By Steve K.
As someone who makes efforts to support others who suffer from addictive behaviours, I’m generally open to the various modalities and mutual-aid organisations that exist for this purpose. As well as attending 12 Step groups over a long period of time, I’ve also taken part in and helped facilitate other types of group work aimed at helping people abstain from alcohol and other drug use.
I’ve recently become interested in the SMART (Self-Management and Recovery Training) model and just completed its Facilitator training with a view to starting a SMART meeting in collaboration with a local addiction treatment provider. Having just finished the training, I thought it would be useful to compare and contrast SMART with the 12 Step approach, although I would like to focus more upon the similarities than differences.
SMART Recovery was established in 1994 (formerly ‘Alcohol and Drug Self-Help Network’) and its origins were formed from an approach called Rational Recovery, which was established in 1985 by social worker Jack Trimpey.
Like 12 Step mutual-aid groups, SMART Recovery meetings are free to attend and operate on a non-profit basis. 12 Step groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are supported by charitable central organisations, as are SMART Recovery meetings (e.g., UK SMART recovery). SMART Recovery meetings offer support for all addictive behaviours, whereas 12 Step fellowships are for specific addictions, although there are various fellowships for a multitude of different addiction problems (e.g., AA, NA, CA etc).
SMART Recovery is generally positioned as an alternative to 12 Step recovery, with the 12 Step approach considered spiritual in nature, compared to SMART Recovery which is secular and science based. Both approaches are abstinence oriented.
While it is true that 12 Step programs are based upon spiritual principles, they are also integrated with medical, psychological, and philosophical concepts. It is also true to say that aspects of the 12 Step approach to recovery (its spirituality) have not yet been scientifically proven effective. However, there is now unequivocal proven scientific research (a large systematic review study published in April 2020, conducted by Harvard and Stanford universities), that shows involvement with 12 Step groups results in positive outcomes in relation to reduced harms and long-term abstinence, equal to, and often better than, other common forms of treatment such as CBT and outpatient treatment.
While SMART Recovery favours behavioural theories for addictive behaviours and 12 Step groups tend to be associated with the medical or ‘disease-model’, both organisations respect their members personal viewpoints and beliefs in relation to the underlying causes of addictive behaviour. They are person-centred in this respect. The same position applies to both 12 Step and SMART Recovery for any spiritual or religious beliefs individual members may hold. An individual’s worldview is left up to them.
Locus of Control
I would suggest that the main difference between SMART Recovery and 12 Step recovery lies in the ‘locus of control’ where recovery is concerned. However, I would also suggest that this is a superficial observation, and the reality is that both approaches are in effect quite similar.
12 Step programs place an emphasis upon the need for a ‘Higher Power’ of one’s own understanding (this can be and often is the group) to recover from addiction. This suggestion comes from members’ lived experience of lacking personal control in relation to their addictive behaviour (which is supported by mainstream scientific research is terms of the neurobiology of addiction and its affect upon behaviour and rational decision making). SMART Recovery places emphasis upon ‘self-empowerment’, individual choice, and personal responsibility in recovery. SMART’s locus of control is internal.
There is no doubt that changing established addictive behaviour is often incredibly difficult for most people (mutual-aid groups wouldn’t exist otherwise) and support is commonly required in the pursuit of abstinence and/or change. Both SMART Recovery and 12 Step recovery provide peer support for people trying to achieve and maintain abstinence from their addictive behaviour. Both approaches are ultimately empowering by enabling freedom from addiction.
Step One of AA’s 12 Step program suggests admitting ‘powerlessness’ in relation to addiction. Admitting a lack of control in relation to addictive behaviour is not irrational considering that compulsiveness is a commonly identified characteristic or symptom of addiction. This is not the same as saying “I have absolutely no choice in my behaviour”, as there are degrees of choice and freedom. Addiction clearly influences the choices we make and makes abstaining difficult but not impossible. Addictive behaviour that is long-standing, complex, and/or severe lessens the sufferer’s ability to control their addiction. Bill Wilson (co-founder of AA) and other early members of Alcoholics Anonymous all suffered from well established and severe forms of addiction and reading accounts of their experiences clearly shows serious problems in controlling their alcoholism.
However, given enough incentive even the most addicted among us can choose a pathway that leads to recovery. The ‘serenity prayer’, often recited by 12 steppers, suggests accepting things beyond our control (many things in life are beyond our personal control) and seeking the courage to change the things we can. Impaired control in relation to addictive behaviour doesn’t necessarily prevent us making efforts to seek help and practice principles and behaviour that can lead to recovery.
In my experience, 12 Step recovery does encourage personal responsibility in relation to changing behaviour. It encourages engaging with recovery activity and being responsible for our own efforts in this regard. The individual in 12 Step recovery is responsible for not taking the first drink or drug. They are also responsible for practicing the 12 Steps, for going to meetings, working with their sponsor, for carrying out service, and helping others to recover. These are all behavioural actions that facilitate personal change and help to maintain recovery from addiction.
Reliance upon a ‘higher power’ ultimately includes an internal locus of control (mine is a non-dual perspective). In the book Alcoholics Anonymous, ‘Appendix II’, there is the suggestion of a connection with an “inner resource”. In the end, a ‘higher power’ is found within the human spirit, I know mine is. It can also be found in help and support from others providing us with inner strength and a changed mindset. Although SMART promotes personal responsibility in recovery, it also facilitates mutual aid from peers. Research suggests that peer support and group meetings are the ‘primary mechanism of change’ within both approaches.
Structured CBT vs Informal CBT
The format of SMART Recovery meetings does differ significantly from 12 Step meetings. SMART meetings operate more in line with traditional therapy or rehab treatment groups. They are generally facilitated by a trained volunteer or professional, encourage feedback and ‘crosstalk’ between members, and teach established Cognitive-Behavioural Therapy (CBT) tools and strategies. SMART Recovery is based on CBT, Rational Emotive Behaviour Therapy (REBT), and Motivational Enhancement Therapy (MET). 12 Step meetings are led by a member of the group (chair), crosstalk is discouraged and group members ‘share’ uninterrupted, and groups are run in accordance with the 12 ‘traditions’ with members practicing the 12 Steps.
SMART Recovery uses CBT, REBT, and MET tools and techniques within its four-point programme: 1. Building and Maintaining Motivation, 2. Coping with Urges/Cravings, 3. Managing Thoughts, Feelings, and Behaviours, 4. Living a Balanced Life.
The SMART Recovery four-point programme works in conjunction with the ‘Stages of Change’ model which is used to identify where group members are in relation to their addictive behaviour and recovery from it. The ‘stages of change’ are not necessarily linear, and individuals can be in more than one stage at a time. Tools and strategies are used in relation to each stage of change and with regard to the 4-point programme.
6 Stages of Change
(Relapse can be at any stage)
12 Step meetings and philosophy abound with informal cognitive and behavioural suggestions and interventions e.g., ‘Bring the body and the mind will follow.’ Step 4 of the AA program suggests ‘making a searching and fearless moral inventory’ and outlines a model for doing so which is comparable to the ABC tool used in SMART Recovery. This inventory/tool considers what happened (Step 4) or the ’activating event’ (SMART), the resulting feeling/behaviour (Step 4) and thinking/belief (SMART), and how it impacts upon self-esteem and emotional security etc (Step 4), and the consequences (SMART). In 12 Step work the inventory is discussed with the person’s sponsor or trusted friend, and in SMART Recovery the ABC tool is discussed within the meetings and used by the individual in their everyday life. Step 10 is the practice of a daily personal inventory in 12 Step recovery.
The psychologist Clifford N Lazarus, Ph.D, considers AA to be a form of CBT as it encourages ‘thinking differently, acting differently, and taking personal responsibility for one’s decisions.’ (1) He suggests.. “Indeed, if we look closely at AA, we see that despite its spiritual underpinnings and focus on working the 12 Steps, it is a very behaviourally oriented process. For example, one of the core recommendations that AA makes is to change people, places, and things. In other words, to change one’s routines, repertoires, and actions.” (2)
If we consider the overall aims and objectives of SMART Recovery and 12 Step recovery, they are very similar. They both encourage abstinence, provide peer support for their members, are free to access, and seek to improve the quality of life and wellbeing of those suffering with addictive behaviour (both approaches have scientific backing in terms of efficacy). They both facilitate changes in thinking, feeling, and behaviour through teaching cognitive and behavioural interventions, although SMART Recovery does this via a structured format and established CBT tools and techniques, whereas 12 Step recovery does this primarily through informal suggestion.
There are differences of course. The spiritual underpinnings of 12 Step recovery vs the focus upon rationality within SMART Recovery, the emphasis upon an ‘internal locus of control’ in SMART, as opposed to the reliance upon a ‘power greater than oneself’ in 12 Step philosophy. There is also a discouraging attitude towards labelling oneself (e.g., alcoholic/addict) within SMART meetings, whereas this is encouraged (although still a personal decision) within 12 Step culture (there are pros and cons in relation to labelling, however, current thinking tends towards viewing labels as being stigmatizing and unhelpful – I tend to agree).
As I’ve already suggested, and hopefully explained, these differences are in effect superficial, and in an effort to reduce the sectarianism that often exists in relation to different addiction recovery pathways, I choose to focus my attention upon the similarities rather than the differences of these two helpful approaches.
Podcast discussion about the above essay..