SMART Recovery’s First Systematic Scientific Review
SMART Recovery’s First Systematic Scientific Review
by Tom Horvath, Ph.D., ABPP
The first systematic scientific review of SMART Recovery was published earlier this year. What is a systematic review? It reports the process of “identifying, summarizing and evaluating the quality of evidence for SMART Recovery” (Beck, Forbes, Baker, Kelly, et al, 2017, p. 2).
Prior reviews had become outdated, and they were “narrative in nature and tend[ed] to focus on the origins, development and principles of SMART Recovery….since Horvath & Yeterian’s narrative review (Horvath & Yeterian, 2012), the evidence base has doubled—an additional four studies, including the first randomized controlled trial (RCT), have been published” (p. 2). Although I regret that our 2012 review is no longer the latest one, I’m pleased to see this development for SMART Recovery specifically, and for the self-empowering recovery approach generally.
This review was published as the lead article in the February, 2017 issue of Psychology of Addictive Behaviors, one of the world’s leading addiction journals. The authors are an international team of eight highly recognized addiction scientists. Put simply, SMART is now “on the map” scientifically.
Like most scientific papers, this one begins with an introduction, to establish the context in which the paper was written, and why the subject of the paper is important. The authors review the burden (costs) of addiction, the chronic nature of addiction for some individuals, the importance of long-term support for these individuals, the role of mutual help groups in providing that support, the value of 12-step groups specifically in providing that support, the unwillingness of some individuals to engage with 12-step groups, the importance of providing alternative mutual help for those who prefer it, and the emergence of SMART Recovery as a mutual help group.
A first for SMART Recovery:
Although there have been “methodologically rigorous systematic reviews of the efficacy and potential mechanisms of change of 12-step models” (p.2), none has been conducted yet for SMART. Therefore, the subject of this paper is important.
The review was conducted according to established guidelines for such reviews. The protocol developed to complete this review was substantial enough to merit its own publication (Beck, Baker, Kelly, Deane, et. al, 2016).
The paper details how 879 records from electronic databases were identified as potentially relevant for inclusion. The rigorous screening process resulted in 37 English language publications that could be classified as clearly about SMART Recovery and falling into the categories of evaluation, review, discussion and other. The 12 documents qualifying as evaluations were then further examined. Eight of these documents were published in peer-reviewed journals, and four were unpublished dissertations. All were published between 2000 and 2016, and all focused on adults with either substance and/or behavioral addictions. Most subjects had alcohol addictions. Three evaluations were of the effectiveness of SMART Recovery.
The review specifically considers what these 12 evaluations tell us about 1) SMART Recovery face-to-face meetings vs. online experiences, (2) SMART Recovery informed interventions (interventions based on SMART Recovery but which are not actual SMART meetings), 3) the efficacy of SMART vs. other forms of mutual help, and 4) the impact of SMART Recovery when no comparison condition is available. Fortunately, the evidence, as viewed through these categories, is promising.
The authors conclude:
The modest sample of articles and diversity of methods prevented us from making conclusive remarks about the efficacy of SMART Recovery, but positive effects were found in dual diagnosis, and correctional settings. Evidence from the sole identified RCT also supported the benefits of SMART Recovery for reducing the severity and consequences of problematic alcohol use (p. 18).
Given the positive effects of SMART Recovery and SMART Recovery-informed interventions to enhance client-centered, collaborative care that is tailored to the needs and preferences of the individuals, clinicians need to be aware of the range of mutual aid support options available, including SMART Recovery, and discuss these options with their clients (p. 19).
Of interest from a cost-effectiveness perspective was this tentative conclusion:
Despite largely comparable addiction related outcomes, the available evidence suggests that the duration of attendance may be shorter for SMART Recovery relative to 12-step participation. Although clearly in need of further investigation, this may be testimony to the feasibility of the SMART Recovery approach. That is, SMART Recovery may represent a more time efficient method for promoting clinically meaningful change (p.18-19).
SMART Recovery quickly announced the publication of this review. The announcement placed the review in the broader context of the history of US mutual help groups and research about them (SMART Recovery, 2017).
I’m personally pleased to note that three of the dissertations reviewed were conducted at Alliant International University, where I am a graduate instructor. I served on all three dissertation committees. I hope to keep building interest about SMART Recovery in Alliant students.
To return to the map analogy, SMART Recovery is now a “village” on the map of recovery services, but by comparison to the AA research metropolis down the road, there is much work to do. AA’s metropolis includes perhaps thousands of publications. Nearly every aspect of AA has been studied, including who might attend, how they respond, and how they fare over time.
Suggestions for future research:
To help build the SMART Recovery research village into it’s own metropolis, the review made a large number of suggestions for future research. Investigators need to assess subjects for their mental health status, their concurrent treatments, the consequences of their substance use (including substances other than alcohol), their personal and social functioning, the severity of their behavioral addictions if present, and the economic effects of their addictive behavior.
These suggestions were about what data to collect. There were also numerous technical suggestions about how to collect that data.
Taken collectively these suggestions could mean that the review authors are chastising, collectively and rather strongly, the authors of the 12 evaluations. However, three of the evaluations were viewed positively and one very positively. Furthermore, the four dissertations, although strong enough to graduate the students, were not the work of seasoned and grant-funded investigators.
Rather, I suggest that this review indirectly acknowledges that the 12 evaluators could only work to the limit of their funding. Funding sources are necessarily conservative. They grant funds based on prior research. For SMART Recovery that research, despite its limitations, now exists. With this review it has been well documented. Therefore, it’s time for more funding, so that we can collect the new data we need, in the manner it needs to be collected.
Most funding for addiction research in the US comes from the various agencies of the federal government. I hope they are listening.
Beck, A.K., Baker, A.L., Kelly, P.J., Deane, F. P., Shakeshaft, A., Hunt, D., & Kelly, J.F. (2016). Protocol for a systematic review of evaluation research for adults who have participated in the “SMART Recovery” mutual support programme. British Medical Journal Open, 6(5), e009934. http://dx.doi.org/10.1136/bmjopen-2015-009934
Beck, A.K., Forbes, E., Baker, A.L., Kelly, P.J., Deane, F. P., Shakeshaft, A., Hunt, D., & Kelly, J.F. (2017). Systematic review of SMART Recovery: Outcomes, process variables, and implications for research. Psychology of Addictive Behaviors, 31 (1), 1-20. DOI/10.1037:adb0000237
Horvath, A., & Yeterian, J. (2012). SMART Recovery: Self-empowering, science-based addiction recovery support. J. of Groups in Addiction and Recovery, 7:2-4, 102-117. dx.doi.org/10.1080/1556035X.2012.705651
SMART Recovery. (2017). On systematic review of SMART Recovery research published in Psychology of Addictive Behaviors. http://www.smartrecovery.org/pressroom/SMART-Statement-PAB-Review-2017.pdf