Alcohol use disorder, severe, in early remission
10 months sober after 20+ year drinking history; recent relapse precipitated by job loss; ambivalent about returning to AA.
Presenting concern
AUDIT pre-treatment: 28. Now in early remission after 30-day residential + 9 months outpatient. Relapsed twice in the past month after job loss. Re-engaged in therapy. Skeptical of 12-step but completed an intensive outpatient program.
History
Drinking onset in college, escalated through 30s. Two prior treatment episodes. Married, two children. Wife threatening separation if pattern continues.
- Stress of unemployment
- Recent relapses (pattern not solidified)
- Marital strain
- Ambivalence about meetings
- Has achieved sustained sobriety once
- Re-engaging quickly post-slip
- Engaged in psychotherapy
- Family system still intact
Conceptualization across modalities
Lapse → abstinence violation effect (AVE: 'I've already blown it') → full relapse. High-risk situations (HRS: job loss, negative affect) interact with low self-efficacy and lack of coping responses to trigger lapse. AVE cognitive distortions widen the gap.
- Map personal HRS
- Build coping menu for each HRS category
- Cognitive work on the AVE — lapse ≠ relapse
- Lifestyle balance to reduce baseline HRS exposure
Ambivalence about meetings is real, not resistance. Pushing 12-step will activate reactance. Evoking his own reasons for sustained recovery is the path.
- Roll with resistance about meetings
- Evoke his own reasons for sobriety
- Explore multiple recovery pathways (SMART, refuge recovery, secular options)
- Decisional balance on recovery community engagement
Treatment plan
Stabilize (1–4)
Address current relapse pattern, HRS map, coping plan.
Build (5–12)
Skills, lifestyle balance, marital communication.
Consolidate (13–20)
Identity and meaning beyond recovery, return to work planning.
90 days sober at session 14. Re-employed by month 5. Marriage stabilizing slowly.