outpatient substance abuse treatment

ken decerchio: â good afternoon everyone,and welcome. my name's ken decerchio. i'm a program director for children and familyfutures, located in lake forest, california. welcome to today's webinar, "practical issuesin the implementation of the matrix model." this is our fourth in a series of webinarsaddressing the implementation of selected evidencebased practices, being implementedby grantees in the regional partnership grant program. regional partnership grants are aprogram of the children's bureau, in the administration on children, youth and families, office ofchild abuse and neglect. i want to welcome the original partnershipgrantees, and to all of our other participants who are not regional partnership grantees,but are joining today's webinar, and who are

interested in today's topic.our previous webinars have included "seeking safety," "nurturing parent programs," "traumainformed organizations," and "traumafocused cognitive behavioral therapy." children andfamily futures also offers a series of webinars to the national center on substance abuseand child welfare and our family drug court learning academy, which is supported by theoffice of juvenile justice and delinquency prevention.you can find those webinars on the children and family futures website. you'll see thatlater at the end of the presentation, as mariana indicated. now i'd like to introduce elainestedt, child welfare program specialist at the office of child abuse and neglect andthe children's bureau, and the federal project

officer for the regional partnership grantprogram. elaine? elaine stedt: â hi, ken. can you hear me?ken: â we can hear you well. good morning. good afternoon, i mean.elaine: â it could be both. [crosstalk]ken: â it could be both. elaine: â [laughs] good morning. good afternoonto everyone. thank you for taking the time to join us for this important webinar on practicalissues and implementation of the matrix model. i know that some of our ongoing work withsupporting grantees along with states, courts, and tribes through the national center isthat we continue to hear questions around the use of the matrix model. we're alwaysinterested in hearing from you all as well.

i would just say, thank you in advance toour presenters. thank you to everyone on the phone for your time today. i really encourageyou all to use the chat function that's available on the side of the window or go to webinar.as ken said, there's a rich number of resources that are available on the national centerwebsite, and lessons learned that we have cataloged over time and continue to learnwith all of your support. please join me in welcoming our presenters,and i'll turn it back over to ken. thank you. ken: â thank you, elaine. i appreciate youjoining us. today's webinar, as elaine mentioned, is broughtto you by the national center on substance abuse and child welfare. the national centerhas been operating since 2002. the national

center has supported the program of the substanceabuse and mental health services administration, and the center for substance abuse treatment,the administration for children and families and the children's bureau, and the officeof child abuse and neglect. we've appreciated the support of samhsa andthe children's bureau in the years that children's and family futures has been operating thenational center. i would like to discuss briefly the agendafor today's webinar in the short time we're be spending together. today's webinar is notintended to train participants to deliver the matrix model. the webinar will providea detailed overview of the key implementation issues to be addressed in implementing thematrix model and measuring the fidelity and

outcomes of the model, joining on the practicalexperiences of the developers of the matrix model.it's my pleasure to introduce today's presenters. our lead presenter is jeanne l. obert, founderand past executive director and present chairperson of the board of matrix institute, a nonprofitcorporation that delivers outpatient treatment and other health services in los angeles,california area. the matrix institute is affiliated with theucla integrated substance abuse programs, and is the site for the national instituteon drug abuse, clinical trials network. jeanne is one of the developers of the matrixmodel of intensive outpatient treatment and the matrix model for teens and young adults.recently she worked with others to create

the soon to be released second edition ofthe hazelden matrix materials and a matrix manual for persons involved in criminal justicesystem. jeanne is also a motivational interviewingtrainer, trained by bill miller and steve rollnick. she's been an active member of themotivational interviewing network of trainers ever since and served as an expert traineron a motivational enhancement study led by yale university as part of the nida communityclinical trials network. joining jeanne today with today's presentationis ahndrea weiner. ahndrea is also at the matrix institute, and currently the directorof training and the clinical supervisor of matrix institute on addictions. she has workedin many different capacities at the matrix

institute since 1992.ahndrea has been lecturing, training and educating, domestically and internationally in the matrixmodel for over 20 years. has been trained as well by bill miller in motivational interviewing.ahndrea is also an instructor in the alcohol and drug studies program at ucla, where sheteaches on cooccurring disorders for the addiction professionals.with that, i would like to turn it over to jeanne. good afternoon, jeanne, and welcome.jeanne obert: â thank you, ken. i want to thank you and mariana for helping us set thisup. i am absolutely delighted to be talking to those of you who have been using the matrixmodel and finding it helpful in your work, and also those of you who are just findingout about it.

we have both, ahndrea and i, have spent alot of years working with patients, and i'm hoping that some of our experience will behelpful to you today. please feel free to ask questions as we go along. we really welcomethat. just to get started, when we developed thematrix model originally, we developed it on the basis of material that was out there thatwas already working. shortly, not too long ago, the second edition of a little book called"the principles of drug addiction treatment" was published by nida, and that's availableto people still. in that book what they did was, look at all the effective treatments.once we looked out, when we developed the matrix and the matrix model and cognitivebehavioral therapy, all these different therapies,

and they pooled all those therapies what infact ware the most important components of effective evidence based treatments.what they listed in their little booklet are that, there be multiple sessions for at leasta hundred and twenty days, and i don't think all of the managed care companies really abideby the hundred and twenty days. but we try to educate people as often as we can, payersas often as we can about the need for people to be in treatment for four months, if it'sat all possible. they also said that it's important for peopleto come in for a minimum of three visits a week and we found out that to be true too.that's why, if you are familiar with the matrix model, you know that it's said out so thatpeople come in monday, wednesday and friday.

although sometimes there are space issues,and so you may have to go to tuesday, wednesday, friday. then another track of patients onmonday, wednesday, thursday. however you do it, it's important to not havethose three days be monday, tuesday, wednesday, to actually spread them out over the weekso that people who are struggling to stay drug free have contact with your treatmentcenter as frequently as possible, with as few days in between visits as possible. sothat's an important part of how the treatment is setup.i am a family therapist and so is ahndrea and so are a lot of the people that we haveworking at matrix. it was important to us from the beginning to make sure that we hadfamily involvement to whatever degree we could

make that happen. that's why the matrix modelis set up so that in the middle of the week, usually on wednesdays, there is a componentof the program that includes family members. now, not everybody has family members thatcan come to that. that's fine. people certainly can come to the education groups by themselves.but if it's at all possible to involve family members, we know now from the research thattreatment is much more effective if you can involve family members.certainly if you are doing adolescent treatment or you are working with children, the familyprogram is really critical. not that children necessarily come to the family education groups,but we'll talk a little bit more about that piece later.the 12step program in the united states is

very popular and very available to people.when we developed the matrix model decided we didn't want to do the body, mind and spiritpart but to really involve people in the 12step program, because it is so well organized,and helps so many people. when somebody finishes the matrix program, they then have a continuousongoing support program whenever they go. it is available in other places in the worldtoo, although there are some countries that don't have as many programs as we are herein the united states. what we did when we designed the matrix programis we put specific sessions in to orient people to the 12step program. we don't do step workin our program. instead, what we try to do is have an onsite 12step meetings at our cliniclocations, so that people can access those

12step meetings in a friendly kind of way.we see our role with regard to the 12step as one of orienting people to it, making peoplecomfortable with it, helping people understand the benefit of being involved in the 12stepprograms. that's not to say that we and maybe some of you who are doing matrix, and havebeen doing it for a while, don't get people coming in who see the matrix program as analternative to the 12step program. we actually like that because we believe thatthere need to be as many doors into treatment as possible. if people view that as anotherdoor into treatment, we don't tell them, "you can't come into treatment unless you're doingthe 12step program." what we tell them is, "come in to treatment. talk with other patientswho are in treatment. see what you think about

it and maybe give it a try since it's hereon site." we actually end up with a fair number of peoplewho were seeing this as an alternative to the 12step program in the beginning, goingto meetings and staying involved once they finish matrix. there are programs still, placeswhere ahndrea and i go and do training, there are some outpatient programs that don't dotesting. either you're in testing or breath alcoholtesting, they trust their patients to let them know when they are in trouble. we believethat that's pretty naã¯ve, when you're doing drug and alcohol treatment, because it's reallyimportant to have some kind of concrete way for clients to be able to show us that theyare not using drugs and alcohol.

as a matter of fact, people do find it useful,often and request that they be tested even after the program ends. we'll talk a littlebit more about that later too. medication, more and more we're seeing medicationsbeing used along with the psychosocial interventions. if we look at the next slide, you can seethat cognitive, there are certain treatments that are mentioned in that principles book,and these are four of them. in the principles book you'll see cbt, cognitive behavioraltherapy mentioned. you'll see contingency management mentioned, and you'll see motivationalinterviewing as having efficacy and then evidence based.you'll also see the matrix model mentioned, and matrix is a little bit different thanthose three, because matrix is made up of

components of each of those first three. whenwe created the matrix model, we didn't really create something that is brand new that'snever been heard of before. what we did create was a way of putting someof those things together in an easy to manage kind of format that works for clients. theother thing that we wanted to do when we developed the matrix model, was bring research findingsthat were known in the universities and in the research settings, down to the level whereour patients could benefit from those. along with the cognitive behavioral contingencymanagement and using the motivational interviewing style, we incorporated some of the researchin very simple terms that clients can understand. we'll talk a little bit more about that inthe future too. i think, mariana, we have

the first poll?mariana corona: â yes, we do. thank you, jeanne. we'd like to see if you could all just takea minute to answer this question for us. we know some of answered it in the registrationprocess as well. our first polling question for today is at what stage of implementationis your site related to the matrix model? the options are exploration, installation,initial implementation, sole implementation or i'm unsure.we are going to give you just a couple of seconds to answer. we have about 40 percentof the attendees who are identifying as being in sole implementation, and then 31 percentof the attendees who are identifying as being in the exploration and information gatheringphase, with the rest distributed between installation

at 5 percent, initial implementation at 10,and unsure at 14 percent of participants. jeanne: â wonderful. we'll try to fill inthe blanks for those of you who are at the exploration information gathering stage. ifyou have questions that we're not answering as we go along, like i said before, pleasefeel free to ask those questions. let's talk about the treatment componentsof the matrix model now. in terms of the things that make up the matrix model, there are individualsessions with clients, as well as a couple of different kinds of groups.the early recovery groups are for people who are in the early stages of treatment, we'lltalk about each of these kinds of groups in more detail in just a minute. the relapseprevention groups are the longerterm groups

that are the core of the group participationfor people. we'll talk about the family education group,the 12step meetings. social support groups are for people who have finished their primarypart of treatment. the relapse analysis is a component that is used as necessary, kindof a prn component of the matrix model, for people who have attained some sobriety andcontinuing to relapse, and drug testing. these are the things that make up the matrixmodel per se. we would like to find out a little bit more about the people that youare actually working with, so mariana has another poll.mariana: â great. thank you, jeanne. our next question, currently, what is the most frequentlyidentified primary substance at intake at

your agency, or treatment center? as you cansee, our options are, prescription pain medication, heroin, methamphetamine, alcohol, or other,and we're going to give you just a couple seconds to reply, please.i can say that the most frequently identified was methamphetamine at 42 percent, alcoholat 23 percent, and then heroin at 19 percent. jeanne: â that's very interesting. thank you,mariana. mariana: â you're welcome.jeanne: â fascinating. one of the things that i haven't said yet, and as we talk about thecomparison of the manuals now, i think it's important to say is that, when we first startedmatrix, we started it with the idea that we were going to develop a treatment for cocaineusers that was specific to them. yeah, that's

the comparison slide.the people using cocaine were being treated with treatments that were appropriate foralcohol users and people who were using opiates, and they weren't really working that well.part of our motivation for starting matrix, was to develop this treatment that was specificallyfor stimulant users. shortly after we were working on developingour model, people from san bernardino county, here in california, came to us and said, "wehave a lot of methamphetamine users," and, "do you think that this model will work aswell with the methamphetamine users, as it does with the cocaine users?"we said, "we don't know, but we'll give it a try." we started a clinic out there in ranchocucamonga, for primarily methamphetamine users.

we did some surveys about this. we discoveredthat the treatment worked just as well with the meth users, as it did with the cocaineusers, since both of those drugs are stimulants, and they have a very similar way of actingin the brain. not identical, but similar. it was after that discovery, when the methamphetamineepidemic hit, and it looks like it's still going on, according to the poll. not justin this country, by the way. i'm going to japan next month, and they want me to comeover and talk about this model, because they have lots of methamphetamine users there using.we're not alone. csat came to us and said, "we want to helpyou publish the manuals, since it's working with meth users." that resulted in the publicationof the csat manual. they also said, once our

demonstration grant is over, and that's whatwe use to look at this, once it's over, we will publish the manual, and make it availableto everybody. three years later, that piece had not yetbeen prioritized at csat, and so hazelden came to us and said, "look, you're using themanual. you have just the manual that you've published yourselves. we would like to publishthe matrix manual." we said, "yes, but it's going to be out there for free, because csatis going to publish it soon," and they said, "never mind. we'll do a different kind ofversion of it, and it will be a broader base." we said, "ok."after that, csat came out with their manual, so you can see why it ended up that we havetwo different versions of the manual. the

csat one was the one that was used in thestudy, and so it was really specific to stimulants. if you use the csat manual, which is availableby download off of the csat website, then you'll notice that all of the handouts, andall of the information, is very specific to stimulants, because it came out of our largedemonstration grants and study, looking at the effectiveness of the matrix model.it is in the public domain though, and the good thing about that is that, if people wantto make changes to it, which we've had other countries that wanted to translate it, andwe have people who want to adapt it for other uses, as i think some of you have, for thechild welfare things that you've been using it for, you're free to make any kind of adaptationto that public domain one, that you want to

make.then we hope following it up with research looking at how effective that is. if you dothat, we'd love to know about it. [laughs] the hazelden manual on the other hand, isa little bit different. there are more individual and conjoint sessions in the hazelden manual.there are 10 individual, slash, conjoint, meaning you see the individual person, and/orthe family in those sessions. hazelden does sell hard copies of the manual. they're notinexpensive. however, any program only needs to buy onecopy of the therapist's manual, and can share that, and can copy the patient manual. it'sset up so that you can do that, so that you buy one manual from hazelden, and then youtake either the dvd, or the hard copy, depending

on which version of the hazelden manual youget, because the new is just coming out, and make patient workbooks yourself, from thosecopies. the patient materials can be duplicated, andare in fact intended to be duplicated. they also broadened the language in the hazeldenone, so that it doesn't just talk about stimulants. it talks about opiates, and alcohol, and prescriptionmedication. it's much broader in terms of, specifically the people that it addresses.not that patients don't do fine with the csat one too, but this is intentionally broader.when you buy the hazelden manual, you also get the free videos with the family educationgroups. you get to see ahndrea in person, delivering one of the lectures. sam minsky,who is one of our national trainers doing

another one, and i'm doing the family one.those are three videos that are really the core of the matrix manual. if patients don'thave the information that's on those core videos, then they don't understand why they'redoing the interventions that they're doing in the groups.those same core things you can get through csat by downloading the dvds that they made.i don't think they're sending out hard copies any more, but it always changes, so checkon the csat site. we made some dvds with patients actually talking, and they're the same contentas the three core videos from the family education groups, in the hazelden manual.those three core groups are really critical for patients to get, but the hazelden manualis under copyright, and it's not in the public

domain, so you can't just take it and useit for whatever you want to use it for. mariana: â ahndrea, jeanne, want to say anything?ahndrea weiner: â i think that the other challenge might be, between the two manuals, is whenyour clients are coming in to treatment, and they don't identify as a stimulant user, theyhave a hard time making the translation in their head.especially when they're a little more oppositional to being there, or maybe in a stage of change,where they're in contemplation, and are challenged by the csat manual that mentions stimulants,or cocaine, or methamphetamine, when perhaps they're someone addicted to alcohol, or prescriptionmedication. many of the sites have reported to us overthe years, there has been some challenges

around that, when they choose the downloadablematerial, as opposed to the hazelden material. jeanne: â great. we're going to talk now,a little bit about each of these components, so that those of you who have not been deliveringthem, know what they are, and those who have, hopefully will, maybe learn something newabout them. this slide says individual session, but itreally is individual conjoint or individual family session. that's what it means. thereare more of these, as we said before, in the hazelden manual than the csat. there aren'tany specific family sessions in the csat manual, but in the hazelden manual, there are.we really felt that that was important to include, especially in some of those cultureswhere they're not working necessarily on just

individualization, and seeing people individually.it's really important to these cultures, that the families be involved in treatment.i remember one time when i did an evaluation with a chinese family, and 10 people showedup for the evaluation session. there were grandparents, and aunts, and everybody whowas interested. i think that's wonderful. we wanted to make sure that the manuals couldbe used effectively in those kinds of cultures, both in this country, and in others.also in the teen manual, one of the...we're going to talk a little bit later, about somespecific manuals, that have come out of our basic manual. the teen manual is one of them.hazelden published the teen manual and the adolescent manual a few years ago.of course, the family parts of the teen manual,

are critically important. in fact, the familyeducation groups are different in the teen manual. we have one set of education groupsfor parents, where there's a lot of parenting taught, and those kinds of communication skillsand so on, and another for the teen, for the adolescents.they don't necessarily do the family education group together, they do the conjoint sessionstogether. certainly, any time that you have a family member paying for treatment, it'simportant to involve them in the treatment process, so these sessions are good for thatsituation too. mariana: â jump in if you have anything, ahndrea.jeanne: â next the early recovery groups, the next slide please. the early recoverygroups have a history to them. we used to

do a lot more individual sessions, than wedo now. once we looked at our outcome data, and looked at what was happening with treatment,we discovered that we didn't need to see everybody individually.we, of course, thought that it would be much more effective if we worked with people individually,but we discovered that wasn't true. we used to have a friday night group that we calledthe stabilization group. patients would come in on friday nights, for this little groupinstead of an individual session. that group grew into what we call the early recoverygroup. the early recovery groups are for those peoplewho are not as stable as other people in the program, and who need to be seen more frequently,and actually need to get some individualized

attention. we do this for the first monthof treatment, assuming that most of the people who are going to be a little bit less stable,are going to be people in the first month of treatment.these stabilization groups, or early recovery groups, now happen on mondays and fridays,right before the relapse prevention groups. these groups can be coled by people who arefurther along in treatment and have something to offer.the relapse prevention groups, as we said earlier, are the main group in the recoveryprocess. they last for, as long as the person is in treatment, two to four months. theyare coled by patients who have graduated from the group and are doing something to activelymaintain their recovery.

we invite them to be coleaders. the informationin the topics from the relapse prevention groups is really important for everybody tohave. the groups are organized in a way that, because they are open groups, and people comein at different stages during the treatment process, the core information that they need,they will get within just a few groups. when you are working with people in the childwelfare system, it's important to include safety planning as part of the relapse planningprocess in these relapse prevention groups, as well as, in the family education group.i think we already talked about most of the things in this slide. i think that in thefamily education groups, those three lectures are really critical. you get those three inwhichever version of the manual that you're

using and then this family education groupis where you can make adaptations to the lectures. there are 16 family education groups. if youhave safety kinds of issues that you want to include, seeking safety type topics, oryou want to include something that is culturally specific to the group that you are workingwith, you're free to use some of these family education groups to do that. to sort of pickand choose the ones, other than the three core ones, the ones that you think are mostimportant to the people that you are working with.the 12step meetings, as we said before, aren't always available in all cultures. but we doinclude them, and we include them on site when we can, so that people can access thosereadily. then there are the social support

groups. the next slide, please.the social support groups are sort of our alumni groups. once people finish treatment,they're eligible for the social support group. in fact that, after the 12 family educationsessions, they actually move into social support for the last four sessions.those are delivered in lieu of the family education groups for the next year in treatment.usually, people come and go in the groups. if they need support they come in for thesocial support group and it's not as tightly led as some of the other groups, and it doesn'thave real specific topics like the other groups do.it's open for the people who are coming to talk about the issues that they do need totalk about, that are important to them. this

is where people really form bonds with otherpeople who have been through the program, so that they can do things outside of thetreatment program that support their recovery with other people who are drug and alcoholfree. the relapse analysis, we talked about therelapse analysis a little bit before. this was developed when we had people who wererelapsing. they'd been clean for six weeks, and then they relapsed. then they were cleanfor six more weeks, and then they relapsed. or two months, or three months, or whateverthat time period was that they just couldn't get past, and the relapse continued to happenat that point. we decided to develop this tool where yousit down and analyze, use the tool to analyze

the person. what's going on with them andwhy these relapses are occurring? it's usually an individual session and it's not for peoplewho have not been able to stop using, but rather for people who have these fairly predictableor frequent relapses after long periods of sobriety.the drug testing is an important part of the program. it should be done on a regular basis.we prefer weekly. it's done for clinical reasons. in some cases, if you've got an agency whois requiring urine testing, and they have consequences for that urine testing, if youcan work with them to do their own urine testing so that you can do the clinical testing, andthey do their mandatory testing, it works better.that's not always possible, and i know in

rancho cucamonga we have a big, active drugcourt program. which by the way, if anybody ever wants to visit that, we welcome visitorsto the drug court program. especially if you're doing in training here at matrix, and wantto add that on. in our drug court program, the judge doeslooks at the urine tests as part of, sort of, the picture. but the judge understandsthat urine testing in that sense is an aid to treatment, and that if somebody is havingtrouble, what they need is increased treatment, not necessarily consequences, negative consequences.that is the drug testing, and now i'll just say a couple words about the adaptations ofthe matrix model, the manualized adaptations on the next slide.we adapted the matrix model for some of the

native american people that we were workingwith. we created a supplement that is not a separate, freestanding manual, but goeswith our manual. we got input from friendship house in san francisco to do this. that manualis available from matrix. nobody publishes that except us, but we do sell that.the spanish manual, hazelden created a spanish manual. csat created one some years ago, butit's not really as up to date as the hazelden one. on the hazelden website, you can geta spanish manual and you can get the education video tapes in spanish.recently we worked with csat to develop another supplement that is a women's supplement. maybethe women's supplement would be really useful for some of you who are working with someof the populations with mothers as part of

it.the women's supplement follows the early recovery groups, so people get the basic matrix skillsfirst. then they move into some of the issues that are specific for women only. we workedpretty hard on this manual with csat, and tested it at a lot of different sites. i thinkit's a really helpful supplement, if it would be useful to any of you.hazelden published a teen manual a few years ago. that's available on their website, andit's a complete manual. it's different from the adult manual. it has different handoutsthat were created to be more attractive to adolescents then the regular manual. i recommendthat if you have an adolescent audience. the medication assisted, we have new manuals thatare just being published from hazelden. those

new manuals published from hazelden includea medication assisted treatment section that we didn't have in the manuals before. beforewe go to the cultures that have used the matrix manual, mariana, do you have some questions?mariana: â i do. we do have a couple of questions coming in from the registered participants.the first one, has anyone broadcast the matrix model as a telemedicine effort, and if so,where has this been done? jeanne: â [laughs] actually, just this lastweekend, we had a strategic planning meeting and that is on our agenda for the next yearin our strategic plans. no, not yet, other than outside agencies doing that, but nota telemedicine full treatment intervention, but we do have that on the drawing board.mariana: â great. thank you. a couple more.

are there any key considerations for usingmatrix within the context of a residential treatment program? many agencies around thecountry are implementing matrix as "a standalone foundation for the substance abuse componentof a larger more comprehensive program." ahndrea: â this is ahndrea, hi. yes, the matrixmodel itself has been adapted in many inpatient settings everywhere. it's not done, necessarilyto structural fidelity. if you have been trained in the matrix model with regards to clinicaland structural fidelity, you are going to have some obstacles regarding structural fidelity,taking an outpatient model and adapting it to an inpatient setting.however, with that said, much of the material, especially a lot of the early recovery material,works very well in a 28day or more residential

setting. it allows the client to build thefoundation for their own recovery, and we have seen a lot of success with our modelbeing implemented in inpatient organizations. mariana: â great. thank you. maybe one morequestion, and then we can move ahead. there was one question about effective strategiesfor engaging parents in matrix model treatment. you've talked a little bit about the groupsthat you use, but maybe specific strategies that you've found helpful for engagement?jeanne: â maybe ahndrea and i can both answer this. one way that i have used in the past,because it's sometimes very difficult. parents are very angry. family members are angry.family members have checked out. they consider it the patient's problem, not theirs. theclient's problem, and they don't want to be

involved.sometimes it works if you say to family members, "look, i understand where you're coming from.what i would like you to do is sort of take a wait and see kind of attitude. give yourfamily member the opportunity to learn what they need to learn, the tools that they needto learn to stay sober. because, it's really hard to do that without knowing these tools."view this as a course in recovery. and after a certain period of time," whatever they'rewilling to say, "after a month or six weeks, if your family member is doing well in treatment,will you then agree to participate in the family part of the program?" sometimes, peopleare willing to say yes to that kind of an agreement when they are not ready to comeinto the door immediately.

ahndrea: â i would also add that, i thinkit's really important with this model that we make the distinction that our family educationgroups are not family therapy groups. they really are education as a way for all peopleto feel safe in the room. sometimes family members feel like they'regoing to be blamed, or the clients are afraid the family members are going to air all theirdirty laundry. with the adult materials, that family education group really does lend itselfto an education format as opposed to family therapy. with the adolescent manual, and thatparticular model, we've set it out so that the parents are with each other, as opposedto mixed with their kids. the issues that are going to come up thathave to do with parenting, living with a child

with an addiction, can be talked about freely,without the kids in the room, while the kids have their own separate education group ona different night. also, one thing to add. when the parents comein for that parent group on that night, the kids do attend the clinic that night, butthey are in a separate room doing separate activities, so that you have them there together,but separate. jeanne: â yeah, and i think, mariana, i thinkone other thing that i think is important to say about this is we didn't really putanything in this presentation about the stages of recovery. but one of the really importantthings that came out of the development of the matrix model, was the identification ofreally predicable stages in recovery, particularly,

with the stimulant users.besides the withdrawal stage, which is the first couple of weeks, and the honeymoon,which is the first month or so, there's this stage that we call the wall, and it's reallyimportant for family members. it's one of the things that we explained in those lecturesthat we were talking about. it's really important that family membershave that piece of information, that this stage is part of the recovery process. becausewhen somebody starts into that wall space it really does look very much like a relapse.it looks like people are sliding backwards, and in fact, if you don't get through thatwall stage, which is long, it's 120 days. that's a long stage. it's a little bit longerwith methamphetamine users than with cocaine

users. if families don't know about that,they're going to not be able to be as supportive in the recovery process. letting them knowthat there's education here that they need too, so that the recovery thing is predictablefor family members. mariana: â great. thank you. i'd just liketo note, we are running a bit behind. would it be possible to perhaps jump to the implementationdriver slide, and then move over to the fidelity? of course, all the materials and the detailsare available on the website and in the powerpoint. if anybody has any questions specific to theother material, please follow up with us, either via the question and answer log orvia email, and we'll make sure to provide that information.jeanne: â let's go to the implementation piece,

and i apologize for us being so wordy. wehave so much to say about this, we could probably talk for days.trainers and key supervisors. this is central to the implementation of the matrix model.we developed a very specific implementation plan for the matrix model. the trainers area little bit different than the key supervisors, because they are really different people.the people that are good trainers are not necessarily good key supervisors, and viceversa. there are two aspects to the implementationthat are critically important, besides the core training itself. of course, the coretraining is central too. but if we look at the next slide, i can talk a little bit moreabout the training slide, the matrix trainers.

matrix trainers are actually people who havedone the matrix model, personally. they have been a therapist delivering thematrix model, and adapting it to various populations and situations. this is true, both here inthe united states. we have limited trainers here. we have plenty of trainers to meet thedemand. we're spread out geographically all over the united states, but we have just ahalf a dozen trainers or so here in the us, and we have a trainer in spain, and we havea trainer in south africa. these are all people who are really expertsat the matrix model, and have extensive experience. we don't train people to be trainers, andthen all they know is the training. we have trainers who have a depth of knowledge thatis really useful.

if you look at the next slide, the key supervisors.those are our partners. those are matrix' partners in the sites where people have receivedmatrix training. if you come to matrix to do a core training, following that core training,is the opportunity for one or two people to stay and get a much smaller training on howto be a key supervisor. the key supervisors are designed to be theclinical people who really support the staff. they are the change agents, if you will, inthe organization. they are the ones who do the supervision, who in some cases, hire theclinicians. they do the training for people. they're responsible for assuring that themodel is being done to fidelity. we really want to support those key supervisors.we're coming up with new plans and new ways

in the next year to really support and beactively engaged with the key supervisors throughout the country.no program can be certified and there's a certification with the matrix model withouta key supervisor on site. these people are the people who make sure that new staff comingin are trained in the matrix model. in our key supervisor training, ahndrea orsam, one of those two people does that training. they give the key supervisors the tools todo training at their sites. they are not encouraged to go out and do training outside of the matrix.in fact we ask them to not do that. but on their site, they're the person who preventsthe turnover from getting in the way of the program on going.let's look at the characteristics of an ideal

key supervisor on the next slide. this isthe person who is really savvy about the organization, and the dynamics of the organization and alsocredible to the clinical staff. it's a person who has excellent communication skills.the person who knows the matrix model well enough that they can say to a clinician, "no,you know about this particular stage of recovery, well, that's what you need to be thinkingabout when you're talking with this patient about this situation. you know about thoughtstopping," which is one of the interventions that we teach, "this is the place with thisparticular client where you might want to review thought stopping even though it's notthe topic for this particular session. the key supervisor is the person who reallycan step in and deliver the model as an expert

at any particular time. mariana, do you wantto do the next polling question? mariana: â yes. why don't we do the next pollingquestion, and if it's ok, jeanne, we'll jump to the fidelity portion?jeanne: â yes, that's great. mariana: â the information about the supervisorswill be in the presentation. our next polling question, do you have someone supervisingyour matrix model clinical staff? options not currently implementing matrix, no activesupervisor, supervisor who is not trained in the matrix model or supervisor who wastrained in the matrix model, and the final option is supervisors who would have beentrained by a matrix trainer. as the response is coming to you jeanne, themajority are not currently implementing the

matrix model that would be 46 percent of thepeople with funding. 25 percent have a supervisor who was trained in the matrix model. 17 percenthave a key supervisor trained by the matrix trainer.jeanne: â ok, great. that's really relevant to the certification process and we'll justbriefly let you know about the certification process. ahndrea is going to talk about that.ahndrea: â after they've been to a matrix core training or we've gone to their agency,and they've also chosen someone to be a key supervisor, they look to this model as a modelthat's going to create retention and specific outcomes that they are looking for withintheir agency. they are also wanting to be recognized asa certified matrix site. the certified matrix

site is the site that has been deliveringthe matrix model for over six months that does have a key supervisor on sight. thereis a process of applying for certification in which we'll come out to the agency, andwe will observe what happens in the agency. we will listen to a group, a relapse preventiongroup. go ahead.jeanne: â let me interrupt them. i think we're confusing the slide person. we are all theway up on fidelity monitoring certification. what ahndrea is talking about is on that slide.mariana: â one more slide please, jonathan. great, thank you.jeanne: â go ahead. ahndrea: â if you want to become a matrixcertified site, there is a process in order

for that to happen. we will listen to an audiotape of an actual relapse prevention group, that the key supervisor, dean, in the mostrepresentative of a matrix relapse prevention group.then we are able to come out to the site to do a site visit. then we meet as a committeeand talk about all the things we've noticed, and hopefully we're able to award a certificateof three years of certification. jeanne: â you learn about all of these inthe core training. the way to start this whole process is to come to one of the matrix trainings,which are all listed on our website. you'll learn about the fidelity monitoring instrumentshere. ahndrea can just for briefly talk about... ahndrea: â sure. part of what is really valuableto our key supervisors is our fidelity instruments.

one is called the minutebyminute instrumentthat really helps with the clinical fidelity for the frontline staff who are deliveringthe matrix model. we talk about style. we talk about content. we look at some of themi, philosophical points that are very important within this model.this gives the supervisor a roadmap to follow, and also gives the frontline staff some understandingof expectations from a clinical perspective. with regards to certifications, we are lookingat a ten of those items being met in order to be certified. we also have the same fidelityinstrument from a structural perspective. jeanne mentioned earlier the importance ofnot doing treatments three consecutive days in a row, but spreading it out. we look atthe fact that you are implementing your groups

three times a week.we look at the staff you are using, the materials you use, progress notes are being writtenand so on and so forth. do you have a good grasp at the matrix model and the brain model?all these things are part and parcel to our fidelity instruments.jeanne: â you do get trained in these instruments that are key supervisor training.mariana: â i believe these are the structural elements you were just referring to, ahndrea?jeanne: â yes. the next four slides are copies of that form that we use, the worksheet thatwe use. this one is the structural elements. it's two pages long. and then there is the...andthose have to do with what ahndrea with just talking about. then there is minutebyminuteelements where we listen to the tapes and

evaluate the therapies on these minutebyminute.the key supervisors can certainly use these within the clinic settings to make sure thatthere staff is meeting fidelity when they are working in their groups.ahndrea: â we used them supervision as well. jeanne: â mariana, would you like to jumpto measuring the impact and the outcome, just that one slide, one or two slides of the researchsetting? mariana: â if we could do the calling questionand then maybe after a couple of questions to you about fidelity. we did receive a couple.jeanne: â perfect. mariana: â great. if you all could just respondto our next calling question which is, "is your agency currently using any of these fidelitymonitoring tools?" the options are yes or

no. perhaps you are using other fidelity monitoringtools, or again not currently implementing the matrix model.ok, jeanne. again, we have the majority, 46 percent of those who responded are not currentlyimplementing the matrix model, another 33 percent are not using fidelity monitoringtools right now, 17 percent are using them and 4 percent are using other tools.jeanne: â ok, great. that's good to know and i am really happy to see that, with thosekinds of numbers, those of you who have not been trained, or using the matrix model andare interested in it and have stayed on for this entire webinar. that's good. [laughs]mariana: â jeanne, if we could ask a couple of questions to you and ahndrea about fidelity?jeanne: â please do.

mariana: â one of the first questions thatcamein in the registration was, "how do you address fidelity when you are implementingthe matrix model in that individual or more individualized setting?"jeanne: â i think that when we talk about fidelity we are actually talking about a veryspecific like setting up a program that has all the same elements as the programs didthat got measured for effectiveness. but if you are going to do individual sessionsand use the matrix material, you could use the minutebyminute fidelity standards to lookout whether or not the person is delivering treatment in the style that the matrix isintended to be delivered, and whether or not they understand all the concepts that a personneeds to understand.

but somehow you would have to work in thosebasic three videos, those core videos, for it could be very meaningful in a completelyindividualized kind of program. i'm not how sure a program will do that, but you certainlycould use the videos as an education piece. mariana: â great. thank you. another questionthat we know is often, or another issue i should say, that we know it has been a challengefor agencies implementing evidencebased practices if staff turnover. i was wondering if youcould speak about how your program addresses staff turnover with implementation of thematrix model, and any suggestions you might have for other programs.jeanne: â yeah. certainly, ahndrea and i are like both going to talk at once. what i wasgoing to say is this is where the key supervisors

come in. because when we develop an implementationplan for the matrix model, we knew that from all of the literature, when you start implementingevidencebased practices and you train people in it, staff turnover is a big problem becausethey leave and the whole thing leaves. that's why the key supervisors is so importantand why we, specifically, train the key supervisors to be able to train new staff in the matrixmodel, and support them in doing that. that is the way that we design the program to addressthat potential pitfall with the implementation. ahndrea: â i would add that we strongly encouragesites to have more than one key supervisor when possible. if you, actually, have a situationwhere is the key supervisor leaving, you still have another key supervisor on site.we have built in in our matrix core training

the opportunity when we go to an agency forthem to send people to us for a free slot and a key supervisor training, because wethink they are that important to the agency's success.jeanne: â good point. mariana: â thank you both so much. we canmove in to the measuring of the impact section now. thank you.jeanne: â this is simply the particular study, the largescale study that was done with regardto looking at the effectiveness of the matrix model. it was a matrix model versus treatmentas usual, study that was done in 2004, and it was funded by csat.it was a huge study with 978 methamphetamine users as subjects in that study. it was amultisite study, so we had clinics in costa

mesa, san diego, heyward, concord, san matteo,billings and honolulu. my favorite clinic to visit [laughs] .in all of those sites, there was one person delivering the matrix model program with oneresearch assistant gathering data. the rest of the people in that site were doing treatmentas usual and people when they came in for treatment, were randomly assigned to theirtreatment as usual or to their matrix model. we looked at the outcomes and what we foundis that the people who were in the matrix program, were randomly assigned to the matrixprograms in those sites, did better in terms of pure, positive urines, and in terms ofstaying in treatment longer. there is a reference there to that article,i believe. there is reference on our website

on the matrix institute website for that particularstudy. then i put a reference to another...mariana, did you send people copies of that secondarticle? mariana: â i don't believe we did, but ifyou can send it to me i can distributed to all registered attendees.jeanne: â i can actually send you both of those articles. the one that i just spokeabout and the second one, which is "the matrix model of intensive outpatient treatment,"a guideline developed by the behavioral health recovery management project. it was writtena while ago, but it's a good explanation if you are not using the model yet of the matrixprogram. i'll send you two or maybe three articles you can distribute to people if youlike.

mariana: â yes. we definitely have a coupleof more questions, thank you so much. we know that there is so much information to go throughthat we really had to sprint through to allow time for questions from the participants.we appreciate it very much and we appreciate your patience on the line.a couple of questions that are going to go back a little bit more towards implementation,jeanne and ahndrea. one the questions that we received, does the matrix model work withan open group model, and if yes, what have you found are effective ways to bring newpeople in to the group? ahndrea: â the model was written as an opengroup model so that you always have different levels or recovery happening at differenttime. in another words, you don't have all

people in withdrawal, all people in the honeymoon, etc. when you build your model, when you set itup, you set it up as an open model program so that there is never waiting list, and youwant to keep the group. you really don't want the group to get any more than, maybe, a caseloadof 15 and a treatment track with a... jeanne: â 8 to 12.ahndrea: â ...8 to 12 is probably be the amount of people that will show up for each group,so that you can manage an hour and a half group. that way, we have found that by keepingit open ended, people coming and going you have a lot more interaction in regard to thegroup and people's growth within the group, along with the matrix coleader who is a graduatefrom matrix who's been part of the group.

he's also a peer mentor within that open groupsettings. jeanne: â the other thing is because of ourearly recovery groups, everybody who comes in is in an early recovery group. we sit downwith them and schedule and we work with them on what's going to happen every hour betweenthe time they leave the clinic and come back to the clinic.those are early recovery groups. those early recovery groups are really what cements peopleinto the treatment process, and where we work with some of the issues that people wouldhave in the first month of treatment. mariana: â thank you very much. another questionwe have and perhaps from our attendees who have been implementing the matrix model. someonecommented, "we have been implementing the

matrix model for some time now, what are someof the most recent or upcoming changes?" jeanne: â i think we are very excited abouta couple of things. one is i don't know if you've been using the hazelden dvds, but ithink that using the csat, and they are available on the csat website. you can download them.i think they are in youtube too. those dvds, the concepts are taught and thepatients comment about them, many people found those helpful. if you are not using those,i would recommend at least taking a look at them and see if you think those would be helpful.we also have two new manuals coming out. we have a criminal justice manual coming outthat is a standalone manual specifically for criminal justice population that deals withcriminogenic behaviors as well as the substance

abuse behavior.it's a very specific manual that hazelden is publishing now. i think it's just in thelast months, really. also, we redid the core manual. the hazelden core manual is brandnew. it's uptodate with stuff about technology in it that you see with patient with medicationassisted treatment covered in it. there's a special individual session for patientsthat may need medication assistance treatment. that manual, i think, is going to be great.those are three of the things that are really important.ahndrea: â i would add on the new revised adult matrix model manual. it's aligned withthe new dsm. jeanne: â in addition to that, if you chooseto come to our matrix training and we hope

you will, ahndrea have reorganized the trainingso that starting in january, you just fly into alx and go into a hotel right there bythe airport, and get the matrix training. stay for the key supervisor training if youwant to. i think it's going to be great doing it that way.ahndrea: â yeah. we've added a criminal justice manual training as well after the training.that's optional if anyone is moving towards that manual and is already have the core training.jeanne: â thank you for that question. mariana: â great. to clarify, a question forboth of you, perhaps. is additional information about those trainings as well as, perhapsthe publication date availability of those manuals available at the matrix institutewebsite?

jeanne: â yeah, correct.mariana: â ok, great. jeanne: â ahndrea's phone number at the secondto last slide shows general information for the matrix model. maybe we can put that up.that has the matrix institute website as well as ahndrea's name, phone number and her trainingemail as the director of training. mariana: â great. thank you. that slide isvisible now for everybody. included in your handout is the contact information for boththe matrix institute and for ahndrea specifically. great.i think we have time perhaps for a couple more questions. i think it goes inline perhapsto put your already talking about, and it may answer this question already. some peoplewere asking about continuing education or

for those people who have been implementingmatrix for a while. what additional training would you recommend for them?jeanne: â these specialized trainings that ahndrea's talking about are brand new. thespecialized trainings are going to be something that might be appropriate for somebody ifthey wanted to do an adolescent training or criminal justice training. if they have notbeen trained as a key supervisor, you can come to just the key supervisor training,and that would be really helpful. in addition to that, we do do onsite training.if you have an organization that has been doing the matrix model for a while and youwould like to have us come do an onsite training with you, or if you want to consider certification,i highly recommend that. you could contact

ahndrea about that and we will come to you.ahndrea: â we have open in roman training in los angeles every other month. that's opento everybody to participate. we will do a matrix sub twoday core training. we'll alsodo key supervisor training in that open enrollment training. our specialization training rightnow the criminal justice manual will be starting in january. as jeanne said, we will also goto europe site to do any one of this training. jeanne: â all of that is on our website, yes.under training. mariana: â ok, great. thank you. is thereanything else you'd like to share, jeanne or ahndrea? as we close up, we just want tothank everybody who's been on the line with us for being patient as we move to the largeamount of information available about the

matrix model, and just to assure everybodythat the webinar will be available and recorded for you to go back to.the handout includes much more information about the process of the key supervisors aswell as i believe, information about training therapist to be ready to implement the matrixmodel. jeanne, anything that you would like to add?jeanne: â only that is somebody thinks of the question that they didn't get to ask before,we're always open to being contacted, both ahndrea and i. we'd be happy to talk to anybodyat any time. we just really appreciate everybody's interest. we're very happy that this is usefulto people. mariana: â great. i think as evidence by someof the responses to our polling questions,

many of you are exploring the matrix model,and this provide a rough interest to the model. as you heard, jeanne and ahndrea are openand willing to answer any of your followup questions. if we at children and family futuresor the national center for substance abuse and child welfare can be of any assistance,we would be available as well. jeanne: â yes. i will send you those articles.everybody will get those. mariana: â i just like to end by providingthe contact information that is the available on the slide now as well as will be availableon your handout. available for you are the national center for substance abuse and childwelfare website, which has a number of resources about working with families in the child welfaresystem, who are affected by substance abuse.

any additional question specific to the webinar,please feel free to contact me, mariana corona, and my email address is available for youthere. the resources and material for this webinar will be posted to our website, www.cffutures.orgfor all of you to access. jeanne: â thank you so much, mariana, forall your help throughout this process. mariana: â thank you very much, jeanne.ken: â thank you, jeanne and ahndrea. we appreciate it.jeanne: â thank you. ahndrea: â yeah.jeanne: â thank you too, ken. mariana: â thank you all for joining us today.have a good afternoon.