Approaches to Drug Abuse Counseling U.S. Department of Health and Human Services, National Institutes of Health Jeffrey A. Hoffman, Ben Jones, Barry D. Caudill, Dale W. Mayo, and Kathleen A. Mack 1. OVERVIEW, DESCRIPTION, AND RATIONALE>
The Living In Balance (LIB) counseling approach is designed as a practical, instructional guide for conducting group-oriented treatment sessions for persons who abuse or are addicted to drugs. This approach has been fully described in Living in Balance: A Comprehensive Substance Abuse Treatment and Relapse Prevention Manual (Hoffman et al. 1995). The LIB program is both a psychoeducational (PE) and an experiential treatment model. It is designed so that clients can enter the program at any point in the cycle of sessions and continue in the program until all sessions are completed. The LIB manual is intended for use by professional counselors who have been trained in the provision of alcohol and other drug treatment and is appropriate for use in outpatient, inpatient, or residential treatment settings.
The LIB manual was initially developed by a team of staff members and expert consultants associated with the Center for Drug Treatment and Research for a cocaine treatment research demonstration project funded by the National Institute on Drug Abuse (NIDA). Although it was originally designed specifically for a cocaine abuse population, it is holistic and generic in content and therefore applicable for the treatment of a wide range of drug abuse disorders, including polydrug abuse.
1.1 General Description of Approach>
The LIB approach is specifically oriented for the group setting and utilizes techniques that draw from cognitive, behavioral, and experiential treatment approaches, with an emphasis on relapse prevention (RP). The LIB manual uses didactic education and instruction, group process interaction through role plays and discussion, daily relaxation and visualization exercises, informational handouts, videotapes, and group-oriented recreational therapy exercises. Both counselors and clients may find the detailed organization and educational orientation of the LIB manual to be unfamiliar or uncomfortable at first, but over time both counselors and clients are likely to find that the manual provides a solid foundation for treatment that can be used in a flexible clinical context.
There are 36 LIB sessions, each covering one specific topic. The major addiction-related topics include RP, drug education, and self-help education. Physical health issues addressed include nutrition, sexually transmitted diseases (STDs), HIV/AIDS, dental hygiene, and insomnia. Psychosocial topics include attitudes and beliefs, negative emotions, anger and communication, sexuality, spirituality, and the benefits of relationships. In addition, there are sessions on money management, education and vocational development, and loss and grieving.
Each session contains a combination of PE, experiential (behavioral rehearsal and role playing), and group process and RP components. Throughout the LIB program, clients learn to monitor their own feelings and behavior and use relaxation and visualization techniques in the self-assessment and goal-setting processes. Throughout the program clients learn to become actively involved in treatment?learning how to conduct self-assessments and actively implement coping and RP skills. One of the strongest emphases in the LIB program is to teach clients how to become their own relapse preventionists. This includes teaching them about the psychological and physiological components of addiction and recovery, and the various types of interventions and “life skills areas,” in which ongoing intervention is necessary. The LIB manual initially included recommendations for the use of several commercial videotapes; however, a set of nine brief videotapes was recently produced to accompany the LIB manual.
1.2 Goals and Objectives of Approach 1.2.1 Goals for Addiction Professionals.>
The LIB approach is designed to provide addiction professionals with a practical guide to conducting a series of 36 group treatment sessions for people who have drug use problems. The intent of the LIB program is to save addiction professionals time and expense by providing pre-prepared sessions, similar to a teacher’s lesson plans.
In many treatment programs, the scope and quality of information and education provided to clients depend on the skills of the counselors working in the program at any given time. Thus, the scope of expertise may be limited, and the accuracy of the information may vary from counselor to counselor. In contrast, the developers of the LIB manual identified the primary issues that should be addressed in treatment and then created therapeutic sessions to address those issues. Thus, the LIB manual provides information about an extensive array of issues of importance to treatment and recovery. Also, the individual sessions of the LIB manual are based on current research in addictive behaviors and RP.
1.2.2 Goals for Clients.>
Clients in treatment place significant emphasis on the following needs:
- Information about treatment and recovery.
- Skills to handle feelings and emotions.
- Information about preventing relapse.
- Practical living skills.
- Open confrontation when engaged in denial or other types of distorted thinking or behaviors.
Thus, the goal of the PE approach of the LIB manual is to provide education, information, and experiences that will show people how to lead healthy and productive lives without using alcohol, cocaine, or other drugs. To achieve this goal, the LIB manual presents accurate information about drugs of abuse, RP, self-help programs, medical and physical health, emotional and social wellness, sexual and spiritual health, daily living skills, and vocational and educational development.
The information is not presented as a long, boring lecture. Rather, each session is divided into manageable segments. Each of the 36 treatment sessions detailed in the manual allows for approximately 90 minutes of counselor interventions, presentations, or client training and includes sufficient time for questions.
After each segment is a question-and-answer session that lets clients intensively interact with the counselor.
During most sessions, there are written assignments that engage clients in an interactive exercise with the information.
When appropriate, there are role-play exercises that encourage intense interaction and discussion among clients.
Each session has one overriding goal with several specific client objectives. Clients are guided through a series of exercises that allow them to develop their own personal goals and objectives for each of the major life areas covered in the various treatment sessions.
Using a combination of cognitive, relaxation, and visualization skills, clients are asked to identify, visualize, and take active steps toward their personal goals and objectives. A sample of a client self-assessment is provided in the Appendix at the end of the chapter.
1.3 Theoretical Rationale/Mechanism of Action>
The basic rationale of the LIB model is that persons addicted to drugs develop a sense of imbalance in major areas of life functioning. Continuous drug use generally impairs a person’s physical health, emotional well-being, social relationships, work performance, and other major areas of functioning. Recovery involves regaining a reasonable balance in these critical areas. Balance in the major areas of life allows clients to free themselves from their addiction to drugs and provides protection against relapse to drug use. The concept of “living in balance” is essentially a broad, holistic approach to RP.
RP is the single most important component of the LIB program. The first section of the program is devoted primarily to developing RP skills; RP sessions are scheduled strategically throughout the program. The understanding and skills that clients develop in these segments are meant to be used throughout the LIB program on a daily basis. The LIB program approach to RP is based in large part on a cognitive-behavioral model of RP developed by Marlatt and Gordon (1985). In this model, the former drug user confronts a high-risk situation for which he or she has no effective coping response. According to the model, high-risk situations can occur for many reasons, including social pressure to use drugs, negative emotions, and, less frequently, withdrawal symptoms and positive emotions. The lack of a coping response combined with positive expectancies for the initial effects of the drug in the situation greatly heighten the risk of a slip (Hall et al. 1991).
Regarding relapse, the model suggests that “a person headed toward a slip makes numerous small decisions at the time which, although seemingly small and irrelevant at the time they are made, actually bring the individual closer to the brink of the slip. A chain of small decisions can lead, over time, to relapse” (Marlatt and Gordon 1985).
The biopsychosocial LIB approach to this patterning and slip chain is to rework it?to offer clients information about high-risk physical, social, and psychological situations and the potential impact of “small decisions”; to offer clients training in coping responses and stress reduction strategies; and to guide clients down alternative paths to pleasure and other life satisfactions.
LIB RP helps clients:
- Identify situations that trigger cravings.
- Understand the chain of events, including “small decisions,” that lead from trigger to drug use.
- Disrupt the chain at an early point.
- Cope with triggers by using thought-stopping, visualization, and relaxation techniques.
- Develop immediate alternatives to drug use.
- Develop a long-term plan for full recovery.
RP is viewed as a fundamental component of treatment and is consequently emphasized in the LIB manual by the use of repeated RP sessions. These sessions are intended to reinforce critical RP concepts and allow clients the opportunity to discuss and process difficult situations that they face in their daily lives that could easily lead to slips or full-blown relapse. Intensive use of visualization exercises is intended to strengthen RP skills and aid in forming and reinforcing personal goals.
1.4 Agent of Change The agent of change in the LIB model is multidimensional, involving interaction among the group counselor, the client, and the other group members. Although a highly structured format is provided for conducting the group sessions, the counselor is encouraged to utilize his or her personal skills and experience to engage and involve the clients in treatment. In addition, group interaction is highly encouraged, and many of the activities such as role plays, discussions, and games are designed to facilitate group interaction and elicit emotional responses and social bonding. Intrapersonal techniques such as visualization, meditation, and even homework exercises are also extensively used, as they require personal responsibility and discipline on the part of the client for maximum benefit. 1.5 Conception of Drug Abuse/Addiction, Causative Factors In the LIB approach, addiction is viewed as a biopsychosocial process that not only handicaps an individual’s functioning but also may destroy the cohesiveness of family and community relationships. Biopsychosocial processes refer to the inherited biological vulnerabilities, psychological predispositions, and pervasive social influences that converge to both form and perpetuate addictive behaviors. 1.5.1 Biological Factors.>
Although related evidence is equivocal regarding biological contributions to addictive behaviors, it has been a common belief that some people are born with a genetic predisposition for developing an addiction when exposed to psychoactive drugs. Following chronic drug use, all people experience a severe biological (neurochemical) imbalance. Drug hunger, intoxication, and withdrawal are all manifestations of drug-induced imbalances of biologic homeostasis.
1.5.2 Psychological Factors.>
Some people begin their drug use to diminish potent emotional and psychiatric symptoms. In turn, addiction causes a variety of psychological problems; drug use and withdrawal can cause numerous psychiatric symptoms. Even recovery can cause severe emotional turmoil. Importantly, addiction causes distortions in thinking such as denial, minimization, and projection.
1.5.3 Social Factors.>
Various environmental factors increase the likelihood of exposure to specific drugs. For instance, certain drugs are more frequently used within certain cultures, and certain drugs are more easily found in certain geographic areas. For many people, drug use occurs in the context of a social network. In addition, addiction frequently causes severe disruptions in people’s social lives. Various social and environmental factors can also contribute to the triggering of drug hunger and relapse.
Addiction is further viewed as a chronic, disabling condition in which relapses are common. Each client’s unique history and evolution of addiction must be evaluated at each of these levels, so that an effective treatment plan can be tailored to the client’s needs, strengths, and weaknesses. The more comprehensive the intervention, the more successful the outcome is likely to be. Because addiction affects multiple areas of clients’ lives, treatment efforts should address all major areas of living.
The LIB program takes a nonjudgmental approach to addiction and lifestyle issues. In general, clients are viewed as people with a compulsive disorder that often overwhelms good intentions and willpower. Clients can be taught RP techniques to avoid a reemergence of the symptoms of addiction: compulsion, loss of control, continued use despite adverse consequences, and relapse.
2. CONTRAST TO OTHER COUNSELING APPROACHES>
Addiction treatment using a PE group approach has been recommended to help clients learn basic life skills in order to confront daily problems and as a means of enhancing self-esteem (La Salvia 1993). The LIB model is most similar to other PE programs that utilize a cognitive-behavioral approach with an emphasis on RP. LIB contrasts with these similar models, as well as the 12-step model originating from Alcoholics Anonymous (AA), which is not highly dissimilar to LIB but instead places an emphasis on different issues.
2.1 Most Similar Counseling Approaches>
The initial development of the LIB model drew some of its basic concepts from the Neurobehavioral Treatment Model (The Matrix Center 1989), particularly regarding the RP strategies. Some of the materials and handouts on RP were adapted from information in the Matrix Center’s manual. The primary difference between the Matrix neurobehavioral model and the LIB model is LIB’s emphasis on structured group counseling. The neurobehavioral model is a more flexible approach utilizing a combination of individual, family, and group therapies, with much less emphasis on group processing and experiences.
The LIB model and the neurobehavioral model are also similar to other cognitive-behavioral approaches such as those developed for alcohol treatment as described in Treating Alcohol Dependence: A Coping Skills Training Guide (Monti et al. 1989). This approach also emphasizes client mastery of skills that will help them maintain abstinence from alcohol and other drugs. Clients are instructed to identify high-risk situations that may lead to relapse and analyze the external events, the internal cognitions, and the emotions that may precipitate relapse. Clients then develop plans and practice skills to cope with these situations, thoughts, and feelings, using various problemsolving, role-play, and homework exercises.
Many of these basic RP concepts and techniques were based on the original work of Marlatt and Gordon (1985) and Gorski and Miller (1986). LIB uses these concepts in a simple and direct manner and expands on this approach to incorporate a comprehensive holistic view toward lifestyle change.
2.2 Most Dissimilar Counseling Approaches>
The 12-step addiction treatment model is most commonly used in addiction treatment programs. Its approach is grounded in the concept of addiction as a spiritual and medical disease, and its content is consistent with the 12?steps of AA. In addition to abstinence, a major goal of this treatment approach is to foster each client’s commitment to participation in AA and Narcotics Anonymous (NA) self-help groups. Therapy sessions generally follow a similar format that includes symptoms inquiry, review and reinforcement for AA/NA participation, and introduction and explication of each session’s theme within the AA/NA philosophy (acceptance and surrender to the higher power, moral inventories, and sober living.) Material introduced during treatment sessions is often complemented by reading assignments from AA and NA literature.
The LIB approach is not completely dissimilar to the 12-step approach and in fact incorporates many of its concepts and encourages participation in its self-help programs. LIB, however, places a much greater emphasis on learning and practicing critical RP skills and on strengthening major areas of a client’s life to reinforce protection against relapse. Like 12-step programs, LIB encourages spiritual exploration (finding a source of involvement greater than the self). But the primary focus remains on making informed decisions in everyday life that help the client regain balance and prevent relapse to drug use.
The LIB counseling approach is designed for group counseling in any type of drug treatment setting. It can be used as a primary modality over a period of 4 to 6 months, in combination with other treatment approaches (e.g.,?medical and psychosocial modalities), and for varying lengths of time. LIB incorporates a self-help approach and encourages participation in self-help programs that the client determines most suitable to his or her needs and personal philosophy.
3.1 Modalities of Treatment>
The LIB program is designed for use in a group counseling format. Groups may range in size from 5 to 20, but a group numbering between 12 and 15 has been found to provide a good balance between individual attention and group processing. LIB can be combined with other modalities such as individual and family psychotherapy and can be modified in accordance with the needs of specific treatment programs.
3.2 Ideal Treatment Setting The LIB program can be used in drug abuse treatment settings as the core treatment or as an adjunct treatment strategy, depending on the clinical setting, level of care, and type of program. The LIB program can be used in all levels of care:
- Inpatient or outpatient.
- Intensive outpatient.
- Partial hospitalization.
- Continuing care and aftercare.
- Evening or weekend programs.
The LIB program can be used in a variety of program types:
- Hospital based.
- Community based.
- Corrections based.
- Counseling centers.
- Methadone treatment.
- Therapeutic communities.
- Halfway houses.
- Therapists in private practice.
The LIB program has been designed by a multidisciplinary team of healthcare professionals for use by trained addiction professionals. In many treatment programs, the LIB manual will be used primarily by addiction counselors and therapists. Some treatment programs may choose to have various healthcare professionals lead some of the group treatment sessions in their areas of expertise. Physicians may lead the sessions on STDs, nurses may lead the sessions on physical well-being, and nutritionists may lead the session on nutrition.
3.3 Duration of Treatment>
The LIB manual is divided into 36 sessions. Each session lasts about 2 hours and is held 3?days a week over a 12-week period (allowing for holidays and special events), or less frequently over a longer period of time. Specific sessions have been identified for different treatment settings, populations, and levels of care. The LIB program is designed so that clients can enter into the program at any session and continue the program until all of the intended sessions are completed.
3.4 Compatibility With Other Treatments The LIB program can be used as the primary modality of treatment in an intensive outpatient program or in combination with other common modalities. Hoffman and colleagues (1994) found that when LIB groups were conducted 5 days a week, adding individual and family psychotherapy contributed little to increasing either the number of days or the number of sessions attended in outpatient treatment for cocaine abuse. However, when LIB groups were offered only twice a week, adding individual and family psychotherapy significantly increased the number of sessions attended. LIB has also been used effectively in methadone treatment programs, particularly during the early phases (Moolchan and Hoffman 1994). When used properly within the confines of a comprehensive treatment program, medication (including methadone) is viewed by the authors of the LIB concept as a useful adjunct in helping clients regain and maintain a life of balance and sobriety. LIB is also currently being used in residential treatment programs and specialized programs for drug-abusing women. 3.5 Role of Self-Help Programs>
The LIB program views the 12-step programs of AA, NA, and Cocaine Anonymous (CA) as important components in the treatment and recovery process for cocaine addiction. The LIB manual introduces clients to this and other self-help programs and encourages clients to attend self-help meetings during and following the formal treatment program. In addition, the manual embraces alternative recovery self-help groups and promotes spiritual awareness. The LIB manual also incorporates 12-step program references and examples throughout the text. Each client must find his or her own sources of support and fulfillment that extend beyond the limits of a treatment program and professional counseling.
4. COUNSELOR CHARACTERISTICS AND TRAINING>
The effectiveness of any treatment model or counseling approach is determined by the personnel who use the model or deliver the program. The background, training, education, and experience of LIB counselors are critical to the effective use of this approach. Counselors who have more clinical training and related experience will be more capable of using various components of the model to effectively address the myriad issues that arise during a treatment session.
4.1 Educational Requirements>
The LIB model is designed to be used by anyone who has experience as a drug abuse counselor or who has other professional addictions training. Certification as an addictions counselor is also recommended but not required. Although an individual who has a high-school diploma would have adequate reading comprehension skills to use this model, it is recommended that the individual have an associate’s, bachelor’s, or master’s degree. This additional education and training would enhance an individual’s ability to fully understand the materials being presented and draw on his or her own experiences in developing certain concepts and ideas that are presented in the various sessions.
Although the LIB manual is written in simple, easy-to-understand language, some of the concepts and exercises actually have very complex underpinnings.
4.2 Training, Credentials, and Experience Required>
Ideally, the individual using the LIB approach should have extensive training in the area of addictions. This level of training is encouraged because it provides a conceptual foundation and the skills requisite for any treatment modality. National certification as an addictions counselor is recommended; however, being a certified addictions counselor is not a requisite for using this counseling model. The effectiveness of the model is contingent on the counselor’s knowledge of the addictions field, his or her knowledge of various treatment techniques, and his or her experience in using those skills and techniques that are critical for working through the denial and resistance that are characteristic of a drug-using population.
4.3 Counselor’s Recovery Status>
The LIB counseling approach can be used by counselors who have had a recovery experience or who have never used drugs. A counselor’s recovery status is a complex issue that needs to be addressed in counselor training and supervision. It has been found that counselors who are recovering addicts can sometimes use their personal experiences to help illustrate certain points and that they have a greater sensitivity to some clients’ responses and concerns. However, it is also important that the recovering counselor have mastery of RP skills and practice them in his or her own life, because a counselor should serve as an example of a person who is leading a relatively balanced life. Counselors in recovery should use their own judgment, preferably in consultation with a supervisor, about when, how, and whether to reveal their own personal recovery experiences. This self-disclosure should be made only with a clear understanding of the potential benefits to the client. At no time should a counselor use the group sessions to discuss or resolve his or her own personal problems.
4.4 Ideal Personal Characteristics of?Counselor>
While ideal counselor characteristics have not been clearly identified, some basic qualities that are useful in any counselor are sensitivity, a nonjudgmental attitude, and a genuine desire to help people struggle through some of the problems that led to their use of alcohol or other drugs. A counselor using the LIB model should be able to lead group discussions and provide basic instruction for those topics that require didactic presentation. Other personal characteristics that are helpful are openness, honesty, an ability to set appropriate limits, and a capacity for demonstrating caring while confronting behaviors that are inimical to the goals and objectives of the model.
4.5 Counselor’s Behaviors Prescribed>
The counselor should be skilled at confronting the client in denial. One of the major impediments to successful treatment is a client’s denial of his or her addiction. This denial expresses itself in many ways and many forms, from outright denial of having a drug problem to expressions of disinterest in the various topics and an unwillingness to discuss certain subjects. The counselor needs to be able to describe the behavior (e.g., avoiding certain topics, expressing denial), demonstrate the pattern of behavior as it appears, and relate the behavior to the defense mechanism of denial as it expresses itself in the course of treatment.
In addition, the counselor must be adept at pointing out both strengths and weaknesses in a client. Periodically during group sessions, a clear effort should be made to identify strengths that the client has demonstrated over the course of treatment and point out areas where continued growth is necessary. The major emphasis, however, should be on noting strengths.
It is very important that a counselor using the LIB model be prepared. He or she should study and review the session materials in advance of every group meeting so that the topic of discussion is thoroughly understood and can be delivered in a clear, natural, and comfortable manner. Lack of preparation will lead to an inaccurate or stifled presentation of information. The information is not intended to be read verbatim; it should be presented in a personalized and meaningful way. The counselor must understand and be familiar enough with the material to allow him or her to concentrate on group processing and individual needs and concerns.
4.6 Counselor’s Behaviors Proscribed>
The LIB approach to group work uses virtually all of the skills and intervention strategies that would normally be used in a group setting. Standard group counseling techniques and interventions are generally appropriate within the LIB model, although the approach relies more heavily on PE rather than psychotherapeutic strategies. The LIB model is designed to identify problems and develop skills and strategies for addressing them.
For this reason, the counselor might refrain from using techniques designed to encourage the client to relive traumatic and unresolved childhood and adult experiences or attempt to treat comorbid psychiatric disorders directly in the group setting. Nevertheless, materials, films, and role-play exercises are likely to elicit strong emotional reactions, and it is appropriate to acknowledge and discuss these feelings. Should intense, unresolved emotional issues arise in a group session, the counselor might suggest that the client address these issues in an individual session. The counselor should use his or her judgment in determining whether to seek the assistance of a trained psychologist or psychotherapist.
The counselor should also discourage detailed discussions of drug use that may glorify use or stimulate or trigger a conditioned craving for drugs. In discussions of RP, it is inevitable that drug use will be discussed to some extent. However, the counselor should be careful to reframe the discussion in terms of understanding the precipitants and associations to drug use and should curtail detailed discussions or storytelling not directly pertinent to learning RP skills. If the counselor comes to believe that the discussion may have triggered a craving in a client, the matter should be addressed immediately, and concrete solutions should be identified for disrupting the pattern of behavior that would likely lead to drug use. These situations can sometimes be difficult for a counselor to handle and should therefore be discussed repeatedly in supervision, as will be discussed in the next section.
4.7 Recommended Supervision>
The primary goal of supervision is to help the counselor use his or her clinical skills to present the information contained in the LIB manual in a manner that engages the group and facilitates individual recovery.
To achieve this goal, the supervisor should:
- Help the counselor develop his or her basic counseling skills, such as reflective listening and reframing.
- Develop the counselor’s skill in the use of the model, particularly in the area of RP training. (The supervisor must ensure that the counselor has a solid grasp of the RP information covered in the LIB manual.)
- Assist in evaluating the emotional state of the group and in helping determine when to use various sessions to meet the treatment needs of the group.
- Assist in dealing with difficult issues in group process, such as clients who dominate the discussion or focus excessively on drug use or drug-related behavior.
The supervisor must know the level of clinical expertise of each counselor under supervision. The supervisor needs to know the extent to which the counselor is comfortable using confrontation, demonstrating empathy,
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