David Gilliver

SMART Recovery is an abstinence program established in the US in the 1990s, using tools and techniques based on cognitive-behavioral principles. Alcohol Concern has helped set up SMART Recovery projects in six pilot areas across England with Department of Health funding, and earlier this month mounted a conference to provide guidance for organizations that want to expand peer-support options in their area. Keynote speaker was SMART Recovery founding president, Dr Joe Gerstein. ‘SMART stands for Self Management and Recovery Training,’ he says. ‘The history goes back about 20 years. The fundamental basis is still the same – CBT – but since that time it’s expanded into a four-point program that covers pretty much the whole panoply of what research has shown to be effective in getting over addiction.’

Those four key points are building and maintaining motivation to abstain; coping with urges; managing thoughts, feelings and behaviors, and lifestyle balance. ‘It’s about managing life’s problems, since most relapses tend to be instigated in some way by problems and personal disappointments,’ he says. ‘A lifestyle that’s about keeping you busy and occupied and getting your enjoyment on a long-term, enduring basis from sources other than booze and drugs. ‘Right now we’re at the start-up phase,’ he says of SMART Recovery UK, but worldwide there have been around 70,000 SMART Recovery meetings since 1994, all provided free of charge.

‘The entire structure is supported by fewer than the equivalent of three full-time people,’ he says. ‘That’s for more than 500 weekly meetings.’ SMART Recovery is based around the concept of REBT (Rational Emotive Behavior Therapy), which uses common sense, self help procedures designed to enhance motivation and allow people to manage their problems without recourse to substances. The program teaches self reliance as the cornerstone of overcoming addictive behavior. ‘A lot of these things are recognized by AA in the ‘Big Book’ – in principle,’ he says. ‘We have nothing against AA – it’s a wonderful program for those that it’s good for. But it’s not 100 per cent universally applicable.’ Key differences between SMART and AA are that there’s no obligation to accept powerlessness in the face of addiction and no element of religion or spirituality. ‘Probably half the people who come to SMART Recovery are religious, according to our surveys,’ he says. ‘But that’s irrelevant. We’re proponents of choice – there are obviously many roads to recovery, and we’re emphatic about actually empowering people.’

Self-empowerment is the program’s touchstone, and he points to studies on the effectiveness of treatment that try to determine the pre-requisites for successful recovery. ‘What are the factors that seem to have predictive value for who will successfully and permanently recover? Number one is the belief that it’s possible.’ Is that tied in with not viewing addiction as a disease, another tenet of the program? ‘It is, but actually we don’t care how you want to view it – if you think it’s a disease, you’d better stop drinking; if you think it’s not a disease, you’d better stop drinking. Ultimately it’s up to the choice of what you want to do and how much you want to do it. As we know, people get better without going to any kind of help whatsoever – millions of people stop drinking and drugging without any contact with organizations or professionals or anything else. It’s called natural recovery and you don’t hear much about it because you don’t see these people – they don’t walk down the street wearing a button that says ‘I recovered from alcoholism’. If you go to clinics or meetings or doctors’ offices you don’t meet them. But you can find them in surveys.’ Large scale surveys in the US, including the National epidemiologic survey on alcohol and related conditions, which surveyed 43,000 people over a number of years, found that significant numbers of people were able to stop drinking on their own, he stresses. ‘Between 25 and 50 per cent, depending on which you look at, so this is common, and we tell people that at meetings. It’s good for them to know that people do it on their own. And of course there are millions of ex-smokers who’ve done it on their own, tens of millions.’ SMART Recovery is funded by donations and the only people to draw any kind of salary are central office web staff. ‘The website has 15,000 active registered users, so it’s a huge enterprise,’ he says. ‘Out in the community, nobody’s paid,’ When someone graduates from the program, however, they have the opportunity to stay on and help others. ‘Most just graduate, but maybe 10 or 20 per cent want to stay on,’ he says. ‘We’ve got people in Massachusetts who’ve been doing it for 15 years and are extremely skilled. On the other hand we’ve designed the program so a complete tyro can facilitate a meeting if necessary. Obviously it’s structured a little differently to one being run by someone who’s been doing it for 15 years, but the important thing is the communication among individuals – it’s an interactive program.’

This communication, however, is very much centered on the present and the future. The organization states ‘We’re certainly not into drunkalogues (war stories), sponsors, and meetings-for-life.’ ‘We want to know the general nature of a person’s problem but we limit that to one or two minutes,’ Gerstein says. ‘The crucial thing is what you’re going to do about it, how you’re going to handle it – the program is directed towards helping people get a different perspective on reality and then changing the way they think about it. That usually ends up changing the way they behave.’ With something that must have seemed so at odds with the prevailing wisdom at the time, what kind of reception did it get in the early days? ‘There was absolutely no interest whatsoever evinced by the local treatment professionals,’ he says. ‘I was amazed by how little interest they had in anything except the straight 12-step program, despite all the scientific data behind the CBT approach.’ He had no substance specialism to begin with but, despite initially not wanting to get deeply involved in the project, he’s gone on to facilitate more than 2,000 of the 14,000 meetings held in Massachusetts, 700 of them in prisons. ‘I’m a physician but my professional interests are internal medicine and pain management,’ he says. ‘I didn’t know a thing about addiction. I thought I did, but what I learned in medical school was all wrong – after bludgeoning people for 12 years to go to AA no matter what their addiction problem was.’

As well as starting up meetings he was ‘running around keeping (others) going’ if no one else was available, all the while still practicing as a physician – presumably an exhausting combination? ‘It was, but it’s worth it. People come up to me and tell me I saved their life – that’s a pretty powerful tonic to keep going.’ Almost all of the other facilitators, however, come from a background of alcohol and drug problems, followed by SMART Recovery training. ‘I started meetings and then other professionals said “I’d like to see a meeting in my area” so most were originally started up by professionals. But when someone’s had about six months of solid sobriety we allow them to take over, so it usually takes six to eight months and then the professional disappears. I’ve stayed in it just to keep the organization alive – it’s difficult to find people to go into prisons, for example.’ He introduced the project to a local prison in 1992, since which time it’s been adopted by prisons around the world. ‘Most of the prisons in Australia use it, prisons in Sweden, Scotland, Vietnam – the so-called ‘re-education centers.’ The federal prison system in the US uses a CBT program that’s similar, but it started when we introduced SMART Recovery to one prison and it was very successful.’

This article was reprinted with permission by Drink and Drug News (DDN). Free online issues of DDN magazine are available at www.drinkanddrugsnews.com.