a non 12 step approach to addiction and recovery
TRANSCRIPT
Science-based, self-empowering mutual help
Tom Horvath, Ph.D., ABPPPractical Recovery, San Diego,
CASMART Recovery
Update on
Continuing Education Objectives
To describe the differences between a self-empowering and powerlessness-based (12-step) approach to addiction recovery
To recall the SMART Recovery slogan: “Discover the power of choice”
To identify one opportunity for further research on SMART Recovery
Organizational Overview
Non-profit Almost entirely volunteer operated 2000 meetings, including closed
mtgs, half in US community, correctional, online related services (training, publications)
Supports choice in recovery
Program Overview
Support for stopping any problematic addictive behavior (vs. state of abstinence)
Tools for recovery (disease or not) Science based (belief in God or not) Focus on self reliance Discussion meetings (“cross-talk”)
Program Overview, 2 No sponsors, labels Months to years typical attendance MAT fully supported Harm reduction fully supported
e.g., stop heroin but not cannabis
Program Overview, 3 The intersection of
Self-empowermentEvidence-based interventions
What works in a mutual help group
A Brief History J. Trimpey, Rational Recovery Self-
help Network, mid-1980s The Small Book, Ellis, REBT Non-profit spin off, 1992 Non-profit ends affiliation, 1994 International Advisory Council, 1998 1994 to present, expansion
International Advisory Council
Aaron Beck, M.D. Carlo DiClemente,
Ph.D. Albert Ellis, Ph.D.* Frederick B. Glaser,
M.D. Nick Heather, Ph.D. Reid Hester, Ph.D. Harald Klingemann,
Ph.D. Richard Longabaugh,
Ed.D.
Alan Marlatt, Ph.D.* Maxie C. Maultsby,
Jr., M.D. Barbara McCrady,
Ph.D. Peter Monti, Ph.D. Stanton Peele, Ph.D. Linda Sobell, Ph.D. Mark Sobell, Ph.D.,
ABPP William White, M.A.
*deceased
Growth, SMART and NA
0
500
1000
1500
2000
2500
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
2016
SMART
050
100150200250300350400450500
1953
-5919
6119
6319
6519
6719
6919
7119
7319
7520
0020
14
NA (1953-1976)
0
10000
20000
30000
40000
50000
60000
70000
1980 2000 2014
NA (1980-2014)
SMART Recovery Today Licensed affiliates in the UK,
Australia Meetings in 20 countries Handbook in 3rd ed. Various editions available in 8
languages Family & Friends, based on CRAFT InsideOut correctional program Multiple studies conducted
SMART Largest of Secular Groups
Women for Sobriety Secular Organizations
for Sobriety® (Rational Recovery®) Moderation
Management® LifeRing Secular
Recovery HAMS
PowerlessnessJoseph Nowinski: “Individual willpower alone is insufficient to sustain sobriety” (pg. 194)
Nowinski, J. (2012). Facilitating 12-step recovery from substance abuse. In S. T. Walters & F. Rotgers (Eds.), Treating substance abuse: Theory and technique (pp. 191-223). New York, NY: Guilford Press.
Self-EmpowermentHorvath & Yeterian: “to increase the participant’s capacity to maintain motivation, identify and cope with cravings, identify and modify irrational thinking and beliefs, and live with greater balance and attention to long-term goals in addition to short-term ones” (pg. 103)
Horvath, A.T., & Yeterian, J. (2012). SMART Recovery: Self-empowering, science-based addiction recovery support. J. of Groups in Addiction & Recovery, 7, 102-117.
Self-Empowering Language
I drink too much (vs. alcoholic) The costs exceed the benefits
(vs. disease) I choose to change (vs. I have
to) I can cope during the
transition (vs. recovery for life) My challenge (vs. my
addiction)
The Serenity Prayer God, grant me Serenity
to accept the things I cannot change, Courage to change the things I can, And Wisdom to know the difference.Adapted from Reinhold Niebuhr, 1943
The Courage Intention I intend to have courage
to change the things I can, serenity to accept the
things I cannot, and wisdom to know the
difference.
The future?
Coping with Temptation
Locus of Control, Attribution
Locus of control: What predicts the future? Is it about me, or the situation?
Attribution theory: What explains the past?Is it about me, or the situation?
4 Models of Helping and Coping
Based on intersection of Hi or Lo responsibility for the problem, and Hi or Lo responsibility for the solution
Brickman, P., Rabinowitz, V.C., Karuza, Jr., J., Coates, D., Cohn, E., & Kidder, L. (1982). Models of helping and coping. American Psychologist, 37, 368-384.
Moral Model Enlightenment Model
Compensatory Model Medical Model
Prob
lem
Res
pons
ibili
tySolution Responsibility
Lo
Hi
Hi
Lo
A Formula for Happiness
I explain my past situationally. My future is based on my own
efforts
It all worksBut for whom?There are as many paths to
recovery as there are individuals
SMART Recovery is one path
The Recovery Bill of Rights,
Faces and Voices of Recovery
Preamble: We must accord dignity to people with addiction and recognize that there is no one path to recovery
Point 2 (of 11): We have the right—as do our families and friends—to know about the many pathways to recovery
Self-Empowering Approaches: Predictions
50% of services in 1-2 decades ultimately US like European
countries dual citizens will be minimal SMART will have a positive influence
on AA
Dual Citizens Horvath, A. (2014, March 24). The dual
citizenship phenomenon. Retrieved from http://www.rehabs.com/pro-talk-articles/the-dual-citizenship-phenomenon-2/
White, B., & Kelly, J. (2014, October 31). Further reflections on “dual citizenship” in recovery. Retrieved from http://www.williamwhitepapers.com/blog/2014/10/further-reflections-on-dual-citizenship-in-recovery-bill-white-and-john-kelly-phd.html
The SMART ApproachSlogan4-Point Program®Tools for recoveryPurposes and Methods
4-Point Program®Enhancing and maintaining
motivation Coping with urgesManaging thoughts, feelings,
and behaviorLiving a balanced life
Tools- Stages of Change- Change Plan Worksheet- ABCs of REBT for Urge Coping- DISARM (Destructive Imagery
& Self-talk Awareness & Refusal Method)
- Brainstorming- Role-playing and Rehearsing
Tools- Cost/Benefit Analysis (Decision
Making Worksheet)- ABCs of REBT for Emotional
Upsets- USA- HOV
How are Tools Updated?
New tools regularly suggested
Peer professional partnershipTolerate significant variationEvolutionary processe.g., mindfulness (cf.
exercise)
“We do not recommend ossifying practice into a list of ‘approved’ evidence-based treatments…while interventions with a strong evidence base are a good starting point, a creative service system will also encourage innovation to accomplish specified goals and to monitor outcomes” (p. 311)
Miller, W.R., & Carroll, K.M. (2006). Drawing the science together: Ten principles, ten recommendations. In W.R. Miller & K.M. Carroll (Eds.), Rethinking Substance Abuse: What the science shows, and what we should do about it (pp. 293-311). New York, NY: Guilford Press
What We Monitor Closely:
SMART Recovery is not the only way AA, moderation, meds are also ways Disease/God, not part of our
approach Natural recovery is the foundation Meetings: balance tools and open
discussion The best teachers are peers Stay on topic (recovery, related
issues) The conduct of our meeting leaders
Code of Conduct
Principles, Behavioral Guidelines Comparable to therapist ethical
codes SMART Recovery happens in public We part company with some
volunteers
Purposes and Methods
1. We help individuals gain
independence from addictive behavior.
2. We Support: enhancing and maintaining motivation coping with urges managing thoughts, feelings, and behavior living a balanced life
3. Our efforts are based on scientific
knowledge, and evolve as scientific knowledge evolves.
4. Individuals who have gained independence from
addictive behavior are invited to stay involved
with us, to enhance their gains and help others.
SurveyWhile using SMART Recovery for your own recovery, please rate the importance of these aspects of SMART Recovery:
Handbook
Website Tools
Face-to-Face Meetings
Survey
4-Point Program
Online Meetings
Power of Choice
SurveyWhile using SMART Recovery for your own recovery, please rate the importance of these aspects of SMART Recovery MEETINGS:
Other Discussions
Tool Discussions Just Being
in Meetings
Survey
The relationships I have made in SMART Recovery
Talking about myself in meetings
Rules for Meetings Participation voluntary Confidential, free Conversation, not monologues Suggestions and ideas, not advice Stay on topic (no debates; no
bashing) “Do SMART Recovery,” don’t talk
about it
Basic Meeting Outline
(60 minutes) Welcome………….…………………...5
min Check-in..…...…………………….....10
min Agenda setting…………………..……5
min Working time………………………..25
min Pass the hat, pass the brochure….
…....5 min Checkout……………………………..10
min Close
Types of Meetings
Officially: Facilitated (requires more training,
skill) Hosted (uses highly structured
script) Unofficially:
Check-in Tool training Topic or handout oriented
Mutual Help as Social Support
Responsive listening Companionship Information Active helping Discussion/debate within SMART:
Tools or Connection? How much community?
Our New Research Process
Obtain initial approval of proposal and investigators from SMART Research Directors John Kelly, PhD, and Julie Yeterian, MA
Obtain IRB approval Re-submit to Research Directors Receive access to SMART
participants
www.smartrecovery.org/resources/pdfs/ResearchApprovalProtocol.pdf
Locus of Control DRIE: SMART participants had
higher internal LOC (p=.00003) SBQ: AA higher on 5 of 7 spiritual
measures (p<.01)
Li, E. C., Feifer, 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.
Chronic Mentally Ill Clients
NIDA funded, 5 years “12-step program might not have
survived” Generally comparable outcomes No matching found
Penn, P. E., & Brooks, A. J. (2000). Five years, twelve steps, and REBT in the treatment of dual diagnosis. J. of Rational-Emotive & Cognitive-Behavior Therapy, 18(4), 2000, 197-208. dx.doi.org/10.1023/A:1007883021936
Religiosity Improvement regardless of group Hi religious preferred AA, WFS Lo religious, SOS SMART, unrelated
Atkins, R.G., & Hawdon, J.E. (2007). Religiosity and participation in mutual-aid support groups for addiction. J Subst Abuse Tx, 33(3), 321-331.
Online Training Online course alone, SMART alone,
or both Increased PDA & reduced DDD &
alcohol problems, all groups; no group differences
6 months results in preparationHester, R.K., Lenberg, K.L., Campbell, W., Delaney,
H.D. (2013). Overcoming Addictions, a web-based application, and SMART Recovery, an online and in-person mutual help group for problem drinkers, part 1: Three-month outcomes of a randomized controlled trial. J Med Internet Res, 15(7):e134. doi:10.2196/jmir.2565
Group Cohesion, Homework
Average of 9 months participation Group cohesion: use of cognitive
restructuring Homework: behavioral activation Both predicted use of CBT First study to examine quality of
facilitation
Kelly, P.J., Deane, F.P., & Baker, A.L. (2015). Group cohesion and between session homework activities predict self-reported cognitive-behavioral skill use amongst participants of SMART Recovery groups. J. Substance Abuse Treatment, 51(4), 53-58.
FacilitatorsFacilitators (n=42)Mostly white, male, well educated (7% MD)Reasons to facilitate: give back (42%), support own recovery (21%), accidental (21%), to provide an alternative (16%)
O'Sullivan, D., Blum, J.B., Watts, J., & Bates, J.K. (2015). SMART Recovery: Continuing care considerings for rehabilitation counselors. Rehabilitation Counseling Bulletin, 58(4), 203-216.
Refusal Self-Efficacy (RSE)
Brief Situational Confidence Question
Greater RSE for-Longer affiliation (3 mos +)-More meetings (10+ per moth)
O’Sullivan, D., Watts, J., Xiao, Y., Bates-Maves, J. (in press). Refusal self-efficacy among SMART Recovery members by affiliation length and meeting frequency. J. of Addictions and Offenders Counseling.
SMART, WFS, LSR, AA Baseline (n=800), 6 mos, 12 mos No comparative longitudinal studies
to date Online survey; subjects recruited in
collaboration with org; AA from online site
18 or older, alcohol dependence, at least one meeting in last 30 days; NIAAA funding
Goals: compare groups and effectiveness
Zemore, S. 12-step alternatives and recovery outcomes in a large, national study. Study in progress, personal communication.
Corrections
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. dx.doi.org/10.1108/JFP-02-2015-0018
Quasi-experimental, retrospective design
N=5,764 inmates, 2007-11,
NSW, AU2343 Getting SMART233 SMART Recovery 306 both2882 matched controlsBlatch, et. al., 2016
SubjectsMostly urban, suburban
(Sydney, 5M)10M in NSW, largest of 7
states, SE70%+ illegal use within 6
mos priorUse increases risk of re-
offending
Blatch, et al., 2016
Getting SMART (SRFT)Medium to hi riskFocuses: Substance use,
criminal/pro-social thinking, emotional and mental well
being12 sessions x 2 hours
Blatch, et al., 2016
Subject Selection Original subject pool: 24,845 At least 8 months to recidivate Up to 4+ years; adjusted for Removed if incomplete data SMART 3,309 Possible controls, 13,042Blatch, et al., 2016
Matching Control Subjects
2882 SMART (excludes 427) to achieve similar risk of re-
offending (25 variables used) Final: 68% male; 27%
Indigenous; 44% had non-English speaking
backgrounds Further analysis confirmed, well-
matchedBlatch, et al., 2016
Significant Outcomes Getting SMART effective
-30% reduction in violent crime SMART itself not significant Getting SMART, then SMART, most
effective-42% reduction in violent crime
Minimum dose 10-11 sessions
Blatch, et al., 2016
Results: Survival analysis - time to first violent
reconviction Getting SMART + SMART Recovery:
best survival curvetho not significant (confidenceinterval of .527 to 1.064)
Getting SMART (green) significantly longer time (approx. 13%) to first violent reconviction cf. controls
Hazard ratio of .867(p= <.05)
SMART Recovery: similar curve but not significant
Control group (blue): fastest time to first reconviction cf. thethree treatment groups
Evaluations of other AOD programs. Benchmarks?Best results from two USA meta analyses :
Washington State Institute of Public Policy* - nine AOD programs - 6% reduction in reoffending
Lipsely, Landenberger & Wilson** - 52 programs, 25 % reduction, 19% in violent crime!
Australian studies: few with similar methodology to enable a
comparison many studies flawed… poor methodology, low
power (small samples), no matched controls, poor program integrity
wanted our methodology to be immune to criticisms of bias & results definitive…..
* Aos, Miller & Drake, 2006 ** 2007
Sessions needed for a therapeutic effect – significantly longer time to
1st reconviction…10-11 sessions of either
SMART program was needed for a significant therapeutic effect-. 23% improvement in survival to firstreconviction hazard ratio of .764, p=<.05
= > 12 sessions: similar curve to 10-11 sessions but not significant (confidence interval = .634 to 1.002)
1-6 sessions (olive): same as control group (red) - no effect
Why? First six sessions of Getting Smart only focus on motivation to change?
)))
Discussion Underestimate because
“intention to treat” “Reasonable confidence” Getting
SMART effective -for this population
SMART Recovery as aftercare www.recoveryanswers.org/pressrelease/can-a-gr
oup-addiction-treatment-program-reduce-rates-of-reconviction-among-offenders-with-alcohol-and-drug-problems/
Blatch, et al., 2016
Research Opportunities Annual surveyswww.smartrecovery.org/resources/participant-surveys.htm Type of meeting, leader, participant
(esp. LOC, development level)? Multiple pathways within SMART? Why facilitators/hosts volunteer? Comparisons with other groups
Continuing Education Objectives
To describe the differences between a self-empowering and powerlessness-based (12-step) approach to addiction recovery
To recall the SMART Recovery slogan: “Discover the power of choice”
To identify one opportunity for further research on SMART Recovery
Conclusions Programmatic research on SMART
just beginning SMART much needed, especially in
US SMART, the best disseminator of
EBT? SMART could transform the
treatment industry, to become like Europe
Central Office7304 Mentor Avenue, Suite F
Mentor, OH 44060440-951-5357Fax 951-5358
[email protected] www.smartrecovery.org
