a non 12 step approach to addiction and recovery

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

“Discover the Power of Choice”

www.SMARTRecovery.org

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

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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

information@smartrecovery.org www.smartrecovery.org

“Discover the Power of Choice”

www.SMARTRecovery.org

Contact info

Tom.Horvath@practicalrecovery.com I’ll email you this presentation