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April 2015

SMART Recovery; Gender non-conforming people; Continuum (TM) is here: Attitudes


In the February 2015 edition of Tips and Topics, I outlined a case presentation of a client who had already been in Level 3.5 Residential addiction treatment service for over four months when she was discharged to outpatient services. The client used alcohol within a day of discharge. The treatment program readmitted her for more weeks in their residential program. It was as if the treatment agency felt several more weeks of the same level of care would produce a better outcome.

Joe Gerstein, MD, FACP, is the Founding President of SMART Recovery Self-Help Network is an internist and pain management consultant. He wrote and shared perspectives and information worth passing onto you this month.

Here’s some of what he said:

“In the 2nd case presented, the woman who had been over 4 months in residential care and relapsed immediately on discharge, there seems to be more than just a failure to observe a rational and patient-centered interpretation of criteria. There seems to be total obliviousness to the likelihood that the therapeutic approach being used may be entirely incorrect for this patient’s temperament and worldview and that “more of the same” will be unlikely to achieve any benefit.”

Dr. Gerstein went on to correctly suggest that there be a re-assessment of the type and style of therapy rather than the “assumption that the fault always lies with the patient’s obstinacy and lack of cooperation and denial.” He then shared the following link as an example of how a change in treatment approach can yield dramatic results.

See by Leigh who is now Regional Coordinator for Wales, UK SMART Recovery Trust.

Many are familiar with Alcoholics Anonymous, Narcotics Anonymous and other 12-Step recovery groups; and I always try to mainstream people into AA or NA since these groups are so readily available. But too few fully understand SMART Recovery as an adjunct or alternative to AA and NA for those who may need a different approach to improve outcomes. Since Joe has facilitated over 3,000 SMART Recovery meetings in communities and prisons around the world; and has written about and lectured at a number of symposia on alternatives to the 12-Step approach, I asked him to explain more about SMART Recovery.


Take a look at what you know or do not know about SMART Recovery

Here’s what Dr. Gerstein explained about SMART.  His comments are indicated with quotation marks:

Some history:

“I certainly would like to clarify things about the origin of SMART Recovery. This was definitely a group endeavor. SMART started out as the non-profit arm of Rational Recovery. As I recall, there were 8 professionals [all except myself from the mental health profession] and 2 lay people who had used the program to achieve sobriety at the first organizational meeting of the Rational Recovery Self-Help Network. The detailed history is capsulized in several sources, which I will note below.

It became clear in the next few years that there were irresolvable differences between the non-profit and the for-profit elements, so the non-profit broke away and renamed itself SMART Recovery (Self-Management And Recovery Training) in 1994. Originally only a 2-Point program, Coping With Urges and Dealing More Rationally With Problems, it rapidly evolved into a 4 Point Program by adding Motivational Enhancement and Lifestyle Balance components. By now there are 13 Tools. Our Correctional Version of SMART Recovery, InsideOut, funded by the National Institute on Drug Abuse (NIDA), contains an additional module, Criminal Thinking Errors.”

SMART in the Prisons and Criminal Justice:

Dr. Gerstein again: “My own particular areas of involvement in the program have been here in Massachusetts where we have had over 25,000 meetings, prison applications of SMART [I have facilitated almost 800 prison meetings and introduced the program into Australian and UK prisons, where it has flourished] and the formation of SMART Australia, SMART UK and SMART South Africa. The Kingdom of Denmark has provided almost $2,000,000 to translate SMART materials and support startup of 24 SMART groups. A recent study from New South Wales (Australia) prisons involved 3,000 inmates exposed to SMART and 3,000 controls matched in 7 parameters. Those inmates attending at least 9 SMART sessions had a 53% reduction in reconviction rate for violent crimes.”

SMART and Science:

  • “The scientific underpinnings of the program are Rational Emotive Behavioral Therapy (REBT)/Cognitive Behavior Therapy (CBT), Motivational Interviewing, Solution-Focused Therapy, Stages of Change and Motivational Enhancement Theory.”
  • “Incidentally, a number of surveys have demonstrated that about 30% of participants who attend SMART meetings fairly regularly and consider SMART their primary recovery modality also attend AA/NA meetings at least occasionally. We have absolutely no problem with this approach. SMART has no objection to use of appropriately-prescribed medication for either the addiction or underlying mental health problems, or both.”
  • “A study by the Walsh Group several years ago demonstrated that progress in recovery via SMART was about the same for people with varying degrees of religiosity or the non-religious.”
  • “A study by Reid Hester funded by NIDA was a randomized control trial (RCT) with 183 new SMART attendees. They were divided into 3 cohorts receiving different types of access to the SMART program and/or to Hester’s interactive online program, “Overcoming Addictions: Introduction to SMART Recovery. All had alcohol as their addictive substance. All had a corroborative person available. We have the 3- month results (6-month results due soon). There was about a 70% reduction in all groups in drinking days, drinks per drinking day and negative social/legal/medical events.”

SMART online and internationally:

“The online experience has been quite a phenomenon. Except for a webmaster (in Uruguay!) and an intermittent web designer, virtually the entire enterprise is run by volunteers. Thousands have had their entire recovery on the website and develop incredible bonds amongst themselves.

SMART Recovery now has 1500 meetings in 17 countries and is in use in a number of treatment facilities. About 150 trainees per month take the interactive online training program, about 2/3 professionals or students training to become professionals. At our 20th Anniversary Conference in Washington last Fall, we were gratified to have Michael Botticelli, Director of National Drug Control Policy, give the welcoming address and bring along a Presidential Proclamation honoring SMART’s contribution to the recovery community.”

Joe Gerstein. MD, FACP

508 733 6469


Atkins, Randolph G., Hawdon James E (2007): “Religiosity and Participation in Mutual-Aid Support Groups for Addiction” J Subst Abuse Treat. 2007 Oct; 33(3): 321-331.

The Walsh Group Study:

Blatch, C., et al. Efficacy of SMART Recovery Program in New South Wales Prisons. Submitted for publication.

A Chronology of SMART Recovery®

Compiled by Shari Allwood and William White

Hester, Reid K, Lenberg, Kathryn L, Campbell, William, Delaney, Harold D. (2013): “Overcoming Addictions, a Web-Based Application, and SMART Recovery, an Online and In-Person Mutual Help Group for Problem Drinkers, Part 1: Three-Month Outcomes of a Randomized Controlled Trial” Journal of Medical Internet Research. Vol 15, No 7 (2013): July. The Hester Study:


Last month I introduced some information on Transgender individuals and an article by Beck Gee.

Beck wrote to me and I’ll share some of the dialogue we exchanged as I learned something new. This led to this month’s SKILLS section:

Dear Dr. Mee-Lee,

“I wanted to thank you for your Tips & Topics discussion this month. One of my friends forwarded it to me as he noticed I was referenced. This topic is very dear to my heart and it is my passion and calling to work with trans-individuals and substance use….. I just wanted to make a small remark. You referenced me with male pronouns. I identify on the spectrum of trans, as gender nonconforming and use them/they/their pronouns. I was assigned female at birth. It’s totally okay that you identified me as male, probably due to my name… these are the things that I continue to work on and help treatment centers and addiction professionals be more aware of. It’s an amazing opportunity, and relevant, and timely. I think if I would have started talking about this 2 years ago, it would not be having the same effect as it is now.”

All the best,


Assistant Director of Clinical Services

Pride Institute

2101 Hennepin Ave #202

Minneapolis, MN 55405

612-825-8714 (main)

My response:

Thank-you, Beck, for writing and for your original article which was informative for me. I am relatively new to the whole subject of transgender people and appreciate your pointing out who I assumed you were -male- and referred to you that way. Yes, your name did lead me to make that assumption, although, as I think about it now, I’m not sure if Beck is a male or female name and so is perfect for gender nonconforming people. This goes to show how I still have more to learn.

So if I had referred to you correctly, how should I have said that: “In their article, Beck Gee emphasizes…..” Would readers understand that “their” was used instead of “his” or “her” because you are a gender nonconforming person? Is this an issue you teach clinicians about – how to refer to each person by asking them do you want to be referred to as “he”, “she” or “they”?

Thanks for writing and helping raise my consciousness about trans people.



Raise your consciousness about gender nonconforming individuals who identify on the spectrum of transgender. Note terminology on how to address them.

Here’s what Beck taught me:

  • You would be correct in using “In their article…” When I train clinicians we can sometimes battle on the grammar piece, when someone comes in who is gender non conforming and uses the pronouns them/they/theirs. In lectures/sessions, I’ve experienced battles with clinicians on grammar. It would be easier if we lived in Sweden, where they use a third gender pronoun
  • Beck pointed to the following article:
  • “I also tell them that in clinical notes, I make a note at the beginning that states “The client uses them/they/their pronouns, therefore all clinical notes will refer to the client with those pronouns”.   I also make note that therapeutic alliance relies heavily on affirmation and respect. If we are not affirming of a client’s identity then we are doing a disservice. And respect must come from the institution as a whole, if someone is misgendering a client, we must correct them. Even where I work, when a client comes in, and someone may misgender them in staffing or report, I instantly correct them. Because even behind closed doors we must be respectful and aware.
  • We also have done away with “What pronouns do you prefer?” question. We ask “What are your pronouns, or what pronouns do you use?” Because it’s not a preference, it just is.”

So was your consciousness raised? Or did you already know all about this and it was just me who was oblivious to these issues?


I don’t know what your high school teachers were like and whether they were as confrontive as some of mine. (Of course this was last century). But I remember one teacher almost yelling at a fellow student who was an unmotivated learner and kind of pouty and negative: “Change your attitude!”

“Change your attitude” indeed.  Not so easy to do.  But then, maybe it is easier than I would have thought.  Society in the USA – even more so in some other countries-  is changing attitudes and cultural norms at a more rapid pace than you would have thought possible even a decade ago:

  • Same-sex marriage is legal in 37 states and the District of Columbia.  I’m no math wiz, but that seems like a pretty substantial majority.
  • Medical marijuana is legal in 23 states and the District of Columbia with nine more states pending.
  • Four states have already legalized recreational use of marijuana and the District of Columbia has legalized possession of small amounts of marijuana. Seven more states are getting ready to legalize it too.
  • Transgender individuals are increasingly being recognized and accepted and will likely get a boost with Bruce Jenner’s recent interview on his transition seen by 17 million people and counting. (Bruce asked to be referred to with male pronouns for the time being.)

When it comes to addiction treatment providers though, it is interesting to see how slowly attitudes are changing in regards to one of the most difficult forms of addiction – nicotine addiction or tobacco use disorder. Ever since the new edition of The ASAM Criteria (2013) published a new chapter on Tobacco Use Disorder, I’ve been quoting a statistic that surprises people:

  • More people die in the USA every year from smoking tobacco and nicotine addiction than from alcohol, heroin and cocaine combined.

Recently, I thought I better check this statistic to make sure this is accurate. I found out I was wrong – or at least only partially correct. Actually…..

  • More people die in the USA every year from smoking tobacco and nicotine addiction than from alcohol, heroin and cocaine; AND from AIDS, car accidents, murders and suicides; AND in World War II… all combined.

Now that is some statistic that you think would change the attitude of addiction treatment providers to make treatment programs smoke and tobacco-free. And in fact, more and more treatment providers are taking nicotine addiction seriously.  But there are still many programs that don’t allow smoking in treatment groups or in the building, but have a smoking gazebo on the grounds where clients and staff can have a cigarette before group treatment.

Well, I’m looking for the beer and wine gazebo where clients and staff can bond and have a beer or glass of wine before group.  What’s the difference?”Change your attitude” indeed.  It’s harder than you think……or is it?

sharing solutions

The ASAM Criteria Software was released on April 25, 2015 at the Annual ASAM Meeting in Austin, Texas. Now branded as Continuum ™, The ASAM Criteria Decision Engine.

Continuum ™ provides counselors, clinicians and other treatment team members with a computer-guided, structured interview for assessing and caring for patients with addictive, substance-related and co-occurring conditions. By branding the software as “Continuum” it means The ASAM Criteria isn’t just about assessment at the front intake part of treatment in order to make a placement decision. It means that The ASAM Criteria is about ongoing chronic disease management across a whole continuum of care.

The book and Continuum ™ are companion text and application. The text delineates the dimensions, levels of care, and decision rules that comprise The ASAM Criteria. The software provides an approved structured interview to guide adult assessment and calculate the complex decision tree to yield suggested levels of care, which are verified through the text.

For more information, go to the website 

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