Relapse Case Summary

Counselor met with Pt. to discuss his updated treatment plan dealing with Relapse Prevention Strategies. Pt. agreed to sign the record of services sheet. Pt. indicated that his current prescribed medication is “doing fine”. Pt. is taking 60 mg of methadone as instructed by AMS Doctor. Counselor asked him whether he has used any illicit drugs since the last session which he replied yes. Pt. read and answered few questions on his treatment plan without objections. Per treatment assignment, Pt. will develop a relapse prevention plan consistent with recovery while identifying social, emotional, and physical pressures that pose risks for relapse. Pt. is currently in the Level 0 + 1 because he continues to use heroin. Counselor prompted Pt. to identify justifications he told himself to make poor decisions and lead to an unhealthy path that eventually led to using heroin recently as evidenced by his previous UDS. Pt. reported that he decided to use opiates recently because he was bored and “I fall back to my old self.” The next step in the session, Counselor encouraged Pt. to recommit to his recovery program by reinstituting some positive behaviors. Counselor tried to
Callahan can benefit from a strong relapse prevention plan that will increase his change at recovery. Pt. appears to agree with the plan of treatment per verbal acknowledgement. His attitude and overall conduct is in keeping with program guidelines. While his dosing attendance has diminished due to employment, his attendance and level of participation in monthly counseling session remains consistent at his moment. Pt. presented as focused on his future. Pt. also appeared eager to learn and as such, demonstrated motivation as evidenced by his willingness to maintain gainful employment and changing few negative habits. Furthermore, Pt. demonstrated the ability to succeed at his recovery but will need to remain committed to his TX goals for