Alcoholism is a disease. It leaves victims powerless and needing to stay in permanent recovery if they are serious about stopping the demon drink from inflicting further damage. Given that most people can’t afford a stay in rehab, the best way for chronic drinkers to tackle their addiction, so the theory goes, is to go to Alcoholics Anonymous (AA), seek the help of a higher power with their struggle, begin using the 12 steps and be ready to attend meetings for the rest of their lives.
Not so, says Joe Gerstein, a retired professor of clinical medicine in the US.
“A myth has grown up that you can’t get over a substance addiction without AA,” he says. “It’s a widely-held belief, but it’s a myth.”
For years, he admits to buying into the myth and referring patients with alcohol problems to AA, with varying degrees of success.
“I would see people in my office during the day who had big, swollen bellies from liver cirrhosis and tell them about how serious their problem was, and then I’d see them again at 7pm coming out of the liquor store carrying a bag that didn’t contain doughnuts,” he says.
Although he describes AA as “an absolutely remarkable program,” given that millions have found it useful over the last 75 years, he also calls it “ethically wrong, medically wrong and psychologically wrong.”
Gerstein is the founding president of Smart Recovery, an alternative to AA that is catching on in the US — where it began in 1994 — and worldwide. He was the main speaker at a conference in London last week, organized by charity Alcohol Concern and funded by the UK’s Department of Health (DH), that was designed to promote Smart Recovery — Self-Management and Recovery Training, to give it its full title — as another way to help England’s 1.1 million problem drinkers.
The DH, keen to expand the number of options for treating the scourge of alcohol, is funding a £100,000 two-year trial of Smart Recovery, which currently has a low profile and is the David to AA’s Goliath. In London, for example, some 300 different AA groups meet regularly. But there are just 20 or so Smart Recovery groups in all of England — even Gerstein is unsure exactly how many — and about the same number in Scotland.
However, it is attracting attention from experts in the field.
“AA is huge, and people wouldn’t go if it didn’t work,” Alcohol Concern’s director of policy and communications, Nicolay Sorensen, says. “Smart Recovery at the moment is the only alternative. It’s got momentum, it’s got a good evidence base and it’s growing in popularity.”
Similarly, Addaction, the UK’s largest drug and alcohol treatment charity, is setting up an alcohol recovery service for over-50s in Glasgow, funded by the brewers Heineken and using Smart Recovery.
Smart is based on cognitive behavioral therapy (CBT), especially an element of it called rational emotive behavior therapy (REBT). Gerstein calls Smart “a self-empowerment program,” and rejects utterly AA’s disease theory of alcohol and labeling of people with serious drink problems as alcoholics.
Smart Recovery and AA are both international not-for-profit organizations. Smart is used in Australia, Uzbekistan and beyond. Its handbook has been translated into Russian, Farsi and Mandarin Chinese, among other languages. Both programs are used in prisons, seek abstinence from participants and are free — although they rely on donations from those attending their groups. But, crucially, Smart is science-based and secular, while AA has heavy religious associations. Many of the people attending the 370 Smart groups across the US have tried AA and been put off by its insistence that members undergo a spiritual awakening, Gerstein says.
For him, though, the key difference is that Smart is a positive philosophy.
“We believe that addiction is a very human condition that can be corrected, and that it’s the people themselves who do that through natural recovery,” he says. “We don’t think people are hopelessly taken over by addiction. Other people use books, medicines, help from family or professionals, whatever works for them. But with Smart Recovery, people do it on their own. That belief that human beings have the capacity within themselves to overcome even severe addictions and go on to lead a meaningful life is vital.”
Where AA has its Big Book, Smart has four key points and a “toolbox” — a set of ways in which problem drinkers can change their behavior. If someone is feeling stressed at the end of their working day, they may choose to use the ABC tool, for instance. That is: A for the Activating Event, the walking out of work; B for the Belief, that the person needs a drink now in order to relax; and C for Consequences, that someone ends up drinking because of their stress.
Smart teaches participants ways to disrupt this irrational belief system by helping them understand why they act as they do — damaging their lives and relationships in the process — and to then challenge that thinking. CBT is also the basis of the “talking therapies” program that the DH has been rolling out in recent years to help people ranging from long-term benefit claimants wanting to resume working to couples whose relationship is in peril.
A key part of the Smart trial is the creation of six Smart Recovery groups in the UK — in Birmingham, Norwich, Croydon, Gateshead, Cumbria and Sheffield — so that alcoholics in those areas needing major help can choose between that and AA.
“The DH has issued some high impact changes for the alcohol sector, one of which is aimed at supporting and improving specialist alcohol treatment,” Don Lavoie of the DH’s Alcohol Policy Team explains. “Involved in that development is the promotion and growth of peer support, and ensuring that there is a range of choices for people with an alcohol problem.”
Who comes, why and how they fare will be evaluated to see which approach works best.
“At Smart Recovery meetings we don’t pray, do the Lord’s prayer or sing Kumbaya,” Gerstein says. “We don’t depend on higher powers to help and we don’t expect people to come forever. They come, recover and get on with their life.”
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