For this paper, I chose to visit an intensive outpatient program named Meridian in Shrewsbury, NJ. The agency is located in a well maintained building, right of a main highway, reachable by train, car and bus. This is essential, since many of the clients have their driving license suspended due to driving under the influence (DWI), and are dependent on public transportation. The agency serves clients who are committed to following the rules of the program. The requirements of the program are: 1. attending three AA/NA meetings per week. 2. Providing clean urine-samples when requested by the addiction counselor. 3. Attending all classes. Some clients are mandated to attend the IOP by either court, division of youth and family services (DYFS), Intoxicated Driver Resource Center (IDRC), or by their significant other, while others attend the program on their own consent.
As the group is composed of age, gender, and ethnicity diversity, the counselor is often confronted with problematic group-dynamics, and needs to have solid facilitating skills to ensure the group runs smoothly and the recovery process is not compromised.
The clients schedule their intake session, where they are interviewed, and a full bio-psychosocial assessment is executed.
At ingestion, the client is requires to take a urine test, which, although many times is expected to come back positive, is still central, to evaluate what types of mind altering substances the client is taking, and to show them that the agency is a serious place, where people come to recover and achieve sobriety.
At intake, the client is provided with an option to see the psychiatrist, to ensure further mental health issues are properly addressed.
Dependent on the client’s diagnosis, they are referred to as either level 1 or level 2 care. Level 1 is usually recommended for a diagnosis of mind altering substances abuse; these are clients who are beginning to develop a problem, but are not yet dependent on the substances. Clients, who are diagnosed with dependence, are referred to as level 2. Since level 1 is a prior level of treatment, their group meets only once a week for three hours during a 6 weeks period, while level 2, a more intense program, meets three times per week for three hours.
Once a week, the group is focused towards the family of the addict. Clients are encouraged to bring their parent(s), significant other, or anyone else they feel can gain from a heightened awareness and understanding of substance abuse issues. This group is important, since their knowledge and participation, can have a positive impact on the overall recovery process. In general clients are not transferred from level 1 to level 2, unless a particular client indicates to develop a dependency, in which, the counselor might decide to transfer that client to level 2.
The counselor monitors group attendance, and randomly administers urine screening to the clients. Depending on each individual client, positive test-results could be a reason to terminate the client.
After completing the 16-week program, clients are encouraged to participate in an after-care group which meets once a week for one hour. This group is facilitated by the same counselor as the IOP, and will ensure the client remains in recovery and not become complacent. Furthermore, the client is provided with a meeting-list and is advised to continue attending at least 90 twelve-step meetings in 90 days.
When a client is mandated to attend to attend the IOP program, a letter will be provided to confirm successful completion of the agenda.
The group follows the Matrix model (Matrix Institute, 2007), which provides the participant with education regarding the dangers of substance abuse, identifying relapse triggers, prevention tools, and follows the twelve-step program of Alcoholics Anonymous.
Richard A. Rawson et al (2003) describes the bio-psychosocial Matrix model as a technique that merges techniques and materials from the cognitive behavioral therapy, and includes providing the client with accurate information on the effects of stimulants, family education, 12-Step program participation and positive reinforcement to alter old behaviors.
Richard A Rawson et al (1995) states, the goals of the Matrix model to be: a) cease drug use b) remain in a treatment process for twelve month c) learn about issues critical to addiction and relapse d) receiving direction and support from a trained therapist e) receive education for family afflicted by the addiction f) become familiar with the self-help programs, and g) receive monitoring via urine testing.
The therapist needs to be a well trained counselor who creates a positive and healthy affiliation with the group that re-enforces positive behavior change. Although the counselor is direct and realistic, extreme caution needs to be exercised to steer clear of confrontation with the client.
Richard A. Rawson et al (1995) understands one of the chief tasks of the therapist as a person who provides confidence, dignity and self-esteem to the client. This humanistic, client-oriented model is crucial for the addict recuperation, since usually clients come in to be treated, after having reached their rock-bottom, as battered people whose self esteem and dignity has been severely beaten. According to Richard A. Rawson (1995) the urine-screenings, randomly performed, are not as a punitive or legal purpose, but rather to assess where the client is holding in the recovery, and as a point of discussion.
Bradford T. Winslow (2007) found that randomly urine tests actually rewards clients, since they feel pleased when they are able to proof their abstinence to the counselor, and motivates them from relapsing during the treatment program.
Jeanne L. Obert et al. (2005) has a slight different perceptive what the role of the counselor should be. They stress that the counselor is that of a cheerleader, teacher, coach and counselor. The task of the psychotherapist is more to proffer education regarding the physical and emotional harm that these mind-altering substances impact on the human body and to teach them skills to prevent relapse. It seems to be more focused on the current day tools, vs. focusing on addictive behaviors, and past resentments often causing the client to start using these chemicals and relapse.
The purpose of the group setting in the Matrix model is well illustrated by Washton (2002); the participants are aided by support of the group, to move toward involvement in treatment, and willingness to change. Peer support is a fundamental element of the logic behind the group-setting, since sharing each others’ experiences, gives the individual the courage to attain the same what has been achieved by his or her peer, and learn different tactics in achieving the goal of sobriety. Another motive of the group-setting is the embarrassment participants will experience if they relapse during the program.
In 2002, Richard A. Rawson, PhD accentuates the advantages of the matrix model over the existing outpatient programs, that is, the structure the matrix model provides in treating the addict, while the traditional outpatient programs are inadequately structured. He further reinforces the elements of individual psychotherapy which is not always implemented into the matrix model. In the agency which I have visited, the agency does not provide individual therapy despite the fact that they follow the matrix model religiously.
Obert et al. (2000) identifies the matrix model as easy to use, research-based materials to front-line clinicians, and their clients. The matrix model is different than other treatment model by the fact that it has been developed in a clinical setting, and has constantly been modified through field-testing. The client get’s an easy to read hand-out with various exercises developed in educating the client in a non-confrontational way. A key component of the model is the fact that the client and the counselor are collaborators in the recovery process, which is achieved by implementing the motivational interviewing approach designed by Miller and Rollnick (2002); this therapeutic alliance encourages the client to put all effort in their recovery process.
Obert et al. (2000) sees the goals of the model as: a) Create explicit structure and expectations b) establish a positive collaborative relationship with the client c) teach clients and their families empirical information and cognitive-behavioral concepts d) positive reinforce desired behavioral change e) provide corrective feedback when necessary f) educate the family regarding stimulant abuse recovery g) introduce and encourage self-help participation h) use urinalysis and breath alcohol analysis to monitor drug and alcohol use on a random schedule.
Critical analysis of treatment
Although research has proven the matrix model to be effective, (Obert et al. 2000), there are many reservations regarding this model. One of the key concerns in opposition to this model is the fact that it is based exclusively upon the cognitive behavioral method, which focuses on modifying current behaviors, but fails to analyze and address underlying issues which play a significant role in causing addiction. Furthermore, manual based therapy compromise the therapeutic relationship with the client, despite it developing a therapeutic bond. Many counselors were skeptical of the matrix model, due to the fact that it treats clients who have not experiences their “bottom” through severe consequences due to their addiction.
Simpson, D et al. (1995) have found that client’s treated by the matrix model, are more focused on the curriculum than the therapeutic process. Furthermore, they identified three problems; 1. Manual-based treatments ignore individual client’s differences 2. Manual-based treatments cannot meet the need of co-occurring disorders 3. Manual-based treatments ignore client’s emotions.
Brown (2004) sees the issue with the matrix model in the lack of focus on the socioeconomic, cultural and gender issues such as domestic and sexual abuse. These issues are mostly present since the matrix model treats any client in a group setting where the content of the group is determined by the manual, preventing counselors to pay attention to these other aspects in the client’s life.
Another important concern to the matrix model is pointed out by Anglin, M.D & Rawson (2000); since the matrix model is performed in a group setting, you often have clients in different stages of recovery interacting in the same group. Although this can be an advantage, since this enables them to learn from one-another, however, this can also have a negative impact on the individual; since individuals need individual focus on the part most applicable to their point in recovery.
Family members play a significant role in recovery. In one study, Morris et al (1992) concluded that substance abuse is considered a family disease, since it affects marital relationships, family and child functioning. This underlines the importance of properly involving family member(s) in the recovery process. This is echoed by Curtis Janzen (2006), who describes the family members as repeatedly experiencing significant mental and physical strain, as a result of their loved one’s addiction. Asher & Brissett (1988) state that: “the family members of substance abusers are part of a dysfunctional family system, in which they often, unwittingly, contribute to the perpetuation of the substance abuse behavior”. The family members’ behavior is often labeled as “enabling” or “co-dependent”.
Obert et al. (2000) describe in detail why the matrix model undermines the need of the family member:
a) Clients are often uncomfortable bringing their family member to group, because they might have disclosed to the group secret information regarding their private lives, and are afraid that this information will accidentally be disclosed by one of the group members. b) It can take clients as much as three to four weeks to stabilize from the crises they often find themselves in when commencing the IOP. It would therefore not be beneficial to bring their family-member to group, since they are unready to discuss their family issues until they have somewhat stabilized their individual situation. c) Clients can be embarrassed to bring in a family member, due to physical or mental issues their family member may have, and which they feel uncomfortable revealing to the group. d) Family members often need numerous sessions to relieve themselves of their experiences, frustration and anger; this need cannot be met by the existing program. e) The family group is mainly focused on educating the family member with the concept that addiction is a disease rather than a “bad behavior”, whereas, what the family member(s) really require is additional intense group therapy to deal with the hurt, guilt and shame experienced when there is addiction in the family. They also need to be given tools to address “enabling” and “codependency”.
Another critique on one of the components of the matrix model is the urine-screening process. Clients who are forced to show abstinence, and are not doing it from their free will, are more likely to relapse as soon as the mandated urine screening procedure is finalized. Furthermore, accuracy of urine-screening is often compromised, by showing a positive result due to consumption of poppy seed, or a negative result caused by flushing the system with specially designed liquid for this purpose. (Dupont & Baumgartner 1995).
Despite the critique on the matrix method, research does have proven the model to be effective. Richard A. Rawson et al (2003), compared outcomes of traditional treatment models to the newly designed matrix model, and found that the clients who were treated by the matrix model were attending more clinical sessions, stayed in treatment longer, provided more negative urine-samples, and had longer periods of abstinence than those treated by more traditional methods. Moreover the matrix model is user friendly and its structure ensures that time invested in the recovery process is properly utilized.
Harm reduction model
Harm reduction is an approach rather than a goal, and its aim is to reduce or eliminate the negative consequences of drug use rather than eliminating the drug itself. There is am emphasis on the aim of reducing the adverse consequences among individuals who cannot be expected to ease their drug use at the present time for various reasons (Riley et al., 1999). The underlying philosophy is to approach the client in a non-judgmental way, and help the client develop goals personally. (Bradley-Springer, 1996) The rights of the individual are of prime importance, which includes; dignity, and the right to make personal decisions. Harm reduction includes a holistic incremental and multidimensional approach to decreasing risks for individuals and communities. Although the harm reduction model is contradictory to the traditional abstinence model, it may however ne compatible with the eventual goal of abstinence. The model proposes that social support, health assistance, education and disease prevention measures should be minimized. (Bradley-Springer, 1996) Harm reduction contrasts to the prohibition philosophy, also known as the abstinence model. This model concentrates on increasing interdiction, treatment and prevention efforts, combined with keeping mind altering drugs illegal (DuPont and Voth, 1995)
The basic process of harm reduction consists of providing the client with a continuum of options for their considerations, ranging from the riskiest behavior to the lease risky behavior. This has dual-purposes; firstly, it allows the client to assess their current behaviors in comparison to both more and less risky behaviors, which may help the client to see where they need to make changes. It may also help the client assess where their behaviors have improved or degenerated over time, giving them a means of measuring the changes in behavior. Furthermore the continuum provides the client with a range of behaviors so that they can choose for themselves the most suitable changes based on their personal circumstances.
The theory of harm reduction acknowledges that there are various external factors which impact upon an individual and may affect their behaviors in ways which they cannot control, or are difficult for them to control. It is for this reason that one of the underpinning criteria of the harm reduction model is that the individual is allowed to choose their own targets based upon what they feel is achievable under their current circumstances. These environmental factors could be family related, peer related, which would impact on any change the individual tried to make. There could be also a wide array of socioeconomic factors, such as background or occupational history of the client which must be considered. However since the prominence of the harm reduction model is based on changing behaviors, the procedure will assist the individual in identifying areas of their life which are causing a probable conflict of interest. Exploitation of the harm reduction model would as well assist them in forming strategies that enable them to make changes which would facilitate transformation in their behavior. For example if a client were to identify that their behavior is negatively influenced by their work environment, the client may choose to implement strategies which would reduce this influence, or even end it altogether. The emphasis would be on the client to choose these changes, rather than the professional to insist that these changes are deployed.
With regards to substance abuse, advocates of using the harm reduction model acknowledge that there are many environmental factors which influence the behavior of a substance abuser. Des Jarlais (1995) claims that the use of non-medical, mind-altering drugs is unavoidable in societies which have access to these drugs. He also states that it is inevitable that drugs will cause harm at both individual and societal levels. Des Jarlais (1995) claims that drug users form an integral part of the larger community and therefore must be included in measures to protect public health. Harm reduction strategies aim to protect substance abusers along with all other members of a community. This is in contrast to prohibition models in which the substance abuser is viewed as an individual describes as ‘a simplistic moral solution to complex human problems’ (Griffin, 1998). Harm reduction accepts that some harm is inevitable but that the ideal of zero tolerance excludes compromise and sets goals which are not achievable (Riley et al., 1999).
The harm reduction model has been applied predominantly to drug misuse issues, however it has successfully been used in many other areas such as; weight loss, tobacco addiction, and alcohol addiction. Many of those who have failed on traditional abstinence programs such as those promoted by Alcoholics Anonymous have made some progress using harm reduction techniques. The techniques have been successful as they set a series of stepping stones which have been decided by the client themselves. This may lead to full abstinence at some time in the future, although that decision is left to the individual themselves and not imposed upon them. (Witkiewitz and Marlatt. 2006).
Strength and limitations
The major strength of the harm reduction model is that the model can be applied in a non-biased pattern to any selection of the population. The underlying principles are based upon approaching the client in a lenient manner, which should eradicate many of the prejudices which may be associated with other models. For example, some of the groups who are more at risk from substance abuse are those of ethnic minorities and low socio-economic status.
Another benefit of the harm reduction model, is that individuals who relapse do not necessary revert all the way back to high risks and unhealthy behaviors. It is imperative that if it happens, that the client is shown that their failure is not absolute, as this will offer encouragement for the client to set new goals and begin the process all over.
The main limitation to the model is that in order for the nonjudgmental principles of the approach to be achieved it is necessary for health professional to remove any personal stigma or prejudice. There is no room in the harm reduction model for personal opinions of the health care or social care professional to allow their personal feelings to become involved in the decisions made regarding treatment. This can be a challenging at times especially for those professionals who have worked in the field with other models.
Harm reduction theories were first applied to substance abuse in the 1920’s when a group of doctors concluded that it may be necessary occasionally to maintain a person on drugs in order to help them lead a more productive life (Griffin, 1998).
Critics of harm reduction reject it as being overly permissive in its rejection of strict ‘zero-tolerance’ policies and its promotion of alternatives to abstinence. Some have labeled it a ‘front’ for drug legalization. Des Jarlais (1995)
Harm reduction programs are often insufficiently coordinated with each other, often overlapping and underfunded. This can lead to a competitive nature between the different harm reduction programs rather than the cooperation which is needed to increase their success (Hilton et al., 2001)
One key example of the application of harm reduction to substance abuse is the creation of needle and syringe exchange programs (NSPs) which can prevent HIV/AIDS infections from spreading by providing users with new, sterile syringes in exchange for used syringes, which reduces transmission through needle sharing. NSPs also provide an opportunity to pass out educational materials and facilitate engagement in formal addiction treatment and other social services. Many studies have found that NSPs are effective in reducing injection related risk behaviors as well as reducing incidence of HIV and other blood-borne diseases such as Hepatitis B and Hepatitis C (Hilton et al., 2001; Blumenthal et al., 1998)
Many countries and organizations have now adopted harm reduction. The World Health Organization (WHO) endorses harm reduction as a strategy to prevent the spread of HIV as it they considered drug use to be less of a threat to individuals and communities than drug use itself (Riley, 1998) Despite current legislation in many countries which prevents the full adoption of the model as the framework for drug misuse treatment, there are still ways in which the principles can be promoted through treatment. The successful reduction of harm is in the interest of all, and harm reduction promises to be a method which is likely to succeed in its objectives by reducing harm to both drug users and those in the wider community.
Although we have described the pros and cons both in the matrix model as well as to the harm reduction model, I would individually have a preference to the matrix model, though in some exceptional cases, I would have selected the harm reduction model. When the addict is in his advanced stages of addiction, and repercussions have been dramatic, I would definitely encourage the implementation and realization of the matrix model, in view of the fact that it seems that in such a condition, the patient will not be able to cut the use, thus total abstinence is apposite. When a client is in the beginning stages of substance use, and did not experience severe consequences, it might be advisable to treat that client with the harm reduction model.
I would also carefully review the individual’s circumstances, in order to assess if self-denial would hinder the clients’ daily performances, hence going by the harm reduction model.
In this paper, I have gained knowledge of the significance of aptly applying the correct model to the client, to ensure their successful recovery. What is also of importance is what seems to be applicable to both models, that is, the concept of motivational interviewing. It is critical to have the client explore their ambivalence, and reach out their own conclusion to seek sobriety. Recovery which is spring out from a person’s own desire is more valuable and more sustainable.
We, as social workers, have to be extremely vigilant in treating the client, with a vision, that our interaction can bring about transformation to the clients’ existence.