Given that most people can’t afford to pay for a stay in a Priory clinic, then the best way for chronic drinkers to tackle their addiction, so the theory goes, is to turn to Alcoholics Anonymous, seek the help of a higher power with their struggle, begin using the 12-step programme, and be ready to attend meetings for the rest of their lives.
Not so, says Joe Gerstein, a retired clinical professor of 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.
He describes AA as “an absolutely remarkable programme” that millions have found useful over the last 75 years. But he criticised the coercion of people into AA, Smart Recovery and other mutual aid support groups as “ethically wrong, medically wrong and psychologically wrong”.
Gerstein is the founding president of Smart Recovery, an alternative to AA that is catching on in America – where it began in 1994 – and worldwide. He was the main speaker at a conference in London yesterday, organised by charity Alcohol Concern, and funded by the 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 ones 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. Nicolay Sorensen, Alcohol Concern’s director of policy and communications, says: “AA is huge, and people wouldn’t go if it didn’t work. 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 behavioural therapy (CBT), and especially an element of it called rational emotive behaviour therapy (REBT). Gerstein calls Smart “a self-empowerment programme”, and rejects utterly AA’s disease theory of alcohol and the labelling of people with serious drink problems as alcoholics.
Smart Recovery and AA are both international not-for-profit organisations. Smart is used in Australia, Uzbekistan and beyond. Its handbook has been translated into Russian, Farsi and Mandarin Chinese, among other languages. Both programmes 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 America 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 behaviour. For instance, if someone is feeling stressed at the end of their working day, they may choose to use the ABC tool. That is: A for the Activating Event, the walking out of work; B for the Belief, that the person needs a drink now 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” programme 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 Birmingham, Norwich, Croydon, Gateshead, Cumbria and Sheffield – so that alcoholics in those areas needing major help can choose between that and AA.
Don Lavoie, a DH alcohol adviser, explains: “The DH has issued some high-impact changes for the alcohol sector – one of which is aimed at supporting and improving specialist alcohol treatment. 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.
Gerstein points out: “At Smart Recovery meetings, we don’t pray, do the Lord’s Prayer or sing Kumbaya. 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”.
• This article was amended on 16 March 2010. Joe Gerstein described the coercion of people into programmes such as AA as ethically, medically and psychologically wrong, not AA itself. This has been corrected.