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IntroductionThe brief treatment approach for substance abuse and co-occurring disorders described in thisguide—Integrated Change Therapy (ICT) for Substance Abuse and Co-Occurring Disorders—is anew clinical approach that draws essential elements of brief treatment from multiple sources.Specific innovations in this new practice are influenced by Screening, Brief Intervention, andReferral to Treatment (SBIRT) models, integrated with motivational interviewing (MI),motivational enhancement therapy (MET), functional analysis, and cognitive behavioral therapy(CBT).A primary goal in creating this guide is to respond to the needs of the working clinician intoday’s changing service delivery environment, with particular attention to behavioral healthclinicians practicing in primary care settings. Students in social work, psychology, andcounseling represent an important target audience, which is the next generation SAMSHA isseeking to reach. ICT’s approach enables ease of adoption of this new clinical practice withoutlarge changes to existing programs and systems. ICT is currently being practiced by cliniciansworking in community health centers, community-based substance abuse and mental healthagencies, and a program serving soldiers of the Army National Guard. The informationpresented here should serve as a relevant and practical resource for use on a daily basis toprovide individualized, patient-centered treatment.The knowledge and practices presented here for delivery of ICT are derived from several bodiesof work on evidence-based brief treatment for substance abuse and co-occurring mentaldisorders. These works include recent accomplishments in brief treatment by the University ofConnecticut Health Center as part of the Connecticut SBIRT initiative (LETSPAY), the BriefTreatment Manual developed by the Massachusetts SBIRT initiative, and the Brief TreatmentManual developed by the Missouri SBIRT team. Each of these three organizations, funded bythe Substance Abuse and Mental Health Services Administration (SAMHSA), developedevidence-based brief treatment manuals for adults with substance use disorders. Thesedocuments build on foundational works in CBT, MI, and other previous works in treatingaddictions, including the following:Beck, J., & Aaron, A. T. (2011). Cognitive behavior therapy: Basics and beyond. (2nd ed.). NewYork, NY: Guilford Press.Carroll, K. M. (1998). A cognitive-behavioral approach: Treating cocaine addiction. Manual 1:Therapy Manuals for Drug Addiction Series. NIH Publication No. 94–4308. Rockville, MD:National Institute on Drug Abuse.Marlatt, G. A., Barrett, K., & Daley, D. C. (1999). Relapse prevention. In M. Galanter & H. D.Kleber (Eds.), The American Psychiatric Press textbook of substance abuse treatment (2nd ed.).Washington, DC: American Psychiatric Press.Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change (3rd ed.).New York, NY: Guilford Press.Integrated Change Therapy1

Sampl, S., & Kadden, R., (2001). Motivational enhancement therapy and cognitive behavioraltherapy for adolescent cannabis users: Five Sessions. Cannabis Youth Treatment Series, Vol. 1.Rockville, MD: Substance Abuse and Mental Health Services Administration.Steinberg, K. L., Roffman, R. A., Carroll, K. M., McRee, B., Babor, T. F., Miller, M., . . . & Stephens,R. (2005). Brief counseling for marijuana dependence: A manual for treating adults. HHSPublication No. (SMA) 05-4022. Rockville, MD: Center for Substance Abuse Treatment,Substance Abuse and Mental Health Services Administration.The following features should help make this guide practical for use:1. Across many evidence-based practices, clinical researchers have identified a commonset of practice elements (Chorpita, Daleiden, & Weisz, 2005; Chorpita & Regan, 2009),and some have proposed that our health care system focus on training anddisseminating these essential skills and/or more universal clinical interventions (Barlow,2008). This guide is informed by such research.2. As a measure of utility for the behavioral health workforce, the guide’s coreinterventions are designed to fit within conventional models of service and can spandiverse practice settings, such as general outpatient services embedded within primarycare settings, including federally qualified health centers (FQHCs), and generaloutpatient substance abuse or mental health settings.3. In consideration of the high rate of staff turnover in the behavioral health workforce,this guide can serve as a model rooted in evidence-based clinical skills and interventionsthat are easily transferable from one setting to another. The clinical sessions are clearlylaid out without being overly prescriptive or restrictive. The interventions are flexibleenough to be integrated into clinicians’ personal styles and creativity.The guide is organized into three main sections. The first provides a review of MI, MET, CBT, thepersonal reflective summary as a treatment tool, and some of the newest thinking on theprocesses of therapy. The second section describes 15 clinical sessions. Some sessions focus onengagement, building motivation, clarifying treatment priorities for the patient, and developinga patient-clinician agreement. Other sessions address skills training, effective and healthyreplacement activities, building personal awareness, developing specific skills to managecravings and urges to use substances, and managing distressing thoughts and emotions. Twosessions cover known beneficial strategies equally useful with all treatment approaches: (1) useof medications in support of treatment and recovery, and (2) engagement with self-help. Theformat of each session in this guide facilitates delivery of ICT according to a commonframework, while at the same time tailoring delivery of selected sessions to a patient’sindividual needs.The third section of the Guide provides a discussion of techniques and tools that supportadoption and sustained implementation of interventions with a focus on enhancing fidelity. Thetechniques include a discussion of proven strategies for enhancing clinical supervision toincrease competency in essential clinical skills. The tools will help clinicians learn andunderstand delivery of each session, facilitate specific session feedback, and reduce paperworkIntegrated Change Therapy2

burdens. Session handouts and forms, other supporting materials, and references appear at theend of the guide.Users of this guide are encouraged to first read it through and then use the session outlines andfidelity tools to support delivery of the interventions. Worksheets, handouts, and other supportmaterials appear in corresponding sections at the end of the guide and may be copied and usedas needed in sessions. Live and online trainings are available and recommended.Integrated Change Therapy3

Section 1. An Overview of Proven Toolsand Techniques for Brief TreatmentCurrent approaches to understanding the treatment of substance use and co-occurringdisorders are driven by empirical advances in neuroscience and behavioral research rather thanby theories alone. There is now good evidence that both biological factors and psychosocialexperiences influence the development and continuation of disorders. Contributing experiencesmay occur at home, at work, or in the community, and a stressor or risk factor may have a smallor profound effect, depending on individual differences. The following review of motivationalinterviewing (MI), motivational enhancement therapy (MET), personal reflective summary(PRS), and cognitive behavioral therapy (CBT) provides context for the treatment sessions andmethodology described later in this guide.Motivational Interviewing and Motivational Enhancement TherapyMI is an effective, evidence-based method for helping patients with a variety of health andbehavioral concerns. Motivational approaches, as developed by William Miller and StephenRollnick (2012), seek to foster the intrinsic drive people have for healing, positive change, andself-development. Since Miller and Rollnick’s original work was published in 1983, more than25,000 articles citing MI and 200 randomized clinical trials of MI have appeared in print. MI’sefficacy has been substantiated by several MI training research projects (Miller, Yahne, Moyers,Martinez, & Pirritano, 2004).MET is a structured intervention approach that uses MI techniques. MET interventions typicallyinvolve both a specific feedback discussion following screening and/or assessment and goalsetting interactions (planning). The descriptions of MET sessions in this guide include scriptsillustrating the effective use of MI techniques.Integrating motivational enhancement and cognitive behavioral skills building to elicitchange—how it works: Motivation enhancement is achieved by building rapport through reflectivediscussions, helping patients understand the pros and cons of use, and helping toestablish collaborative goals based on the patient’s needs. Motivational enhancement strategies assess and increase the patient’s readiness,willingness, and ability to change. The clinician’s first and primary task is to understand how to engage and collaboratewith the patient to build internal motivation. In cognitive behavioral therapy, substance use is viewed as an intrapersonal andinterpersonal issue, a relapsing and habitual disorder that can be successfullytreated. Through treatment, the patient learns to become aware of situations and emotionsand how to avoid, cope, and replace substance use to achieve wellness.Integrated Change Therapy4

MI categorizes helping interactions according to the following three styles: directing, guiding,and following (see figure 1). With a directing style, the helper provides information, instruction,and advice. This is in contrast to a following style, defined by listening, understandin

on Integrated Change Therapy, incorporating works developed by grantees of SAMHSA’s Screening, Brief Intervention, and Referral to Treatment (SBIRT) program. These State grantees are from Connecticut, Massachusetts, and Missouri. Other works in brief treatment, motivational interviewing, and cognitive beh