Understanding the SMART Recovery USA Position on Goals
by A. Thomas Horvath, Ph.D., ABPP
As part of my celebration of SMART Recovery’s 25th Anniversary, this blog is devoted to considering the recently released SMART Recovery USA Position on Goals: “SMART Recovery is abstinence oriented. Our meetings and tools are designed to help participants stop problematic addictive behavior.” I offer the following interpretation of this position.
Isn’t all addictive behavior problematic?
Addictive behaviors are normal human behaviors, including eating, sexuality, and connecting with others. For some individuals these behaviors become problematic. Involvement with pleasurable psychoactive substances or activities is also common, including with alcohol, caffeine, gambling, video games, and many others. For some individuals these involvements become problematic. SMART focuses on problematic addictive behavior, not on all addictive behavior.
What does abstinence-oriented mean?
SMART supports the involvement goal each participant has chosen. Many participants are abstaining from one or more addictive behaviors. All participants are presumably focused on resolving addictive problems. Stopping the problematic aspect of the behavior, or stopping the behavior altogether, is a personal choice. In practice, most participants are pursuing abstinence, for one or more substances, because those who achieve stable moderation typically do not attend meetings regularly.
Why is SMART not entirely abstinence based?
SMART Recovery USA position on goals requires explanation for several reasons, and especially because 1) most US addiction treatment providers and mutual support groups use a substantially different approach, and 2) SMART is potentially of benefit to anyone, not just those with severe addictive problems.
SMART does not assume that resolving addictive problems requires that the individual be required to abstain, or be regularly reminded of such a requirement. Consistent with a self-empowering (and a motivational interviewing) approach SMART does NOT recommend, require, or remind about abstinence or any other specific course of action. Rather, our meetings focus on what abstaining, moderating and cutting back have in common: stopping involvement with the addictive behavior at the chosen point (e.g., before the first drink, after the second, after the 10th, etc.).
There are several substantial advantages to SMART’s approach about goals:
1) Participants are encouraged to attend meetings regardless of the extent of their problems. In other support groups the participant must self-assess to a significant degree before attending or actively participating (e.g., “I am an alcoholic/addict”). These groups understandably have difficulty attracting individuals earlier in the problem development process. “I know I drink too much, and I’d like to do something about it, but I’m no alcoholic, so an abstinence group may not be for me.” 2) Consequently, participants are likely to show up to SMART meetings sooner, rather than waiting for a crisis to occur. Ironically, despite the idea that abstinence is the “best course,” it is generally easier to resolve addictive problems earlier in their development rather than later, and often by moderating.
3) There is no confusion about whether someone on medications (such as buprenorphine or methadone) is accepted. These participants typically have stopped using heroin or similar substances, but are still using another prescribed opiate, a situation entirely acceptable in SMART. This approach to treatment has been highly researched and is likely the most effective approach for addressing opiate problems.
4) SMART easily addresses over-eating, arguably the most widespread addictive problem in the US. Similarly, SMART can be helpful for any addictive behavior where a strict definition of abstinence may not make sense.
5) Although insisting on abstinence may seem like a sensible course when the participant is ambivalent, and this insistence may be effective in the short term, in the longer term effectiveness may diminish substantially because of psychological reactance. When we are told what to do, most of us want to assert our freedom, even if so doing is not in our long-term interest. SMART avoids this problem entirely. Participants can entirely personalize their approach to change, thereby increasing their motivation to change.
6) Stigma is substantially reduced because participants typically no longer label themselves as addicts or alcoholics. Ironically, although the traditional recovery community objects to stigma, the foundation for stigma is established by using labels. SMART is increasing awareness that problematic addictive behavior involves nearly everyone at some point in life, thereby increasing human connection, and reducing stigma toward individuals with severe problems.
7) SMART is for everyone.
Many commonly used recovery terms, including abstinence, chemical dependency, harm reduction, moderation, addiction, alcoholism, addict, and alcoholic, are minimally used by SMART Recovery. These terms do not fit well with a self-empowering approach, and are not required of any participant. Nevertheless, many participants use them, and they are meaningful in other recovery pathways.
When a participant has agreed to abide by an abstinence requirement established by a court, a treatment center, or other authority, the meeting will support this plan. We recognize that for many individuals, particularly those with severe addictive problems, abstinence is the most reliable approach to recovery.
So participants could be seeking abstinence, moderation, or harm reduction, all in the same group?
These three approaches are all compatible with SMART Recovery because they have in common the need to engage in self-control and more rational decision-making. Participants, despite differences in the substances and activities they engage in and the consequences they experience, are united in the desire to stop excessive behavior. Consistent with SMART Recovery’s emphasis on choice, participants decide for themselves where “stopping” is to occur. For instance, goals might include stopping heroin use (but staying on buprenorphine), stopping over-eating, stopping sexual behavior outside of a partnership, limiting gambling to one lottery ticket per month, limiting cannabis to once per weekend, stopping opiates but not alcohol or cannabis, etc. Participant goals may change over time, based on the participant’s continuing experience. Goals are not debated in the meeting. Meetings emphasize ideas and methods (our “tools”) that can be used to accomplish the goal. Each participant is working to develop greater self-control, regardless of the specific goals chosen.
Does a SMART meeting discuss moderation training or harm reduction practices (such as alcohol moderation training, or how to safely inject)?
No. These topics may be mentioned but are not a focus of discussion. Although SMART Recovery supports these and similar activities when appropriate, our focus is on stopping, not on using.
How does SMART’s approach compare with the chemical dependency approach?
Typically individuals in 12-step, disease model oriented recovery for substance problems accept the concept of chemical dependency. Under this concept one needs to abstain from all fully intoxicating substances (such as alcohol, cocaine, heroin, etc.), but does not need to make any plans with respect to food, the mildly intoxicating substances caffeine and nicotine, or activities such as gambling, sex, video games, etc. Ironically, food and tobacco lead to many more premature deaths than all the other substances combined, and other substances and activities can also be highly problematic. The chemical dependency concept has already established the precedent of stopping some problematic addictive behaviors but not others. SMART Recovery individualizes this process. Participants only address substances or activities of concern to them. As their lives improve they may choose to gain greater self-control of other substances and activities as well.
What if someone cannot reduce use and must abstain?
Many participants enter the change process hoping to reduce but not stop use completely. Some accomplish reduction and some do not. The participant is free to understand difficulties in any way that makes sense to the participant. Some may say “I must abstain” but others may say “I see that trying to moderate is not going well, and I’m tired of all the problems I have had, so I now choose to abstain.” To tell a participant “you are someone who must abstain” is to break one of the fundamental rules of a SMART Recovery meeting: No advice. Many participants discover that stopping altogether is indeed much easier for them than to limit use. However, this is a decision made by each participant, just as in any other approach to change. By comparison, the first step of Alcoholics Anonymous (AA) is “we admitted we were powerless over alcohol and that our lives had become unmanageable.” This admission may occur before or after one attends AA meetings. It is a decision ultimately made by each AA participant. The individual moves forward in AA after having made that decision. In SMART the individual moves forward with any stopping goal that makes sense to that individual.
What if someone has the disease of addiction?
Participants are free to understand their addictive problems in any way that makes sense to them. SMART Recovery does not have a position on whether addiction is a disease. Our methods work regardless of whether the participant views addictive problems as a disease or not.
How does SMART Recovery define addiction?
Our meetings focus on problematic addictive behavior (or more succinctly, addictive problems), not on addiction (a term we use less frequently). SMART assumes that all human beings have non-problematic addictive behavior. We all repetitively desire substances and activities, in particular food, sex, and connection with others, because these engagements are survival behaviors. In some cases involvement with substances and activities becomes excessive, meaning that significant problems are occurring. Most of us have problematic addictive behavior at times, so most of us can easily understand how that transition can occur. From SMART’s perspective addressing addictive problems is a nearly universal concern. Addictive problems unite us, rather than divide us. If the general population widely adopted the idea that addictive problems are widespread (as they are with food) presumably stigma against those with substantial addictive problems would reduce.
How do SMART Recovery meetings put these ideas into practice?
Meetings are open to anyone. Meetings focus on the ideas and tools that can be used to accomplish participant goals for stopping excessive substance use or involvement in activities (at whatever point the participant has chosen). Our mutual aid meetings are typically led by non-professional volunteers, and have some similarities to but also fundamental differences from psychotherapy and addiction treatment. No one is required to participate. The meeting leader is in charge of the meeting agenda and enforces meeting guidelines. However, the value of the meeting arises from how deeply participants involve themselves in the discussion. Someone disruptive to the meeting is asked to leave. The primary rule of a SMART meeting is “Do SMART Recovery.” Additional rules include 1) stay on topic (and follow the agenda), 2) keep it conversational (no one dominates), 3) share experience but not advice, 4) allow anyone to remain silent, and 5) keep it confidential.
To summarize: SMART Recovery’s approach to problematic addictive behavior is for everyone. In meetings we work on what we all have in common: Stopping. You decide what to stop, and where to stop it. SMART will help you from there.