Non 12 Step Addiction Treatment * Addiction * Recovery * Mental Health This presentation on addiction and recovery explores the SMART Recovery approach to self-empowering recovery from addiction. If you or a loved one are in need of help for an addiction, visit our website at www.practicalrecovery.com.

1. Science-based, self-
empowering mutual help
Tom Horvath, Ph.D., ABPP
Practical Recovery, San Diego, CA
SMART Recovery
Update on

2. 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

3. “Discover the Power of Choice”
www.SMARTRecovery.org

4. 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

5. 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”)

6. 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

7. Program Overview, 3
 The intersection of
Self-empowerment
Evidence-based interventions
What works in a mutual help group

8. 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

9. 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

10. Growth, SMART and NA
0
500
1000
1500
2000
2500
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
2016
SMART
0
50
100
150
200
250
300
350
400
450
500
1953-59
1961
1963
1965
1967
1969
1971
1973
1975
2000
2014
NA(1953-1976)
0
10000
20000
30000
40000
50000
60000
70000
1980 2000 2014
NA (1980-
2014)

11. 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

12. SMART Largest of Secular Groups
 Women for Sobriety
 Secular Organizations for
Sobriety®
 (Rational Recovery®)
 Moderation Management®
 LifeRing Secular Recovery
 HAMS

13. Powerlessness
Joseph 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.

14. Self-Empowerment
Horvath & 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.

15. 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)

16. 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

17. 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.

18. The future?
Coping with Temptation

20. 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?

21. 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.

22. Moral Model
Enlightenment
Model
Compensatory
Model
Medical Model
ProblemResponsibility
Solution Responsibility
Lo
Hi
Hi
Lo

23. A Formula for
Happiness
I explain my past situationally.
My future is based on my own efforts

25. It all works
 But for whom?
 There are as many paths to recovery as
there are individuals
 SMART Recovery is one path

26. 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

28. 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

30. 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

31. The SMART Approach
 Slogan
 4-Point Program®
 Tools for recovery
 Purposes and Methods

32. 4-Point Program®
 Enhancing and maintaining motivation
 Coping with urges
 Managing thoughts, feelings, and
behavior
 Living a balanced life

33. 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

34. Tools
- Cost/Benefit Analysis (Decision Making
Worksheet)
- ABCs of REBT for Emotional Upsets
- USA
- HOV

35. How are Tools Updated?
 New tools regularly suggested
 Peer professional partnership
 Tolerate significant variation
 Evolutionary process
 e.g., mindfulness (cf. exercise)

36. “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

37. 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

38. Code of Conduct
 Principles, Behavioral Guidelines
 Comparable to therapist ethical codes
 SMART Recovery happens in public
 We part company with some volunteers

39. Purposes and Methods

40. 1. We help individuals gain
independence from
addictive behavior.

41. 2. We Support:
 enhancing and maintaining
motivation
 coping with urges
 managing thoughts, feelings,
and behavior
 living a balanced life

42. 3. Our efforts are based on
scientific knowledge, and
evolve as scientific
knowledge evolves.

43. 4. Individuals who have gained
independence from addictive
behavior are invited to stay
involved with us, to enhance their
gains and help others.

45. Survey
While using SMART Recovery for your own
recovery, please rate the importance of these
aspects of SMART Recovery:
Handbook
Website Tools
Face-to-Face
Meetings

46. Survey
4-Point
Program
Online
Meetings
Power of
Choice

47. Survey
While 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

48. Survey
The relationships I have made
in SMART Recovery
Talking about myself in
meetings

50. 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

51. 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

52. Types of Meetings
 Officially:
 Facilitated (requires more training, skill)
 Hosted (uses highly structured script)
 Unofficially:
 Check-in
 Tool training
 Topic or handout oriented

54. Mutual Help as Social Support
 Responsive listening
 Companionship
 Information
 Active helping
 Discussion/debate within SMART: Tools or
Connection? How much community?

55. 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/ResearchApprovalProtoco
l.pdf

56. 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.

57. 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

58. 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.

59. Online Training
 Online course alone, SMART alone, or both
 Increased PDA & reduced DDD & alcohol
problems, all groups; no group differences
 6 months results in preparation
Hester, 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

60. 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.

61. Facilitators
Facilitators (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.

62. 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.

63. 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.

64. 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

65. Quasi-experimental, retrospective design
 N=5,764 inmates, 2007-11, NSW, AU
 2343 Getting SMART
 233 SMART Recovery
 306 both
 2882 matched controls
Blatch, et. al., 2016

66. Subjects
 Mostly urban, suburban (Sydney, 5M)
 10M in NSW, largest of 7 states, SE
 70%+ illegal use within 6 mos prior
 Use increases risk of re-offending
 Blatch, et al., 2016

67. Getting SMART (SRFT)
 Medium to hi risk
 Focuses: Substance use, criminal/pro-
social thinking,
 emotional and mental well being
 12 sessions x 2 hours
Blatch, et al., 2016

68. 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, 13,042
Blatch, et al., 2016

69. 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-matched
Blatch, et al., 2016

70. 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

71. Results: Survival analysis - time to first
violent reconviction
 Getting SMART + SMART Recovery:
best survival curve
tho not significant (confidence
interval 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. the
three treatment groups

72. 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

73. 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 first
reconviction
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?
 )))

74. Discussion
 Underestimate because “intention to treat”
 “Reasonable confidence” Getting SMART
effective
-for this population
 SMART Recovery as aftercare
 www.recoveryanswers.org/pressrelease/can-a-group-addiction-
treatment-program-reduce-rates-of-reconviction-among-
offenders-with-alcohol-and-drug-problems/
Blatch, et al., 2016

75. Research Opportunities
 Annual surveys
www.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

77. 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

78. 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

79. Central Office
7304 Mentor Avenue, Suite F
Mentor, OH 44060
440-951-5357
Fax 951-5358
information@smartrecovery.org
www.smartrecovery.org

80. “Discover the Power of Choice”
www.SMARTRecovery.org

81. Contact info
 Tom.Horvath@practicalrecovery.com
 I’ll email you this presentation