Why SMART Recovery® Will Never Replace Alcoholics Anonymous
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Reviews completed prior to October 25th, 2013 were completed under prior editorial control. Some reviews and star ratings may have been completed at different times and under different criteria.
There is a belief in SMART Recovery® that in about 20 years, they will become the primary model of recovery over Alcoholics Anonymous because their recovery rates are higher. While there are no studies directly comparing SMART Recovery® with Alcoholics Anonymous, there are studies comparing the SMART Recovery® techniques with those used in AA. SMART Recovery® employs evidence-based tools for recovery. That is to say, in their meetings, they discuss tools to recovery that have been proven to work over the course of several clinical studies. The primary tool in SMART Recovery® is Rational Emotive Behavioral Therapy, REBT, for short. This tool basically assists someone in changing their belief system about alcohol and/or drugs and it’s fairly effective, boasting a recovery rate anywhere between 35% and 50% over a one-year period, depending on the study.
Perhaps the most famous controlled study comparing Alcoholics Anonymous and REBT is the 1980 study dubbed the Brandsma Study. Jeff Brandsma took groups of people in coerced attendance programs and randomly placed them into different groups of therapy, 12-step (from Alcoholics Anonymous) or REBT. Over the course of two years, the REBT group did significantly better abstaining than the 12-step (or AA) group (in fact, more than 10% higher). While there are questions about how the study was conducted, there is no question that this study showed a significantly higher relative value of recovery for REBT practitioners to AA practitioners, keeping in mind that they were required to attend. Other studies show Cognitive Behavioral Therapy, a very similar technique, to be up to 60% effective for abstinence in some studies, with an average recovery rate of 45% over the course of a year. Alcoholics Anonymous doesn’t come close to these rates of abstinence, hovering around the same rate as spontaneous remission (otherwise known as a ‘cold turkey’ approach) in most controlled studies or epidemiological surveys. There are those, of course, who would argue that AA’s recovery rates are higher, but their claim really doesn’t stand up under scientific analysis. Most studies claiming higher rates had flawed designs such as selection bias or lack of control group.
In light of AA’s anemic rates of recovery and SMART Recovery®’s 20-year longevity as a treatment program, many are questioning if SMART Recovery® will ever replace Alcoholics Anonymous. Admittedly, SMART Recovery® seems to just now be getting some media attention, and seems to be gaining ground at the rate of growth of about 10% per year. Fans of evidence-based medicine eagerly await the day when SMART Recovery® overcomes AA. Unfortunately, that day will probably never come.
While SMART Recovery® may grow as a strong alternative, it will never have the dominating presence Alcoholics Anonymous does and there are a few clear cut reasons as to why:
Alcoholics Anonymous thrives as a social network, more than a recovery program. In all honesty, to most members of Alcoholics Anonymous, recovery rates are irrelevant. The real reason for long-term engagement in the society is ultimately the social aspect. In terms of being a place where someone can go on a daily basis to socialize, Alcoholics Anonymous kicks everyone else into the dirt. Clubhouses, halfway houses, and thousands of meetings a day all across the United States place this goliath as #1 in accessibility. Regardless of anything else, their mere size and emphasis on constant contact and socialization is something that no other program has been able to replicate.
SMART Recovery® fails to embrace the social model. While recovery rates are better for SMART Recovery® in clinical settings, SMART Recovery® fails to embrace the idea of building a social network. While they encourage a healthy support group, they really don’t do anything about it. For many people who are trying to make a dramatic change in lifestyle, SMART Recovery® ends up lacking in the vital area of providing social contacts, a social space, or clubhouse. The closest approximation they have is a yearly convention. Most of the board members of SMART Recovery® view the social issue as unnecessary. Ask one if a helpline should be added and their response is that it is not their responsibility; anyone who needs help should call 911. While sponsorship is looked down upon by opponents of AA, SMART Recovery® doesn’t have a very good replacement for this tradition. If there is anything positive about the idea of sponsorship, it is that it allows someone to be oriented into the group through someone who is knowledgeable. The social advantage of having assistance to get acclimated into a new society is simply not present in SMART Recovery®. Finally, since emphasis is placed only on the recovery techniques, SMART feels that only one meeting a week is necessary. While AA is rather zealous in its demands for attending meetings, the fact is that some people do need a new daily social structure to start their new life. Even Dr. Lance Dodes in his book the Sober Truth, a brutally critical account of AA, recognizes that the social aspect of AA is valuable.
Compared to Alcoholics Anonymous, starting and maintaining a SMART Recovery® meeting is complicated. The format of a SMART Recovery® meeting is primarily group therapy with a strong facilitator. The SMART Recovery® board, of course, would prefer all these leaders be qualified therapists. One can start a SMART Recovery® meeting without a professional license, but he must go through a training session online. This means the model of a SMART Recovery® meeting is highly dependent on the constant attendance of one or two members and the online training is not offered frequently enough for quick access. Also, a "strong facilitator" position can often be uncomfortable and intimidating for laypeople. As a replacement for AA, this may be the biggest hurdle SMART Recovery® faces and why their growth rates are so inhibited over their 20 year history.
SMART Recovery® uses vocabulary that is too academic and intimidating. When Bill Wilson founded Alcoholics Anonymous, his primary concern, as a salesman, was making sure Alcoholics Anonymous was accessible to the common man. The Alcoholics Anonymous Big Book was written in a very common language that almost anyone could read (despite Bill Wilson’s convoluted writing style). SMART Recovery®, founded by PhD psychologists and academics, has never been quite able to break out of its academic egg. The Handbook uses terms like Rational-Emotive Behavioral Therapy (REBT), Motivational Interviewing (MI), and a load of other overly academic terms and acronyms. For someone not used to the common terminology of psychologists, it can be fairly intimidating. This is why SMART Recovery® is often considered the “rich man’s” or the “smart man’s” AA. It has a tendency to appeal to the upper crust of the population, rather than speaking on a more relatable level.
SMART Recovery® tolerates external ideas that convolute its message. As a technique for one-on-one therapy, taking a passive stance when an individual expresses an opposing view is a great way to help them eventually arrive at the correct solution. As a volunteer public health program, from an epidemiological perspective, it is actually harmful. There is evidence that the combination of exposing someone to both Alcoholics Anonymous and SMART Recovery® techniques such as REBT at the same time can cause conflict in an individual as each technique holds opposing views on addiction and the power of the self. SMART Recovery® holds all views of recovery as welcome. This can lead to an atmosphere of becoming “Alcoholics Anonymous lite” in many SMART Recovery® meetings. From an epidemiological perspective, behavior modification programs for public health are always designed to deliver a consistent message to the community in order to ensure an optimal effect. SMART Recovery® has primarily ignored this directive in order to establish a more therapeutic atmosphere. Alcoholics Anonymous, on the other hand, is not tolerant of outside views and as a result, their program has met with greater success. Whether its message is right or wrong, a public health program is always more effective when it is more consistent in its messaging, rather than more tolerant of opposing views. Changing the belief system of an entire population is more effective with more direct inundation, rather than a passive approach.
While SMART Recovery® is an admirable and powerful program that works very well for a certain part of the population, it simply has too many barriers to replace the much more accessible society of Alcoholics Anonymous. Most likely, it will simply become the primary alternative to AA in the United States. Even within the last 20 years, SMART Recovery® has managed to open only a thousand meetings or less nationwide. Perhaps SMART Recovery® leadership simply doesn’t envision overtaking AA, but one thing is clear, the model they currently have is not the one that will fill the space if AA suddenly disappeared.
Matthew Leichter is a writer based in Baltimore, Maryland. He is a published healthcare statistican and epidemiologist currently pursuing a doctorate in epidemiology from Capella University and has worked as an epidemiologist for Humana, Blue Cross Blue Shield, IMS Health, Cognilytics, and Walgreens. He last wrote about how Obamacare is killing AA.