Living In Balance Counseling Approach
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. 3. FORMAT
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.
Continuing care and aftercare.
Evening or weekend programs.
The LIB program can be used in a variety of program types:
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, and encouraging supportive group interactions. Also recommended is use of the case conference approach, where LIB counseling staff can develop alternative strategies for problem resolution as each case is reviewed in depth.
Finally, the supervisor must observe group sessions to be able to provide behavioral and skills-based feedback to counselors. These observations are critical in helping counselors develop and enhance their clinical skills. 5. CLIENT-COUNSELOR RELATIONSHIP
The relationship between client and counselor permits the client to use the counselor as a sounding board and to appreciate and value the insights and observations the counselor makes with regard to the client's progress. Therefore, developing a strong relationship, one of caring and concern, is imperative to the counselor's ability to intervene effectively in the life of the client in a manner that is helpful to recovery. 5.1 What Is the Counselor's Role?
In some cases, the counselor is clearly an educator by virtue of the PE approach of the model. The counselor educates the client about matters related to drug abuse, both in terms of the pharmacological or biological impact on the body and the impact that drugs have on other areas of life. In this educator/teacher role, the counselor begins to provide the client with knowledge about the impact of alcohol and other drug use, which will enable the client to make informed decisions regarding his or her use of these drugs.
The counselor also plays the role of therapist in providing clients with a valuable resource for understanding and changing their behaviors in a healthy, productive way. The counselor helps clients understand their feelings about particular areas of their lives and helps them work through their struggles. This model discourages the counselor from being an adviser to the client. The model itself is one that is geared toward empowering the client to take charge and independently make decisions regarding his or her life. 5.2 Who Talks More?
The LIB model requires the counselor to do most of the talking. In most sessions, the counselor initially uses a didactic approach, imparting information regarding a particular subject area. The counselor must then facilitate group discussion and interaction. In a 90-minute session, the counselor will spend about 30 minutes either offering some instruction verbally or engaging the client in some kind of experiential process, where instruction and guidance are offered. The remaining hour of the session is generally devoted to the interactive component of the program, where the client is encouraged to express feelings, reactions, or thoughts regarding a particular topic area. 5.3 How Directive Is the Counselor?
Because LIB requires the counselor to take the lead and guide clients through a structured set of group experiences, the counselor is highly directive. The primary objective of these group experiences is to empower clients to make informed decisions regarding their use of alcohol and other drugs and to begin to lead a more balanced and healthy lifestyle. 5.4 Therapeutic Alliance
The quality of the client-counselor relationship can significantly enhance the impact of any technique used in working with an individual or group. Thus, the most effective counselor develops an alliance with the client that is characterized by honest and clear communication, explicit empathy, respect for the individual, and a clear treatment objective.
The treatment contract is one way of developing such an alliance. The contract should establish explicit goals for the individual and the group, clearly state what the counselor will do to help the group or individual achieve those goals, and articulate behavioral expectations or group rules (e.g., not interrupting, being on time, not leaving the group session unless absolutely necessary).
In situations where the alliance is poor, the counselor needs to explore, with the supervisor, interventions that might strengthen that relationship. For example, if gender is an impediment to establishing a working therapeutic relationship, the counselor needs to determine the efficacy of discussing the issue with the client in an individual session. If the counselor decides to discuss the issue with the client, the counselor should gently state that the client appears to have some discomfort or negative feelings toward the counselor that might be interfering with the client's participation in the group process. The counselor should not be threatening, accusatory, or defensive, but should be accepting of the client's feelings and should try to clarify any wrong perceptions. The counselor should be aware that the client may be reacting to previous negative experiences with treatment. In any case, the counselor should convey concern for the client and work toward improving the alliance. 6. TARGET POPULATIONS
The LIB program was originally designed for an inner-city, predominantly minority, cocaine-abusing population in an intensive outpatient treatment program. Nevertheless, it is applicable for a wide range of drugs of abuse, including heroin and alcohol, and for clients from a wide range of cultural and economic backgrounds. The LIB manual was designed to be universally applicable across various cultural and ethnic backgrounds. Its biopsychosocial and holistic approach to treatment assumes that living a balanced life is a fundamental objective of all people, regardless of race, culture, or ethnic background. Establishing physical, emotional, social, and spiritual well-being is considered to be a central objective in the process of recovery from drug addiction for all individuals.
The role of culture and ethnicity is also a critical element of the recovery process. An addiction counselor's cultural sensitivity is a prerequisite to providing effective treatment. Unless the counselor is aware of and sensitive to the cultural and ethnic issues and concerns of clients in treatment and understands socioeconomic and racial factors, his or her effectiveness will be severely restricted and potentially counterproductive. The counselor must have knowledge of and empathy for the ethnic and cultural experiences, perceptions, and values of his or her clientele. 6.1 Clients Best Suited for This Counseling Approach
Clients best suited for the LIB program are those who are comfortable participating in a group. LIB generally does not involve intense group confrontation or indepth psychodynamic processing; however, the sensitive nature of some of the issues covered requires a minimum level of comfort with group interaction. If a client is not comfortable in this situation, it may be possible for him or her to participate in individual counseling until a later phase of treatment when he or she is more ready to join an LIB group.
The LIB program is generally suitable for clients of all ages (late teens to elderly persons), although it would be ideal to limit participation in each group to specific age ranges so that peers of similar age can address concerns relevant to their experience. LIB can be used with mixed-gender groups and with men-only and women-only groups. (Same-sex groups are preferred and generally recommended when dealing with issues of sexual and emotional abuse .) LIB can be tailored to any ethnic or cultural subgroup and be implemented with users of different types of drugs, and it can include sessions on alcohol and nicotine addiction. LIB has been used with a variety of different groups (e.g., Latino alcoholics, African-American pregnant and postpartum crack-using women, Caucasian methamphetamine users, and mixed ethnic/cultural heroin users).
The LIB program can be used in any type of drug treatment or social service setting and is ideal for use with special populations (e.g., welfare to work, criminal justice, public housing, mental health) where drug abuse problems exist. There are specific sessions that the LIB manual suggests using when dealing with some of the key counseling issues for these populations. LIB complements the 12-step approach, provides information about various self-help-oriented programs, and encourages participation in those programs. 6.2 Clients Poorly Suited for This Counseling Approach
The LIB group counseling approach may not be suitable for clients who are uncomfortable in a group setting. Initial discomfort is common and natural given the implicit pressure to reveal and expose personal feelings to a group of strangers. However, this discomfort quickly diminishes for most clients. Some clients who have high social anxiety, who are extremely introverted, or who have difficulties with logical thought processes may not respond well to this group counseling format. In addition, some of the more educational components of the program may be difficult for clients who have very low reading or cognitive abilities. Although most of the materials are discussed aloud and assistance is available for those who need help with written assignments, clients must have the ability to understand the concepts presented in order to benefit from the program.
The LIB program has been successfully implemented with a diverse group of cocaine-abusers, which included court-referred and dually diagnosed clients. The only notable limitation, as mentioned earlier, is that clients must be able to attend meetings and comprehend the concepts conveyed. Clients with psychotic disorders, for example, may not be suitable candidates for participating in the LIB program if they have difficulty functioning in a group setting or in comprehending the information in an objective manner. However, these clients may be suitable if their severe psychiatric symptomatology is adequately controlled through adjunctive treatments and they can function comfortably in a group setting. 7. ASSESSMENT
An assessment protocol that measures the specific domains covered in the LIB program has not yet been developed. The LIB approach was studied by the authors in a 5-year comparative treatment investigation in Washington, DC, where cocaine-abusing clients were offered either the full 5-day-a-week version or a 2-day version of LIB group therapy. The intensive treatment approach has so far been deemed superior in encouraging higher levels of client participation in treatment, and both approaches appear superior to many prior reports of comparative treatment findings with crack smokers (Hoffman et al. 1994; Wallace 1991).
Measures such as the Addiction Severity Index (ASI) (McLellan et al. 1992), a commonly used measure in addiction research, can be used in assessing the following parameters: client demographics, treatment history, lifestyle and living arrangements, alcohol and other drug use, HIV and AIDS risk behavior, illegal activities and criminal histories, employment status, and mental and physical health status. 8. SESSION FORMAT AND CONTENT
The LIB manual provides a detailed description for 36 treatment sessions in the form of instructional text similar to a teacher's lesson plan. The information is prepared so that counselors can gain a thorough understanding of the topic and present it in manageable segments. 8.1 Format for a Typical Session
In addition to the written instructional text, each session includes:
Handouts for clients. Questionnaires, assignments, exercises, and lists of additional resources for appropriate topics for clients.
Presentation transparencies. "Visuals," which are key words and important phrases and concepts presented in each session.
Videotapes. Nine videotapes that focus on many of the session topics.
Daily progressive relaxation and visualization exercises. Progressive relaxation exercises that teach clients stress reduction skills. (Exercises correspond to session subject matter and are designed to help clients identify and reinforce recovery-oriented goals that relate to session topics.)
Relaxation and visualization audiotape. Substituted for counselor-led relaxation exercises. (Also to be used as an adjunct or a model for leading exercises.)
8.2 Several Typical Session Topics or Themes
The LIB manual, with emphasis on PE, was designed to educate clients on how to conduct self-assessments. The manual focuses on specific "life areas," in which prolonged drug use has had a negative impact. The various topics covered in the LIB program are summarized below.
Visualization, self-assessment, goal setting, planning, and self-monitoring. Clients are offered training in relaxation techniques, goal setting, planning, and self-monitoring. They are instructed in and practice using relaxation exercises as an RP tool to help them intervene in stressful situations and when they experience cravings for alcohol, cocaine, or other drugs. They learn how to set personal goals for recovery, how to conduct self-assessments in key life areas, how to deal with life improvements, and how to practice life skills. Training is repeated throughout the sessions.
Drug education. Clients learn about the psychological and physiological components of addiction and recovery and about the neurophysiology involved in addiction and recovery. They also learn in great detail about the psychological processes involved in craving and relapse. Clients participate in discussions about the classical conditioning that occurs surrounding internal and external "triggers" or conditioned cues that may elicit craving experiences and in role-play-related interventions and learn techniques to diminish the power of conditioned cues.
Relapse prevention. Clients take part in intensive RP sessions, where they practice RP skills in "process sessions." This is where clients talk about their current risk factors and intervention efforts to prevent relapse and where they can role-play responses to high-risk situations. Clients learn about the operant and classical conditioning that occurs and how specific cues (e.g., people, places, and things; certain times of day; special smells and sounds) that they associate with prior drug use can lead to craving their drug of choice and relapse unless they actively plan and intervene. They also learn how to eliminate or extinguish such learned associations and practice specific skills in coping with high-risk situations. Planning for coping with high-risk situations, generating social support for abstinence, and learning how to cope with unanticipated stress or temptations are all central to these sessions.
Self-help education. Clients are encouraged to use specific intervention skills such as implementing stress management techniques (discussed earlier) and eliciting social support (recovery groups such as AA, NA, or one of the more recently established secular groups such as Rational Recovery. The primary goal is to ensure that, as an adjunct to treatment, clients have abstinent role models to help them cope during high-risk times and provide them with a form of ongoing support after they have completed the formal treatment provided by the LIB program.
Sexually transmitted diseases. As part of the session on STDs, clients are given information on various diseases and risk factors for each. An additional session, devoted to HIV and AIDS, emphasizes the risk of contracting HIV within an addict population and explains risk reduction strategies. The various high-risk behaviors that cocaine, alcohol, heroin, and other drug addicts engage in (risky and unsafe sex practices and needle sharing) are discussed, and the importance of reducing all risk behavior for HIV infection is explained. HIV and AIDS testing and treatment are also reviewed.
Physical well-being. The negative impact of illicit drugs and alcohol, cigarettes, and prescription drugs is discussed; diet, exercise, and overall health maintenance (i.e., medical and dental care and personal hygiene and appearance) are emphasized. Group discussions on these topics as they relate to drug addiction and to a more positive lifestyle are integrated into several sessions.
Emotional well-being. Specific areas that are emphasized in this area include depression, anxiety, fear, anger and hostility, and guilt and shame. There are also group discussions of these topics as they relate to emotional problems and drug abuse and to the manner in which emotional strengths and problems can influence other life areas.
Social well-being. Specific topics covered include interactions with friends and relationships with lovers/spouses, parents and parent figures, siblings, offspring, and other significant others (SOs). Discussions in these sessions can show how relationships can be linked to drug abuse and how behaviors associated with drug abuse can be changed. The role that SOs may play in enabling drug use and the peer pressure that can generate drug-abusing behavior and relapse are discussed. Modeling, behavior rehearsal, and role playing are significant components for teaching clients. Generating social support for abstinence and recovery is also a significant part of this topic area.
Sexuality. The topic of sex and drugs is included in several sessions. Sexual dysfunction, sexual abuse, sexual addiction, sexual behavior as a risk behavior for relapse, and healthy sexuality are discussed, along with the effects of drugs in inhibiting sexual behavior.
Education and vocational development opportunities. Specific topic areas include reading and language skills, math and technical skills, possible alternatives for further education, relating education to employment goals, and learning for pleasure.
This is an opportunity for the client to review his or her vocational history, interests and aptitudes, and skills training and preparation to gain, maintain, and enhance employment.
Daily living skills. Specific topics include transportation, housing, legal assistance, financial assistance, and budgeting.
Spirituality and recovery. The concept of spirituality, defined globally in the religious sense and also in terms of simply having some sense of purpose, direction, or meaning in life, and its potential utility for recovering addicts is discussed. Other topics include the role of spirituality in providing a positive meaning for life; ritual and symbolism; peace of mind; and beyond the self.
Grief, loss, and recovery. Each is addressed to educate clients about the relationships between addiction and loss. Responses to loss are addressed, and the process of grief and factors that can affect grief is reviewed. The stages of grief are characterized, and strategies to deal with important losses, including the use of support services, are covered.
Parents and parenting. Sessions are designed to assist clients in understanding the basic needs of children that they or other caregivers must address, as well as the needs that parents and other caregivers have when parenting children. Developmental stages of children are reviewed, and clients are taught how they can help children in meeting their developmental tasks. The issues that children face at different developmental levels are also addressed. Clients are shown specific parenting skills such as communication skills, problemsolving, and positive reinforcement. Through these discussions, clients may gain a greater understanding of their own development, whether or not they are parents.
8.3 Session Structure
As presented in the LIB manual, the group treatment sessions are relatively organized. They include prepared topics, information, exercises, videos, handouts, and so forth. The materials need not be used exactly as provided; they can serve as a resource for less structured sessions. The group counselor is encouraged to study the materials and use them in a personalized manner. Less experienced counselors may prefer to follow the structure of the LIB manual more closely. 8.4 Strategies for Dealing With Common Clinical Problems
The LIB approach is not immune to the usual assortment of clinical problems. During the admission process, clients should be informed of program policies and the consequences of violating those rules. Invariably, clients will miss sessions, arrive late, or come to treatment under the influence. As with any other program, there should be established policies and procedures governing these matters. When problems are addressed in the context of the LIB program, they provide valuable opportunities for behavioral interventions within the group and with the client. Following are some examples of how these problems might addressed. 8.4.1 Lateness.
The program policy should establish lateness as an issue that is discussed in the context of the group. A pattern of lateness affords an opportunity for the counselor to help the group examine how the same faulty planning process that leads to lateness can contribute to relapse. Also, the group can explore the impact of an individual's lateness on his or her social relationships. The group can actually develop a plan to resolve the lateness problem, which can allow clients to develop skills that can be applied to other life situations. 8.4.2 Missed Sessions.
Missed sessions are to be expected; therefore, each program should develop a policy that is consistent with its treatment philosophy. In the context of the LIB approach, however, the focus of the intervention should be on the frequency of, and reasons for, missed sessions. Because a client's absence has an impact on the dynamics of the group, the counselor should use the issue to help group members identify their emotional response to the repeated absences of a member. Also, it is probable that some absences will be a response to feelings that surfaced in the previous session. This presents a perfect opportunity for the counselor to educate the group about the relationship between feelings and behavior. 8.4.3 Attending Sessions Under the Influence.
It is the authors' opinion that a client who comes to a session under the influence of alcohol or other drugs should not be allowed to participate. If a client's condition is such that there is concern about allowing the individual out into the community, the client should be held in a separate room until he or she is capable of leaving the program safely. As soon after the incident as possible, an individual session should be held to review what took place and help the client develop a more effective plan for abstinence. If the incident took place in the presence of the group, it should be the focus of an RP session. Otherwise, the counselor should use his or her clinical judgment regarding the appropriateness of discussing the incident in the group session.
These issues should be addressed in a manner consistent with the philosophy and orientation of the treatment program. Although policies and procedures are necessary and should be applied with consistency, their application should be tempered by the clinical needs of clients. It is the authors' opinion that a blanket sanction for all clients, with no consideration for individual differences and individual growth patterns, is problematic and does not allow for maximizing the individualization of the treatment program. An effort should be made, therefore, to impose sanctions in a manner appropriate to the level of development of the particular client. 8.5 Strategies for Dealing With Denial, Resistance, or Poor Motivation
It is unrealistic to expect every client to enter treatment acknowledging the severity of his or her addiction and be highly motivated for change. In fact, the very essence of treatment is confronting and overcoming the client's denial, resistance, and lack of motivation. Therefore, an effective model of treatment must incorporate a variety of strategies to address these fundamental barriers to long-term recovery. Following are strategies employed in the LIB model to address these clinical issues. 8.5.1 Denial.
Because LIB uses a PE approach to treatment, all of the sessions provide a means for confronting a client's denial. For example, the RP sessions help clients identify thoughts, feelings, and situations that trigger their use of alcohol and other drugs. This process helps teach clients how triggers relate to relapse. Another aspect of denial can be the tendency of clients to blame their drug abuse on others. In the sessions addressing social well-being, clients are guided through an examination of the key relationships in their lives. This examination helps clients understand how their responses to problems in their relationships are reflective of the decisions they make and that their problems cannot be used as rationalizations for their drug abuse. This approach works in many areas of a client's life, such as social relationships, emotional well-being, and other areas where denial may be a factor that prevents the client from moving forward in treatment. 8.5.2 Resistance.
Resistance is another area frequently seen in the treatment sessions that merits considerable time and attention. Clients express their resistance in numerous ways: through arriving late to individual or group sessions, distracting behavior during group sessions, challenging and argumentative behaviors, and so on. The LIB program has built in some mechanisms for dealing with resistance: the use of relaxation and visualization exercises and the communication and presentation of information by way of videotapes, handouts, and role plays. In some cases, the counselor should use the topic of a particular session to help clients begin to examine how their behavior may reflect resistance to treatment.
In light of factors such as denial and resistance, it is imperative that counselors use the group to assist in their interventions. Interventions made by the counselor carry significant weight, but when the group can help a member recognize denial or resistance by observing the member's behavior and sharing their own experiences with denial or resistance, such continued intervention can have a tremendous impact on the client's overcoming resistance to treatment. 8.5.3 Poor Motivation.
Poor motivation is another area that will inevitably need to be addressed during the course of treatment. It is usually best for the counselor to discuss an apparent lack of motivation with the client outside of the group sessions. It may be determined that there are other clinical issues that are upsetting the client or interfering with his or her ability to concentrate or participate in the group sessions. Once the lack of motivation is openly acknowledged, the client will be faced with the choice of engaging in treatment or discontinuing participation. 8.6 Strategies for Dealing With Crises
It is inevitable that clients will come to the program with a variety of crises. When this happens, the counselor should establish the nature of the crisis and evaluate the appropriate intervention to be made at that time. It may be necessary for a client not to participate in the group but to work with a therapist to resolve a personal crisis. In this case, it would be appropriate to excuse the client from group participation until the crisis is resolved. Once the crisis is over, and with the client's permission, a discussion of the crisis in the context of the LIB session might be a valuable learning experience for both the client and the group. This could be accomplished by presenting the issue during RP or in the course of another session. Working the crisis into the session would provide an opportunity for the client to examine how the crisis developed, how he or she dealt with it, and what could be done in the future to avoid it. In addition, it allows the group the opportunity to identify with the dilemma in which the client found himself or herself and to use that person's experience to help others in examining their own feelings and thoughts about the matter. This sharing may also help the other group members work with the client in providing the support and nurturing needed to get through the particular situation. Some crises, however (e.g., recent sexual abuse), may be best dealt with on an individual basis. 8.7 Counselor's Response to Slips and Relapses
While slips and relapses are common symptoms of the condition of addiction, it is not appropriate for the counselor to suggest that clients are expected to have relapses. Therefore, the counselor's first response to slips and relapses should be one of caring and concern, which should be demonstrated to the client through comments, observations, and other means of communicating very clearly that "I am concerned about your health and your ability to stay clean." During RP sessions, the counselor should work with the client to help the client understand how this relapse or slip occurred. The areas to be discussed should include what happened, when it started, how the client addressed it, what should have been done differently to address the problem, and what can be done next time it happens. Through this process, a slip or relapse can be turned into a very powerful learning tool to give the client an opportunity to avoid behaviors that might lead to his or her using alcohol and other drugs in the future. 9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT
It is of vital importance that family members, friends, and others involved with the client be involved in the treatment process, since they have also been affected by the client's use of alcohol and other drugs. The forum recommended for providing involvement for those individuals is family group counseling. Family group counseling can utilize concepts and materials from the various LIB sessions. In this way, families can explore their communication patterns and understand how family issues become triggers for relapse, as well as how the emotional stability and well-being of the family is influenced by the way it handles issues like anger and frustration. Family involvement is included as a separate part of the program, utilizing some of the concepts that have been discussed in the client's group sessions. 10. CONCLUSION
LIB is an intensive, comprehensive, manual-driven drug abuse treatment program that can be implemented in a variety of treatment settings. Its PE and experiential components are geared toward group treatment with the option of adding individual and family group therapy. The LIB manual provides a guide for counselors and facilitators and includes material for 36 counseling sessions, which cover a range of topics to address issues in the key life areas affected by an individual's drug abuse. The manual is intended for use by trained drug abuse professionals who are capable of presenting the material and facilitating group process. The emphasis of the approach is on enabling clients to recognize and forestall relapse to drug abuse and to reestablish a balance and sense of personal fulfillment without the use of drugs. REFERENCES
Gorski, T.T., and Miller, M. Staying Sober: A Guide for Relapse Prevention. Independence, MO: Herald House/Independence Press, 1986.
Hall, S.M.; Wasserman, D.A.; and Havassy, B.E. Relapse prevention. In: Pickens, R.E.; Leukefeld, C.G.; and Schuster, C.R., eds. Improving Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 106. DHHS Pub. No. (ADM)91-1754. Rockville, MD: National Institute on Drug Abuse, U.S. Department of Health and Human Services, 1991.
Hoffman, J.A.; Caudill, B.D.; Landry, M.; et al. Living in Balance: A Comprehensive Substance Abuse Treatment and Relapse Prevention Manual. Washington, DC: Koba Associates, Inc., 1995.
Hoffman, J.A.; Caudill, B.D.; Luckey, J.W.; Flynn, P.M.; and Hubbard, R.L. Comparative cocaine abuse treatment strategies: Enhancing client retention and treatment exposure. J Addict Dis 13(4):115-128, 1994.
La Salvia, T.A. Enhancing addiction treatment through psychoeducational groups. J Subst Abuse Treat 10:439-444, 1993.
Marlatt, G.A., and Gordon, J.R. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press, 1985.
The Matrix Center. The Neurobehavioral Treatment Model: An Outpatient Model for Cocaine Addiction Treatment. Beverly Hills: The Matrix Center, 1989.
McLellan, A.T.; Kushner, H.; Metzger, D.; Peters, R.; Smith, I.; Grissom, G.; Pettinati, H.; and Argeriou, M. The Fifth Edition of the Addiction Severity Index. J Subst Abuse Treat 9(3):199-213, 1992.
Monti, P.M.; Abrams, D.B.; Kadden, R.M.; and Cooney, N.L. Treating Alcohol Dependence: A Coping Skills Training Guide. New York: Guilford Press, 1989.
Moolchan, E.T., and Hoffman, J.A. Phases of treatment: A practical approach to methadone maintenance treatment. Int J Addict 29(2):135-160, 1994.
Wallace, B.C. Crack Cocaine: A Practical Treatment Approach for the Chemically Dependent. New York: Brunner/Mazel Publishers, 1991. AUTHORS
Jeffrey A. Hoffman, Ph.D. Danya International, Inc. 8630 Fenton Street, Suite 121 Silver Spring, MD 20910
Ben Jones, M.S.W., M.Div. New Psalmist Baptist Church 4501-1/2 Old Frederick Road Baltimore, MD 21229
Barry D. Caudill, Ph.D. WESTAT 1650 Research Boulevard Rockville, MD 20850
Dale W. Mayo, M.A. J & E Associates, Inc. 1100 Wayne Avenue, Suite 820 Silver Spring, MD 20910
Kathleen A. Mack Danya International, Inc. 8630 Fenton Street, Suite 121 Silver Spring, MD 20910
APPENDIX. SOCIAL WELL-BEING
NOTE: Either insert the following into today's daily visualization or lead a brief progressive relaxation and visualization with the following information:
Social well-being is an important part of my life. Addiction may have temporarily hurt my social well-being and allowed me to neglect important social relationships.
Therefore, my recovery includes learning to have healthy relationships with others, learning to cooperate and compromise with others, and learning to accept social responsibilities.
My recovery includes learning to find a healthy balance in relationships, such as between positive and negative feelings, between dependence and independence, between leading and following, and between closeness and isolation.
Drugs have had a strong impact on my social life. I may have dropped healthy relationships and made unhealthy relationships that center around drugs. Addiction made it easy for me to have dishonest relationships with my family and friends.
My recovery includes learning to identify my strengths and weaknesses and learning to make goals for myself. I may need to learn how to ask for help. I may receive this help from a friend, a lover, a person I trust, or a group of people. I may receive this help from my Higher Power. I may have to learn to have faith and to be patient.
For the next few moments, I will make a mental image of myself as I am today. As I look at this mental image of myself, I will pay particular attention to my social health and well-being. As I look at this mental image of myself, and as I pay special attention to my social health and well-being, I will make note of my strengths and weaknesses. [Pause for a few moments.]
For the next few moments, I will make a mental image of myself as I would like to be. In terms of social well-being, I am focusing on how I would like to be in the future. I may think about the specific goals that I would like to achieve. This may take work, time, and patience, but I can achieve these goals. [Pause for a few moments.]
After this visualization is over, I will feel comfortable writing down specific goals that I would like to achieve in terms of my emotional well-being. I will also feel comfortable writing down my strengths and weaknesses in this area.
Distribute and Discuss: Handout—Social Well-Being Assessment
HANDOUT—SOCIAL WELL-BEING ASSESSMENT
The following people are important in my life:
In terms of my social well-being, my personal strengths include the following:
In terms of my social well-being, my personal weaknesses include the following:
In terms of my emotional well-being, my most important goal is:
In terms of reaching this goal, I must take the the following steps...
The National Institute on Drug Abuse (NIDA) is part of the National Institutes of Health (NIH) , a component of the U.S. Department of Health and Human Services. Questions? See our Contact Information. Last updated on Thursday, June 19, 2003.
When I was beginning my personal growth journey, a wise person told me that when I was feeling resentful or afraid or sad, that I should remember the phrase "gratitude is the attitude" when I was ready to feel better. That phrase has helped me feel better tens of thousands of times.
Would you share what you are most grateful for? Your story could be just what another person is searching for to renew themselves? Thanks.