Attachment 8 - Living In Balance 6.30.25.pdf

LIVING IN BALANCE

Living in Balance is a research based, flexible, practical, and user-friendly substance abuse treatment curricu-lum that helps clients address issues in lifestyle areas that may have been neglected during addiction. Living in Balance was developed by Danya International with funding from NIDA. Implementation training is available from Hazelden, ensuring customized treatment that best meets your clients’ needs.

FEATURES AND BENEFITS

• uses a research-based treatment approach

• incorporates Twelve Step/spiritual learning with cognitive-behavioral learning

• presents critical core treatment education

• permits parallel treatment, with clients able to enter or leave at any session

• saves you time and expense by providing prepared sessions, similar to a teacher’s lesson plan

• comprehensive, stand alone, easy to implement

• can be embedded within any program

• enhances existing programs

• appropriate for all substances of abuse

• can be used in a variety of program types and levels of care

• residential

• hospital based

• community based

• criminal justice

• counseling centers

• therapeutic communities

• halfway houses

• therapists in private practice

• continuing care

• faith-based initiatives

Hazelden Publishing and Educational Services Phone 1-800-328-9000 • Fax 1-651-213-4590 • Online www.hazelden.org/bookplace

25DPP01102 T1464 Substance Abuse Services

ATTACHMENT 8 - LIVING IN BALANCE

BACKGROUND

Living in Balance was developed by Danya International, a Maryland-based company renowned for prod-uct development and research in substance abuse prevention, treatment, and related issues. In developing LIB, Danya staff members worked with consultants from the Center for Drug Treatment and Research on a cocaine treatment research demonstration project funded by the National Institute on Drug Abuse (NIDA).

Their goal was to provide a systematic, organized, and comprehensive program that utilizes current infor-mation about addiction, learning, relapse prevention, and instructional design.

An evaluation was conducted at two outpatient programs: the Koba Human Services Center in Washington, D.C., and the Matrix Woodland Hills office in Los Angeles, California. In both programs, clients were referred primarily from criminal justice and employee assistance programs. Their primary drug problem was cocaine. Subjects at both sites were randomly assigned to either the 36-session Living in Balance group counseling program or a 36-session Twelve Step group-counseling program. Both programs used manuals to guide counselor-directed group counseling and education sessions. Groups generally met three evenings a week over a period of twelve weeks. Counselors were trained in either the Living in Balance or the Twelve Step approach and were supervised by clinical psychologists at both sites. No other treatment servic-es were provided.

A total of 67 clients received group treatment at the DC site and 65 clients participated in the study at the Los Angeles site. The average age of the DC clients was 35 and for LA clients it was 33. The average years of education completed was 12 for DC and 14 for LA. The DC site had 64 percent males and 36 percent females, while LA had 75 percent males and 25 percent females. The majority of the clients at the DC site were African American, while the majority of the clients at the LA site were white. Given the limited num-ber of subjects, the analyses performed were for both sites combined. With both sites combined, 67 clients participated in the Living in Balance groups and 65 clients participated in the Twelve Step groups.

Approximately 27 percent of the Living in Balance clients and 33 percent of the Twelve Step clients complet-ed the assessments at the end of treatment, while approximately 26 percent for both groups completed the assessments at 3-months post-treatment follow-up.

Hazelden Publishing and Educational Services Phone 1-800-328-9000 • Fax 1-651-213-4590 • Online www.hazelden.org/bookplace

KEY OUTCOMES AND FINDINGS

The following results delineate the differences between the LIB group and the Twelve Step group. You will also find the results in Table 1 (next page).

• retaining clients in treatment, or number of days that clients spent in treatment:

LIB group mean: 38 out of 84 days Twelve Step group mean: 42 out of 84 days Finding: not statistically significant

• exposing clients to treatment, or number of sessions attended:

LIB group mean: 11 out of 36 sessions Twelve Step group mean: 13 out of 36 sessions Finding: not statistically significant

• number of days of cocaine use during the 30 days before follow-up:

LIB group mean: 4 out of 30 days Twelve Step group mean: 5 out of 30 days Finding: not statistically significant

• number of days of cocaine use from intake to followup:

LIB group mean: reduced from 13 days to 4 days Twelve Step group mean: reduced from 10 days to 5 days Finding: statistically significant

• number of days of alcohol use from intake to followup:

LIB group mean: reduced from 7 days to 3 days Twelve Step group mean: reduced from 7 days to 5 days Finding: statistically significant

TABLE 1—KEY OUTCOME VARIABLES AND FINDINGS

LIB

Group Mean

38 42 .012 .913

11 13 .080 .778

13 days 10 days 3.523 .063

6 days 5 days 1.570 .218

4 days 5 days .342 .563

7 days 7 days .040 .842

3 days 5 days .568 .456

4 days 6 days 4.456 .043

12-Step Group Mean

F SignificanceOutcome Variable

Days in Treatment

Number of Sessions Attended

Cocaine Use Past 30 Days—At Intake

Cocaine Use Past 30 Days—End Treatment

Cocaine Use Past 30 Days—3 Month Follow-Up

Alcohol Use Past 30 Days—End Treatment

Alcohol Use Past 30 Days—At Intake

Alcohol Use Past 30 Days—3 Month Follow-Up

“How troubled are you by . . . ?”

The following is a summary of client self-ratings of the question, “How troubled are you by (various problems) at intake and 3-month follow-up?” The responses are based on a 5-point Likert scale from 0 of “not at all” to a 4 of “very troubled.” You will also find the results in Table 2 (next page)

Question: How troubled are you by drug problems?

LIB group mean: 3.22 at intake, 1.82 at follow-up Twelve Step group mean: 3.13 at intake, 1.12 at follow-up Finding: not statistically significant

Alcohol, family, and social problems were not perceived to be severe at intake, and thus showed little change at follow-up. Perception of employment problems, however, tells a different story. This may be attributed to the specific focus on employment issues in some of the LIB sessions.

Question: How troubled are you by employment problems?

LIB group mean: 2.36 at intake, .41 at follow-up Twelve Step group mean: 1.77 at intake, 1.12 at follow-up Finding: statistically significant

TABLE 2—CLIENT SELF-RATINGS: HOW TROUBLED ARE YOU BY . . .

Outcome Variable

Drug Problems:

At Intake

Drug Problems:

3 Mo. Follow-up

Alcohol Problems:

At Intake

Alcohol Problems:

3 Mo. Follow-up

Employment Problems:

At Intake

Family Problems:

At Intake

Employment Problems:

3 Mo. Follow-up

Family Problems:

3 Mo. Follow-up

LIB

Group Mean

3.22

1.82

.72

.47

2.36

.41

1.81

1.76

3.13

1.12

.58

.24

1.77

1.12

1.75

.88

12-Step Group Mean

1.573

.027

1.170

1.447

.094

8.727

.108

.588

F

.212

.872

.281

.238

.760

.006

.743

.449

Social Problems:

At Intake

1.42 1.06 1.450 .231

Social Problems:

3 Mo. Follow-up

.41 .41 .000 1.000

Significance

What this means for you

Cocaine use continues to be a serious problem in the United States, with alcohol generally being the sec-ondary substance problem for cocaine users. In the current economic climate, employment worries are becoming a serious problem as well. Given the relatively low cost of implementing the LIB counseling approach, it appears to offer a promising and effective choice for reducing cocaine use, and for the reduc-tion of alcohol use and other problems.

About the authors

Jeffrey Hoffman is president and CEO of Danya.

Mim J. Landry has spent eight years with the Haight Ashbury Free Medical Clinics in San Francisco. He has also developed protocols for the treatment of substance use and psychiatric disorders. He is director of Editorial Services for Danya.

Barry Caudill is with the Centre for Studies on Alcohol, Rockville, Maryland.

PRODUCT INFORMATION

The Living in Balance core curriculum includes twelve sessions that address basic issues commonly faced by clients in early recovery. Sessions address drugs of abuse, relapse prevention, self-help programs, men-tal and physical health, emotional and social wellness, sexual and spiritual health, daily living skills, and vocational and educational development. The sessions are packaged in a three-ring binder with divider tabs for easy organization.

You can supplement the core curriculum with an additional twenty-one sessions, which are available sep-arately.

Information in each session is presented in manageable, user-friendly segments. Clients are able to per-sonalize how the session topic has affected their lives, and the steps they can take to make changes. Each session allows for counselor interventions, presentations, and client training. After each segment is a question-and-answer session that lets clients interact intensively with the counselor. Written assignments, along with role-play exercises where appropriate, engage clients interactively with the information.

Twelve Core Sessions These sessions can be used in any order that works best for your clients, and can be repeated if necessary.

There is no beginning or ending session. The parallel treatment model allows clients to start anywhere, end anywhere, and stay current even if they miss a session.

• Definitions, Terms, and Self-Diagnosis

• Alcohol and Other Drug Education

• Triggers, Cravings, and Avoiding Relapse

• Planning for Sobriety

• Alcohol and Tobacco

• Spirituality

• Sex, Drugs, and Alcohol

• Stress and Emotional Well-Being

• Skills for Reducing Stress

• Negative Emotions

• Anger and Communication

• Relapse Prevention

Twenty-one Supplemental Sessions These supplemental sessions of Living in Balance provide the greatest opportunity for customization. You can group sessions for specific issues (e.g. sexual abuse, grief and loss), specific client populations (e.g.

clients at high risk for sexually transmitted diseases), or unique treatment tracks (e.g. spirituality and self-help).

• Introduction to Self-Help Groups

• The Twelve Steps

• Sexually Transmitted Diseases

• Focus on AIDS

• Nutrition and Exercise

• Physical Wellness

• Problem Solving

• Attitudes and Beliefs

• Human Needs and Social Relationships

• Family Matters

• You and Your Parents

• Child Development and Parenting Skills

• Educational and Vocational Goals

• Money Management

• Insurance and Consumer Credit

• Sexual Abuse

• Compulsive Sexual Behavior

• Addiction and Loss

• Grief: Responding to Loss

• Spirituality and Personality

• Relapse Prevention, Part Two

Session 1: Definitions, Terms, and Self-Diagnosis Three major parts: “Definitions and Terms,” “Self-Assessment Exercise,” and “Biological Aspects of Addiction.” It contains some of the most up-to-date information available today on how drugs affect the brain.

Clients will:

• understand the nature of drug abuse and its negative effects

• understand how substance abuse affects brain chemicals and biological processes

• understand how to apply diagnostic criteria to themselves

Session 2: Alcohol and Other Drug Education Four major parts: “Stimulant Drugs,” “Psychedelic and Hallucinogenic Drugs,” “Depressant Drugs,” and “A Look at Drugs and the Brain.” Clients will:

• understand the physical and psychological effects of drugs

• understand how MDMA affects brain chemicals

• understand how cocaine cravings are linked to brain changes

Session 3: Triggers, Cravings, and Avoiding Relapse Three major parts: “What Are Triggers?” “How a Trigger Leads to Relapse,” and “Stopping the Trigger from Leading to Relapse.” Relapse prevention is a key goal and objective of Living in Balance, and is revisited several times in the curriculum. Session 3 helps clients understand how the process of triggers can lead to relapse, and how they can interrupt that process. Clients will:

• identify their personal triggers and learn how to defuse them

• understand the four steps that lead from trigger to relapse

• understand how to interrupt thinking about drugs

Session 4: Planning for Sobriety Three major parts: “Planning for Your Sobriety,” “The Road to Recovery,” and “Relapse Decisions and Triggers.” Clients will recognize the recovery components that are most personally challenging, recognize ways in which triggers have led to relapse. Clients will:

• understand why sobriety and relapse are processes

• understand how triggers have led to relapse for them

• recognize which components of their recovery program are personally challenging

Session 5: Alcohol and Tobacco Two major parts: “Alcohol and Alcoholism” and “Tobacco.” Clients will:

• take a self-evaluation of alcohol problems

• understand the process, development, and progression of alcoholism

• understand the reasons why they smoke or use alcohol

Session 6: Spirituality Two major parts: “What Is Spirituality?” and “Your Higher Power and Prayer.” Clients will:

• understand how addiction affects spirituality

• understand ways to increase their spirituality

• explore their own perception of a Higher Power

Session 7: Sex, Drugs, and Alcohol Two major parts: “Sex and Drugs” and “Sexual Problems.” For maximum exchange of thought, gender-specific groups are recommended for this session. Clients will:

• understand the effects of alcohol and other drugs on sex

• understand sexual problems that affect men and women

• understand the relationships between sex and substance abuse

• explore practical tips related to sex and recovery

Session 8: Stress and Emotional Well-Being Two major parts: “Stress” and “Reacting to Stress.” Clients will:

• understand how frustrations, pressures, and conflicts differ

• identify coping techniques and emotional health goals

• understand the three stages of responding to stress

Session 9: Skills for Reducing Stress Three major parts: “Review of Information about Stress,” “Restructuring Your Life,” and “Coping Strategies.” Clients will:

• understand stress, stress reduction, and defenses

• understand methods of reducing stress

• understand the importance of seeking support during times of stress

• recognize the benefits of relaxation and healthy activities

Session 10: Negative Emotions Two major parts: “Depression” and “Guilt and Fear.” Clients will:

• understand the substance abuse-depression link

• recognize how childhood guilt affects adult behaviors

• understand how guilt affects recovery

• recognizing the role of forgiveness in recovery

Session 11: Anger and Communication Two major parts: “Understanding Anger” and “Expressing Anger.” Clients will:

• recognize the biological signs of anger

• recognize how people can repress, delay, dilute or transfer anger

• recognize negative ways and learn positive ways of expressing anger

• explore ways to be assertive and improve communication

Session 12: Relapse Prevention Two major parts: “Relapse” and “Exercises for Relapse Prevention.” Building upon clients’ understanding that relapse prevention is a process, Session 12 helps them carry out the process. It reinforces critical relapse prevention concepts, and allows individuals to process difficult situations that they encounter in their daily lives that could easily lead to relapse. In this final core session, clients will:

• put into action how to interrupt triggers that lead to relapse

• identify triggers and understand how to defuse them

• participate in visualization exercises that can help them avoid triggers

• learn to stop thoughts from becoming triggers

SUPPLEMENTAL SESSIONS

Session 13: Introduction to Self-Help Groups Three major parts: “What Self-Help Groups Can Do for You,” “Twelve Step Fellowships,” and “Alternatives to Twelve Step Programs.” This session is the first step in the continuing care process.

Clients will:

• understand the roles that secrecy and isolation had in their addiction

• know what to expect at a Twelve Step group and why it works

• understand how addiction affects trust and the importance of honesty

• understand why and when alternative groups may be helpful

Session 14: The Twelve Steps Two major parts: “What Are the Twelve Steps?” and “How the Twelve Steps Work.” Clients will:

• understand what the Twelve Steps require

• consider how they can incorporate the Twelve Steps in their lives

• understand Twelve Step principles and the role of spirituality in them

Session 15: Sexually Transmitted Diseases Two major parts: “What Are Sexually Transmitted Diseases?” and “Lowering the Risk of Infection.”

Recommended for gender-specific groups. Clients will:

• recognize the symptoms of STDs

• understand the treatments available for various STDs

• understand what are safer sexual practices

Session 16: Focus on AIDS Two major parts: “Understanding HIV and AIDS” and “HIV/AIDS Risk Reduction and Treatment.”

Recommended for gender-specific groups. Clients will:

• learn about the extent and danger of the HIV/AIDS problem

• learn how HIV testing works

• understand how HIV is and isn’t spread

• assess their own risk of getting HIV

Session 17: Nutrition and Exercise Two major parts: “Nutrition” and “Physical Exercise.” Information on nutrition is the most up-to-date information available. Clients will:

• understand how substance abuse affects eating habits

• understand the types and proportions of foods in balanced diets

• understand the value of exercise in physical and mental well being

• understand the benefits of different types of exercise

Session 18: Physical Wellness Two major parts: “Physical Problems” and “Insomnia.” Clients will:

• understand basic treatments for major health problems

• recognize the significance of insomnia and its role in early sobriety

• practice basic steps to prevent insomnia

Session 19: Problem Solving Three major parts: “Life Problems,” “Problem Solving,” and “Tips and Techniques.” Clients will:

• understand why they had difficulty with problems

• understand how to prioritize and make big problems manageable

• understand the importance of asking for help and brainstorming when stuck

• weigh the benefits and risks of potential solutions

Session 20: Attitudes and Beliefs Three major parts: “Importance of Attitudes and Beliefs,” “Disputing Irrational Beliefs,” and “Building a Positive Self-Attitude.” Clients will:

• understand how attitudes and beliefs affect their response to stress

• review a personal event and dispute the irrational beliefs

• understand that they have an illogical internal critic

• focus on their strengths and accept things they cannot change

Session 21: Human Needs and Social Relationships Three major parts: “Human Needs,” “Social Relationships,” and “Introduction to Parenting.” Clients will:

• understand what they need to develop healthy relationships

• understand how needs must be met before reaching potential

• understand why they should take risks and reveal feelings

• understand the special needs of parents and children

Session 22: Family Matters Three major parts: “Dysfunctional Families,” “Dysfunctional Family Roles,” and “Overcoming Family Dysfunction.” Clients will:

• understand what makes a family dysfunctional

• understand the destructiveness of dysfunctional roles that children assume

• understand the importance of overcoming hurt, anger, and fear

• understand the importance of forgiveness and reconciliation

Session 23: You and Your Parents Three major parts: “Parenting Styles,” “You and Your Mother,” and “You and Your Father.” Clients will:

• understand the effects of different parenting styles

• understand the importance of parents in a child’s life

• consider how their parents continue to influence them

• recognize the importance of their feelings about their parents

Session 24: Child Development and Parenting Skills Two major parts: “Developmental Stages and Tasks” and “Parenting Skills.” Clients will:

• understand emotional, intellectual, and social tasks

• understand healthy and effective parenting

• improve communication, problem solving, and time management for children

• create a healthy environment in which children can learn and grow

Session 25: Educational and Vocational Goals Two major parts: “Educational Goals” and “Vocational Goals.” Clients will:

• understand the education options available to them

• evaluate the jobs that are best suited for them

• understand how to prepare a cover letter, résumé, and participate in a job interview

• prepare for dealing with drug triggers in the workplace

Session 26: Money Management Two major parts: “Determining Your Financial Goals” and “Preparing a Budget.” Clients will:

• gain a clearer picture of their financial priorities

• plan short-term, intermediate, and long-term financial goals

• prepare a monthly and yearly budget

Session 27: Insurance and Consumer Credit Two major parts: “Insurance” and “Consumer Credit.” Clients will:

• understand different types of insurance and consumer credit

• determine if they have a problem with compulsive borrowing

• understand credit problems and scams

• discover where they can go for credit-related problems

Session 28: Sexual Abuse Two major parts: “Rape and Sexual Assault” and “Childhood Sexual Abuse.” Recommended for gender-specific groups. Clients will:

• understand how unrealistic messages about sex confuse people

• understand how support can help rape victims deal with the police and recover from trauma

• understand how childhood sexual abuse affects their adulthood

• understand that recovery from childhood sexual abuse is possible

Session 29: Compulsive Sexual Behavior Three major parts: “Healthy Sexuality,” “Understanding Compulsive Sexual Behavior,” and “Recovery from Compulsive Sexual Behavior.” Recommended for gender-specific groups. Clients will:

• understand the way they talk about sex reveals feelings and insecurities

• recognize the importance of healthy intimate relationships in recovery

• understand how addiction relates to compulsive sexual behavior

• recognize behaviors that accompany sexual compulsion

Session 30: Addiction and Loss Two major parts: “Loss in Addiction and Recovery” and “Regaining What Was Lost.” Clients will:

• understand ways addiction may have destroyed friendships

• understand losses through addiction: jobs, possessions, the ability to decide

• understand where to get support to help them deal with loss

• understand the process of renewal, priorities, and attitudes

Session 31: Grief: Responding to Loss Two major parts: “Understanding Grief” and “Stages of Grief.” Clients will:

• understand how people react to grief

• understand factors that influence the strength of grief

• understand how to deal with grief in a healthy, positive manner

• understand how to work through their grief and grow emotionally

Session 32: Spirituality and Personality Three major parts: “Spirituality and Personality Change,” “How Change Occurs,” and “Meditation.”

Clients will:

• understand how their own personality has changed since sobriety

• understand how to make personality changes and grow spiritually

• understand how meditation can promote spiritual change

• understand different types of meditation and how to meditate

Session 33: Relapse Prevention, Part Two Three major parts: “Relapse and Triggers,” “Building a Wall to Prevent Relapse,” and “Trusting Others to Help You with Your Recovery.” The process of relapse prevention needs to be revisited, adjusted, and reinforced throughout stages of recovery. Clients will:

• maintain their relapse prevention plan

• enhance their ability to avoid and defuse triggers

• understand ways to strengthen their physical and emotional well-being

• recognize their levels of trust in others who assist them

OTHER COMPONENTS OF LIVING IN BALANCE

Facilitator Guide Designed to help you deliver the Living in Balance treatment program to multiple clients at once, the facilitator's guide presents the philosophical context for the curriculum. Practical, session-specific infor-mation helps you lead and assist clients in the recovery process.

Audiotape Relaxation and Guided Imagery Audio Soothing narration and music helps clients release tension, breathe deeply, and relax fully.

FAQs

For whom is Living in Balance designed?

Living in Balance is designed for all addiction professionals. This includes addiction counselors working in addiction treatment programs, addiction counselors who provide individual and group therapy outside of treatment programs, psychologists and psychiatrists who provide individual and group addiction treat-ment, addiction nurse specialists who conduct individual and group sessions, and other behavioral health professionals providing addiction treatment services. For ease of use, we refer to counselors and imply all behavioral health professionals who provide professional therapeutic services to clients for addiction treatment.

What is the Living in Balance goal for clients?

Clients in addiction treatment place significant emphasis on the following needs: (1) to receive informa-tion and education about the drugs of abuse, treatment, and recovery; (2) to learn skills that help them to deal with feelings and emotions; (3) to learn information and skills about relapse prevention; (4) to openly share with others; (5) to learn practical living skills from others; and (6) to be openly confronted when engaged in denial or other types of distorted thinking or behaviors.

The goal of the psychoeducational approach of Living in Balance is to provide education, information, and experiences that will allow people to lead healthy and productive lives without the use of alcohol and other drugs by providing:

• Accurate information about the substances of abuse, relapse prevention, self-help programs, medical and physical health, emotional and social health, sexual and spiritual health, and daily living skills.

• Information for each session divided into manageable segments.

• Written exercises in each session that engage and help clients to better understand the informa tion and receive reinforcement for learned information.

• Several role-play exercises that encourage intense interaction, discussion, and thought-provok ing experiences among clients.

• Relaxation and visualization exercises

How is addiction viewed in Living in Balance?

The conceptual framework for Living in Balance is that addiction is a chronic, progressive, relapsing condi-tion that involves compulsion, loss of control, continued use despite adverse consequences, and relapse.

Living in Balance stresses that addiction is a biopsychosocial problem. That is, the emergence, mainte-nance, and course of addiction are influenced by biological, psychological, and social factors. In turn, addiction has profound effects on people's biological, psychological, and social lives.

Biological factors. Research demonstrates that many addicted people and their family members have a biologically-based increased likelihood for developing addictive behaviors when exposed to psychoactive drugs. In addition and following chronic drug use, all people experience a severe biological (neurochemical) imbalance. Drug hunger, intoxication, tolerance, and withdrawal are all manifestations of drug-induced biologic imbalances.

Psychological factors. Some people begin their drug use to diminish potent emotional and psychi-atric symptoms. In turn, addiction causes a variety of psychological problems. Even recovery can cause severe emotional turmoil as emotions begin to return. Importantly, addiction causes distor-tions in thinking such as denial, minimization, and projection.

Social factors. Various environmental factors increase the likelihood of exposure to specific sub-stance of abuse. For instance, certain substances are more frequently used within certain cultures, and are found in certain geographic areas. For many people, substance use occurs in the context of a social network. As a result, addiction frequently causes severe disruptions in people's social lives. Various social and environmental factors can also trigger drug hunger and relapse.

Why use a biopsychosocial approach?

Since addiction has a significant effect on all areas of clients' lives, effective treatment must likewise have a strong impact on all of these areas. Different therapeutic methods must therefore be implemented to enhance each life area depleted by prolonged drug use.

For instance, didactic information and education may be sufficient to change behaviors with regard to cer-tain health issues. However, information and education is not sufficient to alter distorted thinking such as denial. Rather, the alteration of distorted thinking requires both education and experiential activities. In much the same way, interactive exercises, education, and experiential activities are required to develop relapse prevention skills.

Can Living in Balance be used in an individual treatment setting?

Yes. Living in Balance uses client worksheet sets (much like a workbook), in which clients read and learn information and engage in written exercises. Although there are many advantages to using this program in a group setting, the program can be used in a one-to-one fashion. In some situations, counselors may lead a client through the worksheet sets in an individual counseling session, in much the same fashion as group therapy. In other situations, counselors may use the client worksheet sets as homework assign-ments. This can be done to help clients catch up with others in a treatment group.

However, we suggest using Living in Balance in a group therapy context whenever possible. Learned information is reinforced through the group process, which includes interactive exercises and activities.

Treatment is provided through didactic presentation of educational information, promotion of interactions between clients and the counselor, promotion of interactions among clients, and participation in role-play exercises and other activities.

How can Living in Balance be adapted to different settings or levels of care?

The twelve core sessions provide a great foundation for the educational needs of most clients with sub-stance abuse disorders. The twenty-one supplemental sessions provide additional reinforcement of many key issues and provide an opportunity to focus on targeted issues and client populations.

In certain settings, it may not be practical to utilize all thirty-three sessions. In such situations, the coun-selor may want to select a smaller number of sessions appropriate for the setting. For instance, some man-aged care settings may limit the number of treatment sessions. In that case, the core set of 12 sessions may be most appropriate. In some situations, one session can be provided per day. In other situations, two or three sessions can be provided each day.

Is Living in Balance science based?

Yes. Living in Balance draws from cognitive, behavioral, and experiential treatment approaches by employ-ing the use of didactic education and instruction, written exercises, group process interaction through role plays and discussion, relaxation and visualization exercises, and group-oriented recreational therapy exer-cises. The content was drawn from current research and science in drug addiction and related areas. The methodology draws from current evidence-based treatment practices combined with practical clinical experience of the authors. In addition, the format draws from current instructional education practices shown to enhance learning and retention. Both counselors and clients should find that the program pro-vides a solid foundation for treatment that can be used in a flexible manner.

Relapse prevention is viewed as a fundamental component of treatment and is consequently emphasized by the use of a Relapse Prevention session. This session is intended to reinforce critical relapse prevention concepts, as well as allow individuals to process difficult situations that they encounter in their daily lives that could easily lead to relapse. The use of visualization exercises is also intended to strengthen relapse prevention skills, as well as to assist with the formation and reinforcement of personal goals.

The sessions are intended to last for approximately 1.5 to 2 hours each. The twelve core sessions and twenty-one supplemental sessions can easily fit into any treatment program or system. The program is designed so that clients can enter into the program at any session and continue the program until all ses-sions are completed. In addition, sessions from the twenty-one supplemental sessions can be used for spe-cific issues (e.g., sexual abuse or grief and loss), specific client populations (e.g., clients at high risk for sexually transmitted diseases), or for unique treatment tracks (e.g., spirituality and self-help).

In Living in Balance, addiction is viewed as a biopsychosocial process that not only impairs an individual's functioning, but also destroys 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.

Addiction is viewed as a chronic, disabling condition in which relapses are common. Each client's unique history and evolution of addiction must be continually evaluated at all of these levels. Doing so permits the development of an effective treatment plan that can be tailored to the individual's needs, strengths, weaknesses, and goals. The Living in Balance approach assumes that comprehensive biopsychosocial inter-ventions are required to promote successful treatment outcomes.

The program takes a non-judgmental approach to addiction and lifestyle issues. In general, addicted clients are viewed as people with a compulsive disorder that often overwhelms good intentions and willpower. Clients can be taught relapse prevention techniques to avoid reemergence of the symptoms of addiction: compulsion, loss of control, continued use despite adverse consequences, and relapse.

Living in Balance views the Twelve Step programs of Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA) as important components in the treatment and recovery process.

The program also embraces alternative recovery self-help groups and promotes the seeking of spiritual awareness. Each individual must find his or her own sources of support and fulfillment that extend beyond the limits of a treatment program and professional counseling.

How much preparation time should I allow for each session?

When first using Living in Balance, the counselor will need to read and learn the information provided on the client worksheet sets. Until the material is thoroughly familiar, including the written exercises, the facilitator should review each session for about thirty minutes. Once the material is familiar, facilitators may need about half that time for review. Prior to conducting a client session, it is important to do the following:

• Review the client worksheet set in relation to both the information reviewed and the written exercises.

• Prepare talking points on a whiteboard, flip-chart, or PowerPoint presentation software that fol lows the educational information in the session’s client worksheet set.

• Identify if one of the role-play exercises would be an appropriate addition to the client session.

• Identify the need for any handout materials, such as the list of local self-help groups or other local resources.

What are some general suggestions for implementing the program?

Living in Balance provides educational information, written exercises, and several role-play exercises.

These are designed to help clients relate personally to the topics reviewed in each session. The following are a few general suggestions to successfully implement the program.

• Review the material for each session in advance. In this way, the educational text does not have to be read verbatim, but presented more naturally.

• Make the material your own so that you can convincingly convey its interest and importance.

The best teachers believe in what they are doing. They are deeply interested in what they are teaching.

• Use visual aids. We suggest that you develop talking points based on the client sessions.

• Adapt the material to the clients. Frequently check and see if they understand the concepts being discussed. Is the discussion too complex? Is it too elementary and creating boredom? Is this something the group does not need? Should a particular topic be expanded?

• Make the material culturally relevant and relate it to issues important to the members of ethnic communities represented in your groups.

• Bring in outside guests, role models, and demonstrators, where appropriate.

• Pay attention to process and personal client issues as they arise. If you don't, client attention will be elsewhere, and clients won't be able to attend to the material.

How should I approach the group process in the LIB program?

As you would when facilitating individual sessions, listening to client issues and linking concerns to the material in the program is very important. Clients will be raising issues they find painful, confusing, exciting, or joyful that need to be processed. The material presented in some sessions may elicit painful memories or anxiety responses, and counselors need to be prepared to handle these when they arise.

Although a Living in Balance program group is not a psychotherapy group, a counselor must recognize and attend to client issues to facilitate healing and recovery and to ensure that clients will be able to absorb the material being presented.

How do I handle process issues in a Living in Balance session?

Suggestions for handling these issues include the following:

• Warmly greet and welcome your clients at the start of each session.

• Ask clients if they have any pressing issues to discuss or any questions or comments about the previous session.

• If issues are raised, relate them to the client session material.

• If a client issue requires greater attention than you can give at the time, respond briefly and let the client know that the issue will be addressed in more depth at a later time, either within or outside the group.

• If a client raises an issue that cannot be appropriately handled in the group, ask the client to see you at the break, and take the steps you deem necessary when you meet, such as referring the client to individual therapy.

• In all instances, try to hear the client out and try to provide some closure.

Do I need any special room arrangements?

The physical needs for the therapeutic sessions are generally the same as for any group sessions. There should be:

• Adequate room size

• Comfortable seating

• Comfortable room temperature

• Lighting flexibility

• Flip chart or overhead projector for talking points

• Audio tape player for relaxation tape.

Dimming the lighting, especially if harsh, can greatly enhance the relaxation and visualization exercises.

What skills are needed by a Living in Balance program facilitator?

People who facilitate Living in Balance program groups should have the skills and qualities that all addic-tion counselors possess. They should have a thorough understanding of the drugs of abuse, treatment, recovery, and relapse. They should also possess empathy, warmth, and genuineness.

The National Association of Alcoholism and Drug Abuse Counselors (NAADAC) notes that the counsel-ing or “process” skills most often needed in a therapeutic setting include the following:

• Feedback (the response made by a facilitator after listening to a client) is most helpful when it consists of descriptive and non-judgmental information about what the client is doing. It can also describe the effect that a client is having on the counselor at that moment.

• Attending (tuning in to clients) is a way for clients to know that the counselor is paying atten tion to them. Attending is helped by eye contact, appropriate verbal responses, and body lan guage, such as leaning toward clients or sitting in a relaxed and open position.

•Paraphrasing (restating what clients have stated to demonstrate that the counselor understands, or is trying to understand what is being stated) can help clients clarify and sharpen their meanings.

• Reflecting feelings (the non-judgmental expression or summary of clients' emotions) demon strates that the counselor understands. It can help to bring clients' feelings to the surface, and help them to state emotions that have not been clearly expressed. It gives clients a chance to rec ognize and accept their own feelings.

• Self-disclosure (the facilitator's expression of his or her feelings or experiences that seem relevant to the clients' current situation) creates trust and empathy. Because self-disclosure can have a strong impact, it is important to question if it will be beneficial to clients, or if it might create any problems.

• Confrontation (the use of a question or a statement to get clients to face things that they may be avoiding, consciously or unconsciously) demonstrates open and honest communication and can encourage clients to deal with denied or repressed feelings and behavior. Used only where trust and empathy already exist, confrontation should be positive and constructive, not negative or punitive (NAADAC 1992).

In addition, counselors who facilitate Living in Balance group sessions should also have skills training.

What is skills training? How do I prepare for it?

Skills training emphasizes the following client behaviors characterized by NAADAC (1992) as a valuable part of the recovery process:

• Developing healthy behaviors through modeling and imitation of counselors or other clients, through use of videos, audiotapes, and through role-play exercises.

• Learning relaxation, meditation, and visualization techniques that can reduce anxiety, improve mental and physical functioning, and enhance learning.

• Acquiring concrete problem-solving skills, such as setting goals and learning how to develop strategies to meet those goals.

What's the best way to engage a client in Living in Balance?

The NAADAC study guide notes that the denial and defensiveness that accompanies addiction means that engaging clients is a critical first step. The counselor must work to develop an alliance with the client before anything can be accomplished in the relationship. Particularly important are the following:

• Expressing empathy and acceptance

• Maintaining a non-judgmental and respectful stance

• Encouraging self-exploration and self-understanding

• Working to reduce a client's sense that life is out of control by offering structured sessions

• Helping clients to establish and work toward specific goals

• Helping clients conduct the written exercises in the client worksheet sets

Entering treatment is often an intimidating experience, and establishing a trusting relationship with the client should initially be your primary task. Clients should get the feeling that in each session they will learn something that is personally useful and valuable.

Attending to the client, paraphrasing, and reflecting feelings are particularly important at this stage. Once the relationship and trust level are developed, the counselor can then use clinical judgment about incor-porating counseling techniques such as confrontation and counselor self-disclosure.

It is important to relate the information taught in Living in Balance to clients' experiences. Highlighting program material with client-generated problems, concerns, or issues will help clients relate to the materi-al and incorporate it into their thought processes and their behaviors.

Does the Living in Balance program include attention to relapse prevention?

Yes. Relapse prevention is a critical component of Living in Balance. Through written and other exercises, clients relapse prevention knowledge and skills can be developed and enhanced. The Living in Balance approach to relapse prevention is based in part on a cognitive behavior model of relapse developed by Marlatt and Gordon (1985). In this model, recovering individuals confront high-risk situations for which they have no effective coping response. According to the model, high-risk situations can occur for many reasons, including social pressure to drink or use drugs, negative emotions, withdrawal symptoms, and even positive emotions. The lack of a coping response combined with positive expectancies for the initial effects of the substance in the situation, greatly heighten the risk to drink or use drugs (Hall et al. 1991).

This cognitive behavior model acknowledges that the addiction process involves learned, maladaptive habit patterns. The patterns offer pleasure and relief of stress before or during unpleasant situations, but they are poor coping mechanisms and have unfortunate consequences. The influences of environment, of family and friends, are all important contributors toward the development and maintenance of these mal-adaptive patterns.

Regarding relapse, the model suggests that “a person headed toward a slip makes numerous small deci-sions over 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 Living in Balance approach to this process is to offer the client information about high-risk physical, social, and psychological situations and the potential impact of “small” decisions; to offer training in coping responses and training in stress-reduction strategies; and to guide clients down alternative paths to pleasure and other life satisfactions.

Living in Balance promotes relapse prevention by helping clients to:

• Identify situations that trigger cravings;

• Understand the chain of events, including “small decisions,” that leads 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;

• Work through recovery issues with written exercises.

How do drugs of abuse affect the brain?

Drugs of abuse act on nerve cells in the brain. Neurons process millions of messages that travel from one cell to another and create mental activity, generating perceptions, thoughts and feelings, and functions such as muscle movement. Drugs of abuse change the way messages are sent.

Out of the trillion cells in the human brain, 100 billion are neurons. Each neuron has sprouting from it dozens or even hundreds of thin branches called dendrites that connect to other neurons and collect chemical messages from them. Each neuron has a long tap root called an axon. Axons use electrical impulses and brain chemicals to send messages to other cells. Each cell sends and receives billions of mes-sages through the dendrites and its axon. An axon ends in branches with little knobs at the end of each branch. Each knob nearly connects to the dendrite of another neuron. (Some axons connect to muscle fibers or glands too.) The gap between a knob and a dendrite (or other cell part) is called a synapse. A sin-gle neuron might have thousands and thousands of synapse connections to other cells.

Brain messenger chemicals (neurotransmitters) work by ferrying messages across a synapse. When their job is done they typically return to the cell and are reabsorbed. Many drugs of abuse are active in the synapses. For instance, cocaine interferes with the action of a neurotransmitter and prevents it from being reabsorbed. Drugs of abuse have an effect on such neurotransmitters as norepinephrine, serotonin, and dopamine, a neurotransmitter associated with pleasure. Chronic use of drugs of abuse can make the levels of dopamine, norepinephrine, and serotonin out of balance. When neurochemicals are not in balance, such as when their levels are too low, people can experience depression, anxiety, agitation, and other neg-ative feelings.

How does Living in Balance affect the biology of substance use?

Relapse prevention techniques used in Living in Balance target the brain and seek to repattern and engage both higher and lower brain functions to prevent relapse. Images, such as those used in the program visu-alizations, and role-plays both activate older parts of the brain where drugs such as cocaine have been active. Learning thus is not confined to the strictly logical neocortex. Relaxation techniques can reduce stress hormones affecting the limbic system and increase the flow of blood to the brain.

Living in Balance also resuscitates the higher reasoning and logic that can be used to “outwit” the lower brain. It identifies situations that trigger cravings, for example, and develops plans to avoid them.

Can the Living in Balance program be used with different client groups?

Clients differ with regard to ethnicity, culture, sexual orientation, and gender. The question can be asked, “Should Living in Balance groups be designed to be specific to these characteristics, or should they be mixed?”

There is no simple answer to this question. It depends. Programs differ in relation to the types of clients treated. Programs located in predominantly African-American areas will treat a different group of clients than programs in predominantly Asian-American, Caucasian, or Hispanic areas. Programs that target spe-cific ethnic or racial groups are encouraged to supplement the sessions with culturally-specific materials, videos, exercises, and examples.

Programs that target services to gay men, lesbians, or other diverse clients will treat a different group of clients. Many programs in urban areas treat clients from several different ethnic, racial, and cultural back-grounds. Some programs have specialized tracks, such as tracks for violent men, incest survivors, and vic-tims of domestic violence.

There are circumstances where it may be best to have segregated treatment groups. For instance, addic-tion programs that provide specialized tracks for female incest survivors are likely to limit the group ther-apy and didactic education sessions to women only.