In recent years, as the crack epidemic profoundly affected our nation's inner-cities, numerous clinicians have stated the need for more treatment tools with which to help inner-city addicts who will be returning to extremely challenging environments upon discharge. These clients are often homeless, unemployed, have a spotty work history or even criminal record--circumstances which do not automatically change upon becoming abstinent. Treatment personnel themselves say they have lacked concrete examples of how inner-city addicts can successfully cope with the many stresses and high-risk situations they encounter on a daily basis.
In response to this need, Reelizations began conducting research in November 1992 to determine the most pertinent high-risk situations that precipitated relapse in inner-city addicts, and what relapse prevention techniques successfully-recovering inner-city addicts, defined as maintaining on-going abstinence for over one year. [Research results begin on page 13 of this report] We then began developing a series of videotapes--due for release in early 1995--which can be used by drug/alcohol treatment and correctional facilities to teach relapse pretention techniques (RPT) to inner-city recovering addicts.
The fact is, many inner-city chronic relapsers do recover. And by interviewing everyday "success stories" on camera, we aim to convey that it is altogether possible to recover--even while living in a challenging environment, and that there are specific skills and strategies that can help.
It is also our hope that addiction counselors who treat large inner-city populations may themselves be inspired by the many examples of successfully-recovering inner-city dwellers presented in the tapes and, in turn, teach RPT to this population with renewed vigor.

The Need for Relapse Prevention Specifically Geared for Inner-City Clients

There are many reasons why most existing audio-visual recovery materials are not especially useful for programs treating predominantly inner-city clients. These include:

1. Inner-city residents who watch recovery tapes that were produced with largely white, suburban middle-class recovering audiences in mind (the majority of materials), are likely to come away with even less confidence in their own ability to successfully cope. ("They don't show people living in tenement buildings next door to crack houses in recovery, so maybe it's impossible for me to recover. Maybe only white people who go home to jobs and intact families can recover.")

2. Inner-city neighborhoods constitute high stress environments. Crack use is associated with increased rates of homicide and family disruption (Wachtler 1990). Violent crime is skyrocketing, with shootings "epidemic." (Ropp 1992). Harlem and other inner-city areas have been compared to "natural disaster areas" without the designation (McCord, 1990). Clearly, living in such an area can be stressful. Since unmitigated stress is a risk factor which can precipitate relapse, one can assume that inner-city addicts are at greater risk for relapse on this basis alone.

3. For many of the reasons just stated, inner-city addicts are at high risk for having experienced trauma, and for having Post Traumatic Stress Disorder (PTSD) (Kulka e al, 1990). Other risk factors for PTSD include low education, family substance abuse, and early drug use. (Breslau, 1991). Anecdotally, nearly 90 percent of those we interviewed in Phase I were children of alcoholics or addicts, and many were high school drop-outs who began using drugs as pre-teens. Women crack-users are especially vulnerable to trauma (Fullilove et al., 1992), as many experience domestic violence (Wallace, 1991) and/or are victimized in sex-for-drug exchanges (Fullilove et al, 1990).

4. PTSD is associated with substance abuse (Brown & Anderson, 1991). Therefore, effective RPT for inner-city addicts must address the symptoms of PTSD, including sleep disorders, recurring thoughts and nightmares and emotional numbing.

5. H.I.V. virus and A.I.D.S. is more prevalent among minority, inner-city addicts than among white middle-class alcoholics, the population for whom many of the existing audiovisual aids were produced. Some inner-city drug treatment programs report a full third of their population is H.I.V. positive. Cummings et al (1982) noted that chronic illness can directly or indirectly trigger relapse. Therefore, it is important to address HIV in any relapse prevention effort for inner-city addicts.

6. Among addicts in the inner city, drug sales are a common source of employment. (Wallace, 1991) Many of the men and some of the women we interviewed spoke of relapsing when they were broke, since the only way they felt they had access to money in the past was through dealing drugs. So when broke in recovery, they would start to think that they could "deal a little" and not use. Inevitably, relapse occurred. Therefore, any attempt to reduce relapse among inner-city recovering addicts must address the issue of finances, and making a living.
A high proportion (53%) of female crack addicts have had children placed in foster care by state agencies. (Fullilove, et al., 1992) This often results in profound feelings of shame, a sense of failure in maternal roles, and grief--which, if not addressed, contributes to relapse. Therefore, these child-loss experiences must be addressed, and female role models presented who are successfully coping with this trauma.

7. The old adage "deal with the drinking and things will work out" does not fit poor families (Diaz, 1992). Among inner-city addicts, when the drugging stops, the person's circumstances are often not much better than when he was using. He may still be homeless, unemployed, uneducated, and poor. In one recent study of female crack addicts, fully half were homeless (Chavkin 1991). Among addicts admitted to one therapeutic community, 93% were unemployed upon admission (Baker, et al., 1989). Therefore, again, the necessity of addressing the very real issues of housing, income, money, and jobs.

8. Social pressure has long been recognized as a relapse trap. 20% of relapses in Marlatt's sample (Cummings et al 1980) occurred in situations in which the individual was responding to the influence of others to engage in the behavior. Anecdotally, among the 31 inner-city recovering addicts we interviewed, most describe being literally surrounded by social pressure. One woman described having to walk through a crowd of people smoking crack in the stairwell in order to get to her apartment; others describe having people knock on their doors and windows with offers of drugs, relatives leaving crack in their apartments, etc. Therefore, relapse prevention efforts must address ways to successfully cope with such extreme social pressure.

9. It has long been noted that chemically-dependent people who lack social or family stability or who are part of social networks in which others abuse substances are at higher risk for relapse (Baekeland, 1977; Saxe et al., 1983; Cusack, 1984; Zackon, et al 1985; Daley, 1987; and Hawkins and Fraser, 1987). Among those we interviewed, there was a pronounced lack of positive support systems readily available. Therefore, it is important to emphasize ways in which recovering inner-city addicts have successfully created and used positive support networks through such resources as 12-Step meetings, counseling programs, church groups, etc.

Special Needs of Hispanic Inner-City Recovering Addicts

Hispanics make up a growing portion of inner-city residents. And the special needs of urban Hispanic recovering people extend even beyond those just cited, including:

1. Sex roles in traditional Hispanic families are often highly delineated, with the female role that of "mother" and the male role involving considerable "machismo." (Diaz, 1992) Therefore, the stigma on a Hispanic female who has been deemed an unfit mother due to drug use may be felt even more acutely. And the social pressure on the Hispanic male to act in ways that have the effect of rendering his relationships dysfunctional (i.e. battering), may complicate recovery. It is important, then, to present realistic ways in which Hispanic men and women can deal constructively with these sex role challenges.

2. Immigration status and language problems can be additional stresses on the recovering Hispanic person (Diaz 1992). This too must be taken into consideration in relapse prevention efforts aimed at this population.

3. Fewer than half of inner-city Hispanics ever complete high school (Diaz 1992) Relapse prevention materials must be geared to early reading levels and arrangements made for illiterate clients.

4. The drinking of alcohol is often considered another demonstration of the Hispanic male's machismo (Diaz 1992). He often experiences additional social pressure to participate in family and neighborhood social rituals that involve drinking. Relapse prevention for Hispanic clients, then, must illustrate ways to successfully copes with this pressure without using.

Reelizations' Methodology in Phase I Research

In Phase I we surveyed inner-city recovering addicts and professionals with expertise in the treatment of inner-city addicts. As a result, we identified a broad array of relapse traps and relapse prevention strategies of particular relevance to this population.

From interviews with both our panel and other professionals in the field [see Appendix I on pages 36-37], we drew up a questionnaire to guide us in our interviews with recovering inner-city addicts, and generated a list of 44 relapse traps and 47 relapse prevention strategies which appeared to be relevant to inner-city relapse prevention.

We then asked 31 recovering addicts and our panel of experts to rate each relapse trap and prevention strategy on our survey according to the relevance they felt it had to recovery (their own, in the case of addicts; their clients' in the case of professionals). We used a Likert-type rating of 1 to 3 with "1" being "not important at all," "2" being "somewhat important" and 3 being "very important."

Almost all the surveyed addicts had relapsed many times in the past. Therefore they brought to bear more experiences than just their current success.

The demographic breakdown of our recovering addict sample was, we believe, roughly reflective of the target audience for our series:

Race: 65% African-American, 23% Hispanic, 12% white (non-Hispanic);
Gender: 61% male, 39% female;
Age: 23% age 20-29, 42% age 30-39, 29% age 40-49, and 6% age 50-55.

- Hanging out with friends who still use. 3. (1)
- Living with someone who is an active user. 2.77 (2)
- Still using some drugs (e.g. pot or alcohol) while remaining abstinent from your drug-of-choice. 2.77 (3)
- Offers of drugs. 2.74 (4)

- Low self-esteem 2.67 (5)
- Anger 2.64 (6)
- Abstinence Violation Effect (a single lapse leading to full-blown relapse) 2.62 (7)
- Feelings of failure. 2.56 (9)
- Not having a sense of purpose in life. 2.5 (10)
- Isolation 2.5 (11)
- Testing control 2.48 (12)
- Lying/cheating in intimate relationship. 2.45 (14)
- Feelings of boredom. 2.44 (15)
- Living in the old neighborhood where he or she used to get high. 2.42 (16)
- Intense relationship issues. 2.39 (20)
- No spiritual foundation or beliefs. 2.38 (21)
- Associating sex and drugs together. 2.34 (24)
Note that 6 of the first 9 relapse traps just listed have to do with negative emotional states (low self-esteem, anger, failure, lack of purpose, isolation and boredom). Cummings et al (1980) found that 35% of all relapses came on the heels of such unmanageable feelings.
Several other relapse traps that were originally mentioned by our expert advisors proved "not important at all" to the addict sample. These were:
- Physical illness. 1.77 (41)
- Poor nutrition. 1.54 (43)
- A belief that being straight means "getting white."1.5 (44)

- Feelings related to lack of employment or money. (2.27 compared to 1.67)
- Being broke/needing money. (2.37 compared to 1.83)
- The lure of money and the excitement of dealing (2.39 compared to 2.17)
- Associating success with money. (2.46 compared to 2.0)

--Creating and using a positive support system. 2.97 (1)
--Thinking through to the consequences of things. 2.89 (2)
--Developing self-acceptance. 2.89 (3)
--Staying away from places where you used to get high. 2.87 (4)
--Breaking off with friends who still use. 2.87 (5)
--Knowing how to recognize signs of relapse. 2.75 (7)
--Having a policy of abstaining from all drugs (including alcohol). 2.7 (8)
--Accepting responsibility for your own recovery. 2.69 (9)
--Learning to tolerate uncomfortable feelings. 2.68 (10)
--Participating in 12-step programs. 2.65 (11)
--Having assertiveness skills to say "no" to drugs. 2.63(12)
--Structuring time in early recovery. 2.62 (14)
--Learning to deal constructively with anger. 2.59 (16)
--A strong spiritual faith. 2.58 (17)
--Developing a healthy relationship with children. 2.58 (18)
--Learning assertiveness skills. 2.57 (19)
--Developing self-discipline. 2.57 (20)
--Furthering your education during recovery. 2.47 (24)
--Maintaining honesty in intimate relations. 2.41 (25)
--Volunteer work, community/ political organizing. 2.39 (26)
--Tools for dealing with cravings: an action plan. 2.39 (27)
--Having goals for the future. 2.35 (28)

--Learning natural ways to reduce anxiety. 2.33 (29)
--Learning to have sex without drugs. 2.28 (30)
--Learning to deal with authority constructively. 2.27 (31)
--Having an action plan for handling slips. 2.26 (33)
--Developing supportive relationships with family. 2.25 (34)
--Making amends wherever possible. 2.23 (35)
--Grieving the drug, the life style or other losses. 2.2 (36)
Both addicts and experts agreed that these strategies were less crucial to relapse prevention:
--Membership in a church. 1.86 (42)
--Adjusting behavior and dress to get a job. 1.83 (43)
--Getting regular exercise. 1.78 (44)
--Eating nutritiously. 1.7 (46)

--Developing supportive relationships with family. 2.25 (34)
--Developing awareness about enabling and potential family sabotage. 2.07 (39)
--Learning to recognize dysfunctional family dynamics. 1.81 (45)

--Having or learning a marketable job skill. (2.76)
--Redefining success; valuing yourself above money. (2.62)
--Learning to manage money. (2.55)
--Having a job you like. (2.53)

1. Overview. The following points are important to convey in any relapse prevention effort aimed at inner-city recovering addicts:

a) Recovery is altogether possible--even when one comes from or lives in a challenging environment such as an urban inner-city neighborhood.
b) Lasting recovery is a process, requiring certain skills that can be learned like any other skills. It is most important to learn how to recognize and avoid stressors and cues, as well as how to recognize the signs of a relapse and cut it short if one occurs. Failure to anticipate and cope with such stressors, cues and high-risk situations is the major set-up for relapse.
c) Others have successfully used such skills and strategies to avoid relapse in similar situations.

2. Confidence. Relapse is most likely to occur when one's confidence in his ability to cope is weak. At such a time, a recovering person can easily perceive a high-risk situation as beyond his capacity to deal with and become overwhelmed with feelings of helplessness and anxiety. He then becomes more likely to give in to the urge to get high--especially if drugs/alcohol are readily available in the environment.
Conversely, the more prepared one is with coping responses for high-risk situations, the better his chances of remaining abstinent. As high-risk situations are successfully met, the recovering person's perceived sense of control strengthens, making him, in fact, less likely to relapse.

The three main categories of high-risk situations for recovering addicts in general are a) negative emotional states, b) social pressure and c) interpersonal conflict and anger. Additional common high-risk situations are frustration and stimulus-elicited cravings (i.e. walking by a bar or area where one used to buy or use drugs).

4. Inner-city recovering addicts are likely to face even more high-risk situations than others in early recovery, because the environment they return to after treatment or incarceration is extremely challenging.

a) Inner-city neighborhoods constitute chronic high-stress environments, creating a greater relapse risk on this basis alone.
b) Inner-city addicts are highly likely to have experienced trauma in their past and are at high risk for having Post Traumatic Stress Disorder (PTSD), especially women crack-users. Therefore, effective RPT for inner-city addicts must address the symptoms of PTSD, including sleep disorders, recurring thoughts and nightmares and emotional numbing.
c) H.I.V seropositivity and A.I.D.S. is increasingly prevalent among minority inner-city recovering populations.
Since chronic illness constitutes a high-risk situation in recovery, it is crucial to address H.I.V. and A.I.D.S. in any RPT effort for inner-city addicts.
d) Because the drug trade at various levels constitutes one reliable source of employment in the inner-city, any attempt to reduce relapse among inner-city addicts must address the issue of finances and making a living. Otherwise, when a former dealer finds himself broke in early recovery, he may start to fantasize that he can get money fast by dealing "a little" and not using. Inevitably, of course, re-association with illegal activities and proximity to drugs precipitates a relapse.
e) A high-proportion of inner-city female crack addicts have had children placed in foster care, resulting in profound feelings of shame, a sense of failure in maternal roles and grief--which, if not addressed, can contribute to relapse.
f) Things don't necessarily get better upon abstinence. The old adage, "deal with the drinking/drugging and things will work out" does not apply to many inner-city addicts. Among this population, when the drugging stops, the person's circumstances are often not much better than when he was using. He may still be homeless, unemployed, uneducated and/or poor. Again, we see the necessity of addressing the very real issues of housing, income, money and jobs.
g) Social pressure to use. High rates of addiction in inner-city neighborhoods make it all the more likely that someone in early recovery will be in a situation where people are using. Hanging out with friends who still use is the #1 relapse trap (the one most likely to precipitate relapse) cited by recovering inner-city addicts. Living with someone who is an active user is another common trap, as is being offered drugs.

5. Strengths. There are also a number of strengths inner-city recovering addicts can be encouraged to draw upon whenever possible.

a) Religion has traditionally been a strong influence and source of support in both African-American and Hispanic households, so RPT with this population can include examples of how others have successfully used the church as part of their support system.
b) Strong family ties and extended family involvement are also present in many African-American and Hispanic inner-city households. This can serve as great support when the extended family is functioning well.

6. Dysfunctional family issues. On-the-other-hand, having dysfunctional family members who still use drugs or are otherwise in constant crisis (arrest, conflict, abuse, etc.) can be a serious relapse trap for inner-city recovering addicts. When a person has such destructive family members, the tradition of close family ties can make it even more difficult to "detach." Many of our subjects reported feeling overwhelmed by other family members' problems, which they were often called upon to solve. RPT should help recovering people develop an awareness of enabling, family sabotage and other dysfunctional family dynamics, and skills in "detaching with love."

7. Hispanic issues. Hispanics make up a growing proportion of inner-city residents, and our survey suggests that a substantial portion of recovering Hispanic inner-city addicts feel "doomed" and don't believe that recovery is possible for them. There are a number of factors which may contribute to this discouragement:

a) The stigma on an Hispanic female who has been deemed an unfit mother due to drug use may be even stronger than for other groups.
b) If an Hispanic man feels social pressure to act in ways that emphasize "machismo" in a destructive sense (such as battering), this can have the effect of rendering his relationships dysfunctional and can put him at risk of relapse.
c) Our survey found Hispanic men placed less importance on maintaining complete abstinence than other groups. This may be because Hispanic men in recovery may also feel particular pressure to go on drinking alcohol at family and neighborhood social rituals. RPT efforts must illustrate ways to successfully cope with this pressure--to still feel a sense of belonging--without using.
d) Immigration status and language problems can be additional stressors on the recovering Hispanic person.
e) Fewer than half of inner-city Hispanics ever complete high school, limiting job opportunities in recovery. To be effective, RPT materials must be geared to early reading levels.

8. Relapse traps especially relevant to the inner-city. Some high-risk situations of special concern to inner-city addicts may be currently under-addressed in the treatment field.

a) Unrealistic expectations. Many of our recovering inner-city subjects cited "having unrealistic expectations" as a major relapse trap for them in the past. If they came out of treatment or incarceration expecting everything to fall in place quickly and easily and it didn't, they lost confidence in their ability to recover and became more vulnerable to relapse. Therefore, RPT efforts need to help clients maintain realistic expectations, anticipate occasional or even frequent feelings of discouragement, and have a plan for dealing with them.
b) Money. Many recovering inner-city addicts also find that both having money (on pay-day, for example), and being broke constitute high-risk situations for them. In the first case, they may be tempted to buy drugs, since that's what they are used to doing with large sums of money. In the latter case, being broke can prompt thoughts of dealing and other illegal activities that they may have utilized to get money in the past. Some applicable recovery steps our successfully recovering subjects described taking were: a) having or learning marketable job skills; b) learning to value themselves above money; c) redefining "success;" and d) learning to manage money.
c) Lifestyle addiction. The lure of fast money, the excitement of dealing, and an ongoing attraction to street life in general was considered by many of our subjects to have been a serious relapse trap for them. RPT efforts needs to address this "lifestyle addiction," at the very least by acknowledging it.
d) Certain kinds of feeling states are also especially problematic for inner-city recovering addicts, especially low self-esteem, anger (a feeling which living in a challenging urban environment elicits often), feelings of failure and frustration, boredom (lack of purpose), and isolation. RPT efforts should address and model ways of successfully coping with such feelings, especially creating support systems for going through them without getting high.

9. Gender-specific issues. Recovering female inner-city addicts have some special issues that need addressing in RPT: If they have children in their care, they often report being "overwhelmed by parental responsibilities." They also report "difficulty getting to sleep" more often than their male counterparts, which may be associated with women's higher rates of Post Traumatic Stress Disorder, most common among crack-using females in inner-cities.

Among recovering male inner-city addicts, there are other special issues: Feelings resulting from racism and discrimination and feelings of failure were both rated more highly by males than females. This may reflect the fact that vocational/financial "failure" may be thought by men to reflect on their masculinity. Men also found it more important to participate in a recovery program with people of their own culture/race than women did. There is also some evidence that inner-city men are less likely than their female counterparts to have goals for the future and are less willing to adjust their behavior and dress if necessary to get a job. RPT would do well to address these issues.

10. Effective relapse prevention strategies for this population: Our successfully-recovering inner-city subjects ranked having a positive support system as their #1 (most effective) relapse prevention strategy. Having ways to deal with cravings was also extremely important to our sample, specifically learning to think through a craving to the long-term consequences of satisfying it. Avoiding social pressure by staying away from places (corners, blocks, bars, etc.) where one used to get high or buy drugs, and breaking off with friends who still use were also key strategies. Developing self-acceptance and self-responsibility, and learning to tolerate uncomfortable feelings (such as anger) complete the list.