Wednesday, February 15, 2017

What about Moderation Management?

Moderation

Popular wisdom tells us to be moderate in all things…except abstinence.



 


 


He came to see me on his own with minimal outside pressure. He very candidly shared his history with alcohol, cocaine, and heroin and his success at recovery. He was very high functioning for the population I serve. He worked almost full time and had never had a long stretch of unemployment. He worked low paying food service jobs but tended to keep them for years meaning he could show up on time for work and was productive. He paid his own rent and lived in a boarding house with “a bunch of Cambodian teenagers” who were in actuality all in their 20s. “They’re kind of like my kids.” An impressive attitude for a white man from his generation with little education who is barely scraping by. 

“Eight years of nothing and I was happy about it.” He had started drinking again after a manager he liked quit and his replacement an authoritarian type who often called him a “retard” increased his work stress. Most nights he drank a six pack after work but not every day but two blackouts in the last month had scared him and he had requested to meet with me individually feeling uncomfortable in groups. “It doesn’t look like things are too out of control” I told him. “The things that kept you sober for 8 years will likely help you now. What kind of support do you think you need to reach your abstinence goal? Assuming you want to be abstinent.” He paused. “Sometimes I have a beer in the summer on a hot day. Just the one. I sure would hate to give that up.” I asked him if his goal was to quit all drinking or did he want to try controlling his drinking. “Is that even possible?” he asked surprised. My answer  “I really have no idea.”

If you want to see a group of eyes roll walk into any 12 Step or SMART Recovery meeting and tell them you’re practicing Moderation Management. MM is considered pure nonsense by most people in the USA with any involvement in substance use disorders and the recovery from them. “Once an addict always an addict” the saying goes and it is accepted as fact from the highly educated doctors to the newest recovery coach. People struggling with substance use believe this because no one bothers to dispute it. Research doesn’t support this. Now I’m not going to site sources so you’re going to have to trust me on this. I looked very hard six years ago for information on how many people achieved moderation after being diagnosed and there isn’t much. What I could find was not reliable not using a random sample or control group and relying mostly on self-report. People who are problem drinkers and manage to moderate after treatment don’t come back to tell their counselors of their success. Why would they? They obviously don’t need our help and are like to be told what they have achieve is impossible. What little I could find on the subject put the success rate between 3% and 45%. In other words we have no idea. 

So it might work and it might not work so why was I who argues for research based treatment (at least in the professional setting) printing out drinking diaries and frantically reading the MM website after a session. MM is an unknown but abstinence is proven to work. Here’s a list of reasons I chose to make my first Moderation Management treatment plan as a professional.

1) Abstinence doesn’t always work: 
You quit and you stay quit until you learn to like it. What could be simpler than that? The problem is it’s not at all simple. The majority of people attempting an abstinence plan don’t make it a year, fewer still make it 3 years. If you look at the pattern of people who use while trying to abstain is it that different from people attempting to moderate? What’s worse is that each use can be seen as a failure you can almost see the weight of it on people who have attempted multiple treatments and find themselves back again. Being unable to moderate may not hold the same sense of shame and may increase the client’s motivation to change down the road. It might even work.

2) Many of the skills are the same:
People who try to moderate need the same skills as people. They need to learn to cope with their uncomfortable emotions, they need to overcome social anxiety, they need to address family issues, and they need to like themselves again. Above all they need to change their relationship with alcohol. Abstinence gives us a nice clear cut line moderation is a little blurry. We know a person is abstinent and when they are not but how do we know if they’re moderating? I suggest you look at something besides the tox screen to figure that out. Are they practicing the skills you teach? What about police interaction or ER visits? The world is rarely black and white and a moderation plan will require us to wade around in the grey and don’t forget, it might even work.

3) It doesn’t matter if it works:
If a client’s goal is to moderate I recommend the counselor begin with the assumption that moderation is possible. It could be the client will never be able to moderate even a little but think of the relationship you can build exploring that together. Supporting a client’s goal to moderate shows that you are respecting the client’s autonomy. The therapeutic relationship works best when it operates as two adults making choices together. The alternative is usually the counselor plays the role of a parent, the client a child and children rebel. Successful counseling is about connection and respecting a client’s choice to attempt moderation provides an opportunity to connect before the client is ready to attempt abstinence and that connection can be used to help the client with positive change whatever the level of success. Abstinence will always be there if moderation doesn’t work.

Stanton Peel has made the point that we have an “abstinence fetish” in the United States and it’s something we’ve successfully exported to much of the world. The problem is by focusing on abstinence we invariably become drawn into a moral judgement where using is a sin and the user a sinner. This judgement is poison to the therapeutic relationship and it closes our minds to new ideas. It may be that research will someday prove that moderation is impossible past some  point and on that day I will gladly retract all I have written today. However, if you find yourself drawn to treating people struggling with addiction you are entering  a field that is just coming  out of a dark age of mysticism and faith healing mascaraing as medicine and it will behoove you to keep an open mind. 

Monday, January 2, 2017

Heroin Has an Image Problem

Heroin has an image problem 


The most significant factor in the epidemic of opiates related overdose deaths has nothing to do how strong it is. Yes strong dope can kill you especially when it's laced with one of the many horror show opiates being manufactured overseas and shipped here but opiate overdose is survivable. Even if you don't have a Narcon kit (and if you don't shame on you) a person who overdosed can be kept alive a free from significant brain damage with simple rescue breathing. With Narcon you can have a person up and talking to you within minutes and there is more Narcon on the streets and people trained to administer it yet the bodies continue to pile up. The news feeds us more nonsense on how strong the new synthetic on the streets is and we all gasp and tut tut every now and then someone floats some asinine idea like forcing opiates addicted people into detox and possibly rehab.

http://www.rehabs.com/doing-time-should-we-force-people-to-get-clean/ 

An idea which is almost certain to increase the number of overdose deaths yet people both in and out of the recovery field jump on board screaming "it's about time" completely ignoring the fact that there is no evidence this will work. I can't blame them really. It's an outcry of people who are watching friends, loved ones, and clients die who desperately want to regain control but it is an illusion of control. Forcing people into a 72 hour detox will undoubtedly raise the body count. Opiate tolerance drops dramatically in three days and a daily heroine user freed after three days despairing for some relief is at very high risk of taking too much. But again it's less about how much the individual takes and more about where the person takes it. Not wanting to disappoint family or risk another 3 day incarceration the individual will likely shoot up alone. Opiate overdose happens quietly and the person will likely appear to have fallen asleep. In the dark no one will notice that the person has stopped breathing, that their lips are turning blue, not until it's too late. Narcon doesn't do a thing when it's in your sock drawer and your son or daughter is dying in an alley. There is a solution. Have them shoot up in your home where you can see them. If that's too much for you we can build clinics for safe injection and even supply the heroin so we know it's safe. This isn't a liberal pipe dream it's been and is being done and the success of such places would drive a call for legalization and implementation of these programs if not for one thing. Heroin has an image problem.

Most other drugs have an iconic image attached to them that is in part or completely positive. Marijuana has the harmless hippy or the cool Rastafarian, cocaine has the driven business man, and booze which kills more people and has always killed more people than heroin and is an epidemic all it's own with deaths from alcohol related diseases rising over 30 percent from 2003 to 2014, booze we tell each other to drink a glass at dinner because "it's good for you." But heroin and people who use it must be stopped. Heroin is so bad we are telling our doctors to stop treating pain and forcing people into programs that increase their risk of death because just sharing a world where people use heroin is simply unacceptable. It probably has something to do with the needles, the needles creep people out, but it probably has more to do with the question of who we think does heroin. The answer is of course "other people" and as long as we continue to believe that no grave digger will go without work.

Friday, November 25, 2016

I'm not here to make friends

I'm not here to make friends 


 

When I worked for an inpatient facility I heard it at least once a week. Sometimes it was an individuals justification for isolating or sometimes for a harsh word, perhaps a cover for shyness, not wanting to show weakness. Often it was a declaration meant to show me the counselor how dedicated the individual was to recovery, a vow that the individual was willing to forgo most if not all of the softer parts of rehab and dive head first into the hard work that lay ahead. These folks were never without their journals and worksheets, they carried their Big Books clutched in their hands and read them at every break. "I'm not here to make friends!" They would say though they might have said another common mantra of the newly sober "I'm not like these other people." I would often lay awake at night worrying about these folks.

Two reasons I see this as a red flag 

1) RECOVERY CANNOT BE FOUND IN A WORKSHEET!

Let me say that again 

RECOVERY CANNOT BE FOUND IN A WORKSHEET! This goes for any worksheet. The free ones you find online, the expensive ones you purchase on your own and photocopy without permission, the ones that use a 4th grad vocabulary and the eloquent ones, recovery cannot be found in any of them. For that matter it can't be found in the Big Book either, it's not in a PowerPoint, a self help book, a video or in your favorite therapeutic card trick. In my opinion the vast majority of curriculum in rehab has very little value for the person in recover. These trappings are really more for we the professionals than those that come to us for help. They exist to make us look like we know 
 we are doing. They allow us to say "take two and call me in the morning" and fill the long hours with"programming" which the organization charges a sizable fee. Research indicates that educational lectures, videos and PowerPoints have almost no value for the person in recovery but many continue to lecture and play videos and continue to call it treatment. The videos give us time to catch up on our notes, the lectures are easy and one cannot invent the wheel on a daily basis so who can blame us? Because we put so much importance in these activities clients often mistake them for recovery. The "Not Here for Friends" folks most of all. So we take energy and focus which could be used more effectively and waste it on a hamster wheel.

2) MAKING FRIENDS MAY BE THE SINGLE MOST IMPORTANT THING ONE DOES IN RECOVERY!

The most damaging thing about addiction is how much it isolates. Humans are social creatures and we don't just want to interact with each other we need to. The Rat Park experiment if it can be applied to humans indicates that isolation and an inability to alleviate it by making new connections may be the key difference between someone who abuses substances when in a tough situation but stops when out of that situation and someone who gets trapped in a cycle of substance abuse becoming addicted . As chemical dependency counselors it is important to spot the clients who use our assignments as an excuse to isolate and encourage them to socialize. 

This does not necessarily mean clients should become friends with other clients though inpatient and IOP settings are a great place for clients to practice reconnecting. Your clients will likely come from very diverse backgrounds but all have a shared experience of struggling with substance use and of going through treatment. These things alone can be the basis for a profound connection. Many facilities are concerned with clients forming romantic relationships and discourage contact between clients outside of treatment. While I agree romantic relationships can distract from recovery the friendships that form can be a great support. The romantic relationships seem to form no matter what we do and I have to question if it's really any of our business if adults outside our facilities start to couple.

So we find ourselves with addiction that isolates, which may have been caused by isolation, we pull these people away and isolate them from friends family and work to treat them and to keep the lights on we professionals need to fill their day with programming so we can bill for our services. What's the solution? Obviously I don't know but here are some ideas.

Fewer lessons, more discussion. Keep the clients talking to each other not just to you. If you see that a client isn't joining the discussion prompt them and train you more outgoing group members to draw them out.
Focus on developing social skills. Role play uncomfortable social situations, talk about the clients anxiety over social situations and how to overcome them.
Make your homework social. Tell your clients to go to a meeting or some other sober gathering. Have them talk to 3 or more people. Have them journal about the feelings this inspires.
Make your programming fun. Provide the opportunity for your clients to take social risks and be silly in the safe supportive environment of your program. Play music, dance, tell jokes, or sing.


We may even wish to challenge the practice of isolating the clients from the outside world. Living in the world, rejoining the human experience is the goal of recovery.

Saturday, November 5, 2016

I will not relapse over Donald Trump

I will not relapse over Donald Trump 



I haven't posted any original work in Grey's Recovery for months. There are several reasons for this and I'll briefly mention a few. One reason is that I now work for a mental health organization rather than a treatment center focused almost exclusively on chemical dependency. My title is Substance Abuse Specialist and I still run a group (two groups now) focusing on chemical dependency as well as providing individual counseling but much of my work includes clients who have significant mental illness and/or difficulty meeting basic needs and often I find that while these folks do have Substance Abuse issues they are not the number one priority. A second reason is I'm trying to get into grad school. Writing essays, chasing down people to write recommendations, and studying for the GRE take up much of my free time. Thirdly and the last reason I will present is my anxiety disorder is acting up. Coping skills I have learned in recovery are very effective in coping with anxiety so I have managed to stay functional in spite of the thunderstorm raging in my chest that periodically shocks me with bolts of agony. While my new job and the idea of going back to school at 47 are enough on their own to produce the occasional sleepless night by far the biggest trigger has been the unyielding fear that Donald Trump may soon be president of the United States. I'm almost 9 years away from my last drink but the relentless fear has brought back a longing for numbness for a short gentle oblivion that up until now was a distant fading memory. But I am not the man I was 9 years ago and I win or lose I will not relapse over Donald Trump.

Forget for a second that while the race has tightened Hillary Clinton is still favored to win. Forget also that a President Donald Trump will probably not bring about the apocalypse I fear, though he will most certainly damaged many of the causes I hold dear. I have completed numerous ABC exercises, identified my irrational beliefs and disputed them. I have also chanted the serenity prayer as a mantra that even as a nonbeliever I sometimes find comfort in. These things have helped but they have not been enough to end the silent torture my brain seems determined to inflict upon me. But win or lose I will not relapse over Donald Trump.

While it hasn't worked to address the anxiety itself which has gone off the rails and may not return any time soon that doesn't make me powerless here is what I can do.

 Accept that I am going to be anxious. This is probably the most difficult choice to make but expecting anything else is simply magical thinking. I am going to be anxious and with that anxiety will come a low frustration tolerance, poor sleep, and an ever present physical pain. But I've been here before, this is the devil I know. I have survived it drunk and sober and I will survive it now. I occasionally meditate on the anxiety, not to reduce it but to get to know it. I test its limits and sit with the pain. I step back and observe my mind running away with itself and remember that wherever my mind runs my body remains here. I occasionally take an ibuprofen to address the head and muscle aches but I resist the siren call of the dog's Xanax and of course the liquor store because I know the cost of the relief that will give. Numbing this will only delay the inevitable. I will have to face the anxiety either now or later, and if I send it away with chemicals it will return later with its friends. Worse still a chemical solution may compromise the tolerance I have built up over 9 years and validate the nagging thoughts that tell me I really can't stand this. But I can. Win or lose I will not relapse over Donald Trump.

My rewards for this path are considerable. For every 2 days I cope with the anxiety I get a day or two of feeling invincible, powerful, like nothing can keep me down. My nights have not been completely sleepless, I've even had a few nights where I've slept through the night. On the worst nights I still manage to get 3 to 6 hours of sound sleep. Not ideal but enough to function on. My anxiety is acting as a focus to practice mindfulness. In spite of my poor sleep I've had amazing clarity of mind and my compassion for people struggling with mental illness and addiction as well as my gratitude for those who support me my recovery is growing. My anxiety is killing me, it's helping me grow.

Only a few more days to go.

If anything from my experience helps you I hope you use it, even if you replace the name "Donald Trump" with a far more qualified candidate.

Monday, August 22, 2016

Enabling? Forget it!

The views in this blog are my own and not necessarily the views of my employer or any educational organization I may be affiliated with. But they probably should be.

"Enabler" is one of those words with people use when they want to sound like the know something about addiction, but both in and out of the field it is applied to so many different behaviors and situation that it is practically meaningless. In my experience the concept of "enabling" is usually introduced into the conversation about a difficult case just as the team is preparing itself to discharge the client or to use the threat of discharge to coerce the client into a higher level of care. In public it's most often attached to the parent or loved one of someone struggling with addiction but they never say exactly what they mean and I suspect they don't really know. I have NEVER seen anyone helped by this concept being introduced. I've never seen a case turned around by addressing "enabling." The reason may be that it is only introduced after the team has given up and is looking for a way to get rid of the living reminder of that failure.

So what is an enabler? Tell us Internet!


en·a·bler
noun

  1. a person or thing that makes something possible.
    "the people who run these workshops are crime enablers"

    • a person who encourages or enables negative or self-destructive behavior in another.
      "he criticized her role as an enabler in her husband's pathological womanizing"


So in the business of recovery an enabler is something, a person, policy, or institution, that makes it possible for a person to use drugs. This sounds like a terrible thing. This begs many questions but the first that comes to mind is this. How are we making it possible for them to do drugs? Do we really have that power? In the case of the treatment centers who floated this concept as a reason why it might be in the client's best interest to be kicked out of the program, didn't the client use before they came to us? Then how did we suddenly take on this responsibility? We are not making it possible for the client to use drugs and I offer as evidence that most and possibly all of the clients discharge in in order to stop enabling in my experience continued using as much or more than they did before coming to us. It seems we aren't so powerful after all. 

But it is rare for treatment centers to be called enablers, the term is usually reserved for the parents and loved ones of people struggling with addiction and it is to them that it does the most harm. It is hard to watch someone you love struggle with addiction. Those who have to will at best find themselves awake with worry night after night and at worst will suffer profound trauma. The will watch the person they love go through ups and downs. They may experience numerous heart rending disappointments as promising starts turn to relapse again and again. They may have to bury their child. It is unbelievably cruel to tell them at any point along the way that it is their fault, that they could have stopped it from happening if only the hadn't been so kind.

Parents and loved ones have, like treatment centers, do not have the power to make it possible to use. They are not encouraging the behavior unless they are literally telling their children to use. But so I'm not at risk of being as vague as those who promote the concept I want to give some specific actions/behaviors that ate definitely NOT enabling. 

-Providing your loved one with food IS NOT enabling 
-Allowing your loved one to live in a safe place after a relapse IS NOT enabling 
-Giving your loved one a little money even when you suspect they are using IS NOT enabling 
-Telling your loved one "I love you no matter what. I love you if you relapse and I love you if you never use again" IS NOT enabling 

As for examples of things that definitely are enabling 

-I don't know. I'm not sure I've ever seen any

My recommendation for people with loved ones struggling with substance use is to forget they ever heard the word "enabler" and my advice to my peers in the field is to stop using it completely. Loved ones worry more about how healthy your behaviors are for you, but don't pretend you have the power to stop your child's addiction. If punishment were an effective treatment for addiction the U. S. Prison system would be the greatest treatment center in the world. It's not.


Monday, August 8, 2016

Rethinking Relapse



While standing in line at the pharmacy I was approached by a client I worked with at my former position at a small methadone clinic. There is always some discomfort when seeing a client in public because one must balance politeness with protecting the clients confidentiality, this is doubly important with methadone patients. That being said I love it when clients come up to me in public. He asked me about my new job, if I regretted leaving, might I ever work at a methadone clinic again.  He listened to my answers the told me the best news I'd heard in a long time. "I'm doing great" he said, "I've got take homes." I was barely able to pause long enough to ask permission before hugging him. 

He had struggled with heroin addiction for years, had gone to then dropped out of treatment many times over the last few decades.  He had been with my clinic long before I was hired and the year he worked with me had been filled with sincere promises to stop using followed by drug screens reactive for heroin month after month after month, until the last month. I wish I could take credit for it but it was a therapeutic relationship with a nurse on the team that got him to do what I'd been trying to do for a year. He overcame his shame about being on methadone, started to look at it as medicine instead of an extension of his addiction, and adjusted his dose to a level that let him quite heroin use completely.  All I did was keep the powers that be from kicking him out and I refused to threaten to kick him out. In spite of the reactive screening month after month he was making progress. He rarely missed a day, he was addressing health issues that had gone unmanaged for years, and he was learning and applying self care techniques. I knew if he kept on going as he was eventually the heroin would stop too. I was excited to see the nonreactive screen before I left for my new job, I was thrilled to hear that in the following month he continued to improve, but I was not surprised.

I don't like the word relapse. In my opinion true relapse is rare and almost nonexistent with a client who is engaged in treatment and when it does occur it is usually caused by the reaction of the treatment team rather than the continued use.  AA unofficialy recognizes that not every use is a relapse, the term "slip" is often used to differentiate a one time use from a full blown relapse. SMART Recovery distinguishes between a "lapse" which is a short return to substance use usually a single night to a few days and a "relapse" which can last from several weeks to several years. In the clinical setting we are often behind the support groups and treat every use as a relapse. Relapse is loosely defined as a return of all or some of the symptoms of addiction, one of which is problematic substance abuse and when I say it almost never happens I'm not saying people in treatment don't abuse substances, they do.  What I'm saying is, that when they do, it's not relapse. It's not even a "slip" or a "lapse." What I'm proposing is that the substance abuse in most of what we call relapse isn't the return of a symptom, it's a symptom that, like in the example above, just hasn't gone away yet.

The above client wasn't relapsing for most of the year I worked for him. He simply continued to use, regularly, possibly daily. There were many reasons for this, he had inadequate coping skills to deal with anxiety, he had easy access to large amounts of cash, and I near unlimited supply. But the main reason he kept using was he was so ashamed of using methadone to treat his addiction that he wouldn't let the doctors raise his dose to a therapeutic level. When he didn't supplement his methadone dose with street opiates he went into withdrawal and while he could make it a few days he couldn't achieve the sustained  abstinence from heroin that was his goal, so most days he didn't try. While this continued use may have slowed the clients progress and was a blow to his self esteem he did continue to recover. 

It might be argued that his continued use may not fit the strictest definition of relapse, but his continued use certainly put him at risk for it. I agree it is possible, maybe even likely that the client's use would have spiraled out of control and put all his progress at risk. Haven't all of us even those of us who have worked in the field a short time seen it happen over and over again? A client abuses a substance, maybe they tell us, maybe they just get caught. One use leads to another and after a time you see the clients asking for change on the street, read about them in the arrest section of the paper or worse the obituaries. There is one event that has always occurred between that first use and the sad ending, the clients is either kicked or driven out of a treatment program.

In short, if you are working with a client who walks into your office and reports they got drunk over the weekend I would argue they didn't relapse. They just haven't reached their goal of complete abstinence yet. As long as they continue to work towards that goal they almost can't relapse.

 If this happens

Do

Help them take an inventory of their progress, ask questions like "how are you reacting to this use now? How is that different from a year ago?"

Review coping and grounding skills 

Review needs and supports

Don't 

Discharge or threaten to discharge the client

Pressure or scare the client into a higher level of care 

Call it a relapse.

Sunday, July 31, 2016

AA, it's personal

AA, it's personal 


I love the fellowship of Alcoholics Anonymous. Most of the friends I have made in my adult life I met in the fellowship. It was in AA that I learned to make friends again. AA didn't get me sober, but it helped me stay sober. Does AA help people? If you ask my wife and daughters they will tell you yes. Lacking a higher power it was often their voices that told me I needed a meeting. They were very aware of the transformation that occurred during the time I went to a meeting and the time I came home. AA helped me be a better version of myself.

The 12 Steps... I'm not so thrilled about. I'm a nonbeliever and white I can manage "higher power" as a metaphor I don't believe in the power of prayer. I love books, but I don't like to live my life according to the contents of a book. If I do it's by chance, not design. I have multiple copies of AA's Big Book, I haven't touched any of them for over a year. I went to AA for 7 and 1/2 years and will likely hit a few meetings in the future but I never did the 12 steps. Maybe step 1, but I've since reconsidered it. I learned from the steps, I learned to try and make amends and that doing so requires more than saying "I'm sorry." So what is my problem with AA?

This was/is my personal experience. It's an experience colored by my life situation, socioeconomic status, education, and white male privilege. Even as an atheist I found I was able to be an open atheist surrounded by believers yet I didn't feel like an "other" or "outcast." Because I have supportive parents, because I have a supportive spouse, because my children are heathy and I could get financial support when I needed it I was able to approach AA at my own pace and on my own terms. 

Luck, really good luck played a role. My first sponsor didn't stick but my second (hope he's still reading this) was a perfect match. When I said I wasn't comfortable with the Big Book or with all 12 steps he said "if you don't like 12 Steps, do 3. 1) don't drink, 2) don't think, 3) go to meetings. This 3 step approach worked very well for me.

So though I may sound critical of AA in some of my posts I don't really have a problem with the program itself. AA kept me alive for years, it was there for me when I needed it and it gave me what I needed.

What I have a problem with is this:

1) Court mandated AA. I think the founders would not have liked mandatory meetings either.

2) no training for sponsors. I had/have a great and ethical sponsor, but that is not always the case. Sponsors that are not ethical answer to no one.

3) AA in a clinical setting. AA is free. Anyone in any city in the United States can get free 12 step work. So why would 12 step work be part of  a $50,000 treatment stay? 

4) The rejection of medication assisted recovery. I don't think AA has an official position on methadone. However, the influence of the 12 step movement has been a barrier for people who need methadone and other medications in treatment. Again this is not AA's fault, it's the fault of treatment programs.

If asked about AA in a professional setting I treat it like church. Are you going? Do you think it helps? If yes, keep going. It should always be a choice.

The reason I rarely attend AA these days is also personal. Where I lived in Minnesota AA was pretty much all that was available. SMART Recovery meetings existed but they were few and far between.* after moving to Rhode Island and checking out several AA meetings that didn't quite feel right I went to my first SMART Recovery meeting. I've been going to SMART for a year now and I find it better meets my needs. If things go right I will soon be facilitating my own SMART meeting soon. I also don't have a problem with using SMART tool professionally. They are REBT tool that are very appropriate for a clinical setting and will work for people of any or no faith. Still I know I haven't attended my last AA meeting.