SMART Recovery “down under”: An exploration of digital monitoring for SMART Recovery meetings in Australia

Research shows that attendance at mutual-help organizations, such as Alcoholics Anonymous (AA), is beneficial for individuals with substance use disorders, and alcohol use disorder in particular. While 12-step mutual-help groups (e.g., AA) are the most common, research on other mutual-help groups is important in order to provide empirically supported recommendations for those seeking alternative mutual-help resources. One such resource is  SMART Recovery – a cognitive-behavioral mutual-help group intended to support recovery from a variety of addictive behaviors. In addition, there has been increased emphasis on measuring outcomes of treatment for addiction including recovery support services such as mutual-help organizations. While still rare, routine measurement of recovery-related outcomes of mutual-help organization is rarer still, which is what was unique about this study. The research team investigated the use of a digital platform to monitor recovery-related outcomes in people attending meetings for SMART Recovery in Australia.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Mutual-help groups are among the most accessible forms of support for people seeking recovery worldwide. While the 12-step approach is used by many groups, such as AA, other mutual-help groups are available to those seeking an alternate method. The Self-Management and Recovery Training program (SMART Recovery) is one of the most widely available alternatives but has received less attention by researchers and evaluators.

Developed as an alternative to 12-step approaches, SMART Recovery incorporates both motivational enhancement and cognitive-behavioral therapy (CBT) to promote positive behavioral change for a range of addictive behaviors. Groups are led by facilitators specifically trained in the SMART Recovery approach. The groups aim to help people to: (1) identify the relationship between thoughts, feelings and behaviors; (2) challenge unhelpful thoughts and beliefs; (3) use positive behavioral strategies; and (4) undertake homework activities between sessions, commonly referred to as seven-day action plans in SMART Recovery.

Figure 1.

There is emerging evidence that 12-step alternatives, such as SMART Recovery, may be just as helpful in maintaining alcohol abstinence over a six-month window as 12-step based mutual-help groups for those that choose them. Given the widespread use and minimal research evidence, improved understanding of the experience and outcomes of people who attend SMART Recovery meetings is important. At the same time, evaluation of mutual-help group member experiences has been historically difficult due to reasons like lack of access or standard measures. In a first step toward addressing this knowledge gap, the authors set out to evaluate the feasibility of using a smartphone delivered digital assessment tool among SMART Recovery members.

HOW WAS THIS STUDY CONDUCTED?

In this qualitative study, authors conducted semi-structured, audio-recorded telephone interviews with 20 participants recruited from SMART Recovery groups held across the Australian state of New South Wales. Interviews were guided by a set of prompts which asked participants about: their aims for attending meetings; the impact of their attendance; any experience using technology to monitor their progress; topics that would be useful to track; what might get in the way of collecting outcomes data; their perceptions on the role of the facilitator in this process; what advice they could give researchers in the development of the tools; and, finally, any conclusions they feel are important to consider. Participants also reflected on the benefits and limits of the SMART Recovery process more generally, and they were invited to describe what works and their therapeutic preferences. These 45 min interviews were then transcribed and coded to identify themes across interviews.

Participants ranged in age from 27 to 65 (average age = 46) and 80% identified as male. Most were attending SMART Recovery for alcohol (40%) or other drugs (35%). Many participants reported accessing formal psychological and/or psychiatric support, with many participants having been referred to SMART Recovery groups by their mental health professional.

WHAT DID THIS STUDY FIND?

There were several themes generated from the interviews, including the benefits of SMART, mutual support, outcomes and impact, barriers to implementing digital monitoring, and participant recommendations.

Two noteworthy themes centered on the value of mutual support and group members’ views on digital monitoring:

Mutual support was described as an essential element of SMART Recovery meetings.

While the interview included questions about the program, it did not include questions about mutual support directly. Despite this, mutual support was brought up by participants frequently and passionately described as an essential part of their recovery. Specifically, participants seemed to value the facilitated discussions fostered by clinicians, which enabled them to reflect on their past week, what had worked, and what they needed to further improve. Indeed, discussion at group meetings was described as a key tool in their efforts to reduce or abstain from problematic alcohol and other drug use.

Digital monitoring was viewed as particularly well suited to the SMART program.

Participants viewed digital monitoring as complementary to the customizable and pragmatic nature of the SMART Recovery program due to its emphasis on self-management and planning (i.e., the seven-day plans), as long as the digital collection of this data does not affect their privacy or interfere with group process.

While participants generally viewed digital monitoring as a good match for SMART Recovery, there were also reservations expressed about potential drawbacks such as breaches of confidentiality, and that adoption would be challenging, especially among older participants.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

This project explored SMART Recovery attendees’ perceptions of group benefits and drawbacks, as well as a digital monitoring (i.e., mobile Health; mHealth) app that would track client outcomes and facilitate participant feedback about their group. In doing so, the authors found that participants valued the mutual support fostered within weekly meetings, and that the use of digital monitoring was viewed as a potentially complementary resource to in-person meetings that could feasibly be employed by members.

The findings provide support for findings of other published research about the important role that peers play in group work practice and the motivational and relational benefits of mutual support for participants of behavior change groups. It also highlights the impactful nature of facilitated group work, compared to individual forms of therapy. Study participants passionately described the ways in which SMART Recovery meetings provide opportunities for participants to connect with others facing similar challenges and develop mutual support networks with others who can understand their experiences. The perceived value of shared experiences seems to cut across both SMART and 12-step mutual-help meetings. Research that follows SMART participants over time and uses validated measures to assess behavior (e.g., quantitative, longitudinal studies) can help test this hypothesis.  

While participants were positive about the introduction of outcomes measures so they could track their progress to enhance their recovery, they also felt these should not interfere with group process. It seems that the digital component of collecting these data raised some concerns for them. Consistent with other research on digital monitoring, participants were concerned about access to digital hardware, or the competence to use it effectively. In some cases, there were concerns that the collection of data would negatively affect their privacy and confidentiality, or that elements of the SMART Recovery program would become intrusive, due to automated prompts. Ultimately, participants perceived outcomes measurements were in keeping with the SMART Recovery program, and that digital monitoring could complement the group meetings, but not replace them. Given the importance that participants placed on mutual support, and physical attendance at weekly meetings, it is important for the implementation of digital monitoring to be integrated into meetings in ways to avoid disrupting group process. Importantly, this would parallel advances made in therapy delivery that have come about through routine outcome monitoring at the program level to personalize treatment (i.e., measurement-based care/practice). Addiction treatment that uses outcome monitoring tends to improve outcomes versus no outcome monitoring. Thus, with increased systematic monitoring SMART could determine the utility of the meetings and their constituent part to inform how to best serve the needs of its members.  

LIMITATIONS

1. As with most qualitative studies, it is hard to generalize the findings to the larger population for several reasons. The sample size was quite small, and thus it is unclear to what degree the observations made here generalize to all SMART Recovery attendees. The sample was almost entirely male, making it difficult to know if these findings would be relevant to those of other sexes and gender identities. Also, it is possible that participants with greater motivation (e.g., wanting to express opinions about SMART Recovery) were more likely to complete the survey, making it difficult to generalize to the entire population of SMART participants.
2. The exclusive use of phone interviews is also a possible limitation. While this approach increases access to potential participants, it also hinders assessment of nonverbals that aid the interview process (e.g., participant might have a facial expression that demonstrates uncertainty about a question, or lack of confidence in their own response, etc.).

BOTTOM LINE

CITATIONS

Gray, R. M., Kelly, P. J., Beck, A. K., Baker, A. L., Deane, F. P., Neale, J., . . . McGlaughlin, R. (2020). A qualitative exploration of SMART Recovery meetings in Australia and the role of a digital platform to support routine outcome monitoring. Addictive Behaviors, 101. doi: 10.1016/j.addbeh.2019.106144