3.7 Relapse Prevention & Continuing Care

The Relapse Prevention Framework

G. Alan Marlatt and Judith Gordon's cognitive-behavioral relapse prevention model (1985, updated 2005) remains the dominant framework on the ADC exam. The model holds that relapse is not a sudden event but a chain that begins long before the first use, and that the chain can be interrupted at multiple points. Relapse prevention is built on social-cognitive theory — self-efficacy and outcome expectancies drive behavior.

Core Constructs

• High-risk situations — contexts that threaten self-control. Marlatt's classic categories: negative emotional states, interpersonal conflict, social pressure, positive emotional states, urges/cravings, and testing personal control.
• Coping response — the client's skill (or absence of skill) to manage the high-risk situation. An effective coping response is the single best protector.
• Self-efficacy — confidence to handle the situation. Successful coping raises it; failed coping lowers it.
• Outcome expectancies — the anticipated effect of using ("a drink will calm me down"); RP teaches clients to weigh the delayed negative against the immediate positive.
• Lapse — a single, time-limited episode of use after a period of abstinence or change.
• Relapse — a return to the previous pattern of use.
• Abstinence Violation Effect (AVE) — the cognitive-affective reaction to a lapse: all-or-nothing thinking plus a global, internal, stable attribution ("I am a failure"), which converts a lapse into a full relapse.

Immediate vs Covert Antecedents

• Immediate antecedents: high-risk situations, coping deficits, outcome expectancies, the AVE.
• Covert antecedents: lifestyle imbalance (too many "shoulds," too few "wants"), urges and cravings, rationalizations, denial, and apparently irrelevant decisions (AIDs) — small choices that seem unrelated but lead toward use ("I'll just stop at the gas station for cigarettes" ... which happens to be next to the old bar).

Identifying Triggers

Clients build a personal trigger map: people, places, things, emotions, and times. A useful daily self-check mnemonic the exam reuses often is HALT:

• Hungry
• Angry
• Lonely
• Tired

HALT is not exhaustive. Other common triggers include payday, anniversaries of losses, holidays, boredom, celebrations, and exposure to old using friends or paraphernalia.

Building Recovery Capital

Recovery capital (William White; Granfield & Cloud) is the sum of internal and external resources that support sustained recovery.

• Personal capital: physical health, coping skills, self-efficacy, values.
• Social capital: family, friends, sponsor, sober peers, faith community.
• Community capital: stable housing, employment, transportation, recovery-supportive policy.

More recovery capital correlates with lower relapse risk. Treatment plans should explicitly build capital, not merely remove use.

Mutual Support Groups: Compare and Contrast

All mutual support groups are adjuncts to professional treatment, not substitutes. Match the client to a group whose framework fits their worldview — a mismatched referral (e.g., a committed atheist sent only to a Higher-Power group) reduces attendance and outcomes.

Step-Down Planning and Continuing Care

Discharge from one level of care is rarely the end of treatment. Step-down planning runs the ASAM continuum in reverse: residential -> partial hospitalization (PHP) -> intensive outpatient (IOP) -> outpatient -> aftercare/recovery support. Each transition should be planned, not abrupt.

A strong aftercare plan includes:

1. Continuing therapist or counselor and frequency of contact
2. MOUD/MAT prescriber and pharmacy plan if applicable
3. Mutual-support meeting schedule and a designated home group
4. Sober supports (sponsor, family, peer recovery coach)
5. Recovery housing or a stable housing plan
6. Employment / education plan
7. Medical and mental-health follow-up
8. A written relapse-response plan: warning signs, immediate steps, who to call, where to go for stabilization
9. Crisis numbers, including the 988 Suicide and Crisis Lifeline and the SAMHSA National Helpline, 1-800-662-HELP (4357)

Discharge Documentation

A proper discharge summary is signed by client and counselor and includes presenting problem, course of treatment, progress toward goals, level of functioning at discharge, diagnoses, medications, the continuing-care plan, and the reason for discharge (completed, transferred, against staff advice, or administrative). Per 42 CFR Part 2, no SUD record may be released without proper client consent (covered in Chapter 4).

Reframing a Lapse

When a client returns after a lapse, the CBT-RP sequence is:

1. Normalize — a lapse is information, not a verdict.
2. Analyze — conduct a chain analysis: vulnerability, prompting event, links, behavior, consequences.
3. Refute the AVE — challenge the all-or-nothing, global self-blame thought.
4. Re-engage — update the relapse-prevention plan and adjust level of care if indicated.
5. Reinforce — affirm the client for returning and being honest.