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Cognitive Behavioral

Therapy and Mindfulness

in Addiction Treatment
Tony Pacione, LCSW, CSADC
Harborview Recovery Center
St. Joseph Hospital
Chicago, Illinois
November 2009
In Early Recovery, Cover Your…

 A ccountability

 S tructure

 S upport
… for WHAT you are responsible in
 Understanding your thoughts

 Identifying thinking patterns

 Willingness to change ineffective thinking


… HOW you achieve your goals in recovery

 Thought log
 Challenging thoughts
 ‘Acting as if’ strategies
 Meditation/mindfulness techniques
Support …
…WHO will support your efforts
 Treatment Counselors
 Sponsor
 Therapist
 Psychiatrist
 Self-help
 Family/friends
 How thoughts are:

– Formed
– Maintained
– Discontinued
– Intensity of thoughts
Cognitive Schema

Automatic Thoughts
 Mental reactions to situations
– Real
– Imaginary
– Anticipatory
 Associated with feelings, mood, and
Cognitive Schema

Conditional Beliefs
 More general than automatic thoughts
– Boolean logic: “If… than; and/or”
 Assumptions
 Roles/expectations
 Attitudes/values
Cognitive Schema
Core Beliefs
“We are what we believe”
 Strongly held beliefs, underlying assumptions
about who we are and how we behave
 Develop early in life and are often reinforced as
we age
 Can become a ‘filter’ for interpreting life
experiences (“self-fulfilling prophecies”)
 Can serve us well or become dysfunctional
 Can be identified, confronted, and changed!
Cognitive Schema
Relevant Childhood and Developmental data:
Core Beliefs:
Conditional assumptions (if/then):
Compensatory Strategy:

Automatic Thoughts:
Cognitive Restructuring
1. Observe thoughts 1. Construct
2. Identify thinking thoughts
2. Complete
3. Identify cognitive cognitive schema
3. Behavioral
4. Challenge Experiments
cognitive (“act as if”)

(DPW3 = GTH)
Thought Record
(Steps 1-2) 42 y/o female alcoholic
Rating Mood and Desire/
Situation/Event Automatic Thought Related Feeling Craving (1-10)

I fought with my husband over Anger

missing our son's basketball game “He is not supporting Frustration
to attend an AA meeting. my recovery." Misunderstood 6
My husband doesn’t invites me to
his holiday work party; I
remember last year’s party when “I am an embarrassment to
I had leave because I was so my husband and a bad Guilt
intoxicated. wife. Depression 8

My sister is hosting the holiday

dinner this year and asks you to “She is insensitive and
make a run to the liquor store to buy Putting me in a bad Anger
the supplies for the event. position for a relapse.” Hurt 6

I tell me boss I’ve been “I am a bad employee for

struggling with my recovery and he letting my drinking affect Frustration
really wants to help you get sober. my work.” Guilt 8
I’m celebrating my son’s birthday,
and realize I’ve missed many of his “I am a bad mother for
achievements and milestones, letting him down for so Guilt
because of my drinking long.” Depression 10
Common Thinking Errors
(Step 3)

 All or nothing  ‘Catastrophizing’


 Emotional
 Overgeneralization reasoning

 Mental filters  Personalization

 Jumping to
Burns, D. 1999
Challenging Automatic Thoughts
(Steps 4-5) Using I.C.E. to cool off ‘Hot’ thoughts

 I – Identify and rate the negative thought

 C – Challenge the thought

 E – Evaluate/re-rate the truthfulness of the


Pacione, 2003
(Steps 4-5)
Identify and rate the thought:
“I’ve missed so many of my son’s achievements because of drinking. I
I am a bad mother.” truthfulness rating = 90% (of the time)

Challenge the thought:

I didn’t attend a single one of his I realized I had a problem and sought
basketball games last season, when treatment; If I am sober I can be there
all the other mothers were there. for him from now on.
He did poorly in math class because I I have made sure he always had a roof
wasn’t there to help him with his over his head and food on his plate.
I couldn’t chaperone his class field trip I’ve always made sure to tell him he is
because I didn’t want anyone to see loved and that he is an extraordinary
me with the shakes. person.
I.C.E. cont.
(Step 4-5)

Evaluate/re-rate the thought: Post challenge

truthfulness rating = 30%

Revise the thought:

“I’ve let him down in the past, but I am
doing everything I can now to stay sober; I
can be more present for my son now.”
Cognitive Grid
(Step 6)

 Relevant Childhood and Developmental

Data: Absent parents; alcoholic father
 Core Belief: “I’m un-lovable.”
 Conditional assumptions (if/then): “If I am
a good mother I will feel loved by my son;
then I am lovable!”
 Compensatory strategy: “Make sure I am
always available for him, whatever he needs.”
Cognitive Grid continued

 Situation: Missed a lot of my son’s

achievements while drinking.
 Automatic Thoughts: “I am a bad
mother.” “My son doesn’t love me”
 Emotions: “Depression and guilt”
 Behavior(s): Increased potential for
relapse, and isolation
Example adapted from A Beck, 1991: Cognitive Conceptualization Grid
Challenging Core Beliefs
(‘acting as if’ - Step 7)
 Amended Core Belief: “If I remain sober,
I’ll be a better mother. I can be loved for
who I am.”
 How to ‘act as if’ you’re a good mother:
– Attend my son’s basketball games when I
– Offer to help him with his homework
– Tell him I love him and praise his good
– Set limits and rules for him to follow
Mindfulness = More Aware More Often

“A powerful influence taking us away from being

‘fully present’ in each moment is our automatic
tendency to judge our experience as being not quite
right in some way—that it is not what should be
happening, not good enough, or not what we
expected or wanted. These judgments can lead to
sequences of thoughts about blame, what needs to
be changed or how things could or should be
different. Often, these thoughts will take us, quite
automatically down some fairly well-worn paths in
our minds. In this way, we may lose awareness of
the moment, and also the freedom to choose what if
any, action needs to be taken.”
Segal, et al. 2002
Mindfulness in recovery

Thoughts  Judgments 
Actions Consequences

Becoming more aware more often of

– Thinking patters
– Situations that activate your core belief
– Urges and craving to use
CBT + Mindfulness
 CBT = modifying
– perception,
– beliefs and thoughts
– judgment

 Mindfulness =
– being more aware more often
– Less interested in thought content
– Focus on arising and ceasing of thought

Principles of Mindfulness

1. Non-judging 1. Non-striving
2. Patience 2. Acceptance
3. Fresh Mind 3. Letting Go
4. Trust

Kabat-Zinn, 1990
1. Non-judging

 Become aware of the judging thoughts

 Notice how often we label and
categorize – assigning value to people
and experiences
 Judgments dominate the mind and
make it difficult to find peace within
2. Patience

 Be completely open to each moment

 Accept each moment in its fullness
 Know that life can only unfold in its
own time
3. Fresh Mind

 See things as if for the first time

 Be receptive to new possibilities –
prevents getting stuck

– Try having a fresh mind with your
partner, child, client, or someone else
familiar to you
4. Trust

 Develop trust within yourself

– Knowing when to seek help
– You can’t have all the answers

 Don’t compare yourself to others

 The more we trust ourselves, the
easier it is trust others and seek help
5. Non-striving

 Allowing anything we experience from

moment to moment to just be here
 Thinking of how you “should” be
implies you are not ok right now
– “IF I weren’t so stressed at work, THEN I
would be able to stay sober.”
6. Acceptance

We have to accept ourselves and

situations as they really are before
things can really change.”
Acceptance does NOT mean:
 You have to like everything
 That you have to tolerate things as
they “have to be”
 That you should stop trying or give up
on your own growth
7. Letting Go

 Pay attention to inner experience to

discover what thoughts and feelings
the mind wants to hold on to
 Holding on is the opposite of letting go
 Catching monkeys
CBT and Mindfulness
e Observe thoughts i Construct
-centering meditation/ alternative
t Identify thinking thoughts
patterns -Letting go
-”If your mind has
wandered…” i Complete
a Identify cognitive cognitive schema
-Non-judging/accepting i Behavioral
mind Experiments
e Challenge cognitive (“act as if”)
distortions -Trust/patience
-Fresh mind

(DPW3 = GTH)