**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*

-   ***Counselor's Family Education Manual*** (this document)

-   **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 a yearlong 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 the fifth type of counseling session,
continuing care (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   |                   |                   |                    |
| Trea  |                   |                   |                    |
| tment |                   |                   |                    |
| 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  |                   |                   |                    |
| week  |                   |                   |                    |
| 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 this manual and in the
*Counselor's Treatment 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. 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 clients 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 the
*Counselor's Treatment Manual* 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.

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
the *Counselor's Treatment Manual* 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*

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 Family
Education group is discussed in depth below.

*Social Support Group (Continuing Care)*

Clients begin attending the Social Support group at the beginning of
their last month of 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 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 the 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 facilitating
Family Education groups.

**The Matrix IOP Package**

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

-   *Counselor's Treatment Manual*---The *Counselor's Treatment Manual*
    contains all the materials necessary for a counselor to conduct the
    Individual/Conjoint sessions and ERS, RP, and Social Support groups.
    It is organized by type of group session; each section begins with
    an overview that includes a discussion of

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-   The overall goals for each type of group session

-   The general format and counseling approach of the sessions

-   Special considerations relevant to a particular type of group
    session

> The overview is followed by instructions for conducting each session.
> Copies of the handouts that make up the *Client's Handbook* are at the
> end of each section's instructions for easy reference.

-   *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. Individual handouts are used for Family Education
    sessions because family members attend this group with clients and
    do not have the handouts from the *Client's Handbook*.

-   *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 Family Education Group**

***Overview***

People with substance use disorders often find themselves isolated from
their families or in ongoing conflict with family members. Family
members (including extended family members) and significant others may
experience feelings of abandonment, anxiety, fear, anger, concern,
embarrassment, or guilt. Family members often do not understand
substance use disorders and the changes that have occurred in their
family. They also may not understand the dynamics of recovery and the
changes that recovery brings. Providing education about substance use
disorders and recovery and an opportunity for family members to talk
about their concerns is critical to helping them support the person who
is in treatment and can alleviate anxiety and other negative feelings
they may have.

Education helps families change some behaviors that are common to
families coping with people who have a substance use disorder (such as
protecting people who are dependent on substances from the consequences
of their dependence). These behaviors may be disruptive both to people
in treatment and to their family members. In addition, having some idea
of what to expect as their loved ones progress in their recovery helps
family members adjust to changes that accompany recovery. Treatment is
more likely to succeed if significant others become educated about the
predictable changes that occur within the relationship as recovery
proceeds. In addition to providing specific education, the Family
Education group sessions provide the counselor with an opportunity to
facilitate involvement of significant others in clients' recovery.
Substance abuse can place families in crisis. Counselors should be
mindful that violence can erupt in this kind of environment. A concern
for the safety of clients and the family members involved in treatment
should be foremost in the counselor's mind.

The Family Education group is not family *therapy* and does not attempt
direct intervention into individual familial dynamics. Rather, the
Family Education component of the Matrix IOP package takes a
psychoeducational approach. It provides a relatively nonthreatening
environment in which to present information and an opportunity for
clients and their families to feel comfortable and welcome in the
treatment facility. Information is presented about methamphetamine
dependence, other drug and alcohol use, treatment, recovery, the ways in
which families are affected by a client's drug use and dependence, and
how family members can support a client's recovery.

Matrix treatment experience shows that, if clients are involved closely
with significant others, those significant others are part of the
recovery process regardless of whether those others are involved in
treatment activities. Because the interactions in clients' families
before clients begin treatment often can be negative, clients may be
adamant that they need to "do my program alone." The counselor can work
with clients to help them understand the importance of involving their
families in treatment, but if clients continue to resist family members'
participation, the counselor should not insist.

It is common for family members to believe that "it's not my problem."
They may be angry and unwilling to involve themselves in the client's
treatment. Therefore, the counselor personally invites family members to
attend the sessions and carefully explains the potential value of
attending.

When deciding who should be included in the Family Education group,
programs should use a definition of "family" that accommodates important
people in a particular client's life. For example, a long-term romantic
partner should be considered family whether the partner is married to
the client or not. A client may also consider a close friend or mentor
as family. Older adolescents may be appropriate for the program, but the
Family Education group cannot accommodate and is not useful for younger
children. Programs should consider offering child care during group
sessions to facilitate family members' attendance.

All clients attend Family Education group sessions whether their family
members or significant others attend. These group sessions provide the
structured educational component of treatment for clients. In addition,
clients receive information about the dynamics of family relationships
as they relate to substance use disorders.

The counselor facilitating Family Education group sessions 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 also is 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*.*

The Family Education group counselor should be aware of local 12-Step
and mutual-help groups that can support family members. These groups
include

-   Al-Anon and Alateen: www.al-anon.alateen.org

-   Nar-Anon: www.naranon.com

-   Codependents Anonymous (CoDA): www.codependents.org

-   Jewish Alcoholics, Chemically Dependent Persons and Significant
    Others (JACS): www.jacsweb.org

-   Adult Children of Alcoholics (ACoA): www.adultchildren.org

The counselor should, throughout Family Education, encourage family
members to attend support group meetings. Meeting attendance can be
mentioned, whenever appropriate, in any session. The counselor also may
want to prepare a list of organizations (including Web addresses and
other contact information) that offer local meetings and have copies of
local meeting schedules available at each session.

The sections below provide the counselor with an overview of the Family
Education component of the Matrix IOP package and general guidelines for
conducting sessions. The specific presentation instructions for each
group session are presented in Section II.

***Goals of Family Education Group***

-   Present accurate information about addiction, recovery, treatment,
    and the resulting interpersonal dynamics.

-   Help clients and family members understand how the recovery process
    may affect current and future family relationships.

-   Provide a forum for families to discuss issues of recovery.

-   Present accurate information about the effects of drugs.

-   Teach, promote, and encourage clients' family members to care for
    themselves while supporting clients in their recovery.

-   Provide a professional atmosphere in which clients and their
    families are treated with dignity and respect.

-   Encourage participants to get to know other recovering people and
    their families in a comfortable and nonthreatening environment.

***Group Format***

The Family Education group meets once per week for 12 weeks. Clients and
their families may enter the group at any time and attend for the first
3 months of a client's intensive treatment. Group sessions last for 90
minutes. There is no limit on the number of family members a client can
bring to Family Education sessions. Groups can be run with only 2 people
or as many as 30 people. The counselor should be aware that groups that
are either very small or very large can be unwieldy because they can
work against the free flow of discussion.

Group session techniques vary as follows:

-   Seven sessions are based on PowerPoint slide presentations.

-   Four sessions are multifamily group discussions.

-   One session is a panel presentation.

*Slide Presentations*

Slides for seven sessions are included on the CD-ROM accompanying this
manual. They can also be downloaded from www.kap.samhsa.gov by clicking
on Products, clicking on Resource Documents & Manuals, and then clicking
on the Matrix icon. These slides may be used as PowerPoint presentations
or printed and copied onto overhead transparencies. Each session is
saved as a separate file on the CD-ROM with the session number and title
indicated. The instructions in Section II for presenting these sessions
include talking points for each slide. Each slide presentation is
followed by a focused discussion about the topic. The last part of each
session is used as an open discussion period for participants to talk
about pressing issues.

*Multifamily Group Discussions*

Four sessions are organized as discussion groups with handouts. For the
first part of each session, participants read information or answer
questions on the handouts that prepare participants for group
discussion. The counselor may be instructed to provide some background
information. The remainder of the session is a facilitated discussion.

*Panel Presentation*

The panel format includes individual presentations by panel members
(clients who have completed the program or their family members or both
or members of 12-Step or mutual-help groups in the community). Each
brief presentation is followed by a question-and-answer period, and the
counselor facilitates a final open discussion.

***General Guidelines***

The counselor may want to review this section occasionally to be
reminded of general points that are common to every session. Appendix B
contains notes on group facilitation that the counselor may find useful.

*Before Each Session*

-   Read the instructions for facilitating the session.

-   Become familiar with the handouts and slides.

-   Set up the group room so that chairs are arranged to allow
    participants to see the slides and to encourage discussion. For
    multifamily group discussion sessions, arrange chairs in a circle.

-   Arrange for equipment to display the slides that are on the
    enclosed CD. The slides can also be downloaded from the Knowledge
    Application Program Web site (www.kap.samhsa.gov).

-   Make copies of all handouts for session participants.

-   Find out which clients and family members are new to the group, and
    introduce them at the beginning of their first session.

*During Each Session*

-   Act as host for the group, welcoming clients and families and
    introducing new participants.

-   Take care to refer appropriately to people clients invite to
    sessions. These people could include spouses, partners, adult
    children, friends, employers, colleagues, and others. Avoid using
    limiting terms like "husband" or "wife," and refer to the people
    invited as family members or friends, unless instructed otherwise by
    the client.

-   Encourage clients and family members to ask questions and make
    comments that are appropriate to the topic.

-   Be prepared to provide sources of information. References are
    provided at the end of the talking points for sessions 2, 4, 7,
    and 10. Clients or family members may be curious about the sources
    of statistics and other information presented during these sessions.
    The counselor can provide citations as required.

-   Close the session by thanking participants for attending and
    announcing the following week's topic.

-   Remain in the room after the session to answer questions and to talk
    with anyone who is experiencing problems.

The counselor should recognize that discussions about drug and alcohol
use may serve as triggers for clients and stimulate cravings. The
counselor routinely should encourage anyone experiencing triggers or
cravings to stay after the group to talk until he or she feels focused
on recovery again. The counselor also may suggest that, if the client is
not with a family member, he or she call home and let family members
know he or she has started home. This creates accountability for the
client and begins to strengthen the family's sense of participation in
the client's treatment and recovery.