use (weekends only, every day, binge use)?
What has happened to (or within) you before the most recent episodes of abuse?
How would you describe its effects on you before, during and after you use?
                                                                                           34


                   Replacing Addictive Behaviors with Healthy Ones

Recovery involves replacing addictive behaviors for healthy ones. Below is a list of
healthy behaviors which can be used to replace unhealthy ones. Please identify which
behaviors you plan to use by placing a “check” in the corresponding box.

        Going to AA meetings.
        Doing service work.
        Reading the Big Book.
        Working the Steps.
        Getting a sponsor.
        Calling your sponsor.
        Participating in group.
        Exercise.
        Going to church.
        Practicing good hygiene.
        Socializing with friends who support your recovery.
        Going to work.
        Praying.
        Gardening or yard work.
        Cleaning house.
        Paying bills.
        Taking care of your children.
        Attending community activities.
        Keeping appointments.
        Continue counseling.

Other healthy behaviors?

________________________________________________________________________

________________________________________________________________________

Create Your Own Motivation by acting “As if”.

Don’t wait to be motivated before you do something. Do something and your are likely to
become motivated. Act “as if” your are motivated and your motivation may increase,
leading to more action. It is easier to act your way into a better way of feeling than to feel
your way into a better way of acting.
                                          35


INSERT ACTIVITIES WORKSHEET (LANDSCAPE)
36
                                                                                        37



             Topic 4 – Coping with Craving (focused on the “B” of CBT)

                         Teaching Concepts related to Craving

Instructions for therapists

This section contains CBT concepts related to craving that must be taught by the
therapist. The therapist should present the material in a conversational manner. Don’t be
overly didactic. Invite group members to participate. Ask questions, invite comments and
check understanding. Let it be a collaborative dialogue. Make it simple, concrete and
relevant to the group members.

Below I have listed and explained how therapists can present the material on craving. The
presentation is merely a guide or example. It is not necessary to present the concepts and
techniques as I do. Learn the basic concepts and techniques, then present it in a way that
is consistent with your own style.

1. How to introduce the topic of craving

The therapist may introduce the topic of craving with this simple explanation: “Craving
is a common problem for most people in recovery. You may experience episodes of
intense craving for alcohol or drugs. The experience can be both mystifying and
disturbing if it is not understood and manage effectively. The goals of this session are:
      To understand craving as you experience it.
      To understand that craving is a normal and time-limited experience.
      To learn various coping strategies to help you effectively deal with craving.

2. Questions for group members

After the brief introduction the therapist may begin by asking questions like:
    Describe your own experience of craving?
    When does it typically happen?
    How long does it last?
    What triggers it?
    What are the similarities and differences in your responses?

Try to identify similarities and differences among group members. Group members may
identify common triggers like being around people with who use alcohol or drugs, having
money or getting paid, certain social situations, and certain mood states, such as anxiety,
depression, or joy. They also identify triggers that are unique to themselves. Triggers for
craving can be highly idiosyncratic, thus identification of cues should take place in an
ongoing way throughout treatment.
                                                                                        38




3. Review Pavlov

Review the material on conditioned cues by paraphrasing Pavlov’s dogs. Use concrete
and relevant examples that help clients understand and relate the concept of craving to
their own experience. You may asked questions like: “Can you identify the personal
“bells” that trigger craving alcohol or drugs? Such questions help clients demystify the
experience of craving and enable them to identify and tolerate conditioned craving when
it occurs.

4. The therapist may ask questions like:

What is craving like for you?
What is the feeling like?
Do you experience any physical sensations?
Where in your body do you experience these physical sensations?
How strong is it?
Does it move or change?
Where else does it occur?
How long does it last?
How bothered are you by craving?
How do you try to cope with it?

5. Review the Identifying your Triggers Worksheet

As you review the Identifying Triggers Worksheet focus on identifying the craving and
cues that have been most problematic in recent weeks. Encourage clients to monitor their
craving so that they can identify new, more subtle triggers as they arise.

6. Learning how to Avoiding Cues

Help clients understand that the general strategy of "recognizing, avoiding, and coping" is
particularly applicable to craving. After triggers have been recognized it is important for
clients to avoid them. This may include breaking ties or reducing contact with individuals
who use alcohol or drugs, getting rid of paraphernalia, staying out of bars or other places
where alcohol or drugs are used, or no longer carrying more money than needed.

7. Learning how to Coping With Craving

The therapist may present the following strategies for coping with craving. Present each
coping strategy with questions for discussion.

      Distraction – What activities can you use to distract yourself?
      Talking about craving – Who can you call? What would you say?
                                                                                               39


      Recalling the negative consequences of substance abuse – Can you recall or
       remember the negative consequences of substance abuse? Can you mentally
       rehearse these memories during episodes of craving?
      Using self-talk – What are some self-coping statements you can use during
       episodes of craving? Can you list five self-coping statements you could use to help
       you cope with craving?

8. Demonstrate progressive relaxation

Therapists should explain how progressive relaxation can be used as an effective way to
cope with craving. Therapists may demonstrate this skill by guiding group members
through the following exercise.

The therapist may begin by saying: The physical sensation of craving can create stress
and tension in your body. It‟s important to learn how to relax your body during episodes
of craving. Please allow me to guide you through this progressive relaxation exercise.

      Lean back in your chair and relax your body.
      Go as limp as you can from head to foot.
      Let your shoulder blades go slightly flat.
      Wiggle your feet
      Shake your arms gently and let your hands rest on your lap.
      Roll your head back and forth.

Now, we are going to relax each part of our body. Let‟s begin with your … :

      Legs
           o    Flex the muscles of your left leg by raising it 2 inches off the floor.
           o    Point your toes slightly back toward your head.
           o    Hold this position of tension for about 10 seconds (the therapist counts)
           o    Focus on the tension in your legs.
           o    Then, say to yourself: 'Leg, let go. ' At this point, stop flexing it and let the
                leg drop.
           o    Say to yourself: 'I feel the tension flowing out of my leg ... My leg feels
                relaxed, warm, heavy ... completely relaxed
           o    Run through the entire procedure again for your right leg.
      Thighs
           o  Tighten your thigh muscles, as tightly as you can.
           o  Hold this position of tension for about 10 seconds (the therapist counts).
           o  Then release them, saying 'Let go', to yourself.
           o  Be aware of how relaxed your thigh muscles are.
      Stomach
          o Do the same procedure twice for your abdominal muscles
      Back and Neck
          o Arch your spine, tightening all along it from your tailbone to your neck,
              and finish by telling it: 'Let go'.
                                                                                          40




      Arms and Shoulders
          o Imagine there is a bar on your lap.
          o Wrap your hands around and grab the imaginary bar and clench your fists
               around it as hard as you can.
          o Flex the muscles in your hands and arms and shoulders.
          o Hold this position of tension for about 10 seconds (the therapist counts).
          o Now relax your hands and arms and shoulders soaking up the warm,
               relaxed feelings, letting the tension flow out.
      Jaw
          o Tighten your jaw muscles
          o Clamping down on you back teeth.
          o Hold this position of tension for about 10 seconds (the therapist counts).
          o Now say to yourself 'Let go' and relax.
      Face
          o Tighten your facial muscles into a strong grimace .
          o Hold this position of tension for about 10 seconds (the therapist counts).
          o Say to yourself “Let go.”
          o Rest and focus on the relaxing feeling in your face.
      Entire body
          o Clench your feet and fists.
          o Pull your shoulders up.
          o Tighten your jaw and face.
          o Now simultaneously flex your entire body
          o Hold this position of tension for about 10 seconds (the therapist counts).
          o Then say to yourself, “Let go”
          o Just let yourself go ... all the way, as much as you can.
          o Just sit there and feel the tension drain away.
          o Feel the tension draining out of you.

Now, open your eyes. How do you feel? Are you more relaxed? Do you think you could
use this exercise? How might this relaxation exercise help you during episodes of
craving?

Therapist may encourage the clients to use it regularly, even when they are not craving
alcohol or drugs.

9. Demonstrate Breathing Exercises

To introduce this coping strategy the therapist may say something like: As you know, the
physical sensation of craving can create stress and tension in your body. It‟s important to
learn how to relax your body during episodes of craving. Another coping skill you can
use is breathing exercises. Then give each client the worksheet on the page that follows.
                                                                                         41




                                Breathing Exercises


Breathing exercises can help reduce stress and anxiety. Four different types of breathing
exercises are described below. Read each one carefully. If you don’t understand how to
use them asked your therapist to demonstrate how they are done.


       Deep Breathing – Lie on your back. Breathe evenly and gently, focusing your
       attention on the movement of your stomach. Continue for 10 breaths. The
       exhalation should be longer than the inhalation.

       Measuring your breath by your footsteps – Walk slowly down the hall or in the
       yard or sidewalk. Breathe normally. Determine the length of your breath, the
       exhalation and inhalation, by the number of your footsteps. Let it be natural.
       Continue this for a few minutes and stop.

       Counting your breath – Sit cross-legged on the floor; or sit in a chair with your
       feet on the floor; or kneel; or lie flat on your back; or take a walk. As you inhale,
       be aware that “I am inhaling, 1”. When you exhale, be aware that “I am exhaling,
       1”. Remember to breathe from your stomach. When beginning the second
       inhalation, be aware that “I am inhaling, 2.” And slowly exhaling, be aware that “I
       am exhaling, 2.” Continue on up through 10. After you have reached 10, return to
       1. Whenever you lose count return to 1. Continue this for a few minutes and stop.

       Following your breath while listening to music – Listen to music. Breathe long,
       light, and even breaths. Follow your breath; be master of it while remaining aware
       of the movement and sentiments of the music. Do not get lost in the music, but
       continue to be master of your breath and yourself. Quiet your mind and body. Do
       this for two pieces of music (or songs) and stop.

Which breathing exercise are you willing to try this week? _______________________

When are you going to do your breathing exercise? _____________________________

Share your experience during the next group.
                                                                                    42




10. Explain the Practice Exercises and assign homework

The therapist may assign practice exercises such as the Coping with Craving and Urges
Worksheet, The Daily Record of Craving. Progressive Relaxation
                                                        43


INSERT THE Coping With Cravings and Urges (LANDSCAPE)
                                                 44


INSERT THE Daily Record of Craving (Landscape)
                                                                                        45



                Topic 5 – Refusal Skills (focused on the “B” of CBT)

                                Managing Availability
List sources of alcohol and drugs here and what you'll do to reduce availability (for
example, people who might offer you alcohol or other drugs, places you might get it).
              Source                        Steps I'll take to reduce availability
                                                                             46


                                     Refusal Skills
Tips for responding to offers of alcohol or other drugs:
  Say no first.
  Make direct eye contact.
  Ask the person to stop offering it.
  Don't be afraid to set limits.
  Don't leave the door open to future offers (e.g., not today).



   People who might offer me
                                                     What I'll say to them
         alcohol/drugs

A friend I used to use with:




A coworker:




At a party:
                                                                                         47



                              Topic 6 – Managing Your Mood.

Emotion can be difficult to identify. Below is a list of moods. Although the list is not
comprehensive it may help you describe your feelings in more exact terms. Check these
lists for the exact nuance to describe your moods and intensity of feelings.
Intensity of
Feelings       HAPPY               SAD                  ANGRY            CONFUSED
High           Elated              Depressed            Furious          Bewildered
               Excited             Disappointed         Enraged          Trapped
               Overjoyed           Alone                Outraged         Troubled
               Thrilled            Hurt                 Aggravated       Desperate
               Exuberant           Left out             Irate            Lost
               Ecstatic            Dejected             Seething
               Fired up            Hopeless
               Delighted           Sorrowful
                                   Crushed
Medium         Cheerful            Heartbroken          Upset            Disorganized
               Up                  Down                 Mad              Foggy
               Good                Upset                Annoyed          Misplaced
               Relieved            Distressed           Frustrated       Disoriented
               Satisfied           Regret               Agitated         Mixed up
               Contented                                Hot
                                                        Disgusted
Mild           Glad                Unhappy              Perturbed        Unsure
               Content             Moody                Uptight          Puzzled
               Satisfied           Blue                 Dismayed         Bothered
               Pleasant            Sorry                Put out          Uncomfortable
               Fine                Lost                 Irritated        Undecided
               Mellow              Bad                  Touchy           Baffled
               Pleased             Dissatisfied                          Perplexed
Intensity of
Feelings       AFRAID                    WEAK             STRONG        GUILTY
High           Terrified                 Helpless         Powerful      Sorrowful
               Horrified                 Hopeless         Aggressive    Remorseful
               Scared stiff              Beat             Gung ho       Ashamed
               Petrified                 Overwhelmed      Potent        Unworthy
               Fearful                   Impotent         Super         Worthless
               Panicky                   Small            Forceful
                                         Exhausted        Proud
                                         Drained          Determined

Medium         Scared                    Dependent        Energetic     Sorry
               Frightened                Incapable        Capable       Lowdown
               Threatened                Lifeless         Confident     Sneaky
               Insecure                  Tired            Persuasive
               Uneasy                    Rundown          Sure
               Shocked                   Lazy
                                         Insecure
                                         Shy
Mild           Apprehensive              Unsatisfied      Secure        Embarrassed
               Nervous                   Under par        Durable
               Worried                   Shaky            Adequate
               Timid                     Unsure           Able
               Unsure                    Soft             Capable
               Anxious                   Lethargic
                                         Inadequate
                                                                                             48


                                      Rating Moods

   In addition to identifying moods, it is important to learn to rate the intensity of the
   moods we experience.


    Rating the intensity of your moods allows you to observe how your moods
     fluctuate.
    Rating the intensity of your moods helps alert you to which situations or thoughts
     are associated with changes in our moods.
    You can also use changes in emotional intensity to evaluate the effectiveness of
     strategies your learn in CBT.




                                   Rating Your Mood
What was the situation?

   Situation: ________________________________________________________

What did you feel?


   Mood: ________________________________________


To what degree would you rate the intensity of this feeling?
       _______________________________________________________________
       0       10     20      30      40      50      60       70     80      90      100



Things to Remember
 Moods can usually be described in a word.
 Rating your moods allows you to evaluate their strength and track the fluctuations of
   your emotional reactions.
 Identifying specific moods can help you set and track goals.
 Strong feelings or moods signal that something important is going on in your life.
 Rating your moods can enable you to choose interventions designed to alleviate
   particular moods or reduce their intensity.
 It is important to separate situations, thoughts and moods.
                                                                                         49



                    Disentangling Thoughts, Feelings, and Situations
This exercise will help you better distinguish your thoughts, feelings, and situations.
Circle your answer in the right column to indicate if the item in the left column is a
thought, feeling, or situation.
Depressed                                      Thought            Feeling         Situation
At the bar                                     Thought            Feeling         Situation
I’m crazy                                      Thought            Feeling         Situation
Angry                                          Thought            Feeling         Situation
Irritated                                      Thought            Feeling         Situation
At work                                        Thought            Feeling         Situation
It’s awlful.                                   Thought            Feeling         Situation
At home                                        Thought            Feeling         Situation
I’m good at this                               Thought            Feeling         Situation
Driving a car                                  Thought            Feeling         Situation
Something terrible happened                    Thought            Feeling         Situation
Nothing ever goes right                        Thought            Feeling         Situation
In the garage                                  Thought            Feeling         Situation
Discouraged                                    Thought            Feeling         Situation
I can’t stand this                             Thought            Feeling         Situation
Sitting alone                                  Thought            Feeling         Situation
Furious                                        Thought            Feeling         Situation
I’m a failure                                  Thought            Feeling         Situation
Talking on the phone                           Thought            Feeling         Situation
Panic                                          Thought            Feeling         Situation
She is being inconsiderate                     Thought            Feeling         Situation
I’m a loser                                    Thought            Feeling         Situation
Guilty                                         Thought            Feeling         Situation
Drinking and driving                           Thought            Feeling         Situation
At a friend’s house                            Thought            Feeling         Situation
I’m having a heart attack                      Thought            Feeling         Situation
He took advantage of me                        Thought            Feeling         Situation
Anxious                                        Thought            Feeling         Situation
In bed trying to get to sleep                  Thought            Feeling         Situation
I’m going to loose everthing                   Thought            Feeling         Situation
I’m in trouble                                 Thought            Feeling         Situation
Thrilled                                       Thought            Feeling         Situation
I hate my life                                 Thought            Feeling         Situation
I have to get sober                            Thought            Feeling         Situation
Sad                                            Thought            Feeling         Situation
Sitting in an AA meeting                       Thought            Feeling         Situation
I always work hard                             Thought            Feeling         Situation
I’m lazy                                       Thought            Feeling         Situation
Panic                                          Thought            Feeling         Situation
In the office                                  Thought            Feeling         Situation
                                    50



            Daily Mood Log

Situation                    Mood
                                                                                  51



          Topic 7 – Changing Your Thinking (focused on the “C” of CBT)



                         Examples of Dysfunctional Thoughts


About self

I am a total failure
I should never be afraid
I always mess up.
I will not be able to stay sober.
I am the worst example on earth.
I never follow directions.
I am so stupid.
I can’t solve problems.
I should be perfect.

About others

No one cares about anyone else.
All men (or women) are dishonest and are never to be trusted.
I can control other people.
People are out to get whatever they can from you; you always end up being used.
People never listen to my point of view.
I always get hurt in relationships so I should withdrawal from other people.
All people are out for #1.
I must be accepted by other people.
I have to be on my guard because people always disappointment me.

About treatment

I don’t need help.
All counselors are untrustworthy.
All those people who attend AA meetings gossip.
I will never be able to work the steps.
The people in treatment don’t really want to get sober.
I can’t learn new coping skills.
It’s impossible for me to attend AA meetings.
Counselors are in for the money.
I can’t help the way I feel.
I will never get sober.
I will never be able to maintain sobriety.
Counselors don’t like to work with me.
52
                                                                                          53


                      Ten Common Dysfunctional Beliefs
Read the ten common dysfunctional beliefs and identify which beliefs you are most
vulnerable to when you are upset by placing a check () in the shaded area.


    I should be loved and approved by significant others and live up to their
    expectations.


    I must be highly competent, adequate, intelligent and achieving before I can me
    happy.


    When people act unfairly I should blame them and view them as bad people.


    It is a terrible catastrophe when I am rejected, treated unfairly, or when things aren’t
    as I would like them.


    Since my feelings are caused by external factors, I have little or no ability to control
    or change them.


    I should be greatly concerned about dangerous and fearful things and must center
    my attention on them until the danger has past.


    I can handle difficulties and responsibilities better by avoiding them than by facing
    them.


    People and things should turn out better than they do, and when they don’t I should
    see them as awful, terrible, etc.


    My past remains all-important, and must influence my feelings and behavior now
    because it once did.


    I can achieve happiness by being passive.
                                                                        54




                 Thought Record

 Situation               Thoughts                       Feelings
What happened   List five or more thoughts.       Identify and rate the
                  Describe any images.        intensity of each feeling on
                                                   a scale of 0-100%.
                                                                                       55




                               Socratic Questioning
                21 Questions to Ask Yourself Before You Get Upset



Thought to be Tested ____________________________________________________


   1.  Are my thoughts and/or images true and accurate?
   2.  Are my thoughts and/or images healthy? Are they helpful?
   3.  What evidence supports my ideas?
   4.  What evidence does not support my ideas?
   5.  Are there other more central thoughts and images left unidentified or
       unevaluated?
   6. Have I correctly identified the problem or upsetting event?
   7. Do I completely understand the situation or upsetting event? What is known?
       What remains unknown?
   8. What is the worst possible thing that could happen?
   9. What is the best thing that could happen?
   10. What is the most realistic outcome?
   11. What was going through my mind before I started to feel this way?
   12. Are there other disturbing circumstances that contribute to my upset emotion?
   13. What images or memories do I have about this situation?
   14. If it is true, what does it mean about me? my life? my future?
   15. Is there an alternative explanation?
   16. Am I going to be able to live through this?
   17. What is the effect of my believing this thought or imagining this scene?
   18. What could be the effect of changing my thinking?
   19. What can I do about it? Are their certain aspects about it that are beyond my
       control?
   20. What would I tell a friend if he or she were in the same situation?
   21. Can I speak to myself in the same compassionate way I would talk to a friend?
                                                                  56




                          Labeling Cognitive Distortions
           Category                        Thoughts and Beliefs

Magnifying the negative


All or nothing thinking


Overgeneralizations


Mind reading


Catastrophic exaggerations


Blaming


Assuming


Shoulds (Musts/oughts)


The fairy tale fantasy


Mislabeling


Unfavorable comparisons


Personalizing


Fortune telling


Perfectionism


Making feelings facts


Entitlement
                                                                                             57



         Topic 8 – Changing Your Core Beliefs (focused on the “C” of CBT)


                               Identifying Core Beliefs

Check the core beliefs that you identify with during times of distress. Indicate which core
beliefs you are most vulnerable to when you are upset.

                                    Helpless Core Belief
                 I am helpless                    I can’t get sober
                 I am trapped                     I can’t stay sober
                 I am a failure                   I can’t be successful
                 I am hopeless                    I can’t ask for help
                 I am inadequate                  I can’t work the program
                 I am ineffective                 I can’t improve my life
                 I am incompetent                 I can’t change
                 I am defective                   I can’t work the steps
                 I am useless                     I can’t trust



                                  Unlovable Core Belief
                 I am unlovable                  I am not good enough
                 I am unlikable                  I am different
                 I am unattractive               I am abandon
                 I am unwanted                   I am alone
                 I am rejected                   I am unnecessary
                 I am bad                        I am hated (by myself)
                 I am uncared for                I am hated (by others)
                 I am unworthy                   I am evil
                 I am worthless                  I am insignificant

Understanding Core Beliefs

It is important to understand the following about core beliefs:
       That it is an idea, not necessarily the truth.
       That you can believe it strongly, even “feel” it to be true, and yet have it be
        mostly or entirely untrue.
       That, as an idea, it can be tested.
       That it is usually rooted in past events; that it may or may not have been true at
        the time you first believed it.
       That it continues to be maintained through the operation of your schemas, in
        which you readily recognize data that support the core belief while ignoring or
        discounting data to the contrary.
                                                                                     58


     That you and your counselor working together can use a variety of strategies over
      time to change this idea so that you can view yourself in a more realistic way.



                                Core Belief Record
         Record evidence that this Core Belief is not 100% true all the time.

Dysfunctional Core Belief __________________________________________________


1.


2.


3.


4.


5.


6.


7.


8.


9.


10.
                                                                                          59



                               Modifying Core Beliefs

The purpose of this exercise is to modify dysfunctional core beliefs. Please follow the
instructions and complete the worksheet.


Old Core Belief ________________________________________________________

       What’s the most that you’ve believed this? (0-100%) _________________
       What’s the most that you’ve believed this? (0-100%) _________________
       How much do you believe it right now? (0-100%)      _________________

New Belief ____________________________________________________________


       How much do you believe it right now? (0-100%)         _________________


                          Evidence to Support the New Belief
                     List five or more reasons you believe it is true.


1.



2.



3.



4.



5.
                                                                           60




                                Core Belief Record
               Record evidence that supports an alternative Core Belief.

      New Core Belief __________________________________________________


1.


2.


3.


4.


5.


6.


7.


8.


9.


10.
                                                                            61




                                Core Belief Record
                    Rate Confidence in new Core Belief over time.

       New Core Belief __________________________________________________


Date


Date


Date


Date


Date


Date


Date


Date


Date


Date
                                                                          62




                        Historical Test of New Core Belief
                 To strengthen your new Core Belief review your
                 life history looking for evidence that supports it

     New Core Belief __________________________________________________


Birth - 2


Age 3 - 5


Age 6 -12


Age 13 - 18


Age 19 - 25


Age 26 - 35


Age 36 - 50


Age 51 - 65


Age 66+


Summary ______________________________________________________________

______________________________________________________________________

______________________________________________________________________
                                                                            63




                                Core Belief Record
                    Rate Confidence in new Core Belief over time.

       New Core Belief __________________________________________________


Date


Date


Date


Date


Date


Date


Date


Date


Date


Date
                                                                          64




                        Historical Test of New Core Belief
                 To strengthen your new Core Belief review your
                 life history looking for evidence that supports it

     New Core Belief __________________________________________________


Birth - 2


Age 3 - 5


Age 6 -12


Age 13 - 18


Age 19 - 25


Age 26 - 35


Age 36 - 50


Age 51 - 65


Age 66+


Summary ______________________________________________________________

______________________________________________________________________

______________________________________________________________________
                                                                         65



        Topic 9. – Managing Anger (focused on the “C” of CBT)
                      The ABCD Worksheet

Activating Event                Beliefs             Consequent Emotion




                               Dispute “B”
                                Is it true?
                        Is it helpful or healthy?
                                                                                          66



                   Topic 10 – Developing an All Purpose Coping Plan

If I run into a high-risk situation:

1. I will leave or change the situation.
Safe places I can go: ______________________________________________________

2. I will put off the decision to use for 15 minutes. I'll remember that my cravings usually
go away in ______ minutes and I've dealt with cravings successfully in the past.


3. I'll distract myself with something I like to do.

Good distracters: _________________________________________________________

4. I'll call my list of emergency numbers:

Name:________________________________ Phone #: __________________________
Name:________________________________ Phone #: __________________________
Name:________________________________ Phone #: __________________________


5. I'll remind myself of my successes to this point: ______________________________

_______________________________________________________________________


6. I'll challenge my thoughts and beliefs by: ____________________________________

_______________________________________________________________________
                                                             67



                             Topic 11 – Relapse Prevention

                             Symptoms Leading to Relapse

Not attending meetings.

Not having or working with a sponsor.

Not working the steps.

Not mediating.

Not praying.

Not reading AA material.

Not serving.

Exhaustion.

Dishonesty.

Impatience.

Anger

Conflict in relationships.

Depression.

Frustration.

Self-pity.

Cockiness.

Complacency.

Expecting too much from others.

Entitlement.

The use of mood-altering chemicals.
                                                                                         68



                                Topic 12 – Step Review.


   1. We admitted we were powerless over alcohol - that our lives had become
       unmanageable.
   2. Came to believe that a power greater than ourselves could restore us to sanity.
   3. Made a decision to turn our will and our lives over to the care of God as we
       understood Him.
   4. Made a searching and fearless moral inventory of ourselves.
   5. Admitted to God, to ourselves, and to another human being the exact nature of our
       wrongs.
   6. Were entirely ready to have God remove all these defects of character.
   7. Humbly asked Him to remove our shortcomings.
   8. Made a list of all persons we had harmed, and became willing to make amends to
       them all.
   9. Made direct amends to such people wherever possible, except when to do so
       would injure them or others.
   10. Continued to take personal inventory and when we were wrong, promptly
       admitted it.
   11. Sought though prayer and meditation to improve our conscious contact with God
       as we understood Him, praying only for knowledge of His will for us and the
       power to carry that out.
   12. Having had a spiritual awakening as the result of these steps, we tried to carry this
       message to alcoholics and to practice these principles in all our affairs.


Discussion:
Discuss how these steps can be incorporated into group and individual counseling.
You may also read the 12 traditions and process them in group.

Possible Discussion Questions
Why are these steps read at the beginning of each AA meeting?
What role do the 12 steps play in recovery?
Why do you have to work each step one at a time?
What is a sponsor’s role in relation to the 12 steps?
How do you get a sponsor? (Role play asking someone to be a sponsor).
How do you feel about asking someone to sponsor you?
What should you expect from your sponsor?
Why is it important to read the Big Book?
Why is it important to attend meetings?
What should you expect when you go to meetings?
                                                                                   69


                                   References
Alcoholics Anonymous: The Big Book: 4th Ed. (2001). Alcoholics

      Anonymous World Services, Inc. Works Publishing Incr. New York, NY.

Beck, J. (1995). Cognitive Therapy: Basics and Beyond. Guildford Press. New

      York, NY.

Burns, D. D. (1999). The Feeling Good Handbook. New York: William Morrow

      and Co.

Carroll, K.M. (1998) A Cognitive-Behavioral Approach: Treating Cocaine

      Addiction. National Institute On Drug Abuse (NIDA). Therapy Manuel for

      Drug Abuse. Manual 1: Retrieved June 2006 at

      http://www.nida.nih.gov/TXManuals/CBT/CBT1.html

Corey, G. (2007). Theory and Practice of Group Counseling 4 th Ed. Brooks/Cole

      Publishing. Belmont CA.

Ellis, A. (1975) A New Guide to Rational Living. Wilshire Book Company,

      Chatsworth, CA.

Kadden, R.; Carroll, K.M.; Donovan, D.; Cooney, N.; Monti, P.; Abrams, D.; Litt,

      M.; and Hester, R. (1992). Cognitive-Behavioral Coping Skills Therapy

      Manual: A Clinical Research Guide for Therapists Treating Individuals with

      Alcohol Abuse and Dependence. NIAAA Project MATCH Monograph

      Series Vol. 3. DHHS Pub. No. (ADM) 92-1895. Rockville, MD: National

      Institute on Alcohol Abuse and Alcoholism.

Miller, W.R., & Rollnick, S. (1991). Motivational Interviewing: Preparing People to

      Change Addictive Behavior. New York: Guilford Publications.

Monti, P.M.; Abrams, D.B.; Kadden, R.M.; and Cooney, N.L. Treating Alcohol
                                                                             70


      Dependence: A Coping Skills Training Guide in the Treatment of

      Alcoholism. New York: Guilford, 1989.

Sinacola, Richards, S. & Peters-Strickland, Timothy. (2006). Basic

      psychopharmacology for counselors and psychotherapist. Boston, M.A.

      Allyn and Bacon Publishers.

Twelve Steps and Twelve Traditions. Alcoholics Anonymous World Services,

      Inc. Works Publishing Incr. New York, NY.

White, W. & Kurtz E. (2005). The Varieties of Recovery Experience. Chicago, IL.

      Great Lakes Addiction Technology Transfer Center.