Small towns, big change A different type of addiction In Rio Arriba County, New Mexico, alcohol claims more lives than other drugs, but now an alternative treatment program could help.

After being sober for 27 years, Bruce Bender started drinking again.

It started just as a drink, something to help him deal with the crushing loneliness he felt living alone in Washington, D.C. It was the first time in his adult life he had lived by himself.

He rationalized the drinking, told himself he had control over it, that it was just a little booze and that, being an adult, he was entitled to drink whenever he wanted. Besides, since he had already stopped drinking once, he could do it again.

But Bender knew he was, and is, an alcoholic. Soon, a few drinks turned into a lot of drinks, and then, he started getting blackout drunk.

Five years after his first drink in 27 years, his doctor told him repeatedly that his liver was enlarged and he needed to quit drinking or he would soon face a death sentence. He signed up for an outpatient therapy program that day and joined an alternative peer support group. Over time, Bender was able to get sober again.

Bender represents alcoholism, a legal side of the American substance abuse problem. He is also part of a growing contingent of alcoholics and other substance abusers who, in search of peer support, are turning to alternatives to the 81-year-old stalwart in the field, Alcoholics Anonymous.

While Española and Rio Arriba County are known for the crushing epidemic of overdoses, the deaths from alcohol abuse, while not as easily tracked, are far higher than deaths caused by illegal drugs.

According to the 2016 epidemiology report for New Mexico by the New Mexico Department of Health, which tracked alcohol-related deaths between 2010 and 2014, Rio Arriba County had, on average, 65 deaths per year related to alcohol abuse. Its per capita rate of 126 deaths per 100,000 people is far and above the rest of the state. McKinley County is second, with a rate of 114 per 100,000. The national average is 30 deaths per 100,000 people.

“For the past 15 years, New Mexico's death rate from alcohol-related chronic disease has consistently been first or second in the nation, and 1.5 to two times the national rate,” the report states. “Furthermore, while the national death rate from alcohol-related chronic disease decreased 12% from 1990-2011, New Mexico's rate increased seven percent from 1990 to 2012.”

Research on the issue of what works and what doesn't shows that peer support groups of any stripe help alcoholics to recover. But in response to patient demand – and legal decisions – such approaches increasingly are incorporating scientific findings into treatment, and are dispensing with Alcoholics Anonymous' faith-based foundation. They're also incorporating support for family members of addicts, helping them change the environment the alcoholic comes back to or lives in, improving outcomes of addicts and the lives of those who love them.

Five years into his renewed drinking problem, and after multiple warnings from his doctor about the potential for failing health, Bender enrolled immediately in intensive outpatient therapy.

Bender had previously turned to Alcoholics Anonymous, a world-wide 12-step program that helps alcoholics quit drinking and stay sober. In Española alone, there are 15 different Alcoholics Anonymous meetings over the course of the week. This time, though, he wanted to move to something different because, for him, Alcoholics Anonymous just wasn't clicking.

Bender found the smaller, secular, science-based four-step peer support group program called SMART, or Self-Management and Recovery Training. Many years sober again, he moved to Santa Fe, where he facilitates SMART group sessions once a week. Bender has been to many different types of programs, often coupled with intensive outpatient therapy like the last time he relapsed, for that five-year stretch.

Many of those other groups, including Alcoholics Anonymous, did not strike the right chord with him. However, he saw many addicts who came out of Alcoholics Anonymous meetings injected with energy, having found the support group that worked for them. SMART Recovery's Regional Coordinator Demian Rubalcaba, who runs a group session in Albuquerque, said many in the program feel strongly about it because of the emphasis SMART places on the individual. “It's a humanistic approach,” Rubalcaba said. “It believes in the person's ability to make the decision to heal. SMART focuses on empowering you.”

While many self-help recovery programs focus on ideals steeped in morality and spirituality, SMART is different. It focuses on addressing addiction using many of the same approaches taken by mental health professionals. “You can be spiritual but it is not a part of the program,” Rubalcaba said. “Praying can help with recovery, but it requires a lot more than praying. It uses a lot of things you would learn from a well-trained psychologist.”

The program's facilitators work to help alcoholics break the bonds of addiction by stressing SMART Recovery's 4-Point Program. The first point, “Building and Maintaining Motivation,” works to stress the importance of recovery through positive motivation while the second point, “Coping with Urges” offers participants alternative solutions to address the urges that lead to relapse. Point three, “Managing Thoughts, Feelings and Behaviors” teaches clients how to employ cognitive behavior therapy tools to avoid letting negative thinking lead to destructive behavior. The last and final point, “Living a Balanced Life,” helps clients avoid the pitfalls of working, which can also lead to substance use issues.

Rubalcaba said the motivational point is at the top of the list because it is a direct contrast to many of the other programs.

“This is one of the most important ones,” he said. “It uses a motivational model, as opposed to the purity (abstinence) model. In SMART, we will tell you to try other programs, for example — anything to get better.”

SMART Recovery client Kevin, who asked that his last name not be used, attended Alcoholics Anonymous for a couple years before he started with the SMART groups. Kevin said he felt like the various 12-step groups, based on the original Alcoholics Anonymous program, asked too much belief from him. He found comfort in a secular program.

SMART was one of several programs that have emerged to accommodate the preferences of patients like Kevin. A 2012 paper in the Journal of Groups in Addiction & Recovery, by Tom Horvath and Julie Yeterian, addressed why many in the addiction treatment community wanted an alternative to Alcoholics Anonymous and the 12-step program.

“The context in which SMART Recovery emerged was one of increasing frustration with the lack of diversity in addiction recovery,” Horvath and Yeterian wrote. “As (cognitive behavioral therapy) and other non-12-step approaches to treatment and recovery were emerging in the scientific literature, evidence-based practitioners observed that the treatment industry was adopting these developments very slowly or not at all.”

Others were irked by the lack of a non-religious alternative. “In addition to professional frustration in the United States with the lack of alternatives to 12-step recovery, atheists and agnostics and their organizations object to the higher-power belief proposed by the 12 steps,” they wrote.

Pressure also came from the United States judiciary. Between 1996 and 2007, five U.S. Appeals courts ruled that addicts cannot be ordered to attend 12-step programs because of their religious nature.

Does it work?



There is plenty of research on the question of whether peer support groups are actually effective. Generally, these studies show that peer support groups of all stripes, including Alcoholics Anonymous, help alcoholics get sober and stay sober. One study from 2000, published in the Journal of Studies on Alcohol, found that those who attended groups, received treatment or both did better over eight years than those who did not.

“This finding is especially striking for abstinence; 54 percent of helped individuals achieved abstinence, as noted, but only 26 percent of untreated individuals did so,” the study states. “We also obtained two important findings regarding help for problem drinking among help seekers: Informal treatment alone was at least as effective as formal treatment alone and, in the long term, there were no differential outcomes between types of help.”

Since science-based approaches such as SMART are newer, the evidence on their success isn't conclusive.

The final evaluation report by Middlesex University of a pilot project in the United Kingdom found that 79 percent of the people going to the group found it “very helpful” while 21 percent found it “quite helpful.” “When compared with other self-help groups, SMART Recovery was reported to be either much more useful (33%) or more useful (39%), with 19% stating it was about as useful as other self-help groups,” the Middlesex researchers wrote. “Only 2% thought it was less useful than alternative self-help groups.”

A 2013 study, published in the Journal of Medical Internet Research by researchers based in Albuquerque, found that a web application built for the SMART website, called Overcoming Addictions, as well as SMART groups themselves, both help to decrease drinking.

The study was conducted with 189 “heavy problem drinkers,” Reid Hester wrote in the study that lasted for three months. For the study, Hester randomly assigned the 189 drinkers to three groups — one group just participated in the online course, one just attended SMART meetings and one group attended the meetings and also participated in the internet course.

“Participants in all groups significantly increased their percent days abstinent from 44% to 72% (P<.001), decreased their mean drinks per drinking day from 8.0 to 4.6 (P<.001), and decreased their alcohol/drug-related problems (P<.001),” Hester wrote. They found participants who went to more meetings abstained from drinking more, has an improvement in alcohol-related problems and drank less overall. Everyone in the group saw their drinking decrease. However, the study lacked a control group.

On the other hand, a 1996 study in the Journal of Consulting and Clinical Psychology, by Paige Ouimette, John Finney and Rudolf Moos, found those attending 12-step groups as well as cognitive-behavioral therapy, which SMART is based on, had similar outcomes after a year, although those going through the 12-step program had a slightly higher abstinence from alcohol rate.

“Our main finding was that patients in 12-step and (cognitive behavioral therapy) treatment for substance abuse generally do not differ on outcomes 1 year postdischarge,” they wrote. “This lack of difference is consistent with the broader literature on comparative psychotherapy outcome, which generally finds no differential effectiveness among treatments for mental health problems.”

In general, whatever the approach, research shows that there's a big difference between participating in a peer support group and not going at all. A 2005 study published in the BioMed Central Public Health Journal found the most significant difference in treatment came from those who attended at least one session, versus no sessions.

“Most of the improvement was instantaneous, occurring at week 1, before the participants had received the bulk of their treatment,” wrote Robert Cutler and David Fishbain.

The researchers' theory for that outcome was self-selection. That is, people who were ready to get better were going to regardless because they had already made that decision.

They found their results borne out by a study in the late 1970s by the RAND corporation. “Participants were patients who attended inpatient or outpatient treatment at centers across the United States,” they wrote. “They found that ‘it is possible that the correlation [between attendance and outcome] arises from selection effects, such that the better motivated or more successful patients continue in treatment, whereas the more intractable cases drop out.’”

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Psychologists, recovering alcoholics, family members of substance abusers and counselors all stressed the importance of therapy and teaching coping behaviors and mechanisms as an integral part of each individual's treatment.

Dr. Ricardo Gonzalez, a psychologist for Las Clinicas del Norte, which runs four clinics, said that many of his clients in Rio Arriba County do not have the kind of support networks already in place to help them get sober. Because families and friends are oftentimes part of the triggers that lead to relapses, his clients having someone else to turn to can make a difference. “Moods, family, domestic violence, abuse and trauma, treating those traumas is key to trying to get better,” Gonzalez said.

Indeed, for Bender, those support group meetings help him get out of the house and have positive social interactions on a much more consistent basis, combating one of the triggers for his own alcoholism — loneliness.

Many clients dealing with depression, post-traumatic stress disorder, anxiety and other disorders turn to alcohol to self-medicate. If they get into the clinic and see a doctor, they can instead get help for those disorders, which will allow them to stop self-medicating. “(People) are dealing with their feelings and their stressors (by drinking),” Gonzalez said. “It takes them a while to figure it out, that they're using substance to cope with their moods, emotions and stress. They see it as an important aspect of coping.”

Edna Gonzales-Anzaldua, a licensed substance abuse counselor and social worker for Las Clinicas, said her clients need to develop healthy coping skills and new ways of dealing with stress and their emotions. Part of the education, aside from therapy and coping skills, revolves around teaching clients what constitutes binge drinking and other overconsumption patterns. For some, however, the problem of alcohol is too fraught of an issue because a social drink too easily becomes binge drinking. “They're not just drinking to get a buzz,” Gonzalez said. “It's not that simplistic.”

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The elephant in the room



Most of the subject experts interviewed for this story agreed on a single idea, especially relevant in Rio Arriba County — families are a part of the problem and can become part of the solution. Gonzales-Anzaldua said she has seen many patients go into intensive inpatient therapy, come out clean, detoxified and sober, only to go back into their homes or communities and start using again.

The solution to the problem is simple: family and friends must change their behavior to help the addict reduce or eliminate relapses. “Addiction is a generational term,” Gonzalez said.

In Rio Arriba County, Gonzalez sees clients who have been brought up in homes where everyone drank and was part of the social norm. In addition, the behavior is modeled for the children and made a part of the implicit culture.

Abusing substances leads to abuse or trauma, or both. To cope with that trauma, the client then turns to alcohol and, often, later to drugs, to deal with the trauma and ongoing violence. Hence, a generational cycle of addiction becomes perpetuated, he said. Gonzalez said part of the complexity in dealing with alcohol abuse happens because it becomes a gateway drug to heroin, prescription opiates and benzodiazepines, such as Xanax and Valium. When a substance abuser kicks the heroin habit, he returns to alcohol, starting the addiction cycle again.

Charmaine Quintana came to the family support group side of SMART later on in life, 30 years after the troubles with her daughter began. In Buddhist teaching, “Life is suffering” is a tenet and it's something Quintana is very familiar with. She was married to an alcoholic and had a tumultuous relationship with her daughter, who ran away from home starting at the age of 12, and moved on to using heroin at age 15. Her daughter continues to use.

During those troubled years, after her daughter started running away, and before she started using heroin, Quintana reached an internal breaking point. Filled with homicidal and suicidal thoughts directed at her daughter and herself, she realized she needed help. Thirty years later and after many visits to other family support groups, including the Alcoholics Anonymous version called Al-Anon, Quintana found the SMART program. For her, it just clicked, unlike the other support groups she had previously tried.

Quintana jokes that we all have coping mechanisms for living and while some turn to alcohol and others to heroin or other drugs, she turned to food. As a SMART family support group facilitator, Quintana sees it as her role to give the family members who come to the group the tools to help themselves and, in doing so, increase the chances of helping their addicted loved one.

Those families who choose not to get help and choose not to change can become harmful. Quintana said there is a very fine line between helping a loved one and enabling. Part of her job as a SMART facilitator is to encourage family members to seek therapy, themselves — something Gonzalez also touts as part of the solution.

As part of her group, she helps family members understand how they can change from negative to positive reinforcement, set concrete boundaries and put themselves first. “SMART is solutions-oriented,” she said. She found that at support groups like Al-Anon, the focus was more on venting, a necessary part of the process. Where SMART began to work for her was the use of cognitive behavior therapy tools to address the behaviors at the root of the ranting. In addition, the program stresses teaching coping skills as well as behavior changes.

According to the Mayo Clinic, cognitive behavior therapy helps participants understand their own inaccurate or negative thoughts in order to more clearly see problems and respond to them. “It can be an effective tool to help anyone learn how to better manage stressful life situations,” the Mayo Clinic's website states.

In the SMART jargon, Bender and Quintana call it “cross talk,” that is, taking a problem and looking at the cognitive behavior skills to address it. “It's about the power of choice, that is the meat of this (program),” Quintana said. “It's about changing your behaviors so you may have a positive influence on your loved one.”

Quintana sees that when dealing with parents who have been enabling an adult child for some time. When boundaries are mentioned, the families begin to spin up worst-case scenarios, often ending with the family member's death if they do not enable them.

“My takeaway is, you can detach from the pain that their addiction is causing you, but you will never not love that person,” she said. “You don't have to stop loving them.”

Gonzalez said part of the problem with the family, and staying in the same home, comes from the triggers, developed since childhood, that cause each person to drink. Many of the triggers are usually within family dynamics, family interactions or in the family home. However, with a high poverty rate, 24 percent in Rio Arriba County according to the 2010 census, addicts have a hard time moving away from their parents due to a lack of jobs, mobility and education.

Barron Jones, Rio Grande Sun staff writer, contributed to this story.

This story is part of the "Small towns, big change" project through the Solutions Journalism Network.