By Denis Campbell
Originally published by The Guardian, March 10th,  2010

Joe Gerstein, founder of the SMART Recovery treatment program that is spreading from the US as an alternative to AA, explains why he rejects the myth that alcoholism is a ‘disease’ to be endured rather than cured

Alcoholism is a disease that leaves victims powerless and needing to stay in permanent recovery if they are serious about stopping the demon drink from inflicting further damage, conventional wisdom holds. Given that most people can’t afford to pay for a stay in a Priory clinic, then the best way for chronic drinkers to tackle their addiction, so the theory goes, is to turn to Alcoholics Anonymous, seek the help of a higher power with their struggle, begin using the 12-step program, and be ready to attend meetings for the rest of their lives.

Not so, says Joe Gerstein, a retired clinical professor of medicine in the US. “A myth has grown up that you can’t get over a substance addiction without AA,” he says. “It’s a widely-held belief, but it’s a myth.”

For years, he admits to buying into the myth and referring patients with alcohol problems to AA, with varying degrees of success. “I would see people in my office during the day who had big, swollen bellies from liver cirrhosis and tell them about how serious their problem was, and then I’d see them again at 7pm coming out of the liquor store carrying a bag that didn’t contain doughnuts,” he says.

Joe Gerstein, founding president of the SMART Recovery program, says: "We don't depend on higher powers to help."

Although he describes AA as “an absolutely remarkable program”, given that millions have found it useful over the last 75 years, he also calls it “ethically wrong, medically wrong and psychologically wrong”.

Gerstein is the founding president of SMART Recovery, an alternative to AA that is catching on in America – where it began in 1994 – and worldwide. He was the main speaker at a conference in London yesterday, organized by charity Alcohol Concern, and funded by the Department of Health (DH), that was designed to promote SMART Recovery – Self-Management and Recovery Training, to give it its full title – as another way to help England’s 1.1 million problem drinkers.

The DH, keen to expand the number of options for treating the scourge of alcohol, is funding a £100,000 two-year trial of SMART Recovery, which currently has a low profile and is the David to AA’s Goliath. In London, for example, some 300 different AA groups meet regularly. But there are just 20 or so SMART ones in all of England – even Gerstein is unsure exactly how many – and about the same number in Scotland.

However, it is attracting attention from experts in the field. Nicolay Sorensen, Alcohol Concern’s director of policy and communications, says: “AA is huge, and people wouldn’t go if it didn’t work. SMART Recovery at the moment is the only alternative. It’s got momentum, it’s got a good evidence base, and it’s growing in popularity.”

Similarly, Addiction, the UK’s largest drug and alcohol treatment charity, is setting up an alcohol recovery service for over-50s in Glasgow, funded by the brewers Heineken and using SMART Recovery.

SMART is based on cognitive behavioral therapy (CBT), and especially an element of it called rational emotive behavior therapy (REBT). Gerstein calls SMART “a self-empowerment program”, and rejects utterly AA’s disease theory of alcohol and the labeling of people with serious drink problems as alcoholics.

SMART Recovery and AA are both international not-for-profit organizations. SMART is used in Australia, Uzbekistan and beyond. Its handbook has been translated into Russian, Farsi and Mandarin Chinese, among other languages. Both programs are used in prisons, seek abstinence from participants, and are free – although they rely on donations from those attending their groups. But, crucially, SMART is science-based and secular, while AA has heavy religious associations. Many of the people attending the 370 SMART groups across America have tried AA and been put off by its insistence that members undergo a spiritual awakening, Gerstein says.

For him, though, the key difference is that SMART is a positive philosophy. “We believe that addiction is a very human condition that can be corrected, and that it’s the people themselves who do that through natural recovery,” he says. “We don’t think people are hopelessly taken over by addiction. Other people use books, medicines, help from family or professionals, whatever works for them. But with SMART Recovery, people do it on their own. That belief that human beings have the capacity within themselves to overcome even severe addictions and go on to lead a meaningful life is vital.”

Where AA has its Big Book, SMART has four key points and a “toolbox” – a set of ways in which problem drinkers can change their behavior. For instance, if someone is feeling stressed at the end of their working day, they may choose to use the ABC tool. That is: A for the Activating Event, the walking out of work; B for the Belief, that the person needs a drink now to relax; and C for Consequences, that someone ends up drinking because of their stress.

SMART teaches participants ways to disrupt this irrational belief system by helping them understand why they act as they do – damaging their lives and relationships in the process – and to then challenge that thinking. CBT is also the basis of the “talking therapies” program that the DH has been rolling out in recent years to help people ranging from long-term benefit claimants wanting to resume working to couples whose relationship is in peril.

A key part of the SMART trial is the creation of six SMART Recovery groups – in Birmingham, Norwich, Croydon, Gateshead, Cumbria and Sheffield – so that alcoholics in those areas needing major help can choose between that and AA.

Don Lavoie, a DH alcohol adviser, explains: “The DH has issued some high-impact changes for the alcohol sector – one of which is aimed at supporting and improving specialist alcohol treatment. Involved in that development is the promotion and growth of peer support, and ensuring that there is a range of choices for people with an alcohol problem.” Who comes, why, and how they fare will be evaluated to see which approach works best.

Gerstein points out: “At SMART Recovery meetings, we don’t pray, do the Lord’s Prayer or sing Kumbaya. We don’t depend on higher powers to help and we don’t expect people to come forever. They come, recover, and get on with their life”.

Before you begin to make changes in your life, it might be useful to understand the process. The theory called the Stages of Change Model (SCM) describes the mind/body stages we go through when we do change.

James Prochaska, Ph.D and Carlo Diclemente, Ph.D (1982) developed SCM  in the late 1970’s and early 1980’s while at the University of Rhode Island. They were studying how smokers were able to give up their habits. The model has been applied to a broad range of behaviors including weight loss, injury prevention, overcoming alcohol, and drug problems among others.

This a model of change which is unique in many ways. First, it is empirically driven: it is based on the researchers’ scientific investigation of change in humans. Second, the model conceptualizes change as entailing a number of stages which all require alterations in attitude in order to progress. Third, the model depicts change as a cycle, rather than an all or nothing step or series of steps. The authors contend that it is quite normal for people to require several trips through the stages to make lasting change. Additionally, each of us progresses through the stages at our own rate.

One of the reason the SCM is attractive, is that it recognizes change as flexible to individual needs. Some people make lasting change quite rapidly, others require a few times through the stages to acquire more knowledge and build skills. Just as some can master skiing on the first try, others require a couple of seasons to get to the intermediate level.

In this sense relapse can be viewed as a normal part of the change process, as opposed to a complete failure. This does not mean that relapse is desirable or even invariably expected. It simply means that change is difficult, and it is unreasonable to expect everyone to be able to modify a habit perfectly with out any slips. Relapses can vary in severity, as can our reactions to them. Some relapses can be so discouraging that people return to a precontemplative stage for a long time before contemplating change again. Others get right back on track, considering the antecedents to relapse, where they need to put more effort, and swiftly move back into action again.

We enter the stages of change from a state of precontemplation– during which the idea of change is not seriously considered. The cycle begins when we start to contemplate the need for change. Hopefully we will tip the scales in favor of change and become determined to take action. Then specific alterations in thinking and behaving will be initiated. It is hoped that the alterations become accepted and eventually ingrained or automatic. If we are able to maintain our accomplishments, we can exit the cycle entirely.

The Stages of Change

In brief, the stages of change are:

• Precontemplation – Not acknowledging that there is a problem behavior that needs to be changed.
• Contemplation – Acknowledging that there is a problem but not yet wanting to make a change.
• Preparation - Planning to make the changes.
• Action - Actively changing behavior and thoughts.
• Maintenance – Maintaining the behavior change.
• Lapses - Returning to old behaviors and abandoning the new changes. This can happen at any point in the stages.

Stage One: Precontemplation

In the precontemplation stage, people are not thinking seriously about changing and are not interested in any kind of help. People in this stage tend to defend their current bad habit(s) and do not feel it is a problem. They may be defensive in the face of other people’s efforts to pressure them to quit. They do not focus their attention on quitting and tend not to discuss their bad habit with others. It would be easy to call this “denial,” but a much more accurate view would be to describe Precontemplation as a state when a person is “uninformed” in the sense that no personally convincing reason for change has been presented as of yet. In this stage people simply do not yet see themselves as having a problem.

Stage Two: Contemplation

In the contemplation stage, people are more aware of the personal consequences of their habit. They start to think about their problem. Although they are able to consider the possibility of changing, they tend to be ambivalent about it. In this stage, people are weighing the pros and cons of quitting or modifying their behavior. Although they think about the negative aspects of their bad habit and the positives associated with giving it up (or reducing), they may doubt that the long-term benefits associated with quitting will outweigh the short-term costs. It might take as little as a couple weeks or as long as a lifetime to get through the contemplation stage. On the plus side, people are more open to receiving information about their bad habit. They become more likely to use educational interventions and reflect on their own feelings and thoughts concerning their bad habit.

Stage Three: Preparation

People in the preparation/determination are planning to take action and are making the final adjustments before they begin to change their behavior. Their motivation for this change may be reflected by statements such as: “I’ve got to do something about this. What can I do?”

This is sort of a research phase as they start taking steps toward cessation of their behavior. They attempt to gather information about what they will need to do to change their behavior, or seek help to understand how to successfully change. At this stage it is important to gather resources and knowledge that will help with success.

It is also important to establish a goal which works with you. A goal which is reasonable for one person, may be unreasonable or inadequate for another. Our goals must be consistent with our capabilities, our values, and our needs. Sometimes, especially by experts in the field of addiction treatment, a successful outcome is mandated as the only realistic goal.

Too often, people skip this stage: they try to move directly from contemplation into action and fail because they haven’t adequately researched or accepted what it is going to take to make this major lifestyle change. For example, many people with intentions for change believe that they must undergo a drastic lifestyle and identity change in order to alter a habit. For example, many recovering substance abusers believe that they must abstain not only from the substance they have abused, but also from all past behaviors, deny all pleasure, and assume a stoic lifestyle. Rarely is this drastic a lifestyle change necessary, or even ideal for lasting change. Often with this “all-or-nothing” approach to change, is that people find that it is virtually impossible to bare, or that they just hate it. They eventually become discouraged and stop the whole change process.

So, at this stage, it is important to examine what specifically you want to modify in your life, and what about your lifestyle is better left unchanged. Understand what you want to change, the motivation for the change, and most importantly, have a destination or way-point defined so that you can recognize the change.

Stage Four: Action

This is the stage where people not only have a desire to change, but also believe they have the ability to change their behavior and are actively involved in taking steps to change their behavior.

The amount of time people spend in action varies: but, in general it lasts about 6 months. This step requires the greatest commitment of time and energy. Mentally, they review their commitment to themselves, practice new skills, and develop plans to deal with both personal and external pressures that may lead to slips. They may use short-term rewards to sustain their motivation, and analyze their behavior change efforts in a way that enhances their self-confidence. People at this stage also tend to be open to receiving help and are also likely to seek support from others: this can be a very important element.

As people make conscience efforts to quit or change the behavior, they are at greatest risk for relapsing to old behaviors. Being mindful of triggers, and the reactions to them, is important. This is where actively building skills, changing thoughts toward the old behavior, and developing alternative coping behaviors comes in to play.

Stage Five: Maintenance

Maintenance involves being able to successfully practicing new skills and avoiding the temptations to return to the old habit. The goal of the maintenance stage is to maintain the new status quo. People in this stage tend to remind themselves of how much progress they have made, while still being cognizant of what it took to make the change.

People in maintenance constantly reformulate the rules of their lives and are acquiring even more skills to deal with life and avoid relapse. They are able to anticipate the situations in which a relapse could occur and prepare coping strategies in advance. They remain aware that what they are striving for is worthwhile and personally meaningful. They are accepting of themselves and recognize that it takes time to let go of old behavior patterns and to become proficient at new ones: realizing that ultimately the new behavior will become as comfortable to live with as the old. Even though they may have thoughts of returning to their old bad habits, they resist the temptation and stay on track.

As you progress through your own stages of change, it can be helpful to re-evaluate your progress in moving through these stages.

Lapses

Along the way to permanent cessation of a habit, many people experience a lapse. These are often accompanied by feelings of discouragement and seeing oneself as a failure.

There is a real risk that people who lapse will experience an immediate sense of failure that can seriously undermine their self-confidence. One of the most significant problems with the 12-step model is the all-or-none manner in which lapses are construed. Regardless of the intensity, slips and lapses have been viewed as failure, time to “start over.”

It is important to remember that experiencing a lapse is common.  In fact, most successful self-changers go through the stages three or four times before they make it through successfully without a lapse. Many will return to the contemplation stage of change; others return to the planning stage to implement what they have learned from the lapse. Consequently, the Stages of Change Model considers a lapse to be normal.

Rather than seeing a failure, analyze how the slip happened and use it as an opportunity to learn how to cope differently. People who lapse may need to learn a more effective ways anticipate high-risk situations, control environmental cues that tempt them to engage in their bad habits,  learn how to handle unexpected episodes of stress, or redefine their personal boundaries. Analyzing what happened gives a stronger sense of self control and the ability to get back on track. In fact, relapses can be important opportunities for learning and becoming stronger.

Transcendence

In addition, there is one more stage that Marc Kern Ph.D., CAS added which is not part of Prochaska-DiClemente original Stages of Change model: Transcendence.

Eventually, if you “maintain maintenance” long enough, you will reach a point where you will be able to work with your emotions and understand your own behavior and view it in a new light. This is the stage of “transcendence.” In this stage, not only is your old habit no longer an integral part of your life but to return to it would seem atypical, abnormal, even weird to you. When you reach this point in your process of change, you will know that you have transcended the old habits and that you are truly becoming a new “you”, who no longer needs the old behaviors to sustain yourself.

References

DiClemente, C. C. & Prochaska, J. O. (1982). Self-change and therapy change of smoking behavior: A comparison of processes of change in cessation and maintenance. Addictive Behaviors, 7, 133-142.

Many newcomers to Self Management and Recovery Training (SMART) meetings have previous experience with Alcoholics Anonymous (AA). Although they have decided to investigate SMART because of dissatisfaction with AA, frequently with its “spiritual” component, they are still unclear about both what they themselves are looking for (aside from either not drinking or cutting back), and what SMART specifically stands for and how it differs from AA. One member of the Washington, DC Area SMART groups offers some thoughts on the subject (which may differ from other members of the groups):

1. SMART Recovery is not an ideology, that is, a fixed set of beliefs. The emphasis is not on belief, but on rational analysis and action. Unlike AA, SMART works to provide an analytical framework which allows each participant to chart his or her own path to freedom from addiction. The mainstay of this framework is Albert Ellis’ Rational-Emotive Behavior Therapy (REBT), but this is not the only approach used in our meetings. SMART’s view, unlike AA’s, is that we should “utilize and analyze.”
2. It follows from this that SMART does not consider that all addicts are alike. Thus, no one “solution” fits all. Objective scientific studies have shown that everything from drinking patterns (for example, daily use to binge drinking) to degree of dependency, age at the outset of addiction, sex, family patterns, psychological reasons to use (i.e., to get “high” or to avoid feelings of inadequacy or discomfort) etc., produce strikingly different types of addicts.
3. Therefore, SMART does not claim that it is the best program for everyone with addiction problems. SMART emphasizes the goal of abstinence, as does AA. SMART might be best for some, AA for others, Moderation Management for others, religious denomination-based programs for others, or even personal determination to quit. The only way for a person with an addiction habit he or she wishes to end is to experience SMART Recovery or AA or some other program and see if it works; if it doesn’t something else should be tried.
4. Thus, we see that, SMART emphasizes personal choice and responsibility for one’s actions. It is up to each addict to determine what is best for him or her, not have the choice forced upon him or her. This point is in particularly strong contrast with AA’s emphasis on “powerless.” Rather, SMART believe strongly in rational analysis leading to freedom for the individual and his or her empowerment through self-knowledge leading to control over one’s decisions.
5. While SMART fully respects diverse religious views, and indeed some of its participants hold personal religious and spiritual beliefs, they do not view religious and spiritual beliefs as essential in solving our problems of addiction. SMART does not consider that a malevolent or benevolent “Higher Power” is either responsible for our addiction problems nor will it intervene to aid us in our individual efforts to overcome them.
6. SMART also does not consider “alcoholism” a life-long preoccupation. They prefer the term “addiction,” which refers to the physical addiction experienced while using (and for some time thereafter during withdrawal). After this physical addiction is over, the real problem is psychological—and solvable by the individual. Following this—or occurring simultaneously with it—the individual can move on to work on his or her other goals in life.
7. Simple observation as well as scientific studies show that there is no single “alcoholic personality” type or profile which can usefully describe an individual and his or her addictive actions. SMART instead observes that conflicting desires exist within each individual, some strong to use, but others equally earnestly desiring to end the addiction. We do not dwell on the historical sources of these desires, as is often done in traditional psychoanalysis, but instead on identifying and analyzing the underlying rational and irrational beliefs causing these desires in the here and now.
8. SMART meetings are self-help groups, not support groups. While attendees sympathize with, and try to assist others in the group, the primary goal of participants in our meetings is to support and strengthen their own efforts to be free of addiction. Unlike AA, probing discussion through cross-talk and feedback is encouraged. Like AA, however, these groups are confidential and administered by their own participants. Also like AA, SMART meetings are free, with minimal contributions encouraged but not required.
9. SMART has no definitive and incontrovertible text, such as AA’s Big Book. They have developed and continue to develop our own suggested reading material, which is available at meetings, but also draw on other sources in our discussions.

For more information on Self Management and Recovery Training and their meetings, please visit SMARTRecovery.org.

Differences Between SMART an AA