Group Cohesion and Between Session Homework Activities Predict Self-Reported Cognitive–Behavioral Skill Use Amongst Participants of SMART Recovery Groups | SMART Recovery Australia

06 Sep 2015 Originally published in: Journal of Substance Abuse Treatment April, 2015 – Volume 51, Pages 53–58 Authors: Peter J. Kelly, Ph.D, Frank P. Deane, Ph.D, Amanda L. Baker, Ph.D Received: April 14, 2014; Received in revised form: October 20, 2014 Accepted: October 27, 2014 Published Online: November 04, 2014 Article Outline 1. Introduction 2. Materials and methods 2.1. Participants 2.2. Measures 2.2.1. Background information 2.2.2. Problematic behaviours 2.2.3. Mental health 2.2.4. Cognitive behavioral skills 2.2.5. Group cohesion 2.2.6. Quality of facilitation 2.2.7. Homework 2.3. Procedures 2.4. Statistical analysis 3. Results 3.1. SMART Recovery participants 3.2. Problematic behaviours 3.3. Mental health 3.4. Use of cognitive behavioral skills, group cohesion, quality of group facilitation and homework 3.5. Predicting the use of cognitive behavioral skills 4. Discussion Highlights SMART Recovery groups are cognitive–behaviourally oriented mutual support groups for individuals with addictions. Participants attending SMART Recovery present with a complex clinical profile, including high rates of self reported co-occurring mental illness. Participants were more likely to report the use of cognitive restructuring than behavioural activation. Group cohesion was positively correlated with the use of both cognitive and behavioural skill utilisation by participants attending SMART Recovery. Abstract SMART Recovery groups are cognitive–behaviourally oriented mutual support groups for individuals with addictions. The aim of the study was to assess the extent to which the quality of group facilitation, group cohesion and the use of between session homework activities contribute to self-rated use of cognitive–behavioural skills amongst group participants. Participants attending SMART Recovery groups in Australia completed a cross-sectional survey (N = 124). The survey included measures of cognitive and behavioural skill utilisation, group cohesion, quality of group facilitation and a rating of how frequently participants leave group meetings with an achievable between session homework plan. On average, participants had been attending SMART Recovery meetings for 9 months. Participants were most likely to attend SMART Recovery for problematic alcohol use. Regression analyses indicated that group cohesion significantly predicted use of cognitive restructuring, but that only provision of homework at the end of each group session predicted self-reported behavioural activation. Both group cohesion and leaving a group with an achievable homework plan predicted participant use of cognitive behavioural skills. The concrete actions associated with homework activities may facilitate behavioural activation. There is a need for longitudinal research to examine the relationship between the utilisation of cognitive and behavioural skills and participant outcomes (e.g. substance use, mental health) for people attending SMART Recovery groups. 1. Introduction Mutual support groups are the most widely accessed form of alcohol or other substance abuse treatment (Dawson et al., 2006, Kessler et al., 1997). The major advantages of mutual support groups are that they are cost-effective to deliver, they are generally easy to access and free of charge for participants, and they are able to provide ongoing continuing care (Kelly, Magill, & Stout, 2009). The large majority of mutual support groups use the 12-step approach (e.g. Alcoholics Anonymous, Narcotics Anonymous). Consequently, research examining mutual support groups has largely focused on 12-step meetings, where they have been demonstrated to be at least as effective as other types of therapeutic interventions (see Kelly et al., 2009 for review). Twelve step groups also appear to improve treatment outcomes for people who are accessing other types of formal treatment (Dawson et al., 2006) or following inpatient treatment for alcohol or substance use disorders (Gossop et al., 2003). Whilst there is increasing empirical support for the use of 12-step approaches, the importance of offering alternate types of mutual help groups has been highlighted in the literature (Horvath, 2000, Horvath and Yeterian, 2012). It is likely that there are a sub-section of participants who may not be willing to attend 12-step meetings for a range of philosophical reasons. For example, longitudinal research has identified that there are a range of client variables that predict early dropout from 12-step meetings. These client variables include having lower motivation for behaviour change, a low belief in the disease model of addiction, low religious affiliation, and limited previous involvement in 12-step groups (Kelly & Moos, 2003). It is probable, at least for a proportion of participants, that alternate approaches to 12-step groups may be beneficial. Self-Management and Recovery Training (SMART Recovery) is a not-for-profit organisation that provides mutual help groups for people experiencing problematic behaviours (Horvath, 2000, Horvath and Yeterian, 2012). Incorporated as an organisation in 1992, by 2012 there were 698 SMART Recovery meetings being held regularly throughout the world (Allwood & White, 2013). SMART Recovery was originally developed as an alternative to 12-step approaches, with the major distinction being that SMART Recovery incorporated cognitive behavioural therapy (CBT) to promote positive behavioural change (Horvath, 2000). This includes helping participants to (1) identify the relationship between thoughts, feelings and behaviours; (2) challenge unhelpful thoughts and beliefs; (3) utilise positive behavioural strategies; and (4) use between group homework activities (referred to as achievable 7-day action plans in SMART Recovery). Whilst previous research has not examined the effectiveness of CBT within a SMART Recovery context, the utility of CBT approaches across alcohol and illicit substance abuse treatment has been well established (Magill & Ray, 2009). Another major distinction between SMART Recovery and 12-step groups is that a facilitator leads each SMART Recovery group. The facilitator may be a professional or non-professional person, who has completed training in the SMART Recovery approach. The purpose of the facilitator is to maintain the structure of the meetings and to help facilitate active involvement of participants (Horvath & Yeterian, 2012). Whilst the theoretical framework used by SMART Recovery was intentionally developed to reflect current evidence based approaches (Horvath, 2000, Horvath and Yeterian, 2012), there has been a lack of published research specifically examining SMART Recovery (Horvath & Yeterian, 2012). The limited research to date has largely focused on comparisons between 12-step approaches and SMART Recovery. This research has included examining between group differences on specific variables such as religiosity, spiritual beliefs and locus of control (Atkins et al., 2007, Li et al., 2000). Additionally, one study compared outcomes for people diagnosed with a co-occurring mental illness who were alternatively assigned to SMART Recovery groups or 12-step groups (Brooks & Penn, 2003). Length of time attending mutual support groups, including SMART Recovery and 12-step groups, has been demonstrated to be positively associated with decreased substance use (Atkins & Hawdon, 2007). Whilst the comparison of SMART Recovery groups and 12-step approaches is of importance, there has been a lack of research examining the ‘active ingredients’ associated with SMART Recovery. The identification and evaluation of ‘active ingredients’ has increasingly played a greater role in addiction research (Kelly et al., 2009, Moos, 2008, Morgenstern and Longabaugh, 2000), particularly as the field moves to refining current approaches and disseminating “elements that are essential to effective practice” (Miller, Sorensen, Selzer, & Brigham, 2006, p. 34). The use of cognitive and behavioural skills is considered to be the primary mechanism through which SMART Recovery participants make positive behavioural changes (Horvath & Yeterian, 2012). However, previous research has not examined the extent to which these skills are ‘actually’ used by participants. Understanding the use of these skills by participants is an important first step in starting to establish a specific evidence base for SMART Recovery. Likewise, research has not previously examined the factors that might promote the use of cognitive or behavioural skills by group members. With it being unlikely that SMART Recovery group facilitators are ‘experts’ in CBT, it is very important that the ‘active ingredients’ associated with successfully facilitating SMART Recovery groups are clearly articulated. This may provide an opportunity to further refine facilitator training or modify the current SMART Recovery approach. It is likely that the longer participants have been attending SMART Recovery groups, the more likely that they are to use cognitive and behavioural skills. However, it is possible that group processes might play an important role in helping to promote the use of these skills. Whilst it has not previously been examined, SMART Recovery group facilitators presumably play a primary role in encouraging participants to develop and utilise cognitive and behavioural skills. Additionally, as has been identified in research examining 12-step approaches, support from group members and the cohesion of the group are likely to play an important role in promoting the use of these skills (Moos, 2008). The use of between-session homework activities (i.e. ‘achievable 7-day action plans’) is a process level variable that is likely to promote the use of cognitive and behavioural skills. Homework has an extensive history in the broader psychotherapy literature (Kazantzis et al., 2000, Kazantzis et al., 2010) and is primarily used to help generalise skills developed in session to the person’s broader world. The current study was conducted as a cross-sectional survey of people attending SMART Recovery groups across Australia. As this was the first study to examine SMART Recovery within an Australian context, the first aim was to provide a description of participants accessing these meetings. This will provide, for the first time, a description of the potential clinical complexities associated with people attending these groups and is likely to help inform an understanding of the needs of people accessing these groups. The second aim was to examine how frequently participants used cognitive and behavioural skills outside of group meetings. The third aim was to examine the variables that may predict participants’ self-reported use of cognitive and behavioural skills, as measured by the Cognitive–Behavioural Therapy Skills Questionnaire (Jacob, Christopher, & Neuhaus, 2011). It was hypothesised that the longer participants had attended the SMART Recovery meetings, the more likely they would be to use cognitive and behavioural skills. Additionally it was hypothesised that group factors (i.e. group cohesion and participants’ perceptions of the quality of group facilitation) and process factors (i.e. how regularly participants left sessions with homework) would also predict the use of cognitive and behavioural skills. 2. Materials and methods 2.1. Participants All participants were attending SMART Recovery groups being conducted in Australia. At the time the survey was distributed, there were 104 active SMART Recovery groups. Due to the nature of the way SMART Recovery groups are organised and delivered, there is no central register of the number of participants who attend these groups. With group facilitators reporting that an average of about five to six participants attend each group (unpublished data collected by the research team), we estimate that approximately 582 people attend SMART Recovery each week in Australia. During the study period, 124 SMART Recovery participants completed the survey (approximately 21%). 2.2. Measures Participants were asked to complete a detailed survey that was composed of the following measures sections: 2.2.1. Background information Demographic information was collected including age, gender, country of birth, language spoken at home, and indigenous status. Participants were asked to report how long they had been attending SMART Recovery groups (months), how frequently they attended the groups, and whether they were currently attending any other types of treatment (i.e. 12-step groups, residential rehabilitation, detoxification, methadone maintenance, individual counselling or mental health services). 2.2.2. Problematic behaviours Participants were asked to identify the problem behaviour(s) that caused them concern. Options included tobacco, alcohol, drug, sex, pornography, gambling, Internet, shopping or food addictions. Participants were asked more specifically about possible alcohol or other substance abuse problems, and “how long” the person has had “problems with alcohol or other substances of abuse” (years). They were also asked to identify the substance “currently” causing the greatest concern, and to identify the types of substances that they had used in the past 12-months. 2.2.3. Mental health Participants were asked if they had “previously received treatment for a mental health problem” (yes/no), if they were “currently prescribed medication for any mental health conditions” (yes/no), if they had “ever attempted suicide” (yes/no) and if they had “attempted suicide in the last 30-days” (yes/no). Psychological health was assessed by the Kessler-10 (K10; Kessler et al., 2003). The K10 is 10-items in length. Each item is rated on a 5-point scale (1 = ‘none of the time’, 5 = ‘all of the time’). The items were summed to provide a total summed score that indicates the level of psychological distress. Items predominantly measure symptoms associated with depression (e.g. “In the last four weeks, about how often did you feel hopeless?”) and anxiety (e.g. “In the last four weeks, about how often did you feel nervous?”). The K10 has been widely used in population-based research and has been demonstrated to have good psychometric qualities (Andrews and Slade, 2001, Kessler et al., 2003). In the current study, the K10 was found to have high internal consistency (α = 0.95). 2.2.4. Cognitive behavioural skills The Cognitive–Behavioural Therapy Skills Questionnaire (Jacob et al., 2011) was used to examine how frequently participants use cognitive and behavioural skills. The questionnaire was the first self report measure to be developed to assess the use of cognitive and behavioural skills for people presenting with “complex clinical profiles” (Jacob et al., 2011, p. 595). The questionnaire consists of two subscales: (1) cognitive restructuring (e.g. “find evidence to support my thoughts before buying into them”) and (2) behavioural activation (e.g. “engage in activity instead of a harmful behaviour”). The cognitive restructuring subscale has 9-items and the behavioural activation subscale as 7-items. All items in the questionnaire are rated from 1 (“I don’t do this”) to 5 (“I always do this”), with the items summed for each of the subscales. In the current study, both subscales had high internal consistency (cognitive restructuring, α = 0.90; behavioural activation, α = 0.87). 2.2.5. Group cohesion Group cohesion was measured using the Group Climate Questionnaire (GCQ, MacKenzie, 1983). The GCQ has been used extensively in therapeutic research, and is the most widely used measure of group process (Johnson et al., 2006). To minimise burden on participants, only the Engagement Scale was used in the current study. This approach has previously been used to examine the role of group cohesion in mental health settings (Deane, Mercer, Talyarkhan, Lambert, & Pickard, 2012). This subscale is 5-items in length (e.g. “The group members liked and cared about each other”), and each item is rated from 0 (‘not at all’) to 6 (‘extremely’). A total score is obtained by summing the five items, with higher scores representing higher levels of group cohesion. In the current study, the GCQ Engagement Scale was found to have high internal consistency (α = 0.92). 2.2.6. Quality of facilitation The participants’ perceived quality of the SMART Recovery group facilitation was examined using a 5-item measure taken from the 2010 SMART Recovery Participant Survey (SMART Recovery, 2014). This survey has previously been used to conduct a national survey of SMART Recovery participants attending groups in the United States. Participants were asked to rate their “regular SMART Recovery group facilitator” across six factors, namely (1) knowledge about SMART program, (2) patience with participants, (3) skills in guiding discussions, (4) ability to keep the group on track, (5) dealing with disruptive comments, and (6) creativity presenting and using tools. Items were rated from 1 (‘poor’) to 5 (‘excellent’). In the current study, the Quality of Facilitation Scale was found to have high internal consistency (α = 0.94). 2.2.7. Homework A single-item homework question was used to examine the frequency with which participants leave each session with homework. The item was: “When I attend SMART Recovery groups I always leave each session with an achievable plan that can be completed during the next 7-days”. The question was rated from 1 (‘definitely false’) to 7 (‘definitely true’). 2.3. Procedures In June 2013, hard copies of the research instruments were sent to each of the SMART Recovery group facilitators responsible for each meeting. Facilitators were encouraged to distribute the surveys to the group participants within a 1-month period. Participants were provided with a copy of the participant information sheet, survey and a reply paid envelope. Facilitators were provided with a standard script to introduce the survey. This script included providing the participants with information on who was conducting the study, the voluntary and anonymous nature of the survey and instructions to return the survey. Participants were encouraged to either complete the survey at the end of their group meeting or to complete the survey at home. The surveys were returned to the research team at the University of Wollongong. Group members were informed that participation was entirely voluntary and that the questionnaire was anonymous. No incentives were provided to the group facilitators or participants to promote the dissemination or completion of the survey. The University of Wollongong Human Research Ethics Committee provided approval to conduct the study. 2.4. Statistical analysis Reliability alpha coefficients were calculated for each of the scales. Spearman’s correlations were used to examine the relationship between the subscales of the Cognitive Behavioural Therapy Skills Questionnaire and the length of time the participant had been attending SMART Recovery groups, the GCQ Engagement Scale, the Quality of Facilitation Scale and the Homework Frequency item. Both the cognitive restructuring and behavioural activation subscales were normally distributed. Two separate regression analyses were used to predict how frequently the participants use cognitive restructuring and behavioural activation, as measured by the Cognitive–Behavioural Therapy Skills Questionnaire. Stepped regression analyses were used to firstly examine the contribution of group delivery variables (i.e. quality of facilitation and group cohesion), followed by the contribution of homework activities. At the first step, the GCQ engagement subscale and quality of facilitation scale were entered as independent variables. At the second step, the frequency of homework item was entered as an independent variable. In both models, the residuals were normally distributed. The length of time that the person had been attending the SMART Recovery groups was not included, as it was not significantly