Counselor’s 

Treatment 

Manual

Matrix Intensive Outpatient

Treatment for People With 

Stimulant Use Disorders
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Counselor’s Treatment 


Manual
 

Matrix Intensive Outpatient Treatment for 


People With Stimulant Use Disorders
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

1 Choke Cherry Road 

Rockville, MD 20857 
Acknowledgments 

Numerous people contributed to this document, which is part of the Methamphetamine Treatment Project (MTP). 

The document was written by Jeanne L. Obert, M.F.T., M.S.M.; Richard A. Rawson, Ph.D.; Michael J. McCann, 

M.A.; and Walter Ling, M.D. The MTP Corporate Authors provided valuable guidance and support on this document. 

This publication was developed with support from the University of California at Los Angeles (UCLA) Coordinating 

Center through Grant No. TI11440. MTP was funded by the Center for Substance Abuse Treatment (CSAT), 

Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human 

Services (HHS). The research was conducted from 1998 to 2002 in cooperation with the following institutions: 

County of San Mateo, San Mateo, CA (TI11411); East Bay Recovery Project, Hayward, CA (TI11484); Friends 

Research Institute, Inc., Concord, CA (TI11425); Friends Research Institute, Inc., Costa Mesa, CA (TI11443); Saint 

Francis Medical Center of Hawaii, Honolulu, HI (TI11441); San Diego Association of Governments, San Diego, CA 

(TI11410); South Central Montana Regional Mental Health Center, Billings, MT (TI11427); and UCLA Coordinating 

Center, Los Angeles, CA (TI11440). The publication was produced by JBS International, Inc. (JBS), under 

Knowledge Application Program (KAP) contract numbers 270-99-7072 and 270-04-7049 with SAMHSA, HHS. 

Christina Currier served as the CSAT Government Project Officer. Andrea Kopstein, Ph.D., M.P.H., served as the 

Deputy Government Project Officer. Cheryl Gallagher, M.A., served as CSAT content advisor. 

Disclaimer 

The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the 

views, opinions, or policies of SAMHSA or HHS. 

Public Domain Notice 

All materials appearing in this publication except those taken from copyrighted sources are in the public domain 

and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is 

appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written 

authorization of the Office of Communications, SAMHSA, HHS. 

Electronic Access and Printed Copies 

This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Web page at 

http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español). 

Recommended Citation 

Center for Substance Abuse Treatment. Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment for 

People With Stimulant Use Disorders. HHS Publication No. (SMA) 13-4152. Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 2006. 

Originating Office 

Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance 

Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, 

MD 20857. 

HHS Publication No. (SMA) 13-4152 

First Printed 2006 

Reprinted 2007, 2008, 2009, 2010, 2011, 2013, and 2014 
Contents
 

I. Introduction to the Matrix Intensive Outpatient Treatment for People 


With Stimulant Use Disorders Approach and Package ................... 1
 

Background ................................................................ 1
 

Matrix IOP Approach ......................................................... 2
 

The Role of the Counselor .................................................... 6
 

Working With Client Co-Leaders and Client–Facilitators ............................. 7
 

The Matrix IOP Package ...................................................... 8
 

Introduction to the Counselor’s Treatment Manual .................................. 9
 

II. The Role of Drug and Breath-Alcohol Testing in Matrix IOP.............. 11
 

Philosophy ................................................................ 11
 

Procedure ................................................................ 11
 

Addressing a Positive Urine Test .............................................. 12
 

III. Individual/Conjoint Sessions ................................... 15
 

Introduction ............................................................... 15
 

Session 1: Orientation ....................................................... 17
 

Session 2: Client Progress/Crisis Intervention .................................... 19
 

Session 3: Continuing Treatment Planning....................................... 21
 

Handouts for Individual/Conjoint Sessions ....................................... 22
 

IV. Early Recovery Skills Group.................................... 31
 

Introduction ............................................................... 31
 

Session 1: Stop the Cycle .................................................... 37
 

Session 2: Identifying External Triggers ......................................... 40
 

Session 3: Identifying Internal Triggers.......................................... 43
 

Session 4: Introducing 12-Step or Mutual-Help Activities ............................ 45
 

Session 5: Body Chemistry in Recovery ......................................... 48
 

Session 6: Common Challenges in Early Recovery ................................ 50
 

Session 7: Thinking, Feeling, and Doing......................................... 52
 

Session 8: 12-Step Wisdom .................................................. 55
 

iii 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Handouts for Early Recovery Skills Group Sessions ............................... 56
 

V. Relapse Prevention Group ..................................... 85
 

Introduction ............................................................... 85
 

Session 1: Alcohol......................................................... 92
 

Session 2: Boredom ....................................................... 94
 

Session 3: Avoiding Relapse Drift............................................. 96
 

Session 4: Work and Recovery ............................................... 98
 

Session 5: Guilt and Shame ................................................ 100
 

Session 6: Staying Busy ................................................... 102
 

Session 7: Motivation for Recovery........................................... 104
 

Session 8: Truthfulness .................................................... 106
 

Session 9: Total Abstinence ................................................ 108
 

Session 10: Sex and Recovery ............................................... 110
 

Session 11: Anticipating and Preventing Relapse ................................ 112
 

Session 12: Trust.......................................................... 114
 

Session 13: Be Smart, Not Strong ............................................ 116
 

Session 14: Defining Spirituality .............................................. 118
 

Session 15: Managing Life; Managing Money ................................... 120
 

Session 16: Relapse Justification I ............................................ 122
 

Session 17: Taking Care of Yourself........................................... 124
 

Session 18: Emotional Triggers .............................................. 126
 

Session 19: Illness......................................................... 128
 

Session 20: Recognizing Stress .............................................. 130
 

Session 21: Relapse Justification II............................................ 133
 

Session 22: Reducing Stress ................................................ 136
 

Session 23: Managing Anger ................................................ 138
 

Session 24: Acceptance .................................................... 140
 

Session 25: Making New Friends ............................................. 142
 

Session 26: Repairing Relationships........................................... 144
 

Session 27: Serenity Prayer ................................................. 146
 

Session 28: Compulsive Behaviors............................................ 148
 

iv 
Contents 

Session 29: Coping With Feelings and Depression ............................... 150 

Session 30: 12-Step and Mutual-Help Programs ................................. 153
 

Session 31: Looking Forward; Managing Downtime............................... 156
 

Session 32: One Day at a Time .............................................. 158
 

Elective Session A: Client Status Review ....................................... 160
 

Elective Session B: Holidays and Recovery ..................................... 162
 

Elective Session C: Recreational Activities...................................... 164
 

Handouts for Relapse Prevention Group Sessions................................ 165
 

VI. Social Support Group ....................................... 233
 

Introduction .............................................................. 233
 

Social Support Group Topics ................................................ 234
 

Appendices
 

Appendix A. The Methamphetamine Treatment Project ............................ 243
 

Appendix B. Notes on Group Facilitation ....................................... 245
 

Appendix C. Sample Agreement for Co-Leaders and Client–Facilitators ............... 247
 

Appendix D. Acronyms and Abbreviations List ................................... 249
 

Appendix E. Further Reading ................................................ 251
 

Appendix F. Field Reviewers................................................. 253
 

Appendix G. References .................................................... 255
 

Appendix H. Acknowledgments............................................... 257
 

v 
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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 

1 
Counselor’s Treatment Manual: Matrix Intensive Outpatient 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. 

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.) 

2 
 

I. Introduction 

Figure I-1. Sample Matrix IOP Schedule 

Schedule Intensive Treatment 

Weeks 1 through 4* 

Intensive Treatment 

Weeks 5 through 16† 

Continuing Care 

Weeks 13 through 48 

Monday 

6:00–6:50 p.m. 

Early Recovery Skills 

7:15–8:45 p.m. 

Relapse Prevention 

7:00–8:30 p.m. 

Relapse Prevention Nothing scheduled 

Tuesday 12-Step/mutual-help 

group meetings 

12-Step/mutual-help 

group meetings 

12-Step/mutual-help 

group meetings 

Wednesday 7:00–8:30 p.m. 

Family Education 

7:00–8:30 p.m. 

Family Education 

or 

7:00–8:30 p.m. 

Social Support 

7:00–8:30 p.m. 

Social Support 

Thursday 12-Step/mutual-help 

group meetings 

12-Step/mutual-help 

group meetings 

12-Step/mutual-help 

group meetings 

Friday 

6:00–6:50 p.m. 

Early Recovery Skills 

7:15–8:45 p.m. 

Relapse Prevention 

7:00–8:30 p.m. 

Relapse Prevention Nothing scheduled 

Saturday and 

Sunday 

12-Step/mutual-help 

group meetings 

12-Step/mutual-help 

group meetings 

12-Step/mutual-help 

group meetings 

* 1 Individual/Conjoint session at week 1 

† 2 Individual/Conjoint sessions at week 5 or 6 and at week 16 

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 concepts. 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 

3 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

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 pages 7 

and 8 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 

4 
I. Introduction 

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 coleader facilitate the RP group sessions (see 

pages 7 and 8 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. 

5 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

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 

6 
I. Introduction 

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 mutualhelp 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. 

7 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

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 coleader 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 on page 9), 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 clientidentifying information was listed. 

8 
■ Counselor’s Family Education Manual and 

Slide Presentations—The Counselor’s 

Family Education Manual contains 

• 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 

I. Introduction 

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 

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. 

9 
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II. The Role of Drug and Breath-


Alcohol Testing in Matrix IOP
 

Philosophy 

In the Matrix Intensive Outpatient Treatment 

for People With Stimulant Use Disorders (IOP) 

model, drug and breath-alcohol testing is viewed 

and presented to clients as a valuable tool to 

help clients become abstinent and enter recovery, not as a punitive monitoring measure. Its 

use should not be presented or perceived as 

an indication of mistrust of a client’s honesty. 

Instead, the counselor should help clients accept 

that people in outpatient treatment for substance 

use disorders need as many tools as possible 

to recover. To regain control of their lives, clients 

need ways to impose structure on their behavior. 

Urine or saliva drug and breath-alcohol test 

results can provide invaluable clinical data when 

a lapse or relapse has occurred and the client 

is unable to talk about it. The occurrence of 

relapse and, often, denial of use make testing for 

substances an essential component of outpatient 

substance abuse treatment programs. 

The goals of testing for substances in treatment 

include 

■ Deterring a client from resuming 

substance use
 

■ Providing a counselor with objective information about a client’s substance use 

■ Providing a client who is denying use with 

objective evidence of use 

■ Identifying a substance use problem 

severe enough to warrant residential or 

hospital-based treatment 

Procedure 

This section assumes that the counselor’s 

program has established procedures for 

collecting, identifying, storing, ensuring chain 

of custody for collecting, and transporting 

specimens. If drug screens are required (e.g., 

if they have been ordered by the court), clients 

should be so informed. 

Testing Schedule 

In the Matrix IOP approach, all clients are 

asked to provide a urine or saliva specimen 

for drug analysis and to take a breath-alcohol 

test once each week. Occasionally, the testing 

day should be random but should be on a day 

that most closely follows a period of high risk 

(e.g., weekends, payday). Unexplained missed 

appointments, unusual behavior in sessions or 

groups, or family reports of unusual behavior 

may indicate a need for immediate testing. The 

counselor should be sensitive to possible client 

embarrassment and avoid any unnecessary 

public discussion or joking about the tests. 

A program can screen for a client’s substance 

of choice or for a broad range of substances. 

The program may want to use BreathalyzerTM 

screening every time or only when alcohol use 

is suspected. Full drug screens should be done 

when the counselor suspects other substance use. 

Addressing Tampering 

Occasionally a client may attempt to conceal 

drug use by tampering with a urine specimen. 

At the time the suspect specimen is submitted, 

11 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

the client should be taken into a private setting 

and told that there is some uncertainty about 

the specimen. Staff members should not be 

accusatory and should attempt to make the 

client comfortable. However, staff persons 

should avoid tension-relieving jokes that might 

communicate the wrong message about the 

purpose or importance of urine specimen collection and testing. 

Tampered urine specimens usually indicate 

substance use. Clients who alter their specimens 

rarely admit it. Specimen tampering is a critical 

concern in treatment and may signal a relapse. 

Drug use combined with denial may reflect a 

breakdown of the therapeutic process. If a 

client attempts to alter more than one specimen 

sample, it may be necessary to observe the 

client giving another sample immediately and on 

subsequent testing occasions until the client’s abstinence is reasonably verified. Doing so should 

be viewed as a last resort to establish the client’s 

drug use and to encourage truthfulness. 

If a situation warrants observing urine collection, 

the counselor should consult with a supervisor 

for approval and direction. The counselor should 

follow the agency’s policy and procedures for 

observing urine collection. Observing urine 

specimen collection is uncomfortable for staff 

members and may be humiliating for the client. 

Urine collection procedures should be explained 

to the client at the first individual session 

including the possibility that urine collections 

may be observed occasionally. 

An observed urine collection procedure is a 

last resort for clients who are having difficulties 

in the recovery process. It is important to view 

this procedure as a therapeutic activity. In many 

cases, drug testing can move clients back on 

track and prompt them to tell the truth about 

drug use. 

Addressing a Positive Urine 

Test 

A positive drug test is a significant event in 

treatment. It might mean one use, or it might 

indicate a return to chronic use. In response to 

a positive result, the counselor should take the 

following steps: 

■ Reevaluate the period surrounding the 

test. Were there other indications of a 

problem such as missed appointments, 

unusual behavior, discussions in treatment sessions or groups, or family reports 

of unusual activity? 

■ Give the client an opportunity to explain 

the result, for example, by stating, “I 

received a positive result from the lab on 

your urine test from last Monday. Did anything happen that weekend you forgot to 

tell me about?” 

■ Avoid discussion about the validity of the 

results (e.g., the lab could have made an 

error; the bottle might have been mixed 

up with another client’s). 

■ Consider temporarily increasing the 

frequency of testing to determine the 

extent of use. 

■ Reinforce a client’s honesty if he or she 

admits to use, and stress the therapeutic 

importance of the admission. This interaction may result in admissions of other 

instances of substance use that had gone 

undetected. 

■ Collaborate with corrections or court staff 

as appropriate. 

Sometimes a client responds to the news of a 

positive urine test with a partial confession of 

drug involvement, for instance, that he or she 

12 
II. The Role of Drug and Breath-Alcohol Testing 

was at a party and was offered drugs but did not 

use them. These partial confessions are often 

the closest the client can get to actually admitting 

drug use. 

Occasionally a client reacts angrily to notification 

of positive test results. Typically, the client may 

accuse the counselor of lack of trust and display 

indignation at the suggestion of drug use. These 

reactions can be convincing and may cause a 

counselor initially to react defensively. However, 

the counselor calmly should inform the client 

that discussing a positive test result is necessary for treatment and that the counselor’s 

questioning is in the client’s best interest. If the 

client is unresponsive to these explanations, the 

counselor should attempt to move on to other 

issues. At some other time, the topic of truthfulness may be revisited and the client given 

another opportunity to discuss the urine test 

result. 

A client should not be discharged from the Matrix 

IOP intervention because of positive drug test or 

Breathalyzer results. If there are repeated positive 

test results, however, it may be necessary for the 

counselor to stress that abstinence is the goal 

of the Matrix IOP approach and to consider 

increasing the frequency of a client’s visits. For 

example, the counselor could place a client back 

into the Early Recovery Skills group if the client 

has already completed those group sessions but 

has had repeated positive test results, or more 

individual sessions could be scheduled for a 

client who is at an earlier stage in the treatment 

process. If a client continues to have positive 

drug tests, the counselor may be required to refer 

the client to a higher level of care. 

Even if the client denies drug or alcohol use, 

the counselor must proceed as if there were 

use. Lapses should be analyzed with the client 

(possibly in an individual session), and a plan for 

avoiding relapse reformulated. It may become 

necessary to assess the need for inpatient or 

residential treatment. The counselor’s confidence 

in and certainty of the test results are critical at 

this point and may be instrumental in inducing 

an honest explanation from the client of what 

has been happening. If the urine testing process 

succeeds in documenting out-of-control drug 

use and establishes the need for increasing the 

intensity of outpatient treatment or considering 

residential or hospital-based treatment, it has 

served a valuable function. 

13 
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III. Individual/Conjoint Sessions
 

Introduction 

Goals of Individual/Conjoint Sessions 

■ Provide clients and their families with an 

opportunity to establish an individualized 

connection with the counselor and learn 

about treatment. 

■ Provide a setting where clients and their 

families can, with the counselor’s guidance, work out crises, discuss issues, 

and determine the continuing course of 

treatment. 

■ Allow clients to discuss their addiction 

openly in a nonjudgmental context with 

the full attention of the counselor. 

■ Provide clients with reinforcement and 

encouragement for positive changes. 

Session Guidelines 

Three individual sessions are scheduled in the 

Matrix Intensive Outpatient Treatment for People 

With Stimulant Use Disorders (IOP) model. 

These sessions are 50 minutes long. The initial 

session orients the client to treatment, and 

the final session helps the client plan for posttreatment recovery; these are the first and last 

sessions of the client’s Matrix IOP experience. 

The remaining session should be scheduled 5 

or 6 weeks into treatment or when a client has 

relapsed or is experiencing a crisis. This session focuses on assessing the client’s progress, 

supporting successes, and providing resources 

to keep recovery strong. Whenever possible, 

the counselor should involve the client’s family 

or other significant and supportive persons in 

the individual sessions; these are called conjoint 

sessions. Substance abuse can place a family in 

crisis. The counselor should be mindful that 

violence can erupt in this kind of environment. 

A concern for the safety of the client and the 

family members involved in treatment should be 

foremost in the counselor’s mind. 

Starting individual sessions on time is important. 

The client should feel that the visit is an important 

part of the counselor’s day. The counselor should 

try to accommodate the client by scheduling 

individual sessions at convenient times. 

Generally, the counselor sees each client alone 

for the first half of the session and then invites 

family members to join the client for the second 

half. This arrangement should be communicated 

to the client and family members before they 

arrive for the sessions so that family members 

can bring along something to occupy them for 

the first 25 minutes of the session. 

Session Format and Counseling 

Approach 

The connection between the client and counselor 

is the most important bond that develops in treatment. The counselor should use common sense, 

courtesy, compassion, and respect in interacting 

with the client and family members. 

Session 1: Orientation 

The client’s family members may be included 

for the orientation portion of the first session. 

Family members are informed of how the Matrix 

IOP approach works and what is expected of 

the client. The counselor also explains how 

family members can support the client’s recovery and answers questions the client or family 

members have. 

15 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 2: Client Progress/Crisis Intervention 

During the second session, the counselor 

ensures that the client and family members 

have an opportunity to describe urgent issues 

and to discuss emotionally charged topics. 

During the first portion of the session, when 

the counselor meets alone with the client, the 

counselor determines whether urgent issues, 

such as strong cravings or a relapse, need to be 

addressed immediately. If a crisis needs to be 

addressed, the counselor may want to bring the 

family members into the session earlier than the 

halfway point. 

If the client’s recovery is going well, the counselor 

introduces the scheduled material for the session. Any positive changes in the client’s behavior or attitude need to be strongly reinforced. 

For example, a client who has done a good job 

of stopping drug and alcohol use, scheduling, 

and attending group sessions, but who has 

not exercised, needs to be given unqualified 

reinforcement for the accomplishments. The 

counselor should mention that the client would 

benefit from exercise, but the counselor should 

not engage in a struggle over one area of 

resistance. 

Session 3: Continuing Treatment Planning 

The final Individual/Conjoint session is also 

one of the final sessions of Matrix intensive 

outpatient treatment. The counselor reviews the 

client’s treatment experience and underscores 

the importance of recovery activities (e.g., 

scheduling, exercise, regularly attending a 

12-Step program) that help prevent relapse. The 

counselor works through a goal-setting exercise 

with the client and helps the client plan steps 

that will make the goals attainable. The client 

is encouraged to work on issues that may have 

been put on hold during treatment, such as 

couples or family therapy. 

16 
III. Individual/Conjoint Sessions 

Session 1: Orientation 

Goals of Session 

■ Help clients understand what is expected of them during treatment. 

■ Orient clients and their family members to the Matrix IOP approach. 

■ Help clients make a treatment schedule. 

■ Enlist family members’ help in supporting clients’ recovery. 

Handout 

■ IC 1—Sample Service Agreement and Consent 

Session Content 

This session is conducted before the first group session and gives the client and family members an 

opportunity to meet the counselor and learn about the program. The counselor also uses this session 

to ensure that the client and family members are oriented properly to treatment. At this session, the 

counselor gives each client a copy of the Client’s Treatment Companion. Programs should not distribute 

the Client’s Handbook during the orientation session. Clients receive the Client’s Handbook during the 

first group session. Clients have their own copies and make personal use of them but should not take 

them home. Programs collect and store the handbooks in a secure location until clients return for the 

next group session. (Programs may choose to give clients photocopies of the handouts from the Client’s 

Handbook, rather than provide an individual copy of the book to each client.) 

After greeting the client and family members, the counselor gives them a brief overview of the Matrix 

IOP model. This overview takes about 10 minutes and includes the following: 

■ A general introduction to the principles on which the Matrix IOP model is based (see pages 1–6) 

■ A description of the various components of the Matrix IOP model 

• Individual/Conjoint group sessions 

• Early Recovery Skills group sessions 

• Relapse Prevention group sessions 

• Social Support group sessions 

• Urine and breath tests 

• 12-Step or mutual-help group attendance 

■ A program schedule that shows the client and family members what a typical week of the Matrix 

IOP intervention looks like and how sessions change as the client moves through treatment (see 

Figure I-1, page 3) 

17 
 

Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

The counselor brings to the session a list of the program’s Matrix IOP meetings and times. With the 

counselor’s help, each client selects a schedule. The counselor then provides a copy of this schedule 

to the client. The goal is for the client to leave the session with a copy of the schedule and a clear idea 

of what the next steps are. 

The counselor gives the client a copy of the program’s service agreement and consent form. (Handout 

IC 1—Sample Service Agreement and Consent is provided as an example of such a form; programs 

are free to use or adapt this form if they do not have service agreement and consent forms of their 

own.) The counselor reads aloud while the client and family members follow along. It is important for 

the counselor to take time going over this document; the counselor should pause after each numbered 

item on the form to be sure the client understands what he or she is initialing. The counselor should 

ensure that the client understands the consequences for not abiding by the agreement. 

The counselor allows ample time for questions during and at the end of the session. It is imperative that 

the client and family members feel knowledgeable about and comfortable with the Matrix IOP approach. 

18 
III. Individual/Conjoint Sessions 

Session 2: Client Progress/Crisis Intervention 

Goals of Session 

■ Help clients assess progress. 

■ Help clients address any crises they may be experiencing. 

■ Reinforce recovery principles clients have learned in treatment. 

Handouts 

■ IC 2A—Recovery Checklist 

■ IC 2B—Relapse Analysis Chart 

Session Content 

The second Individual/Conjoint session is conducted about 5 or 6 weeks after a client enters treatment. 

The counselor begins the session by briefly discussing with the client how the recovery is progressing. 

At this point, the session can take one of two different directions, depending on the client’s response: 

■ If the client’s recovery is on track, this session is used to assess progress, review relapse prevention skills, give positive reinforcement for the client’s successes, and identify areas in which 

the client can improve. The client completes handout IC 2A—Recovery Checklist. The counselor 

either reads the handout with the client or gives the client a few minutes to complete it. 

The counselor reviews the client’s answers with the client. It is important that the counselor 

praise the client’s progress before moving on to the final two questions on the handout, which 

address relapse prevention activities the client may be struggling to implement. The counselor 

may wish to make reference to Early Recovery Skills and Relapse Prevention session descriptions or handouts when reviewing recovery skills with the client. Useful session descriptions and 

handouts include 

• Early Recovery Skills sessions 1, 2, 3, 6, and 7 (in Section IV) 

• Handout IC 2B (in this section) 

• Handouts ERS 3B, 5, 6A, 6B, and 7B (in Section IV) 

• Handout SCH 1 (in Section IV) 

• Relapse Prevention sessions 3, 7, 11, 13, 16, 18, and 21 (in Section V) 

• Handouts RP 3A, 3B, 4, 8, 12, 13, 17, 19, and 22 (in Section V) 

■ If the client has been struggling with recovery or is experiencing a personal crisis, the counselor 

spends the session addressing these issues, allowing time for the client to talk about what is 

going on and, when appropriate, developing a plan to help the client maintain or get back to 

recovery. If a client recently has had a relapse or feels that a relapse is imminent, the client 

19 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

completes handout IC 2B—Relapse Analysis Chart. The counselor can read the handout with 

the client or give the client a few minutes to complete it. The goal of completing this sheet and 

discussing it is to sensitize the client to the events and feelings that precede a relapse. The 

counselor may wish to refer to the notion of “mooring lines” that keep recovery anchored, as 

discussed in Relapse Prevention session 3 (Avoiding Relapse Drift) and its accompanying 

handouts, RP 3A and 3B. The session descriptions and handouts listed above also may make 

the client aware of the subtle ways in which behavior can imperil recovery. 

Relapse does not occur suddenly or unpredictably, although it often feels that way to the client. 

The counselor needs to help the client understand the context of the relapse. Handout IC 2B— 

Relapse Analysis Chart helps the client see relapse as an event that both has antecedents 

and can be avoided. Many people who successfully complete outpatient treatment experience 

a relapse at some point in the process. The critical issue is whether the client continues the 

recovery process following the relapse. The counselor should stress to the client that relapse 

does not indicate failure; it should be viewed as an indication that the treatment plan needs 

adjusting. 

20 
III. Individual/Conjoint Sessions 

Session 3: Continuing Treatment Planning 

Goals of Session 

■ Help clients evaluate their progress in recovery. 

■ Help clients set continuing treatment goals. 

■ Help clients draft a continuing treatment plan. 

Handouts 

■ Handout IC 3A—Treatment Evaluation 

■ Handout IC 3B—Continuing Treatment Plan 

Session Content 

The final Individual/Conjoint session is scheduled when the client is about to complete or after he or 

she has completed 16 weeks of the Matrix IOP intervention (i.e., after clients have completed Family 

Education and Relapse Prevention sessions). The counselor begins the discussion by asking the client 

general questions about the treatment experience: 

■ What aspects of treatment have been most helpful? 

■ Were there parts of treatment that have not been helpful? What were they? 

■ What would you change about treatment, if you could? 

■ How are you a different person now than you were when you entered treatment? 

■ Have you started attending Social Support group sessions? How have they helped you? 

The counselor then works with the client to complete handout IC 3A—Treatment Evaluation, addressing 

the eight categories listed on the left side of the handout and helping the client evaluate behavioral 

changes, current status, and hoped-for progress. Examining the discrepancy between the client’s current 

situations and the goals often generates motivation for the client to formulate steps to reach the desired 

goals. The counselor encourages the client to make the goals realistic and helps the client set realistic 

timetables for achieving the goals. 

After the client has identified goals and established timetables, the counselor goes over handout IC 

3B—Continuing Treatment Plan, stressing the importance of ongoing therapy and attending Social 

Support group sessions and 12-Step or mutual-help meetings. The counselor should think of this 

session as the final opportunity for case management. Earlier group sessions underscored the importance of continuing with 12-Step or mutual-help meetings after the end of treatment. During those 

sessions, the counselor provided the client with a list of local meetings and discussed ways to facilitate 

the client’s attendance. The counselor should provide the client with another copy of the list of meetings 

and discuss in detail the client’s plans for attending meetings. 

21 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment

The client uses items from handout IC 3A—Treatment Evaluation to draft a continuing recovery plan at 

the end of handout IC 3B—Continuing Treatment Plan. The counselor assists the client in writing this 

plan. The counselor helps the client finish treatment with a clear understanding of how to maintain 

recovery, with short- and long-term recovery goals and with a realistic plan for accomplishing those goals. 

Handouts for Individual/Conjoint Sessions 

The handouts that follow are to be used by the client and the counselor to make the most of the three 

Individual/Conjoint sessions. 

22 
 

 

 

 

 

 

IC 1 Sample Service Agreement 


and Consent
 

[Each program uses an agreement and consent form that it has developed to meet its particular needs. 

This form is provided as a sample.] 

It is important that you understand the kinds of services you will be provided and the terms and 

conditions under which these services will be offered. 

I, _____________________________________________, am requesting treatment from the staff of 

__________________________________________. As a condition of that treatment, I acknowledge 

the following items and agree to them. (Please initial each item.) 

I understand: 

_____ 1. The staff believes that the outpatient treatment strategies the program uses provide a 

useful intervention for chemical dependence problems; however, no specific outcome can 

be guaranteed. 

_____ 2. Treatment participation requires some basic ground rules. These conditions are essential for 

a successful treatment experience. Violation of these rules can result in treatment termination. 

I agree to the following: 

a.	 It is necessary to arrive on time for appointments. At each visit I will be prepared to take 

urine and breath-alcohol tests. 

b.		 Conditions of treatment require abstinence from all drug and alcohol use for the entire 

duration of the treatment program. If I am unable to make this commitment, I will discuss 

other treatment options with the program staff. 

c.	 I will discuss any drug or alcohol use with the staff and group while in treatment. 

d.	 Treatment consists of individual and group sessions. Individual appointments can be 

rescheduled, if necessary. I understand that group appointments cannot be rescheduled 

and attendance is extremely important. I will notify the counselor in advance if I am 

going to miss a group session. Telephone notification may be made for last-minute 

absence or lateness. 

e.	 Treatment will be terminated if I attempt to sell drugs or encourage drug use by other 

clients. 

f.	 I understand that graphic stories of drug or alcohol use will not be allowed. 

1 of 2
 
 

 

 

 

 

IC 1 Sample Service Agreement 


and Consent
 

g.	 I agree not to become involved romantically or sexually with other clients. 

h.	 I understand that it is not advisable to be involved in any business transactions with 

other clients. 

i.	 I understand that all matters discussed in group sessions and the identity of all group 

members are absolutely confidential. I will not share this information with nonmembers. 

j.	 All treatment is voluntary. If I decide to terminate treatment, I will discuss this decision 

with the staff. 

_____ 3. Staff: Services are provided by psychologists, licensed marriage and family counselors, 

master’s-level counselors-in-training, or other certified addiction staff people. All nonlicensed 

counselors are supervised by a licensed counselor trained in the treatment of addictions. 

_____ 4. Consent to Videotape/Audiotape: To help ensure the high quality of services provided by the 

program, therapy sessions may be audiotaped or videotaped for training purposes. The client 

and, if applicable, the client’s family consent to observation, audiotaping, and videotaping. 

_____ 5. Confidentiality: All information disclosed in these sessions is strictly confidential and may not 

be revealed to anyone outside the program staff without the written permission of the client or 

the client’s family. The only exceptions are when disclosures are required or permitted by law. 

Those situations typically involve substantial risk of physical harm to oneself or to others or 

suspected abuse of children or the elderly. 

_____ 6. Accomplishing treatment goals requires the cooperation and active participation of clients 

and their families. Very rarely, lack of cooperation by a client may interfere substantially with 

the program’s ability to render services effectively to the client or to others. Under such 

circumstances, the program may discontinue services to the client. 

I certify that I have read, understand, and accept this Service Agreement and Consent. This 

agreement and consent covers the length of time I am involved in treatment activities at 

this facility. 

Client’s Signature: __________________________________________ Date: _____________ 

2 of 2
 
IC 2A Recovery Checklist
 

Outpatient treatment requires a great deal of motivation and commitment. To get the most 

from treatment, it is necessary for you to replace many old habits with new behaviors. 

Check all the things that you do regularly or have done 

since entering treatment:

□ Schedule activities daily

□ Visit physician for checkup

□ Destroy all drug paraphernalia

□ Avoid people who use alcohol

□ Avoid people who use drugs

□ Avoid bars and clubs 

□ Stop using alcohol

□ Stop using all drugs

□ Pay financial obligations promptly 

□ Identify addictive behaviors 

□ Avoid triggers (when possible)

□ Use thought stopping for cravings

□ Attend Individual/Conjoint sessions 

□ Attend Early Recovery Skills and 

Relapse Prevention sessions 

□ Attend 12-Step or mutual-help meetings

□ Get a sponsor 

□ Exercise daily

□ Discuss thoughts, feelings, and behaviors honestly with your counselor 

What other behaviors have you decided to start since you entered 

treatment? 

Which behaviors have been easy for you to do? 


Which behaviors take the most effort for you to do? 


Which behavior have you not begun yet? What might need to change 

for you to begin this behavior? 

Behavior Not Begun Change Needed 

1 of 1
 
IC 2B Relapse Analysis Chart
 Name: _____________________________________ Date of Relapse: _______________ A relapse episode does not begin when you take a drug. Often, things that happen before you use indicate the beginning of a relapse. Identifying your patterns of behavior will help you recognize and interrupt the relapse. Using the chart below, note events that occurred during the week immediately before the relapse. Career Events Personal Events Treatment Events Drug- Related Behaviors Behavioral Patterns Relapse Thoughts Health Status Feelings about the above events 

1 of 1
 
IC 3A Treatment Evaluation
 Recovery requires specific actions and behavioral changes in many areas of life. Before you end your treatment, it is important to set new goals and plan for a different lifestyle. This guide will help you develop a plan and identify the steps necessary for reaching your goals. Write your current status and goals for the areas of life listed in the left column. Subject Where are you now? Where would you like to be? What steps do you need to take? When? Family Work/Career Friendships Financial, Legal

Obligations 

1 of 2
 
Subject Where are you now? Where would you like to be? What steps do you need to take? When? 

EducationExerciseLeisureActivities12-Step orMutual-HelpMeetings

___________________________________ _________ _________________________________ ________ 

IC 3A Treatment Evaluation
 

2 of 2
 

Client’s Signature Date Counselor’s Signature Date 
IC 3B Continuing 


Treatment Plan
 

Recovery is a lifelong process. You can stop drug and 

alcohol use and begin a new lifestyle during the first 4 months of treatment. 

Developing an awareness of what anchors your recovery is an important part of 

that process. But this is only the beginning of your recovery. As you move forward 

with your recovery after treatment, you will need a lot of support. And you may need 

different kinds of support than you did during treatment. You and your counselor can 

use the information below to help you decide how best to support your recovery. 

Group Work 

You should participate in at least one regular recovery 

group every week after treatment. The program offers a 

Social Support group that meets once a week. Other 

recovery groups are often available in the community. 

Ask your counselor about local recovery groups. 

Individual Therapy 

Individual sessions with an addiction counselor might be helpful. When your current 

treatment ends, you have choices about continuing with therapy. You may choose this 

time to enter therapy with another professional. You may want to return to therapy with 

the professional who referred you for the Matrix IOP method. Or you may choose to 

continue to see your current Matrix IOP counselor. 

Couples Therapy 

It is often a good idea at this point for couples to begin seeing a marriage counselor 

together to work on relationship issues. 

12-Step or Mutual-Help Meetings 

Attendance at a 12-Step or mutual-help meeting is a critical part of the recovery 

process. It is essential to find a meeting that you will attend regularly. 

1 of 2 
IC 3B Continuing 


Treatment Plan
 

My plan for the months following treatment is: 

__________________________________________________________ _____________ 

Client’s Signature Date 

__________________________________________________________ _____________ 

Counselor’s Signature Date 

2 of 2
 
 

IV. Early Recovery Skills Group
 

Introduction 

Goals of Early Recovery Skills Group 

■ Provide a structured group meeting for 

new clients to learn about recovery skills 

and 12-Step and mutual-help programs. 

■ Introduce clients to the basic tools of 

recovery and aid clients in stopping drug 

and alcohol use. 

■ Introduce 12-Step or mutual-help 

involvement and create an expectation 

of participation as part of treatment. 

■ Help clients adjust to participation in a 

group setting such as Relapse Prevention 

(RP) or Social Support group sessions or 

12-Step or mutual-help meetings. 

■ Allow the recovering co-leader to provide a 

model for strengthening initial abstinence. 

■ Provide the recovering co-leader with 

increased self-esteem and reinforce his 

or her progress. 

Session Format and Counseling 

Approach 

Counselor and Co-Leader 

The Early Recovery Skills (ERS) group is led by 

a counselor and co-led by a recovering client. 

This co-leader is usually a current client with 

more than 8 weeks of abstinence. The client 

must be progressing successfully through the 

program, abstaining from using drugs and 

drinking, and actively participating in an outside 

recovery group. The counselor should invite 

clients from the program’s RP group who meet 

these criteria to fill the role of recovering coleader. The co-leader should be paired up with 

the same counselor for 3 months. 

The counselor and co-leader should meet for 

15 minutes before the start of each group session 

to go over the session’s topic and new issues 

about individual clients. No confidential information 

can be given to the client co-leader. He or she is a 

volunteer and a client, not an employee. The coleader should be instructed to share experiences 

about the topic and not attempt to be a counselor. 

After each group session, the counselor should 

debrief the co-leader to ensure that the co-leader 

is refocused and stabilized, if necessary. 

Group and Session Characteristics 

The ERS component comprises eight group 

sessions that are held twice per week during 

the first month of intensive treatment. A typical 

ERS group is small (6–10 people), and sessions 

are relatively short (approximately 50 minutes). 

ERS sessions cover a substantial amount of 

material in a short time; counselors may need to 

move briskly from topic to topic. This group must 

stay structured and on track. The counselor and 

co-leader should be serious and focused and 

not contribute to the high-energy, out-of-control 

feeling that may characterize clients in early 

recovery. 

The counselor begins every session by stating 

that the group’s objective is to teach basic 

abstinence skills. All clients are introduced and 

asked to state how far they have progressed in 

treatment. First-time participants should be given 

several minutes to give a brief history. Clients 

giving detailed drug or alcohol histories can be 

interrupted politely and asked to discuss issues 

that prompted treatment. Any time a new client 

joins the ERS group, the counselor should explain the importance of scheduling and marking 

progress, regardless of which ERS session is the 

client’s first. The instructions for session 1 in ERS 

go into detail about scheduling. The instructions 

31 
 

Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

for session 2 in ERS discuss marking progress 

in detail. The recovering co-leader is introduced 

as someone who is currently going through the 

recovery process and who can give a personal 

account of how the program is working for him 

or her. 

The ERS sessions should begin on a positive 

note by emphasizing benefits that each client 

derives from recovery and the length of time 

clients have remained abstinent. Five minutes is 

set aside after introductions so clients can place 

a mark on their calendar handout for each day 

of abstinence, share positive stories with the 

group, and encourage other members. 

Following the marking of progress, the counselor 

introduces the new topic, tells participants which 

handouts from their Client’s Handbook they will 

use for the current session, gives an overview 

of why this topic is important to clients’ recovery 

and abstinence, and discusses the topic with 

clients in the group. The session outlines that 

follow have specific questions and suggestions to 

structure and enrich discussions. The counselor 

should use these questions but may find that 

clients have other concerns that the questions 

do not address. The counselor should feel free 

to take the discussion in directions that will be 

most helpful to the group. The recovering coleader can relate how each topic was useful 

during the early stages of his or her recovery. 

The counselor should ask all participants to 

describe how they can use the skills being 

discussed. If clients are having problems, the 

counselor can solicit advice from other group 

members, and the counselor and recovering coleader can offer suggestions. About 35 minutes 

is spent on group topics. 

The remaining part of each ERS group session 

is devoted to scheduling and to following up on 

the previous session’s homework assignment. 

All clients must have a plan for the time between 

the current session and the next session. The 

more rigorously clients can plan, the more likely 

it is that they will abide by their schedules and 

avoid relapse. The goal is to map every day until 

the next ERS group meeting. After scheduling 

is explained in the first ERS session, 5 minutes 

is set aside in each session for this activity. The 

counselor should use part of this time to allow 

clients to discuss successes and challenges with 

scheduling. Specific Alcoholics Anonymous (AA), 

Cocaine Anonymous, Narcotics Anonymous, or 

mutual-help meetings can be suggested. Clients 

should be discouraged from planning activities 

with one another or other clients in early recovery, 

except for meeting one another at 12-Step or 

mutual-help meetings. Following up on clients’ 

homework also should take the form of a brief 

discussion. The counselor should strive to involve 

all clients, fostering in them an interest in completing the homework and an understanding that 

working on recovery takes full-time commitment. 

At the end of group sessions, any clients who 

will be moving on can be given several minutes 

to discuss what benefits the ERS group has 

provided in their first month of abstinence. Any 

clients who are struggling should be able to 

meet briefly with their counselor or schedule a 

time to do so. The recovering co-leader is not 

to engage in one-on-one counseling. There is 

a 15-minute break between the ERS group 

session and the RP group session. 

Special Considerations 

Clients in the ERS group probably have 

achieved only brief periods of abstinence. Their 

behavior may require that the counselor sometimes intervene and assert control in a strong, 

yet tactful fashion. The examples below illustrate 

how to handle some common situations. 

32 
IV. Early Recovery Skills Group 

Clients Who Spend Too Much Time Describing 

Episodes of Substance Use 

Failing to interrupt and redirect a client who is 

going into detail about episodes of use can turn 

the session into an unstable experience that 

might trigger some clients to relapse. The 

counselor should 

■ Make it clear to clients new to the group 

that it is inappropriate for anyone to go 

into detail about episodes of substance 

use or feelings that led to using 

■ Interrupt a client who begins to talk in 

detail about using 

■ Remind the group that such talk can lead 

to relapse 

■ Pose a new question or topic for 

discussion 

Clients Who Resist Participation in 12-Step, 

Mutual-Help, or Other Spiritual Groups 

In discussions about 12-Step or mutual-help 

program involvement, clients frequently express 

dissenting opinions about the value of participation. Resistance to 12-Step or mutual-help group 

involvement is an important issue. To address 

client concerns, the counselor should 

■ State clearly that the treatment outcome 

for people who attend 12-Step or mutualhelp programs is better than for people 

who do not. The Matrix Institute has 

conducted several surveys on treatment 

outcomes and 12-Step or mutual-help 

program involvement and consistently 

has found a strong positive relationship. 

However, clients may state that they do 

not find meetings helpful and are not 

going to attend. 

■ Acknowledge that it is not uncommon for 

people initially to find participating in such 

programs uncomfortable. 

■ Avoid arguing with reluctant clients or 

trying to compel them to attend 12-Step 

meetings. 

■ Provide clients with a list of local meetings 

and encourage clients to attend different meetings until they find one that feels 

comfortable. 

■ Encourage clients who are resistant to the 

spiritual aspects of 12-Step or mutual-help 

programs to attend for the fellowship and 

support. Social activities, coffee after the 

meetings, and the availability of others 

to call in times of trouble are encouraging aspects of participation for ambivalent 

members. 

Those who feel uncomfortable going to unfamiliar 

meetings in the community may want to attend 

them with the recovering co-leader or other 

group members. Program graduates may want 

to start a 12-Step meeting at the treatment center, 

providing clients with a way to become familiar 

with 12-Step or mutual-help group philosophies 

and meeting structures while in a familiar 

environment. 

Some clients may be willing to attend 12-Step 

meetings but resist getting a sponsor and working the steps. It is important to allow clients to 

engage in 12-Step activities on their schedules, 

when they are ready. The more involved clients 

are in a 12-Step or mutual-help program, the 

stronger their recovery is likely to be. Clients 

should choose a sponsor who is accepting of 

concurrent involvement in professional treatment. 

Clients who are looking for an alternative to 

traditional 12-Step programs should be encouraged to explore the following groups: 

■ Women for Sobriety (http://www. 

womenforsobriety.org) helps women 

overcome alcohol dependence through 

emotional and spiritual growth. 

33 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

■ Jewish Alcoholics, Chemically Dependent 

Persons and Significant Others (JACS) 

(http://www.jbfcs.org/JACS) helps people 

explore recovery in a nurturing Jewish 

environment. 

■ Self-Management and Recovery Training 

(SMART) (http://www.smartrecovery.org) is 

a cognitive–behavioral group approach that 

focuses on self-reliance, problemsolving, 

coping strategies, and a balanced lifestyle. 

■ Secular Organizations for Sobriety (http:// 

www.secularhumanism.org) maintains that 

sobriety is a separate issue from religion 

or spirituality and credits the individual for 

achieving and maintaining sobriety. 

■ Community-based spiritual fellowships, 

which take place in churches, synagogues, mosques, temples, and other 

spiritually focused meeting sites, often 

form the basis for support, lifestyle 

change, and clarification of values in 

peoples’ lives. 

The counselor should consult local directories 

for these groups and be prepared to provide 

contact information, if clients request. 

Note: The list of alternatives to 12-Step programs 

is referred to in session 4 and session 8 of ERS 

and in session 30 of RP. The counselor should 

take a copy of this list to every session, in case a 

client requests information. 

Clients Who Provide Inaccurate or 

Dangerous Suggestions to Other Clients 

Clients sometimes may provide suggestions 

during group meetings that are inaccurate or 

possibly dangerous. When a client makes a 

potentially harmful recommendation to another 

client, the counselor 

■ Maintains a polite and respectful attitude 

toward all members of the group while 

remaining clearly in control 

■ Redirects the conversation as in the 

example that follows 

Client A states that her prescribed antidepressants are not helping with her depression and are making her tired. Client B 

says, “You should really just stop taking 

your antidepressants. If you’re tired, you 

may end up relapsing to meth because 

you can’t stay awake during the day. 

You’ve worked so hard to quit using meth 

and remain abstinent.” The counselor 

should step in at this point to address the 

situation. “Client B, although I know you 

have good intentions, Client A needs to 

discuss her medication with her doctor. 

But you raise an important point: being 

tired can be a trigger for relapse. Let’s talk 

about how thought stopping can help you 

cope with triggers when they arise.” 

Clients Who Cannot Take Direction or Limit 

Their Input 

Sometimes, unstable clients are unable to take 

subtle direction or appropriately limit their input. 

In situations such as these, the counselor should 

■ Defuse the situation by saying something 

like, “You have a lot of energy tonight. 

Let’s make sure everyone has a chance 

to talk. Just listen for a while.” 

■ Address the client directly and ask the 

client to cease the disruptive behavior, if 

the counselor’s attempt to defuse the 

situation does not succeed. 

■ Ask the client to leave the group for 

that session, if the disruptive behavior 

continues. 

34 
IV. Early Recovery Skills Group 

■ Speak with the client alone after the group 

meeting about his or her specific problem, 

if possible. 

A client who is disruptive or out of control may 

be experiencing an attention deficit disorder 

or a more serious mental disorder. Counselors 

should be alert to the possibility of co-occurring 

substance use and mental disorders and make 

referrals to appropriate psychiatric care when 

necessary. 

Clients Who Appear Intoxicated 

If a client seems intoxicated, the counselor should 

■ Ask the client to step outside the session 

room with the counselor. The recovering 

co-leader can continue the group while the 

counselor attempts to evaluate the client’s 

condition and discusses the circumstances 

leading to the drug or alcohol use, if no 

other counselor is available or the client is 

not capable of engaging in treatment. 

■ Help the client find another counselor on 

site who can work with the client, if the 

client is capable of engaging productively 

in one-on-one treatment. 

■ Ensure that the client has safe transportation home and forgo any discussion of the 

matter until the next treatment appointment, depending on the degree of the 

client’s intoxication. 

■ Avoid confrontation. 

Clients Who Relapse 

Clients who are beyond the first month of 

treatment but have relapsed and are struggling 

to impose structure on their recovery may 

benefit from repeating the ERS group while 

they attend RP sessions. Once the counselor 

determines that these clients have stabilized, 

they may stop attending ERS sessions and 

attend only RP sessions. 

Rational Brain Versus Addicted Brain 

The ERS group session descriptions use the 

metaphorical struggle between a client’s rational 

brain and addicted brain as a way to talk about 

recovery. The terms rational brain and addicted 

brain do not correspond to physiological regions 

of the brain, but they give clients a way to conceptualize the struggle between the desire to stay 

committed to recovery and the desire to begin 

using stimulants again. 

Adapting Client Handouts 

Client handouts are written in simpler language 

than the session descriptions for counselors. 

The client materials should be understandable 

for someone with an eighth grade reading level. 

Difficult words (e.g., abstinence, justification) are 

occasionally used. Counselors should be prepared to help clients who struggle with the material. Counselors should be aware that handouts 

will need to be adapted for clients with reading 

difficulties. 

Session Descriptions 

Pages 37–56 provide structured guidance to 

the counselor for organizing and conducting 

the eight ERS group sessions in the intensive 

outpatient program. The handouts indicated in 

the session guidance are provided after the session descriptions for the counselor’s use and are 

duplicated in the Client’s Handbook. Figure IV-1 

provides an overview of the eight ERS sessions. 

35 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Figure IV-1. Early Recovery Skills Sessions Overview 

Session 

Number Topic Content Pages 

1 Stop the 

Cycle 

Clients learn about triggers and cravings and how they are 

related to substance use. Clients learn to use thoughtstopping techniques to disrupt relapse and scheduling to 

organize their recovery. 

37–39 

2 

Identifying 

External 

Triggers 

Clients learn to identify their external triggers and that 

charting their external triggers can help prevent relapse. 40–42 

3 

Identifying 

Internal 

Triggers 

Clients learn to identify their internal triggers and that 

charting their internal triggers can help prevent relapse. 43–44 

4 

Introducing 

12-Step or 

Mutual-Help 

Activities 

Clients learn about the format, benefits, and challenges of 

12-Step programs and about 12-Step meetings in their area. 

Clients also learn about alternatives to 12-Step meetings, 

such as mutual-help groups. 

45–47 

5 

Body 

Chemistry 

in Recovery 

Clients learn that their bodies must adjust to recovery as they 

work through the stages of recovery. Clients identify ways to 

overcome the physical challenges posed by recovery. 

48–49 

6 

Common 

Challenges 

in Early 

Recovery 

Clients learn new coping techniques that do not involve 

substance use. Clients identify challenging situations and 

ways to address them that help maintain abstinence. 

50–51 

7 

Thinking, 

Feeling, 

and Doing 

Clients learn how thoughts and emotions contribute to 

behavior and that responses to thoughts and emotions can 

be controlled. Clients identify behaviors that are related to 

substance use. 

52–54 

8 12-Step 

Wisdom 

Clients learn 12-Step sayings and identify situations in which 

they will use them. Clients also learn to recognize when they 

are most vulnerable to relapse. 

55–56 

36 
IV. Early Recovery Skills Group 

Session 1: Stop the Cycle 

Goals of Session 

■ Help clients understand what triggers and cravings are. 

■ Help clients identify individual triggers. 

■ Help clients understand how triggers and cravings can lead to use. 

■ Help clients learn techniques for stopping thoughts that can lead to use. 

■ Help clients learn the importance of scheduling time. 

Handouts 

■ ERS 1A—Triggers 

■ ERS 1B—Trigger–Thought–Craving–Use 

■ ERS 1C—Thought-Stopping Techniques 

■ SCH 1—The Importance of Scheduling 

■ SCH 2—Daily/Hourly Schedule 

Topics for Group Discussion (35 minutes) 

1. Discussing the Concept of Triggers 

Over time certain people, places, things, situations, and even emotions become linked with substance 

use in the mind of the person who abuses substances. Being around those triggers can bring on a 

craving for the substance, which can lead to use. 

■ Go over handout ERS 1A—Triggers. 

■ Ask clients to identify their triggers on the handout. 

■ Discuss specific things that have acted as triggers for clients. 

■ Ask clients to think about possible triggers they will face when they leave the program. 

■ Introduce the importance of scheduling to avoid triggers; the last 15 minutes of this session (and 

the last 5 minutes of every other ERS session) is devoted to clients’ scheduling their time from 

the end of one session to the beginning of the next. 

2. Discussing Cravings 

Cravings are impulsive urges to use that have a physiological basis. Cravings will not stop just because 

clients have decided not to use. Clients will need to alter their behavior to avoid the triggers that can 

lead to cravings. Planning for behavior changes will accomplish much more than mere good intentions 

and strong commitment will. 

37 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

■ Discuss how clients will have to change their behaviors to avoid triggering cravings. 

■ Discuss the importance of removing paraphernalia associated with substance use. 

■ Ask what changes clients already have made to reduce cravings. What effect have these 

changes had?
 

■ Have the recovering co-leader discuss how the intensity of cravings has changed over time as a 

result of behavior changes. It is important for clients to know that cravings will subside eventually. 

3. Discussing the Principle of Thought Stopping 

In addition to changing behaviors to avoid triggers, clients can interrupt the sequence that leads from 

trigger to thinking about using to craving and then to using. Even though the triggering of cravings 

seems like an automatic process, clients still can avoid using by stopping their thoughts about using. 

■ Go over handout ERS 1B—Trigger–Thought–Craving–Use. 

■ Help clients understand that cravings do not have to overwhelm them; they can block the 

thoughts that lead to cravings.
 

■ Have clients discuss the images that will help them stop their thoughts of using. 

4. Discussing and Practicing Thought-Stopping Techniques 

Thought stopping is a useful skill if clients practice it. When they encounter a trigger to use, clients must 

be able to use thought-stopping techniques to break the link between thinking of using and cravings. 

Clients should know that triggers do not automatically lead to using; by stopping their thoughts, clients 

can choose not to use. 

■ Go over handout ERS 1C—Thought-Stopping Techniques. 

■ Discuss with clients which of the four techniques (visualization, snapping, relaxation, calling 

someone) they think will be most helpful to them. 

■ Solicit suggestions for concrete applications of the techniques. What will clients visualize? What 

will they do to relax? Whom will they call? 

■ Make it clear to clients that thought-stopping techniques will hold cravings at bay, buying clients 

time until they can take action (e.g., go to a meeting, work out at the gym). 

■ Have clients suggest other techniques that might help them stop their thoughts about using (e.g., 

taking a walk, going to a movie, taking a bath). 

■ Emphasize to clients that cravings will pass; most only last 30 to 90 seconds. 

■ Have the co-leader discuss thought-stopping techniques that work for him or her. 

38 
IV. Early Recovery Skills Group 

Scheduling (15 minutes) 

One of the main goals of scheduling is to ensure that the rational part of clients’ brains takes charge of 

their behavior rather than the emotional addicted part of their brains where cravings start. When clients 

make a schedule and stick to it, they put their rational brains in charge. People in outpatient treatment 

need to structure their time if they are serious about recovery. It is important for clients to plan their activities and to write them down in their schedules. Schedules that exist only in one’s head are too easy 

to revise or abandon. Clients need to schedule every hour of the day and stick to the schedule. When 

clients are making their schedules, special attention should be paid to weekends and any other times 

clients feel they are particularly vulnerable to substance use. 

■ Go over handout SCH 1—The Importance of Scheduling. 

■ Help clients understand that scheduling their time rigorously and sticking to the schedule are part 

of the recovery process. Scheduling will help clients’ rational brains govern their behavior and 

aid them in making good decisions. 

■ Have clients complete handout SCH 2—Daily/Hourly Schedule; encourage them to be thorough 

in their scheduling, leaving no holes in their schedules. 

Clients will undertake this scheduling exercise at the close of all eight sessions in the ERS portion of 

treatment. Fifteen minutes is allotted to this activity in session 1 so that the counselor can introduce it. 

In sessions 2 through 8, 5 minutes is devoted to scheduling, and a new activity—marking progress—is 

added to the beginning of each session. 

Homework 

Encourage clients to use pages 6 and 7 of their Client’s Treatment Companion to keep a log of the 

triggers they encounter and how they combat them. Encourage clients to keep a list of thoughtstopping techniques that work best for them. 

39 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 2: Identifying External Triggers 

Goals of Session 

■ Help clients understand what external triggers are. 

■ Help clients identify individual external triggers. 

■ Help clients understand how external triggers can lead to use. 

■ Help clients review the need for scheduling to avoid external triggers. 

■ Help clients learn the importance of marking recovery progress. 

Handouts 

■ CAL 1—Marking Progress 

■ CAL 2—Calendar 

■ ERS 2A—External Trigger Questionnaire 

■ ERS 2B—External Trigger Chart 

■ SCH 2—Daily/Hourly Schedule 

Marking Progress (5 minutes) 

Keeping a daily record of abstinence keeps clients mindful that their recovery is a day-to-day process. 

Marking progress also allows clients to take pride in how far they have come. Clients who are newly 

abstinent may experience a distortion in which time seems to pass more slowly than when they were 

using substances. Charting their progress in short units may make the daunting process of recovery 

seem more manageable. The first 5 minutes of each session in the ERS portion of treatment is 

devoted to this activity. 

■ Go over handout CAL 1—Marking Progress. 

■ Have clients place a checkmark on each day on handout CAL 2—Calendar for which they have 

not used substances. 

Topics for Group Discussion (35 minutes) 

1. Discussing the Concept of External Triggers 

In session 1, clients learned what triggers are and identified and discussed specific triggers. Now 

they undertake a more detailed examination of situations and circumstances that are linked to using 

substances. The counselor helps clients understand that external triggers are aspects of their lifestyle 

and the choices they make that are under their control. These are things that they can change. 

■ Go over handout ERS 2A—External Trigger Questionnaire. 

■ Have clients place a checkmark next to all external triggers that apply to them and a zero next to 

those that do not. 

40 
IV. Early Recovery Skills Group 

■ Encourage clients to think of external triggers that are not on the handout and list these 

separately.
 

■ Have clients list situations and people who are not linked with substance use for them (i.e., who 

are “safe”). 

■ Discuss clients’ external triggers. 

■ Review the method for responding to triggers discussed in session 1 (ERS 1C—ThoughtStopping Techniques). 

■ Review the importance of scheduling to avoid triggers. 

2. Charting External Triggers 

Now that clients have made lists of their external triggers and of those people, places, and situations 

that are “safe,” clients can classify them according to the strength of their association with substance 

use. Completing the External Trigger Chart (ERS 2B) helps clients realize that an episode of using 

substances is not set off by random events. Clients also realize that they have the knowledge to help 

themselves avoid substance use. By altering their behavior, clients can exercise control and reduce 

the chances of using substances. The counselor can encourage clients to bring this chart (and ERS 

3B—Internal Trigger Chart [discussed in session 3]) to their individual counseling sessions to help 

address issues with triggers. Clients should keep this chart handy and add triggers to it, if new triggers 

arise (see Homework below). 

■ Go over handout ERS 2B—External Trigger Chart. 

■ Have clients list people, things, and situations on the chart, rating them for their potential as 

triggers. 

■ Encourage clients to share those items that are particularly troublesome and those that they feel 

are “safe.” 

■ Have the recovering co-leader discuss how using the External Trigger Chart has helped him or 

her understand and gain control of triggers. 

Scheduling (5 minutes) 

The counselor should remind clients that scheduling their time rigorously and sticking to the schedule 

are part of the recovery process. People who abuse substances are not accountable to schedules; 

taking responsibility for sticking to a schedule helps clients stop using. Following through on decisions 

made during scheduling helps keep clients’ rational brains in charge of behavior. 

■ Ask clients how the schedule they made at the end of the previous session helped them remain 

drug free. 

■ Ask clients what they learned about scheduling that will affect how they make future schedules. 

■ Have clients complete handout SCH 2—Daily/Hourly Schedule for the time between this session 

and session 3. 

41 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Homework (5 minutes) 

Ask clients to share briefly their experience of doing the homework from the previous session. The 

counselor can decide how detailed the followup on homework should be. The goal of asking is not to 

discover which clients have not done the homework but to encourage clients to work on their recovery 

between sessions and to share that work with the group. 

Encourage clients to update their list of external triggers on handout ERS 2B—External Trigger Chart 

as their recovery continues. 

42 
IV. Early Recovery Skills Group 

Session 3: Identifying Internal Triggers 

Goals of Session 

■ Help clients understand what internal triggers are. 

■ Help clients identify individual internal triggers. 

■ Help clients understand how internal triggers can lead to use. 

■ Help clients understand the individual thoughts and emotions that act as triggers. 

■ Help clients review the importance of scheduling and marking progress. 

Handouts 

■ CAL 2—Calendar 

■ ERS 3A—Internal Trigger Questionnaire 

■ ERS 3B—Internal Trigger Chart 

■ SCH 2—Daily/Hourly Schedule 

Marking Progress (5 minutes) 

Before introducing the session topics, the counselor gives clients time to chart their progress on CAL 2— 

Calendar and encourages clients to share positive events they have experienced since the last session. 

Topics for Group Discussion (35 minutes) 

1. Discussing the Concept of Internal Triggers 

In session 1 clients learned what triggers are and identified and discussed specific triggers. Now they 

undertake a more detailed examination of thoughts and emotions that are linked with using substances. 

Early recovery can be a chaotic time, especially emotionally. Many clients may feel depression, shame, 

fear, confusion, or self-doubt. Although clients may feel that their thoughts and emotions are not under 

their control during this time, the counselor can help clients understand that how they respond to those 

internal triggers is under their control. 

■ Go over handout ERS 3A—Internal Trigger Questionnaire. 

■ Have clients place a checkmark next to all internal triggers that apply to them and a zero next to 

those that do not. Clients also should include thoughts or emotions that once acted as triggers, 

even if they no longer do. 

■ Have clients complete the rest of the handout, with special attention to thoughts or emotions that 

have triggered recent use. 

■ Discuss clients’ internal triggers. As clients describe their internal states, reflect back what they 

say and ask whether it is accurate. 

■ Review the method for responding to triggers discussed in session 1 (ERS 1C—ThoughtStopping Techniques). 

43 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

■ Discuss other ways that clients can cope with triggers. If a certain internal state is no longer a 

problem for a client, have that client share how he or she got control over the internal trigger. 

2. Charting Internal Triggers 

Now that clients have listed their internal triggers, they should classify the triggers according to the 

strength of their association with substance use, just as they did for their external triggers. Charting 

their internal triggers allows clients to identify particularly safe and unsafe emotional states, which, in 

turn, should help them anticipate and head off problems. Completing the Internal Trigger Chart (ERS 

3B) helps clients visualize the choices they make and the consequences of those choices. By seeking 

to avoid situations that provoke dangerous emotions, clients can exercise control over their recovery. 

The counselor can encourage clients to bring this chart (and ERS 2B—External Trigger Chart) to their 

individual counseling sessions to help address issues with triggers. Clients should keep the Internal 

Trigger Chart handy and add triggers to it, if new triggers arise (see Homework below). 

■ Go over handout ERS 3B—Internal Trigger Chart. 

■ Have clients list thoughts and emotions on the chart, rating them for their potential as triggers. 

■ Encourage clients to share the items that are particularly troublesome and those that they feel 

are “safe.” 

■ Have the recovering co-leader discuss how using the Internal Trigger Chart has helped him or 

her understand and gain control of triggers. 

Scheduling (5 minutes) 

The counselor should remind clients that scheduling their time rigorously and sticking to the schedule 

are part of the recovery process. People who abuse substances are not accountable to schedules; 

taking responsibility for sticking to a schedule helps clients stop using. Following through on decisions 

made during scheduling helps keep clients’ rational brains in charge of behavior. 

■ Ask clients how the schedule they made at the end of the previous session helped them remain 

drug free. 

■ Ask clients what they learned about scheduling that will affect how they make future schedules. 

■ Have clients complete handout SCH 2—Daily/Hourly Schedule for the time between this session 

and session 4. 

Homework (5 minutes) 

Ask clients to share briefly their experience of doing the homework from the previous session. The 

counselor can decide how detailed the followup on homework should be. The goal of asking is not to 

discover which clients have not done the homework but to encourage clients to work on their recovery 

between sessions and to share that work with the group. 

Encourage clients to update their list of internal triggers on handout ERS 3B—Internal Trigger Chart as 

their recovery continues. 

44 
IV. Early Recovery Skills Group 

Session 4: Introducing 12-Step or Mutual-Help Activities 

Goals of Session 

■ Help clients understand the structure and format of 12-Step programs. 

■ Help clients identify the challenges and benefits of participating in 12-Step programs. 

■ Help familiarize clients with options for local 12-Step meetings. 

■ Help clients recognize that participation in 12-Step or mutual-help programs is integral to recovery. 

■ Help clients review the importance of scheduling and marking progress. 

Handouts 

■ CAL 2—Calendar 

■ ERS 4A—12-Step Introduction 

■ ERS 4B—The Serenity Prayer and the 12 Steps of Alcoholics Anonymous 

■ SCH 2—Daily/Hourly Schedule 

Marking Progress (5 minutes) 

Before introducing the session topics, the counselor gives clients time to chart their progress on 

CAL 2—Calendar and encourages clients to share positive events they have experienced since the 

last session. 

Topics for Group Discussion (35 minutes) 

1. Discussing Clients’ Prior Participation in 12-Step or Mutual-Help Programs 

Participation in a 12-Step or mutual-help program during and after treatment is central to recovery. 

Clients should view 12-Step or mutual-help group participation as important to their recovery as 

attending treatment sessions. Research shows that a combination of professional substance abuse 

treatment and participation in 12-Step support groups is often the most effective route to recovery. 

The most important aspect of 12-Step or mutual-help group participation is that it surrounds clients 

with supportive people who are going through the same struggles. Participation in a 12-Step or mutualhelp group also reinforces the message that recovery is not an individual process. The client must do 

the work of quitting substance use, but the knowledge and support of others who have remained 

abstinent are essential to recovery. 

■ Ask how many clients have participated in 12-Step or mutual-help programs. 

■ Ask those who have participated to share briefly their negative experiences with meetings. The 

recovering co-leader can start this discussion, if clients are reticent. Negative experiences might 

include the following: 

• Some people in meetings are not interested in change. 

• It is hard to reveal problems, even (or especially) in front of strangers. 

45 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

• The structure is too rigid. 

• Meetings are too time consuming. 

• The spiritual elements are intrusive. 

• Going to meetings can make one feel like using again. 

■ Ask clients who have not attended meetings to express their concerns about 12-Step or 

mutual-help group participation.
 

■ Ask clients who have participated in 12-Step or mutual-help programs to share their positive 

experiences. Again, the recovering co-leader can initiate this discussion. 

2. Discussing Clients’ Knowledge of 12-Step Programs 

The preceding discussion gives the counselor a good idea of clients’ understanding of the structure 

and processes of 12-Step meetings. Meetings can have different characteristics. If clients do not feel 

that the first meeting they try suits them, they should try to find one with which they are more comfortable. It is important for clients to know that many different types of meetings are available, especially 

in metropolitan areas, including language-specific meetings, gender-specific meetings, open meetings, 

meetings based on participants’ sexual orientation, and meetings for people who also have a mental 

disorder (“double trouble” or Dual Recovery Anonymous meetings). 

■ Go over handout ERS 4A—12-Step Introduction. 

■ Go over handout ERS 4B—Serenity Prayer and the 12 Steps of Alcoholics Anonymous. 

■ Emphasize that meetings are not religious but spiritual. Clients decide for themselves what the 

higher power of the 12 Steps refers to. Metropolitan areas may have special secular 12-Step 

meetings. Crystal Meth Anonymous (CMA) is a 12-Step program for people who are in recovery from methamphetamine dependence. CMA meetings can be found in many large cities and 

some smaller communities, especially in the West, Midwest, and South. 

■ Early in recovery, encourage clients to find a home meeting and attend as many meetings as 

their schedule permits. 

■ Stress the importance of finding and working with a sponsor. 

■ Have the recovering co-leader tell his or her story of finding a 12-Step meeting to attend and 

how doing so has helped him or her. 

■ Share with clients information about the 12-Step programs in the area. Ensure that you are 

knowledgeable about the characteristics of each group program. Provide a list of programs—with 

addresses, phone numbers, contacts, and a brief description—to each client. 

46 
IV. Early Recovery Skills Group 

3. Introducing Alternative Mutual-Help Groups 

The counselor should research local options to 12-Step programs and expose clients to other types of 

recovery support in addition to 12-Step programs. Many clients find help from the organizations listed 

on pages 33 and 34. 

Scheduling (5 minutes) 

The counselor should remind clients that scheduling their time rigorously and sticking to the schedule 

are part of the recovery process. People who abuse substances are not accountable to schedules; 

taking responsibility for sticking to a schedule helps clients stop using. Following through on decisions 

made during scheduling helps keep clients’ rational brains in charge of behavior. 

■ Ask clients how the schedule they made at the end of the previous session helped them remain 

drug free. 

■ Ask clients what they learned about scheduling that will affect how they make future schedules. 

■ Have clients complete handout SCH 2—Daily/Hourly Schedule for the time between this session 

and session 5. 

Homework (5 minutes) 

Ask clients to share briefly their experience of doing the homework from the previous session. The 

counselor can decide how detailed the followup on homework should be. The goal of asking is not to 

discover which clients have not done the homework but to encourage clients to work on their recovery 

between sessions and to share that work with the group. 

Encourage clients to attend at least one 12-Step or mutual-help meeting before session 5. 

47 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 5: Body Chemistry in Recovery 

Goals of Session 

■ Help clients understand that recovery is a physical process that requires the body to adjust. 

■ Help clients understand specific physical symptoms that may occur during recovery. 

■ Help clients identify the stages of recovery and the challenges associated with them. 

■ Help clients consider ways to overcome the physical challenges of early recovery. 

Handouts 

■ CAL 2—Calendar 

■ ERS 5—Roadmap for Recovery 

■ SCH 2—Daily/Hourly Schedule 

Marking Progress (5 minutes) 

Before introducing the session topics, the counselor gives clients time to chart their progress on 

CAL 2—Calendar and encourages clients to share positive events they have experienced since the 

last session. 

Topics for Group Discussion (35 minutes) 

1. Discussing Recovery as a Physical Process 

In addition to experiencing behavioral and emotional changes while in recovery, clients also experience 

physical changes. Clients’ bodies also must adjust. The chemistry of the brain is altered by habitual 

substance use; clients can think of this adjustment period as a “healing” of the brain. During early recovery 

clients may experience symptoms such as depression, low energy, sleep disturbances, headaches, and 

anxiety. These symptoms are part of the body’s healing process. If clients understand this, they are better 

able to focus on their recovery. Good nutrition, exercise, sufficient sleep, relaxation, and leisure activities 

to reduce stress may be beneficial, particularly during the early stages of recovery. 

■ Ask clients to share their experiences with prior attempts at recovery. 

■ Ask clients what physical symptoms they experienced during recovery. How long did these 

symptoms persist? 

■ Ask the recovering co-leader to share personal experiences of the physical difficulties of early 

recovery. What strategies or activities helped the recovering co-leader through the physical 

discomfort of early recovery? 

2. Discussing the Stages of Recovery 

Recovery from stimulant use can be divided into four stages: withdrawal, early abstinence (a.k.a. the 

Honeymoon), protracted abstinence (a.k.a. the Wall), and readjustment. These four stages were 

originally developed to describe recovery from cocaine addiction. The length of time for various stages 

48 
IV. Early Recovery Skills Group 

may vary for other stimulants. For example, because methamphetamine has a longer half-life in the 

body than cocaine, recovery from methamphetamine will lag behind the time periods listed on handout 

ERS 5—Roadmap for Recovery. The stages are a rough outline of the progress of recovery, and every 

client’s experience is different. However, being familiar with the typical changes and challenges that 

come with recovery helps prepare clients for them. 

■ Go over handout ERS 5—Roadmap for Recovery. Explain to clients that the time periods listed 

provide a general outline of recovery and that their recovery may take slightly longer. 

■ For each stage, focus on the substances that people in the group had been using (e.g., if no one 

in the group used opioids, focus on stimulants and alcohol). 

■ Ask clients to discuss the symptoms they are experiencing. 

■ Caution clients about the intense cravings and risk of impulsive actions during the first 2 weeks 

of abstinence—the withdrawal stage. Also be certain that clients are aware of the challenges 

posed by the stage known as the Wall. Most relapses occur during one of these two stages. 

■ Remind clients of the need to continue attending treatment sessions and 12-Step or mutual-help 

meetings, even if, after several weeks of abstinence, they feel as if their substance use is 

behind them. 

Scheduling (5 minutes) 

The counselor should remind clients that scheduling their time rigorously and sticking to the schedule 

are part of the recovery process. People who abuse substances are not accountable to schedules; 

taking responsibility for sticking to a schedule helps clients stop using. Following through on decisions 

made during scheduling helps keep clients’ rational brains in charge of behavior. 

■ Ask clients how the schedule they made at the end of the previous session helped them remain 

drug free. 

■ Ask clients what they learned about scheduling that will affect how they make future schedules. 

■ Have clients complete handout SCH 2—Daily/Hourly Schedule for the time between this session 

and session 6. 

Homework (5 minutes) 

Ask clients to share briefly their experience of doing the homework from the previous session. The 

counselor can decide how detailed the followup on homework should be. The goal of asking is not to 

discover which clients have not done the homework but to encourage clients to work on their recovery 

between sessions and to share that work with the group. 

Encourage clients to try one new activity or strategy to combat the physical symptoms of early 

abstinence. Remind them to eat well, exercise, get enough sleep, and try new leisure activities. 

49 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 6: Common Challenges in Early Recovery 

Goals of Session 

■ Help clients understand that it is necessary to find new coping techniques that do not involve 

substance use. 

■ Help clients identify challenges and new solutions that maintain abstinence. 

■ Help clients understand the importance of stopping alcohol use. 

Handouts 

■ CAL 2—Calendar 

■ ERS 6A—Five Common Challenges in Early Recovery 

■ ERS 6B—Alcohol Arguments 

■ SCH 2—Daily/Hourly Schedule 

Marking Progress (5 minutes) 

Before introducing the session topics, the counselor gives clients time to chart their progress on 

CAL 2—Calendar and encourages clients to share positive events they have experienced since the 

last session. 

Topics for Group Discussion (35 minutes) 

1. Discussing Challenges Clients Often Face in Early Recovery 

Many aspects of clients’ lives require change if clients are to maintain abstinence. But certain areas and 

situations have proved to be particularly troublesome for people in recovery. Examining the five challenges listed on ERS 6A and discussing solutions help clients address these challenges more effectively. 

In the past, clients probably turned to substance use when they encountered one of these problem 

situations. Part of the recovery process is learning a new repertoire of responses to cope with these 

situations. Recovery consists of assembling new coping techniques one solution at a time. The wider the 

variety of coping techniques clients can call on, the better they are able to manage their problems. 

■ Go over handout ERS 6A—Five Common Challenges in Early Recovery with clients. 

■ Ask clients what solutions they think will be helpful to them when they face these scenarios. Do 

clients have suggested solutions that are not listed? 

■ Ask clients which challenges are particularly troublesome. How do they plan to address them? 

■ Ask the recovering co-leader to discuss how he or she handled these common early recovery 

challenges. 

■ Remind clients of the importance of scheduling. Many of the solutions on the handout involve 

planning abstinent outings or setting aside time for new activities. Rigorous scheduling helps 

clients maintain their abstinence. 

50 
IV. Early Recovery Skills Group 

2. Discussing the Importance of Stopping Alcohol Use 

Some clients have problems giving up alcohol; some feel that giving up stimulants is enough work 

without making another major life adjustment. As discussed in session 5, when the Honeymoon stage 

ends after about 6 weeks of treatment, clients may experience intense cravings for stimulants. This also 

is the time when many clients return to alcohol use. Seeing no connection between alcohol and stimulants, clients may try to rationalize their return to alcohol use. It is important for clients to understand 

that it is necessary to abstain from alcohol to allow the brain to heal and that abstaining from alcohol 

will help them abstain from stimulants. 

■ Go over handout ERS 6B—Alcohol Arguments. 

■ Ask clients whether they have had some of these “arguments” with themselves. What other 

rationalizations for using alcohol have clients faced? 

■ Ask clients how they have responded to these rationalizations. 

■ Draw on the recovering co-leader’s experience to help clients address their rationalizations of a 

return to alcohol use. What strategies has the co-leader used to abstain from alcohol? 

Scheduling (5 minutes) 

The counselor should remind clients that scheduling their time rigorously and sticking to the schedule 

are part of the recovery process. People who abuse substances are not accountable to schedules; 

taking responsibility for sticking to a schedule helps clients stop using. Following through on decisions 

made during scheduling helps keep clients’ rational brains in charge of behavior. 

■ Ask clients how the schedule they made at the end of the previous session helped them remain 

drug free. 

■ Ask clients what they learned about scheduling that will affect how they make future schedules. 

■ Have clients complete handout SCH 2—Daily/Hourly Schedule for the time between this session 

and session 7. 

Homework (5 minutes) 

Ask clients to share briefly their experience of doing the homework from the previous session. The 

counselor can decide how detailed the followup on homework should be. The goal of asking is not to 

discover which clients have not done the homework but to encourage clients to work on their recovery 

between sessions and to share that work with the group. 

When clients are confronted with a problem, encourage them to try one of the alternatives discussed on 

handout ERS 6A—Five Common Challenges in Early Recovery. In addition to the arguments listed on 

handout ERS 6B—Alcohol Arguments, have clients think of another argument for remaining abstinent 

from alcohol and record it in their Client’s Treatment Companion on page 8. 

51 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 7: Thinking, Feeling, and Doing 

Goals of Session 

■ Help clients understand the connections among thoughts, emotions, and behavior. 

■ Help clients understand how thoughts and emotions contribute to behavior. 

■ Help clients understand that responses to thoughts and emotions can be controlled. 

■ Help clients identify behaviors that are related to substance use. 

Handouts 

■ CAL 2—Calendar 

■ ERS 7A—Thoughts, Emotions, and Behavior 

■ ERS 7B—Addictive Behavior 

■ SCH 2—Daily/Hourly Schedule 

Marking Progress (5 minutes) 

Before introducing the session topics, the counselor gives clients time to chart their progress on CAL 2— 

Calendar and encourages clients to share positive events they have experienced since the last session. 

Topics for Group Discussion (35 minutes) 

1. Discussing Connections Among Thoughts, Emotions, and Behavior 

Many people assume that thoughts and emotions happen outside their control. Because they feel that 

they cannot influence or change their thoughts and emotions, these people may not consider the effects 

that their thoughts and emotions can have on behavior. In session 1, the group discussed how emotions 

can act as triggers for substance use and how thoughts, if not stopped, can lead to cravings. It is important for clients to become aware of thoughts and emotions, to be able to observe and analyze them. 

Clients can look for patterns in their thoughts and emotions. They also can pay attention to how their 

thoughts and feelings are expressed in body language, physical changes, and behavior. Attuned to their 

thoughts and feelings, clients are better able to recognize which thoughts and emotions are connected to 

substance use. This recognition helps clients exercise control over their responses. 

■ Go over handout ERS 7A—Thoughts, Emotions, and Behavior. 

■ Ask clients about the differences between thoughts and emotions. How do clients respond 

to each? 

■ Review thought-stopping techniques, and ask clients to share the visualizations they use to stop 

thoughts of using. 

■ State that usually positive emotions (e.g., excitement, joy, gratitude) are considered good things. 

What are some positive emotions that can lead to substance use? 

■ Ask the recovering co-leader to discuss how he or she controls thoughts and emotions. 

52 
 

 

IV. Early Recovery Skills Group 

■ Ask clients what connections they can make between thoughts and behavior and between 

emotions and behavior. 

■ Remind clients of the importance of scheduling. Planning time thoroughly is one way of gaining 

control of behavior. Attending 12-Step or mutual-help meetings, finding new activities, and 

resuming old hobbies also are good ways of steering behavior in productive directions. 

2. Discussing the Importance of Recognizing Early Movement Toward Addictive Behaviors 

People who abuse substances often feel that their behavior is out of their control because they experience uncontrollable urges to use substances. By breaking down a behavior into the steps that precede 

it, clients are able to control how they respond to urges. In session 1, clients learned about thoughtstopping techniques (handout ERS 1C) that can interrupt the sequence of events that leads to craving 

and then to using substances. Another way to prevent the reemergence of addictive behaviors is for 

clients to recognize the early warning signs of substance abuse: behaviors that clients know are linked 

to substance abuse for them. Clients cannot maintain a successful recovery from substance abuse if 

they continue to engage in the behaviors that accompanied substance abuse. 

■ Go over handout ERS 7B—Addictive Behavior. 

■ Ask clients to assess honestly which behaviors from the list on the handout are related to their 

substance abuse. 

■ Ask clients what behaviors that place them at risk for relapse are not listed. 

■ Ask clients to think about how they can monitor their behavior (e.g., regular 12-Step attendance, 

keeping a diary, staying in touch with their sponsors). 

■ Ask clients what they will do to avoid returning to substance use if they recognize that they have 

slipped into one of these addictive behaviors. 

■ Ask the recovering co-leader to share experiences with addictive behaviors and how he or she 

avoided relapsing to substance use. 

■ Ask the recovering co-leader to describe the benefits of being vigilant about addictive behaviors. 

Scheduling (5 minutes) 

The counselor should remind clients that scheduling their time rigorously and sticking to the schedule 

are part of the recovery process. People who abuse substances are not accountable to schedules; 

taking responsibility for sticking to a schedule helps clients stop using. Following through on decisions 

made during scheduling helps keep clients’ rational brains in charge of behavior. 

■ Ask clients how the schedule they made at the end of the previous session helped them remain 

drug free. 

■ Ask clients what they learned about scheduling that will affect how they make future schedules. 

■ Have clients complete handout SCH 2—Daily/Hourly Schedule for the time between this session 

and session 8. 

53 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Homework (5 minutes) 

Ask clients to share briefly their experience of doing the homework from the previous session. The 

counselor can decide how detailed the followup on homework should be. The goal of asking is not to 

discover which clients have not done the homework but to encourage clients to work on their recovery 

between sessions and to share that work with the group. 

Have clients use pages 10 and 11 in their Client’s Treatment Companion to list a feeling that is linked 

with substance use, then list three ways of coping with that feeling that do not involve substance use. 

54 
IV. Early Recovery Skills Group 

Session 8: 12-Step Wisdom 

Goals of Session 

■ Help clients identify 12-Step sayings that are helpful in recovery. 

■ Help clients identify situations in which 12-Step sayings are helpful. 

■ Help clients understand that people are more vulnerable to relapse when they are hungry, angry, 

lonely, or tired. 

Handouts 

■ CAL 2—Calendar ■ ERS 8—12-Step Sayings ■ SCH 2—Daily/Hourly Schedule 

Marking Progress (5 minutes) 

Before introducing the session topics, the counselor gives clients time to chart their progress on CAL 2— 

Calendar and encourages clients to share positive events they have experienced since the last session. 

Topics for Group Discussion (35 minutes) 

1. Discussing the Usefulness of 12-Step Sayings 

Many sayings that originated in Alcoholics Anonymous and became part of other 12-Step programs 

have taken root in popular discourse, too. Such phrases as “One day at a time” and “Keep it simple” 

may be familiar even to clients who have not participated in a 12-Step program. Because the phrases 

are familiar, clients may take them for granted. The counselor should present these sayings in the 

context of 12-Step programs so that clients can understand their value. The direct approach to 

recovery that these sayings convey can be used to support the usefulness of 12-Step participation. 

■ Go over handout ERS 8—12-Step Sayings (up to discussion of the HALT acronym). 

■ Ask clients which 12-Step sayings they find useful. Why? 

■ Ask clients to imagine situations in which they would call on these phrases for strength or 

encouragement.
 

■ Ask the recovering co-leader to discuss what 12-Step wisdom means and how it has helped him 

or her in recovery. 

2. Using 12-Step Wisdom To Avoid Relapse 

The counselor explains the acronym, HALT. Clients who have participated in 12-Step programs before 

will be familiar with it and should be called on to help explain its importance. Recovery is a process of 

returning the body to a normal, healthy state. Controlling hunger by eating regularly is an important part 

of recovery. Anger is a frequent cause of relapse; it can drag clients down, making them feel bitter and 

resentful. It is important for clients to learn how to recognize and control anger. Loneliness is a common 

experience for clients in recovery; clients may feel isolated from friends and loved ones. The supportive 

fellowship of others in recovery helps combat loneliness. Feeling tired is often a warning sign of a 

relapse. Along with eating well, regular exercise and rest mitigate fatigue. 

55 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

■ Go over the HALT acronym presented in handout ERS 8—12-Step Sayings. 

■ Ask clients to share their answers to the questions at the end of the handout. 

■ Ask clients which of the HALT states poses the greatest relapse risk for them. What strategies 

will help them avoid the relapse pitfalls mentioned in HALT? 

■ Ask clients what other relapse risks exist for them. List these and perhaps make an acronym that 

represents them. 

■ Ask the recovering co-leader to explain how HALT has helped him or her avoid relapse. 

3. Offering an Alternative Approach 

The counselor should research local options to 12-Step programs and expose clients to other types of 

recovery support in addition to 12-Step programs. Many clients find help from the organizations listed 

on pages 33 and 34. 

Scheduling (5 minutes) 

The counselor should remind clients that scheduling their time rigorously and sticking to the schedule 

are part of the recovery process. People who abuse substances are not accountable to schedules; 

taking responsibility for sticking to a schedule helps clients stop using. Following through on decisions 

made during scheduling helps keep clients’ rational brains in charge of behavior. 

■ Ask clients how the schedule they made at the end of the previous session helped them remain 

drug free. 

■ Ask clients what they learned about scheduling that will affect how they make future schedules. 

■ Have clients complete handout SCH 2—Daily/Hourly Schedule for the time between this session 

and their next treatment group session. 

Homework (5 minutes) 

Ask clients to share briefly their experience of doing the homework from the previous session. The 

counselor can decide how detailed the followup on homework should be. The goal of asking is not to 

discover which clients have not done the homework but to encourage clients to work on their recovery 

between sessions and to share that work with the group. 

This is the final session of the Early Recovery Skills portion of treatment. Have clients take some time 

to reflect on what they have learned. Encourage them to write on pages 10 and 11 of their Client’s 

Treatment Companion and describe how they will use the skills they have learned to help them in 

their recovery. 

Handouts for Early Recovery Skills Group Sessions 

The handouts that follow are to be used by clients with the counselor’s guidance. The handouts will 

help clients make the most of the eight ERS sessions. 

56 
SCH 1 The Importance 


of Scheduling
 

Scheduling may be a difficult and boring 

task if you’re not used to it. It is, however, 

an important part of the recovery process. People with substance use 

disorders do not schedule their time. 

Scheduling your time will help you 

achieve and maintain abstinence. 

Why Is Scheduling Necessary? 

If you began your recovery in a hospital, 

you would have the structure of the 

program and the building to help you 

stop using. As a person in outpatient 

treatment, you have to build that structure to help support you as you continue 

functioning in the world. Your schedule 

is your structure. 

Do I Need To Write Down My 

Schedule? 

Absolutely. Schedules that are in your 

head are too easily revised. If you write 

down your schedule while your rational 

brain is in control and then follow the 

schedule, you will be doing what you 

think you should be doing instead of 

what you feel like doing. 

What if I Am Not an Organized 

Person? 

Learn to be organized. Buy a schedule 

book and work with your counselor. 

Thorough scheduling of your activities 

is very important to treating your substance use disorder. Remember, your 

rational brain plans the schedule. If you 

follow the schedule, you won’t use. Your 

addicted brain wants to be out of control. 

If you go off the schedule, your addicted 

brain may be taking you back to using 

drugs or drinking. 

Who Decides What I Schedule? 

You do! You may consider suggestions 

made by your counselor or family members, but the final decision is yours. Just 

be sure you do what you wrote down. 

Follow your schedule; try not to make 

any changes. 

Most people can schedule a 24-hour 

period and follow it. If you can, you are 

on your way to gaining control of your 

life. If you cannot, you may need to 

consider a higher level of care as a start. 

1 of 1
 
SCH 2 Daily/Hourly Schedule
 

1 of 1
 

7:00 AM 

8:00 AM 

9:00 AM 

10:00 AM 

11:00 AM 

12:00 PM 

1:00 PM 

2:00 PM 

3:00 PM 

4:00 PM 

5:00 PM 

6:00 PM 

7:00 PM 

8:00 PM 

9:00 PM 

10:00 PM 

11:00 PM 

How many hours will you sleep? _____ 

From _______ To _______ 

Notes: 

Reminders: 

Date: 
CAL 1 Marking Progress
 

It is useful for both you and your counselor to know where you are in the recovery 

process at all times. Marking a calendar as you go helps in several ways: 

●		 It’s a reminder of how far you’ve come in your recovery. 

●		 A feeling of pride often results from seeing the number of days you have 

been abstinent. 

●		 Recovery can seem very long unless you can measure your progress 

in short units of time. 

Make a mark to record on the calendar pages every day of abstinence you achieve. 

You may decide to continue the exercise following the program. 

If you record your abstinent days regularly, this simple procedure will help you and 

your counselor see your progress. 

1 of 1
 
CAL 2 Calendar
 

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 

Month: 

1 of 1 
ERS 1A Triggers Use

Trigger 

Thought 

Craving Triggers are people, places, objects, feelings, and times that 

cause cravings. For example, if every Friday night someone cashes a paycheck, goes 

out with friends, and uses stimulants, the triggers might be 

●		 Friday night ● After work ● Money 

●		 Friends who use ● A bar or club 

Your brain associates the triggers with substance use. As a result of constant 

triggering and using, one trigger can cause you to move toward substance use. 

The trigger–thought–craving–use cycle feels overwhelming. 

Stopping the craving process is an important part of treatment. The best way to do 

that is to do the following: 

1.	 Identify triggers. 

2.	 Prevent exposure to triggers whenever possible (for example, 

do not handle large amounts of cash). 

3.	 Cope with triggers differently than in the past (for example, schedule 

exercise and a 12-Step or mutual-help meeting for Friday nights). 

Remember, triggers affect your brain and cause cravings even though you have 

decided to stop substance use. Your intentions to stop must translate into behavior 

changes, which keep you away from possible triggers. 

What are some of the strongest triggers for you? 

What particular triggers might be a problem in the near future?
 

1 of 1
 
TRIGGER THOUGHT CRAVING USE 

ERS 1B Trigger–Thought–Craving–Use
 

The Losing Argument 

If you decide to stop drinking or using but at some point end up moving toward using 

substances, your brain has given you permission by using a process called relapse 

justification. Thoughts about using start an argument inside your head—your rational 

self versus your substance-dependent self. You feel as though you are in a fight, and 

you must come up with many reasons to stay abstinent. Your mind is looking for an 

excuse to use again. You are looking for a relapse justification. The argument inside 

you is part of a series of events leading to substance use. How often in the past has 

your substance dependence lost this argument? 

Thoughts Become Cravings 

Craving does not always occur in a straightforward, easily recognized form. Often the 

thought of using passes through your head with little or no effect. But it’s important to 

identify these thoughts and try to eliminate them. It takes effort to identify and stop a 

thought. However, allowing yourself to continue thinking about substance use is choosing 

to relapse. The further the thoughts are allowed to go, the more likely you are to relapse. 

The “Automatic” Process 

During addiction, triggers, thoughts, cravings, and use seem to run together. However, 

the usual sequence goes like this: 

Thought Stopping 

The only way to ensure that a thought won’t lead to a relapse is to stop the thought 

before it leads to craving. Stopping the thought when it first begins prevents it from 

building into an overpowering craving. It is important to do it as soon as you realize 

you are thinking about using. 

1 of 1
 
ERS 1C Thought-Stopping 


Techniques
 

A New Sequence 

To start recovery, it is necessary to interrupt the trigger–thought–craving–use 

sequence. Thought stopping provides a tool for disrupting the process. 

Trigger Thought 

Cravings Continued 

Thoughts Use 

ThoughtStopping 

Techniques 

This process is not automatic. You make a choice either to continue thinking about 

using (and start on the path toward relapse) or to stop those thoughts. 

Thought-Stopping Techniques 

Try the techniques described below, and use those that work best for you: 

Visualization. Imagine a scene in which you deny the power of 

thoughts of use. For example, picture a switch or a lever in your mind. 

Imagine yourself actually moving it from ON to OFF to stop the 

using thoughts. Have another picture ready to think about in place 

of those thoughts. 

1 of 2
 
ERS 1C Thought-Stopping 


Techniques
 

Snapping. Wear a rubberband loosely on your wrist. Each 

time you become aware of thoughts of using, 

snap the rubberband and say, “No!” to the 

thoughts as you make yourself think about another 

subject. Have a subject ready that is meaningful 

and interesting to you. 

Relaxation. Feelings of hollowness, heaviness, and cramping in the stomach are 

cravings. These often can be relieved by breathing in deeply (filling lungs with air) 

and breathing out slowly. Do this three times. You should be able to feel the tightness 

leaving your body. Repeat this whenever the feeling returns. 

Call someone. Talking to another person provides an outlet for your feelings and 

allows you to hear your thinking process. Have phone numbers of supportive, 

available people with you always, so you can use them when you need them. 

ALLOWING THE THOUGHTS TO 

DEVELOP INTO CRAVINGS IS 

MAKING A CHOICE TO REMAIN 

DEPENDENT ON SUBSTANCES. 

2 of 2
 
ERS 2A External Trigger 

Questionnaire 

Place a checkmark next to activities, situations, or settings in which you frequently used 

substances; place a zero next to activities, situations, or settings in which you never 

have used substances. 

□ Home alone 

Home with friends 

Friend’s home 

Parties 

Sporting events 

Movies 

Bars/clubs 

Beach 

Concerts 

With friends who 

use drugs 

When gaining weight 

Vacations/holidays 

When it’s raining 

Before a date 

□ During a date 

Before sexual activities 

During sexual activities 

After sexual activities 

Before work 

When carrying money 

After going past 

dealer’s residence 

Driving 

Liquor store 

During work 

Talking on the phone 

Recovery groups 

After payday 

□ Before going out to

dinner 

Before breakfast 

At lunch break 

While at dinner 

After work 

After passing a 

particular street or exit

School

The park

In the neighborhood 

Weekends 

With family members 

When in pain 

□ □

□ □ □

□ □ □

□ □ □

□ □ □

□ □ □

□

□ □ □

□ □ □

□ □

□ □ □

□ □ □

□ □ □

□

List any other activities, situations, or settings where you frequently have 

used. 

List activities, situations, or settings in which you would not use.
 

List people you could be with and not use.
 

1 of 1
 
ERS 2B External Trigger Chart

Name: __________________________ Date:_________ 

Instructions: List people, places, objects, or situations below 

according to their degree of association with substance use. 

 0%100% 

Chance of Using Chance of Using 

Never Use Almost Never Use Almost Always Use Always Use 

These situations are These situations are These situations are Involvement in 

“safe.” low risk, but caution high risk. Staying these situations is 

is needed. in these situations deciding to stay 

is extremely addicted. Avoid 

dangerous. totally. 

1 of 1
 
ERS 3A Internal Trigger 


Questionnaire
 

□

□

□

□

□

□

□

□

□

During recovery certain feelings or emotions often trigger the brain to think about using 

substances. Read the following list of feelings and emotions, and place a check mark 

next to those that might trigger thoughts of using for you. Place a zero next to those 

that are not connected with using. 

Afraid 

Frustrated 

Neglected 

Angry 

Guilty 

Nervous 

Confident 

Happy 

Passionate 

Criticized 

Inadequate 

Pressured 

Depressed 

Insecure 

Relaxed 

Embarrassed 

Irritated 

Sad 

□

□

□

□

□

□

□

□

□

Excited 

Jealous 

Bored 

Exhausted 

Lonely 

Envious 

Deprived 

Humiliated 

Anxious 

□

□

□

□

□

□

□

□

□

Aroused 

Revengeful

Worried 

Grieving

Resentful 

Overwhelmed 

Misunderstood 

Paranoid 

Hungry 

□

□

□

□

□

□

□

□

□

What emotional states that are not listed above have triggered you to 

use substances? 

Was your use in the weeks before entering treatment 

_____ 

_____ 

Tied primarily to emotional conditions? 

Routine and automatic without much emotional triggering? 

Were there times in the recent past when you were not using and a 

specific change in your mood clearly resulted in your wanting to use 

(for example, you got in a fight with someone and wanted to use in 

response to getting angry)? Yes _____ No _____ If yes, describe: 

1 of 1
 
ERS 3B Internal Trigger Chart 

Name: __________________________ Date:_________ 

Instructions: List emotional states below according to their degree 

of association with substance use. 

 0%100%
 

Chance of Using Chance of Using
 

Never Use Almost Never Use Almost Always Use Always Use 

These emotions are These emotions are These emotions are Persisting in 

“safe.” low risk, but caution high risk. these emotions is 

is needed. deciding to stay 

addicted. Avoid 

totally. 

1 of 1
 
ERS 4A 12-Step 


Introduction
 

Meetings
 

What Is a 12-Step Program?
 

In the 1930s, Alcoholics Anonymous (AA) was founded by two men who could not cope 

with their own alcoholism through psychiatry or medicine. They found a number of specific principles helped people overcome their alcohol dependence. They formed AA 

to introduce people who were dependent on alcohol to these self-help principles. The 

AA concepts have been adapted to stimulant and other drug addictions (for example, 

Crystal Meth Anonymous, Narcotics Anonymous [NA], and Cocaine Anonymous) and to 

compulsive behaviors such as gambling and overeating. 

People dependent on drugs or alcohol have found that others who also are dependent 

can provide enormous support and help to one another. For this reason, these groups 

are called fellowships, where participants show concern and support for one another 

through sharing and understanding. 

Do I Need To Attend 12-Step Meetings? 

If treatment in this program is going to work for you, it is essential to establish a network 

of support for your recovery. Attending treatment sessions without going to 12-Step 

meetings may produce a temporary effect. But without involvement in self-help programs, it is very unlikely that you will successfully recover. Clients in these programs 

should attend three 12-Step meetings per week during their treatment involvement. 

Many successfully abstinent people go to 90 meetings in 90 days. The more you 

participate in treatment and 12-Step meetings, the greater your chance for recovery. 

Are All Meetings the Same? 

No. There are different types of meetings: 

●		 Speaker meetings feature a person in recovery telling his or her story of 

drug and alcohol use and recovery. 

1 of 5
 
ERS 4A 12-Step 


Introduction
 

● Topic meetings have a discussion on a specific 

topic such as fellowship, honesty, acceptance, or
 

patience. Everyone is given a chance to talk, but no one is forced.
 

●		 Step/Tradition meetings are special meetings where the 12 Steps and 12 

Traditions are discussed. 

●		 Book study meetings focus on reading a chapter from the main text 

of the 12-Step group. (For AA, this is the Big Book; for NA, the Basic 

Text.) Book study meetings often focus on someone’s experience or a 

recovery-related topic. 

●		 Depending on where you live, there may be language-specific 

meetings, gender-specific meetings, open meetings, meetings 

based on participants’ sexual orientation, and meetings for people 

who also have a mental disorder (“double trouble” Dual Recovery 

Anonymous meetings). 

Are the 12-Step Programs Religious? 

No. None of the 12-Step programs are religious, but spiritual growth is considered 

a part of recovery. Spiritual choices are very personal and individual. Each person 

decides for himself or herself what the term “higher power” means. Both nonreligious 

and religious people can find value and support in 12-Step programs. 

How Do I Find a Meeting? 

You can call directory assistance or check the phonebook for Alcoholics Anonymous, 

Cocaine Anonymous, or Narcotics Anonymous. Listings for Crystal Meth Anonymous 

meetings can be found at http://www.crystalmeth.org. You can call the numbers 

available from the Web site and speak to someone who can tell you when and where 

meetings are scheduled. At meetings, directories are available that list meetings by 

city, street address, and meeting time and include information about the meeting (for 

2 of 5
 
ERS 4A SCH 2 12-Step 


Introduction
 

example, speaker, step study, nonsmoking, men’s, or women’s). 

Another way to find a good meeting is to ask someone who 

goes to 12-Step meetings. 

Sponsors 

The first few weeks and months of recovery are frustrating. Many things happen that 

are confusing and frightening. During this difficult period, there are many times when 

people in recovery need to talk about problems and fears. A sponsor helps guide a 

newcomer through this process. 

What Do Sponsors Do? 

●		 Sponsors help the newcomer by answering questions and 

explaining the 12-Step recovery process. 

●		 Sponsors agree to be available to listen to their sponsorees’ 

difficulties and frustrations and to share their insights and solutions. 

●		 Sponsors provide guidance and help address problems their sponsorees 

are having. This advice comes from their personal experiences with longterm abstinence. 

●		 Sponsors are people with whom addiction-related secrets and guilt feelings can be shared easily. They agree to keep these secrets confidential 

and to protect the newcomer’s anonymity. 

●		 Sponsors warn their sponsorees when they get off the path of recovery. 

Sponsors often are the first people to know when their sponsorees experience a slip or relapse. So, sponsors often push their sponsorees to attend 

more meetings or get help for problems. 

●		 Sponsors help their sponsorees work through the 12 Steps. 

3 of 5
 
ERS 4A 12-Step 


Introduction
 

How Do I Pick a Sponsor? 

The process of choosing a sponsor is easy. The newcomer simply asks someone 

to be his or her sponsor. But you need to think carefully about whom you will ask to 

sponsor you. Most people select a sponsor who seems to be living a healthy and 

responsible life, the kind of life a person in recovery would want to lead. 

Some general guidelines for selecting a sponsor include the following: 

●		 A sponsor should have several years of abstinence from all 

mood-altering drugs.
 

●		 A sponsor should have a healthful lifestyle and not be struggling with 

major problems or addiction. 

●		 A sponsor should be an active and regular participant in 12-Step 

meetings. Also, a sponsor should be someone who actively “works” 

the 12 Steps. 

●		 A sponsor should be someone to whom you can relate. You may not 

always agree with your sponsor, but you need to be able to respect your 

sponsor. 

●		 A sponsor should be someone you would not become romantically 

interested in. 

Alternatives to 12-Step Programs 

There are alternatives to 12-Step groups, many of which are not based on the concept 

of a higher power. Although the philosophies of these groups differ, most offer a 

mutual-help approach that focuses on personal responsibility, personal empowerment, 

and strength through an abstinent social network. Here are a few notable alternatives 

to 12-Step groups: 

4 of 5 
ERS 4A 12-Step 


Introduction
 

● Women for Sobriety 

(http://www.womenforsobriety.org) helps women overcome alcohol 

dependence throughemotional and spiritual growth. 

●		 Jewish Alcoholics, Chemically Dependent Persons and Significant 

Others (JACS) (http://www.jbfcs.org/JACS) helps people explore recovery 

in a nurturing Jewish environment. 

●		 Self-Management and Recovery Training (SMART) 

(http://www.smartrecovery.org) is a cognitive–behavioral group approach 

that focuses on self-reliance, problemsolving, coping strategies, and 

a balanced lifestyle. 

●		 Secular Organizations for Sobriety (http://www.secularhumanism.org) 

maintains that sobriety is a separate issue from religion or spirituality and 

credits the individual for achieving and maintaining sobriety. 

●		 Community-based spiritual fellowships, which take place in churches, 

synagogues, mosques, temples, and other spiritually focused settings, 

often help people clarify their values and change their lives. 

Questions To Consider 

●		 Have you ever been to a 12-Step meeting? If so, what was your 

experience? 

●		 Have you attended any other types of recovery meetings (such as those 

listed above)? 

●		 Do you plan to attend any 12-Step meetings? Where? When? 

●		 How might you make use of 12-Step meetings to stop using? 

●		 Are there alternatives to 12-Step meetings that you might consider 

attending? 

5 of 5 
ERS 4B The Serenity Prayer and the
 

12 Steps of Alcoholics
 

Anonymous
 

The Serenity Prayer 

God grant me the serenity to accept the things I cannot change, the courage to 

change the things I can, and the wisdom to know the difference. 

The 12 Steps of Alcoholics Anonymous*
 

*The Twelve Steps are reprinted with permission of Alcoholics Anonymous World Services, Inc. (A.A.W.S.). Permission to reprint the Twelve Steps does not 

mean that A.A.W.S. has reviewed or approved the contents of this publication, or that A.A.W.S. necessarily agrees with the views expressed herein. A.A. is a 

program of recovery from alcoholism only—use of the Twelve Steps in connection with programs and activities which are patterned after A.A., but which address 

other problems, or in any other non-A.A. context, does not imply otherwise. 

1 We admitted that we were powerless 

over alcohol—that our lives had become 

unmanageable. 

2 Came to believe that a Power greater 

than ourselves could restore us to sanity. 

3 Made a decision to turn our will and 

our lives over to the care of God as we 

understood Him. 

4 Made a searching and fearless moral 

inventory of ourselves. 

5 Admitted to God, to ourselves, and to 

another human being the exact nature of 

our wrongs. 

6 Were entirely ready to have God 

remove all these defects of character. 

7 Humbly asked Him to remove our 

shortcomings. 

8 Made a list of all persons we had 

harmed and became willing to make 

amends to them all. 

9 Made direct amends to such people 

wherever possible, except when to do so 

would injure them or others. 

10 Continued to take personal inventory, and when we were wrong, promptly 

admitted it. 

11 Sought through prayer and meditation to improve our conscious contact 

with God as we understood Him, praying 

only for knowledge of His will for us and 

the power to carry that out. 

12 Having had a spiritual awakening as 

a result of the steps, we tried to carry this 

message to alcoholics and to practice 

these principles in all our affairs. 

1 of 1
 
ERS 5 Roadmap for


Recovery
 

Recovery from a substance use disorder is not a 

mysterious process. After the use of substances 

is stopped, the brain goes through a biological 

readjustment. This readjustment process is 

essentially a “healing” of the chemical changes 

that were produced in the brain by substance use. It is important for people in the 

beginning stages of recovery to understand why they may experience some physical 

and emotional difficulties. The durations of the stages listed below are a rough guide 

of recovery, not a schedule. The length of stages will vary from person to person. The 

substance used will affect the client’s progress through the stages, too. Clients who 

had been using methamphetamine will tend to spend more time in each stage than 

clients who were using cocaine or other stimulants. 

The Stages
 

Withdrawal Stage (1 to 2 weeks)
 

During the first days after substance use is stopped, some people experience difficult 

symptoms. The extent of the symptoms often is related to the amount, frequency, and 

type of their previous substance use. 

For people who use stimulants, withdrawal can be accompanied by drug craving, 

depression, low energy, difficulty sleeping or excessive sleep, increased appetite, and 

difficulty concentrating. Although people who use stimulants do not experience the 

same degree of physical symptoms as do people who use alcohol, the psychological 

symptoms of craving and depression can be quite severe. Clients may have trouble 

coping with stress and may be irritable. 

1 of 3
 
People who drank alcohol in large amounts may have the
 

most severe symptoms. The symptoms can include nausea,
 

low energy, anxiety, shakiness, depression, intense emotions,
 

insomnia, irritability, difficulty concentrating, and memory problems. These symptoms
 

typically last 3 to 5 days but can last up to several weeks. Some people must be
 

hospitalized to detox safely.
 

ERS 5 Roadmap for 

Recovery 

For people who used opioids or prescription drugs, the 7- to 10-day withdrawal period 

(or longer for people who use benzodiazepines) can be physically uncomfortable and 

may require hospitalization and medication. It is essential to have a physician closely 

monitor withdrawal in people dependent on these substances. Along with the physical 

discomfort, many people experience nervousness, trouble sleeping, depression, and 

difficulty concentrating. Successfully completing withdrawal from these substances is a 

major achievement in early recovery. 

Early Abstinence (4 weeks; follows Withdrawal) 

For people who used stimulants, this 4-week period is called the Honeymoon. Most 

people feel quite good during this period and often feel “cured.” As a result, clients 

may want to drop out of treatment or stop attending 12-Step meetings during the 

Honeymoon period. Early abstinence should be used as an opportunity to establish 

a good foundation for recovery. If clients can direct the energy, enthusiasm, and optimism felt during this period into recovery activities, they can lay the foundation for 

future success. 

For people who used alcohol, this 4-week period is marked by the brain’s recovery. 

Although the physical withdrawal symptoms have ended, clients still are getting used 

to the absence of substances. Thinking may be unclear, concentration may be poor, 

nervousness and anxiety may be troubling, sleep is often irregular, and, in many ways, 

life feels too intense. 

2 of 3 
For those who used opioids or prescription drugs, there is 

essentially a gradual normalization during this period. In 

many ways the process is similar to the alcohol recovery timetable. Slow, gradual 

improvement in symptoms is evidence that the recovery is progressing. 

ERS 5 Roadmap for 

Recovery 

Protracted Abstinence (3.5 months; follows Early Abstinence) 

From 6 weeks to 5 months after clients stop using, they may experience a variety of 

annoying and troublesome symptoms. These symptoms—difficulties with thoughts 

and feelings—are caused by the continuing healing process in the brain. This period 

is called the Wall. It is important for clients to be aware that some of the feelings during this period are the result of changes in brain chemistry. If clients remain abstinent, 

the feelings will pass. The most common symptoms are depression, irritability, difficulty 

concentrating, low energy, and a general lack of enthusiasm. Clients also may experience strong cravings during protracted abstinence. Relapse risk goes up during this 

period. Clients must stay focused on remaining abstinent one day at a time. Exercise 

helps tremendously during this period. For most clients, completing this phase in 

recovery is a major achievement. 

Readjustment (2 months; follows Protracted Abstinence) 

After 5 months, the brain has recovered substantially. Now, the client’s main task is 

developing a life that has fulfilling activities that support continued recovery. Although 

a difficult part of recovery is over, hard work is needed to improve the quality of life. 

Because cravings occur less often and feel less intense 6 months into recovery, clients 

may be less aware of relapse risk and put themselves in high-risk situations and 

increase their relapse risk. 

3 of 3
 
ERS 6A Five Common Challenges 


in Early Recovery
 

Everyone who attempts to stop using substances runs into situations 

that make it difficult to maintain abstinence. Listed below are five of 

the most common situations that are encountered during the first few weeks of treatment. 

Next to these problems are some suggested alternatives for handling these situations. 

Challenges New Approaches 

Friends and 

associates 

who use: You want to 

continue associations 

with old friends or 

friends who use.

● Try to make new friends at 12-Step or mutual-help 

meetings. 

● Participate in new activities or hobbies that will 

increase your chances of meeting abstinent people. 

● Plan activities with abstinent friends or family members. 

Anger, 

irritability: 

Small events can create 

feelings of anger that 

seem to preoccupy your 

thoughts and can lead 

to relapse.

● Remind yourself that recovery involves a healing of 

brain chemistry. Strong, unpredictable emotions are 

a natural part of recovery. 

● Engage in exercise. 

● Talk to a counselor or a supportive friend. 

Substances

in the home: 

You have decided to 

stop using, but others 

in your house may still 

be using. 

● Get rid of all drugs and alcohol. 

● Ask others to refrain from using and drinking at home. 

● If you continue to have a problem, think about 

moving out for a while.

1 of 2
 
ERS 6A Five Common Challenges 


in Early Recovery
 

Challenges New Approaches 

 Boredom, 

loneliness: 

Stopping substance use 

often means that activities 

you did for fun and the 

people with whom you did 

them must be avoided. 

●		 Put new activities in your schedule. 

●		 Go back to activities you enjoyed before your 

addiction took over. 

●		 Develop new friends at 12-Step or mutual-help 

meetings. 

Special 

occasions: 

Parties, dinners, business 

meetings, and holidays 

without substance use 

can be difficult. 

●		 Have a plan for answering questions about not 

using substances. 

●		 Start your own abstinent celebrations and traditions. 

●		 Have your own transportation to and from events. 

●		 Leave if you get uncomfortable or start feeling 

deprived. 

Are some of these issues likely to be problems for you in the next few 

weeks? Which ones? 

How will you handle them?


2 of 2
 
 

ERS 6B Alcohol Arguments

Have you been able to stop using alcohol completely? At about 6 weeks into the 

recovery process, many people return to alcohol use. Has your addicted brain played 

with the idea? These are some of the most common arguments against stopping the use 

of alcohol and answers to the arguments. 

I came here to stop using speed, not to stop drinking. Part of stopping 

methamphetamine use is stopping all substance use, including alcohol use. 

I’ve had drinks and not used, so it doesn’t make any difference. Drinking 

over time greatly increases the risk of relapse. A single drink does not necessarily 

cause relapse anymore than a single cigarette causes lung cancer. However, with 

continued drinking, the risks of relapse greatly increase. 

Drinking actually helps. When I have a craving, a drink calms me 

down, and the craving goes away. Alcohol interferes with the brain’s chemical healing process. Continued alcohol use eventually intensifies cravings, even if one 

drink seems to reduce cravings. 

I’m not an alcoholic, so why do I need to stop drinking. If you’re not an 

alcoholic, you should have no problem stopping alcohol use. If you can’t stop, maybe 

alcohol is more of a problem than you realize. 

I’m never going to use drugs again, but I’m not sure I’ll never drink again. 

Make a 6-month commitment to total abstinence. Give yourself the chance to make 

a decision about alcohol with a drug-free brain. If you reject alcohol abstinence 

because “forever” scares you, then you’re justifying drinking now and risking relapse 

to substance use. 

Has your addicted brain presented you with other justifications? If so, 

what are they? 

How are you planning to handle alcohol use in the future?
 

1 of 1
 
ERS 7A Thoughts, Emotions, and 

Behavior 

Habitual substance use changes the way people think, how they feel, and how they 

behave. How do these changes affect the recovery process? 

Thoughts 

Thoughts happen in the rational part of the brain. They are like pictures on the TV 

screen of the mind. Thoughts can be controlled. As you become aware of your thoughts, 

you can learn to change channels in your brain. Learning to turn off thoughts of substance use is a very important part of the recovery process. It is not easy to become 

aware of your thinking and to learn to control the process. With practice it gets easier. 

Emotions 

Emotions are feelings. Happiness, sadness, anger, and fear are some basic emotions. 

Feelings are the mind’s response to things that happen to you. Feelings cannot be 

controlled; they are neither good nor bad. It is important to be aware of your feelings. 

Talking to family members, friends, or a counselor can help you recognize how you feel. 

People normally feel a range of emotions. Drugs can change your emotions by changing 

the way your brain works. During recovery, emotions are often still mixed up. Sometimes 

you feel irritated for no reason or great even though nothing wonderful has happened. 

You cannot control or choose your feelings, but you can control what you do about them. 

Behavior 

What you do is behavior. Work is behavior. Play is behavior. Going to treatment is 

behavior, and substance use is behavior. Behavior can result from an emotion, from 

a thought, or from a combination of both. Repeated use of a substance changes your 

thoughts and pushes your emotions toward substance use. This powerful, automatic 

process has to be brought back under control for recovery to occur. Structuring time, 

attending 12-Step or mutual-help meetings, and engaging in new activities are all ways 

of regaining control. The goal in recovery is to learn to combine your thinking and 

feeling self and behave in ways that are best for you and your life. 

1 of 1 
ERS 7B Addictive Behavior
 

People who abuse substances often feel that their lives are out of control. Maintaining 

control becomes harder and harder the longer they have been abusing substances. 

People do desperate things to continue to appear normal. These desperate behaviors 

are called addictive behaviors—behaviors related to substance use. Sometimes 

these addictive behaviors occur only when people are using or moving toward using. 

Recognize when you begin to engage in these behaviors. That’s when you know to 

start fighting extra hard to move away from relapse. 

Which of these behaviors do you think are related to your drug or 

alcohol use? 

□ Lying 

□ Stealing 

□ Being irresponsible (for example, 

not meeting family or work 

commitments) 

□ Being unreliable (for example, 

being late for appointments, 

breaking promises) 

□ Being careless about health and 

grooming (for example, wearing “using” clothes, avoiding 

exercise, eating poorly, having a 

messy appearance) 

□ Getting sloppy in housekeeping 

□ Behaving impulsively (without 

thinking) 

□ Behaving compulsively (for 

example, too much eating, 

working, sex) 

□ Changing work habits (for 

example, working more, less, 

not at all, new job, change in 

hours) 

□ Losing interest in things (for 

example, recreational activities, 

family life) 

□ Isolating (staying by yourself 

much of the time) 

□ Missing or being late for 

treatment 

□ Using other drugs or alcohol 

□ Stopping prescribed medication 

(for example, disulfiram, 

naltrexone) 

1 of 1
 
ERS 8 12-Step Sayings
 

The program of Alcoholics Anonymous has developed some short sayings that help 

people in their day-to-day efforts at staying sober. These concepts are often useful 

tools in learning how to establish sobriety. 

One day at a time. This is a key concept in staying abstinent. Don’t obsess about 

staying abstinent forever. Just focus on today. 

Turn it over. Sometimes people with addictions jeopardize their recovery by tackling 

problems that cannot be solved. Finding a way to let go of issues so that you can focus 

on staying abstinent is a very important skill. 

Keep it simple. Learning to stay abstinent can get complicated and seem overwhelming if you let it. In fact, there are some simple concepts involved. Don’t make this 

process difficult: keep it simple.
	

Take what you need and leave the rest. Not everyone benefits from every part
	

of 12-Step meetings. It is not a perfect program. However, if you focus on the parts you 

find useful, rather than the ones that bother you, the program has something for you. 

Bring your body, the mind will follow. The most important aspect of 12-Step 

programs is attending the meetings. It takes a while to feel completely comfortable. Try 

different meetings, try to meet people, and read the materials. Just go and keep going. 

HALT 

This acronym is familiar to people in the 12-Step programs. It is a shorthand way of 

reminding people in recovery that they are especially vulnerable to relapse when they 

are too hungry, angry, lonely, or tired. 

Hungry: When people are using, they often ignore their nutritional needs. People in 

recovery need to relearn the importance of eating regularly. Being hungry can cause 

changes in body chemistry that make people less able to control themselves or avoid 

cravings. Often the person feels anxious and upset but doesn’t associate the feelings 

with hunger. Eating regularly increases emotional stability. 

1 of 2
 
ERS 8 12-Step Sayings 

Angry: This emotional state is probably the most common cause of relapse to drug 

use. Learning to cope with anger in a healthy way is difficult for many people. It is 

not healthy to act in anger without thinking about the consequences. Nor is it healthy 

to hold anger in and try to pretend it doesn’t exist. Talking about anger-producing 

situations and how to handle them is an important part of recovery. 

Lonely: Recovery is often a lonely process. People lose relationships because of their 

substance use. As part of staying abstinent, people in recovery may have to give up 

friends who still use. The feelings of loneliness are real and painful. They make people 

more vulnerable to relapse. 

Tired: Sleep disorders are often a part of early recovery. People in recovery frequently 

have to give up chemical aids to sleep that they used in the past. Being tired is often 

a trigger for relapse. Feeling exhausted and low on energy leaves people vulnerable 

and unable to function in a healthy way. 

How often do you find yourself in one or more of these emotional states? 

What could you do differently to avoid being so vulnerable?
 

2 of 2
 
V. Relapse Prevention Group
 

Introduction 

Goals of Relapse Prevention Group 

■ Allow clients to interact with other people 

in recovery. 

■ Alert clients to the pitfalls of recovery and 

precursors of relapse. 

■ Give clients the strategies and tools to 

use in sustaining their recovery. 

■ Allow group members to benefit from 

the long-term sobriety experience of the 

recovering co-leader. 

■ Allow the counselor to witness the 

personal interactions of clients.
 

■ Allow clients to benefit from participating 

in a long-term group experience. 

Session Format and Counseling 

Approach 

New Member Introductions 

Each 90-minute Relapse Prevention (RP) group 

meeting begins with new members introducing 

themselves and giving a brief description of their 

substance use history. This description should 

not be detailed or graphic, nor should it be a 

litany of “war stories.” New members provide 

basic information such as type of substances 

used and their reasons for entering treatment. 

Clients who ramble or provide unnecessary substance use details should be prompted gently to 

finish their introduction. 

Topic Presentation and Discussion 

Following the introductions and during the first 15 

minutes of the session, the counselor presents 

a specific topic in a casual, didactic manner. The 

counselor then opens up the topic for discussion 

by the group for 45 minutes. Over the first hour 

of the meeting, the counselor ensures that all 

the important aspects of the topic are covered 

and that premature digressions from the main 

topic are avoided. Clients with concerns or 

questions unrelated to the topic can be assured 

that the final 30 minutes of the group meeting 

will be devoted to issues that individual clients 

are struggling with. The counselor wraps up the 

discussion period with a reiteration of the session 

topic and the important issues relevant to it. 

Open Discussion 

During the last 30 minutes of each group session, 

the counselor asks clients whether they have 

had any recent problems or whether they wish 

to bring up any matters. Individual clients, particularly those who have been having problems 

or those who have not participated in the group 

session, should be encouraged to participate. 

General questions that usually evoke a response 

include the following: 

■ How are things going? 

■ Are there any new developments with the 

problem you brought up last time? 

■ Have you had any cravings? 

■ If so, how did you handle them? 

■ How are you planning to stay abstinent 

this week? 

End of Session 

The counselor ties up loose ends, summarizes 

the discussion, and acknowledges any unresolved issues. Discussion of these issues can be 

carried over to the next meeting. The counselor 

can ask clients who during the session mentioned 

cravings or who appear troubled, angry, or depressed to stay afterward to talk briefly and to 

85 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

schedule them for individual sessions as soon 

as possible. All sessions should end on a positive note and with a reminder that what is said 

in group stays in group and a commitment by 

clients to attend the next RP group meeting. 

Special Considerations 

Clients who are quiet and uncommunicative may 

be concealing issues that should be elicited and 

discussed. 

The group provides an opportunity for clients 

to solicit input from and give encouragement to 

other group members. The counselor should ask 

for comments from all clients on the issue being 

discussed, especially if particular group members have coped with the issue. For example, 

clients who have moved beyond the protracted 

abstinence period could be asked to describe 

how they handled problems they encountered 

during that time. The counselor should not, however, relinquish control of the group or promote 

directionless crosstalk about how each person 

feels about what the others have said. The counselor must maintain the group’s focus and direction and be ready to redirect discussions that 

are moving into redundancy, irrelevance, 

inappropriateness, or volatility. 

The recovering co-leader can be a positive role 

model, reinforce suggestions, and share advice 

from experiences. Rather than lecture or talk 

down to the group, the recovering co-leader 

should speak in the first person about his or her 

experiences. The recovering co-leader may be 

effective in instances where clients are resistant 

to the counselor’s input. In such cases, the 

co-leader’s discussion of what worked for 

him or her may be offered in a “for what it’s 

worth” manner, with the aim of providing a 

strategy that worked for one person and the 

encouragement that comes with knowing that 

others have succeeded. 

Balancing Group Cohesion With Excessive 

Interdependence 

Along with 12-Step or other mutual-help meetings, 

the RP group is the most consistent element of 

Matrix treatment. Each of the initial 16 weeks 

of treatment features an RP group meeting on 

Monday and Friday. The frequency and intensity 

of these group meetings foster interdependence 

among clients. The resulting bonding and 

cohesion can support and motivate clients and 

help sustain treatment involvement. However, 

balancing clients’ responsibility to their fellow 

group members with the need to take charge of 

their own recovery can be tricky. The counselor 

needs to ensure that clients gain support and 

encouragement from the group without developing exclusive dependence on the group for their 

abstinence and recovery. Each client should 

view recovery as a personal achievement that 

has been supported and encouraged by other 

group members. If several group members 

experience relapse, the independence of each 

client’s personal recovery can help prevent 

relapse contagion, in which relapse seems to 

spread from member to member of a group like 

an infectious disease. 

The camaraderie and cohesion of an RP 

group are extremely valuable to the treatment 

process. However, clients should be cautioned 

against treatment program romances and 

outside involvement with other group members 

(e.g., entering into a business relationship). 

When they start treatment, clients must sign 

an agreement to avoid intense relationships 

outside group. The counselor should remind 

clients of this agreement and discuss with them 

the rationale for prohibiting intense personal 

involvement between group members. If two 

clients are becoming inappropriately involved, 

the counselor should meet with them briefly after 

group to remind them that such relationships are 

discouraged and to discuss appropriate ways that 

the clients can handle the situation. 

86 
 

V. Relapse Prevention Group 

In the first few months of recovery, the main 

forums for social support in the context of the 

Matrix method are the RP group and outside 

spiritual and mutual-help support groups. Clients 

should be encouraged to find a long-term support system through their involvement in these 

groups. By attending meetings and socializing 

with 12-Step members, recovering clients will 

be able to find a sponsor to help guide their 

recovery as well as make recovering friends with 

whom to pursue substance-free activities. To 

build a vital support system that will help them 

avoid relapse, clients in early recovery need 

to expand their network of support beyond the 

people they meet in treatment to include people 

with longer term abstinence. 

Handling Troublesome Client Behaviors 

At times, the counselor may need to intervene 

assertively in response to specific types of client 

behavior in the group. This intervention may 

consist of quieting a client, limiting a client’s 

involvement in the group, or removing a client 

from the group. Below are some strategies for 

handling troublesome client behaviors. 

Behavior: Occupying too much session time 

with an issue that has been addressed. 

Intervention: Politely suggest that it is 

time to allow others to discuss their issues and 

move on. 

Behavior: Arguing in favor of behavior that 

is counter to recovery (e.g., using, dropping out 

of group, using self-control instead of avoiding 

triggers) after receiving repeated feedback. 

Intervention: Point out the futility of these 

sorts of approaches in light of the realities of addiction and the experience of others. If the client 

continues along the same lines, ask him or her 

to listen and not to speak for the remainder of the 

group; this client’s concerns should be discussed 

individually after the group meeting. 

Behavior: Making threatening, insulting, 

or personally directed remarks; behaving in a 

manner obviously indicative of intoxication. 

Intervention: Take the client out of the 

group, and let the recovering co-leader lead 

the group. Have a brief individual session with 

the difficult client, or have another counselor 

intervene. Be sure that the client has calmed 

down before leaving him or her. Arrange for 

transportation home, if the client cannot drive 

or get home safely. 

Behavior: Having a general lack of commitment to treatment, as evidenced by poor attendance, resistance to treatment intervention, 

disruptive behavior, or repeated relapses. 

Intervention: Reassess and adjust the 

treatment plan in an individual or conjoint 

session with the uncommitted client. If the client 

agrees not to show up intoxicated or engage in 

inappropriate behavior, he or she can be allowed 

to attend the meeting but should be asked to 

listen and not to speak. The client should be 

given some discussion time at the end of this 

session, contingent on appropriate behavior. 

Addressing Drug Dreams During Recovery 

It is not unusual for clients in recovery to have 

frequent and intense dreams about substance 

use. The counselor should reassure clients that 

these dreams—which can be frightening—are a 

normal part of recovery. Stimulant use interferes 

with normal sleep patterns; when people stop 

using substances, vivid dreams are part of the 

brain’s recovery process. Intense dreams of substance use can produce feelings that persist into 

the waking day and can act as triggers for use. 

Clients who have detailed dreams about using 

should be alert to the added risk of relapse 

during the ensuing day. The counselor should 

encourage clients to express their concerns 

about drug dreams during the open discussion 

period of RP sessions. However, clients should 

87 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

be discouraged from describing their dreams of 

using in detail because they may act as triggers 

for other clients. If, during a group session, a 

client mentions having dreamed about using 

substances, the counselor should have clients 

look at handout RP 33—Drug Dreams During 

Recovery and go over it with them. The handout 

discusses how drug dreams affect early (0–6 

weeks), middle (7–16 weeks), and late (17–24 

weeks) recovery and provides some suggestions to help clients address the issue of drug 

dreams. This handout also can be used to 

supplement RP sessions that focus on triggers 

and cravings (e.g., sessions 3, 9, 11, 13, 16, 18, 

and 21). 

Rational Brain Versus Addicted Brain 

The RP group session descriptions use the 

metaphorical struggle between a client’s rational 

brain and addicted brain as a way to talk about 

recovery. The terms rational brain and addicted 

brain do not correspond to physiological regions of the brain, but they give clients a way to 

conceptualize the struggle between the desire 

to stay committed to recovery and the desire to 

begin using stimulants again. 

Adapting Client Handouts 

Client handouts are written in simpler language 

than the session descriptions for counselors. 

The client materials should be understandable 

for someone with an eighth grade reading level. 

Difficult words (e.g., abstinence, justification) 

are occasionally used. Counselors should be 

prepared to help clients who struggle with the 

material. Counselors should be aware that 

handouts will need to be adapted for clients 

with reading difficulties. 

Session Descriptions 

Pages 92 through 165 provide structured 

guidance to the counselor for organizing and 

conducting the RP group sessions. Figure V-1 

provides an overview of the RP sessions. 

Following the presentation of the 32 RP sessions 

are descriptions of 3 elective sessions that can 

be used as substitute sessions whenever the 

counselor deems appropriate. For example, 

Elective Session B addresses the difficulties 

clients may face around major holidays, such as 

Christmas or the Fourth of July. The counselor 

may wish to substitute this session for 1 of the 

32 regular sessions if a holiday is approaching. 

The handouts indicated in all the RP session 

descriptions are provided after the session 

descriptions for the counselor’s use and are 

duplicated in the Client’s Handbook. 

88 
V. Relapse Prevention Group 

Figure V-1. Relapse Prevention Sessions Overview 

Session 

Number Topic Content Pages

 1 Alcohol Clients learn how alcohol can jeopardize recovery. Clients discuss 

and plan for situations in which they are likely to drink. 92–93

 2 Boredom 

Clients learn that boredom in recovery is to be expected and 

will diminish over time. Clients discuss activities to help alleviate 

boredom. 

94–95

 3 Avoiding 

Relapse Drift 

Clients learn about relapse drift and discuss things that anchor 

their recovery. 96–97

 4 Work and 

Recovery 

Clients learn how their work life affects their recovery and explore 

ways to balance work and recovery. 98–99

 5 Guilt and 

Shame 

Clients learn to distinguish between guilt and shame and 

discuss ways to cope with each. 100–101

 6 Staying Busy Clients learn that idle time can be a trigger and discuss how 

scheduling activities can help them avoid relapse. 102–103

 7 Motivation 

for Recovery 

Clients learn that the same motivation that brought them to 

treatment may not sustain them. Clients discuss new motivations 

and strategies for staying abstinent. 

104–105

 8 Truthfulness 

Clients learn that although truthfulness is not always easy, 

it is integral to successful recovery. Clients discuss the 

consequences and benefits of always telling the truth. 

106–107

 9 Total 

Abstinence 

Clients learn that substance use of any kind will cloud their 

decisionmaking and endanger recovery. Clients discuss changes 

they must make to eliminate all substance use. 

108–109 

10 Sex and 

Recovery 

Clients learn that impulsive sex can be a form of dependence 

and can lead to relapse. Clients discuss the ways that stable 

relationships can contribute to recovery. 

110–111 

11 

Anticipating 

and Preventing Relapse 

Clients learn to recognize the warning signs of relapse and 

explore strategies for avoiding relapse. 112–113 

12 Trust Clients learn the necessity of restoring lost trust and discuss ways 

to cope with being suspected of continued substance abuse. 114–115 

13 Be Smart, 

Not Strong 

Clients learn that recovery is not a test of will but of commitment 

and smart planning. Clients discuss the efficacy of their approach 

to recovery. 

116–117 

89 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Figure V-1. Relapse Prevention Sessions Overview 

(continued) 

Session 

Number Topic Content Pages 

14 Defining 

Spirituality 

Clients explore the difference between spirituality and religion 

and discuss ways that spiritual beliefs can support recovery. 118–119 

15 

Managing 

Life; 

Managing 

Money 

Clients identify aspects of their life that have been neglected 

and explore ways to manage their lives responsibly. 120–121 

16 Relapse 

Justification I 

Clients learn about relapse justification. Clients discuss 

justifications to which they are susceptible and formulate plans 

to counter them. 

122–123 

17 Taking Care 

of Yourself 

Clients learn the importance of self-esteem to recovery and 

explore aspects of their lives that require change. 124–125 

18 Emotional 

Triggers 

Clients learn that emotions can act as triggers and discuss tools 

that will help them avoid dangerous emotions. 126–127 

19 Illness Clients learn that becoming ill can be a trigger and discuss 

ways to keep their recovery on track when they are sick. 128–129 

20 Recognizing 

Stress 

Clients learn the threat that stress poses to recovery. Clients 

discuss how to identify and cope with stressful situations. 130–132 

21 Relapse 

Justification II 

Clients learn that moving closer to relapse (e.g., to test the 

strength of their recovery) is dangerous. Clients explore 

strategies to resist relapse justifications. 

133–135 

22 Reducing 

Stress 

Clients are reminded that stress can endanger their recovery 

and discuss strategies to reduce stress. 136–137 

23 Managing 

Anger 

Clients learn that anger can be a trigger. Clients discuss ways 

to recognize and address a buildup of anger. 138–139 

24 Acceptance Clients learn that accepting their substance use disorder is not 

a sign of weakness. Clients explore strengths to rely on. 140–141 

25 Making New 

Friends 

Clients learn that abstinent friends can support their recovery. 

Clients discuss people who can serve as supportive friends and 

how to meet them. 

142–143 

90 
V. Relapse Prevention Group 

Figure V-1. Relapse Prevention Sessions Overview 

(continued) 

Session 

Number Topic Content Pages 

26 Repairing 

Relationships 

Clients learn the importance of making amends and discuss how 

to address people who refuse to forgive them. 144–145 

27 Serenity 

Prayer 

Clients learn to distinguish between things that can be changed 

and those that cannot. Clients discuss things in their lives that 

they will change. 

146–147 

28 Compulsive 

Behaviors 

Clients learn what compulsive behaviors are and how they can 

endanger recovery. Clients discuss ways to recognize and eliminate compulsive behaviors. 148–149 

29 

Coping With 

Feelings and 

Depression 

Clients learn to recognize their emotional responses, especially 

signs of depression. Clients explore strategies for coping with 

depression. 

150–152 

30 

12-Step and 

Mutual-Help 

Programs 

Clients learn how 12-Step and mutual-help programs support 

recovery. Clients explore the variety of 12-Step and mutual-help 

programs available. 

153–155 

31 

Looking 

Forward; 

Managing 

Downtime 

Clients learn that boredom can be a relapse trigger. Clients discuss ways to break the monotony of recovery. 156–157 

32 One Day at 

a Time 

Clients learn to avoid feeling overwhelmed by the past and explore strategies for focusing on the present. 158–159 

Elective 

Session 

A 

Client Status 

Review 

Clients learn that establishing a regular pattern of self-review will 

help support recovery. Clients discuss areas in which they need 

to improve. 

160–161 

Elective 

Session 

B 

Holidays and 

Recovery 

Clients learn that holidays pose risks for recovery and discuss 

ways to alleviate the added stress that comes with holidays. 162–163 

Elective 

Session 

C 

Recreational 

Activities 

Clients learn how new hobbies and pursuits can help support 

recovery. Clients discuss old hobbies they would like to pick up 

again or new pursuits they wish to try. 

164–165 

91 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 1: Alcohol 

Goals of Session 

■ Help clients understand that alcohol is a substance whose use can jeopardize recovery. 

■ Help clients identify the situations in which they are most likely to drink. 

■ Help clients plan for those situations so they can remain abstinent. 

Handout 

■ RP 1—Alcohol 

Presentation of Topic (15 minutes) 

1. Understanding the Effects of Alcohol on the Brain 

Because alcohol affects the rational, reasoning part of the brain, people who are drinking are especially 

ill equipped to evaluate the detriments of drinking and the benefits of quitting. Drinking also lessens 

people’s inhibitions and makes them feel less self-conscious, more sociable, and more sexual. Some 

clients will have to address the fact that they have used alcohol to make themselves feel comfortable 

in social situations. Some clients may have to address the fact that sexuality is linked with alcohol for 

them. Clients who are accustomed to consuming alcohol in social or sexual situations may find that, 

for a time, these activities are uncomfortable without alcohol. 

2. Being Alert for External and Internal Triggers for Drinking 

Alcohol consumption is a significant and pervasive part of U.S. culture. Clients who are trying to stop 

using alcohol face a difficult struggle. External triggers bombard clients; consumption of alcohol is 

assumed to be the norm, especially at social functions and celebrations. It is hard for clients to go 

through a typical day without coming across many reminders—both cultural and personal—of alcohol. 

Advertisements, movies, and TV shows link drinking with being happy, popular, and successful. Clients 

encounter colleagues, friends, and family members with whom they used to drink and pass by bars or 

liquor stores that they used to frequent. 

Internal triggers also pose problems for clients. Depression, anxiety, and loneliness are all characteristic 

of recovery. These emotional states also are cues to drink for many people. Facing the emotional 

fallout from quitting other substances, clients feel justified in turning to alcohol to “relieve” their mental 

state. It is difficult for clients to realize that alcohol may be responsible for their depression or other 

emotional problems. 

3. Preparing for Situations Involving Alcohol 

Drinking often accompanies certain activities: wine with dinner, a beer at the game, a drink after work. 

Alcohol also is integral to celebrations such as parties and weddings. For some clients, alcohol seems to 

be an inextricable part of these activities; they cannot conceive of enjoying certain activities without drinking. Not drinking may mean that clients feel left out of the fun, less cool. It is important for clients to know 

that they will have these feelings and to prepare for them. Clients should be encouraged to think about 

ways of celebrating that do not involve alcohol. If they know that being around others who are drinking will 

make them feel left out, clients should avoid such situations until their recovery is well underway. 

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V. Relapse Prevention Group 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 1—Alcohol. 

■ Ask clients who already have covered the material to recall the discussion of triggers from Early 

Recovery Skills (sessions 2 and 3) and share what they learned about external and internal 

triggers with the group. The recovering co-leader can share his or her experiences with triggers. 

■ Ask clients to discuss what people, places, situations, and mental and emotional states act as 

triggers for them. 

■ Survey clients’ success at stopping drinking. How many have tried? How many have succeeded? 

■ Ask clients to recall a time when they saw that someone else’s judgment was affected by 

drinking. What does this tell them about their ability to make smart decisions about recovery 

while they still are drinking? 

■ Encourage clients to discuss ways they have become dependent on alcohol in social situations. 

(Note: Although it is important for clients to discuss their experiences, the counselor should 

ensure that clients do not detour into elaborate descriptions of substance use that could act 

as triggers.) 

■ Ask clients how they can prepare themselves for situations in which they formerly used alcohol. 

■ Urge clients to think about situations to avoid if they are to remain abstinent. 

■ Ask clients what changes they can make in their celebrations with family and friends to remain 

abstinent. 

The counselor should end this portion of the group session by reassuring clients that everyone who 

stops drinking must work through the same difficulties. The longer clients are abstinent, the easier it 

will be for them to manage these difficult situations. 

Open Discussion (30 minutes) 

Although it is important for clients to be able to speak about what is on their minds, the counselor 

should make sure that the session’s topic has been explored completely. 

Homework 

To prepare for abstinence, instruct clients to use their journal or pages 6 and 7 of their Client’s 

Treatment Companion to solidify their plans. Ask clients to write down situations that pose the greatest 

threat to their sobriety and, for each situation, detail three alternatives to help them avoid drinking. 

93 
 

Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 2: Boredom 

Goals of Session 

■ Help clients understand that boredom poses a risk to their recovery. 

■ Help clients understand that the situation will improve with time. 

■ Help clients identify new activities and techniques that will help them through their boredom. 

Handout 

■ RP 2—Boredom 

Presentation of Topic (15 minutes) 

1. Understanding the Risk Boredom Poses 

Boredom is a precursor to relapse. For many clients, boredom is a trigger: when they were bored, they 

would use. Unless clients take some action, the boredom—and the relapse risk that accompanies it— 

will not dissipate. To have a successful recovery, clients must continue to make progress. Standing still 

can mean losing ground. Clients need to take action to combat the inertia that boredom represents. 

2. Understanding the Reasons for Boredom 

Some of the boredom clients feel can be attributed to the shift from a substance-using to a substancefree lifestyle. When contrasted with the emotional highs and lows of substance use, an abstinent life can 

seem dull. The brain still is adjusting to the lack of substances. While the brain heals, clients may feel listless or bored. The period from 2 to 4 months into recovery (known as the Wall) is often characterized by 

emotional flatness and boredom. Finally, the structure clients must impose to have a successful recovery 

may not offer them the short-term emotional rewards of a substance-using lifestyle. 

It is important for clients to know that, as their body and mind adjust to recovery, boredom will become 

less of an issue. 

3. Addressing Boredom 

There are several ways clients can reduce feelings of boredom. The skills clients learn in the Early 

Recovery Skills group can be put to use. For example, scheduling every hour of every day helps clients 

identify unplanned sections of time that can be used to explore interesting activities. Starting new 

hobbies or picking up interests that were abandoned while clients were using is a good way to defeat 

boredom. Some clients schedule something that they can look forward to: a long weekend, a visit with 

family, a concert, a movie. It also may help clients to discuss their feelings of boredom with a spouse, 

loved one, or trusted friend. Starting new friendships with substance-free people met through 12-Step 

or mutual-help groups also can help alleviate clients’ boredom. (The counselor should remind clients 

that intense personal involvements—including romantic or sexual relationships—among group members 

are discouraged.) 

The danger of boredom during recovery is that it encourages clients just to float along. Before they know 

it, clients can drift from abstinence into relapse. The most important thing clients can do is take an active 

94 
V. Relapse Prevention Group 

role in their recovery. Engaging in some kind of process and working toward a goal—taking up a hobby, 

planning a vacation, starting a friendship—also help clients move toward their recovery goals. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 2—Boredom. 

■ Ask clients whether they are having trouble with boredom. When did they first notice it? 

■ Ask what actions clients have taken to counter boredom. 

■ Ask the recovering co-leader to share his or her experiences with boredom. 

■ Ask clients to list new activities they have tried or might try to help them during recovery. How 

have these activities affected or will they affect their recovery? 

■ Survey the clients to learn how many are scheduling activities. Ask them to share how scheduling 

has helped them. 

■ Ask clients what kinds of activities they can plan and anticipate to help them counter boredom. 

■ Remind clients that although structure is important to recovery, sometimes boredom results from 

too much routine. People who are stuck in a boring rut can be heading toward relapse. Boredom 

can indicate that clients are not challenging themselves enough in their daily lives. Encourage 

clients to try new things that will advance their personal growth and bolster their recovery. 

■ Ask the recovering co-leader to share with clients the activities and techniques that helped him 

or her defeat boredom. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Have clients keep a record of their emotional states, staying vigilant for signs of boredom. 

95 
 

 

Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 3: Avoiding Relapse Drift 

Goals of Session 

■ Help clients understand the process of relapse drift. 

■ Help clients identify things in their lives that are anchoring their recovery. 

■ Help clients identify things that must be avoided because they threaten to send clients into 

relapse drift. 

Handouts 

■ RP 3A—Avoiding Relapse Drift 

■ RP 3B—Mooring Lines Recovery Chart 

Presentation of Topic (15 minutes) 

1. Understanding How Relapse Drift Can Lead to Relapse 

In the group session on boredom (RP session 2) clients learned that boredom can be a sign that they 

are not taking an active role in their recovery, that they are just going with the flow. Relapse drift is the 

process by which people slide from abstinence to relapse without even realizing what is happening. A 

useful comparison is that of sailors who anchor a boat before going to sleep below decks. If the anchor 

is not properly set, the boat will drift away during the night; the sailors wake up to find they 

are in unfamiliar waters, far from their safe anchorage. 

Although relapse may feel like a sudden occurrence—an unforeseeable disruption of recovery—often 

it is the result of a gradual movement away from abstinence that is so subtle clients can explain it away 

or deny responsibility for it. Relapse rarely occurs without warning signs. Clients need to remain vigilant 

for signs of relapse. (In Early Recovery Skills session 7, these early warnings of relapse were referred 

to as addictive behaviors.) 

2. Understanding the Importance of Mooring Lines 

People who are successful in recovery find ways to remain abstinent. Pursuing certain activities or 

avoiding certain people and situations becomes essential to maintaining recovery. Identifying these 

recovery-supporting behaviors and checking to make sure they are in place also are essential to maintaining abstinence. These recovery-supporting behaviors are the “mooring lines” of people in recovery. 

They keep clients anchored in recovery and alert them to the first signs of relapse drift. Clients need 

to examine their recovery process and identify their mooring lines. Doing so allows them to list and 

monitor the things that are anchoring their recovery. 

3. Monitoring Mooring Lines 

To monitor their mooring lines, clients need to identify them and list them as specifically as possible. 

Merely listing “Exercise” is not as helpful to the client as listing “Ride bike for at least 30 minutes, 4 times 

a week.” Likewise, listing a friend as a mooring line is not as helpful as writing “Talk on the phone with 

Louisa once a week.” Clients should avoid listing attitudes or things that are not quantifiable as mooring 

lines. Although a feeling of optimism may help clients stay abstinent, it is not easy to monitor. The goal is 

96 
V. Relapse Prevention Group 

to have clients make a list of activities or behaviors whose presence or absence they can note. Detailed, 

concrete listings give clients better indications of whether their mooring lines are secure. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to read handout RP3—Avoiding Relapse Drift and complete handout 

RP3B—Mooring Lines Recovery Chart before the discussion begins. Clients should not be forced to 

comply if they find it difficult or uncomfortable to complete the handout in the group. The handout is 

primarily a tool for discussion. The counselor steers clients away from reading their responses and 

encourages them to converse about the issues the handout raises. The counselor ensures that all 

clients have an opportunity to participate. 

■ Go over handout RP 3A—Avoiding Relapse Drift. Cover any aspects of the topic that were not 

addressed in the didactic portion of the session. 

■ Go over handout RP 3B—Mooring Lines Recovery Chart. Give clients 5 to 10 minutes to 

complete this chart. 

■ Ask clients to share the activities, behaviors, and people they identified as mooring lines. 

■ Have clients explain how one of their mooring lines helps keep them abstinent and secure in 

their recovery. 

■ Ask the recovering co-leader to share his or her experience with mooring lines. Have they 

stayed the same over time? Or has the co-leader added new mooring lines as recovery has 

progressed? 

■ Ask clients to share the activities, behaviors, and people they must avoid if their recovery is to 

remain anchored. 

■ Ask clients how often they will check their mooring lines. It is recommended that they check 

them at least weekly. 

■ Review with clients the steps they can take if they realize that more than two of their mooring 

lines are missing and they are drifting toward relapse. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Instruct clients to check their mooring lines once before the next RP session. 

97 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 4: Work and Recovery 

Goals of Session 

■ Help clients understand how their work life affects their recovery. 

■ Help clients examine possible solutions to problems that work poses to their recovery. 

Handout 

■ RP 4—Work and Recovery 

Presentation of Topic (15 minutes) 

1. Understanding Conflicts Between Work and Recovery 

Recovery takes a total commitment from clients, yet few people can afford to ignore their jobs or stop 

job-hunting and focus solely on their recovery. As a result, many clients experience conflicts between 

employment issues and recovery. Some conflicts may be difficult to resolve; it is important to acknowledge conflicts that exist and work toward solutions. 

2. Finding Balance Between Work and Recovery 

Although the four work situations on the handout RP 4—Work and Recovery are very different, some 

general principles can help clients address them. Because treatment must coexist with work, clients 

may have to find ways to cut back on their work commitments to incorporate all the activities and demands of recovery. Finding this balance may require employees to request that their work schedules be 

adjusted. 

Clients who are in jobs that contributed to their substance use problem (e.g., where other people use 

substances or where the client is paid in cash) face a dilemma. Clients may feel that it is better to quit 

such a job, yet major change or upheaval is not recommended during the first 6 months to a year of 

recovery. Unemployment may seem preferable if the job poses risks to relapse. However, without the 

structure of and income from work, clients may have difficulties committing to recovery. 

Although it is unpaid, recovery is work in a real sense. And recovery may be more important to clients’ 

happiness and success than their paying work. Clients should be encouraged to devote as much time 

and effort as they can to their recovery. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to read the handout before the discussion begins. The handout is 

primarily a tool for discussion. The counselor encourages clients to converse about the issues the 

handout raises. The counselor ensures that all clients have an opportunity to participate. 

■ Go over handout RP 4—Work and Recovery. 

■ Ask clients to share which of the work situations best fits them. Are there other situations that 

are not listed on the sheet that apply? 

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V. Relapse Prevention Group 

■ Ask what compromises and changes clients have made to find time for recovery. 

■ Ask the recovering co-leader to share his or her experience with balancing work and recovery. 

Has striking that balance gotten easier as recovery has progressed? 

■ Allow clients to debate the pros and cons of leaving a job that is obstructing recovery. 

■ Ask clients whether they have worked with their bosses or their company’s employee assistance 

program to make it easier to commit to treatment activities. 

■ Ask whether there are clients in the group who opted for intensive outpatient treatment over 

inpatient treatment because of the demands of their jobs. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Ask clients to examine their commitment to recovery and come up with two new strategies for 

effectively balancing work and recovery. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 5: Guilt and Shame 

Note: This topic should not be used when there is a client attending his or her first RP group session. 

If there is a client new to the group, the counselor should choose a different topic for the session so 

that a new member is introduced to the group with a less daunting subject. 

Goals of Session 

■ Help clients understand the difference between guilt and shame. 

■ Help clients learn strategies for coping with guilt and shame. 

Handout 

■ RP 5—Guilt and Shame 

Presentation of Topic (15 minutes) 

1. Differentiating Guilt From Shame 

Guilt refers to feeling bad about things one has done or failed to do. For example, one might feel guilty 

for cheating on a spouse or for neglecting to keep promises to a child. Shame goes beyond a response 

to a specific action or behavior. Shame means feeling bad about who one is—a belief that one is 

defective or unworthy. 

Feelings of guilt and shame are often part of people’s responses to substance abuse. But it is important 

for clients to distinguish between the two. Guilt can be a useful reaction in recovery, indicating to clients 

that they have done something that goes against their value system. Guilt can motivate clients to seek 

forgiveness and make amends for the pain and trouble they have caused others. However, if clients 

are convinced they are bad people, they may feel unworthy of recovery and feel that they have a license to use substances. Shame can be an impediment to abstinence. 

2. Addressing Feelings of Guilt and Shame 

Both guilt and shame can erode a client’s self-esteem and self-confidence. Focusing on negative 

feelings can cause clients to turn to substance use to alter their mood or to escape. Clients should be 

reminded that their substance abuse is not related to their being bad or weak. To stay abstinent, clients 

need to be smart and work hard, and part of being smart and working hard is understanding their feelings. What things do they feel guilty about? What has contributed to their feelings of shame? Clients 

may need time to work through feelings of guilt and shame. Clients need to give themselves time to 

feel better about themselves and their behaviors. Talking about feelings of guilt and shame also may 

help clients, as can making amends. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

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V. Relapse Prevention Group 

■ Go over handout RP 5—Guilt and Shame. 

■ Ask clients to list the things that they feel guilty for doing and for neglecting to do. 

■ Remind clients that it is all right to have made mistakes; they cannot change the things they did 

in the past. Ask whether they are able to forgive themselves for past mistakes. 

■ Have clients discuss the difference between moving past guilt by forgiving themselves and 

simply letting themselves off the hook. 

■ Ask the recovering co-leader to share his or her experience of overcoming guilt. How did the 

co-leader balance the need to take responsibility for past actions with the need to forgive those 

actions? 

■ Have clients discuss how they can get over feelings of guilt and shame. What positive behaviors 

can they engage in that will aid this process? 

■ Ask clients who are attending 12-Step or mutual-help meetings whether guilt and shame have 

been discussed in meetings. Ask how these discussions have been helpful. 

■ Ask the recovering co-leader to discuss how mutual-help fellowship has helped him or her cope 

with guilt and shame. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Encourage clients to think about people from whom they may need to ask forgiveness. How will they 

approach these people? What can they do to put things right with the people they have hurt? 

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Session 6: Staying Busy 

Goals of Session 

■ Help clients understand the importance of scheduling activities. 

■ Help clients understand how idle time can be a trigger to use. 

■ Help clients learn and share strategies for scheduling and staying busy. 

Handout 

■ RP 6—Staying Busy 

Presentation of Topic (15 minutes) 

1. Understanding the Importance of Scheduling and Structure to Recovery 

Most clients in this session already will have been introduced to the practice of scheduling in the 

Early Recovery Skills group (Early Recovery Skills session 1). However, the structure that scheduling 

provides is so important to recovery that the principle should be reviewed here. Clients are reminded 

that many people who abuse substances organize their days around procuring, using, and recovering 

from the substances. Without these activities to structure their time, many people with a substance 

use disorder feel a void or sense of loss. Finding new activities and new ways to occupy their time 

and replace that sense of loss is a major component of recovery for clients. It is important for clients to 

write down their schedules. Schedules that exist only in one’s head are too easy to revise or abandon. 

When clients are making their schedules, special attention should be paid to weekends and other times 

clients feel they are particularly vulnerable to substance use. 

2. Understanding How Free Time Can Act as a Trigger 

Because using was a habitual activity for clients, their minds gravitate back to thoughts of using if they 

have nothing to do and nowhere to go. Then, the thought–craving–use process begins, and clients are 

on their way to relapse. Being alone also can be a trigger for clients. Before they entered treatment, 

many probably isolated themselves from friends and loved ones when they used. For this reason, it is 

important not just that clients schedule substance-free activities but that these activities involve other 

people who are living a substance-free life (e.g., people clients meet at mutual-help meetings) or are 

committed to the clients’ recovery (e.g., family members and friends). 

3. Incorporating New Activities and New People 

Even clients who are committed to recovery can miss aspects of a substance-using lifestyle. Scheduling 

activities and staying busy are ways to keep clients engaged in their new lives without substance use. 

Some clients are interested sufficiently by picking up old hobbies or activities; others need the increased 

interest that is generated by new activities and new acquaintances. Although the focus of their lives 

must be recovery, clients are encouraged to think of recovery as a time to try something they have put 

off: volunteering, taking up a new sport, learning to play a musical instrument. 

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Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 6—Staying Busy. 

■ Ask clients to think about how unfilled time and an unoccupied mind can act as triggers. 

■ Ask whether clients have felt tempted to use when they had too much free time on their hands. 

How did they respond? 

■ Ask the recovering co-leader to share his or her strategies for staying busy to keep recovery 

on track. 

■ Ask clients whether they always used in groups or tended to use alone. Discuss the dangers of 

being alone for those who tend to isolate themselves. 

■ Ask clients what activities have helped them stay busy and stay abstinent since they stopped 

using. 

■ Solicit suggestions from clients for hobbies or activities they would like to try that they feel will 

help them stay abstinent. 

■ Ask clients whether they have made new friends through mutual-help meetings. What activities 

have they pursued outside meetings? 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Instruct clients to make a wish list of activities they would like to pursue. The lists could include 

activities that they learned about from other clients in the group. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 7: Motivation for Recovery 

Goals of Session 

■ Help clients understand that the motivation that brought them into treatment may change as 

they progress in treatment. 

■ Help clients recognize new motivations and strategies for staying abstinent. 

■ Help clients identify benefits from recovery. 

Handout 

■ RP 7—Motivation for Recovery 

Presentation of Topic (15 minutes) 

1. Understanding That Reasons for Staying in Treatment Evolve Over Time 

Clients know that they must remain steadfast in recovery. This knowledge may lead some to believe 

that their motivation for remaining abstinent must always be the same. It does not matter what brings 

clients into treatment in the first place. What is important is what motivates clients to stay abstinent 

each day. The counselor might remind clients that, although staying abstinent is a lifelong goal, they 

can achieve it only hour by hour and day by day. Clients may find that their reasons for staying abstinent change over time. Some clients may realize this for the first time as a result of handout RP 7 and 

the ensuing discussion. 

2. Using New Strategies as Motivations Evolve 

Clients may enter treatment because they are afraid of what will happen if they do not stop using 

substances. Clients may find that if they focus on staying abstinent, their initial motivation for not 

using drugs and alcohol will evolve into a personal, internal desire to maintain their new lives. 

3. Remaining Abstinent Long Enough To See the Benefits of Recovery 

When clients have been abstinent long enough to experience the benefits that abstinence brings, the 

desire to see those benefits persist becomes a powerful motivator for clients to stay in recovery. Clients 

are able to address problems with family, friends, and employment that resulted from substance abuse. 

In place of feeling the shame and having the self-defeating attitude that characterize many people who 

abuse substances, clients now can take pride in their abstinence and their new lives. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

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■ Go over handout RP 7—Motivation for Recovery. 

■ Ask clients what assumptions they made about the various motivations for starting treatment 

listed on RP 7—Motivation for Recovery. Which motivations seem the strongest? 

■ Ask clients to discuss the reasons that brought them to treatment. 

■ Ask whether the same things are motivating them today that motivated them when they 

started treatment.
 

■ Ask what motivates clients to stay in treatment and be abstinent now. 

■ Ask the recovering co-leader to discuss how his or her motivations evolved from the start 

of treatment.
 

■ Ask clients whether they feel that they are running out of reasons for staying in treatment. 

■ Ask the group to suggest reasons for staying abstinent and in treatment. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Ask clients to add to the list of current motivations they made during this session. Instruct them to 

identify three more reasons for them to stay in treatment. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 8: Truthfulness 

Goals of Session 

■ Help clients understand that substance dependence and truthfulness are irreconcilable states. 

■ Help clients acknowledge that truthfulness will not always be easy. 

■ Help clients understand that continued truthfulness is integral to successful recovery. 

Handout 

■ RP 8—Truthfulness 

Presentation of Topic (15 minutes) 

1. Understanding That Substance Dependence Is Based in Unreality and Recovery Is 

Based in Truth 

Substance dependence represents an escape from the realities of life, a flight from responsibility, and 

a denial of consequences. Maintaining a substance-abusing lifestyle requires people to lie and make 

excuses continually. Entering recovery represents the first step toward acknowledging the truth of 

substance dependence. To be successful, recovery must continue to be grounded in truth. This means 

not just that clients acknowledge that they have a substance use problem but also that they make a 

commitment to behave truthfully with the people in their lives. 

2. Understanding the Difficulties Posed by Truthfulness 

Often it is hard for clients to be honest with themselves about their substance abuse. Having taken the 

step to enter treatment and be truthful with themselves, they now face the more daunting task of being 

honest with those around them. Being honest with friends and loved ones can be harrowing. Clients 

risk driving away friends and alienating family members when they give an honest account of their 

actions while they were using. Clients may be embarrassed to admit their actions. Loved ones may 

be offended by clients’ blunt approach to truth telling. 

The RP group is a good place for clients to get used to telling the truth. Other group members may 

take offense, but that, too, provides good practice for addressing the responses of family members 

and friends. 

3. Understanding That Recovery Cannot Be Successful Without Truthfulness 

If clients choose to be in treatment without being totally truthful, they have not committed fully to recovery. It is as if by continuing to deceive and be less than truthful, these clients are holding back, refusing 

to become involved fully in their recovery. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

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V. Relapse Prevention Group 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 8—Truthfulness. 

■ Ask clients to make an honest assessment of the ways they were dishonest when they were 

using. Encourage them to look beyond obvious lies and discuss ways in which they misled 

people or let them believe something that was not true. 

■ Discuss the limits of truth telling. What types of things should clients be sure they are always 

honest about? Are there situations in which it is all right not to be completely honest? 

■ Ask clients to think about the consequences of telling the truth to friends and family members. 

Does the prospect of doing so upset them? 

■ Ask the recovering co-leader to discuss his or her experiences of telling the truth to friends and 

family members. 

■ Ask whether clients are experiencing difficulty telling the truth in group. 

■ Ask what problems clients have encountered. What positive experiences have come from 

being honest? 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Encourage clients to speak truthfully about their substance abuse with a friend or family member 

before the next RP group meeting. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 9: Total Abstinence 

Goals of Session 

■ Help clients understand that they need to stop using alcohol and all mood-altering drugs. 

■ Help clients understand that continued substance use will cloud their decisionmaking and 

endanger recovery.
 

Handout 

■ RP 9—Total Abstinence 

Presentation of Topic (15 minutes) 

1. Understanding the Connection Between Alcohol and Other Substance Use and Relapse 

to Stimulants 

Substance abuse clouds judgment and throws lives out of balance. People and things that had been 

priorities before a person became substance dependent—family, friends, work—often get ignored as 

substance abuse takes precedence. To put their lives back into balance and to reorient their priorities, 

clients need to be able to think and act clearly. Stopping stimulant use is an important part of this 

process. But continued use of marijuana, another drug, or alcohol can jeopardize this process. 

Clients may not think these other substances pose a problem. Some may even argue that occasional 

use of alcohol or marijuana helps them cope with the stress of stopping stimulant use. Clients need to 

be convinced that any substance use will interfere with their brain’s ability to heal and their mind’s ability to reason clearly. Any substance use interferes with recovery. However, the counselor makes it clear 

that clients should continue to take prescribed medications required to treat chronic physical or mental 

disorders. 

2. Understanding That It Is Not Possible To Learn How To Cope Without Stimulants if Clients Turn to 

Alcohol or Marijuana or Other Substances To Escape 

The counselor reminds clients that they signed an agreement not to use any substances when they 

began treatment. Even if clients have not used stimulants during treatment, use of alcohol or other 

mood-altering substances is a way of avoiding a full commitment to recovery. By continuing to use 

substances, clients are hedging their bets, using alcohol or marijuana as an escape hatch in the event 

that recovery is too hard. Clients lessen their chances of successful recovery for stimulant dependence 

if they continue to use alcohol and other substances, even once in a while. Alcohol use makes relapse 

to stimulant use eight times more likely; marijuana use makes relapse three times more likely (Rawson 

et al. 1995). 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to read the handout before the discussion begins. The handout is 

primarily a tool for discussion. The counselor encourages clients to converse about the issues the 

handout raises. The counselor ensures that all clients have an opportunity to participate. 

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V. Relapse Prevention Group 

■ Go over handout RP 9—Total Abstinence. 

■ Ask clients to share their responses to the “no substance use” agreement they signed on 

admittance to treatment.
 

■ Ask whether clients find themselves coming up with justifications for drinking or getting high. 

What are these justifications? 

■ Ask whether some clients have come to appreciate the logic of ceasing all substance use. 

What changed their minds? 

■ Ask the recovering co-leader to discuss his or her experiences with the “no substance use” 

policy. 

■ Ask clients to think about what changes they have made or will have to make in their lives to 

eliminate use of alcohol and marijuana (e.g., get rid of all the alcohol in the house, ask family 

members or housemates not to bring home pot, advise loved ones that they have stopped 

drinking and getting high). 

■ Ask clients who have stopped all substance use to share with the group reasons why total 

abstinence is a good idea. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Instruct clients to list the steps they will take to begin totally abstinent recovery. Ask clients who are 

already in compliance with the “no substance use” agreement to list reasons they will maintain total 

abstinence. Clients can use their journals or pages 8 and 9 of their Client’s Treatment Companion. 

109 
 

Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 10: Sex and Recovery 

Note: This topic should not be used when there is a client attending his or her first RP group session. 

If there is a client new to the group, the counselor should choose a different topic for the session so 

that a new member is introduced to the group with a less sensitive and intimate subject. 

Goals of Session 

■ Help clients understand distinctions between intimate sex and impulsive sex. 

■ Help clients understand that impulsive sex can be a form of dependence and can lead to relapse. 

■ Help clients appreciate the importance of stable relationships. 

Handout 

■ RP 10—Sex and Recovery 

Presentation of Topic (15 minutes) 

1. Understanding What Distinguishes Intimate Sex From Impulsive Sex 

The counselor should anticipate that this topic will be met with some nervous laughter and joking from 

clients. This response may be unavoidable. However, the counselor and recovering co-leader need to 

take a serious approach to the topic and maintain a serious atmosphere during discussion. 

The distinction between intimate and impulsive sex depends on the relationship with the sexual partner. 

Intimate sex is a caring act that takes place in the context of a relationship. It is an extension of the 

feelings that two people have for each other. Impulsive sex is a selfish act in which the sexual partner 

is being used to achieve a type of high. The feelings of the partner are irrelevant. Impulsive, selfish sex 

need not even involve another person; excessive masturbation is a form of impulsive sex. 

Counselors should ensure that all clients understand that they run the risk of contracting HIV/AIDS and 

other sexually transmitted diseases if they engage in impulsive and unprotected sex. 

2. Understanding How Impulsive Sex Can Act as a Trigger for Substance Use 

For some clients, impulsive sex was linked with substance use before they came into treatment. They 

usually would have sex when they were using. Other clients may turn to impulsive sex to achieve a 

kind of high after they have stopped using substances. In both cases, impulsive sex is a trigger for 

substance use and can lead to relapse. Clients even can become dependent on impulsive sex just 

as they were dependent on substances. 

3. Understanding How Intimacy and Stable Relationships Can Support Recovery 

Many components of a stable relationship also are important to a successful recovery. Clients who 

have relationships characterized by trust, honesty, and support should find it easier to participate fully 

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V. Relapse Prevention Group 

in recovery activities, support others in group sessions, and be truthful about their lives. A stable 

relationship that includes intimate sex can help support recovery. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 10—Sex and Recovery. 

■ As the discussion begins, be sure to keep the group focused on the importance of these issues 

to recovery. 

■ Ensure that clients understand the difference between impulsive sex and intimate sex. 

■ If clients are not in a relationship, help them determine whether they need a period of celibacy 

to support their recovery. For some clients, sex and stimulant use are so intertwined that any 

feelings of arousal can act as a trigger. With abstinence from substances, the connection 

between arousal and stimulant use will diminish. 

■ Ask clients to discuss the connection between impulsive sex and substance use in their lives. 

■ Ask clients to discuss rewarding, caring relationships they have had or currently have. 

■ Ask what features of these relationships help support clients’ recovery. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Have clients list specific ways they can make their current relationship more caring, supportive, and 

intimate. If clients are not in a relationship, ask them to focus on ways to improve their next relationship. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 11: Anticipating and Preventing Relapse 

Goals of Session 

■ Help clients understand what relapse is and how it develops. 

■ Help clients recognize the warning signs of relapse. 

■ Help clients develop strategies for avoiding relapse. 

Handout 

■ RP 11—Anticipating and Preventing Relapse 

Presentation of Topic (15 minutes) 

1. Understanding That Staying Abstinent Is Different From Deciding To Stop Using Substances 

The decision to stop using substances and enter treatment is important. But having decided once to 

stop using, clients must now decide every day not to start using again. Now that they have stopped 

using and are in treatment, clients need to be vigilant about signs of relapse. Using is familiar and 

comfortable behavior; clients’ bodies and minds will want to return to using. So clients must anticipate 

and prevent relapse. 

2. Learning To Recognize Emotional Buildup and Addictive Behaviors 

Being on guard for relapse means that clients are attuned to their physical and emotional well-being. 

Persistent, nagging emotions (e.g., boredom, anxiety, irritability, depression) or physical symptoms 

(e.g., insomnia, headaches) often can serve as triggers in the relapse process. Likewise, clients may 

find themselves engaging in the behaviors that used to accompany their substance abuse (e.g., lying, 

stealing, acting compulsively). These addictive behaviors are like an alarm bell; they tell clients that a 

relapse is on the way unless the clients take action. 

3. Enacting a Plan To Avoid Relapse 

Clients need to plan in advance how they will intervene when they are at risk of relapse. Different 

interventions work for different clients. Common actions that help are talking with a trusted friend or 

family member, going to a mutual-help meeting, talking to a counselor, exercising, or doing something 

to move out of a rut, such as taking a day off from work. Clients should think about what will work for 

them and be prepared to put their plan into action at the first sign of a relapse. 

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V. Relapse Prevention Group 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 11—Anticipating and Preventing Relapse. 

■ Make sure clients understand what relapse is and appreciate the importance of relapse 

prevention.
 

■ Ask clients to describe the activities that they engaged in when they were using. These are 

addictive behaviors. Have these behaviors crept back into their lives? 

■ Ask the recovering co-leader to give examples of addictive behavior from his or her experience. 

■ Emotional buildup may be a difficult concept for clients to grasp. Ask the recovering co-leader to 

describe how emotions can build up and lead to relapse. 

■ The concept of addictive thinking will be addressed further in two sessions on relapse justification. 

For now, have clients discuss justifications for engaging in behaviors that could lead to relapse. 

■ Ask clients what indications of an impending relapse they will look out for. 

■ Ask clients to share their plans for avoiding relapse. Encourage them to be specific about 

their plans.
 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Ask clients what they are doing on a regular basis to avoid relapse. Have clients record the steps they 

are taking to avoid triggers and stop thoughts of using. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 12: Trust 

Goals of Session 

■ Help clients understand the role that trust plays in their relationships. 

■ Help clients understand the necessity of restoring lost trust. 

■ Help clients cope with suspicions of continued substance abuse. 

Handout 

■ RP 12—Trust 

Presentation of Topic (15 minutes) 

1. Understanding the Damage That Substance Abuse Does to Trusting Relationships 

People who use substances often find themselves concealing their behavior from those they care 

about with deceit and lies. If the substance abuse comes to light, the people who have been lied to 

often have a hard time trusting the person who has been deceiving them. Once trust has been violated, 

it is not easy to win back. Trust that has been earned over years can be demolished with a single act. 

And it may take a long time to convince people that the person who destroyed their trust is worthy of 

being trusted again. 

2. Restoring Trust in Relationships 

The only way for clients to rebuild trusting relationships with those they have wronged is by staying 

abstinent and making amends for the harm they have done. The process of restoring the trust is more 

laborious than the blow that brought it down. Clients cannot expect their friends and family members to 

believe that they will remain abstinent. Clients have to provide evidence that they can be trusted again. 

3. Coping With Suspicions of Continued Substance Use 

Earning back people’s trust can be a frustrating process. Clients may feel that they have been 

abstinent long enough for their loved ones to trust them again. However, clients must understand 

that restoring trust does not happen on the clients’ schedule. Rebuilding a trusting relationship may 

take time, even if both parties are committed to the process. Clients should be prepared to cope with 

the frustration that comes from being suspected of using even though they have not done so. 

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Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 12—Trust. 

■ Ask clients to discuss relationships that they have damaged by losing the trust of others. 

■ Ask clients whether they can work to rebuild these relationships. 

■ Ask clients to put themselves in the shoes of someone whose trust they violated. Encourage 

them to empathize with that person. How might it feel for clients to have their trust taken 

from them? 

■ Ask the recovering co-leader to discuss a relationship that was damaged by substance abuse 

and how he or she is working to restore the other person’s trust. 

■ Ask clients to discuss how they will respond if their loved ones are suspicious of them even 

though clients have stopped using and are doing their best to repair damaged relationships. 

■ Ask clients what they can do, in addition to staying abstinent, to earn back the trust of those 

they care about. 

■ Ask clients how they will respond if some relationships are severely damaged, if it seems that 

the lost trust cannot be restored. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Have clients list three positive ways in which they can respond to a loved one who refuses to trust them 

even though the clients have remained abstinent. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 13: Be Smart, Not Strong 

Goals of Session 

■ Help clients understand that recovery is not mainly a test of will, but of commitment and smart 

planning. 

■ Help clients understand the importance of avoiding triggers and relapse situations. 

■ Help clients assess the efficacy of their approach to recovery. 

Handout 

■ RP 13—Be Smart, Not Strong 

Presentation of Topic (15 minutes) 

1. Understanding That Substance Dependence Is Stronger Than the Individual 

When people become dependent on a substance, chemical processes are at work on a biological level 

that cause cravings. Clients cannot conquer these cravings merely by an assertion of will anymore 

than they can concentrate and make feelings of hunger disappear. With longer abstinence, cravings 

will fade. The physical processes that clients set in motion when they became dependent on stimulants 

are stronger than their willpower. Most people who come into treatment have tried very hard on their 

own not to use. But quitting is not just a matter of deciding not to use and then gritting one’s teeth. It 

requires clients to be smart and make plans to remain abstinent. 

2. Understanding the Importance of Avoiding Triggers to Abuse and Likely Abuse Situations 

No matter how strong clients’ desire to remain abstinent, wanting to be abstinent is not enough by 

itself. People who are able to stop using and stay abstinent do so by being smart. Clients need to use 

the relapse prevention skills they learn in these sessions and in Early Recovery Skills sessions to 

ensure that they are avoiding triggers and relapse situations. Clients should take a hard, honest look 

at the people, emotions, and situations that are linked to their substance abuse, make a list of these 

triggers, and then make a commitment to avoid them. Likewise, clients should analyze situations for 

their risk potential. If a group of friends always winds up at a bar, clients need to avoid that group of 

friends. If substances are prevalent at a certain club, clients need to avoid that club. 

3. Assessing How Well Prepared Clients Are To Avoid Relapse 

Clients need to have an accurate idea of how smart their approach to recovery is. Avoiding triggers and 

relapse situations is not all there is to recovery. But doing these things helps support the complete lifestyle change necessary for a solid recovery. The more skills clients have at their disposal to help them 

avoid triggers and prevent relapse, the stronger their recovery will be. The techniques clients learn in 

Early Recovery Skills sessions should be thought of as tools to use to stay abstinent. For recovery to 

be successful, clients need to have as many tools in their toolboxes as possible. 

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V. Relapse Prevention Group 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 13—Be Smart, Not Strong. 

■ Ask clients whether the statements at the top of the handout sound familiar. 

■ Ask clients to discuss the difference between being strong and being smart, in the context of 

recovery. 

■ Ask the recovering co-leader to discuss his or her experience with trying to be strong and 

being smart. 

■ Have clients calculate their Recovery IQ. 

■ Review the various techniques listed on the chart. Do clients understand the importance of all 

these techniques? 

■ Ask clients what they can do to work on the techniques they currently are not practicing. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Have clients choose 1 of the 11 relapse prevention techniques for which they rated themselves fair or 

poor and describe how they will work to improve that rating. Clients can write in their journals or on 

pages 10 and 11 of their Client’s Treatment Companion. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 14: Defining Spirituality 

Note: Clients may have passionately held beliefs about religion and spirituality. This session is not 

designed to change clients’ ideas about religion. The goal is to provide clients a constructive way 

to approach 12-Step meetings and recovery that is not explicitly religious. Because the material is 

potentially contentious, the counselor may want to take a few moments at the start of this session to 

remind clients to be respectful of one another. 

Goals of Session 

■ Help clients understand the difference between religion and spirituality. 

■ Help clients explore their beliefs so they can understand better what will bring them happiness. 

■ Help clients see that success in recovery can be bolstered by spiritual beliefs. 

Handout 

■ RP 14—Defining Spirituality 

Presentation of Topic (15 minutes) 

1. Understanding That Spirituality Is About Inner Strength and Peace, Not Necessarily About Belief 

in God 

Spirituality has been shown to be an important component in recovery. It occupies a prominent place 

in 12-Step and mutual-help programs. It should be expected that some clients will have objections to 

this part of the recovery process. Some may feel that spirituality equates with belief in the Christian God 

and excludes people of other faiths. Some may feel that it is a sign of weakness to look for help outside 

themselves. Some may feel that their struggle with substance abuse is physical and cannot be aided by 

appealing to God. These clients should be reassured that spirituality is not the same as organized religion 

and does not always involve belief in God. Likewise, including spirituality as an aspect of recovery is not a 

sign of weakness. Clients’ spirituality should be seen as a source of strength that they may not be using. 

2. Assessing What Spirituality Means for Individual Clients 

Many people are more concerned with the physical aspects of their lives than with the spiritual aspects. 

During recovery, clients should examine the quality of their spiritual lives. Spirituality can be a source 

of strength, but clients first must understand what spirituality means to them and how it affects their 

lives. The goal is for clients to find a source they can draw on for inner strength and peace—a quiet 

satisfaction—that supplants their desire to abuse substances. 

3. Linking Spirituality With 12-Step or Mutual-Help Groups 

Along with fellowship, spirituality is the foundation of 12-Step and mutual-help programs. Clients who are 

closed off to the spiritual aspects of recovery have a hard time benefiting from these recovery groups. 

Twelve-Step programs invoke a higher power and often close with the Serenity Prayer. Clients who are uncomfortable with a strictly religious meaning of the prayer can think of these elements in the broadest terms: 

higher power can refer to the inner source of strength provided by spirituality, and the Serenity Prayer can 

be thought of as a wise saying about achieving inner peace rather than as a supplication to God. 

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V. Relapse Prevention Group 

Twelve-Step and mutual-help groups are not the only means to incorporate spirituality into one’s life. 

The counselor should be familiar with other supportive options that may be better suited to clients, 

depending on their values, religion, or culture. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 14—Defining Spirituality. 

■ Have clients discuss the four definitions of spirituality provided plus additional definitions that 

clients may suggest. It is important for clients to understand that spirituality may include one or 

more of the definitions listed on the handout. In other words, clients should not be led to believe 

that the first response listed is wrong. 

■ Ask the recovering co-leader to share what spirituality means to him or her. How has spirituality 

played a part in the co-leader’s recovery? 

■ Encourage clients to be honest and detailed in their responses to the four questions on the 

handout. The questions are personal, but all clients in the group can benefit from listening to 

one another’s honest appraisals of the spiritual aspects of their lives. 

■ Clients who use spirituality to help themselves achieve inner peace and support their recovery 

should be encouraged to share their experiences. What has helped these clients? Meditation? 

Reading certain writers or philosophers? Keeping a journal? 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Encourage clients to attend a 12-Step, mutual-help, or spiritually oriented meeting before the next RP 

session. Have them focus on the spiritual aspects of the meeting that they can apply to their recovery. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 15: Managing Life; Managing Money 

Goals of Session 

■ Help clients identify important, practical areas in their lives that they have been neglecting. 

■ Help clients prioritize aspects of their lives. 

■ Help clients make a plan to be responsible about managing their lives. 

■ Help clients understand the importance of taking “baby steps.” 

Handout 

■ RP 15—Managing Life; Managing Money 

Presentation of Topic (15 minutes) 

1. Understanding How Substance Dependence Encourages Irresponsibility 

People who are substance dependent spend much of their time and energy preparing to use, using, 

and recovering from using. People who are abusing substances narrow their world until most activities 

not related to substance use are excluded. They neglect the normal day-to-day activities that are 

necessary for a healthy and satisfying life. 

People in recovery need to widen their view. They need to stop focusing on substance abuse and take all 

aspects of their lives into account. Clients can think about entering recovery as an end to the tunnel vision 

of substance dependence. Now, instead of focusing on a tiny portion of their lives and being surrounded 

by darkness, as in a tunnel, clients can lift their heads and see the full panorama of their lives. 

2. Understanding the Necessity of Bringing Life Back Into Control if Recovery Is To 

Be Successful 

People who are substance dependent often spend their time and money in irresponsible ways. Along 

with deciding to stop abusing substances, clients need to decide to use their time and money more 

wisely because these practices go a long way in determining quality of life. Exercising discipline in 

how they spend time and money helps support clients in their recovery. Behaving responsibly also 

helps them move beyond the guilt and shame they experienced as a result of abusing substances. 

3. Understanding the Importance of Setting Goals To Be Responsible in Daily Living 

The newfound awareness of all that they had been neglecting can be overwhelming to people in 

recovery. The counselor should reassure clients that they are capable of taking up long-forgotten 

responsibilities and getting on with their lives. Setting reasonable goals is integral to reassuming 

responsibilities. Taken together, home repairs, debts, taxes, and court dates may seem like too much 

for anyone to handle. Clients should prioritize the things they need to accomplish—set a goal that they 

can achieve, achieve the goal, and then move on to the next goal. 

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V. Relapse Prevention Group 

4. Understanding the Importance of Taking “Baby Steps” 

Clients often want to do too much too early in their recovery. The counselor should stress that clients 

need to set small, manageable goals to avoid becoming overwhelmed and placing their recovery at risk. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 15—Managing Life; Managing Money. 

■ Ask clients to discuss the ways in which their lives were out of control when they were using. 

■ Ask clients what changes they have made since entering treatment that have helped them 

regain control. 

■ Ask clients whether they are still struggling with problems related to daily life. What are they? 

■ Ask clients to determine which problems to tackle first. 

■ Ask the recovering co-leader to recount how he or she regained control of daily activities. 

■ Ask clients whether they have changed how they handle money since they have entered treatment. 

■ Ask clients what plans they have for opening a savings account and paying off debts. 

■ Ask the recovering co-leader to share how he or she regained control of finances. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Have clients write a step-by-step plan for achieving one of their financial goals. Clients can write in their 

journals or use pages 14 and 15 of their Client’s Treatment Companion. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 16: Relapse Justification I 

Goals of Session 

■ Help clients understand what relapse justification is. 

■ Help clients identify the justifications to which they are susceptible. 

■ Help clients formulate plans to counter relapse justifications. 

Handout 

■ RP 16—Relapse Justification I 

Presentation of Topic (15 minutes) 

1. Understanding the Dangers Posed by Relapse Justifications 

Relapse justifications narrow the distance between abstinence and relapse so that it is easier for 

people in recovery to go back to using. A relapse justification can seem harmless. A client’s addicted 

brain may be telling him it is OK to hang out at a club where he used to use. The client is not intending 

to use when he goes out, but he makes relapse much more likely by giving himself permission to go 

to the club. Another example is a woman who reasons that it is fine to go out with her old using friends 

because they all know she is in recovery now and say they are supportive. Her addicted brain convinces 

her she is reconnecting with old friends who say they want to help, but she also is placing herself in a 

situation that makes relapse a distinct possibility. 

2. Understanding Specific Justifications to Which Clients Are Susceptible 

Relapses often seem to come out of nowhere. However, the addicted brain of a person who has entered 

recovery recently is often busy making dangerous behaviors seem reasonable. This happens at a subconscious level. Using a substance as a response to a certain event (e.g., a fight with a spouse, the loss 

of a job) seems to be an automatic process. But the justification was ready, just waiting for the right set 

of circumstances to emerge. Clients need to understand and anticipate the situations in which they are 

vulnerable to relapse justifications. Knowing their weaknesses in advance allows clients to halt the 

automatic process that leads from event to justification to relapse. 

3. Addressing Specific Situations That Might Lead to Relapse 

Relapse justifications are hard to avoid. Clients still may feel a physiological craving for the substance 

until their minds and bodies are fully healed. Addicted brains will try to push clients to respond to 

situations in ways that put them at risk. Although the justifications may pop into clients’ minds, clients 

need to use their rational brains to resist relapse justifications and choose behaviors that support 

recovery. The counselor should encourage clients to recognize the justifications that have worked 

against them in the past and find safer responses to those dangerous situations. Clients should plan 

what they will say if, for example, friends they formerly used with call to invite them out. Having a plan 

allows clients to avoid hesitating, then being cajoled into going along. Clients should consider making 

a list of potential relapse situations and determining how to avoid them in the future. 

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V. Relapse Prevention Group 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 16—Relapse Justification I. 

■ Ask whether clients have tried to stop using before and ended up relapsing. How did the 

relapses occur? Did they seem to come out of the blue?
 

■ Ask clients to discuss the relapse justifications to which they feel especially vulnerable. 

■ Have the recovering co-leader discuss experiences with relapse justifications, both the times when 

relapse occurred and the times when anticipating a potential relapse situation helped prevent 

relapse. 

■ Have clients discuss specific catastrophic events and negative emotions that make them more 

likely to use. Are there events and emotions not listed on the worksheet that are troublesome? 

■ Ask clients whether they are more vulnerable to relapse from positive or negative emotions. 

■ Have clients discuss specific relapse justifications their addicted brains have used on them. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Have clients identify a relapse justification, write a description of it, and script a response that will help 

them avoid relapse. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 17: Taking Care of Yourself 

Goals of Session 

■ Help clients understand the importance of taking care of themselves. 

■ Help clients understand the importance of self-esteem to recovery. 

■ Help clients identify aspects of their lives that require change. 

Handout 

■ RP 17—Taking Care of Yourself 

Presentation of Topic (15 minutes) 

1. Understanding the Ways in Which Taking Care of Themselves Can Aid Clients’ Recovery 

One of the many things clients can do to support their recovery is boost their self-esteem. Client’s 

substance abuse may have resulted partly from low self-esteem; low self-esteem also can be one of 

the effects of substance dependence. Clients can get caught in a downward spiral in which they feel 

bad about their lives, so they use. Using confirms that their lives have little value, which lowers their 

self-esteem and leads to more substance abuse. 

Clients in treatment have stopped their substance use, but they also need to break the cycle of low 

self-esteem and begin to see value in their lives and themselves. Looking after their health and grooming 

helps clients respect themselves. Clients who respect themselves have more of an investment in their 

future and in succeeding in recovery. 

2. Prioritizing Aspects of Life That Require Change 

Some people can make a lot of changes to their lives at once and be successful. However, most people 

need to take major life changes one step at a time. Most clients need to prioritize their changes, first 

making those that are most urgent. Overdue visits to the doctor and the dentist probably should come 

before other lifestyle changes. Even before clients implement any changes, they already will have begun 

to take control of their lives by prioritizing the changes they need to make. As clients begin to address 

their health and grooming, the whole process of reclaiming their self-esteem gathers momentum. After 

clients have visited a doctor for a checkup, they are more likely to eat right and exercise. When their diet 

and fitness are under control, clients are more likely to pay attention to their clothes and hygiene. 

The counselor might draw connections between the concerns raised in this session and those raised 

in Session 15: Managing Life; Managing Money. The counselor should help clients see that staying 

healthy, managing finances, paying attention to personal grooming, and attending to the responsibilities 

of day-to-day living are part of the larger picture of recovery. As was noted in session 15, however, the 

counselor should ensure that clients do not feel overwhelmed by this larger picture. They can address 

one aspect of their lives at a time and gradually fill in the larger picture. 

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V. Relapse Prevention Group 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 17—Taking Care of Yourself. 

■ Make sure that clients understand that self-esteem can help support recovery. 

■ Ask clients how they felt about their self-esteem when they were using. 

■ Ask clients whether they feel more self-respect now that they are in treatment and abstaining 

from substance use. 

■ Ask the recovering co-leader to discuss the changes in his or her self-esteem from the period 

of substance dependence to treatment and recovery. 

■ Ask clients to identify and discuss the areas of their lives that need particular attention. 

■ Have each client propose and share with the group a plan to address the most important area 

in his or her life. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to 

share that work with the group. 

Homework 

Have clients write their plans for addressing the first thing they need to do to take better care of 

themselves. Encourage them to be as detailed as possible. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 18: Emotional Triggers 

Goals of Session 

■ Help clients understand how certain emotions can act as triggers. 

■ Help clients examine and understand their emotions. 

■ Help clients identify tools that will help them avoid emotions that can act as triggers. 

Handout 

■ RP 18—Emotional Triggers 

Presentation of Topic (15 minutes) 

1. Learning To Look Out for Dangerous Emotional Triggers 

Each client probably has emotional triggers that are unique to him or her. Feelings that might lead 

to relapse for one client may not cause the same response in others. For example, some clients are 

at greater risk of relapse when things are going well than when negative emotions arise. But some 

emotions are dangerous triggers for most clients: loneliness, anger, and feeling deprived. If clients 

are feeling these emotions, they should be aware that they are at a higher risk of relapse. Loneliness 

arises because clients often feel isolated—they cannot hang out with using friends, and other friends 

and family may not be ready to trust them again. Anger is a consequence of the frustrating struggle to 

remain abstinent. Clients may begin to feel deprived because the life of partying with friends that they 

left behind for abstinence and recovery begins to look appealing. These feelings of deprivation are a 

signal that clients are very vulnerable to relapse. 

2. Ensuring That Certain Emotions, if Encountered, Do Not Lead to Relapse 

Like relapse justifications, some emotions may seem to lead automatically to substance abuse. 

Clients need to understand their emotional responses and know which ones put them at increased 

risk of relapse. As was discussed in Early Recovery Skills session 7, it is important for clients to be 

able to separate emotions from behavior. The goal is for clients to examine their emotions in the 

abstract so that they can experience a negative feeling without having it result in substance abuse. 

In this way, clients’ rational minds, not their emotions, control their behavior. 

3. Using Strategies for Understanding Emotions and Avoiding Relapse 

One of the best ways for clients to gain a better understanding of their emotions and how they respond 

to them is by writing about their feelings. Some clients already may be keeping a journal or writing in 

a diary. Others may be new to the practice. For both groups, the process of writing about a problem to 

understand it better can be beneficial. This is focused writing; clients should write with a specific emotional question or issue in mind. The writing process itself, though, should be fluid. This often is called 

free writing; the writer does not let punctuation, penmanship, or spelling stop the flow of ideas. Clients 

do not need to write for a long time; they just need to write honestly and focus on the question they 

decided to address. When they have finished writing, they should go back and read what they have 

written, returning to it several more times in subsequent days. 

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V. Relapse Prevention Group 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 18—Emotional Triggers. 

■ Ask clients which emotions make them feel most vulnerable to relapse. 

■ Ask clients to recall times when one of these emotions seems to have caused a relapse. 

■ Ask clients whether they have experienced loneliness and anger and felt deprived since they 

have been in treatment. 

■ Ask clients whether emotions have acted as triggers. If so, how did they respond? 

■ Have the recovering co-leader share how he or she became more aware of these “red flag” 

emotions (e.g., loneliness, anger, feeling deprived). How did that awareness help the co-leader 

avoid relapse? 

■ Ask clients whether they have kept a diary or a journal or written about their problems. 

■ Ask clients how this process has helped them. 

■ Ask the recovering co-leader to share his or her experience with writing about emotional 

problems as a way to avoid relapse.
 

■ Ask clients what other strategies they have used to try to understand their emotions better. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Have clients set aside 15 minutes to write about an emotional problem that has been troubling them. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Session 19: Illness 

Goals of Session 

■ Help clients understand that becoming ill can be a relapse trigger. 

■ Help clients understand the importance of engaging in healthful behaviors. 

■ Help clients understand the importance of being responsible about recovery, even during illness. 

Handout 

■ RP 19—Illness 

Presentation of Topic (15 minutes) 

1. Understanding That Fighting a Physical Illness Takes Energy and Focus Away From Recovery 

Illness can be a major setback to recovery. Missing treatment sessions at the clinic and skipping 

mutual-help meetings can let clients slip toward relapse. However, clients also should be aware that 

sickness poses more subtle relapse risks. Early Recovery Skills session 8 (in which some clients 

already may have participated) points out that people are vulnerable to relapse when they are tired. 

(This concept should be familiar to clients who have attended 12-Step meetings.) Sickness saps the 

physical and mental energy clients need to maintain abstinence. 

2. Taking Responsibility for Preventing Illness and Maintaining Recovery 

Clients should view staying healthy in the same way they view avoiding triggers. Doing their best not to 

get sick should be regarded as an important goal in clients’ recovery, especially early in recovery. The 

same behaviors that help ward off sickness also support recovery in general. Clients should be sure to 

get enough sleep, eat healthful meals, exercise regularly, and minimize the stress in their lives. They 

also should avoid activities that will leave them fatigued or prone to illness (e.g., excessive work, 

elective surgery). 

3. Keeping Recovery on Track Even During Periods of Illness 

No matter how healthful a lifestyle clients lead, everyone gets sick at some point. It is important for 

clients to recognize early on when they are getting sick so they can be on the alert for thoughts and 

feelings that might lead to relapse. The unstructured time alone that is part of being sick can be a trigger for some people. Being sick also can encourage relapse justifications. For example, clients may 

think, I can’t stop myself from getting sick; it’s out of my control, just like my substance use. Or clients 

might use because at a time when they do not feel good, they think substance use will help them feel 

better. Clients also may slide into relapse because typical behavior is suspended when people are sick. 

Without the structure of work and responsibilities, it is easier for clients to set aside their commitment to 

remain abstinent. 

Because illness can be a relapse trigger, clients should ensure that they get the rest and medical 

attention they need to recover. If clients seek medical attention, they should be sure to inform the 

doctor that they are in recovery so the doctor can take this into consideration if prescribing medication. 

Clients should do all they can to minimize the amount of time they are ill. Getting healthy will allow 

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them to return to their regular recovery activities (e.g., attending treatment sessions, going to mutualhelp meetings, following their scheduled activities) more quickly. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to read the handout before the discussion begins. The handout is 

primarily a tool for discussion. The counselor encourages clients to converse about the issues the 

handout raises. The counselor ensures that all clients have an opportunity to participate. 

■ Go over handout RP 19—Illness. 

■ Ask whether any client has been sick since entering treatment. Was it hard to maintain 

abstinence while sick?
 

■ Ask clients what recovery activities they abandoned when they were sick. What effect did this 

have on their recovery? 

■ Ask the recovering co-leader to share his or her experiences with being sick during early recovery. 

How did he or she remain abstinent when faced with diminished mental and physical energy? 

■ Ask clients to discuss their current approach to maintaining good health. Are they regularly 

eating healthful meals? Are they exercising three or four times a week? 

■ Ask the recovering co-leader to discuss the importance of diet and exercise to his or her recovery. 

■ Ask clients to plan for illness. Do they usually get sick during certain times of the year (e.g., flu 

in the winter, allergies in the spring)? They should be thinking ahead and preparing for the times 

when they are sick. What can they do to limit the amount of time they are sick? What can they 

do to keep their focus on recovery, even if they are tired? 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Have clients list the ways in which their lifestyles are unhealthful and measures they can take to live a 

healthier life. 

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Session 20: Recognizing Stress 

Goals of Session 

■ Help clients recognize signs of stress in their lives. 

■ Help clients understand the threat stress poses to recovery. 

■ Help clients identify strategies to cope with stress. 

Handout 

■ RP 20—Recognizing Stress 

Presentation of Topic (15 minutes) 

1. Recognizing Signs of Stress 

The prevalence of the term “stress” has tended to empty it of specific meaning; clients may equate 

stress with worry, anxiety, nervousness, tension, or other similar words. Stress refers to an accumulation of concerns that unbalances a person’s life. Stress represents an overload that throws people’s 

lives out of equilibrium. People complain about stress so much that clients may assume it is a fact of 

modern life about which they can do little. However, clients need to recognize the signs of stress and 

minimize the effects that it has on their lives. Stress makes it harder for clients to remain abstinent and 

focused on recovery. It is easy for people to become accustomed to a certain level of stress and not 

even be aware of its presence until physical warning signs appear. 

Clients should be on the alert for the following warning signs of stress: 

■ Irritability ■ Constant fatigue 

■ Difficulty communicating ■ Memory problems 

■ Sleep disturbances ■ Disorientation or confusion 

■ Headaches ■ Difficulty making decisions 

■ Weight loss or gain ■ Depression 

■ Tremors or muscle twitching ■ Apathy 

■ Gastrointestinal problems 

These are the warning signs that clients may not be able to handle the level of stress in their lives. 

Staying committed to recovery is more difficult when stress reaches high levels. 

2. Understanding That Stress May Indicate That Clients Are Trying To Do Too Much 

Stress can result when people place excessive demands on themselves. People in recovery often 

want to try to live a perfect life or make up for the damage they have done when they were substance 

dependent. They take on too much responsibility or too much work in too short a time, and their 

recovery suffers. An example is an employee who often missed work because of substance abuse 

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now putting in a lot of overtime to compensate. Clients should be reminded that it is important to 

balance the various aspects of their lives and that recovery needs to come first. If they are too busy 

and are experiencing stress that could distract them from their recovery, they may need to back away 

from some other obligations. 

3. Coping With Stress 

RP session 22 will address ways to help clients reduce stress in various areas of their lives. For now, 

clients should know that many of the practices they explore in Early Recovery Skills and Relapse 

Prevention sessions also will help reduce stress. Exercise is an excellent way to manage stress. 

Scheduling activities helps impose order and exerts control over clients’ lives. Talking with supportive 

friends and mentors (e.g., participating in mutual-help groups) helps manage stress levels. Being 

aware of triggers and staying alert for relapse help keep recovery on track and help clients understand 

themselves better. Being mindful of how one conducts one’s life is key to reducing stress. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 20—Recognizing Stress. 

■ Ask clients to discuss how they know they are experiencing stress in their lives. What physical 

or emotional changes do they notice? 

■ Sometimes people are unaware of signs of stress that are obvious to others. Ask clients whether 

they have noticed signs of stress in other group members. 

■ Ask clients whether they think there is an acceptable level of stress. Is some stress unavoidable 

in today’s world? 

■ Ask the recovering co-leader to share his or her experience of recognizing and coping with 

stress during recovery. 

■ Ask clients how they coped with stress when they were abusing substances. 

■ Ask clients whether they are experiencing different types of stress now that they are in recovery. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not been 

addressed fully. Although it is important for clients to be able to speak about what is on their minds, the 

counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

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the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Have clients list two sources of stress in their lives, the emotional or physical signs of stress, and the 

danger the stress poses to their recovery. 

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Session 21: Relapse Justification II 

Goals of Session 

■ Help clients understand the processes by which relapse justifications lead to relapse. 

■ Help clients understand that moving closer to substance use is never a good idea. 

■ Help clients identify strategies to resist relapse justifications. 

Handout 

■ RP 21—Relapse Justification II 

Presentation of Topic (15 minutes) 

1. Recognizing That Overconfidence in Personal Strength Is Dangerous 

Often, after several weeks of abstinence, clients begin to feel that their substance dependence is 

under control. This is called the Honeymoon—usually weeks 3 through 7 of recovery. (Clients who 

have already participated in Early Recovery Skills session 5 will be familiar with this term and concept.) Clients begin to have more energy during this time and may begin to feel more positive about 

recovery. An optimistic approach to recovery is welcome, but it can prompt some clients to think their 

substance dependence is “cured.” 

Clients who feel that they are in control of their substance use disorder are vulnerable to relapse; 

they may try to test the strength of their recovery by putting themselves in situations where drugs are 

prevalent. They may go to a club or call up friends they formerly used with. Overconfident clients also 

may decide that it is all right to try just a little bit of the substance they were dependent on, just to 

prove to themselves that they have conquered their problem. 

2. Remembering That for Recovery Being Smart Is Part of Being Strong 

Although it is true that it requires personal strength to stop taking drugs and to remain abstinent, 

clients cannot rely on this strength in all situations. Clients who try to test themselves as discussed 

above are relying exclusively on their willpower rather than their intelligence. Some clients feel that 

only by getting close to substance use and not using will they be able to gauge their recovery. But the 

most important measurement in recovery is abstinence. Anything that moves clients closer to using and 

farther from abstinence is a bad idea. Clients’ willpower might fail them, but sticking to a smart plan for 

abstinence will help clients maintain their recovery. 

3. Countering Relapse Justifications 

Relapse justifications abound. Clients will be able to think of a lot of reasonable-sounding excuses 

for why they should use again. No matter how clients try to rationalize using, the end point of all 

justifications is relapse, with the danger of a return to life driven by substance abuse. 

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A good way for clients to short circuit the connection between relapse justification and relapse is to 

anticipate likely relapse situations and plan their responses. Each client knows best the relapse justifications to which he or she is susceptible and how his or her addicted brain has been successful in 

the past. Some people might not be swayed at all by the temptation to hang out with old using friends 

or to use drugs as part of a celebration. But the notion of drinking while watching a sporting event or 

testing their willpower by trying a little of the drug on which they were dependent formerly might seem 

very appealing. Clients need to be honest with themselves about their vulnerabilities and plan detailed 

responses to specific relapse justifications. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 21—Relapse Justification II. 

■ This session is a continuation of RP session 16. If necessary, return to the description of session 

16, and review what relapse justification is. 

■ Ask clients whether they have entered the Honeymoon stage of recovery. Do they feel as if they 

have their substance use problem under control now? What are the inherent dangers in feeling 

this way? 

■ Personal strength is part of recovery. But clients should rely on being smart, not strong, to 

maintain their recovery. Ask clients to discuss this idea. How much of their recovery is the 

result of personal strength? How much is the result of being smart? How do clients balance 

being strong with being smart? 

■ Ask the recovering co-leader to discuss his or her experiences with the relapse justifications 

listed on the handout. 

■ Celebrations may pose particular challenges to recovery for many clients. Celebrations are 

usually public events, and drinking or other substance use often is expected. Ask clients how 

they plan to handle, for example, a toast at a wedding, when friends and strangers are encouraging them to take a drink. 

■ Have clients discuss specific strategies and responses they can use when confronted with 

relapse justifications. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

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Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Have clients identify a relapse justification, write a description of a dangerous relapse situation, and 

script a response that will help them avoid relapse. (Clients who have already participated in RP 

session 16 should address a different scenario.) 

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Session 22: Reducing Stress 

Goals of Session 

■ Help clients understand that stress can affect recovery adversely. 

■ Help clients identify the aspects of their daily lives that are stressful. 

■ Help clients identify strategies to reduce stress. 

Handout 

■ RP 22—Reducing Stress 

Presentation of Topic (15 minutes) 

1. Understanding the Risk Posed by Accumulation of Daily Stress 

Clients who enter treatment have added major stressors to their lives. In addition to the stress of 

stopping all substance use, clients must handle the demands that treatment places on their time, their 

families, and their emotions. Faced with these imposing sources of stress, clients may be less attuned 

to the accumulation of daily stress in their lives. A previous RP session (session 20) addressed ways 

for clients to recognize signs of stress. It is important for clients to be alert to signs of stress so that 

they can prevent a buildup of stressors that will put their recovery in jeopardy. Energy that is sapped 

by coping with stress is energy that cannot be directed toward recovery. 

2. Focusing on Signs of Stress 

Clients should be encouraged to undertake a thorough examination of their lives, looking for signs 

and sources of stress. They might approach this task as they would taking an inventory, checking 

each aspect of their lives (e.g., family, work, friends) for stressors. Minimizing stress is important to 

recovery. Clients should make this survey of stressors a regular practice. 

When clients are experiencing stress, they need to find a way to relax. Often, physical activity helps 

people minimize stress. Stretching, deep breathing, exercise, even a brief walk help defuse stress. 

Clients need to explore various options for reducing stress, find out what works for them, and then 

use that intervention when they feel stress. 

3. Making Changes to Daily Life To Reduce Stress 

It may help clients to have a few general strategies that they can apply to minimize stress in their lives: 

■ Moderation. One useful strategy is to do things in moderation; balance is always important 

to a healthy, happy life, but never more so than during recovery. Clients need to ensure that 

they do not experience large swings in physical energy from sleeping too much or not enough, 

from overeating or eating infrequently, from exercising too much or not at all, or from ingesting 

too much caffeine or sugar. 

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■ Management. A second strategy that clients may find useful is planning ahead (scheduling) 

and breaking down goals into small steps that can be tackled one at a time. This practice helps 

clients assert control over their lives. The feeling that events in life are not under control can be 

a major source of stress. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 22—Reducing Stress. 

■ Ask clients how they know when they are coping with a stressful situation. How does stress 

manifest itself physically? Emotionally? 

■ Ask clients what long-term effects of stress they have observed in their lives. 

■ Ask clients about their techniques for relaxing when they are in a stressful situation. What 

techniques work for them?
 

■ Ask clients how they work to minimize the stress that enters their lives. Have they tried applying 

the principles of moderation and management? 

■ Ask the recovering co-leader to share his or her experiences coping with and minimizing stress. 

■ Ask clients whether they make it a habit to reflect quietly on their lives. This can be meditation, 

prayer, writing in a diary, or just taking a few minutes before going to sleep. But it is important 

for clients to think about their lives and calmly address the things that produce stress. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

On each day between this session and the next RP session, have clients set aside a few minutes to 

reflect on their lives, focusing on the factors that produce the most stress. Clients can use their journals 

or pages 16 and 17 of their Client’s Treatment Companion to write about five ways they reduce stress. 

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Session 23: Managing Anger 

Goals of Session 

■ Help clients understand that anger can be an emotional trigger that leads to relapse. 

■ Help clients recognize when anger is building up. 

■ Help clients identify strategies to address anger positively. 

Handout 

■ RP 23—Managing Anger 

Presentation of Topic (15 minutes) 

1. Understanding How Anger Can Lead to Relapse 

For many people, substance use is a way to cope with feelings that are uncomfortable. When faced 

with a troubling emotion, such as anger, people often choose not to cope with it and turn to substance 

use instead. Clients in recovery no longer can turn to drugs and alcohol for a temporary escape from 

difficult emotions. However, these emotions still act as triggers for substance use. Once clients are in 

recovery, their refusal to come to terms with their troubling feelings can lead to relapse. 

2. Recognizing How Anger Builds Up 

People usually think of anger as a response to a person or an event. Someone makes a nasty remark 

or cuts you off in traffic, and this causes you to be angry. However, anger is not caused by people or 

events but is caused by how one thinks about them. If clients look for someone to blame when they 

feel angry, they can end up feeling victimized. This can lead to a downward spiral in which the more 

clients focus on being victims, the angrier they get. 

3. Exploring Ways To Understand and Manage Anger 

The following steps may help clients better understand and manage their anger: 

■ Be honest with yourself. Admit when you are experiencing anger. 

■ Be aware of how your anger shows itself. Physical sensations and patterns of 

behavior can help you recognize when you are angry. 

■ Think about how anger affects others. Being aware of anger’s effects on those 

you care about might motivate you to minimize its effects in your life. 

■ Identify and implement coping strategies. Keep using strategies that have always 

worked, and find new ones that may be useful. 

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Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 23—Managing Anger. 

■ Ask clients to discuss times when they have felt victimized. How did they break out of the cycle 

of anger and victimization? 

■ Ask clients to discuss the physical and behavioral clues that let them know they are angry. Why 

is it important to be aware of anger? 

■ Ask clients about the advantages of speaking their mind when they are angry, as opposed to 

bottling up their anger. What are the potential disadvantages to speaking up? 

■ Ask clients what it means when someone is passive–aggressive. What types of behaviors are 

typical of this response? Why is this an unhealthy way to manage anger? 

■ Ask clients what strategies for coping with anger have worked for them in the past. What new 

strategies might be helpful? 

■ Ask the recovering co-leader to share his or her experiences with anger in recovery. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Have clients identify one new strategy for coping with anger and write the benefits of the strategy. 

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Session 24: Acceptance 

Goals of Session 

■ Help clients understand that accepting their substance use disorder is the first step in gaining 

control of their lives. 

■ Help clients understand that accepting their substance use disorder is not a sign of weakness. 

■ Help clients identify sources of strength to draw on. 

Handout 

■ RP 24—Acceptance 

Presentation of Topic (15 minutes) 

1. Accepting the Power of Substance Dependence 

Clients confront a paradox when admitting and accepting the power of their substance use disorder. 

Remaining abstinent and in recovery will require that clients be smart and strong. Before they can get 

to the point where their recovery is underway, clients must admit that substance dependence is stronger 

than they are and that it controls their lives. Even though it may seem counterintuitive to clients, especially those who have made attempts to stop using on their own without the benefit of treatment or 

support groups, surrendering control is the first step to reclaiming control. Clients who have attended 

12-Step meetings may be familiar with this idea because it constitutes the first of the 12 Steps. 

2. Understanding That People Have Limits and That Some Things Are Beyond Their Control 

It is normal for clients not to recognize the extent of their substance use disorder. Knowing that they 

are substance dependent, in part, because their bodies now have a chemical need for drugs may help 

some clients accept that their problem is beyond their control. In this sense, substance use disorders 

are much like any other chronic medical disorder, such as diabetes or heart disease. There is no shame 

in admitting the need for help, just as there is no shame in admitting the need for insulin by people who 

have diabetes. This is not to say that their substance dependence is out of clients’ hands. Clients need 

to take responsibility for their actions, but the first step in that process is admitting that they cannot stop 

using substances on their own. 

3. Identifying Sources of Support and Strength 

Clients should be aware that admitting and accepting that they have a problem is not something they 

do only once at the beginning of treatment. Even people who have been in recovery for months can 

let down their guard and begin to think they are stronger than the substance dependence that brought 

them to treatment in the first place. (In fact, clients who are several weeks into recovery often feel that 

they are “cured.” This often happens during the Honeymoon stage of recovery, as discussed in Early 

Recovery Skills session 5.) 

Because acceptance can be an ongoing problem throughout recovery, clients need sources of strength 

they can draw on to help them stay abstinent. The fellow members of 12-Step, mutual-help, or spiritually 

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oriented programs can be a strong support during recovery. Clients should find a meeting group they are 

comfortable with and attend regularly. Friends and loved ones also can provide needed support. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 24—Acceptance. 

■ Ask clients to discuss their experiences with trying to stop using substances before they entered 

treatment. Did they try to “just say no”? Were some clients practicing “white-knuckle sobriety,” 

just hanging on for dear life? 

■ Ask clients whether they have accepted their substance dependence. How did their approach to 

abstinence and recovery change once they accepted their problem? 

■ Ask the recovering co-leader to discuss the negative effects of his or her substance use. 

■ Some clients may have heard that it is necessary to “hit bottom” before they can begin recovery. 

Tell clients that studies indicate that “hitting bottom” is not correlated with success in recovery. 

■ Ask the recovering co-leader to discuss the paradox of surrendering control to take back control 

of his or her life. Have clients discuss this paradox as well. 

■ Introduce the idea that substance dependence can be thought of as a disorder just like other 

chronic medical disorders. Discuss with clients whether this concept makes them feel less guilt 

and shame. 

■ Ask the recovering co-leader to share the supports and sources of strength that helped him 

or her during early recovery. What sources of strength can clients draw on to help them stay 

abstinent and in recovery? 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Have clients make a list of at least three sources of strength and support on which they can draw 

during recovery. 

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Session 25: Making New Friends 

Goals of Session 

■ Help clients understand the need to surround themselves with supportive, abstinent friends. 

■ Help clients learn how to determine whether people they meet will be appropriate friends. 

■ Help clients explore new places and ways to meet people and make friends. 

Handout 

■ RP 25—Making New Friends 

Presentation of Topic (15 minutes) 

1. Understanding the Important Role Friends Play in Recovery 

Sometimes when clients enter treatment, they expect to stop using substances but maintain old friendships with people who still use. Clients who are serious about living a substance-free life will need to find 

new friends who can be supportive of their recovery. Relationships with friends help shape individuals. 

Being around people who are committed to recovery and people whose lives are balanced and fulfilling 

has a positive effect on clients, especially those who are new to abstinence and recovery. Perhaps the 

most important role friends can play for clients in recovery is to be a resource for support and strength. 

However, clients also rely on friends for fun activities that are an important part of recovery. 

2. Recognizing That Behavior Change May Be Necessary for Clients To Make New Friends 

Friendships are built on common interests. Many clients entering treatment will have had friendships 

that were based primarily on substance use. Some clients’ social skills for making new friends might 

be rusty. Clients who are reluctant to seek out new friendships will gain confidence and self-assurance 

as their recovery progresses. The counselor should remind clients that friendship is a two-way street. 

In addition to looking for support from friends, clients can benefit from being a good friend to others in 

recovery or to new people they meet. 

3. Exploring New Places and Ways To Meet People and Make Friends 

The counselor should encourage clients to attend 12-Step, mutual-help, or spiritually oriented meetings; 

try to make abstinent friends; and find a sponsor. Clients also should be encouraged to resume old 

hobbies or activities that they allowed to languish or explore new interests. Taking a class, joining a 

club or a gym, and volunteering are good ways to meet people with whom clients can form meaningful 

friendships. The counselor should remind clients that personal friendships and business dealings with 

other clients in group are not recommended, especially early in recovery. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

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The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 25—Making New Friends. 

■ Ask clients whether they have friends from before they entered treatment who will be good 

friends to keep now that they are in recovery. What qualities do these friends have? 

■ Ask clients how the friends they used substances with affected their lives. 

■ Ask clients whether they have spoken with friends with whom they used to use substances. 

What have they talked about? Have clients severed these friendships? Tried to maintain them? 

■ Ask the recovering co-leader to share his or her experience with friends during the transition 

from using to recovery. Did any of the former friendships last? 

■ Ask clients how they met new people and made friends while they were abusing substances. 

Will they be able to meet new nonusing friends in the same ways? 

■ Ask clients what qualities they look for in a good friend. What role do acquaintances play in 

clients’ lives? How is this different from the role friends play? 

■ Ask the recovering co-leader to discuss personal changes he or she made to find new friends 

after entering treatment. 

■ Have clients discuss ways to meet new friends. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Have clients identify three things (other than attending 12-Step or mutual-help meetings) that will help 

them meet new friends. 

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Session 26: Repairing Relationships 

Goals of Session 

■ Help clients understand the need to repair relationships by making amends. 

■ Help clients understand that making amends must go beyond stopping substance use. 

■ Help clients prepare to address people who refuse to forgive. 

Handout 

■ RP 26—Repairing Relationships 

Presentation of Topic (15 minutes) 

1. Acknowledging Past Behaviors for Which Amends Should Be Made 

As discussed in RP session 24, clients first must admit to themselves that they have a substance use 

disorder and that it has control over their lives. Another aspect of recovery is clients’ acknowledgment 

that they have hurt the people close to them because of their substance abuse. In addition to clients’ 

being honest with themselves about the hurt they have done to others, clients must rebuild the relationships that were broken as a result of their substance abuse. Clients who have attended 12-Step 

meetings may be familiar with the process of acknowledging that amends must be made; this process 

constitutes Step 8 of the 12 Steps. 

2. Exploring Ways To Make Amends and Repair Relationships 

Stopping substance use, entering treatment, and staying abstinent are difficult. Some clients may 

feel that by accomplishing these things they have done enough work toward repairing their damaged 

relationships. By themselves, these things are not sufficient. Clients must speak with the people they 

have wronged, acknowledge the harm they caused, and explain that they have entered treatment and 

are in recovery. For some people, clients’ taking responsibility for the harm they have caused will be 

enough to repair past damage. Others may not be so quick to forgive. Clients may have to work with 

the people they have hurt to restore relationships. As discussed in RP session 12, restoring trust can 

be an arduous process. 

3. Forgiving Oneself and Others 

The damage done to relationships by substance use disorders is not a one-way street. Friends and 

loved ones do hurtful things to the person who is abusing substances, too. Clients should be prepared 

to forgive people who have hurt them, even if the people are not ready to acknowledge the hurt or 

apologize for it. Clients should work to let go of grudges and resentment; bitterness is a dangerous 

emotion (like anger) that can act as a trigger for relapse. To leave bitterness behind, clients must be 

able to forgive themselves for their past behaviors. They cannot change the past; once they have 

entered treatment, made amends, and resolved not to make the same mistakes again, clients have 

done all they can do to address past mistakes. 

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Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 26—Repairing Relationships. 

■ Ask clients to whom they need to make amends. 

■ Ask clients what they need to make amends for. 

■ Ask clients to discuss the difference between apologizing and making amends. 

■ Ask clients how they plan to handle a situation where someone is still angry and refuses to 

forgive them. 

■ Ask the recovering co-leader to share his or her experience with going to people to make 

amends. How did the co-leader handle people who refused to forgive and accept him or her? 

■ Ask clients how they are prepared to make amends. Beyond apologizing, what else might they 

have to do to repair relationships? 

■ Ask the recovering co-leader to share the various ways he or she went about making amends. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Have clients list one person to whom they need to make amends and the measures they will take to 

repair the relationship. Clients can use their journals or pages 18 and 19 of their Client’s Treatment 

Companion. 

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Session 27: Serenity Prayer 

Goals of Session 

■ Help clients understand the importance of distinguishing between things that can be changed 

and those that cannot. 

■ Help clients understand that the Serenity Prayer is not strictly religious and is applicable in many 

situations. 

■ Help clients identify things that they can change. 

Handout 

■ RP 27—Serenity Prayer 

Presentation of Topic (15 minutes) 

1. Distinguishing Things That Can Be Changed From Those That Cannot 

Making distinctions between what can be changed and what cannot is a critical skill for clients in recovery. 

If clients are unsuccessful at making these distinctions, they can experience frustration, anger, and 

increased stress that make them more vulnerable to relapse. Staying abstinent and progressing in recovery 

demand clients’ full attention; clients do not have time or energy for worrying about things over which they 

have no control. The counselor should take clients through some specific scenarios and have clients 

discuss and evaluate whether they can change the situations and how they should respond. For example: 

■ A client is stuck in traffic and is late for an appointment. 

■ The grocery store is out of a key ingredient a client needs to make a special dish. 

■ A client’s boss reprimands him for being late to work. 

■ A client’s partner still does not trust her, even though she has been abstinent for months. 

2. Understanding What Serenity Means in the Context of Recovery 

The Serenity Prayer was popularized by Alcoholics Anonymous (AA). (A version of the 12 Steps, 

adapted for people who are recovering from stimulant use, is available at http://www.crystalmeth.org.) 

Like 12-Step programs, the Serenity Prayer has specific religious overtones: the first word in the saying 

is God. Prayer provides many people with inner calm, but the serenity that is beneficial to recovery can 

be achieved through other means, such as meditation or journal writing. Clients who are not religious or 

do not believe in God can benefit still from the principles in the Serenity Prayer. These clients can think 

of the prayer as a poem or a wise saying. Every aspect of the Matrix method or 12-Step meetings may 

not be useful to clients. The counselor should encourage clients to take what they can use and leave the 

rest. In other words, clients should accept the wisdom of this saying even if its form is not to their liking. 

3. Identifying Areas That Require Change 

Achieving the inner peace mentioned in the Serenity Prayer requires not only the ability to set aside 

those things that clients cannot change but also the commitment to work on those things that they 

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can change. The important aspects of clients’ lives are things that will support them in recovery. 

Relationships with friends and family can be a powerful source of strength during recovery. Often, 

relationships can be improved and are worth repairing. The counselor should help clients identify other 

areas of their lives that are both important to recovery and capable of being changed. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should not 

be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. The 

handout is primarily a tool for discussion. The counselor steers clients away from reading their responses 

and encourages them to converse about the issues the handout raises. The counselor ensures that all 

clients have an opportunity to participate. 

■ Go over handout RP 27—Serenity Prayer. 

■ Ask clients to discuss what this saying means to them. 

■ The name of this saying focuses on serenity, but courage and wisdom also are mentioned in the 

saying. Ask clients how courage and wisdom are part of recovery. How do courage and wisdom 

contribute to serenity? 

■ Ask clients whether they are troubled by the fact that, according to the saying, God provides 

serenity. Can clients appreciate the saying even if they are not religious or do not believe in God? 

■ Ask the recovering co-leader to discuss his or her understanding of the Serenity Prayer. Did the 

co-leader struggle with the religious aspects of the saying? Was the idea of a higher power 

comforting and helpful? 

■ Have clients discuss the things in their lives that they cannot change. How do they identify 

these things? 

■ Ask clients what things in their lives should be changed. What steps are they taking to make 

those changes? 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Ask clients to identify one thing about their lives that they can change and that would help strengthen 

their recovery. Have clients list the steps they will take to make that change. 

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Session 28: Compulsive Behaviors 

Goals of Session 

■ Help clients understand what compulsive behaviors are and how compulsive behaviors other 

than substance abuse can affect recovery negatively. 

■ Help clients understand the dangers of abstinence violation syndrome. 

■ Help clients recognize and eliminate compulsive behaviors. 

Handout 

■ RP 28—Compulsive Behaviors 

Presentation of Topic (15 minutes) 

1. Getting Life Under Control by Eliminating Compulsive Behaviors 

The counselor should define “compulsive behaviors” as irrational or destructive actions people take in 

response to irresistible impulses. 

As clients used stimulants and became more dependent on them, what started out as a casual practice—something they did when they were at a party or with certain friends—progressed to compulsive 

use. Now that clients are abstinent and in recovery, they may be replacing their compulsive stimulant 

use with other compulsive behaviors. Signs of compulsion include overindulging in food, tobacco, 

caffeinated sodas and coffee, sweets, exercise, work, and masturbation. Gambling, spending a lot of 

money, and abusing drugs other than stimulants also may be compulsive behaviors. It is important for 

clients to eliminate compulsive behaviors from their lives. As long as some aspect of their life is out of 

control, it is easy for clients to slip back into the out-of-control use of stimulants. 

Some clients may need help beyond the scope of substance abuse treatment to address compulsive 

behaviors (e.g., eating disorders, gambling addictions). The counselor should be alert for clients who 

need more help and refer them for additional treatment. 

2. Understanding How Abstinence Violation Syndrome Can Derail Recovery 

Clients can feel as if they are walking a narrow path when they are in recovery. For some clients, as 

long as everything in their recovery goes according to plan, they are fine. But if they make even one 

small misstep, they can feel that they have fallen off the recovery path. This pattern of thinking is called 

abstinence violation syndrome, and it is dangerous. By this strict logic, even a small slip-up is the equivalent of using again. A client who skips his regular evening swim may end up relapsing because in his 

mind he already has ruined his recovery. Clients need to understand that no one’s recovery happens 

“perfectly”; making a mistake does not mean that all is lost and that using drugs again is inevitable. 

3. Balancing Lifestyle Change With a Healthful and Successful Recovery 

Clients may have different approaches to the goal of eliminating compulsive behaviors from their lives. 

Some people find that it is easier to make sweeping changes all at once. They figure they already are 

girding themselves to do something difficult, so they might as well tackle all their compulsive behaviors 

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at once. Other people need to make changes gradually, one or two at a time. For them, the thought of 

trying to eliminate all their compulsive behaviors at once is overwhelming. Clients need to work toward 

the goal of eliminating their compulsive behaviors in a way that is comfortable for them and allows them 

to keep their lives and recovery in balance. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 28—Compulsive Behaviors. 

■ Ensure that clients understand what it means to act compulsively and what compulsive 

behaviors are. 

■ Ask clients to discuss their compulsive behaviors. Did clients find themselves engaging in more 

compulsive behaviors when they became abstinent? 

■ Ask clients what steps they have taken to eliminate compulsive behaviors. How much success 

have they had? What approach are they using? Are they tackling all behaviors at once or one or 

two at a time? 

■ Ask the recovering co-leader to discuss his or her experiences with abstinence violation syndrome. 

■ Small things go wrong during recovery. Ask clients to discuss their attitude toward small slipups. Encourage clients to put small missteps in perspective. If they are overly rigid in their 

approach to recovery, they may overreact—and relapse—because of a minor problem. 

■ Ask clients to discuss relapse prevention techniques they have learned about. If clients are new 

to recovery, make sure they understand the necessity to avoid triggers, practice thought stopping, and use scheduling. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Have clients choose one of the relapse prevention strategies on handout RP 28 that they think will 

work best for them. Have them describe when and how they will put this strategy into action. 

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Session 29: Coping With Feelings and Depression 

Goals of Session 

■ Help clients recognize and understand their emotional responses. 

■ Help clients recognize signs of depression. 

■ Help clients explore strategies for coping with emotions and depression. 

Handout 

■ RP 29—Coping With Feelings and Depression 

Presentation of Topic (15 minutes) 

1. Understanding Emotional Patterns in Recovery 

It is important for people in recovery to be able to recognize and understand their emotional responses. 

Accustomed to experiencing emotions that make them uncomfortable (e.g., shame, anger, sadness), 

some clients may have ceased to be honest with themselves about what they are feeling. Until clients 

can label their feelings accurately, they cannot address feelings that may build up and cause problems. 

Even if clients experience negative or painful emotions, it is important that they acknowledge these feelings. The counselor should remind clients that there is nothing wrong with having these feelings; clients 

still can choose not to act on emotions that trouble them. 

Clients also can gain a better understanding of their feelings by looking for patterns in how they 

respond to situations and to people. Are clients more susceptible to some feelings than others? Do 

certain situations always make clients depressed? Do certain people always make clients angry? 

2. Understanding the Importance of Identifying and Addressing Depression 

People in recovery often experience bouts of depression. For some clients, this is just a normal part of 

the recovery process. They become depressed right after becoming abstinent or several months into 

recovery (during the period known as the Wall). If these clients stay abstinent and keep their recovery 

on track, the depressive symptoms should abate. In other clients, however, stimulant use had masked 

symptoms of a depressive disorder that is laid bare once they are abstinent. The counselor should be 

alert for clients with symptoms of depression that do not improve and ensure that these clients receive 

proper evaluation and treatment. 

Counselors may find the following resources from the Substance Abuse and Mental Health Services 

Administration (SAMHSA) helpful: 

■ Treatment Improvement Protocol 42, Substance Abuse Treatment for Persons With 

Co-Occurring Disorders (CSAT 2005a)
 

■ SAMHSA’s Co-Occurring Center for Excellence (http://www.samhsa.gov/co-occurring) 

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3. Using Coping Strategies To Manage Emotions and Depression 

Many of the best ways to address symptoms of depression coincide with strategies clients already 

should be using to prevent relapse. It is especially important for clients to reach out to supportive 

friends and family if they are feeling depressed. Talking to a counselor or a physician also is a good 

idea. Activities that get clients out of the house and force them to interact with other people also are a 

good way to cope with depression. Exercise can stabilize the body’s rhythms, allowing clients to return 

to more regular patterns of eating and sleeping. Exercise also can help alleviate symptoms of depression that occur during the Wall. 

However, when these steps do not help mitigate a client’s depression, the counselor should consider 

whether the client is experiencing clinical depression and should be referred for more intensive treatment. 

The counselor should follow up immediately with clients who are suspected of being clinically depressed. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should not be 

forced to comply if they find it difficult or uncomfortable to complete the handout in the group. The handout is primarily a tool for discussion. The counselor steers clients away from reading their responses and 

encourages them to converse about the issues the handout raises. The counselor ensures that all clients 

have an opportunity to participate. 

■ Go over handout RP 29—Coping With Feelings and Depression. 

■ Ask clients whether they are being honest with themselves about their feelings. Do they feel that 

there are some feelings that are off-limits? 

■ Encourage clients to accept the emotions that they experience. If clients feel that some emotions 

are off-limits, ask them why they feel this way. 

■ Ask clients whether they notice patterns in their feelings. Do they often feel angry? Sad? Bitter? 

If so, what are these emotions in response to? 

■ Ask the recovering co-leader to share his or her experiences with depressive episodes in recovery. 

Did the depressive feelings abate after the Wall? 

■ Ask clients whether they have been through depressive episodes before. How do they recognize 

them? 

■ Ask clients whether they feel depressed now. What symptoms are they experiencing? 

■ Ask clients to share strategies that have helped them cope with periods of depression. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

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Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Have clients write down three responses, other than the ones listed on the handout, that they can use 

to combat depression. 

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Session 30: 12-Step and Mutual-Help Programs 

Goals of Session 

■ Help clients understand how 12-Step and mutual-help programs can support recovery. 

■ Help clients realize the many benefits from 12-Step and mutual-help programs. 

■ Help clients understand the breadth of 12-Step and mutual-help programs available. 

Handout 

■ RP 30—12-Step Programs 

Presentation of Topic (15 minutes) 

1. Understanding the Basics of 12-Step Groups (e.g., what meetings are like, how to find a meeting) 

Some clients will be familiar with AA and other 12-Step groups. The counselor should take time to walk 

clients through the rudiments of 12-Step group participation. Professional substance abuse treatment 

combined with 12-Step participation is one of the most effective interventions for substance dependence. 

These components are very important to recovery; clients should be given every opportunity to understand and become comfortable with 12-Step programs. Important points to cover include the following: 

■ Meeting format. Meetings are held throughout the day and evening and usually last 1 hour, 

with time before and after for socializing. The counselor should provide clients with a list of local 

meetings and contact information. 

■ Participant-specific meetings. Large communities may have special group meetings 

(e.g., for doctors, lawyers, members of other professions, people with mental disorders; 

gender-specific meetings; meetings based on participants’ sexual orientation). Some 

communities have meetings especially for people in recovery from methamphetamine use. 

(See http://www.crystalmeth.org to access a list of communities that have methamphetaminespecific meetings.) 

■ Types of meetings. The content of some meetings has a special focus: 

• Speaker meetings feature a person in recovery telling his or her story of drug and alcohol use 

and recovery. 

• Topic meetings have a discussion on a specific topic such as fellowship, honesty, acceptance, 

or patience. Everyone is given a chance to talk, but no one is forced. 

• Step/Tradition meetings are special meetings where the 12 Steps and 12 Traditions are 

discussed. 

• Book study meetings focus on reading a chapter from the main text of the 12-Step group. (For 

AA, this is the Big Book; for Narcotics Anonymous [NA], the Basic Text.) Book study meetings 

often focus on someone’s experience or a recovery-related topic. 

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Clients should visit different meetings until they find a group they like. Not every aspect of a meeting 

or a particular discussion will be useful. But clients should strive to find a group they can attend regularly and try to learn something that will strengthen their recovery each time they go to a meeting. 

2. Understanding the Social and Emotional Support Available Through 12-Step Attendance 

Twelve-Step groups consist of people with the same problem working together to help one another. 

The group process reminds clients that they are not alone and provides them the opportunity to make 

abstinent friends and begin to build a support network. Clients can receive guidance and encouragement 

from others who have been in recovery longer than they have. 

3. Exploring Alternatives to 12-Step Programs 

Twelve-Step programs such as AA, Cocaine Anonymous, and NA are the most prevalent groups available. 

But they may not be for everyone. Crystal Meth Anonymous is a 12-Step group that provides fellowship 

and support for people in recovery from methamphetamine use (see http://www.crystalmeth.org). The 

counselor should research local options to 12-Step programs and expose clients to other types of 

recovery support in addition to 12-Step programs, such as mutual-help groups. (In small communities, 

a 12-Step meeting may be clients’ only option.) Even groups that do not adhere to 12-Step principles 

offer the fellowship and support that are crucial to recovery. The counselor may want to discuss the 

alternatives to traditional 12-Step meetings listed on pages 33 and 34. 

The counselor also may want to devote some time to describing the various support programs for 

families of clients (e.g., Nar-Anon, Al-Anon, Alateen). 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to read the handout before the discussion begins. The handout is primarily 

a tool for discussion. The counselor encourages clients to converse about the issues the handout 

raises. The counselor ensures that all clients have an opportunity to participate. 

■ Go over handout RP 30—12-Step Programs. 

■ Take care to respect group members who are reluctant to attend 12-Step meetings; ensure that 

they do not feel coerced to attend 12-Step meetings. 

■ Ask clients whether they have participated in 12-Step or any of the other groups mentioned 

above. Ask clients who have participated to describe the ways in which attending meetings 

helped them. 

■ Ask clients whether they attend any special-focus meetings that they find helpful. 

■ Ask the recovering co-leader to discuss any reservations or difficulties that he or she had with 

attending 12-Step meetings when first starting in recovery. 

■ Ask clients to discuss the spiritual dimensions of 12-Step meetings. Do they find comfort in the 

notion of a higher power? 

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■ Ask clients whether they are troubled by the references to a higher power in 12-Step meetings. 

If so, how do they reconcile those objections with continued attendance? 

■ Ask clients whether they have attended mutual-help or spiritually oriented meetings. If so, ask 

them to describe their experiences. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Have clients attend a 12-Step or mutual-help meeting and write down five benefits from the meeting. 

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Session 31: Looking Forward; Managing Downtime 

Goals of Session 

■ Help clients appreciate the risks of boredom as a relapse trigger. 

■ Help clients understand the benefits of planning rewards and downtime. 

■ Help clients explore different ways to break the monotony of recovery. 

Handout 

■ RP 31—Looking Forward; Managing Downtime 

Presentation of Topic (15 minutes) 

1. Understanding That Boredom Can Be a Relapse Trigger 

It is normal for clients to feel bored, listless, and unexcited during recovery. This boredom may be 

caused by chemical changes that are part of the brain’s healing. It also may be a function of the rigid 

structure of recovery. Although the structure of recovery is necessary, the boredom that it can breed 

acts as a relapse trigger for many clients; using was the way many clients filled their free time and 

made their lives more interesting. In addition, clients who are bored may lack the mental energy to 

maintain a smart and strong recovery. It is necessary for clients to fight through their feelings of 

boredom to keep their recovery on track. 

2. Understanding the Benefits of Breaking Recovery Into Manageable Chunks of Time 

One way for clients to combat the routine nature of recovery is to plan little rewards for themselves 

every couple of weeks. These rewards need not be large purchases or big events. In fact, it is better if 

clients think of small things that they enjoy but that still constitute a special treat (e.g., eating a favorite 

meal, buying a new CD, taking a day trip). The rewards should be things that clients can look forward 

to and that will pull them through the dreary parts of recovery. It also is important that the rewards not 

disrupt recovery. For example, leaving town for more than a few days would not be a good idea during 

treatment. Clients can think of these rewards as extensions of the marking progress activity from the 

Early Recovery Skills sessions. Both components are exercises in breaking the sameness of recovery 

into smaller periods that are punctuated by rewards. 

3. Exploring Ways To Enhance Recovery by Planning Activities and Structuring Downtime 

In addition to occasional rewards such as rest and fun, clients may need more frequent breaks from the 

predictability of the recovery routine. For most clients, relaxing from the stress of everyday life used to 

involve substance use. Now that they are in recovery, many clients need to find new ways to unwind 

or to cope with the stress of their lives. Physical activity is an excellent way for clients to relax. Exercise 

is known to reduce stress levels. When clients exercise, they also boost their self-esteem and help ameliorate any remaining physical symptoms from stopping substance use. Exercise need not be vigorous— 

just consistent; walking or bicycling several times a week is good exercise during recovery. 

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Activities that involve clients’ minds are important, too. Starting a new hobby or picking up an old 

interest is an excellent way to fight boredom. Clients might consider taking lessons or classes; learning something new (e.g., how to play a musical instrument or speak another language) orients clients 

toward the future. When clients become engaged in learning something or participating regularly in an 

activity, they make a commitment that supports their recovery. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 31—Looking Forward; Managing Downtime. 

■ Ask clients whether they have been experiencing boredom and emotional tedium. To what do 

they attribute these feelings? 

■ Ask clients what effect boredom has on their recovery. What do they do now to relieve daily 

boredom? 

■ Ask the recovering co-leader to discuss how he or she used the practice of building islands 

(from handout RP 31) to stay engaged in the recovery process. 

■ Ask clients what activities they can use as rewards to combat the routine nature of treatment 

and recovery. 

■ Ask clients how they know whether they need to relax. What physical or emotional signs tell 

them that they need some downtime? 

■ Ask clients to describe hobbies and activities that they have found relaxing and satisfying. 

■ Ask the recovering co-leader to discuss his or her experience using activities to combat 

boredom. To relieve stress, what does the co-leader do in place of substance use?
 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not done 

the homework but to encourage clients to work on their recovery between sessions and to share that 

work with the group. 

Homework 

Have clients explain in detail one of their islands and one of the activities or hobbies they are going 

to pursue. 

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Session 32: One Day at a Time 

Goals of Session 

■ Help clients avoid feeling overwhelmed by the past. 

■ Help clients understand that the past does not define the future. 

■ Help clients explore different strategies for focusing on the present. 

Handout 

■ RP 32—One Day at a Time 

Presentation of Topic (15 minutes) 

1. Avoiding Defeatist and Fatalistic Ideas About the Past 

When many clients enter treatment, their immediate past is characterized by failure. They can use little 

in their histories to build their self-confidence. Little in their experience convinces them that they can 

succeed in recovery. Paradoxically, once clients are in recovery, the process of clearing up problems 

from the past often leaves them overwhelmed and unable to face the present or the future optimistically. 

Negative feelings and a bleak outlook on the future add stress to clients’ lives and increase the chances 

of relapse. The counselor needs to persuade clients that they are capable of making a break with their 

past behavior. As evidence that this is possible, the counselor can point to the fact that clients made the 

decision to enter treatment. They can build on this decision to make their future different from the past. 

2. Understanding That the Future Is Determined by the Individual, Not by Past Behavior 

Clients often feel that, because they have failed to stay abstinent in the past, they will fail to do so 

in the future. Although it is true that people often repeat past behavior, they do so by choice, for the 

most part. The mere fact that a client had quit using and then went back to stimulant use does not 

mean that the same thing will happen again. Clients decide whether they will be abstinent. Taking a 

smart approach to recovery helps clients succeed where before they did not. 

The counselor should remind clients of the times in their lives when they decided to change their 

behavior and succeeded. For example, perhaps some clients altered their diet or gave up cursing. 

Most clients probably can identify some point in their lives when they made a decision to change their 

behavior and stuck with it. 

The counselor also should be aware that some clients come to treatment with serious psychological 

problems other than substance use. These problems may be the result of significant trauma that 

has scarred clients. If the counselor notices serious psychological problems in clients, the counselor 

should refer the clients to a mental health professional for assessment. 

3. Exploring Strategies To Keep Recovery on Track by Focusing on the Present 

The phrase “One Day at a Time” comes from 12-Step programs and is useful for clients to bear in 

mind. Twelve-Step and mutual-help programs teach clients a new way to structure their experience so 

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V. Relapse Prevention Group . Relapse Prevention Group 

that they are focused more on their immediate reality. Clients should strive to be less concerned about 

the past and less fretful about the future. The counselor might suggest exercise (especially repetitive 

exercise like walking, running, or swimming), meditation, or journal writing, but clients will know better 

than the counselor what practices and thoughts will help them focus more on the present. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP 32—One Day at a Time. 

■ Ask clients whether they let thoughts from the past affect their current behavior. What kind of 

thoughts about the past do they have? 

■ Ask clients whether they tend to focus on negative thoughts about the past. What positive 

aspects of their past could clients recall instead?
 

■ Ask clients whether fears about the future overwhelm them. What fears do clients have about 

the future? 

■ Ask clients whether they find it hard to make changes in their lives. Can they point to a time 

when they made a change in their lives and stuck with it? 

■ Ask the recovering co-leader to share his or her experiences of letting go of past worries and 

future fears and focusing on the present. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Have clients describe one activity that will help them focus more on the present and put it into practice 

before the next RP session. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Elective Session A: Client Status Review 

Goals of Session 

■ Help clients see an overview of the many issues involved in their recovery. 

■ Help clients establish a pattern of regular self-review. 

Handout 

■ RP Elective A—Client Status Review 

Presentation of Topic (15 minutes) 

1. Understanding That Recovery Is a Dynamic Process That Must Be Actively Managed 

Recovery is a complicated process. Remaining abstinent is the most important part of recovery, but 

there is much more to recovery. As clients are going through treatment, it is important for them to realize that once the structure of daily group sessions is gone, they will need to manage the complicated 

process of recovery on their own. From the beginning of the Matrix intervention, clients have been 

encouraged to attend 12-Step or mutual-help meetings. By the time they leave treatment, all clients 

should be attending meetings and benefiting from the structure and support meetings provide. Clients 

also will have the support of their families, friends, and, for those who are in a 12-Step program, 

sponsors. But it will be up to clients to make daily decisions that influence their recovery and monitor 

how they are doing in the various aspects of recovery. Successful relapse prevention requires regular, 

frequent reviews of the broad spectrum of issues that are involved in recovery. 

2. Using Members of the Group To Explore Ways To Improve Recovery 

Clients should be encouraged to draw inspiration and take suggestions from other members of the 

group. A client who has been successful in a certain aspect of recovery should talk about the success 

so that the rest of the group can be encouraged and can use or adapt the client’s strategies and 

approach. Clients should treat the group as a think tank of good ideas and approaches to recovery, 

taking the best ideas and applying them to their lives. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP Elective A—Client Status Review. 

■ Ask clients to assess honestly their progress in the aspects of recovery listed on the handout. 

This type of self-review should become a regular part of clients’ lives because it will help them 

remain abstinent. 

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V. Relapse Prevention Group . Relapse Prevention Group 

■ Ask clients whether they can discern patterns in their responses. Do some aspects of recovery 

come more easily for them? Why? 

■ Ask clients to focus on the areas with which they are most satisfied. Have them share their 

ideas on why they have been successful. Encourage each client to share at least one story of 

success along with the approach that led to the success. 

■ Ask clients what they can do to improve the areas with which they were unsatisfied. 

■ Ask the recovering co-leader to discuss how gleaning ideas and suggestions from other people 

in recovery has helped his or her recovery. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Ask clients to write down one of the ideas from the group discussion that they think will help them 

improve their recovery. Have them explain how they will implement this idea and how it will help them. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Elective Session B: Holidays and Recovery 

Goals of Session 

■ Help clients understand that the added stress of holidays increases the risk of relapse. 

■ Help clients assess their level of holiday stress and identify ways to alleviate it. 

Handout 

■ RP Elective B—Holidays and Recovery 

Presentation of Topic (15 minutes) 

1. Understanding That Holidays Pose Particular Risks for Recovering Individuals 

The counselor should consider using this session before a major holiday. The weeks around Christmas 

and New Year’s Day can be a particularly troublesome time, but the Fourth of July, Memorial Day, 

Labor Day, and other holidays also feature celebrations and parties that put clients at increased risk of 

relapse. Holidays come with increased stressors, such as hectic schedules, travel, and increased spending. In addition, many people experience intense emotional swings during the holidays—either joyous or 

depressed. In this environment, faced with increased triggers, clients find it easier to relapse. 

2. Understanding the Importance of Scheduling and Planning To Avoid Triggers 

Clients experience disruptions in the normal routine of recovery during holidays. They may be away from 

home, find themselves with more unstructured time, and have difficulty going to meetings. As a holiday 

nears, clients need to be aware of the added risks and make plans that will help them avoid triggers. If 

clients have gotten away from the practice of scheduling their activities, they should reinstitute the practice as a holiday approaches. If clients know they will be out of town, they should make arrangements to 

keep up the activities that have been preventing them from relapsing. This may mean locating a 12-Step 

meeting in the town they are visiting, scheduling phone calls with their sponsor, being sure they can get 

some exercise, or setting aside some time for meditation or journal writing. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP Elective B—Holidays and Recovery. 

■ Ask clients whether holidays are stressful times for them. How can holidays affect their recovery? 

■ Ask clients whether they have tried to remain abstinent through holidays, for example Christmas 

and New Year’s. What additional stressors did they face during holidays? 

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V. Relapse Prevention Group . Relapse Prevention Group 

■ New Year’s Eve can be an especially troubling holiday for people in recovery. People are 

expected to be festive, to drink alcohol, and to assess the previous year—all of which can 

be stressful for people in recovery. Ask clients how they plan to cope with the added stress of 

New Year’s Eve this year. 

■ Ask clients about the specific risks posed by holidays. 

■ Ask the recovering co-leader to discuss his or her experience with planning and scheduling to 

keep recovery on track during holidays. 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Have clients select the holiday that is most stressful for them or think about the next holiday. Have 

them write a plan for how they will avoid relapse during this time. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Elective Session C: Recreational Activities 

Goals of Session 

■ Help clients understand the importance of introducing new activities into their lives. 

■ Help clients understand that new activities and old pursuits may not feel like fun right away. 

Handout 

■ RP Elective C—Recreational Activities 

Presentation of Topic (15 minutes) 

1. Understanding the Role Activities and Hobbies Play in Recovery 

Activities and hobbies are important during recovery for several reasons. Any interest clients take up 

helps orient them toward the future. The whole notion of pursuing a hobby or an activity suggests that 

clients are involved in a process that stretches out in front of them. In this way, the activities that clients 

choose help them reengage in their lives and enhance their commitment to recovery. 

Physical exercise helps the body and mind get over lingering effects of substance use, relieves stress, 

and bolsters clients’ self-esteem. Taking a class, joining a club, or volunteering helps clients meet 

people who share their interests and builds a repertoire of interests and activities that do not focus 

on substance use. 

2. Finding Activities That Are Stimulating and Engaging May Take Patience 

As clients resume old activities or pick up new ones, they should not be surprised if the activities are 

not rewarding immediately. Their motivation at the beginning of an activity should be to strengthen 

their recovery. As they become involved in activities over time, clients will enjoy them more. The 

counselor should encourage clients to look on recovery as a fresh opportunity. Now that they are not 

spending time, energy, and money supporting their substance use, clients can explore and develop 

interests that they have been putting off or that seemed beyond their reach. 

Handout and Focused Discussion (45 minutes) 

Clients should be given time to complete the handout before the discussion begins. Clients should 

not be forced to comply if they find it difficult or uncomfortable to complete the handout in the group. 

The handout is primarily a tool for discussion. The counselor steers clients away from reading their 

responses and encourages them to converse about the issues the handout raises. The counselor 

ensures that all clients have an opportunity to participate. 

■ Go over handout RP Elective C—Recreational Activities. 

■ Ask clients what activities they would like to pursue now that they are abstinent and in recovery. 

Clients should be encouraged to imagine and describe a lot of different activities, helping one 

another think of fun and involving interests to pursue. It is important to note here that personal 

164 
V. Relapse Prevention Group . Relapse Prevention Group 

friendships among clients in the group are not encouraged. The counselor may want to discourage 

clients from making arrangements to pursue activities with people who have been abstinent for 

less time than they have. 

■ Ask clients about former hobbies they used to enjoy. What were the benefits of those activities? 

How did they enrich clients’ lives? 

■ Ask clients whether they have begun new activities or resumed old hobbies. How has their 

recovery been affected? 

■ Ask clients whether they have begun exercising since entering treatment. How has their recovery 

been affected? 

■ Ask the recovering co-leader to discuss the role that exercise, interests, and hobbies played in 

his or her recovery. How has the co-leader used these activities to help him or her avoid triggers 

and prevent relapse? 

Open Discussion (30 minutes) 

The counselor should carry over from the previous discussion any important issues that have not 

been addressed fully. Although it is important for clients to be able to speak about what is on their 

minds, the counselor should make sure that the session’s topic has been explored completely. 

Five minutes before the end of open discussion, the counselor should ask clients to share briefly their 

experience of doing the homework from the previous session. The counselor can decide how detailed 

the followup on homework should be. The goal of asking is not to discover which clients have not 

done the homework but to encourage clients to work on their recovery between sessions and to share 

that work with the group. 

Homework 

Have clients list five new activities they have pursued or want to pursue to help them avoid triggers 

and prevent relapse. Clients can use their journals or pages 20 and 21 of their Client’s Treatment 

Companion. 

Handouts for Relapse Prevention Group Sessions 

The handouts that follow are to be used by clients with the counselor’s guidance. The handouts will 

help clients make the most of the 32 RP sessions. 

165 
RP 1 Alcohol 

It is often difficult for people to stop drinking when they 

enter treatment. Some reasons for this follow. 

Triggers for alcohol use are everywhere. It is sometimes hard to do anything social 

without facing people who are drinking. How can you get together with your 

friends without drinking? 

Many people use alcohol in response to internal triggers. Depression and anxiety 

seem to go away when they have a drink. It’s difficult for people to realize that 

sometimes the alcohol causes the depression. What moods and feelings make 

you want to have a drink? 

If a person is dependent on an illicit drug and uses alcohol less often, alcohol may 

not be viewed as a problem until the person tries to stop drinking. What challenges 

have you faced in stopping drinking since you entered treatment? 

Alcohol affects the rational, thinking part of the brain. It is difficult to think reasonably 

about a substance that makes thinking clearly more difficult. How does it feel to be 

sober at a party and watch people drink and act stupidly? 

Alcohol dulls the rational brain. Alcohol lowers people’s inhibitions and can make people 

more sexually aggressive, less self-conscious, and more sociable. People who use 

alcohol to decrease inhibitions and help them socialize may feel uncomfortable without it. 

In what ways have you depended on alcohol? For sexual or social reasons? 

1 of 2
 
RP 1 Alcohol 

Many of us grow up using alcohol to mark special occasions. It 

is hard to learn how to celebrate those times without drinking. What special 

occasions did your family celebrate with alcohol? 

How do you celebrate now? 


In many families and social groups, drinking is a sign of strength or maturity. Drinking 

often is seen as a way of being “one of the gang.” Do you feel less “with it” when 

you are not drinking? If so, in what ways? 

Drinking can become linked to certain activities. It can seem difficult during early 

recovery to do those things without a beer or other drink (for example, eating certain 

kinds of foods, going to sporting events). What activities seem to go with drinking 

for you? 

It is important to remember that everyone who stops drinking has these problems at 

first. As you work through the difficult situations and spend more time sober, it does get 

easier. 

2 of 2
 
RP 2 Boredom 

Often people who stop using drugs say life feels boring. Some reasons for this feeling 

include the following: 

●		 A structured, routine life feels different from a lifestyle built around substance use. 

●		 Brain chemical changes during recovery can make people feel 

listless (or bored). 

●		 People who use substances often have huge emotional swings 

(high to low and back to high). Normal emotions can feel flat by 

comparison. 

People who have been abstinent a long time rarely complain of continual boredom. The 

problem of boredom in recovery does improve. Meanwhile you should try some 

different activities to help remedy the problem of boredom in recovery. 

List five recreational activities you want to pursue. 

1. ___________________________________________________________________ 

2. ___________________________________________________________________ 

3. ___________________________________________________________________ 

4. ___________________________________________________________________ 

5. ___________________________________________________________________ 

Have you started doing things that you enjoyed before using drugs? Have 

you begun new activities that interest you? What are they? 

1 of 2
 
RP 2 Boredom 

Can you plan something to look forward to? What will you plan?
 

How long has it been since you’ve taken a vacation? A vacation doesn’t have 

to involve travel—just time away from your regular routine. What kind of 

break will you plan for yourself? 

Here are some tips to reduce feelings of boredom: 

●		 Recognize that a structured, routine life feels different from a lifestyle built 

around substance use. 

●		 Make sure you are scheduling activities. Forcing yourself to write down 

daily activities helps you fit in more interesting experiences. 

●		 Try not to become complacent in recovery. Do something that will 

further your growth. Sometimes boredom results from not challenging yourself enough in your daily living. 

Which of the suggestions listed above might work for you? It is important to try new 

ways of fighting boredom. Boredom can be a trigger that moves you toward relapse. 

2 of 2
 
RP 3A Avoiding Relapse Drift 

How Relapse Happens 

Relapse does not happen without warning, and it does not happen quickly. The gradual 

movement from abstinence to relapse can be subtle and easily explained away or 

denied. So a relapse often feels as if it happens suddenly. This slow movement away 

from abstinence can be compared to a ship gradually drifting away from where it was 

moored. The drifting movement can be so slow that you don’t even notice it. 

Interrupting Relapse Drift 

During recovery people do specific things that keep them abstinent. These activities 

can be called “mooring lines.” People need to understand what they are doing to keep 

themselves abstinent. They need to list these mooring lines in a specific way so they 

are clear and measurable. These activities are the “ropes” that hold recovery in place 

and prevent relapse drift from happening without being noticed. 

Maintaining Recovery 

Use the Mooring Lines Recovery Chart (RP 3B) to list and track the things that are 

holding your recovery in place. Follow these guidelines when filling out the form: 

●		 Identify four or five specific things that now are helping you stay abstinent 

(for example, working out for 20 minutes, 3 times a week). 

●		 Include items such as exercise, therapist and group appointments, scheduling activities, 12-Step meetings, eating patterns. 

●		 Do not list attitudes. They are not as easy to measure as behaviors. 

●		 Note specific people or places that are known triggers and need to 

be avoided during recovery. 

You should complete your Mooring Lines Recovery Chart weekly. Place a checkmark 

1 of 2
 
RP 3A Avoiding Relapse Drift 

next to each mooring line that you know is secure and record the date. When two or 

more items cannot be checked, it means that relapse drift is happening. Sometimes 

events interfere with your mooring lines. Emergencies and illnesses cannot be controlled. The mooring lines disappear. Many people relapse during these times. Use the 

chart to recognize when you are more likely to relapse, and decide what to do to keep 

this from happening. (After 5 weeks when the chart is full, transfer the list of mooring 

lines to a journal or pages 12 and 13 of your Client’s Treatment Companion, and 

continue to check your mooring lines.) 

2 of 2
 
RP 3B Mooring Lines Recovery 

Chart 

You have learned new behaviors that keep you in recovery. These behaviors are the 

mooring lines that keep your recovery steady and in place. It is important to chart the 

new behaviors and check every week to make sure the lines are secure. Dropping one 

or more of the mooring lines allows you to drift toward relapse. 

Use the chart below to list activities that are important to your continuing recovery. If there are specific people or things you need to 

avoid, list those. Check your list each week to make sure you are 

continuing to stay anchored in your recovery. 

Mooring Line Behaviors Date Date Date Date Date 

I Am Avoiding Date Date Date Date Date 

1 of 1
 
RP 4	 Work and 


Recovery
 

Certain employment situations can 

make treatment and recovery more 

difficult. Some difficult situations are outlined below. 

Employed in a Demanding Job That 

Makes Treatment Difficult 

Your treatment won’t work unless you give it 100 percent of your 

effort. People in recovery need to find a way to balance work with 

treatment so they can give recovery their full effort. Some jobs require 

long or unusual hours. Often the very nature of the work schedule has contributed 

to the substance use problem. The first task, if you have such a job, is to adjust your 

schedule to accommodate treatment. Work with your counselor and your boss or representative from your employee assistance program to do this. You also should find out 

whether flextime is an option. Recovery needs to be the first priority while you are in 

treatment. 

Working in an Unsatisfactory Job; Thinking of Making 

a Change 

During recovery major changes (in jobs, in relationships, etc.) should be delayed for 6 

months to 1 year whenever possible. Reasons for this include the following: 

●		 People in recovery go through big changes. Sometimes they change their 

views on personal situations. 

●		 Any change is stressful. Major stress should be avoided as much 

as possible during recovery. 

1 of 2
 
RP 4 Work and Recovery 

Working in a Situation Where Recovery Will Be Difficult 

Some jobs lend themselves to recovery more than others. Work situations that are 

difficult to combine with outpatient treatment include 

●		 Situations where it is necessary to be with other people 

who are drinking or using 

●		 Jobs in which large sums of cash are available at unpredictable times 

People in these types of jobs may want to plan for a job change. 

Unemployed and Needing To Find a Job 

When people are out of work, treatment becomes more difficult for 

the following reasons: 

● Looking for work is often the first priority. 

●		 Abundant free time is difficult to fill, and the structure that 

makes outpatient treatment effective is lacking. 

●		 Resources often are more limited, making transportation 

and child care more of a problem. 

If you are out of work and in treatment, remember that recovery still needs to be your 

first priority. Make sure the counselor knows your situation, and strive to balance jobseeking activities and treatment. 

There are no easy solutions to these problems. It is important to be aware of the issues 

so that you can plan to make your recovery as strong as possible. 

2 of 2
 
RP 5 Guilt and Shame 

Guilt is feeling bad about what you’ve done: “I am sorry I spent 

so much time using drugs and not paying attention to my family.” 

What are some things you have done in the past that you feel guilty about?
 

Feeling guilty can be a healthy reaction. It often means you have done something that 

doesn’t agree with your values and morals. It is not unusual for people to do things they 

feel guilty about. You can’t change the past. It is important to make peace with yourself. 

Sometimes that means making amends for things you’ve said and done. 

Remember the following: 

●		 It’s all right to make mistakes. 

●		 It’s all right to say, “I don’t know,” “I don’t care,” or “I don’t 

understand.”
 

●		 You don’t have to explain yourself to anyone if you’re acting 

responsibly.
 

Do you still feel guilty about the things you listed? What can you do to 

improve the situation? 

Shame is feeling bad about who you are: “I am hopeless and worthless.”
 

Do you feel ashamed of being dependent on substances? Yes ___ No ___
 

1 of 2 
RP 5 Guilt and Shame 

Do you feel you are weak because you couldn’t or can’t stop using? 

Yes ___ No ___ 

Do you feel you are stupid because of what you have done? 

Yes ___ No ___ 

Do you feel that you are a bad person because you are involved with 

substance use? Yes ___ No ___ 

Recovery is always a hard process. No one knows why some people can stop using 

substances once they enter treatment and decide to be abstinent and other people 

struggle to maintain abstinence. Research shows that family histories, genes, and 

individual physical differences in people play a role. Being dependent on drugs or 

alcohol does not mean you are bad, stupid, or weak. 

What we do know is that you cannot recover by 

● Trying to use willpower ● Trying to be good 

● Trying to be strong 

Two things to make recovery work are 

● Being smart 

● Working hard 

Everyone who is successful at recovery will tell you, “It was the hardest thing I ever 

did.” No one can do it for you, and it will not happen to you. 

2 of 2
 
RP 6 Staying Busy 

Learning to schedule activities and structure your recovery is important in outpatient 

treatment. Staying busy is important for several reasons. 

Often relapses begin in the head of a person who has nothing to do and nowhere to 

go. The addicted brain begins to think about past using, and the thoughts can start the 

craving process. How has free time been a trigger for you? 

How could you respond to prevent relapse if free time led to thoughts 

of using? 

Often people who abuse substances begin to isolate themselves. Being around people 

is uncomfortable and annoying. Being alone results in fewer hassles. Did you isolate 

yourself when you used? If so, how did this isolation affect your substance 

abuse? 

How does being alone now remind you of that experience?
 

1 of 2
 
RP 6 Staying Busy 

Being involved with people and doing things keeps 

life interesting. Living a substance-free life can 

sometimes feel pretty tame. You begin to think 

being abstinent is boring and using is exciting and 

desirable. People have to work at finding ways 

to make abstinence fun. What have you done 

lately to have fun? 

When people’s lives become consumed with substance use, many things they used to do 

and people they used to do them with get left behind. Beginning to reconnect or to build a 

life around substance-free activities and people is critical to a successful recovery. How 

have you reconnected with old activities and friends? How have you built 

new activities and brought new people into your life? 

If you have not reconnected with old activities and friends or added some 

new activities and people to your life, what are your plans to do so? 

2 of 2
 
RP 7 Motivation for Recovery 

Ask any group of people who are new to recovery why they want to stop using right 

now and you will get many different answers: 

●		 I was arrested, and it’s either this or jail. 

●		 My wife says if I don’t stop, we are finished. 

●		 Last time I used I thought I was going to die; I know I’ll die if 

I use again.
 

●		 They are going to take the children from us unless we stop. 

●		 I’ve been using for 20 years now; it’s time to change. 

Which of the people quoted is most likely to be successful in recovery? It seems 

logical to think that people who want to stop using for themselves and not because 

someone else wants them to are more likely to do well in treatment. However, that may 

not be true. Research shows that the reasons people stop using don’t predict whether 

they will be able to lead substance-free lives. 

What does make a difference is whether they can stay substance free long enough 

to appreciate the benefits of a different lifestyle. When debts are not overwhelming, 

relationships are rewarding, work is going well, and health is good, the person in 

recovery wants to stay abstinent. 

FEAR WILL GET PEOPLE INTO TREATMENT, 

BUT FEAR ALONE IS NOT ENOUGH 

TO KEEP THEM IN RECOVERY. 

1 of 2
 
RP 7 Motivation for Recovery 

List some of your reasons for entering treatment (for example, medical 

problems, family pressure, job problems, depression). 

List some of your reasons for continuing to work on your recovery today.
 

Do you feel that your reasons for initially stopping substance use are the 

same as your reasons for staying abstinent today? Why or why not? 

2 of 2
 
RP 8 Truthfulness 

During Substance Dependence 

Not being truthful is part of substance dependence. It is hard to 

meet the demands of daily living (relationships, families, jobs) 

and use substances regularly. As you become more dependent 

on the substance, the activities that are necessary to obtain, 

use, and recover from the substance take up more of your life. 

It becomes more and more difficult to keep your life on track. People 

who are substance dependent often find themselves doing and saying whatever is 

necessary to avoid problems. Telling the truth is not important to them. 

In what ways were you less than truthful when you were using substances? 

During Recovery 

Being honest with yourself and with others during the recovery process is critically 

important. Sometimes being truthful is very difficult for the following reasons: 

●		 You may not seem to be a nice person. 

●		 Your counselor or group members may be unhappy with 

your behavior. 

●		 You may be embarrassed. 

●		 Other people’s feelings may be hurt. 

1 of 2
 
 

 

 

 

RP 8 Truthfulness 

Being in treatment without being truthful may make everything you are doing a waste 

of time. 

How has truthfulness been difficult for you in recovery? 

Being partly honest is not being truthful. Do you ever
 

Decide to let someone believe a partial truth? Yes ___No ___
 

Tell people what they want to hear? Yes ___No ___
 

Tell people what you wish were true? Yes ___No ___
 

Tell less than the whole truth? Yes ___No ___
 

Attending groups, Attending Meetings, going to A 

HospitAl, And going to A Counselor Are WAstes of 

tiMe And Money WitHout trutHfulness. 

RECOVERY FROM ADDICTION IS IMPOSSIBLE 

WITHOUT TRUTHFULNESS. 

2 of 2
 
RP 9 Total Abstinence 

Have you ever found yourself saying any of the following? 

●		 My problem is my meth use. Alcohol (or marijuana) is not a problem 

for me. 

●		 Having a beer or glass of wine is not really drinking. 

●		 I drink only when I choose to. My drinking is not out of control. 

●		 I don’t really care about alcohol. I drink only to be sociable. 

If you entered the program to stop using stimulants, you may have wondered why 

you were asked to sign an agreement stating your willingness also to stop using other 

substances, including alcohol. For many reasons, total abstinence is a necessary goal 

for people in recovery: 

●		 Followup studies show that people who use stimulants are eight times 

more likely to relapse if they use alcohol and three times more likely 

to relapse if they use marijuana than people who do not use these 

substances. You can reduce your chances of relapsing greatly by 

maintaining total abstinence. 

●		 Places and people associated with drinking often are the very places 

and people who are triggers for substance use. 

●		 When you’re learning to handle problems without taking stimulants, 

using another drug or alcohol to numb the uncomfortable learning 

process is harmful for two reasons. First, such use prevents you 

from directly confronting your stimulant use problem. Second, it 

puts you at risk of becoming dependent on alcohol or another substance while you try to overcome your dependence on stimulants. 

Remember, if it’s more difficult to stop drinking than you expected, maybe you are more 

dependent on alcohol than you think. 

1 of 1
 
RP 10 Sex and Recovery 

Intimate Sex 

Intimate sex involves a significant other. The sex is a part of the relationship. Sometimes 

the sexual feelings are warm and mellow. Sometimes they are wild and passionate. 

But they result from and add to the feelings each partner has for the other. 

Impulsive Sex 

In this definition of impulsive sex, the partner is usually irrelevant; the person is a 

vehicle for the high. Impulsive sex can take the form of excessive masturbation. Impulsive sex can be used and abused in the same way drugs are used and abused. It is 

possible to become addicted to impulsive sex. 

What kind of experiences have you had with impulsive sex? 

Is impulsive sex linked to your drug use? How?
 

Describe a healthy, intimate sexual relationship that you have had or hope to 

have. 

Impulsive sex is not part of a healthy recovery lifestyle. It can be the first step in the 

relapse process. Like using alcohol or a drug other than stimulants, engaging in 

impulsive sex can trigger a relapse and result in use of stimulants. 

1 of 1 
RP 11 Anticipating and 

Preventing Relapse 

Why Is Relapse Prevention Important? 

Recovery is more than not using drugs and alcohol. The first step in treatment is stopping drug and alcohol use. The next step is not starting again. This is very important. 

The process for doing it is called relapse prevention. 

What Is Relapse? 

Relapse is going back to substance use and to all the behaviors and patterns that 

come with it. Often the behaviors and patterns return before the substance use. 

Learning to recognize the beginning of a relapse can help people in recovery stop 

the process before they start using again. 

1 of 3
 
RP 11 Anticipating and 

Preventing Relapse 

What Are Addictive Behaviors? 

The things people do as part of abusing drugs or alcohol are called addictive behaviors. 

Often these are things that addicted people do to get drugs or alcohol, to cover up 

substance abuse, or as part of abusing. Lying, stealing, being unreliable, and acting 

compulsively are types of addictive behaviors. When these behaviors reappear, people 

in recovery should be alerted that relapse will soon follow if they do not intervene. 

What are your addictive behaviors? 

What Is Addictive Thinking? 

Addictive thinking means having thoughts that make substance use seem OK. 

(In 12-Step programs this is known as “stinking thinking.”) Some examples follow: 

● I can handle just one drink. 

● If they think I’m using, I might as well. 

● I have worked hard. I need a break. 

How have you tried to find excuses to use substances? 

2 of 3
 
 

 

 

 

 

 

 

 

_______________________________ 

_______________________________ 

RP 11 Anticipating and 


Preventing Relapse
 

What Is Emotional Buildup? 

Feelings that don’t seem to go away and just keep getting stronger cause emotional buildup. Sometimes the feelings seem 

unbearable. Some feelings that can build are boredom, anxiety, 

sexual frustration, irritability, and depression. 

Have you experienced a buildup of any of these emotions?
 

The important step is to take action as soon as you recognize the danger signs. 

Which actions might help you prevent relapse? 

□ Calling a counselor 

□ Calling a friend 

□ Taking a day off 

□ Talking to your family 

□ Going to a 12-Step or outside 

mutual-help support meeting 

□ Exercising 

□ Talking to your spouse 

□ Scheduling time more rigorously 

□ Other: _________________________ 

3 of 3
 
RP 12 Trust 

How has substance use affected the trust between you and people you 

care about? 

If you tell someone you’re not using and the person doesn’t believe you, does 

it make you feel like using? Do you think, “If people are going to treat me as 

if I’m using, I might as well use”? 

People who are substance dependent find it difficult to have open, honest relationships. 

Things are said and done that destroy trust and damage relationships. Substance 

abuse becomes as important as or more important than other people. 

When substance abuse stops, the trust does not return right away. To trust means to 

feel certain you can rely on someone. People cannot be certain just because they want 

to be. Trust can be lost in an instant, but it can be rebuilt only over time. Trust will return 

gradually as the person who violated the trust gives another person reasons to trust 

again. One or both people may want the trust to return sooner, but it takes time for 

feelings to change. 

How do you cope with suspicions about drug use? 

What can you do to help the process of reestablishing trust?
 

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RP 13 Be Smart, Not Strong 

“I can be around drugs or alcohol. I’m sure I don’t want to use, 

and once I make up my mind, I’m very strong.” 

“I have been doing well, and I think it’s time to test myself to see 

whether I can be around friends who are using. It’s just a matter 

of willpower.” 

“I can have a drink and not use. I never had a problem with 


alcohol anyway.”
 

Staying abstinent has little to do with how strong you are. People who maintain abstinence 

do it by being smart. They know that the key to not drinking and not using is to keep far 

away from situations in which they might use. If you are in an environment where drugs 

might appear (for example, at a club or party) or with friends who are drinking and using, 

your chances of using are much greater than if you weren’t in that situation. Smart 

people stay abstinent by avoiding triggers and relapse situations. 

DON’T COUNT ON BEING STRONG. BE SMART. 

How smart are you being? Rate how well you are doing in avoiding relapse. 

(Circle the appropriate number.) 

Poor Fair Good Excellent 

1. Practicing thought stopping 1 2 3 4 

2. Scheduling 1 2 3 4 

3. Keeping appointments 1 2 3 4 

1 of 2
 
Poor Fair Good Excellent 

4. Avoiding triggers	 1 2 3 4
 

5.	 Not using alcohol 1 2 3 4
 

6.	 Not using drugs 1 2 3 4
 

7.	 Avoiding people who use
 

drugs and alcohol 1 2 3 4
 

8.	 Avoiding places where you might
 

encounter drugs or alcohol 1 2 3 4
 

9.	 Exercising 1 2 3 4
 

10.	 Being truthful 1 2 3 4
 

11.	 Going to 12-Step or
 

mutual-help meetings 1 2 3 4
 

RP 13 Be Smart, Not Strong
 

Add up the circled numbers. The higher your total, the better your Recovery 

IQ. The best possible Recovery IQ is 44. 

I scored ___________. 

This is your Recovery IQ. What can you do to improve your Recovery IQ? 

2 of 2
 
 

RP 14	 Defining Spirituality 

Look at these definitions of spirituality. Which ones 

describe what spirituality means to you? 

Spirituality is 

1. 	 A person’s relationship with God 

2.	 The deepest level from which a human being operates 

3.	 The philosophical context of a person’s life (values, rules, 

attitudes, and views) 

4.	 The same as religion 

5.	 Other: _________________________________________________________ 

The second and third definitions describe spirituality in a broad sense. When it comes 

to recovery, these broad definitions are the most useful way to think of spirituality. They 

describe being spiritual as having to do with a person’s spirit or soul, as distinguished 

from his or her physical being. Some people believe the level and degree of spirituality 

in a person’s life help determine the quality of life. One way to assess the quality of 

your spirituality is by answering the following questions: 

What do you want from life? Are you getting it? 

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RP 14 Defining Spirituality
 

On what is your spiritual security based? (What would it take to destroy your 

sense of self-worth?) 

Who do you have to be before you approve of yourself? (What qualities are 

most important to you?) 

What does success mean to you? (What does “making it” mean?)
 

To live an abstinent life, the person in recovery has to be comfortable 

within himself or herself. Gaining a sense of spirituality gives many people the inner 

peace that makes abusing substances unnecessary. Twelve-Step and mutual-help 

programs provide one way to gain or regain a love of oneself and of life. 

2 of 2
 
RP 15 Managing Life; 


Managing Money
 

Managing Life 

Maintaining a substance-dependent lifestyle takes a lot of time and energy. People who 

are substance dependent give little time or thought to everyday responsibilities. When 

recovery begins, long-neglected responsibilities come flooding back. It sometimes is 

overwhelming to think about all the things that need to be done. It also is frustrating 

and time consuming to catch up on so many responsibilities. 

Determine how well you are managing your life by answering the following questions: 

Do you have outstanding traffic tickets? _____ 

Have you filed all your tax returns to date? _____ 

Are there unpaid bills you need to make arrangements to pay? _____ 

What repair and maintenance does your house or apartment need? 

Does your car need to be serviced or repaired? _____
 

Do you have adequate insurance? _____
 

Do you have a checking account or a way to manage your finances? _____
 

Are you handling daily living chores (for example, buying groceries, doing 


laundry, cleaning)? _____
 

If you try to do all this at once, you may feel overwhelmed and hopeless. Take one item 

each week and focus on clearing up one area at a time. Handling these issues will help 

you regain control over your life. 

The first item I need to take care of is: 

I will start by: 

The second item I need to take care of is: 

I will start by: 

1 of 2
 
RP 15 Managing Life; Managing 

Money 

Managing Money 

Being in control of your finances is being in control of your life. When people who are 

substance dependent are using, the out-of-control lifestyle often affects their finances. 

How many of the following have been true for you?
 

_____

_____

_____

_____

_____

_____

_____

Any amount of money over __________ is a trigger to buy drugs.
 

I have concealed money to buy drugs.
 

I have large debts.
 

I gamble with my money.
 

I spend compulsively when I feel bad.
 

I frequently argue about money with family members.
 

I have stolen to get money to buy substances.
 

When they first enter treatment, some clients choose to give control of their money to 

someone they trust. If you make that decision, you are controlling your finances and 

asking the trusted person to act as your banker. Together with your counselor, you 

should decide when you can handle money again safely. Then you can begin working 

toward financial maturity. You may choose to have some of the following goals: 

●		 Arrange to pay off large debts 

in small, regular payments. 

●		 Budget your money carefully, 

as you schedule your time. 

●		 Arrange spending agreements with anyone who 

shares your finances.
 

● Use bank accounts to help 

you manage your money. 

● Live within your means. 

●		 Make a savings plan. 

What are your other financial goals? 


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RP 16 Relapse Justification I
 

Once a person decides not to use drugs anymore, how does he or she end up using 

again? Do relapses happen completely by accident? Or are there warning signs and 

ways to avoid relapse? 

Relapse justification is a process that happens in people’s minds. A person may have 

decided to stop using, but the person’s brain is still healing and still feels the need for 

the substances. The addicted brain invents excuses that allow the person in recovery to 

edge close enough to relapse situations that accidents can happen. You may remember 

a time when you intended to stay substance free but you invented a justification for using. 

Then, before you knew it, you had used again. 

Use the questions below to help you identify justifications invented by your addicted 

brain. Identifying and anticipating the justifications will help you interrupt the process. 

Someone Else’s Fault 

Does your addicted brain ever convince you that you have no choice but to use? 

Does an unexpected situation catch you off guard? Have you ever said any of 

the following to yourself? 

• An old friend called, and we decided to get together. 

• I had friends come for dinner, and they brought me some wine. 

• I was in a bar, and someone offered me a beer. 

• Other: 

Catastrophic Events 

Is there one unlikely, major event that is the only reason you would use? 

What might such an event be for you? 

• My spouse left me. There’s no reason to stay clean. 

• I just got injured. It’s ruined all of my plans. I might as well use.
 

1 of 2
 
RP 16 Relapse Justification I 

• I just lost my job. Why not use? 

• There was a death in the family. I can’t get through this without using. 

• Other: ___________________________________________________ 

For a Specific Purpose 

Has your addicted brain ever suggested that using drugs or alcohol is the 

only way to accomplish something? 

• I’m gaining weight and need stimulants to control my weight. 

• I’m out of energy. I’ll function better if I use. 

• I need drugs to meet people more easily. 

• I can’t enjoy sex without using. 

• Other: ___________________________________________________ 

Depression, Anger, Loneliness, and Fear 

Does feeling depressed, angry, lonely, or afraid make using seem like 

the answer? 

• I’m depressed. What difference does it make whether I use? 

• When I get mad enough, I can’t control what I do. 

• I’m scared. I know if I use, the feeling will go away. 

• If my partner thinks I’ve used, I might as well use. 

• Other: ___________________________________________________ 

What might you do when your addicted brain suggests these excuses to use? 

2 of 2
 
RP 17 Taking Care of 


Yourself
 

People who are substance dependent often do not take care of 

themselves. They don’t have the time or energy to pay attention to 

health and grooming. Health and personal appearance become less important than 

substance use. Not caring for oneself is a major factor in losing self-esteem. 

To esteem something means to see value in it, to acknowledge its importance. 

People in recovery need to recognize their own value. In recovery, your own health and 

appearance become more important as you care more for yourself. Taking care of yourself is part of starting to like and respect yourself again. 

Paying attention to the following concerns will strengthen your image of yourself as a 

person who is healthy, abstinent, and recovering: 

● Have you seen a doctor for a 

checkup?	 

●		 When was the last time you 

went to the dentist?	 

●		 Have you considered getting 

a new look? 

●		 Are you paying attention to 

what you are eating? 

● Do you wear the same 

clothes you wore when you 

were using?

● Do you need to have your 

vision or hearing checked?

● Do you exercise regularly? 

● Is your caffeine or nicotine 

intake out of control? 

Some people find it is easier to make sweeping lifestyle changes all at once. However, 

if addressing all these health and grooming issues at once is too overwhelming, work 

on one or two items each week. Decide which are the most important, and do those 

first. As you look and feel better, you will increase both the strength and the pleasure of 

your recovery. 

The first thing I need to do to take care of myself is: 

1 of 1
 
RP 18 Emotional Triggers 

Thought

Trigger 

Craving

Use 

For many people certain emotional states are directly connected 

to substance use, almost as if the emotion causes the substance use. It seems to 

people in recovery that if they could avoid ever feeling those emotions (for example, 

loneliness, anger, feeling deprived), they would never relapse. These emotional 

triggers should act as warnings or “red flags” for clients. 

The most common negative emotional triggers are the following: 

Loneliness: It is difficult to give up friends and activities that are part of a substanceusing lifestyle. Being separated from friends and family leaves people feeling lonely. 

Often friends and family members who do not use are not ready to risk getting back 

into a relationship that didn’t work earlier. The person in recovery is stranded between 

groups of friends. The feeling of loneliness can drive the person back toward using. 

Anger: The intense irritability experienced in the early stages of recovery can result in 

floods of anger that act as instant triggers. A person in that frame of mind is only a few 

steps from substance use. Once a person uses, it can be a long trip back to a rational 

state of mind. 

Feeling Deprived: Maintaining abstinence is a real accomplishment. Usually people 

in recovery feel justifiably good and proud about what they have been able to achieve. 

Sometimes people in recovery feel as if they have to give up good times and good 

things. Recovery seems like a jail sentence, something to be endured. This reverses 

the actual state of recovery: substance use begins to look good and recovery seems 

bad. This upside-down situation quickly leads to relapse. 

It is important to be aware of these red flag emotions. Allowing yourself to be flooded with 

these powerful negative emotions is allowing yourself to be swept rapidly toward relapse. 

Have some of these emotional states been a trigger for you in the past? 

Which ones? 

1 of 2
 
RP 18 Emotional Triggers 

Are there other negative emotional states that are dangerous for you? 

What are they? 

One of the goals during the recovery process is learning to separate thoughts, 

behaviors, and emotions so that you can control what you think and how you behave. 

It is important to recognize and understand your emotions so that your actions are not 

always dictated by your feelings. 

Many people find that writing about their feelings is a good way to recognize and 

understand their emotions. You don’t need to be a good writer to use this tool. People 

who do not like to write and who have never written much in the past still can learn 

valuable things about themselves by putting their feelings into words. Follow the simple 

instructions, and try a new way of getting to know yourself: 

1.	 Find a private, comfortable, quiet place and a time just for writing. Try to 

write each day, even if you can write only for a few minutes. 

2.	 Begin by taking several deep breaths and relaxing. 

3.	 Write in a response to a question that you have asked yourself about your 

feelings (for example, “What am I feeling right now?” “Why am I angry?” 

“Why am I sad?”). 

4.	 Forget spelling and punctuation; just let the words flow. 

Writing about your feelings makes them clearer to you. It also can help you avoid the 

emotional buildup that often leads to relapse. 

2 of 2
 
RP 19 Illness
 

Getting sick often predicts a relapse. This might seem strange, even unfair. After all, 

you can’t really do anything about getting sick, right? Many people get a few colds a 

year. Although you may not be able to prevent yourself from getting sick, you can be 

aware of the added relapse risk that comes with illness, and you can take precautions 

to avoid getting sick. 

Sickness as Relapse Justification 

Illness can be a powerful relapse justification. When you are sick, you make a lot of 

exceptions to your regular routine. You stay home from work; you sleep more than usual; 

you eat different foods. You may feel justified in pampering yourself (for example, “I’m 

sick, so it’s OK if I watch TV and lie around most of the day”; “I don’t feel good— 

I deserve a few extra cookies”). Because people feel that getting sick is out of their 

control, it seems OK to take a break from their regular behaviors. You need to be careful 

that, while you are taking a break from other routines, you don’t allow sickness to be an 

excuse for using. 

Relapse Risks During Illness 

When you are sick, you are physically weaker. You also may have less mental energy 

to maintain your recovery. In addition to lacking the energy to fight your substance use 

disorder, you may face the following relapse risks when you are sick: 

● Missing treatment sessions 

● Missing mutual-help meetings 

● Not exercising 

The following relapse risks also can act as triggers when you’re sick: 

● Spending a lot of time alone 

1 of 2
 
RP 19 Illness
 

●		 Recovering in bed (which reminds some people of recovering from using) 

●		 Having a lot of unstructured time 

Healthful Behaviors 

Although you can’t always prevent yourself from getting sick, you can do things to minimize your chances of getting sick. The following behaviors help support your recovery 

in general and help keep you healthy: 

●		 Exercise regularly (even when you feel as if you’re 

getting sick, light exercise can be good for you). 

●		 Eat healthful meals. 

●		 Get adequate sleep. 

●		 Minimize stress. 

Early in recovery from substance use, you also should avoid activities that put your 

health at risk or require recovery time. Elective surgery, serious dental work, and 

extended exertion may leave you fatigued and make you susceptible to illness. 

Recognize When You’re at Risk 

Because you may be more likely to relapse when you’re sick, you should be alert for 

the signs of illness. Soreness, tiredness, headaches, congestion, or a scratchy throat 

can signal the onset of illness. Even something like premenstrual syndrome (PMS) 

can weaken you physically and make relapse more likely. 

If you do get sick, try to keep the negative effects of illness from interfering with your 

recovery by getting well as quickly as possible. Get proper rest and medical attention 

so that you can return to your regular recovery routine as soon as possible. You will 

feel stronger, and your recovery will be stronger. 

2 of 2
 
□

□

□

□

□

□

RP 20 Recognizing Stress
 

Stress is a physical and emotional response to difficult 

or upsetting events, particularly those that continue 

for a long time. 

Stress is the experience people have when 

the demands they make on themselves or those 

placed on them disrupt their lives. Sometimes we 

are unaware of this emotional state until the stress produces physical symptoms. Place 

a checkmark next to any of the following problems you have experienced in 

the past 30 days: 

Sleep problems (for example, difficulty falling asleep, waking up off and 

on during the night, nightmares, waking up early and being unable to 

fall back to sleep) 

Headaches 

Stomach problems 

Chronic illness 

Fatigue 

Moodiness 

□

□

□

□

Irritability 

Difficulty concentrating 

General dissatisfaction with life 

Feeling overwhelmed 

If you checked two or more of these items, you may need to make some 

changes in your life to reduce the level of stress. Becoming more aware 

of stress is the first step to reducing it. You may have been accustomed 

to turning to substance use in times of stress. Learning new ways to cope 

with stress is part of the recovery process. Another Relapse Prevention session will address techniques for reducing stress. 

1 of 1
 
RP 21 Relapse Justification II
 

Once a person decides not to use drugs anymore, how does that person end up using 

again? Do relapses happen completely by accident? Or are there warning signs and 

ways to avoid relapse? 

Relapse justification is a process that happens in people’s minds. A person may have 

decided to stop using, but the person’s brain is still healing and still feels the need for 

the substances. The addicted brain invents excuses that allow the person in recovery 

to edge close enough to relapse situations that accidents can happen. You may 

remember a time when you intended to stay drug free but you invented a justification 

for using, and before you knew it, you had used again. 

Understanding and anticipating the justifications help you interrupt the process. Use 

the questions below to help you identify justifications you might be susceptible to. 

Substance Dependence Is Cured 

Has your addicted brain ever convinced you that you could use just once or 

use just a little? For example, have you said any of the following? 

•	 I’m back in control. I’ll be able to stop when I want to. 

•	 I’ve learned my lesson. I’ll only use small amounts and only once 

in a while. 

•	 This substance was not my problem—stimulants were. So I can 

use this and not relapse. 

•	 Other: ___________________________________________________ 

1 of 2
 
RP 21 Relapse Justification II 

Testing Yourself 

It’s very easy to forget that being smart, not being strong, is the key to staying abstinent. 

Have you ever wanted to prove you could be stronger than drugs? For 

example, have you said any of the following? 

• I’m strong enough to be around it now. 

• I want to see whether I can say “No” to drinking and using. 

• I want to see whether I can be around my old friends. 

• I want to see how the high feels now that I’ve stopped using. 

• Other: ___________________________________________________ 

Celebrating 

You may be encouraged by other people or your addicted brain to make an exception 

to your abstinence. Have you ever tried to justify using with the following 

thoughts? 

• I’m feeling really good. One time won’t hurt. 

• I’m on vacation. I’ll go back to not using when I get home. 

• I’m doing so well. Things are going great. I owe myself a reward. 

• This is such a special event that I want to celebrate. 

• Other: ___________________________________________________ 

What might you do when confronted with these excuses to use? 

2 of 2
 
 

 

RP 22 Reducing Stress
 

Answering the following questions as honestly as possible will help you identify which 

parts of your daily living are most stressful. Take steps to correct these problems, and 

you will reduce stress in your life. 

1. In deciding how to spend your time, energy, and money, you determine the 

direction of your life. Are you investing them in work and hobbies that you find 

rewarding? Yes ___ No ___ If not, how might you change this? 

2. Focusing on the present means giving your attention to the task at hand without 

past and future fears crippling you. Are you usually able to stay in the here and 

now? Yes ___ No ___ If not, what prevents you from focusing on the 

present? How can you change the situation? 

3. Do you take time each day to do something relaxing (for example, playing with your children, taking a walk, reading a book, listening to music)? 

Yes ___ No ___ If not, what relaxing activity will you add to your day? 

4. Are you challenging yourself to do things that increase self-confidence? 

Yes ___ No ___ If not, what changes could you make to boost your selfconfidence? 

5. Do you tackle large goals by breaking them into smaller, more manageable 

tasks? Yes ___ No ___ If not, how do you think breaking goals into smaller 

steps would help you manage stress? 

1 of 2
 
 

 

 

 

 

 

RP 22 Reducing Stress
 

6. Are you careful to make your environment (home, workplace) peaceful, whenever possible? Yes ___ No ___ If 

not, how can you make your environment more peaceful? 

7. Can you and do you say “No” when that is how you feel? Yes ___ No ___ 

If not, how do you think saying “No” could help you cope with stress in 

your life? 

8. Do you know how to use self-relaxation techniques to relax your body? 

Yes ___ No ___ If not, what can you do to learn more about ways to relax? 

9. Are you careful to avoid large swings in body energy caused by taking in 

excess sugar and caffeine? Yes ___ No ___ If not, what changes can you 

make to limit your intake of sugar and caffeine? 

10. Are there specific ways you cope with anger to get it out of your 

system? Yes ___ No ___ If not, how would reducing anger help you 

manage stress? 

11. What techniques can you start using that will help you get rid of anger?
 

2 of 2
 
RP 23 Managing Anger 

Anger is an emotion that leads many people to relapse. This is 

particularly true early in treatment. Frequently, anger slowly builds 

on itself as you constantly think about things that make you angry. 

Sometimes it seems that the issue causing the anger is the only important thing in life. 

Often a sense of victimization accompanies the anger. Do the following questions 

seem familiar to you? 

•	 Why do I get all the bad breaks? 

•	 How come she doesn’t understand my needs? 

•	 Why won’t he just do what I want him to do? 

How do you recognize when you are angry? Does your behavior change? 

Do you notice physical changes (for example, pacing, clenching your jaw, 

feeling restless or “keyed up”)? 

How do you express anger? Do you hold it in and eventually explode? 

Do you become sarcastic and passive–aggressive? 

What positive ways do you know to cope with anger? 

Here are some alternative ways to cope with anger. Which of the following will 

work for you? 

•	 Talk to the person you are angry with. 

•	 Talk to a counselor, a 12-Step sponsor, or another person who 

can give you guidance. 

•	 Talk about the anger in an outside support group meeting. 

•	 Write about your feelings of anger. 

•	 Exercise. 

•	 Other: ___________________________________________________ 

1 of 1
 
 

 

RP 24 Acceptance
 

“Just say no” is good advice to stop people from trying drugs. But 

it does not help people who are substance dependent. Overcoming substance dependence requires that you recognize its power and accept the personal limitations that 

occur because of it. Many people accept the hold that substance dependence has over 

them when they enter treatment. But entering treatment is the first act of acceptance. 

It cannot be the only one. Recovery is an ongoing process of accepting that substance 

dependence is more powerful than you are. 

Accepting that dependence on drugs has power over you means accepting that human 

beings have limits. Refusal to accept a substance use disorder is one of the biggest 

problems in staying drug free. This refusal to give in to treatment can lead to what is 

called “white-knuckle abstinence”—hanging on to abstinence desperately because you 

isolate yourself and refuse to accept help. Admitting that you have a problem and seeking help are not weaknesses. Does getting treatment for diabetes or a heart condition 

mean you are a weak-willed person? 

Accepting the idea that you have a substance use disorder does not mean you cannot 

control your life. It means there are some things you cannot control. One of them is the 

use of drugs. If you continue to struggle with trying to control the disorder, you end up 

giving it more power. 

There is a paradox in the recovery process. People who accept the reality of substance 

dependence to the greatest degree benefit the most in recovery. Those who do not 

fight with the idea that they have a substance use disorder are the ones who ultimately 

are most successful in recovery. The only way to win this fight is to surrender. The only 

way to be successful in recovery and get control of your problem is first to admit that it 

has control over you. 

YOU DO NOT NEED TO “HIT BOTTOM” TO BEGIN RECOVERY. 

I have a substance use disorder. Yes____ No____ 

I hope someday I can use again. Yes____ No____ 

I need to work on acceptance of 

1 of 1
 
RP 25 Making New 

Friends 

A blessed thing it is for any person to have a friend: 

One human soul whom we can trust utterly, who knows the best and 

worst of us, and who loves us in spite of our faults. 

Anonymous 

Relationships are very important to the recovery process. Friends and family can offer 

strength and help us understand who we are. The relationships you establish can support 

or weaken recovery. It has been said, “You will become like those people with whom you 

spend your time.” Use the following questions to help you think about your friendships. 

Do you have any friends like the one described in the poem above? If yes, 

who are they? 

Have you become like the people around you? In what ways?
 

What is the difference between a friend and an acquaintance?
 

Where can you make some new acquaintances who might become friends?
 

To whom are you a friend?
 

What behaviors do you need to change to be better able to have honest 

relationships? 

1 of 1
 
RP 26 Repairing 


Relationships
 

Friends and family of people who are substance dependent often get hurt as a result of 

the substance abuse. People who are substance dependent often cannot take care of 

themselves and certainly cannot take care of others. 

As part of your recovery, you should think about whom you have hurt. You should also 

think about whether you need to do anything to repair the relationships that are most 

important to you. In 12-Step programs this process is called “making amends.” 

What are some of the past behaviors you might want to amend? 

Are there things you neglected to do or say when you were using that should 

be addressed now? 

How are you planning to make amends?
 

Do you feel that being in recovery and stopping the use of drugs is enough?
 

Making amends does not have to be complicated. Acknowledging the hurt you caused 

while you were using substances will probably help reduce conflict in your relationships. Not everyone will be ready to forgive you, but an important part of this process 

is beginning to forgive yourself. Another aspect of repairing relationships involves your 

forgiving others for things that they did when you were using substances. 

Whom do you need to forgive? 

What resentments do you need to let go of?
 

1 of 1
 
RP 27 Serenity Prayer
 

God grant me the serenity to accept the things I 

cannot change, 

The courage 

to change the things I can, 

And the wisdom 

to know the difference. 

What does this saying mean to you? 


How can you find meaning in this saying, even if you are not religious or 

don’t believe in God? 

What parts of your life or yourself do you know you cannot change?
 

What have you changed already?
 

What parts of your life or yourself do you need to change?
 

1 of 1
 
RP 28 Compulsive Behaviors
 

Many people who are substance dependent enter treatment just to stop using a certain 

drug. They do not intend to change their lives entirely. When they enter treatment, they 

are told that recovery requires making other changes in the way they live. The lifestyle 

changes put people in recovery back in control of their lives. 

In what ways was your life out of control before you entered treatment? 

Have you noticed yourself behaving excessively in any of the following ways? 

•	 Working all the time 

•	 Abusing prescription 

medications 

•	 Using illicit drugs other than the 

one you entered treatment for 

•	 Drinking a lot of caffeinated 

sodas or coffee 

•	 Smoking 

• Eating foods high in sugar 

• Exercising to the extreme 

•	 Masturbating compulsively 

•	 Gambling

•	 Spending too much money

•	 Other: _____________________

What changes have you tried to make so far? 

Does the following sound familiar? “I stopped smoking and using drugs. It was hard. 

Then one day I gave in and had a cigarette. I felt so bad that I had messed up, I 

ended up using.” This pattern is called the “abstinence violation syndrome.” Once you 

compromise one part of your recovery, it becomes easier to slide into relapse. 

1 of 3 
 

RP 28 Compulsive Behaviors
 

Do you have a similar story from the past? What event led to your relapse?
 

What major lifestyle changes are you making in recovery?
 

Is it uncomfortable for you to make these changes? Yes ___ No ___ 

Are you avoiding being uncomfortable by switching to other compulsive 

behaviors? If so, what are they? 

Are there changes you still need to make? If so, what are they?
 

Relapse and Sex 

Like substance use, high-risk sex is controlled by a trigger process. (High-risk sex 

includes sex with a stranger, unprotected sex, and trading sex for drugs.) Triggers lead 

to thoughts of sex. Thoughts of sex lead to arousal and action. For many people, highrisk sex is associated with substance use. High-risk sex can be a trigger for substance 

use. Engaging in high-risk sex can bring on a relapse to substance use. 

What are some of your triggers for substance use?
 

What are some of your triggers for high-risk sex?
 

Have you experienced a relapse when sex was a trigger to use?
 

Prevention 

Once you are aware of the things that are triggers for you, you can take steps to 

prevent a relapse. Here are some suggestions you can do to prevent a relapse: 

2 of 3
 
 

 

 

RP 28 Compulsive Behaviors
 

●		 Prevent exposure to triggers. Stay away from people, places, and 

activities that you associate with drug use. 

●		 Stop the thoughts that may lead to relapse. Many techniques 

can be used to do this. Some examples of thought-stopping techniques are the following: 

Relaxation—Take three slow, deep breaths. 

Snapping—Wear a rubberband loosely on your wrist 

and every time you become aware of a triggering thought, snap the 

rubberband and mentally say, “No!” to the thought. 

Visualization—Imagine an ON/OFF switch in your head. Turn it to 

OFF to stop the triggering thoughts. 

●		 Schedule your time. Structure your day and fill blocks of free time with 

activities. You can exercise, do volunteer work, or spend time with friends 

who do not use drugs. 

●		 Break your typical pattern. Take a trip out of town. Go to a 

movie or watch a video. Go out to eat. Go to a 12-Step or mutualhelp meeting at a time you normally would be doing something else. 

What are some other things you could do to prevent a relapse? 

What do you plan to do next time you’re aware of being in a relapse situation?
 

3 of 3
 
RP 29 Coping With Feelings 


and Depression
 

Feelings 

Can You Recognize Your Feelings? 

Sometimes people don’t allow themselves to have certain emotions (for example, you 

tell yourself, “Feeling angry is not all right”). Sometimes people aren’t honest with themselves about their emotions (for example, saying, “I’m just having a bad day,” when the 

truth is they’re sad). When you mislabel emotions or deny them, you cannot address 

them and they build up inside you. 

Are You Aware of Physical Signs of Certain Feelings? 

Maybe you get an upset stomach when you are anxious, bite your fingernails when you 

are stressed, or shake when you are angry. Think about the emotions that trouble you, 

and try to identify how they show physically. 

How Do You Cope With Your Feelings Now? 

How do you respond when you experience negative emotions? How do your feelings 

affect you and others around you? For instance, do your feelings interfere with your relationships with others? Do people avoid you, try to keep you from getting upset, or try to 

make you feel better? Focus on one or two emotions you need to cope with better. 

How Do You Express Your Emotions? 

It is important to find an appropriate way to express emotions. You can express feelings 

indirectly (to a trusted group, friend, or counselor), or you can express feelings directly 

to others about whom you have the feelings. You need to learn in which situations it is 

appropriate to express feelings directly. You also can change your thinking in ways that 

result in your feeling different. For example, instead of saying, “I am so angry she 

doesn’t agree with me, I feel like using,” you can frame your feelings as, “It’s all right 

for someone not to agree with me, and using will not make anything better.” 

Do not let out-of-control feelings drive you back to using. Learning to cope with 

emotions means allowing yourself to feel and balancing an honest response with 

intelligent behavior. 

1 of 3
 
RP 29 Coping With Feelings 


and Depression
 

Depression 

Although we know drug use and depression are related, it is not always clear how the 

two interact. Most people in recovery report having problems with depression from time 

to time. Depression can be a particular problem for people who have been using stimulants. Stimulants make people feel “high” by flooding the brain with chemicals called 

neurotransmitters that regulate feelings of pleasure. During recovery there are periods 

when the brain doesn’t supply enough of those neurotransmitters. The undersupply of 

neurotransmitters causes a temporary feeling of depression. But this is different from 

being clinically depressed. For some people, depression left untreated can result in 

relapse. It is important to be aware of signs of depression and be prepared to cope with 

the feelings. If you feel that you cannot cope with your depression or if your depression 

lasts for a long time, seek help from a mental health professional. Your counselor or 

someone else at your treatment program can refer you to someone for help. 

These are some symptoms that might indicate depression. Check all that apply to you: 

□ Low energy 

Overeating or not eating 

Sad thoughts 

Losing interest in career or 

hobbies 

Sleeping more than usual 

Decreased sex drive 

Increased thoughts of drinking 

Insomnia 

Stopping attendance at 12-Step 

or mutual-help meetings 

□ Stopping exercise program 

Avoiding social activities 

Feelings of boredom, irritability, 

or anger 

Crying spells 

Suicidal thoughts or actions 

Stopping normal 

activities such as

work, cleaning

house, buying

groceries 

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RP 29 Coping With Feelings 


and Depression
 

What other signs indicate depression? 

Responses to depression include the following: 

● Increase exercise. 

● Plan some new activities. 

● Consult a doctor; medication 

● Talk to a spouse. 

● Talk to a friend. 

● Talk to a counselor may help. 

Do you have any other ways of coping effectively with depression? 

3 of 3
 
RP 30 12-Step Programs
 

What Is AA? 

Alcoholics Anonymous (AA) is a worldwide organization. It has been in existence since 

the 1930s. It was started by two men who could not recover from their alcoholism with 

psychiatry or medicine. AA holds free, open meetings to help people who want to stop 

being controlled by their need for alcohol. Meetings are available throughout the day 

and evening, 7 days a week. The principles of AA have been adapted to help people 

who are dependent on drugs or who have other compulsive disorders, such as 

gambling or overeating. 

Are These Meetings Like Treatment? 

No. They are groups of people in recovery helping one another stay abstinent. 

Does a Person Need To Enroll or Make an Appointment? 

No, just show up. Times and locations of meetings are available through this treatment 

program or by calling AA directly. 

What Are the 12 Steps? 

The basis of groups such as AA is the 12 Steps. These beliefs and activities provide 

a structured program for abstinence. There is a strong spiritual aspect to both the 12 

Steps and AA. 

* The Twelve Steps are reprinted with permission of Alcoholics Anonymous World Services, Inc. (A.A.W.S.). Permission to reprint the Twelve Steps does not mean 

that A.A.W.S. has reviewed or approved the contents of this publication, or that A.A.W.S. necessarily agrees with the views expressed herein. A.A. is a program of 

recovery from alcoholism only—use of the Twelve Steps in connection with programs and activities which are patterned after A.A., but which address other problems, or in any other non-A.A. context, does not imply otherwise. 

1 of 4
 
RP 30 12-Step Programs
 

The 12 Steps of Alcoholics Anonymous* 

1.	 We admitted that we were powerless over alcohol—that our lives had 

become unmanageable. 

2.	 Came to believe that a power greater than ourselves could restore us to sanity. 

3.	 Made a decision to turn our will and our lives over to the care of God, as 

we understood Him. 

4.	 Made a searching and fearless moral inventory of ourselves. 

5.	 Admitted to God, to ourselves, and to another human being the exact 

nature of our wrongs. 

6.	 Were entirely ready to have God remove all these defects of 

character. 

7.	 Humbly asked Him to remove our shortcomings. 

8.	 Made a list of all persons we had harmed and became willing to make 

amends to them all. 

9.	 Made direct amends to such people wherever possible, except when to 

do so would injure them or others. 

10.	 Continued to take personal inventory, and when we were wrong, promptly 

admitted it. 

11.	 Sought through prayer and meditation to improve our conscious contact 

with God, as we understood Him, praying only for 

knowledge of His will for us and the power to carry it out. 

12.	 Having had a spiritual awakening as a result of these Steps, 

we tried to carry this message to addicts and to practice these 

principles in all our affairs. 

2 of 4
 
RP 30 12-Step Programs
 

What Are CA and NA? 

Cocaine Anonymous and Narcotics Anonymous. Other 12-Step groups include Marijuana Anonymous, Pills Anonymous, Gamblers Anonymous, Overeaters Anonymous, 

Emotions Anonymous, and more. Here are the Web site addresses for these support 

groups: 

● Cocaine Anonymous (CA): http://www.ca.org 

● Narcotics Anonymous (NA): http://www.na.org 

● Marijuana Anonymous (MA): http://www.marijuana-anonymous.org 

● Pills Anonymous (PA): http://www.pillsanonymous.org 

● Gamblers Anonymous (GA): http://www.gamblersanonymous.org 

● Overeaters Anonymous (OA): http://www.oa.org 

● Emotions Anonymous (EA): http://www.emotionsanonymous.org 

The methods and principles of the groups are similar although the specific focus differs. 

Spinoff groups that use the 12 Steps include Al-Anon and Alateen, Adult Children of 

Alcoholics, Co-Dependents Anonymous, and Adult Children of Dysfunctional Families. 

Here are the Web site addresses for some of these support groups: 

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

● Nar-Anon: http://www.naranon.com 

● Adult Children of Alcoholics (ACoA): http://www.adultchildren.org 

● Co-Dependents Anonymous (CoDA): http://www.coda.org 

Often people go to more than one type of group. Most people shop around for the type 

of group and the specific meetings that they find most comfortable, relevant, and useful. 

3 of 4
 
RP 30 12-Step Programs
 

What Is CMA? 

Crystal Meth Anonymous (http://www.crystalmeth.org). CMA is a 12-Step group that 

offers fellowship and support for people who want to stop using meth. CMA meetings are 

open to anyone with a desire to end dependence on meth. Like other 12-Step programs, 

CMA has a spiritual focus and encourages participants to work the 12 Steps with the help 

of a sponsor. CMA advocates complete abstinence from nonprescribed medication. 

What if a Person Is Not Religious? 

One can benefit from 12-Step or mutual-help meetings without being religious or working the 12 Steps. Many people in 12-Step and mutual-help groups are not religious. 

These people may think of the higher power mentioned in the 12 Steps as a bigger 

frame of reference or a bigger source of knowledge than themselves. 

What Do 12-Step Programs Offer? 

● A safe place to go during recovery 

● A place to meet other people who don’t use drugs and alcohol 

● A spiritual component to recovery 

● Emotional support 

● Exposure to people who have achieved long-term abstinence 

● A worldwide network of support that is always available 

It is strongly recommended that you attend 12-Step 

or mutual-support meetings while you are in treatment. Ask other clients for help in choosing the best 

meeting for you. Try several different meetings. Be 

open to the ways that 12-Step meetings can support 

your recovery: social, emotional, or spiritual. 

4 of 4
 
RP 31 Looking Forward; 


Managing Downtime
 

Islands To Look Forward To 

There are many important elements to a successful recovery. Structure is important. 

Scheduling is important. Balance is important. Your recovery works because you work 

at it. Amid the hard work and the structure of recovery, do you feel as if something is 

missing? The activities and routines of recovery can seem stifling. Do you feel that you 

need to take a break from the routine and get excited about something? 

The emotional flatness you experience during recovery may be explained by the following: 

●		 Many people feel particularly bored and tired 2 to 4 months into recovery 

(during the period known as the Wall). 

●		 The recovery process the body is going through may prevent you from 

feeling strong emotions of any kind. 

●		 Life feels less “on the edge” than it did when you were using. 

Planning enjoyable things to look forward to is one way to put a sense of anticipation 

and excitement into your life. Some people think of this as building islands of rest, 

recreation, or fun. These are islands to look forward to so that the future doesn’t seem 

so predictable and routine. The islands don’t need to be extravagant things. They can 

be things like 

●		 Going out of town for a 3-day weekend 

●		 Taking a day off work 

●		 Going to a play or a concert 

●		 Attending a sporting event 

●		 Visiting relatives 

●		 Going out to eat 

1 of 3
 
RP 31 Looking Forward; 


Managing Downtime
 

● Visiting an old friend 

● Having a special date with your partner 

Plan these little rewards often enough so that you don’t get too 

stressed, tired, or bored in between them. 

List some islands that you used 

to use as rewards. ___________

What are some possible islands

___ for you now? 

Handling Downtime 

The Problem 

Being in recovery means living responsibly. Always acting intelligently and constantly 

guarding against relapse can be exhausting. It is easy to run out of energy and become 

tired and bitter. Life can become a cycle of sameness: getting up, going to work, coming 

home, lying on the couch, going to bed, and then doing it again the next day. People in 

recovery who allow themselves to get to this state of boredom and exhaustion are very 

vulnerable to relapse. It is difficult to resist triggers and relapse justifications when your 

energy level is so low. 

The Old Answer 

Drugs and alcohol provided quick relief from boredom and listlessness. All the reasons 

for not using substances can be forgotten quickly when the body and mind desperately 

need refueling. 

2 of 3
 
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RP 31 Looking Forward; 


Managing Downtime
 

A New Answer 

Each person needs to decide what can replace substance use and provide a refreshing, satisfying break from the daily grind. What works for you may not work for someone 

else. It doesn’t matter what nonusing activities you pursue during your downtime, but it 

is necessary to find a way to relax and rejuvenate. The more tired and beaten down you 

become, the less energy you will have for staying smart and committed to recovery. 

Notice how often you feel stressed, impatient, angry, or closed off emotionally. These 

are signs of needing more downtime. Which activities listed below would help 

rejuvenate you? 

Walking 

Reading 

Meditating or doing 

yoga 

Listening to music 

Playing with a pet 

Becoming active in 

a church 

Talking with a friend

who does not use 

Taking a class 

Playing team sports

Bicycling 

Painting, drawing 

Exercising at the 

gym 

Cooking 

Going to 12-Step 

or mutual-help 

meetings 

Going to the movies 

Writing 

Knitting 

Fishing

Scrapbooking

Window shopping

Playing a musical

instrument 

On a day when you’re stressed and you realize that in the past you would 

have said, “I really need a drink” or “I need to get high today,” what will 

you do now? What will you do in your downtime? 

3 of 3
 
RP 32 One Day at a Time
 

People in recovery usually do not relapse because they cannot handle one difficult day 

or one troubling situation. Any given day or any single event usually is manageable. 

Things become unmanageable when the person in recovery allows events from the 

past or fears of the future to contaminate the present. 

Beating yourself up about the past makes you less able to handle the present. You 

allow the past to make your recovery more difficult when you tell yourself 

● “I can never do anything right. I always mess up every opportunity.” 

● “If I try to do something difficult, I will fail. I always do.” 

● “I always am letting people down. I always have disappointed everyone.” 

You need to find a way to reject those negative thoughts when they come up. The 

thought-stopping techniques you learned in Early Recovery Skills (session 1) can help 

you move past these negative thoughts. Exercise, meditation, and journal writing also 

help you focus your mind and control your thoughts. 

Can you think of a recent situation in which you allowed the past to make the 

present more difficult? 

Don’t allow things that might happen in the future to overwhelm you in the present. You 

can plan ahead and be prepared, but you can do little else about the unknown. You can 

address only what is happening right now, today. You are filling yourself with fear when 

you tell yourself 

1 of 2
 
RP 32 

● “Tomorrow something will happen to ruin this.” 

● “That person is going to hate me for this.” 

● “I will never be able to make it.” 

What things do you tell yourself that make you fear the future? 

When you have these thoughts, it may help to remind yourself of times when you 

did not let your past behavior influence the future. Think of times when you broke 

away from an old, destructive pattern. Calling a friend who can remind you of your 

successes is a good way to keep yourself focused on today and reject fearful thoughts 

of the future. 

What things can you tell yourself that will bring you back to the present? 

2 of 2
 
RP 33 Drug Dreams During 


Recovery
 

Early Recovery (0–6 weeks) 

Drug use interferes with normal sleeping. When people stop using, they experience 

frequent and intense dreams. The dreams seem real and frightening. These dreams 

are a normal part of the recovery process. You are not responsible for whether you 

use in a dream. Regular exercise may help lessen the dream activity. 

Middle Recovery (7–16 weeks) 

For most people, dreams are less frequent during this phase of recovery. When they 

do occur, however, dreams can leave powerful feelings well into the following day. It 

is important to be careful to avoid relapse on days following powerful dream activity. 

Often dreams during this period are about choosing to use or not to use, and they can 

indicate how you feel about those choices. 

Late Recovery (17–24 weeks) 

Dreaming during this period is very important and can be helpful in warning the person 

in recovery. Sudden dreaming about drug or alcohol use can be a clear message that 

there may be a problem and that the dreamer is more vulnerable to relapse than usual. 

It is important to review your situation and correct any problems you discover. 

Listed below are some of the actions people take when their dreams become intense 

and troubling. Add to the list things that would help you in this situation: 

• Exercise 

• Go to a 12-Step or mutual-help meeting 

• Call a counselor 

• Talk to friends 

• Take a break from your normal routine 

• Other: ________________________________________ 

1 of 1
 
RP Elective A Client Status Review

1 of 2

Name: _________________________________________________ Date: __________Rate how satisfied you are with the following areas of your life by placing a checkmark in the appropriate boxes.

Area

Very 

Dissatisfied

Somewhat 

Dissatisfied Neutral

Somewhat 

Satisfied

Very 

Satisfied

CareerFriendsFamily

Romantic Relationships

Drug Use/CravingsAlcohol Use/CravingsSelf-EsteemPhysical Health

Psychological Well-Being

Sexual FulfillmentSpiritual Well-Being
RP Elective A Client Status Review
 

 Name: _____________________________________________ Date: __________
 

Rate how satisfied you are with the following areas of your life by placing a 


checkmark in the appropriate boxes.
 

Which of these areas improved the most since you entered treatment?
 

Which are your weakest areas? How are you planning to improve them?
 

What would need to change for you to be satisfied with the areas you rated 

lowest? 

2 of 2

RP Elective B Holidays and Recovery
 

Holiday seasons and the celebrations that come with them are difficult for people in 

recovery. Many things can happen to increase the risk of relapse. Review the list 

below and check the items that might cause problems for you and your 

recovery program during the holidays. Then total up the number of 

checkmarks and assess your relapse risk below: 

□ More alcohol and drugs at parties 

□ Shortage of money because of travel or gift buying 

□ More stress caused by hectic pace (for example, traffic, crowds) 

□ Normal routine of life interrupted 

□ Stopping exercise 

□ Not going to AA meetings 

□ Not going to therapy 

□ Party atmosphere 

□ More contact with family 

□ Increased emotions from holiday memories 

□ Increased anxiety regarding triggers and craving 

□ Frustration of not having time to meet responsibilities 

□ Coping with “New Year’s Eve” type occasions 

□ Extra free time with no structure 

□ Other: _________________________________________________ 

1 of 2
 
2 of 2

RP Elective B Holidays and Recovery

Mild: If you checked one to three items, the holidays produce only a slightly increased 

risk of relapse.

Moderate: If you checked four to six items, the holidays add a lot of stress to your life. 

Relapse risk is related to how well you cope with increased stress. Your score indicates 

that you need to plan carefully for your recovery during the holidays. 

Severe: If you checked seven or more items, the holidays add a major amount of 

stress to your life. Relapse prevention means learning how to recognize added stress 

and taking extra care during dangerous periods. Your score indicates the holidays are 

one of these periods for you.

NO ONE HAS TO RELAPSE. NO ONE BENEFITS FROM A RELAPSE. THINK ABOUT YOUR RECOVERY PLAN. ADD SOME 

MEETINGS. SCHEDULE YOUR TIME. SEE YOUR COUNSELOR. 

TO GET THROUGH THIS STRESSFUL TIME, USE THE TOOLS 

THAT HAVE HELPED YOU STAY ABSTINENT IN RECOVERY.

NO ONE HAS 

TO RELAPSE!
RP Elective C Recreational 


Activities
 

In addition to abstaining from substance use, it is important for you to put some 

interesting activities in your life. For many people in recovery, substance use was the 

main thing they did to relax and have a good time. Now that you are abstinent and in 

recovery, it is important to find fun things to do that can take the place of substance 

use. You might try returning to old activities you used to enjoy before you started 

using substances. 

What are some hobbies or activities that you used to enjoy and might like to 

try again? 

New activities and hobbies are an excellent way to support your recovery while you 

meet new people. Now is the time to take a class, learn a new skill, try your hand at 

making art, take up a new sport, do volunteer work, or try out other new interests. Ask 

your friends about hobbies that they enjoy. See about adult classes that are offered at 

local colleges. Consult your local community’s directory or Web site for listings of activities and classes. Check the newspaper for lectures, movies, plays, and concerts. 

What new activities and interests would you like to pursue? 

It is important to remember that not all new activities will be fun right away. It may take 

a while before you can really enjoy a new activity or become proficient at a new skill. 

Old activities that you enjoyed may not feel the same now that you’re 

abstinent and in recovery. Regardless of how new or old activities feel, 

you need to make them part of your life. 

1 of 1
 
VI. Social Support Group
 

Introduction 

Goals of Social Support Group 

■ Provide a safe discussion group where 

clients practice resocialization skills. 

■ Provide opportunities for clients who are 

advanced in treatment and recovery to 

serve as role models for clients who have 

been in recovery for less time. 

■ Encourage clients to broaden their support system of abstinent, recovering contacts with whom they can attend 12-Step 

or mutual-help meetings. 

■ Provide a less structured and more independent group environment that helps 

clients progress from treatment in the 

more structured environments of Early 

Recovery Skills and Relapse Prevention 

groups to recovery maintained with group 

support but without clinical support. 

Session Format and Counseling Approach 

The Social Support component of the Matrix 

Intensive Outpatient Treatment for People With 

Stimulant Use Disorders (IOP) model comprises 

36 group sessions that are held once a week 

over 36 weeks. Social Support group sessions 

overlap with the final 4 weeks of the intensive 

phase of Matrix IOP method and allow clients to 

continue group work for nearly 9 months after 

the conclusion of major treatment components 

(Early Recovery Skills, Relapse Prevention, and 

Family Education). Clients who have attained a 

stable recovery and have completed 12 weeks 

or more of Early Recovery Skills and Relapse 

Prevention group sessions should begin attending Social Support group sessions. Social 

Support groups are primarily discussion sessions. 

They are 90 minutes long and should be limited 

to 10 people per group so that each client has 

time to participate. 

Clients who have been co-leaders during Early 

Recovery Skills or Relapse Prevention group 

meetings can act as facilitators, under the counselor’s supervision. Client–facilitators should be 

screened carefully for emotional stability, intellectual competence, and strength of recovery. 

They should commit to attending regularly for 

6 months and should meet with the counselor 

before the group session to be briefed on the 

topic and issues relevant to individual clients. 

The client–facilitator’s job is to help the discussion run smoothly so that clients can get the 

most benefit from the Social Support group. The 

counselor should provide the client–facilitator the 

following guidelines for aiding the discussion: 

■ Listen to clients, help them clarify what 

they are saying, but do not speak for them 

or provide answers. 

■ Encourage group members to accept and 

support one another. 

■ Focus on the members; do not assume 

a position of authority or monopolize the 

discussion. 

■ Permit clients to depart briefly from the 

session’s topic if the discussion seems 

beneficial to all clients in the group. 

■ Steer participants away from lengthy 

stories of using that might act as triggers 

for others. 

■ Make sure that the group is not dominated 

by one or two members and that everyone 

in the group gets time to speak. 

■ Avoid making generalizations. 

233 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

■ Avoid asking “why” questions of members 

(e.g., questioning their actions or 

motivations). 

The counselor opens the group session by 

welcoming clients and introducing the topic for 

the session. The counselor then facilitates a 

discussion that can include the session topic, 

abstinence issues, and problems the clients are 

experiencing in establishing a substance-free 

lifestyle. The following section lists the one-word 

session topics, along with questions, that the 

counselor and client–facilitator use to encourage 

discussion. If clinical issues arise that require 

the counselor’s attention before the end of the 

session (e.g., a client has relapsed recently or 

is going through a personal crisis that places 

recovery in jeopardy), the client–facilitator 

should notify the counselor privately. If the 

group is broken into smaller discussion groups, 

the counselor should reconvene the larger 

group 5 or 10 minutes before the end of the 

session to recapitulate important issues relevant 

to the session’s topic and to address any problems or concerns that arose during discussion. 

Social Support Group 

Topics 

The 36 topics below address key concepts in 

recovery and are suggested focal points for 

discussion in the Social Support groups. Each 

topic includes questions that the counselor and 

client–facilitator can pose to initiate and sustain 

group discussion. Relevant session descriptions 

and handouts from the Early Recovery Skills 

and Relapse Prevention portions of treatment 

are listed after the questions for some topics. 

During the course of discussion, the counselor 

may wish to refer to information included in the 

session descriptions or the handouts. 

The counselor may choose to use topics that 

are not listed here, as the needs of the clients 

in the groups dictate. The topics are presented 

alphabetically and can be used in any order the 

counselor deems most useful to the group. 

Aging 

1. How do you view the aging process? 

What negative aspects do you see? What 

positive developments come with age? 

2. How does getting older affect your staying abstinent and in recovery? 

3. Is this your first time in recovery? If not, 

have you approached recovery differently 

this time? 

4. As you grow older, is it important for you 

to find a 12-Step meeting or mutual-help 

group that has people your own age? 

5. As you spend more time in recovery, how 

will you keep your recovery strong? 

Anger 

1. How do you feel about the way you 

handle your anger? 

2. How do you feel when anger is directed 

at you? 

3. Is anger a relapse trigger for you? In what 

ways? 

4. What strategies or behaviors help you 

cope with anger? 

5. How do you avoid being passive– 

aggressive when someone angers you? 

■ Relapse Prevention Session 23: Managing 

Anger 

■ Handout RP 23—Managing Anger 

234 
VI. Social Support Group 

Codependence 

1. How do you understand the concept of 

codependence? 

2. With whom do you have codependent 

relationships? 

3. How do these relationships affect your 

recovery? 

4. During recovery, what changes have 

you made to address codependent 

relationships? 

5. What strategies and techniques will you 

use to avoid codependence in the future? 

Commitment 

1. What does commitment mean to your 

recovery? 

2. What people or things have you been 

committed to in the past? What are you 

committed to now? 

3. How important is the commitment of 

family and friends to your recovery? 

4. How important is your commitment to 

friends and fellow clients who are in 

recovery? 

5. How will you maintain your commitment 

to recovery? 

Compulsions 

1. What have you done to avoid transferring 

your substance dependence to other 

compulsive behaviors? 

2. To what compulsive behaviors are you 

vulnerable? 

3. Are all compulsive behaviors bad? 

4. How has being in recovery helped you 

get your life under control? 

5. What can you do to avoid abstinence 

violation syndrome? 

■ Relapse Prevention Session 28: 

Compulsive Behaviors
 

■ Handout RP 28—Compulsive Behaviors 

Control 

1. How do you distinguish between things 

that you can control and things you 

cannot? 

2. How do you respond to things you cannot 

control? 

3. How has attending 12-Step or mutualhelp meetings helped you address these 

issues? 

4. What actions do you take to achieve 

balance and inner calm in your life? 

5. What aspects of your life do you still need 

to change to remain abstinent and in 

recovery? 

■ Relapse Prevention Session 27: Serenity 

Prayer 

■ Handout RP 27—Serenity Prayer 

Cravings 

1. Do you still experience cravings for substances? How have the cravings changed 

since you’ve been in recovery? 

2. Do you feel as if your recovery is in 

jeopardy because of cravings? Why or 

why not? 

3. When are you aware of cravings? 

4. What changes have you made to reduce 

cravings? 

5. What strategies and techniques will you 

use to keep cravings under control? 

■ Early Recovery Skills Session 1: Stop 

the Cycle 

■ Handout ERS 1A—Triggers 

235 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

■ Handout ERS 1B—Trigger–Thought– 

Craving–Use 

■ Handout ERS 1C—Thought-Stopping 

Techniques 

Depression 

1. Is depression a trigger for you? How do 

you recognize that you’re depressed? 

2. How have your feelings of depression 

changed as you’ve been in treatment and 

recovery? 

3. What people, events, and feelings 

contribute to your depression?
 

4. How do you respond when you recognize 

that you are depressed? 

5. What strategies and techniques help 

you avoid becoming depressed? What 

strategies and techniques help you get 

over depression? 

■ Relapse Prevention Session 29: Coping 

With Feelings and Depression 

■ Handout ERS 5—Roadmap for Recovery 

■ Handout RP 29—Coping With Feelings 

and Depression 

Emotions 

1. Do certain emotions act as triggers for 

you? Which emotions? 

2. How has the process of recovery helped 

you become more aware of your 

emotions? 

3. How do you cope with dangerous 

emotions, such as loneliness, anger, and 

feelings of deprivation? 

4. During recovery, what have you learned 

about separating emotions from behavior? 

5. What strategies and techniques help you 

maintain an emotional balance? 

■ Relapse Prevention Session 18: 

Emotional Triggers
 

■ Relapse Prevention Session 29: Coping 

With Feelings and Depression 

■ Handout RP 18—Emotional Triggers 

■ Handout RP 29—Coping With Feelings 

and Depression 

Fear 

1. When you entered treatment, what 

aspects of recovery were you afraid of? 

2. Have your fears about recovery changed 

since you’ve been in treatment? 

3. What helped you move past your fear? 

4. What things concern you when you think 

about leaving treatment? 

5. As you move forward with your recovery, 

what strategies and techniques will help 

you minimize your fears? 

Friendship 

1. How has your understanding of friendship 

changed since you’ve been in treatment? 

2. Before you entered treatment, what were 

your friendships based on? 

3. Now, what qualities do you look for in a 

friend? 

4. What has being a friend to others contributed to your recovery? 

5. What plans do you have for making new, 

supportive friends and maintaining current 

friendships? 

■ Relapse Prevention Session 25: Making 

New Friends 

■ Relapse Prevention Session 26: Repairing 

Relationships 

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VI. Social Support Group 

■ Handout RP 25—Making New Friends 

■ Handout RP 26—Repairing Relationships 

Fun 

1. How have your fun and relaxing activities 

changed since you’ve been in treatment? 

2. What do you do now to have fun and 

relax? 

3. With whom do you have fun? 

4. What role does having fun play in staying 

abstinent and in your recovery? 

5. How will you incorporate new activities 

and hobbies into your life? 

■ Relapse Prevention Session 31: Looking 

Forward; Managing Downtime 

■ Elective Session C: Recreational Activities 

■ Handout RP 31—Looking Forward; 

Managing Downtime
 

■ Handout RP Elective C—Recreational 

Activities 

Grief 

1. What experience have you had with grief? 

2. Is grief a trigger for you? In what ways? 

3. How has the way you cope with grief 

changed since you’ve been in recovery? 

How do you cope with feelings of grief 

now? 

4. To whom do you turn when you experience grief? 

5. What strategies or techniques do you use 

to keep grief from disrupting your recovery? 

Guilt 

1. How is guilt different from shame? 

2. Can guilt be a positive factor in your 

recovery? In what ways? 

3. How can guilt derail your recovery? 

4. What can you do to reduce the guilt you 

feel? 

5. What role has taking responsibility for 

past actions played in your recovery? 

■ Relapse Prevention Session 5: Guilt and 

Shame 

■ Handout RP 5—Guilt and Shame 

Happiness 

1. Since you’ve been in treatment, when have 

you been happy? What made you happy? 

2. Since you’ve been in treatment, how has 

what makes you happy changed? 

3. Do you feel that happiness is essential to 

your recovery? Why or why not? 

4. How have friendships helped you be 

happy? 

5. What strategies or techniques can you 

use to help you through unhappy times? 

Honesty 

1. How important is honesty to your staying 

abstinent and in recovery? 

2. In treatment, how have you learned to be 

honest with yourself? 

3. In treatment, how have you learned to be 

honest with others, especially family and 

friends? 

4. How does honesty relate to your selfesteem? 

5. What strategies or techniques will you use 

to continue being honest in your recovery? 

■ Relapse Prevention Session 8: 

Truthfulness
 

■ Handout RP 8—Truthfulness 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Intimacy 

1. Since you’ve been in treatment, how has 

your understanding of intimacy changed? 

2. What concerns or fears do you have 

about intimacy? 

3. Does sex function as a trigger for you? In 

what ways? 

4. What do you look for in an intimate, 

caring relationship? 

5. In what ways can intimate relationships 

support your recovery? 

■ Relapse Prevention Session 10: Sex and 

Recovery 

■ Handout RP 10—Sex and Recovery 

Isolation 

1. Are free time and being alone triggers for 

you? In what ways? 

2. How was feeling isolated related to your 

substance abuse? 

3. In what ways has scheduling activities 

helped you avoid isolation? 

4. How has attending 12-Step or mutualhelp meetings helped you avoid isolation? 

5. What activities can you pursue on your 

own that will help keep you from isolation? 

■ Relapse Prevention Session 2: Boredom 

■ Relapse Prevention Session 6: Staying 

Busy 

■ Handout RP 2—Boredom 

■ Handout RP 6—Staying Busy 

Justifications 

1. What relapse justifications are you vulnerable to? 

2. What emotions make you more likely to 

try to justify a relapse? 

3. What are the dangers of assuming that 

your substance dependence is under 

control? 

4. How is being smart important to your 

staying abstinent and in recovery? 

5. In treatment, what strategies or techniques have you learned to help counter 

relapse justifications? 

■ Relapse Prevention Session 16: Relapse 

Justification I 

■ Relapse Prevention Session 21: Relapse 

Justification II 

■ Handout RP 16—Relapse Justification I 

■ Handout RP 21—Relapse Justification II 

Masks 

1. How do you use masks to hide the way 

you feel, presenting yourself as feeling 

one way when you really feel another? 

2. In what circumstances do you mask your 

feelings? 

3. How has the masking of your feelings 

changed since you’ve been in treatment? 

4. How does masking your true feelings 

affect your recovery? 

5. How is being honest with yourself and 

others important to your recovery? 

■ Relapse Prevention Session 8: 

Truthfulness
 

■ Handout RP 8—Truthfulness 

Overwhelmed 

1. What contributes to your feeling 

overwhelmed?
 

238 
VI. Social Support Group 

2. How does feeling overwhelmed affect 

your behavior? 

3. How has your response to being overwhelmed changed since you’ve been in 

treatment? 

4. What risk does feeling overwhelmed pose 

to your recovery? 

5. What can you do to ensure that you do 

not feel overwhelmed? 

■ Relapse Prevention Session 20: 

Recognizing Stress
 

■ Relapse Prevention Session 22: Reducing 

Stress 

■ Handout RP 20—Recognizing Stress 

■ Handout RP 22—Reducing Stress 

Patience 

1. How has patience helped you in your 

recovery? 

2. When is it hard for you to be patient? 

3. Are there situations in which you can be 

too patient? What are they? Why can it 

be bad to be too patient? 

4. How has attending 12-Step or mutual-help 

meetings helped you be more patient? 

5. What strategies and techniques have you 

learned to help you be more patient? 

Physical 

1. How is your recovery related to your selfesteem? 

2. During recovery, how has your body 

changed? 

3. What new exercise or activity have you 

begun since entering treatment? 

4. How have you begun to take better care 

of your health? 

5. Why is it important to stay healthy to keep 

your recovery on track? 

■ Relapse Prevention Session 19: Illness 

■ Relapse Prevention Session 17: Taking 

Care of Yourself 

■ Handout RP 19—Illness 

■ Handout RP 17—Taking Care of Yourself 

Recovery 

1. Has your motivation for recovery changed 

since you’ve been in treatment? In what 

ways? 

2. What has been your biggest challenge in 

recovery so far? Your biggest triumph? 

3. From whom do you draw inspiration and 

encouragement in your recovery? Do you 

have a recovering role model? 

4. How has attending 12-Step or mutualhelp meetings helped you in your recovery? 

5. As you move forward with recovery, what 

are the most important aspects for you to 

focus on? 

■ Relapse Prevention Session 7: Motivation 

for Recovery 

■ Handout RP 7—Motivation for Recovery 

Rejection 

1. Did feeling rejected contribute to your 

substance abuse? In what ways? 

2. How have the ways you cope with rejection 

changed since you’ve been in treatment? 

3. How has support from friends and family 

helped you cope with rejection? 

239 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

4. As you make amends and repair relationships, some people may refuse to forgive 

you. How will you cope with this rejection? 

5. What strategies and techniques will you 

use to address rejection as you go forward with your recovery? 

■ Relapse Prevention Session 26: Repairing 

Relationships 

■ Handout RP 26—Repairing Relationships 

Relaxation 

1. How have the things you do to relax 

changed since you’ve been in treatment? 

2. Are leisure and downtime triggers for you? 

3. How have you managed to separate 

relaxing from substance abuse? 

4. Do you prefer to relax alone or with 

friends and family? Why? 

5. How have you used scheduling and 

islands of enjoyment to help you relax 

and keep your recovery on track? 

■ Relapse Prevention Session 31: Looking 

Forward; Managing Downtime 

■ Elective Session C: Recreational Activities 

■ Handout RP 31—Looking Forward; 

Managing Downtime
 

■ Handout RP Elective C—Recreational 

Activities 

Rules 

1. How do you respond to rules in general? 

How have you responded to the rules 

you’ve encountered in treatment? 

2. What rules do you impose on yourself? 

3. How do you balance the structure that 

rules provide with the need to relax and 

enjoy yourself? 

4. How have the guidelines of 12-Step or 

mutual-help programs supported your 

abstinence and recovery? 

5. What rules will be important for you as 

you move forward with your recovery? 

Scheduling 

1. In what ways have you used scheduling 

during your recovery? How has it helped 

support your recovery? 

2. Do you use scheduling all the time or 

only once in a while? At what times do 

you find it is helpful to use scheduling? 

3. What makes scheduling difficult for you? 

4. How have friends and family supported 

your use of scheduling? 

5. Do you think you will continue to use 

scheduling after you leave treatment? 

Why or why not? 

■ Early Recovery Skills Session 1: Stop the 

Cycle 

■ Handout SCH 1—The Importance of 

Scheduling 

Selfishness 

1. In what ways did selfishness contribute to 

your substance dependence? 

2. Are there times when it is a good idea to 

be selfish? What are they? 

3. How can selfishness be harmful to your 

recovery? 

4. How have family and friends helped you 

become less selfish? How have 12-Step 

or mutual-help programs helped you 

become less selfish? 

240 
VI. Social Support Group 

5. Do you think it is selfish to take time 

alone for exercising, relaxing, meditating, 

or writing in a diary? Why or why not? 

Sex 

1. Is sex a trigger for you? In what ways? 

2. What distinguishes impulsive sex from 

intimate sex? 

3. How can impulsive sex lead to relapse? 

4. How can an intimate relationship help 

support your recovery? 

5. What will you do to encourage healthy, 

intimate relationships in your life? 

■ Relapse Prevention Session 10: Sex and 

Recovery 

■ Handout RP 10—Sex and Recovery 

Smart 

1. Why is sheer willpower not enough to 

help you stay abstinent and in recovery? 

2. How is being smart part of having a 

strong recovery? 

3. How has anticipating situations in which 

you would be prone to relapse helped 

you stay abstinent and in recovery? 

4. When have you tried to be strong, 

instead of smart? What were the results? 

5. What strategies and techniques will you 

use to be smart as you go forward with 

your recovery? 

■ Relapse Prevention Session 13: Be 

Smart, Not Strong 

■ Handout RP 13—Be Smart, Not Strong 

Spirituality 

1. How would you define spirituality? Has 

that definition changed as a result of 

being in treatment? 

2. Why is it important for your recovery to 

have a spiritual component? 

3. How has attending 12-Step or mutualhelp group meetings helped you stay 

abstinent and in recovery? 

4. What qualities are important to you in 

choosing a 12-Step or mutual-help group 

to attend? 

5. Aside from attending meetings, what 

other spiritual elements have you incorporated into your life during recovery? 

Will you continue these practices? 

■ Relapse Prevention Session 27: Serenity 

Prayer 

■ Relapse Prevention Session 30: 12-Step 

and Mutual-Help Programs 

■ Handout RP 27—Serenity Prayer 

■ Handout RP 30—12-Step Programs 

Thought Stopping 

1. How has thought stopping helped you 

cope with cravings to use? Give some 

specific examples. 

2. Which thought-stopping techniques are 

most effective for you? Why? 

3. What do you visualize when you use 

thought-stopping techniques? 

4. Do you feel that you are more in control 

of your thoughts now than you were when 

you entered treatment? Why or why not? 

5. What role will thought stopping play in 

your recovery after you leave treatment? 

■ Early Recovery Skills Session 1: Stop the 

Cycle 

■ Handout ERS 1C—Thought-Stopping 

Techniques 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

Triggers 

1. What triggers do you still encounter in 

your daily life? 

2. Are there triggers you cannot avoid? How 

do you cope with those triggers? 

3. How has charting your external and 

internal triggers helped strengthen your 

recovery? 

4. How have family and friends helped you 

cope with triggers? 

5. What strategies and techniques have 

helped you stop triggers you encounter 

from becoming cravings for substances? 

■ Early Recovery Skills Session 2: 

Identifying External Triggers
 

■ Early Recovery Skills Session 3: 

Identifying Internal Triggers
 

■ Handout ERS 1A—Triggers 

■ Handout ERS 2B—External Trigger Chart 

■ Handout ERS 3B—Internal Trigger Chart 

Trust 

1. How has lack of trust damaged relationships in your life? 

2. Why is it important for your recovery that 

your friends, family, and others be able to 

trust you? 

3. In addition to staying abstinent, what can 

you do to earn back people’s trust? 

4. If people are slow to trust that you are 

abstinent and in recovery, how will you 

respond? What will you do if trust never 

returns to some relationships? 

5. How has placing your trust in fellow treatment group members and 12-Step or 

mutual-help group members helped your 

recovery? 

■ Relapse Prevention Session 12: Trust 

■ Handout RP 12—Trust 

Work 

1. How has your work life affected your 

recovery? Have there been positive 

effects? Negative effects? 

2. What steps have you taken to balance 

work with recovery? Have they been 

successful? 

3. How has the balance of work and recovery changed since you’ve progressed in 

recovery? 

4. Have you considered leaving your job? 

What are the potential pitfalls of doing 

this? What are the benefits? 

5. Aside from the money, what do you find 

rewarding about your work? 

■ Relapse Prevention Session 4: Work and 

Recovery 

■ Handout RP 4—Work and Recovery 

242 
VI. Social Support Group 

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% 

*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. 

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 past 30 days 11.53 days 

Preferred route of methamphetamine 

administration 

Smoking 65% 

Intravenous 24% 

Intranasal 11% 

243 
 

Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

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 methamphetaminedependence 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 methamphetaminefree 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). 

244 
VI. Social Support Group 

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. 

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Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

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 2005b), a free publication from 

the Center for Substance Abuse Treatment. 

246 
 

_____ 

_____ 

_____ 

_____ 

_____ 

_____ 

_____ 

_____ 

_____ 

_____ 

VI. Social Support Group 

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 coleaders) 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 

247 
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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 

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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. 

251 
Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment 

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. 

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. 

252 
VI. Social Support Group 

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 

253 
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Appendix G.
 

References
 

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth 

Edition. 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. HHS Publication No. 

(SMA) 05-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005a. 

CSAT (Center for Substance Abuse Treatment). Substance Abuse Treatment: Group Therapy. 

Treatment Improvement Protocol (TIP) Series 41. HHS Publication No. (SMA) 05-3991. 

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005b. 

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. 

255 
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Appendix H.
 

Acknowledgments
 

Lynne MacArthur, M.A., A.M.L.S., served as JBS KAP Executive Project Co-Director; Barbara Fink, 

RN, M.P.H., served as JBS KAP Managing Project Co-Director; and Emily Schifrin, M.S., and Dennis 

Burke, M.S., M.A., served as JBS KAP Deputy Directors for Product Development. Other JBS KAP 

personnel included Candace Baker, M.S.W., Senior Writer; Elliott Vanskike, Ph.D., Senior Writer; 

Wendy Caron, Editorial Quality Assurance Manager; Frances Nebesky, M.A., Quality Control Editor; 

Pamela Frazier, Document Production Specialist; and Claire Speights, Graphic Artist. 

257 
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HHS Publication No. (SMA) 13-4152

First Printed 2006

Reprinted 2007, 2008, 2009, 2010, 2011, 2013, and 2014

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration