Information for Referring Professionals
Establishing a positive and collaborative relationship with the client
The context of The River’s Model is characterized by a positive and collaborative relationship between the patient and therapist. Within this model, the therapist is required to be directive but to also maintain a client-centered therapeutic stance. As cited in much psychotherapy research, it is essential to deliver accurate empathy, positive regard, warmth, and genuineness. This means treating patients with dignity, respect, and listening attentively and reflectively to their unique experience without imposing judgment.
A collaborative relationship will develop when you actively listen to patient’s concerns and opinions while striving to see the world from his/her perspective. This allows the creation of a spirit of cooperation and mutual effort. Conversely, use of a confrontational and therapist imposition of treatment goals and demands will create an adversarial relationship which can frequently contribute to premature treatment termination. Setting mutually agreed upon goals engages your client as an active participant. In addition, it validates and acknowledges his expertise and experiences, thereby reinforcing the therapeutic alliance. This collaborative climate increases the client’s readiness to learn new skills and practice more adaptive coping strategies while establishing an environment where the successes and failures of using these new strategies can be shared.
The Motivational Interviewing techniques developed by Miller and Rollnick (1991; 2002) are all extremely valuable in building a successful therapeutic relationship with patients in outpatient treatment. The clinical skills incorporated within this approach are of tremendous value throughout treatment and especially during the early weeks of treatment.
Structure and Expectations
Structure is a critical element in any effective outpatient program. In outpatient settings, structure is created by defining for patients the activities that are required parts of their treatment involvement. These activities include attendance at the individual and group sessions of the program, participation in community self-help groups, and the scheduled daily activities that minimize contact with drugs, alcohol, and other high risk situations. The structure provided by treatment helps to define for the patient exactly what is expected of him/her in treatment and provides a “roadmap” for recovery. This information can be useful in reducing the anxiety that is commonly experienced by substance dependent individuals upon treatment initiation. Functioning within a structure can decreases stress and provide consistency and predictability which are all incompatible in an addict’s spontaneous, unplanned, chaotic lifestyle.
The primary component of structure during outpatient treatment is the daily, hour by hour schedule of his/her activities. The purpose of this exercise is not to create a list of one activity after another. Rather, the intent is to impart the concept of proactive planning of work activities, treatment and recovery activities, family and recreational activities, and relaxation activities. Within the context of this scheduling exercise, it is possible to teach the identification and avoidance of high risk settings and people, and to promote engagement in new, non-drug related alternative behaviors. Creating a 24-hour schedule with the patient can help operationalize how to stay abstinent “one day at a time”. This exercise can reduce feelings of being overwhelmed in early recovery and/or of neglecting oneself in an attempt to immediately resolve problems created by the addiction.
The patient should keep the schedule and refer to it during day to day activities. It is important that the counselor keep a copy of the schedule and review it at the beginning of the next session. During early stages of treatment, many patients forget to follow the schedule or decide to ignore the schedule. Frequent lapses will occur and these lapses can reinforce the importance of the schedule procedure. Patients should realize that they can change their plan when essential but they should take the time to actually change the written schedule and write in the new activity. This process allows the patient time to think through the feasibility and advisability of the schedule change.
Some challenges and solutions:
- Patients (and therapists) may forget to schedule in leisure activities, time to rest, or time to relax. The schedule can become a marathon of productive activities. This type of unrealistic scheduling will lead to noncompliance with the schedule and quickly will make the scheduling activity pointless. One helpful way to make sure that the schedule is realistic is to review the events of typical drug-free days and see what a normal routine is for that person. If the schedule created is too different from normal habits, it will be difficult for the client to incorporate it into his/her routine.
- Many patients have difficulty making an hour-by-hour schedule. If this is the case, it is necessary to simplify the process. One way to do that is to simply use a small, pocket- sized card with the day divided into four sections; morning, midday, afternoon and evening. Beginning scheduling is easier if the patient can just plan activities for those four times of day. At first, some have trouble learning this skill. If this is the case, it can be helpful to have them describe what they did for the past 24 hours and then guess at what they are likely to do in the next 24 hours. You can write their schedule as they talk about it.
- Some families want to help “plan” (dictate) a patient’s schedule. Spouses and parents, especially, have lots of ideas for things that have been neglected or things that the patient should do. Since many patients are trying to win back the support of their families, they can be easily convinced that they should do whatever family members want rather than what they need to in order to sustain a plan for their recovery. If someone else’s wishes and desires are the basis for the schedule regularly, sooner or later the recovering person will get resentful and will not find the scheduling useful or helpful. It will be viewed as a sentence” imposed by the family member and the therapist will be viewed as a colluding compatriot.
It is important for the patient to be the person who is responsible for constructing the schedule with input from the therapist.
Teaching Psycho-Educational Information
A key component of the Rivers Model is information regarding conditioning and neurobiology. Accurate, understandable information helps patients understand what has been happening in the past and also what predictable changes that will occur in their thinking, mood, and relationships over the course of several months. This education process identifies and normalizes symptoms, thereby empowering them to draw upon resources and techniques to help manage the symptoms.
The use of patient education as a treatment component is a not a new treatment concept, unique to the River Model. However, teaching patients and their families about how the chronic use of drugs or alcohol produces changes in brain functioning in a manner that has direct application to patients’ behavior is a relatively new strategy. Much of the information about drug-induced changes in the brain is highly technical and requires extensive scientific knowledge to comprehend the concepts fully. Without scientific training, it is not intuitive to substance abusing individuals, or to their families, to understand that the behavior associated with drug use may, in part, be explained by modifications in brain chemistry.
Two very basic “brain chemistry made simple” lectures were developed to be delivered in the treatment setting by a senior clinical staff person to patients and their families. (These lectures are also available in commercially produced video and DVDs through Hazelden Publishing.) New therapists are coached in explaining the essence of this brain chemistry change process along with the concept of classical conditioning as it relates to craving. Classically conditioned craving occurs independently of rational choice or renewed resolve to stop drug use. This fact provides a reassuring explanation of past behavior and an uncompromising context for recovery. From this premise follows many of the treatment handouts and exercises such as time scheduling (to avoid depending on in-the-moment, addiction-compromised thought processes) thought- stopping (to prevent initiation of the craving sequence), and avoidance of triggers (which also trigger release of neurotransmitters and simulate a desire to use). Without any more sophisticated knowledge than seeing the red areas of the brain light up with repeated cocaine dosing, clinical staff could refer to the “addicted brain” with science on their side and work collaboratively with patients to overcome the effects of this now very obvious physical alteration in the working brain.
The second basic lecture involves continuing changes in brain chemistry as the healing brain attempts to regain normal functioning. New scientific information continues to provide supportive evidence for the stages of recovery that patients have reported over the last 16 years. Studies are consistently showing that the recovery process often results in some brain functions getting worse before they get better, the brain needing a drug free environment for the healing to occur, and the entire recovery taking a much longer time to return to normal than we ever imagined. Even without a technical understanding of how and why these issues are occurring, counselors can now say that they are occurring with certainty and can provide pictures to support their claims. This knowledge sets the stage for the continued teaching of the relapse prevention activities and supports vigilant treatment participation far beyond the initial withdrawal phase. Patients are comforted by the existence of a roadmap delineating the process of recovery and are more secure in the knowledge that activities they are asked to do relate directly to their recovery from a very physical disease state.
In the model the science-made-simple lectures are delivered midweek during the family education group for patients and their families. They are part of a series of 8 educational groups that the senior clinical person in each clinic conducts. New counselors are required to sit in on the education groups and to complete a formal training process that includes reading scientific articles and publications, becoming familiar with professional guidelines, viewing educational videotapes and observing a required number of groups, individual sessions and hotline phone calls.
Some challenges and solutions:
- The presentation of psycho-educational information based on science can be dull and tedious for patients and families if presented improperly.
- The individual who presents this material as part of the program has to be well versed in the neurobiological concepts and other research information. For the material to be understood and used by patients, the presenter must have credibility, they must be able to expand on the material, and make the material relevant to patients’ clinical challenges. Literature has to be “translated” into non-technical language and presented at an 8-10th grade level. Visual aids, including clear pictures and videos, can be very useful to convey this information. It is important that the material be presented in a context of clinical issues so that patients and their family members understand the relevance of the information and how it applies to their addiction recovery.
Cognitive Behavioral Skills
Knowledge and skills that have been developed within the field of cognitive behavioral therapy (CBT) play a large role in the Matrix Model. The work of Marlatt and Gordon (1985), Carroll and colleagues (Carroll et al., 1994; Carroll and Onken, 2005), and others have contributed greatly to the content of the group treatment activities at Matrix. This approach teaches patients that drug use and relapse are not random events, and that they can learn skills that can be applied in daily life to promote abstinence and prevent relapse. One of these skills is self-monitoring to bring into awareness any dysphoric or uncomfortable symptoms, thoughts, warning signs, high- risk situations, and subtle precipitating events. Patients learn skills to identify triggers, develop coping skills, and manage immediate problems. They are encouraged to practice and experiment with new behaviors outside the clinic setting. In the group, patients report back on what worked and what didn’t work, what obstacles were encountered, and what changes need to be made to make the interventions successful in the future. In this process patients become the experts on their own individual recovery processes.
Each of the Matrix groups is anchored with a specific CBT topic for each session. The topic is introduced by the therapist and a brief explanation is given about how this topic is related to the achievement of a successful recovery. There is a review of a handout/worksheet that explains
the concept and includes questions that are used to personalize the concept and make it relevant to each person. Each patient in the group discusses how the topic is a factor in his/her life and how the skills being introduced could help with specific challenges each faces in recovery. The discussion is never confrontational and while the primary exchange is typically between the patient and the therapist/group leader, frequently other patients can make observations about similarities and differences between their experiences and those of other patients. Frequently the therapist will suggest to one or more of the group members to apply the skill in the following days as a homework assignment.
Some challenges and solutions:
- A cognitive-behavioral orientation can be very engaging, and a nonjudgmental stance communicates positive regard for the patient. However, if the topic is not accompanied with useful real world examples of how the topic can actually relate to patient challenges and benefits, the sessions can feel excessively didactic and academic, in short, boring. An important part of therapist training in the Matrix Model is the art of CBT delivery to keep the topic interesting and relevant and find ways to apply it to patients in the group.
- Other challenges include maintaining a stimulating pace, staying on topic and managing the time of the group. At times, group members may be disruptive and interrupt the group with cross talk or impulsive behaviors. Speaking calmly and redirecting clients is an effective way to keep the group focused and on task. (With methamphetamine use there may be some cognitive impairment, which should not be confused with “resistance” or “noncompliance.”)
- Some patients (particularly those who are mandated) may be at a state of readiness where they are not receptive to total abstinence, lifestyle change, or even any modification in their current drug or alcohol use. Often the cohesiveness and positive momentum of the group can move them towards change. A skilled therapist will need to limit negative, counterproductive input from such a patient and at the same time be accepting, positive, and without judgment.
- On occasion, an intoxicated patient may show up for group. If another counselor is available on site, he or she can work with the patient to ensure safe transportation home. Any discussion on the matter regarding the drug or alcohol use should be avoided until the next appointment. If possible, an individual session should be scheduled to address the particular issues surrounding the relapse. The effect of such an event on other group members should not be ignored. They may need to discuss their reactions, and possible triggering, resulting from being in such close proximity to a relapsing colleague.
There is a large amount of research supporting the efficacy of the systematic use of reinforcement for meeting specific behavioral criteria in the treatment of addictions (Higgins et al., 1994, 2000; Iguchi et al. 1997; Petry et al., 2000; Rawson et.al., 2002, 2006). Contingency management research with substance abuse problems usually has targeted drug-free urine results, attendance at treatment sessions, or achieving treatment goals as the basis for receiving incentives. Participants in research studies usually receive certificates that are redeemable for items with monetary values ranging from as little as one dollar to as much as one hundred dollars. Coupled with social recognition, relatively inexpensive items can have a strong effect on behavior. This approach has long been a part of both the educational system and of parenting skills training.
The Matrix model involves family members in the treatment program. “Family” includes all those people who are part of their everyday existence and are close to them. This includes biological family as well as partners, close friends, associates and people who are part of their extended family. Providing the family with education such as information on classically conditioned craving helps make the patient’s behavior prior to entering treatment understandable and it helps to demystify treatment and recovery. It is also important for significant others to be better prepared for the range of events such as relapses that may happen during the recovery process.
In the initial stages of treatment, family members will need to decide whether they are willing to be part of the recovery process. It is often necessary for therapists using the River Model to schedule a session with family members to explain the manners in which they can be helpful in participating in the treatment process and strongly encouraging them to attend scheduled sessions. Addiction is presented to the family as a chronic condition which they can be helpful in remediating by providing support for the patient. By presenting their role as providing supportive and positive assistance, as opposed to entering “therapy” for their family systems pathology, family members are often more willing to help support the recovery process and attend treatment.
Not all family members will want to be a part of the recovery process, despite the urging by the therapist or patient. There are many reasons for this. One may be that the family members feel they have been through tremendous stress and disappointment and that they cannot put themselves through any more of the emotional turmoil. These people usually still care very deeply for their affected family member but cannot stand to keep watching them destroy their life. Usually they have been involved in previous treatment attempts and are exhausted, emotionally and financially, from multiple unsuccessful attempts at recovery.
It is important for the patient to be the person who is responsible for constructing the schedule with input from the therapist. Other family members say they are just tired of all the deception and turmoil that is part of the addiction and they are not willing to invest more energy into helping the patient recover. These family members might say something like “This is your problem not mine. Go get fixed and when you are all better we can continue leading our lives together.” In these circumstances, if the patient initiates treatment and demonstrates some positive progress, family members can then be approached again and invited to participate.
AA/NA meetings are widely available, are free of charge, and provide a place where recovering people can meet others who are dealing with many of the same issues. Recently there have been some well-designed studies that have demonstrated empirically the usefulness of participation in 12-Step programs. It makes sense for patients to use the meetings as an ongoing resource if they find them beneficial, and the River’s Model includes topics designed to familiarize patients with this resource.
Not everyone responds favorably to the concepts of the 12-Steps or to the groups themselves. Many patients are not willing to attend 12-Step meetings, or they sample one or two meetings and find them unhelpful/aversive. Much of the resistance to the 12-Step program concerns the “spiritual” dimension of AA/NA. This resistance can be reduced by urging patients to focus on other benefits of the program which they can find useful. For example, one basic principle of the River approach is the creation of structure and development of non-drug related activities. The 12-Step groups can be presented as a means to construct a schedule with drug-free activities during high-risk time periods. Often motivational interviewing strategies can be helpful in addressing resistance to participation in 12-Step program involvement.
Urine and Breath Alcohol Testing
The River’s approach requires accurate information on the drug use status of patients as they progress through treatment. The most accurate means of monitoring clients for drug and alcohol use during treatment is through the use of urine and breath alcohol testing. The variety of testing options available today makes it much easier for programs to regularly administer the tests than in the past. Tests can be analyzed on site or sent out to laboratories. Specimens can be monitored with temperature strips; they can be observed or unobserved. Regardless of the specific procedure used, the objective is the same: to monitor drug use and to provide feedback to the patient.
Some patients may resist the necessity of urine testing. They may view the procedure as coercive or indicative of mistrust by the treatment program staff. It is possible to mitigate this resistance by describing the purpose of the testing as offering objective evidence of the patient’s abstinence, if situations occur when family members or others make accusations of drug use. Patients will often say things like, “You don’t need to test me. Why would I come in here and lie about using? I will tell you if I use.” It’s important to let new patients know that the testing procedure is a standard part of the program, and that urine testing is not a way of “catching” misbehavior.
One important point to take into consideration is that urine testing should not be presented primarily as a monitoring measure. Instead of being used as a policing device, testing should be seen as a way to help a person not use drugs. Urine and breath alcohol testing done in a clinical setting for clinical purposes is quite different from urine testing that is done for legal monitoring.
The River’s Model provides an integrated treatment experience for drug and alcohol users through a cognitive/behavioral approach, imbued with a motivational interviewing style, and supplemented with contingency management. The program as outlined here is typical and ideal. It has also been delivered within the context of medication-assisted treatment, our experience is that some variation on the ideal does not sacrifice effectiveness as long as there is adherence to the cognitive/behavioral elements of treatment.
In the future, we plan to augment this treatment approach with additional evidence-based interventions in order to sustain and increase effectiveness, and to expand the focus of treatment. For example, we hope to successfully extend patient care beyond the initial intensive phase through applications of contingencies targeting attendance in continuing care groups, or through mind body practices included using guided imagery, mindfulness and hypnotherapy to address any underlying any trauma the clients present within our program.