Matrix Model of Outpatient Treatment for Substance Dependence

1. 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

2. 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.

3. Drugs Sedatives Stimulants Opioids Alcohol Medical Treatment Yes No Yes Yes Treatment Medical & Behavioral Behavioral Treatment Yes Yes Yes Yes

4. www.drugabuse.gov

5. Manuals in Psychosocial Treatment • Reduce therapist differences • Ensure uniform set of services • Can more easily be evaluated • Enhance training capabilities • Facilitate research to practice

6. Matrix ModelAn Integrated, Empirically-based, Manualized Treatment Program

7. What Research Tells Usabout Addiction People with drug and alcohol dependencies do not have unique personalities

8. 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

9. 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

10. Assumptions in Working with Mandated Clients

11. 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.

12. 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.

13. Motivational Goals • Increase Motivation • Decrease Resistance • Increase retention • Better outcomes

14. Four Principles ofMotivational Interviewing 1. Express empathy 2. Develop discrepancy 3. Avoid argumentation 4. Support self-efficacy

15. 1. Express Empathy Acceptance facilitates change Skillful reflective listening is fundamental Ambivalence is normal

16. 2. Develop Discrepancy Awareness of consequences is important Discrepancy between behaviors and goals motivates change Have the client present reasons for change

17. 3. Avoid Argumentation Resistance is signal to change strategies Labeling is unnecessary Shift perceptions Clients attitudes shaped by their words, not yours

18. 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

19. MATRIX MODEL TREATMENT INFORMATION/EDUCATION

20. Triggers & Cravings

22. 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.

23. Triggers and Cravings Pavlov’s Dog

24. Cognitive Process During Addiction IntroductoryPhase Relief From Depression Anxiety Loneliness Insomnia Euphoria Increased Status Increased Energy Increased Sexual/Social Confidence Increased Work Output Increased Thinking Ability May Be Illegal May Be Expensive Hangover/Feeling Ill May Miss Work AOD

25. 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

26. Food School Sports TV Hobbies Girlfriend Job AOD Family Parties Exercise Development of Obsessive ThinkingIntroductory Phase

27. Development of Craving Response Introductory Phase EnteringUsing Site Use of AODs AOD Effects Heart/Pulse Rate Respiration Adrenaline Energy Taste

28. 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

29. 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

30. Development of Obsessive Thinking Abuse Phase Food School AOD TV Hobbies Girlfriend Job AOD Family Parties Exercise

31. 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

32. 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

33. 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

34. Development of Obsessive Thinking Addiction Phase Food AOD AOD TV AOD Girlfriend Job AOD Family Parties AOD

35. Development of Craving Response Addiction Phase 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

36. Cognitive Process During Addiction Severe Dependency Phase Relief From Fatigue Relief From Stress Relief From Depression Weight Loss Paranoia Loss of Family Seizures Severe Depression Unemployment Bankruptcy

37. Conditioning Process During Addiction Severe Dependency Phase 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

38. AOD AOD AOD AOD AOD AOD AOD AOD AOD AOD AOD Development of Obsessive ThinkingSevere Dependency Phase

39. Development of Craving Response Severe Dependency Phase Thoughts of AOD Using Place Powerful Physiological Response  Heart Rate  Breathing Rate  Energy  Adrenaline Effects

40. IMPLEMENTINGMATRIX MODELOUTPATIENT TREATMENT

41. 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)

42. 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

43. MATRIX TREATMENT MODELDifferent from General Therapy • Focus on behavior vs. feelings • Visit frequency results in strong transference • Transference is encouraged • Transference is utilized • Goal is stability (vs. emotional catharsis)

44. 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

45. 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

46. 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

47. COMPONENTS OF THE MATRIX MODELGroups • Early Recovery • Relapse Prevention • Family Education Lectures

48. COMPONENTS OF THE MATRIX MODELOther • Social Support • Conjoint Sessions • Urine Testing • Relapse Analysis

50. 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. EARLY RECOVERY GROUP