**Appendix A. The Methamphetamine**

**Treatment Project**

**Overview**

Conducted over 18 months between 1999 and 2001, the Methamphetamine
Treatment Project (MTP) is (to date) the largest randomized clinical
trial of treatment approaches for methamphetamine dependence; 978
individuals participated in the study (Rawson et al. 2004). MTP
researchers randomly assigned participants at each treatment site into
either the Matrix model treatment or the program's treatment as usual
(TAU). The study design did not standardize TAU across sites, so each
program offered different outpatient treatment models (including lengths
of treatment ranging from 4 to 16 weeks). All TAU models, along with the
Matrix model, either required or recommended that participants attend
12-Step or mutual-help groups during their treatment, and all treatment
models encouraged participation in continuing care activities after
primary treatment.

The characteristics of a cross-section of participants in MTP (both TAU
and Matrix participants) were found to be consistent with those of the
clinical populations who participated in similar studies of treatment
for methamphetamine abuse (Huber et al. 1997; Rawson et al. 2000).
Figure A-1 lists specific client characteristics.

+----------------------------------------------+-----------------------+
| **Figure A-1. Characteristics of MTP         |                       |
| Participants**                               |                       |
+==============================================+=======================+
| Male                                         | 45%                   |
|                                              |                       |
| Female                                       | 55%                   |
+----------------------------------------------+-----------------------+
| Caucasian                                    | 60%                   |
|                                              |                       |
| Hispanic/Latino                              | 18%                   |
|                                              |                       |
| Asian/Pacific Islander                       | 17%                   |
|                                              |                       |
| Other\*                                      | 5%                    |
+----------------------------------------------+-----------------------+
| Average age                                  | 32.8 years            |
+----------------------------------------------+-----------------------+
| Married and not separated                    | 16%                   |
+----------------------------------------------+-----------------------+
| Average education                            | 12.2 years            |
+----------------------------------------------+-----------------------+
| Employed                                     | 69%                   |
+----------------------------------------------+-----------------------+
| Average lifetime methamphetamine use         | 7.54 years            |
|                                              |                       |
| Average days of methamphetamine use in the   | 11.53 days            |
| past 30 days                                 |                       |
+----------------------------------------------+-----------------------+
| Preferred route of methamphetamine           | 65%                   |
| administration                               |                       |
|                                              | 24%                   |
| Smoking                                      |                       |
|                                              | 11%                   |
| Intravenous                                  |                       |
|                                              |                       |
| Intranasal                                   |                       |
+----------------------------------------------+-----------------------+

\*Two percent of participants in the Other category were African
American (personal correspondence with Jeanne Obert, Matrix Institute,
November 2004).

Source: Rawson et al. 2004, p. 711.

Participants' histories indicated multiple substance use. During the
study, participant self-reports and drug and breath-alcohol tests
confirmed that some clients had used marijuana or alcohol, as well as
methamphetamines, but no other substances of abuse were identified.

All MTP participants completed baseline assessments including the
methamphetamine-dependence checklist in the *Diagnostic and Statistical
Manual of Mental Disorders*, Fourth Edition (American Psychiatric
Association 1994), and the Addiction Severity Index (McLellan et al.
1992). The assessments were repeated at several points during
participants' active treatment, at discharge from treatment, and at 6
and 12 months after their dates of discharge from the program. Urine
drug testing was conducted weekly throughout active treatment.

**Results**

No significant differences in substance use and functioning were found
between TAU and Matrix groups at discharge and at 6-month followup.
However, the MTP study found that the Matrix model participants (Rawson
et al. 2004)

-   Had consistently better treatment retention rates than did TAU
    participants

-   Were 27 percent more likely than TAU participants to complete
    treatment

-   Were 31 percent more likely than TAU participants to have
    methamphetamine-free urine test results while in treatment

At 6-month followup, more than 65 percent of both Matrix and TAU
participants had negative urine tests for methamphetamine and other
drugs (Rawson et al. 2004).

**Appendix B. Notes on Group Facilitation**

All clients in a group develop individual relationships with their
counselor. The degree to which the counselor can instigate positive
change in clients' lives is related directly to the credibility that the
counselor establishes. The counselor must be perceived as a highly
credible source of information about substance use. Two keys to
establishing credibility with clients are the degree to which the
counselor engages and maintains control over a group and the counselor's
ability to make all participants perceive the group as a safe place.

These two elements are highly interrelated. For a group to feel safe,
the members need to view the counselor as competent and in control.
Sometimes, group members enter the group with a lot of energy and are
talkative and boisterous. Frequently this situation occurs during
holidays, particularly if several members have relapsed. The counselor
should use verbal and nonverbal methods of calming the group and
focusing the group on the session topic. Conversely, there may be times
when group members are lethargic, sluggish, and depressed. During these
times, the counselor should infuse energy and enthusiasm. He or she
needs to be aware of the emotional tone of the group and respond
accordingly.

In a similar manner, the members of a group need to feel that the
counselor is keeping the group moving in a useful and healthful
direction. The counselor must be willing to interrupt private
conversations in the group, terminate a graphic drug use story, or
redirect a lengthy tangential diversion. He or she must be perceived as
clearly in control of the time in the group. Each member must be given
an opportunity to have input. The counselor should ensure that a few
members do not monopolize the group's time. Clients must feel that the
counselor is interested in their participation in the group as it
relates to abstinence. The counselor must be clearly, actively,
unquestionably in control of the group.

The counselor needs to be sensitive to emotional and practical issues
that arise in group. At times it also may be necessary to be directive
and confrontational or to characterize input from group members as a
reflection of addictive thinking. In these instances the counselor
should focus on the addiction as opposed to the person. In other words,
care should be taken to avoid directing negative feedback toward the
client, focusing instead on the addiction-based aspects of the client's
behavior or thinking.

The counselor is preferably the professional who also sees the members
of the group for the prescribed Individual/Conjoint sessions. The
advantage of this dual role (group leader and individual counselor) is
that the counselor can coordinate more effectively and guide the
progressive recovery of each individual. The frequency of contact also
strengthens the therapeutic bond that can hold the client in treatment.
A potential disadvantage of the dual role is the possible danger that
the counselor may inadvertently expose confidential client information
to the group before the client chooses to do so. It is a violation of
boundaries for the counselor even to imply that information exists and
to attempt to coerce a client into sharing that information if the
client has not planned to do so in the group.

Another danger to be avoided is the counselor's being perceived as
showing preference to some clients. It is important that the counselor
be equally supportive of all group members and not allow them to engage
in competition for attention.

The counselor can find discussions of group development, leadership,
concepts, techniques, and other helpful information for conducting group
therapy in Treatment Improvement Protocol 41, *Substance Abuse
Treatment: Group Therapy* (CSAT 2005*b*), a free publication from the
Center for Substance Abuse Treatment.

**Appendix C. Sample Agreement for Co-Leaders and Client--Facilitators**

All clients serving as group co-leaders or client--facilitators are
required to read and agree to abide by the conditions below, as
indicated by initialing each item and signing at the bottom of the form.

As a co-leader or client--facilitator I agree to the following:

\_\_\_\_\_\_\_ To commit to participating in \_\_\_\_ group sessions per
week for at least 3 months (for co-leaders) or 6 months (for
client--facilitators).

\_\_\_\_\_\_ To participate in regular pregroup and postgroup meetings
with my assigned group counselor.

\_\_\_\_\_\_ To be on time for scheduled groups. If I am unable to
attend a scheduled group, I will call and notify the program 24 hours in
advance.

\_\_\_\_\_\_ To abstain from using illicit drugs or alcohol and from
abusing prescription drugs.

\_\_\_\_\_\_ To respect and maintain client confidentiality with respect
to information disclosed in group sessions.

\_\_\_\_\_\_ Not to become involved socially, sexually, or economically
with group members or with other program clients.

\_\_\_\_\_\_ To abide by the program's statement of ethical conduct.

\_\_\_\_\_\_ That I am entering this agreement on a strictly volunteer
basis; I understand that I will not be paid for my time.

\_\_\_\_\_\_ To actively participate in some form of ongoing recovery
support or treatment.

\_\_\_\_\_\_ That any departure from the above conditions could result
in my termination from the co-leader or client--facilitator position.

Co-Leader's Signature: Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Client--Facilitator's Signature: Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Counselor's Signature: Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Program Director's Signature: Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Appendix D. Acronyms and Abbreviations List**

AA Alcoholics Anonymous

ACoA Adult Children of Alcoholics

Al-Anon A support group for families and loved ones of people who are
addicted to alcohol

Alateen A support group for young family members and loved ones of
people who are addicted to alcohol

ASI Addiction Severity Index

CA Cocaine Anonymous

CAL Calendar (for worksheets used during scheduling)

CMA Crystal Meth Anonymous

CoDA Co-Dependents Anonymous

CSAT Center for Substance Abuse Treatment

EA Emotions Anonymous

ERS Early Recovery Skills

GA Gamblers Anonymous

HALT Hungry Angry Lonely Tired

IC Individual/Conjoint

IOP Intensive Outpatient Treatment for People With Stimulant Use
Disorders

JACS Jewish Alcoholics, Chemically Dependent Persons and Significant
Others

MA Marijuana Anonymous

meth Methamphetamine

MTP Methamphetamine Treatment Project

NA Narcotics Anonymous

Nar-Anon A support group for families and loved ones of people who are
addicted to narcotics

OA Overeaters Anonymous

PA Pills Anonymous

RP Relapse Prevention

SAMHSA Substance Abuse and Mental Health Services Administration

SCH Schedule (for worksheets used during scheduling)

SMART Self-Management and Recovery Training

SS Social Support

TAU Treatment as Usual

**Appendix E. Further Reading**

The articles listed below provide more information about treatment for
methamphetamine dependence in general and the Matrix model in
particular.

Anglin, M.D.; Burke, C.; Perrochet, B.; Stamper, E.; and Dawud-Noursi,
S. History of the methamphetamine problem. *Journal of Psychoactive
Drugs* 32(2):137--141, 2000.

Anglin, M.D., and Rawson, R.A. The CSAT Methamphetamine Treatment
Project: What are we trying to accomplish? *Journal of Pscyhoactive
Drugs* 32(2):209--210, 2000.

Brecht, M.-L.; von Mayrhauser, C.; and Anglin, M.D. Predictors of
relapse after treatment for methamphetamine use. *Journal of
Psychoactive Drugs* 32(2):211--220, 2000.

Brown, A.H. Integrating research and practice in the CSAT
Methamphetamine Treatment Project. *Journal of Substance Abuse
Treatment* 26(2):103--108, 2004.

Cohen, J.B.; Dickow, A.; Horner, K.; Zweben, J.E.; Balabis, J.;
Vandersloot, D.; Reiber, C.; and Methamphetamine Treatment Project.
Abuse and violence history of men and women in treatment for
methamphetamine dependence. *American Journal on Addictions*
12(5):377--385, 2003.

Cretzmeyer, M.; Sarrazin, M.V.; Huber, D.L.; Block, R.I.; and Hall, J.A.
Treatment of methamphetamine abuse: Research findings and clinical
directions. *Journal of Substance Treatment* 24(3):267--277, 2003.

Domier, C.P.; Simon, S.L.; Rawson, R.A.; Huber, A.; and Ling, W. A
comparison of injecting and noninjecting methamphetamine users. *Journal
of Psychoactive Drugs* 32(2):229--232, 2000.

Freese, T.E.; Obert, J.; Dickow, A.; Cohen, J.; and Lord, R.H.
Methamphetamine abuse: Issues for special populations. *Journal of
Psychoactive Drugs* 32(2):177--182, 2000.

Hartz, D.T.; Frederick-Osborne, S.L.; and Galloway, G.P. Craving
predicts use during treatment for methamphetamine dependence: A
prospective, repeated-measures, within-subject analysis. *Drug and
Alcohol Dependence* 63(3):269--276, 2001.

Maglione, M.; Chao, B.; and Anglin, M.D. Correlates of outpatient drug
treatment drop-out among methamphetamine users. *Journal of Psychoactive
Drugs* 32(2):221--228, 2000.

Obert, J.L.; Brown, A.H.; Zweben, J.; Christian, D.; Delmhorst, J.;
Minsky, S.; Morrisey, P.; Vandersloot, D.; and Weiner, A. When treatment
meets research: Clinical perspectives from the CSAT Methamphetamine
Treatment Project. *Journal of Substance Abuse Treatment*
28(3):231--237, 2005.

Obert, J.L.; London, E.D.; and Rawson, R.A. Incorporating brain research
findings into standard treatment: An example using the Matrix Model.
*Journal of Substance Abuse Treatment* 23(2):107--113, 2002.

Peck, J.A.; Reback, C.J.; Yang, X.; Rotheram-Fuller, E.; and Shoptaw, S.
Sustained reductions in drug use and depression symptoms from treatment
for drug abuse in methamphetamine-dependent gay and bisexual men.
*Journal of Urban Health* 82(1 suppl 1):i100--i108.

Rawson, R.A.; Anglin, M.D.; and Ling, W. Will the methamphetamine
problem go away? *Journal of Addictive Diseases* 21(1):5--19, 2002.
www.asam.org/jol/Articles/Rawson%20et%20al%20article.pdf \[accessed
March 1, 2006\].

Rawson, R.; Huber, A.; Brethen, P.; Obert, J.; Gulati, V.; Shoptaw, S.;
and Ling, W. Methamphetamine and cocaine users: Difference in
characteristics and treatment retention. *Journal of Psychoactive Drugs*
32(2):233--238, 2000.

Rawson, R.A.; Huber, A.; Brethen, P.; Obert, J.; Gulati, V.; Shoptaw,
S.; and Ling, W.

Status of methamphetamine users 2--5 years after outpatient treatment.
*Journal of Addictive Diseases* 21(1):107--119, 2002.

Rawson, R.A.; Marinelli-Casey, P.; Anglin, M.D.; Dickow, A.; Frazier,
Y.; Gallagher, C.; Galloway, G.P.; Herrell, J.; Huber, A.; McCann, M.J.;
Obert, J.; Pennell, S.; Reiber, C.; Vandersloot, D.; Zweben, J.; and
Methamphetamine Treatment Project. A multi-site comparison of
psychosocial approaches for the treatment of methamphetamine dependence.
*Addiction* 99(6):708--717, 2004.

Rawson, R.A.; McCann, M.J.; Huber, A.; Marinelli-Casey, P.; and
Williams, L. Moving research into community settings in the CSAT
Methamphetamine Treatment Project: The coordinating center perspective.
*Journal of Psychoactive Drugs* 32(2):201--208, 2000.

von Mayrhauser, C.; Brecht, M.-L.; and Anglin, M.D. Use ecology and drug
use motivations of methamphetamine users admitted to substance abuse
treatment facilities in Los Angeles: An emerging profile. *Journal of
Addictive Diseases* 21(1):45--60, 2002.

Zweben, J.E.; Cohen, J.B.; Christian, D.; Galloway, G.P.; Salinardi, M.;
Parent, D.; Iguchi, M.: and Methamphetamine Treatment Project.
Psychiatric symptoms in methamphetamine users. *American Journal on
Addictions* 13(2):181--190, 2004.

**Appendix F. Field Reviewers**

Rosie Anderson-Harper, M.A., RSAP

Mental Health Manager

Missouri Department of Mental Health

Jefferson City, MO

Stephen R. Andrew, M.S.W., LCSW, LADC, CGP

Director

Health Education Training Institute

Portland, ME

Michelle M. Bartley

Behavioral Health Specialist

Division of Behavioral Health

Anchorage, AK

Frances Clark, Ph.D., MAC, LADAC, QSAP, CCJS

Director of Behavioral Services

Metro Public Health Department

Nashville, TN

María del Mar García, M.H.S., LCSW

Continuing Education Coordinator

Caribbean Basin and Hispanic Addiction Technology Transfer Center

Universidad Central del Caribe

Bayamón, PR

Darcy Edwards, Ph.D., M.S.W., CADC II

Substance Abuse Treatment Coordinator

Oregon Department of Corrections

Salem, OR

Marty Estrada, CAS, CSS-III

Ventura, CA

Eric Haram, LADAC

Administrative Specialist

Mercy Recovery Center

Westbrook, ME

Sherry Kimbrough, M.S., NCAC

Vice President

Lanstat, Inc.

Port Townsend, WA

Thomas A. Peltz, LMHC, LADAC-1

Therapist

Private Practice

Beverly Farms, MA

John L. Roberts, M.Ed., CCDC III-E, LPC, MAC

Consultant/Trainer

Continuing Education Center

Cincinnati, OH

Jim Rowan, M.A., LAC

Program Manager

Arapahoe House, Inc.

Thornton, CO

Angel Velez, CASAC

Addiction Program Specialist II

Office of Alcohol and Substance Abuse

Services

New York, NY

**Appendix G. References**

American Psychiatric Association. *Diagnostic and Statistical Manual of
Mental Disorders*, 4th ed. Washington, DC: American Psychiatric
Association, 1994.

CSAT (Center for Substance Abuse Treatment). *Substance Abuse Treatment
for Persons With Co-Occurring Disorders.* Treatment Improvement Protocol
Series (TIP) 42. DHHS Publication No. (SMA) 05-3992. Rockville, MD:
Substance Abuse and Mental Health Services Administration, 2005*a*.

CSAT (Center for Substance Abuse Treatment). *Substance Abuse Treatment:
Group Therapy.* Treatment Improvement Protocol (TIP) Series 41. DHHS
Publication No. (SMA) 05-3991. Rockville, MD: Substance Abuse and Mental
Health Services Administration, 2005*b.*

CSAT (Center for Substance Abuse Treatment). *Improving Cultural
Competence in Substance Abuse Treatment.* Treatment Improvement Protocol
(TIP) Series. Rockville, MD: Substance Abuse and Mental Health Services
Administration, forthcoming.

Huber, A.; Ling, W.; Shoptaw, S.; Gulati, V.; Brethen, P.; and Rawson,
R. Integrating treatments for methamphetamine abuse: A psychosocial
perspective. *Journal of Addictive Diseases* 16(4):41--50, 1997.

McLellan, A.T.; Kushner, H.; Metzger, D.; Peters, R.; Smith, L.;
Grissom, G.; Pettinati, H.; and Argeriou, M. The fifth edition of the
Addiction Severity Index. *Journal of Substance Abuse Treatment*
9:199--213, 1992.

Obert, J.; McCann, M.J.; Marinelli-Casey, P.; Weiner, A.; Minsky, S.;
Brethen, P.; and Rawson, R. The Matrix model of outpatient stimulant
abuse treatment: History and description. *Journal of Psychiatric Drugs*
32(2):157--164, 2000.

Rawson, R.; Huber, A.; Brethen, P.; Obert, J.; Gulati, V.; Shoptaw, S.;
and Ling, W. Methamphetamine and cocaine users: Difference in
characteristics and treatment retention. *Journal of Psychoactive Drugs*
32(2):233--238, 2000.

Rawson, R.A.; Marinelli-Casey, P.; Anglin, M.D.; Dickow, A.; Frazier,
Y.; Gallagher, C.; Galloway, G.P.; Herrell, J.; Huber, A.; McCann, M.J.;
Obert, J.; Pennell, S.; Reiber, C.; Vandersloot, D.; and Zweben, J. A
multi-site comparison of psychosocial approaches for the treatment of
methamphetamine dependence. *Addiction* 99(6):708--717, 2004.

Rawson, R.A.; Shoptaw, S.J.; Obert, J.L.; McCann, M.J.; Hasson, A.L.;
Marinelli-Casey, P.J.; Brethen, P.R.; and Ling, W. An intensive
outpatient approach for cocaine abuse treatment: The Matrix model.
*Journal of Substance Abuse Treatment* 12(2):117--127, 1995.

Shoptaw, S.; Rawson, R.A.; McCann, M.J.; and Obert, J.L. The Matrix
model of outpatient stimulant abuse treatment: Evidence of efficacy.
*Journal of Addictive Diseases* 13(4):129--141, 1994.