Section 2
Clinician Guidance for 16 Sessions of Integrated Cognitive Behavioral Therapy

Introduction

As a framework for treatment, this section provides detailed guidance to clinicians for delivering any or all of the included sessions. Each session is organized according to the following headings:

• Introduction to the session
• The patient's experience: what the patient learns (intended outcome)
• Clinician preparation for the session
• Session outline, steps
• Protocol with scripts (and sidebar tips; some appear in the appendices)
• Handouts (appearing in corresponding sections at end of guide)

Sessions 1–7 are viewed as core skills and may be completed by all patients. Session 1 supports engagement and developing a richer understanding of your patient's life. This session can aid both clinician and patient to gain a richer contextual understanding. Session 2 initiates the process of functional analysis to help the patient build situational awareness of internal and interpersonal factors affecting mental and substance use disorders and is used to individualize treatment strategies. Sessions 3–7 are universally beneficial and necessary skill‐training sessions for addressing SUD and behavioral health concerns. The clinician and patient may decide to target other sessions based on identified needs. While the model is flexible, the clinician should not assume that the patient has sole responsibility for deciding the number or sequence of sessions. Rather, the clinician should guide the course and plan for treatment with considerable input from the patient. The clinician must balance patient motivation and needs with clinical judgment when deciding on a reasonable duration of treatment for each patient.

We recommend that Sessions 1 and 2 are completed first and in order. These two sessions provide you (and your patient) valuable insights for setting priorities and for individualizing care. However, beyond that, we encourage you to sequence sessions based upon your patient’s need. For instance, early in treatment, some patients might benefit from mindfulness training and from working with self‐limiting thoughts. Also, we know that trauma is common in many patients; if your client seems easily triggered for a trauma response (e.g., heightened anxiety/panic), before Session 2, consider completing Session 7, which targets basic mindfulness to better manage uncomfortable affect.

Clinicians using the MI/MET and CBT approach are encouraged to integrate the skills and techniques Section 1 describes in detail. You are encouraged to undertake the following activities and to practice the skills outlined:

• Review relevant sections of the manual before each session.
• Develop and practice a natural style of conveying the material; avoid reading text to the patient or appearing overly didactic, dogmatic, or as though presenting a lecture. Practice helps you develop a more natural style.
• Maintain a motivational style; use open‐ended questions and reflections, and avoid a directive, resistance‐building style.
• Always provide a rationale for what you are doing. In this context, a patient rationale is describing why this activity is important to the patient.
• Encourage involvement and participation by the patient.
• If working with a patient of a different culture, review Enhancing Cultural Relevance in Clinical Practice. With humility, reinforce that your patient is the expert in their life.
• Allow time for practice and feedback.
• Build self‐efficacy; help the patient identify and acknowledge skills already in use.
• Avoid overwhelming the patient; present only one or two new skills per session.
• Remember to take a few minutes to review the between‐session exercises at the start of each session.
• Attend to shifts in the patient's motivation and readiness for change.
• Explain practice exercises carefully; probe for the patient's understanding.

Law of Thirds

ICBT is a structured treatment grounded in the “law of thirds.” Studies in psychotherapy have determined that most successful therapy sessions occur in three phases, known informally as the law of thirds (Carroll, 1996) or the 20/20/20 rule. The law of thirds describes the first third of the therapy session as engaging, building, or reestablishing rapport and reviewing progress since the last contact and between‐session practice activities. The second third is the core of that session's activity and addresses a particular skill to be introduced and practiced during the session. The final third summarizes what took place during the session, and the clinician and patient identify a real‐life practice opportunity and make a mutual commitment to practice the new skill in the coming week outside of the session (Figure 1).

Figure 1 Sample Therapy Sessions According to the Law of Thirds

First Third

The key goal of the First Third of the session is to connect and engage. Using the MI spirit is especially useful within this part of the session, which involves three key activities:

1. Establish and Strengthen Rapport. The clinician works to develop or strengthen rapport by using the MI spirit (compassion, acceptance, autonomy, evocation) and core MI skills (open‐ended questions, affirmations, reflections, summaries) while engaging the patient in non‐problem‐focused rapport building (i.e., exploring areas of their life not directly related to treatment).
2. Review Progress. This is the clinician's opportunity to identify and explore any changes in the patient's substance use, mental health, and related experiences since the previous session. The clinician asks the patient about what has gone well, what has not gone so well, changes they have made since the last session, and any other element of the patient's experience that is related to their identified challenges and treatment goals.

    Using the MI core skills of open‐ended questions, affirmations, reflections, and summaries allows the clinician to learn more about the patient's thoughts and feelings around what they think is going well or not so well and why. In addition, progress review serves as a feedback loop for the clinician to learn how the treatment to date is or is not working and the reasons for the treatment response (or lack thereof). Some clinicians may find it beneficial to structure their review of progress, using a tool that suggests key domains relevant to most patients, on an ongoing basis over the course of treatment. We provide an optional Review of Progress handout at the end of this chapter. The domains assessed include physical activity, sleep, diet, pleasurable activities, mastery activities, work/school, substance use, and mood states.

3. Review Between‐session Challenge. In addition to reviewing progress over the course of treatment, it is critical in the ICBT framework to directly review the progress of between‐session challenges. These give patients the opportunity to apply the awareness and skills they are learning in the sessions so they gain more confidence and practice applying the skills on their own in the real world. By reviewing the patient's application of newly learned skills, the clinician can reinforce the patient's efforts, explore how skill application worked or did not work, and support the patient in identifying how to best continue working toward that skill on an ongoing basis. Some patients will benefit from re‐training of the skill to maximize its utility for them.
   • It is imperative for the clinician to ensure the patient knows the importance of the between‐session challenges and is expected to report on the application of new skills in every session. When a between‐session challenge has not been completed, the clinician explores with the patient the barriers that led to that outcome. Common barriers include lack of motivation or perceived relevance of the skill, uncertainty about how to apply a newly learned skill, and external challenges outside of the patient's control (e.g., sudden crisis situation that takes priority, medical illness). The clinician continues to use the core MI skills and other MI tools (e.g., decisional balance) to explore motivation around skills application. Revisiting the rationale for the skill and its relevance to the patient can increase the patient's willingness and perceived importance to complete the between‐session challenge.
   • General troubleshooting can also be helpful to identify solutions to other barriers. By focusing attention on the review of between‐session challenges, the clinician reinforces the expectation of patient skills practice outside of the session. Where appropriate, the clinician can use a portion of the session to support the patient applying any missed between‐session challenges. For example, if a patient previously committed to making an assertive request to a colleague, the patient and clinician could role play a similar scenario to provide the patient an opportunity to practice and explore the outcome of their use of assertive communication.

Second Third

The key goal of the Second Third of the session is to transfer a new skill to the patient. It represents the core of a session's activity, when teaching and skill building occur. The Second...