**I. Introduction** **to** **the Matrix Intensive Outpatient Treatment
for People With Stimulant Use Disorders Approach and Package**

The Matrix Intensive Outpatient Treatment for People With Stimulant Use
Disorders (IOP) package provides a structured approach for treating
adults who abuse or are dependent on stimulant drugs. The approach
followed in the treatment package was developed by the Matrix Institute
in Los Angeles, California, and was adapted for this treatment package
by the Knowledge Application Program of the Center for Substance Abuse
Treatment of the Substance Abuse and Mental Health Services
Administration (SAMHSA). The Matrix IOP package comprises five
components:

-   ***Counselor's Treatment Manual*** (this document)

-   *Counselor's Family Education Manual*

-   CD-ROM that accompanies the *Counselor's Family Education Manual*

-   *Client's Handbook*

-   *Client's Treatment Companion*

The Matrix IOP model and this treatment package based on that model grew
from a need for structured, evidence-based treatment for clients who
abuse or are dependent on stimulant drugs, particularly methamphetamine
and cocaine. This comprehensive package provides substance abuse
treatment professionals with an intensive outpatient treatment model for
these clients and their families: 16 weeks of structured programming and
36 weeks of continuing care.

**Background**

The Matrix IOP method was developed initially in the 1980s in response
to the growing numbers of individuals entering the treatment system with
cocaine or methamphetamine dependence as their primary substance use
disorder. Many traditional treatment models then in use were developed
primarily to treat alcohol dependence and were proving to be relatively
ineffective in treating cocaine and other stimulant dependence (Obert et
al. 2000).

To create effective treatment protocols for clients dependent on
stimulant drugs, treatment professionals at the Matrix Institute drew
from numerous treatment approaches, incorporating into their model
methods that were empirically tested and practical. Their treatment
model incorporated elements of relapse prevention,
cognitive--behavioral, psychoeducation, and family approaches, as well
as 12-Step program support (Obert et al. 2000).

The effectiveness of the Matrix IOP approach has been evaluated numerous
times since its inception (Rawson et al. 1995; Shoptaw et al. 1994).
SAMHSA found the results of these studies promising enough to warrant
further evaluation (e.g., Obert et al. 2000; Rawson et al. 2004).

In 1998, SAMHSA initiated a multisite study of treatments for
methamphetamine dependence and abuse, the Methamphetamine Treatment
Project (MTP). The study compared the clinical and cost effectiveness of
a comprehensive treatment model that follows a manual developed by the
Matrix Institute with the effectiveness of treatment approaches in use
at eight community-based treatment programs, including six programs in
California, one in Montana, and one in Hawaii. Appendix A provides more
information about MTP.

**Matrix IOP Approach**

***Overview***

The Matrix IOP approach provides a structured treatment experience for
clients with stimulant use disorders. Clients receive information,
assistance in structuring a substance-free lifestyle, and support to
achieve and maintain abstinence from drugs and alcohol. The program
specifically addresses the issues relevant to clients who are dependent
on stimulant drugs, particularly methamphetamine and cocaine, and their
families.

For 16 weeks, clients attend several intensive outpatient treatment
sessions per week. This intensive phase of treatment incorporates
various counseling and support sessions:

-   Individual/Conjoint family sessions (3 sessions)

-   Early Recovery Skills group sessions (8 sessions)

-   Relapse Prevention group sessions (32 sessions)

-   Family Education group sessions (12 sessions)

-   Social Support group sessions (36 sessions)

Clients may begin attending Social Support groups once they have
completed the 12-session Family Education group but are still attending
Relapse Prevention group sessions. Overlapping Social Support group
attendance with the intensive phase of treatment helps ensure a smooth
transition to continuing care.

The Matrix IOP method also familiarizes clients with 12-Step programs
and other support groups, teaches clients time management and scheduling
skills, and entails conducting regular drug and breath-alcohol testing.
A sample schedule of treatment activities is shown in Figure I-1.

+-------+-------------------+-------------------+--------------------+
| **F   |                   |                   |                    |
| igure |                   |                   |                    |
| I-1.  |                   |                   |                    |
| S     |                   |                   |                    |
| ample |                   |                   |                    |
| M     |                   |                   |                    |
| atrix |                   |                   |                    |
| IOP   |                   |                   |                    |
| Sched |                   |                   |                    |
| ule** |                   |                   |                    |
+-------+-------------------+-------------------+--------------------+
|       | **Intensive       |                   | **Continuing       |
|       | Treatment**       |                   | Care**             |
+-------+-------------------+-------------------+--------------------+
|       | **Weeks 1 through | **Weeks 5 through | **Weeks 13 through |
|       | 4\***             | 16^^**           | 48**               |
+-------+-------------------+-------------------+--------------------+
| **Mon | 6:00--6:50 p.m.   | 7:00--8:30 p.m.   |                    |
| day** | Early Recovery    | Relapse           |                    |
|       | Skills            | Prevention        |                    |
|       |                   |                   |                    |
|       | 7:15--8:45 p.m.   |                   |                    |
|       | Relapse           |                   |                    |
|       | Prevention        |                   |                    |
+-------+-------------------+-------------------+--------------------+
| *     | 12                |                   |                    |
| *Tues | -Step/mutual-help |                   |                    |
| day** | group meetings    |                   |                    |
+-------+-------------------+-------------------+--------------------+
| **W   | 7:00--8:30 p.m.   | 7:00--8:30 p.m.   | 7:00--8:30 p.m.    |
| ednes | Family Education  | Family Education  | Social Support     |
| day** |                   |                   |                    |
|       |                   | **or**            |                    |
|       |                   |                   |                    |
|       |                   | 7:00--8:30 p.m.   |                    |
|       |                   | Social Support    |                    |
+-------+-------------------+-------------------+--------------------+
| **    | 12                |                   |                    |
| Thurs | -Step/mutual-help |                   |                    |
| day** | group meetings    |                   |                    |
+-------+-------------------+-------------------+--------------------+
| **Fri | 6:00--6:50 p.m.   | 7:00--8:30 p.m.   |                    |
| day** | Early Recovery    | Relapse           |                    |
|       | Skills            | Prevention        |                    |
|       |                   |                   |                    |
|       | 7:15--8:45 p.m.   |                   |                    |
|       | Relapse           |                   |                    |
|       | Prevention        |                   |                    |
+-------+-------------------+-------------------+--------------------+
| **Sat | 12                |                   |                    |
| urday | -Step/mutual-help |                   |                    |
| and   | group meetings    |                   |                    |
| Sun   | and other         |                   |                    |
| day** | recovery          |                   |                    |
|       | activities        |                   |                    |
+-------+-------------------+-------------------+--------------------+
| \* 1  |                   |                   |                    |
| Indi  |                   |                   |                    |
| vidua |                   |                   |                    |
| l/Con |                   |                   |                    |
| joint |                   |                   |                    |
| se    |                   |                   |                    |
| ssion |                   |                   |                    |
| at    |                   |                   |                    |
| week  |                   |                   |                    |
| 1     |                   |                   |                    |
|       |                   |                   |                    |
| **    |                   |                   |                    |
| ^^** |                   |                   |                    |
| 2     |                   |                   |                    |
| Indi  |                   |                   |                    |
| vidua |                   |                   |                    |
| l/Con |                   |                   |                    |
| joint |                   |                   |                    |
| ses   |                   |                   |                    |
| sions |                   |                   |                    |
| at    |                   |                   |                    |
| week  |                   |                   |                    |
| 5 or  |                   |                   |                    |
| 6 and |                   |                   |                    |
| at    |                   |                   |                    |
| week  |                   |                   |                    |
| 16    |                   |                   |                    |
+-------+-------------------+-------------------+--------------------+

***Program Components***

This section describes the logistics and philosophy of each of the five
types of counseling sessions that are components of the Matrix IOP
approach. Detailed agendas and instructions for conducting each type of
group and individual session are provided in the designated sections of
this manual and in the *Counselor's Family Education Manual*.

The Matrix materials use step-by-step descriptions to explain how
sessions should be conducted. The session descriptions are methodical
because the treatment model is intricate and detailed. Counselors who
use these materials may want additional training in the Matrix approach,
but these materials were designed so that counselors could implement the
Matrix treatment approach even without training. The Matrix materials do
not describe intake procedures, assessments, or treatment planning.
Programs should use the procedures they have in place to perform these
functions. If the guidelines presented in this manual conflict with the
requirements of funders or credentialing or certifying bodies, programs
should adapt the guidelines as necessary. (For example, some States
require that sessions last a full 60 minutes to be funded by Medicaid.)

All Matrix IOP groups are open ended, meaning that clients may begin the
group at any point and will leave that group when they have completed
the full series. Because the Matrix groups are open ended, the content
of sessions is not dependent on that of previous sessions. The counselor
will find some repetition of information among the three
Individual/Conjoint sessions as well as group sessions. Clients in early
recovery often experience varying degrees of cognitive impairment,
particularly regarding short-term memory. Memory impairment can manifest
as clients' difficulty recalling words or phrases. Repeating information
in different ways, in different group contexts, and over the course of
clients' treatment helps clients comprehend and retain basic concepts
and skills critical to recovery.

*Individual/Conjoint Sessions*

In the Matrix IOP intervention, the relationship between counselor and
client is considered the primary treatment dynamic. Each client is
assigned one primary counselor. That counselor meets individually with
the client and possibly the client's family members three times during
the intensive phase of treatment for three 50-minute sessions and
facilitates the Early Recovery Skills and Relapse Prevention groups. The
first and last sessions serve as "bookends" for a client's treatment
(i.e., begin and end treatment in a way that facilitates treatment
engagement and continuing recovery); the middle session is used to
conduct a quick, midtreatment assessment of the client's progress, to
address crises, and to coordinate treatment with other community
resources when appropriate.

Conjoint sessions that include both the client and family members or
other supportive persons are crucial to keeping the client in treatment.
The importance of involving people who are in a primary relationship
with the client cannot be overestimated; the Matrix IOP approach
encourages the inclusion of a client's most significant family member or
members in each Individual/Conjoint session in addition to Family
Education group sessions. The counselor who tries to facilitate change
in client behavior without addressing family relationships ultimately
makes the recovery process more difficult. It is critical for the
counselor to stay aware of how the recovery process affects the family
system and to include a significant family member in part of every
Individual/Conjoint session when possible.

*Early Recovery Skills Group*

Clients attend eight Early Recovery Skills (ERS) group sessions---two
per week for the first month of primary treatment. These sessions
typically involve small groups (10 people maximum) and are relatively
short (50 minutes). Each ERS group is led by a counselor and co-led by a
client who is advanced in the program and has a stable recovery (see
below for information about working with client co-leaders). It is
important that this group stay structured and on track. The counselor
needs to focus on the session's topic and be sure not to contribute to
the high-energy, "out-of-control" feelings that may be characteristic of
clients in early recovery from stimulant dependence.

The ERS group teaches clients an essential set of skills for
establishing abstinence from drugs and alcohol. Two fundamental messages
are delivered to clients in these sessions:

1.  You can change your behavior in ways that will make it easier to
    stay abstinent, and the ERS group sessions will provide you with
    strategies and practice opportunities to do that.

2.  Professional treatment can be one source of information and support.
    However, to benefit fully from treatment, you also need 12-Step or
    mutual-help groups.

The techniques used in the ERS group sessions are behavioral and have a
strong "how to" focus. This group is not a therapy group, nor is it
intended to create strong bonds among group members, although some
bonding often occurs. It is a forum in which the counselor can work
closely with each client to assist the client in establishing an initial
recovery program. Each ERS group has a clear, definable structure. The
structure and routine of the group are essential to counter the
high-energy or out-of-control feelings noted above. With newly admitted
clients, the treatment routine is as important as the information
discussed.

*Relapse Prevention Group*

The Relapse Prevention (RP) group is a central component of the Matrix
IOP method. This group meets 32 times, at the beginning and end of each
week during the 16 weeks of primary treatment. Each RP group session
lasts approximately 90 minutes and addresses a specific topic. These
sessions are forums in which people with substance use disorders share
information about relapse prevention and receive assistance in coping
with the issues of recovery and relapse avoidance. The RP group is based
on the following premises:

-   Relapse is not a random event.

-   The process of relapse follows predictable patterns.

-   Signs of impending relapse can be identified by staff members and
    clients.

The RP group setting allows for mutual client assistance within the
guiding constraints provided by the counselor. Clients heading toward
relapse can be redirected, and those on a sound course to recovery can
be encouraged.

The counselor who sees clients for prescribed Individual/Conjoint
sessions and a client co-leader facilitate the RP group sessions (see
below for information about working with client co-leaders).

Examples of the 32 session topics covered in the RP group include

-   Guilt and shame

-   Staying busy

-   Motivation for recovery

-   Be smart, not strong

-   Emotional triggers

*Family Education Group*

Twelve 90-minute Family Education group sessions are held during the
course of the 16-week program. This group meets once per week for the
first 3 months of primary treatment and is often the first group
attended by clients and their families. The group provides a relatively
nonthreatening environment in which to present information and provides
an opportunity for clients and their families to begin to feel
comfortable and welcome in the treatment facility. A broad spectrum of
information is presented about methamphetamine dependence, other drug
and alcohol use, treatment, recovery, and the ways in which a client's
substance abuse and dependence affect family members as well as how
family members can support a client's recovery. The group format uses
PowerPoint slides, discussions, and panel presentations.

The counselor personally invites family members to attend the series.
The often negative interactions within clients' families just before
beginning treatment can result in clients' desire to "do my program
alone." However, Matrix treatment experience shows that, if clients are
closely involved with significant others, those significant others are
part of the recovery process regardless of whether they are involved in
treatment activities. The chances of treatment success increase
immensely if significant others become educated about the predictable
changes that are likely to occur within relationships as recovery
proceeds. The primary counselor educates participants and encourages
involvement of significant others, as well as clients, in the 12-session
Family Education group. The material for the twelve 90-minute Family
Education group sessions is in the *Counselor's Family Education
Manual.*

*Social Support Group (Continuing Care)*

Clients begin attending the Social Support group at the beginning of
their last month in primary treatment and continue attending these group
sessions once per week for 36 weeks of continuing care. For 1 month,
intensive treatment and continuing care overlap.

Social Support group sessions help clients learn or relearn
socialization skills. Persons in recovery who have learned how to stop
using substances and how to avoid relapse are ready to develop a
substance-free lifestyle that supports their recovery. The Social
Support group assists clients in learning how to resocialize with
clients who are further along in the program and in their recovery in a
familiar, safe environment. This group also is beneficial to the
experienced participants who often strengthen their own recovery by
serving as role models and staying mindful of the basic tenets of
abstinence. These groups are led by a counselor, but occasionally they
may be broken into smaller discussion groups led by a
client--facilitator, a client with a stable recovery who has served as a
co-leader and makes a 6-month commitment to assist the counselor.

Social Support group sessions focus on a combination of discussion of
recovery issues being experienced by group members and discussion of
specific, one-word recovery topics, such as

-   Patience

-   Intimacy

-   Isolation

-   Rejection

-   Work

**The Role of the Counselor**

To implement the Matrix IOP approach, the counselor should have several
years of experience working with groups and individuals. Although
detailed instructions for conducting sessions are included in this
manual, a new counselor may not have acquired the facility or the skills
necessary to make the most of the sessions. The counselor who is willing
to adapt and learn new treatment approaches is an appropriate Matrix IOP
counselor. The counselor who has experience with cognitive--behavioral
and motivational approaches and has a familiarity with the neurobiology
of addiction will be best prepared to implement the Matrix IOP
intervention. Appropriate counselor supervision will help ensure
fidelity to the Matrix treatment approach.

In addition to conducting the three Individual/Conjoint sessions, a
client's primary counselor decides when a client moves from one group to
another and is responsible for integrating material from the various
group-counseling formats into one coordinated treatment experience.

Each client's primary counselor

-   Coordinates with other counselors working with the client in group
    sessions (e.g., in Family Education sessions)

-   Is familiar with the material to which the client is being exposed
    in the Family Education sessions

-   Encourages, reinforces, and discusses material that is being covered
    in 12-Step or mutual-help meetings

-   Helps the client integrate concepts from treatment with 12-Step and
    mutual-help material, as well as with psychotherapy or psychiatric
    treatment (for clients who are in concurrent therapy)

-   Coordinates with other treatment or social services professionals
    who are involved with the client

In short, the counselor coordinates all the pieces of the treatment
program. Clients need the security of knowing that the counselor is
aware of all aspects of their treatment. Many people who are stimulant
dependent enter treatment feeling out of control. They are looking to
the program to help them regain control. If the program appears to be a
disjointed series of unrelated parts, these clients may not feel that
the program will help them regain control, which may lead to
unsuccessful treatment outcomes or premature treatment termination.
Appendix B provides more notes on the counselor's role in group
facilitation.

In facilitating sessions, the counselor should be sensitive to cultural
and other diversity issues relevant to the specific populations being
served. The counselor needs to understand culture in broad terms that
include not only obvious markers such as race, ethnicity, and religion,
but also socioeconomic status, level of education, and level of
acculturation to U.S. society. The counselor should exhibit a
willingness to understand clients within the context of their culture.
However, it is also important to remember that each client is an
individual, not merely an extension of a particular culture. Cultural
backgrounds are complex and are not easily reduced to a simple
description. Generalizing about a client's culture is a paradoxical
practice. An observation that is accurate and helpful when applied to a
cultural group may be misleading and harmful when applied to an
individual member of that group. The forthcoming Treatment Improvement
Protocol *Improving Cultural Competence in Substance Abuse Treatment*
(CSAT forthcoming) provides more information on cultural competence*.*

**Working With Client Co-Leaders and Client--Facilitators**

Using clients as group co-leaders is an essential part of the Matrix IOP
approach. Clients who have completed at least the first 8 weeks of the
program and been abstinent over that period can be client co-leaders for
ERS groups. Ideally, client co-leaders for RP groups will have completed
the full year of Matrix treatment and been abstinent over that period.
These advanced clients bring a wealth of experience to group sessions.
As persons who are recovering successfully, the client co-leaders are in
a position to address controversial, difficult issues from a perspective
similar to that of clients in the group, often by sharing personal
experiences. The client co-leaders also are able to strengthen their
recovery in the process and give back to the program and to other
clients.

Client co-leaders should be chosen carefully. Clients may be considered
for co-leading an ERS group if they meet the following criteria:

-   A minimum of 8 weeks of uninterrupted abstinence from illicit drugs
    and alcohol

-   Regular attendance at scheduled RP group and Individual/Conjoint
    sessions

-   A willingness to serve as co-leaders once or twice a week for at
    least 3 months

Clients may be considered for co-leading an RP group if they meet the
following criteria:

-   A minimum of 1 year of uninterrupted abstinence from illicit drugs
    and alcohol

-   Completion of the Matrix IOP intervention (i.e., completed 1 year of
    treatment)

-   Active participation in a Social Support group and attending 12-Step
    or mutual-help group meetings

-   A willingness to serve as co-leaders once or twice a week for at
    least 6 months

When selecting client co-leaders, the counselor also should consider
whether clients are respected by other group members and are able to
work well with the counselor.

The counselor should ask client co-leaders to sign a formal agreement;
an example of such an agreement is in Appendix C.

Before clients begin serving as co-leaders, the counselor needs to
orient them to the role. Client co-leaders need to understand the
following:

-   They are not counselors; their input needs to be made in the first
    person (e.g., "What helped me was ..." rather than "You should
    ...").

-   They must maintain the confidentiality of group participants.

-   They need to be willing to talk to the counselor about any issues or
    problems that arise for them while they serve as co-leaders.

The counselor should meet with the co-leader before each group session
to discuss briefly the topic and any issues that might arise. After each
group session, the counselor should meet again with the co-leader to

-   Make sure the co-leader is not distressed by anything that occurred
    during group

-   Discuss briefly how the group went and provide feedback on anything
    the co-leader did particularly well or that could use improvement
    (e.g., monopolizing the conversation, confronting a client
    inappropriately, giving advice rather than relating his or her own
    experience)

Meeting regularly with client co-leaders provides opportunities for the
counselor and co-leaders to improve the way they work together and to
maximize the benefits to the co-leaders and other group members.

Clients who have served as co-leaders for ERS or RP group sessions can
act as client--facilitators for Social Support group sessions. The
counselor should follow the guidelines above when selecting and working
with client--facilitators.

**The Matrix IOP Package**

In addition to this *Counselor's Treatment Manual* (introduced in detail
below), the Matrix IOP package consists of these components:

-   *Client's Handbook*---This illustrated handbook contains an
    introduction and welcome and all the handouts that are used in the
    Matrix IOP program, except for those used in the Family Education
    group sessions. Counselors will notice that the *Client's Handbook*
    uses large type and has art on most of the pages. People in recovery
    from stimulant use experience memory impairments. But these
    impairments are much worse for word recall than for picture recall.
    Clinical experience has shown that clients respond better to the
    Matrix approach when the treatment materials are accompanied by
    pictures and visual cues.

> If the counselor has enough copies of the *Client's Handbook* to
> distribute one book to each client, he or she should do so. If not,
> the counselor should make copies of the handouts (either from the
> *Counselor's Treatment Manual* or from the *Client's Handbook*) and
> give one set to each client at the client's first ERS session. Clients
> keep their handbooks at the clinic, take notes in them, and are given
> them to keep when they graduate from the Matrix intervention.
>
> Note: During the course of MTP, which served as the model for this
> treatment manual, copies of the *Client's Handbook* were stored in a
> locked cabinet until group members arrived, when clients retrieved
> their handbooks for use during the session. In the interests of client
> confidentiality, clients put only their first names on the handbooks;
> no other client-identifying information was listed.

-   *Counselor's Family Education Manual* and Slide Presentations---The
    *Counselor's Family Education Manual* contains

```{=html}
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```
-   Introductions to the Matrix IOP package and to the manual

-   Instructions for conducting each session

-   Handouts for participants

> Session instructions are presented in a format similar to that
> provided for the other types of sessions.
>
> The *Counselor's Family Education Manual* is accompanied by a CD-ROM
> containing slide presentations for 7 of the 12 sessions.

-   *Client's Treatment Companion*---The *Client's Treatment Companion*
    is for clients to carry with them in a pocket or purse. It contains
    useful recovery tools and concepts and provides space for clients to
    record their relapse triggers and cues, write short phrases that
    help them resist triggers, and otherwise personalize the book. Ideas
    are included for ways to personalize and make the *Client's
    Treatment Companion* a useful tool for recovery.

**Introduction to the *Counselor's Treatment Manual***

This manual contains all the materials necessary for a counselor to
conduct individual and group sessions using the Matrix IOP approach.
After the introductory sections, this manual is organized by type of
session (i.e., Individual/Conjoint, Early Recovery Skills, Relapse
Prevention, and Social Support). The presentation of each type of
session begins with an overview that includes a discussion of

-   The general format and flow of the individual or group sessions

-   Any special considerations relevant to the particular type of
    session

-   The overall goals for each type of session

The overview is followed by instructions for conducting each specific
session. These instructions include

-   The goals of the session

-   A list of client handouts

-   Notes to the counselor about anything to keep in mind during the
    session

-   Topics for group discussion, including key points to cover

-   Guidelines for helping clients recognize their progress, manage
    their time, and address any concerns they have about time management

-   Homework assignments for clients

[]{.mark}

Copies of the handouts that make up the *Client's Handbook* are located
at the end of each section's instructions for easy reference. The
counselor should review thoroughly the session instructions before
conducting each group or individual session.

Readers who are interested in learning more about the Matrix approach to
treatment for stimulant use disorders will find a list of articles for
further reading in Appendix E.