Step 4: Respond to Cognitive Distortions
In the last chapter, you took a very close look at your triggers, the different types of “red flag thoughts” that enter your mind when you find yourself exposed to a trigger, and some of the errors in thinking that you are prone to making when you are tempted to drink or use. Now that you have a really thorough understanding of how triggers convert into cravings or urges, it’s time to start developing a repertoire of coping skills that will enable you to get through those urges without turning to alcohol or drugs.
Just like it sounds, cognitive behavioral therapy has both cognitive and behavioral skills components. So, when you find yourself triggered or tempted to drink or use, you have two “go-to” sets of therapeutic strategies that you can choose from. In this chapter, you will learn to use both of these types of skills to cope with the distorted thoughts that you experience when you are triggered. As you practice these new skills, pay special attention to which ones are the most useful to you, as well as which ones don’t work quite as well. From this chapter forward, based on your own observations and reflections about your experiences trying out these different techniques, you will start forming your individualized relapse prevention plan.
Outsmarting Your Addicted Brain
We’ve talked about your addicted brain and how the exercises in this workbook will help you “defeat it” by making your rational brain stronger. That’s what the cognitive part of CBT is all about. The red flag thoughts you identified in chapter 5 are the byproducts of your addicted brain. This is the part of you that finds ways of justifying a relapse to feed those uncomfortable urges. With practice, you can challenge these thoughts successfully and “outsmart” your lower, addicted brain. When you do that repeatedly, your rational mindset will start to become the new normal for you, and you can begin to break free from the thoughts that have been interfering with the goals you’ve set for your recovery.
As you learn to outsmart your addicted brain, the most powerful cognitive technique you will use is the skill of thought challenging. As you practice this method of transforming irrational thinking into balanced, realistic thoughts, you will learn to take a scientific approach to correcting the thoughts that are leading you down a path to self-destructive behaviors, like drinking and using drugs.
One of the most important things you will get out of learning CBT techniques like thought challenging is something that applies not only to overcoming addiction, but also to coping with other problems that stem from irrational thoughts (like depression, anxiety, and other emotional difficulties). You will learn to understand and change your behavior by being scientific, and sticking to the facts. What does that mean, exactly? you might be wondering. How can I be “scientific”? It’s not as complicated as it might sound, actually. You can achieve this by learning to notice and respond to your thoughts in several ways.
To put the thought challenging process into action, you’re going to need a framework. First, we’ll take a look at a few examples of how to challenge common red flag thoughts. Once you get the hang of it, you can complete the worksheet using your own examples. This worksheet can be used to review patterns of thinking that have led you to drink or use in the past. And if you slip or relapse at any time in the future, the exercises can help you (and your treatment provider, if you have one) to understand how the relapse unfolded and what you can do differently going forward.
Scott Gets Triggered
Scott has a strong urge to drink a glass of wine. On a scale from 0 to 10, he rates his craving as a 7. He thinks about it and realizes that it is because he is at a party with some friends he used to drink with.
Scott can try thought challenging by following three steps, which we will call the three T’s: identifying the triggering situation, and the red flag thoughts about drinking or using that followed, and placing the thoughts on trial:
Lucy Gets Triggered
Lucy has a strong urge to use cocaine. On a scale from 0 to 10, she rates her craving as an 8. She thinks about it and realizes that it is because she is feeling depressed and low in energy, and she’s looking for something to “pick her up.”
Lucy tries thought challenging, using the three T’s:
Brian Gets Triggered
Brian has a craving to use marijuana. On a scale from 0 to 10, he rates his craving as a 7. Upon reflection, he realizes that it’s because he is nervous about going to a party by himself, and he’d like to smoke some pot to take the edge off.
Brian tries thought challenging, using the three T’s:
Superficial Truths: Watch Out for Them!
You might have noticed that in both Brian and Lucy’s examples, they were tempted to use by certain thoughts that turned out to be superficial truths. That means that some short-term benefit of drinking or using gives the decision to slip or relapse some major appeal. This can get somewhat confusing—because it is a rational element of your thought process about drinking and using. It does feel good at first. That’s true. It can relieve anxiety in the short-term. That’s true. If you really think about it, you will find that it makes sense that there are some positive effects that drinking or using drugs has on you—otherwise you wouldn’t have found yourself doing more of it in the first place!
The key is to consider those positives in the bigger context of why you’re trying to quit. Yes, it feels good at first in certain situations, but then what happens? What is it about the sequence that starts with feeling good that led you to pick up this book and work so hard to stop? One of the goals of thought challenging is to be able to recognize when you are allowing yourself to be persuaded to make choices about drinking or using by superficial truths, and challenge them.
Exercise 6.1: Thought Challenging Worksheet
Use this worksheet to challenge the evidence for your red flag thoughts using the three T’s.
Triggering situation:
Red flag thoughts:
Thought on trial:
Evidence that the thoughts are accurate:
Evidence that the thoughts are superficial truths or not accurate:
Response (What can you tell yourself to get back into the recovery mindset?):
Responding to the Most Common Thought Errors
In chapter 5, you learned about different kinds of mistakes in thinking that can lead to red flag thoughts. Before you continue to practice thought challenging using the errors in thinking that you wrote down on the Thought Challenging Worksheet, take a look at the table that follows for some suggestions about how to respond to the most common mistakes in thinking. Remember, the first thing to do once you recognize that you’ve made one of the thought errors below is to make yourself aware of it by starting an internal dialogue about what just happened. (Okay, wait a minute. I’m starting to do that black-or-white thinking again…) Then, once you have become aware of it, you can use the three T’s and respond to your thought error using the kinds of thoughts or responses you see in the right hand column of the table below.
Exercise 6.2: Challenging Your Red Flag Thoughts
Now that you have some examples to work from, try the thought-challenging exercise again, using one of the thoughts that you wrote down in chapter 5, when you identified your most common mistakes in thinking. In this exercise, we’ll assume that you already know what the trigger is, and you are making yourself aware of the thought error you’re making.
Red flag thoughts:
Thoughts on trial:
Evidence that the thoughts are accurate:
Evidence that the thoughts are superficial truths or not accurate:
Response (What can you tell yourself to get back into the recovery mindset?):
Now that you’ve had some practice with thought challenging, you can build on the self-monitoring skills you learned in chapter 5, adding on the exercise of challenging red flag thoughts after you notice them. Practice completing the worksheet that follows (also available at http://www.newharbinger.com/32783) on a daily basis, any time you get triggered. You can review your entries with your counselor or therapist (if you have one) as part of your treatment.
Some people can change their behavior by thinking their way through their irrational brain’s ideas, challenging them, and converting them into healthy, rational thoughts. Sometimes, and for some people, rather than correcting red flag thoughts using cognitive techniques like thought challenging, it works better to change what they’re doing, using behavioral coping strategies. There are a few reasons why that might be. For some, it has to do with the timing in recovery. That is, in early recovery, when cravings for alcohol and drugs can be very strong and emotions can be overwhelming, it might be hard to concentrate or think clearly enough to have the inner dialogue that thought challenging requires. For others, it’s just a general preference for getting out of their own head. They may find it an easier way of preventing relapse than using a cognitive strategy.
Exercise 6.3: Thought Challenging Form
| Triggering Situation | Red Flag Thoughts | Thoughts on Trial (Questions I asked myself to examine the evidence) | | Alternative Responses |
|---|---|---|---|---|
The average length of a craving is about fifteen minutes. Even though that can feel like a lifetime when you’re so uncomfortable physically and emotionally, you might find it helpful to keep it in perspective and remember that it will end! For some people, it’s useful to imagine the craving as a wave in the ocean—it will climb until it peaks, and then it will crash and subside. If you can get through that brief period of time by riding it out, the discomfort will pass, and your recovery will grow stronger. As you are riding the urge out, you will experience the urge sensations weakening and going away. The goal is to ride it out without reacting to it by drinking or using. You will learn more about how to use similar techniques to this one in the next chapter, on becoming mindful.
Have you ever noticed, when you experience an urge to drink or use, that the longer you spend thinking about it, the harder it is to resist it? This is a very common experience, so if you’ve had it, you are not alone. In a way, thinking about drinking or using is like entertaining a fantasy, and the more invested you are in imagining how it will play out, the more you want it. The more you want it, the less you are able to weigh the pros and cons and make a rational decision about it. With this knowledge, you can choose to distract yourself from the urge before your imagination runs away with it and leads you to a relapse. Here are some ways that you can distract yourself early on, when you first notice the urge:
Start experimenting with these distraction techniques and see what works for you. We’ll put them into your personalized relapse prevention plan later. If you think of some distracting activities not listed here that are helpful to you, list them here:
Now that you have some ideas about how to distract yourself from an urge or craving, you can use these distractions to delay the decision about whether or not to drink or use for at least fifteen or twenty minutes. This can be a very useful way to fight off the impulse to give in to an urge, which usually lasts only fifteen or twenty minutes. You’ll find, more often than not, that once you’ve made it through that initial period of time and the urge has subsided, it is easier to make a firm commitment to not drink or use. If you are still uncertain after fifteen or twenty minutes, repeat the exercise: distract yourself and delay the decision for another fifteen or twenty minutes.
Although red flag thoughts and cravings are very common, especially when you first quit or cut back on drinking or using drugs, there are ways that you can prevent them from coming on in the first place. When you became a self expert in chapter 5, you learned how to identify your triggers. One way to build on this skill is to schedule how you will spend your days in advance, so you can anticipate when you might find yourself in a triggering situation, and plan for it. Consider an example:
Scott’s schedule for Monday is as follows:
By writing out his schedule, Scott identified three potentially triggering situations: First, he has been having some difficulties at work, and he gets very stressed when he meets with his boss, which has triggered cravings and urges for him in the past. His meeting with his boss on Monday is just before lunch hour, and since he doesn’t have any lunch meetings, Scott might be tempted to go out for lunch and have a glass of wine with his meal—lunch hour was often the time when he had his first drink of the day. Another risky time for him is when he is alone. After putting his kids to bed at 7:30, he can anticipate experiencing an urge to drink while waiting for his wife to get home from her late shift at work.
Scott will need to plan out what he will do at each of these risky times. The key, however, is that he was able to identify them in advance because he wrote out his schedule. Finding an effective coping strategy is easiest to do when you’ve planned for it. To practice this, use the daily schedule that follows. Once we’ve reviewed some more behavioral coping skills that you can use during these risky times, you will start using the Urge Planner (exercise 6.5) to plan ahead for them.
Exercise 6.4: Daily Schedule
When you complete your daily schedule, try to fill in as much as you can, including what time you wake up, shower, eat, exercise, and work; any appointments you have; social or family plans; errands; and anything else you are able to think of. As you begin to keep a detailed schedule, notice which planned activities might be triggering for you and place asterisks (**) next to them. It will also help to pay attention to blocks of time in your day when you might not have anything planned; these, for some people, are vulnerable times when cravings or urges often come up. By noticing and paying special attention to these high-risk times, you can start to structure your time more, as needed, with activities that are not compatible with drinking or using (for example, going to a 12-step or other recovery-oriented meeting, or spending time with a sober friend or loved one).
Date:
7:00 a.m.
8:00 a.m.
9:00 a.m.
10:00 a.m.
11:00 a.m.
12:00 p.m.
1:00 p.m.
2:00 p.m.
3:00 p.m.
4:00 p.m.
5:00 p.m.
6:00 p.m.
7:00 p.m.
8:00 p.m.
9:00 p.m.
10:00 p.m.
11:00 p.m.
12:00 a.m.
Planning for High-Risk Situations
A high-risk situation is any situation that might be triggering for you. While scheduling your time can help you to avoid high-risk situations, some are unavoidable—for example, stressful interactions with coworkers or family members, obligatory work functions where others might be drinking, or any experience that brings up unpleasant emotions. Like Scott, you can plan for upcoming high-risk situations by thinking ahead of time about how you can handle them.
Let’s take one of Scott’s anticipated urges as an example. Scott has a meeting scheduled with his boss just before his lunch hour. Those meetings are always stressful, and Scott anticipates that he will be tempted to go out to lunch by himself afterward and drink a glass of wine.
To be ready to cope with this situation, Scott needs to have at least two ideas: a plan and a backup plan. These are the plans he comes up with:
Now it’s your turn to use the Urge Planner for any high-risk situations you might have identified in your schedule for the upcoming week.
Exercise 6.5: Urge Planner
What situations do you anticipate this week that will trigger urges to drink or use?
High-risk situation #1 (include day, time, and situation):
How can you plan to cope with the urges?
Plan:
Backup plans: (1)
(2)
High-risk situation #2 (include day, time, and situation):
How can you plan to cope with the urges?
Plan:
Backup plans: (1)
(2)
High-risk situation #3 (include day, time, and situation):
How can you plan to cope with the urges?
Plan:
Backup plans: (1)
(2)
Are you someone who gets more out of cognitive strategies than behavioral ones, or vice versa? Are both types of skills helpful to you? Does it depend on the situation? As you are developing your personal relapse prevention plan, you’ll want to ask yourself these questions. If this workbook is your first exposure to CBT, then you are still in the process of gathering evidence to answer those questions. As you continue your cognitive and behavioral coping skills practice, give some thought to which ones work for you best, so that you can emphasize them when you make your relapse prevention plan in chapter 10.
In this chapter, you’ve started to form a repertoire of skills to cope with your triggers, thoughts, and cravings without turning to alcohol or drugs. You’ve learned cognitive skills, such as identifying red flag thoughts and superficial truths and challenging them. You’ve also been practicing behavioral skills, which include distracting yourself and keeping a schedule. The best way for you to begin to develop a relapse prevention plan that works for you is to continue to practice these techniques week after week (including making use of the Urge Planner, the daily schedule, and the thought challenging form), and make notes in your workbook about the ones that you have found to be the most helpful.
All of these skills require practice before using them will come naturally to you in a risky situation, so the more you work on them, the better. And don’t be too hard on yourself if it doesn’t always occur to you to use them. Just as it took a while for your use of alcohol or drugs to form an addiction, it will also take some time for you to learn new ways of responding to your urges to drink or use. Be patient with yourself.
In the next chapter, you will learn a different, equally useful approach to dealing with uncomfortable cravings or urges: rather than trying to change your thoughts or distract yourself from them, you are going to practice accepting and exploring them.