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PREVENTING RELAPSE
AMONG INNER-CITY RECOVERING ADDICTS
Donna Boundy, M.S.W.
Tom Colello, M.A.
Reelizations
P.O.Box 555
Woodstock, NY 12498
A Research Report from Phase I, SBIR Grant
# 1 R43 DA08140-01
Funded by National Institute on Drug Abuse
We gratefully acknowledge Drs. Arthur Horton
and Arturo Cazares of the National Institute
on Drug Abuse, Project Officers for Phase
I and Phase II respectively, who contributed
substantially to the success of this project. |
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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. |
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A REVIEW
OF PERTINENT LITERATURE |
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The Importance of Relapse
Prevention Training
Recovery is not an "event"
that occurs in a treatment program,
no longer an issue once the client becomes
abstinent. Indeed, recent research suggests
that lasting recovery--the ability to
remain abstinent over time--is a process,
requiring certain skills that can be
taught like any other skills.
According to Marlatt (1985), the most
important stage of the change process
is the maintenance stage, which begins
the moment after the initiation of abstinence.
It is during this stage that the recovering
person is faced with a plethora of temptations,
stressors, and the pull of powerful
old habit patterns.
As noted by Marlatt, many alcoholics
in inpatient treatment report few, if
any, cravings to drink while in the
hospital. This may lead, he suggests,
to the illusory impression that treatment
has been "successful" and
that the craving to drink [or drug]
has been permanently quelled. But return
to the pretreatment environment often
shakes this illusory confidence, as
the person is exposed to old stressors
and cues, and the urge to use returns.
Failure to anticipate and cope with
these stressors and cues is the major
set-up for relapse.
Recovering people with few effective
ways to deal with high-risk situations
are reported to be at the highest risk
for relapse (Donovan & Chaney, 1985).
Hunt, Barnett & Branch (1971) found
that between 65% and 80% of people treated
for heroin, smoking, and alcohol addictions
relapsed within the first year of recovery--and
most of those within the first three
months.
Relapse Prevention Training (RPT) is
a treatment approach which teaches clients
to recognize, anticipate, and cope successfully
with high risk situations--without using
drugs or alcohol. Substantial evidence
has emerged which demonstrates that
teaching addicts relapse prevention
techniques prior to their return to
the community substantially improves
their chances of prolonged abstinence.
For example, RPT for alcoholics decreased
the length and severity of drinking
episodes, compared to standard treatment
alone. (Chaney et al 1978; Oei and Jackson,
1982.) Other studies have had similar
results with polysubstance abusers (Hawkins,
et al., 1986), and cigarette smokers
(Davis et al, 1986; Hall et al, 1984).
Carroll et al (1991) evaluated Relapse
Prevention Training (RPT) as treatment
for ambulatory cocaine abusers, and
compared it to interpersonal psychotherapy
(IPT). Subjects assigned to RPT were
more likely than those assigned to IPT
to complete treatment (67% versus 38%),
to attain abstinence (57% versus 33%),
and to maintain abstinence for three
consecutive weeks (43% versus 19%).
In the Carroll study, there were even
more substantial differences when the
severity of addiction was considered.
For those judged to have severe addictions,
subjects given RPT were significantly
more likely to achieve abstinence (54%
versus 9%) and to remain abstinent for
three consecutive weeks (54% versus
0%) than high severity subjects who
received IPT. It is generally believed
that many chronic inner-city addicts
are similarly "hard-core"
(high-severity) addicts. This finding,
then, underscores the appropriateness
of creating and using RPT audiovisual
and other aids for this population. |
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Relapse Prevention Training
Fosters Confidence
According to George & Marlatt (1986),
the likelihood of relapse depends almost
entirely on one's ability to cope with
high-risk situations. A high-risk situation
is any situation that poses a threat
to the individual's sense of control
and increases the risk of potential
relapse (Marlatt 1985). People in early
recovery often experience themselves
as "in control" until a high
risk situation is encountered.
In an analysis of 311 relapse episodes
by Cummings et al (1980), three broad
categories of high-risk situations were
identified: 1) negative emotional states
(which preceded 35% of relapses studied;
2) social pressure (20%) and 3) interpersonal
conflict (16%). Marlatt cites interpersonal
anger, frustration, and stimulus-elicited
cravings (i.e. walking by a bar) as
additional high-risk situations.
Relapse is most likely to occur when
one's confidence in his ability to cope
is weak. A recovering person who is
inadequately prepared to cope can easily
perceive a high-risk situation as beyond
his capacity to deal with, and become
overwhelmed with feelings of helplessness
and anxiety. As his expectation of coping
successfully declines, he then becomes
more likely to give in passively to
the urge to get high--especially if
drugs are readily available in the environment
(George, 1986).
Conversely, the more prepared one is
with coping responses for high-risk
situations, the better his chances of
remaining abstinent. That's because
as high-risk situations are successfully
met, the recovering person's perceived
sense of control strengthens, making
him in fact less likely to relapse.
(Annis & Davis, 1987) In other words,
an expectation of successful coping
in future high-risk situations (based
on prior successful coping) contributes
to the likelihood of successful coping.
Success begets success. This is all
the more reason to give recovering addicts
the skills they need to insure early
successful experiences in high-risk
situations. |
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The Drug Treatment Field
Has Been Slow to Embrace Relapse Prevention
Training
Despite the fact that relapse is the
norm among recovering addicts, despite
the highly negative consequences of
relapse, and despite the fact that RPT
has been proven effective, many drug
treatment programs have been amazingly
slow to incorporate relapse prevention
training into their treatment. (Annis,
87)
Even the discussion of relapse has been
something of a taboo in some drug treatment
programs. There may be a couple reasons
for this: 1) Some counselors may fear
that by talking about the possibility
of relapse with a client, they convey
an expectation of relapse, or imply
permission (Washton and Boundy, 1989).
2) If a program's treatment philosophy
calls for the attainment of abstinence,
even a single incident of relapse may
be considered failure on the part of
the treatment program or clinician,
and elicit feelings of frustration and
incompetence.
Ironically, it is this mistaken notion--that
relapse is synonymous with failure--that
contributes more than any other factor
to high relapse rates (Washton &
Boundy, 1989). Because relapse is viewed
as something to be ashamed of and treated
as a taboo, many clients don't learn
how to recognize and avoid high-risk
situations, notice the warning signs
of a relapse, and cut one short if it
occurs. Yet these skills are the essence
of relapse prevention.
Lastly, researchers have found that
a clinician's own knowledge of relapse
is a variable affecting his patients'
relapse rates (Daley, 1988; Gorski &
Miller, 1982). If a counselor lacks
knowledge himself of relapse traps and
countering prevention strategies, he
cannot teach these skills to his clients. |
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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.
In both African-American and Hispanic
inner-city households, religion is often
reported to have a strong influence.
And while involvement in organized religion
didn't turn out to be a major relapse
prevention strategy employed by our
particular subjects, relapse prevention
efforts directed to this population
may want to include examples of recovering
African-Americans and Hispanics who
have successfully used the church as
part of their support system.
In both African-American and Hispanic
inner-city households there are often
strong family ties and extended family
involvement. Physically or emotionally
separating from family members who are
addicted or otherwise dysfunctional
may not be seen as an option. Therefore,
relapse prevention efforts should include
examples of recovering people who have
utilized strong family ties as part
of their support system, as well as
others who have successfully created
some emotional distance from dysfunctional,
or even destructive, family members. |
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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.
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| RESEARCH FINDINGS |
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| 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.
The interviews, lasting from one to
three hours, were conducted personally
by Donna Boundy or Tom Colello. All
but three were in person, meeting with
the recovering person in his home city
of Bronx, NY; Bridgeport, CT; New Haven,
CT; Washington DC or Miami, FL. All
interviewees had been abstinent a minimum
of one year. They had come into recovery
variously through in-patient treatment,
hospitals, out-patient programs, jails,
and a surprising number through drug
programs in homeless shelters. The majority
listed crack cocaine among their drugs-of-choice,
with other favored drugs including cocaine
powder, alcohol, and heroin. Almost
all had problems with more than one
substance.
Following our interviews with recovering
addicts, we sent a revised version of
the survey to our experts and asked
them to rate each relapse trap and prevention
strategy as to the importance they gave
it.
Drawing from the survey results, we
developed an extended outline for the
proposed video series.
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Recruitment of Subjects.
Subjects for Phase I were recruited
by contacting various drug and alcohol
treatment facilities in the cities mentioned.
We asked treatment staff to refer individuals
they knew to be recovering from drug
or alcohol addiction, with at least
one year of abstinence while living
in the community, who come from an inner-city
environment, and have a good ability
to articulate their experiences in recovery.
We monitored the referrals we were receiving
to maintain the demographic breakdown
we felt would best reflect our target
audience. |
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Overview of Results
With a few notable exceptions, both
the recovering people and our expert
consultants agreed on the most important
relapse traps and strategies. More than
half of the relapse traps that we tested
(26 of 44) and more than half the prevention
strategies (29 of 43) were ranked "very
important" by half or more of both
addict and expert respondents.
We found that some factors that addicts
considered important to their recovery
were not considered so important by
our expert panel. These included the
relapse trap of "having unrealistic
expectations" regarding how quickly
and easily things will come together
in recovery. Also, several relapse traps
concerning money and finances were collectively
rated as "very important"
by addicts surveyed, and "not important
at all" by the experts. These differences
suggest that there may be relapse traps
that are especially relevant to inner-city
addicts which are not being adequately
addressed in the field.
The weight given some relapse traps,
of course, varied greatly according
to the specific circumstances of that
person's life. For example, if a person
came from a highly dysfunctional family,
then "having a family member who
sabotages your recovery" was regarded
as a serious relapse trap, while a person
from a supportive family would rate
such a trap "not important at all." |
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Findings Regarding Relapse
Traps
The relapse traps with the highest rating
for both groups, followed by the mean
of all addict responses, and the rank
position that puts it in out of 44 relapse
traps, were:
- 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)
Note that 3 of these 4 have to do with
"social pressure." While Cummings
et al (1980) found that 20% of relapses
come on the heels of social pressure,
it appears that, among our sample at
least, an even greater portion of relapses
may be associated with such pressure.
This could reflect the high rates of
addiction presently found in inner-cities,
especially since crack's arrival, making
it all the more likely that someone
in early recovery will be placed in
high-risk situations containing social
pressure.
The following relapse traps were also
rated "Very Important" by
more than half the addicts in our survey,
and at least "Somewhat Important"
by all of the experts:
- 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)
While "negative physical states"
is listed by Marlatt as a significant
relapse trigger (1985), it appears that
those we interviewed did not consider
it very important, perhaps in comparison
to what felt like more pressing, immediate
concerns.
Likewise, they did not consider "poor
nutrition" to be worthy of much
of their focus. While a good number
verbally expressed concern about maintaining
good nutrition and fitness, in early
recovery these appeared low on their
priority list. |
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Differences Between Addicts
and Experts Regarding Relapse Traps
One relapse trap was considered much
more important by the drug users than
the experts. "Having unrealistic
expectations of recovery" scored
2.62 among addicts, and only 1.83 among
experts. Many of the recovering people
recalled anecdotally how, leading up
to previous relapses, they had expected
to get the job they wanted, expected
relationships to come together, a great
family life--all quickly. When it didn't
turn out that way, they were disillusioned,
frustrated, and angry. These negative
mood states, then, led back to use.
The problem was not that their recoveries
were actually failing, but that their
expectations were so high that when
they were not met, they thought they
were failing, and were greatly discouraged.
On the heels of these feelings, they
would then relapse.
Addicts also tended to consider issues
of money to be more serious relapse
traps than experts did, including:
- 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)
Since all four of these relapse traps
were rated fairly low by the experts,
but fairly high by the addicts, this
again indicates an area that may be
under-addressed in treatment programs.
It is worth noting too that there is
little in the literature about these
specific situations, although certainly
the feelings related to unemployment
and lack of money would fall under the
category of "negative emotional
states." |
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Comparisons Between Subgroups
Gender: We compared subgroups
of male and female respondents and found
some relapse traps to be more important
for one gender than another, with a
degree of confidence of 90%.
As might be expected, "Being overwhelmed
by parent responsibility" had a
mean of 2.5 among women, compared to
1.55 among men. Similarly, "difficulty
getting to sleep" had a mean of
2.5 for women and 1.79 for men. This
may suggest simply that being a mother
often results in losing sleep due to
childcare responsibilities. But it may
also suggest the association of sleeplessness
with PostTraumatic Stress Disorder,
most common among crack-using females
in inner-cities (Fullilove et al, 1992).
For males, "feelings resulting
from discrimination," and "feelings
of failure" were significantly
more important than they were for females.
This may reflect the fact that in our
society generally men often feel "failure"
reflects negatively on their masculinity.
If we take this to be so, it follows
that recovering men may be more vulnerable
to negative emotional states resulting
from what they experience as failure,
or a loss of status.
Race/ethnicity:
Because of the low number of whites
(non-Hispanic) in our sample, there
was little validity to comparisons with
their subgroup. We did compare Hispanic
to African-American responses and found
the following differences at the 90%
degree of confidence level: Hispanics
gave a significantly higher rating to
the relapse trap, "feeling doomed;
not believing recovery is possible."
This suggests that perhaps Hispanics
see more barriers to their successful
functioning, such as language, immigration
status, etc. Further exploration of
this is needed. |
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Other Findings Regarding
Relapse Traps
Some relapse traps had a mid- or low-range
mean but a high frequency of "1"
and "3" scores, indicating
that most respondents found it either
very important or not important at all.
One was the relapse trap "associating
sex and drugs". Several interview-
ees identified this as the single most
important cause of their relapse and
related specific sexual events that
triggered drug use for them. Therefore,
while it does not apply equally to all
recovering people, this association
of sex with drugs appears to be a powerful
trap for some.
Likewise, the relapse traps "not
recognizing dysfunctional family dynamics"
and "having a family member who
sabotages recovery" also showed
a high frequency of "1" and
"3" scores--with little in-between.
Of course, people who come from a highly
dysfunctional family and continue to
interact with them during recovery were
likely to rate this as a crucial relapse
trap. Conversely, those whose families
are in relatively good shape or who
have little contact with their family
wouldn't find this problematic. |
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Relapse Prevention Strategies
Here again, both groups--addicts and
experts--agreed on the most important
relapse prevention strategies. On 28
on the 46 strategies included in the
survey, more than half of the recovering
addicts rated them "very important."
22 of those same 28 popular strategies
were also ranked as "very important"
by our expert advisors. Listed with
mean score for drug users, followed
by the rank that gives it, out of 46
strategies:
--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)
The following relapse prevention strategies
were ranked "somewhat important"
on average by both groups:
--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) |
| |
Comparisons Among Subgroups
Gender: Again, when gender
subgroups were compared, we found a
few significant differences at the confidence
level of 90%. "Participating in
a recovery program with people of your
own culture" was a prevention strategy
rated significantly higher by males
than females. This is consistent with
the finding that males rated the relapse
trap "feelings resulting from discrimination"
higher also.
"Developing
a healthy relationship with your children"
was rated 2.82 by females, while males
rated it 2.4. An unexpected finding
was that "Having goals for the
future" was much more important
to females, who rated it 2.75 compared
to males at 2.07. Women also ranked
"adjusting your behavior and dress
if necessary to get a job" as more
important than men did.
"Grieving
the drug, the life style or other losses"
was rated 2.5 by women and 2.1 by men.
This may reflect the frequent experiences
of loss described by women whose children
were placed in foster care during their
addiction. It may also reflect the tendency
of women to acknowledge feelings of
loss more readily than men.
Race/ethnicity: There were two
important differences between African-American
and Hispanics at the 89% degree of confidence
level. Hispanics placed less importance
on "Having a policy of abstaining
from all drugs." Several of our
interviewees and experts spoke to us
about the emphasis in Hispanic culture
on drinking, especially for males, the
ability to "hold your liquor"
being for some a measure of "machismo." |
| |
Other Findings About Relapse
Prevention Strategies:
A number of relapse prevention strategies
also scored a high frequency of "1"
and "3" responses, with few
"2"s. These include:
--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)
Like the corresponding relapse traps,
whether you come from a family that
is supportive or highly dysfunctional
determines, of course, the importance
you give this strategy.
"Participating
in on-going counseling" rated only
2.1 by addicts, although this also had
a high frequency of 1 and 3 scores.
If you assume that most on-going counseling
is insight-oriented, it does strengthen
our contention that focusing on relapse
traps is more relevant to people in
early recovery than insight-oriented
counseling. However, for those who chose
to be in counseling, it was usually
ranked "very important," with
females ranking it higher than males.
Not surprisingly, the experts ranked
this strategy somewhat higher than did
the addicts.
The relapse prevention strategy "Maintaining
realistic expectations in recovery,"
like its corresponding relapse trap
"unrealistic expectations"
was ranked much higher by addicts than
by the experts.
Addicts also ranked relapse prevention
strategies related to money much higher
than the experts did, including:
--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)
Finally, the relapse prevention strategy,
"learning to enjoy the evenness
of recovery" was rated as more
important by the drug users. This suggests
a lack of appreciation in the field
regarding the pull that the excitement/thrills
of the addiction/ /dealing lifestyle
(criminal activity, handling large amounts
of money, sex and drugs, etc.) can have
on clients in early recovery. |
| |
SUMMARY:
Implications of this Research for
Addiction Counselors and Administrators |
| |
Relapse prevention training should
prepare an addict to return to the community
by helping him anticipate high-risk
situations that he may encounter and
develop strategies in advance to deal
with those situations. The likelihood
of relapse depends almost entirely on
one's ability to cope with high-risk
situations.
Our research identified a broad array
of relapse traps and prevention strategies
particularly relevant to our sample
of inner-city recovering addicts, which
we believe can be somewhat generalized
to inner-city recovering drug users
in general.
Our research, combined with an extensive
review of the literature, leads us to
provide the following summary:
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
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