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“SMART & Healthy”A group wellness program based

on SMART Recovery®

Presented at the 13th Annual Summer Institute,

Prescott, AZ, July, 2014

Marie Davila-Woolsey, PhD

Pat Penn, PhD

La Frontera Arizona, Tucson, AZ www.lafronteraaz.org

Acknowledgements

Studies supported by grants to Penn from:

- NIDA RO1 DA08637

- SAMHSA CSAT #KD1 TI12539

Co-Investigators:

Audrey Brooks, PhD, Denali Brooke, MSW,

Sandra Gallagher, PhD

Presentation Overview

• Background and need

• Results from our previous studies

• Introduction to SMART Recovery®

• Smart & Healthy adaptation

• Meeting simulation

• Thoughts from participants - videos

• Conclusions and Implications

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Background

• Participants in a CBHC dual diagnosis program who reported having a chronic health problem (30%) were significantly less likely to complete substance abuse treatment (Brooks & Penn, 2003).

• Women with both psychiatric and medical problems were significantly less likely to be retained in substance abuse treatment (Comfort & Kaltenbach, 2000).

• Studies documenting higher mortality rates and inefficient use of medical care in persons with chronic mental illness have been available for decades (Felker, Yazel, & Short, 1996).

Our Survey of Health and

Health Behaviors of CBHC Clients

• We surveyed 418 CBHC clients stratified by

service line to represent our client base

• 73% reported at least one chronic health

problem

• 47% rated their health between “fair” and

“very poor”

• 79% reported recurrent pain in at least one

site

Health and Health Behaviors of

CBHC Clients, cont.

• 66% smoke

• 66% were overweight or obese

• 63% reported high to very high daily stress levels

• 37% get little or no exercise (likely an underestimate of # sedentary)

• 25% drink 5+caffeinated beverages/day

• 76% drink fewer that the recommended 8 glasses of water/day

Health and Health Behaviors of

CBHC Clients, cont.

• 51% of those currently smoking were

interested in quitting or cutting down

• 47% were interested in getting more exercise

to improve their health

• 44% were interested in learning stress

management skills

• 36% reported interest in changing their diet to

improve health

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Our Focus Groups

• Conducted two focus groups with 13 persons

with co-occurring conditions

• 50% female, mean age = 42, mean education

= 12, 23% married or with a domestic partner

• Questions covered four related areas:

• The interaction of mental illness, substance use,

and physical health/chronic pain

• Strategies for managing multiple problems

• Treatment experiences

• Suggestions for improving treatment

Focus Group Themes

• Obstacles (191 comments)

– Behavioral health system, staff, stigma,

negative treatment experiences, medical

system, communication gaps, personal,

complexity

• Facilitative Condition (68 comments)

– Personal strengths, awareness, positive

treatment experiences, living with pain

• Suggested Solutions (20 comments)

Challenges

• Clients with multiple, complicated

challenges and sometimes low

readiness

• Finding effective interventions

• Limited resources

Co-occurring Conditions:

where to go?

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To meet these challenges…

we got SMART!

Because…

Based on a previous study* we conducted

and our clinical experiences, we chose

an intervention that has been successful

for persons with co-occurring conditions

(SMART Recovery®) and modified it for

health behavior change.(*Brooks & Penn, 2003)

Intro to SMART Recovery®Self Management & Recovery Training

• Derived from Albert Ellis’ REBT

• Non-profit self-help program since 1994

• Branched off from Rational Recovery

• Alternative/addition to 12-Step

The main cause of self-defeat is how we think

- We can change how we think if we want to

- Change may be difficult, but it is possible

Motivation for change can be enhanced

Assumptions of SMART

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Nothing New…

“People are disturbed not by things, but by the views they take of them.”

- Epictetus

“There is nothing either good or bad, but thinking makes it so.”

- Shakespeare/Hamlet

Identify ‘irrational’, non-helpful beliefs

Change them to rational, helpful ones

Practice applying new thoughts and behaviors

JJ

The Central Aims of SMART

SMART Four Point Program

Increasing & maintaining motivation to change

Coping with urges without acting on them

Developing new ways of solving problems

Creating a healthy, positive lifestyle

Characteristics of SMART

• Encourages people to use any approaches

that work for them, including medications

• Meetings led by trained facilitators

• Meetings use discussion and “cross talk”

• Uses cognitive, behavioral & motivational

methods

• Originated as a mutual help modality

• Can be used for individual and group treatment

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“As soon as you have made a

thought, laugh at it”

- Lao Tzu

CP

Brenda’s Experience

Why SMART Recovery®?

• CBT has demonstrated efficacy with co-

occurring conditions (CC)

• SMART uses common elements of CBT

• Group formats of CBT are rare

• CBHCs predominately use groups

• SMART is a well developed group format

• Designed for open enrollment

Why SMART Recovery®?

• Is a versatile approach

• Can be used for any unwanted behavior

• Is easy to learn and use

• Useful at all change stages

• Implementation is feasible for CBHCs

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Why SMART?

Data: Our Study # 1

• Public sector treatment for CC

• IOP modality – 6 months

• Participants: had SMI, multiple moderate to

severe challenges (N=112)

• Compared SMART and 12-Step approaches

• Measures: ASI, quality of life and others

Outcomes for SMART:

12 Month Follow-up

• Alcohol use reduced

• Increased employment

• Improved health status

SMART Results:

Clients liked it

• Fewer client complaints

• 25% higher completion rate

• Higher client satisfaction

– Courtesy and respect from staff

– Program structure met needs

– Total scores higher

We do not see things as they are.

We see things as we are.

- The Talmud

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Russell’s Experience

Why SMART?

Data: Our Study #2

• Two focus groups were conducted: Clients

(12), Counselors (8)

• All had experience with both 12-Step &

SMART Recovery® mutual-help

• All participants from a CBHC

Why SMART - Data (cont.)

Clients like it:

• Positive to negative comment ratio:

– 12-Step – 0.3:1

– SMART – 16:1

• Is person-centered

• Led by a trained facilitator

• Is fun

Focus Group Results-

Clients re: SMART

• Tools are taught and practiced

• Wide applicability of tools - treats the whole

person

• Harm reduction approach (abstinence goal)

• Respectful method – no labeling

• Builds self confidence

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Focus Group Results-

Counselors re SMART

• Noted many of the same strengths

• Works even for early stages of recovery

• Useful for persons with co-occurring

conditions

• Helps some be able to use 12-Step programs

Client Comments about SMART

• “SMART gave me pride. It showed me how

to get self-worth. It was basically building

me up in order to be receptive to everything

else.”

• “Cognitive therapy has been good… More

of a positive outlook, the way I talk and the

things I do.”

• “I will never again say that I’m an alcoholic

or addict… that’s a very small portion of

what I am. So that’s what I love about

SMART. We don’t have to self-deprecate.”

What SMART Recovery® Offers

• Excellent support materials

• Annual trainings

• Self help groups

• Online meetings, information, support

• Professional advisors

www.smartrecovery.org

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The Roles of the Coordinator

Facilitate:

Choice

Responsibility

Acceptance

Commitment

Techniques

DB

Welcome

Opening statement/overview

Personal updates and agenda setting

SMART work: discussion, skill building

Homework

Wrap-up and pass the hat

Socialize, sign papers, etc.

JJ

SMART Session: Typical Outline

SMART Recovery® Tools Include:

• Cognitive Restructuring – ‘ABCs’

• Building Motivation – “CBAs’

• ‘Exchange Vocabulary’

• Imagery/mental rehearsal

• Brainstorming, role playing

• Homework, personal incentives

CBA: Cost Benefit Analysis

What do I enjoy about

my problem?

What do I think I’ll like

about giving up my

problem?

What do I hate about

my problem?

What do I think I won’t

like about giving up my

problem?

Consider short and long term consequences

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A=Activating Event: past, present, or predicted adversities

ex: conflict with father

B=Beliefs: thoughts, attitudes, assumptions

“He shouldn’t treat me this way.”

“I can’t stand him anymore.”

C=Consequences: emotions and actions

angry, depressed; avoidance, using

ABC… Components

D=Dispute (Beliefs): identify and change beliefs

“He shouldn’t treat me this way.”

“I would like to be treated differently.”

“I can’t stand him anymore.”

“I can stand this, although I don’t like to.”

The Next Step…D

Four Helpful Questions About Beliefs

“Is this statement factually true?”

“Is it helpful to believe this?

“Is this belief logical?”

“Is this thought relevant?”

“Exchange Vocabulary”

Irrational Rational

must…

should…

have to…

need…

can’t…

prefer…

it is desirable…

choose to…

want…

choose not to…

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…and E

E=Effects: new emotions and actions

Old: angry, depressed;

avoidance, drinking, eating

New: disappointment, sadness; assertiveness, healthy activity

Lisa’s Experience

Smart & Healthy

• Modified SMART Recovery® for health behavior change

• Focus on teaching cognitive-behavioral methods for changing beliefs and behaviors

• Clients chose one or more health behaviors to which they applied the skills learned

Smart & Healthy

• Emphasized three core skills:

– A * B * C method

– Cost/Benefit analyses

– Brainstorming

• To promote healthful behavior change

such as increased exercise, healthful

food choices, and stress management

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Evaluation Measures• BASIS-32

- A standardized measure of symptoms and functioning

• SF-12

- Short form of the Medical Outcomes study quality of life

• CISS (Coping Inventory for Stressful Situations)

- 48 item measure of task, emotion, avoidance, distraction, social diversion

• POMS (Profile of Mood States)

- Standardized mood measure; anxiety, depression, vigor, fatigue, confusion, friendliness

• GES (Group Environment Scale)

- Used to rate group cohesion, support, expressiveness, independence, task orientation and other dimensions

• WAI (Working Alliance Inventory)

- Characterizes client perceptions of the working relationship with group facilitator

- Short form of the Medical Outcomes study quality of life

Evaluation

• BASIS-32, SF-12,

POMS, CISS

• GES, WAI

• Other measures:

Weight, BP, LOT,

IDLER, PANAS,

AIOS, DIRES

• 3 time points: baseline,

exit, follow-up

• 2 time points: baseline,

3 weeks (WAI), exit

• Varying numbers of

measurement points

Participants received small incentives for completing assessments

Results

• Enrolled 10 persons with CC, 2 dropped

within 2 sessions, 8 participated in most

sessions, 6 completed baseline, exit, and

follow-up assessments

• Met weekly for 12 weeks with the first and

last meetings being primarily assessment

Pre to Post Intervention Results

• The intervention was well received

• The pre- to post-intervention results were

encouraging despite the small sample

• There was significant improvement in:

– Total BASIS-32 scores (t = 3.1, p< .04),

– SF-12 physical (t = 3.3, p< .03) and social

functioning (t = 4.0, p< .02),

– Less emotion-focused coping (t = 3.5, p< .03),

and

– Working alliance (t = 2.7, p< .05).

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Follow-up Results

• Statistically significant (or approaching) within-participant improvement over time:

• BASIS-32 Total

• BASIS-32 Relation to Self

• POMS (Depression)

• PANAS Negative affect

• Group Environment Scale - Leader Support

• Group Environment Scale - Innovation

• Working Alliance Inventory

Devin‘s Experience

Now for some Practice!

Role Induction

Take a minute or two and think

about a person with co-occurring

health conditions and get ready to

ready to participate in a SMART &

Healthy session!

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Tasks:

• Volunteer topics, choose one

• Choose technique – ABC, CBA …

• Work with technique

• Group interaction

• Wrap-up

Summary & Implications

• Persons with co-occurring conditions suffer

higher rates of illness and premature death

• Reasons for this are many but include

negative health behaviors

• Persons with co-occurring conditions

indicate interest in modifying their health

behaviors to support improved health and

well-being

Summary & Implications

• Behavioral interventions seem appropriate for the purpose of changing health behaviors

• SMART Recovery® has many advantages

• Pilot testing of SMART & Healthy showed promising results

• Participants found SMART & Healthy acceptable and enjoyable

• Behavioral health staff have the skills to deliver these interventions

Summary & ImplicationsWhy SMART?

Uses best practices for CC:

• Is an integrated approach

• Builds motivation and skills

• Is client-centered

• Can be used with several change stages

• Can be used in treatment and self-help

aftercare

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Summary & ImplicationsWhy SMART?

Clients like it:

• Is person-centered

• Teaches easy to use skills

• Respectful methods used

• Is engaging

• Can be used for any problem

behavior

• Builds self-confidence

Summary & ImplicationsWhy SMART?

Feasible for community treatment:

• Designed for open enrollment groups

• Useful for many problems and different

types of clients

• Is easy, inexpensive to learn and use

• Makes typical CBT and motivational

methods practical to use

Summary & Implications

• CBHCs are appropriate for delivery of

health promotion interventions

• Behavioral health should support clients’

total well being – bio-psycho-social-

spiritual, holism in theory and practice – in

order to offer the best chance at recovery

(not just management of symptoms) and

quality of lifeThank you for participating!!

“The mind is everything;

what you think,

you become”

- Buddha