Matrix Model of Outpatient Treatment for Substance Dependence

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Matrix Model of OutpatientTreatment for
Substance Dependence

• Originally Developed Specifically For Stimulant
  Abuse and Dependence
• METH SUMMIT
• May 19-21, 2003
• Fargo, North Dakota
• Ahndrea Weiner M.S., LMFT
• Clinical Director
• Matrix Institute on Addictions

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Methamphetamine Treatment Admissions

• In 1993, amphetamine treatment admission rates
  were high in a few Western States - - California,
  Oregon, Hawaii and Nevada.
• By 1999, high amphetamine treatment admission
  rates were seen in most States west of the
  Mississippi.
• Between 1993 and 1999, amphetamine treatment
  admission rates increased by 250 percent or more
  in 14 States and by 100 to 249 percent in another
  10 States.
• Methamphetamine is the primary form of
  amphetamine
• seen in the United States and made up 94 percent
  of all amphetamine treatment admissions reported
  to
• SAMHSA's Treatment Episode Data Set (TEDS) in
  1999.

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Definition of Effectiveness
The degree to which a therapeutic technique
decreases the amount of frequency of drug or
alcohol use, promotes prosocial behavior change
compatible with a drug-free lifestyle and/or
increases the engagement or retention of patients
in process of treatment or self-help.
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Treatment Medical Behavioral

• Drugs
• Sedatives
• Stimulants
• Opioids
• Alcohol

• Medical Treatment
• Yes
• No
• Yes
• Yes

• Behavioral Treatment
• Yes
• Yes
• Yes
• Yes

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www.drugabuse.gov
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Manuals in Psychosocial Treatment

• Reduce therapist differences
• Ensure uniform set of services
• Can more easily be evaluated
• Enhance training capabilities
• Facilitate research to practice

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Matrix ModelAn Integrated, Empirically-based,
Manualized Treatment Program
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Motivation for Treatment

• Why is it harder for a stimulant abuser to enter
  the treatment system?
• What does it mean to say someone is motivated to
  do treatment?
• How can we compete with the pull of drugs like
  methamphetamine?

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Methamphetamine Withdrawal

• Depression
• Difficulty Concentrating
• Severe Cravings
• Paranoia
• Exhaustion
• Confused

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How Stimulants Effect the Willingness to Enter
Treatment
Methamphetamine does NOT make you sick
therefore, the drug use is not the
problem. Methamphetamine allows long periods of
no drug use certainly the drug is not the
problem.
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What Research Tells Usabout Addiction

• People with drug and alcohol dependencies do not
  have unique personalities

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What Research Tells Usabout Denial

• People with dependencies show no higher level of
  denial than the normal population
• Measures of denial are not clearly related to
  treatment or outcome

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What Research Tells Usabout Treatment

• Patient drug use, compliance, and outcome are
  powerfully influenced by therapist
  characteristics and environment
• Direct confrontation yields poorer compliance
  and outcomes

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Assumptions in Working with Mandated Clients
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Assumptions in Working with Mandated Clients
The stick is enough. There is no need for a
carrot.
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Assumptions in Working with Mandated Clients

• Clients are either motivated or not.
• If they are not, there is little we can do.

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Assumptions in Working with Mandated Clients

• People change only when they have to.
• The first and most important step in recovery is
  to admit and accept the fact that you have the
  disease of addiction.

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Assumptions in Working with Mandated Clients

• Someone who continues to use is
• in denial.
• The best way to break through the
• denial is direct confrontation.

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Motivational Goals

• Increase Motivation
• Decrease Resistance
• Increase retention
• Better outcomes

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Four Principles ofMotivational Interviewing
1. Express empathy 2. Develop discrepancy 3. Avoi
d argumentation 4. Support self-efficacy
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1. Express Empathy
Acceptance facilitates change Skillful reflective
listening is fundamental Ambivalence is normal
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2. Develop Discrepancy
Awareness of consequences is important Discrepancy
between behaviors and goals motivates
change Have the client present reasons for change
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3. Avoid Argumentation
Resistance is signal to change strategies Labeling
is unnecessary Shift perceptions Clients
attitudes shaped by their words, not yours
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4. Support Self-Efficacy
Belief that change is possible is important
motivator Client is responsible for choosing
and carrying out actions to change There is hope
in the range of alternative approaches available
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MATRIX MODEL TREATMENT
INFORMATION/EDUCATION
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Triggers Cravings

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Trigger
Definition A trigger is a stimulus which has
been repeatedly associated with the preparation
for, anticipation of or the use of drugs and/or
alcohol. These stimuli include people, things,
places, times of day, and emotional states.
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Triggers and Cravings
Pavlovs Dog
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Cognitive Process During Addiction
Introductory Phase
Relief From Depression Anxiety Loneliness Insomnia
Euphoria Increased Status Increased
Energy Increased Sexual/Social Confidence Increase
d Work Output Increased Thinking Ability
May Be Illegal May Be Expensive Hangover/Feeling
Ill May Miss Work
AOD

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Conditioning Process During Addiction
Introductory Phase
Strength of Conditioned Connection
Mild

• Triggers
• Parties
• Special Occasions

• Responses
• Pleasant Thoughts about AOD
• No Physiological Response
• Infrequent Use

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Development of Obsessive Thinking Introductory
Phase
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Development of Craving Response
Introductory Phase
Entering Using Site
Use of AODs
AOD Effects Heart/Pulse Rate Respiration
Adrenaline Energy Taste
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Cognitive Process During Addiction
Abuse Phase
Vocational Disruption Relationship
Concerns Financial Problems Beginnings of
Physiological Dependence
Depression Relief Confidence Boost Boredom
Relief Sexual Enhancement Social Lubricant
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Conditioning Process During Addiction
Abuse Phase
Strength of Conditioned Connection

• Triggers
• Parties
• Friday Nights
• Friends
• Concerts
• Alcohol
• Good Times
• Sexual Situations

• Responses
• Thoughts of AOD
• Eager Anticipation of AOD Use
• Mild Physiological Arousal
• Cravings Occur as Use Approaches
• Occasional Use

Moderate
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Development of Craving Response
Abuse Phase
Entering Using Site
Physiological Response
Use of AODs
AOD Effects

• ? Heart
• Rate
• ? Breathing Effects
• ? Adrenaline Effects
• ? Energy
• ? Taste

? Heart ? Blood
Pressure ? Energy
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Cognitive Process During Addiction
Addiction Phase
Social Currency Occasional Euphoria Relief From
Lethargy Relief From Stress
Nose Bleeds Infections Relationship
Disruption Family Distress Impending Job Loss
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Conditioning Process During Addiction
Addiction Phase
Strength of Conditioned Connection

• Triggers
• Weekends
• All Friends
• Stress
• Boredom
• Anxiety
• After Work
• Loneliness

• Responses
• Continual Thoughts of AOD
• Strong Physiological Arousal
• Psychological Dependency
• Strong Cravings
• Frequent Use

STRONG
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Thinking of Using
Mild Physiological Response
Entering Using Site
? Heart Rate ? Breathing Rate ? Energy ?
Adrenaline Effects
Powerful Physiological Response
Use of AODs
AOD Effects
? Heart Rate ? Breathing Rate ? Energy ?
Adrenaline Effects
Heart Blood Pressure Energy
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Cognitive Process During Addiction
Severe Dependency Phase
Relief From Fatigue Relief From Stress Relief
From Depression
Weight Loss Paranoia Loss of Family Seizures Sever
e Depression Unemployment Bankruptcy
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Strength of Conditioned Connection
OVERPOWERING

• Responses
• Obsessive Thoughts About AOD
• Powerful Autonomic Response
• Powerful Physiological Dependence
• Automatic Use

• Triggers
• Any Emotion
• Day
• Night
• Work
• Non-Work

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Development of Obsessive Thinking Severe
Dependency Phase
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Development of Craving Response
Severe Dependency Phase
Thoughts of AOD Using Place
Powerful Physiological Response
? Heart Rate ? Breathing Rate ? Energy ?
Adrenaline Effects
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IMPLEMENTINGMATRIX MODELOUTPATIENT
TREATMENT

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MATRIX TREATMENT MODELDifferent from Residential
Treatment

• Less confrontational
• Progresses more slowly
• Focus is on present
• Core Issues not immediately addressed
• Allegiance is to therapist (vs. group)

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MATRIX TREATMENT MODELDifferent from Residential
Treatment

• Nonjudgmental attitude is basis of
  client-therapist bond
• Change recommendations based on scientific data
• Changes incorporated immediately into lifestyle

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MATRIX TREATMENT MODELDifferent from General
Therapy

1. Focus on behavior vs. feelings
2. Visit frequency results in strong transference
3. Transference is encouraged
4. Transference is utilized
5. Goal is stability (vs. emotional catharsis)

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MATRIX TREATMENT MODELDifferent from General
Therapy

• Focus is on abstinence
• Bottom line is always continued abstinence
• Therapist frequently pursues less motivated
  clients
• The behavior is more important than the reason
  behind it

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Treatment Components of the Matrix Model

• Individual Sessions
• Early Recovery Groups
• Relapse Prevention Groups
• Family Education Group
• 12-Step Meetings
• Social Support Groups
• Relapse Analysis
• Urine Testing

MATRIX
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MATRIX MODEL OFOUTPATIENT TREATMENT
Organizing Principles of Matrix Treatment

• Create explicit structure and expectations
• Establish positive, collaborative relationship
  with patient
• Teach information and cognitive-behavioral
  concepts
• Positively reinforce positive behavior change

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MATRIX MODEL OFOUTPATIENT TREATMENT
Organizing Principles of Matrix Treatment (cont.)

• Provide corrective feedback when necessary
• Educate family regarding stimulant abuse recovery
• Introduce and encourage self-help participation
• Use urinalysis to monitor drug use

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COMPONENTS OF THE MATRIX MODELGroups

• Early Recovery
• Relapse Prevention
• Family Education Lectures

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COMPONENTS OF THE MATRIX MODELOther

• Social Support
• Conjoint Sessions
• Urine Testing
• Relapse Analysis

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EARLY RECOVERY GROUP

• Goals
• To provide structured place for new patients to
  learn about recovery skills and self-help
  programs.
• Introduce patients to basic tools of recovery.
• To introduce outside involvement and create an
  expectation of participation as part of Matrix
  treatment.

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EARLY RECOVERY GROUP

• Goals
• Help patients adjust to participating in groups
  at Matrix and outside.
• Allow the patient co-leader to provide a model
  for gaining initial abstinence.
• Provide the patient co-leader with increased
  self-esteem and reinforce his or her progress.

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EARLY RECOVERY GROUP

• Topics
• Scheduling and Calendars
• Triggers
• Questionnaires and Chart
• 12 Step Introduction
• Alcohol Issues
• Thoughts Emotions and Behaviors
• KISS (and other 12-step slogans)

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RELAPSE PREVENTION GROUP

• Goals
• To allow clients to interact with other people in
  recovery.
• To present specific relapse prevention material.
• To allow co-leader to share long term sobriety
  experience.

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RELAPSE PREVENTION GROUP

• Goals (continued)
• To produce some groups cohesion among clients
• To allow group leader to witness interpersonal
  interaction of clients.
• To allow clients to benefit from participating in
  a long-term group experience.

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RELAPSE PREVENTION GROUP Sample Topics

• Alcohol -The Legal Drug
• Boredom
• Avoiding Relapse Drift/Mooring Lines
• Guilt and Shame
• Motivation for Recovery
• Truthfulness
• Work and Recovery
• Staying Busy
• Relapse Prevention
• Dealing with Feelings

• Total Abstinence
• Sex and Recovery
• Trust
• Be Smart Not Strong
• Defining Spirituality
• Relapse Justification
• Reducing Stress
• Managing Anger
• Compulsive Behaviors
• Repairing Relationships

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MATRIX MODEL FAMILY INVOLVEMENT
Family Education Family Support Groups Conjoint
Sessions Encouraging Family to Get
Assistance Encouraging Family to Support Sobriety
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MATRIX MODELSELF-HELP GROUPS
Source of Support and Camaraderie Source of
Spiritual Strength Source of New Activities and
Friends Lifelong Support System Multiple Forms of
12-Step Groups Alternative to 12-Step Groups
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MATRIX MODELURINALYSIS AND BREATH TESTING
Method for Monitoring Treatment
Progress Treatment Accountability Assistance for
Patient Reduce Arguments and Capriciousness Provid
es Data for Family or Employer
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Web sitematrixinstitute.org orahndrea_at_matrixi
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