by A. Tom Horvath, Ph.D., ABPP
Problematic addictive behaviors (substances or activities) are common in psychotherapy clients. In addition to therapy, these clients often benefit from mutual help groups. The most well-known and available group is Alcoholics Anonymous (AA). There are also several dozen similar groups (e.g., Narcotics Anonymous, Cocaine Anonymous), collectively known as 12-step groups. This article presents basic information about another widely available option in San Diego, SMART Recovery.
Finding a mutual help group
The ideal method for choosing mutual help meetings is to sample several, then choose the ones that appear most likely to be helpful. Because of the availability of 12-step meetings, they are typically recommended, sometimes to the exclusion of other options. Many clients are willing to attend a mutual help group, but not 12-step groups specifically. Common objections include that the 12-step program of recovery is oriented around having a belief in a higher power, and that meetings are not conversational.
Nevertheless, there are many advantages to participating in 12-step meetings in general and AA, in particular. These advantages include the high frequency and size of meetings, the large informal 12-step community, the availability of a “sponsor” who will guide a newcomer through the process of using the 12-step approach, and the now scientifically established efficacy of attending AA meetings specifically, if the individual is willing to attend consistently and engage with the AA community (Kelly, 2017). It is worthwhile to review the client’s objections to attending 12-step meetings, to determine if these objections might be overcome. However, many clients will remain unwilling to attend 12-step meetings. Fortunately, other groups are available.
In San Diego, secular groups include SMART Recovery, LifeRing, Women for Sobriety, Moderation Management, and Refuge Recovery. This article will focus on SMART Recovery, which has 60 meetings per week in San Diego County, and has been operating here since 1990.
The SMART Recovery organization
SMART Recovery is an international, non-profit organization with meetings in 23 countries. The SMART Recovery Handbook, the primary publication for participants, is available in 14 languages. Currently there are approximately 2,000 community meetings worldwide.
San Diego has one of the largest concentrations of SMART meetings anywhere. There are two San Diego SMART community centers, one in Kearny Mesa and another in Encinitas. In addition to regular meetings, there are also several Family & Friends meetings (SMART’s version of Al-Anon).
The SMART approach
The SMART approach for resolving problematic addictive behavior was recently found to be as effective as three other groups: AA, LifeRing, and Women for Sobriety (Zemore, Lui, Mericle, Hemberg, and Kaskutas, 2018). A review of 25 years of research on AA concluded that “most of the empirically supported mechanisms of AA are found to be more social, cognitive and affective” rather than spiritual (Kelly, 2017, pg. 5). Consequently, we can hypothesize that all mutual help groups base their effectiveness on the same underlying principles. Yalom (1995) suggested that there are 11 common factors in effective groups. These factors may work in both group psychotherapy and mutual help groups: instillation of hope, universality, imparting information, altruism, corrective recapitulation of the primary family group, development of socializing techniques, imitative behaviors, interpersonal learning, group cohesiveness, catharsis, and existential factors.
Although all groups may work by common factors, the surface appeal of addiction recovery groups is diverse. For instance, on the basis of descriptions of SMART Recovery and AA, some individuals may willingly attend one but not the other. Nevertheless, a minority of individuals, in various stages of change, attend both.
SMART supports individuals who wish to stop entirely or limit their problematic addictive behavior, and to pursue a more meaningful, purposeful, and connected life. Rather than relying on a higher power, SMART participants learn SMART ideas and cognitive and behavioral “tools” in order to empower themselves, over time, to act with greater attention to their long-term goals, while not acting on their short-term desires to engage in problematic addictive behavior.
In addition to not insisting on complete abstinence, accepting medication-assisted treatment, and the self-empowering rather than powerlessness orientation, there are several other significant differentiators between SMART and AA. In SMART, there are no sponsors. Individuals desiring a sponsor relationship are encouraged to become involved in AA, instead of or in addition to SMART. In SMART, participants are not required to use the labels “addict” or “alcoholic” (but use of these terms is accepted). In SMART, whether to believe in a higher power, or whether addiction is a disease, or whether moderation of use is a good idea generally, are questions left entirely up to the participant, and not discussed in meetings. SMART’s slogan is “Discover the Power of Choice.”
How SMART meetings operate
In SMART, participants choose their own limits. The meetings focus on how to stay within these limits. Although each participant’s limits may be different, the process of staying within limits (including resisting temptation, advancing self-control, and coping with underlying issues) is common for all. For instance, a participant might choose to abstain from heroin, meth and coke, but smoke pot once a weekend, and have a drink even less frequently. The focus in the meeting is how stay within each of these limits. Participants are also encouraged to identify and pursue other goals. Stopping drinking is more likely to be effective when it is a step in the direction of accomplishing a highly desired goal, rather than simply an end in itself.
SMART offers a set of “tools” for change. These tools would be familiar to any clinician who is familiar with CBT and MI (motivational interviewing).
SMART meetings are primarily conversational, rather than being a sequence of non-interacting monologues as in a 12-step meeting. The typical meeting agenda is a welcome, check-in (around the circle), agenda setting for the discussion period, the discussion period itself (the longest part of the meeting), announcements and pass-the-hat (donations are accepted but there is no charge), and check out. The primary rules are that no one is required to participate, no one can talk too long, the meetings are confidential, the discussion focuses on resolving problematic addictive behavior and related topics, and ideas and suggestions are welcome but advice is not allowed. Meetings are led by facilitators or hosts. Facilitators complete an intensive online course lasting 20-30 hours over eight weeks. Hosts are trained “on the job” in meetings, and a shorter online training course is available.
Scientific investigation of SMART
Scientific investigation of SMART has increased significantly in recent years. The landmark study already mentioned (Zemore et al. 2018), found equivalent efficacy for four different mutual help groups. This finding suggests that ideas like “AA is the only way” or “AA is the best way” are not only inaccurate, but also unhelpful to individuals who prefer to use a different approach.
Penn and Brooks (2000) found that the 12-step and SMART approaches were equally effective in a day treatment setting for chronically mentally ill clients with substance problems. Li, Feiffer, and Strohm (2000) found that 12-step participants had higher external locus of control, whereas SMART participants had higher internal locus of control (until SMART was founded there were few options for individuals approaching addiction recovery from an internal locus of control perspective). Atkins and Hawdon (2007) found that SMART meetings appealed to individuals, and were viewed as meaningful, regardless of their religious or spiritual orientation. Other groups did not have this broad appeal. Blatch, O’Sullivan, Delaney, and Rathbone (2016), in a five-year longitudinal study involving 5,764 Australian prisoners, found a significantly lower rate of reconviction, for inmates who had been involved with SMART, especially among those committing violent crimes. A recent systematic review of SMART identified 12 studies worthy of review (three of them conducted by Alliant doctoral students), and suggested issues to be addressed in future research (Beck et al., 2017).
Recognition of SMART
Recognition of SMART has increased significantly in recent years. Organizations that recognize SMART as an important mutual help option include NIDA, NIAAA, SAMHSA, the National Association of Drug Court Professionals, National Drug Court Institute, Federal Bureau of Prisons, National Institute for Health and Care Excellence (in the UK), Public Health England, Department of Health and Ageing (Australia), and the National Health and Medical Research Council (Australia) (SMART Recovery, 2018).
William White compiled a bibliography of SMART that includes approximately 100 publications (Chaney & White, 2017). The first Surgeon General’s report on addiction, Facing addiction in America: The Surgeon General’s report on alcohol, drugs, and health, mentions SMART as a mutual help option (US Department of Health and Human Services (HHS), Office of the Surgeon General, 2016).
SMART Recovery and multiple pathways of change
Individuals needing to resolve problematic addictive behavior are a highly diverse group. There is no likelihood that any single approach will be effective for most people. Having multiple pathways for change (Fletcher, 2002) increases the odds that an individual will find an appealing and effective pathway. In San Diego there are now enough SMART Recovery meetings to be an easily available option for those interested in attending them.
The national website is www.SMARTRecovery.org
The local website is www.SMARTRecoverySD.org
For professionals or individuals desiring more information about SMART in San Diego, the local website is the place to begin, followed by attending a meeting. Meetings are open to the public. No reservations are necessary.
Atkins, Jr., R. G., & Hawdon, J. E. (2007). Religiosity and participation in mutual-aid support groups for addiction. Journal of Substance Abuse Treatment, 33(3), 321-331.
Blatch, C., O’Sullivan, K., Delaney, J. J., & Rathbone, D. (2016). Getting SMART, SMART Recovery programs and reoffending. Journal of Forensic Practice, 18(1), 3-16.
Beck, A.K., Forbes, E., Baker, A., Kelly, P., Deane, F., Shakeshaft, A, Hunt, D., & Kelly, J. (2017). Systematic review of SMART Recovery: Outcomes, process variables, and implications for research. Psychology of Addictive Behaviors, 31(1), 1-20.
Chaney, R., & White, W. (2017). SMART Recovery bibliography.
Fletcher, A. M. (2002). Sober for good: New solutions for drinking problems—advice from those who have succeeded. Plano, TX: Rux Martin/Houghton Mifflin Harcourt,
Kelly, J. F. (2017). Is Alcoholics Anonymous religious, spiritual, neither? Findings from 25 years of mechanisms of behavior change research. Addiction, 112, 929–36.
Li, E. C., Feiffer, C., & Strohm, M. (2000). A pilot study: Locus of control and spiritual beliefs in Alcoholics Anonymous and SMART Recovery members. Addictive Behaviors, 25(4), 633-640.
Penn, P. E., & Brooks, A. J. (2000). Five years, twelve steps, and REBT in the treatment of dual diagnosis. Journal of Rational-Emotive and Cognitive-Behavior Therapy, 18(4), 197-208.
SMART Recovery. (2018) https://www.smartrecovery.org/wp-content/uploads/2018/02/Global-Support-for-SMART-2.pdf. Retrieved 8/20/18.
US Department of Health and Human Services (HHS), Office of the Surgeon General (2016). Facing addiction in America: The Surgeon General’s report on alcohol, drugs, and health. Washington, DC: HHS
Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books.
Zemore, S.E., Lui, C.K., Mericle, A., Hemberg,J., Kaskutas, L.A. (2018). A longitudinal study of the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups for those with AUD. Journal of Substance Abuse Treatment , 88, 18-26
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