Welcome, everyone. My name is Christopher Blazes. I'm from OHSU and along with NYU and, of course, the American Academy of Addiction Psychiatry. We are grateful to be able to present this series on advanced addiction psychotherapy. This course series is a great opportunity to interact with some of the top experts in our community. Please feel free to ask questions anytime during the presentation by clicking the question button in the lower portion of your control panel and typing in the question. The chat feature is also available for comments throughout the presentation. We will reserve some time at the end of the presentation for Q&A. If you'd like to ask the question yourself, please click the reaction button and raise your hand. Please also be mindful that there are some polling questions throughout the presentation. You'll be prompted to click on a pop up that will come up on your screen to answer. After the session, you can claim credit by logging into the triple AP account and accessing this course. Complete the evaluation and follow the prompts provided to claim your credit. Additional courses continuously are added. So remember to click on the new courses title to register and get calendar invites that will be emailed to you. Next month's presentation is Drs. Goldfarb and Dr. Metrican from NYU who will be presenting on the psychodynamic and psychoanalytic psychotherapy for addictions part one. This evening sessions is an update on smart recovery. Thanks, Chris. Hi, everyone. Again, I'm David Stifler. It's my pleasure to introduce Dr. Tom Horvath. He's a clinical psychologist with a very distinguished career, was one of the founders of smart recovery in 1994 and was the past president for 20 years. He also founded practical recovery, which is a non 12 step based drug rehab and alcohol treatment program. I think this talk is well timed since our last discussion was on 12 step facilitation. So it's nice to hear kind of a different approach with a lot of background and clinical experience. I'll just share that my first introduction to smart recovery was during fellowship at the Manhattan VA. I was given a huge binder of smart recovery based lesson plans to pick one and watch somebody else do one of the groups at the VA and then go in and do my group. That was quite an experience, but I did like knowing that all these different kind of lesson plans were available to, you know, kind of use in the future in different kind of clinical scenarios and also familiarize myself so I was better at kind of guiding the right type of person towards smart recovery. So just a little bit more on Dr Horvath. He's had numerous positions and awards in professional societies, including the secretary treasurer and being the past president of the American Psychological Association's Society of Addiction Psychology. In 2016 he was elected as a fellow of the American Psychological Association. And finally, he's the author of a book titled sex drugs gambling and chocolate a workbook for overcoming addictions, and I will turn it over to you Dr Horvath. Thank you Dr Stifler and Dr blazes. I have. stuck on advancing slides let's try that again there we go nothing to disclose. And here's our first poll. That should show up on your screen in a moment. I hope we have individuals across this spectrum. We'll get the results in a moment. The short summary of this entire presentation is that AA is not the only option for obtaining mutual help for addictive problems. This is a good time to say that. We'll get into a little more detail about what the other options are. Here we are. 62 percent know part of it and know a little bit about it. Perfect. Thank you. This one will pop up also. This is a trick question because there's actually an international slogan and the US slogan. If you know either one, that would be fine. Slogans are an important part of a business's brand. Nike is just do it, McDonald's is I'm loving it, Burger King, have it your way. These are quick ways that people identify a company, a product. In smart internationally, the slogan is life without addiction. I think that's problematic for a number of reasons that I'll describe later. The US slogan, which we haven't discontinued, is discover the power of choice, which I think is a good summary of what smart recovery is about. This presentation will have three parts. The primary part, the first 40 percent or so, we'll talk about the self-empowering approach after some introduction, and then meetings themselves, a brief section on the organization, and about a third of the presentation on the scientific investigation about smart, specifically, also some about AA and about mutual help. These are the four main ideas that I will try to get across. I already mentioned the summary of these, that AA is not the only way. There are other options. The slogan, discover the power of choice. We'll look at a number of surface differences between smart and AA. That's a reasonable comparison to make because the world of mutual help can be divided into all the 12-step approaches and all the non-12-step approaches. Of the non-12-step approaches, smart is probably larger than all of the other ones put together. Now, that may change over time, but distinguishing between the powerless-based and the self-empowering approach is a reasonable distinction, and most of the non-12-step groups would also fall into that self-empowering category. But we're also going to talk about underlying similarities, and they turn out to be much more significant than I had ever imagined they would be based on some recent research, but it did make sense to me when I saw the data. And another major point here is that there actually are as many ways to change in the problem as there are individuals. So people will put together all sorts of, call them programs of recovery. So these are the four main ideas that I hope to convey to you, and we'll come back to this slide at the very end. So there's that slogan again, discover the power of choice, and the acronym self-management and recovery training. The most broad context we could look at would be social support. And within social support, mutual help is one important component. Social support is often thought to include listening, active helping, providing information, just providing companionship. You think of helping a friend move, sitting in the waiting room while somebody you love is in surgery, listening to someone's concerns. That's all social support. And then we have these specific groups that have multiple names. Mutual help is the one I'm using, but you've also heard self-help. Mutual help, or excuse me, self-help support group, mutual aid tends to be used more internationally. These groups are free. They are widely available, particularly the 12-step groups. When I say time-honored, they actually go back centuries, probably on the order of a thousand years. There were circles of monks that were helping one another in the Middle Ages try to control their drinking. And AA certainly took over the field when it started in 1935 and becomes the most well-known mutual help group, but they go back much longer. And as I'll show you, they actually are an effective modality, even though they're not operated by professionals. And they can be very flexibly applied if you've got somebody who just wants to go to your IOP one day a week, you know, that doesn't fit with the typical IOP of three days a week. And then the insurance company doesn't want to reimburse for that. In the case of mutual help groups, you can show up when you want. One question that is, to me, interesting is that of what I would call the big three of behavioral health, which is substance problems, anxiety, and depression. Now, if you're a clinician, you cannot avoid seeing these things. However specialized you may be, at least the caregiver or parent or somebody of your client is going to have one of these three problems at times. Why is it that mutual help is so prominent with addictive problems and a very minor component of our approach to anxiety and depression? It would be something to talk about. My initial answer is that stigma does not apply to anxiety and depression in the same way that it does to addictive problems, but possibly for discussion. So SMART Recovery specifically is a community. Now, some people will describe SMART Recovery as a program. The problem with describing it as a program is that it implies that SMART somehow knows exactly what everybody needs and the sequence in which they need it. And that's really overreaching our knowledge. This is a community of people devoted to learning about and practicing the self-empowering approach. And the self-empowering term is chosen as a pointed contrast to the powerlessness approach of AA. Both approaches can work. One is not better than the other, although it will be for specific individuals. But this is just a different way to approach these issues. And by self-empowerment, I mean that our focus is not, to make the contrast, accepting guidance from a sponsor, from a group, from a higher power. It's focusing on changing myself, specifically my beliefs and my behaviors, perhaps most importantly, rather than waiting for changes from the outside. Now, certainly the world around us changes, and sometimes it changes for the better, sometimes for the worse, but rather than waiting for any kind of change, the emphasis in self-empowerment is, what can I do? And in many cases, the thing that you can do is seek help. That's an active thing. So that's fine. But at every step, we're asking, what can I do? This self-empowering approach and SMART specifically is important because if we offer multiple pathways, then you can offer choice. And when you offer choice to your patients, there will be increased engagement. People like to choose what they do. There is a term in the psychology literature for probably 60 years called psychological reactance. When I do something that appears to infringe upon your freedom, you will take active steps to show me that you're still free. So if I tell you, you have to go to a mutual help group, my automatic response in many cases, and interestingly, particularly among drinkers, is nobody's gonna tell me what to do, and therefore I'm not going. So we can offer them a choice. I encourage you to attend a mutual help group. They're free, they're widely available. They have a wide range of people in them, particularly the 12-step groups because they have larger meetings. You're almost certain to run into somebody who looks like or sounds like or acts like you, and that's a person you wanna study a bit. If they could do this, maybe you could too. SMART also is explicitly supportive of using psychiatric medications and addiction medications. You just don't have to worry that your patient's gonna be talked out of using their meds. We expect that our clients will have multiple problems, so we're comorbidity-friendly, and as I'm gonna show you in a moment, we're actually suitable across the entire continuum of addictive problems. One of the reasons that I think addiction is stigmatized as it is, is that we have allowed the mentality that there are two kinds of people. You're either an addict and an alcoholic or an alcoholic on the one hand, or you're normal on the other, and what stigma means in the root sense is that you put a mark on something. It's a brand you put on your steer, and that identifies it as yours. If you brand people with, that is, stigmatize them with this label, then you set up the foundation for making them perceived to be different. One of the things I like about SMART is that we welcome individuals who have no history of addictive problems to facilitate our groups. We will train them, and I'm hopeful that over time, we'll get a lot of so-called normal people who, when it comes to talking around the dining room table at Thanksgiving someday, will say, well, I facilitate a SMART meeting, and in many ways, these people have clear addictive problems, but they're normal people otherwise, and I've gotten to like them, and I just think about them differently now that I've been facilitating this meeting. So that's another reason I think that SMART is important. So that ends our introduction. This would be a very small mutual help group. One of the unanswered questions to me is, is there an ideal size of a mutual help group? I get meeting reports. I operate in San Diego. We have about 40 SMART recovery meetings a week. Most of us submit to our Google Listserv discussion group a quick report of our meetings, and the meetings I run typically have 20 or 30 people, but a lot of people will lead meetings with only five or eight people, and it's clear they can have a very meaningful discussion. You get more airtime in a smaller group, so that's an advantage. You get to see more models in a larger group. It may be that attending both sides is important. I think it's an area for future research. So I want to remind you of the information on this slide. Now, you know all of this, and you probably have it burned into your brain in one way, but it may be that nobody ever lined this information up to you quite this way before. This continuum would also apply to a non-substance problem like gambling, which of course is in the DSM, but other activities could be called behaviors or processes might end up in a DSM someday. The category of most interest at the moment for us is misuse, which I'm going to call also subclinical use, but there's harmful use, high risk use, problematic use, many terms for it. It's someone who is having more problems than you would call moderation, but does not yet qualify for a substance use disorder. Maybe they meet one criterion, not two. Maybe they come close to meeting several, but don't actually meet any. As you know, it requires training, which many of you are in the process of getting, and experience to know when someone meets a criterion or not, and anyone who reads English can read these criteria, and you'll see people diagnose others all the time, not on the basis of experience and training. And the typical problem in substance problems is over-diagnosis. You can be somewhat sympathetic to that because that makes it more likely you'll get reimbursed by insurance, but it does tend to inflate the kinds of problems that people have. So this continuum was important, and specifically now because smart recovery will welcome people even in the misuse phase, which might be very brief. It might be one episode of drinking that was heavy, and the poor judgment to drive, and a DUI arrest. It's not enough to qualify for a diagnosis in itself, but it's still a significant problem. So there is a continuum, and if you're looking at a specific mutual help group, you'd wanna know which parts of the continuum it addresses. The 12-step groups began by addressing severe substance use disorders, and maybe moderate, but because there wasn't much alternative, they sometimes got, well, people got elevated into those categories so that it would be considered suitable for the 12-step groups. I wanna remind everybody that human beings are quite diverse, and this picture doesn't begin to do justice to it, and we should never have expected that there would be only one approach to resolving addictive problems. That's just, on the face of it, a completely unrealistic idea. And I wanna remind you of this document from Faces and Voices of Recovery, which I think at this time has become the leading advocacy group for individuals in recovery, as we say. I actually don't like that term, but that's a separate talk. Faces and Voices of Recovery has published a recovery bill of rights, and the importance of multiple pathways is apparently so important to them that they put it in here twice. It's in the preamble, and it's 0.2 of 11 points in the document. So there are many pathways to recovery. I would say there are as many pathways as there are individuals. So let's look at differences between SMART and AA across this slide and the next slide. Perhaps the biggest difference is, and you could say it this way, SMART is a harm-reduction-oriented group, although that's not quite accurate because many of the groups have a very strong focus on abstinence, and most of the people who stay around tend to be those who are abstaining. But at least according to our primary documents, as recently revised, we support progress, and you as a participant establish your own goals. So I could come in with a goal of wanting to moderate. I could come in with a goal of wanting to abstain, to abstain from alcohol, but moderate my cannabis use, abstain from stimulants and opiates, but moderate my alcohol and cannabis use. All of those are options. In order to support someone doing that, regardless of whether they view addiction as a disease, that turns out to be irrelevant for us. We provide some information from the psychology literature. We teach some tools, typically CBT-oriented tools, and we break the overarching task of stopping an addictive problem, which is not the same as stopping an addictive behavior, stopping an addictive problem into four broad tasks, which we call the four points. I'll come back to those. Based on our own surveys, it turns out that most participants believe in some kind of higher power or identify themselves as spiritual, perhaps two thirds of them, but it's just not part of what we do in our meetings. You know, if you take your broken arm to a Catholic hospital, they don't pray on it, they practice medicine. We practice self-empowering approach, the self-empowering approach to change, and your thoughts about a higher power are entirely up to you. People occasionally mention them in meetings, but it's just to describe their own orientation. They're not there or we would not allow anyone trying to proselytize one way or the other. As you might imagine, we're a haven for agnostics and atheists. But as I said, the majority of our participants don't fall into that category. Another way to talk about self-empowerment is that we focus on self-reliance. It's just a different way to say it. Our meetings are filled with what a 12-step meeting would call crosstalk. People talk with one another, and that's the best part of the meeting in many ways. So people who come to us from a 12-step meeting are sometimes shocked by that, but it's considered to be very important. We do not have a sponsor system. We do not use the labels addict or alcoholic ourselves, but if a participant wants to use those labels, we don't object. If someone feels they need a sponsor, we approach that in several ways. We encourage them to go to more meetings or get a therapist or also go to 12-step, or maybe you'd be better off in 12-step with a sponsor. It's entirely up to the participants. Typically, participation is typically months to years. We've had some people around for decades. We're not that old. We got started in 94, so we're at 28 years. What's this, 29 years? And some folks have been around that long. We actually have more long-term volunteers than we have participants. We do support medication, as I mentioned. The terms abstinence, moderation, and harm reduction actually become, I would say, secondary to the term progress. We want people to be making and maintaining progress as they have decided about it. Discover the power of choice. There's that slogan. And choice, you can make distinctions between different substances. So we do not endorse a notion of chemical dependency. Just like the DSM, we view each substance as separate. So let's look at how some of these differences play out in several spheres. One of them is language. In SMART, you might say, well, I drink too much. I have decided that the cost of this excessive drinking, well, that's what I mean by excessive. I'm having costs now that exceed any benefits. There are benefits, and we actually actively work to help people recognize, build the benefits of whatever they're doing. Help them recognize that they don't have to change, but they can choose to change. That's an important difference. Whether you follow along with SMART Recovery or not, I think this would be one take-home message for everybody with your patients about all sorts of issues. Encourage them to make choices. I sometimes remind them that a choice is also a decision. And decide has the same root as suicide and homicide. It means to kill off an option. So if I take job A, I don't, maybe in the second week, I don't show up at job B, which I also consider. I made a choice. I pick one and I go with it. So if I'm choosing some path, I didn't have to do it, but at least for the time being, unless I make a new decision, I kill off that other option. There is typically a transition period, often 90 days, but could be, that's the big effort. But the transition period could last for several years. But we don't encourage a notion of recovery for life. And if somebody wants to be somewhat anonymous about what they're dealing with, they can just talk about their challenge versus a specific addictive behavior. If you have any familiarity with 12-step, you've probably come across this serenity prayer. And we like the underlying concept, so we modified it slightly as the courage intention. Same underlying idea. So that's how a self-empowering approach might shift something. In a sense, everything that is in AA is also in SMART. It's just maybe framed somewhat differently. On the powerlessness issue, I don't know who did your 12-step facilitation course last week, but Joseph Nowinski is the one who wrote the book when they did Project Match in the early 1990s and middle 1990s. And this is one of the statements from a chapter he wrote. Individual willpower alone is insufficient to sustain sobriety. And there's a lot of truth to that. But in the self-empowering approach, we're focusing on motivation, coping with cravings, becoming more rational in our thinking, and achieving greater lifestyle balance. And those are actually the four points of SMART recovery. Maintaining motivation, coping with urges, modifying thoughts, feelings, and behaviors, and living with greater lifestyle balance. So rather than just saying individual willpower won't be sufficient, we're providing some guidance about what to do. Now let me pull in two psychological theories that have been around for a long time. One is locus of control and the other is attribution theory. Locus of control is about our thoughts about the future and how is the future going to unfold. Do I create my future or is my future about what happens to me? Now obviously both of these are true. Because if there's an earthquake in your community tomorrow, that's going to have a big impact on your future regardless of what you are trying to do. But many people move forward with a very self-empowered perspective of making something happen. Attribution theory looks to the past. Was it about me? That's why this happened? Or was it the situation that was drawing certain kinds of behavior out of me? So Brickman and colleagues decades ago put those together but changed the language slightly to talk about problem and solution. And just look at a simple model where we had higher low responsibility for the problem and higher low responsibility for the solution. And that leads to this matrix. All of us have problems of all four types. For instance, in the upper left-hand corner, if you don't pay your bills on time and you get charged late fees, this is pretty much your problem and you're the one who's going to need to fix it. In the lower right-hand corner, if you get cancer, probably not your problem. Or probably you didn't cause it. You might have contributed to it, granted. But basically you've got some bad luck there and you're going to need some experts to help you solve it. The lower left, where this is a smart recovery model, we're not particularly focused on how addictive problems began by whatever combination of circumstances. But the self-empowering approach, we want you to take charge of solving it as well as you can. In the Enlightenment or AA model, you are considered primarily responsible for your disconnection from a higher power, your focus, your failure to rise above your dysfunctional character traits, your character defects. But you're not going to solve it yourself. You're going to need to rely on the sponsor, the group, and the higher power. So it's a way to put together all of these. And I think, again, we all have problems of all four types, but this is a nice way to contrast SMART and AA. So let's look at SMART specifically. On the surface and at the beginning, people come to SMART because they want to stop addictive problems. But in order to do so, they are most likely going to need to become more productive and more connected to other people, which means they can lead a more meaningful life. And that meaningful life makes it, well, hopefully pushes them to the point where they don't want to go backwards into the addictive problems they have, because why would I give up life now? It's pretty good. Aristotle suggested that the ultimate purpose of life was to become happier. Of course, he lived in simpler times. Other people are talking about just having a meaningful life or having a satisfying life. That's an issue we don't need to solve today. But certainly people come in on the surface to stop addictive problems, and then hopefully we push them on to having a better life. In the process of stopping the addictive problem, we encourage them to pay attention to these four areas of motivation, graving, managing thoughts, feelings, and behaviors, and improved lifestyle balance. We, in the early days, thought that this was probably a pretty good summary of the broad tasks that most anyone would need to address in some fashion. Maybe motivation was already high or craving wasn't a big issue or lifestyle balance was already there. So if you've already solved this, then that's fine. But these appear to be pretty widely applicable. If, then, you have challenges with any of these, there would be a large number of subsidiary tasks that you might need to tackle. I've listed a few possibilities there. There could be hundreds of them that people can talk about in meetings. They're having trouble with their boss, their partner, their children. They don't know how else to relax, et cetera. So we hope to provide them with some coping information and some guidance on the books and websites and videos that are available to help people learn about those things. If you're at all familiar with Smart Recovery, you know that we are very big on tools. And I have listed some of these. If you know something about CBT or MI, none of this will be really new to you. You might not recognize the names, but all the concepts here you already understand. I'll come back to REBT in a moment. This rounds out a typical list of 10 tools that we use in Smart Recovery. HOV is hierarchy of values. USA is unconditional self-acceptance. The two most commonly used tools are the cost-benefit analysis, CBA, and the ABC, which I'll get to on the next slide. So cost-benefit analysis, we almost always begin by asking, and I'll just focus on alcohol because that's easiest, but this could apply to any substance or any addictive activity. We would usually ask, what do you like about drinking? What does it do for you? What's good about it? Some version of that question. We want people to know the answer to that question because it tells you what they need to develop. In simple terms, if I drink to relax and I quit drinking, how am I going to relax? Maybe I should start focusing on learning how to relax before I quit drinking. We certainly want to acknowledge the value of being able to relax. We'll recognize that as you're building up your relaxation skills and lowering your alcohol consumption, that change might take some time. Then there's the activating event, underlying belief, and emotional or behavioral consequence of events in rational emotive behavior therapy developed by Albert Ellis out of New York City. These are ideal for addressing any sort of emotional upset. This is the essence of cognitive behavior therapy. It's the essence of stoicism. It is not events, but my view of them that shapes how I will move forward. We also talk about an ABC for urges or cravings. We use those terms interchangeably. But actually, this is information. It's not a tool. You can think urges or cravings. You can think hunger. You can think desire to drink. You can think sexual arousal. All of it is time-limited. There may be different time frames. Hunger can take hours to go away, but typically a craving to drink, for instance, might only last a few minutes. It might last longer. It's not harmful to you, and it doesn't force you to do anything. When you remember that, time-limited, not harmful, doesn't force me to do anything. Then the sensible approach to dealing with them, if I want to stop drinking, or at least reduce my drinking, is to wait them out because they're going to go away. So that's information, but extremely valuable information. If there is a fundamental tool in SMART, I would say it's that we have the capacity to reinterpret our experience. I'm going to say even more broadly that the fundamental task of all psychotherapy, this is a broad statement, is to reinterpret our experience. Sometimes placing that experience in a broader context is a very helpful guideline, but probably not the only one. Towards the bottom of the slide, I have listed various contexts or ideas that different approaches to psychotherapy might consider. When, in the course of psychotherapy, I learn more about the kinds of things listed there, it allows me to reinterpret some of the experiences that I am having now. This is a bold statement, but I invite your attention to it. I think it describes a lot of what you're doing during the day when you're interacting with patients. We also provide basic information, and we encourage people to practice with that information. We tell people about extinction. We've already talked about craving. If you just wait, it's going to go away, but it also applies to fear. In CBT, we teach people that automatic thoughts can be inaccurate. Just because a thought pops into your head doesn't mean it's true. We have the capacity to soothe ourselves, and we give them different opportunities to practice. Hopefully, they will practice on their own as well. To summarize what happens in SMART Recovery, or what we're hoping will happen, whatever long-term goal people have, whether that's happiness, meaningfulness, satisfaction, we assume it's along the pathway of being more productive and more connected. To remind you, Freud said, to love and to work. I've just put it in different words, but that's where we're going with that. Of course, as a prelude to that, to stop addictive problems, we use those four points, which are really tasks, motivation, coping with craving, managing thoughts, feelings, and behaviors, and having a better lifestyle balance, and whatever subtasks are needed. We teach some tools. We do provide social support in the broad sense of that term, and I have suggested that the fundamental tool is reinterpretation. You could call that creating a new story, writing a new narrative, however you want to do that. Okay. I think we're ready for this one. How is this one going to work? Is this going to pop into the chat or where? Is this coming up on the screen, Nicholas? Nicholas, are you there? Is this where people should just put any kind of responses they have into the chat box? Correct, I believe so. And then maybe a discussion. Okay. Common challenges or complaints that you have heard about mutual help groups. Although we won't have a lot of time for this because we're right on schedule, but I don't want to fall too far behind. I'm going to assume a few people are typing, so I'll wait just one moment. I don't understand the poll. I think this is just a question that we were just placing for people to have some kind of response that wouldn't, I guess it doesn't really correlate with the poll because there's not a multiple choice answer. A mutual help group is a good place to learn more about drug use. That's absolutely true. A hospital, which is the place that you want to get cured is also a great place to catch an infection. Consequently, mutual help groups and hospitals need to be run as carefully as possible so that that sort of thing doesn't happen. Hospitals may have more control over it. We can't stop people from talking in the parking lot, so we do our best. They can be hard for people with trauma. We have identified some specific groups like in SMART, we have veterans only groups and other special populations. As we get bigger, I hope to have more of those where people are screened before they come in so that they truly are with peers. That's the big fear, Dr. Stifler, that no one will understand me, but the most common when I check out with a group asking what was most meaningful to you, and very often the comment is, I'm not alone. Let us move on for now. Thank you. SMART recovery is this intersection of what is a self-empowering perspective. Does it have a foundation and evidence-based treatments and would it actually work in a mutual help group? We're not prescribing anti-abuse or doing couples therapy. But the therapies that we do rely on are mostly CBT and MI, but we can draw tools from a variety of sources. We do support medication and we do attempt to support the relationship orientation of common factors in psychotherapy. In the future, we will probably draw more on third-wave psychotherapies. We may introduce the cognitive biases like confirmation bias. There's an entirely different approach to change, a non-willpower approach to change developed by David DeStaino at Northeastern University that looks at enhancing the pro-social emotions of gratitude, authentic pride, and compassion. We haven't done much with this yet, but I hope that we will. I know in San Diego, we've made a big emphasis on creating more community, and I hope that nationally we'll be in a position to do that. If this were a SMART recovery meeting, I would say, welcome, my name is Tom, I'll be facilitating today's meeting. I will give a brief introduction. The most important rule is that no one is required to participate. I will go around the circle probably several times when it comes to you, just wave your hand or say pass if you'd prefer not say anything. If it's a Zoom meeting, you can put listening after your name, or you can leave your screen off and I won't call on you, or you can change your mind in the middle of the meeting as well. This is a confidential meeting and a free meeting. No one gets to talk too long or too often. We want this to be conversational. We do not give advice. We do not tell you how to talk. Use the language that you like. We may have some suggestions and ideas for you to consider. We hope that they'll be helpful. But ultimately, our slogan is discover the power of choice. We want you to help figure out what works for you. We do stay on the topic of addictive problems and how to resolve them. And we focus on making whatever progress makes sense to you. One of our other slogans is to do SMART recovery. We're not going to talk about SMART, we're going to do SMART in this meeting. After this introduction, or welcome, we're going to go around the room. Again, say pass if you wish, otherwise tell us what you'd like us to know. We'll take a moment and figure out what to talk about. That's my job, but I will ask for some input. The majority of this 60-minute meeting, we also have a 90-minute meeting, will be discussion. We'll figure that out at the time. I'll make some announcements, and then we'll check out. When we check out, that will be your chance. Pass if you wish, otherwise tell us what was most meaningful to you about the discussion, or give us any final thought that you have, or perhaps most importantly, say thank you to someone for something they said. We have multiple types of meetings. We offer facilitator training, host training. Some meetings are just check-in, go around the circle, and by the time you're done, the meeting's over. We sometimes use a tag format, so I'll ask for one volunteer, and then that volunteer picks the next person to check in, and so forth. Turns out to be a great way to build community. So somebody says, okay, yeah, that's my check-in. David, I want to hear from you. I know you were doing that job interview last week. How did it go? And people really like the fact that somebody remembered what they talk about. And we have other more topic-oriented meetings as well. In this organization now, we're certainly not faced with problems like of the U.S. government or the Catholic Church. I mean, we're not that size, but you can only monitor so many things. So these are the kinds of things that we try to monitor. We are not the only way. We want to support choice and the others that are listed here. We do pay some attention to the conduct of our meeting leaders. This is important because we don't want them misbehaving. So we have a code of conduct that is similar to a therapist's code of conduct, and they have gone to some training in order to run a SMART meeting. And one of our phrases is also that SMART recovery happens in public. So we don't have private one-on-one sponsor meetings because we can't monitor those. And we do over the course of the year now with, well, we've had tens of thousands of volunteers over the year, and we do part company with some of them. Imagine, I'll switch topics here slightly, imagine that you come across a handful of individuals and they are doing each of them this activity, and you ask them, what are you doing? And you get the following answers. I'm laying bricks. I'm building a wall. I'm building a community center. I am making a contribution to my community. I am making a contribution to humanity. Each of those persons is laying bricks, but they conceptualize what they're doing in different ways. I gave them in a hierarchy to the most advanced way I could think of. And I believe that one of the advantages of SMART recovery is it can talk to people at different levels of psychological development or conceptual development. And that, I think, is a huge advantage. That can happen also in 12-step meetings, but it might not be as easy there. Despite these surface differences, which I've tried to describe in some detail, we have people who go to both meetings, and I take into calling them dual citizens. I wrote about it some years ago, and Bill White and John Kelly picked up on the idea. I'm very curious to see what happens if SMART ever reached parity with the 12-step groups. Would we still have them? I don't know. And this would be an example of doing an exercise in a SMART recovery meeting. Let's talk about the organization. This is an international nonprofit. The 3,000 meetings was true probably pre-COVID. I honestly don't know what it is now. Most of them are on Zoom. We operate in multiple settings, both the community, of course, but in prisons and jails. Online, we have publications. In addition to offering meetings and related services, we support the notion of choosing your own pathway. And the history... SMART is a spin-off from a predecessor organization called Rational Recovery. It may be that most of the people on this call are young enough that they've never heard of Rational Recovery, which is fine, but for those who are interested in the history of this, that organization got started in the 80s. Jack Trimpey, the founder, wrote the small book, and in case you missed it, that's the opposite of the big book, and he applied REVT to addiction. He spun off a nonprofit. A bunch of us actually showed up in 1991. We stayed involved, and by 94, the nonprofit ended its affiliation, became SMART Recovery, and we've continued to expand since then. Rational Recovery has gone off in its own direction and stopped running mutual help groups around the year 2000. One of the biggest boosts for us was a set of First Amendment court decisions. The First Amendment of the U.S. Constitution states in part, quote, Congress shall pass no law respecting an establishment of religion or prohibit the free expression thereof, unquote. And that means that because AA is viewed by the courts as religious enough, the government cannot require you to attend an AA meeting. It can require you to attend a mutual help meeting. There have been court cases about this, and damages have been assessed. So if you work for the government, don't put yourself in the situation of requiring someone to attend a 12-step meeting. You could be sued, and there are many parts of the country that violate this, but in time, this will spread out where it needs to be. These are some other resources. Bill White, William White, the preeminent historian of American treatment, and he's done quite a bit of work documenting the histories of multiple mutual help groups, and the link at the bottom is where his papers about SMART can be found. When Google donated an ad campaign 15 years ago or so, that was a big help to us. We started in prisons in 2001. This International Advisory Council was really just for the U.S. A number of these individuals have since passed on. We don't really use them anymore in favor of a Global Research Advisory Committee, but I mention them because we want to honor the fact that they helped us get going at the beginning. We have affiliates now. This was a U.S.-based organization. About five years ago, we moved everything into an international organization, so the U.S. is now an affiliate of the international along with a few other countries. I think we're up to 31 or 32 countries now with a handbook in over a dozen languages. Let's look a little bit at the science. AA is now well-established by Cochrane Review to be, essentially, I'll gloss over some details, as effective as CBT, and CBT is widely thought to be as effective as anything, as a psychotherapy. If anything, AA is even more effective than CBT for helping people accomplish abstinence. If you're familiar with Cochrane Reviews, I believe this is the state of the art for how to review literature. And it's not without its challenges, but this is a very solid finding based on multiple studies. AA is effective and presumably as effective as anything. I also point out here, this is a paper over a decade ago, but it looked at the different psychotherapies for alcohol use disorder specifically, and concluded that there was no adequate basis for declaring that any one psychotherapy was more effective than another. And there were some therapies in here you might not expect to do as well against CBT like a psychodynamic approach. And this was another nudge in the direction of recognizing common factors in psychotherapy. And this was John Kelly's, he was the principal author of the first paper, the Cochrane Review. What's noteworthy about this quote is that on the one hand, John Kelly is a Harvard research professor. He's the first endowed chair in addiction psychology, which is quite impressive. And he's a hard scientist. He does a lot of number crunching, which is what hard scientists in psychology often do. And he ends up quoting Carl Jung, who is anything but a hard scientist. Certainly an important figure, but not someone anybody would call a hard scientist. And he quotes Jung to say that what AA does is to provide the protective wall of human community. That's the best summary that John can come up with given all the data he's crunched. So I think that's noteworthy. And that leads him to conclude after looking at the various mechanisms, there's six different mechanisms of action in AA, quite different from one another. AA helps different people in different ways. And if you wanna remember any take-home message about AA, I think that's the important one. AA helps different people in different ways. That's on the same page of this article. This study was the first longitudinal study to compare AA with three other mutual help groups, Women for Sobriety, Life Ring, and SMART. So this was a big finding for us because at 12 months, she and her research team, Sarah Zemo, are saying results tentatively suggest that these three groups are as effective as 12-step groups for those with alcohol use disorder with a reasonably large sample after one year follow-up. So that's the kind of data we were looking for, but there was actually at least two other studies that make that head-to-head comparison. This one's relatively old. This went for five years, funded by NIDA. They had to make the 12-step program less confrontational. Remember, this is 20 years ago, 25 years ago, because if they continued with the typical 12-step confrontational approach, the 12-step program might not have survived, but the subjects kept dropping out. If you've ever conducted any research, you know that there's nothing that gets your fire alarm ringing better than having subjects drop out of your study. Once they could stabilize the groups, they discovered that in this population, in a day hospital situation, the results were comparable. And this was just a survey, but it got the same results that we expected. This is some years ago. What was noteworthy here for us is that SMART and SMART outcomes were unrelated to someone's religious orientation, whereas religious orientation did have an influence on participation in the other groups. And this is exactly what we wanted. We were trying to be agnostic about religion. You could have whatever religion you wanted. The biggest study about SMART was conducted in Australia, published a few years ago, looked at 5,764 inmates. Some of them got a didactic course called Getting SMART. Some of them went to SMART recovery meetings. 306 of them went to both. There were matched controls. The outcome measures were reconviction for a violent crime, not charges, but an actual reconviction. If you went to the SMART didactic presentation, provided you did at least 10 to 11 sessions, there was a 30% lower reconviction rate for violent crime, and it was 42% lower if you did both the didactic and the SMART. If you did both the didactic presentation and SMART meetings, that's a pretty good outcome in itself, and it's certainly a cost-saving outcome. One study looked at locus of control. We talked about locus of control earlier, what predicts the future. The problem with this study is that it's a cross-section in time. By the time these surveys, the p-values are, well, the first one's quite remarkable. You don't typically see a p-value of 0.00003, but I think all of these participants were socialized to know what to say if you're a SMART participant or an AA participant. You're either self-empowered or powerlessness, but it would be interesting to see if people varied on locus of control to begin with, if they oriented to one group or another. This top reference is a systematic review of 12 studies that was published now six years ago in Psychology of Addictive Behaviors, which is arguably the leading addiction psychology journal. There is William White's set of papers about SMART. And now we're gonna look for just a few minutes at the study by Hannah Reddy and her colleagues and she looks at, I think it was, 30 different mutual help groups. So I've just listed here a number of mutual help groups. These are the ones I'm calling secular. They don't have any particular spiritual or religious orientation. The bottom one is interesting because it's all done in virtual reality. I've done some of those meetings and they can be completely anonymous. It potentially will be a platform that people would attend even if they wouldn't attend any other. And here are some religious or spiritual groups typically affiliated with a church and one could find them by seeking out one's church. So Reddy, as part of a larger study, identified what in the eyes of the participants are 14 components or factors that make a mutual help group meaningful to them. And they identified that these factors are actually present in the groups that they attended and that they were important to the participant. And five of those factors, which I have bolded, stood out. The way I sequence these, although she did not give them a sequence, I think people come to groups because they hope to develop coping skills and to learn about what she's calling a sober lifestyle. They can bond and support with others and they have the chance to give back. They discover that something they've said touches someone else. And all of that builds self-confidence that this is a challenge they can rise to. So there are those five components again in that order. And it leads her to this statement. Despite the variety of different recovery groups involved, all with different structures, underlying approaches and theoretical frameworks, it seems that participants rated the components similarly. This supports the suggestion that recovery groups have universal components, and this has been an idea for a while. And it is the similarities, not the differences that make the groups successful. This is a paper about psychotherapy that comes to the same conclusion that there are common factors in psychotherapy and they have been variously identified, but the client brings, of course, some level of motivation, but there's the alliance, the goal setting, the implementation, the commitment. I would also add empathy, the capacity of the therapist to empathize and listen well. And it might lead you to wonder about just what the therapist's role is. So I'm gonna make a comparison. At one time, someone might've argued, I'm leaving out the upper left-hand quadrant, that Italian food or Chinese food or Mexican food was really the best food. It's the most nutritious, the most healthful, healthful. And you could probably argue that without serious objection until somebody figured out that what's common in food is proteins, carbs, fats, and the micronutrients. And then you could also figure out that there are some foods like McDonald's and french fries, hamburgers and french fries that might have ingredients you don't want in your food. So these common factors, until we thoroughly understand them, we can still allow room for taste in food, but food needs to address those common factors. And both the chef and the psychotherapist increasingly need to pay attention. Well, chefs have been doing this for a long time, but psychotherapists need to do this as well. What are the common factors? I can pick, I would say, my orientation to psychotherapy as one that suits me. And as long as I get the common factors in, I can do a good job. Now, given all this, which mutual help group do you think people choose? I'm gonna tell you about a facility in Chicago, and this is not in print. I'm hoping for them to conduct a study, but I communicate intermittently with the executive director. He's also on the board of Smart Recovery, which I am on. And he has a clientele that is anything but sophisticated. This is inner city Chicago. They are typically relatively less educated on parole or probation. Many of them have been homeless. They are typically black, but there's a wide range of people there. I've been to the facility twice. 75 to 90% of them, when given an equal introduction to AA and Smart Recovery, choose Smart, even though they're not the kind of egghead population that Smart is supposed to appeal to. So I find that a noteworthy finding. But also what's important about groups, and particularly non-Telstra step groups, is that the leader is very important. You'd probably rather attend a group led by the woman on the left than the guy on the right. So in Smart, we work to make people show up to meetings with a smile on their face. So here's another question. This is a survey. What are the four points of Smart? And then we're going to wind to a close and hopefully have some questions. So you're going to be thinking about those. So put your answer into question number four. And we'll see the results in a moment. From what I can see, all of these things would be pretty good to do. But there is only one right answer. I don't know whether this is a test of you or a test of me. Knowing that this question was coming, I did try to repeat the four points at least three times. But I live with them all day long, so I don't know that others would remember them as easily. Well, that's pretty good. Thank you. I guess we both did pretty well. OK, so we just did an update on SMART. Those were the objectives, the slogan, the differences, underlying similarities. We looked at 14 of them. I highlighted five of them. Hopefully, you will just remember that there are multiple effective pathways and SMART is one of them. There's that slogan again. We looked at these key differences. There's five here. There's five here. And these were on the opening slides. Those were the components, the five highlighted. And here's the conclusion that AA provides a protective wall of human community, which is, of course, what all the mutual help groups do, which means they help people in different ways. That's the National Office of SMART Recovery. And if you wish to reach me, that is how to do that. And I think that is the end of our show. And that leaves us almost 20 minutes for discussion. Dr. Virginia, do you make a distinction between disease and illness? I'm having trouble understanding how SMART supports medications for moderate to severe substance use disorders, but does not see substance use disorder as a disease. So help me. Why would it be necessary to view a substance use disorder as a disease in order to take a medication for it? We know that the medications are helpful. There's good evidence, particularly for medications for opioid use disorder, but also in the antibuse and naltrexone. And yeah, elucidate your thinking a little more. What is your concern about? And here she is. Hi, yeah. Thank you for that. Yeah, I mean, I guess I'm not necessarily advocating for putting a label on people, and particularly if they don't see their behavior as a disease or an illness. But I guess I'm wondering, because I'm not that familiar with SMART, whether there is an emphasis on really not seeing addiction as a disease. And again, I don't have a particularly strong opinion on whether to call addiction a disease or not, and we can have a conversation about that. But it's certainly been useful from a medical standpoint in getting a lot of funding, first of all, but also for a lot of folks, it's been helpful to find an explanation to what they're going through and to put a name to it and, I mean, yeah, I mean, honestly, substance use disorders are in the DSM-5. They're a psychiatric illness like any other illness. So I guess I don't see a real negative connotation to calling someone with a substance use disorder. And I understand that not everybody attending a SMART meeting might meet criteria for a substance use disorder. But for those who do, I wonder whether there is a big emphasis on not seeing it as a disease and whether that might be, I think harmful is maybe too strong of a term, but whether that might be unhelpful to them, I guess. So in SMART, at one time, we were explicit that addiction was not a disease. And about 15 years ago, we said, we don't need to fight this battle. And it also turned out that about a third of our participants view addiction as a disease, a third don't, and a third don't know or don't care. That was very interesting data. And I think you and I have both seen individuals for whom arriving at the conclusion that I have a disease is a major step forward for them. And so I certainly want to support that when I see it. And we have participants in the group who see it that way. And we have others who don't. And one thing we are pretty clear about is we're not going to fight about that issue. If people want to discuss it, that's certainly fine. And if you don't view it as a disease but the medications are helpful, then use them. And if you do view it as disease but you don't want the medications, and I've seen that, well, have another conversation with your psychiatrist and see what you want to do. We're trying to stay clear of that whole issue. I will tell you, and maybe it flavors some of my perspectives, that I do view all addictive problems across the continuum as learning disorders, recognizing that biology is a key part. But that's an entirely separate conversation. Different conversation, yeah. Yeah, so we're not going to go down that road today. OK, yeah, thank you for clarifying that. I feel much better, much better understanding now. Yeah, thanks. Yeah, thanks for your question. Dr. Horvath, first of all, thank you for the lecture. I feel smarter for having attended and learned much more about SMART recovery. But one of the questions I'm having is about the facilitators. It seems like it's such an important part of this. And there's probably a lot of variability depending upon if you have a good facilitator versus not a good facilitator. Are there requirements to be a facilitator? Is it the same facilitator each week? Can you go a little bit further into describing that? Well, you have insightfully gotten to the heart of one of our major challenges. We typically have the same facilitator each week. Quite a few professionals volunteer. Since the pandemic began, I have run over 450 SMART Zoom meetings. One point I was running one a day, and then I dropped back to four a week for a couple of years. Professionals are very involved in the organization. And I think it's fair to say we run better meetings than the average layperson. But we have some excellent laypeople, and we do train them. But in an effort to make the training simpler, I, over the last couple of years, have drafted about five dozen meeting scripts. So the script has the introduction. I gave you an introduction earlier. I just wrote that out. Somebody can read it. And then I have 200 words on a topic, what I was calling earlier a subsidiary task. So assertiveness, communication, stress management, 60 of them. And then a set of questions, and the questions are often very broad, like what ways do you relax when you're stressed out? And I just have the facilitator go around the room. Everybody answers the same question, and then they talk about it if they want. It's striking, and I ran one group only using the script. I sort of tamped down my own facilitator skills, and I just used the script as an experiment. The answer changes as you go around the room. People are responding to one another. And if there's something going on that's important in their lives at that time, they always manage to get it into the discussion somehow. So you never actually rule them out of what they want to talk about. And the advantage of the script is as long as someone's got basic human ability to talk with people, they don't have to know a huge amount about smart recovery or even addictive problems. They stick to the script, and they can run a meeting. And I have been an advocate within SMART for running meetings this way. I've gotten some significant pushback from within SMART because there are people who've spent years learning all those tools I showed you across two slides, two sets of tools, change plan worksheet, et cetera. And they're a bit offended that somebody who could just sit there and read a script is going to run this meeting, but it has been one way to address this problem. And fortunately, your question could also be applied to sponsors in a 12-step approach who we think are in a position, and generally that relationship is very good and very helpful. So I don't want to criticize it in general, but if it goes wrong, it can go wrong in a big way. The advantage SMART has is that everything happens in public. So at least in San Diego, if something's going wrong, I fairly quickly hear about it and can jump in and do something about it. So that's my best answer so far. Are facilitators more often kind of outsiders who do not have problems with drugs or alcohol, or is it a mixture of both? It's almost always somebody who has come up within the meetings. We would like, I'm looking now, I won't mention the name, but I'm looking to partner with a national service organization to recruit facilitators from their ranks. How well we'll do, I don't know, but yes, we'd like to get the public more involved. We need more meetings. It's our biggest single problem. Well, just- So let me ask the audience, Dr. Blazer, you had another question? No, you please go. Okay, what has been your experience of attempting to persuade your patients to attend a mutual help group of any type? How did it go? How successful were you? What arguments seem persuasive, if any? Anybody like to share their experience? Well, Dr. Blazin and Dr. Stifler, I think one of you is gonna have to answer this question. Yeah, I mean, in my experience, it's not a lot of people that I'm working with are going to a meeting like for the first time after already meeting with me and like engaging in individual treatment or maybe, you know, seeing me and a therapist. The people, so of that small group of people that actually have gone to a meeting and maybe engaged, I think, I mean, it kind of echoes SMART, like it's the power of choice. I think the best way I frame it is tap into their motivation and have it feel like, you know, they have a strong desire to get better, you know, whatever that means. They're not as better as they'd like to be yet. And so I view my job as like, as the expert in this working, you know, collaborative work that we do is to like present them with options that are supported. And, you know, and I think that's the most likely way for people to actually go, as opposed to me, you know, bringing it up or beating over the head with it or just bringing it up once and then not bringing it up again. And that seems to have worked for a few people. Do you remember a time when it was standard to refer people by saying, you need to go to meetings? And of course, what you meant was 12-step meetings and there was really no other alternative to present. Were you professionally active during that era and did you make the change? What was it like? No, because, yeah, I mean, I was introduced to SMART during fellowship. So my memory is that I was, you know, options were available and I personally can imagine why people have a lot of difficulty, you know, engaging or kind of like accepting some of the premise of what it is to go to a 12-step meeting, like the powerlessness and, you know, identifying as an addict or having, you know, just kind of having that modeled. So I was, you know, very interested in people having like an alternate option to that. And then, yeah, that's what my experience was. Okay. My experience is that, you know, it becomes a significant part of literally every encounter I have with patients and I bring it up with everybody and not just once. I, you know, the data is so strong and from my anecdotal experience, people who engage in some sort of self-help almost always universally do better. So I asked them, what was the meeting like? You know, tell me something that you liked about it or didn't like about it, not just did you go to a meeting, you know? And I also, there's like apps that have like meeting guides so that I encourage them to look up the app and put it on their smartphone right at that moment. I mean, and that's another question, is there something similar for smart recovery? You know, I think that it would be great to have more options like that to pass along to people. But yeah, I think it's an incredibly important aspect as an adjunct to what we do in the office and, you know, free and readily available. Yeah. There is a smart app, which I think you can download from the national website. If you want to look at the meeting scripts that I mentioned, they are on the San Diego website. So that's smartrecoverysd.org. And between either the national site or the San Diego site, if someone at the last minute says, hey, you got to run the group that starts at, what is it here? Eastern time, almost 7 p.m. You got to run the 7 p.m. group tonight. You can pull up a script or a handout and have something ready to go almost instantly. So it's a good resource to have. And if you can, well, if you can get people to go, it's a big help. And I think another recent finding is that most people who are successful end up doing multiple things over time and maybe half a dozen. Maybe in a sequence, you know, they make new friends, they have new activities, they go to yoga classes, they exercise more, they spend more time with their kids. There's a lot of stuff. We should look to promote all of those things and encourage them. Dr. Jonathan, your hand is up. There we go. Yeah, I'm sorry. Let me close the door because the dogs are barking. Yeah. Well, I'd say most of my talk with patients about going to mutual help groups occurs in a residential treatment facility. And I ask patients what their experience has been with, you know, with groups, usually I ask about 12-step groups. And, you know, and then I talk with them about it. Often the, you know, for instance, the most recent patient I saw objected to the religious nature of AA. And she had been raised by a Jehovah's Witness mother who took her out of the gifted and talented group at school because it was, her homework was taking too much time away from Bible study. So what I do in that case is I ask, actually we have a non-denominational chaplain in with the program. And I talked with the patient about whether they'd be willing to talk with the chaplain because, you know, I see that as a, well, and hopefully the chaplain can help them understand the difference between religion and spirituality. And so I've, anyway, that's one of the, that's how I go about it, as well as, you know, then I encourage patients to try a multiplicity of groups that I say, you know, particularly for women, if you're going to buy a dress, an expensive dress, you wouldn't just look in one shop, look around, there are different meetings. And, you know, I encourage patients to look in one shop look around and meet, there are different meetings and, you know, you got to find one you like. That general theme of checking things out and trying different options, talking to as many people as possible, all of that is very helpful. And to respond to Dr. Virginia, yes, at least in the meetings in San Diego, we've tried to make the, sometimes talk about low threshold approaches to treatment. We've tried to make it as simple as possible. You're not required to participate, not required to put your screen on. And hopefully people find something they like. I would say one of our biggest successes has been the people, quite a few of them now, who are required to attend for DUI requirements and they continue attending after their requirements are completed. I'm going to try to squeeze in one more question. So I love the fact that smart recovery seems to have like a harm reduction spirit from where it starts. And I think this may have led to a little bit of my own bias that I get the sense that, you know, maybe people who are more serious about, you know, recovery might, I might try to direct them towards AA and people who like are more ambivalent, I might direct towards to smart recovery. Is that an inaccurate bias to have that I should overcome? Well, most of the people who stay in smart are pretty serious. I think a smart meeting is less likely to turn someone off than a 12-step meeting. But I, you know, I don't know for sure. That may be my bias. If I were only referring them to one because they were right on the edge of not going, I would send them to smart. I do remember this was a stunning moment in my career and it's probably 20 years ago. I had this man who's had drinking problems for 10 years. He's in his fifties. And I said, well, have you ever been to a mutual help meeting? And he said, no. Well, I encourage you between now and our next session, go to smart, go to AA and come back and tell me what you think. He had gotten to me, I don't know how. He wasn't looking for a self-empowering approach. He just wanted to shrink who dealt with addiction. So he comes back and I practically fall off my chair because he said, you know, I didn't see any difference between these groups. They're just a bunch of people trying to help each other. And that's when I realized that I'd been spending the last 15 years of my career building up a difference between these two groups that didn't mean something to everybody. So if they'll go to multiple groups, that would be great. If they only go to one, it might be better for smart, but there would be other individual factors to consider. And I'm gonna jump in because it's 4 p.m. here in San Diego. I very much appreciate this invitation. I hope it's meaningful to everybody. I'll hang out for a moment, but I'm gonna turn this back over to the moderators. Well, again, thank you again, Dr. Horvath. And everybody, you know, next month, we have the psychoanalytic psychodynamic approach to psychotherapy for addiction. So please join us for that. Please fill out the evaluation form and fill out your form through the AAAP website to get credit for your CME. So thank you again, Dr. Horvath. Thank you, Dr. Horvath. Thank you. Bye.

SMART Recovery

self-empowering approach

addiction treatment

differences with 12-step programs

CBT

MI

medication-based treatments

multiple pathways to recovery

maintaining motivation

coping with cravings

managing thoughts

achieving lifestyle balance