Matrix Institute on Addictions, STAGES OF RECOVERY Drug Court Conference Normal, OK. September, 2014 Matrix Institute on Addictions, Sam Minsky, MA, LMFT

THE STAGES OF RECOVERY A ROADMAP © 2006 Matrix Institute

Early Abstinence/Honeymoon Adjustment/Resolution Roadmap for Recovery Withdrawal Early Abstinence/Honeymoon Protracted Abstinence/The Wall Adjustment/Resolution Slide 2 Stages to be discussed: Withdrawal Early Abstinence/Honeymoon Protracted Abstinence/The Wall Adjustment/Resolution

STAGES OF RECOVERY OVERVIEW Honeymoon The Wall Adjustment Withdrawal DAY 180 DAY DAY 15 DAY 45 DAY 120 These stages are most pertinent for stimulant users but when discussed in group all clients can subjectively relate to the stages of recovery. Honeymoon The Wall Adjustment Withdrawal Resolution © 2006 Matrix Institute

Stages of Recovery - Stimulants WITHDRAWAL STAGE DAY DAY 15 Some of the issues that may lead to client termination or dropout during the Withdrawal stage. Medical Problems Alcohol Withdrawal Depression Difficulty Concentrating Severe Cravings PROBLEMS ENCOUNTERED Contact with Stimuli Excessive Sleep © 2006 Matrix Institute

MATRIX MODEL TREATMENT Primary Manifestation of Withdrawal Stage Behavioral Cognitive Confusion Inability to Concentrate Behavioral Inconsistency Emotional Relationship Depression/Anxiety- Self-Doubt Mutual Hostility- Fear

MATRIX MODEL TREATMENT Relapse Factors - Withdrawal Stage Unstructured time Proximity of triggers Alcohol/marijuana use Powerful cravings Paranoia Depression Disordered sleep patterns Relapse factors during the withdrawal stage - During withdrawal, patients are disoriented, depressed, fatigued, and feel very much out of control. They do not understand what is happening to them, and require very explicit direction during this period. During this stage, drug and alcohol triggers, thoughts, and cravings may be prevalent. A depleted neurochemistry translates into irritability, depression and disordered sleep. © 2006 Matrix Institute

Stages of Recovery - Stimulants HONEYMOON STAGE DAY 15 DAY 45 Also known as the “Pink Cloud”. Feels relatively good to the clients especially when compared to how they felt during the Wall but still rife with clinical challenges. Many feel cured. Over-involvement With Work Overconfidence Inability to Initiate Change Inability to Prioritize Alcohol Use Episodic Cravings Treatment Termination PROBLEMS ENCOUNTERED © 2006 Matrix Institute

Primary Manifestation of Inability to Prioritize MATRIX MODEL Primary Manifestation of Honeymoon Stage Behavioral Cognitive High Energy- Unfocused Behavior Inability to Prioritize Emotional Relationship Overconfidence/ Feeling Cured Denial of Addiction Disorder

MATRIX MODEL Primary Manifestation of the Wall Stage Behavioral Cognitive Sluggish Low Energy/Inertia Relapse Justification Emotional Relationship Depression/Anhedonia Irritability/ Mutual Blaming/Impatience

MATRIX MODEL TREATMENT Relapse Factors - Honeymoon Stage Overconfidence Secondary alcohol or other drug use Discontinuation of structure Resistance to behavior change Return to a chemical influenced lifestyle Inability to prioritize Periodic paranoia Slide 21 Relapse factors during the Honeymoon Stage - During this stage, the patient’s mood typically improves, energy increases, cravings diminish, confidence and optimism increase; and, it may feel as if the problem with chemical substances is over. This stage is also popularly known as the pink cloud stage. Many patients become over-involved with work to the point of workaholism. An inability to prioritize may be a problem during this period. One of the most important treatment activities during this stage involves channeling, in some order of importance, the honeymoon energy toward specific recovery tasks. It is critical that patients recognize that this period is temporary. They need to use the energy available during this period to put together a solid structure of activities and build momentum that will carry through subsequent recovery stages. © 2006 Matrix Institute

Stages of Recovery - Stimulants THE WALL DAY 45 DAY 120 Inertia Depression Return to Cocaine Stimuli Relapse Justification Cognitive Rehearsal Treatment Termination Alcohol Use Relapse The main event of the recovery process particularly when the DOC is a stimulant. PROBLEMS ENCOUNTERED © 2006 Matrix Institute

“The Wall” One Patient’s Account Physical Symptoms: “Lack of energy was almost constant even if I slept for hours. Lack of memory, inability to concentrate and a grey film over my vision clouded my world. My sleep became mixed-up. I would be dead tired during the day and experience insomnia at night.” © 2006 Matrix Institute

“The Wall” One Patient’s Account Apathy: “Throughout The Wall I didn’t care about anything or anybody. Including myself. Nothing seemed important, nothing felt good. Boredom and hopelessness were constant companions. I felt the whole thing would never end.” © 2006 Matrix Institute

“The Wall” One Patient’s Account Loneliness and Isolation: “More than anything I felt alone. I felt like I was the only person in the world who knew how I felt. Even my therapist and my C.A group didn’t understand. I went to meetings and often still felt alone.” © 2006 Matrix Institute

Some handout samples. © 2006 Matrix Institute

THE BENEFITS OF EXERCISE Aerobic/Cardio seems to be the best for reducing or in some cases eliminating Post Acute Withdrawal Syndrome (Wall) 20 or more minutes a day Increase respiration Increase pulse rate Light sweat Increases endorphin production which may help stabilize neurotransmitter regulation

Adjustment/Resolution Stage Stages of Recovery - Stimulants Adjustment/Resolution Stage DAY 120 DAY 180 In an outpatient Tx model it is better to address more “psychodynamic” issues after a base of at least some abstinence has been established. Sometimes well intentioned clinicians can hasten client dropout or relapse by charging prematurely into deeper issues. The clients do not have adequate coping mechanisms in place and may resort back to using after leaving the clinic if the groups have unleashed too much emotionality. The MM philosophy posits that if these issues can be placed on the back burner or dealt with more in the individual sessions the clients will benefit more from treatment. The groups in the MM are primarily skill building groups. Anger Guilt Isolation Boredom PROBLEMS ENCOUNTERED Vocational Dissatisfaction Relationship Problems Overconfidence Lack of Goals Underlying Psychopathology resurfaces © 2006 Matrix Institute

Primary Manifestation of Commitment to Recovery MATRIX MODEL Primary Manifestation of Adjustment Stage Behavioral Cognitive Sloppiness Regarding Limits Drifting From Commitment to Recovery Emotional Relationship Experiencing Normal Emotions Surfacing of Long-Term Issues

Stages of Recovery Relapse Factors - Adjustment Stage Secondary alcohol or other drug use Relaxation of structure Struggle over acceptance of addiction Maintenance of recovery momentum/commitment I feel cured syndrome Re-emergence of underlying pathology Relapse factors during the Adjustment/Resolution stage - Some of the problems associated with stage are as follows. Recovering patients often have an implicit feeling of being “cured”, which translates into resuming drug and alcohol use, relaxation of structure, and discontinuation of recovery activities or behaviors (post treatment syndrome), therefore relapsing. Other relapse factors are drifting back to using friends, secondary drug and/or alcohol use, compulsive behaviors, neglecting recovery activities or exercise, not dealing with emotional issues, and losing the momentum of recovery. Other problems are related to the acceptance of the addiction and the possible re-emergence of underlying pathology. Material from individual psychotherapy or relationship issues may emerge requiring additional attention. A. Preventing relapse requires the use of some self-monitoring skills, which will provide warning signals if a person begins to move towards relapse. B. Underlying issues need to be addressed in a counseling or psychotherapeutic setting. C. Ongoing participation in self-help programs and treatment support groups are vitally important in maintaining long-term sobriety. © 2006 Matrix Institute

Traditional View of Psychotherapy for Substance Abuse Until 1960 psychodynamic oriented psychotherapy was the primary professional approach to substance abuse treatment. Assumed that substance abuse behavior was a manifestation of underlying psychopathology. If resolution of underlying psychopathology could be achieved, substance abuse would be lessened.

MATRIX MODEL DIFFERENCES General Psychotherapy Matrix Model Focus on feelings Emotional catharsis as a means to gain sobriety Addiction or abstinence may or may not be discussed Unmotivated clients are not pursued Behavioral focus a priority CBT as a means to laying foundation for recovery Abstinence is highlighted and tools are discussed Ambivalent or unmotivated clients are accepted and the norm © 2006 Matrix Institute

MATRIX TREATMENT MODEL Different from General Therapy Focus on behavior vs. feelings Visit frequency results in strong bonding with the counselor and the group This bonding encouraged and utilized Goal is stability (vs. emotional catharsis) © 2006 Matrix Institute

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 © 2006 Matrix Institute

MANUALIZED TREATMENT The Matrix Model Reduces therapist differences Ensures uniform set of services Enhances training capabilities Facilitates research to practice Can be more easily evaluated MATRIX The benefits of using manualized formats in the psychosocial treatment of drugs and alcohol. © 2006 Matrix Institute

EVIDENCE BASED THERAPIES (EBT’S) THAT ARE INCORPORATED IN THE MATRIX MODEL Cognitive Behavioral Therapy Motivational Interviewing Contingency Management 12- Step Facilitation Community Participation Family Therapies © 2006 Matrix Institute

INTENSIVE OUTPATIENT PROGRAM SCHEDULE A sample schedule for the Matrix IOP program is illustrated in the following table: INTENSIVE OUTPATIENT PROGRAM SCHEDULE Week Monday Tues. Wed. Thurs. Friday Saturday & Sunday Weeks 1 Through 4 6-7 PM Early Recovery Skills 7-8:30 PM Relapse Prevention 12-step Meeting Or other community participation Family Education Group 12-Step/ Spiritual Meetings and Other Activities 5 16 or Social Support 17 52 Urine testing and breath-alcohol testing conducted weekly Ten individual sessions during the first 16 weeks © 2006 Matrix Institute

MATRIX MODEL Organizing Principals STRUCTURE Create explicit structure and expectations Establish positive, collaborative relationship w/ clients Teach information and cognitive-behavioral concepts Positively reinforce positive behavior change Provide corrective feedback when necessary Educate family regarding substance abuse recovery Introduce and encourage self-help participation Use urinalysis to monitor drug use © 2006 Matrix Institute

MATRIX MODEL Organizing Principals STYLE Nonjudgmental, supportive attitude Engagement & Retention Strong bond with individual counselor or group Minimal use of confrontation Use of recovering role models in group Ability to work with relapse

COGNITIVE BEHAVIORAL THERAPY Key Concepts Encouraging and reinforcing behavior change Recognizing and avoiding high risk settings Behavioral planning (scheduling) Coping skills Conditioned “triggers” Understanding and dealing with craving Understanding basic psychopharmacology principles Self-efficacy (MI Concept) © 2006 Matrix Institute

TRIGGERS AND CRAVINGS & ROADMAP TO RECOVERY Foundation of the Matrix Model & are 2 of the FAM ED topics Material needs to be learned by the counselor so they can teach it to the clients. Information is woven through all the topics Clients will begin speaking the language of the model and integrating it into their recovery Brain Chemistry and Functioning Classical Conditioning & Cognitive Behavior Therapy Stages of Recovery