Relapse Prevention Plan for Adolescent Substance Use Recovery

Psychosocial History and Assessment

The client is a 17-year-old heterosexual male born in November 1996. Family history information was provided by the client, his adopted father, medical documents, and consent from his legal guardians. The client's mother became pregnant while enrolled in Job Corps. The biological father has not been involved in his son's care or development. When the mother was approximately five months pregnant, she met the client's adoptive father, and they were living together at the time of the client's birth.

At the time of birth, medical documents indicated suspicion of Fetal Alcohol Syndrome (FAS). At age seven, in 2004, the client's biological mother was arrested on federal drug charges and sentenced to 11 years in prison. At this time, the client and his younger sister were placed with his paternal grandparents, and he was subsequently adopted by his stepfather. During the mother's incarceration, the adoptive father was also arrested on drug charges and sent to prison. The children then lived with their paternal grandparents. Currently, the client lives with his adoptive father and the adoptive father's girlfriend. The biological mother has requested contact with her children following her parole, although she and the adoptive father will not reconcile.

The client reports no major illnesses, injuries, diseases, or physical handicaps. However, he has used marijuana, alcohol, acid, and mushrooms, and has tried Ecstasy and Dramamine. He has undergone extensive mental health evaluations and received previous diagnoses including Attention-Deficit/Hyperactivity Disorder (ADHD), Dyslexia, Reactive Attachment Disorder, and Cognitive Disorder, Not Otherwise Specified.

Upon entering ninth grade, the client reports he "fell in with the wrong crowd." At age 14, he began smoking and chewing tobacco, using drugs, dating peers his own age, skipping school, and experiencing conflicts with the legal system. Within a 30-day period between February and March, the client accumulated nine misdemeanor charges, one felony charge, and one status offense. He demonstrates significant impulsivity and makes poor judgments based on limited information. The client began cannabis use at age 16, smoking approximately 1 gram every four months, with usage patterns increasing depending on involvement with legal entities and social stressors. He reports last using cannabis in January 2013. He has used smokeless chewing tobacco since age 15, consuming one can within two days on a daily basis. He denies ever experiencing withdrawal symptoms when discontinuing drug use.

Relapse Prevention Framework: Steps One Through Three

The first step in developing a relapse prevention plan is stabilization. The client is currently in residential placement and therefore sober and presumably abstinent from substance use. However, stabilization extends beyond abstinence; it addresses toxicity and impairment in cognitive function, memory, and emotional regulation. The client may experience occasional lapses within the public school setting despite placement restrictions. Within the group home environment and structure, he has minimal access to alcohol, tobacco, or drugs. Stabilization is accomplished through placement in a structured group home setting that provides daily routine and weekly counseling.

The second step is self-assessment, which identifies patterns that initiated substance use or caused past relapses and addresses the underlying pain associated with these problems. The client was born with suspected FAS. His biological mother entered prison when he was eight years old, followed by his adoptive father's incarceration approximately five years before the assessment. His adoptive father's return to his life at approximately age 11 preceded the onset of the client's drug use at age 14. While the client has not yet developed a pattern of sobriety and relapse, a timeline of use has been established, along with areas of concern that may represent root causes.

Given the possibility of FAS at birth, both parents' incarceration on drug charges, the diagnosis of Reactive Attachment Disorder, and apparent lack of supervision at home, it is evident that underlying causes reside in the home and family relationships. This will be central to the client's warning sign identification process. The client requires gentle guidance from a counselor while in the group home setting to support self-assessment. The ultimate goals are to determine why he felt compelled to begin using substances, what he perceives as missing in his life, whom he feels angry toward, what he envisions for his future, and what steps are necessary to achieve those goals.

The client appears to be in the positive side of the contemplation stage of change and moving toward preparation, according to the Transtheoretical Model of Change. He appears willing to try new behaviors and indicates a desire for a better life. He acknowledges that this better future excludes alcohol and other drugs (AODs) and criminal activities. He recognizes that associating with his "using friends" will lead to increased drug use. He expresses sadness about separation from his family. When asked about his strengths, he identifies being fun, having a good sense of humor, and being athletic.

The third step is relapse education. The client needs instruction in four major areas. First, he must understand that relapse is a normal part of recovery from chemical dependence and should not be accompanied by guilt. Second, while there is no shame in relapse, he must recognize and accept responsibility for identifying relapse warning signs. Third, he must learn to recognize these warning signs and manage them effectively. Fourth, he must understand that recovery is always possible. Working through Gorski's Guide to Relapse Prevention with the client will familiarize him with symptoms of progressive relapse and help him identify relevant warning signs (Gorski & Miller, 1986).

Step four involves identifying and developing a list of the client's personal warning signs—indicators that he is on a dangerous path and at risk of active relapse without intervention. Because of his family history, developing a trusting relationship with him in a counseling setting is essential. This relationship should allow him to address childhood hurts, traumas, and broken relationships. Specific warning signs the client should monitor include tunnel vision, loneliness, defensiveness, depression, irritability, sleep disturbance, an "I don't care" attitude, and loss of daily structure. Many of these are common experiences for adolescents in residential placement. If he can develop coping skills in a structured environment, he is more likely to implement them in other settings after returning home. Loss of daily structure will be a major focus, as he will experience a significant decrease in structure upon discharge from placement.

Warning Sign Identification and Management

Step five involves creating an action plan for each warning sign to interrupt the potential spiral toward relapse. Many symptoms are common in adolescence because the brain undergoes a pruning process that leaves critical thinking skills underdeveloped. According to Gorski (1986), tunnel vision occurs when an individual views their life as separate, unrelated parts and focuses on one element instead of the whole. This is common in placement; the client may focus only on going home and overlook the therapeutic work necessary for success once discharged. He may believe that being "good" will automatically lead to discharge, causing him to neglect emotional processing work.

This pattern is often seen in youth who achieve behavioral compliance but fail to address emotional issues, resulting in difficulty controlling emotions later. The client will engage in individual therapy focused on personal issues, family therapy addressing relational problems, and group therapy, preferably within a 12-step setting to support personal growth and lifestyle change.

To manage tunnel vision, the therapist will help the client recognize this thinking pattern. He will learn to accept feedback from others when they identify tunnel vision. Eventually, he will learn to recognize it independently and approach his therapist and family for insight into what he is overlooking in the "big picture" of his life.

The second warning sign, overwhelming loneliness, frustration, anger, and tension, requires attention because the client is at high risk for relapse. He has not yet developed relapse prevention skills or daily abstinence strategies. Residential placement and separation from family for an undetermined period is emotionally demanding. The placement itself creates stress and loneliness. Therapeutic work can generate frustration, creating tension both within the milieu and during conversations with therapist and family. The client needs to openly express feelings of loneliness, frustration, anger, and tension. He will identify sources of these feelings and discuss them with his therapist, family counselor, and members of his 12-step group.

The third warning sign, defensiveness, is another common adolescent experience. Due to underdeveloped rational thinking, adolescents often believe they are invincible. Additionally, cannabis use may produce "amotivational syndrome" (Doweiko, 2012, p. 134). Furthermore, reluctance to discuss personal problems due to lack of trust may be a significant issue for this client, given his Reactive Attachment Disorder diagnosis and experience of two parental figures' incarceration. He will work through defensiveness progressively: first in one-on-one sessions with his therapist, second within the 12-step group environment, and finally in family counseling. Building trust first with his counselor, then with group members, and finally with family should establish a stable progression toward trusting others and reducing defensive responses regarding his recovery and other life areas.

The fourth warning sign, depression, is common among individuals in recovery. Because depression can be progressive with varying intensity, the client must learn to recognize its symptoms: loss of interest in previously enjoyable activities, loss of motivation, feelings of worthlessness, suicidal thoughts, and sleep disturbance. When aware of depressive symptoms, he will discuss them with his therapist, family, group home staff, and 12-step group members.

The fifth warning sign, loss of daily structure, is crucial to practice while in a structured setting. He will reduce structure gradually during public school attendance, group home outings, and home visits. The client will consciously monitor his behaviors and attitudes in less structured situations. He will discuss observations with his therapist, family counselor, and 12-step group. This practice in thinking through how to maintain abstinence, sobriety, and clear thinking in unstructured environments will prepare him for successful transition home.

With a minimum of five warning signs identified, it is essential for the client to evaluate daily whether these symptoms have appeared. Gorski recommends taking a personal inventory twice daily—once in the morning and once in the evening. To establish this habit, the group home schedule will include five to ten minutes each morning for the client to read a daily entry from Twenty-Four-Hour-A-Day Book by Richmond Walker and write a brief outline of his daily plans. The outline, recorded in his journal, will address these questions: "Am I prepared for this day? What can I do to help me physically and emotionally meet today's challenges and maintain comfort in my sobriety?" (Gorski, 1986, p. 165).

In the fifteen to thirty minutes before bedtime, the client will write in his journal a review of tasks completed during the day, identifying what he handled well, areas for improvement, strengths he used to meet challenges, and ways to build on those strengths. He will also note weaknesses he identified, how to correct them, and how to improve in those areas.

Initially, the journal will be shared with the therapist during one-on-one sessions to ensure compliance. Completing this task daily within the group home structure will establish it as a habit. During home visits, the client will continue the practice and share the journal with his therapist to demonstrate his ability to complete the task outside the structured environment. This ensures continuity of the inventory process as he approaches discharge.

Inventory Training and Self-Monitoring

As part of his therapeutic work, the client will evaluate his recovery program every three months to determine what is helping, what needs to change, and what progress has been made. This will be addressed through one-on-one counseling, with feedback from family counseling used to identify new treatment targets, areas without improvement, and areas of success.

Throughout residential stay, family members, peers in the group home milieu, and members of the 12-step group will provide feedback and alert staff to any emerging warning signs. This approach helps the client understand that maintaining sobriety is not a solitary endeavor. It also develops social skills such as accepting feedback, building trusting relationships, and seeking help from others when needed.

Upon release from the group home, the client will continue participation in a 12-step meeting in his local community at least once weekly. He will follow up with a community counselor regarding personal and relational issues at least one to two times monthly. These meetings will evaluate his relapse prevention plan and address stressors. This structure allows him to modify his recovery plan as needed to sustain long-term abstinence and successful community reintegration.