Quantitative

A total of 75 SMART Recovery groups were run by the pilot sites, with a total of 486 attendances (138 face-to-face and 348 online, an average attendance of 6.5 people per meeting). Not all attendances were unique with people often attending groups regularly. Attendees from the face-to-face groups were invited to take part in the study, with 31 participants agreeing.

In total, 71% of participants reported a reduction in alcohol/drug use since their previous SMART Recovery meeting, with 19% reporting no change (see Fig. 1). Importantly the majority of those who reported no change were abstinent, with only 2 participants reporting no change who were not abstinent from their primary drug of concern (PDOC). Thus, 94% of respondents reported a reduction in use, or maintenance of abstinence, of their PDOC. A single sample t-test against a hypothetical mean of zero, which would indicate no change, revealed that participants’ consumption of their PDOC significantly reduced (t(30) = 4.49, p < 0.001).

Fig. 1

Reported changes in AOD use since attending SMART Recovery groups. Of the 6 participants who reported “no change”, 4 reported they were abstinent from their primary drug of concern and only 2 reported consumption of their PDOC in the preceding 7 days

In other domains, 74% reported a positive change in their physical health and 71% reported a positive change in their mental health and wellbeing since their last SMART Recovery meeting (see Fig. 2). Single sample t-tests against a hypothetical mean of zero, which would indicate no change, revealed that participants’ physical health (t(30) = 4.28, p < 0.001) and mental health and wellbeing (t(30) = 4.97, p < 0.001) significantly improved.

Fig. 2

Reported changes in physical and mental health and wellbeing. Change in physical health reflects answers to the question “Since your last SMART group, how much better or worse is your physical health?”. Change in mental health reflects answers to the question “Since your last SMART group, how much better or worse is your mental health and wellbeing?”

Similar trends were noted in respect to lifestyle factors with 74% reporting that they were better able to take care of their personal responsibilities, and a single sample t-test (against a value of zero) revealed this improvement was significant (t(30) = 5.80, p < 0.001). Further, 81% reported they were better connected with others since their last SMART Recovery meeting (see Fig. 3), with a single sample t-test (against zero) revealing this improvement was also significant (t(30) = 6.40, p < 0.001). Encouragingly, only 1 participant reported a decline in personal responsibilities and feeling more disconnected from others.

Fig. 3

Reported changes in personal responsibilites and connectedness. Taking care of responsibilities reflects answers to the question “Since your last SMART group, how much better or worse are you in taking care of your personal responsibilities?”. Connected with others reflects answers to the question “Since your last SMART group, do you feel more connected with others?”

Responses to the three additional items showed participants significantly agreed with all three statements, with 97% indicating that they could better manage problematic substance use (t(30) = 10.81, p < 0.001), 90% that they were better able to cope with life’s challenges (t(30) = 8.86, p < 0.001), and 97% that they felt supported by members of the group during the meetings (t(30) = 11.31, p < 0.001; Fig. 4). Single sample t-tests for these three measures, which had response options ranging from 0 to 10, were tested against a hypothetical mean of 5, which would indicate a neutral position (i.e. neither agreeing nor disagreeing with the statement).

Fig. 4

Participants level of agreement with post meeting statements

Qualitative responses

Analysis of qualitative interviews revealed four common themes related to participants’ experiences of SMART, which corroborate and provide further insights to the quantitative component. Further, the qualitative data reveals participants’ experiences of attending SMART run by existing AOD services both online and in-person. The first theme was, motivation—participants discussed their reasons for attending SMART Recovery. Secondly, participants highlighted the many active ingredients that likely underpin the benefits shown in the quantitative data. Participants also discussed the integration of SMART into existing AOD services. Findings from this theme helped to explain why uptake was strong and how the integration of SMART into AOD services conferred multiple benefits. Finally, due to the transition to online halfway through the study, many participants commented on the advantages and disadvantages of online groups. As illustrated in Fig. 5, several sub-themes were identified.

Fig. 5

Themes from qualitative interviews

Motivation

As illustrated in Fig. 5, participants were motivated to attend SMART Recovery (theme 1) for a number of different reasons. Some felt that formal treatment was no longer relevant to them (e.g., their AOD use had stabilised), and they viewed SMART Recovery as an informal support that they could use, as a ‘safety-net’ if needed.

“For me I use it mainly just for lifestyle and wellbeing right now, but I know if I were to have cravings or anything or thoughts like that, I know I'd be able to talk about that.” (Gregory)

“I just needed to have something to fall back on if I started to struggle.” (Kylie)

Others felt that the program provided them with the opportunity to focus on the ‘bigger picture’ beyond substance use (e.g., learning to function in everyday life). SMART provided participants with an opportunity to actively engage in their recovery, supported self-efficacy and was a welcome alternative to 12-step programs, due to its secular nature, flexible approach and focus on broader life goals.

“The reason I got into this group was for recovery and I did it to live life, and it’s not just about the behaviour of using, I have to learn to live life again and that entails everything. So a group like SMART, I’ve really been able to talk a bit more and focus a bit more about life and how to do that now I’m sober, because it’s really different, even interacting with people and talking with people, having a conversation, going to the shops and paying bills, walking out the front to go to the letterbox that was something I couldn’t do.” (Linsey)

“I don’t really get into the higher power thing, and I think NA has a tendency to get off topic and people just sharing war stories, and it's more about using, and sometimes it can trigger me I guess. I prefer SMART how it’s all goal based and stuff.” (Gregory)

Another participant recognised that attending SMART Recovery gave a sense of purpose, perhaps through helping others in their recovery journeys or by providing structure to their week.

“I really have benefited. It gives me purpose. While I’m unemployed, when you have a substance abuse problem you have no purpose in life. SMART gives me purpose. But also you have to restart.” (Esme)

Participants also indicated that they liked the harm-reduction focus of SMART Recovery and its embracing of behaviour change at all levels, recognising that recovery is not a linear journey and that an individuals’ goals may change over time.

“I believe that I’m probably alive because of SMART. I believe stopping drinking and reducing drinking has preserved me in a way that wouldn’t have happened otherwise, and that’s the important thing about SMART’s harm minimisation focus.” (Joshua)

“If you don’t want to be abstinent, if in the future you eventually want to have a glass of wine a week, I’m not in that place at the moment, but you know there is none of that discussion in AA.” (Anton)

These motivations may have been an important ingredient in the emergence of the benefits demonstrated in the quantitative data, such as participants reporting they felt better able to manage substance use, to cope with life’s challenges, and the non-substance related benefits such as improved wellbeing and physical health. The motivation (theme 1) to attend was in pursuit of the reported benefits. Whereas theme 2 identified the active ingredients underpinning the reported benefits.

Active ingredients

Participants discussed experiences that likely contributed to the benefits seen in the quantitative data. Participants discussed the opportunities for and benefits of peer to peer learning and social connections within SMART. Most participants expressed that they gained something from peers such as learning about recovery. The statements tended to place a high sense of worth on what was, or could be learnt from peers, due to their rich life experiences.

“What I like about SMART is there’s that diversity, so there’s different life experiences that people talk about that you can learn from.” (Ben)

“Every week I get something out of it, what other people suggest, even if it’s just a phrase or an idea, I take that away." (Esme)

Participants seemed to value connection with other group members highly, due to a feeling that the members of the group were being genuine, and as a way to connect and overcome loneliness. It was apparent that many participants attended the group to establish connections with others, for some in which they were unable to do with their personal networks because they felt they could be more honest with the members of SMART or because they had to distance themselves from friends who were actively using substances. At a base level, SMART groups circumvented feelings of isolation.

“I would recommend it to anyone who even just feels lonely. Addiction can be a very isolating thing.” (Linsey)

“Everyone has been really open and willing to share about everything, no one was hiding behind anything, you could feel it was genuine and there was trust. …it’s easier to talk to people who aren’t your close friends.” (Ben)

“I really appreciate the ability to just connect with people.” (Linsey)

“You have to restart your life all over again because obviously you have to wipe everyone that’s a user, or it's handy to. So it’s the positive connections you get out of the group." (Esme)

As illustrated above many indicated that groups foster social connection and trust.

Participants developed the capacity to manage and drive their own recovery, providing a sense of agency.

“I like the fact that if I’m abstaining, I get support, but if I change my mind and I want to try and manage my drinking, I get support—I’m not left alone.” (Joshua) who also said “I’ve been challenged about trying to modify my drinking and that’s probably been helpful.” (Joshua)

Further illustrating the subtheme of agency was the common perception that individual goal setting was helpful, and that its iterative nature and focus on small, achievable objectives helped to build confidence and motivation. Feedback from peers and facilitators could help adjust goals that were not met to make them more achievable, further fostering agency.

“I also think just having that short-term goal and planning for the week ahead and then coming back and talking about how you went and what you can do differently. Like it's really easy to make small adjustments and move forward.” (Gregory)

The active ingredients of SMART Recovery groups that emerged from the qualitative data such as peer-to-peer learning, connection with others and agency (particularly around goal setting) likely underpin many of the reported benefits from the quantitative data, e.g., feeling better able to cope with life’s challenges, taking care of personal responsibilities, feeling better connected with others, and improved mental health as well as reduced substance use.

SMART as an adjunct to formal treatment

This theme covers participants’ views on the integration of SMART into formal AOD treatment and addresses research question (iii). Several participants noted how SMART Recovery represents an informal source of support that intersects with and complements formal treatment.

“Those medical services and individual counsellors you’re coming across, the stuff you’re learning in SMART is not too different to that, there might be more acceptance and commitment therapy in some of those services than there is in SMART, but it slots in very nicely with those and the medical model.” (Joshua)

Having the SMART Recovery group embedded within the AOD treatment system provided a level quality assurance.

“With non-SMART groups there aren’t the same checks and balances on things compared to if you were employed at a professional service.” (Joshua)

“I’ve been a client of [service name removed] for years and also given consumer feedback so…I know the kind of high-quality organisation it is, which adds a great deal of weight to their meeting. It’s like a guarantee almost, of quality.” (Elizabeth)

This also provided the opportunity to maintain the relationships they had developed during the earlier stages of their recovery. Knowing that their trusted clinicians/peer workers were running groups, motivated some participants (particularly those new to SMART Recovery, or who experienced high anxiety) to attend and contribute to group discussion.

“I think because you’re a part of the service you kind of have a different relationship with the facilitators...but [name removed] isn’t just a facilitator she’s also a worker for me and I’ve known [name removed] since 2016, so I have a relationship with them...With SMART the relationships are there. There are benefits to that – they know when I don’t want to talk and when to push.” (Julia)

Several participants also acknowledged that they would not have attended SMART Recovery were it not for the pilot, even if they had prior knowledge of its existence in the community.

“I probably wouldn’t have been aware of it if it was a free-standing group. I think for that reason and others it's good that it was connected to [service name removed]. Yeah you don’t know what’s out there until someone says “oh you should go to this group” you know?" (Esme)

Advantages and disadvantages of online groups

Finally, a common theme that emerged was around participants perceived advantages and disadvantages of online groups. Many recognised the affordances of online groups, including the convenience in terms of ease of access (e.g., not needing to travel to a venue), which enabled people in regional areas to attend.

“I wouldn’t be able to go to the group and get the support I need if they weren’t online so it would be a shame if they didn’t carry on.” (Joshua)

“There is no current SMART meeting in Geelong. I wouldn’t be able to do [service name]’s meeting face to face because you’re in Melbourne and I’m in Geelong! It’s a two train trip!” (Elizabeth)

Others appreciated the greater anonymity and safety, particularly for those who might be new to peer support, or anxious about attending an in-person group:

“I think zoom is just as effective. I think that I’m an extravert and I like to be around people and I like face-to-face [meetings], but I had severe anxiety when I first got clean, so Zoom was perfect for me because it wasn’t so daunting…. but for where I am now, I prefer face-to-face, but it could be very daunting for people who are early in recovery and really anxious. Zoom may be good for them." (Esme)

However, several also noted the advantages of face-to-face meetings included opportunities for more organic bonding and connections with group members that are not easily emulated online, where discussion is more stilted.

“We got chatting a bit beforehand in face-to-face groups so there’s that social interaction that’s not part of the actual group whereas with the remote group we just wait silently on mute until everyone is in the room and there isn’t that social element to it before or after we kick off.” (Ben)

"I think having the option of both online and face-to-face groups would be good, but for me who wants a social connection maybe there’s a bit more of that in the face-to-face groups." (Ben)