Presentation on theme: "Matrix Model of Outpatient Treatment for Substance Dependence"— Presentation transcript:
1 Matrix Model of Outpatient Treatment for Substance Dependence Originally Developed Specifically For Stimulant Abuse and DependenceMETH SUMMITMay 19-21, 2003Fargo, North DakotaAhndrea Weiner M.S., LMFTClinical DirectorMatrix 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 amphetamineseen in the United States and made up 94 percent of all amphetamine treatment admissions reported toSAMHSA'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 DrugsSedativesStimulantsOpioidsAlcoholMedical TreatmentYesNoBehavioral TreatmentYes
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 differencesEnsure uniform set of servicesCan more easily be evaluatedEnhance training capabilitiesFacilitate 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?
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 populationMeasures 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 environmentDirect confrontation yields poorer compliance and outcomes
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” thedenial is direct confrontation.
20 Four Principles of Motivational Interviewing 1. Express empathy2. Develop discrepancy3. Avoid argumentation4. Support self-efficacy
21 1. Express Empathy Acceptance facilitates change Skillful reflective listening is fundamentalAmbivalence is normal
22 2. Develop Discrepancy Awareness of consequences is important Discrepancy between behaviors and goals motivates changeHave the client present reasons for change
23 3. Avoid Argumentation Resistance is signal to change strategies Labeling is unnecessaryShift perceptionsClients attitudes shaped by their words, not yours
24 4. Support Self-Efficacy Belief that change is possible is important motivatorClient is responsible for choosing and carrying out actions to changeThere is hope in the range of alternative approaches available
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 TriggerDefinitionA 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 2Definition 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 PhaseRelief FromDepressionAnxietyLonelinessInsomniaEuphoriaIncreased StatusIncreased EnergyIncreased Sexual/Social ConfidenceIncreased Work OutputIncreased Thinking AbilityMay Be IllegalMay Be ExpensiveHangover/Feeling IllMay Miss WorkAODSlide 12Alcohol 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 PhaseStrength of Conditioned ConnectionMildTriggersPartiesSpecial OccasionsResponsesPleasant Thoughts about AODNo Physiological ResponseInfrequent UseSlide 13Unknowingly, 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 SportsFoodSchoolTVGirlfriendHobbiesJobAODFamilyExercisePartiesSlide 14During this Introductory Phase, AOD use is one small component of a person’s overall thought process.
33 Development of Craving Response Introductory PhaseEntering Using SiteUse of AODsAOD EffectsHeart/Pulse RateRespirationAdrenalineEnergyTasteSlide 15Craving 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 PhaseVocational DisruptionRelationship ConcernsFinancial ProblemsBeginnings of Physiological DependenceDepression ReliefConfidence BoostBoredom ReliefSexual EnhancementSocial LubricantSlide 16During 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 ConnectionTriggersPartiesFriday NightsFriendsConcertsAlcohol“Good Times”Sexual SituationsResponsesThoughts of AODEager Anticipation of AOD UseMild Physiological ArousalCravings Occur as Use ApproachesOccasional UseModerateSlide 17Conditioning 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 PhaseAODFoodSchoolTVGirlfriendHobbiesJobFamilyExercisePartiesSlide 18Thoughts of AOD use begin to occur more frequently.
37 Development of Craving Response Physiological Response Abuse PhaseEntering Using SitePhysiological ResponseUse of AODsAOD Effects HeartRate Breathing Effects Adrenaline Effects Energy Taste Heart Blood Pressure EnergySlide 19A 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 PhaseSocial CurrencyOccasional EuphoriaRelief From LethargyRelief From StressNose BleedsInfectionsRelationship DisruptionFamily DistressImpending Job LossSlide 20During 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 ConnectionTriggersWeekendsAll FriendsStressBoredomAnxietyAfter WorkLonelinessResponsesContinual Thoughts of AODStrong Physiological ArousalPsychological DependencyStrong CravingsFrequent UseSTRONGSlide 21It 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 PhaseAODFoodTVGirlfriendJobFamilyPartiesSlide 22During 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 PhaseThinking of UsingMild Physiological ResponseEntering Using Site Heart Rate Breathing Rate Energy Adrenaline EffectsPowerful Physiological ResponseUse of AODsAOD EffectsSlide 23In 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 EffectsHeartBlood PressureEnergy
42 Cognitive Process During Addiction Severe Dependency Phase Relief From FatigueRelief From StressRelief From DepressionWeight LossParanoiaLoss of FamilySeizuresSevere DepressionUnemploymentBankruptcySlide 24In 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 ConnectionOVERPOWERINGResponsesObsessive Thoughts About AODPowerful Autonomic ResponsePowerful Physiological DependenceAutomatic UseTriggersAny EmotionDayNightWorkNon-WorkSlide 25Here 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 AODSlide 26Thoughts of AODs dominate the user’s consciousness.
45 Development of Craving Response Severe Dependency PhaseThoughts of AOD Using PlacePowerful Physiological Response Heart Rate Breathing Rate Energy Adrenaline EffectsSlide 27In 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.
47 MATRIX TREATMENT MODEL Different from Residential Treatment Less confrontationalProgresses more slowlyFocus is on present“Core Issues” not immediately addressedAllegiance is to therapist (vs. group)
48 MATRIX TREATMENT MODEL Different from Residential Treatment Nonjudgmental attitude is basis of client-therapist bondChange recommendations based on scientific dataChanges incorporated immediately into lifestyle
49 MATRIX TREATMENT MODEL Different from General Therapy Focus on behavior vs. feelingsVisit frequency results in strong transferenceTransference is encouragedTransference is utilizedGoal is stability (vs. emotional catharsis)
50 MATRIX TREATMENT MODEL Different from General Therapy Focus is on abstinenceBottom line is always continued abstinenceTherapist frequently pursues less motivated clientsThe behavior is more important than the reason behind it
51 Treatment Components of the Matrix Model Individual SessionsEarly Recovery GroupsRelapse Prevention GroupsFamily Education Group12-Step MeetingsSocial Support GroupsRelapse AnalysisUrine TestingMATRIX
52 MATRIX MODEL OF OUTPATIENT TREATMENT Organizing Principles of Matrix TreatmentCreate explicit structure and expectationsEstablish positive, collaborative relationship with patientTeach information and cognitive-behavioral conceptsPositively reinforce positive behavior change
53 MATRIX MODEL OF OUTPATIENT TREATMENT Organizing Principles of Matrix Treatment(cont.)Provide corrective feedback when necessaryEducate family regarding stimulant abuse recoveryIntroduce and encourage self-help participationUse urinalysis to monitor drug use
54 COMPONENTS OF THE MATRIX MODEL Groups Early RecoveryRelapse PreventionFamily Education Lectures
55 COMPONENTS OF THE MATRIX MODEL Other Social SupportConjoint SessionsUrine TestingRelapse 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 Chart12 Step IntroductionAlcohol IssuesThoughts Emotions and BehaviorsKISS (and other 12-step slogans)
60 RELAPSE PREVENTION GROUP GoalsTo 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 clientsTo 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 DrugBoredomAvoiding Relapse Drift/Mooring LinesGuilt and ShameMotivation for RecoveryTruthfulnessWork and RecoveryStaying BusyRelapse PreventionDealing with FeelingsTotal AbstinenceSex and RecoveryTrustBe Smart; Not StrongDefining SpiritualityRelapse JustificationReducing StressManaging AngerCompulsive BehaviorsRepairing Relationships
63 MATRIX MODEL FAMILY INVOLVEMENT Family EducationFamily Support GroupsConjoint SessionsEncouraging Family to Get AssistanceEncouraging Family to Support Sobriety
64 MATRIX MODEL SELF-HELP GROUPS Source of Support and CamaraderieSource of Spiritual StrengthSource of New Activities and FriendsLifelong Support SystemMultiple Forms of 12-Step GroupsAlternative to 12-Step Groups
65 MATRIX MODEL URINALYSIS AND BREATH TESTING Method for Monitoring Treatment ProgressTreatment AccountabilityAssistance for PatientReduce Arguments and CapriciousnessProvides Data for Family or Employer
66 Web site matrixinstitute.org or firstname.lastname@example.org