1. Matrix Model of Outpatient Treatment 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. 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.

3. 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.

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

5. www.drugabuse.gov Principles of Drug Addiction Treatment
Three decades of scientific research and clinical practice have yielded a variety of effective approaches to drug addiction treatment. In April 1998, NIDA held The National Conference on Drug Addiction Treatment: From Research to Practice which summarized this extensive body of research. Based on the findings reported at this conference, NIDA published in October 1999, Principles of Drug Addiction Treatment: A Research-Based Guide to foster more widespread use of scientifically-based components of drug addiction treatment. Key components of this guide are highlighted in the following slides.

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

7. Matrix Model An Integrated, Empirically-based, Manualized Treatment Program

8. 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?

9. Methamphetamine Withdrawal
Depression
Difficulty Concentrating
Severe Cravings
Paranoia
Exhaustion
Confused

10. 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.

11. What Research Tells Us about Addiction
People with drug and alcohol dependencies do not have unique personalities

12. What Research Tells Us about 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

13. What Research Tells Us about Treatment
Patient drug use, compliance, and outcome are powerfully influenced by therapist characteristics and environment
Direct confrontation yields poorer compliance and outcomes

14. Assumptions in Working with Mandated Clients

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

16. Assumptions in Working with Mandated Clients
Clients are either motivated or not.
If they are not, there is little we can do.

17. 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.

18. 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.

19. Motivational Goals Increase Motivation Decrease Resistance
Increase retention
Better outcomes

20. Four Principles of Motivational Interviewing
1. Express empathy
2. Develop discrepancy
3. Avoid argumentation
4. Support self-efficacy

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

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

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

24. 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

25. MATRIX MODEL TREATMENT
INFORMATION/EDUCATION

26. Triggers & Cravings Slide 1 Introduction:
Understanding and dealing with triggers and cravings is critically important in order to understand the seemingly irrational behavior of the active addict/alcoholic, and to begin the first steps in recovery. Triggers cause cravings, and cravings lead to using or drinking. Common sense would suggest that being around people, places, or situations that have resulted in past use, might increase the chances of using/drinking again. The additional influence that these triggers have upon the brain makes the advice to avoid triggers more than just a good idea; there is no other way to reliably avoid cravings and relapse.
This lecture describes the development of the craving process with regard to the underlying effects drugs and alcohol have upon the brain. Our hope is that an understanding of this process will allow both patients and families to view the addiction in a new and more understandable way as well as to see what is behind much of the advice given to patients early in treatment.

27. Slide 3: Brain regions and neuronal pathways
Certain parts of the brain govern specific functions. Point to areas such as the sensory (orange), motor (blue) and visual cortex (yellow) to highlight their specific functions. Point to the cerebellum (pink) for coordination and to the hippocampus (green) for memory. Indicate that nerve cells or neurons connect one area to another via pathways to send and integrate information. The distances that neurons extend can be short or long. For example; point to the reward pathway (orange). Explain that this pathway is activated when a person receives positive reinforcement for certain behaviors ("reward"). Indicate that you will explain how this happens when a person takes an addictive drug. As another example, point to the thalamus (magenta). This structure receives information about pain coming from the body (magenta line within the spinal cord), and passes the information up to the cortex. Tell the audience that you can look at this in more detail.

28. 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.
Slide 2
Definition of a trigger.

29. Triggers and Cravings Pavlov’s Dog Slide 9
Pavlov would feed dogs and ring a bell at the same time. The dogs would see and smell the food which would then stimulate, or trigger, their lower brains ( the autonomic nervous systems) causing the dogs to produce saliva and secrete gastric fluids in anticipation of digestion. In a relatively short amount of time, Pavlov and his colleagues would ring the bell without the presence of food, and the dogs would still produce saliva and gastric fluid as if food were present. The dogs connected the sound of the bell, the trigger, with anticipation of eating, and responded involuntarily physically to the powerful trigger, or stimulus, of the bell. Once a dog has been conditioned in this way, no matter how smart or well-trained the dog is, a dog will continue to produce fluids at the sound of the bell. He has no choice. The human brain responds in exactly the same way to the conditioned drugs and alcohol triggers that produce cravings. Drugs and alcohol produce changes in the brain, which result in feelings of pleasure. When triggers cause a person to experience cravings, the brain responds as if the actual chemicals are taken into the system. In other words, the brain is “drooling” in reaction to these triggers. This reaction occurs whether or not the person intends to use. The only way that Pavlov’s dog can avoid drooling is by avoiding the bell. The chemically dependent person can also avoid his or her brain’s reaction by avoiding triggers.
Pavlov’s Dog

30. Cognitive Process During Addiction
Introductory Phase
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
Slide 12
Alcohol and other drug (AOD) use is relatively infrequent during the Introductory Phase of the cognitive process of addiction. It may be limited to a few times a year, by chance or on special occasions. The positives of AOD use seem to outweigh the negatives.

31. 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
Slide 13
Unknowingly, the AOD user is conditioning his brain every time a dose of his/her drug of choice is ingested. There is no automatic limbic response associating people, places or times with AOD use.

32. Development of Obsessive Thinking Introductory Phase
Sports
Food
School TV
Girlfriend
Hobbies
Job
AOD
Family
Exercise
Parties
Slide 14
During this Introductory Phase, AOD use is one small component of a person’s overall thought process.

33. Development of Craving Response
Introductory Phase
Entering Using Site
Use of AODs
AOD Effects
Heart/Pulse Rate
Respiration
Adrenaline
Energy
Taste
Slide 15
Craving response is the combined experiences of AOD triggers activating the limbic system and the continuing AOD thoughts associated with these triggers.
During this Introductory Phase, the limbic system is activated directly AODs, and depending upon whether the substance is a stimulant or a depressant, results in the increase or decrease of physiological arousal.

34. 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
Slide 16
During the Maintenance Phase of the cognitive process during addiction, the frequency of AOD use increases, to perhaps, monthly or weekly. In terms of effects and negative consequences, the scales are beginning to lean more in the negative direction.

35. Abuse Phase Conditioning Process During Addiction
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
Slide 17
Conditioning has begun. The people, places and things associated with AOD use have become triggers. Exposure to these triggers causes thoughts about AOD use. These thoughts originating in the brain are mild physiological reactions producing drives to find and use AODs.

36. Development of Obsessive Thinking
Abuse Phase
AOD
Food
School TV
Girlfriend
Hobbies
Job
Family
Exercise
Parties
Slide 18
Thoughts of AOD use begin to occur more frequently.

37. Development of Craving Response Physiological 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
Slide 19
A mild physiological arousal occurs in situations closely associated with AOD use. As the person encounters AOD triggers, the limbic system is activated and AOD cravings occur. When drugs and/or alcohol are finally ingested, a concurrent physiological state (arousal or quiescence in relation to the properties of the drug ingested) will usually occur.

38. 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
Slide 20
During the Disenchantment Phase of the cognitive process of a developing addiction, the scales tip from the positive to the negative. The consequences of AOD use are severe and the user’s life begins to become unmanageable. At this point the cortical rational decision is to stop using, but the cortex is not in control any longer. Thinking, evaluating, and decision making appear to be happening, but behavior is contradictory. The user may sincerely resolve to quit using, and yet, may find himself out of control at the first thought of AODs, the first encounter with a fellow user, or at the availability of cash or other potent triggers.

39. Addiction Phase Conditioning Process During Addiction
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
Slide 21
It is usually at this point that a person crosses the line into addiction. Despite the negative consequences of continued AOD use the addiction is evidenced by the loss of rational control. Triggers in this phase produce a powerful physiological response that drives the user to acquire and use AODs. The higher rational brain is observing that it makes to use anymore.

40. Development of Obsessive Thinking
Addiction Phase
AOD
Food TV
Girlfriend
Job
Family
Parties
Slide 22
During the Disenchantment Phase, the frequency of AOD thinking increases, which begins to crowd out thoughts of other aspects in life.

41. 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
Slide 23
In this phase, the craving response is a powerful event. The person feels an overpowering physical reaction in situations further and further removed from the drugs themselves. The craving response is almost as powerful as the actual AOD’s physical reaction.
 Heart Rate
 Breathing Rate
 Energy
 Adrenaline Effects
Heart
Blood Pressure
Energy

42. 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
Slide 24
In the Disaster Phase, the AOD use is often robotic and automatic. There is no rational restraint upon the drug use; it makes no sense at all. The user’s behavior in the phase is much like the behavior of addicted laboratory animals that use drugs until they die.

43. 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
Slide 25
Here the person is either using daily or in binges, which most likely will be interrupted by physical collapse, hospitalization, or arrest. The constant powerful craving from the limbic system and/or severe physiological dependency overwhelms the cortex.

44. Development of Obsessive Thinking Severe Dependency Phase
AOD
Slide 26
Thoughts of AODs dominate the user’s consciousness.

45. Development of Craving Response
Severe Dependency Phase
Thoughts of AOD Using Place
Powerful Physiological Response
 Heart Rate
 Breathing Rate
 Energy
 Adrenaline Effects
Slide 27
In the Disaster Phase, the craving can often be compared to actual AOD effects, and in some cases, these powerful effects may be the result of merely thinking about certain drugs.

46. IMPLEMENTING MATRIX MODEL OUTPATIENT TREATMENT

47. MATRIX TREATMENT MODEL Different from Residential Treatment
Less confrontational
Progresses more slowly
Focus is on present
“Core Issues” not immediately addressed
Allegiance is to therapist (vs. group)

48. MATRIX TREATMENT MODEL Different from Residential Treatment
Nonjudgmental attitude is basis of client-therapist bond
Change recommendations based on scientific data
Changes incorporated immediately into lifestyle

49. MATRIX TREATMENT MODEL Different 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)

50. MATRIX TREATMENT MODEL Different 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

51. 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

52. MATRIX MODEL OF OUTPATIENT 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

53. MATRIX MODEL OF OUTPATIENT 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

54. COMPONENTS OF THE MATRIX MODEL Groups
Early Recovery
Relapse Prevention
Family Education Lectures

55. COMPONENTS OF THE MATRIX MODEL Other
Social Support
Conjoint Sessions
Urine Testing
Relapse Analysis

57. 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.

58. 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.

59. 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)

60. 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.

61. 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.

62. 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

63. MATRIX MODEL FAMILY INVOLVEMENT
Family Education
Family Support Groups
Conjoint Sessions
Encouraging Family to Get Assistance
Encouraging Family to Support Sobriety

64. MATRIX MODEL SELF-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

65. MATRIX MODEL URINALYSIS AND BREATH TESTING
Method for Monitoring Treatment Progress
Treatment Accountability
Assistance for Patient
Reduce Arguments and Capriciousness
Provides Data for Family or Employer

66. Web site matrixinstitute.org or ahndrea@matrixinstitute.org