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A Non 12 Step Approach to Addiction and Recovery

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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.

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A Non 12 Step Approach to Addiction and Recovery

  1. 1. Science-based, self- empowering mutual help Tom Horvath, Ph.D., ABPP Practical Recovery, San Diego, CA SMART Recovery Update on
  2. 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. 3. “Discover the Power of Choice” www.SMARTRecovery.org
  4. 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. 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. 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. 7. Program Overview, 3  The intersection of Self-empowerment Evidence-based interventions What works in a mutual help group
  8. 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. 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. 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. 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. 12. SMART Largest of Secular Groups  Women for Sobriety  Secular Organizations for Sobriety®  (Rational Recovery®)  Moderation Management®  LifeRing Secular Recovery  HAMS
  13. 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. 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. 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. 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. 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. 18. The future? Coping with Temptation
  19. 19. 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?
  20. 20. 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.
  21. 21. Moral Model Enlightenment Model Compensatory Model Medical Model ProblemResponsibility Solution Responsibility Lo Hi Hi Lo
  22. 22. A Formula for Happiness I explain my past situationally. My future is based on my own efforts
  23. 23. It all works  But for whom?  There are as many paths to recovery as there are individuals  SMART Recovery is one path
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. The SMART Approach  Slogan  4-Point Program®  Tools for recovery  Purposes and Methods
  28. 28. 4-Point Program®  Enhancing and maintaining motivation  Coping with urges  Managing thoughts, feelings, and behavior  Living a balanced life
  29. 29. 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
  30. 30. Tools - Cost/Benefit Analysis (Decision Making Worksheet) - ABCs of REBT for Emotional Upsets - USA - HOV
  31. 31. How are Tools Updated?  New tools regularly suggested  Peer professional partnership  Tolerate significant variation  Evolutionary process  e.g., mindfulness (cf. exercise)
  32. 32. “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
  33. 33. 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
  34. 34. Code of Conduct  Principles, Behavioral Guidelines  Comparable to therapist ethical codes  SMART Recovery happens in public  We part company with some volunteers
  35. 35. Purposes and Methods
  36. 36. 1. We help individuals gain independence from addictive behavior.
  37. 37. 2. We Support:  enhancing and maintaining motivation  coping with urges  managing thoughts, feelings, and behavior  living a balanced life
  38. 38. 3. Our efforts are based on scientific knowledge, and evolve as scientific knowledge evolves.
  39. 39. 4. Individuals who have gained independence from addictive behavior are invited to stay involved with us, to enhance their gains and help others.
  40. 40. 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
  41. 41. Survey 4-Point Program Online Meetings Power of Choice
  42. 42. 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
  43. 43. Survey The relationships I have made in SMART Recovery Talking about myself in meetings
  44. 44. 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
  45. 45. 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
  46. 46. Types of Meetings  Officially:  Facilitated (requires more training, skill)  Hosted (uses highly structured script)  Unofficially:  Check-in  Tool training  Topic or handout oriented
  47. 47. Mutual Help as Social Support  Responsive listening  Companionship  Information  Active helping  Discussion/debate within SMART: Tools or Connection? How much community?
  48. 48. 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
  49. 49. 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.
  50. 50. 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
  51. 51. 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.
  52. 52. 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
  53. 53. 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.
  54. 54. 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.
  55. 55. 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.
  56. 56. 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.
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. 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
  63. 63. 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
  64. 64. 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
  65. 65. 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
  66. 66. 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?  )))
  67. 67. 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
  68. 68. 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
  69. 69. 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
  70. 70. 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
  71. 71. Central Office 7304 Mentor Avenue, Suite F Mentor, OH 44060 440-951-5357 Fax 951-5358 information@smartrecovery.org www.smartrecovery.org
  72. 72. “Discover the Power of Choice” www.SMARTRecovery.org
  73. 73. Contact info  Tom.Horvath@practicalrecovery.com  I’ll email you this presentation

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