Spiritual self-schema therapy

1. Introduction

Version followed: the 3-S+ Individual Therapy Counselor Treatment Manual (12 sessions, plus a separate HIV harm-reduction education session) by S. Kelly Avants and Arthur Margolin, Yale University School of Medicine, ©2003 with text citing studies to 2007, as posted free on the Yale Spiritual Self-Schema site, together with its 3-S+ Client Workbook. Where the earlier 8-session 3-S individual manual differs, this is noted. [source: Yale 3-S+ manual page; 3-S+ Theoretical foundation; 3-S and 3-S+ session overviews]

Spiritual Self-Schema (3-S) therapy is a manualised, skills-training individual therapy for people in treatment for drug addiction (originally heroin and cocaine users, many on methadone). It targets drug use, HIV risk behaviour and, in 3-S+, HIV medication adherence. It combines cognitive self-schema theory with Theravada Buddhist psychology, which it uses in a non-sectarian way as a framework. It does not aim to convert anyone to Buddhism and is presented as suitable for clients of any faith. [source: 3-S+ Theoretical foundation; 3-S+ Session 1]

Theory of change, as the authors put it: long addiction builds an elaborate, well-rehearsed, mostly negative "addict self" schema. Once activated, it runs drug seeking, needle sharing, unsafe sex and non-adherence on automatic pilot. The therapy builds a competing "spiritual self" schema from the client's own beliefs, defined as compassionate and committed to doing no harm. Repetition, cues and rehearsal make it the more accessible schema. The core loop is Identify (notice that the addict self is active), Interrupt (break its automaticity) and Refocus (activate the spiritual self). This loop is trained through the Buddhist "three trainings": mastery of the mind (samadhi), morality (sila) and wisdom (panna), taught through the Noble Eightfold Path. Spiritual qualities (paramis), described as "spiritual muscles", are strengthened one or two per week. The claim that clients have a "true" or "spiritual nature" is the model's own Buddhist-informed premise, not an established fact. [source: 3-S+ Theoretical foundation; 3-S+ Session 1]

2. Framework

Format. 12 weekly 60-minute individual sessions. An optional 12-session manual-guided group is available as adjunctive practice, not stand-alone treatment. The programme is designed to sit inside methadone maintenance or other addiction treatment, alongside case management and pharmacotherapy. Length can be adapted by varying didactic content, practice and discussion. The earlier 3-S individual version has 8 sessions and omits the HIV-specific sessions (medication mindfulness, stopping HIV, stigma, serenity). [source: 3-S+ Theoretical foundation; 3-S sessions overview; 3-S+ Session 1]

Phases (3-S+ individual). [source: 3-S+ Individual Session Topics and Format; 3-S+ Client Workbook]

Phase	Session and topic	Spiritual quality	New home practice (cumulative)
Introduction	1. Introduction to 3-S+ (addict self, spiritual self, paramis)	Strong determination	Self check-in 3x daily; daily 3-S stretch
Mastery of the mind	2. Right effort, mindfulness, concentration: breath meditation	Effort	Daily breath (anchor) meditation
	3. Addict self intrusions: Identify, Interrupt, Refocus	Equanimity	Affirmation or prayer to refocus
	4. Medication mindfulness (HIV care)	Gratitude	Medication mindfulness ritual
Morality	5. Preventing harm: right speech, action, livelihood (followed by the HIV/hepatitis education session)	Morality	Attend education session; craving and impermanence practice
	6. Everyday ethics	Loving kindness and tolerance	Metta in meditation and in conflict
	7. Stopping HIV (social responsibility)	Courage	Encourage at least one person to test
Wisdom	8. Filling the mind: right thinking, right view	Wisdom	Blueprint and Daily Plan
	9. Coping with stigma	Forgiveness	Ask forgiveness of one person and forgive one person
	10. Renouncing the addict self	Renunciation and generosity	Act "as if" you are the spiritual self
	11. Serenity and insight (grief, impermanence)	Serenity	Daily Serenity Prayer meditation
Termination	12. Maintaining the path	Truth	Contact one community resource

Fixed session format. (1) Welcome and renewal of commitment, with a timed 5-minute breath meditation from Session 3 onward. (2) Review of the previous session and the home practice, from Session 2. (3) New material in didactic and experiential segments. (4) Cumulative home-practice assignments. (5) Summary. (6) The 3-S stretch with that week's quality. (7) End and next appointment. [source: 3-S+ Individual Session Topics and Format]

Entry criteria. The client is in addiction treatment (in 3-S+, also HIV-positive), has completed detoxification where appropriate, and is medically stable. The client is not in precontemplation, is willing to examine the addict self, and is interested in developing a spiritual self-schema. Psychiatric screening comes first. The manual says the programme is not suitable for people with psychotic or dissociative disorders or other serious psychiatric illness. Dually diagnosed clients who are not excluded receive concurrent appropriate care and are referred if they deteriorate. It is not designed for clients who want only in-depth psychodynamic exploration. Before treatment, the authors used the Fetzer Brief Multidimensional Measure of Religiousness/Spirituality to identify beliefs compatible and incompatible with the model and to judge fit. (This is a licensed instrument; its items are not reproduced here.) [source: 3-S+ Theoretical foundation; 3-S Front matter disclaimer]

Moving between sessions. Sequencing is fixed rather than criterion-based. Each session assumes the previous skills and adds one cumulative assignment. The criteria the manual does state:

Review the prior session at the start of every session and summarise at the end (more fully if the client has cognitive impairment).
If extended hospitalisation interrupts treatment before 4 sessions are completed, restart at Session 1.
Daily meditation is built up in steps toward about 60 minutes a day by the end of treatment, adjusted to progress (the therapist and workbook texts differ on the starting length; see section 4).

Any further mastery check, such as requiring the client to demonstrate a technique before moving on, is [synthesis]. Fidelity: session-specific rating scales score therapist adherence and competence (0–4) and client mastery of concepts, and the authors recommend recording sessions. [source: 3-S+ Theoretical foundation; Session 3 and 4 manuals]

Therapist requirements. Experience delivering CBT to drug users (in 3-S+, to HIV-positive drug users) and an interest in spirituality. A personal daily practice of mindfulness, prayer or contemplation, plus a few minutes of metta (loving-kindness) directed toward the client before each session. Working knowledge of HIV regimens and of local disclosure and partner-notification law. Training: over 17 hours of free DVD training, then supervisor-rated mock sessions, a quiz on theory, and supervised cases. Someone other than the 3-S therapist should collect urine screens and record infractions. [source: 3-S+ Theoretical foundation]

3. Guiding principles

[source: 3-S+ Theoretical foundation; 3-S+ Session 1; Session 3 and 4 manuals, unless marked]

Therapist as coach. You assign exercises, push for daily practice and reflect back which self is active. Practically: be warm but expect practice, like a trainer. The manual phrases it as a coach, not a "critic or cop".
Teach and model actively. Unlike motivational enhancement, the therapist teaches and demonstrates each method, and meditates with the client. Practically: show, then have the client do it in the room.
All faiths, no proselytising. Buddhist concepts are a shared, faith-neutral language. Practically: record the client's beliefs and practices in Session 1 and translate every tool (prayer, chant, object, destination) into the client's tradition. No religious faith is required.
Tailor to compassionate, not punitive, beliefs. Practically: assess whether the client's religious images are compassionate or punishing (e.g. HIV as God's punishment) and gently explore and reframe punitive ones, because the authors hold that these activate the addict self and "ought" self.
The addict self is a habit, not the person. Practically: always use distancing language ("the addict self is active") and never call the client an addict.
Empathy without confrontation. Practically: point out addict-self thinking gently, and avoid triggering it with drug talk or arguing.
Stay in the present and recent past. Practically: do not explore trauma or past negative events in session. This is a skills programme.
Intrusions and lapses are expected, not failures. The only failure is not noticing. Practically: greet lapses, missed homework and missed sessions as evidence of addict-self activity to be analysed, without moral judgement.
Predict sabotage in advance. Practically: in Session 3, list with the client how the addict self will undermine treatment, and agree that you will name it when it happens.
Experiential, not talk-only. Practically: every session includes practice (meditation, role-play, ritual, stretch), and new skills are rehearsed against the client's real high-risk situations.
Reinforce the emerging spiritual self at every opportunity. The client's environment mostly reinforces the addict self. Practically: name each quality you see ("that took determination"), even when attending the session is the only one.
Cumulative, embedded practice. Practically: most assignments change how routine tasks are done rather than adding time, and each week adds one assignment.
Do no harm to self or others is the foundation. Practically: frame abstinence, HIV prevention, partner notification and adherence as expressions of the client's own spiritual commitment, and follow the law on disclosure and reporting.
Meet practical needs. Practically: refer for housing, employment and medical care, and keep urine monitoring with another staff member to protect the coaching alliance.
Therapist's own practice. Practically: keep a daily contemplative practice and do brief metta for the client before each session.

4. Intervention inventory

Order follows the 12 sessions. Steps are paraphrased from the therapist manual for Sessions 1, 3 and 4, and from the Theoretical foundation text. For Sessions 2 and 5–12, the therapist session files are not drawn on, so steps come from the 3-S+ Client Workbook (client-facing) and the theory text. Steps there are thinner and marked [uncertain] where the therapist procedure is unknown. All example language is illustrative unless quoted with a source.

Session 1 — Introduction (quality: strong determination)

4.1 Commitment to My Spiritual Path (signed commitment)

Purpose / when: First segment of Session 1. It secures commitment to the therapy and to practice, and is renewed at the start of every later session. [source: 3-S+ Session 1]
Steps:
1. Confirm the client's sincere interest in spiritual development.
2. Present the worksheet's three commitments, in paraphrase: to strengthen and use a spiritual path in recovery; to do no harm to self or others; to practise diligently in and between sessions with determination and effort.
3. Read them aloud, have the client sign and date, and congratulate them.
4. Insert the signed sheet at the front of the client journal.
5. Later, suggest keeping it somewhere visible and rereading it, especially when practice lapses.
Example language (illustrative): "Before we start, I'd like us to make this official. These three commitments are what the work rests on. Read them with me, and sign if they fit for you."
Watch for: hesitation about "do no harm" (current risk behaviour) or about the word "spiritual". Explore the hesitation rather than pushing a signature. It is working when the client refers back to the commitment unprompted. [synthesis for the last two points]

4.2 Orientation and assessment of beliefs; establishing the coaching role

Purpose / when: Session 1, segment 2. It establishes that the therapy is for all faiths and tailored to the client, and gathers the information used to tailor every later tool. [source: 3-S+ Session 1; 3-S+ Theoretical foundation]
Steps:
1. Ask about the client's spiritual or religious beliefs and practices, past and present, and record them in the chart.
2. Explain that their spiritual path may be overgrown from drug use but is still there.
3. Explain the coaching role: assigning exercises, encouraging practice, and reflecting back whether the addict self or the spiritual self is operating.
4. State that no faith will be imposed.
5. Clarify expectations and personal goals, and check that the model fits the client's capacities.
6. If the client sees a conflict with their beliefs, tailor the approach together.
7. Note whether religious images are compassionate or punitive.
Example language: manual wording includes "3-S therapy is for people of all faiths." and "You can think of me as your coach." [source: 3-S+ Session 1]. Illustrative: "Whatever your path is, Christian, Muslim, something else or none you'd name, we'll use your language for it."
Watch for: punitive beliefs (illness as punishment), discomfort with Buddhist terms, or no belief system at all. With a client who has no religious frame, the authors' sources do not say how to proceed. See section 5.

4.3 Characterising and distancing from the addict self

Purpose / when: Session 1, segment 3. It builds the self-schema concept and creates psychological distance from the "addict" label. The resulting list also serves as a baseline for self-schema assessment. [source: 3-S+ Session 1; 3-S+ Theoretical foundation]
Steps:
1. Ask whether the client has been called, or called themselves, an "addict".
2. Have the client list characteristics of an addict while actively using (prompt with words such as selfish, desperate or risk-taking if needed). Ask whether these described them when using, and write the list down.
3. Link the addict self to suffering, including in 3-S+ the double burden and stigma of HIV and addiction.
4. Frame it as an automatic pilot with a one-track mind that was created to relieve pain but caused more, and that is not who the client really is.
5. Stay with the present and recent past. Express empathy, do not confront, and avoid drug talk that activates craving.
Example language: manual phrase: "The addict self is just a habit pattern of the mind." [source: 3-S+ Session 1]. Illustrative: "When the auto-pilot is running, what does it make you do that you wouldn't choose?"
Watch for: shame spirals, or the client concluding "that's who I really am". Return to the habit framing. It is working when the client starts saying "the addict self" rather than "I".

4.4 Introducing the spiritual qualities (paramis, "spiritual muscles")

Purpose / when: Session 1, segment 5, then one or two qualities each week. The qualities are framed as already present in the client but weakened by addiction. 3-S+ lists 14: generosity, morality, renunciation, wisdom, effort, tolerance, truth, strong determination, loving kindness, equanimity, gratitude, courage, forgiveness and serenity. The 8-session 3-S overview refers to 10 qualities. [source: 3-S+ Session 1; 3-S sessions overview]
Steps:
1. Briefly review the list in the workbook and define unfamiliar terms.
2. Explain that the qualities are to be uncovered and strengthened, not acquired.
3. Assign the week's quality. In Session 1 this is strong determination, which you point out the client is already showing by attending.
Example language: manual phrase: "It is already clear to me that you have that quality." [source: 3-S+ Session 1]
Watch for: the client dismissing the qualities as not applying to them. Find concrete behavioural evidence from the week.

4.5 Resistance-training role-play ("spiritual gym")

Purpose / when: Session 1, segment 6, used again in later sessions. The client experiences and labels the spiritual muscles in action. The manual says this is not primarily a drug-refusal drill, though it may also serve that purpose. [source: 3-S+ Session 1]
Steps:
1. Beforehand, learn the client's drug of choice, usual context of use, a high-risk situation and a person linked to past use.
2. Explain the gym metaphor: resistance builds spiritual muscles as weights build physical ones.
3. Tell the client to do and say anything to resist.
4. Play a persuasive using associate, with a name, for about 3–5 minutes.
5. Applaud the effort.
6. Debrief: did the client notice addict-self thoughts or feelings, and which qualities did they use? Name them together (e.g. determination, effort, renunciation, equanimity, truth).
7. Ask the client to use these qualities in high-risk situations this week.
Example language (illustrative): "I'm going to be 'Ray', someone you used with. Do whatever it takes to stay on your path... Okay, let's stop. Which muscles did you just use?"
Watch for: cue-induced craving after the role-play. Check craving level before closing and use the anchor if needed [synthesis]. Keep the setting safe and supportive throughout. [source: 3-S+ Session 1]

4.6 Self check-in (three times daily)

Purpose / when: Assigned from Session 1 and continued throughout. Builds awareness of which schema is active, the precondition for change. In Session 3 it becomes component-specific (checking for particular feelings, thoughts or behaviours). [source: 3-S+ Session 1; Session 3 manual]
Steps:
1. Choose an everyday cue that will catch the client by surprise (e.g. a phone ringing; in Session 4, medication times).
2. At least three times a day, pause and notice whether the addict self or the spiritual self is active. In Session 1, observe only and change nothing.
3. Record the cue in the journal and the therapist file, and review it next session.
4. If check-ins are forgotten, change the cue.
Example language (illustrative): "When the phone rings, before you answer, ask: which self is running right now? Just notice. No need to fix anything yet."
Watch for: check-ins becoming mechanical. Vary the cue. It is working when the client reports catching the addict self earlier. In the published case report, a client named the daily log of distinguishing the two selves as the most helpful element. [source: 3-S+ Theoretical foundation]

4.7 The 3-S (spiritual) stretch

Purpose / when: Ends every session and is practised daily, in the morning and in later sessions also at bedtime. It is a physical and verbal affirmation of commitment, and a reminder that spiritual practice covers bodily action too. [source: 3-S+ Session 1; Session 3 and 4 manuals; 3-S+ Client Workbook]
Steps:
1. Stand with the client and perform the stretch slowly together, using the posture sequence diagrammed in the manual appendix and the workbook.
2. At each posture, speak an affirmation of the week's quality across thoughts, words, emotions, actions and perceptions (and openness), closing with an affirmation that the client is their spiritual nature.
3. Have the client repeat each phrase after you until familiar, and correct mistakes gently.
4. Assign it daily, on waking. If it is forgotten, show the diagram again or suggest involving a family member.
Posture details: in the appendix ("3-S+ Stretch Diagram"), which is not drawn on [uncertain]. Do not improvise postures for clients with mobility limits without adapting them [synthesis].
Example language (illustrative): "May my thoughts be filled with [this week's quality]" (structure only; use the manual's own phrasing).
Watch for: awkwardness. The manual suggests asking the client to notice what arises when raising open arms and speaking of openness, and contrasting this with the closed, guarded feel of the addict self. [source: 3-S+ Session 1]

4.8 Home-practice set-up and the 3-S Journal (client workbook)

Purpose / when: End of every session. Assignments are cumulative, so by the last session the client practises all of them. [source: 3-S+ Session 1; 3-S+ Individual Session Topics and Format]
Steps:
1. Give the client workbook (session summaries, assignments, worksheets, journal pages), and keep a spare copy in the office. Do not require the client to bring it.
2. State each new assignment, link it to the week's quality, and ask for explicit commitment.
3. Do not overload: emphasise the newest one or two.
4. Next session, check each assignment as a coach. Credit any practice as determination and effort, treat non-practice as addict-self activity, and solve the specific barrier.
Example language: manual phrase: "Walking a spiritual path means walking it every moment." [source: 3-S+ Session 1]
Watch for: literacy limits. Modify verbal presentation and pacing. [source: 3-S+ Theoretical foundation]

4.9 Session summary

Purpose / when: Penultimate segment of every session. It consolidates learning and is extended for clients with cognitive impairment. [source: 3-S+ Theoretical foundation; Session 1, 3 and 4 manuals]
Steps: restate the session's key concepts (e.g. in Session 3: intrusions are expected; identify, interrupt, refocus; equanimity restores balance) and the new practice. Reassure the client that they need not remember everything at once.
Watch for: comprehension. Ask the client to restate the key points in their own words [synthesis].

Sessions 2–4 — Mastery of the mind

4.10 Anchored breath meditation (anapanasati)

Purpose / when: Taught in Session 2 and practised as a timed 5-minute meditation at the start of every session from Session 3, plus daily at home. Develops effort, mindfulness and concentration, and an "anchor" in emotional storms. [source: Session 3 and 4 manuals; 3-S+ Client Workbook]
Steps:
1. Time 5 minutes and meditate alongside the client.
2. Posture: sit upright, feet flat, hands in lap, eyes closed if comfortable.
3. Breathe normally through the nose without controlling the breath. Attend to sensations at the anchor (around the nostrils and above the upper lip): tingling, warmth, coolness, pressure, long or short breaths.
4. When the mind wanders, silently note that it wandered and return gently to the anchor.
5. Debrief: did the client feel the sensations and return each time? Correct misunderstandings.
6. Troubleshooting:
  - Sensations hard to feel: widen the focus to inside the nostrils and the top of the nose. If sensations fade, take one or two short, sharp breaths, then resume normal breathing.
  - Constant wandering: normalise it as early insight into "monkey mind". Offer the image of firmly but gently guiding a child away from harm. Offer "one breath at a time", or counting each out-breath up to ten, restarting at one if the mind wanders, then dropping the count after ten. Practise ten breaths together. Counting is a tool, not the goal.
7. Session 2 also includes a guided visualisation of using the anchor during an upcoming stressor, and choosing a daily meditation place. [source: 3-S+ Theoretical foundation]
Home dose of practice: the therapist manual (Sessions 3–4) assigns about 15 minutes daily, increasing by 5–10 minutes per session toward 60 minutes daily by the end of treatment. The client workbook says at least 10 minutes, increasing by 5 per week. [uncertain: the versions differ; follow the therapist manual and adjust to the client]
Example language (illustrative): "Let the breath breathe itself. Feel it just at the rim of the nostrils... and when you notice you've drifted, that noticing is the practice. Come back."
Watch for: distress, dissociation, panic, intrusive memories or depersonalisation during sitting. These are documented meditation adverse effects, but the 3-S sources do not discuss them [synthesis]. See section 5. It is working when the client can return to the anchor and uses it spontaneously under stress.

4.11 Identify: breaking the addict self into its parts

Purpose / when: Session 3, segment 1 (quality: equanimity). Maps the feelings, thought scripts and behaviours (action plans) that make up the addict self. The authors describe these as a chain reaction: activating one component activates the rest. [source: Session 3 manual]
Steps:
1. Frame intrusions (a sudden urge or thought of using in the middle of something else) as expected at this stage. The only failure is not noticing.
2. Ask for a recent intrusion and trace it backwards: the emotion beforehand (e.g. boredom), the thought script (e.g. a "deserve a little excitement" line), then the behaviours (isolating, seeing using peers).
3. The client dictates while you write on the Session 3 worksheet.
4. Show how the components are bundled, so that interrupting any one can stop the chain.
5. Link this to mindfulness as the means of early detection.
Example language (illustrative): "Let's slow the film down. Before the thought of using, what were you feeling? And just before that?"
Watch for: denial that intrusions happen, or difficulty naming thoughts. Use the worksheet list, normalise, and stay with concrete recent examples. Counter the client's conclusion "this is who I really am". [source: Session 3 manual]

4.12 Anticipating sabotage

Purpose / when: Session 3, segment 1. Turns predictable non-adherence into something the client and therapist expect and catch together. [source: Session 3 manual; 3-S+ Theoretical foundation]
Steps:
1. Ask what the two of you should be prepared for.
2. Work through the worksheet checklist: missed sessions; missed methadone doses, counselling or urine tests; denying or minimising use or harm; isolating; high-risk people, places and activities.
3. Add the client's personal items.
4. Agree that you will flag sabotage when you see it, framed as an addict-self intrusion.
Example language (illustrative): "If the addict self wanted to get you out of this programme, how would it go about it?"
Watch for: it is working when, later, the client names a missed session as "the addict self" without shame.

4.13 Interrupt: changing routine

Purpose / when: Session 3, segment 2. Uses a small, harmless change in a frequent habit to break automaticity and trigger a check-in. [source: Session 3 manual]
Steps:
1. Explain the idea.
2. Choose one or more routine changes, e.g. moving a watch to the other wrist, a different route home, switching chairs, moving the coffee pot, an hourly alarm.
3. Each time the changed routine jolts attention, do a check-in.
4. Rotate the routines over time as they become automatic.
Example language (illustrative): "Every time you glance at the wrong wrist and the watch isn't there, let that be your bell: which self is on?"
Watch for: the cue losing its surprise. Rotate it.

4.14 Interrupt: thought stopping (guided demonstration)

Purpose / when: Session 3, segment 2. Demonstrates that addict-self thinking can be interrupted. [source: Session 3 manual]
Steps (as the manual describes):
1. The client sits upright, eyes closed, and you guide them to relive their last intrusion, inserting the feelings and thoughts they identified.
2. Without warning, you strike the table and say "Stop" loudly.
3. Ask whether they are still thinking about drugs. Usually they are not, which shows that interruption is possible.
4. Practise: the client silently says "stop" at the first warning sign. Repeat the visualisation as needed, and confirm they can use it in daily life and during check-ins.
Safety (synthesis):
- The unannounced loud startle can be frightening for clients with trauma histories, PTSD, hyperarousal or violent pasts.
- Ask permission and describe the exercise first; for these clients, use a softer cue or skip the loud demonstration and teach the silent version directly.
- Thought stopping is less favoured in current CBT because of rebound concerns about thought suppression. Pair it immediately with refocusing (4.17), as the manual does, rather than using it alone. [synthesis]
Example language (illustrative): after the demonstration: "Where did the craving thought go just then? That's what we're training: a firm inner 'stop', then straight to your anchor or your prayer."
Watch for: startle distress, or the guided recall raising craving. Check craving afterwards and close with the anchor [synthesis].

4.15 Interrupt: observe and name

Purpose / when: Session 3, segment 2. Creates distance from feelings and thoughts by labelling them without "I". It is also the first step of the craving practice in 4.24. [source: Session 3 manual]
Steps:
1. When a feeling or thought arises, silently name it ("anger", "boredom", "craving is here") rather than "I am angry". The emphasis is on no "I", "me" or "mine".
2. Acknowledge that this feels strange, and explain that it is an ancient practice.
3. Demonstrate with the same guided recall as in 4.14, naming instead of stopping.
4. Ask the client to demonstrate it, and ask for a commitment to daily use.
Example language (illustrative): "Instead of 'I'm so bored', just: 'boredom... boredom is here'. Watch what it does."
Watch for: confusion about the no-self framing. Keep it practical and do not argue philosophy [synthesis]. It is working when the client reports feelings passing without action.

4.16 Self check-in, component-specific version

Purpose / when: Session 3. The Session 1 check-in now looks for the specific feelings, thoughts and behaviours mapped in 4.11. Confirm the client knows the difference between the general and the specific check-in. [source: Session 3 manual]

4.17 Refocus: the "arsenal" (prayer or affirmation, song, object, anchor)

Purpose / when: Session 3, segment 3. Interrupting is not enough. The client must immediately activate something incompatible with drug use. [source: Session 3 manual; 3-S+ Client Workbook]
Steps:
1. Prayer, mantra or affirmation. It should be short, memorable, personally meaningful and consistent with the client's tradition. The manual's own example is an affirmation that the client is not the addict self but their spiritual nature. Its faith examples include a short Christian prayer formula, a Muslim phrase of submission to God's will, and a plea to God for strength. Write it on the worksheet and the workbook. The client copies it onto 5–10 index cards for home, car and work, and you write the first card together.
2. Song, hymn or chant. The client chooses one to hum softly after interrupting, which blocks the addict self's "voice" much as a child hums to block out a voice. The client may set their affirmation to a melody. Record the title only.
3. Spiritual object. A small item kept in view or carried, e.g. a religious image, jewellery, a photo of a loved one, a picture of nature.
4. Anchor. Return to the breath at the nostrils.
5. Introduce equanimity ("a calm and balanced mind") as what each tool should restore.
Example language (illustrative): "Stop, then straight away: your words. Say them now so we know they work under pressure."
Watch for: generic affirmations the client does not believe. Rework them in the client's own words. It is working when the client can describe a real intrusion that ended with the refocus.

4.18 "The whole earth is medicine": four elements and mindful handling of natural objects

Purpose / when: Session 3, segment 4 (experiential). Develops equanimity and mindfulness, and models healthy "self-medication" from nature in place of drugs. [source: Session 3 manual]
Steps:
1. Explain that drug use is self-medication that ultimately worsens pain and narrows attention.
2. Introduce the Zen saying the manual cites: "The Whole Earth is Medicine."
3. Discuss earth, water, air and fire as sources of support around and within us: nature, food and people; listening to water when agitated; breath, sky and clouds; sun, moon, stars and vital energy when tired.
4. Use the example of absorption in a sunset as a moment without "me".
5. Hand the client rocks, shells, feathers or leaves one at a time to explore mindfully (texture, weight), and ask whether their equanimity changed.
6. Homework: collect small natural objects for home or work as refocusing cues.
Example language (illustrative): "Take your time with this shell. Notice the weight, the ridges, the cool. Just this."
Watch for: the client calling it silly. The manual suggests acknowledging that the addict self may ridicule it and inviting the spiritual self's view. [source: Session 3 manual]

4.19 HIV and treatment education with adherence assessment (3-S+)

Purpose / when: Session 4, segment 1 (quality: gratitude). Opens a dialogue linking spiritual well-being to medical care, and assesses adherence. [source: Session 4 manual]
Steps:
1. Cover how HIV affects the immune system, the meaning of viral load and CD4 count, that treatment controls but does not cure, why missed doses breed resistant virus, and superinfection.
2. If the client is prescribed medication, ask about each medicine's name and purpose, doses and timing, food requirements, memory aids, side effects and coping, when doses are missed, the hardest part of the regimen, beliefs about medication, and the latest CD4 and viral load. Inability to answer suggests poor adherence.
3. If not prescribed, confirm there is an HIV specialist, regular visits and a known next appointment, and refer if needed.
Currency warning (synthesis): the manual's medical content dates from about 2003–2007 (e.g. a 90–95% adherence threshold, and the statement that undetectable viral load does not mean transmission is impossible). Current guidance has changed, notably undetectable = untransmittable for sexual transmission and newer regimens and testing windows. Update this content from current national HIV guidance or the client's HIV team before teaching it. [uncertain]
Watch for: do not give individual medical advice. Refer questions to the prescriber. [source: Session 4 manual]

4.20 The addict self versus the spiritual self in medical care

Purpose / when: Session 4, segment 2. HIV-related stress can activate the addict self, which wants immediate gratification and avoids side effects. [source: Session 4 manual]
Steps:
1. Contrast how each self views medical recommendations.
2. Ask how the addict self has interfered or could interfere (stopping medication, using to cope with side effects, missing appointments).
3. Pick one specific recommendation and analyse the sabotage.
Example language (illustrative): "What would the addict self say about the 8 pm dose? And what would your spiritual self say?"

4.21 Medication mindfulness ritual (3-S+)

Purpose / when: Session 4, segment 3, then at every dose. Uses mindfulness to take medication exactly as prescribed. Clients without prescriptions apply it to other medicines or a vitamin. [source: Session 4 manual; 3-S+ Client Workbook]
Steps (co-create so it is personally meaningful):
1. Self check-in: which self is active?
2. A brief ritual from the client's own tradition: a short prayer, a candle, a bowed head, or five breaths on the anchor.
3. Count the pills out and lay them in front of you, never directly from the bottle, to keep track. Fill pill organisers mindfully too.
4. Notice the weight of the bottle and the colour, shape and texture of each pill.
5. Notice the sensations of swallowing.
6. Give thanks for the medication and for the chance to train the mind.
Example language (illustrative): "Let's design your version. What would make this moment feel like part of your path rather than a chore?"
Watch for: missed doses at particular times. Make medication times the check-in cue. It is working when self-reported missed doses fall; confirm with the medical team.

4.22 Coping with side effects, high-risk reminders and talking with providers

Purpose / when: Session 4, segment 3. [source: Session 4 manual]
Steps:
1. Side effects: always report them to the provider. If they must be tolerated, use observe and name. Investigate the sensation (where it starts and ends, hot or cold, sharp or dull), see that it is made of smaller sensations arising and passing, rest in equanimity, and use a short phrase such as "this too shall pass".
2. High-risk moments (possible drug use, unsafe sex, shared equipment): remind oneself of the risk of reinfection or infecting others, and that substances work against the medication.
3. Provider communication: prepare questions; be concise and clear; check the provider understood; listen, take notes and ask for repetition or written information; summarise back; use eye contact and engaged posture. Contrast this with how the addict self deals with providers.
Watch for: sensation-focus increasing distress in clients with health anxiety. Switch to the anchor or an external focus [synthesis].

4.23 Adherence scenario rehearsal or provider role-play (resistance training)

Purpose / when: Session 4, segment 4. Rehearses adherence as exercise for spiritual muscles such as gratitude, effort and asking for help. [source: Session 4 manual]
Steps:
1. Pick the scenario most relevant to the client. The manual's three: an all-day court appearance with a dose that must be taken with food; doses forgotten while at the methadone clinic; an overnight stay at a friend's who does not know the client's status, with medication needing refrigeration.
2. The client describes a plan and how the spiritual self helps.
3. Coach with questions about access, memory aids, pre-filled organisers, food, disclosure or enlisting help, and realism, then give feedback on feasibility.
4. If the client is not on medication, role-play their next appointment, with you as the provider (giving no medical advice) and the client practising mindful communication.
5. Name the muscles used.
Example language (illustrative): "You're at court from 8 till 5 and the pill needs food. Walk me through your day."

Sessions 5–7 — Morality

4.24 Right speech, action and livelihood; craving practice ("stare down the craving monster")

Purpose / when: Session 5 (quality: morality). Introduces doing no harm through speech, action and livelihood. The theory text describes identifying "addict speech", "addict behaviour" and "addict livelihood" (e.g. dealing or other crime), and mindful action versus automatic reaction. Includes the craving practice. [source: 3-S+ Theoretical foundation; 3-S+ Client Workbook] Therapist steps are not drawn on [uncertain].
Steps (from the workbook and theory):
1. Identify the client's addict speech, actions and livelihood and the harm each causes to self and others, and the spiritual-self alternative.
2. Craving practice: when craving arises, acknowledge it ("craving has arisen"). Investigate its bodily sensations (temperature, pressure, pain, location). Keep observing more closely until the sensations break up, dissolve and pass. Recall that craving is impermanent: "starve, don't feed" it, and "this too shall pass".
3. In session, the workbook's exercise examines craving "as if under a microscope", watching sensations arise and pass.
Example language (illustrative): "Where is the craving right now: chest, throat, hands? What's its temperature? Stay with it like a scientist... notice it's already changing."
Watch for: craving escalating rather than passing. Stop, anchor, and use the refocus tools. Do not do this exercise at the end of a session without settling [synthesis]. It is working when the client reports urges peaking and fading without use.

4.25 HIV, hepatitis and STD harm-reduction education session

Purpose / when: A separate educational session scheduled immediately after Session 5 (Session 4 in the 8-session 3-S), attended mindfully as homework. It has its own text and illustrations on the Yale site, which are not drawn on, so its content is [uncertain]. Use current harm-reduction guidance and local services (testing, needle and syringe programmes, PrEP/PEP, hepatitis C treatment) [synthesis]. [source: 3-S+ Individual Session Topics and Format; Yale 3-S+ manual page]

4.26 Everyday ethics and metta (loving-kindness) meditation

Purpose / when: Session 6 (quality: loving kindness and tolerance). Applies ethics to daily speech, action and livelihood. Metta replaces the repetitive harmful "background music of the mind" with compassionate repetition, and is also used to defuse conflict. [source: 3-S+ Client Workbook] Therapist steps are not drawn on [uncertain].
Didactic points (workbook): anger harms the angry person first, then others; "you are heir to your actions"; compassion for oneself comes before compassion for others; all beings want happiness and freedom from suffering.
Steps (workbook practice):
1. After breath meditation, imagine the body filled with love and compassion.
2. Bring to mind that all beings want to be happy.
3. Repeat three times a wish that oneself be happy and free from suffering, and all beings too.
4. Then extend the wish to a neutral person, then to others and people around the world, by name, three times each.
5. Home practice: add metta to daily meditation, and repeat a metta phrase silently during a negative encounter until the emotion passes.
Example language (illustrative): "Start with yourself, which can be the hardest. 'May I be happy. May I be free from suffering.' Notice any resistance and keep going gently."
Watch for: self-directed metta triggering shame or grief. Start with a neutral person and return to self later [synthesis]. Do not ask clients to direct metta at an abuser [synthesis].

4.27 Stopping HIV: social responsibility (3-S+)

Purpose / when: Session 7 (quality: courage). Personal responsibility for preventing transmission. [source: 3-S+ Client Workbook; 3-S+ Theoretical foundation]
Steps (workbook):
1. Teach the routes of transmission.
2. Invite a personal commitment that no one will get HIV from the client.
3. Discuss ways to keep it: being alert to the addict self as the spreader; bearing witness and telling one's story; notifying drug and sexual partners; advocating testing; sharing prevention knowledge.
4. In-session exercise: bearing witness to HIV-related suffering and practising encouraging someone to test, plus metta.
5. Homework: encourage at least one person to get tested.
Legal: follow federal, state and local disclosure and partner-notification law. [source: 3-S+ Theoretical foundation] Disclosure carries real risks (violence, rejection, legal exposure in some jurisdictions). Plan disclosure safety with the client and use public-health partner-notification services where available [synthesis].
Currency: the workbook's six-month testing window is outdated for current tests. Use current testing guidance [uncertain].
Example language (illustrative): "Who in your life would you most want to get tested? Let's practise what you'd say."

Sessions 8–11 — Wisdom

4.28 Blueprint for constructing a spiritual path

Purpose / when: Session 8 (quality: wisdom), on right thinking (intention) and right view. Makes the spiritual self concrete. [source: 3-S+ Client Workbook] The theory text does not describe the blueprint [uncertain re therapist procedure].
Steps (workbook worksheet):
1. Name the ultimate destination in the client's own terms (e.g. union with God, heaven, nirvana, enlightenment).
2. Foundation = morality.
3. Building materials = chosen spiritual qualities.
4. Traffic lanes = habitual scripts (affirmations, prayers, metta, songs) and action plans (meditation building toward 60 minutes, the stretch once or twice daily, optional yoga or tai chi, harm reduction, adherence, acts of kindness).
5. On-ramps = sensory cues in each sense (e.g. a magnet with a question about identity, chimes, a scent, a flavoured tea, prayer beads).
Example language (illustrative): "If your spiritual self were a road you travelled every day, what would it be paved with, and where are the on-ramps?"

4.29 Daily Plan for filling the mind with the spiritual self

Purpose / when: Session 8 and onward. Saturates the day with spiritual-self cues so that this schema becomes the most accessible. [source: 3-S+ Client Workbook; 3-S+ Theoretical foundation]
Steps:
1. Build a written schedule with the client:
  - On waking: recite a script, renew the commitment, a mirror note, a spiritual song while washing, a scent cue while dressing.
  - Morning: meditation with metta, the stretch, the medication ritual, a mindful breakfast with thanks, an inspirational recording while travelling.
  - Daytime: mindful work, forgiveness, encouraging testing, frequent check-ins and interruptions, the anchor, "this too shall pass", accepting what cannot be controlled, reciting scripts with breath or steps in spare moments, noticing nature.
  - Evening: medication ritual, mindful meal, entertainment compatible with the spiritual self, observing cravings.
  - Bedtime: the stretch, gratitude review, prayer or meditation.
2. The theory text adds: write short affirmations together and repeat them through the day, cued by the watch on the non-usual wrist. Express them artistically (music, chant, poetry, colour, shape). Look for their themes in the environment. Use mantras, mandalas, rosaries or bells as cues.
3. Review and revise the plan weekly.
Watch for: an overly ambitious plan. Start with three or four anchor points and add more [synthesis].

4.30 Coping with stigma: "this is not me; this is not mine" (3-S+)

Purpose / when: Session 9 (quality: forgiveness). The authors hold that internalised dual stigma (HIV plus addiction) can become self-fulfilling and activate the addict self. [source: 3-S+ Client Workbook; 3-S+ Theoretical foundation]
Steps (workbook):
1. Discuss stigma and dual stigma.
2. Right view: how others see you through stigma is not your true nature. The client recites the maxim given in this heading.
3. Right thinking: take responsibility; make amends and ask forgiveness without expecting it, then move on; if harmed, forgive and move on. The workbook's maxim is that hatred harms the hater most.
Example language (illustrative): "When that look comes from the pharmacist, what could you say inside yourself?"

4.31 Forgiveness practice

Purpose / when: Session 9. Avoids a cycle of hatred that the authors hold activates the addict self. [source: 3-S+ Client Workbook; 3-S+ Theoretical foundation]
Steps:
1. Practise asking for and offering forgiveness in session (role-play).
2. Homework: ask forgiveness of at least one person the client harmed, and forgive at least one person who harmed them.
Watch for (synthesis): forgiveness of abusers must never be pressed. Contacting an abuser or a person harmed can be unsafe. Agree that "forgiving" can be private and need not include contact, reconciliation or excusing harm. Screen amends for risks to others and for legal implications.

4.32 Visualisation: fading the addict self, sharpening the spiritual self

Purpose / when: Described in the theory text for Session 10 (the workbook's Session 10 instead emphasises renunciation and acting "as if"; the versions differ) [uncertain]. [source: 3-S+ Theoretical foundation]
Steps (theory text):
1. The client imagines the addict self on a TV screen and learns to control and fade the image.
2. They then project the spiritual self and sharpen it until it is vivid and many-sided.
3. Audio recordings may be given for home practice, with a log.
Example language (illustrative): "Let the picture of the addict self go grey... smaller... now bring up the spiritual self: how does that person stand, speak, look at people?"
Watch for: vivid addict imagery provoking craving. Fade it quickly and end on the spiritual image [synthesis].

4.33 Renunciation and generosity; five hindrances and five faculties; acting "as if"

Purpose / when: Session 10 (quality: renunciation and generosity). Renouncing the addict-self identity and assuming the spiritual-self identity. [source: 3-S+ Client Workbook; 3-S+ Theoretical foundation]
Steps (workbook):
1. Define renunciation as giving up whatever separates the client from their spiritual nature (addict thoughts, speech, emotions, behaviour), and generosity as giving one's true nature to self and others.
2. Teach the Buddhist "five enemies" (craving for sensual pleasure, ill will, sluggishness, agitation, doubt about the path) and "five friends" (faith, effort, awareness, concentration, wisdom).
3. The client visualises taking on the role of the spiritual self like an actor, then acts "as if" during the coming week, especially in an identified high-risk situation. The workbook links this to the 12-step phrase "fake it until you make it". The client commits to abstinence and to living that identity daily.
Example language (illustrative): "This week you're playing the part of your spiritual self. In that situation on Friday, what does that person do?"

4.34 Serenity and insight: grief, impermanence and Serenity Prayer meditation (3-S+)

Purpose / when: Session 11 (quality: serenity). Addresses grief and fear of death after an HIV diagnosis, which the authors hold can activate the addict self. Uses impermanence (anicca): suffering is held to come from clinging to the impermanent. [source: 3-S+ Client Workbook; 3-S+ Theoretical foundation]
Steps:
1. Discuss stages of grief (the workbook lists denial, anger, bargaining, depression, acceptance, hope).
2. Meditation:
  - Sit with the eyes closed on the anchor, and feel serenity as the client's birthright (the model's framing).
  - Recite each line of the Serenity Prayer silently and reflect on it: the wish for peace; acceptance and impermanence; courage to train the mind and act morally; wisdom as right view and right thinking.
  - Return to the anchor, then open the eyes.
3. Homework: daily Serenity Prayer meditation.
Faith fit: the prayer addresses God. Offer a non-theistic wording for clients who prefer one [synthesis].
Watch for: depression, hopelessness or suicidal thinking surfacing with death themes. Assess risk using standard practice and do not rely on the meditation [synthesis].

Session 12 — Termination

4.35 Maintaining the path through truth; Taking Refuge worksheet; community referral

Purpose / when: Session 12 (quality: truth). Consolidates the path and builds external support. [source: 3-S+ Client Workbook; 3-S+ Theoretical foundation]
Steps:
1. Discuss honesty with oneself, others and the environment.
2. Taking Refuge worksheet: the client lists spiritual guides; teachings (scriptures, books, recordings); members of their spiritual community with contact details; and community resources (places of worship, meditation groups, AA/NA or other fellowships, with times and places).
3. Recap the essentials: do no harm, stay vigilant for intrusions, remember one's true nature and the anchor.
4. Homework: contact at least one community resource, with follow-up on the referral.
5. The theory text names referral to AA/NA and to the client's place of worship.
Example language (illustrative): "Who and what will hold you on this path when our sessions end? Let's make the first call while you're here."
Watch for: referrals to groups whose ethos conflicts with the client's needs (e.g. a punitive congregation, or a 12-step group's stance on medication). Match the referral to the client [synthesis].

4.36 Adjunctive 3-S+ group (12 sessions)

Purpose / when: Optional 60-minute manual-guided groups, used alongside the individual sessions for extra practice of skills taught one-to-one. Not stand-alone. [source: 3-S+ Theoretical foundation] The group manual is not drawn on, so its session content is [uncertain].

5. Handling problems

From the manuals [source: 3-S+ Theoretical foundation; Session 1, 3 and 4 manuals]

Missed homework. Stay a coach, not a critic. Credit any partial practice. If none was done, treat forgetting as a sign the addict self was active and solve the specific barrier:
- Check-ins forgotten: change the cue.
- Stretch forgotten: show the diagram again, link it to waking, or involve a family member.
- Meditation skipped: choose a more convenient time and place, check technique and posture, and get a renewed commitment.
- Then ask the client for a concrete example from the week of determination, effort or equanimity, so the session still strengthens the spiritual self. Suggest posting the signed commitment where it will be seen.
Missed sessions, missed methadone or urine tests, denial and minimising. These are predicted in Session 3 as addict-self sabotage. Name them when they happen, as agreed, without moral judgement.
Drug use during treatment. If the client is sincere about change, treat it as addict-self activation, not moral failure, and respond with compassion and without punishment. Analyse it with Identify, Interrupt, Refocus. Urine monitoring and infraction records stay with other staff. Follow mandated reporting rules for behaviour that transmits disease.
Extended hospitalisation. If fewer than 4 sessions were completed, restart at Session 1.
Cognitive impairment, literacy or language barriers. Review the prior session first, summarise at the end, and slow the pace and simplify verbal delivery. Spanish and Russian manuals exist on the Yale site.
Belief conflict, or stern and punitive religious images. Tailor the tools to the client's tradition. Explore punitive images (e.g. illness as divine punishment) and reframe them toward compassion. Never impose a faith.
Clients who find exercises silly (natural objects, the stretch). Acknowledge that the addict self may ridicule them. Invite the client to notice what arises, and contrast it with the closed, paranoid feel of the addict self.
Meditation difficulties. Use the widening-focus, short-sharp-breath, one-breath-at-a-time and counting techniques (4.10). Normalise the wandering mind.
Shock at intrusions ("this is who I really am"). Reframe the addict self as an automated process, not the self. Awareness is progress.
Poor medication adherence or misinformation. Assess the regimen, educate, use the ritual and scenario rehearsal, and link the client to the HIV provider. Never give medical advice yourself.
Psychiatric deterioration in dually diagnosed clients. Make sure appropriate concurrent care is in place and refer.

Not addressed in the sources: own guidance, all [synthesis]

Non-religious, atheist or anti-religious clients. The manual requires interest in developing a spiritual self-schema. If that interest is absent, do not persuade.
- Either offer a secular framing ("values self" or "recovery self"; ethical commitments instead of a spiritual destination; secular affirmations and songs) and be clear that this departs from the manual,
- or use a non-spiritual alternative such as CBT relapse prevention or mindfulness-based relapse prevention.
Clients hurt by religion (religious abuse, rejection over sexuality or HIV). Proceed only if the client chooses. Let them define "spiritual", and avoid congregational referrals that may re-harm them.
Meditation adverse effects (anxiety, panic, depersonalisation or derealisation, re-experiencing trauma, dissociation; rarely, psychotic or manic episodes in vulnerable people). The 3-S sources do not discuss these, beyond excluding psychotic and dissociative disorders.
- Screen for trauma, PTSD, psychosis or bipolar history, and dissociation before Session 2.
- Keep eyes-open options, shorter sits and external anchors (sounds, feet on the floor).
- Do not push the build-up toward 60 minutes daily for clients who become distressed. Shorten, move to walking or other movement practice, or pause.
- Ask about these effects directly at each review.
- If psychotic, manic or severe dissociative symptoms appear, stop meditation practice and arrange psychiatric assessment.
Overwhelm or high distress in session (grief, a new diagnosis, a crisis). The skills format can feel too narrow.
- Set the agenda aside for a stabilisation session (safety, practical needs, the anchor) and resume the sequence next time, telling the client you are doing so.
- The manual's "no trauma exploration" rule means arranging trauma-focused care separately, not ignoring trauma.
Suicide risk. HIV diagnosis, grief, stigma and relapse raise risk. Assess with your service's standard risk-assessment protocol. Safety-plan, including lethal-means counselling (safe storage or removal of medications and other means) and crisis contacts. Do not substitute serenity or forgiveness practices for risk management.
Client arrives intoxicated. Do not deliver new material. Check safety and medical status, keep the session short and supportive, document, and reschedule. Treat the episode as an intrusion to analyse when the client is sober.
Shame or guilt deepened by the moral framing ("morality", "do no harm", "heir to your actions").
- Keep the emphasis on the habit-pattern framing and on self-compassion (self-metta first).
- Stop using "you are heir to your actions" if the client hears it as deserving HIV or past suffering.
Rupture with the coach stance (client feels pushed or policed). Name the tension openly, renegotiate the home-practice load, and restate that you are not monitoring drug use (urine screens sit with other staff). Repair before adding assignments.
Partner notification and disclosure dilemmas. Assess the risks of intimate partner violence and of legal exposure. Know local law and public-health notification services, and document carefully. Mandated reporting and confidentiality limits must be explained at the outset.
Outdated medical content. Update HIV, hepatitis and testing information to current guidance before teaching it (see 4.19 and 4.27), and coordinate with the medical team.
Cultural respect. Buddhist terms (paramis, sila, samadhi, panna, anicca) are the authors' adaptation of Theravada teachings. Present them as the model's framework, not as truths the client must accept. Refer clients who want Buddhist practice proper to qualified teachers or communities.

Sources

Sources (all on Yale School of Medicine's Spiritual Self-Schema site and file store):