The Self-Managed Recovery Pathway
We recently noted the promotion of therapeutic communities by Secretary Kennedy. We recognized the benefits of these communities and their greater popularity in Europe, and it was not that approach that we criticized but a pattern of promotions by the Secretary that retarded the development of evidence-based treatments. In that article we recognized that there are many pathways to recovery from substance use disorder, and touched on three, general pathways defined by the Recovery Research Institute – Self-Managed, Non-clinical, and Clinical. Perhaps a review of each of those pathways will be helpful.
Chronologically the oldest form of treatment has been self-managed although that pathway has become much more professionalized in recent years. In the early years of the United States drinking was frowned upon and excessive drinking was considered to be a moral failing. There were temperance societies in every community in early America almost always affiliated with a Christian church. Historically, the most well-known of these now is the Women’s Christian Temperance Union (WTCU) and their most famous daughter Carrie Nation.
One tool in the temperance movement effort was “The Pledge” where an individual and sometimes a group would commit to abstain from one or more behaviors and speficially alcohol. The Pledge was usually in written and signed form, filed with the temperance organization and often the church. The Pledge from the WCTU read,
“I hereby solemnly promise, God helping me, to abstain from all distilled, fermented and malt liquors, including wine beer and hard cider, and to employ all proper means to discourage the use of and traffic in the same”
This effort evolved outside of temperance organizations to include a commitment usually from a chronic “inebriate”, expressly taken with a minister of one’s faith, asking for divine assistance and involved a commitment to abstain from alcohol. Evidence of the success of the pledge on any individual seems limited. It is reported by Ann-Kathrin Koessler (“Pledges and how social influence shapes their effectiveness”, Journal of Behavioral and Experimental Economics, Volume 98, June 2022) that the influences, motivations, and social settings in which the pledge was taken heavily influenced the outcome. It may seem obvious, but the greater the internal motivation the greater probability for success.
Interestingly, “The Washingtonians” was an organization that evolved from temperance societies, built on the pledge, and modeled many of the tenets eventually incorporated by the founders of Alcoholics Anonymous (we will review this group in future articles about Non-clinical Pathways).
Self-Managed systems of recovery have evolved to be a regular part of physical medicine and behavioral health. A study from 2015 posted on PubMed (“Self-Management and Self-Management Support Outcomes: A Systematic Review and Mixed Research Synthesis of Stakeholder Views”, Boger E, Ellis J, Latter S, Foster C, Kennedy A, Jones F, Fenerty V, Kellar I, PLoS One, July 2015) reviewed articles related to self-management in physical health conditions. “Six broad themes were identified which together describe the self-management outcomes in use expressed in the included papers; applicable knowledge, independence, positive network, being me, self-management skills and attributes and optimal bio-psychosocial health. No outcome can be claimed to be more important than the others.”
The review identified targeted outcomes from the perspective of the patient. “Our findings suggest that biomedical outcomes were important to all stakeholders but exist side by side with and may potentially be at tension with patients’ need to ‘be me’, achieve independence and to adapt knowledge to individual contexts. Our review found that indicators of health were not confined to physical aspects of health, but included and were inter-connected with, emotional and social SM outcomes.” In other words, the stronger a patient’s need for individual identity the more likely self-management would be a more effective alternative. It seems likely that the choice of self-management was motivated by this need for identity as well.
A meta-analysis of studies more specifically focused on mental health issues was published online by Cambridge University Press (“Self-management interventions for people with severe mental illness: systematic review and meta-analysis”; Melanie Lean, Miriam Fornells-Ambrojo, Alyssa Milton, Brynmor Lloyd-Evans, Bronwyn Harrison-Stewart, Amina Yesufu-Udechuku, Tim Kendall, Sonia Johnson, Cambridge University Press Online, March 2019). As to effectiveness in mental health issues they found, “Self-management did demonstrate a significant, medium-sized effect on global functioning and a small but significant effect on quality life at both end of treatment and 1 year follow-up. Furthermore, self-management seems to confer a benefit on outcomes valued especially highly by consumers, i.e. outcomes related to personal recovery and an individual's sense of empowerment, hope and self-efficacy. A moderate to large effect on overall recovery and self-efficacy was seen at both end of treatment and follow-up; the effect on the recovery-related concepts of empowerment and hope were significant at follow-up only.” Again, the key seems to be a strong value on individual identity.
The authors did note areas where success was not as evident. “Despite the positive effect on symptoms, the findings were inconsistent for variables related to relapse and readmission. This was in contrast to a previous meta-analysis of self-management interventions for those with schizophrenia which found a significant impact on relapse and readmission. In the present review, few studies reported relapse as an outcome and, of those that did, only a small number of participants experienced relapse events which may account for the lack of effect.”
One might note that none of the studies nor “the pledge” are strictly self-managed but involve an organization, advice from one or more sources viewed as experts such as a physician, or involving help from a deity and/or minister. Today those sources of assistance for “self-managed” recovery are exploding. They range from physician assisted or led to online systems through subscription and even include wearables such as smart watches. The key seems rather to be independence of action as defined, perhaps, in a greater need for independent personality.
An online search will yield a large number of such approaches. Let us review just a couple here. A study of Nurse-Led approaches examined several programs offered through health care systems and independent nurses (“Designing a Nurse-Led Program for Self-Management of Substance Addiction Consequences: A Modified e-Delphi Study”, Paulo Seabra, Inês Nunes , Rui Sequeira, Ana Sequeira , Ana Simões, Fernando Filipe , Paula Amaral , Marissa Abram , Carlos Sequeira, International Journal of Environmental Research and Public Health, January 2023). That study concluded, “The consensus … led to the conclusion that a nurse-led program for self-management of substance addiction consequences is pertinent and necessary to support an individual’s needs. Our results show that a nurse-led model of addiction treatment must be flexible enough to incorporate local needs and be transferable enough to be applied in the face of various normative guidelines and practice settings. It must be capable of being implemented with fidelity and sustainably, and allow for an evaluation of the process and impact. The nurse-led intervention must be comprehensive and focus on an individual’s identified needs. It should have an adapted duration, be measurable and implementable, consider environmental factors, have a biopsychosocial approach, and may utilize brief interventions to achieve observable behavioral changes.”
Smart Phones are also being studied as a means to support self-managed recovery. A study posted on the PubMed tested whether or not feedback and prompting via smart phones can provide assistance to make a difference in recovery rates for self-managed care participants versus other, more traditional approaches to recovery (“Using smartphones to decrease substance use via self-monitoring and recovery support: study protocol for a randomized control trial”, Christy K Scott, Michael L Dennis, David H Gustafson, Trials, August 2017). The study was designed to test the effectiveness of two components of smart phone apps: ongoing self-monitoring through Ecological Momentary Assessments (EMAs) and immediate recovery support through Ecological Momentary Interventions (EMIs). EMAs help people to self-monitor behaviors at the time and in the context in which they occur. Self-monitoring asks patients to note internal and external factors that take place with a target behavior such as substance use. EMIs provided interventions at that time. Based on a study enrolling 400 participants the study found, “… that smartphone-delivered self-initiated EMIs following community-based SUD treatment engagement have a statistically significant additional effect on reducing alcohol and drug use in the 6 months following treatment engagement relative to receiving no EMIs.” Interestingly for discussion of self-managed care, the study found that the use of these technologies made a significant difference in abstinence as an adjunct to other forms of treatment.
SMART Recovery (Self-Management and Recovery Training) was founded in 1994 and is designed to allow for self-tailored approaches as opposed to what many think of as one-size-fits-all approaches in twelve step programs such as AA. From their web page:
“SMART Recovery is an evidenced-informed recovery method grounded in Rational Emotive Behavioral Therapy (REBT) and Cognitive Behavioral Therapy (CBT), that supports people with substance dependencies or problem behaviors to:
Build and maintain motivation
Cope with urges and cravings
Manage thoughts, feelings and behaviors
Live a balanced life”
Further,
“SMART Recovery uses evidence-based methods, including cognitive-behavioral, non-confrontational motivational enhancement, and other methods. Our meetings focus on the application of these methods, as guided by our 4-Point Program®:
Building and Maintaining Motivation,
Coping with Urges,
Managing Thoughts, Feelings, and Behaviors; and
Living a Balanced Life.”
SMART Recovery provides a variety of tools and options including group meetings, online tool kits, and publications. Some studies have compared SMART with other modalities of recovery. They have found that comparative success depends on the motivation of the participant. When motivation is similar the results are similar across modalities including SMART.
A review of 58 randomized trials for self-managed approaches was reported in 2019. (“Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice”, Sarah Dineen-Griffin, Victoria Garcia-Cardenas, Kylie Williams, Shalom I Benrimoj, PLoS One, August 2019). The review discussed evidence from 58 randomized controlled trials examining the effectiveness of primary health care providers (HCP) delivered self-management support for adult patients, with any condition, compared to usual standard of care. From their report, “This review demonstrates that SMS (self-managed systems) interventions delivered face-to-face by primary HCPs, which are multicomponent and tailored to explicitly enhance patient self-management skill set can lead to improvements in clinical and humanistic outcomes. The various tools and strategies that provide a structure to interventions delivered face-to-face include adapting interventions according to patients’ readiness to change, action planning and goal setting by collaboratively breaking down individual health goals into small achievable actions. The effectiveness of multicomponent SMS interventions is not surprising. But it raises the question of how to focus efforts on the best combination of active components within interventions.”
We have reported previously that currently reported rates of treatment availability ranging from 7.5-18% based on the substance in question is wholly insufficient. Further, and in part a result, recovery rates at less than 10% as defined by one year, continuing abstinence are unacceptable. We have also stated our belief that there are many paths to recovery and any should be discounted with caution. Given these principles, the need for continuing research in effective approaches is important and should continue.
Several studies have demonstrated significant improvements to outcomes both self-reported by the client and in terms of continued abstinence when used as a measure of success. These and other studies have demonstrated effectiveness when self-managed approaches are organized and tailored to the individual by a licensed professional herein defined as a nurse or physician (we would add licensed alcohol and drug counselors from our experience).
While the development of self-managed approaches has existed for many years, recent interest is resulting in a wider and more available selection of choices. As one would expect, research about the effectiveness of such approaches follows this trend and is yet evolving. A few reports catch our attention as important. One is that the lack of regulation of the industry where self-managed approaches are not “clinical” or “medical” in nature allows for a wide array of marketing of approaches that may or may not have been tested. One should take care to research and understand any service offered that is not supported by legitimate research and testing.
Another concern has to do with the tendency of isolation that many active substance use disorder sufferers experience. This may be a continuation of the shame that has plagued this disease at the advent of the United States (and before). The studies cited here discuss the importance of individual identity shown by those seeking self-managed recovery. It is fair to ask if any client looking for self-managed recovery is motivated by this strong personal identity of reacting to the shame still present for many forms of behavioral health issues including substance abuse.
In terms of the effectiveness of self-managed systems, the study by Dineen-Griffin et al noted “…the importance of peer relationships and social activities, moving beyond the sole receiving of support toward reciprocal relationships in which opportunities for giving are also recognized.” Further, “With respect to strategies fostering functional recovery, one of our most striking findings is the perceived contribution made by concrete activities that allow an individual to play a role in society.” In other words, the individual is able to maintain or regain a sense of functioning through actions that are meaningful to that person and others.” This socialization and reciprocal benefit is exactly what the founders of Alcoholics Anonymous developed in the early years. This kind of identification and socialization may be thwarted by isolating for self-managed care.
Regardless these concerns and notes, our view is that the development of evidenced-based self-managed systems of recovery is an important and welcome trend. Next, we will discuss so-called “Non-clinical Pathways”.
Gene Gilchrist
April 2025
