MATRIX Treatment Model

MATRIX Treatment Model

DR. SH.KARIMI. PSYCHIATRIST
The Matrix Model: An Evidence-based Treatment for Substance Abuse Disorders DR. SH.KARIMI PSYCHIATRIST

Methamphetamine Methamphetamine is a powerful central nervous system stimulant that strongly activates multiple systems in the brain. Methamphetamine is closely related chemically to amphetamine, but the central nervous system effects of methamphetamine are greater.

Methamphetamine History
1887 1919 1932 Amphetamine developed Methamphetamine developed Amphetamine & methamphetamine used as decongestant

Methamphetamine History, continued
WW II Extensive use by: - RAF fighter pilots - German Panzer troops - Japanese workers - Led to Kamikaze fever

Self-Reported Reasons for Starting Methamphetamine Use

Natural Rewards Elevate
Dopamine Levels 50 100 150 200 60 120 180 Time (min) % of Basal DA Output NAc shell Empty Box Feeding Source: Di Chiara et al. FOOD 100 150 200 DA Concentration (% Baseline) Mounts Intromissions Ejaculations 15 5 10 Copulation Frequency Sample Number 1 2 3 4 6 7 8 9 11 12 13 14 16 17 Scr Bas Female 1 Present Female 2 Present Source: Fiorino and Phillips SEX

Effects of Drugs on Dopamine Levels
Source: Di Chiara and Imperato Effects of Drugs on Dopamine Levels 100 150 200 250 1 2 3 4 5hr Time After Morphine % of Basal Release Accumbens 0.5 1.0 2.5 10 Dose (mg/kg) MORPHINE 100 200 300 400 1 2 3 4 5 hr Time After Cocaine % of Basal Release DA DOPAC HVA Accumbens COCAINE 100 200 300 400 500 600 700 800 900 1000 1100 1 2 3 4 5 hr Time After Amphetamine % of Basal Release DA DOPAC HVA Accumbens AMPHETAMINE 100 150 200 250 1 2 3 hr Time After Nicotine % of Basal Release Accumbens Caudate NICOTINE

Meth Treatment is Challenging
Very euphoric Prolonged meth use changes the brain Cognitive and emotional consequence of use can last months or years

Drug Use in the Early 1980’s: the Cocaine Epidemic
Drug use was acceptable. Cocaine wasn’t addictive. Cocaine wasn’t physically addicting in contrast to heroin.

A New kind of Addiction Cocaine users had brief histories of use in contrast to alcohol users. There were periods of abstinence and relapse. Users described powerful, overwhelming cravings. They weren’t in denial; they were confused.

Meth and Women: Typical gender ratio of heroin users in treatment : 3 men to 1 woman Typical gender ratio of cocaine users in treatment : 2 men to 1 woman Typical gender ratio of methamphetamine users in treatment : 1 man to 1 woman * *among large clinical research populations

Treatment Admission Data
All Primary Substances Methamphetamine/ Amphetamine Primary Substance Male 61% 46.9% Female 39% 53.1%

Addiction is, Fundamentally, a Brain Disease

Treatment in the early 1980’s
“Drug treatment” was primarily for heroin users. “Treatment” was primarily medication (methadone). “Alcohol treatment” was usually 12-Step based and insight-oriented. The 28-day program.

Comparison of Treatment
A comparison of treatment outcomes between individuals diagnosed with methamphetamine dependence and all other diagnostic groups indicated no between group significant differences in any treatment outcome measures including: Retention in treatment rates Urinalysis data during treatment Rates of treatment program completion.

Not Ready Cocaine users were ready for treatment.
The treatment system was not ready for them. They were “resistant,” “in denial,” “not ready.” Treatment failure was their fault. There was no effective medication (and still no FDA-approved med for cocaine).

We Need to Treat the Whole Person!

The Most Effective Treatment Strategies Will Attend to All Aspects of Addiction:
Biology Behavior Social Context

Medications Currently, there are no medications that can quickly and safely reverse life threatening MA overdose. There are no medications that can reliably reduce paranoia and psychotic symptoms, that contribute to episodes of dangerous and violent behavior associated with MA use.

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.

Methamphetamine: the “5%” Myth
Myth: Only 5% of meth users are successful in treatment Wide dissemination may be self-fulfilling Communities won’t support treatment Funders won’t fund treatment Meth users won’t enter treatment Practitioners won’t expect treatment to work

In 1984, these were not our Goals:
To develop a model of treatment. To develop an evidence-based practice. To train anyone outside or our own office.

Matrix Institute began as a response to the cocaine epidemic

Matrix Model SAMHSA (Substance Abuse and Mental Health Services Administration) National Registry of Evidence-based Programs and Practices (NREPP)

Our Goals To develop a treatment that was relevant to our patients.
To develop a treatment that was effective with most of our patients, most of the time.

Matrix Model Content Information
A Key Premises Classical conditioning and craving The brain and addiction Confusion and ambivalence vs denial

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

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 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

Matrix Model: Key Elements
Relies primarily on group therapy Therapist functions as a teacher/coach A positive, encouraging relationship – not confrontational Time planning and scheduling Accurate information Relapse Prevention Family Involvement Self Help Involvement Urinalysis / Breath Testing

Matrix Institute Overview
Training and dissemination Evidence-based requirements Methamphetamine treatment experience The Hazelden Manuals (English and Spanish) CSAT Manual: Matrix Model for stimulant users Over 2000 agencies in 50 states Thailand, Viet Nam, Mexico, South Africa, Nicaragua, UAR, Guam, Spain, Japan, Curacao, Columbia and Saudi Arabia Key Supervisors and Certification

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

Treatment Components of the Matrix Model
Individual Sessions Early Recovery Groups Relapse Prevention Groups Family Education Group 12-Step and other community support Meetings Social Support Groups Urine Testing

Program Schedule A sample schedule for the Matrix 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

The Matrix Model: Then and Now

North Dakota’s Response
Human Service Centers (HSC’s) treat individuals using meth in low intensity outpatient, intensive outpatient, day treatment, and residential levels of care. A variety of methods used. version of MATRIX adopted for inpatient use. HSC’s trained in MATRIX model by UCLA– April 2006 Currently beginning stages of implementation UCLA training on-going One MATRIX group at each HSC

Triggers and Cravings Human Brain
Slide 4: The brain is your body’s “Command Central.” Your brain controls more than the way you think. The brain controls our physical sensations and body movements. How we understand what we see, hear, smell, taste, and touch. Our sense of balance and coordination. Memory. Feelings of pleasure and reward. The ability to make judgments. When we catch a football, dance, jog, speak, sing, laugh, whistle, smile, cry—that’s our brain receiving, processing, and sending out messages to different parts of our body. When we feel good for whatever reason—laughing with a friend or seeing a good movie or eating our favorite ice cream—the brain’s reward system is activated. As we said before, the reward system is the part of the brain that makes you feel good. The reward system is a collection of neurons that release dopamine, a neurotransmitter. When dopamine is released by these neurons, a person feels pleasure. Scientists have linked dopamine to most drugs of abuse—including cocaine, marijuana, heroin, alcohol, and nicotine. These drugs all activate the reward system and cause neurons to release large amounts of dopamine. Over time, drugs damage this part of the brain. As a result of this damage, things that used to make you feel good—like eating ice cream, skateboarding, or getting a hug—no longer feel as good. Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates. and Marijuana. © 2006 Matrix Institute

Potency of Cravings DRUG ,,Slide 10
The part of the brain affected by mood-altering substances is the same part of the brain that makes us seek food when we are hungry, water when we are thirsty, and is responsible for sexual pleasure. It promotes our survival modes. When a person hasn’t eaten for a long period of time, the focus on getting food or water overpowers all other concerns. When long-term drugs or alcohol use occurs, the brain can become “short-circuited” and adapt to these chemicals as if survival depends on them. There is a demonstration, discussed in a lecture by the late Dr. Sidney Cohen that reflects the power of drugs on the brain and behavior. If you release a caged rodent and it has the option to run into a well-lit area or a dark area, it will always run into the dark. Mice and other small rodents have been conditioned to automatically seek out the dark, which will protect them from predators. This is a ingrained survival mechanism evolving over millions of years to this species. If the rodent is given doses of cocaine in the light,in a relatively short time, the next time the rodent is released, it will automatically go into the lit field. Thus reversing the conditioning that took place over millions of years. This demonstrates that the power of drugs has the ability to grossly distort normal mammalian brain chemistry.

“You need this to survive”
Message from the Brain “You need this to survive”

Information: Conditioning
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

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.

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.

Cognitive Process During Addiction
Disenchantment 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.

Cognitive Process During Addiction Relief From Depression
Disaster 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. © 2006 Matrix Institute

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

Conditioning and the Brain: Message to Patients
Will power, good intentions are not enough Behavior needs to change Insight will not affect cravings Deal with cravings: avoid external triggers Deal with cravings: identify emotional triggers Deal with cravings: thought-stopping Scheduling

Roadmap for Recovery Adjustment/Resolution 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 Adjustment Withdrawal The Wall
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 Difficulty Concentrating
WITHDRAWAL STAGE DAY DAY 15 Some of the issues that may lead to client termination or dropout during the Withdrawal stage. Medical Problems 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 Over-involvement With Work Overconfidence Inability to Initiate Change 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. 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 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

THE WALL Stages of Recovery - Stimulants PROBLEMS ENCOUNTERED Inertia
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

Loneliness and Isolation:
“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

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

Matrix Model Content Information
The Roadmap to Recovery (Stages of Recovery)

Early Recovery Skills Group Topics
Drug cessation Identify triggers Get rid of paraphernalia Avoid triggers-schedule time Thought-stopping for cravings 12-step community introduction (spiritual and/or secular programs)

Early Recovery Skills Group
Establishing structure Time scheduling Attending treatment and community meetings Exercising Work or school GOD Scheduled leisure

Relapse Prevention Topics
Overview of the concept; things don’t “just happen” Using Behaviors Old behaviors need to change Re-emergence signals relapse risk Relapse Justification “Stinking thinking” (Thinking errors that precede or lead to relapse) Recognize and stop

Relapse Prevention Topics
Dangerous Emotions Loneliness, anger, deprivation Be Smart, not Strong Avoid the dangerous people and places Don’t rely on will power Avoiding Relapse Drift Identify “mooring lines” Monitor drift

Identify Triggers, Create Structure
Self-designed portable structure (scheduling) Eliminate avoidable triggers Reduces anxiety Counters the drug-using lifestyle Provides basic foundation for ongoing recovery Slide 5 Inpatient treatment is an available option to fewer addicts and alcoholics due to cost and the rise of managed care companies promoting the use of outpatient treatment. It is possible to achieve abstinence on an outpatient basis. In fact, current research indicates that for many addicts outpatient treatment is as effective, or better, than inpatient treatment. In outpatient treatment, one doesn’t have the inherent structure of the four walls of an inpatient facility. Therefore, to implement effective outpatient treatment services, structure must be created, so the recovering addict can take this structure with them into the world when they leave the clinic. Treatment contacts must be frequents. The content of initial treatment sessions must include a behavioral plan structuring their time between sessions (time scheduling). The sessions alone are a valuable part of the behavioral structure. These allow the patient to reduce the overwhelming task of lifelong recovery to a “one day at a time” task. Part of each treatment session is to provide coaching to help the patient schedule time until his/her next session. Patients should be encouraged to plan and be reinforced for planning their time in new non-drug related activities. During the session, the patient should write down their plan.. In-depth therapy issues should be avoided until a basic behavioral routine is established. And a structure for the patient’s life is created. Assisting patients with planning their time creating structure is a simple enough concept, but one which is often very difficult to implement for out of control alcohol and drug abusers. This slide lists some of the specific reasons why structure is important in recovery. Scheduling is an exercise in the higher brain (cortical) control versus limbic control of behavior. This higher brain control and proactive behavior (planning) reduces anxiety and encourages self-reliance, thus reducing “accidental relapses”. Finally, structure is a counterpoint to the addict lifestyle. It helps promote balance within a person’s life, and it is a practical application of the “one day at a time” philosophy.

The Wall Treatment implications Message to patients Simple Redundant
Frequent visits for an extended period Message to patients It takes a while for your brain to heal Don’t make mistakes explaining your feelings Be patient; Don’t give up

Information Examples Protracted Abstinence: “The Wall”
days after last use

Return to Old Behaviors Protracted Abstinence
Roadmap for Recovery THE WALL Return to Old Behaviors Anhedonia Anger Depression Emotional Swings Unclear Thinking Isolation Family Problems Slide 22 Protracted abstinence, or the Wall, is the “main event” of the recovery process. A. During the Wall, there is a shift back from the high of the Honeymoon phase to a point, not as low as Withdrawal, but still not “normal.” B. After abstaining for some time, it may not be obvious that there may be some feelings still related to the after-effects of drug and alcohol use. The person in recovery needs to be reminded that the Wall is temporary and that it is a sign of the brain “getting well.” C. A person in the Wall typically experiences a lack of energy and an emotional state ranging from apathy to depression. 1. It is important to continue the behavioral changes that have developed to this point. 2. A sequence of inertia, boredom, loss of recovery, focus, relapse justification, and finally relapse can be prevented. D. The addicted brain may begin to influence behavior, and using drugs and alcohol can seem to start making sense again. E. Things can be kept in check if treatment contact is continued. 1. Treatment termination is a threat during the Wall. 2. Preparation for these feelings during the Honeymoon period and constant encouragement during the Wall are critical to ensure treatment continuation. Cravings Return Abstinence Violation Protracted Abstinence

Breaking Down Triggers: People
Drug-using friends/dealer Voices of drug friends/dealer Absence of significant other Sexual partners Groups discussing drug use Slide 13 People who are triggers.

Breaking Down Triggers: Places
Drug dealer’s home Bars and clubs Drug use neighborhoods Freeway offramps Worksite Street corners Slide 14 Places that are triggers.

Breaking Down Triggers: Things
Paraphernalia Sexually explicit magazines/movies/internet Money/bank machines Music Movies/TV shows about alcohol and other drugs Secondary alcohol or other drug use Slide 15 Objects or things that are triggers.

Breaking Down Triggers: Times
Periods of idle time Periods of extended stress After work Payday/AFDC payment day Holidays Friday/Saturday night Birthdays/Anniversaries Slide 16 Periods of time that are triggers.

Breaking Down Triggers: Emotional States
 Anxiety  Fatigue  Anger  Boredom  Frustration  Adrenalized states  Sexual arousal  Sexual deprivation  Gradually building emotional states with no expected relief Slide 17 The reality for most addicts/alcoholics is that any emotional state, positive or negative, can be a trigger if it has been historically associated with drug or alcohol use.

Matrix Model Groups Focus on the present
Focus on behavior vs. feelings Structured, topics, information, analysis of behavior Drug cessation skills and relapse prevention Lifestyle change in addition to not using

Matrix Model Groups Therapist frequently pursues less motivated clients Non-confrontational; must be safe Goal is abstinence; relapse is tolerated and analyzed

Relapse Prevention Group
What happens in group: Introduction of new members Review topic minutes and discuss Discuss problems, progress, and plans for minutes Focus on the recent past and immediate future (assessing relative relapse risks)

Relapse Prevention Groups
Patients need to develop new behaviors Recovery is more than not using D.O.C. Recovery is more than not using drugs and alcohol Learn to monitor signs of vulnerability to relapse

Relapse Analysis Session to be done when relapse occurs after a period of sobriety Functional analysis Continued drug use is better addressed with Early Recovery topics Relapse should be framed as learning experience for client

Relapse and Sex Part of the challenge of treatment
Particularly Methamphetamine treatment

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