Systematic Review of SMART Recovery: Outcomes, Process Variables, and Implications for Research

Alison K. Beck, Erin Forbes, and Amanda L. Baker Peter J. Kelly and Frank P. Deane University of Newcastle University of Wollongong

Anthony Shakeshaft David Hunt National Drug and Alcohol Research Centre, University of New SMART Recovery Australia, Haymarket, New South Wales South Wales, Australia

John F. Kelly Recovery Research Institute, Massachusetts General Hospital, Boston, Massachusetts, and Harvard Medical School

Clinical guidelines recommend Self-Management and Recovery Training (SMART Recovery) and 12-step models of mutual aid as important sources of long-term support for addiction recovery. Methodologically rigorous reviews of the efficacy and potential mechanisms of change are available for the predominant 12-step approach. A similarly rigorous exploration of SMART Recovery has yet to be undertaken. We aim to address this gap by providing a systematic overview of the evidence for SMART Recovery in adults with problematic alcohol, substance, and/or behavioral addiction, including (i) a commentary on outcomes assessed, process variables, feasibility, current understanding of mental health outcomes, and (ii) a critical evaluation of the methodology. We searched six electronic peer-reviewed and four gray literature databases for English- language SMART Recovery literature. Articles were classified, assessed against standardized criteria, and checked by an independent assessor. Twelve studies (including three evaluations of effectiveness) were identified. Alcohol-related outcomes were the primary focus. Standardized assessment of nonalcohol substance use was infrequent. Information about behavioral addiction was restricted to limited prevalence data. Functional outcomes were rarely reported. Feasibility was largely indexed by attendance. Economic analysis has not been undertaken. Little is known about the variables that may influence treatment outcome, but attendance represents a potential candidate. Assessment and reporting of mental health status was poor. Although positive effects were found, the modest sample and diversity of methods prevent us from making conclusive remarks about efficacy. Further research is needed to understand the clinical and public health utility of SMART as a viable recovery support option.

Keywords: systematic review, SMART Recovery, mutual aid, self-help groups, addiction

Supplemental materials: http://dx.doi.org/10.1037/adb0000237.supp

The burden of addiction is considerable, with a profound and Shaw, McCormick, & Allen, 2013; Laudet, 2011). Together, the detrimental impact on mortality (Whiteford et al., 2013) as well as harms from alcohol, substance, and behavioral addictions such as health, relationships, employment, and quality of life (Black, gambling have been estimated to cost over $28 billion per year This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Alison K. Beck, Erin Forbes, and Amanda L. Baker, School of Alison K. Beck and Erin Forbes have no competing interests to declare. Medicine & Public Health, University of Newcastle; Peter J. Kelly and Amanda L. Baker, Peter J. Kelly, Frank P. Deane, Anthony Shakeshaft, and Frank P. Deane, School of Psychology, University of Wollongong; John F. Kelly are all members of the SMART Recovery Australia Research Anthony Shakeshaft, National Drug and Alcohol Research Centre, Advisory Committee. Amanda L. Baker is a SMART Recovery Australia University of New South Wales; David Hunt, SMART Recovery Aus- board member. David Hunt was employed by SMART Recovery as the area tralia, Haymarket, New South Wales, Australia; John F. Kelly, Recov- coordinator for South Australia, Tasmania, and Victoria. ery Research Institute, Massachusetts General Hospital, Boston, Mas- Alison K. Beck is supported by the National Health and Medical Research sachusetts, and Department of Psychiatry, Harvard Medical School. Council’s Centre of Research Excellence for Mental Health and Substance Use. Preliminary findings from this article were presented as part of a sym- The funder had no involvement in the development, conduct, or interpretation of posium conducted at the 35th Conference of the Australasian Professional this systematic review. We thank Mary Kumvaj for her assistance with designing Society on Alcohol and Other Drugs, Perth, Australia, October–November, the search strategy. Protocol Registration: PROSPERO CRD42015025574. 2015. A link to the symposium presentation is available on the SMART Correspondence concerning this article should be addressed to Alison K. Recovery Australia website (http://smartrecoveryaustralia.com.au/2015/ Beck, Level 5, McCauley Centre, Calvary Mater Newcastle, Edith Street, 11/). Waratah, 2298 Australia. E-mail: [email protected]

1 2 BECK ET AL.

(Australian Government Productivity Commission, 2010; Man- including the first randomized controlled trial (RCT), have been ning, Smith, & Mazerolle, 2013). Because the course of addiction published. is often chronic and characterized by multiple relapses (Sheedy & The current review is reported here following established guide- Whitter, 2009), accessible, long-term support is important. lines for conducting systematic reviews (Moher, Liberati, Tetzlaff, “Mutual aid” programs represent one avenue for accessing such Altman, & the PRISMA Group, 2009). We advance the current support. Mutual aid refers to the social, emotional, and informa- literature by using an established methodology (Higgins & Green, tional support provided by, and to, group members undergoing 2011) to provide a comprehensive, systematic overview and crit- recovery from addiction (Public Health England, 2015). Twelve- ical evaluation of both published and unpublished evidence for step models (e.g., Alcoholics Anonymous [AA]) are the largest SMART Recovery and include recommendations for future re- and most researched source of addiction mutual aid. Within the search. We aim to explore whether, for adults with experience of 12-step model, addiction is conceptualized as a medical and spir- substance and/or behavioral addiction(s), SMART Recovery itual disease, and a key feature of the recovery process is relin- results in changes in the severity of addiction and its consequences quishing control to a user-defined higher power (Donovan, In- and whether any observed changes are influenced by process galsbe, Benbow, & Daley, 2013). For adults with moderate to variables (e.g., treatment engagement). To help guide understand- severe alcohol use disorder, evidence has suggested that improve- ing of the applicability of these research findings to “real world” ment following community 12-step participation is at least equiv- settings, we also describe the feasibility of the SMART Recovery alent to that of professional interventions (Ferri, Amato, & Davoli, approach, including a commentary on economic outcomes and 2006; Humphreys et al., 2004; J. F. Kelly, Magill, & Stout, 2009), service user satisfaction. To better inform research and clinical and in the longer term, active participation increases the likelihood care, we also describe the treatment contexts and clinical presen- of full sustained remission and recovery (Moos & Moos, 2006; tations of participants (e.g., addiction only vs. dual diagnosis). Public Health England, 2015). However, individuals may fail to Given not only the high prevalence but also considerable impact of engage with 12-step groups for a variety of reasons, including a comorbid mental health conditions on addiction recovery (Mills et mismatch between personal beliefs and the 12-step philosophy al., 2010), the assessment and/or change in mental health status (Horvath & Sokoloff, 2011). To enhance engagement, clinical reported within the research on SMART Recovery is also dis- guidelines advocate for tailored addiction support that accounts for cussed. individual needs and preferences (e.g., National Institute for Method Health Excellence, 2011, 2012). Choice over mutual aid support options is therefore important, and fortunately, alternatives are The current systematic review is exempt from review by a available (see Humphreys et al., 2004, for a review). research ethics committee or institutional review board because no One such alternative is Self-Management and Recovery Train- primary data collection was undertaken from study participants. ing (SMART Recovery). SMART Recovery is one model recommended alongside 12-step by clinical guidelines for both addiction Criteria for Selecting Studies for This Review (National Institute for Health Excellence, 2011, 2012) and dual Methods were informed by the Cochrane Handbook for System- diagnosis (Mills et al., 2010). SMART Recovery is a not-for-profit atic Reviews of Interventions (Higgins & Green, 2011) and are organization that provides mutual aid in group and online formats extensively detailed in the review protocol (Beck et al., 2016). The (Horvath & Yeterian, 2012). SMART Recovery focuses on self- population of interest was adults (ages Ն18) attending SMART empowerment and adopts key principles (e.g., self-efficacy) and Recovery with current or past problematic experience of at least therapeutic approaches (e.g., motivational interviewing and one addictive behavior (substance and/or behavioral). Study par- cognitive–behavioral therapy) shown to be effective in promoting ticipants could be residing in community, rehabilitation, treatment, recovery from addiction (see Australian Psychological Society, and/or correctional settings. The intervention of interest (SMART 2010, for a recent review of the efficacy of these approaches). Recovery) could be delivered in a group format, of any intensity or Unlike 12-step approaches that offer addiction-specific support frequency (including stand alone and/or as an adjunct), by a lay or groups (e.g., Alcoholics Anonymous, Narcotics Anonymous, professional facilitator. SMART Recovery could be compared to Gamblers Anonymous), SMART Recovery offers support for a inactive and/or active conditions of any intensity, frequency, and This document is copyrighted by the American Psychological Association or one of its alliedrange publishers. of addictive behaviors (Horvath & Yeterian, 2012). delivery method. Evaluations without a comparator group were This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. also eligible. Studies had to provide data for SMART Recovery Objectives and Importance of the Current Review participants for at least one of the following: (a) severity of addiction and its consequences, (b) process variables (e.g., treat- Relative to the methodologically rigorous systematic reviews of ment engagement), or (c) feasibility (see Beck et al., 2016, for the efficacy (Ferri et al., 2006) and potential mechanisms of definitions). We included the following designs: randomized con- change (J. F. Kelly et al., 2009) of 12-step models, to date, reviews trolled trials (cluster and parallel design), crossover trials, case of SMART Recovery (e.g., Horvath & Yeterian, 2012) are narra- series or case controls, one-arm trials, nonrandomized trials, cross- tive in nature and tend to focus on the origins, development, and sectional or cohort studies, and case reports. Qualitative-only principles of SMART Recovery. A systematic approach to iden- designs were not included. tifying, summarizing, and evaluating the quality of evidence for SMART Recovery has yet to be undertaken. Furthermore, since Search Methods for Identification of Studies Horvath & Yeterian’s, narrative review (Horvath & Yeterian, Figure 1 summarizes the procedure used to identify studies, 2012), the evidence base has doubled—an additional four studies, including databases searched, search terms used, exclusion cri- SMART RECOVERY SYSTEMATIC REVIEW 3

110 records returned from electronic scienﬁc databases: Medline (4); PubMed (9); Embase (7); CINAHL Complete (4); PsychInfo (83); CENTRAL (3). With search terms “SMART Recovery” OR “Self Management And Recovery Training” AND 879 records returned from alcohol*OR alcohol related disorder OR alcohol abuse OR alcohol non-scienﬁc electronic dependence OR substance use disorder OR substance abuse OR substance databases: Google Scholar dependen* OR gambling OR Addicve behav*r OR addict* (855); Virginia AND Commonwealth University addicon severity OR absnen*OR harm reducon OR recurrence OR

Idenﬁcaon relapse OR (19); Project Cork (5); alcohol drinking OR alcohol consumpon OR substance us* OR Prevenon, Informaon and “dollars lost” OR expenditure OR “hours spent” OR “me spent” Evidence Library (0), search

OR terms: “SMART Recovery” paent compliance OR adherence OR parcipaon OR aendance OR engagement

17 Duplicates removed

859 excluded because Not about SMART Recovery 972 Manual search of Not published in English

Screening tles/abstract Not a journal arcle, report, book chapter or newsleer (e.g. book review)

81 excluded because Not about SMART Recovery (62) Qualitave Only Design (4) Evaluaon - Don’t focus on adults 5 records from with problemac addicve behaviour other sources 118 full text arcles (2) (reference lists/ Evaluaon – Do not report outcome author assessed for eligibility measures of interest for SMART correspondence) Eligibility parcipants (3)

Not a journal arcle, report, book chapter or newsleer (e.g. conference abstract, book review) (4) Conference proceedings later published (6)

37 publicaons classiﬁed

Evaluaon Discussion Reviews Other

Classiﬁcaon 12 15 4 6

This document is copyrighted by the American Psychological Association or one of its allied publishers. 12 Evaluaon Studies This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Analysis

Selected for Inclusion Crical

Figure 1. Flowchart of the study selection process. See the online article for the color version of this figure.

teria, and study classification. The full MEDLINE search strat- were hand-searched to identify any additional publications. All egy is provided in File 1 of the online supplemental materials. publications were organized in the reference manager Endnote Abstract, title, key words, and subject headings specific to each 2015 (Version X7). The searches were performed in May–June database were searched. Subject headings were exploded. No 2015 and rerun in April 2016. Articles were identified and limits were placed on publication year. Publications had to be classified according to three steps, explained in the next three available in English. Reference lists of identified publications sections. 4 BECK ET AL.

Step 1: Identification and screening. Alison K. Beck per- score from 0 to 8 points. Raters achieved 100% consistency in their formed the searches and reviewed the titles and/or abstracts of the independent ratings. identified 989 publications and used the inclusion criteria to ex- Cochrane Collaboration’s Risk of Bias tool (Higgins & Green, clude clearly ineligible articles. If eligibility was unclear, the 2011). Risk of bias (within and across all studies) was assessed full-text article was accessed. using the Cochrane Collaboration’s Risk of Bias tool. This tool Step 2: Eligibility and classification. The full-text versions provides an overall risk of bias (“high,” “low,” or “unclear”) based of 118 publications were manually reviewed. Eighty-one publica- on the following methodological characteristics: sequence gener- tions were excluded. The remaining 37 were classified as “evaluation, allocation concealment, blinding of participants and person- ation,” “review,” “discussion,” or “other” according to published nel, blinding of outcome assessment, incomplete outcome data, definitions (see Beck et al., 2016). selective outcome reporting, and “other” potential sources of bias. Step 3: Crosschecking. The 118 publications from Step 2 Raters achieved 89.2% consistency in their independent ratings. were cross-checked by having a research assistant (Erin Forbes) Discrepancies were resolved by discussion, and consensus ratings who was blinded to the results of the initial classification reclassify across all items were obtained. the publications. The articles excluded in Step 1 were not cross- checked, because they were not relevant to the review. The 12 Results studies independently classified by Alison K. Beck and Erin Forbes as “evaluation” were retained for further examination. Description of Studies Twelve studies were identified (eight published in peer- Data Collection and Analysis reviewed journals, four unpublished dissertations). The studies were predominantly cross-sectional (eight of 12). The effective- Data extraction was performed by Alison K. Beck and checked ness of SMART Recovery was explored in one RCT (Hester, by Erin Forbes. Extraction forms were piloted on several articles Lenberg, Campbell, & Delaney, 2013), one pre- and posttreatment and modified as needed before use. When multiple reports of the (prepost) design (described across two publications; Brooks & same study were identified (Brooks & Penn, 2003; Penn & Brooks, Penn, 2003; Penn & Brooks, 2000), and one quasi-experimental 2000), data from each report was extracted separately and then pseudoprospective study (Blatch, O’Sullivan, Delaney, & Rath- combined across multiple data collection forms. Criteria for data bone, 2016). Concurrent mental illness and substance use disorder extraction (detailed in the protocol; Beck et al., 2016) were was the focus of only one study (described across two articles; adapted from the Downs and Black Scale (Downs & Black, 1998) Brooks & Penn, 2003; Penn & Brooks, 2000). and the Cochrane Handbook for Systematic Reviews of Interven- The SMART Recovery intervention and comparison condition tions (Higgins & Green, 2011). was often poorly described. Intervention content and delivery Assessment of methodological quality and risk of bias. methods were clearly detailed for only SMART informed or Assessment of quality and bias was undertaken independently by adapted interventions (Blatch et al., 2016; Brooks & Penn, 2003; Alison K. Beck and Erin Forbes. Hester et al., 2013; Penn & Brooks, 2000). For community-based Downs and Black Scale (Downs & Black, 1998). All nonran- SMART Recovery groups (and comparison conditions), assess- domized studies were evaluated using this 27-item checklist ment and/or reporting of SMART Recovery tools, strategies, con- (which is recommended by the Cochrane guidelines for assessing tent, delivery methods, facilitator experience, and training was the quality of nonrandomized trials; Higgins & Green, 2011). scarce. Thus, adherence to SMART Recovery guidelines was Consistent with previous concerns about the two items regarding unclear. Assessment and reporting of concurrent treatment (including pharmacological and psychological) for addiction and/or men- blinding of subjects and therapists (e.g., Baker, Hiles, Thornton, tal health was also lacking. Hides, & Lubman, 2012), these items were not used. Scoring of Outcomes assessed. Item 27 (power) was unclear, so the following convention was Severity of addiction and its consequences. The severity of used: 0 (no power calculation reported),1(power analysis re- addiction and its consequences tended to be assessed in terms of ported, but insufficient power achieved), and 2 (power analysis quantity, frequency, and/or duration of use. Other indices (e.g., This document is copyrighted by the American Psychological Association or one of its alliedreported publishers. and sufficient power achieved). Item ratings were number of hospitalizations and recidivism) were assessed in three This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. summed for a total maximum score of 27, with higher scores studies (Blatch et al., 2016; Brooks & Penn, 2003; Milin, 2007; reflecting greater methodological quality. Raters achieved 80.5% Penn & Brooks, 2000), and quality of life in only one study consistency in their initial independent ratings. Discrepancies were (Brooks & Penn, 2003; Penn & Brooks, 2000). Despite high then resolved following discussion, and consensus ratings were comorbidity between mental health conditions and substance mis- obtained for all items. use, standardized assessment of mental health status occurred in Physiotherapy Evidence Database (PEDro) Scale (Centre for only three studies (Brooks & Penn, 2003; Hester et al., 2013; Penn Evidence Based Physiotherapy, 2009). The one RCT identified & Brooks, 2000; P. J. Kelly, Deane, & Baker, 2015). was also assessed against the 11-item PEDro Scale, a widely Alcohol-related outcomes were the primary focus of the litera- implemented and validated tool for assessing the quality of ran- ture. However, only three studies utilized standardized assessment domized trials. Again, the two items regarding blinding were of alcohol use (Brooks & Penn, 2003; Hester et al., 2013; Milin, deemed inappropriate (e.g., Baker et al., 2012) and not scored. The 2007). The remainder relied on subjective accounts, including remaining items were assigned a 1 (yes) or 0 (no) rating (Centre self-reported duration of “abstinence” or “sobriety” (Atkins & for Evidence Based Physiotherapy, 2009), generating a quality Hawdon, 2007; Guarnotta, 2014; Trumble, 2015) and “problems” SMART RECOVERY SYSTEMATIC REVIEW 5

(P. J. Kelly et al., 2015; O’Sullivan, Blum, Watts, & Bates, 2015). Bogdonoff, 2002; Guarnotta, 2014; Milin, 2007) explored the Only three studies explicitly reported on nonalcohol substance use relationship between these and treatment outcome. (Brooks & Penn, 2003; P. J. Kelly et al., 2015; Milin, 2007). Feasibility. Feasibility tended to be indexed by attendance, Within these, the focus was on illicit drugs, to the relative neglect including the number of sessions (Hester et al., 2013), duration of of other common forms of substance use like smoking (reported by involvement (Brooks & Penn, 2003; P. J. Kelly et al., 2015; Li, only P. J. Kelly et al., 2015) and misuse of prescription medication Feifer, & Strohm, 2000; Milin, 2007; O’Sullivan et al., 2015; Penn (reported by only Milin, 2007). Brooks and Penn (2003) were the & Brooks, 2000), and proportion of participants accessing differ- only authors to utilize a standardized clinical interview to assess ent types of mutual aid (Blatch et al., 2016). No studies assessed nonalcohol substance use. Theirs was also the only study to em- economic outcomes. Two studies (Milin, 2007; O’Sullivan et al., ploy physiological verification of alcohol and/or substance use 2015) did report some qualitative data regarding satisfaction. (urine analysis; Brooks & Penn, 2003; Penn & Brooks, 2000). The Methodological quality and risk of bias in included studies. severity and impact of behavioral addictions has yet to be assessed, The one identified RCT (Hester et al., 2013) received 6 from a but two studies did provide limited prevalence data (P. J. Kelly et possible 8 points using the PEDro Scale and 22 from a maximum al., 2015; O’Sullivan et al., 2015). 27 points using the Downs and Black Scale. The methodological Process variables. Treatment engagement was the most com- quality of nonrandomized trials varied considerably, with Downs mon process variable assessed (10 of the 12), but only three studies and Black ratings ranging from 8 to 19. explored its relationship to treatment outcome (Blatch et al., 2016; The level of risk of bias is presented separately for each study in Brooks & Penn, 2003; Penn & Brooks, 2000; Hester et al., 2013). Figure 2 and as a combined assessment of ratings in Figure 3. File Other process variables assessed included elements of the thera- 2 of the online supplemental materials contains justification for peutic process (e.g., readiness to change, group cohesion), locus of each risk assessment. Hester et al. (2013) was the only study to control, spirituality or religiosity, self-efficacy, resilience, coping, report both appropriate sequence generation and allocation con- and social support, but few studies (Atkins & Hawdon, 2007; cealment, thereby the only study assessed as having a low risk of Outcomes outcomes All – – Blinding of outcome Blinding of outcome (detection assessment bias) All bias) (attrition bias) bias) (reporting Other bias Allocation concealment Allocation concealment bias) (selection Incomplete outcome data Selective reporting Random sequence sequence Random (selection bias) generation and Blinding of participants (performance researchers Hester et al. (2013) Brooksand Penn (2003) ? ?

Penn and Brooks (2000) ? ? ? ? ? ? Blatch et al .(2016) ? Li et al. (2000) ? Atkinsand Hawdon (2007) ? This document is copyrighted by the American Psychological Association or one of its allied publishers. O’Sullivan et al. (2015) This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. ? Kelly et al. (2015) ? Guarnotta (2014) ? Milin (2007) ? ? Trumble (2015) ? ? Bogdonoff (2002)

Risk of bias: Low ? Unclear High

Figure 2. Risk of bias summary. Review authors’ judgments about each risk of bias item for each included study. See the online article for the color version of this figure. 6 BECK ET AL.

Random sequence generaon (selecon bias) Effects of Interventions

Allocaon concealment (selecon bias) A summary of key findings for the four types of comparisons Blinding of parcipants and researchers (performance bias) - All outcomes

Blinding of outcome assessment (detecon bias) - All outcomes identified (community SMART Recovery groups vs. an online

Incomplete outcome data (arion bias) intervention, alone or in combination; SMART Recovery– Selecve reporng (reporng bias) informed interventions vs. active and/or control comparison con- Other bias ditions; community SMART Recovery groups vs. other forms of 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Low Unclear High mutual aid; and community SMART Recovery groups without a comparison condition) are presented in Table 2 and discussed in Figure 3. Risk of bias graph. Review authors’ judgments about each risk turn in the next four sections. of bias item presented as percentages across all included studies. See the Summary of evidence comparing SMART recovery to a online article for the color version of this figure. SMART Recovery–informed online intervention (alone or in combination). Hester and colleagues (2013) conducted the sole selection bias. Masking of participants and providers in trials of identified RCT and compared SMART Recovery to a SMART psychological interventions is generally not possible, and therefore Recovery–informed web application (Overcoming Addictions there was a high risk of bias in this domain. However, Hester et al. [OA]), alone or in combination. At the 3 months follow-up, (2013; Brooks & Penn 2003; Penn & Brooks, 2000) and Blatch et SMART Recovery participants with a history of problematic al- al. (2016), used objective outcome assessment and/or collateral cohol use demonstrated significant improvement in all outcome information and were therefore deemed to be at low risk of measures (percentage of days abstinent, standard drinks per drink- performance bias. Risk of detection bias was assessed as low in ing day, and alcohol-related problems; Hester et al., 2013). The only one article (Hester et al., 2013), and three provided insuffi- level of improvement did not significantly differ between treat- cient information to make a determination (Blatch et al., 2016; ment conditions (Hester et al., 2013). Although mental health Brooks & Penn, 2003; Penn & Brooks, 2000). Four articles ade- symptoms were recorded at baseline (mean Brief Symptom Inven- quately addressed attrition and missing data and were deemed low tory ϭ 19.35, SD ϭ 12.5), change across time was not assessed. risk of attrition bias (Bogdonoff, 2002; Brooks & Penn, 2003; In the SMART Recovery only condition, the number of meet- Hester et al., 2013; Penn & Brooks, 2000), whereas the remaining ings attended was identified as a significant predictor of improve- eight provided insufficient information. Risk of reporting bias was ment in all three primary outcomes (Hester et al., 2013). For the deemed low in 10 studies, because all planned outcomes were OA plus SMART Recovery group, the total amount of support reported (or an explanation provided) and post hoc analyses were (including SMART Recovery or other meetings and counselor clearly specified. visits) emerged as the strongest predictor of alcohol-related SMART recovery participant characteristics. A total of change. Sixty-eight participants allocated to the SMART Recovery 7,655 participants were recruited to the included evaluations only group (70%) completed the 3 months follow-up assessment. (1,177 SMART Recovery and 6,478 comparison conditions). Fifty-eight (85%) of these 68 had attended at least two SMART Baseline demographic and clinical characteristics of SMART Re- Recovery meetings, defined by Hester et al. (2013) as the threshold covery participants are presented in Table 1. Mean age ranged for being considered “treated.” Of note, the authors had to abandon from 34.2 to 51. The gender distribution (% male) ranged from their original plan to randomize to an OA-only condition because 39% to 71%. The majority of participants were Caucasian. Be- potential participants were unwilling to be allocated to a treatment tween 25% and 82% attained at least a college- or graduate-degree condition that would prevent them from attending SMART Re- level of certification. Employment (full- or part-time) ranged from covery meetings. 30.7% to 63%. The proportion of individuals who were single or Summary of evidence for interventions informed by divorced ranged from 23% to 63.9%. The dual diagnosis popula- SMART Recovery. Two evaluations of face-to-face intervention had fewer years of education (M ϭ 11.6 years’ education), tions informed by SMART Recovery were identified. First, Brooks were less likely to be employed (full- or part-time; 20.4%), and and Penn (2003; Penn & Brooks, 2000) used a prepost design to more likely to be single or divorced (80%). From the data avail- compare an intensive, outpatient and partial hospitalization adap- able, mental health problems and impairment were common. tation of SMART Recovery for dual diagnosis to a similarly This document is copyrighted by the American Psychological Association or one of its allied publishers. Average years of alcohol use ranged from 10 to 19.25 years. The adapted 12-step program for adults with serious Axis I mental This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. majority of participants reported prior treatment and/or multiple illness and concurrent substance dependence. In this dual diagnosis quit attempts. The two studies that used the Alcohol Use Disorders population, there was an overall reduction in alcohol and substance Identification Test (AUDIT) at baseline both reported scores Ͼ20 use across time for both conditions (Brooks & Penn, 2003; Penn & (Hester et al., 2013; Milin, 2007), consistent with hazardous alco- Brooks, 2000). Improvement in Addiction Severity Index (ASI) hol use and likely dependence. Amphetamines (7.3%) and mari- Alcohol (but not ASI Drug) was superior for 12-step relative to juana (3.3%) were variously identified as the most common self- SMART Recovery participants (Brooks & Penn, 2003). However, reported primary nonalcohol substance of abuse. Self-reported interpretation is complicated because 12-step baseline ASI Alco- multidrug use was as high as 70%. In one study, 24.4% of hol scores were also significantly higher. Urine analysis indicated participants endorsed behavioral addiction (sex, pornography, that 12-step participants were less likely than SMART Recovery food, spending) alone or in combination with drugs and/or alcohol participants to use marijuana at 2 months follow-up (no other (O’Sullivan et al., 2015). In another, food (10.5%), gambling substances or follow-up intervals reached significance; Brooks & (9.7%), and shopping (6.5%) emerged as the top three nonsub- Penn, 2003). Both groups also demonstrated improvement across stance problematic behaviors (P. J. Kelly et al., 2015). several indices of functioning (financial well-being and life This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Table 1 Demographic and Clinical Characteristics of SMART Recovery Participants

Addiction Gender Ethnicity Education or Study N Age: M (SD) (% male) (% Caucasian) degree Employment Marital status Mental health Alcohol Substance Behavioral

Established community SMART groups versus SMART informed online intervention (alone or in combination) Hester et al. 86 43.4 (10.6) 39 88.4 M ϭ 15.93 — — Brief Symptom Hazardous alcohol Substance dependence Not assessed (2013) (SD ϭ 2.5) Inventory: M ϭ use excluded years 19.35 (SD ϭ 12.5)

SMART informed interventions versus active and/ or control comparison conditions

Blatch et al. 2,882a — 68 27 ATSI — — — Not assessed Not assessed Not assessed Not assessed REVIEW SYSTEMATIC RECOVERY SMART (2016) Brooks and 58 34.2 (8.4) 67.2 72.4 M ϭ 11.6 20.4% (full- or 80% single or 44.8% mood ASI: M ϭ .2825; Substance dependence: Not assessed Penn (SD ϭ 2.4) part-time in divorced disorder, 20.7% years of use: 8.8% polysubstance, 14% (2003) years past 3 thought disorder, M ϭ 10.5 cocaine, 10.5% years) 15.5% (SD ϭ 9.6); amphetamines, 8.8% personality Longest marijuana; Mean years of disorder; Mean duration of use: polysubstance: 9.1 no. times of abstinence ϭ (SD ϭ 8.4), marijuana: psychiatric 6.5 monthsb; 8.6 (SD ϭ 8.6), cocaine: hospitalization ϭ Mean no. times 4.4 (SD ϭ 5.7); Mean 8.2 (SD ϭ 10.5 of alcohol no. times of substance treatment ϭ 3.4 use treatment ϭ 3.2 (SD ϭ 6) (SD ϭ 5.5)

Established community groups: SMART Recovery versus other forms of mutual aid Atkins and 321a 47 (no SD) 58.1b 90.3 — Mean income 43.4% single 21.4% reported Years of use: Ͼ10 Ͼ70% polysubstance use Not assessed Hawdon $55,000 or divorced prior psychiatric (78.8%); Past (2007) hospitalization hospitalization (35%); Past outpatient treatment (48.7%) Bogdonoff 53 36 (no SD) 24.5 32.4 5.9% 12.9% (full- or 23% single, Not assessed Past treatment No independent assessment Not assessed (2002; bachelors part-time) divorced, (60.4%) of substance use unpublished or graduate separated dissertation) Guarnotta 58 42.1 (13.4) 45.1 87.7 51.7% — 63.9% single Not assessed Mean no. days No independent assessment Not assessed (2014; college or or divorced abstinent ϭ of substance use unpublished graduate 322.4 (SD ϭ dissertation) 323.79) Li et al. 33 45.79 (11.8) 67 — 82% college — — Not assessed Not assessed Not assessed Not assessed (2000) or graduate (table continues) 7 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 8

Table 1 (continued)

Addiction Gender Ethnicity Education or Study N Age: M (SD) (% male) (% Caucasian) degree Employment Marital status Mental health Alcohol Substance Behavioral

Milin 60 44 (no SD) 56.7 97 30.2% 64.6% full- or 52.6% single Self-reported History of Drug of choice: cocaine Not assessed (2007; college part-time or divorced diagnosis: major problematic (1.7%), prescription unpublished depression alcohol use: meds (1.7%); Current dissertation) (40%), severe Mean no. of abuse: marijuana (3.3%) anxiety/ panic months and prescription (26.7%), ADHD abstinent ϭ medication (6.7%) only; (8.3%), bipolar 7.13 (SD ϭ Ever abuse: marijuana (11.7%), SZ 10.93); Past (56.7%), cocaine (0%), OCD treatment: (46.7%), heroin (8.3%), (5%), other inpatient (25%), methamphetamine (25%), (1.7%) residential hallucinogens (33.3%), (15%), prescription meds individual (31.7%) (46.7%), outpatient (25%)

Trumble 70 51.62 (11.74) 64 95 41% 48%: — Not assessed Mean no. of days No independent assessment Not assessed AL. ET BECK (2015; bachelors income ϭ abstinent ϭ of substance use unpublished $35,000 to 1,417.6 (SD ϭ dissertation) $100,000 1,985.28)

SMART Recovery without a comparison condition Kelly et al. 124 40.65 (11.38) 56.5 6.5 ATSI — 30.7% full- or — Self-reported 85.6% used Primary substance of abuse: Food (10.5%), (2015) part-time diagnosis: 46.7% alcohol within amphetamine (7.3%), gambling depression, 29% the preceding heroin (5.6%), tobacco (9.7%), anxiety, 5.6% 12 months; (4.8%), marijuana shopping bipolar, 4.8 % Mean years of (3.2%); use Յ 12 (6.5%), PTSD, 3.2% SZ problems months: tobacco (63%), pornography or psychotic (alcohol or marijuana (44%), heroin (4.8%), sex disorder, 6.5% substance) ϭ (32.3%), amphetamines (3.2%) other; 29% 18.11 (SD ϭ (27.4%), analgesics reported a prior 10.97) (22.6%), cocaine suicide attempt; (12.1%), ecstasy (11.3%) Mean K10: 21.74 (SD ϭ 4.91): 47% in high or very high range (Ͼ22), 66.4% reported prior treatment, 46.8% reported current medication management SMART RECOVERY SYSTEMATIC REVIEW 9

ϭ satisfaction; ASI Psychiatric, Employment, and Legal composite ϩ ϩ scores; psychiatric hospitalization), with between-groups differ-

ϩ ences on employment and number of psychiatric hospitalizations,

alcohol (7.3%), drugs (2.4%), both (7.4%) both of them in favor of SMART Recovery (Brooks & Penn, 2003; 7.3%, Penn & Brooks, 2000). Observed changes in substance use but not functional outcomes were predicted by attendance (Brooks & Penn, 2003). Overall (i.e., irrespective of treatment condition),

alcohol greater attendance was associated with less marijuana use but posttraumatic stress disorder. ϩ slightly more alcohol use. This latter finding may have been due to ϭ alcohol both (7.4%)

ϩ ϩ floor effects because participants who attended more also had less Addiction Addiction Severity Index; ADHD baseline alcohol use. Between-groups differences emerged in the

ϭ duration of attendance, with SMART Recovery participants at- (9.9%), (9.9%),

Drugs (14.8%), tending significantly fewer days and weeks of treatment relative to 12-step participants (Brooks & Penn, 2003).

medications; PTSD Blatch and colleagues (2016) used a quasi-experimental design ϭ 7.39) 11.5); to compare Getting SMART, a SMART Recovery–informed in- ϭ ϭ tervention for offenders (alone, or in combination with SMART Alcohol Substance Behavioral SD SD Sobriety attempt: 1st (26.6%); 2–5 (50.6%); 6–10 (11.4%); Mean years of individual counseling 5.14 ( abuse: 15.62 ( Recovery), to a propensity-matched control group. For custodial

Mean years of offenders, all indices of recidivism were consistently lower for Getting SMART participants relative to controls (Blatch et al., 2016; see Table 2). Observed reductions in reconviction (for “any” and “violent” crimes) were even more pronounced for participants who attended both Getting SMART and SMART Recovery. Con-

Aboriginal or Torres Strait Islander; ASI versely, the improvements seen following participation in SMART “psychiatric disability”

ϭ Recovery only did not significantly differ from that of controls.

obsessive–compulsive disorder; meds Completion of 10–11 sessions (Getting SMART and/or SMART

ϭ Recovery) was required to detect a significant therapeutic effect (defined as 25% increase in days to first reconviction; Blatch et al., 2016), and over a third of participants met this threshold (see Table 2). Neither baseline nor change in either mental health status or alcohol or drug use outcomes were reported. Summary of evidence for SMART Recovery relative to

schizophrenia; OCD other forms of mutual aid. Five cross-sectional studies com- Full-sample gender distribution (41.2% male) was skewed by women-only group (Women for Sobriety), so revised ϭ b pared SMART Recovery to other forms of mutual aid, most 63% employed 34.6% single 51% endorsed commonly AA. Only Atkins and Hawdon (2007) and Milin (2007) included some index of mental health status, with Atkins and Hawdon reporting on prior psychiatric hospitalization and Milin

degree Employment Marital status Mental health assessing self-reported diagnosis (see Table 2 for data on SMART graduate or bachelors Education or

Self-Management and Recovery Training; ATSI Recovery participants). Atkins and Hawdon, as well as Bogdonoff

ϭ (2002) and Trumble (2015), all reported an equivalent duration of sobriety for SMART Recovery and AA participants. Conversely, Guarnotta (2014) found that the duration of abstinence for AA

Ethnicity participants was approximately double that of SMART Recovery (% Caucasian) participants, but the statistical significance of this effect was not This document is copyrighted by the American Psychological Association or one of its allied publishers.

Kessler Psychological Distress Scale; SZ assessed. With the exception of years of abuse (which did not This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. ϭ significantly differ), Milin (2007) described a more severe addic- Gender

(% male) tion profile for AA relative to SMART Recovery participants

) (including greater substance-related problems, impaired function- SD

( ing, and poorer quality of life). However, corrections were not

M made for multiple comparisons. Milin (2007) also found that “readiness to change” was greater Age:

) for SMART Recovery relative to AA participants, but contrary to expectations, it did not predict alcohol-related problems. Bog- N 81 48 (13.1) 66.7 90.1 66.6% donoff (2002) found that relative to their AA counterparts,

continued SMART Recovery participants’ demonstrated greater future ori- entation, greater approach coping skills, less conflict, and higher . Dashes indicate that data were not reported. SMART

Study social support. However, contrary to prediction, none of these et al. (2015) Data available only across all treatment conditions (SMART not available alone). gender distribution without Women for Sobriety participants is reported. Table 1 ( Note a O’Sullivan attention-deficit/hyperactivity disorder; K10 variables predicted abstinence. Conversely, Guarnotta (2014) This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 10

Table 2 Summary of Methodology and Key Findings From Evaluations of SMART Recovery

Key findings Country design Study quality rating risk treatment or Severity of addiction and its of bias Aim target population comparison groups consequences Process variables Feasibility

Established community SMART groups versus SMART informed online intervention (alone or in combination) Hester et al. (2013); To evaluate the United States; Significant improvement in No. days of face-to-face meetings, OA: Logged onto the program Downs & Black: 22 effectiveness of a web RCT; all conditions at 3 months online meetings and/or “any support” on average 7.2 times (SD ϭ (max ϭ 27), application informed by OA (n ϭ 19) vs. follow-up (no between- were identified as significant 6.4); PEDro: 6 (max ϭ 8), SMART Recovery OA SMART (n ϭ 86) groups differences); predictors of change in alcohol use SMART: 71% attended at Overall risk of bias: Low and SMART Recovery vs. OA ϩ PDA: Significant main effect (the relationships that emerged least two online meetings; in a sample of problem SMART (n ϭ 83) (44% vs. 72%); F(1, varied according to treatment Days of face-to-face AL. ET BECK drinkers new to SMART 149) ϭ 160.93, p Ͻ .001; condition and outcome measure). meetings (M ϭ 3.31), days Recovery. Group differences F Ͻ OA: No. of days of online SMART of online meetings (M ϭ Participants had Յ4 weeks’ 1.0; meetings identified as a significant 5.90), days of “any attendance at SMART DDD: Significant main predictor of PDA (p ϭ .25). support” (M ϭ 14.85); and hazardous alcohol effect (8.0% vs. 4.6%); SMART: No. of days of face-to-face OA ϩ SR: 85% attended at use as indexed by Ն8on F(1,149) ϭ 61.73, p Ͻ meetings identified as a significant least two face-to-face AUDIT and alcohol .001; Group differences predictor of all three outcome meetings; Days of face-to- consumption outside F Ͻ 1.0; measures (PDA: r ϭ .358, p ϭ .003; face meetings: (M ϭ 1.82), recommended guidelines. InDUC: Significant main DDD: r ϭϪ.250, p ϭ .039; InDUC: days of online meetings effect (40.8% vs 19.5%); r ϭϪ.244, p ϭ .045) and change in (M ϭ 4.42), days of “any F(1,149) ϭ 122.28, p Ͻ these from baseline (PDA: r ϭ .274, support” (M ϭ 12.8) .001; Group differences p ϭ .024; DDD: r ϭ .478, p Ͻ .001; F Ͻ 1.0; Change in and InDUC: r ϭ .403, p ϭ .001). mental health status not OA ϩ SMART: No. of days of “any assessed support” identified as a significant predictor of PDA (r ϭ .306, p ϭ .012) and improvement in InDUC (r ϭ .305, p ϭ .012). This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Table 2 (continued)

Key findings Country design Study quality rating risk treatment or Severity of addiction and its of bias Aim target population comparison groups consequences Process variables Feasibility

SMART-informed interventions vs. active and/or control comparison conditions Blatch et al. (2016); To determine reconviction Australia; Relative to controls: Attendance at 10–11 sessions (of either 81% attended Getting Smart Downs & Black: 16 outcomes for male and Quasi-experimental, Time to “any” reconviction: program, alone or in combination) only; 8% attended SMART (max ϭ 27), female offenders who pseudo- Getting SMART: ϳ8% was associated with a significant only; 11% attended Getting therapeutic effect (25% reduction in SMART ϩ SMART; 37% ;ءOverall risk of bias: High participated in Getting prospective study reduction (HR ϭ .918 attended Ͼ12 sessions; 19% %95 ;ءSMART (a 12-session design; 95% CI [.848, .995]). reconviction rate; HR ϭ .764 adaptation of SMART Getting SMART Neither reduction in CI [.612, .953]). attended between 9 and 11 for custodial offenders) (n ϭ 2,343) vs. SMART (ϳ13%) nor Brief exposure (1–6 sessions) mirrored sessions. and/or SMART Getting Getting SMART ϩ the control group. REVIEW SYSTEMATIC RECOVERY SMART Recovery relative to a SMART ϩ SMART (ϳ8%) reached propensity score-matched SMART (n ϭ significance. control group that did 306) vs. SMART Time to “violent” not participate in either (n ϭ 233) vs. reconviction: Getting program. Control (n ϭ SMART: ϳ13% longer CI %95 ;ءParticipants were offenders 2,882) (HR ϭ .867 who served custodial [.763, .985]); Neither sentences in New South change in SMART (ϳ16% Wales between 2007 and longer) nor Getting 2011. SMART ϩ SMART (ϳ25% longer) reached significance. Reconviction rate (any): Getting SMART: ϳ19% ; ءءreduction (HR ϭ .808 95% CI [.747, .875]); Getting SMART ϩ SMART: ϳ22% reduction CI %95 ;ءHR ϭ .784) [.647, .950]); SMART did not reach significance. Reconviction rate (violent): Getting SMART: ϳ30% CI; ءءlower (HR ϭ .704 [.621, .799]); Getting SMART ϩ SMART: ϳ42% lower (HR ϭ ,CI [.407 %95 ; ءء578. .821]). SMART did not reach significance. Mental health status not reported. (table continues) 11 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 12

Table 2 (continued)

Key findings Country design Study quality rating risk treatment or Severity of addiction and its of bias Aim target population comparison groups consequences Process variables Feasibility

Brooks and Penn (2003); To compare the United States; Improvement over time for Attendance was identified as a SMART participants attended Downs & Black: 14 effectiveness of a multivariate multiple both groups on the significant predictor of marijuana use significantly fewer days (max ϭ 27), SMART and 12-step- baseline following: Addiction (better attendance, less likely to use than did 12-step Overall risk of bias: High; informed intervention for comparison Severity Index (Alcohol, at 2 months; Odds ratio ϭ .05). participants: M ϭ 81 Penn and Brooks dual diagnosis in an (alternate Substance, Employment, Greater attendance increased the slope, (SD ϭ 18.3) vs. M ϭ 94 (2000); Downs & intensive outpatient or allocation); Legal and Psychiatric indicating that alcohol use (ASI) (SD ϭ 21.6); t(48) ϭ 2.26, SMART ;ءBlack: 8 (max ϭ 27), partial hospitalization SMART-informed subscales); decreased less with greater p Ͻ .028 Overall risk of bias: setting; (n ϭ 58) vs. 12- Urine analysis: marijuana attendance (time linear slope: participants attended High Participants had severe step-informed and “other” (cocaine, attendance coefficient ϭ .0001, significantly fewer weeks than did 12-step .(ءmental illness (n ϭ 54) heroin, amphetamines, and SE ϭ .0001, t ϭ 2.51 (schizophrenia, bipolar barbiturate use); Lehman participants: M ϭ 26 disorder, schizoaffective Quality of Life (Financial (SD ϭ 3.2) vs. 28 (SD ϭ disorder, major and Life Satisfaction 4.7), respectively; t(48) ϭ ءdepression) and subscales); 2.46, p Ͻ .018

concurrent substance use No. of psychiatric AL. ET BECK disorder (as indexed by hospitalizations; diagnostic interview and Significant between- collateral information). groups differences emerged on only Addiction Severity Index: Alcohol (in favor of 12- step; intercept coefficient ϭϪ.0076, SE ϭ .0033; t ϭϪ2.28, p Ͻ .05); 2 months urine analysis: Marijuana (in favor of 12-step; odds ratio ϭ .05); Addiction Severity Index: Employment (in favor of SMART; coefficient ϭϪ.0076, ;(ءSE ϭ .0033, t ϭϪ2.28 Psychiatric hospitalization (in favor of SMART): Significant Time ϫ Treatment interaction, F(2, 78.6) ϭ 4.239, p Ͻ .024; M ϭ 0 vs. 5.52 (SD ϭ 13.7) This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Table 2 (continued)

Key findings Country design Study quality rating risk treatment or Severity of addiction and its of bias Aim target population comparison groups consequences Process variables Feasibility

Established community groups: SMART Recovery versus other forms of mutual aid Atkins and Hawdon To explore the relationship United States; Mutual aid group was not Significant predictors of sobriety Mutual aid group ϭ (2007); between participants’ icross-sectional predictive of “number of identified were significant predictor of :participation. SMART ءءءDowns & Black: 16 personal religious or (national survey) days clean and sober” age: ␤ϭ.272, coefficient ϭ .054 (max ϭ 27), spiritual beliefs, the SMART (n ϭ (Wald ␹2 ϭ 1.11, p ϭ (SE ϭ .009); ␤ϭϪ.193, Overall risk of bias: High religious or spiritual 321) vs. 12-step .267) no. of close friends in recovery: coefficient ϭϪ3.02 (SE ϭ ,SE ϭ 1.09); WFS: ␤ϭϪ.211) ءءءbeliefs of their mutual (n ϭ 161) vs. ␤ϭ.240, coefficient ϭ .418 ءaid group and level of WFS (n ϭ 236) .093); coefficient ϭϪ3.63 ϭ participation vs. Secular participation (as indexed by a study- (SE 1.04); SOS: REVIEW SYSTEMATIC RECOVERY SMART In participants who Organisations for specific instrument): ␤ϭ.177, ␤ϭϪ.191, ءSE ϭ .013). coefficient ϭϪ4.73) ءءءidentified as being “in Sobriety (n ϭ coefficient ϭ .045 recovery” and were able 104) Religiosity and belief in a higher power (SE ϭ 1.71). to identify a “primary did not emerge as significant Authors concluded that recovery group.” predictors of sobriety. relative to 12-step, all other groups were less likely to participate. Bogdonoff (2002; To explore the predictive United States; At 90-day follow-up Neither mutual aid group nor any of Did not report on feasibility unpublished relationship between Cross-sectional, “sobriety” did not the following factors were identified dissertation); recovery and resilience prospective, significantly differ to be significant predictors of Downs & Black: 17 (including self-efficacy, quasi-experimental; between 12-step (39.5%) abstinence: Resilience and optimism (max ϭ 27), coping skills and internal SMART (Ϯ short- and SMART (39.6%) (adult resiliency belief system), self- Overall risk of bias: High locus of control or long-term groups (as indexed by efficacy regarding drinking (Drug constructs embedded residential dichotomous self-report Taking Confidence Questionnaire), within resilience) and to rehabilitation; n ϭ assessment (yes/no) of locus of control (drinking-related compare these 53) vs. 12-step (Ϯ abstinence over the internal-external locus of control), characteristics in short- or long- preceding 90 days). coping (Coping Response Inventory), SMART Recovery and term residential and social support resources (Family/ 12-step groups to see if rehabilitation; n ϭ Social Composite score on the either type of group was 86) Addiction Severity Index). more effective in Of potential relevance to the differing supporting abstinence underlying philosophies (i.e., the role during the early period of relinquishing to a higher power in of the first 90 days of 12-step), SMART Recovery recovery. participants demonstrated greater Participants had a history “approach” coping skills (including of alcohol and substance logical analysis, seeking guidance, abuse and/or dependence and problem solving), F(1, 132) ϭ and were in the “early 7.11, p ϭ .009. stage of recovery” (Ͻ30 self-reported days abstinent). (table continues) 13 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 14

Table 2 (continued)

Key findings Country design Study quality rating risk treatment or Severity of addiction and its of bias Aim target population comparison groups consequences Process variables Feasibility

Guarnotta (2014; To explore the relationship United States; Self-reported duration of Self-efficacy (as indexed by the Did not report on feasibility unpublished between abstinence and Cross-sectional, abstinence for AA (M ϭ General Self Efficacy Scale) did not dissertation); self-efficacy for quasi-experimental; 677.2, SD ϭ 1,576.4; significantly differ between AA Downs & Black: 17 individuals in SMART SMART (n ϭ 58) range ϭ 30 to 4,589) was (M ϭ 30.58, SD ϭ 6.3) and SMART (max ϭ 27), Recovery and how this vs. AA (n ϭ 64) approximately double that (M ϭ 30.28, SD ϭ 5.9), p ϭ .79. Overall risk of bias: High compared to the of SMART (M ϭ 322.4, Self-efficacy was identified as a relationship between SD ϭ 323.79; range ϭ 30 significant predictor of abstinence for self-efficacy and to 1,012), but significance AA (r ϭ .345, p Ͻ .01) and abstinence for not reported SMART (r ϭ .378, p Ͻ .01) individuals attending participants, explaining AA. approximately 10.4% of the variance Participants demonstrated a in abstinence time (R2 ϭ .104).

history of problematic AL. ET BECK alcohol use (as indexed by Michigan Alcohol Screening Test), were abstinent from alcohol or illicit substances for a maximum of 30 days, and reported a “strong commitment” to attend mutual aid. Li et al. (2000); To investigate whether United States; This study explored only Significantly higher percentage of AA Self-reported duration of Downs & Black: 14 AA’s higher power Cross-sectional process measures. (96%) than SMART (48%) involvement (months) was (max ϭ 27), concept encourages (survey): SMART participants reported belief in a significantly longer for AA Overall risk of bias: High externally dependent (n ϭ 33) vs. AA higher power, ␹2(1) ϭ 24.42, p Ͻ (M ϭ 66.48, SD ϭ 76.24; behavior by testing (n ϭ 48) .0001; range ϭ 3–252) relative to whether AA and AA participants demonstrated a more SMART (M ϭ 18.76, SMART members are external locus of control (DRIE: SD ϭ 15.54; range ϭ 2– equal on measures of M ϭ 5, SD ϭ 3.23; range ϭ 0–13) 48), t ϭ 3.58, p ϭ .0006 locus of control. than did SMART participants (M ϭ Participants were “in 2.09, SD ϭ 2.66; range ϭ 0–13), recovery” (at least 8 p ϭ .00003. weeks’ mutual aid The relationship between process attendance). variables and outcome measures was not explored. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Table 2 (continued)

Key findings Country design Study quality rating risk treatment or Severity of addiction and its of bias Aim target population comparison groups consequences Process variables Feasibility

Milin (2007; unpublished To examine the relationship United States; Outcomes for SMART were Levels of precontemplation were Duration of involvement was dissertation); between consequences of Cross-sectional, consistently superior significantly greater in AA significantly longer for AA Downs & Black: 17 alcohol abuse and between-subjects, relative to AA, including (M ϭϪ5.59, SD ϭ 3.95) relative to (4.95, SD ϭ 1.63) relative (max ϭ 27), motivation to change correlational. the following: less SMART (M ϭϪ7.42, SD ϭ 3.42), to SMART (3.55, SD ϭ Overall risk of bias: High drinking behavior and to SMART (n ϭ 60) hazardous use of alcohol p Ͻ .01. 1.8) participants, where explore similarities and vs. AA (n ϭ 56) as indexed by AUDIT Similarly, levels of contemplation were 1 ϭϽ30 days, 2 ϭ 30 differences between (M ϭ 22.5, SD ϭ 6.64 vs. significantly higher in SMART days to 3 months, 3 ϭ 3–6 members of AA and M ϭ 26.57, SD ϭ 7.31; (M ϭ 5.77, SD ϭ 2.68) relative to months, 4 ϭ 6 months to 1 MR EOEYSSEAI REVIEW SYSTEMATIC RECOVERY SMART SMART. p ϭ .002); AA (M ϭ 3.98, SD ϭ 4.48), p Ͻ year, 5 ϭ 1 to 2 years, and Participants were currently lower severity and less .05. 6 ϭ 2 years or more. attending mutual aid. functional impact of However, readiness to change was not addiction as indexed by identified as a significant predictor the ASI; ASI Alcohol of alcohol-related problems (all (M ϭ .48, SD ϭ .28, vs. models failed to reach significance). M ϭ .64, SD ϭ .19; p ϭ .001); ASI Drug (M ϭ .05, SD ϭ .09, vs. M ϭ .27, SD ϭ .23; p Ͻ .001); ASI Psychiatric (M ϭ .29, SD ϭ .21, vs. M ϭ .42, SD ϭ .25; p ϭ .003); ASI Employment (M ϭ .39, SD ϭ .24, vs. M ϭ .57, SD ϭ .33; p ϭ .001); ASI Family/Social Problems (M ϭ .29, SD ϭ .23, vs. M ϭ .49, SD ϭ .25; p ϭ .001); ASI Legal (M ϭ .06, SD ϭ .21, vs. M ϭ .24, SD ϭ .37; p ϭ .002). Fewer alcohol-related problems: DrINC-R Total (M ϭ 55.27, SD ϭ 23.43, vs. M ϭ 88.48, SD ϭ 25.34; p Ͻ .001; DrINC Lifetime (M ϭ 31.88, SD ϭ 7.62, vs. M ϭ 37.11, SD ϭ 7.39; p Ͻ .001 (table continues) 15 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 16 Table 2 (continued)

Key findings Country design Study quality rating risk treatment or Severity of addiction and its of bias Aim target population comparison groups consequences Process variables Feasibility

Trumble (2015; The purpose of the study United States; The duration of sobriety did Both groups demonstrated internal Did not report on feasibility unpublished was to replicate the results Cross-sectional, not significantly differ locus of control (as indexed by low dissertation); from Li et al.’s 2000 quasi-experimental; between groups (p ϭ .09); scores on the DRIE). SMART was Downs & Black: 19 study (that AA will be SMART (n ϭ 70) AA: M ϭ 2,506.17days more internal (M ϭ 2.08 SD ϭ 2.47) (max ϭ 27), more externally controlled vs. AA (n ϭ 36) (SD ϭ 6.87 years) vs. relative to AA (M ϭ 4.67, SD ϭ Overall risk of bias: High and SMART more SMART: M ϭ 1,417.60 4.01), p ϭ .001. internally oriented) and to days (SD ϭ 3.88 years) The relationship between locus of explore the relationship to control treatment outcome was not faith in a higher power. assessed. Participants were currently attending mutual aid.

SMART Recovery without a comparison condition Kelly et al. (2015); To provide a description of Australia; Duration of alcohol or Group cohesion ϭ significant predictor The majority of participants Downs & Black: 13 participants, including Cross-sectional substance use problems (17% of variance) of cognitive attended weekly (72.8%); (max ϭ 27), potential clinical (survey); was 18.11 years (SD ϭ restructuring (␤ϭ.23), F(3, 113) ϭ duration of attendance: M ϭ Overall risk of bias: High complexities; to examine SMART alone (n ϭ 10.97). 8.42, p Ͻ .001; 8.78 months, SD ϭ 14.11; how frequently 124) Homework ϭ significant predictor range ϭ 1 week to 96 participants used (21% of variance) of behavioral months. AL. ET BECK cognitive and behavioral activation (␤ϭ.26), F(3, 113) ϭ skills outside of 10.99, p Ͻ .001; meetings; to examine the significant positive correlation between variables that may quality of facilitation and group predict participants’ self- cohesion (r ϭ .38). reported use of cognitive Relationship to treatment outcome was and behavioral skills. not assessed. Participants were currently attending SMART meetings. O’Sullivan et al. (2015); To describe members of the United States; Duration of problematic The relationship between process Frequency of attendance: M ϭ Downs & Black: 10 SMART Recovery Cross-sectional addiction was M ϭ 15.62, variables and treatment outcome was 4.69 meetings per month (max ϭ 27), community, their (two-sample SD ϭ 11.5; range ϭ 3 not explored. (SD ϭ 2.64). Overall risk of bias: High motivations for exploratory months to 40 years. Duration of attendance: M ϭ membership; describe descriptive 1.58, SD ϭ 1.81; range: 3 SMART facilitators and survey; n ϭ 81) months to 10 years. On a their educational and 9-point scale (higher training backgrounds; rank scores ϭ greater order of members’ and confidence), mean facilitators’ recovery confidence in SMART’s goals. ability to meet recovery Participants had Ն3 months’ goals ϭ 8.16 (SD ϭ 1.24) attendance at SMART meetings. Note. SMART ϭ Self-Management and Recovery Training; max ϭ maximum; PEDro ϭ Physiotherapy Evidence Database; AUDIT ϭ Alcohol Use Disorders Identification Test; OA ϭ Overcoming Addictions; AA ϭ Alcoholics Anonymous; RCT ϭ randomized controlled trial; PDA ϭ percentage of days abstinent; DDD ϭ standard drinks per drinking day; InDUC ϭ Inventory of Drug and Alcohol Use Consequences; HR ϭ hazard ratio; CI ϭ confidence interval; ASI ϭ Addiction Severity Index; WFS ϭ Women for Sobriety; SOS ϭ Secular Organisations for Sobriety; DRIE ϭ Drinking Related Internal-External Locus of Control Scale. .p Ͻ .001 ءءء .p Ͻ .01 ءء .p Ͻ .05 ء SMART RECOVERY SYSTEMATIC REVIEW 17

found significant, moderate, positive correlations between absti- to prior experience with 12-step approaches (e.g., higher power or nence and self-efficacy for both SMART Recovery and AA par- religion, perception of powerlessness; see Table 3). ticipants. Atkins and Hawdon (2007) identified additional predic- Summary of evidence for SMART recovery without a com- tors of sobriety, including participation and number of close parison condition. Two studies without a comparison condition friends in recovery. were identified (P. J. Kelly et al., 2015; O’Sullivan et al., 2015). When Milin (2007) asked SMART Recovery participants about P. J. Kelly and colleagues (2015) explored potential mechanisms what they “liked” about their mutual aid group, qualitative findings of change in SMART Recovery by assessing the extent to which revealed that both general group processes (support, nonjudgment) quality of group facilitation, group cohesion, and homework con- and key features of the SMART Recovery approach (empower- tributed to self-rated use of cognitive–behavioral skills. Group ment, tools or resources, and scientific or theoretical approach) cohesion emerged as a significant predictor of cognitive restruc- featured in the top five themes extracted (see Table 3). When turing, whereas homework was identified as a significant predictor SMART Recovery participants were asked about what they dis- of behavioral activation (P. J. Kelly et al., 2015). Although quality liked about prior approaches, responses again pertained to general of group facilitation was not identified as a significant predictor of group processes (e.g., poor boundaries) but this time also referred either cognitive restructuring or behavioral activation, a positive

Table 3 Summary of Qualitative Findings

Study Question and treatment condition

Milin (2007) What do you like about your current primary self-help group?a 12-step (n ϭ 56) SMART Recovery (n ϭ 60) Supportive environment (e.g., helping others, people trying to do Internal locus of control (e.g., self-directed, the right thing; n ϭ 29) self-empowered; n ϭ 22) Fellowship (n ϭ 12) Supportive environment (e.g., giving and getting help; positive reinforcement; n ϭ 20) 12-steps give a sense of direction or purpose (e.g., plan of action, Many tools or resources for relapse prevention (n ϭ 17) structure; n ϭ 10) People have common problem (e.g., shared experiences, relate Scientific nature, theoretical (e.g., CBT, REBT; n ϭ 14) with other alcoholics, sober people; n ϭ 7) Availability of groups (e.g., always there, somewhere to go and Nonjudgmental (e.g., absence of guilt, slip is not not drink; n ϭ 4) catastrophic; n ϭ 7)

What did you dislike about self-help groups you attended in the pasta Prior 12-step Prior 12-step Negative attributes of group members (e.g., complaining or Higher power, religious (n ϭ 21) whining, cussing or vulgarity, closed off, dishonesty; n ϭ 8) Disparity among different types of 12-step groups (e.g., NA too rigid Powerlessness (n ϭ 19) about alcohol, lack of sponsorship in MA, could not identify with CA or NA, too much mixing of NA and AA; n ϭ 6) Repetitious (e.g., no new information, retell same stories; n ϭ 5) Dogmatic, authoritative, rigid (e.g., have to do it one way, problem for life, moderation not an option; n ϭ 18) Lack of seriousness (e.g., some not serious about sobriety; n ϭ 5) Labeling (e.g., “alcoholic,” “disease”; n ϭ 11) Frequent relapses (n ϭ 3) People with poor boundaries (intimidating or domineering people, ask me for money, unwanted advances from men, disrespectful, not trustworthy or dishonesty; n ϭ 10) This document is copyrighted by the American Psychological Association or one of its allied publishers. Prior SMART Prior SMART This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Lack of sponsorship (n not reported) I don’t like counseling or advice (n ϭ 1) Abstinence is not required (n ϭ 1) Same stories repeated (n ϭ 1) Easy to be facetious online (n ϭ 1)

O’Sullivan et al. Reasons for switching from another mutual aid approach to SMART Recoveryb (2015) Alignment with SMART philosophy, principles, and format (e.g., CBT 51.6%) Difficulties with surrendering to religious affiliations such as a higher power or adoption of a powerlessness identity (26.6%) Still attending both types of mutual aid (18.8%) Outlier responses (3%) Note. SMART ϭ Self-Management and Recovery Training; CBT ϭ cognitive–behavioral therapy; REBT ϭ rational emotive behavioral therapy; NA ϭ Narcotics Anonymous; MA ϭ Marijuana Anonymous; CA ϭ Cocaine Anonymous; AA ϭ Alcoholics Anonymous. a The top five from the 13 identified themes are reported here. b 79% had switched from another approach (primarily 12-step), and qualitative findings are derived from thematic analysis. 18 BECK ET AL.

relationship was detected with group cohesion (P. J. Kelly et al., The modest sample of articles and diversity of methods pre- 2015). O’Sullivan and colleagues (2015) sought to explore the vented us from making conclusive remarks about the efficacy of recovery goals of SMART Recovery members and facilitators, to SMART Recovery, but positive effects were found in dual diag- describe the educational and training backgrounds of SMART nosis (Brooks & Penn, 2003; Penn & Brooks, 2000) and correc- Recovery facilitators, and to describe SMART Recovery members tional settings (Blatch et al., 2016). Evidence from the sole iden- and their motivations for attending. When SMART Recovery tified RCT also supported the benefits of SMART Recovery for members were asked to describe their reasons for switching from reducing the severity and consequences of problematic alcohol use another mutual aid approach, their responses closely mirrored (Hester et al., 2013). It is important to note that this RCT was those described by Milin (2007; see Table 3). The majority of independently evaluated by two assessors to be of high quality and participants reported that they attended SMART Recovery relative at low risk of bias, thereby increasing our confidence in these to other forms of mutual aid due to alignment with key features of findings. However, an important limitation of these studies is the the SMART Recovery approach (e.g., cognitive–behavioral ther- limited (Hester et al., 2013) or absent (Blatch et al., 2016; Brooks apy; 51.6%) or prior difficulties with 12-step approaches (e.g., & Penn, 2003; Penn & Brooks, 2000) assessment and reporting of higher power or religion, perception of powerlessness; 26.8%; see concurrent treatment (pharmacological and psychological) for ad- Table 3). diction and/or mental health. Accordingly, the relative contribution of mutual aid and formalized treatment (alone or in combination) to the performance of SMART Recovery remains unclear and Discussion represents an important question for future research. The comparative influence of SMART Recovery on addiction This review was designed to provide a comprehensive overview outcomes relative to other forms of mutual aid and/or evidence- and critical analysis of the current state of evidence for SMART based treatments (alone or as an adjunct) has yet to be systemat- Recovery in adults with substance and/or behavioral addictions. ically evaluated. This is not without methodological challenges. We sought to comment on (a) whether participation in SMART SMART Recovery groups are freely accessible in the community; Recovery results in changes in the severity of addiction and its therefore, it may be impractical and possibly unethical (McCrady consequences, (b) what factors might influence any changes ob- & Miller, 1993) to randomize some participants to this resource served, (c) the feasibility of this approach, and (d) future research while prohibiting others. Indeed, in the one RCT study the authors directions. Further, given the prevalence of comorbid mental had to abandon their original research design, because participants health conditions and their impact on addiction recovery (Mills et were unwilling to be randomized to a condition where they would al., 2010), we also sought to comment on the assessment, report- be unable to continue face-to-face SMART Recovery meetings. ing, and/or change in mental health status within the included Preference-based trials, evaluation of professionally delivered studies. SMART Recovery groups, or embedding research methods within A modest body of research, comprising 12 studies, was identi- new community groups as they are established may help bridge fied. Although predominantly cross-sectional, three evaluations of this gap between methodological rigor and real-world relevance. effectiveness were identified (Blatch et al., 2016; Brooks & Penn, The literature has also suggested that the sobriety of SMART 2003; Hester et al., 2013; Penn & Brooks, 2000). Participants with Recovery participants is at least equivalent to that of participants in alcohol addictions were the primary focus of existing research. The alternative forms of mutual aid (Atkins & Hawdon, 2007; Bog- relationship between SMART Recovery and the severity and im- donoff, 2002; Trumble, 2015), with some evidence to suggest that pact of behavioral addictions has yet to be assessed. Functional the severity and consequences of alcohol addiction is less for outcomes were rarely reported. Feasibility was largely indexed by SMART Recovery relative to AA participants (Milin, 2007). Con- attendance, and economic analysis has not been undertaken. Little versely, the duration of abstinence has been identified as longer for is known about variables that may influence treatment outcome, AA relative to SMART Recovery participants (Guarnotta, 2014). although attendance (Blatch et al., 2016; Brooks & Penn, 2003; Clinical guidelines have advocated tailoring addiction support to Hester et al., 2013; Penn & Brooks, 2000) represents a potential the goals of the individual (Mills et al., 2010; National Institute for candidate. Health Excellence, 2011; 2012), so although abstinence may be Despite high rates of comorbidity between mental health and encouraged, moderated use and/or harm reduction approaches This document is copyrighted by the American Psychological Association or one of its allied publishers. substance use disorders within the community (Mills et al., 2010), might also be employed. Moreover, in the case of polysubstance This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. assessment and reporting of mental health status is limited. Only use, some but not all substances may be identified as an important three studies (Brooks & Penn, 2003; Hester et al., 2013; Penn & focus of treatment. Accordingly, such global ratings of abstinence Brooks, 2000; P. J. Kelly et al., 2015) utilized standardized instru- and sobriety are unlikely to be adequate indicators of clinically ments to establish a baseline diagnosis or severity, and only one meaningful change. reported on change in mental health outcomes (psychiatric hospi- Consistent with the broader literature (e.g., Reardon, Cukrow- talization; Brooks & Penn, 2003; Penn & Brooks, 2000). Within icz, Reeves, & Joiner, 2002), attendance was identified as a sig- the literature identified, mental health condition(s), distressing nificant predictor of change (e.g., Hester et al., 2013). Further symptoms, and past suicide attempts appear common among research is needed to clarify not only whether an optimal threshold SMART Recovery participants. Given that comorbid mental health of attendance exists but to identify the factors involved in engaging conditions have the potential to complicate the course and severity participants and encouraging attendance. It is interesting that, of addiction and vice versa (Mills et al., 2010), improved assess- despite largely comparable addiction related outcomes, the avail- ment and reporting of mental health outcomes represents an im- able evidence suggests that the duration of attendance may be portant priority for future research. shorter for SMART Recovery relative to 12-step participants SMART RECOVERY SYSTEMATIC REVIEW 19

(Brooks & Penn, 2003; Li et al., 2000; Milin, 2007; Penn & Australian Government Productivity Commission. (2010). Gambling Brooks, 2000). Although clearly in need of further investigation, (2010): Inquiry report. Retrieved August 5, 2015, from http://www.pc this may be testimony to the feasibility of the SMART Recovery .gov.au approach. That is, SMART Recovery may represent a more time Australian Psychological Society. (2010). Evidence-based psychological efficient method for promoting clinically meaningful change. interventions in the treatment of mental disorders: A literature review. Retrieved May 5, 2014, from https://www.psychology.org.au/ However, further research on the relationship between attendance practitioner/resources/interventions/ and the change process within and across different mutual aid Baker, A. L., Hiles, S. A., Thornton, L. K., Hides, L., & Lubman, D. I. groups is needed before firm conclusions can be drawn. (2012). A systematic review of psychological interventions for excessive It is important to acknowledge the methodological limitations of alcohol consumption among people with psychotic disorders. Acta Psy- this review. First, it covers a small number of heterogenous stud- chiatrica Scandinavica, 126, 243–255. http://dx.doi.org/10.1111/j.1600- ies. Drawing comparisons between studies was complicated by 0447.2012.01885.x differences in outcome assessment, intervention, and comparator Beck, A. K., Baker, A., Kelly, P. J., Deane, F. P., Shakeshaft, A., Hunt, D., groups. Additionally, the studies varied in methodological quality. . . . Kelly, J. F. (2016). Protocol for a systematic review of evaluation Only one received a high-quality rating (Hester et al., 2013), and research for adults who have participated in the “SMART Recovery” was the only study deemed to be at low risk of bias. We also mutual support programme. British Medical Journal Open, 6(5), restricted our literature search to English language publications, so e009934. http://dx.doi.org/10.1136/bmjopen-2015-009934 the cross-cultural generalizability of our findings is restricted. Black, D. W., Shaw, M., McCormick, B., & Allen, J. (2013). Pathological gambling: Relationship to obesity, self-reported chronic medical conditions, poor lifestyle choices, and impaired quality of life. Comprehensive Conclusions Psychiatry, 54, 97–104. http://dx.doi.org/10.1016/j.comppsych.2012.07 Implications for practice. Given the positive effects of .001 SMART Recovery and SMART Recovery–informed interven- Blatch, C., O’Sullivan, K., Delaney, J. J., & Rathbone, D. (2016). Getting SMART, SMART Recovery programs and reoffending. Journal of Fo- tions, to enhance client-centered, collaborative care that is tailored rensic Practice, 18, 3–16. http://dx.doi.org/10.1108/JFP-02-2015-0018 to the needs and preferences of the individuals, clinicians need to Bogdonoff, D. A. (2002). Resilience as a predictor of abstinence in the be aware of the range of mutual aid support options available, recovery from alcohol dependence. Dissertation Abstracts Interna- including SMART Recovery, and discuss these options with their tional: Section B. The Sciences and Engineering, 63, 4361. clients. Brooks, A. J., & Penn, P. E. (2003). Comparing treatments for dual Implications for research. To increase understanding of the diagnosis: Twelve-step and self-management and recovery training. role of SMART Recovery in facilitating recovery from addiction and American Journal of Drug and Alcohol Abuse, 29, 359–383. http://dx to consolidate confidence in the effectiveness of this approach, future .doi.org/10.1081/ADA-120020519 research may benefit from improved assessment and reporting of (a) Centre for Evidence-Based Physiotherapy. (2009). PEDro Scale: Centre mental health status (e.g., diagnosis, treatment history, symptoms, and for Evidence-Based Physiotherapy. Retrieved May 5, 2015, from http:// functioning); (b) concurrent treatment (pharmacological and psycho- www.pedro.org.au logical) for mental health and addiction; (c) use and consequences of Donovan, D. M., Ingalsbe, M. H., Benbow, J., & Daley, D. C. (2013). 12-step interventions and mutual support programs for substance use nonalcohol substance use, including greater attention to smoking and disorders: An overview. Social Work in Public Health, 28, 313–332. prescription opiate misuse; (d) personal and social functioning (e.g., http://dx.doi.org/10.1080/19371918.2013.774663 quality of life); (e) severity and consequences of behavioral addic- Downs, S. H., & Black, N. (1998). The feasibility of creating a checklist for tions; and (f) economic outcomes. the assessment of the methodological quality both of randomised and We also offer the following suggestions to improve the quality non-randomised studies of health care interventions. Journal of Epide- of future research. First, greater utilization of validated data col- miology and Community Health, 52, 377–384. http://dx.doi.org/10.1136/ lection methods, including interviewer administered (e.g., timeline jech.52.6.377 follow-back), service user–rated scales (e.g., AUDIT), and biolog- Endnote. (2015). (Version X7.3.1) [Computer software]. Philadelphia, PA: ical indices (e.g., saliva) is an important priority. Second, there is Thomson Reuters. a need for greater attention to the relationship between “active Ferri, M., Amato, L., & Davoli, M. (2006). Alcoholics Anonymous and ingredients” (e.g., self-management skills), attendance, and the other 12-step programmes for alcohol dependence. Cochrane Database of Systematic Reviews, 3, CD005032. http://dx.doi.org/10.1002/ This document is copyrighted by the American Psychological Association or one of its alliedchange publishers. process within and across different mutual aid groups. 14651858.CD005032.pub2 This article is intended solely for the personal use ofThird, the individual user and is not to be disseminatedwhere broadly. possible, future research would benefit from greater Guarnotta, E. (2014). A comparison of abstinence and perceived self- attention to the use and reporting of random sequence generation, efficacy for individuals attending SMART Recovery and Alcoholics allocation concealment, attrition, missing data, and power. Finally, Anonymous (Unpublished dissertation). School of Professional Psychol- preference-based trials, evaluation of professionally delivered ogy, Alliant International University, San Diego, California. SMART Recovery groups, and/or embedding research methods Hester, R. K., Lenberg, K. L., Campbell, W., & Delaney, H. D. (2013). within new community groups may help to clarify the relative Overcoming addictions, a Web-based application, and SMART Recov- impact of SMART Recovery on addiction outcomes compared to ery, an online and in-person mutual help group for problem drinkers, other forms of mutual aid and/or evidence-based treatments. Part 1: Three-month outcomes of a randomized controlled trial. Journal of Medical Internet Research, 15, e134. http://dx.doi.org/10.2196/jmir References .2565 Higgins, J. P. T., & Green, S. (2011). Cochrane handbook for systematic Atkins, R. G., Jr., & Hawdon, J. E. (2007). Religiosity and participation in reviews of interventions (v. 5.1.0.) Retrieved May 5, 2015, from http:// mutual-aid support groups for addiction. Journal of Substance Abuse handbook.cochrane.org/ Treatment, 33, 321–331. http://dx.doi.org/10.1016/j.jsat.2007.07.001 Horvath, A. T., & Sokoloff, J. (2011). Individuals seeking non-12-step 20 BECK ET AL.

recovery. In G. W. Lawson & A. W. Lawson (Eds.), Alcoholism & Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & the PRISMA Group. substance abuse in diverse populations (2nd ed., pp. 75–90). Austin, TX: (2009). Preferred reporting items for systematic reviews and meta- PRO-ED. analyses: The PRISMA statement. PLoS Medicine, 6, e1000097. http:// Horvath, A., & Yeterian, J. (2012). SMART Recovery: Self-empowering, dx.doi.org/10.1371/journal.pmed.1000097 science-based addiction recovery support. Journal of Groups in Addic- Moos, R. H., & Moos, B. S. (2006). Participation in treatment and Alco- tion & Recovery, 7(2–4), 102–117. http://dx.doi.org/10.1080/1556035X holics Anonymous: A 16-year follow-up of initially untreated individ- .2012.705651 uals. Journal of Clinical Psychology, 62, 735–750. http://dx.doi.org/10 Humphreys, K., Wing, S., McCarty, D., Chappel, J., Gallant, L., Haberle, .1002/jclp.20259 B.,...Weiss, R. (2004). Self-help organizations for alcohol and drug National Institute for Health Excellence. (2011). Alcohol-use disorders: problems: Toward evidence-based practice and policy. Journal of Sub- Diagnosis, assessment and management of harmful drinking and alcohol stance Abuse Treatment, 26, 151–158. http://dx.doi.org/10.1016/S0740- dependence. Retrieved from https://www.nice.org.uk/guidance/cg115 5472(03)00212-5 National Institute for Health Excellence. (2012). Drug use disorders in Kelly, J. F., Magill, M., & Stout, R. L. (2009). How do people recover from adults: Quality standard. Retrieved from https://www.nice.org.uk/ alcohol dependence? A systematic review of the research on mecha- guidance/qs23 nisms of behavior change in Alcoholics Anonymous. Addiction Re- O’Sullivan, D., Blum, J. B., Watts, J., & Bates, J. K. (2015). SMART search & Theory, 17, 236–259. http://dx.doi.org/10.1080/16066350 Recovery: Continuing care considerings for rehabilitation counselors. 902770458 Rehabilitation Counseling Bulletin, 58, 203–216. http://dx.doi.org/10 .1177/0034355214544971 Kelly, P. J., Deane, F. P., & Baker, A. L. (2015). Group cohesion and Penn, P. E., & Brooks, A. J. (2000). Five years, twelve steps, and REBT in between session homework activities predict self-reported cognitive- the treatment of dual diagnosis. Journal of Rational-Emotive & behavioral skill use amongst participants of SMART Recovery groups. Cognitive-Behavior Therapy, 18, 197–208. http://dx.doi.org/10.1023/A: Journal of Substance Abuse Treatment, 51, 53–58. http://dx.doi.org/10 1007883021936 .1016/j.jsat.2014.10.008 Public Health England. (2015). Improving mutual aid engagement: A Laudet, A. B. (2011). The case for considering quality of life in addiction professional development resource. Retrieved August 18, 2015, from research and clinical practice. Addiction Science & Clinical Practice, 6, http://www.nta.nhs.uk 44–55. Reardon, M. L., Cukrowicz, K. C., Reeves, M. D., & Joiner, T. E. (2002). Li, E. C., Feifer, C., & Strohm, M. (2000). A pilot study: Locus of control Duration and regularity of therapy attendance as predictors of treatment and spiritual beliefs in Alcoholics Anonymous and SMART Recovery outcome in an adult outpatient population. Psychotherapy Research, 12, members. Addictive Behaviors, 25, 633–640. http://dx.doi.org/10.1016/ 273–285. http://dx.doi.org/10.1080/713664390 S0306-4603(99)00052-0 Sheedy, C. K., & Whitter, M. (2009). Guiding principles and elements of Manning, M., Smith, C., & Mazerolle, P. (2013). The societal costs of recovery-oriented systems of care: What do we know from the research? alcohol misuse in Australia (Trends & Issues in Crime and Criminal (HHS Publication No. SMA 09–4439). Retrieved August 17, 2015, Justice No. 454). Retrieved from http://www.aic.gov.au/publications/ from http://store.samhsa.gov current%20series/tandi/441-460/tandi454.html Trumble, R. G. (2015). Comparison of drinking-related locus of control in McCrady, B. S., & Miller, W. R. (Eds.). (1993). Research on Alcoholics Alcoholics Anonymous members and SMART Recovery participants Anonymous: Opportunities and alternatives. New Brunswick, NJ: Rut- (Unpublished dissertation). School of Professional Psychology, The gers Center of Alcohol Studies. University of the Rockies, Denver, Colorado. Milin, M. (2007). Which types of consequences of alcohol abuse are Whiteford, H. A., Degenhardt, L., Rehm, J., Baxter, A. J., Ferrari, A. J., related to motivation to change drinking behavior? Dissertation Ab- Erskine, H. E.,...Vos, T. (2013). Global burden of disease attributable stracts International: Section B. The Sciences and Engineering, 68, to mental and substance use disorders: Findings from the Global Burden 6322. of Disease Study 2010. Lancet, 382, 1575–1586. http://dx.doi.org/10 Mills, K. L., Deady, M., Proudfoot, H., Sannibale, C., Teeson, M., Mattick, .1016/S0140-6736(13)61611-6 R., & Burns, L. (2010). Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and Received August 16, 2016 other drug treatment settings Retrieved August 18, 2015, from https:// Revision received October 26, 2016 ndarc.med.unsw.edu.au Accepted October 27, 2016 Ⅲ This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.