*Brief* COUNSELING *for*

MARIJUANA

DEPENDENCE

*A Manual for Treating Adults*

**.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES**

*Brief* COUNSELING *for*

MARIJUANA DEPENDENCE

*A Manual for Treating Adults*

**U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES**

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

1 Choke Cherry Road

Rockville, MD 20857

**Acknowledgments**

Numerous people contributed to this document, which is part of the
Marijuana Treatment Project (MTP) Cooperative Agreement. The document
was written by Karen L. Steinberg, Ph.D., Roger A. Roffman, D.S.W.,
Kathleen M. Carroll, Ph.D., Bonnie McRee, M.P.H., Thomas F. Babor,
Ph.D., M.P.H., Michael Miller, Ph.D., Ronald Kadden, Ph.D., David
Duresky, M.A., and Robert Stephens, Ph.D. The MTP Research Group
provided valuable guidance and support on this document. See appendix B
for a full list of contributors.

This publication was developed with support from the Center for
Substance Abuse Treatment (CSAT) to the University of Connecticut School
of Medicine through Grant No. TI1 1323. This study was funded by the
Substance Abuse and Mental Health Services Administration (SAMHSA),
CSAT, U.S. Department of Health and Human Services (DHHS). The research
was conducted in Farmington, Connecticut (UR4 TI1 1273 and UR4 TI1
1310), Miami, Florida (UR4 TI1 1274), and Seattle, Washington (UR4 TI1
1270), in cooperation with the following institutions: University of
Connecticut Health Center, The Village South, Inc., University of
Washington, and Evergreen Treatment Services. The publication was
produced by Johnson, Bassin & Shaw, Inc. (JBS), under the Knowledge
Application Program (KAP) contract numbers 270-99-7072 and 270-04-7049
with SAMHSA, DHHS. Christina Currier served as the CSAT Government
Project Officer. Andrea Kopstein, Ph.D., M.P.H., served as the Deputy
Government Project Officer. Jean Donaldson, M.A., served as Government
Project Officer for the MTP Cooperative Agreement. Lynne McArthur, M.A.,
A.M.L.S, served as JBS KAP Executive Project Director; Barbara Fink,
R.N., M.P.H., served as JBS KAP Managing Director; and Emily Schifrin,
M.S., and Dennis Burke, M.S., M.A., served as JBS KAP Deputy Directors
for Product Development. Other JBS KAP personnel included Candace Baker,
M.S.W., Senior Writer; Elliott Vanskike, Ph.D., Senior Writer; Wendy
Caron, Editorial Quality Assurance Manager; Frances Nebesky, M.A.,
Quality Control Editor; and Pamela Frazier, Document Production
Specialist.

**Disclaimer**

The opinions expressed herein are the views of the authors and do not
necessarily reflect the official position of CSAT, SAMHSA, or DHHS. No
official support of or endorsement by CSAT, SAMHSA, or DHHS for these
opinions or for particular instruments, software, or resources described
in this document is intended or should be inferred. The guidelines in
this document should not be considered substitutes for individualized
client care and treatment decisions.

**Public Domain Notice**

All materials appearing in this volume except those taken directly from
copyrighted sources are in the public domain and may be reproduced or
copied without permission from SAMHSA/CSAT or the authors. Do not
reproduce or distribute this publication for a fee without specific,
written authorization from SAMHSA's Office of Communications.

**Electronic Access and Copies of Publication**

Copies may be obtained free of charge from SAMHSA's National
Clearinghouse for Alcohol and Drug Information (NCADI), 800-729-6686 or
301-468-2600; TDD (for hearing impaired) 800-487-4889; or electronically
through the following Web site: www.ncadi.samhsa.gov.

**Recommended Citation**

Steinberg, K.L.; Roffman, R.A.; Carroll, K.M.; McRee, B.; Babor, T.F.;
Miller, M.; Kadden, R.; Duresky, D.; and Stephens, R. *Brief Counseling
for Marijuana Dependence: A Manual for Treating Adults.* DHHS
Publication No. (SMA) 05-4022. Rockville, MD: Center for Substance Abuse
Treatment, Substance Abuse and Mental Health Services Administration,
2005.

**Originating Office**

Practice Improvement Branch, Division of Services Improvement, Center
for Substance Abuse Treatment, Substance Abuse and Mental Health
Services Administration, 1 Choke Cherry Road, Rockville, MD 20857.

DHHS Publication No. (SMA) 05-4022

Printed 2005

**TABLE OF CONTENTS**

**I. Introduction 1**

Me? Hooked on Pot? 1

Case Examples 2

Brief Marijuana Dependence Counseling 3

Background 3

Current Findings About Marijuana Use 4

Overview of the Marijuana Treatment Project 5

Who Should Use This Manual? 7

Organization of This Manual 7

**II. Overview of the Brief Marijuana**

**Dependence Counseling Model and**

**Manual 10**

General Theoretical Assumptions 10

BMDC Therapeutic Tasks 12

Target Population 12

Structure of BMDC and the Individual Sessions 12

How To Use the Manual 13

**III. Common Treatment Issues 14**

Client--Counselor Relationship 14

Orienting the Client and Confidentiality 14

Preventing Attrition 15

Practice Exercises 17

Termination 17

Strategies for Addressing Common Clinical Problems 17

Summary 20

**IV. Getting Started:**

**Assessment Session 21**

Building Rapport 21

Assessing Marijuana Use 21

Overview of Assessment Session: Building Rapport and Assessing

Marijuana Use 23

Assessment Session Protocol 23

Forms for Assessment Session 34

**V. Enhancing Motivation:**

**Sessions 1 and 2 63**

Key Concepts: Motivational Interviewing Skills 63

Tips for the Counselor 69

Overview of Session 1: Reviewing the PFR 70

Session 1 Protocol 71

Overview of Session 2: Change Plan, Treatment Plan, and

Supporter Involvement 78

Session 2 Protocol 79

Forms for Sessions 1 and 2 82

**VI. Changing Marijuana Use Through Skill**

**Building: Sessions 3 Through 9 99**

Why Focus on Skills? 99

What Is Cognitive Behavioral Counseling? 100

Integrating MET and CBT 100

Tips for the Counselor 101

Overview of Session 3: Skill Topic 1, Coping With Other Life Problems
102

Session 3 Protocol 103

Overview of Session 4: Skill Topic 2, Understanding Marijuana Use
Patterns 109

Session 4 Protocol 110

Overview of Session 5: Skill Topic 3, Coping With Cravings and

Urges To Use 113

Session 5 Protocol 114

Overview of Session 6: Skill Topic 4, Managing Thoughts About

Marijuana Use 119

Session 6 Protocol 120

Overview of Session 7: Skill Topic 5, Problemsolving 126

Session 7 Protocol 126

Overview of Session 8: Skill Topic 6, Marijuana Refusal Skills 130

Session 8 Protocol 130

Elective Skill Topics 133

Overview of Session 9: Elective Skill Topic 1, Planning for Emergencies

and Coping With a Lapse 135

Session 9 Protocol: Elective Skill Topic 1 135

Overview of Session 9: Elective Skill Topic 2, Recognizing Seemingly

Irrelevant Decisions 137

Session 9 Protocol: Elective Skill Topic 2 137

Overview of Session 9: Elective Skill Topic 3, Managing Negative Moods

and Depression 141

Session 9 Protocol: Elective Skill Topic 3 141

Overview of Session 9: Elective Skill Topic 4, Demonstrating
Assertiveness 145

Session 9 Protocol: Elective Skill Topic 4 145

Forms for Sessions 3 Through 9 148

**VII. Supplemental Readings 170**

Supplemental Reading A: Who Needs Treatment? The Nature, Prevalence,

and Consequences of Marijuana Dependence 170

Supplemental Reading B: How Effective Is Treatment for Marijuana

Dependence? The Marijuana Treatment Project and Related Studies 174

Supplemental Reading C: Implementing Brief Marijuana Dependence

Counseling 177

**Appendix A. Session Rating Form 182**

**Appendix B. Contributors 187**

**Appendix C. Field Reviewers 189**

**References 191**

+-----------------------------------------------------------------------+
| **SECTION I.**                                                        |
|                                                                       |
| **INTRODUCTION**                                                      |
+-----------------------------------------------------------------------+

The Center for Substance Abuse Treatment (CSAT), part of the Substance
Abuse and Mental Health Services Administration, funded three clinical
sites and a Coordinating Center (CC) to design and implement the
Marijuana Treatment Project (MTP) in the late 1990s. A major focus of
CSAT is rigorous testing of approaches to treat marijuana dependence in
both adults and adolescents. MTP studied the efficacy of treatments for
adults who are dependent on marijuana. At the time of funding, MTP was
one of the largest Knowledge Development and Applications initiatives
funded by CSAT. Another was the Cannabis Youth Treatment (CYT) Study,
which resulted in the CYT Series, a five-volume resource that provides
unique perspectives on treating adolescents for marijuana use (Godley et
al. 2001; Hamilton et al. 2001; Liddle 2002; Sampl and Kadden 2001; Webb
et al. 2002).

This manual for Brief Marijuana Dependence Counseling (BMDC) is based on
the research protocol used by counselors in MTP. The manual provides
guidelines for counselors, social workers, and psychologists in both
public and private settings who treat adults dependent on marijuana. The
10 weekly one-on-one sessions in the BMDC manual offer examples of how a
counselor can help a client understand certain topics, keep his or her
determination to change, learn new skills, and access needed community
supports (exhibit I-1). Stephens and colleagues (2002) describe the MTP
rationale, design, and participant characteristics. Findings from MTP
are presented in supplemental reading B of section VII.

**Me? Hooked on Pot?**

Many individuals for whom this intervention was designed often have
difficulty accepting that they are dependent on marijuana. The topic is
controversial, even for those who walk through a counselor's door to
talk about their marijuana use.

People who become clients in BMDC may have

> • Put off actions and decisions to the point of being a burden on
> family and friends
>
> • Given up personal aspirations
>
> • Had nagging health concerns, such as worries about lung damage
>
> • Made excuses for unfinished tasks or broken promises
>
> • Experienced disapproval from family and friends
>
> • Been involved in the criminal justice system.

<table>
<colgroup>
<col style="width: 17%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><strong>Exhibit I-1. Brief Marijuana Dependence
Counseling</strong></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Assessment</strong></td>
<td colspan="6"><strong>Treatment</strong></td>
</tr>
<tr class="odd">
<td><strong>Assessment</strong></td>
<td><p><strong>Session</strong></p>
<p><strong>1</strong></p>
<p></p></td>
<td><p><strong>Session</strong></p>
<p><strong>2</strong></p>
<p></p></td>
<td><p><strong>Session</strong></p>
<p><strong>3</strong></p>
<p></p></td>
<td><p><strong>Session</strong></p>
<p><strong>4</strong></p>
<p></p></td>
<td><p><strong>Session</strong></p>
<p><strong>5</strong></p>
<p></p></td>
<td><p><strong>Session</strong></p>
<p><strong>6</strong></p>
<p></p></td>
<td><p><strong>Session</strong></p>
<p><strong>7</strong></p>
<p></p></td>
<td><p><strong>Session</strong></p>
<p><strong>8</strong></p>
<p></p></td>
<td><p><strong>Session</strong></p>
<p><strong>9</strong></p>
<p></p></td>
</tr>
<tr class="even">
<td><p>• Building rapport</p>
<p>• Motivational enhancement therapy (MET) techniques for engaging
clients</p>
<p>• Overview for client</p></td>
<td colspan="2"><p>• MET</p>
<p>• Review of <em>Personal</em></p>
<p><em>Feedback Report</em></p>
<p>• Beginning cognitive behavioral therapy</p></td>
<td colspan="7"><p>• Core skill-building topics</p>
<p>• Elective skill-building topics</p>
<p>• Case management as needed</p></td>
</tr>
</tbody>
</table>

**Case Examples**

***Doug***

A Caucasian father of two teenagers, Doug was in his early 40s when his
wife forced him to talk to a counselor about marijuana. He was not happy
to be in the counselor's office. "What's the big deal?" he asked. "It's
just pot." Doug's wife had given him an ultimatum: either he quit
getting high or she would move out. She delivered this ultimatum when
their 15-year-old son was suspended from school for smoking marijuana.

When they were younger, Doug and his wife smoked pot together. As their
children grew older, however, his wife gave it up. For a long time, she
tolerated Doug's continued use, with their agreeing that he'd be
discreet. Both felt that the children should not know about his using.
Doug tried to be careful, but a few times his son had walked in on him
using marijuana.

"Why can't you settle for my promising to try harder to hide it from the
kids?" he argued. "It's not as if it's really a problem. After all, our
family benefits from my income."

Given what he said in the first several minutes he spent with the
counselor, he saw the real issue as his wife's refusal to be reasonable.
But Doug also mentioned that he wondered, "What will people think if
word gets out that I smoke marijuana?"

***Shirley***

Shirley struggled with thoughts about marijuana and its effects. An
African-American mother of three girls, Shirley was troubled by what she
perceived as a conflict between her personal and professional lives.

Getting high helped her relax and sleep. Shirley had first smoked pot
with a favorite uncle, and other members of her close-knit family had
experienced getting high. No one was critical of her smoking. However,
Shirley wanted to be an elementary school teacher. While student
teaching, she was struck by the incongruity of having chosen a
profession that called for being a good role model for children yet
regularly getting stoned. She had thought a lot about quitting. When she
tried to stop, she felt agitated and had difficulty sleeping. Shirley
worried that she might not

succeed in changing. She started seeing a counselor to sort out her
confusion.

Like Doug, Shirley was grappling with a complicated issue. Doug and
Shirley perceived aspects of their marijuana experiences as positive,
yet they were troubled by possible consequences.

***Miguel***

A 36-year-old married Hispanic man, Miguel has known for years that
getting high is no longer a casual part of his life. When he tried to
stop, he got angry at the slightest provocation, could not relax, and
inevitably returned quickly to frequent use.

Not too long ago, Miguel made an appointment at a drug treatment agency
but never showed up. The agency employee who answered the phone asked
him, "Is marijuana the only drug you use?" He thinks that he needs help
but doubts that anyone would understand how he feels. He does not want
to be treated like an addict.

**Brief Marijuana Dependence Counseling**

These three examples illustrate several important questions commonly
asked by people about their marijuana use:

> • Is it possible to be dependent on marijuana?
>
> • Do I want to stop using because of what I've experienced?
>
> • Can I succeed in stopping, given the challenges I've faced in the
> past?

The counseling approach presented in this manual addresses these issues
among others. It comprises three key intervention components:
motivational enhancement, cognitive behavioral skills training, and case
management. Each session presents examples of how a counselor might
introduce certain topics, facilitate the client's resolution to stop
using marijuana, provide skills training, and help the client access
needed community supports.

**Background**

Before 1994, no published, controlled trials of treatment for marijuana
use disorders existed, which is surprising because marijuana long has
been the most frequently used illicit substance in the United States.
Interest in treatment for people who use marijuana may have been lacking
because of myths that extensive marijuana use did not lead to dependence
and that no adverse consequences were associated with misuse (Roffman et
al. 1988; Stephens and Roffman 1993). The relatively mild withdrawal
symptoms associated with marijuana use may have led to a belief that
dependence was unlikely and that people who needed treatment abused
other substances and their marijuana use was a secondary concern (e.g.,
Rainone et al. 1987). Similarly, most early reviews found few serious
negative consequences associated with marijuana use (e.g., Hollister
1986; Wert and Raulin 1986*a*, 1986*b*). However, recent research shows
that a significant number of adults are dependent on marijuana and
experience negative consequences secondary to their use of marijuana.

**Current Findings About Marijuana Use**

Marijuana is the most commonly used illicit substance in the United
States (Clark et al. 2002; Substance Abuse and Mental Health Services
Administration 2003). According to the 2003 National Survey on Drug Use
and Health, 14.6 million people ages 12 and older had smoked marijuana
in the preceding month (Substance Abuse and Mental Health Services
Administration 2004). It is estimated that approximately 4.3 million
people used marijuana at levels consistent with abuse or dependence in
the past year. Given that it is an illicit substance, any use of
marijuana carries with it some significant risks. However, this document
focuses on people who use marijuana heavily or are dependent on it. This
treatment manual is directed primarily at these persons but may be
useful for other persons with substance abuse or substance use
disorders.

Studies have demonstrated that tolerance and withdrawal develop with
daily use of large doses of marijuana or THC (Haney et al. 1999*a*;
Jones and Benowitz 1976; Kouri and Pope 2000). About 15 percent of
people who acknowledge moderate-to-heavy use reported a withdrawal
syndrome with symptoms of nervousness, sleep disturbance, and appetite
change (Wiesbeck et al. 1996). Many adults who are marijuana dependent
report affective (i.e., mood) symptoms and craving during periods of
abstinence when they present for treatment (Budney et al. 1999). The
contribution of physical dependence to chronic marijuana use is not yet
clear, but the existence of a dependence syndrome is fairly certain. An
Epidemiological Catchment Area study conducted in Baltimore found that 6
percent of people who used marijuana met *Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition* (DSM-IV) (American
Psychiatric Association 1994), criteria for dependence and 7 percent met
DSM-IV criteria for substance abuse (Rosenberg and Anthony 2001). Coffey
and colleagues (2002) found that persons who use marijuana more than
once a week are at significant risk for dependence. In the 1990s, the
number of people who sought treatment for marijuana dependence more than
doubled (Budney et al. 2001). Therefore, a large group of adults who
smoke marijuana is dependent and may need and benefit from treatment.

Surveys of people using marijuana who are not in treatment consistently
show that a majority report impairment of memory, concentration,
motivation, self-esteem, interpersonal relationships, health,
employment, or finances related to their heavy marijuana use (Haas and
Hendin 1987; Rainone et al. 1987; Roffman and Barnhart 1987; Solowij
1998). Similar marijuana-related consequences are seen among those
seeking treatment for their marijuana use (Budney et al. 1998; Stephens
et al. 1994*b*, 2000). People using marijuana who participated in
previous treatment studies averaged more than 10 years of near-daily use
and more than six serious attempts to quit (Stephens et al. 1994*b*,
2000). These individuals had persisted in their use despite multiple
forms of impairment (i.e., social, psychological, physical), and most
perceived themselves as unable to stop.

During the past decade evidence has emerged that a variety of problems
are associated with chronic marijuana use. Although the severity of
these problems appears to be less than that of problems caused by other
drugs and alcohol, the large number of people using who may have these
problems raises the possibility of a significant public health problem.
Like those who use other mood-altering substances, many individuals who
use marijuana chronically perceive the problems to be severe enough to
warrant treatment.

The results of earlier studies on treatments for marijuana problems
indicated that some adults who used marijuana responded well to several
types of interventions, such as cognitive behavioral, motivational
enhancement, and voucher-based treatments (Budney et al. 2000; Stephens
et al. 1994*b*, 2000). Relapse rates following treatment were similar to
those for other drugs of abuse and, as found with other types of
substance abuse treatment, improvements in drug use were accompanied by
other positive gains, including improvements in dependence symptoms,
problems related to marijuana use, and anxiety symptoms. However, the
generalizability of the treatment findings appeared to be limited by the
predominantly white, male, and socioeconomically stable (i.e., educated
and employed) characteristics of the samples. Therefore, the results of
these studies may be limited to this fairly homogeneous group of people
who are marijuana users.

**Overview of the Marijuana Treatment Project**[^1]

CSAT funded MTP to design and conduct a study of the efficacy of
treatments for marijuana dependence, to extend this line of research,
and to broaden the applicability of the approach to a more diverse group
than that used in earlier trials (Stephens et al. 1994*b*, 2000). The
treatment sites were the University of Connecticut School of Medicine,
Department of Psychiatry, Farmington, Connecticut; The Village South,
Miami, Florida; and the University of Washington, School of Social Work,
Seattle, Washington. The CC was at the University of Connecticut,
Department of Psychiatry.

The study examined the efficacy of treatments of different durations for
a diverse group of adults who were marijuana dependent. Two
treatments---one lasting two sessions, the other nine sessions---were
compared with a delayed treatment control (DTC) condition, in which
subjects were offered treatment 4 months after their baseline
assessment. The same counselors delivered treatments of both durations
to avoid confounding the mode of treatment, length of treatment, and
counselor experience. A case management component was incorporated in
the longer treatment to help clients identify and overcome barriers to
successful behavior change in their everyday environments. The
hypothesis was the nine-session and two-session interventions would
produce outcomes superior to the DTC in terms of higher abstinence rates
and associated negative consequences. Although the limited prior
research suggested no differences between brief and extended treatments,
it also was hypothesized that the nine-session intervention would yield
outcomes superior to the two-session intervention when delivered by
counselors with the same level of expertise.

The study improved on the methodology of the previous treatment studies
in several other ways. Structured diagnostic interviews were used to
arrive at formal diagnoses of marijuana dependence, and the Addiction
Severity Index, a widely used measure of problem severity, was included
to compare the findings of this study with those of other studies of
drug abuse. Supplemental reading B in section VII provides a detailed
discussion of study methodology.

As the first well-controlled multisite trial of manual-guided treatments
for marijuana dependence, this study produced several noteworthy
findings:

> • The results of the randomized trial suggest that both a two-session
> motivational enhancement therapy (MET) treatment and a nine-session
> treatment incorporating MET, coping skills training, and case
> management were significantly more effective in reducing marijuana use
> than a DTC condition.
>
> • The more intensive the treatment, the better the outcomes.
>
> • Outcomes of these brief treatments were durable; data from a 1-year
> followup of the treated groups demonstrated treatment's sustained
> effect even after treatment termination.
>
> • Reductions in drug use were linked to other positive outcomes (e.g.,
> sustained reductions in marijuana-related problems).
>
> • Treatment effects were robust across a number of participant
> characteristics, including gender and ethnicity.

Taken together, these findings suggested that treatment for marijuana
dependence was effective.

Few studies have evaluated active treatments with respect to a DTC
condition. The findings from the DTC group are not consistent with the
view that marijuana dependence is benign and that individuals improve
without treatment. Instead, these findings suggest that well-structured
treatments may be necessary to increase abstinence rates among the
chronic marijuana-using population. Many subjects reported difficulties
finding help for their marijuana-related problems through the current
substance abuse treatment system.

The findings are also generally consistent with the results of prior
studies of behavioral treatments for cannabis-related disorders (Budney
et al. 1998; Stephens et al. 1994*b*, 2000) in suggesting that
well-defined behavioral treatments for marijuana dependence produce
encouraging improvement and that treatment is associated with meaningful
benefits. These findings support other results in the literature
pointing to the efficacy of behavioral treatments in producing
significant and durable improvement for a range of substance-related
disorders, particularly alcohol and cocaine dependence.

Findings indicate a robust dose-effect relationship for this study's
treatments and contrast with earlier studies of cannabis treatment that
have not demonstrated differences in outcome related to intensity. The
MTP study, one of only a few studies that have focused on treatment
intensity, contrasted the brief two-session treatment with the more
intensive nine-session treatment; treatment participation was high in
both conditions. However, further research is needed to determine
whether treatment outcomes might be improved with more treatment or
whether different distributions of treatment sessions might help people
who use marijuana sustain the positive treatment outcomes.

In addition to the overall reductions observed in the frequency of
marijuana smoking, reductions also were evident in marijuana dependence
symptoms, marijuana-related problems, and anxiety symptoms. In each
measure, the nine-session treatment group showed the greatest
improvements, the two-session group showed intermediate reductions, and
the DTC group showed little change.

Finally, countering the historical portrayal of marijuana as a benign
drug, the MTP study and previous research (Stephens et al. 1993*a*,
1994*b*, 2000) suggest that individuals can develop recurrent
psychological, social, and medical problems with chronic marijuana use.
Individuals who use marijuana as their primary drug tend not to seek
treatment in traditional drug treatment settings. Clients in real-life
treatment settings, as compared with volunteers in randomized clinical
trials, tend to present with complex difficulties in addition to
substance use disorders. When people present for marijuana treatment,
they may want and need help with family and other relationships,
regulating their emotions, employment and financial problems, or
addressing health worries. These problems may have preceded, resulted
from, or co-occurred with the substance use difficulties. Increasing
evidence suggests that counseling for marijuana dependence is effective
and accompanied by other positive changes in clients' lives (Steinberg
et al. 2002).

**Who Should Use This Manual?**

The manual is designed for use by experienced clinicians. Counselors
should follow the outlined procedures and should have the opportunity
for regular consultation with clinical supervisors familiar with the
BMDC approach. Detailed treatment protocols define goals for each
session and standardize counseling techniques but also permit
flexibility.

All BMDC counselors should meet the following criteria:

• A master's degree in counseling, psychology, social work, or a closely
related field

• At least 2 years of clinical experience after completion of degree or
certification

• Experience in conducting treatment consistent with BMDC

• Experience in treating people who abuse or are dependent on drugs or
alcohol.

This manual is a blueprint for treatment and is not a substitute for
training and supervision. The material may not be appropriate for all
clients or clinical programs. This manual should be viewed as a
supplement to careful assessment of each client, appropriate case
formulation, monitoring of clinical status, and clinical judgment.

Supplemental reading C in section VII provides detailed information on
effectively implementing and managing BMDC; appendix A provides a
session rating form to guide supervisors.

**Organization of This Manual**

***Section II. Overview of the Brief Marijuana Dependence Counseling
Model and Manual***

Section II describes the theoretical basis for BMDC treatment. It
explains the therapeutic tasks of the BMDC approach, describes the
target population, and provides an overview and the suggested sequencing
of BMDC sessions.

***Section III. Common Treatment Issues***

Section III presents potential pitfalls in BMDC and guidelines for
handling issues that may arise. Some problems identified are not
specific to marijuana treatment and may apply generally to substance use
disorders or clinical counseling.

***Section IV. Getting Started: Assessment Session***

Section IV details the strategies for initiating BMDC treatment with a
client dependent on marijuana. The assessment session outlines
strategies for building rapport, assessment procedures, and MET
techniques for engaging the client and identifying goals and change
strategies. Clinical information for assessing and evaluating the
client's status, level of marijuana use, problems related to use, and
reasons for wanting to change is gathered by the counselor during the
initial evaluation and is used to develop an individualized treatment
plan. The session includes assessment and scoring tools for completing a
client's *Personal Feedback Report* (PFR), a critical tool in the
implementation of BMDC.

***Section V. Enhancing Motivation: Sessions 1 and 2***

Sessions 1 and 2 of BMDC follow MET principles. During session 1, the
counselor uses the completed PFR to make the client aware of the effects
of marijuana use on critical life areas and to increase motivation.
Using motivational interviewing strategies, the counselor elicits and
reinforces the client's motivation for change. If the client is ready to
change, the discussion shifts from motivational enhancement to cognitive
behavioral strategies, goal setting, and the skills to accomplish goals.
The guidelines for session 2 instruct the counselor on how to reinforce
the client's efforts to initiate change, review goals and plan
alternative strategies for behavior change, and encourage support from
the friend or relative who has been invited to the session by the
client.

***Section VI. Changing Marijuana Use Through Skill Building: Sessions
3***

***Through 9***

Section VI outlines material for the remaining seven sessions of BMDC,
including the use of cognitive behavioral strategies for building client
motivation and maintaining treatment gains. This section describes the
six core skill topics and four elective skill topics used with clients
in BMDC (exhibit I-2).

+-----------------------------------------------------------------------+
| **Exhibit I-2. Core and Elective Skill Topics in Brief Marijuana      |
| Dependence Counseling**                                               |
+-----------------------------------------------------------------------+
| **Core Skill Topics (sessions 3--8)**                                 |
+-----------------------------------------------------------------------+
| > Session 3: Coping with other life problems                          |
| >                                                                     |
| > Session 4: Understanding marijuana use patterns                     |
| >                                                                     |
| > Session 5: Coping with cravings and urges to use                    |
| >                                                                     |
| > Session 6: Managing thoughts about marijuana use                    |
| >                                                                     |
| > Session 7: Problemsolving                                           |
| >                                                                     |
| > Session 8: Marijuana refusal skills                                 |
+-----------------------------------------------------------------------+
| **Elective Skill Topics (session 9)**                                 |
+-----------------------------------------------------------------------+
| > Topic 1: Planning for emergencies and coping with a lapse           |
| >                                                                     |
| > Topic 2: Recognizing seemingly irrelevant decisions                 |
| >                                                                     |
| > Topic 3: Managing negative moods and depression                     |
| >                                                                     |
| > Topic 4: Demonstrating assertiveness                                |
+-----------------------------------------------------------------------+

The counselor and client jointly select one of the four elective topics
that they decide is most appropriate. The guidelines for sessions 3
through 9 are twofold:

> • The sessions follow detailed protocols for using cognitive
> behavioral skills to build on client strengths and to overcome
> specific skill deficits associated with substance dependence.
>
> • The sessions identify other problems that can interfere with
> recovery from marijuana dependence and suggest clinical case
> management interventions.

***Section VII. Supplemental Readings***

*A. Who Needs Treatment? The Nature, Prevalence, and Consequences of
Marijuana Dependence*

This section provides a comprehensive review of the literature on the
epidemiology of marijuana dependence, the significance of the problem,
and the rational for developing effective and replicable treatments.

*B. How Effective Is Treatment for Marijuana Dependence? The Marijuana
Treatment Project and Related Studies*

This section presents the design, rationale, and findings from major
clinical trials that have focused exclusively on marijuana dependence
treatment, including MET.

*C. Implementing Brief Marijuana Dependence Counseling*

This section is intended for program developers, administrators, and
supervisors who are responsible for establishing and maintaining an
infrastructure to support clinical implementation of BMDC. These
guidelines can be used in identifying an appropriate site for BMDC,
selecting and supervising counselors, easing the transition to
marijuana-specific treatment, and monitoring effectiveness.

+-----------------------------------------------------------------------+
| **SECTION II.**                                                       |
|                                                                       |
| **OVERVIEW OF THE BRIEF MARIJUANA DEPENDENCE COUNSELING**             |
|                                                                       |
| **MODEL AND MANUAL**                                                  |
+-----------------------------------------------------------------------+

The Brief Marijuana Dependence Counseling (BMDC) approach combines
elements from previously demonstrated treatments for substance use
disorders:

> • Motivational enhancement therapy (MET) (CSAT 1999*b*; Miller and
> Rollnick 2002)
>
> • Cognitive behavioral therapy (CBT) (CSAT 1999*a*; Kadden et al.
> 1994; Monti et al. 1989)
>
> • Case management (CSAT 1998).

MET strategies are perceived as potentially useful with the chronic
marijuana-using population because of their success in addressing
substance use disorders.

The client-centered engagement approach of MET is a good fit for
individuals who, in many cases, never have been involved in treatment
before and have been frustrated with previous attempts at locating
marijuana-specific treatment opportunities. MET provides the overall
theoretical framework, and specified MET strategies are used heavily
during sessions 1 and 2. Although the remaining seven sessions focus
increasingly on skill building rather than motivation, MET concepts and
strategies are incorporated throughout all treatment sessions. The
counselor is encouraged to pay attention to the client's readiness for
change and its implications for treatment engagement and behavioral and
attitudinal changes.

CBT provides a secondary, but complementary, approach in the BMDC model.
The CBT sessions focus on building the client's behavioral, cognitive,
and emotional skills necessary to undertake a major life change such as
stopping marijuana use.

The case management components are introduced in session 3, which is
devoted to identifying life problems that are extraneous to or
aggravated by the client's marijuana problems. The counselor teaches the
client how to access support services to address these additional
problems.

**General Theoretical Assumptions**

***Clinical Engagement and Therapeutic Alliance***

BMDC fosters the development of a strong working alliance between
counselor and client to explore marijuana-related problems, identify
realistic goals, and initiate change strategies. From the outset of
treatment, the counselor focuses on engaging the client in the treatment
process by establishing trust and showing an accurate reflection of the
client's concerns. Throughout treatment, the counselor demonstrates
respect, warmth, and empathy and shows concern for the client's needs.
Any disruptions to the therapeutic relationship are handled carefully
and respectfully.

***Meeting Clients "Where They Are"***

The counselor develops a clear picture of the client's past and current
marijuana use upon admission to treatment, the problems that have been
created through continued use, the reasons the client has identified for
making lifestyle changes related to marijuana, and the goals the client
wants to achieve. An understanding of where the client is on his or her
particular path to abstinence helps the counselor guide growth and
change. The counselor listens to the client's core concerns about
marijuana and his or her treatment goals and provides an environment
that motivates the client to take steps toward recovery. The counselor
does not impose goals or values during the treatment process, nor does
he or she communicate disapproval or judgment about the client's
objectives or readiness to change. Rather, the counselor encourages the
client to express his or her goals and to participate in developing
objectives. This approach presents an apparent conundrum: the client's
goal of abstinence will be served by the therapist's not demanding
abstinence of the client immediately upon entering treatment. It is
important to note that meeting clients "where they are" is a therapeutic
necessity that is consistent with a goal of abstinence.

The client-centered aspects of MET and case management allow the
counselor to adjust session content to a client's background and culture
(Steinberg et al. 2002). Focusing on the individual is not meant to
preclude the client's participating in mutual-help or 12-Step programs
between sessions. If the client shows an interest in attending such
groups, the counselor should make available a list of local meetings.

***Supporting Client Efficacy and Pointing Out Discrepancies***

As the BMDC counselor engages the client in treatment and establishes a
positive working relationship with him or her, the counselor looks for
opportunities to refine goals and examine motivation levels. The
counselor achieves this in a variety of ways, including supporting the
client's efficacy and pointing out discrepancies. Supporting client
efficacy is essential because it communicates belief in the client's
inherent wisdom and ability to solve problems effectively. The counselor
conveys the message that, although treatment entails learning new
techniques or skills for handling difficult problems, the client
possesses the ability to learn, process information, and carry out his
or her plans. Discrepancies may exist between goals and behaviors,
previously stated and currently stated concerns, or perceived benefits
and actual consequences of marijuana use. By pointing out these
discrepancies or inconsistencies to the client the counselor can enhance
the client's motivation and determination.

***Learning About Marijuana Use Patterns***

The BMDC model is based on the principle that substance use disorders
result from learned behavior patterns rather than basic character
defects. The counselor presents this framework to the client as a way of
both understanding how the client's problems developed and thinking
about how to ameliorate the situation. For example, marijuana dependence
can result from repeated use to relieve painful emotions or to
self-medicate. Therefore, recovery from marijuana dependence requires
making new choices involving healthier lifestyle patterns.

**BMDC Therapeutic Tasks**

BMDC is a short-term treatment to assist clients. The BMDC counselor
engages the client in a treatment process that builds on the client's
motivation to change. The approach integrates several models and
accompanying strategies and is flexible within the general treatment
structure. The BMDC treatment approach can be tailored to specific
clinical situations while retaining its specific set of therapeutic
tasks. Those tasks include

> • Encouraging therapeutic engagement
>
> • Performing a thorough assessment of the client's marijuana problem,
> as well as his or her strengths and resources
>
> • Facilitating motivation for change
>
> • Addressing psychosocial problems beyond marijuana use
>
> • Building skills to establish and sustain change.

Client factors such as marijuana problem severity, general acuity, and
psychosocial stresses and supports determine when activities to address
these tasks are initiated.

**Target Population**

BMDC is for people seeking treatment to stop their marijuana use. People
with a pattern of long-term marijuana use may have chronic symptoms of
physiological and psychological dependence as well as impairments in
other life areas, such as family relationships, intrapersonal and
interpersonal capabilities, work, and educational achievement. BMDC has
been effective with clients who participate voluntarily, but whether it
would be effective with individuals who are mandated to treatment is not
known. BMDC appears to be effective with clients who are ambivalent
about stopping their marijuana use; in fact, the treatment model helps
clients explore and resolve such ambivalence (Steinberg et al. 2002).
BMDC has been used in outpatient treatment settings with individuals who
require a low intensity of service. With clients who require more
intensive services or who have significant co-occurring disorders, BMDC
may be used adjunctively with other treatments but should not replace
needed services.

**Structure of BMDC and the Individual Sessions**

BMDC comprises nine sessions that are organized into three sections:

• Getting Started: Assessment Session

• Enhancing Motivation (sessions 1 and 2)

• Changing Marijuana Use Through Skill Building (sessions 3 through 9).

Each section begins with an introduction that provides an overview of
the basic rationale, goals, counselor skills, and client activities that
are used in the sessions in that section. The introduction is followed
by an overview and a specific protocol for each session.

Each session description begins with a box that provides the following
information:

• Session Title

• Total Time

• Delivery Method

• Materials

• Goals for This Session

• Session Outline, including the major subheadings and points to
remember.

The box is followed by a detailed protocol that walks the counselor
through the session content, provides session-specific background
information and rationale, and offers samples of interactions between
counselor and client. *Italicized text* is used to denote a sample
script of what a counselor might say to a client to illustrate a
principle, an example of a possible dialog between a counselor and a
client, or an example of a role play between a counselor and a client.

Although each weekly session is unique in content, each includes the
following three phases:

• **Check-in.** This includes asking the client about recent events,
progress made, and any lapses that may have occurred since the last
session. The counselor also reviews any between-session exercises
assigned during the previous session.

• **Presentation of the session material or skill topic.** This phase is
presented in detail in the session protocol.

• **Summary.** The counselor briefly summarizes the session, asks the
client whether he or she understands major points covered, and provides
clarification as necessary.

**How To Use the Manual**

The counselor should read through the entire manual before beginning
treatment. Counselors should have basic training in both motivational
enhancement and cognitive behavioral treatment techniques, but the
manual provides a solid review of basic principles and information
specific to working with clients who are marijuana dependent.
Supplemental reading C in section VII provides details on BMDC-specific
training.

The detailed session protocols are not designed to be taken into a
session and followed literally. They offer the counselor suggestions on
how to transition from one topic to the next during a session. The
counselor needs to become familiar with the session content before
meeting the client. However, the boxed overview and outline at the
beginning of each session can be pulled out of the manual and taken into
the session to be used as a cue sheet.

The forms used in each session are at the end of that section.
Counselors should make copies of the forms before each session for their
clients.

+-----------------------------------------------------------------------+
| **SECTION III.**                                                      |
|                                                                       |
| **COMMON TREATMENT ISSUES**                                           |
+-----------------------------------------------------------------------+

This section highlights problems that may arise when working with people
who are dependent on marijuana. Clients in Brief Marijuana Dependence
Counseling (BMDC) may differ from clients with mental disorders and from
clients who abuse other substances. For example, this may be the
client's first experience in any type of treatment setting. Clients may
be uncertain about what they are supposed to do in therapy. To alleviate
feelings of uncertainty, a counselor can provide clients with general
information about the client--counselor relationship and treatment
expectations and parameters.

**Client--Counselor Relationship**

In BMDC the client--counselor relationship is at the core of the change
process; a positive relationship is the foundation of treatment. Even
though BMDC treatment is brief, the quality of the relationship is
important.

A strong relationship positively affects compliance and retention. The
counselor can promote the therapeutic relationship through listening
empathically, providing support and encouragement, displaying genuine
concern, responding to client concerns, addressing disagreements
promptly, and providing clarifications and explanations.

The counselor should avoid strategies that may elicit resistance,
including aggressive confrontation of denial, excessive questioning,
interrupting the client, or arguing with the client. The counselor
should respond to client concerns and complaints while providing a
consistent structure for the sessions. Clients who have never
participated in psychotherapy or psychosocial treatment may need extra
guidance about the process of treatment to foster therapeutic
engagement.

**Orienting the Client and Confidentiality**

As part of the assessment session, the counselor spends time describing
the treatment and session format and answering questions. The counselor
provides an overview at the beginning of each session and spends a few
minutes at the end summarizing the topics addressed to help the client
develop a framework for the sessions and retain the material that was
discussed.

The counselor also should discuss confidentiality issues during the
assessment session. The client may be unfamiliar with the
confidentiality of information disclosed in therapy and the limits to
confidentiality. He or she may need updated information on new rules
such as the Health Insurance Portability and Accountability Act.
Although the client may have signed an informed consent or other
admissions forms, the counselor should not assume that the client
understands the issues surrounding confidentiality; it is good clinical
practice to discuss them.

**Preventing Attrition**

During the assessment session, it is important to anticipate potential
obstacles to successful treatment, especially factors that can lead to
early attrition. The counselor should explore any instances in which the
client previously dropped out of treatment and urge the client to
discuss any thoughts of quitting treatment. Open discussion can resolve
problems and prevent the client from dropping out. Progress in treatment
is not steady---there are ups and downs. Most clients experience
hopelessness, anger, frustration, and other negative feelings at times.
Clients should be encouraged to discuss their feelings, even if they
fear that the discussion might be embarrassing or difficult.

The counselor can point out that prematurely terminating treatment may
be one of a series of seemingly irrelevant decisions that eventually
lead to a relapse. For this reason, any hint that a client is
considering dropping out should be taken seriously and discussed fully.

Many clients quit treatment after their first relapse. Clients should be
warned that, even with efforts to maintain abstinence, some might slip
and begin using. They should be encouraged to continue attending after a
using episode so that they can receive help in regaining abstinence,
coping with their reaction to the slip, and avoiding future lapses.

A delicate balance exists between setting the stage for clients to feel
they may return after a lapse and giving them permission to use.
Counselors should ensure that clients understand this distinction
clearly.

***Recognizing Change Readiness***

Following is a list of questions to assist counselors in determining
clients' readiness to accept, continue in, and comply with a change
program (Zweben and O'Connell 1988):

• Has the client missed previous appointments or canceled sessions
without rescheduling?

• If the client was coerced into treatment, have his or her
reactions---anger, relief, confusion, acceptance---to this forced
attendance been discussed?

• Is the client hesitant to schedule future sessions?

• Is treatment different from what the client has experienced before? If
so, have the differences and the client's reactions been discussed?

• Does the client seem guarded during sessions? Is he or she hesitant or
resistant when a suggestion is offered?

• Does the client perceive treatment to be a degrading experience rather
than a new lease on life?

If the answers to these questions suggest a lack of readiness for
change, the counselor may explore the client's uncertainties and
ambivalence about abstinence and change. This could be an opportunity to
use motivational enhancement therapy (MET) strategies to enhance client
determination.

The counselor should proceed carefully with clients who make a
commitment to change too quickly or too emphatically. Even when a person
seems to enter treatment committed to change, his or her motivation
should be assessed before beginning treatment. Likewise, the counselor
should not assume that, once the client has decided to change, he or she
will no longer experience ambivalence.

***Ambivalence***

If the client is reluctant to commit to making a change in behavior, the
counselor should not push too hard. If the client commits to a change he
or she is not ready to make, he or she may drop out of treatment rather
than renege on an agreement. Premature commitment evokes resistance and
undermines the MET process.

The counselor should not assume that ambivalence has been resolved and
commitment is firm. It is safer to assume that the client is still
ambivalent and to continue using motivation-building and
commitment-strengthening strategies.

The counselor should reflect and explore the client's expressions of
uncertainty and ambivalence. It can be helpful to "normalize"
ambivalence and concerns, for example:

**Counselor (C):** *What you're feeling is quite common, especially in
these early stages. Of course you're feeling confused. You're still
attached to smoking, and you're thinking about changing a pattern that
has developed over many years. Give yourself time.*

The counselor also should reinforce any self-motivational statements and
indications of willingness to change and provide reassurances that
people can change, often with only a few consultations. The client may
reconsider resistance to change after accepting that the counselor
understands his or her reasons for being hesitant to change.
Alternatively, pushing the client may result in a treatment dropout.

***Treatment Dissatisfaction***

A client may say that the treatment is not going to help or may want a
different treatment. The counselor should first reinforce the client's
honesty. The counselor should confirm that the client has the right to
quit treatment at any time (unless mandated into treatment), seek help
elsewhere, or decide to work on the problem in another way. The
counselor should explore the client's feelings further. Concerns that
arise in the first session are probably reservations about an approach
the client has not tried. No one can guarantee that a particular
treatment will work, but the counselor can encourage the client to try
it for the planned period. The counselor can add that, should the
problem continue or worsen, other possible approaches can be discussed.

***Compliance Enhancement Procedures***

A variety of strategies can facilitate compliance and overall client
retention in treatment. They include devoting time to educating clients
about treatment participation, treatment expectations, and potential
barriers to involvement in treatment, such as transportation or
childcare needs and work or school conflicts.

***Didactic Material***

The counselor gives brief presentations of the material in clear and
concise language. It is important not to overload clients with too much
material or use a lot of jargon. At the end of each session, the
counselor asks whether the client understands major points of the
presentation rather than assumes that the client comprehends.

**Practice Exercises**

Whenever possible, the counselor encourages the client to complete
between-session practice exercises. The counselor provides a careful
rationale and description of the exercise, gives specific instructions,
and explains how the task relates to treatment goals. The counselor
ensures that the client understands each practice exercise, follows up
on between-session exercises during the next session, and examines
obstacles. When the counselor ignores noncompliance with the exercise,
early dropout may follow.

**Termination**

Termination can be a problem for many clients and can lead to clinical
deterioration or some emotional dysregulation just before the end of
treatment. Several weeks before the last session, the counselor should
review the treatment timetable to sensitize himself or herself and the
client to termination issues. Session 6 is a good time to broach the
topic of termination. The degree of attention to termination can vary
according to the client. As the end of treatment nears, it is useful to
remind the client of the number and the topics of the sessions remaining
and respond to the client's reactions.

The final session explores one of four elective skill topics, but the
counselor should ensure that enough time is devoted to termination
issues. Whatever the structure or content of the final session, the
counselor must allow sufficient time to process the ending of treatment
with the client. Processing includes summarizing what happened in
treatment, discussing aspects of treatment that were most helpful and
least helpful from the client's perspective, eliciting client reactions
and feelings about treatment, and exploring next steps for the client.

**Strategies for Addressing Common Clinical Problems**

The counselor should respond to common clinical problems in a manner
consistent with the treatment approach, that is, reflection and
reframing that follow the principles of MET and, when indicated, a more
active problemsolving approach.

***Counselor's Response to Missed Session***

The counselor should attempt immediately to phone a client who does not
show up for a scheduled therapy session to find out why the session was
missed. Clients sometimes miss sessions because they slipped and are
embarrassed to admit their failure to the counselor or they are
ambivalent about making a permanent change. Careful inquiry by the
counselor reveals which situation is the case.

The counselor should cover six basic points when speaking with the
client again:

• Clarify the reasons for the missed appointment.

• Affirm the client and reinforce him or her for having entered the
program.

• Express eagerness to see the client again.

• Briefly mention serious concerns that have emerged in treatment and
express appreciation (when appropriate) that the client is exploring
them.

• Express optimism about the prospects for change.

• Reschedule the appointment.

If no reasonable explanation (e.g., illness, lack of transportation) is
offered for the missed appointment, the counselor can explore with the
client whether the missed appointment might reflect any of the
following:

• Uncertainty about whether the treatment is needed (e.g., "I don't
really have a problem").

• Ambivalence about making a change.

• Frustration or anger about having to participate in treatment
(particularly in clients who were mandated to enter the program).

• Embarrassment about a relapse. If client's absence was because of a
slip, the counselor should be nonjudgmental and should encourage the
client to come to a session clear headed and process the experience,
noting that both the client and the counselor will learn from the
discussion.

When a client returns to treatment after a missed session, the counselor
should show appreciation.

***Counselor's Response to Slips***

If a client slips and continues to use episodically, making statements
such as "I messed up," "I'm a failure," or "This isn't working," the
counselor can commend the client on his or her honesty and convey the
idea that occasional slips are common in the course of treatment; they
do not mean that the treatment is not working or that the client is a
failure:

**C:** *You may find it hard to stay abstinent. Slips are actually
common occurrences and nothing to feel ashamed about. You were abstinent
for about 3 weeks before the slip. That was a significant amount of
time! What are some things you can do to remain abstinent and not slip?*

***Goal of Abstinence From Marijuana***

Marijuana Treatment Project participants were told that their counseling
would focus on achieving abstinence. It was made clear, however, that
individuals who wanted to reduce use would not be dropped automatically
from the program. People working toward a moderation objective were
encouraged to learn to be abstinent for several months. The rationale
for this suggestion included two main points:

> 1\. *Learning refusal skills during a period of abstinence develops
> many important strengths needed to become permanently abstinent.*
>
> 2\. *A period of abstinence likely gives the client more information
> about what it is like not being intoxicated on an ongoing basis.*

When following the BMDC approach, the counselor explains that ambivalent
feelings about accepting abstinence as a goal are common. He or she
encourages the client to discuss these feelings and any slips that
occur. In addition, clients whose initial goals were to reduce use may
make abstinence their new goal later.

***Handling Marijuana Use or Intoxication***

Before beginning treatment, the client should be told to refrain from
using any substances. This should be communicated in a nonpunitive way,
with the counselor explaining that the client can benefit most from the
sessions if he or she is not under the influence of marijuana or other
substances. Clients also might receive a handout with this expectation
highlighted.

If a client comes to a session intoxicated, the counselor can proceed in
several ways. The counselor should determine during the check-in what
the client's use pattern has been since the last session and make a
clinical judgment about whether the session should be rescheduled. For
example, if the client appears to be intoxicated (e.g., has difficulty
concentrating on the content of the session, seems unusually tangential
in speech pattern), the counselor should suggest that they reschedule.
If the counselor reschedules because of the client's appearing
intoxicated, the treatment program should find alternative
transportation home so that the client does not drive. Anyone asked to
leave a session is encouraged to return to the next session abstinent
and to continue in treatment. If the client smoked marijuana shortly
before the appointment, but the counselor determines that the client can
participate meaningfully in the session, the session can proceed as
planned.

The client should be given specific guidelines for handling the
immediate aftermath of a using episode. He or she should be advised to
get rid of the marijuana, leave the setting in which the using occurred,
and call someone for help (a spouse, a friend, or the supporter
identified in session 2). The client should be cautioned about the
feelings of guilt and self-blame that often accompany a slip and warned
not to allow such reactions to prompt further drug use. Sessions 4, 5,
6, and 7 and elective skill topic 1 provide specific guidelines on
preventing and handling slips.

***Marijuana Withdrawal***

Some clients report withdrawal symptoms such as flulike symptoms,
increased anxiety, or difficulty sleeping after they stop using
marijuana. These symptoms usually are not severe, start 12 to 24 hours
after the last use, and last less than 2 weeks. In most cases,
withdrawal symptoms are manageable without medical intervention. Clients
can be encouraged to use behavioral strategies such as relaxation
techniques for anxiety or to decrease caffeine intake for insomnia.
However, if a client either reports having severe withdrawal symptoms or
anticipates having a difficult time based on previous experience, the
counselor can suggest that the client see a physician for assistance and
request permission to discuss the problem with the client's primary care
physician. In some cases, the client may show more severe problems with
anxiety, depression, or cognitive functioning than normally expected
from a withdrawal syndrome. In these circumstances, the counselor can
suggest that the client see a psychiatrist for an assessment and
possible assistance during and after the withdrawal period.

***Use of Alcohol***

Abstinence from alcohol should be determined on a client-by-client
basis. The counselor might point out that some individuals find that
overcoming marijuana dependence is more likely if they abstain from
drinking alcohol. The client who is concerned about being tempted to
substitute alcohol for marijuana should stop all use of alcohol. If a
counselor determines that a client has begun to abuse other drugs or
alcohol during this treatment approach, the client should be treated
appropriately.

***Clients With Special Needs***

It is important to be sensitive to the special needs of clients. For
example, clients with children may need flexible schedules or assistance
with childcare. Some clients may be cognitively impaired or function at
a generally low cognitive level and need adaptations in the treatment
approach or techniques that increase the likelihood of their absorbing
the material. Strategies may include additional practice with new
behavioral skills and repetition of key concepts. The counselor may
minimize the use of long and complex sentences or condense the
information from cognitive behavioral session handouts (forms in
sessions 3--9) onto index cards for some clients. The client-centered
aspects of MET allow the counselor to adapt the sessions to the client's
needs.

***Arranging for Additional or Followup Treatment***

The counselor and client should address the need for additional care.
For example, some clients with a substance use disorder have
co-occurring mental disorders, most commonly depression. The counselor
is encouraged to assess the presence and severity of other problems that
might require attention. The counselor can explain that the client can
continue to make progress after treatment ends because the client now
has the skills and the ability to continue to improve and progress as
these skills are used in new situations. If after a careful discussion
of these issues, the client asks for a referral or information about
further substance abuse treatment, the counselor can provide this
information readily.

**Summary**

The counselor has a complex task that involves relationship building,
teaching, supporting, encouraging, monitoring progress and setbacks, and
recognizing signs that the client may be withdrawing from treatment or
losing his or her motivation to change. The counselor views these common
clinical problems as part of the treatment process that can lead to
client growth and the strengthening of the therapeutic alliance.

+-----------------------------------------------------------------------+
| **SECTION IV.**                                                       |
|                                                                       |
| **GETTING STARTED: ASSESSMENT SESSION**                               |
+-----------------------------------------------------------------------+

This section guides counselors through the assessment session. It
outlines strategies for assessing individuals who present for Brief
Marijuana Dependence Counseling (BMDC) treatment. These people have been
determined to be appropriate for treatment based on a brief telephone
contact or an initial triage or evaluation appointment.

The BMDC assessment session focuses on building rapport with the client
while assessing his or her marijuana use. This section includes
diagnosis and assessment instruments. The assessment findings are used
to complete the *Personal Feedback Report* (PFR), which the counselor
reviews with the client in subsequent sessions. An accurate assessment
provides data that can be used as

> • A starting point for therapy
>
> • Motivation and feedback for the client
>
> • A measure of therapy outcomes over time.

**Building Rapport**

One of the most important aspects of treatment, especially during the
assessment session, is building rapport; through expressions of warmth,
support, and empathy, the counselor gets to know the client. Although
the assessment session focuses primarily on gathering information, the
rapport established during this session defines the client--counselor
relationship for remaining sessions.

**Assessing Marijuana Use**

BMDC uses the criteria identified in *Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition* (DSM-IV) (American Psychiatric
Association 1994), to diagnose marijuana dependence (exhibit IV-I) and
marijuana abuse (exhibit IV-2). These criteria help the counselor
determine a client's level of substance involvement and the associated
consequences, as well as appropriate level of treatment. These criteria
also can be used in later sessions to measure treatment effectiveness.

The symptoms of substance dependence typically are assessed first;
substance abuse is considered a less severe substance use disorder, and
its symptoms are assessed only if the client does not meet the criteria
for a diagnosis of substance dependence. For this reason, tolerance,
withdrawal, and symptoms describing impaired control over use are not
included in the diagnosis of substance abuse. However, it may be useful
to complete the assessment of abuse criteria even if dependence has been
diagnosed to learn more about the nature and extent of negative
consequences that result from the dependent use pattern.

The guidelines presented here will help the counselor make a diagnosis
of marijuana dependence or abuse. If the counselor does not have the
credentials required for making a diagnosis, he or she must receive
verification from a State-qualified individual.

+-----------------------------------------------------------------------+
| **Exhibit IV-I. DSM-IV Substance Dependence Criteria**                |
+-----------------------------------------------------------------------+
| > 1\. Tolerance, as defined by either of the following:               |
| >                                                                     |
| > • A need for markedly increased amounts of the substance to achieve |
| > intoxication or desired effect                                      |
| >                                                                     |
| > • Markedly diminished effect with continued use of the same amount  |
| > of the substance.                                                   |
| >                                                                     |
| > 2\. Withdrawal, as manifested by either of the following:           |
| >                                                                     |
| > • The characteristic withdrawal syndrome for the substance          |
| >                                                                     |
| > • The substance is taken to relieve or avoid withdrawal symptoms.   |
| >                                                                     |
| > 3\. The substance is often taken in larger amounts or over a longer |
| > period than was intended.                                           |
| >                                                                     |
| > 4\. There is a persistent desire or unsuccessful efforts to cut     |
| > down or control substance use.                                      |
| >                                                                     |
| > 5\. A great deal of time is spent in activities necessary to obtain |
| > the substance, use the substance, or recover from its effects.      |
| >                                                                     |
| > 6\. Important social, occupational, or recreational activities are  |
| > given up or reduced because of substance use.                       |
| >                                                                     |
| > 7\. The substance use is continued despite knowledge of having a    |
| > persistent or recurrent physical or psychological problem that is   |
| > likely to have been caused by or exacerbated by the substance.      |
| >                                                                     |
| > Reprinted with permission from the *Diagnostic and Statistical      |
| > Manual of Mental Disorders,* Copyright 1994. American Psychiatric   |
| >                                                                     |
| > Association (1994).                                                 |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Exhibit IV-2. DSM-IV Substance Abuse Criteria**                     |
+-----------------------------------------------------------------------+
| > 1\. Recurrent substance use resulting in a failure to fulfill major |
| > role obligations at work, school, or home                           |
| >                                                                     |
| > 2\. Recurrent substance use in situations in which it is physically |
| > hazardous                                                           |
| >                                                                     |
| > 3\. Recurrent substance-related legal problems                      |
| >                                                                     |
| > 4\. Continued substance use despite having persistent or recurrent  |
| > social or interpersonal problems caused by the effects of the       |
| > substance                                                           |
|                                                                       |
| Reprinted with permission from the *Diagnostic and Statistical Manual |
| of Mental Disorders,* Copyright 1994. American Psychiatric            |
|                                                                       |
| Association (1994).                                                   |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Overview of Assessment Session: Building Rapport and Assessing      |
| Marijuana Use**                                                       |
|                                                                       |
| **Total Time:** 1 hour, 30 minutes (1 hour, 20 minutes for session;   |
| 10 minutes to prepare PFR)                                            |
|                                                                       |
| **Delivery Method:** MET-focused individual therapy                   |
|                                                                       |
| **Materials (all forms include instructions and are at the end of     |
| this section):**                                                      |
|                                                                       |
| > • *Sample Timeline Follow-Back Calendar* for past month (form AS1)  |
| >                                                                     |
| > • *Timeline Follow-Back Grid* (form AS2)                            |
| >                                                                     |
| > • *Timeline Follow-Back Marijuana Use Summary Sheet* (form AS3)     |
| >                                                                     |
| > • *Structured Clinical Interview for DSM-IV* (form AS4)             |
| >                                                                     |
| > • *Marijuana Problem Scale* (form AS5)                              |
| >                                                                     |
| > • *Reasons for Quitting Questionnaire* (form AS6)                   |
| >                                                                     |
| > • *Self-Efficacy Questionnaire* (form AS7)                          |
| >                                                                     |
| > • *Personal Feedback Report* and percentage tables (form AS8)       |
|                                                                       |
| **Goals for This Session:**                                           |
|                                                                       |
| > • To build rapport with the client, creating a nonthreatening       |
| > therapeutic environment                                             |
| >                                                                     |
| > • To collect and document baseline marijuana use information to     |
| > monitor therapeutic outcomes                                        |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > 1\. Build rapport and give an overview of the assessment process    |
| >                                                                     |
| > 2\. Conduct an overview assessment using open-ended and summary     |
| > questions                                                           |
| >                                                                     |
| > 3\. Use the timeline follow-back (TLFB) method to assess marijuana  |
| > use                                                                 |
| >                                                                     |
| > • Complete the *TLFB Calendar* (form AS1)                           |
| >                                                                     |
| > • Complete the *TLFB Grid* (form AS2)                               |
| >                                                                     |
| > • Complete the *TLFB Marijuana Use Summary Sheet* (form AS3)        |
| >                                                                     |
| > 4\. Administer the *Structured Clinical Interview for DSM-IV* (form |
| > AS4)                                                                |
| >                                                                     |
| > • Assess substance dependence                                       |
| >                                                                     |
| > • Assess substance abuse                                            |
| >                                                                     |
| > 5\. Explain and ask client to complete the *Marijuana Problem       |
| > Scale* (form AS5); evaluate consequences of marijuana use           |
| >                                                                     |
| > 6\. Administer *Reasons for Quitting Questionnaire* (form AS6);     |
| > evaluate reasons for seeking treatment                              |
| >                                                                     |
| > 7\. Explain and ask client to complete *Self-Efficacy               |
| > Questionnaire* (form AS7); assess targets for intervention          |
| >                                                                     |
| > 8\. Conclude the session                                            |
| >                                                                     |
| > 9\. Prepare the PFR before session 1                                |
+-----------------------------------------------------------------------+

**Assessment Session Protocol**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor assesses the client's marijuana
use while laying the foundation for a positive client--counselor
relationship.

***Build Rapport and Give an Overview of the Assessment Process***

To build rapport and engage the client during the assessment session,
the counselor informs the client about the sequence of events for this
session and what to expect in the overall treatment approach.
Introducing session topics, providing information, and responding to
client concerns are the primary tasks during this part of the session.
The counselor could begin the first session of BMDC with the following
introduction:

**Counselor (C):** *Let's talk about what we'd like to accomplish in the
assessment session. We need a clear description of your marijuana
use---how much marijuana you use, how often you use it, and what types
of problems marijuana might be causing you. I'll ask you detailed
questions about your marijuana and other drug and alcohol use, and I'll
also ask you questions about how marijuana use has affected your daily
life.*

*I'll summarize this information in the* Personal Feedback Report *that
I'll give you during our next session. We'll use the PFR to compare your
marijuana consumption with national averages and to get an idea about
how to set your treatment goals. The session will take about 1 hour and
20 minutes. Some questions may be difficult to answer and a real test of
your memory; just do your best to be honest and patient! Remember that
the information is confidential and is used only to help you accomplish
your therapy goals.*

***Conduct an Overview Assessment Using Open-Ended and Summary
Questions***

Most assessment tools, including a few presented later in the session,
use closed-ended questions *(How many days in the past month did you
smoke marijuana?)*, but the counselor starts the session by using
open-ended questions to engage the client (*Tell me about your marijuana
use pattern over the last month*) before transitioning to more detailed
tasks. Open-ended questions allow the counselor to establish a dialog
with the client and build rapport by

> • Showing genuine interest
>
> • Conveying a nonjudgmental and accepting attitude
>
> • Demonstrating the ability to track accurately what the client is
> saying
>
> • Expressing empathy with the client.

The dialog might go as follows:

**C:** *How did you hear about this program?*

**Shirley (S):** *I've seen the ads in the paper for several weeks.
Originally my husband left one on the kitchen table for me.*

**C:** *You've worked with your husband to get here, and the two of you
have given this a great deal of thought. Have you tried to quit on your
own?*

**S:** *I try to quit almost every day, or at least I think about it.
I'm going to be an elementary school teacher; in fact, I'm doing my
student teaching now. I feel that quitting is the right thing to do---to
be a good example to the kids. But nothing ever changes.*

**C:** *But you keep trying. What brings you here today?*

**S:** *Well, I know someday I will quit, and I've been looking at the
ad for this program. I never thought anyone would offer treatment for
pot smokers!*

**C:** *This was the opportunity you were waiting for. What would you
like to see happen as a result of coming to treatment?*

**S:** *I guess I thought I'd get help on how to quit. But I realize
that ultimately it's up to me, and it's way past time to do something.*

**C:** *You understand that it's your decision on what to do, but you
also think that being here might help you. How confident are you at this
point that you'll succeed?*

***Use the TLFB Method To Assess Marijuana Use***

The assessment or evaluation component of this session can be a powerful
element of treatment. Marijuana Treatment Program (MTP) participants
reported increased motivation after receiving feedback from
assessment-related activities.

During the session the counselor and client complete several forms to
assess the client's marijuana use. Quantity of marijuana use is
difficult to measure because of varying potency levels and smoking
methods (e.g., pipe, joint); therefore, frequency of use is the most
reliable criterion for consumption measures. The TLFB method helps the
counselor and client identify patterns and possible consequences of use
(Sobell and Sobell 2000; Sobell et al. forthcoming). For instance, a
person who uses heavily on weekends may be at risk of driving an
automobile while high. A chronic, daily use pattern might indicate that
an individual has developed cannabis dependence. In addition to
providing a precise measure of marijuana consumption, the TLFB method
can assess changes in a client's marijuana use and helps the counselor
determine treatment effectiveness. The counselor begins by asking the
client to estimate generally how many days and how many times a day he
or she smoked marijuana in the past month:

**C:** *In the past month, about how many days did you smoke marijuana?*
\[Waits for client's response before asking the next question.\] *In the
past month, on a typical day when you smoked marijuana, about how many
times per day did you smoke?*

Once the counselor has a general sense of the client's use, the formal
TLFB assessment process begins. The counselor uses the following
instruments to assess the pattern, severity, and nature of the client's
marijuana use:

> • *TLFB Calendar* for the past month (form AS1)
>
> • *TLFB Grid* (form AS2)
>
> • *TLFB Marijuana Use Summary Sheet* (form AS3).

The counselor uses the *TLFB Calendar* to help the client recall his or
her marijuana use and the *TLFB Grid* to record summary information from
the completed calendar. When completed, the *TLFB Marijuana Use Summary
Sheet* provides an overview of basic information about the client's
marijuana use, alcohol consumption, and tobacco smoking. (The *TLFB
Calendar* and *TLFB Marijuana Use Summary Sheet* procedures are modified
from procedures developed by Sobell and Sobell \[1992, 2000, 2003\] and
Sobell and colleagues \[forthcoming\]. Some administration guidelines
are adapted from the Form 90 procedure developed by Miller \[1996\].)

*Complete the* TLFB Calendar

The counselor begins by developing a detailed history of daily marijuana
use for a specified period, called the *assessment window*. This manual
suggests an assessment window of 1 month. To arrive at a diagnosis of
dependence or abuse, the DSM-IV advises that symptoms be present for 12
months. However, assessing symptoms for the last 12 months may tell
little about the client's current use, especially if the client's use
pattern has changed significantly over the year prior to entering
treatment. (If the client had attempted to quit using or cut back usage
in preparation for treatment, the counselor should ask the client to
recall a period of usual marijuana use.) Understanding marijuana use at
treatment entry is helpful for treatment planning and for motivating the
client to change. The TLFB method uses memory aids (exhibit IV-3) to
help the client recall his or her marijuana use. The counselor and
client select a month to investigate. The counselor fills in the days on
the *TLFB Calendar* (form AS1) and indicates which days in that
particular month are holidays or other special days for the client (see
exhibit IV-4 for a sample).

+-----------------------+-----------------------+-----------------------+
| **Exhibit IV-3. Key   |                       |                       |
| Events To Record on   |                       |                       |
| the Calendar**        |                       |                       |
+-----------------------+-----------------------+-----------------------+
| **Atypical Events**   | **Recurring Events**  | **Discrete Events**   |
+-----------------------+-----------------------+-----------------------+
| > • Holidays          | > • Paydays           | > • Jail time         |
| >                     | >                     | >                     |
| > • Birthdays         | > • Religious         | > • Hospitalizations  |
| >                     | > services            | >                     |
| > • Anniversaries     | >                     | > • Illness           |
| >                     | > • School or classes | >                     |
| > • Parties           | >                     | > • Treatment         |
| >                     | > • Standing          |                       |
| > • Medical           | > appointments        |                       |
| > appointments        | >                     |                       |
| >                     | > • Child visitations |                       |
| > • Accidents         | >                     |                       |
| >                     | > • Meetings          |                       |
| > • Court appearances | >                     |                       |
| >                     | > • Work schedule     |                       |
| > • Beginning or      | >                     |                       |
| > termination of      | > • Weekends          |                       |
| > employment          |                       |                       |
| >                     |                       |                       |
| > • Marital arguments |                       |                       |
| >                     |                       |                       |
| > • Vacations         |                       |                       |
| >                     |                       |                       |
| > • Separations or    |                       |                       |
| > reconciliations     |                       |                       |
| >                     |                       |                       |
| > • Sporting events   |                       |                       |
| >                     |                       |                       |
| > • Major news events |                       |                       |
| >                     |                       |                       |
| > • Concerts          |                       |                       |
+-----------------------+-----------------------+-----------------------+

The calendar is used as a memory aid. The counselor asks the client to
recall daily consumption of marijuana by linking memories to salient
life events. The counselor mentions recurring and atypical events to
help the client recall his or her marijuana use. Recurring events (e.g.,
work schedule, payday) provide a context for describing typical
marijuana use patterns (e.g., client always buys marijuana on payday and
smokes all day on days off). Atypical events (e.g., medical appointment,
marital argument) provide anchor points for describing exceptions to a
regular use pattern (e.g., client did not smoke on the day of a medical
appointment; smoked more on the day of a marital argument). Discrete
events (e.g., jail time, hospitalizations) help identify use and nonuse
periods:

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="28"><strong>Exhibit IV-4. Sample Completed
Calendar</strong></td>
</tr>
<tr class="even">
<td colspan="28">December 2002</td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Sunday</strong></td>
<td colspan="4"><strong>Monday</strong></td>
<td colspan="4"><strong>Tuesday</strong></td>
<td colspan="4"><strong>Wednesday</strong></td>
<td colspan="4"><strong>Thursday</strong></td>
<td colspan="4"><strong>Friday</strong></td>
<td colspan="4"><strong>Saturday</strong></td>
</tr>
<tr class="even">
<td colspan="4"><p><strong>1</strong></p>
<p><strong>-------------------</strong></p>
<p><strong>Church/visit mom</strong></p></td>
<td colspan="4"><p><strong>2</strong></p>
<p><strong>----------------------</strong></p></td>
<td colspan="4"><p><strong>3</strong></p>
<p><strong>----------------------</strong></p></td>
<td colspan="4"><p><strong>4</strong></p>
<p><em><strong>Typical Pattern</strong></em></p>
<p><strong>------------------------</strong></p></td>
<td colspan="4"><p><strong>5</strong></p>
<p><strong>----------------------Payday</strong></p></td>
<td colspan="4"><p><strong>6</strong></p>
<p><strong>----------------------</strong></p></td>
<td colspan="4"><p><strong>7</strong></p>
<p><strong>-------</strong></p></td>
</tr>
<tr class="odd">
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
</tr>
<tr class="even">
<td colspan="4"><p><strong>8</strong></p>
<p><strong>Church/visit mom</strong></p></td>
<td colspan="4"><strong>9</strong></td>
<td colspan="4"><strong>10</strong></td>
<td colspan="4"><strong>11</strong></td>
<td colspan="4"><strong>12</strong></td>
<td colspan="4"><p><strong>13</strong></p>
<p><strong>-------------------</strong></p>
<p><strong>Funeral - Ohio</strong></p></td>
<td colspan="4"><p><strong>14</strong></p>
<p><strong>A</strong></p>
<p><strong>-----------------</strong></p>
<p><strong>Ohio</strong></p></td>
</tr>
<tr class="odd">
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><p><strong>15</strong></p>
<p><strong>A</strong></p>
<p><strong>---------------</strong></p>
<p><strong>Ohio</strong></p></td>
<td colspan="4"><p><strong>16</strong></p>
<p><strong>-------------------</strong></p>
<p><strong>Ohio (home)</strong></p></td>
<td colspan="4"><strong>17</strong></td>
<td colspan="4"><strong>18</strong></td>
<td colspan="4"><p><strong>19</strong></p>
<p><strong>Payday</strong></p></td>
<td colspan="4"><p><strong>20</strong></p>
<p><strong>Christmas party @ work</strong></p></td>
<td colspan="4"><strong>21</strong></td>
</tr>
<tr class="odd">
<td colspan="4"><p><strong>22</strong></p>
<p><strong>Church/visit mom</strong></p></td>
<td colspan="4"><p><strong>23</strong></p>
<p><strong>Day off</strong></p></td>
<td colspan="4"><p><strong>24</strong></p>
<p><strong>Day off</strong></p>
<p><strong>Christmas Eve</strong></p></td>
<td colspan="4"><p><strong>25</strong></p>
<p><strong>A</strong></p>
<p><strong>Christmas</strong></p></td>
<td colspan="4"><strong>26</strong></td>
<td colspan="4"><strong>27</strong></td>
<td colspan="4"><strong>28</strong></td>
</tr>
<tr class="even">
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
</tr>
<tr class="odd">
<td colspan="4"><p><strong>29</strong></p>
<p><strong>Church/visit mom</strong></p></td>
<td colspan="4"><strong>30</strong></td>
<td colspan="4"><p><strong>31</strong></p>
<p><strong>New Year’s Eve</strong></p>
<p><strong>party @ house</strong></p></td>
<td colspan="4" rowspan="2"></td>
<td colspan="4" rowspan="2"></td>
<td colspan="4" rowspan="2"></td>
<td colspan="4" rowspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td></td>
<td></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
<td><strong>X</strong></td>
</tr>
</tbody>
</table>

C: *I'd like to start by asking you questions about your marijuana use,
other drug use, and drinking during the period from about a month ago
until yesterday.* \[Places the calendar in front of the client.\] *We'll
reconstruct this period by using notes on the calendar to help you
remember things that have happened to you. Then we'll use these events
to help you remember when you used marijuana on each day.*

After the counselor and client determine on which days the client
smoked, they record the number of smoking episodes per day by breaking
each calendar day into four quadrants. (As the client breaks down daily
use into quadrants, it may be helpful for the counselor to have a card
that lists the quadrants for the client to refer to.) The four boxes on
each calendar day in exhibits IV-4 and IV-5 correspond to these
following quadrants:

• Quadrant 1 = 6 a.m. to 12 noon (morning)

• Quadrant 2 = 12 noon to 6 p.m. (daytime)

• Quadrant 3 = 6 p.m. to midnight (evening)

• Quadrant 4 = 12 midnight to 6 a.m. (nighttime).

For instance, in the example in exhibit IV-5, the client smoked in the
second and third quadrants on December 22, in all quadrants on December
23, and in the first quadrant on December 24. The counselor explains
that this information reveals the context in which marijuana use occurs.

<table>
<colgroup>
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="12"><strong>Exhibit IV-5. Using Quadrants To Determine Use
Frequency</strong></td>
</tr>
<tr class="even">
<td colspan="4"><strong>December 22</strong></td>
<td colspan="4"><strong>December 23</strong></td>
<td colspan="4"><strong>December 24</strong></td>
</tr>
<tr class="odd">
<td colspan="4">Church/visit mom</td>
<td colspan="4">Day off</td>
<td colspan="4"><p>Day off</p>
<p>Christmas Eve</p></td>
</tr>
<tr class="even">
<td></td>
<td>X</td>
<td>X</td>
<td></td>
<td>X</td>
<td>X</td>
<td>X</td>
<td>X</td>
<td>X</td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

The counselor records any other drug or alcohol use that occurred during
the assessment window. By asking questions about alcohol and drug use,
the counselor determines whether the client is substituting other drugs
or alcohol on days when marijuana is not used.

Once the memorable events have been recorded, the counselor focuses on
the client's longest span of invariant or unchanging behavior, such as
abstinence, and determines whether a steady marijuana use pattern
exists:

**C:** *Looking at the calendar and thinking about these events, what is
the longest period you can remember when you went without smoking at
all?*

If the client has had a reasonably consistent pattern of use from week
to week, the counselor asks him or her to describe a typical week and to
identify the weeks during the period that fit the steady pattern and
record those weeks on the calendar:

**C:** *During this period when you were using marijuana, was your
pattern of use similar from one week to the next? Although a person's
marijuana use will vary from day to day, I'm wondering whether there was
any consistency from week to week.*

The counselor starts with weekdays, beginning in one quadrant and moving
through the week for that quadrant, the second quadrant, and so on:

**C:** *Could you describe a usual or typical week of marijuana use?
Thinking about a typical week, starting with weekdays, Monday through
Friday, did you normally use marijuana in the morning, between 6 a.m.
and noon?*

This phrasing encourages the client to report use in the morning. The
client points out variations in day-to-day use (e.g., *I smoke before I
go to work on 2 mornings a week*). The counselor records variations on
particular days. After constructing the morning quadrants, the counselor
proceeds until all the appropriate quadrants have been checked to
establish the weekday pattern. The counselor then asks about weekend
use. This exercise reveals the client's steady use pattern during the
assessment window.

The counselor and client now turn to reconstructing the client's use on
days when no pattern exists. If the client reports no consistent
pattern, the entire assessment window must be constructed one day at a
time.

For days not covered by pattern or abstinent days, the counselor focuses
on days immediately before and after invariant periods (such as periods
of abstinence and steady pattern use):

**C:** *What happened at this point? How did your marijuana use change?*

To help the client recall use, the counselor focuses on events that
affect the availability of marijuana and the client's marijuana use
(e.g., hospitalizations, family outings, work changes). The counselor
pays close attention to inconsistencies in the client's descriptions of
marijuana use and asks questions to ensure that the information is
accurate.

*Complete the* TLFB Grid

The *TLFB Grid* (form AS2) is used to summarize and record calendar data
and to monitor changes over time. The grid provides spaces for the
counselor to total the days of use under various categories. When the
information is presented on the grid, the counselor and client see use
patterns emerge (e.g., the client usually smokes late at night or before
work). Additional grids can be filled out in later sessions and compared
with this baseline grid to monitor changes over time and help determine
causes for slips or relapses.

*Complete the* TLFB Marijuana Use Summary Sheet

The counselor uses the *TLFB Marijuana Use Summary Sheet* (form AS3) to
gather additional information about the client's marijuana consumption
prior to entering treatment. The counselor asks questions that help the
client think about and summarize his or her marijuana use, including use
in hazardous situations (e.g., taking care of children, driving). The
*TLFB Marijuana Use Summary Sheet* increases awareness of the frequency
of using marijuana, other drugs, alcohol, and tobacco and often elicits
concerns from the client. These stated concerns can increase motivation
to change.

***Administer the* Structured Clinical Interview for DSM-IV**

Several self-report scales assess substance dependence and substance
abuse symptoms, but none assesses specifically for marijuana.
Identification of cannabis use disorders is accomplished most reliably
using a structured interview to assess diagnostic criteria. The
*Structured Clinical Interview for DSM-IV* (SCID-IV) (form AS4) used in
this manual has been adapted for clients who use marijuana (First et al.
1996). A typical structured interview starts with objective questions to
obtain a brief history of the client's substance use and proceeds
through a series of questions that assess for the presence of DSM-IV
diagnostic criteria for dependence (questions 1 through 7) and abuse
(questions 8 through 11). Each objective question can be followed by
open-ended prompts to elicit information relevant to the symptom being
assessed.

The counselor asks the client each SCID-IV question and circles the
appropriate clinical rating for the response. If the counselor is
convinced that a particular symptom is present, he or she should not
allow a client's denial of the symptom to go unchallenged. In rare
cases, an item may be rated as present even when the client steadfastly
denies it. It is not necessary for the client to agree that the symptom
is present. The counselor uses all sources of information, including the
forms completed in the TLFB process, to determine the appropriate rating
for the client in response to SCID-IV questions. In some cases, the
counselor may need to explore discrepancies between the client's account
and other sources of information. Form AS4 provides additional
instructions for completing the SCID-IV.

*Information for Assessing Cannabis Dependence Criteria*

To administer the SCID-IV and assess for the presence of each symptom,
it is important to understand the intent of substance use disorder
criteria and the ways in which symptoms can be manifested in people who
use marijuana.

*Tolerance.* Tolerance refers to needing more or higher quality
marijuana to get high than when the client first began using it (DSM-IV
symptom 1 in exhibit IV-1; SCID-IV question 6, *Have you found that you
need to use a lot more or higher quality marijuana to get high than you
did when you first started using it regularly?*). This symptom reflects
the body's adaptation to or compensation for the chronic presence of
marijuana, and it may predict the development of withdrawal symptoms if
use continues. To determine tolerance level, the counselor asks the
client to compare the current effects of marijuana with past effects.

According to DSM-IV, the client must use at least 50 percent more
marijuana than when he or she first started using to meet the tolerance
criterion, so it is important to ask the client to quantify how much
more is used now to achieve the same effect compared with when he or she
began to smoke regularly. The tolerance criterion can be met if the
client reports markedly diminished effects from the same amount of
marijuana that used to get him or her high.

*Withdrawal.* Withdrawal symptoms associated with cessation of cannabis
use are another indication that the body has made physiological
adaptations to the presence of cannabinoids and may motivate the person
to continue using (DSM-IV symptom 2 in exhibit IV-1; SCID-IV question 7,
*In the past month, have you had withdrawal symptoms? Have you felt sick
when you cut down or stopped using? Or after not using for a few hours
or more, have you smoked to keep from getting sick?*). Although a
cannabis withdrawal syndrome is not described in DSM-IV, symptoms
associated with marijuana cessation have been documented in several
studies. Withdrawal symptoms can include

• Appetite disturbance • Sleep disturbance (e.g., vivid dreams)

• Night sweats • Headaches

• Nausea • Irritability

• Restlessness

In general, when withdrawal symptoms occur, they are present for a short
period (i.e., a few days to 2 weeks). It is not known to what extent
these symptoms motivate continued use of marijuana or whether they play
a clinically meaningful role in the process of modifying marijuana use.
However, more than half the clients presenting for treatment report
experiencing some withdrawal symptoms or continuing to use marijuana to
avoid withdrawal symptoms. The counselor asks the client about the
occurrence of withdrawal symptoms when he or she has cut down or stopped
using *and* whether he or she used marijuana to avoid withdrawal
symptoms. If the client acknowledges either experience, then the
criterion for this symptom is met.

*Impaired control.* To assess impaired control over use, the counselor
asks whether the client often ended up smoking more than was intended
and whether he or she sometimes smoked for a longer period than was
intended (DSM-IV symptom 3 in exhibit IV-1; SCID-IV question 1, *In the
past month, have you found that, when you started using marijuana, you
ended up smoking much more of it than you were planning to?* or *Have
you used it over a much longer period than you were planning to?*; an
affirmative answer to either question should lead the counselor to
inquire about specific instances and the circumstances leading to
overuse). The repeated failure to terminate marijuana use as planned is
evidence of impaired control.

Impaired control over marijuana use also is assessed by asking whether
the client has made repeated unsuccessful attempts to quit or reduce use
or has had a persistent desire to do so (DSM-IV symptom 4 in exhibit
IV-1; SCID-IV question 2, *In the past month, have you tried to cut down
or stop using marijuana?* or *Did you ever stop using altogether?*).
Typically, these attempts include self-imposed rules or other strategies
to avoid marijuana entirely or to limit the frequency of use. It is
useful to ask specifically about the number of times the client has
attempted to cut down during the period being assessed and whether these
attempts were because of concern about the extent of use. Resumption of
marijuana use after seeking professional help or joining a mutual-help
group (e.g., Narcotics Anonymous) is evidence of lack of success. These
experiences suggest impairment in control. If the client denies any
attempts at reducing marijuana use, the counselor asks specifically
whether he or she would like to stop or reduce use but has not done so
for some reason. Evidence of impaired control includes the client's
wanting to stop or reduce use but not making an attempt because he or
she knew that the attempt would be unsuccessful.

*Salience.* An important aspect of dependence relates to the primacy of
the substance in a person's life. The salience of marijuana is
investigated by asking the client about how much time he or she spends
obtaining it, using it, and recovering from its effects (DSM-IV symptom
5 in exhibit IV-1; SCID-IV question 3, *In the past month, did you spend
a lot of time using marijuana or doing whatever you had to do to get
it?*). The phrase "a lot of time" is not defined precisely, but it often
becomes clear that marijuana-related activities occupy an excessive
amount of time. For instance, if the client is intoxicated on marijuana
most of the day, most days of the week, for a month or more, then
salience is apparent. At other times, the counselor determines the
appropriateness of the amount of time given to marijuana-related
activities. If marijuana use is confined to recreational times of the
day or week, this symptom may not be present.

Another determinant of the salience of marijuana can be when the client
reports that he or she has given up or reduced involvement in important
social, occupational, or recreational activities because of marijuana
use (DSM-IV symptom 6 in exhibit IV-1; SCID-IV question 4, *In the past
month, did you use marijuana so often that you used it instead of
working or spending time on hobbies or with your family or friends?*; a
yes response to this question indicates that marijuana use has a higher
priority than activities such as work or spending time with friends or
family, hobbies, or exercising.) This breakdown in the normal processes
of social control is an indication of dependence on the drug.

The persistence of marijuana use despite knowledge that it causes or
exacerbates psychological or physical problems is an indication of
either the salience of the drug or impaired control over its use (DSM-IV
symptom 7, exhibit IV-1; SCID-IV question 5, *Do you forget things or
have trouble concentrating? Are you anxious or sad a lot? Has marijuana
caused you physical problems such as difficulty breathing, many colds,
or a chronic cough? Has it made a physical problem worse?*).

The counselor assesses whether marijuana use leads to problems with
motivation, depression, anxiety, concentration, memory, or other
psychological problems. Similarly, the client's awareness about the
effect of marijuana use on breathing, chronic cough, or other physical
conditions is ascertained. If the client acknowledges a relationship
between marijuana use and any of these physical or psychological
problems but continues to use anyway, marijuana use may have a higher
priority than his or her health or the client may be unable to limit use
effectively.

*Diagnosing cannabis dependence.* To complete the diagnosis, the
counselor counts the number of dependence symptoms that are present,
that is, questions 1 through 7 on the SCID-IV that receive a rating of
3. If three or more questions have a rating of 3, the client meets
DSM-IV criteria for cannabis dependence. In general, the dependence
syndrome occurs on a continuum, so more symptoms indicate greater
severity of dependence. Even when the client does not meet the criteria
fully, the counselor should discuss symptoms that signal the beginning
of a potential disorder and the level of impairment associated with the
symptoms.

*Information for Assessing Cannabis Abuse Criteria*

In the absence of cannabis dependence, the counselor assesses recurrent
negative consequences associated with marijuana to diagnose cannabis
abuse. The counselor inquires about missed days at school or work
related to marijuana use and asks whether marijuana has affected the
client's abilities at school or on the job (DSM-IV symptom 1 in exhibit
IV-2; SCID-IV question 8, *In the past month, have you missed work or
school because you were high or hung over? How often did this occur?*).
It may be appropriate to ask whether marijuana has interfered with
keeping the house clean or taking care of children.

Other examples of abuse are driving when feeling high or engaging in
other dangerous activities when under the influence of marijuana (DSM-IV
symptom 2 in exhibit IV-2; SCID-IV question 9, *In the past month, did
you use marijuana in situations in which it might have been
dangerous?*), experiencing legal problems (DMS-IV symptom 3 in exhibit
IV-2; SCID-IV question 10, *Has your use of marijuana gotten you into
trouble with the law in the past month*), and continuing use despite
awareness that use causes problems with friends, family, or co-workers
(DSM-IV symptom 4 in exhibit IV-2; SCID-IV question 11, *Has your use of
marijuana caused you problems with other people, such as with family
members, friends, or people at work? Have you gotten into physical
fights or had bad arguments about your marijuana use?*).

*Diagnosing cannabis abuse.* For a cannabis abuse diagnosis, at least
one of the symptoms described above must have occurred two or more times
during the period being assessed. More information is available in First
and colleagues (1996, 2000).

***Explain and Ask Client To Complete* Marijuana Problem Scale*;
Evaluate Consequences of Marijuana Use***

The *Marijuana Problem Scale* (MPS) (form AS5), developed by Stephens
and colleagues (1994*a*), is a self-report assessment that helps the
client identify areas in his or her life affected by marijuana use. It
contains 19 items that represent potential negative effects of marijuana
on social relationships, self-esteem, motivation and productivity, work
and finances, physical health, memory impairment, and legal problems.
The items were chosen based on existing self-report drug abuse severity
measures and on data from people who sought treatment for marijuana use.

Some questions on the MPS are similar to those in the SCID-IV. However,
the MPS is a self-report instrument and the counselor should not base
diagnostic decisions on the MPS alone. Clinical judgment is needed to
make a diagnosis of cannabis abuse.

The counselor gives the form to the client and instructs the client to
take a few moments to respond to each item by indicating whether he or
she experienced a particular problem related to marijuana use in the
past month. After reading each question, the client circles the
corresponding number on the questionnaire:

Not a problem (0) A minor problem (1) A serious problem (2).

After answering all the questions, the client gives the form back to the
counselor who counts the number of items identified as either minor or
serious problems. Higher scores generally indicate more serious problems
with marijuana. However, it is important to review the specific problem
items with clients because the nature of the problems reported may be
more important than the total score. For instance, although nearly all
people who use marijuana and seek treatment report feeling bad about
their use, a smaller number will indicate serious problems with friends,
family, work, or finances. Exhibit VII-1 in section VII presents the
frequency of problems reported by MTP participants.

The counselor keeps the form and uses the information to complete the
client's PFR, which is discussed in the next session.

***Administer* Reasons for Quitting Questionnaire*; Evaluate Reasons for
Seeking Treatment***

The *Reasons for Quitting Questionnaire* (form AS6) is based on earlier
work with tobacco cessation and has been modified based on initial
results with people who use marijuana and seek treatment (McBride et al.
1994). The 26 items assess reasons for quitting marijuana in the
following broad categories: health concerns, desire for self-control,
and social and legal

influences. The counselor gives the client the form and asks him or her
to take a few moments to indicate the degree to which each reason
applies to him or her using a 5-point scale:

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Very much
(4).

The counselor reviews the items that have been circled 2, 3, or 4. These
responses represent the client's motivation for change. The items
identified are used in the PFR. Reviewing the items that the client
endorses stimulates discussion and elicits self-motivational statements
during therapy.

Exhibit VII-1 presents the most common marijuana-related problems
reported by MTP participants.

The counselor keeps the form and uses the information to complete the
client's PFR, which is discussed in the next session.

***Explain and Ask Client To Complete* Self-Efficacy Questionnaire*;
Assess Targets for Intervention***

The *Self-Efficacy Questionnaire* (form AS7), based on the Situational
Confidence Questionnaire (Annis 1988), is a measure on which clients
rate their ability to resist the temptation to smoke marijuana in a
variety of different situations. The rating scale has a range of 1 (not
at all confident) to 7 (extremely confident). The counselor asks the
client to take a few moments to rate 20 statements about situations that
might create a temptation to smoke marijuana.

When the form is completed, the client returns it to the counselor who
records in the PFR all items coded 1 to 3 (low confidence to resist
marijuana).

***Conclude the Session***

To conclude the session, the counselor explains that he or she will use
the information from all the forms to complete the client's PFR, which
they will review during the next session. The counselor asks the client
for feedback, responds empathically to his or her comments, and
troubleshoots any difficulties.

***Prepare the PFR Before Session 1***

The PFR is a therapeutic tool used by the counselor to summarize the
results obtained during assessment session. The goal of assessment
feedback is to point out discrepancies between the client's current
behavior and important personal goals identified by the client.

For the next session with the client, the counselor prepares the PFR by
compiling the pertinent information from the TLFB process and the
SCID-IV. Information also is gathered from the questionnaires completed
by the client: *Marijuana Problem Scale, Reasons for Quitting
Questionnaire,* and *Self-Efficacy Questionnaire.* All the information
from these forms is consolidated on the PFR by the counselor.
Instructions for preparing the PFR are included in form AS8.

**Forms for Assessment Session**

During the assessment session the counselor and client review or
complete eight forms. These forms and instructions for completing them
are provided on the remaining pages in this section.

Form AS1

  ------------- -- -- -- -------- -- -- -- --------- -- -- -- ----------- -- -- -- ---------- -- -- -- -------- -- -- -- ---------- -- -- --
  **Sample                                                                                                                                
  Timeline                                                                                                                                
  Follow-Back                                                                                                                             
  Calendar**                                                                                                                              

  Sunday                 Monday            Tuesday            Wednesday            Thursday            Friday            Saturday         

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          
  ------------- -- -- -- -------- -- -- -- --------- -- -- -- ----------- -- -- -- ---------- -- -- -- -------- -- -- -- ---------- -- -- --

**Form AS2**

  -----------------------------------------------------------------------
  **Timeline Follow-Back Grid**

  -----------------------------------------------------------------------

*Start date: \_\_\_/\_\_\_/\_\_\_ End date: \_\_\_/\_\_\_/\_\_\_*

+-------+-------+-------+-------+-------+-------+-------+-------+-------+
|       | \# of | \# of | \# of | \# of | \# of | \# of | \# of | \# of |
|       | days  | days  | days  | days  | days  | days  | days  | days  |
|       |       |       |       |       |       |       |       |       |
|       | used  | used  | used  | used  | used  | used  | used  | used  |
|       | from  | from  | from  | from  |       |       | other | any   |
|       |       |       |       |       | mari  | al    |       |       |
|       | 6     | 12    | 6     | 12    | juana | cohol | drugs | subs  |
|       | a.m   | no    | p.m   | m     |       |       |       | tance |
|       | .--12 | on--6 | .--12 | id--6 |       |       |       | in    |
|       | noon  | p.m.  | mid   | a.m.  |       |       |       |       |
|       |       |       |       |       |       |       |       | the   |
|       |       |       |       |       |       |       |       | week  |
+-------+-------+-------+-------+-------+-------+-------+-------+-------+
| *     |       |       |       |       |       |       |       |       |
| *Week |       |       |       |       |       |       |       |       |
| 1**   |       |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+-------+
| *     |       |       |       |       |       |       |       |       |
| *Week |       |       |       |       |       |       |       |       |
| 2**   |       |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+-------+
| *     |       |       |       |       |       |       |       |       |
| *Week |       |       |       |       |       |       |       |       |
| 3**   |       |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+-------+
| *     |       |       |       |       |       |       |       |       |
| *Week |       |       |       |       |       |       |       |       |
| 4**   |       |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+-------+
| **To  |       |       |       |       |       |       |       |       |
| tal** |       |       |       |       |       |       |       |       |
|       |       |       |       |       |       |       |       |       |
| *     |       |       |       |       |       |       |       |       |
| *(for |       |       |       |       |       |       |       |       |
| P     |       |       |       |       |       |       |       |       |
| FR)** |       |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+-------+

**Form AS3**

  -----------------------------------------------------------------------
  **Timeline Follow-Back Marijuana Use Summary Sheet**

  -----------------------------------------------------------------------

**(*To be completed after the calendar data have been collected.*)**

**I would like to ask you a few more questions about your marijuana and
alcohol use.**

1\. During the past month, from \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_to
\_\_\_\_\_\_\_\_\_\_\_\_\_\_, on average, how much marijuana **per
week** do you think you used in ounces?

*Probe by asking the participant how many ounces of marijuana he or she
buys (or receives) per week. If the client seems uncertain about level
of use, the counselor helps him or her approximate by using the
following types of probes: "Would you say it was more like 1/8 ounce or
closer to 1 ounce per week?" The counselor continues until the client
seems comfortable with the estimate and says, "So, you think it was
closer to an ounce. Was it just an ounce, a little more than that, or a
little less?"*

\_\_\_\_\_\<1/16 \_\_\_\_\_1/16 \_\_\_\_\_1/8 \_\_\_\_\_1/4 \_\_\_\_3/8

\_\_\_\_\_1/2 \_\_\_\_\_5/8 \_\_\_\_\_3/4 \_\_\_\_\_7/8 \_\_\_\_1 oz.

2\. During the past month, when you smoked, how many average-sized
joints/pipes/blunts, do you think you smoked per day?

\_\_\_\_ joints, pipes, or blunts per day

3\. During the past month, when you smoked, how many hours did you feel
high on those days?

\_\_\_\_ hours

4\. During the past month, on average, how many times a day did you get
high?

\_\_\_\_ times

5\. During the past month, did you use marijuana 1 hour **before** the
following activities? If yes, would you say (*read coding options to
client*)?

\(1\) less than weekly (2) weekly (3) less than daily (4) daily or
almost daily

\_\_\_\_5a. Driving a vehicle

\_\_\_\_5b. Taking care of children

\_\_\_\_5c. Operating dangerous equipment or heavy machinery

\_\_\_\_5d. Working on a paid job

6\. During the past month, how many standard drinks did you have on a
typical day? *One standard drink is a 12-ounce can or bottle of beer, a
5-ounce glass of wine, or a 1.5-ounce shot of hard liquor straight or in
a mixed drink*.

\_\_\_\_ drinks per drinking day

7\. During the past month, did you have six or more drinks in a single
day?

If yes, would you say (*read coding options to participant*)?

\(1\) less than weekly (2) weekly (3) less than daily (4) daily or
almost daily

8\. During the past month, how many tobacco cigarettes did you smoke on
a typical day?

\(0\) none (1) less than 10 (2) About 1/2 pack (3) About 1 pack (4) More
than a pack

**Form AS4**

+-----------------------------------------------------------------------+
| **Structured Clinical Interview for DSM-IV**[^2]                      |
|                                                                       |
| **(Non-Alcohol Substance Use Disorders Module Modified for Marijuana  |
| Use, Past Month)**                                                    |
+-----------------------------------------------------------------------+

How old were you when you first started smoking marijuana regularly
(i.e., 3 or more times a week)? \_\_\_\_

*age of onset of regular use*

How old were you when your marijuana use began to cause you problems?
\_\_\_\_

*age of problem use*

**Current Marijuana Dependence**

Now I am going to ask you several questions about your marijuana use for
the past month, that is since \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ .

(*give anchor date*)

*Current marijuana dependence is characterized by a maladaptive pattern
of marijuana use leading to clinically significant impairment or
distress, as manifested by three or more of the following occurring
during the assessment period. The counselor circles the appropriate
clinical rating based on the chart below.*

+-----------------------+-----------------------+-----------------------+
| **Interview           | **Clinical Rating**   | **DSM-IV Dependence** |
| Questions**           |                       |                       |
|                       |                       | **Criteria**          |
+-----------------------+-----------------------+-----------------------+
| 1\. In the past       | **? 1 2 3**           | *3. Marijuana often   |
| month, have you often |                       | is taken in larger    |
| found that, when you  |                       | amounts or over a     |
| started using         |                       | longer period than    |
| marijuana, you ended  |                       | was intended.*        |
| up using much more    |                       |                       |
| than you were         |                       |                       |
| planning to?          |                       |                       |
|                       |                       |                       |
| *If no:* Have you     |                       |                       |
| used it over a much   |                       |                       |
| longer period than    |                       |                       |
| you were planning to? |                       |                       |
+-----------------------+-----------------------+-----------------------+

+-----------------------------------------------------------------------+
| ***Clinical Rating***                                                 |
|                                                                       |
| *? = Could not determine based on information provided.*              |
|                                                                       |
| *1 = Absent or false; the symptom described in the criterion clearly  |
| is absent or the criterion statement clearly is false.*               |
|                                                                       |
| *2 = Subthreshold; the threshold for the criterion is almost, but not |
| quite, met.*                                                          |
|                                                                       |
| *3 = Threshold or true; the threshold for the criterion is met or the |
| criterion statement is true.*                                         |
+-----------------------------------------------------------------------+

**Form AS4**

+-------------------------+-------------------+------------------------+
| **Structured Clinical   |                   |                        |
| Interview for DSM-IV    |                   |                        |
| (continued)**           |                   |                        |
|                         |                   |                        |
| **(Non-Alcohol          |                   |                        |
| Substance Use Disorders |                   |                        |
| Module Modified for     |                   |                        |
| Marijuana Use, Past     |                   |                        |
| Month)**                |                   |                        |
+-------------------------+-------------------+------------------------+
| **Interview Questions** | **Clinical        | **DSM-IV Dependence**  |
|                         | Rating**          |                        |
|                         |                   | **Criteria**           |
+-------------------------+-------------------+------------------------+
| 2\. In the past month,  | **? 1 2 3**       | *4. There is a         |
| have you tried to cut   |                   | persistent desire or   |
| down or stop using      |                   | one or more            |
| marijuana?              |                   | unsuccessful efforts   |
|                         |                   | to cut down or control |
| *If yes:* In the past   |                   | marijuana use.*        |
| month, did you ever     |                   |                        |
| stop using marijuana?   |                   |                        |
| (How many times did you |                   |                        |
| try to cut down or      |                   |                        |
| stop?)                  |                   |                        |
|                         |                   |                        |
| *If no:* Did you have a |                   |                        |
| desire to stop or cut   |                   |                        |
| down?                   |                   |                        |
|                         |                   |                        |
| *If yes:* Is this       |                   |                        |
| something you worry     |                   |                        |
| about?                  |                   |                        |
+-------------------------+-------------------+------------------------+
| 3\. In the past month,  | **? 1 2 3**       | *5. A great deal of    |
| did you spend a lot of  |                   | time is spent in       |
| time using marijuana or |                   | activities necessary   |
| doing whatever you had  |                   | to obtain marijuana,   |
| to do to get it?        |                   | use marijuana, or      |
|                         |                   | recover from its       |
| Did it take you a long  |                   | effects.*              |
| time to get back to     |                   |                        |
| normal? (How much time? |                   |                        |
| As long as several      |                   |                        |
| hours?)                 |                   |                        |
+-------------------------+-------------------+------------------------+
| 4\. In the past month,  | **? 1 2 3**       | *6. Important social,  |
| did you use marijuana   |                   | occupational, or       |
| so often that you used  |                   | recreational           |
| it instead of working   |                   | activities are given   |
| or spending time on     |                   | up or reduced because  |
| hobbies or with your    |                   | of marijuana use.*     |
| family or friends?      |                   |                        |
+-------------------------+-------------------+------------------------+

+-----------------------------------------------------------------------+
| ***Clinical Rating***                                                 |
|                                                                       |
| *? = Could not determine based on information provided.*              |
|                                                                       |
| *1 = Absent or false; the symptom described in the criterion clearly  |
| is absent or the criterion statement clearly is false.*               |
|                                                                       |
| *2 = Subthreshold; the threshold for the criterion is almost, but not |
| quite, met.*                                                          |
|                                                                       |
| *3 = Threshold or true; the threshold for the criterion is met or the |
| criterion statement is true.*                                         |
+-----------------------------------------------------------------------+

**Form AS4**

+-------------------------+-------------------+------------------------+
| **Structured Clinical   |                   |                        |
| Interview for DSM-IV    |                   |                        |
| (continued)**           |                   |                        |
|                         |                   |                        |
| **(Non-Alcohol          |                   |                        |
| Substance Use Disorders |                   |                        |
| Module Modified for     |                   |                        |
| Marijuana Use, Past     |                   |                        |
| Month)**                |                   |                        |
+-------------------------+-------------------+------------------------+
| **Interview Questions** | **Clinical        | **DSM-IV Dependence**  |
|                         | Rating**          |                        |
|                         |                   | **Criteria**           |
+-------------------------+-------------------+------------------------+
| 5\. Do you forget       | **? 1 2 3**       | *7. Continued          |
| things? Do you have     |                   | marijuana use despite  |
| trouble concentrating?  |                   | knowledge of having a  |
| Are you anxious or sad  |                   | persistent or          |
| a lot? Do you think     |                   | recurrent              |
| this has anything to do |                   | psychological or       |
| with marijuana?         |                   | physical problem that  |
|                         |                   | is likely to have been |
| Has marijuana caused    |                   | caused or exacerbated  |
| you physical problems   |                   | by the use of the      |
| such as difficulty      |                   | marijuana.*            |
| breathing, many colds,  |                   |                        |
| or a chronic cough or   |                   |                        |
| made a physical problem |                   |                        |
| worse?                  |                   |                        |
|                         |                   |                        |
| *If yes to either:* In  |                   |                        |
| the past month, did you |                   |                        |
| keep on using marijuana |                   |                        |
| anyway?                 |                   |                        |
+-------------------------+-------------------+------------------------+
| 6\. Have you found that | **? 1 2 3**       | *1. Tolerance, as      |
| you need to use a lot   |                   | defined by either of   |
| more or higher quality  |                   | the following:*        |
| marijuana to get high   |                   |                        |
| than you did when you   |                   | > *(a) A need for      |
| first started using it  |                   | > markedly increased   |
| regularly (e.g., three  |                   | > amounts of marijuana |
| or more times a week)?  |                   | > (at least 50%        |
|                         |                   | > increase) to achieve |
| *If yes:* How much      |                   | > intoxication or      |
| more?                   |                   | > desired effect*      |
|                         |                   | >                      |
| *If no:* Do you find    |                   | > *or*                 |
| that, when you use the  |                   | >                      |
| same amount, it affects |                   | > *(b) Markedly        |
| you much less than it   |                   | > diminished effect    |
| did before?             |                   | > with continued use   |
|                         |                   | > of the same amount   |
|                         |                   | > of marijuana.*       |
+-------------------------+-------------------+------------------------+

+-----------------------------------------------------------------------+
| ***Clinical Rating***                                                 |
|                                                                       |
| *? = Could not determine based on information provided.*              |
|                                                                       |
| *1 = Absent or false; the symptom described in the criterion clearly  |
| is absent or the criterion statement clearly is false.*               |
|                                                                       |
| *2 = Subthreshold; the threshold for the criterion is almost, but not |
| quite, met.*                                                          |
|                                                                       |
| *3 = Threshold or true; the threshold for the criterion is met or the |
| criterion statement is true.*                                         |
+-----------------------------------------------------------------------+

**Form AS4**

+-------------------------+-------------------+------------------------+
| **Structured Clinical   |                   |                        |
| Interview for DSM-IV    |                   |                        |
| (continued)**           |                   |                        |
|                         |                   |                        |
| **(Non-Alcohol          |                   |                        |
| Substance Use Disorders |                   |                        |
| Module Modified for     |                   |                        |
| Marijuana Use, Past     |                   |                        |
| Month)**                |                   |                        |
+-------------------------+-------------------+------------------------+
| **Interview Questions** | **Clinical        | **DSM-IV Dependence**  |
|                         | Rating**          |                        |
|                         |                   | **Criteria**           |
+-------------------------+-------------------+------------------------+
| 7\. In the past month,  | **? 1 2 3**       | *2. Withdrawal, as     |
| have you had withdrawal |                   | manifested by either   |
| symptoms, that is, felt |                   | of the following:*     |
| sick when you cut down  |                   |                        |
| or stopped using?       |                   | > *(a) The             |
|                         |                   | > characteristic       |
| *If yes:* What symptoms |                   | > withdrawal syndrome  |
| did you have?           |                   | > for marijuana, e.g., |
|                         |                   | > appetite             |
| *If no:* After not      |                   | > disturbance, sleep   |
| using marijuana for a   |                   | > disturbance (vivid   |
| few hours or more, have |                   | > dreams), night       |
| you often used it to    |                   | > sweats, headaches,   |
| keep yourself from      |                   | > irritability,        |
| getting sick            |                   | > restlessness*        |
| (withdrawal)?           |                   | >                      |
|                         |                   | > *or*                 |
|                         |                   | >                      |
|                         |                   | > *(b) Marijuana or a  |
|                         |                   | > closely related      |
|                         |                   | > substance is taken   |
|                         |                   | > to relieve or avoid  |
|                         |                   | > withdrawal           |
|                         |                   | > symptoms.*           |
+-------------------------+-------------------+------------------------+
| *Record the total       | *Number of        | *If three or more      |
| number of items (1--7)  | dependence        | items are coded as     |
| coded "3."*             | criteria met:*    | "3," the client meets  |
|                         |                   | the DSM-IV diagnosis   |
|                         | \_\_\_\_\_        | of current marijuana   |
|                         |                   | dependence.*           |
+-------------------------+-------------------+------------------------+

+-----------------------------------------------------------------------+
| ***Clinical Rating***                                                 |
|                                                                       |
| *? = Could not determine based on information provided.*              |
|                                                                       |
| *1 = Absent or false; the symptom described in the criterion clearly  |
| is absent or the criterion statement clearly is false.*               |
|                                                                       |
| *2 = Subthreshold; the threshold for the criterion is almost, but not |
| quite, met.*                                                          |
|                                                                       |
| *3 = Threshold or true; the threshold for the criterion is met or the |
| criterion statement is true.*                                         |
+-----------------------------------------------------------------------+

Form AS4

+-------------------------+-------------------+------------------------+
| **Structured Clinical   |                   |                        |
| Interview for DSM-IV    |                   |                        |
| (continued)**           |                   |                        |
|                         |                   |                        |
| **(Non-Alcohol          |                   |                        |
| Substance Use Disorders |                   |                        |
| Module Modified for     |                   |                        |
| Marijuana Use, Past     |                   |                        |
| Month)**                |                   |                        |
+-------------------------+-------------------+------------------------+
| **Current Marijuana     |                   |                        |
| Abuse**                 |                   |                        |
|                         |                   |                        |
| Now I am going to ask   |                   |                        |
| you a few more          |                   |                        |
| questions about your    |                   |                        |
| marijuana use for the   |                   |                        |
| past month, that is,    |                   |                        |
| since                   |                   |                        |
| \_\_\_\_\_\_            |                   |                        |
| \_\_\_\_\_\_\_\_\_\_\_. |                   |                        |
|                         |                   |                        |
| *(give anchor date)*    |                   |                        |
|                         |                   |                        |
| *Current marijuana      |                   |                        |
| abuse is characterized  |                   |                        |
| by a maladaptive        |                   |                        |
| pattern of marijuana    |                   |                        |
| use leading to          |                   |                        |
| clinically significant  |                   |                        |
| impairment or distress, |                   |                        |
| as manifested by one or |                   |                        |
| more of the following   |                   |                        |
| occurring during the    |                   |                        |
| assessment period.*     |                   |                        |
+-------------------------+-------------------+------------------------+
| **Interview Questions** | **Clinical        | **DSM-IV Abuse**       |
|                         | Rating**          |                        |
|                         |                   | **Criteria**           |
+-------------------------+-------------------+------------------------+
| 8\. In the past month,  | **? 1 2 3**       | *1. Recurrent (two or  |
| have you missed work or |                   | more times) marijuana  |
| school because you were |                   | use resulting in a     |
| high or hung over? Have |                   | failure to fulfill     |
| you done a bad job at   |                   | major obligations at   |
| work or failed courses  |                   | work, school, or home  |
| because of your         |                   | (e.g., repeated        |
| marijuana use?          |                   | absences or poor work  |
|                         |                   | performance related to |
| *If no:* Have you not   |                   | marijuana use;         |
| kept your house clean   |                   | marijuana-related      |
| or not taken proper     |                   | absences, suspensions, |
| care of your children   |                   | or expulsions from     |
| because of your use of  |                   | school; neglect of     |
| marijuana?              |                   | household or           |
|                         |                   | children).*            |
| *If yes:* How often did |                   |                        |
| this occur?             |                   |                        |
+-------------------------+-------------------+------------------------+

+-----------------------------------------------------------------------+
| ***Clinical Rating***                                                 |
|                                                                       |
| *? = Could not determine based on information provided.*              |
|                                                                       |
| *1 = Absent or false; the symptom described in the criterion clearly  |
| is absent or the criterion statement clearly is false.*               |
|                                                                       |
| *2 = Subthreshold; the threshold for the criterion is almost, but not |
| quite, met.*                                                          |
|                                                                       |
| *3 = Threshold or true; the threshold for the criterion is met or the |
| criterion statement is true.*                                         |
+-----------------------------------------------------------------------+

**Form AS4**

+-------------------------+-------------------+------------------------+
| **Structured Clinical   |                   |                        |
| Interview for DSM-IV    |                   |                        |
| (continued)**           |                   |                        |
|                         |                   |                        |
| **(Non-Alcohol          |                   |                        |
| Substance Use Disorders |                   |                        |
| Module Modified for     |                   |                        |
| Marijuana Use, Past     |                   |                        |
| Month)**                |                   |                        |
+-------------------------+-------------------+------------------------+
| **Interview Questions** | **Clinical        | **DSM-IV Abuse**       |
|                         | Rating**          |                        |
|                         |                   | **Criteria**           |
+-------------------------+-------------------+------------------------+
| 9\. In the past month,  | **? 1 2 3**       | *2. Recurrent (two or  |
| did you use marijuana   |                   | more times) marijuana  |
| in a situation in which |                   | use in situations in   |
| it might have been      |                   | which it is physically |
| dangerous? (Did you     |                   | hazardous (e.g.,       |
| drive while you were    |                   | driving a car;         |
| high?)                  |                   | operating dangerous    |
|                         |                   | equipment like a       |
| *If yes:* How often did |                   | lawnmower, chain saw,  |
| this occur?             |                   | stove, gun, or         |
|                         |                   | tractor; or skiing,    |
|                         |                   | swimming, biking or    |
|                         |                   | taking care of         |
|                         |                   | children when impaired |
|                         |                   | by marijuana).*        |
+-------------------------+-------------------+------------------------+
| 10\. Has your use of    | **? 1 2 3**       | *3. Recurrent (two or  |
| marijuana gotten you    |                   | more times)            |
| into trouble with the   |                   | marijuana-related      |
| law in the past month?  |                   | legal problems (e.g.,  |
|                         |                   | arrests for            |
| *If yes:* How often did |                   | marijuana-related      |
| this occur?             |                   | disorderly conduct).*  |
+-------------------------+-------------------+------------------------+
| 11\. Has your use of    | **? 1 2 3**       | *4. Continued use      |
| marijuana caused you    |                   | despite having         |
| problems with other     |                   | persistent or          |
| people, such as with    |                   | recurrent social or    |
| family members,         |                   | interpersonal problems |
| friends, or people at   |                   | caused or exacerbated  |
| work? Have you gotten   |                   | by the effects of      |
| into physical fights or |                   | marijuana (e.g.,       |
| had bad arguments about |                   | arguments with spouse, |
| your marijuana use?     |                   | physical fights).*     |
|                         |                   |                        |
| *If yes:* In the past   |                   |                        |
| month, did you keep on  |                   |                        |
| using marijuana anyway? |                   |                        |
+-------------------------+-------------------+------------------------+
| > *Record the total     | *Number of abuse* | > *If one or more      |
| > number of items       |                   | > items (8--11) are    |
| > (8--11) coded "3."*   | *criteria met*    | > coded as "3," the    |
|                         |                   | > client meets the     |
|                         | \_\_\_\_\_        | > DSM-IV diagnosis of  |
|                         |                   | > current marijuana    |
|                         |                   | > abuse.*              |
+-------------------------+-------------------+------------------------+

+-----------------------------------------------------------------------+
| ***Clinical Rating***                                                 |
|                                                                       |
| *? = Could not determine based on information provided.*              |
|                                                                       |
| *1 = Absent or false; the symptom described in the criterion clearly  |
| is absent or the criterion statement clearly is false.*               |
|                                                                       |
| *2 = Subthreshold; the threshold for the criterion is almost, but not |
| quite, met.*                                                          |
|                                                                       |
| *3 = Threshold or true; the threshold for the criterion is met or the |
| criterion statement is true.*                                         |
+-----------------------------------------------------------------------+

**For Official Use**

**MPS Score: \_\_\_\_\_**

Form AS5

  -----------------------------------------------------------------------
  **Marijuana Problem Scale**

  -----------------------------------------------------------------------

Following are different types of problems you may have experienced as a
result of smoking marijuana. Please circle the number that indicates
whether each item has been a problem for you in the past month.

+-----------------------------------+-----------------------------------+
| **Has marijuana use caused        | **No Minor Serious**              |
| you...**                          |                                   |
|                                   | **Problem Problem Problem**       |
+-----------------------------------+-----------------------------------+

  -----------------------------------------------------------------------
  1\. Problems between you and your partner 0 1 2

  2\. Problems in your family 0 1 2

  3\. To neglect your family 0 1 2

  4\. Problems between you and your friends 0 1 2

  5\. To miss days at work or miss classes 0 1 2

  6\. To lose a job 0 1 2

  7\. To have lower productivity 0 1 2

  8\. Medical problems 0 1 2

  9\. Withdrawal symptoms 0 1 2

  10\. Blackouts or flashbacks 0 1 2

  11\. Memory loss 0 1 2

  12\. Difficulty sleeping 0 1 2

  13\. Financial difficulties 0 1 2

  14\. Legal problems 0 1 2

  15\. To have lower energy level 0 1 2

  16\. To feel bad about your use 0 1 2

  17\. Lowered self-esteem 0 1 2

  18\. To procrastinate 0 1 2

  19\. To lack self-confidence 0 1 2
  -----------------------------------------------------------------------

Form AS5

  -----------------------------------------------------------------------
  **Marijuana Problem Scale (continued)**

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  **Marijuana Problem Scale Scoring Instructions**

  -----------------------------------------------------------------------

*To obtain the* Marijuana Problem Scale *(MPS) Score, add the number of
items reported as either a "minor problem" or "serious problem." This
score is used in the* Personal Feedback Report *(form AS8) and compared
with the scores in table C at the end of the instruction for creating
the PFR.*

*Items circled as 1 or 2 by the client should be checked on part II of
the* Personal Feedback Report *(form AS8).*

**For Office Use**

**MPS Score: \_\_\_\_\_**

Form AS6

  -----------------------------------------------------------------------
  **Reasons for Quitting Questionnaire**

  -----------------------------------------------------------------------

People who want to stop smoking marijuana may have several reasons for
quitting. I am interested in finding out your reasons for wanting to
quit.

There are no right or wrong reasons. Any reason is a good one. Below is
a list of reasons that a person may have. Please read each statement and
circle the number that best describes how much this reason applies to
you at this time.

+-------------------------------------+--------------------------------+
| **I want to quit smoking marijuana  | **Not at A Little Moder- Quite |
| at this time...**                   | Very**                         |
|                                     |                                |
|                                     | **All Bit ately a Bit Much**   |
+-------------------------------------+--------------------------------+
| 1\. To show myself that I can quit  |                                |
| if I want to 0 1 2 3 4              |                                |
+-------------------------------------+--------------------------------+
| 2\. Because I will like myself      |                                |
| better if I quit 0 1 2 3 4          |                                |
+-------------------------------------+--------------------------------+
| 3\. Because I won't have to leave   |                                |
| social functions                    |                                |
|                                     |                                |
| or other people's houses to smoke 0 |                                |
| 1 2 3 4                             |                                |
+-------------------------------------+--------------------------------+
| 4\. So that I can feel in control   |                                |
| of my life 0 1 2 3 4                |                                |
+-------------------------------------+--------------------------------+
| 5\. Because my family and friends   |                                |
| will stop                           |                                |
|                                     |                                |
| nagging me if I quit 0 1 2 3 4      |                                |
+-------------------------------------+--------------------------------+
| 6\. To get praise from people I'm   |                                |
| close to 0 1 2 3 4                  |                                |
+-------------------------------------+--------------------------------+
| 7\. Because smoking marijuana does  |                                |
| not fit in                          |                                |
|                                     |                                |
| with my self-image 0 1 2 3 4        |                                |
+-------------------------------------+--------------------------------+
| 8\. Because smoking marijuana is    |                                |
| becoming less                       |                                |
|                                     |                                |
| socially acceptable 0 1 2 3 4       |                                |
+-------------------------------------+--------------------------------+
| 9\. Because someone has told me to  |                                |
| quit or else 0 1 2 3 4              |                                |
+-------------------------------------+--------------------------------+
| 10\. Because I will receive a       |                                |
| special gift if I quit 0 1 2 3 4    |                                |
+-------------------------------------+--------------------------------+
| 11\. Because of potential health    |                                |
| problems 0 1 2 3 4                  |                                |
+-------------------------------------+--------------------------------+
| 12\. Because people I am close to   |                                |
| will be upset                       |                                |
|                                     |                                |
| if I don't quit 0 1 2 3 4           |                                |
+-------------------------------------+--------------------------------+
| 13\. So that I can get more things  |                                |
| done 0 1 2 3 4                      |                                |
+-------------------------------------+--------------------------------+
| 14\. Because I have noticed that    |                                |
| smoking marijuana                   |                                |
|                                     |                                |
| is hurting my health 0 1 2 3 4      |                                |
+-------------------------------------+--------------------------------+
| 15\. Because I want to save the     |                                |
| money I spend                       |                                |
|                                     |                                |
| on marijuana 0 1 2 3 4              |                                |
+-------------------------------------+--------------------------------+

Form AS6

  -----------------------------------------------------------------------
  **Reasons for Quitting Questionnaire (continued)**

  -----------------------------------------------------------------------

+-------------------------------------+--------------------------------+
| **I want to quit smoking marijuana  | **Not at A Little Moder- Quite |
| at this time...**                   | Very**                         |
|                                     |                                |
|                                     | **All Bit ately a Bit Much**   |
+-------------------------------------+--------------------------------+
| 16\. To prove that I'm not addicted |                                |
| to marijuana 0 1 2 3 4              |                                |
+-------------------------------------+--------------------------------+
| 17\. Because there is a             |                                |
| drug-testing policy at work 0 1 2 3 |                                |
| 4                                   |                                |
+-------------------------------------+--------------------------------+
| 18\. Because I know others with     |                                |
| health problems                     |                                |
|                                     |                                |
| caused by smoking marijuana 0 1 2 3 |                                |
| 4                                   |                                |
+-------------------------------------+--------------------------------+
| 19\. Because I am concerned that    |                                |
| smoking                             |                                |
|                                     |                                |
| marijuana will shorten my life 0 1  |                                |
| 2 3 4                               |                                |
+-------------------------------------+--------------------------------+
| 20\. Because of legal problems      |                                |
| related to marijuana 0 1 2 3 4      |                                |
+-------------------------------------+--------------------------------+
| 21\. Because I don't want to be a   |                                |
| bad example                         |                                |
|                                     |                                |
| for children 0 1 2 3 4              |                                |
+-------------------------------------+--------------------------------+
| 22\. Because I want to have more    |                                |
| energy 0 1 2 3 4                    |                                |
+-------------------------------------+--------------------------------+
| 23\. So that my hair and clothes    |                                |
| won't smell                         |                                |
|                                     |                                |
| like marijuana 0 1 2 3 4            |                                |
+-------------------------------------+--------------------------------+
| 24\. So that I won't burn holes in  |                                |
| clothes or furniture 0 1 2 3 4      |                                |
+-------------------------------------+--------------------------------+
| 25\. Because my memory will improve |                                |
| 0 1 2 3 4                           |                                |
+-------------------------------------+--------------------------------+
| 26\. So that I will be able to      |                                |
| think more clearly 0 1 2 3 4        |                                |
+-------------------------------------+--------------------------------+

Use the spaces below to list the three most important reasons for
wanting to stop smoking marijuana. If any of the statements above are
among your most important reasons, list them in the spaces below.
Otherwise, write your own reasons.

27\. My three most important reasons, in order of importance, for
wanting to quit smoking marijuana are:

1\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Form AS6

  -----------------------------------------------------------------------
  **Reasons for Quitting Questionnaire (continued)**

  -----------------------------------------------------------------------

Please check the box that applies to you.

 I have not yet quit smoking marijuana (answer only 28).

 I have stopped smoking marijuana already (answer only 29).

28\. If you have not yet quit smoking marijuana, circle the number that
indicates how ready you are RIGHT NOW to stop smoking marijuana.

0%\-\-\-\-\-\-\--20%\-\-\-\-\-\-\-\-\--40%\-\-\-\-\-\-\-\-\-\--60%\-\-\-\-\-\-\-\-\-\--80%\-\-\-\-\-\-\-\-\-\-\--100%

ready ready

to quit to quit

29\. If you have stopped smoking marijuana already, circle the number
that indicates how ready you are RIGHT NOW to remain abstinent.

0%\-\-\-\-\-\-\--20%\-\-\-\-\-\-\-\-\--40%\-\-\-\-\-\-\-\-\-\--60%\-\-\-\-\-\-\-\-\-\--80%\-\-\-\-\-\-\-\-\-\-\--100%

ready ready

to remain abstinent to remain abstinent

  -----------------------------------------------------------------------
  **Reasons for Quitting Questionnaire Scoring Instructions**

  -----------------------------------------------------------------------

*For a total* Reasons for Quitting *(RFQ) Score, add the number of items
the client reported as a reason to quit smoking marijuana. Count only
those responses coded as 2, 3, or 4 (moderately, quite a bit, or very
much). Include any open-ended items in question 27 that are not in the
list.*

*Items circled as 2, 3, or 4 by the client are his or her most relevant
reasons for quitting marijuana. These items should be checked on part
III of the* Personal Feedback Report *(form AS8).*

**For Office Use**

**RFQ Score: \_\_\_\_\_**

**Form AS**7

  -----------------------------------------------------------------------
  **Self-Efficacy Questionnaire**[^3]

  -----------------------------------------------------------------------

Please circle how confident you are that you could **resist** the
temptation to smoke marijuana in the following situations.

+---------------------------------------+---------------------+--------+
| **How confident are you that you      | **Not at all**      | *      |
| could resist the temptation to smoke  |                     | *Extre |
| marijuana if you were...**            | **Confident**       | mely** |
|                                       |                     |        |
|                                       |                     | *      |
|                                       |                     | *Confi |
|                                       |                     | dent** |
+---------------------------------------+---------------------+--------+

+-----------------------------------------------------------------------+
| 1\. Doing monotonous work 1 2 3 4 5 6 7                               |
+-----------------------------------------------------------------------+
| 2\. Wanting to feel more confident 1 2 3 4 5 6 7                      |
+-----------------------------------------------------------------------+
| 3\. Vacationing 1 2 3 4 5 6 7                                         |
+-----------------------------------------------------------------------+
| 4\. Seeing someone else smoking marijuana                             |
|                                                                       |
| and enjoying it 1 2 3 4 5 6 7                                         |
+-----------------------------------------------------------------------+
| 5\. Feeling depressed or worried 1 2 3 4 5 6 7                        |
+-----------------------------------------------------------------------+
| 6\. Drinking alcohol 1 2 3 4 5 6 7                                    |
+-----------------------------------------------------------------------+
| 7\. Feeling like celebrating good news or                             |
|                                                                       |
| an accomplishment 1 2 3 4 5 6 7                                       |
+-----------------------------------------------------------------------+
| 8\. Feeling frustrated 1 2 3 4 5 6 7                                  |
+-----------------------------------------------------------------------+
| 9\. Wanting to feel better about yourself 1 2 3 4 5 6 7               |
+-----------------------------------------------------------------------+
| 10\. Feeling angry about something or someone 1 2 3 4 5 6 7           |
+-----------------------------------------------------------------------+
| 11\. Enjoying a pleasant social situation 1 2 3 4 5 6 7               |
+-----------------------------------------------------------------------+
| 12\. Having time to yourself, free of responsibilities 1 2 3 4 5 6 7  |
+-----------------------------------------------------------------------+
| 13\. Using other drugs recreationally 1 2 3 4 5 6 7                   |
+-----------------------------------------------------------------------+
| 14\. Being at a party with people who are                             |
|                                                                       |
| smoking marijuana 1 2 3 4 5 6 7                                       |
+-----------------------------------------------------------------------+
| 15\. Feeling embarrassed 1 2 3 4 5 6 7                                |
+-----------------------------------------------------------------------+
| 16\. Being with a spouse or close friend who is                       |
|                                                                       |
| smoking marijuana 1 2 3 4 5 6 7                                       |
+-----------------------------------------------------------------------+
| 17\. Being in an uncomfortable social situation 1 2 3 4 5 6 7         |
+-----------------------------------------------------------------------+
| 18\. Being offered marijuana by someone 1 2 3 4 5 6 7                 |
+-----------------------------------------------------------------------+
| 19\. Being bored, with nothing to do 1 2 3 4 5 6 7                    |
+-----------------------------------------------------------------------+
| 20\. Feeling stressed out and needing to calm down 1 2 3 4 5 6 7      |
+-----------------------------------------------------------------------+

**Form AS7**

  -----------------------------------------------------------------------
  **Self-Efficacy Questionnaire (continued)**

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  **Self-Efficacy Questionnaire Scoring Instructions**

  -----------------------------------------------------------------------

*To obtain the* Self-Efficacy *(SE) Score, add the numbers circled for
each item and divide by the total number answered (the denominator
should be 20 unless an item was skipped).*

*Items circled as 1, 2, or 3 indicate that the particular situations
would be more difficult to resist and would affect the client's ability
to remain abstinent. These items should be checked on part IV of the*
Personal Feedback Report *(form AS8).*

**For Office Use**

**SE Score: \_\_\_\_\_**

Form AS8

  -----------------------------------------------------------------------
  **Instructions for Creating the Personal Feedback Report**

  -----------------------------------------------------------------------

The items in **bold font** are the statements to be filled in on the
PFR. The means of obtaining the information is in *italics*.

The assessments to be completed (by interview or self-report) by the
client include

> • *TLFB Grid* (summarized from the calendar) (form AS2)
>
> • *TLFB Marijuana Use Summary Sheet* (form AS3)
>
> • SCID-IV (form AS4)
>
> • *Marijuana Problem Scale* (form AS5)
>
> • *Reasons for Quitting Questionnaire (*form AS6)
>
> • *Self-Efficacy Questionnaire (*form AS7).

Reference tables can be found at the end of these instructions and
include

> • Table A. Marijuana Use for Americans Ages 12 and Older
>
> • Table B. Marijuana Use for Treatment-Seeking Adults
>
> • Table C. Marijuana Consequences
>
> • Table D. Confidence in Avoiding Use.

**Part I. Your Marijuana Consumption**

**You reported that you have been smoking regularly for \_\_\_\_
years.**

*Calculate using age of onset of regular use from SCID-IV (form AS4).*

**In the past month, you smoked marijuana on \_\_\_\_ days.**

*Insert total number of days used marijuana from* TLFB Grid *(form
AS2).*

**You said you smoked \_\_\_\_ joints/pipes/blunts per day during that
same period.**

*Insert number from question 2 on* TLFB Marijuana Use Summary Sheet
*(form AS3).*

**Relative to other Americans, this places you in the \_\_\_\_th
percentile. This means that \_\_\_\_ percent of other Americans smoke
less than you do.**

*Use table A to determine the percentile based on the number of days
smoked in the past 30 days. Look up the number of days used, and record
the percentile. Use the same number in the* Personal Feedback Report *to
illustrate the percentage of other Americans who smoke less than the
client does.*

**Relative to other adults who have sought counseling for their
marijuana use, you fall in the \_\_\_\_th percentile. This means that
you smoke more marijuana than \_\_\_\_ percent of individuals seeking
marijuana treatment.**

*Use table B to determine the percentile based on the number of days
smoked in the past 30*

*days. See above.*

Form AS8

  -----------------------------------------------------------------------
  **Instructions for Creating the Personal Feedback Report (continued)**

  -----------------------------------------------------------------------

**Part II. Your Problems Related to Marijuana**

***For these items, use* Marijuana Problem Scale (*form AS5*).**

**You indicated that your marijuana use causes a number of problems for
you, including:**

*On the* Personal Feedback Report, *check off the items indicated as a
minor or serious problem.*

**You identified \_\_\_\_ problems caused by your marijuana use.**

*Insert the MPS Score.*

**This places you in the \_\_\_\_th percentile relative to other adults
seeking marijuana treatment. This means that you experience more
problems than \_\_\_\_ percent of people seeking treatment for their
marijuana use.**

*Look up the MPS Score in table C and record the percentile. Place the
same number in both blanks.*

***For these items, use SCID-IV (form AS4)***

**You also indicated that**

*On the* Personal Feedback Report*, check off any criteria coded as a
"3" on the SCID-IV.*

**As you reflect on the consequences of smoking marijuana and how they
affect your life, what else might you add?**

*Record any other comments or reflections the client states.*

**Part III. Your Reasons for Quitting Marijuana**

***For these items, use* Reasons for Quitting Questionnaire (*form
AS6*).**

**You listed the following personal reasons for quitting marijuana and
said that they applied to you moderately, quite a bit, or very much at
this time.**

*On the* Personal Feedback Report*, check off items indicated
moderately, quite a bit, or very much.*

**You listed these reasons because they have personal significance for
you. Do you have any other important reasons for quitting that you would
like to add?**

*List the three most important reasons the client indicates for wanting
to quit (question 27).*

*Record any other reasons the client mentions.*

**Your number of personal reasons for quitting marijuana is
\_\_\_\_\_\_.**

*Insert the RFQ Score.*

Form AS8

  -----------------------------------------------------------------------
  **Instructions for Creating the Personal Feedback Report (continued)**

  -----------------------------------------------------------------------

**Part IV. Difficult Situations for Maintaining Abstinence**

***For these items, use* Self-Efficacy Questionnaire (*form AS7*).**

**You predicted your most difficult situations for maintaining
abstinence from marijuana. These high-risk situations include**

*Check off items reported as "1," "2," or "3."*

**As you think about highly tempting situations, are there situations
that you'd like to add?**

*Record other comments or tempting situations the client adds.*

**Your responses indicate how confident you are that you could avoid
smoking marijuana in these situations and resulted in an SE Score of
\_\_\_\_.**

*Insert SE Score.*

**This places you in the \_\_\_\_th percentile compared with other
adults who have sought counseling to help them stop smoking marijuana.**

*Match the SE Score with the scores on table D, and record the
percentile.*

**This means that you are more confident that you could resist the
temptation to smoke marijuana than \_\_\_\_ percent of treatment-seeking
individuals.**

*Place the same number in this blank.*

  ----------------------------------- -----------------------------------
  **Table A. Marijuana Use for        
  Americans Ages 12 and Older (Past   
  30 Days)**                          

  **\# Days Used in the Past 30       **Percentile Ranking**
  Days**                              

  1 day                               94

  2-3 days                            95

  4-7 days                            96

  8-14 days                           97

  15-24 days                          98

  \>25 days                           99
  ----------------------------------- -----------------------------------

Source: Substance Abuse and Mental Health Services Administration 2001.

Form AS8

  -----------------------------------------------------------------------
  **Instructions for Creating the Personal Feedback Report (continued)**

  -----------------------------------------------------------------------

+----------------+-----------------+-----------------+-----------------+
| **Table B.     |                 |                 |                 |
| Marijuana Use  |                 |                 |                 |
| for            |                 |                 |                 |
| Tre            |                 |                 |                 |
| atment-Seeking |                 |                 |                 |
| Adults (Past   |                 |                 |                 |
| 30 Days)**     |                 |                 |                 |
+----------------+-----------------+-----------------+-----------------+
| **\# Days Used | **Rounded       | **\# Days Used  | **Rounded       |
| in the Past 30 | Percentile**    | in the Past 30  | Percentile**    |
| Days**         |                 | Days**          |                 |
|                | **Ranking**     |                 | **Ranking**     |
+----------------+-----------------+-----------------+-----------------+
| 0              | 0               | 16              | 11              |
+----------------+-----------------+-----------------+-----------------+
| 1              | 0               | 17              | 12              |
+----------------+-----------------+-----------------+-----------------+
| 2              | 1               | 18              | 13              |
+----------------+-----------------+-----------------+-----------------+
| 3              | 1               | 19              | 14              |
+----------------+-----------------+-----------------+-----------------+
| 4              | 2               | 20              | 19              |
+----------------+-----------------+-----------------+-----------------+
| 5              | 2               | 21              | 20              |
+----------------+-----------------+-----------------+-----------------+
| 6              | 2               | 22              | 21              |
+----------------+-----------------+-----------------+-----------------+
| 7              | 3               | 23              | 26              |
+----------------+-----------------+-----------------+-----------------+
| 8              | 4               | 24              | 27              |
+----------------+-----------------+-----------------+-----------------+
| 9              | 4               | 25              | 32              |
+----------------+-----------------+-----------------+-----------------+
| 10             | 5               | 26              | 34              |
+----------------+-----------------+-----------------+-----------------+
| 11             | 6               | 27              | 44              |
+----------------+-----------------+-----------------+-----------------+
| 12             | 7               | 28              | 53              |
+----------------+-----------------+-----------------+-----------------+
| 13             | 8               | 29              | 64              |
+----------------+-----------------+-----------------+-----------------+
| 14             | 8               | 30              | 100             |
+----------------+-----------------+-----------------+-----------------+
| 15             | 11              |                 |                 |
+----------------+-----------------+-----------------+-----------------+

Sources: Stephens et al. 1994*b*, 2000; Vendetti et al. 2002.

+----------------+-----------------+-----------------+-----------------+
| **Table C.     |                 |                 |                 |
| Marijuana      |                 |                 |                 |
| Consequences** |                 |                 |                 |
+----------------+-----------------+-----------------+-----------------+
| **Marijuana    | **Rounded       | **Marijuana     | **Rounded       |
| Problem**      | Percentile**    | Problem**       | Percentile**    |
|                |                 |                 |                 |
| **Score**      | **Ranking**     | **Score**       | **Ranking**     |
+----------------+-----------------+-----------------+-----------------+
| 0              | 0               | 10              | 57              |
+----------------+-----------------+-----------------+-----------------+
| 1              | 1               | 11              | 68              |
+----------------+-----------------+-----------------+-----------------+
| 2              | 3               | 12              | 77              |
+----------------+-----------------+-----------------+-----------------+
| 3              | 5               | 13              | 85              |
+----------------+-----------------+-----------------+-----------------+
| 4              | 8               | 14              | 91              |
+----------------+-----------------+-----------------+-----------------+
| 5              | 11              | 15              | 95              |
+----------------+-----------------+-----------------+-----------------+
| 6              | 16              | 16              | 98              |
+----------------+-----------------+-----------------+-----------------+
| 7              | 23              | 17              | 99              |
+----------------+-----------------+-----------------+-----------------+
| 8              | 32              | 18              | 100             |
+----------------+-----------------+-----------------+-----------------+
| 9              | 44              | 19              | 100             |
+----------------+-----------------+-----------------+-----------------+

Sources: Stephens et al. 2000; Vendetti et al. 2002.

Form AS8

  -----------------------------------------------------------------------
  **Instructions for Creating the Personal Feedback Report (continued)**

  -----------------------------------------------------------------------

+-----------------+-----------------+-----------------+-----------------+
| **Table D.      |                 |                 |                 |
| Confidence in   |                 |                 |                 |
| Avoiding Use**  |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| **              | **Rounded       | **              | **Rounded       |
| Self-Efficacy** | Percentile**    | Self-Efficacy** | Percentile**    |
|                 |                 |                 |                 |
| **Score**       | **Ranking**     | **Score**       | **Ranking**     |
+-----------------+-----------------+-----------------+-----------------+
| 1.00-1.25       | 2               | 3.50-3.50       | 41              |
+-----------------+-----------------+-----------------+-----------------+
| 1.28-1.35       | 3               | 3.53-3.53       | 42              |
+-----------------+-----------------+-----------------+-----------------+
| 1.37-1.50       | 4               | 3.55-3.56       | 43              |
+-----------------+-----------------+-----------------+-----------------+
| 1.53-1.58       | 5               | 3.58-3.58       | 44              |
+-----------------+-----------------+-----------------+-----------------+
| 1.60-1.70       | 6               | 3.60-3.60       | 45              |
+-----------------+-----------------+-----------------+-----------------+
| 1.75-1.85       | 7               | 3.61-3.63       | 46              |
+-----------------+-----------------+-----------------+-----------------+
| 1.90-2.00       | 8               | 3.65-3.68       | 47              |
+-----------------+-----------------+-----------------+-----------------+
| 2.05-2.05       | 9               | 3.70-3.70       | 48              |
+-----------------+-----------------+-----------------+-----------------+
| 2.10-2.15       | 10              | 3.72-3.76       | 49              |
+-----------------+-----------------+-----------------+-----------------+
| 2.20-2.22       | 11              | 3.78-3.79       | 50              |
+-----------------+-----------------+-----------------+-----------------+
| 2.25-2.32       | 12              | 3.80-3.80       | 51              |
+-----------------+-----------------+-----------------+-----------------+
| 2.33-2.37       | 13              | 3.83-3.84       | 52              |
+-----------------+-----------------+-----------------+-----------------+
| 2.39-2.40       | 14              | 3.85-3.89       | 54              |
+-----------------+-----------------+-----------------+-----------------+
| 2.41-2.44       | 15              | 3.90-3.90       | 55              |
+-----------------+-----------------+-----------------+-----------------+
| 2.45-2.47       | 16              | 3.94-3.95       | 56              |
+-----------------+-----------------+-----------------+-----------------+
| 2.50-2.58       | 17              | 4.00-4.05       | 58              |
+-----------------+-----------------+-----------------+-----------------+
| 2.60-2.60       | 18              | 4.05-4.05       | 59              |
+-----------------+-----------------+-----------------+-----------------+
| 2.61-2.65       | 19              | 4.06-4.06       | 60              |
+-----------------+-----------------+-----------------+-----------------+
| 2.67-2.72       | 20              | 4.10-4.11       | 61              |
+-----------------+-----------------+-----------------+-----------------+
| 2.74-2.79       | 21              | 4.12-4.16       | 62              |
+-----------------+-----------------+-----------------+-----------------+
| 2.80-2.80       | 22              | 4.17-4.20       | 63              |
+-----------------+-----------------+-----------------+-----------------+
| 2.83-2.84       | 23              | 4.21-4.22       | 64              |
+-----------------+-----------------+-----------------+-----------------+
| 2.85-2.89       | 24              | 4.25-4.26       | 65              |
+-----------------+-----------------+-----------------+-----------------+
| 2.89-2.94       | 25              | 4.28-4.28       | 66              |
+-----------------+-----------------+-----------------+-----------------+
| 2.95-2.95       | 26              | 4.30-4.32       | 67              |
+-----------------+-----------------+-----------------+-----------------+
| 3.00-3.00       | 27              | 4.33-4.35       | 68              |
+-----------------+-----------------+-----------------+-----------------+
| 3.05-3.05       | 28              | 4.39-4.40       | 69              |
+-----------------+-----------------+-----------------+-----------------+
| 3.06-3.11       | 29              | 4.42-4.42       | 70              |
+-----------------+-----------------+-----------------+-----------------+
| 3.15-3.16       | 30              | 4.44-4.45       | 71              |
+-----------------+-----------------+-----------------+-----------------+
| 3.17-3.20       | 31              | 4.47-4.55       | 72              |
+-----------------+-----------------+-----------------+-----------------+
| 3.21-3.21       | 32              | 4.56-4.58       | 73              |
+-----------------+-----------------+-----------------+-----------------+
| 3.22-3.25       | 33              | 4.60-4.65       | 74              |
+-----------------+-----------------+-----------------+-----------------+
| 3.26-3.28       | 34              | 4.67-4.74       | 75              |
+-----------------+-----------------+-----------------+-----------------+
| 3.30-3.33       | 35              | 4.75-4.78       | 76              |
+-----------------+-----------------+-----------------+-----------------+
| 3.35-3.35       | 36              | 4.79-4.80       | 77              |
+-----------------+-----------------+-----------------+-----------------+
| 3.37-3.39       | 37              | 4.83-4.85       | 78              |
+-----------------+-----------------+-----------------+-----------------+
| 3.40-3.40       | 38              | 4.89-4.90       | 79              |
+-----------------+-----------------+-----------------+-----------------+
| 3.42-3.45       | 39              | 4.94-4.95       | 80              |
+-----------------+-----------------+-----------------+-----------------+
| 3.47-3.47       | 40              | 5.00-5.00       | 81              |
+-----------------+-----------------+-----------------+-----------------+

Form AS8

  -----------------------------------------------------------------------
  **Instructions for Creating the Personal Feedback Report (continued)**

  -----------------------------------------------------------------------

+-----------------+-----------------+-----------------+-----------------+
| **Table D.      |                 |                 |                 |
| Confidence in   |                 |                 |                 |
| Avoiding Use    |                 |                 |                 |
| (continued)**   |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| **              | **Rounded       | **              | **Rounded       |
| Self-Efficacy** | Percentile**    | Self-Efficacy** | Percentile**    |
|                 |                 |                 |                 |
| **Score**       | **Ranking**     | **Score**       | **Ranking**     |
+-----------------+-----------------+-----------------+-----------------+
| 5.05-5.06       | 82              | 5.72-5.78       | 92              |
+-----------------+-----------------+-----------------+-----------------+
| 5.11-5.16       | 83              | 5.79-5.84       | 93              |
+-----------------+-----------------+-----------------+-----------------+
| 5.17-5.21       | 84              | 5.89-6.05       | 94              |
+-----------------+-----------------+-----------------+-----------------+
| 5.22-5.28       | 85              | 6.06-6.16       | 95              |
+-----------------+-----------------+-----------------+-----------------+
| 5.30-5.33       | 86              | 6.17-6.30       | 96              |
+-----------------+-----------------+-----------------+-----------------+
| 5.37-5.42       | 87              | 6.33-6.55       | 97              |
+-----------------+-----------------+-----------------+-----------------+
| 5.44-5.47       | 88              | 6.56-6.75       | 98              |
+-----------------+-----------------+-----------------+-----------------+
| 5.50-5.56       | 89              | 6.83-6.95       | 99              |
+-----------------+-----------------+-----------------+-----------------+
| 5.58-5.63       | 90              | 7.00-7.00       | 100             |
+-----------------+-----------------+-----------------+-----------------+
| 5.65-5.70       | 91              |                 |                 |
+-----------------+-----------------+-----------------+-----------------+

Sources: Stephens et al. 1994*b*, 2000; Vendetti et al. 2002.

Form AS8

  -----------------------------------------------------------------------
  **Personal Feedback Report**

  -----------------------------------------------------------------------

This report summarizes information about your marijuana use. The
information may be useful in developing strategies to resist marijuana.

**Part I. Your Marijuana Consumption**

**You reported that you have been smoking regularly for \_\_\_\_
years.**

**In the past month, you smoked marijuana on \_\_\_\_ days.**

**You said you smoked \_\_\_\_ joints/pipes/blunts per day during that
same period.**

**Relative to other Americans, this places you in the \_\_\_\_th
percentile. This means that \_\_\_\_ percent of other Americans smoke
less than you do.**

**Relative to adults who have sought counseling for their marijuana use,
you fall in the \_\_\_\_th percentile. This means that you smoke more
marijuana than \_\_\_\_ percent of individuals seeking marijuana
treatment.**

**Part II. Your Problems Related to Marijuana**

**You indicated that your marijuana use causes a number of problems for
you, including:**

\_\_\_\_\_ Problems between you and your partner

\_\_\_\_\_ Problems in your family

\_\_\_\_\_ To neglect your family

\_\_\_\_\_ Problems between you and your friends

\_\_\_\_\_ To miss days at work or miss classes

\_\_\_\_\_ To lose a job

\_\_\_\_\_ To have lower productivity

\_\_\_\_\_ Medical problems

\_\_\_\_\_ Withdrawal symptoms

\_\_\_\_\_ Blackouts or flashbacks

\_\_\_\_\_ Memory loss

\_\_\_\_\_ Difficulty sleeping

\_\_\_\_\_ Financial difficulties

\_\_\_\_\_ Legal problems

\_\_\_\_\_ To have lower energy level

\_\_\_\_\_ To feel bad about your use

\_\_\_\_\_ Lowered self-esteem

\_\_\_\_\_ To procrastinate

\_\_\_\_\_ To lack self-confidence

Form AS8

  -----------------------------------------------------------------------
  **Personal Feedback Report (continued)**

  -----------------------------------------------------------------------

**You identified \_\_\_\_ problems caused by your marijuana use.**

**This places you in the \_\_\_\_th percentile relative to other adults
seeking marijuana treatment. This means that you experience more
problems than \_\_\_\_ percent of people seeking treatment for their
marijuana use.**

**You also indicated that**

\_\_\_\_\_

\_\_\_\_\_

\_\_\_\_\_

\_\_\_\_\_

\_\_\_\_\_

\_\_\_\_\_

\_\_\_\_\_

\_\_\_\_\_

\_\_\_\_\_

\_\_\_\_\_

\_\_\_\_\_

\_\_\_\_\_

You often have found that when you start using marijuana, you end up
smoking much more of it than you were planning to. (SCID-IV, question 1)

You frequently thought about or tried unsuccessfully to cut down or
control your use of marijuana. (SCID-IV, question 2)

You spent a great deal of time trying to get marijuana, smoking it, or
recovering from its effects. (SCID-IV, question 3)

You sometimes gave up or did not participate in important occupational,
social, or recreational activities because you were using marijuana.
(SCID-IV, question 4)

You continued using marijuana despite knowing that it was contributing
to social, psychological, or physical problems in your life. (SCID-IV,
question 5)

You needed to smoke more marijuana than you had smoked in the past to
get the same effect. (SCID-IV, question 6)

You noticed that you were not getting as high as you used to when you
smoked the same amount of marijuana. (SCID-IV, question 6)

You experienced withdrawal symptoms when you tried to stop using
marijuana (e.g., difficulty sleeping, irritability, excessive
perspiration). (SCID-IV, question 7)

You often used marijuana to relieve or avoid experiencing
marijuana-related withdrawal symptoms. (SCID-IV, question 7)

You were frequently high or recovering from being high when you were
supposed to be attending to your obligations at work, school, or home.
(SCID-IV, question 8)

You were frequently high or recovering from being high when you were
doing something dangerous like driving a car. (SCID-IV, question 9)

You have gotten into trouble with the law because of your marijuana use.
(SCID-IV, question 10)

Form AS8

  -----------------------------------------------------------------------
  **Personal Feedback Report (continued)**

  -----------------------------------------------------------------------

\_\_\_\_\_

You have experienced problems with family members, friends, or people at
work because of your marijuana use. (SCID-IV, question 11)

**As you reflect on the consequences of smoking marijuana and how they
affect your life,**

**what else might you add?**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Part III. Your Reasons for Quitting Marijuana**

**You listed the following personal reasons for quitting marijuana and
said that they applied to you moderately, quite a bit, or very much at
this time.**

\_\_\_\_\_ To show myself that I can quit if I want to

\_\_\_\_\_ Because I will like myself better if I quit

\_\_\_\_\_ Because I won't have to leave social functions or other
people's houses to smoke

\_\_\_\_\_ So I can feel in control of my life

\_\_\_\_\_ Because my family and friends will stop nagging me if I quit

\_\_\_\_\_ To get praise from people I'm close to

\_\_\_\_\_ Because smoking marijuana does not fit in with my self-image

\_\_\_\_\_ Because smoking marijuana is becoming less socially
acceptable

\_\_\_\_\_ Because someone has told me to quit or else

\_\_\_\_\_ Because I will receive a special gift if I quit

\_\_\_\_\_ Because of potential health problems

\_\_\_\_\_ Because people I am close to will be upset if I don't quit

\_\_\_\_\_ So that I can get more things done

\_\_\_\_\_ Because I have noticed that smoking marijuana is hurting my
health

\_\_\_\_\_ Because I want to save the money I spend on marijuana

Form AS8

  -----------------------------------------------------------------------
  **Personal Feedback Report (continued)**

  -----------------------------------------------------------------------

\_\_\_\_\_ To prove that I'm not addicted to marijuana

\_\_\_\_\_ Because there is a drug-testing policy at work

\_\_\_\_\_ Because I know others with health problems caused by smoking
marijuana

\_\_\_\_\_ Because I am concerned that smoking marijuana will shorten my
life

\_\_\_\_\_ Because of legal problems related to marijuana

\_\_\_\_\_ Because I don't want to be a bad example for children

\_\_\_\_\_ Because I want to have more energy

\_\_\_\_\_ So my hair and clothes won't smell like marijuana

\_\_\_\_\_ So I won't burn holes in clothes or furniture

\_\_\_\_\_ Because my memory will improve

\_\_\_\_\_ So that I will be able to think more clearly

**You listed these reasons because they have personal significance for
you. Do you have any other important reasons for quitting that you would
like to add?**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Your number of personal reasons for quitting marijuana is \_\_\_\_**.

**Part IV. Difficult Situations for Maintaining Abstinence**

**You predicted your most difficult situations for maintaining
abstinence from marijuana.**

**These high-risk situations include**

\_\_\_\_\_ Doing monotonous work

\_\_\_\_\_ Wanting to feel more confident

\_\_\_\_\_ Vacationing

\_\_\_\_\_ Seeing someone else smoking marijuana and enjoying it

Form AS8

  -----------------------------------------------------------------------
  **Personal Feedback Report (continued)**

  -----------------------------------------------------------------------

\_\_\_\_\_ Feeling depressed or worried

\_\_\_\_\_ Drinking alcohol

\_\_\_\_\_ Feeling like celebrating good news or an accomplishment

\_\_\_\_\_ Feeling frustrated

\_\_\_\_\_ Wanting to feel better about myself

\_\_\_\_\_ Feeling angry about something or someone

\_\_\_\_\_ Enjoying a pleasant social situation

\_\_\_\_\_ Having some time to myself, free of responsibilities

\_\_\_\_\_ Using other drugs recreationally

\_\_\_\_\_ Being at a party with people who are smoking marijuana

\_\_\_\_\_ Feeling embarrassed

\_\_\_\_\_ Being with a spouse or close friend who is smoking marijuana

\_\_\_\_\_ Being in an uncomfortable social situation

\_\_\_\_\_ Being offered marijuana by someone

\_\_\_\_\_ Being bored, with nothing to do

\_\_\_\_\_ Feeling stressed out and needing to calm down

**As you think about highly tempting situations, are there situations
that you'd like to add?**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Your responses indicate how confident you are that you could avoid
smoking marijuana in these situations and resulted in an SE Score of
\_\_\_\_.**

**This places you in the \_\_\_\_th percentile compared with other
adults who have sought counseling to help them stop smoking marijuana.**

**This means that you are more confident that you could resist the
temptation to smoke marijuana than \_\_\_\_ percent of treatment-seeking
individuals.**

+-----------------------------------------------------------------------+
| **SECTION V.**                                                        |
|                                                                       |
| **ENHANCING MOTIVATION: SESSIONS 1 AND 2**                            |
+-----------------------------------------------------------------------+

This section presents the content of sessions 1 and 2. It also presents
information on motivational interviewing and the stages-of-change
concept. The counselor uses this concept throughout the remaining
sessions to measure the client's readiness for change and to adjust the
sessions to accommodate the client's stage. The section provides
examples of motivational interviewing strategies, highlighting how to
use these techniques in treatment sessions. Finally, it presents
sessions 1 and 2; these sessions are based primarily on principles of
motivational enhancement and secondarily on cognitive behavioral skills.

After completing the initial assessment session, the counselor
introduces the client to more targeted motivational strategies. Session
1 focuses on

> • Reviewing the completed *Personal Feedback Report* (PFR)
>
> • Exploring the client's experiences with marijuana
>
> • Eliciting, acknowledging, and reinforcing the client's expressions
> of motivation to change
>
> • Building the alliance between the client and counselor
>
> • Integrating the client's feedback about marijuana use and associated
> problems
>
> • Setting goals
>
> • Planning treatment.

The protocol for session 2 guides the counselor in

> • Reinforcing successful efforts the client has made at initiating
> change
>
> • Discussing how and when assistance may be offered by the friend or
> relative invited to the session by the client
>
> • Refining goals
>
> • Reviewing change strategies
>
> • Assessing the client's social support for initiating changes.

**Key Concepts: Motivational Interviewing Skills**

***Identifying the Individual's Stage of Change***

The stages-of-change model (Prochaska and DiClemente 1982) describes a
sequence of stages through which individuals progress as they think
about and change their behaviors. It gives the counselor insight into
the client's thinking so that the counselor can select strategies
specific to the client's stage. This model was adapted for the Marijuana
Treatment Project and assumes

> • Progress in overcoming marijuana dependence (e.g., getting ready for
> the first day of abstinence, getting through the first 3 months)
> depends on the client's readiness for change.
>
> • Client readiness may shift and evolve and may be influenced by the
> therapist.

The model comprises five stages: precontemplation, contemplation,
preparation, action, and maintenance (exhibit V-1). Individuals move
back and forth between the stages and progress through the stages at
different rates. For example, in the assessment session the client may
be committed to maintaining abstinence, but in session 2 he or she may
be ambivalent. The Center for Substance Abuse Treatment's Treatment
Improvement Protocol (TIP) 35, *Enhancing Motivation for Change in
Substance Abuse Treatment* (CSAT 1999*b*), as well as the *KAP Keys*
(CSAT 2001*c*) and the *Quick Guide* (CSAT 2001*d*) that accompany TIP
35, provides detailed information about this model.

+----------------+-----------------------------------------------------+
| **Exhibit V-1. |                                                     |
| C              |                                                     |
| haracteristics |                                                     |
| of the         |                                                     |
| St             |                                                     |
| ages-of-Change |                                                     |
| Model**        |                                                     |
+----------------+-----------------------------------------------------+
| **Stages**     | **Characteristics**                                 |
+----------------+-----------------------------------------------------+
| **Prec         | > • Is not considering change                       |
| ontemplation** | >                                                   |
|                | > • May be unwilling to change behaviors            |
|                | >                                                   |
|                | > • Is unaware of adverse consequences from         |
|                | > marijuana use, although others may believe        |
|                | > problems exist                                    |
+----------------+-----------------------------------------------------+
| **C            | > • Becomes aware that problems exist               |
| ontemplation** | >                                                   |
|                | > • Recognizes causes for concern and reasons to    |
|                | > change                                            |
|                | >                                                   |
|                | > • Typically is ambivalent and continues to use    |
|                | > marijuana                                         |
|                | >                                                   |
|                | > • May seek information and reevaluate marijuana   |
|                | > use behavior                                      |
|                | >                                                   |
|                | > • Weighs the pros and cons of making a change     |
|                | >                                                   |
|                | > • Could remain in this stage for years            |
+----------------+-----------------------------------------------------+
| *              | > • Commits to changing                             |
| *Preparation** | >                                                   |
|                | > • Recognizes that advantages of changing outweigh |
|                | > benefits of not changing                          |
|                | >                                                   |
|                | > • Thinks about capabilities of success (i.e.,     |
|                | > self-efficacy)                                    |
|                | >                                                   |
|                | > • Continues using marijuana but intends to stop   |
|                | > or cut back soon                                  |
|                | >                                                   |
|                | > • May have attempted to reduce or stop use        |
|                | >                                                   |
|                | > • Sets goals and may tell others about them       |
+----------------+-----------------------------------------------------+
| **Action**     | > • Chooses and begins to pursue a goal             |
|                | >                                                   |
|                | > • Modifies habits                                 |
|                | >                                                   |
|                | > • Can last months following termination of        |
|                | > marijuana use                                     |
+----------------+-----------------------------------------------------+
| *              | > • Makes efforts to sustain gains achieved during  |
| *Maintenance** | > the action phase                                  |
|                | >                                                   |
|                | > • Works to prevent recurrence of use              |
|                | >                                                   |
|                | > • Learns how to detect and guard against risky    |
|                | > situations                                        |
|                | >                                                   |
|                | > • Requires prolonged behavior change and          |
|                | > continued vigilance for 6 months to several years |
+----------------+-----------------------------------------------------+

***Using Motivational Interviewing Strategies***

Sessions 1 and 2 rely heavily on the motivational interviewing
strategies described in Miller and Rollnick (2002). Motivational
interviewing is a technique used in motivational enhancement therapy
(MET). The counselor assesses the client's motivation by using
motivational interviewing strategies, which include asking open-ended
questions, listening reflectively, affirming the client, summarizing the
client's views of change, eliciting self-motivational statements,
recognizing and addressing resistance, recognizing readiness for change,
and identifying discrepancies (see CSAT 1999*b*). Once the client's
stage is identified, the counselor uses these strategies to support
continued progress through the stages.

*Close- Vs. Open-Ended Questions*

Close-ended questions are an efficient way of obtaining information
quickly; however, they allow the client to be passive, answering each
question and quietly waiting for the next. The interviewer is in
control, and the interviewee responds to each cue. Open-ended questions
encourage the client to express himself or herself and to adopt an
active role in his or her treatment. Exhibit V-2 presents examples of
both types of questions.

+-----------------------------------+-----------------------------------+
| **Exhibit V-2. Examples of Close- |                                   |
| and Open-Ended Questions**        |                                   |
+-----------------------------------+-----------------------------------+
| **Close-Ended Questions**         | **Open-Ended Questions**          |
+-----------------------------------+-----------------------------------+
| > • How old were you when you     | > • Tell me about your early      |
| > first smoked marijuana?         | > experiences with marijuana.     |
| >                                 | >                                 |
| > • Was it offered to you by a    | > • How did your marijuana use    |
| > family member?                  | > change over time?               |
| >                                 | >                                 |
| > • How old were you when you     | > • Please describe some of your  |
| > began using it daily?           | > recent experiences with         |
| >                                 | > marijuana.                      |
| > • Have you ever had a bad       | >                                 |
| > experience with marijuana?      | > • What was it that made you     |
| >                                 | > think you had a problem with    |
| > • When did you first think you  | > marijuana?                      |
| > had a marijuana problem?        |                                   |
+-----------------------------------+-----------------------------------+

*Listening Reflectively*

A reflection can take the form of simply repeating the client's words or
paraphrasing his or her comments. Sometimes the reflection adds to what
the client has said as a way of testing a counselor's hunch. The skilled
listener using reflective listening skills can help the client explore
his or her thoughts and feelings:

**Miguel (M):** *I've tried to quit before but have never made it for
longer than a month.*

**Counselor (C):** *Keeping it going has been hard.*

**M:** *Yeah. I can't help feeling pessimistic about what will happen if
I try it again.*

or

**M:** *My wife is pressuring me to quit. I've got to want to do it for
me if this is going to work.*

**C:** *Pressure from your wife is distracting you from tuning in to
your needs about quitting.*

**M:** *It's almost as if I resist because I want to feel that she
doesn't control my life.*

or

**M:** *My buddies say they'll support me if I decide to quit, but
knowing that they're getting high will make me feel left out.*

**C:** *You'd like to figure out a way to stay connected to these
friends and stop smoking.*

**M:** *I guess I've been thinking that's not possible.*

A double-sided reflection captures two opposing sides to an individual's
ambivalence:

**Linda (L):** *I know I'm getting high too much, but it's summer and I
want to have fun before school starts.*

**C:** *On the one hand, you don't want to miss having fun during the
summer, but on the other hand, you're thinking that you use too often.*

*Affirmation of the Client*

Admitting drug dependence, seeking help by enrolling in a program,
summoning the courage to change, and undertaking other aspects of
overcoming a dependence are tremendously difficult. The counselor can be
supportive by frequently offering genuine compliments and expressions of
awareness:

**C:** *You've been thinking about quitting for a long time, and now
you're taking the first steps. I'm guessing you feel good about that.*

**C:** *Telling your father that you needed counseling for a marijuana
problem must have been difficult.*

**C:** *Deciding to give up the extra income that came from selling pot
wasn't a minor decision. It requires a real commitment to leave that
behind.*

*Summarizing the Client's Views of Change*

As the client reveals facets of his or her thinking about change, the
counselor can be supportive by summarizing key issues. Hearing the
counselor consolidate the client's statements helps the client become
aware and ready to resolve his or her mixed motivations:

**C:** *If I understand you correctly, you're aware of reasons for
changing but you're thinking of other reasons not to quit. On the side
of quitting are being a good role model for your children and overcoming
a tendency to procrastinate. On the side of not quitting are your fears
that you'll lose friends and won't make it for long. Have I got it
right? What are your thoughts about this?*

*Eliciting Self-Motivational Statements*

Whereas some clients begin counseling with a strong commitment to stop
marijuana use, others have considerable ambivalence that may increase
over time. Motivational enhancement sessions help the ambivalent client
strengthen his or her determination to quit. It is hoped that these
counseling sessions lead the client to recognizing his or her problem
*(I guess I really have to face that I'm out of control with
marijuana)*, becoming concerned about it *(I'm worried about whether I
can overcome this)*, expressing an intention to change *(Now's the time
for me to leave this behind)*, and feeling positive about the prospects
of succeeding *(I can picture a time when I'll be clean, and---for once
in my life---that seems possible).* The counselor elicits expressions of
motivation from the client with open-ended questions:

> **• Recognizing the problem**
>
> **C:** *How has your marijuana use gotten in the way of things that
> are important?*
>
> **C:** *What convinces you that marijuana has become a problem?*
>
> **• Expressing concern**
>
> **C:** *What aspects of your marijuana use have made you, or people
> close to you, worry?*
>
> **C:** *What do you imagine could happen if you continued to smoke
> marijuana the way you have been doing?*
>
> **• Encouraging intentions to change**
>
> **C:** *When you joined our program, you probably had some hope that
> things would get better. What would improve in your life if your hopes
> were met?*
>
> **C:** *Why should you stop smoking marijuana? Why do you think it's
> time to change?*
>
> **• Expressing optimism**
>
> **C:** *What leads you to think that you could succeed in quitting if
> you decided to do that?*
>
> **C:** *Is there a part of you that feels encouraged about changing?*

With these questions, the counselor helps the client take ownership of
the problem and elicit expressions of readiness to change.

*Recognizing and Addressing Resistance*

A conventional way of interpreting actions of a client who argues with
the counselor, frequently interrupts, or denies that a behavior is a
problem is that the individual is not motivated to change. An
alternative view is that the counselor does not understand the client's
thoughts and feelings. When the counselor considers these behaviors a
signal that he or she needs to understand the client's experience
better, a confrontation between counselor and client is less likely to
occur. The counselor shows that he or she is listening and is not being
judgmental. The counselor's reflections can prompt the client to explore
his or her thoughts and feelings:

**M:** *I don't understand why you folks want everyone to quit smoking
dope. Maybe I'd be better off if I just cut back.*

**C:** *I hear you saying that it's important to you to change your
marijuana use, but you're not sure whether stopping completely is best
for you right now. I can see that you're eager to find the best goals.*

In this example, the counselor might have offered a defense of the
program's abstinence objectives, listed reasons why the client ought to
change, and so forth. Those responses probably would have led the client
to become even more resistant. The strategy illustrated above is termed
"rolling with resistance," an approach that conveys the counselor's
acceptance of the client's point of view and invites the client to be
open to a slight variation. In the following examples of this approach,
the counselor accepts the client's comments, conveys empathy for the
client's feelings, and reframes what has been said:

**M:** *Most of the people I know get high. Why is everyone on my back?*

**C:** *It's hard to figure out why you're getting all this pressure.
Kind of makes you wonder how you could be the only one who is having
problems with pot.*

or

**M:** *I know I'll have more energy if I quit, but I need it to relax.*

**C:** *On the one hand, you'd benefit from more energy. On the other
hand, you'd need to find other ways to relax.*

or

**M:** *I can't see living for the rest of my life without getting
high.*

**C:** *Slow down. It's too early to be talking about forever. Let's
talk about what you're working on right now.*

or

**M:** *I think a lot about quitting, but I've never really tried it.*

**C:** *You've invested a lot of time and energy in this already.*

*Recognizing Readiness for Change*

Expressions of motivation take a variety of forms. The counselor needs
to listen carefully and acknowledge those expressions:

**M:** *I hate having so many people angry at me. Why don't they get off
my back?*

**C:** *It's important to find a way to stop people from being angry
with you.*

or

**M:** *One thing that I see happening over and over is my promising
that I'll limit how often I get high, and then I go right ahead and
break every one of these promises.*

**C:** *You'd really like to stop disappointing yourself.*

or

**M:** *I've got three beautiful children, and I don't want my pot
smoking to interfere with my being a good father.*

**C:** *An important priority in your life is your role as a father.*

*Identifying Discrepancy*

Clients who are drug dependent have probably seen their reliance on
drugs interfere with important aspects of their lives. The counselor
helps the client focus on the costs of continued drug use by pointing
them out to the client and seeking the client's perspectives:

**C:** *I've heard you talk about how important it is that your children
grow up in a safe and happy home. That's a goal. But you've also talked
about not wanting anyone, including your wife, to dictate what you do,
and this is causing tension in your home. Relieving this tension is
another goal. I wonder what your thoughts are about these two goals.*

**C:** *You've told me that when you smoke a joint on your lunch break,
you have a hard time concentrating at work for the rest of the day.
You've also said that doing your job well is important so that you can
get promoted. I'm a little confused.*

***The Context for Motivational Interviewing and Skills Training***

As the client expresses increasing interest in addressing his or her
problems modifying use, the counselor carefully supports these efforts
to change without *prescribing* the change. When the client expresses a
commitment to change, the counselor asks the client about the steps he
or she will take to make the change. The counselor provides a menu of
self-change and assisted-change options depending on the client's
inclinations and experience in making changes.

It is important for the counselor to show genuine interest in the
client's perspectives on and skills for making change. For example, if
the client has quit smoking tobacco, lost a lot of weight, or left a
destructive relationship, the counselor explores these experiences to
reinforce and highlight the client's capacity and desire for
self-development. Self-change advice may be in the form of a brief
written handout concerning behavioral changes. Sessions 1 and 2 provide
several take-home handouts that reinforce motivational advice given by
the counselor during the sessions. These handouts are available at the
end of this section.

**Tips for the Counselor**

> • Review relevant sections of the manual before each session.
>
> • Develop a natural style of conveying the material; avoid reading
> text to clients.
>
> • Maintain a motivational style; use open-ended questions and
> reflections; and avoid a directive, resistance-building style.
>
> • Encourage involvement and participation by the client.
>
> • Attend to shifts in the client's motivation and readiness for
> change.
>
> • Explain practice exercises carefully; probe for the client's
> understanding.

+-----------------------------------------------------------------------+
| **Overview of Session 1: Reviewing the PFR**                          |
|                                                                       |
| **Total Time:** 1 hour, 30 minutes                                    |
|                                                                       |
| **Delivery Method:** MET-focused individual therapy                   |
|                                                                       |
| **Materials (all forms except the PFR are at the end of this          |
| section):**                                                           |
|                                                                       |
| > • Two copies of client's completed PFR (form AS8 from the           |
| > assessment session)                                                 |
| >                                                                     |
| > • *Learning New Coping Strategies* (form 1A)                        |
| >                                                                     |
| > • *A Guide to Quitting Marijuana* (form 1B)                         |
| >                                                                     |
| > • A blank copy of the *Quit Agreement* (form 1C)                    |
|                                                                       |
| **Goals for This Session:**                                           |
|                                                                       |
| > • To present the data gathered during the assessment session        |
| > concerning marijuana use, its consequences, and the likely benefits |
| > and costs of stopping or reducing use                               |
| >                                                                     |
| > • To facilitate the client's candid reflection on consequences of   |
| > marijuana use                                                       |
| >                                                                     |
| > • To explore the client's attitudes about change, including         |
| > ambivalent attitudes                                                |
| >                                                                     |
| > • To acknowledge the client's expressions of readiness for change,  |
| > help set goals, and identify change strategies                      |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > **1.** Assess the client's readiness to proceed                     |
| >                                                                     |
| > • Ask client for his or her feelings and thoughts about the         |
| > assessment session                                                  |
| >                                                                     |
| > • Ask whether any changes have occurred since the last meeting      |
| >                                                                     |
| > • Reinforce expressions of motivation                               |
| >                                                                     |
| > **2.** Review the PFR                                               |
| >                                                                     |
| > • Age of onset                                                      |
| >                                                                     |
| > • Comparison of use patterns to the national average                |
| >                                                                     |
| > • Problems caused by use                                            |
| >                                                                     |
| > • Tolerance level                                                   |
| >                                                                     |
| > • Reasons for quitting                                              |
| >                                                                     |
| > • Risk factors                                                      |
| >                                                                     |
| > **3.** Summarize the PFR review                                     |
| >                                                                     |
| > **4.** Elicit and reinforce client's readiness to change            |
| >                                                                     |
| > **5.** Assist the client in preparing for change                    |
| >                                                                     |
| > • Ask him or her to select a stop date (if the client has not       |
| > already stopped using)                                              |
| >                                                                     |
| > • Discuss                                                           |
| >                                                                     |
| > --- Whether the client will stop "cold turkey"                      |
| >                                                                     |
| > --- What the client will do with current marijuana supply and       |
| > paraphernalia                                                       |
| >                                                                     |
| > --- How the client will disclose plans to family and friends        |
| >                                                                     |
| > --- How the client will address problems in maintaining abstinence  |
| >                                                                     |
| > **6.** Help the client identify specific behavior change strategies |
| >                                                                     |
| > • Discuss *Learning New Coping Strategies* (form 1A) and *A Guide   |
| > to Quitting Marijuana* (form 1B)                                    |
| >                                                                     |
| > • Discuss barriers to quitting and vulnerabilities to slipping      |
| >                                                                     |
| > --- Managing general stress (HALT)                                  |
| >                                                                     |
| > --- People, situations, and thoughts that increase vulnerability    |
| >                                                                     |
| > --- Significant life changes likely to produce stress               |
| >                                                                     |
| > --- Supportive people who will provide help                         |
| >                                                                     |
| > • Review previous successful experiences at quitting to identify    |
| > useful strategies                                                   |
| >                                                                     |
| > **7.** Assign between-session exercises                             |
| >                                                                     |
| > • Prepare *Quit Agreement* (form 1C)                                |
| >                                                                     |
| > • Review *Learning New Coping Strategies* (form 1A)                 |
| >                                                                     |
| > • Review *A Guide to Quitting Marijuana* (form 1B)                  |
| >                                                                     |
| > **8.** Ask client to invite a supporter to next session             |
| >                                                                     |
| > **9.** Review and conclude session                                  |
+-----------------------------------------------------------------------+

**Session 1 Protocol**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor uses MET techniques while
reviewing the client's PFR and helping the client prepare for change.

***Assess the Client's Readiness To Proceed***

The counselor asks the client to express his or her thoughts and any
major changes that have occurred since the assessment session. Some
possible responses from the client might be

> • Abstinence since entering treatment
>
> • A reduction in the client's marijuana use
>
> • Seeking additional treatment or attendance at a mutual-help program
>
> • Conversations about his or her use or about this program with family
> or friends.

The counselor responds empathically, uses opportunities to support the
client's self-efficacy for change, and reinforces expressions of
motivation.

**Counselor (C):** *Thank you for being on time. How are things going?*

**Shirley (S):** *After answering all those questions about my smoking,
I am more aware of it than ever! Nothing has changed yet, but I am
thinking about it. My husband has been very supportive.*

**C:** *And his support means a lot to you.*

**S:** *You bet! He is someone I can count on.*

**C:** *That's good to hear. Let's be sure to talk about specific
requests you might make of him for support in the future.*

or

**C:** *You arrived a little late for your appointment. Is this a good
time for you, or would a different time work better?*

**Doug (D):** *No; this is fine. There was a lot of traffic.*

**C:** *How are things?*

**D:** *Worse. My wife and my son are on my back; they are treating me
as if I'm a leper.*

**C:** *That sounds like an uncomfortable situation for you.*

**D:** *Yeah; I feel like everyone is against me.*

**C:** *How has this affected your smoking?*

**D:** *At times I find myself smoking just to prove that it's not a
problem for me!*

**C:** *It's more of a problem for them.*

**D:** *That's right. I don't think either one really understands me.*

**C:** *You'd like them to understand you; that might remove some
reasons for getting high.*

**D:** *Yeah. At least I wouldn't be trying to get back at them.*

***Review the PFR***

The PFR review takes approximately 30 minutes. The counselor explains
that by reviewing the PFR (form AS8), the client will understand reasons
for and against changing and what and when problems might arise.

The counselor leads the client through a systematic review of the PFR,
giving the client an opportunity to explore each point. The counselor
avoids simply verifying the information obtained during the assessment
session. The counselor periodically seeks the client's thoughts and
feelings during the review. The counselor listens reflectively to
acknowledge expressions of readiness for change. Reviewing the PFR
provides an ideal opportunity to use motivational interviewing
techniques, for example, expressing empathy, identifying discrepancy,
eliciting self-motivational statements, rolling with resistance, and
supporting self-efficacy.

The client may respond to elements in the PFR review with arguments
about the validity of the items *(I didn't say smoking pot was causing
me money problems!)*. In such cases, the counselor maintains a
nondefensive tone, acknowledges that the client knows best which areas
of his or her life have been affected by marijuana use, and moves on to
the next item. The counselor may make changes to the PFR based on the
client's feedback during this review.

In keeping with the MET approach, the counselor uses open-ended rather
than close-ended questions. For example, *Did you say you used in unsafe
situations?* is a close-ended question that invites a mere yes or no
answer and possible disagreement with the PFR item. Saying instead *Tell
me about using in unsafe situations* invites elaboration and discussion.

The counselor spends more time on the sections that are likely to
produce the most constructive discussion. The sections on marijuana
problems and reasons for quitting are especially conducive to
motivational interviewing. After reviewing the PFR with the client, the
counselor asks the client for reactions and responds to them with
empathy. Before moving on to the next phase of this session, the
counselor ensures that the following PFR items are discussed:

> • **Age of onset (part I of the PFR).** The counselor tells the client
> that substance use disorders tend to be more severe when they begin at
> an early age. This means that the earlier the age of onset, the
> greater the risk of developing severe problems if the substance use
> continues. In the PFR, the age of onset of regular marijuana smoking
> is the age the client began smoking marijuana three or more times a
> week.
>
> • **Comparisons of use patterns (part I of the PFR).** When preparing
> the PFR, the counselor uses tables A and B to compare the client's use
> with that of others who use marijuana. The percentiles indicate the
> percentage of people in the comparison group who scored at or below
> the client's score. These comparisons allow the client to compare his
> or her use with that of people who experienced significant problems
> related to marijuana use. The counselor can present the information in
> the following way:
>
> **C:** *You smoked marijuana on 24 of the past 30 days. That puts you
> in the top 98 percentile relative to all Americans. This means that 98
> percent of American adults smoke less often than you do and about 2
> percent smoke more often.*
>
> **S:** *Wow!*
>
> **C:** *That surprises you.*
>
> **S:** *It sounds like a lot. I never thought it was that much!*
>
> **C:** *What are you thinking, now that you know that?*
>
> **S:** *I don't like it. I knew I was getting high a lot, but I always
> thought that a lot of other people got loaded as much as I did. This
> isn't good news.*
>
> **C:** *You'd like this to be different.*
>
> **S:** *Yeah.*
>
> • **Problems caused by marijuana use (part II of the PFR).** The
> counselor tells the client where he or she falls, relative to others
> seeking treatment, based on his or her responses to the *Marijuana
> Problem Scale* (form AS5) and the data in table C. The counselor
> reviews the criteria listed on the *Structured Clinical Interview for
> DSM-IV* (SCID-IV) (form AS4) that were coded as 2 or 3. The results
> provide an overview of the problems and symptoms that the client
> identified as resulting from his or her marijuana use.
>
> • **Tolerance level (part II of the PFR).** Question 6 of the SCID-IV
> was used to measure the client's tolerance level. Tolerance is defined
> as the need for a markedly increased amount of marijuana (at least a
> 50-percent increase) to achieve the desired effect or a markedly
> diminished effect with continued use of the same amount of marijuana.
>
> • **Reasons for quitting (part III of the PFR).** To reinforce the
> client's motivation, the counselor reviews the reasons the client gave
> on the *Reasons for Quitting Questionnaire* (form AS6) and asks the
> client whether he or she would like to add other reasons to the list.
>
> • **Risk factors for relapse (part IV of the PFR).** The counselor
> points out the risky situations the client identified on the
> *Self-Efficacy Questionnaire* (form AS7) as the client's risk factors
> for relapse. The counselor explains that risk factors are warning
> signs that require the client's attention and indicate a
> susceptibility to problems associated with marijuana use. A person who
> uses substances besides marijuana is at risk for additional reasons.
> Decreased use of one drug may result in increased use of another, a
> phenomenon called substance substitution. In addition, combining
> different drugs compounds their effects, sometimes with dangerous
> results. Tolerance for one substance can increase tolerance for
> another; people who take multiple substances simultaneously can
> develop cross-tolerance for several substances and be at risk for
> injury, arrest, or overdose if severely intoxicated.

***Summarize the PFR Review***

The counselor summarizes the highlights from the PFR, including
reactions and modifications offered by the client during this session:

**C:** *Let's review and summarize what we've talked about so far. How
does that sound to you?*

**S:** *I'm ready!*

**C:** *Your PFR shows that your smoking has caused several problems
including missing work, difficulty sleeping, and feeling bad about your
use. Is there anything else you want to add?*

**S:** *No; those are the main problems.*

**C:** *You also mentioned reasons for quitting, including so your
husband will quit nagging you, so you won't lose the privilege of
teaching, and because you have health concerns.*

**S:** *Being a good teacher is really important.*

**C:** *Being a good teacher is important to you, and your smoking gets
in the way. You can't properly prepare for class; the kids can find out;
you can lose your job.*

**S:** *It's my biggest reason for wanting to stop.*

**C:** *When you talk about being a teacher, you get enthusiastic, but
when you talk about your smoking, you get discouraged.*

**S:** *I never noticed that before, but you're right.*

**C:** *You also stated that high-risk situations for you would include
being with others who smoke and seeing them enjoy it. Anything else?*

**S:** *Not really, but that is a major concern for me as I try to quit.
So many people in my life use drugs.*

**C:** *You've already identified how difficult it may be, but you've
also identified some very strong reasons for changing your smoking
habits.*

**S:** *I know it'll be difficult, but I think it's worth it.*

**C:** *Despite the obstacles, you're ready to take on this challenge.*

**S:** *I really am.*

***Elicit and Reinforce Client's Readiness To Change***

When the client expresses motivation to change, the counselor
acknowledges these expressions, seeks elaboration, and offers
reinforcement:

**C:** *You said that your smoking has caused problems including feeling
that you have lower energy. Could you tell me about that?*

**Miguel (M):** *I find I mean to do things, but they never get done. It
seems that I'm tired all the time. I can't help but think it's related
to my smoking.*

**C:** *Related to your smoking?*

M: *I don't think it affected me when I was young. But now, well, I'm
not getting any younger!*

**C:** *You think smoking is affecting you more as you get older. You
feel less productive.*

**M:** *I think that's related to the lower energy. I don't finish my
work at my job, and I'm not as creative. I feel that I'm drowning in
backed-up work at home, at my job, everywhere.*

**C:** *And you think that if you quit smoking, you will increase your
productivity.*

**M:** *Yeah.*

**C:** *That's important to you. You'd like to regain your creativity
and productivity.*

**M:** *I really would like that.*

***Assist Client in Preparing for Change***

The counselor assists the client in preparing to stop using marijuana by
discussing several key issues. If the client has not stopped already, he
or she needs to select a day to stop. The counselor helps the client
consider several alternative stop dates.

Topics to consider include what the client will do with his or her
marijuana supply and paraphernalia, how the client will disclose the
plan to stop to family and friends (both supporters and those who might
sabotage the client's efforts), and how the client will address possible
problems in maintaining abstinence (e.g., sleep difficulties, boredom,
anxiety, restlessness) in the first week.

***Help Client Identify Specific Behavior Change Strategies***

The counselor discusses specific coping strategies to handle
vulnerabilities to slipping. The counselor gives the client *Learning
New Coping Strategies* (form 1A) and *A Guide to Quitting Marijuana*
(form 1B). If time permits, the counselor reviews these forms with the
client, highlighting sections that seem particularly relevant to the
client. The counselor explains that many concepts touched on in the
forms are discussed in detail in later sessions and the client should
bring the forms to the next session (session 2).

Because managing one's stress level is important, particularly in the
early weeks and months of treatment, the counselor advises the client
about HALT:

> • Don't let yourself become too **H**ungry.
>
> • Don't let yourself become too **A**ngry.
>
> • Don't let yourself become too **L**onely.
>
> • Don't let yourself become too **T**ired.

The counselor asks the client to think about people, situations (e.g.,
certain times of day, days of the week, places, moods), and thoughts
that can increase vulnerability to slipping. Some of these were
mentioned on the *Self-Efficacy Questionnaire* (form AS7). For example,
a client may describe plans to spend time with a smoking buddy. A client
may face significant life changes (e.g., job or relationship changes,
illness in the family or of a close friend) likely to produce stress
that could place the client at risk for slipping. The counselor and
client identify and discuss coping strategies for each situation.

The counselor helps the client identify people from whom he or she can
seek and get support. The counselor encourages the client to consider
several options rather than only one or two and to think creatively.
With the counselor, the client can practice making requests and can
benefit from the counselor's modeling and feedback. Practicing
interactions during treatment sessions can lessen the anxiety the client
may have about asserting himself or herself with friends and family:

**M:** *I'll be going away for a few days, and I have concerns that no
one will be watching me.*

**C:** *What concerns do you have?*

**M:** *I'll be at a meeting with several people who smoke. For years
we've gone out and partied after the meetings. I don't know what I'll
do.*

**C:** *You just identified a high-risk situation.*

**M:** *Yeah. What should I tell them? I thought about saying I had a
cold, but that's lying.*

**C:** *You would prefer to tell them the truth. What are your concerns
about that?*

**M:** *I guess I'm afraid they would think I'm judging them. I really
like these people.*

**C:** *That is a difficult situation for you. Maybe if you and I
rehearsed a couple of different ways to tell them, it would make it
easier for you. Would you be willing to try that?*

**M:** *Sure, what should we do?*

**C:** *Why don't I play the role of one of your colleagues on this
trip, and you try different ways you might handle it. Ready?*

***Assign Between-Session Exercises***

The counselor gives the client the *Quit Agreement* (form 1C) and asks
the client to bring the completed form to the next session. The
counselor explains that the agreement summarizes

1\. The client's date for quitting marijuana use

2\. The client's reasons for seeking to change

3\. Strategies that the client will use.

The counselor also asks the client to review *Learning New Coping
Strategies* (form 1A) and *A Guide to Quitting Marijuana* (form 1B)
several times before the next session.

***Ask Client To Invite a Supporter to Next Session***

People who are trying to overcome an addiction can benefit greatly from
the support of a close relative or friend. The counselor asks the client
to invite someone to attend the next session and to think carefully
about the pros and cons of particular people to invite. For example, a
friend who is dependent on another drug or alcohol is not a good
prospect. Factors to consider include closeness to the client, emotional
characteristics of the relationship, emotional availability of the
supporter regarding the client's desire to quit marijuana use, substance
use by the supporter, and accessibility during times of stress. The
ideal person would be someone who is a good listener, cares about the
client, and is interested in providing support. This person will be
asked to sign the *Supporter Agreement* at session 2.

***Review and Conclude Session***

The counselor reviews the content of the session, asks the client for
feedback, responds empathically to his or her comments, troubleshoots
any difficulties, and reminds the client to review the handouts over the
next week.

+-----------------------------------------------------------------------+
| **Overview of Session 2: Change Plan, Treatment Plan, and Supporter   |
| Involvement**                                                         |
|                                                                       |
| **Total Time:** 1 hour                                                |
|                                                                       |
| **Delivery Method:** MET-focused individual therapy with case         |
| conference elements                                                   |
|                                                                       |
| **Materials (all forms except the PFR are at the end of this          |
| section):**                                                           |
|                                                                       |
| > • Copy of client's PFR (form AS8)                                   |
| >                                                                     |
| > • *Learning New Coping Strategies* (form 1A)                        |
| >                                                                     |
| > • Blank copy of the *Quit Agreement* (form 1C)                      |
| >                                                                     |
| > • *Supporter Strategies* (form 2A)                                  |
| >                                                                     |
| > • Two blank copies of *Supporter Agreement* (form 2B)               |
|                                                                       |
| **Goals for This Session:**                                           |
|                                                                       |
| > • To specify how a supporter can help the client achieve and        |
| > maintain change                                                     |
| >                                                                     |
| > • To help the client develop a change plan with coping strategies   |
| > for high-risk situations                                            |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > **1.** Assess client's progress and readiness to proceed            |
| >                                                                     |
| > • Ask client how he or she feels about continuing therapy           |
| >                                                                     |
| > • Address client comments and questions about session 1 handouts    |
| >                                                                     |
| > • Review the client's *Quit Agreement*                              |
| >                                                                     |
| > **2.** Welcome supporter                                            |
| >                                                                     |
| > • Stress importance of supporter's participation                    |
| >                                                                     |
| > • Provide basic information about intervention                      |
| >                                                                     |
| > • Answer questions                                                  |
| >                                                                     |
| > **3.** Examine client's recent experiences                          |
| >                                                                     |
| > • Did client make an effort to stop? Cut down?                      |
| >                                                                     |
| > • Did he or she experience any high-risk or tempting situations?    |
| >                                                                     |
| > • Did the client use any strategies from *Learning New Coping       |
| > Strategies?*                                                        |
| >                                                                     |
| > • Were the strategies successful?                                   |
| >                                                                     |
| > **4.** Examine client's experience with supportive and              |
| > nonsupportive relationships                                         |
| >                                                                     |
| > **5.** Discuss ambivalence                                          |
| >                                                                     |
| > **6.** Establish a change plan                                      |
| >                                                                     |
| > • Suggest interim goals if client is not ready for abstinence       |
| >                                                                     |
| > • Encourage client to set general and specific goals                |
| >                                                                     |
| > **7.** Involve supporter and review *Supporter Strategies* and      |
| > *Supporter Agreement*                                               |
| >                                                                     |
| > • Elicit supporter's concerns and hopes for the client              |
| >                                                                     |
| > • Give supporter *Supporter Strategies* (form 2A)                   |
| >                                                                     |
| > • Complete *Supporter Agreement* (form 2B)                          |
| >                                                                     |
| > • Review *Supporter Agreement*                                      |
| >                                                                     |
| > • Help client and supporter decide which items they can agree to    |
| >                                                                     |
| > • Review *Supporter Agreement* with client, even if no supporter    |
| > attends, and role play asking for support                           |
| >                                                                     |
| > **8.** Assign between-session exercises                             |
| >                                                                     |
| > **9.** Review and conclude session                                  |
+-----------------------------------------------------------------------+

**Session 2 Protocol**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor helps the client develop a
change plan and obtain support from an important person in the client's
life.

***Assess Client's Progress and Readiness To Proceed***

The counselor asks the client how he or she feels about the two previous
counseling sessions and responds empathically to his or her concerns.
The counselor addresses any client comments or questions that have
arisen since the previous session about the PFR (form AS8), *Learning
New Coping Strategies* (form 1A), or the *Quit Agreement* (form 1C). The
counselor reviews the *Quit Agreement* with the client and discusses
adjustments (e.g., Is the client setting unrealistically high standards
that may set him or her up for failure? Has the client identified
salient reasons for wanting to make changes in marijuana use?). The
counselor photocopies the agreement to maintain a record of client
goals.

***Welcome Supporter***

If the client has brought a supporter, the counselor welcomes him or her
and thanks the individual for his or her willingness to participate. The
counselor provides general information about the intervention and asks
whether the supporter has questions.

In the course of the session, the counselor

> • Provides the supporter with information and answers his or her
> questions about the treatment
>
> • Fosters motivation by encouraging the supporter and client to
> discuss the effect of the client's marijuana use on their relationship
>
> • Formulates a change plan
>
> • Identifies how the supporter can help the client with treatment
> goals and abstinence.

The counselor emphasizes the importance of the supporter's participation
and indicates that in a few minutes the counselor will want to hear more
from the supporter but that first the counselor will talk with the
client about what has been happening recently:

**Counselor (C):** *I want to thank you both for coming today. Shirley
has told me how much help you've been to her. We'll meet for about an
hour today to discuss your role as a supporter for Shirley. Does either
of you have any questions?*

**Husband (H):** *I want you to know how proud of her I am; I'm willing
to do whatever I can to help her out.*

**C:** *That's very encouraging to hear. Before we begin, I'd like to
take a few minutes to ask Shirley how things have been going since we
last met.*

***Examine Client's Recent Experiences***

The counselor asks the client to describe his or her recent experiences
with marijuana:

> *•* Did the client stop use since the previous session?
>
> • Did the client make an effort to stop?
>
> • Was the client confronted with any high-risk or tempting situations?
>
> • What strategies did the client use? Did the client try any of the
> strategies in *Learning New Coping Strategies* (form 1A)? Were they
> successful?
>
> • Were there any instances when the client effectively handled a "hot"
> situation (i.e., very high risk)?

The counselor acknowledges client efficacy and reinforces the strategies
that the client found useful. The client's report on the week's events
provides the counselor with an opportunity to use motivational
interviewing techniques. As the client talks, the counselor's objective
is to elicit information and to use that information to provide
reflections, express empathy, identify discrepancies, elicit
self-motivational statements, and roll with resistance:

**Shirley (S):** *Well, I've almost completely stopped smoking since our
last session.*

**C:** *You seem very pleased with yourself! How did you do that?*

**S:** *Right after the last session I kept thinking about how pot has
kept me from doing the things I want to do. I really want to be a
teacher, and I realized that as long as I kept smoking, I would always
feel bad. So I went home and smoked one last time, then flushed the
remainder of my stash down the toilet! During the last week I've wanted
to get high several times, but I didn't.*

**C:** *What did you do when you felt like smoking?*

**S:** *Well, I talked to my husband. I read about that in the handout
you gave me last week.*

***Examine Client's Experience With Supportive and Nonsupportive
Relationships***

The counselor helps the client reevaluate relationships that have
enhanced or impeded change:

**C:** *Talking to someone else helped.*

**S:** *Yes, it did. And I kept cards and notes from my students in my
purse and would take them out and look at them. Boy, I love those kids!*

**C:** *Your love for the children you teach and your husband's support
are powerful tools!*

**S:** *You bet!*

or

**Doug (D):** *My wife chose not to come today. She says this is my
problem, and I need to solve it or find a new wife. After all these
years of me smoking around her, now she wants immediate change and
doesn't want to help me!*

**C:** *As you work on making changes, you may not have the support you
would like. How are things different since we met last?*

**D:** *I've tried to cut down to a couple of days a week, but it's
harder than I thought.*

**C:** *When you were successful, what did you do differently?*

**D:** *I didn't take pot to work 2 days last week, so I couldn't smoke.
It wasn't that bad. If I didn't have it in my car, I didn't leave work
on an "errand" to smoke.*

**C:** *You found that you could make changes if you didn't have
marijuana in easy reach, and it may have been easier than you thought it
might be. Did other things help?*

***Discuss Ambivalence***

The client may be reluctant to disclose ambivalence for fear of
disapproval. However, strong ambivalence may be manifested in nonverbal
behavior and possibly in an impaired therapeutic alliance (e.g., missed
sessions, reluctance to establish treatment goals). The counselor needs
to be vigilant about maintaining the client's level of motivation for
change and engagement in treatment.

***Establish a Change Plan***

The counselor helps the client establish a long-term plan for behavior
change, focusing particularly on the next 12 months. The counselor
summarizes indications of motivation that the client has made. If the
client has given no indications of a desire to change, he or she may not
be ready to commit to change, and the counselor points this out.

The counselor explains that articulating goals increases the likelihood
that the counseling will be meaningful and useful. For clients whose
goal is immediate and permanent abstinence, articulating goals is
straightforward. However, many clients are not at this stage of change
early in treatment. If clients say they are not ready to give up
marijuana, the counselor suggests setting other interim goals such as
learning more about the skills that will help them quit or reduce
marijuana use in the future. Goals may be general, such as quitting
marijuana use within the next 2 weeks or reducing marijuana use to no
more than four joints per week. Other goals may be more specific. For
example, the client may set goals of figuring out how to stay away from
substance use opportunities, identifying ways to get past cravings,
learning new social skills, and participating in activities that are
incompatible with marijuana use. Although the program's goal is to help
clients achieve abstinence, the counselor needs to meet the clients
where they are to avoid alienating them and to keep the door open for
improvement and possible future abstinence.

***Involve Supporter and Review* Supporter Strategies *and* Supporter
Agreement**

If a supporter is attending this session, the counselor shifts the focus
of the session to the relationship between the client and supporter. The
counselor asks the supporter why he or she wants to participate,
eliciting the supporter's concerns and hopes for the client. The
counselor gives the supporter *Supporter Strategies* (form 2A) and
reviews its contents.

The counselor introduces the *Supporter Agreement* (form 2B), and the
client and supporter read the list to determine which items they will
agree to:

**C:** *We have a list of ideas and strategies that have been helpful
for some people. Let's see whether any of these could work for you two.*
\[To husband\] *As we begin to look at ways that you and your wife can
work together on this change, what concerns do you have?*

**H:** *Shirley has a habit of getting excited about something and then
giving up when things get tough. I want to help, but I'm not going to
nag her. This is something she's going to do, not me. I'll help, but I
won't push her.*

**C:** *You recognize that Shirley needs to make her own decisions, and
you don't want to be a policeman, is that right?*

**H:** *Pretty much, but I don't want to give you the idea that I won't
support her.*

**C:** *It sounds as if you have some ideas of what you would be willing
to do. I've given the two of you a* Supporter Agreement*. We've listed
some ways that Shirley might reach her goals. As we look at these
together, I'd like you to identify some things you might be willing to
do. How does that sound?*

Even if the client has not brought a supporter to the session, the
counselor reviews the *Supporter Agreement*. The client may choose to
identify a supporter later. The counselor and client can role play ways
of asking for support.

***Assign Between-Session Exercises***

The counselor asks the client to continue reviewing the forms handed out
at this session and last week's session.

***Review and Conclude Session***

The counselor reviews the content of the session, asks the client for
feedback, responds empathically to his or her comments, and
troubleshoots any difficulties. The counselor should also discuss with
the client the likely scenarios for future treatment sessions. For
example:

**C:** *When we meet next time, we're going to shift gears somewhat. I'm
going to talk with you about other areas of your life besides your
marijuana use---areas in which you may be experiencing difficulty. These
problems may be directly related to your marijuana use, but not
necessarily. We're going to work on these other areas of life because
doing so may help you be successful in your goal to stop using
marijuana.*

**Forms for Sessions 1 and 2**

During the enhancing motivation sessions, the counselor and client
review or complete five forms. These forms are provided on the remaining
pages of this section.

Form 1A

  -----------------------------------------------------------------------
  **Learning New Coping Strategies**

  -----------------------------------------------------------------------

**Some Alternatives to Marijuana Use**

You can do many things to stop using marijuana. Some may work better
than others. Some help you resist the urge to smoke or avoid tempting
situations or satisfy your needs in more constructive ways than smoking
marijuana. Expect to try several and add any that may be helpful. Think
about what worked when you gave up marijuana before or when you made
other changes in your life.

Be kind to yourself as you begin this change process---you're doing
something to take care of yourself, and you deserve all the comfort and
self-acceptance you can get! Remind yourself that learning and changing
inevitably mean giving up old ways and that, in time, you will feel more
comfortable. Remember the changes your body and mind went through when
you learned to drive, got to know a new person, started a new job, or
learned a new skill. Chances are you felt awkward, uncomfortable, silly,
dumb, scared, frustrated, impatient, or anxious, in addition to hopeful,
excited, and challenged. What helped you then? How long did it take you
to feel relaxed? Did you learn all at once, or were improvement and
progress gradual?

***Actions***

Avoid or escape from situations that make you want to smoke marijuana.
Sometimes this is the easiest and most effective way to resist
temptation, especially at the beginning.

Delay decisions to give in to temptation; for example, you could wait 15
minutes. Take several deep breaths. Focus on the fresh air entering your
lungs, cleansing and nourishing your body. Let out tension with each
exhalation.

Change your physical position. Stand up and stretch, walk around the
room, or step outside.

Carry things to put in your mouth: toothpicks, gum, mints, plastic
straws, low-calorie snacks.

Carry objects to fiddle with: a rubber ball to squeeze, a small puzzle,
a pebble, worry beads.

Have a distracting activity available: a crossword puzzle, magazine,
book, a postcard to write.

***Thoughts***

**Self-talk.** Give yourself a pep talk; remind yourself of your reasons
for quitting; remind yourself of the consequences of using marijuana;
challenge any wavering in your commitment to quit.

**Imagery and visualization.** Visualize yourself as a nonsmoker, happy,
healthy, and in control; imagine your lungs getting pink and healthy; or
focus on negative imagery and imagine yourself with cancer, emphysema,
unable to breathe, needing constant care. Visualize yourself in a jail
made of marijuana cigarettes symbolizing the way marijuana controls your
life.

**Thought-stopping.** Tell yourself loudly to STOP; get up and do
something else.

Form 1A

  -----------------------------------------------------------------------
  **Learning New Coping Strategies (continued)**

  -----------------------------------------------------------------------

**Distraction.** Focus on something different: the task at hand, a
daydream, a fantasy, counting backwards from 150 by 3s.

***Lifestyle***

Exercise or take a brisk daily walk. Get your body used to moving; use
stairs instead of elevators; park farther away from your destination;
walk instead of drive.

Practice relaxation or meditation techniques regularly.

Take up a hobby or pick up an old hobby you used to enjoy.

Drink less coffee; switch to decaf; drink herbal teas.

Engage in an enjoyable activity that is not work related several times a
week.

Change routines associated with smoking marijuana, at least temporarily;
for example, don't turn on the TV when you get home from work; don't
spend time with friends who smoke.

***Social Interactions and Environment***

Remove smoking paraphernalia (pipes, papers, bongs, ashtrays, matches,
lighters, marijuana) from your home and car.

Go to places where it's difficult to get high, such as a library,
theater, swimming pool, sauna, steam bath, restaurant, and public
gatherings (not rock concerts).

Spend time with friends who don't smoke. Enlist support from family and
friends. Announce that you've quit; ask people not to offer you pot, to
praise you for stopping, to provide emotional support, and not to smoke
around you.

Learn to be appropriately assertive; learn to handle frustration or
anger directly instead of by smoking.

**Specific Suggestions for Some Common High-Risk Situations**

Below are several high-risk situations that people who use marijuana
confront, along with suggestions for coping without smoking.

***Tension Relief and Negative Emotions*** (e.g., depression, anxiety,
nervousness, irritability)

Develop relaxation techniques, exercise, write down your feelings or
talk to a friend or counselor, do something enjoyable that requires
little effort, figure out what you're feeling and whether you can do
anything about it.

Form 1A

  -----------------------------------------------------------------------
  **Learning New Coping Strategies (continued)**

  -----------------------------------------------------------------------

***Anger, Frustration, and Interpersonal Conflict***

Try to handle the situation directly rather than hide your feelings; if
appropriate, be assertive; get some release by squeezing a rubber ball,
pounding a pillow, or doing some physical activity; write down your
feelings or tell them to someone; take deep breaths.

***Fatigue and Low Energy***

Do muscle relaxations; take a brisk walk; do something enjoyable; eat
properly and get enough sleep.

***Insomnia***

Don't fight being unable to sleep. Get up and do something constructive
or relaxing. Read a book, watch TV, or do muscle relaxations until you
feel sleepy. Remember that no one dies from losing a night's sleep.

***Timeout***

Read, do a crossword puzzle, prepare a healthy snack, take up a hobby,
knit or do other needlework (things you can carry with you for easy
access).

***Self-Image***

Try a new image: get a new haircut or buy new clothes.

***Social Pressure***

Be aware when others are smoking. Remember your commitment not to smoke
marijuana. Be assertive and request that people not offer you pot. If
appropriate, ask that they not smoke around you for a while. If
necessary, be prepared to leave the situation, especially when you've
recently quit.

***Situations Involving Alcohol***

After you've quit marijuana, you may continue to associate drinking with
smoking pot. Alcohol can make you less vigilant about resisting
marijuana. It tends to make people less concerned about long-term
consequences. You might consider not drinking or cutting down during the
first few weeks after quitting. If you don't want to do this, be
especially careful when you drink.

Form 1A

  -----------------------------------------------------------------------
  **Learning New Coping Strategies (continued)**

  -----------------------------------------------------------------------

***Cravings and Urges***

The only way to interrupt cravings is to break the chain of responding
to them. That is, don't give in. Eventually they will decrease. Do
something to distract yourself; use the techniques listed under
Thoughts; breathe deeply; call a friend; go for a walk; move around;
time the urge, and you'll find that it will disappear like a wave
breaking.

Form 1B

  -----------------------------------------------------------------------
  **A Guide to Quitting Marijuana**[^4]

  -----------------------------------------------------------------------

**About Marijuana and How It Affects the Body**

Cannabis is the general name given to a variety of preparations derived
from the plant *Cannabis sativa*. The main psychoactive ingredient in
cannabis is delta-9-tetrahydrocannabinol or THC. Some 400 other
chemicals also are in the cannabis plant.

When a person smokes marijuana, THC enters the bloodstream through the
walls of the lungs and is taken to the brain. THC is stored in fatty
tissues and can be detected in urine for days, weeks, or sometimes
months. The effects of marijuana depend on the person, the environment,
the potency of the drug, and how long the person has been using the
drug. It is possible to become addicted to marijuana and feel dependent
on it to get through the day. Each year thousands of people seek help to
stop using marijuana.

**Why Do You Smoke Marijuana?**

You may have many reasons for smoking marijuana: to relax, to help you
sleep, to calm down. However, meditation or exercise often can
accomplish these same results. You may smoke to improve social
interactions, but many find that after years of smoking, relationships
and social life in general have deteriorated. Or you may smoke to avoid
life's problems. However, the problems don't go away by themselves.

Below, identify your specific reasons for smoking.

+-----------------------------------------------------------------------+
| **Why I Use Marijuana**                                               |
|                                                                       |
| 1\.                                                                   |
|                                                                       |
| 2\.                                                                   |
|                                                                       |
| 3\.                                                                   |
+-----------------------------------------------------------------------+

**Why Do You Want To Give Up Marijuana?**

Researchers, health professionals, and people who smoke marijuana have
identified health, social, legal, and financial reasons to quit.

***Health Risks***

> • Respiratory diseases such as chronic bronchitis.

Form 1B

  -----------------------------------------------------------------------
  **A Guide to Quitting Marijuana (continued)**

  -----------------------------------------------------------------------

> • Changes to cells in the body that may signal the development of
> cancer. Marijuana smoke contains substantially higher levels of
> cancer-causing chemicals than does tobacco smoke.
>
> • Problems with attention, concentration, and memory that get worse
> with continued use of marijuana and only partially improve after
> quitting.
>
> • An increased risk of developing cancers in the mouth, throat, and
> lungs.
>
> • An increased risk of birth defects or leukemia in children exposed
> to marijuana during pregnancy. Using marijuana also may disrupt sperm
> production and ovulation.
>
> • Poor educational achievement and difficulties in learning.
>
> • An increase in symptoms for people who suffer from heart disease,
> asthma, bronchitis, emphysema, or schizophrenia.

Identify the health risks that concern you the most.

+-----------------------------------------------------------------------+
| **Health Fears**                                                      |
|                                                                       |
| 1\.                                                                   |
|                                                                       |
| 2\.                                                                   |
|                                                                       |
| 3\.                                                                   |
+-----------------------------------------------------------------------+

***Social Reasons for Quitting***

Some people give up marijuana because they are tired of their lifestyle
and feel they are stagnating. Are you

> • Worried that your social life is restricted to people who smoke
> dope?
>
> • Feeling low and avoiding people?
>
> • Worried that some relationships are not going well?
>
> • Arguing with your partner?
>
> • Aware of your partner's concerns about your smoking?
>
> • Worried about smoking around children?

Many people use marijuana to avoid problems. Often their problems just
continue to get worse. Your decision to quit might make some problems
seem worse in the short term, but you will feel much better in the long
run. You will be able to handle problems better, and the problems caused
by your smoking will diminish. Remember: No pain, no gain.

***Financial Costs***

Are you concerned about the amount of money you spend on marijuana? In
the blanks below, fill in how much you spend on marijuana, and calculate
what getting stoned costs you per year.

Form 1B

  -----------------------------------------------------------------------
  **A Guide to Quitting Marijuana (continued)**

  -----------------------------------------------------------------------

+-----------------------------------------------------------------------+
| \$\_\_\_\_\_\_\_\_\_\_\_\_\_ per week x 52 or                         |
| \$\_\_\_\_\_\_\_\_\_\_\_\_\_ per month x 12                           |
|                                                                       |
| TOTAL COST PER YEAR \$\_\_\_\_\_\_\_\_\_\_\_\_\_                      |
+-----------------------------------------------------------------------+

You might want to include the costs of tobacco, papers, bongs, and
munchies as well as days off work. It all adds up.

***Other Reasons for Quitting***

What about other hassles? Do you

> • Feel addicted to marijuana or unable to control your marijuana use?
>
> • Feel anxious and paranoid?
>
> • Feel as if your thoughts are racing except when you're stoned?
>
> • Have trouble sleeping?
>
> • Feel you are not doing your job properly?
>
> • Drive when stoned?
>
> • Waste time trying to get marijuana?
>
> • Risk getting arrested for growing your own marijuana?
>
> • Worry about getting arrested for possession?
>
> • Have arrests, fines, court hearings, a criminal record, or other
> legal issues to address?
>
> • Fear going to jail?

**How Do You Give Up Marijuana?**

If you are serious about quitting, the best way is to stop "cold
turkey." You might be surprised that it's easier than you think. Soon
after quitting, you'll find that your thinking becomes clearer.

To quit using marijuana, you have to confront your desire to get stoned.
You will be going into battle against a part of yourself that you no
longer wish to exist. Giving up marijuana, especially if you've been
using for some time, is a bit like losing an old friend. Quitting may
feel like a funeral, but it is also the beginning of a new life.

Think of quitting as a positive step. You must be well prepared and have
a plan worked out in advance. If you follow the suggestions in this
guide, you will find it easier to achieve your goal. If you are serious
about stopping, it is time to decide when you are going to quit. Review
the *Quit Agreement* (form 1C).

**The Decision**

Designate a day as Quit Day. Remember that the decision is yours, and
the commitment you make to quit marijuana use is with yourself. Sign and
date a contract with yourself now. You might want to consider making
other changes at this time, such as quitting cigarettes as well.

Form 1B

  -----------------------------------------------------------------------
  **A Guide to Quitting Marijuana (continued)**

  -----------------------------------------------------------------------

***Quit Strategies***

The following strategies may prove useful in quitting:

> • Set a date, and stick to it.
>
> • Replace marijuana use with new activities and interests.
>
> • Avoid situations where you used to get stoned.
>
> • Ask a friend for support. You do not have to go it alone.
>
> • Say to others, "I don't get stoned anymore."

Identify several strategies that will help you quit, and write them
down.

+-----------------------------------------------------------------------+
| **Three Things I Can Do To Give Up Marijuana**                        |
|                                                                       |
| 1\.                                                                   |
|                                                                       |
| 2\.                                                                   |
|                                                                       |
| 3\.                                                                   |
+-----------------------------------------------------------------------+

***Changing Old Habits***

When you used marijuana, you established a link between the situation in
which you used and getting stoned. Certain situations, people, and
places that you subconsciously associated with smoking may trigger a
desire to use. Below list the places where you usually used, other
persons present, and your mood just before using. A final item to
include is a substitute for the situation.

  ----------------- ------------------ ------------------ ----------------
  **Where**         **With Whom**      **Mood**           **Substitute**

  Living room       Alone              Down               Go for a walk

                                                          

                                                          

                                                          

                                                          
  ----------------- ------------------ ------------------ ----------------

**Check Your Feelings**

When you give up using, and for a week or more after, you may feel out
of sorts. Several "withdrawal symptoms" are caused by stopping use of
marijuana. You might experience

Form 1B

  -----------------------------------------------------------------------
  **A Guide to Quitting Marijuana (continued)**

  -----------------------------------------------------------------------

> • Anxiety • Moodiness
>
> • Irritability • Tremors
>
> • Sweating • Nausea.
>
> • Sleep disturbances

These experiences are normal. Your body is flushing out the toxins from
the marijuana. Take it easy; stay with your determination to quit. These
feelings and problems will go away soon.

**How Do You Stay Off?**

When you have taken the initial steps to quit, you will experience times
when you want to break your contract. Resuming old habits is one reason
people fail. Alter your lifestyle to accommodate the new you without
marijuana. Reread and use the strategies listed on *Learning New Coping
Strategies* (form 1A). Write those that will be most helpful in the
spaces below.

+-----------------------------------------------------------------------+
| **Strategies I Can Use To Stay Off Marijuana**                        |
|                                                                       |
| 1\.                                                                   |
|                                                                       |
| 2\.                                                                   |
|                                                                       |
| 3\.                                                                   |
+-----------------------------------------------------------------------+

**Lapses**

Sometimes you will be unable to fight the urge to use. If you slip, try
not to think of it as a failure. Think of it as a lapse in
concentration, and renew your commitment to quit. Remind yourself that
you are capable of not smoking.

**Reward Yourself**

Now that you have given up marijuana, reward yourself in new ways. Give
yourself a gift at the end of each week that you fulfill your contract.
Try to match the cost of the gift with the average weekly cost of
getting stoned. You may like to keep a record of this.

Form 1B

  -----------------------------------------------------------------------
  **A Guide to Quitting Marijuana (continued)**

  -----------------------------------------------------------------------

  ----------------------- ----------------------- -----------------------
  **Week**                **Gift**                **Cost**

  Week                    Movie and dinner for    \$80
                          two                     

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  
  ----------------------- ----------------------- -----------------------

Form 1C

  -----------------------------------------------------------------------
  **Quit Agreement**

  -----------------------------------------------------------------------

I, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, am
quitting marijuana because (fill in reasons for quitting)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

As of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
I intend to stop smoking marijuana and to refrain from use in the future
by (fill in strategies to be used)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Signatures: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Supporter Participant**

**Form 2A**

  -----------------------------------------------------------------------
  **Supporter Strategies**[^5]

  -----------------------------------------------------------------------

**Maintaining Motivation**

Help your partner or friend maintain motivation by keeping it from
lagging in the first place. Don't wait for a problem to arise. *Let him
or her know how impressed you are with his or her success in quitting
marijuana*. Tell him or her that you know the change requires much
effort and that you can see the benefits of the change. Don't assume the
journey away from marijuana is over when he or she has been abstinent
for 2 or 3 months.

If you see signs of motivation dwindling, such as your partner's or
friend's starting to talk about using marijuana or wanting to visit
friends who still use, ask him or her how he or she is feeling about
marijuana use. Don't assume that his or her motivation is decreasing
until you've talked about it. Bring up the topic in a noncritical way;
perhaps start with a compliment about his or her success. Then ask about
his or her motivation for staying away from marijuana.

If you see that motivation is on the wane, offer to help get it back.
Review the list of reasons for quitting or the *Quit Agreement*
together. Ask whether he or she is feeling deprived and needs some help
finding fun things to do.

*Don't be critical. Motivation is difficult to maintain. Your partner or
friend needs support and encouragement* to increase motivation.
Criticizing his or her lack of willpower or threatening with ultimatums
can provoke a negative mood and lower self-esteem.

**Lifestyle Changes**

*Help your partner or friend make the lifestyle changes that will keep
him or her from needing pot.* Talk about your observations of his or her
lifestyle. Can stress be reduced? What activities can he or she do at
those times of the day when he or she might be tempted to use? Can you
do any of them together, such as an exercise program? It reduces stress,
clears out the lungs, and can be rewarding in many ways.

Having a positive, supportive conversation regularly is important.
Lifestyles need to be watched so that people don't slip into old ruts.
Talking about the upcoming week and discussing how to build some fun
time into it can become a weekly activity.

**High-Risk Situations**

Help your partner or friend plan for and cope with high-risk situations
regularly at least during the first year. After a while, coping with the
old week-to-week situations that promote use will become automatic.
However, you still need to be on guard for those unexpected or unusual
situations for which a coping strategy hasn't been planned or practiced.
Examples might include an upcoming vacation, a visit with old friends,
unemployment, or an argument with someone. *If you see something coming
up that's likely to pose a risk for marijuana use, alert your partner or
friend. Then help plan for coping with the situation if it should
occur.*

Form 2A

  -----------------------------------------------------------------------
  **Supporter Strategies (continued)**

  -----------------------------------------------------------------------

If an event occurs without a chance to plan for it, you can go straight
to a coping mode, distract your partner or friend or offer support
depending on the situation. You don't have to point out that you're
doing it to prevent a return to pot smoking unless you think that would
be helpful.

**Coping With a Slip**

Chances are a slip will happen. A slip is marijuana use that occurs
after a period of abstinence. A slip doesn't mean a person will return
to regular marijuana use. That would be a relapse. Slips occur when
motivation is lagging or when a high-risk situation occurs unexpectedly.
Slips do not mean that all the success and progress to date have been
lost. How your partner or friend responds to a slip can mean the
difference between returning to abstinence or going into a relapse. Here
are some things to do if a slip occurs:

> • **Ask your partner or friend how the slip came about.** Did he or
> she see it coming or was it a sudden urge related to a situation? What
> was the situation? How was your friend feeling before smoking? Was he
> or she feeling down or angry or bored or wanting to celebrate?
>
> • **Ask about any attempts at avoiding the situation or coping
> strategies used in the situation.** If he or she anticipated the
> situation and made little effort to avoid or cope with it, a
> motivation problem probably exists. Refer to the ideas in the section
> above on maintaining motivation.
>
> • **Ask whether any clues could have warned of a difficult
> situation.** If the urge to use came up suddenly or the coping
> strategies used simply weren't effective, help your friend learn from
> this slip to prevent more slips in the future. Help him or her find
> new coping strategies to use in the future. Suggest other ways of
> coping.
>
> • **Help your partner or friend regain motivation and learn from what
> happened.** Come from a position of support and encouragement. If your
> friend says things like, "I guess I just can't quit" or "Smoking pot's
> not really that bad," then challenge these statements. You know
> neither is true.

Your goal is to get your partner or friend back on track, not to punish
him or her for slipping. Attack the rationalization *(I'm only going to
smoke this one time)* not the person. Say that those statements are
rationalizations, they're a symptom of losing motivation, and it's time
to focus on getting motivation back. Don't put the person down,
criticize his or her willpower, or say the situation is hopeless. Making
the person feel bad is likely to promote a return to marijuana use. When
you show the person how his or her actions are a sign of losing
motivation and show how to get that motivation back, you can help a slip
stay merely a slip.

**Feeling Appreciated**

Does your partner or friend appreciate your efforts? Do you feel that
you're working harder at this than he or she is? If so, it's time to
talk to him or her about it. You won't be any help if you are feeling
burned out and unrewarded.

Form 2A

  -----------------------------------------------------------------------
  **Supporter Strategies (continued)**

  -----------------------------------------------------------------------

Let your partner or friend know how you feel without accusing him or her
of neglecting you. Point out that this would be a good time to
renegotiate the *Supporter Agreement.* Start your conversation with the
words "I feel," not "You haven't." Make sure you ask for what you
want---a little acknowledgment, a relaxing or fun evening, a chance to
talk, or whatever you feel is a reward for your efforts.

Form 2B

  -----------------------------------------------------------------------
  **Supporter Agreement**[^6]

  -----------------------------------------------------------------------

In this document, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ will be
referred to as the Supporter and \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
will be referred to as the Participant. To maintain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_'s success in quitting marijuana, we
agree to the following arrangements.

**Types of Support. *Supporter and Participant initial all conditions
that apply to the agreement.***

  ---------- -------- --------------------------------------------------------------
  Initials            

  \_\_\_     \_\_\_   Supporter will let Participant know how pleased he or she is
                      with the Participant's success at not using marijuana.

  \_\_\_     \_\_\_   Supporter will ask Participant about his or her motivation for
                      remaining abstinent from marijuana if Supporter notices that
                      motivation may be decreasing.

  \_\_\_     \_\_\_   Participant will let Supporter know that he or she appreciates
                      the support received.

  \_\_\_     \_\_\_   Supporter will remind Participant of his or her reasons for
                      quitting marijuana and of the consequences that marijuana
                      caused, if motivation seems to lag.

  \_\_\_     \_\_\_   Participant will review the *Reasons for Quitting
                      Questionnaire* or the *Quit Agreement* with the Supporter if
                      they agree that motivation needs a boost.

  \_\_\_     \_\_\_   Supporter will discuss and participate with Participant in
                      lifestyle changes that will reduce the need for marijuana.

  \_\_\_     \_\_\_   Supporter will ask Participant about upcoming high-risk
                      situations that Supporter anticipates but is not sure whether
                      the Participant anticipates. In addition, Supporter will help
                      Participant plan to cope with high-risk situations.

  \_\_\_     \_\_\_   Supporter will help Participant cope with a marijuana use slip
                      and return to abstinence by asking about Participant's
                      motivation and the circumstances of the slip.

  \_\_\_     \_\_\_   Supporter will help restore motivation and develop a coping
                      plan for future situations that led to the slip.

  \_\_\_     \_\_\_   Participant will negotiate rewards for Supporter's continued
                      support and involvement.

  \_\_\_     \_\_\_   Supporter will avoid being critical of Participant in
                      communicating concerns about motivation, high-risk situations,
                      and slips. Supporter will focus on questioning Participant's
                      motives and coping plans and on challenging rationalizations
                      for using.

  \_\_\_     \_\_\_   Participant will listen to what Supporter has to say about
                      observations of lagging motivation, upcoming high-risk
                      situations, or rationalizations for using marijuana.

  \_\_\_     \_\_\_   Supporter may express disappointment if Participant fails to
                      accept Supporter's input.

  \_\_\_     \_\_\_   Participant will suggest another time (within 24 hours) to
                      discuss Supporter's observations or concerns if Participant's
                      current mood or situation does not allow him or her to be open
                      to Supporter's comments at the moment.
  ---------- -------- --------------------------------------------------------------

Form 2B

  -----------------------------------------------------------------------
  **Supporter Agreement (continued)**

  -----------------------------------------------------------------------

**Specific Conditions or Support Agreements. *List additional
conditions.***

\_\_\_ \_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_ \_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_ \_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Signatures: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Supporter Participant**

+-----------------------------------------------------------------------+
| **SECTION VI.**                                                       |
|                                                                       |
| **CHANGING MARIJUANA USE THROUGH SKILL BUILDING:**                    |
|                                                                       |
| **SESSIONS 3 THROUGH 9**                                              |
+-----------------------------------------------------------------------+

In sessions 3 through 9, the counselor builds on the client's motivation
by encouraging the use of specific strategies and skills for
accomplishing treatment goals. The counselor offers tools to enhance the
client's motivation to change. This approach is based on cognitive
behavioral therapy (CBT) models for substance abuse treatment, with an
emphasis on relapse prevention. The Center for Substance Abuse
Treatment's (CSAT's) Treatment Improvement Protocol (TIP) 34, *Brief
Interventions and Brief Therapies for Substance Abuse* (CSAT 1999*a*),
as well as the *KAP Keys* (CSAT 2001*a*) and the *Quick Guide* (CSAT
2001*b*) that accompany TIP 34, provides background material on this
approach. The CBT sessions follow the approach of Monti and colleagues
(1989).

**Why Focus on Skills?**

***Motivation Leads to Skills Development***

Once the individual commits to changing his or her behavior, Brief
Marijuana Dependence Counseling (BMDC) focuses on building and
strengthening skills for becoming and remaining abstinent. The client's
motivation and commitment may vary during treatment, but the
motivational enhancement therapy (MET) strategies remain integral to
treatment.

The counselor begins by reexploring the client's commitment to
abstinence and using MET strategies (e.g., rolling with resistance,
identifying discrepancies) when the client's motivation wavers. In these
sessions, the counselor and client work on developing specific skills
(e.g., refusing offers, coping with cravings). This approach is usually
slower and somewhat less structured than other CBT approaches, but many
individuals who are marijuana dependent find this helpful.

***Focusing on the Skills Taught***

After completing the engagement, rapport-building, and goal-setting
tasks during the early sessions, the client prepares to learn new
skills, begins to eliminate problems associated with marijuana use, and
addresses other life concerns. During this phase, the counselor coaches
the client to develop supportive social connections and establish links
with resources to address family, mental, and employment problems. The
counselor adjusts the focus, the content of skill topics, and the
general approach to meet the client's needs and provides structure and
guidance. These sessions typically have a more didactic tone than the
earlier sections, which are strictly MET. However, these sessions should
*not* be delivered as lectures; the counselor maintains a balance
between guiding and teaching, on the one hand, and the client-centered
focus of the treatment, on the other.

**What Is Cognitive Behavioral Counseling?**

A CBT social learning model focuses on teaching interpersonal and
self-management skills (CSAT 1999*a*). CBT is a skill-building rather
than a deficit-oriented approach. Marijuana dependence is considered a
learned behavior that developed in response to external (e.g.,
environmental, relational) and internal (e.g., feelings, thoughts)
conditions. A CBT perspective suggests that the addictive behavior has
become a favored strategy because of its repeated associations with
predictable outcomes. For example, someone uses marijuana when he or she
is sad, angry, lonely, or upset; he or she feels less bad when smoking
and associates marijuana use with feeling better (at least in the short
term). Over time, marijuana may be selected more often as a strategy to
escape negative feelings or thoughts.

CBT views compulsive or addictive behaviors and certain negative moods
as learned and not the result of a character defect. Because these
behaviors are learned, they can be unlearned. The unlearning occurs
through learning new skills and enhancing the client's capabilities.

The client develops skills to identify and cope with high-risk internal
states and external situations that increase the likelihood of a slip.
The counselor assigns the client homework to practice using the new
skills. The client's participation and the counselor's positive feedback
enhance client confidence in managing situations and create long-lasting
behavior change.

This perspective of addiction as learned is therapeutic because it

> • Reduces blame and criticism
>
> • Fosters hope and optimism
>
> • Identifies development and improvement processes.

CBT differs from other models of treatment because it

> • Addresses interpretations of events as important cues for compulsive
> behavior
>
> • Provides structure (every week the counselor devotes a specific
> amount of time at a specific time in the session to a particular
> activity)
>
> • Informs and teaches (but is still collaborative).

**Integrating MET and CBT**

Counselors in the Marijuana Treatment Project (MTP) integrated
motivational interviewing skills and techniques (Stephens et al. 2002)
as they moved toward building skills and changing cognitions and
behavior. Rather than using a traditional cognitive behavioral style of
Socratic questioning and didactic teaching, the MTP MET/CBT approach
used open-ended questions, gradual presentation of skills, frequent
assessment of the client's wish to hear more about a particular skill or
concept, and give-and-take in the didactic portion of the sessions.
Counselors frequently assessed the client's level of motivation,
renegotiating goals and repeating issues when necessary.

The CBT component of BMDC comprises six core elements and four elective
skill topics (see exhibit I-2). The sequence of the sessions should be
in an order that works best for the counselor and client. The six core
skill topics represent the fundamental building blocks for CBT and are
recommended for most clients entering treatment. To meet a particular
client's needs, a different group of skill topics may be chosen. For
example, a client who has experience in similar interventions (e.g.,
relapse prevention) may not require a review of all the core skill
topics. The counselor can select some core skills and add relevant
elective materials in developing the session sequence for the client.
Another client may have concerns about depression or difficulty
regulating moods. The counselor can substitute the elective skill topic
on depression in place of a core skill. The counselor and client
determine whether and how much the treatment deviates from the
established method (10 sessions including 1 assessment, 2 MET, 6 core
CBT, and 1 elective).

**Tips for the Counselor**

> • Review relevant sections of the manual before each session.
>
> • Develop a natural style of conveying the material; avoid reading
> text to clients.
>
> • Maintain a motivational style; use open-ended questions and
> reflections; and avoid a directive, resistance-building style.
>
> • Encourage involvement and participation by the client.
>
> • Allow time for role plays and feedback.
>
> • Build self-efficacy; help the client identify and acknowledge skills
> already in use.
>
> • Avoid overwhelming the client; 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 client's motivation and readiness for
> change.
>
> • Explain practice exercises carefully; probe for the client's
> understanding.

+-----------------------------------------------------------------------+
| **Overview of Session 3: Skill Topic 1, Coping With Other Life        |
| Problems**                                                            |
|                                                                       |
| **Total Time:** 1 hour                                                |
|                                                                       |
| **Delivery Method:** CBT-focused individual therapy                   |
|                                                                       |
| **Materials (all forms are at the end of this section):**             |
|                                                                       |
| > • *Problem Checklist* (form 3A)                                     |
| >                                                                     |
| > • *Support Plan* (form 3B)                                          |
| >                                                                     |
| > • Community resource directory (compiled by the program, this       |
| > should include information on community agencies that the client    |
| > can access to address concerns listed on the *Problem Checklist*)   |
|                                                                       |
| **Goal for This Session:**                                            |
|                                                                       |
| > • To begin to address the client's non--substance-related problems  |
| > that can pose obstacles to abstaining from marijuana                |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > **1.** Determine whether and when to use psychosocial               |
| > problemsolving                                                      |
| >                                                                     |
| > **2.** Use the *Problem Checklist* (form 3A) to identify and        |
| > prioritize psychosocial problems other than substance use           |
| >                                                                     |
| > • Consider information gathered during the assessment               |
| >                                                                     |
| > • Encourage client to be specific about psychosocial problems       |
| >                                                                     |
| > • Have client evaluate the severity of each problem in relation to  |
| > remaining abstinent                                                 |
| >                                                                     |
| > • Help the client prioritize problems                               |
| >                                                                     |
| > **3.** Identify goals and resources                                 |
| >                                                                     |
| > **4.** Develop a *Support Plan* (form 3B)                           |
| >                                                                     |
| > **5.** Discuss implementation issues                                |
| >                                                                     |
| > • Use motivational strategies when client demonstrates ambivalence  |
| >                                                                     |
| > • Convey confidence in the client's ability to carry out the        |
| > *Support Plan*                                                      |
| >                                                                     |
| > • Explore the relationship between the client's psychosocial        |
| > problems and his or her marijuana use                               |
| >                                                                     |
| > • Engage in role plays                                              |
| >                                                                     |
| > **6.** Help the client identify others who can help with the        |
| > *Support Plan*                                                      |
| >                                                                     |
| > **7.** Assign between-session exercise                              |
| >                                                                     |
| > **8.** Plan to monitor progress                                     |
| >                                                                     |
| > **9.** Review and conclude session                                  |
+-----------------------------------------------------------------------+

**Session 3 Protocol**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor uses problemsolving and
motivational strategies to teach the client how to use the social
service system independently. The counselor helps the client identify
problem areas and develop plans to address them. The client builds
self-efficacy in recognizing problems and using the social service
agencies. The case management model is based on the general model of
problemsolving described by D'Zurilla and Goldfried (1971). CSAT's TIP
27, *Comprehensive Case Management for Substance Abuse Treatment* (CSAT
1998), provides more information on the case management process.

***Determine Whether and When To Use Psychosocial Problemsolving***

Clients who present for marijuana-dependence treatment often experience
problems in other areas. They may be depressed or anxious. They may have
lost their jobs or feel they are not doing work they enjoy. They may
have health or relationship worries. These difficulties may be related
to their long-term marijuana use or may be co-occurring mental
disorders.

Although most clients indicate concerns about other life areas, not all
want to focus on these problems during treatment. The counselor asks
generally about the client's life problems. The counselor and the client
decide whether and how much to focus on these other problems, depending
on their severity and the degree to which the client wants help with
them. If no further attention is warranted, the counselor proceeds to
another skill topic. However, the client who indicates significant
concerns or who wants help with a non--substance-related problem may
benefit from one or more problemsolving sessions.

***Use the* Problem Checklist *To Identify and Prioritize Psychosocial
Problems Other Than Substance Use***

Problems unrelated to marijuana use that may be a hindrance to the
client's abstinence efforts

include

> • Lack of housing or financial support
>
> • Unemployment
>
> • Chronic or acute medical conditions
>
> • Legal problems
>
> • Family or parental pressures
>
> • Social isolation
>
> • Need for transportation and childcare.

By reviewing the client's intake or initial session assessments,
including the measures of motivation and marijuana-related problems
identified on the *Personal Feedback Report* (PFR) (form AS8), the
counselor develops a sense of the type and severity of the client's
psychosocial problems. Careful assessment requires extensive input from
and collaboration with the client.

The counselor and client use the *Problem Checklist* (form 3A) to
prioritize problems. The counselor asks the client about each category,
encouraging the client to identify each problem as specifically as
possible *(I need a job paying at least \$9 an hour* rather than *I have
no money)*, the effect of the problem on the client's abstinence from
marijuana, and a realistic and concrete goal for the problem *(I'll be
attending a trade course at the community college by the end of March*
rather than *I'll get a job next week)*:

**Counselor (C):** *You've said that although you're not happy living at
your brother's, you recognize that it's a stable place for you for now.
However, you'd like to start saving some money for your own place. You
mentioned that getting a job is a priority for you; it would keep you
occupied and help you get your own apartment. That sounds like a good
idea because you think you might use if you have nothing to do all day.
How do you see it?*

**Bob (B):** *That sounds right, but I don't think I can get a job
without a car or driver's license.*

**C:** *Transportation is another issue, and we should add it to our
list. How have you been getting to our meetings?*

**B:** *I get a ride from my sister-in-law on her way to work and take
the bus home.*

**C:** *That's pretty resourceful; how did you set that up?*

**B:** *I knew the bus lines because I used to work near here.*

**C:** *It sounds as if you're good at figuring out how to do what you
need to do. As we begin to think through how you can reach your goal of
getting a job, we'll need to consider how you'll get there. A lot of
jobs and training programs are on bus lines, so it may not be difficult.
What other difficulties can you foresee that might make it hard for you
to reach your goals? You've told me you don't have any medical or legal
problems; are there any problems associated with your former marriage or
your kids?*

**B:** *No; I'd like to see the kids more, but that's okay. I guess
that's all I can think of, for now.*

**C:** *Do you think your relationship with your kids is connected with
your marijuana use?*

**B:** *I think I'd be a better dad and see them more often if I wasn't
smoking.*

**C:** *So it sounds as if that's an important goal for you and another
reason for stopping. You may become aware of other problems as we go on;
we can talk about them and how they may be associated with your
marijuana use as they come up.*

or

**C:** *During your initial assessment, you noted housing,
transportation, and a family medical concern as problems.*

**Shirley (S):** *I'm concerned about my older sister. She has bipolar
disorder and whenever she goes off her medication, my husband and I
spend a couple of hundred dollars to get her back to a psychiatrist and
on medication. We have only one car, so we argue about who will use it.
Now that I've started student teaching, I need the car every day. It was
difficult for me to get here today because my husband was late.*

**C:** *As you think about these three areas, how would you prioritize
them? Which seems more pressing for you?*

**S:** *Right now transportation is a top priority, then my sister, and
then a new house. We're going to see whether I get a teaching job this
fall before we start looking for a house.*

**C:** *Let's start with transportation. What would you like to happen
and when?*

**S:** *We don't have the money for a second car right now.*

***Identify Goals and Resources***

The counselor and client specify goals for improving the client's
situation. The program's community resource directory should describe
services offered, eligibility, and contact personnel at community
agencies. The directory should include information about housing
assistance, vocational training, financial assistance, legal services,
medical services, mental health services, parenting and childcare
resources, support groups, homeless shelters, women's shelters,
emergency services, food assistance, education and training resources,
unemployment counseling, rape crisis centers, and transportation
resources.

The counselor and client use the directory to identify relevant
resources, determine whether the services offered match the client's
goals, and devise a plan for contacting the agency or service (e.g., who
will do the contacting, what the specific goal of the contact is, when
contact will be made). Because a major goal of this session is to build
client self-efficacy in negotiating the social service system, the
counselor encourages the client to contact the agency. If the client
does not have the skills to make initial contacts effectively, the
counselor and client role play a contact with an agency. If the agency
requires that the counselor make the initial contact, he or she makes
the call during the session to model effective negotiation skills.

The counselor helps the client transform his or her goals into a plan
for obtaining services, and together they plan the steps:

**C:** *So, although you have a problem, you're not sure of possible
solutions?*

**S:** *The solution would be more money, and we don't have that right
now!*

**C:** *Money would help. But did you know the county offers discounted
bus fares for students?*

**S:** *No; I was wondering about that because the bus runs right by my
school.*

**C:** *I have a book here with the phone number to call for
information. Do you want to call?*

***Develop a* Support Plan**

Once the *Problem Checklist* is completed, goals have been developed,
and the resource list has been reviewed, the counselor and client work
on the *Support Plan* (form 3B)---a concrete strategy outlining how the
client will follow through on reaching goals. For each goal, the
*Support Plan* includes whom (or which agency) to contact, when to make
the contact, what services or support to request, and what the outcome
was. The *Support Plan* is a record of the client's efforts to obtain
services and bolsters his or her self-efficacy:

**S:** *I'd like to know how much the bus pass costs and what time the
bus runs. I wouldn't need it every day; maybe 2 or 3 days a week. Can we
call now?*

**C:** *Sure. Let's write down on the Support Plan what you would like
to see happen. First, we need to find out how much a bus pass costs with
the student discount. Second, we need the bus route and schedule between
your home and the school. We need to know whether the bus schedule fits
with your school schedule. Here's the phone. I'll read you the number.*

***Discuss Implementation Issues***

The client may be ambivalent about addressing psychosocial problems that
are barriers to abstinence. He or she may question whether he or she has
the skills needed, wonder whether change may bring on new challenges,
and question changing the status quo. The counselor remains alert to
signs of client ambivalence.

The stages-of-change model is applicable to acquiring psychosocial
support (see sessions 1 and 2). For example, some clients may be
precontemplators, unaware of barriers affecting their life; others may
be contemplators, aware of barriers but not sure they are ready to
overcome them; and others may be ready to engage with resource
providers.

The counselor uses the following motivational strategies to encourage
the client to address psychosocial problems other than marijuana:

• **Elicit self-motivational statements**

> **C:** *Tell me how not having a job has affected you.*
>
> **C:** *You've said it's tough not having a safe place to live and
> that it makes it harder to stop smoking, but you haven't convinced me
> that you're ready to do something about it. Should we go ahead with
> our plans?*

• **Listen with empathy**

> **C:** *It sounds as if you're worried about taking all this on at
> once.*
>
> **C:** *You feel not seeing Jerry as much would be an important step
> forward, but you worry about not seeing a friend you've been close to
> for a long time.*

**• Roll with resistance**

> **C:** *You're not sure you're ready to spend time finding a new place
> to live.*
>
> **C:** *I think you're jumping ahead. We're not talking about moving
> right now; we're just looking at how living in your current
> neighborhood may be interfering with your goal of quitting marijuana
> use.*

• **Communicate free choice**

> **C:** *It's up to you what to do about this.*
>
> **C:** *You can take this on now or wait for another time.*

**• Review consequences of action and inaction**

> **C:** *What do you see happening if you don't see a doctor?*
>
> **C:** *It sounds as if you're concerned about calling your probation
> officer right now; what do you think will happen if you don't?*

Throughout the sessions, the counselor praises all the client's efforts
to carry out the *Support Plan*, even small steps. The counselor conveys
confidence that the client has the resources and skills to carry out the
plan and obtain services, during treatment and after treatment:

**C:** *I'm impressed that you arranged a place at Transitional Housing.
You questioned whether you could handle the steps, but you hung in
there. You were persistent when you were put on hold several times, and
you kept rescheduling those interviews until you got them. It wasn't
easy, but you made it happen. How do you feel about how you handled it?*

**B:** *It wasn't easy, and once or twice I felt like telling them off,
but I just kept telling myself I need a drug-free place to live and that
I could do it.*

**C:** *You sound proud of yourself, and your pride is well deserved.
Knowing how to contact the social service system is an important skill,
and you're getting better at it. Have you thought about your next step?*

The counselor encourages the client who lacks confidence and
communication skills to make initial phone calls during the sessions;
the counselor provides support and coaching if necessary. After each
call, the counselor and client talk about the call, and the counselor
praises the client's efforts, offers constructive criticism, and reviews
the next steps in the client's change plan.

A key strategy in this session is exploring the relationship between
other life problems and marijuana use. What are their roles in the
client's marijuana use, and how are they frustrating his or her efforts
to become involved in treatment?

**C:** *You've told me your concerns about problems you're having,
including not having a place of your own or a job, and your probation
officer is concerned about these problems, too. How do you see these
problems making it harder for you to stop smoking?*

**B:** *Well, I'm staying at Jerry's, and he's always smoking. I don't
have anything to do all day, and time moves when you're partying. I
wasn't smoking as much when I was working. The thing is, I don't know
anybody who doesn't smoke.*

**C:** *So it sounds as if finding a place to live where you won't be
with people who smoke and getting a job will help you reach your goal of
stopping smoking. Meeting some new people who don't smoke might help
also. These are important goals. Let's talk about how you might tackle
these problems. Are you concerned about other problems that might make
it hard to stop?*

If the client lacks assertiveness skills, the counselor engages the
client in role plays of contacts with agency representatives. To break
the ice, the counselor plays the person seeking service and the client
plays the agency representative. After the initial role play, the
counselor comments on the skills that were demonstrated (e.g.,
assertiveness, asking for a specific service, eliciting information,
avoiding arguments). Then the counselor plays the agency representative
and the client plays the person requesting service. Afterward, the
counselor points out effective behavior and provides constructive
criticism:

**C:** \[A person requesting services\] *Hello. My name is Shirley, and
I'm calling because I would like information about your center and how I
might set up an appointment with a family counselor for me, my husband,
and our children.*

**S:** \[As agency representative\] *Well, we have a long waiting list.
You might want to call back next month.*

**C:** *Okay, I understand that your program is filled, but could you
direct me to another family counseling center that might have a shorter
wait?*

***Help the Client Identify Others Who Can Help With the* Support Plan**

Because the counselor's role is helping the client identify barriers to
addressing marijuana use, formulating a *Support Plan* (form 3B), and
helping the client implement the plan, it may be useful to identify
others who can help the client carry out the *Support Plan* and ways
they can help (e.g., accompanying the client to appointments, helping
with some of the legwork, helping in negotiating the system or with
transportation or childcare, providing financial assistance). The
counselor adds the names of these people to the *Support Plan*.

The client may have withdrawn from friends and family who do not use
drugs, reducing his or her social circle to only people who use drugs.
As the client recognizes the importance of reducing contacts with people
who use drugs while trying to overcome dependence, he or she may fear
social isolation when he or she needs others' support the most. The
counselor explores the nature and extent of the client's social network
and suggests expansion of that network as a treatment goal.

***Assign Between-Session Exercise***

The counselor asks the client to select a problem to work on during the
week. The client should complete a *Support Plan* for the problem and be
prepared to discuss his or her efforts to solve the problem at the
beginning of the next session.

***Plan To Monitor Progress***

Even though the client is responsible for following the *Support Plan*
and obtaining services, the counselor monitors all efforts to complete
the plan; these efforts should be discussed in every session during the
check-in phase. The counselor asks about the client's efforts to
implement the *Support Plan* since the preceding session. A portion of
the closing of the session should be devoted to reviewing what the
client will do to implement the *Support Plan* during the coming week.

***Review and Conclude Session***

The counselor reviews the content of the session, asks the client for
feedback, responds empathically to his or her comments, and
troubleshoots any difficulties. The counselor explains that the client
will report back on his or her efforts to complete the plan at the next
session.

+-----------------------------------------------------------------------+
| **Overview of Session 4: Skill Topic 2, Understanding Marijuana Use   |
| Patterns**                                                            |
|                                                                       |
| **Total Time:** 1 hour                                                |
|                                                                       |
| **Delivery Method:** CBT-focused individual therapy                   |
|                                                                       |
| **Materials (all forms except form 1A, which is in Section V, are at  |
| the end of this section):**                                           |
|                                                                       |
| > • *Marijuana Use Self-Awareness Record* (form 4A)                   |
| >                                                                     |
| > • *Learning New Coping Strategies* (form 1A)                        |
| >                                                                     |
| > • *Future-Self Letter* (form 4B)                                    |
| >                                                                     |
| > • *Pleasant Activities* (form 4C)                                   |
| >                                                                     |
| > • *Relaxation Training* (form 4D)                                   |
| >                                                                     |
| > • *Boredom Management* (form 4E)                                    |
|                                                                       |
| **Goals for This Session:**                                           |
|                                                                       |
| > • To introduce the client to the reasoning behind coping skills     |
| > training                                                            |
| >                                                                     |
| > • To examine the client's high-risk situations and coping           |
| > strategies                                                          |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > **1.** Explore the development of addictive patterns                |
| >                                                                     |
| > • Give examples of how marijuana can change how one feels; ask      |
| > client how these examples fit with his or her experience            |
| >                                                                     |
| > • Give examples of environmental triggers for use; ask client for   |
| > other triggers he or she has experienced                            |
| >                                                                     |
| > • Give examples of beliefs or automatic thoughts people may have    |
| > about marijuana; use examples provided by the client; and ask the   |
| > client for more examples                                            |
| >                                                                     |
| > • Suggest that the client start the process of change by            |
| > understanding his or her behavior; ask, *Does this make sense to    |
| > you?*                                                               |
| >                                                                     |
| > **2.** Assess high-risk situations                                  |
| >                                                                     |
| > • Ask client about                                                  |
| >                                                                     |
| > --- Typical use situations (places, people, activities, time, days) |
| >                                                                     |
| > --- Triggers for use                                                |
| >                                                                     |
| > --- A recent use situation                                          |
| >                                                                     |
| > --- Thoughts and feelings at use times (tense, bored, stressed,     |
| > etc.)                                                               |
| >                                                                     |
| > • Complete *Marijuana Use Self-Awareness Record* (form 4A) and      |
| > summarize the list                                                  |
| >                                                                     |
| > **3.** Build coping strategies                                      |
| >                                                                     |
| > • Emphasize the importance of coping strategies                     |
| >                                                                     |
| > • Reintroduce *Learning New Coping Strategies* (form 1A)            |
| >                                                                     |
| > • Ask client to identify strategies he or she has tried and those   |
| > that might work best                                                |
| >                                                                     |
| > **4.** Assign between-session exercises                             |
| >                                                                     |
| > • Give client a blank copy of the *Marijuana Use Self-Awareness     |
| > Record* (form 4A) to document episodes of craving/desire between    |
| > sessions                                                            |
| >                                                                     |
| > • Choose additional assignments based on the client's current needs |
| >                                                                     |
| > --- Writing a *Future-Self Letter* (form 4B)                        |
| >                                                                     |
| > --- *Pleasant Activities* (form 4C)                                 |
| >                                                                     |
| > --- *Relaxation Training* (form 4D)                                 |
| >                                                                     |
| > --- *Boredom Management* (form 4E)                                  |
| >                                                                     |
| > **5.** Review and conclude session                                  |
+-----------------------------------------------------------------------+

**Session 4 Protocol**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor draws on information from
previous sessions to increase the client's understanding about use
patterns.

***Explore the Development of Addictive Patterns***

The counselor asks the client to look closely at his or her behavior,
environment, and beliefs to identify addictive patterns:

**Counselor (C):** *We think of repeated marijuana use as learned
behavior. When people start to use marijuana a lot, they learn that it
changes the way they feel. For example, some people use it like a
tranquilizer to help them cope with stressful situations. Some use it
when they feel blue. Others expect it to enhance positive feelings. Some
think it makes them more confident. And some use it to avoid thinking
about troublesome things. How does that fit with your experience?*
\[Waits for answer.\]

**C:** *After a while, things in the environment can trigger use,
sometimes without your even realizing it. The environment can trigger
cravings. Things in the environment that can trigger use include seeing
or smelling marijuana, being around people who are smoking, or being in
stressful situations. During the assessment session, we talked about the
connection you've noticed between getting paid on Fridays and buying
pot. Are there other connections like that for you?*

**C:** *People often develop beliefs about marijuana and their using.
These are ideas or "automatic thoughts" you've come to believe about you
and your marijuana use. I've heard you say things in previous sessions
like, "I can't be creative or work effectively without it," "I can't
take the way I feel when I've tried to quit," "I need to change, but
it's not worth the effort." What other beliefs do you have about you and
marijuana?*

**C:** *Marijuana can change the way a person feels, acts, and thinks.
To help you avoid or cope with the situations in which you smoke and to
help you find things you can do instead of smoking, let's start by
working on understanding your behavior. Does this make sense to you?*

***Assess High-Risk Situations***

The counselor explains that marijuana use behavior is learned over time.
The client's understanding of his or her use patterns can help the
client change those patterns. Understanding high-risk situations can
help the client avoid or cope with those situations:

**C:** *If using marijuana changes the way a person acts, thinks, and
feels, it's helpful to begin by identifying use patterns and habits.
Once your patterns are identified, you may find it easier to change your
behavior. You can find ways to cope with your high-risk situations
without using. Change involves learning specific skills and strategies.
Once you know about the situations and problems that contribute to your
using marijuana, you can look for other ways to handle those situations.
What do you think about that?*

The counselor focuses on the client's behaviors and high-risk
situations:

**C:** *In what situations do you use marijuana (e.g., places, people,
activities, specific times, days)?*

**C:** *What are your triggers for using (e.g., when you're in a social
situation, when you've had a tense day, when you're faced with a
difficult problem, when you want to feel relaxed)?*

**C:** *Can you describe a recent situation when you used (e.g., a
relapse story)?*

**C:** *Can you remember your thoughts and feelings at the time you used
(e.g., tense, bored, depressed, stressed, overwhelmed, angry)?*

**C:** *What were the consequences of using?*

The counselor asks the client about marijuana use behavior using
motivational interviewing techniques (e.g., reflection, expressing
empathy) while finding out important information about the client's use
environment:

**C:** *In what situations do you find yourself smoking?*

**Doug (D):** *When things get hectic at home. Between my wife and my
son, it seems as if everyone is out to get me. When I smoke, I can cope
with them.*

**C:** *Smoking helps you cope with stress at home. Are there other
situations when you smoke?*

**D:** *Not right now. When I go home, I should be able to relax, but
with all the nagging, I end up smoking to escape.*

**C:** *You want your home to be peaceful, but conflicts over your
smoking push you to smoke.*

**D:** *Yeah; sounds crazy, doesn't it?*

**C:** *Your situation is difficult. Things you identify that lead you
to smoke are called triggers. You've said that conflicts at home trigger
you to smoke. What are your thoughts and feelings during times of
conflict at your house, right before you light up?*

**D:** *I'm thinking that if everyone would get off my back, I might be
able to quit smoking. But they don't, and it's the only way I know how
to relax.*

**C:** *You find yourself in a bind. Let's use the* Marijuana Use
Self-Awareness Record \[presents form 4A\] *to list the things we're
talking about. You said smoking marijuana helps you relax. What else
does it do for you?*

**D:** *It helps me sleep. When I don't get high, it's hard getting to
sleep. I used to enjoy the high a lot more than I do now. I keep
smoking, but I don't even get that high anymore.*

**C:** *Sounds as if you're listing the negative parts of smoking. Are
there others?*

Together the counselor and client fill out the *Marijuana Use
Self-Awareness Record* (form 4A).

***Build Coping Strategies***

The counselor emphasizes the importance of coping strategies:

**C:** *We've talked about your high-risk situations for triggering
marijuana use. This is important because many people are unaware of how
they put themselves at risk for using. Now we'll focus on coping with
these situations in ways that will help you resist the urge to smoke.
You've already read the* Learning New Coping Strategies \[presents form
1A\]*. Let's take a few moments to go through it and identify the
strategies you've tried and others that might work. Remember, some
strategies involve things you can do or specific actions you can take,
some involve ways of thinking, and some involve other people or your
surroundings.*

The counselor records responses on the *Marijuana Use Self-Awareness
Record* (form 4A) and summarizes the list. The counselor follows up by
asking for other examples.

***Assign Between-Session Exercises***

The counselor gives the client a blank copy of the *Marijuana Use
Self-Awareness Record* and asks the client to document episodes of
craving or desire for marijuana between this session and the next one.
In addition, the counselor chooses an appropriate assignment from among
the following and reviews the instructions with the client:

> • Write a *Future-Self Letter* (form 4B)
>
> • Increase your *Pleasant Activities* (form 4C)
>
> • Practice *Relaxation Training* (form 4D).

If struggling with boredom is a particular problem, the counselor gives
the client the *Boredom Management* handout (form 4E).

***Review and Conclude Session***

The counselor reviews the content of the session, asks the client for
feedback, responds empathically to his or her comments, and
troubleshoots any difficulties. The counselor explains that the client
will report back on his or her efforts to complete the between-session
exercises at the next session.

+-----------------------------------------------------------------------+
| **Overview of Session 5: Skill Topic 3, Coping With Cravings and      |
| Urges To Use**                                                        |
|                                                                       |
| **Total Time:** 1 hour                                                |
|                                                                       |
| **Delivery Method:** CBT-focused individual therapy                   |
|                                                                       |
| **Materials (all forms are at the end of this section):**             |
|                                                                       |
| > • *Coping With Cravings and Urges* (form 5A)                        |
| >                                                                     |
| > • *Urge Surfing* (form 5B)                                          |
| >                                                                     |
| > • *Daily Record of Urges To Use Marijuana* (form 5C)                |
|                                                                       |
| **Goals for This Session:**                                           |
|                                                                       |
| > • To enhance the client's understanding about cravings and urges    |
| > for marijuana use                                                   |
| >                                                                     |
| > • To identify specific triggers or cues for cravings (see Carroll   |
| > 1998)                                                               |
| >                                                                     |
| > • To review and practice specific skills for addressing cravings    |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > **1.** Give reasons for focusing on cravings                        |
| >                                                                     |
| > • Provide basic information about the nature of cravings            |
| >                                                                     |
| > --- Cravings are experienced most often early in abstinence but can |
| > occur weeks, months, even years later                               |
| >                                                                     |
| > --- Cravings may feel very uncomfortable but are a common           |
| > experience                                                          |
| >                                                                     |
| > --- An urge to smoke does not mean something is wrong               |
| >                                                                     |
| > • Give client *Coping With Cravings and Urges* (form 5A)            |
| >                                                                     |
| > **2.** Identify cues for cravings                                   |
| >                                                                     |
| > • Give client examples of common cues                               |
| >                                                                     |
| > --- Exposure to marijuana or paraphernalia                          |
| >                                                                     |
| > --- Seeing other people using                                       |
| >                                                                     |
| > --- Contact with people, places, times of day, or situations        |
| > associated with using                                               |
| >                                                                     |
| > --- Particular emotions and physical feelings                       |
| >                                                                     |
| > **3.** Discuss strategies for coping with triggers                  |
| >                                                                     |
| > • Getting involved in a distracting activity                        |
| >                                                                     |
| > • Talking it through                                                |
| >                                                                     |
| > • Urge surfing (*Urge Surfing*, form 5B)                            |
| >                                                                     |
| > • Delaying decisions                                                |
| >                                                                     |
| > • Using imagery                                                     |
| >                                                                     |
| > • Challenging and changing thoughts                                 |
| >                                                                     |
| > • Using self-talk                                                   |
| >                                                                     |
| > **4.** Complete exercises                                           |
| >                                                                     |
| > • Make a list of craving triggers                                   |
| >                                                                     |
| > • Make a plan for managing craving                                  |
| >                                                                     |
| > **5.** Assign between-session exercises                             |
| >                                                                     |
| > • Encourage client to review material on handouts before the next   |
| > session                                                             |
| >                                                                     |
| > • Encourage client to practice urge surfing                         |
| >                                                                     |
| > • Complete *Daily Record of Urges To Use Marijuana* (form 5C)       |
| >                                                                     |
| > **6.** Review and conclude session                                  |
+-----------------------------------------------------------------------+

**Session 5 Protocol**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor supports the client's experience
and efficacy in making desired changes.

***Give Reasons for Focusing on Cravings***

The counselor gives the client *Coping With Cravings and Urges* (form
5A) and explains the importance of recognizing cravings:

**Counselor (C):** *Cravings often are experienced when a person first
tries to quit, but they may occur weeks, months, even years later.
Cravings may feel uncomfortable, but they are common experiences. An
urge to smoke doesn't mean something's wrong. Many people learn to
expect cravings on occasion and how to cope with them.*

*Things that remind you of using marijuana can trigger urges or
cravings. Physical symptoms include tightness in the stomach or feeling
nervous throughout the body. Psychological symptoms include thoughts
about how using marijuana or drugs feels, recollections of smoking
marijuana, developing plans to get marijuana, or feeling that you need
marijuana.*

*Cravings and urges usually last only a few minutes or at most a few
hours. Rather than increase until they become unbearable, they usually
peak after a few minutes and then die down, like a wave. Urges become
less frequent and less intense as you learn more methods for coping with
them.*

***Identify Cues for Cravings***

The counselor talks about triggers or cues:

**C:** *It's important to learn how to recognize triggers so you can
reduce your exposure to them. Common triggers include*

> • *Exposure to marijuana or paraphernalia*
>
> • *Seeing other people using*
>
> • *Contact with people, places, times of day, and situations
> associated with using (such as people you used with, parties, bars,
> weekends)*
>
> • *Particular emotions (such as frustration, fatigue, feeling
> stressed), even positive emotions (elation, excitement, feelings of
> accomplishment)*
>
> • *Physical feelings (feeling sick, shaky, tense).*

*Some triggers are hard to recognize. Self-monitoring can help you
identify them.*

*The easiest way to cope with cravings and urges is to minimize their
likelihood of occurring. You can reduce your exposure to triggers by
getting rid of marijuana in the house, not going to parties or bars, and
limiting contact with friends who use.*

***Discuss Strategies for Coping With Triggers***

The counselor presents several coping strategies:

**C:** *Many times cravings can't be avoided, and it becomes necessary
to cope with them. Here are some possible strategies for coping with
craving:*

***Get involved in a distracting activity.** Reading, engaging in a
hobby, calling a friend, going to a movie, and exercising (jogging,
biking) are good examples of distracting activities. Once you get
interested in something else, you'll find that the urges go away in no
time.*

***Talk it through.** Talking to your supporter or a friend or family
member can pinpoint the source of the craving and help relieve the
feeling. It also can restore honesty in your relationship.*

***Urge surfing.*** \[Gives client *Urge Surfing* handout (form 5B) and
reads sheet aloud.\]

***Delay the decision to use.** Most urges to use are like waves---they
build to a peak and then dissipate. If you wait 15 minutes, the wave
will pass. Try imagining you're a surfer riding the wave of craving
until it subsides, or use another image that works for you.*

***Use imagery.** If you feel as though you are about to be overwhelmed
by urges to use, imagine scenes that portray those urges as storms that
end with calmness, mountains that can be climbed, or waves that can be
ridden. Everyone can find an image to maintain control until the urge
peaks and then dissipates. Some people imagine being a warrior who can
defeat urges as if they were an enemy or an explorer who can slice
through tropical underbrush and carve out a trail. Images can be made
vivid by using relaxation techniques and all the senses (e.g., seeing
the thick green jungle, hearing the blade swishing through the leaves,
smelling the tropical plants). Photographs of loved ones also can
distract you.*

***Challenge and change your thoughts.** When experiencing cravings,
many remember only the good effects of using and forget the negative
consequences. You may find it helpful to remind yourself of the benefits
of not using and the negative consequences of using. Remind yourself
that you won't feel better if you just get a little high and that you
lose a lot by using. It's helpful to have these benefits and
consequences listed on a small card to carry around.*

***Self-talk.** People constantly think about their actions and things
that happen to them. These thoughts can influence strongly the way you
feel and act. What you tell yourself about your urges to use affects how
you experience and handle them. Your self-talk can be used to strengthen
or weaken your urges. Making self-statements is so automatic you may not
notice it. For example, a self-statement that is automatic for you may
be, "I am a skilled photographer" or "I have no willpower." Hidden or
automatic self-statements about urges can make them hard to handle. ("I
want to get high now. I can't stand this. The urge is going to get
stronger and stronger until I use. I won't be able to resist.") Other
types of self-statements can make the urge easier to handle. ("Even
though my mind is made up to stay clean, my body is taking longer to
learn this. This urge is uncomfortable, but in 15 minutes or so, I'll
feel like myself again.") We will discuss these automatic thoughts more
in the next session.*

*There are two basic steps in using self-talk constructively:*

*1. Pinpoint the things you tell yourself that make it harder to cope
with an urge. One way to tell whether you're on the right track is when
you hit on a self-statement that increases your discomfort, for example,
"I will never be able to withstand this urge." That discomfort-raising
self-statement is a leading candidate for challenge.*

*2. Use self-talk constructively to challenge the statement. An
effective challenge makes you feel better (less tense, anxious, panicky)
even though it may not make the feelings disappear entirely. The most
effective challenges are ones tailored to specific self-statements.
Listed below are some challenges that people find useful:*

> *• **What is the evidence?** What is the evidence that if I don't get
> high in the next 10 minutes, I'll die? Has anyone ever died from not
> using? What's the evidence that people recovering from a marijuana
> problem don't have the feelings I'm having? What is the evidence that
> I'll never improve?*
>
> *• **What's so awful about that?** What's so awful about feeling bad?
> Of course I can survive it. Who said that abstinence would be easy?
> What's so terrible about experiencing an urge? If I hang in, I'll feel
> fine. These urges are not like being hungry or thirsty; they're more
> like a craving for a particular food or an urge to talk to a
> particular person---they'll pass.*
>
> *• **I'm a human being and have a right to make mistakes.** Maybe I
> worry about being irritable, preoccupied, or hard to get along with.
> What's so bad about that? We all make mistakes and in a situation
> that's complicated, there is no "right" or "perfect" way to get
> along.*

*Some of these strategies will be necessary or helpful only initially to
distract yourself from persistent urges; in the long run, you'll have an
easier time if you replace the thoughts with other activities. After a
while, abstinence will feel more natural; the urges will diminish in
intensity and will come less often. You will also know how to cope with
them.*

In the example below the counselor and client discuss craving triggers
and self-talk strategies:

**C:** *You identified one of your strongest triggers as seeing other
people smoking, especially family members. Let's try to pinpoint exactly
what's going on.*

**Shirley (S):** *I feel that if I don't smoke with some family members,
they might think I'm above them. They already make fun of me, calling me
the college girl, and I want to fit in.*

**C:** *You're sensitive to your family members and concerned that
they'll think you're trying to be better than they are by not smoking.
What is the evidence that this will happen?*

**S:** *Well, I guess it's more of a fear than a fact. I really do love
them and know that they love me. But I don't know how they would
respond.*

**C:** *What thoughts have you had about telling them?*

**S:** *I almost told my uncle the other day when he lit up. But then I
ended up smoking, and I just couldn't.*

**C:** *You realize that once you get high, it's difficult to make
changes.*

**S:** *I've been thinking that I need to tell them when there's no
chance that we would be smoking. But I dread it!*

**C:** *What are some other ways you might let them know?*

***Complete Exercises***

The counselor introduces the following exercises:

**C: *Make a list of craving triggers.*** *Circle the triggers that you
can avoid or to which you can reduce your exposure (such as having
marijuana in your home).*

***Make up a craving plan.** Pick two or three of the general strategies
that were discussed and plan how to put them into practice if you
experience an urge. Cravings can come when you least expect them! For
example, if you think distracting activities would be helpful, which
activities would you pick? Which are available? Which take preparation?
If you were feeling a craving, whom would you call? If you haven't tried
urge surfing before, practice with me before trying it when facing an
urge.*

***Assign Between-Session Exercises***

The counselor encourages the client to review the material on the
handouts between sessions and to practice urge-surfing techniques. The
counselor also gives the client a blank *Daily Record of Urges To Use
Marijuana* (form 5C), shows the client a completed form (exhibit VI-I)
as an example, and asks him or her to fill it out during the week.

+-------+-------------------+--------------+---------------------------+
| **Ex  |                   |              |                           |
| hibit |                   |              |                           |
| VI-1. |                   |              |                           |
| Daily |                   |              |                           |
| R     |                   |              |                           |
| ecord |                   |              |                           |
| of    |                   |              |                           |
| Urges |                   |              |                           |
| To    |                   |              |                           |
| Use   |                   |              |                           |
| Mari  |                   |              |                           |
| juana |                   |              |                           |
| (Samp |                   |              |                           |
| le)** |                   |              |                           |
+=======+===================+==============+===========================+
| **D   | **Situation       | **Intensity  | **Coping Behaviors Used** |
| ate** | (include**        | of**         |                           |
|       |                   |              |                           |
|       | **thoughts and    | **Cravings   |                           |
|       | feelings)**       | (1--100)**   |                           |
+-------+-------------------+--------------+---------------------------+
| 5/    | Was feeling       | 75           | Shut myself in office and |
| 16/03 | stressed.         |              | breathed deeply to relax. |
|       |                   |              | Felt better after 20      |
|       | Had a             |              | minutes.                  |
|       | disagreement with |              |                           |
|       | my boss.          |              |                           |
+-------+-------------------+--------------+---------------------------+
| 5/    | Restless at       | 60           | Took a hot shower,        |
| 17/03 | bedtime.          |              | listened to relaxing      |
|       |                   |              | music. Shower was better  |
|       | Trouble getting   |              | than music.               |
|       | ready for bed.    |              |                           |
+-------+-------------------+--------------+---------------------------+
| 5/    | Went dancing at   | 80           | Hung around with "clean   |
| 18/03 | club where I      |              | friends." It was a close  |
|       | always used to    |              | call. Should have         |
|       | get high.         |              | prepared in advance.      |
+-------+-------------------+--------------+---------------------------+
| 5/    | Payday. Bob       | 65           | Suggested we go for       |
| 19/03 | wanted to party   |              | coffee instead. Bob       |
|       | after work.       |              | agreed! Boy---was I       |
|       |                   |              | surprised!                |
+-------+-------------------+--------------+---------------------------+

Source: Monti et al. 1989.

***Review and Conclude Session***

The counselor reviews the content of the session, asks the client for
feedback, responds empathically to his or her comments, and
troubleshoots any difficulties. The counselor explains that the client
will report back on his or her efforts to complete the between-session
exercises at the next session.

+-----------------------------------------------------------------------+
| **Overview of Session 6: Skill Topic 4, Managing Thoughts About       |
| Marijuana Use**                                                       |
|                                                                       |
| **Total Time:** 1 hour                                                |
|                                                                       |
| **Delivery Method:** CBT-focused individual therapy                   |
|                                                                       |
| **Material (form is at the end of this section):**                    |
|                                                                       |
| > • *Managing Thoughts About Marijuana* (form 6A)                     |
|                                                                       |
| **Goal for This Session:**                                            |
|                                                                       |
| > • To identify and learn to cope with automatic thoughts associated  |
| > with marijuana use                                                  |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > **1.** Reinforce that thoughts about marijuana use are normal       |
| >                                                                     |
| > **2.** Identify thought patterns associated with use                |
| >                                                                     |
| > **3.** Discuss automatic thoughts and strategies for coping         |
| >                                                                     |
| > • Explain situations that may trigger automatic thoughts            |
| >                                                                     |
| > --- Nostalgia                                                       |
| >                                                                     |
| > --- Testing control                                                 |
| >                                                                     |
| > --- Crisis                                                          |
| >                                                                     |
| > --- Feeling irritable when abstinent                                |
| >                                                                     |
| > --- Escape                                                          |
| >                                                                     |
| > --- Relaxation                                                      |
| >                                                                     |
| > --- Socialization                                                   |
| >                                                                     |
| > --- Improved self-image                                             |
| >                                                                     |
| > --- To-hell-with-it thinking                                        |
| >                                                                     |
| > --- No control                                                      |
| >                                                                     |
| > **4.** Explore conceptual difficulties                              |
| >                                                                     |
| > • Review material and probe for client's understanding of basic     |
| > concepts                                                            |
| >                                                                     |
| > • Use illustrations and examples                                    |
| >                                                                     |
| > • Walk client through a using episode to understand thought         |
| > processes                                                           |
| >                                                                     |
| > **5.** Develop skills for coping with automatic thoughts            |
| >                                                                     |
| > • Explain three general principles for coping with thoughts about   |
| > using                                                               |
| >                                                                     |
| > --- A commitment to abstinence                                      |
| >                                                                     |
| > --- Recognition of drug-related thoughts                            |
| >                                                                     |
| > --- Need for time to master automatic thoughts                      |
| >                                                                     |
| > • Describe specific strategies for managing thoughts about using;   |
| > review *Managing Thoughts About Marijuana* (form 6A)                |
| >                                                                     |
| > **6.** Practice skills for coping with automatic thoughts           |
| >                                                                     |
| > • Demonstrate self-talk                                             |
| >                                                                     |
| > --- State a using thought and follow it with a challenging          |
| > statement                                                           |
| >                                                                     |
| > --- Make eye contact and speak clearly and confidently              |
| >                                                                     |
| > --- Repeat with other examples as necessary                         |
| >                                                                     |
| > • Have client practice with one of his or her using thoughts        |
| >                                                                     |
| > --- Support client's phrasing of both thought and challenge         |
| >                                                                     |
| > --- Encourage client to be specific                                 |
| >                                                                     |
| > --- Identify any problems in client's practice and ask client to    |
| > try again                                                           |
| >                                                                     |
| > **7.** Assign between-session exercises                             |
| >                                                                     |
| > **8.** Prepare for end of treatment                                 |
| >                                                                     |
| > **9.** Review and conclude session                                  |
+-----------------------------------------------------------------------+

**Session 6 Protocol**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor helps the client manage thoughts
about marijuana use.

***Reinforce That Thoughts About Marijuana Use Are Normal***

The counselor discusses the relationships among thoughts, feelings, and
using marijuana:

**Counselor (C):** *For people who have smoked marijuana for a long
time, thoughts about using are normal; almost anyone who stops using
thinks about starting up again. Thinking about using is not a problem
provided you don't act on those thoughts. You may feel guilty about
thoughts, and you may try to get them out of your mind. This skill topic
will help you learn new ways to manage your thoughts before you slip.
Sometimes the thoughts are obvious, but sometimes they creep up on you
without notice.*

***Identify Thought Patterns Associated With Use***

The counselor explains how negative thinking relates to marijuana use:

**C:** *People who used marijuana need to be aware of a state of mind
that predisposes them to a relapse. This state of mind is characterized
by dangerous attitudes and thought processes and is called "negative
thinking." Negative thinking is dangerous because it induces people who
have used marijuana to let down their guard (decrease vigilance). The
thought itself isn't the problem; it's how people cope with their
thoughts. If people learn to dismiss this thinking from their minds
whenever it appears, recognize it for what it is, or counter it with a
challenging thought, it need not lead to a relapse. You can learn
strategies for coping with these thoughts.*

***Discuss Automatic Thoughts and Strategies for Coping***

The counselor describes situations that may trigger automatic thoughts
or thoughts that could lead to a lapse:

**C: *Nostalgia.*** *Some people who formerly used marijuana remember
using nostalgically, as if marijuana were an old friend. For example, "I
remember the good old days when I'd go out dancing and smoke a few
joints."*

> ***Testing control.** After a period of abstinence, people in recovery
> may become overconfident. For example, "I bet I can use tonight and go
> back on the wagon tomorrow morning." Curiosity also can be a problem:
> "I wonder what it would be like to get high again?"*
>
> ***Crisis.** A person may respond to stress by saying, "I can handle
> this only if I'm high" or "I went through so much, I deserve to get
> high" or "When this is over, I'll stop using again."*
>
> ***Feeling irritable when abstinent.** Some people find new problems
> arise after they become abstinent and think using will solve these
> problems. For example, "I'm short-tempered and irritable around my
> family---maybe it's more important for me to be a good-natured parent
> and spouse than it is to stop using right now" or "I'm no fun to be
> around when I'm not using; I don't think I should stop because if I
> do, people won't like me as much."*
>
> ***Escape.** Individuals want to avoid unpleasant situations,
> conflicts, or memories. Failure, rejection, disappointment, hurt,
> humiliation, embarrassment, and sadness tend to demand relief. People
> get tired of feeling hassled, upset, and lousy. They want to get away
> from it all and from themselves. They seek numbness and the perceived
> absence of problems.*
>
> ***Relaxation.** Thoughts of wanting to unwind are normal, but
> sometimes people look for a shortcut, trying to unwind without doing
> something relaxing. The individual may choose the more immediate route
> through marijuana.*
>
> ***Socialization.** This overlaps with relaxation but is confined to
> social situations. Individuals who are shy or uncomfortable in social
> settings may feel they need a social lubricant to decrease awkwardness
> and inhibitions.*
>
> ***Improved self-image.** This situation involves a pervasive negative
> view of oneself and associated low self-esteem. When individuals
> become unhappy with themselves, feel inferior to others, regard
> themselves as lacking essential qualities, feel unattractive or
> deficient, or doubt their ability to succeed, they begin to think of
> using marijuana again because using previously may have provided
> immediate, but temporary, relief from these painful feelings.*
>
> ***To-hell-with-it thinking.** During the weeks and months of trying
> to be abstinent, a person may become discouraged and think to hell
> with it. Thinking this way might result from a disappointing
> experience, feeling tired from coping with temptations, or other
> difficult situations.*
>
> ***No control.** The attitude of being unable to control cravings
> ensures relapse. Individuals give up the fight, conceding defeat
> before attempting to resist marijuana use; they may feel out of
> control in other aspects of their lives as well. Marijuana is
> considered a viable option. This attitude differs from the
> to-hell-with-it attitude in which individuals do not necessarily feel
> powerless; they just don't want to continue abstaining.*

***Explore Conceptual Difficulties***

A client may have difficulty understanding the concepts of *cognitive
analysis* and *restructuring*. If a concept is not understood, then the
benefits of cognitive coping skills are lost. The counselor probes for
the client's understanding before moving on to the next concept. Using
illustrations and examples helps convey the basic principles.

Initially a client may be unaware of the thoughts and feelings that
precede decisions to use marijuana. He or she may be unaware of triggers
and state, *I just start using, that's all.* The client may admit that
usually some external force occurs immediately before use but cannot
remember what it is. The client denies personal responsibility for
actions and attributes behavior to forces beyond his or her control,
making it difficult for the client to initiate appropriate coping
skills.

To help the client grasp cognitive concepts, the idea of "slowing down
the action" (as in an instant replay or a slow-motion film sequence) of
the thought process is useful. The counselor assists the client in
breaking down the sequence of thoughts and feelings that lead to
particular actions. He or she learns to observe, for example, that a
tense interaction with a colleague may lead to feelings of frustration
and to thoughts about not being good enough (e.g., smart, competent, or
skilled enough), which lead to thoughts about wanting to use marijuana.
Once the client can analyze the series of thoughts that might have led
to a previous relapse, the notions of self-motivating (or
self-awareness) and of modifying one's thoughts (cognitive
restructuring) can be introduced. The goal is to make the client aware
of his or her thought processes and enable the client to replace using
thoughts with coping thoughts that enhance abstinence:

**C:** *Try to identify your thoughts about resuming marijuana use and
rationalizations for using. What thoughts preceded your last using
episode after a period of abstinence? What thoughts about marijuana seem
to be the most frequent or strongest? Under what circumstances do these
resumption thoughts tend to occur? Although this activity may feel
strange, like most skills, it becomes easier with time.*

***Develop Skills for Coping With Automatic Thoughts***

The counselor helps the client identify automatic thoughts and reviews
some of the techniques used in previous sessions:

**C:** *Everyone trying to stop marijuana use has thoughts about using.
It's not the thought that creates the problem but how people cope with
it. If you learn to recognize these thoughts and counter them with
contrary thoughts, they need not lead to a lapse.*

> *The three general principles for coping effectively with thoughts
> about using are*
>
> *1. It's easier to choose to remain abstinent and not to give in to
> persistent thoughts if you are committed firmly to quitting.*
>
> *2. It's easier to challenge drug-related thoughts and change them if
> you are aware of them.*
>
> *3. This coping skill takes a long time to master; these thoughts can
> return months and years after you stop using.*

The counselor reviews strategies for managing thoughts about using
marijuana and shows the client *Managing Thoughts About Marijuana* (form
6A):

**C: *Challenge them.*** *Use other thoughts to challenge the resumption
thoughts. For example, "I cannot get a little high without increasing my
risk of using more" or "I don't have to use marijuana to unwind after
work; I can use relaxation exercises" or "I can have good times without
marijuana; it may feel strange at first, but in time I'll feel more
comfortable."*

*An important aspect of challenging thoughts about using (as well as
forms of thought distraction and substituting behaviors incompatible
with using) is to avoid visualizing what you are not going to do and
instead picture a behavior that you will do. You might try developing a
mental picture of the new behavior when the old habit pops into mind.*

> ***List and recall benefits of not using.** Thoughts about the
> personal benefits of abstinence can weaken excuses for using. Benefits
> to think about include better physical health, improved family life,
> job stability, more money for recreation and paying bills, increased
> self-esteem, and self-control. It is important to pay attention to
> these positive aspects and the progress you're making; don't focus on
> what you're giving up. Carry a card with you listing the benefits, add
> items as you think of them, and review them regularly.*
>
> ***Recall and list unpleasant using experiences.** Recall the pain,
> fear, embarrassment, and negative feelings associated with using
> marijuana. Make a list of unpleasant experiences, such as memory
> problems, lack of motivation, procrastination, arrests, withdrawal,
> paranoia, and sleep disturbances on the back of the card that lists
> the benefits of abstinence. Read the card regularly. Counteract the
> positive thoughts you have about using with the negative aspects of
> using and the benefits of abstinence. Visualize the possible using
> episode to the end and include all the detrimental consequences that
> occur with using marijuana.*
>
> ***Find distractions.** Think about something pleasant, like holiday
> plans, vacation spots, loved ones, relaxation, or hobbies. Focus on a
> task you want to get done.*
>
> ***Promote self-reinforcement.** Remind yourself of your success---for
> example, 2 weeks of abstinence, involvement in treatment, staying in
> the treatment program.*
>
> ***Leave or change the situation.** Try a different activity, such as
> a hobby or physical exercise.*
>
> ***Call your supporter or a friend.***
>
> ***Use self-talk.** As mentioned in session 5, self-talk refers to
> constructive things you can say to yourself that replace negative
> thoughts. We talk to ourselves all the time. Our thoughts have a
> powerful effect on how we feel and act and on our decisions. One way
> to be sure negative thoughts don't sabotage your effort to quit is to
> learn how to recognize them and challenge them effectively. Self-talk
> is an effective way of coping with thoughts that make staying away
> from marijuana difficult.*

***Practice Skills for Coping With Automatic Thoughts***

The counselor and client practice self-talk:

**C:** *Let's practice self-talking in response to concerns about
quitting. We'll choose a general concern about quitting to work on. Then
you'll do two things:*

> *1. State the concern in your own words, using an "I" statement.*
>
> *2. After stating the concern, follow it with a challenging statement.
> Again, use the pronoun "I" when making a challenging statement, and
> say it forcefully.*

The counselor illustrates how to self-talk by focusing on a particular
automatic thought that might trigger marijuana use *(*e.g., *I guess I
wasn't as dependent on marijuana as I thought)*. The counselor states
that thought and follows it with a challenging statement:

**C: *1. Automatic thought.*** *Quitting marijuana was easier than I
thought. I must not have been dependent on it in the first place.*

***2. Challenge.** I must be crazy. What am I saying? Quitting hasn't
been easy. I had the urge to smoke all the time until the last few days.
If I weren't dependent on it, I could have quit long ago. I'm just
missing the feeling of being high and starting to talk myself out of
quitting. I think I'll do something else.*

When conducting the demonstration, the counselor makes eye contact,
speaks clearly and confidently, and repeats the demonstration if
necessary. After the counselor gives a few demonstrations, the client
practices using any concerns he or she has. Other examples of automatic
thoughts include *I'm not feeling that much better now that I've quit*
or *I bet I can smoke once in a while*.

It is important to support the client's phrasing of the automatic
thoughts and the challenges. The counselor encourages the client to be
specific *(What do you mean by "No one cares whether I smoke or not?")*,
deliver responses as if the situation were real, and use the first
person. If the client gives an unsatisfactory response, the counselor
specifies the problem (e.g., not the first person, not specific in the
challenge, not said in a forceful tone) and asks the client to try
again. The counselor gives constructive feedback and avoids judgments or
disapproval.

The following factors contribute to the client's ability to formulate a
positive response although not all need to be present all the time:

> • Acknowledgment of negative or ambivalent feelings
>
> • Reminder of the positive side (e.g., motivation and commitment,
> long-term positive outcomes, enhanced self-esteem, improved health)
>
> • Specific positive alternatives
>
> • Humor
>
> • Absence of self-condemnation
>
> • Self-reinforcement or self-appreciation.

**Miguel (M):** *Sometimes, I just want to smoke. It's easy to forget
why I wanted to quit.*

**C:** *It gets easier with experience. You are changing a habit that
was formed over many years and are finding it difficult at times. People
need to remind themselves of how hard that can be. Let's go over the
skills that may help you and see whether you think they will work.*

***Assign Between-Session Exercises***

At the end of the session, the counselor explains the between-session
exercises on *Managing Thoughts About Marijuana* (form 6A). To complete
this exercise, the client writes out lists of

> • 5 to 10 benefits of not using
>
> • 5 to 10 negative consequences associated with using
>
> • 5 to 10 stumbling blocks or high-risk situations for maintaining
> abstinence.

The client uses this information (the benefits of abstinence and the
negative consequences of using) to rate his or her commitment to
quitting. The client's perceived level of commitment can range from 1
(no commitment) to 10 (extremely high level of commitment).

***Prepare for End of Treatment***

Once treatment is halfway completed, the counselor prepares the client
for termination:

**C:** *We have three sessions remaining. How do you feel this has been
going? What would you like to accomplish in our remaining time
together?*

***Review and Conclude Session***

The counselor reviews the content of the session, asks the client for
feedback, responds empathically to his or her comments, and
troubleshoots any difficulties. The counselor explains that the client
will report back on his or her efforts to complete the between-session
exercises at the next session.

+-----------------------------------------------------------------------+
| **Overview of Session 7: Skill Topic 5, Problemsolving**              |
|                                                                       |
| **Total Time:** 1 hour                                                |
|                                                                       |
| **Delivery Method:** CBT-focused individual therapy                   |
|                                                                       |
| **Materials (form is at the end of this section):**                   |
|                                                                       |
| > • *Problemsolving* (form 7A)                                        |
| >                                                                     |
| > • Large paper, posterboard, or dry-erase board to diagram           |
| > problemsolving steps                                                |
|                                                                       |
| **Goals for This Session:**                                           |
|                                                                       |
| > • To introduce a strategy for solving problems                      |
| >                                                                     |
| > • To apply the problemsolving approach to marijuana use and related |
| > problems                                                            |
| >                                                                     |
| > • To prepare for termination of treatment                           |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > **1.** Discuss the importance of solving problems                   |
| >                                                                     |
| > • Explain that problem situations result in use when people think   |
| > they have no effective coping responses to handle them              |
| >                                                                     |
| > **2.** Describe problemsolving skills                               |
| >                                                                     |
| > • Recognize the problem                                             |
| >                                                                     |
| > • Identify or elaborate the problem                                 |
| >                                                                     |
| > • Consider various approaches                                       |
| >                                                                     |
| > • Select the most promising approach                                |
| >                                                                     |
| > • Evaluate effectiveness                                            |
| >                                                                     |
| > **3.** Practice problemsolving skills                               |
| >                                                                     |
| > • Work through the process, identifying and applying problemsolving |
| > skills                                                              |
| >                                                                     |
| > • Role play solutions and evaluate effectiveness                    |
| >                                                                     |
| > **4.** Assign between-session exercise                              |
| >                                                                     |
| > **5.** Review and conclude session                                  |
+-----------------------------------------------------------------------+

**Session 7 Protocol**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor explains the steps involved in
problemsolving. Providing formal training in solving problems may
accelerate the development of higher order coping strategies that go
beyond situation-specific skills. This training helps clients act as
their own counselors when they are no longer engaged in a formal
treatment situation. The problemsolving approach used in BMDC is adapted
from D'Zurilla and Goldfried (1971; see also CSAT 1998).

***Discuss the Importance of Solving Problems***

The counselor explains the rationale for learning an approach to solving
difficult problems:

**Counselor (C):** *Situations become problems when people think they
have no effective coping responses to handle them. Individuals can be
flooded by emotions when faced with a problem and may be unable to
manage the problem constructively. People who use marijuana and other
drugs may encounter the following types of problems:*

> • *Situations where drug use had occurred*
>
> *• Situations that arise after drug use has been stopped (e.g., social
> pressure to use, cravings, slips)*
>
> *• Difficulties developing new activities that help maintain
> abstinence (e.g., new recreational habits).*

The counselor describes steps to solve problems and situations where the
approach is helpful:

**C:** *Effective problemsolving requires recognizing when you're
confronted with a problem and resisting the temptation to respond
impulsively or to do nothing. Coming up with an effective solution
requires that you assess the situation to decide the best action.*

> *Sometimes the problem involves wanting to use drugs, such as at a
> party. At other times, the problem may be the urge to find a quick and
> easy solution. The pressure may get to you and trigger using.
> Effective problemsolving strategies must be part of your abstinence
> program because the occurrence of problems can set the stage for a
> relapse.*

***Describe Problemsolving Skills***

The problemsolving approach involves the following phases:

> 1\. Recognize the problem
>
> 2\. Identify or elaborate the problem
>
> 3\. Consider various approaches
>
> 4\. Select the most promising approach
>
> 5\. Evaluate effectiveness.

The counselor describes the steps involved in solving problems and
provides examples:

**C: *Recognize the problem*** *(*adapted from Intagliata 1979*). What
clues indicate a problem? You get clues from your body (e.g.,
indigestion, craving), your thoughts and feelings (e.g., feelings of
anxiety, depression, loneliness, fear), your behavior (e.g., have you
been meeting your own behavioral standards?), the way you respond to
others (e.g., anger, lack of interest, withdrawal), and the way others
respond to you (e.g., they appear to avoid you, criticize you).*

***Identify or elaborate the problem.** What is the problem? Having
recognized that something is wrong, you identify the problem precisely
by gathering as much information as you can. Break the problem down into
specific parts; you may find it easier to manage several parts than to
confront the entire problem all at once.*

> ***Consider various approaches** (*adapted from Bedell et al. 1980*).
> What are the options? Develop several solutions; the first one that
> comes to mind may not be the best. Use the following methods to find a
> good solution:*
>
> **• *Brainstorm.*** *Generate ideas without stopping to evaluate how
> good or bad they are. Write down all the ideas you come up with (even
> impractical ones) so that you can review them as you decide which to
> try. More is better. Don't judge these ideas.*
>
> ***• Consider both behavioral and cognitive coping strategies**
> (*Sanchez-Craig 1983*). When the problem involves conflict with
> others, speak up assertively (behavioral coping) to improve the
> situation. When the problem involves negative emotional reactions to
> uncontrollable events, change the way you think about the situation
> (cognitive coping). Some problems require both behavioral and
> cognitive coping.*
>
> ***Select the most promising approach.** What will happen if . . . ?
> Identify probable outcomes for each approach; include positive and
> negative outcomes and long- and short-term consequences. Consider the
> resources you'll need for each solution. Rank the possibilities by
> their consequences and desirability. The solution with the most
> positive and fewest negative consequences is the one to try first.*
>
> ***Evaluate effectiveness.** How did it work? Evaluate the strengths
> and weaknesses of your plan. What difficulties did you encounter? Are
> you getting the expected results? Can you do something to make the
> approach more effective? Use the same clues as before (e.g., from your
> body, thoughts, feelings, other people) to decide whether your
> solution is effective. If you give the plan a fair chance and it
> doesn't solve the problem, move to your second choice and follow the
> same procedure.*

***Practice Problemsolving Skills***

The counselor encourages the client to work through the
problem-recognition stage: identifying problems, describing each, and
writing solutions on paper. The counselor asks the client to weigh
alternatives, select the most promising one, and describe both
advantages and disadvantages for every alternative. Finally, the client
prioritizes the alternatives. The counselor and client role play and
evaluate the effectiveness of the most promising solutions:

**C:** *Your upcoming business trip will put you in a tough situation
because you'll be around old friends with whom you got high. What is the
problem as you see it?*

**Miguel (M):** *I remember the good old times when we would get
together and have a great time.*

**C:** *Like nostalgia.*

**M:** *Yeah; I see these colleagues two or three times a year, and we
always smoked together.*

**C:** *That's a good description of the situation, but how do you see
the problem?*

**M:** *I'm worried that being out of town, away from my family, I'll
give in and get high. I know that if I do, I'll be upset later.*

**C:** *You want to see these people, but you're concerned about a
possible lapse because you'll want to smoke with them. Have you thought
of solutions and how effective they'll be?*

***Assign Between-Session Exercise***

The counselor presents *Problemsolving* (form 7A), reviews it, and asks
the client to complete the practice exercise for the next session.

***Review and Conclude Session***

The counselor reviews the content of the session, asks the client for
feedback, responds empathically to his or her comments, and
troubleshoots any difficulties. The counselor explains that the client
will report back on his or her efforts to complete the between-session
exercise at the next session. The counselor might remind the client that
treatment will be ending soon and solicit the client's feelings about
termination and input on the best way to spend the remaining sessions.

+-----------------------------------------------------------------------+
| **Overview of Session 8: Skill Topic 6, Marijuana Refusal Skills**    |
|                                                                       |
| **Total Time:** 1 hour                                                |
|                                                                       |
| **Delivery Method:** CBT-focused individual therapy                   |
|                                                                       |
| **Material (form is at the end of this section):**                    |
|                                                                       |
| > • *Marijuana Refusal Skills* (form 8A)                              |
|                                                                       |
| **Goal for This Session:**                                            |
|                                                                       |
| > • To learn about and practice assertive responses to offers of      |
| > marijuana use                                                       |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > **1.** Discuss the effects of social relationships                  |
| >                                                                     |
| > • Explain that marijuana use limits one's social group to those who |
| > use; explain that this makes it harder to stay abstinent because it |
| > increases                                                           |
| >                                                                     |
| > --- Direct and indirect pressure to use                             |
| >                                                                     |
| > --- Cravings associated with people, places, activities, etc.       |
| >                                                                     |
| > --- Positive expectancies about the effects of use                  |
| >                                                                     |
| > --- Access to and availability of marijuana                         |
| >                                                                     |
| > **2.** Discuss social pressures, risky situations, and              |
| > assertiveness                                                       |
| >                                                                     |
| > • Explain that avoidance of risky social situations is the safest   |
| > behavior                                                            |
| >                                                                     |
| > • Explain that refusing marijuana requires assertiveness skills     |
| >                                                                     |
| > • Provide guidance for marijuana refusal: nonverbal behavior, oral  |
| > responses, requesting behavior change, changing the subject,        |
| > avoiding excuses                                                    |
| >                                                                     |
| > **3.** Rehearse behaviors                                           |
| >                                                                     |
| > • Role play refusal skills with client                              |
| >                                                                     |
| > • Process the role play                                             |
| >                                                                     |
| > • Reverse roles with client and model a refusal skill               |
| >                                                                     |
| > **4.** Assign between-session exercise                              |
| >                                                                     |
| > **5.** Review and conclude session                                  |
+-----------------------------------------------------------------------+

**Session 8 Protocol**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor explains that marijuana-use
offers and pressures are common high-risk situations for individuals who
have stopped using marijuana. The counselor and client role play
marijuana refusal skills.

***Discuss the Effects of Social Relationships***

The counselor explains that, as a person's marijuana use increases, his
or her social relationships narrow. The individual spends less time with
friends who do not use, and his or her peer group becomes mostly those
who support and reinforce use. Being with such individuals increases the
risk of relapse through increased

> • Direct and indirect pressure to use
>
> • Cravings associated with people, places, activities, and emotional
> states related to using
>
> • Positive expectancies about the effects of using
>
> • Access to and availability of substances.

**Counselor (C):** *People experience two forms of social or peer
pressure: direct and indirect. Direct social pressure begins with an
offer of marijuana. Indirect social pressure comes with a return to the
same settings, people, and activities that generate feelings associated
with using.*

*Because social pressure increases risk greatly, avoiding risky social
situations is the safest behavior. However, avoiding social pressure is
not always possible or practical.*

*Being able to refuse marijuana requires more than a decision to stop
using. It requires assertiveness to act on that decision. Practicing
refusing marijuana will help you respond quickly and effectively when
real situations arise.*

***Discuss Social Pressures, Risky Situations, and Assertiveness***

The counselor describes offers that may occur and with the client
devises strategies for avoiding such situations. It is best to avoid
situations where people are using marijuana or to leave as soon as
possible. But if the client is unable to avoid certain people and
situations, the next level of response is to refuse to participate in
smoking marijuana. The counselor tells the client that the more quickly
the person says no, the less likely he or she is to relapse. Being
unsure and hesitant allows the client to begin rationalizing (e.g., *One
hit wouldn't be so bad*). The goal is to be ready and to say no
immediately and convincingly.

An assertive response to an invitation to use depends on who offers the
marijuana and how the offer is made. Sometimes a simple *No, thank you*
is sufficient; at other times, additional strategies are necessary.
Telling the person about prior using problems is useful in eliciting
helpful support; at other times, it is unnecessary or even detrimental
to share that information.

The counselor provides guidance for marijuana refusal:

**C: *Nonverbal behaviors.*** *Make direct eye contact with the person
to increase the effectiveness of your message. Don't feel guilty. You
won't hurt anyone by not using. In many situations, people won't even
know that you're not using. You have a right not to use. Stand up for
your rights!*

***Oral responses.** Speak in a clear, firm, and unhesitating voice.
Otherwise you invite questions about whether you mean what you say. "No"
should be the first word out of your mouth. Suggest something else to do
(e.g., go for a walk to talk, go to the movies instead of using on a
Saturday night). Suggest having something to eat or a cup of coffee.*

***Requesting a behavior change.** If a person repeatedly pressures you,
ask him or her not to offer you marijuana any more. For example, if the
person says, "Oh, come on, let's get high the way we used to," an
effective response might be, "If you want to be my friend, then don't
offer me marijuana."*

***Changing the subject.** After saying "No," change the subject to
avoid getting drawn into a debate about using. You could say, "No,
thanks, I don't get high. You know, I'm glad I came to this party. I
haven't seen a lot of these people in a while, including you. In fact, I
was wondering what you've been up to lately."*

***Avoiding excuses.** Avoid excuses ("I'm on medication for a cold
right now") and avoid vague responses ("Not tonight"). They imply that
at some date you'll accept an offer.*

***Rehearse Behaviors***

The counselor acknowledges that the client may feel uncomfortable at
first about role playing and that this is a normal reaction. The
counselor assures the client that, with practice, the client will get
into a scene realistically and focus on his or her role. Resistance can
take subtle forms such as focusing on other issues or asking many
questions.

The counselor develops scenes for role plays that are relevant to the
client. Meaningful scenarios increase engagement in the role play and
the likelihood that the client achieves a sense of mastery over the
situation. The following strategies are useful in generating scenes:

> • **Recalling events.** The counselor asks the client to recall a
> recent event in which he or she could have used the skill being
> taught.
>
> • **Anticipating future triggers.** The counselor asks the client to
> anticipate a difficult situation that may arise in which the skill can
> be used.
>
> • **Making suggestions.** The counselor suggests an appropriate
> situation based on his or her knowledge of the client's circumstances.

The counselor and the client anticipate a future trigger in this role
play.

**C:** *It might help to practice what you can say to your colleagues
when they are socializing after your business meeting.*

**Miguel (M):** *Sure, I'm willing to try it.*

**C:** *I'll play one of your colleagues, and you practice some
responses. Hey, Miguel! Good to see you. Why don't you come to my room
and we'll burn a few?*

**M:** *It's good to see you too! I hope you won't be offended, but
since I saw you last, I've stopped smoking. I'd love to spend some time
with you though.*

**C:** *Aw come on! Just a few tokes for old times' sake?*

**M:** *How about we just sit and talk. I really don't want to smoke pot
anymore.*

**C:** *Great job!*

After completing a role play, the counselor and client must process it
effectively. Processing provides an opportunity for a client to receive
praise and constructive criticism and includes the following:

> • The counselor and client react to the role play, considering how
> they felt about the way the situation was handled and the effects of
> the interaction.
>
> • The counselor's comments provide sincere reinforcing and
> constructive criticism. Positive and negative feedback focuses on
> specific aspects of the person's behavior and points out what was
> particularly effective or ineffective.
>
> • The counselor tries a role reversal. The client plays the role of
> the target person. This strategy is useful if a client has difficulty
> using a skill or is pessimistic about the approach's effectiveness. By
> playing the other person, the client has an opportunity to experience
> the effects of the skill.

In another situation, the counselor and client switch roles. The
counselor plays a person who is offered marijuana at a party. The client
plays the person offering marijuana by saying, "Here, help us
celebrate." The client ignores the counselor's refusal and says, "Oh,
come on, getting high won't hurt you." The counselor, in the role of the
person being pressured, demonstrates an effective and assertive way to
handle the situation.

Some role plays require using more than one partner, such as a group of
people sitting around a dining room table offering multiple prompts to
use. The counselor encourages the client to visualize such scenarios
even though the individual therapy setting does not provide multiple
partners. The counselor attempts to rehearse a variety of scenes
involving colleagues, parties, restaurants, old friends, and new
acquaintances. The counselor elicits the client's suggestions about how
the person offering marijuana will react to the client's refusal to use.

***Assign Between-Session Exercise***

The counselor reviews *Marijuana Refusal Skills* (form 8A) and asks the
client to complete the form before the next session.

***Review and Conclude Session***

The counselor reviews the content of the session, asks the client for
feedback, responds empathically to his or her comments, and
troubleshoots any difficulties. The counselor explains that the client
will report back on his or her efforts to complete the between-session
exercise at the next session. The counselor might remind the client that
treatment will be ending soon and solicit the client's feelings about
termination and input on the best way to spend the remaining session.

**Elective Skill Topics**

The four sessions that follow are elective. The counselor and client
determine which topic would be the most helpful and use that as session
9. Following are the elective skill topics:

> • Planning for emergencies and coping with a lapse
>
> • Recognizing seemingly irrelevant decisions
>
> • Managing negative moods and depression
>
> • Demonstrating assertiveness.

At the end of session 9, the counselor and client discuss termination
issues. The following topics are suggested:

> • **The course of treatment.** What were the pros and cons? Did the
> treatment meet the client's expectations?
>
> • **Thoughts, feelings, and concerns about terminating from
> treatment.** The counselor encourages the client to process feelings
> about ending, saying goodbye, and moving on.
>
> • **Future plans.** What does the client anticipate in the upcoming
> weeks and months regarding marijuana use, possible high-risk
> situations, use of coping strategies, involvement in further treatment
> for marijuana use, or other concerns?
>
> • **Continuing care.** The counselor offers the client a list of
> mutual-help resources available in the community.

**Note:** The counselor stresses that if a client lapses or feels the
need for more treatment, he or she can return to the facility.

+-----------------------------------------------------------------------+
| **Overview of Session 9: Elective Skill Topic 1, Planning for         |
| Emergencies and Coping With a Lapse**                                 |
|                                                                       |
| **Total Time:** 1 hour                                                |
|                                                                       |
| **Delivery Method:** CBT-focused individual therapy                   |
|                                                                       |
| **Materials (all forms except forms 1A, 1B, and 1C, which are in      |
| section V, are at the end of this section):**                         |
|                                                                       |
| > • *Personal Emergency Plan: High-Risk Situation* (form 9A)          |
| >                                                                     |
| > • *Personal Emergency Plan: Lapse* (form 9B)                        |
| >                                                                     |
| > • *Learning New Coping Strategies* (form 1A)                        |
| >                                                                     |
| > • *A Guide to Quitting Marijuana* (form 1B)                         |
| >                                                                     |
| > • The client's *Quit Agreement* (form 1C)                           |
|                                                                       |
| **Goals for This Session:**                                           |
|                                                                       |
| > • To increase preparedness for unexpected triggers and situations   |
| > likely to promote relapse                                           |
| >                                                                     |
| > • To learn techniques to manage the aftermath of a lapse or relapse |
| > of marijuana use                                                    |
| >                                                                     |
| > • To review the client's treatment                                  |
|                                                                       |
| **Session Outline**:                                                  |
|                                                                       |
| > **1.** Explain the effects of major life changes                    |
| >                                                                     |
| > **2.** Present *Personal Emergency Plan: High-Risk Situation* (form |
| > 9A)                                                                 |
| >                                                                     |
| > **3.** Present *Personal Emergency Plan: Lapse* (form 9B)           |
| >                                                                     |
| > **4.** Review Previous Skill Topics                                 |
| >                                                                     |
| > • Review strategies from previous skill topics that the client      |
| > found helpful                                                       |
| >                                                                     |
| > • Review *Learning New Coping Strategies* (form 1A), *A Guide to    |
| > Quitting Marijuana* (form 1B), and the client's *Quit Agreement*    |
| > (form 1C)                                                           |
| >                                                                     |
| > **5.** Terminate treatment                                          |
+-----------------------------------------------------------------------+

**Session 9 Protocol: Elective Skill Topic 1**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor helps the client develop an
emergency plan to follow in high-risk situations.

***Explain the Effects of Major Life Changes***

The counselor explains that life changes, both negative (e.g., health
problems, unemployment, financial losses) and positive (e.g., a new job,
graduating from school, moving to a new home) can threaten a client's
efforts to remain abstinent. In these situations, the client needs an
emergency plan to cope with stressors. The counselor asks the client to
consider possible high-risk situations and ways to address them.

***Present* Personal Emergency Plan: High-Risk Situation**

The counselor gives the client *Personal Emergency Plan: High-Risk
Situation* (form 9A), and together they review the form. The counselor
and client fill out the form with the high-risk situations just
identified in mind. The client might want to plan alternative enjoyable
activities for high-risk times; the counselor can help the client with
these plans. The counselor encourages the client to review compelling
reasons for continued abstinence, as noted on the PFR (form AS8; see
assessment session) or *Future-Self Letter* (form 4B).

***Present* Personal Emergency Plan: Lapse**

The counselor explains that lapses are not uncommon and asks what might
help the client leave a setting where a lapse occurred and whom he or
she can call for immediate support.

The counselor presents *Personal Emergency Plan: Lapse* (form 9B) and
asks the client to think of strategies to cope with a lapse. The
counselor helps the client specify how the strategies would be carried
out, such as how to dispose of the marijuana (e.g., throw it away, flush
it down the toilet), how to challenge negative thoughts (e.g., *I'll
quit again after I finish this stash; My life is just too stressful; I
was so irritable when I quit last time, I should continue using because
I'm nicer to be around*). The client already should have removed
paraphernalia from his or her home, but strategies may need to be
reviewed.

***Review Previous Skill Topics***

The counselor and client discuss strategies from previous skill topics
that the client found helpful (e.g., urge surfing, challenging negative
thinking) and review *Learning New Coping Strategies* (form 1A), *A
Guide to Quitting Marijuana* (form 1B), and the client's *Quit
Agreement* (form 1C).

***Terminate Treatment***

If this is the final treatment session with this client, the counselor
discusses termination issues (see pages 17 and 134).

+-----------------------------------------------------------------------+
| **Overview of Session 9: Elective Skill Topic 2, Recognizing          |
| Seemingly Irrelevant Decisions**                                      |
|                                                                       |
| **Total Time:** 1 hour                                                |
|                                                                       |
| **Delivery Method:** CBT-focused individual therapy                   |
|                                                                       |
| **Material (form is at the end of this section):**                    |
|                                                                       |
| > • *Seemingly Irrelevant Decisions* (form 9C)                        |
|                                                                       |
| **Goals for This Session:**                                           |
|                                                                       |
| > • To increase awareness of the decisionmaking process               |
| >                                                                     |
| > • To recognize how certain choices increase the likelihood of a     |
| > return to marijuana use                                             |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > **1.** Provide information on effects of seemingly irrelevant       |
| > decisions                                                           |
| >                                                                     |
| > • Tell George's story                                               |
| >                                                                     |
| > **2.** Help the client anticipate thoughts of himself or herself as |
| > a victim                                                            |
| >                                                                     |
| > **3.** Discuss valuing self-reflection                              |
| >                                                                     |
| > • Explain that though people commonly act in an automatic way, it's |
| > important when learning new behaviors to be aware of and reflect on |
| > decisions and actions                                               |
| >                                                                     |
| > • Encourage the client to become aware of activities and choices    |
| >                                                                     |
| > • Encourage the client to think about every choice he or she makes  |
| >                                                                     |
| > **4.** Discuss the role of consciousness in decisionmaking          |
| >                                                                     |
| > **5.** Introduce topic exercises                                    |
| >                                                                     |
| > • Ask about the client's most recent use and trace back the         |
| > decisionmaking chain                                                |
| >                                                                     |
| > • Ask about weekend plans and develop a plan to avoid risky         |
| > situations                                                          |
| >                                                                     |
| > **6.** Terminate treatment                                          |
+-----------------------------------------------------------------------+

**Session 9 Protocol: Elective Skill Topic 2**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor helps the client recognize and
handle seemingly irrelevant decisions.

***Provide Information on the Effects of Seemingly Irrelevant
Decisions***

The counselor helps the client understand that apparently irrelevant
decisions can have major repercussions (see Marlatt and Gordon 1985):

**Counselor (C):** *Many ordinary choices seem to have nothing to do
with using. Although they may not involve choosing directly whether to
use, they move you closer to making that choice.*

> *Through a series of minor decisions, you come to a point where using
> becomes likely. These seemingly unimportant decisions that put you on
> a path to resuming marijuana use are called seemingly irrelevant
> decisions.* \[Refers to form 9C.\]

The counselor tells a story about relapsing (adapted from Carroll 1998):

**C:** *George was driving home from work and decided to take the scenic
route. He realized he had forgotten to call his wife to say he'd be
late. While looking for a pay phone, he remembered that his old smoking
buddy Ric lived nearby, so he decided to stop at Ric's to use the phone.
It was a Friday evening, which he remembered was party night for Ric.
George noticed several cars parked at Ric's house. He paused a moment to
deliberate, deciding that he needed to call his wife and told himself
that he would go in for a minute to use the phone. Ric answered the door
clearly stoned and invited him to reconnect with old friends. George
entered the smoke-filled house and recognized friends from his using
days who passed him a blunt. Debating only a second, George took it and
began to smoke. That was the first of many he had that night. Because
George's marijuana use was linked with these friends, his choosing Ric's
house to make his call led to his getting high that night.*

*You can see that George made several decisions that led up to his final
decision to smoke. At each point, George could have made a different
decision that would have kept him from a dangerous situation. Did he
have to call his wife? Did he have no alternative but Ric's house? Could
he have said no to his friends? Each decision brought George closer to
danger.*

*Ultimately, George's decision to have that blunt led to his relapse to
marijuana use.*

***Help the Client Anticipate Thoughts of Himself or Herself as a
Victim***

The counselor helps the client anticipate future thoughts:

**C:** *People often think of themselves as victims ("Things happened, I
ended up in a risky situation, and I got high; I couldn't help it").
They don't recognize that their little decisions gradually bring them to
their predicament. After the fact, it's easy to see how you set yourself
up for relapse, but it's harder to see what can happen when you're
making the decision. So many choices don't seem to involve using at the
time. Each choice may take you a little bit closer to making a big
choice. When marijuana isn't on your mind, it's hard to connect using to
a minor decision that seems removed from using.*

***Discuss Valuing Self-Reflection***

The counselor reminds the client that acting without thinking it through
is common. People develop automatic processes that allow important tasks
to be completed, but in treatment the client is encouraged to be aware
of activities and choices. During the early phases of learning something
new and essential to one's survival or emotional health and well-being,
such as stopping substance use, the client needs to be aware of his or
her choices and decisions. This increases the likelihood that each
choice moves the person toward his or her goals.

The counselor stimulates the client's ability to be aware of his or her
thoughts and choices:

**C:** *Think about every choice you make, no matter how seemingly
irrelevant it is to using marijuana. By thinking ahead about each option
you have and where each choice may lead, you can anticipate dangers that
may lie along certain paths.*7

*By paying more attention to the decisionmaking process, you'll have a
greater chance to interrupt the chain of decisions that could lead to a
relapse. It's easier to stop the process early, before you wind up in a
high-risk situation, than later, when you're in a situation that's hard
to handle because you're exposed to triggers.*

*When you pay attention to your decisionmaking process, you can
recognize certain thoughts that can lead to risky decisions, such as the
thought George had to call home. Thoughts like you have to go to a
party, have to see a certain person you used marijuana with, or have to
drive by a particular place often occur at the beginning of a seemingly
irrelevant decision and should be treated as a warning or red flag.
Other red flag thoughts often start "It doesn't matter whether I..." or
"I can handle...".*

***Discuss the Role of Consciousness in Decisionmaking***

The counselor encourages the client to plan coping approaches:

**C:** *When faced with a decision, you should choose a low-risk option,
one that will help you avoid a risky situation. However, if you select a
high-risk option, you must plan to protect yourself. By becoming aware
of seemingly irrelevant decisions, you can take action to avoid
high-risk situations. It is easier to avoid a high-risk situation than
it is to resist temptation once you're in it.*

***Introduce Topic Exercises***

The counselor introduces several exercises pertinent to this session:

**C:** *Think about your most recent marijuana use. Follow the
decisionmaking chain. What was the starting point (e.g., exposure to a
trigger, certain thoughts)? Can you recognize the points where you chose
to make a risky decision?*

*Have you made plans for this weekend? If no, why not? Is this a
seemingly irrelevant decision? Sometimes not making any plans means
planning to use. What plans can you make for this weekend to avoid a
risky situation?*

*Here are other examples of situations involving seemingly irrelevant
decisions that can be setups for a relapse. Which ones apply to you?
What is a low-risk option for each?*

> *• Whether to keep marijuana in the house*
>
> *• Whether to offer a ride home to a friend you used to smoke with*
>
> *• Whether to tell a friend you've quit using.*

In the following dialog the counselor inquires about potential seemingly
irrelevant decisions:

**C:** *You've gone several weeks without smoking. That's quite an
accomplishment.*

**Doug (D):** *Yeah, I never thought I could go that long.*

**C:** *What caught your attention during our talk about seemingly
irrelevant decisions?*

**D:** *I put a secret stash in the garage several months ago. Sometimes
I forget it's there, but I guess I want a way out if things get too
tough.*

**C:** *You seem concerned about it.*

**D:** *Yeah, that idea that not making plans may mean planning to smoke
hit me right between the eyes. As long as I keep pot around, I guess I'm
planning to smoke it sooner or later.*

**C:** *What are you thinking about now that you know that?*

***Terminate Treatment***

If this is the final treatment session with this client, the counselor
discusses termination issues (see pages 17 and 134).

+-----------------------------------------------------------------------+
| **Overview of Session 9: Elective Skill Topic 3, Managing Negative    |
| Moods and Depression**                                                |
|                                                                       |
| **Total Time:** 1 hour                                                |
|                                                                       |
| **Delivery Method:** CBT-focused individual therapy                   |
|                                                                       |
| **Materials (all forms are at the end of this section):**             |
|                                                                       |
| > • *Thinking Errors That Dampen One's Mood* (form 9D)                |
| >                                                                     |
| > • *Managing Negative Moods and Depression* (form 9E)                |
| >                                                                     |
| > • *Pleasant Activities* (form 4C)                                   |
|                                                                       |
| **Goals for This Session:**                                           |
|                                                                       |
| > • To become more aware of how moods affect marijuana use            |
| >                                                                     |
| > • To learn strategies to recognize, process, and cope with these    |
| > emotions                                                            |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > **1.** Address the possibility of negative moods                    |
| >                                                                     |
| > **2.** Discuss the importance of emotional triggers                 |
| >                                                                     |
| > • Review *Thinking Errors That Dampen One's Mood* (form 9D)         |
| >                                                                     |
| > • Ask the client to identify which automatic negative thoughts he   |
| > or she may engage in before or during depressed, anxious, or        |
| > irritable moods                                                     |
| >                                                                     |
| > • Discuss with the client guidelines for evaluating these thoughts  |
| >                                                                     |
| > • Give client *Managing Negative Moods and Depression* (form 9E)    |
| >                                                                     |
| > • Engage the client in problemsolving to address problems           |
| > contributing to his or her negative moods                           |
| >                                                                     |
| > • Give the client *Pleasant Activities* (form 4C) and help generate |
| > a list of appealing activities                                      |
| >                                                                     |
| > • Discuss balancing "have to" activities with "want to" activities  |
| >                                                                     |
| > • With a depressed client, discuss strategies that may help the     |
| > client start a necessary or desirable activity                      |
| >                                                                     |
| > **3.** Link negative moods and marijuana use                        |
| >                                                                     |
| > • Explore the relationship between the client's marijuana smoking   |
| > and his or her experience of negative moods                         |
| >                                                                     |
| > • Review *Thinking Errors That Dampen One's Mood* (form 9D)         |
| >                                                                     |
| > • Explain "cognitive distortions"                                   |
| >                                                                     |
| > • Explore automatic thought patterns that appear to lead to         |
| > negative mood states                                                |
| >                                                                     |
| > • Explore methods of changing the client's automatic thoughts       |
| >                                                                     |
| > **4.** Terminate treatment                                          |
+-----------------------------------------------------------------------+

**Session 9 Protocol: Elective Skill Topic 3**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor assesses the client's level of
depression and determines whether additional services are required. The
client learns to recognize and cope with negative affective states.

***Address the Possibility of Negative Moods***

The counselor explains that negative moods (e.g., anxiety, irritability,
depression) are common among people overcoming marijuana dependence:

**Counselor (C):** *Moods may relate to the effects of stopping
marijuana use or the losses in one's life (e.g., family, job, finances)
resulting from marijuana use. Difficulties with negative mood states
(e.g., depression) may have started before marijuana use and may serve
as a trigger for continued use. Abstinence from marijuana usually leads
to improved mood (especially as clients start to cope effectively with
other problems), but some individuals experience depression or other
moods even after being abstinent for several weeks.*

Because negative moods often pose a risk for relapse, the client should
address them directly during treatment. The counselor focuses on
negative moods through problemsolving and increasing pleasant
activities. If after session 3 the counselor suspects that the client
can benefit from additional counseling or psychotropic medications, the
counselor explores these possibilities with the client, particularly a
client who is severely depressed, has an anxiety disorder, or has a
personal or family history of mental disorders or aggression.

The counselor discusses the following strategies to help clients with
mild to moderate levels of depression identify negative feelings:

> • Increase awareness of negative moods and overly negative thinking
>
> • Challenge negative thoughts
>
> • Solve problems
>
> • Change the client's activity level
>
> • Decrease negative activities.

The counselor asks the client whether he or she experiences mood swings,
low energy level, changes in appetite and sleep, and suicidality. If
indicated (e.g., in the case of suicidality) the client should be
referred for assessment by a mental health professional. He or she
encourages the client to be aware of possible distorted perceptions that
may precede or coincide with negative moods. The counselor encourages
the client to pay attention to the contexts associated with mood changes
and to watch for times when confidence level changes.

***Discuss the Importance of Emotional Triggers***

The counselor and client review *Thinking Errors That Dampen One's Mood*
(form 9D). The counselor explains that a connection exists among how
people think, feel, and behave and that the client can experience fewer
negative moods if he or she thinks in realistic, balanced ways rather
than in overly negative, self-defeating ways. The client identifies
which automatic negative thoughts he or she engages in. If the client
has difficulty identifying these thoughts, the counselor tells the
client to slow down the action (as if watching a movie in slow motion)
or look at what the situation means. Sometimes writing down the most
distressing thoughts helps a client remember his or her thoughts.

Once the client identifies his or her automatic negative thoughts, the
counselor gives the client *Managing Negative Moods and Depression*
(form 9E). The counselor tells the client to fill out the form thinking
about distressing situations to avoid and recognizing that an event
often can be interpreted in more than one way (Emery 1981).

The counselor engages the client in problemsolving to address problems
contributing to negative moods. The problemsolving steps are reviewed
briefly, emphasizing brainstorming and selecting the most promising
approach.

The counselor encourages the client to consider increasing involvement
in positive activities and reducing involvement in negative ones.
Increasing positive activities improves mood by counteracting fatigue
and improving motivation. *Pleasant Activities* (form 4C) (adapted from
MacPhillamy and Lewinsohn l982) or the calendar of events section in the
local newspaper may help the client generate a list of enjoyable
activities.

The counselor tells the client to consider activities that vary in price
and that can be enjoyed when a person is abstinent and to balance
pleasant activities (e.g., a walk in a park, attending the theater) with
required activities (e.g., working, cleaning, studying). Engaging in a
pleasant activity for 30 minutes two or three times a week (e.g.,
exercising, reading a favorite author) can fit easily into the client's
schedule.

A depressed client may need to schedule fewer activities and record them
on a calendar. The client may need to be rewarded in some way (unrelated
to using substances) for completing these activities (e.g., spouse
agrees to prepare dinner).

Decide which activities the client must do and which can be delegated to
others. If the activity cannot be delegated, the client explores ways to
change the context associated with the activity (e.g., call a friend
only after an hour of studying, combine studying with music that is not
distracting). If the client reports difficulty starting a necessary
activity, he or she might try to do the activity for only a short time,
perhaps 15 minutes. Some less desirable activities can be eliminated by
problemsolving, time management (e.g., prioritizing tasks, setting time
limits to complete tasks), and setting appropriate limits on others'
requests.

***Link Negative Moods and Marijuana Use***

The counselor explores the relationship between marijuana smoking and
the experience of negative moods and the role of automatic thoughts:

**Shirley (S):** *I miss smoking pot when I'm overwhelmed by bad
feelings. I felt better after getting high.*

**C:** *Smoking helped you cope with your negative mood.*

**S:** *Yeah, but I would get depressed again when I came down from the
high.*

**C:** *What works for you in the short term causes other problems
later.*

**S:** *Yeah.*

**C:** *Today we've reviewed ways to cope with negative thoughts. You
said getting up and moving around helps. Researchers have found that
often the negative feelings don't just happen. That is, they don't come
from nowhere. In fact, negative feelings may be related to the way we
think about things or the way we interpret situations.* Thinking Errors
That Dampen One's Mood *lists types of thoughts that increase the
chances of feeling depressed. We call them cognitive distortions because
they don't reflect what's going on but are based on an interpretation of
events. Let's look at automatic thought patterns you have that lead to
depression.*

***Terminate Treatment***

If this is the final treatment session with this client, the counselor
discusses termination issues (see pages 17 and 134).

+-----------------------------------------------------------------------+
| **Overview of Session 9: Elective Skill Topic 4, Demonstrating        |
| Assertiveness**                                                       |
|                                                                       |
| **Total Time:** 1 hour                                                |
|                                                                       |
| **Delivery Method:** CBT-focused individual therapy                   |
|                                                                       |
| **Materials (all forms are at the end of this section):**             |
|                                                                       |
| > • *Assertiveness* (form 9F)                                         |
| >                                                                     |
| > • *Assertiveness Practice Exercises* (form 9G)                      |
| >                                                                     |
| > • Chalkboard or newsprint                                           |
|                                                                       |
| **Goal for This Session:**                                            |
|                                                                       |
| > • To improve the ability to express feelings and needs to others in |
| > an effective way                                                    |
|                                                                       |
| **Session Outline:**                                                  |
|                                                                       |
| > **1.** Elicit client's definition of assertiveness                  |
| >                                                                     |
| > **2.** Define aggressive, passive, passive--aggressive, and         |
| > assertive                                                           |
| >                                                                     |
| > **3.** Explain benefits of assertiveness                            |
| >                                                                     |
| > • Increases chances that a person will meet goals                   |
| >                                                                     |
| > • Increases likelihood that a person will feel good about a         |
| > situation                                                           |
| >                                                                     |
| > **4.** Introduce skill guidelines                                   |
| >                                                                     |
| > • Review *Assertiveness* (form 9F)                                  |
| >                                                                     |
| > • Discuss handling situations with negative consequences            |
| >                                                                     |
| > **5.** Model assertiveness                                          |
| >                                                                     |
| > • Role play passive, aggressive, passive--aggressive, and assertive |
| > responses                                                           |
| >                                                                     |
| > • Ask the client to identify each behavior and its influence on     |
| > preventing a slip                                                   |
| >                                                                     |
| > **6.** Practice assertive responses to past difficult situations    |
| >                                                                     |
| > • Review *Assertiveness Practice Exercises* (form 9G)               |
| >                                                                     |
| > **7.** Terminate treatment                                          |
+-----------------------------------------------------------------------+

**Session 9 Protocol: Elective Skill Topic 4**

The counselor welcomes the client and provides an overview of the
session. In this session, the counselor explains and models assertive
behavior. The counselor may be surprised about the misconceptions a
client has about assertiveness.

***Elicit the Client's Definition of Assertiveness***

The counselor asks the client to define *assertiveness*, writing this
definition on a chalkboard or newsprint. The counselor compares the
client's definition with the one presented in this skill topic, pointing
out differences. The client may give an appropriate definition, but
during role plays, it may become apparent that his or her behavior is
inconsistent with that definition:

**Counselor (C):** *Today we're going to talk about assertiveness. When
you hear that word, what do you think of?*

**Doug (D):** *People who are pushy, trying to get their way all the
time.*

**C:** *We'll be looking at four styles of interacting: aggressive,
passive, passive--aggressive, and assertive.* \[Writes them on the
chalkboard.\]

**D:** *I guess I was thinking of the aggressive style, not assertive.*

**C:** *Let's define each style and see whether you identify with them.
We can look at ways to communicate thoughts and feelings without
offending other people or compromising your needs.*

***Define Aggressive, Passive, Passive--Aggressive, and Assertive***

The counselor helps the client understand the concept:

**C:** *Assertiveness means recognizing your right to decide what to do
in a situation rather than give in to others. It recognizes and respects
the rights of the people. Rights refer to*

> *• The right to inform others of your opinion*
>
> *• The right to inform others of your feelings in a way that is not
> hurtful*
>
> *• The right to ask others to change their behavior that affects you*
>
> • *The right to accept or reject what others say to you or request
> from you.*

*We can express our needs to others in several ways: passive,
aggressive, passive--aggressive, and assertive.*

***Passive** people give up their rights if a conflict exists between
what they want and what someone else wants. They usually fail to let
others know what they're thinking or feeling. They bottle up their
feelings, even when the situation doesn't require it, and often feel
anxious or angry. Sometimes they feel depressed by their ineffectiveness
or hurt when others have not drawn them out or figured out what they
wanted. People do not know what the passive person wants, and passive
people seldom get their needs met.*

***Aggressive** people protect their rights by running over others'
rights. They may satisfy their short-term needs, but the long-term
effects are negative. Because they disregard others to achieve their
goals, they earn the ill will of others, who may seek to get even.*

***Passive--aggressive** people are indirect. They hint at what they
want, make sarcastic comments, or mumble, without stating what is on
their minds. They may act out by slamming doors, giving someone the
silent treatment, or being late. They may get what they want without
interacting directly. Frequently people around them become confused or
angry, so the passive--aggressive person ends up feeling frustrated or
victimized.*

***Assertive** people decide what they want, plan an appropriate way to
involve others, and act on the plan. The most effective plan is to state
one's feelings or opinions and request the changes one would like from
others without making threats, demands, or negative statements. Usually
assertive people decide in certain circumstances that a passive response
is safest (e.g., with an insensitive boss) or that an aggressive
response is necessary (e.g., in confronting a pusher who won't back
off). Assertive people adapt their behavior so that it fits the
situation; they don't respond in the same manner to all situations.
Assertive people feel satisfied with their actions and are well
regarded.*

***Explain Benefits of Assertiveness***

The counselor explains the benefits of assertiveness:

**C:** *Assertiveness is the most effective way to let others know
what's going on or what effect their behavior has. By expressing
themselves, assertive people resolve uncomfortable feelings that
otherwise build up. Because being assertive often results in correcting
a source of stress and tension, it can lead to feeling more in control
of life. Assertive people do not feel like victims of circumstances.
However, their goals can't be met in all situations; it isn't possible
to control how another person will respond. Nevertheless, behaving
assertively has two benefits: it increases the chances that goals will
be met, and it makes people feel better about their role in the
situation.*

***Introduce Skill Guidelines***

The counselor explains that the guidelines in *Assertiveness* (form 9F)
can help the client become assertive:

**C:** *Take a moment to think before you speak. What did the other
person do or say? Try not to assume the other person's intentions. Don't
assume that he or she knows your mind.*

*Plan the most effective way to make statements. Be specific and direct.
Address the problem without bringing in other issues. Be positive. Don't
put others down; blaming others makes them defensive and less likely to
hear your message.*

*Pay attention to your body language: eye contact, posture, gestures,
facial expression, and tone of voice. Make sure your words and your
expression communicate the same message. To get your point across, speak
firmly and be aware of your appearance.*

*Be willing to compromise. Let others know that you're willing to work
things out. No one has to leave the situation feeling as if he or she
has lost everything. Try to find a way for everyone to win. Give others
your full attention when they reply, try to understand their views, and
seek clarification. If you disagree, have a discussion. Don't dominate
or submit to others. Strive for equality in the relationship.*

*If you feel you're not being heard, restate your assertion. Persistence
and consistency are necessary parts of assertiveness. Changing the way
you respond requires effort. The first step is to become aware of
habitual responses and make an effort to change.*

*The most difficult situations in which to respond assertively are those
that may end with negative consequences. Examine the thoughts that
prevent you from acting assertively ("My boss will fire me if I can't
work overtime because I have my counseling session"). This examination
uses many skills we discussed under managing thoughts about marijuana:*

> *• **Determine the thought or fear.** What am I afraid will happen?
> What's the worst that could happen?*
>
> *• **Assess the probabilities.** How likely is the negative
> consequence?*
>
> *• **Evaluate the catastrophe.** What would happen if the worst
> occurred? Would it really be so terrible?*
>
> *• **Identify the rules.** What assumptions and beliefs govern
> feelings?*

***Model Assertiveness***

The counselor and client role play a situation in which the counselor
plays a person refusing to get high; the client plays the person
offering the marijuana. The counselor models passive, aggressive,
passive--aggressive, and assertive responses. After each response, the
counselor asks the client to identify the behavior and determine the
success of that approach.

***Practice Assertive Responses to Past Difficult Situations***

The counselor asks the client to list difficult situations he or she has
experienced and to role play assertive responses. If the client has
trouble thinking of situations, the counselor suggests some easy ones
(e.g., returning an item bought in a store, dismissing a pesky
salesperson) and some difficult ones (e.g., asking a friend to repay a
loan several months old, confronting a supervisor who took credit for an
idea of the client's). Following is an example of the counselor
demonstrating how to assert feelings about being accused of smoking:

**C:** *You have said that you've been both passive and aggressive with
your wife and son.*

**D:** *I get annoyed at first; then I get high and don't talk to them.*

**C:** *Would you like to role play some methods that we reviewed
earlier in the skill topic?*

**D:** *Sure, since what I'm doing now isn't working!*

**C:** *Why don't you be your wife, and I'll try some responses we've
talked about. Ready?*

**D:** *Yeah. Have you been smoking again? I can tell when you're
sneaking around!*

**C:** *I haven't been smoking, and I don't appreciate the way you're
confronting me.*

The counselor gives the client *Assertiveness Practice Exercises* (form
9G) and asks the client to practice the exercises at home.

***Terminate Treatment***

If this is the final treatment session with this client, the counselor
discusses termination issues (see pages 17 and 134).

**Forms for Sessions 3 Through 9**

During the skill-building sessions, the counselor and client review or
complete several forms. These forms are provided on the remaining pages
of this section.

Form 3A

+--------------+-----------------------+-------+-----------------------+
| **Problem    |                       |       |                       |
| Checklist**  |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| **Category** | **Describe Problem**  | **    | **Goal**              |
|              |                       | Sever |                       |
|              |                       | ity** |                       |
|              |                       |       |                       |
|              |                       | **(   |                       |
|              |                       | 1--10 |                       |
|              |                       | )\*** |                       |
+--------------+-----------------------+-------+-----------------------+
| Hou          |                       |       |                       |
| sing/shelter |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Childcare    |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Tr           |                       |       |                       |
| ansportation |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Financial    |                       |       |                       |
| support      |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Job training |                       |       |                       |
| or           |                       |       |                       |
| employment   |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Medical      |                       |       |                       |
| problems     |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Legal        |                       |       |                       |
| problems     |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Family       |                       |       |                       |
| problems     |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Social or    |                       |       |                       |
| in           |                       |       |                       |
| ter-personal |                       |       |                       |
| problems     |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Social       |                       |       |                       |
| support      |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Emotional or |                       |       |                       |
| ps           |                       |       |                       |
| ycho-logical |                       |       |                       |
| problems     |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Education    |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+
| Other        |                       |       |                       |
+--------------+-----------------------+-------+-----------------------+

\* 1 indicates no problem, 10 indicates a very severe problem that is
likely to thwart your efforts to remain abstinent if not addressed.

Form 3B

+-------------------+----------------+---------------+----------------+
| **Support Plan**  |                |               |                |
+-------------------+----------------+---------------+----------------+
|                   | **Goal 1**     | **Goal 2**    | **Goal 3**     |
+-------------------+----------------+---------------+----------------+
| What are my       |                |               |                |
| goals?            |                |               |                |
+-------------------+----------------+---------------+----------------+
| Who is to be      |                |               |                |
| contacted?        |                |               |                |
|                   |                |               |                |
| (Phone numbers    |                |               |                |
| and               |                |               |                |
|                   |                |               |                |
| addresses)        |                |               |                |
+-------------------+----------------+---------------+----------------+
| When will the     |                |               |                |
| contact           |                |               |                |
|                   |                |               |                |
| be made?          |                |               |                |
+-------------------+----------------+---------------+----------------+
| Who is            |                |               |                |
| responsible for   |                |               |                |
|                   |                |               |                |
| contacting?       |                |               |                |
+-------------------+----------------+---------------+----------------+
| What services     |                |               |                |
| will be           |                |               |                |
|                   |                |               |                |
| requested?        |                |               |                |
+-------------------+----------------+---------------+----------------+
| Outcome           |                |               |                |
+-------------------+----------------+---------------+----------------+

Others who can help with the plan:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Signature**

**Form 4A**

  -----------------------------------------------------------------------
  **Marijuana Use Self-Awareness Record**

  -----------------------------------------------------------------------

*As a way to increase awareness about your patterns of use, we'll use
this form to identify the kinds of situations, thoughts, feelings, and
consequences that are associated with your marijuana use. It may be
difficult initially, but once you get accustomed to paying more
attention, you will become skilled at discovering the ways in which you
typically use marijuana.*

**Trigger** (What types of events tend to make you want to use? For
example, an argument, disappointment, loss, or frustration; spending
time with friends who use; having marijuana easily available to you;
recalling positive memories of past use.)

1\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Thoughts and Feelings** (What were you thinking or how were you
feeling in relation to the triggers you have identified? For example,
thinking you were incompetent or stupid or that you could never achieve
a particular goal; feeling angry, sad, frightened, or glad.)

1\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Behavior** (What did you actually do when you were thinking and
feeling in these ways? For example, smoked marijuana, went out to
dinner, isolated yourself from people.)

1\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Positive Consequences** (What good came out of your response to the
situation? For example, I felt much better for a short period.)

1\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Negative Consequences** (What negative things happened as a result of
your response? For example, I felt bad about myself for smoking; I
couldn't complete the work I needed to finish.)

1\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Form 4B**

  -----------------------------------------------------------------------
  **Future-Self Letter**

  -----------------------------------------------------------------------

**Optional Creative Expression Exercise**

Sometime during the next week, imagine that a year has passed and that
you haven't used marijuana for a year. Making believe that it's next
year, write a letter to yourself (the old you). Write about your life as
it has become. Include the reasons why you stopped a year earlier, what
your lifestyle is like in the new year, and the benefits you enjoy from
not smoking. Mention in your letter any problems you faced during the
past year in giving up marijuana use. Describe yourself without
marijuana as clearly as you can. As you visualize yourself in the future
without marijuana, it may help to think about friendships, self-esteem,
health, employment, recreational activities, and general lifestyle
satisfaction.

If you prefer, draw, sketch, or paint a picture of this image of
yourself in the future, rather than depict it in writing. Choose a
medium that will allow you to see another possibility for yourself.

This exercise is extremely useful. It helps you visualize your journey
and your goal. Having a clear picture of where you're going, why, and
how you're going to get there will be useful in the months ahead. At our
next session, we'll talk about the future you foresee for yourself.

**Form 4C**

  -----------------------------------------------------------------------
  **Pleasant Activities**^1^

  -----------------------------------------------------------------------

**Optional Assignment**

In stopping your marijuana use, you are giving up an activity that has
taken up a great deal of your time. It is important that you identify
other activities that bring you pleasure and integrate them into your
everyday life. Your assignment is to do something nice for yourself
every day, something you wouldn't necessarily spend the time, effort, or
money to do for yourself otherwise. You may need to get your partner's,
supporter's, or someone else's cooperation to do this, but don't
hesitate to ask. It doesn't matter whether it's having dinner out,
shopping for something you've been wanting, taking a hot bath,
jogging---something that makes you feel as if you're treating yourself.
You deserve it! If it involves spending a little more money than usual,
remember that you'll be saving money by not smoking marijuana. You'll
gradually find ways to treat yourself that are less expensive. Keep a
record of these over the next week, and we'll discuss them next time.

  ------- ------------------------------------ ---------------------------
          **Plan for Increasing Pleasant       **Followup (What did you
          Activities (List at least one target end up doing each day?)**
          for each day)**                      

  **Day                                        
  1**                                          

  **Day                                        
  2**                                          

  **Day                                        
  3**                                          

  **Day                                        
  4**                                          

  **Day                                        
  5**                                          

  **Day                                        
  6**                                          

  **Day                                        
  7**                                          
  ------- ------------------------------------ ---------------------------

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^1^Source: MacPhillamy and Lewinsohn 1982.

Form 4D

  -----------------------------------------------------------------------
  **Relaxation Training**^2^

  -----------------------------------------------------------------------

**Optional Assignment**

**Deep Muscle Relaxation Practice Exercise**

Arrange to spend some quiet time in a room where you will not be
interrupted. Try to practice this relaxation technique at least three
times during the next week. Proceed through the eight groups of muscles
in the list below, *first tensing* each for 5 seconds and *then
relaxing* each for 15 to 20 seconds.

*Settle back as comfortably as you can, take a deep breath, and exhale
very slowly. You may feel most comfortable if you close your eyes.
Notice the sensations in your body; you will soon be able to control
those sensations. Begin by focusing your attention on your hands and
forearms.*

> • Squeeze both hands into fists, with arms straight. Then relax hands.
>
> • Flex both arms at the elbows. Then relax arms.
>
> • Shrug shoulders toward head. Tilt chin toward chest. Then relax
> shoulders and neck.
>
> • Clench jaw, gritting your teeth together. Then relax jaw.
>
> • Close your eyes tightly. Then relax eyes.
>
> • Wrinkle up your forehead and brow. Then relax these muscles.
>
> • Harden your stomach muscles, as if expecting someone to punch you
> there (continue to breathe slowly as you tense your stomach). Then
> relax stomach.
>
> • Stretch out both legs, point your toes toward your head, and press
> your legs together. Then relax legs.

**Self-Rating Task**

Each day that you engage in this exercise, rate your relaxation level
before *and* after, using the following guide: 0=highly tense; 100=fully
relaxed.

  ----------------- ----------------- ----------------- -----------------
  **Day**           **Time**          **Before**        **After**

                                                        

                                                        

                                                        

                                                        

                                                        
  ----------------- ----------------- ----------------- -----------------

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^2^Source: Monti et al. 1989.

**Form 4E**

  -----------------------------------------------------------------------
  **Boredom Management**

  -----------------------------------------------------------------------

**Optional Exercise**

For many people who use marijuana, boredom is a trigger to smoke.
Sometimes it is boredom associated with a tedious or uninteresting job.
Perhaps it is a way to fill weekday evening hours after dinner but
before bedtime. At other times, getting stoned is a way to spend a
weekend when nothing else has been planned.

Boredom is a complex and interesting emotion. Many different feelings
may be associated with it. For instance, boredom may be accompanied by
anxiety, apathy, irritability, or lethargy. It's not a really strong
emotion; it just kind of nags at you. It can sneak up because it's hard
to identify. Discussing boredom and how to handle it can make you aware
of its influence on your behavior and prepare you to cope with it.

**A Boring Story**

Jan was in her mid-30s when she began to think she needed to quit
smoking pot. Sometimes she enjoyed it, but after 15 years of regular use
Jan was unhappy with herself for smoking so much marijuana. She began
every day with a hit and smoked every hour or two throughout the day.

Several times in the past few years she had tried to cut back to smoking
just in the evenings and on weekends. A few times she kept to her
limits, but inevitably she'd inch her way back up. When she thought
about it, she recognized that she slipped back to getting stoned because
she couldn't handle the boredom she felt when she was straight. Her job
wasn't stimulating; she was a receptionist in a travel agency. When she
tried to get through a day without smoking, the tedium of her job got to
her.

Now as she thought about quitting pot completely, she couldn't imagine
how she'd cope with being bored at work. On top of that, she was sure
that the evenings and weekends would be miserable if she didn't get
high. Being bored was torture for Jan. Boredom was an endless emptiness
and an inner void, with unpleasant restlessness and anxiety. She
wondered whether she had a chance of quitting marijuana.

Jan lived by herself and liked it that way. She had two close friends
and worried about how these friendships would be affected if she stopped
getting high. She feared that her being straight would alienate at least
one friend. With fewer friends, boredom would be even worse!

> 1\. *What does boredom feel like to you?*
>
> 2\. *Is it always a miserable experience?*
>
> 3\. *What makes boredom so uncomfortable?*
>
> 4\. *How would you cope with being bored if you were Jan?*

**Form 5A**

  -----------------------------------------------------------------------
  **Coping With Cravings and Urges**^3^

  -----------------------------------------------------------------------

> • Urges are common in the recovery process. Do not regard them as
> signs of failure. Instead, use your urges to help you understand what
> triggers your cravings.
>
> • Urges are like ocean waves. They get stronger only to a point; then
> they start to subside.
>
> • You win every time you defeat an urge to use. Urges get stronger the
> next time if you give in and "feed" them. However, if you don't feed
> it, an urge eventually will weaken and die.

**Practice Exercise**

For the next week, make a daily record of urges to use drugs, the
intensity of those urges, and the coping behaviors you used.

Fill out the *Daily Record of Urges To Use Marijuana* (form 5C):

> • Date.
>
> • Situation: Include anything about the situation and your thoughts or
> feelings that seemed to trigger the urge to use.
>
> • Intensity of cravings: Rate your craving---1=none at all, 100=worst
> ever.
>
> • Coping behaviors used: Note how you attempted to cope with the urge
> to use marijuana. If it helps, note the effectiveness of your coping
> technique.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^3^Source: Kadden et al. 1994.

Form 5B

  -----------------------------------------------------------------------
  **Urge Surfing**

  -----------------------------------------------------------------------

Many people try to cope with their urges by gritting their teeth and
toughing it out. Some urges, especially when you first return to your
old using environment, are too strong to ignore. When this happens, it
can be useful to stay with your urge to use until it passes. This
technique is called *urge surfing.*

Urges are like ocean waves. They are small when they start, grow in
size, and then break up and dissipate. You can imagine yourself as a
surfer who will ride the wave, staying on top of it until it crests,
breaks, and turns into less powerful, foamy surf. The basis of urge
surfing is similar to that of many martial arts. In judo, one overpowers
an opponent by first *going with* the force of the attack. By joining
with the opponent's force, one can take control of it and redirect it to
one's advantage. This type of technique of gaining control by first
going with the opponent allows one to take control while expending a
minimum of energy. Urge surfing is similar. You can join with an urge
(rather than meet it with a strong opposing force) as a way of taking
control of your urge to use. After you have read and become familiar
with the instructions for urge surfing, you may find this a useful
technique when you have a strong urge to use.

Urge surfing has three basic steps:

> *1. Take an inventory of how you experience the craving. Do this by
> sitting in a comfortable chair with your feet flat on the floor and
> your hands in a comfortable position. Take a few deep breaths and
> focus inward. Allow your attention to wander through your body. Notice
> where in your body you experience the craving and what the sensations
> are like. Notice each area where you experience the urge and tell
> yourself what you are experiencing. For example, "Let me see---my
> craving is in my mouth and nose and in my stomach."*
>
> *2. Focus on one area where you are experiencing the urge. Notice the
> exact sensations in that area. For example, do you feel hot, cold,
> tingly, or numb? Are your muscles tense or relaxed? How large an area
> is involved? Notice the sensations and describe them to yourself.
> Notice the changes that occur in the sensation. "Well, my mouth feels
> dry and parched. There is tension in my lips and tongue. I keep
> swallowing. As I exhale, I can imagine the smell and taste of
> marijuana."*
>
> *3. Refocus on each part of your body that experiences the craving.
> Pay attention to and describe to yourself the changes that occur in
> the sensations. Notice how the urge comes and goes.*

Many people notice that after a few minutes of urge surfing the craving
vanishes. The purpose of this exercise, however, is not to make the
craving go away but to experience the craving in a new way. If you
practice urge surfing, you will become familiar with your cravings and
learn how to ride them out until they go away easily.

**Form 5C**

  ---------------- ---------------------- -------------------- ---------------------
  **Daily Record                                               
  of Urges To Use                                              
  Marijuana**^4^                                               

  **Date**         **Situation (include   **Intensity of       **Coping Behaviors
                   your thoughts and      Cravings (1--100)**  Used**
                   feelings)**                                 

                                                               

                                                               

                                                               

                                                               

                                                               

                                                               

                                                               

                                                               

                                                               

                                                               

                                                               

                                                               

                                                               

                                                               

                                                               

                                                               
  ---------------- ---------------------- -------------------- ---------------------

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^4^Source: Kadden et al. 1994.

Form 6A

  -----------------------------------------------------------------------
  **Managing Thoughts About Marijuana**^5^

  -----------------------------------------------------------------------

Here are several ways of managing thoughts about marijuana:

> • Challenge your thought: Do you really need to use?
>
> • Think of the benefits of not using (see Creating Your List below).
>
> • Remember the unpleasant drug experiences and aftereffects (read list
> on card \[see below\]).
>
> • Find distractions: Think of something unrelated to marijuana use.
>
> • Think positively: Remind yourself of your successes so far.
>
> • Leave or change the situation.
>
> • Call your supporter or a friend and try to talk it out.
>
> • Use self-talk.
>
> • Use images of riding out the wave of craving until it passes.
>
> • Use images or pictures of loved ones who would be disappointed if
> you used.
>
> • Use the decision-delay technique: If nothing else is working, then
> look at your watch and put off a decision to use marijuana for 15
> minutes or more (use images to tough it out until the urge passes).

**Creating Your List**

One way to cope with thoughts about using marijuana is to remind
yourself of the benefits of not using, the unpleasant consequences of
using, and the stumbling blocks or high-risk situations that may make it
hard to keep your commitment to abstinence. Use this form to make a list
of 5 to 10 reminders in each category, then transfer this list onto an
index card. Carry the card with you, and read it whenever you start to
have thoughts about using marijuana.

Positive benefits of not using:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^5^Source: Monti et al. 1989.

Form 6A

  -----------------------------------------------------------------------
  **Managing Thoughts About Marijuana (continued)**

  -----------------------------------------------------------------------

Unpleasant effects or negative consequences of using:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Stumbling blocks or high-risk situations that make it difficult to keep
commitment to abstinence:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Overall level of personal commitment to remain abstinent:

1 2 3 4 5 6 7 8 9 10

*None Extremely High*

Overall confidence level in ability to remain abstinent:

1 2 3 4 5 6 7 8 9 10

*None Extremely High*

Form 7A

  -----------------------------------------------------------------------
  **Problemsolving**

  -----------------------------------------------------------------------

Here is a brief list of the steps in the problemsolving process:

> • *Is there a problem?* Recognize that a problem exists. We get clues
> from our bodies, our thoughts and feelings, our behaviors, our
> responses to other people, and the ways that other people respond to
> us.
>
> • *What is the problem?* Identify the problem. Describe the problem as
> accurately as you can. Break it into manageable parts.
>
> • *What can I do?* Consider various approaches to solving the problem.
> Brainstorm to think of as many solutions as you can. Consider acting
> to change the situation; consider changing the way you think about the
> situation.
>
> • *What will happen if . . . ?* Select the most promising approach.
> Consider all the positive and negative aspects of each approach, and
> select the one most likely to solve the problem.
>
> • *How did it work?* Assess the effectiveness of the selected
> approach. After you have given the approach a fair trial, determine
> whether it worked. If it did not, consider what you can do to improve
> the plan, or give it up and try one of the other approaches.

**Practice Exercise**

Select a problem that does not have an obvious solution. Describe it
accurately. Brainstorm a list of possible solutions. Evaluate the
possibilities, and number them in order of your preference.

Identify the problem:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

List brainstorming solutions:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Form 8A**

  -----------------------------------------------------------------------
  **Marijuana Refusal Skills**^6^

  -----------------------------------------------------------------------

When others urge you to use, keep the following in mind:

> • Say no.
>
> • Speak in a clear, firm, and unhesitating voice.
>
> • Make direct eye contact.
>
> • Suggest an alternative: something else to do or something to eat or
> a cup of coffee.
>
> • Ask the person to stop offering you marijuana and not to do so
> again.
>
> • Change the subject.
>
> • Avoid using vague answers or excuses.
>
> • Don't feel guilty about refusing to use marijuana.
>
> • Leave if the offerer persists.

**Practice Exercise**

Listed below are some people who might offer you marijuana in the
future. Give some thought to how you will respond to them, and write
your responses after each item.

Someone close to you who knows about your using problem:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Colleague:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Boss:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

New acquaintance:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Someone at a party with others present:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Relative at a family gathering:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Boyfriend/girlfriend:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^6^Source: Monti et al. 1989.

Form 9A

  -----------------------------------------------------------------------
  **Personal Emergency Plan: High-Risk Situation**^7^

  -----------------------------------------------------------------------

If I encounter a high-risk situation,

> • I will leave or change the situation or environment.
>
> • I will put off the decision to use for 15 minutes. I will remember
> that most cravings are time limited and that I can wait it out and not
> use.
>
> • I will challenge my thoughts about using. Do I really need
> marijuana? I will remind myself that my only true needs are for air,
> water, food, and shelter.
>
> • I will think of something unrelated to using.
>
> • I will remind myself of my successes to this point.
>
> • I will call people on my list of emergency numbers:
>
> Names Phone Numbers

1\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Remember: Riding out this crisis will strengthen my program.**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^7^Source: Monti et al. 1989.

Form 9B

  -----------------------------------------------------------------------
  **Personal Emergency Plan: Lapse**

  -----------------------------------------------------------------------

A lapse can represent a crisis in recovery. Returning to abstinence
requires an all-out effort. Here are some things you can do.

If I do experience a lapse,

> • I will get rid of the marijuana and get away from the setting where
> I lapsed.
>
> • I will realize that a little marijuana or even 1 day of drug use
> does not have to result in a full-blown relapse. I will not give in to
> feelings of guilt or blame myself because I know these feelings will
> pass in time.
>
> • I will call someone for help.

**Remember: This lapse is only a temporary detour on the road to
abstinence.**

Write a detailed emergency plan for coping with high-risk lapse
situations.

1\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Form 9C**

  -----------------------------------------------------------------------
  **Seemingly Irrelevant Decisions**

  -----------------------------------------------------------------------

When making any decision, whether large or small, do the following:

> • Consider what options you have.
>
> • Think about the possible outcomes of each option. What positive or
> negative consequences can you anticipate, and what are the risks of
> relapse?
>
> • Choose an option that will minimize your relapse risk. If you decide
> to choose a risky option, plan how to protect yourself while in the
> high-risk situation.
>
> • Watch for "red flag" thinking: thoughts like "I have to . . ." (do
> something, go somewhere, see someone) or "I can handle . . ." (a
> certain high-risk situation) or "It really doesn't matter whether . .
> ." (I'll just have a hit).

**Practice Exercise**

Think about a decision you made recently or are about to make. The
decision could involve any aspect of your life, such as your job,
recreational activities, friends, or family. Identify safe choices and
choices that might increase your risk of relapsing.

Decision to be made:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Safe alternatives:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Risky alternatives:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Form 9D

  ---------------------- ------------------------------------------------
  **Thinking Errors That 
  Dampen One's Mood**^8^ 

  **Type of Error**      **Example**

  Personalizing          Thinking all situations and events revolve
                         around you. *Everyone was looking at me.*

  Magnifying             Blowing negative events out of proportion. *This
                         is the worst thing that could happen to me.*

  Minimizing             Downplaying the positives. *I got the job, but
                         probably no one else applied.*

  Either/or thinking     Not taking into account the full continuum. *I'm
                         either a loser or a winner.*

  Taking events out of   After a successful experience, focusing on one
  context                or two rough points. *I may have gotten the job,
                         but I blew that one question in the interview.*

  Jumping to conclusions Making a premature conclusion without enough
                         data. *I have a swollen gland. It must be
                         cancer.*

  Overgeneralizing       Making a sweeping judgment based on one event.
                         *I failed this time; I fail at everything I ever
                         try.*

  Self-blame             Blaming oneself rather than specific behaviors
                         that can be changed. *I'm no good.*

  Mindreading            Believing that you know what everyone else is
                         thinking. *Everyone there thought I was fat and
                         ugly.*

  Comparing              Comparing yourself unfavorably with someone
                         else. *That supermodel has a better figure than
                         I do.*

  Catastrophizing        Focusing on the worst possible outcome or
                         explanation. *He didn't call, and I know
                         something terrible has happened to him.*
  ---------------------- ------------------------------------------------

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^8^Source: Emery 1981.

Form 9E

  -----------------------------------------------------------------------
  **Managing Negative Moods and Depression**^9^

  -----------------------------------------------------------------------

Use the Three As to overcome your depression.

> 1\. Be **aware** of the symptoms of depression.
>
> • Be aware of your moods and the situations that influence them.
>
> • Be aware of your automatic negative thoughts.
>
> 2\. **Answer** or respond to these thoughts.
>
> • Ask questions and challenge the assumptions behind these thoughts.
>
> • Replace the negative thoughts with positive ones.
>
> 3\. **Act** differently.
>
> • Increase your positive activities.
>
> • Decrease your involvement in unpleasant activities.
>
> • Reward yourself for the positive steps you're taking.

**Practice Exercise**

Use this worksheet to become aware of the issues involved in your
depression and the steps you can take to change your moods.

1\. What are the ways that I show my depression in my moods, attitudes,
and actions? What are

my symptoms?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. What are the automatic negative thoughts that go along with my
depression? What do I think

about myself, my current situation, and my world in general?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. What questions can I ask myself to challenge these automatic
negative thoughts? \_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. What steps am I going to take to act differently? What
problemsolving strategies have I come

up with to cope with my problems? What pleasant activities might I
increase? What

unpleasant activities might I avoid or minimize?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^9^Source: Kadden et al. 1994.

**Form 9F**

  -----------------------------------------------------------------------
  **Assertiveness**

  -----------------------------------------------------------------------

Remember the following points in practicing assertiveness:

Take a moment to think before you speak.

Be specific and direct in what you say.

Pay attention to your body language (use direct eye contact;

face the person you're addressing).

Be willing to compromise.

Restate your assertion if you feel that you're not being heard.

**Form 9G**

  -----------------------------------------------------------------------
  **Assertiveness Practice Exercises**^10^

  -----------------------------------------------------------------------

These exercises will help you become aware of your style of handling
various social situations. The four common response styles are passive,
aggressive, passive--aggressive, and assertive.

Pick **two** different social situations. Write brief descriptions of
them and of your responses to them.

Then decide which of the four common response styles best describes each
response.

**Situation 1 (describe):**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Your response:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Circle response style: *passive aggressive passive--aggressive
assertive*

If your response was *not* assertive, think of an assertive response and
write it down here: \_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Situation 2 (describe):**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Your response:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Circle response style: *passive aggressive passive--aggressive
assertive*

If your response was *not* assertive, think of an assertive response and
write it down here: \_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^10^Source: Monti et al. 1989.

+-----------------------------------------------------------------------+
| **SECTION VII.**                                                      |
|                                                                       |
| **SUPPLEMENTAL READINGS**                                             |
+-----------------------------------------------------------------------+

**Supplemental Reading A: Who Needs Treatment? The Nature, Prevalence,
and Consequences of Marijuana Dependence**

Brief Marijuana Dependence Counseling (BMDC) is based on findings that
show regular marijuana use can lead to a drug dependence syndrome
characterized by impaired control over marijuana use, preoccupation with
its use, tolerance of its effects, and recognizable withdrawal symptoms
following abrupt discontinuation of its use. The syndrome typically
develops over the course of years rather than months, with daily or
near-daily marijuana smoking being the hallmark symptom.

***The Nature of the Syndrome***

A syndrome is a cluster of symptoms that signals the presence of an
underlying disorder (see section IV of this manual for *Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition \[DSM-IV\]*
\[American Psychiatric Association 1994\] criteria for marijuana
dependence).

The marijuana dependence syndrome includes behavioral, psychological,
and physiological symptoms that are typically reported by people who
chronically smoke marijuana and who have difficulty controlling their
use (Stephens and Roffman 1993). People who use marijuana daily develop
tolerance for its subjective effects (e.g., feelings of being high) and
cardiovascular effects (e.g., increased heart rate) (Compton et al.
1990; Wiesbeck et al. 1996). Some experience such difficulty in
controlling their marijuana use that they continue to use despite
adverse personal consequences of use (Stephens and Roffman 1993; Swift
et al. 1998*a*, 1998*b*).

The relatively low intensity of physiological withdrawal symptoms
resulting from heavy marijuana use may have contributed to marijuana's
not being viewed as dependence producing. However, studies have
documented that people who use marijuana heavily and chronically may
develop both physiological and psychological dependence and that
cessation from use may produce a withdrawal syndrome broadly
characterized by restlessness, irritability, mild agitation, insomnia,
decreased appetite, sleep disturbance, anxiety, stomach pain, nausea,
runny nose, sweating, and cramping (Crowley et al. 1998; Haney et al.
1999*b*; Wiesbeck et al. 1996). These symptoms commonly abate within a
few days to 2 weeks of abstinence from marijuana.

Considerable evidence of a biological basis for marijuana dependence has
accumulated since the identification of a specific cannabinoid receptor
in the brain (Pertwee 1999) and the discovery of anandamide, a compound
that binds to and activates the same receptor sites in the brain as
delta-9-tetrahydrocannabinol (THC), the active ingredient in marijuana
(Devane et al. 1992). Subsequently, researchers discovered a cannabinoid
antagonist, a compound that blocks anandamide action in the brain
(Rinaldi-Carmona et al. 1994). With increased knowledge of the
neurochemical basis of marijuana's reinforcing effects on brain systems,
the biological basis of marijuana dependence is becoming better
understood.

***Prevalence***

Marijuana is the most widely used illicit substance in the United States
and is the third most widely used mood-altering substance after alcohol
and tobacco. In 2003, more than 75 percent of illicit drug users (14.6
million people) smoked marijuana. For nearly 55 percent of illicit drug
users, marijuana was the only substance they used (Substance Abuse and
Mental Health Services Administration 2004). The proportion of young
adults who use marijuana regularly has increased since the 1960s, and
the age of initiation has declined (Hall et al. 1999). More risky
patterns of smoking developed with the increased popularity of
waterpipes or bongs, which permit the delivery of large doses of THC
(Hall and Babor 2000). These conditions, combined with increased social
tolerance of marijuana use, reduced penalties for possession, and the
development of a substantial black market industry to distribute
marijuana products, likely have increased the possibility that a
substantial number of persons exposed to marijuana during their youth
will continue to use the drug regularly into adulthood.

Epidemiological studies conducted in the last two decades have tracked
trends in the prevalence of marijuana dependence. In the 1980s, the
Epidemiological Catchment Area Study found that 4.4 percent of adults
had been dependent on marijuana at some point in their lives (Anthony
and Helzer 1991). About a decade later, the National Comorbidity Study
estimated that 4.2 percent of the U.S. population met diagnostic
criteria for marijuana dependence (Anthony et al. 1994). Whereas overall
marijuana use was stable among the adult population in the 1990s, rates
of dependence and abuse (as classified by the DSM-IV) increased
significantly during the same period (Compton et al. 2004). These
studies indicate that marijuana dependence is one of the most prevalent
substance use disorders in the United States, exceeded only by nicotine
and alcohol dependence.

***The Natural History of Marijuana Dependence***

For those who have used marijuana at least once, the relative
probability of ever becoming dependent on the substance is estimated to
be 9 percent. This level of risk is considerably lower than risk
estimates of dependence for those who have used tobacco (32%), heroin
(23%), cocaine (17%), or alcohol (15%) (Anthony et al. 1994). However,
the risk of developing marijuana dependence may be higher among
individuals who have smoked marijuana more frequently. Among those who
have used marijuana five or more times, the risk of dependence is
estimated to be 17 percent (Hall et al. 1999). For people who use daily
or near daily, the risk may increase to 33 percent (Kandel and Davies
1992).

People using marijuana who are recruited into treatment outcome studies
averaged more than 10 years of near-daily use and more than six serious
attempts at quitting in the past (Stephens et al. 1994*b*, 2000). Their
use had persisted in the face of multiple forms of social,
psychological, and physical impairment, and most clients perceived
themselves as unable to stop. In one study of 450 clients who used
marijuana chronically (Stephens et al. 2002), clients had begun smoking
in early adolescence, had begun regular smoking in their late teens, had
begun to experience problems by age 27, and had felt they needed
treatment by age 36.

***Consequences of Marijuana Use***

A number of potential adverse health and behavioral effects related to
both acute intoxication and chronic ingestion have been identified in
epidemiological studies and clinical research (Hall 1995; Hall and Babor
2000). Several surveys of people using marijuana heavily who are not in
treatment show that a majority report impairment of memory,
concentration, motivation, self-esteem, interpersonal relationships, and
health related to their marijuana use (Rainone et al. 1987; Roffman and
Barnhart 1987). A similar profile of marijuana-related consequences is
seen in samples of adults seeking treatment for marijuana dependence
(Budney et al. 1998; Stephens et al. 1994*b*, 2000).

Exhibit VII-1 shows the frequency of self-reported problems in a group
of 450 people who chronically used marijuana participating in the
Marijuana Treatment Project (MTP) (Stephens et al. 2002). The table
shows that clients who presented for treatment with primary marijuana
dependence demonstrated a high prevalence of social, legal, medical, and
psychological problems, which tend to be directly or indirectly
connected with chronic marijuana use and acute marijuana intoxication
(Hall et al. 1999).

+----------------------------------+-----------------------------------+
| **Exhibit VII-1. Percentage of   |                                   |
| MTP Participants Who Endorsed**  |                                   |
|                                  |                                   |
| **Each Marijuana Problem Item    |                                   |
| (N=450)**                        |                                   |
+----------------------------------+-----------------------------------+
| **Has marijuana caused you**     | **% of Sample**                   |
+----------------------------------+-----------------------------------+
| To feel bad about your use       | 90.2                              |
+----------------------------------+-----------------------------------+
| To have lower energy level       | 86.0                              |
+----------------------------------+-----------------------------------+
| To procrastinate                 | 86.0                              |
+----------------------------------+-----------------------------------+
| Memory loss                      | 76.4                              |
+----------------------------------+-----------------------------------+
| To have lower productivity       | 75.1                              |
+----------------------------------+-----------------------------------+
| Lowered self-esteem              | 74.2                              |
+----------------------------------+-----------------------------------+
| To lack self-confidence          | 68.4                              |
+----------------------------------+-----------------------------------+
| Withdrawal symptoms              | 61.1                              |
+----------------------------------+-----------------------------------+
| Problems between you and your    | 58.0                              |
| partner                          |                                   |
+----------------------------------+-----------------------------------+
| Financial difficulties           | 48.9                              |
+----------------------------------+-----------------------------------+
| Difficulty sleeping              | 46.0                              |
+----------------------------------+-----------------------------------+
| Problems in your family          | 44.4                              |
+----------------------------------+-----------------------------------+
| To neglect your family           | 38.7                              |
+----------------------------------+-----------------------------------+
| Medical problems                 | 33.6                              |
+----------------------------------+-----------------------------------+
| Problems between you and your    | 26.4                              |
| friends                          |                                   |
+----------------------------------+-----------------------------------+
| To miss days at work or miss     | 19.8                              |
| classes                          |                                   |
+----------------------------------+-----------------------------------+
| To lose a job                    | 8.2                               |
+----------------------------------+-----------------------------------+
| Blackouts or flashbacks          | 7.6                               |
+----------------------------------+-----------------------------------+
| Legal problems                   | 7.1                               |
+----------------------------------+-----------------------------------+

Source: Stephens et al. 2002.

Driving performance following marijuana use has been studied in several
contexts. Whereas marijuana impairs performance in laboratory and
simulated driving settings, studies of on-road driving performance have
found only modest impairments (e.g., Chesher 1995; Robbe 1994).
Controlled epidemiological studies have not established an increased
risk of motor vehicle crashes among those who use only marijuana (Smiley
1999). Marijuana's major public health significance for road safety may
be to potentiate the adverse effects of alcohol on the performance of
drivers who combine alcohol and marijuana intoxication (Hall and Babor
2000).

Reasonable evidence exists that marijuana use may precipitate
schizophrenia in vulnerable individuals (Andreasson et al. 1987;
Thornicroft 1990) and that continued use worsens the prognosis of
persons with schizophrenia (Hall and Solowij 1998).

People whose use of marijuana is chronic and heavy report

> • Subtle impairment in the ability to focus attention and filter out
> complex irrelevant auditory information (Solowij et al. 1991)
>
> • Reduced verbal and logical reasoning abilities, diminished short-
> and long-term memory, and altered visual spatial ability (Lundqvist
> 1995)
>
> • Mathematical and verbal expressive skill deficits (Block and Ghoneim
> 1993)
>
> • Short-term deleterious impairment of executive functions (Pope et
> al. 1995); impairment in these abilities is likely to have an effect
> on occupational, academic, and interpersonal functioning.

Together, these cognitive impairments may make an individual feel
isolated, misunderstood, and inadequate.

Because marijuana is most often smoked, the person who uses heavily may
be at greater risk of respiratory diseases. Marijuana smoke is similar
in composition to tobacco smoke and has been shown to increase chronic
and acute bronchitis, cause functional alterations in the respiratory
tracts, and produce morphologic changes in the airways that may precede
malignant change (Hall and Babor 2000; Tashkin 1999). These adverse
effects appear to occur with fewer marijuana cigarettes per day and at
earlier ages in people who use marijuana than in tobacco smokers. In
addition, concurrent marijuana use augments many of the effects of
tobacco smoking. Approximately 50 percent of those who seek treatment
for marijuana dependence also smoke tobacco (Budney et al. 1998;
Stephens et al. 1993*a*), a rate that is significantly higher than for
people of comparable age in the general population. The possibility that
cancer may be induced by chronic marijuana smoking has been raised by
case reports, which have described cancers of the aerodigestive system
in young adults with a history of heavy marijuana use (e.g., Donald
1991; Taylor 1988). A recent epidemiological study found that chronic
marijuana use may increase the risk of head and neck cancer with a
strong dose-response pattern (Zhang et al. 1999).

Some studies have found maternal marijuana use to be related to preterm
deliveries, low birth weights (Hatch and Bracken 1986; Zuckerman et al.
1989), and signs of neurological distress in newborns (Scher et al.
1988). Recent studies suggest subtle forms of cognitive impairment that
do not become apparent until later in life in children born to mothers
who use marijuana (e.g., Day et al. 1994; Richardson et al. 1995).

***Conclusion***

Research suggests that individuals can develop a dependence syndrome
that is associated with recurrent psychological, social, and physical
problems. The respiratory, psychological, and interpersonal problems
often reported by people dependent on marijuana can lead to significant
impairments in health and the quality of life.

**Supplemental Reading B: How Effective Is Treatment for Marijuana
Dependence? The Marijuana Treatment Project and Related Studies**

Despite the need for marijuana dependence treatment in the United
States, research on how to intervene effectively with this problem has
been conducted only recently. This section describes the results of
controlled trials conducted in the last decade to evaluate interventions
for adults who are marijuana dependent. Special consideration is given
to MTP, which is the largest study ever conducted of people who smoke
marijuana.

***Controlled Studies***

The first controlled trial of marijuana dependence treatment (Stephens
et al. 1994*b*) compared the effects of 10 sessions of cognitive
behavioral therapy (CBT) with 10 sessions of group discussion. The
participants were 212 people who had used marijuana daily or almost
daily for an average of 10 years. Both counseling approaches were
modestly effective in helping a significant portion of participants
achieve either abstinence or improvement. Contrary to predictions, the
CBT approach was no more effective than social support with adults who
were marijuana dependent. Higher levels of pretreatment marijuana use
predicted higher use levels following treatment. Lower socioeconomic
status predicted more problems associated with marijuana use after
treatment. Finally, individuals who before treatment indicated greater
self-efficacy for avoiding marijuana use had more successful
posttreatment outcomes (Stephens et al. 1993*b*).

In a related study (Stephens et al. 2000), a brief, 2-session individual
treatment was compared with 14 sessions of CBT skills training. In this
study a delayed treatment control group was included to determine the
extent to which self-initiated change occurs in this population in the
absence of formal treatment. This group was placed on a waiting list and
asked to come back in 4 months. The sample consisted of 291 adults who
smoked marijuana daily. The 14 CBT skills training sessions were
delivered in a group setting over a 4-month period. This treatment
emphasized the learning of coping strategies to deal with situations
presenting high risk of relapse. It also provided additional time to
build group cohesion and support. The second active treatment consisted
of two motivational enhancement therapy (MET) counseling sessions
delivered as individual therapy over a 1-month period.

An important element involved giving participants normative information
so they could compare their marijuana use with that of the general
population and that of other people seeking treatment for marijuana
dependence. The counselor reviewed with each participant a written
personal feedback report generated from questions asked during a
comprehensive intake assessment. The counselor used the client's
reaction to the personal feedback report to promote discussion and
bolster the client's motivation to abstain from marijuana use. The
information also was used to reinforce clients' confidence in their
ability to end marijuana use and to offer support in goal-setting
strategies for behavior change. One month later, the second session
reviewed efforts to abstain and the coping skills used in the interim
period. In both treatment conditions, participants had the option of
involving a support person.

The results showed that both active treatments produced substantial
reductions in marijuana use relative to the delayed treatment control
condition. Following treatment, there were no differences between the
two active treatments in abstinence rates, days of marijuana use,
severity of problems, or number of dependence symptoms. Similarly, at
the 16-month assessment, 29 percent of group counseling participants and
28 percent of individual counseling participants reported having been
abstinent for the past 90 days. The results of this study suggest that
minimal interventions consisting of as little as two sessions may be
more cost-effective than lengthier treatments.

In another study (Budney et al. 2000), 60 adults who were marijuana
dependent were randomly assigned to one of three 14-week treatments: (1)
MET, (2) MET plus coping skills training, or (3) MET plus coping skills
training and voucher-based incentives. In the last condition,
participants whose abstinence from marijuana and other drugs was
documented by urinalysis received vouchers that were exchangeable for
retail items (e.g., movie passes, sports equipment, educational
classes). The value of each voucher increased with each successive
instance of confirmed abstinence. Conversely, the occurrence of a
cannabinoid-positive urine specimen (or the failure to submit a sample)
led to a reduction of each voucher's value to its initial level. The
results showed that participants in the voucher-based incentive
condition were more likely to achieve continuous abstinence from
marijuana during treatment than were participants in the other two
conditions. Moreover, a greater percentage of participants in the
voucher-based condition (35%) were abstinent at the end of treatment
than was the case in the skills training (10%) or MET (5%) conditions.

The results of these studies indicate that a substantial proportion of
adults who were marijuana dependent and who sought treatment have been
aided in either stopping or decreasing their marijuana use. However, it
is also apparent that not all of those treated achieved the initial goal
of sustained abstinence from marijuana. Given the evidence of
marijuana's dependence potential and adverse health and behavioral
consequences, continuing development and testing of marijuana dependence
interventions are clearly warranted.

***Marijuana Treatment Project***

MTP was funded by the Center for Substance Abuse Treatment in 1997 and
conducted in three States (Connecticut, Florida, and Washington) over a
3-year period. MTP compared two active treatments with a delayed
treatment control condition (Stephens et al. 2002). One active treatment
consisted of nine individual counseling sessions delivered over a
12-week period. The initial sessions focused on MET. These were followed
by CBT skills training along with additional case management if needed.
With some minor modifications, the BMDC described in this manual was
based on the nine-session treatment evaluated in MTP. The other active
treatment used in MTP consisted of two MET sessions delivered over a
1-month period.

A total of 450 participants from diverse ethnic and socioeconomic
backgrounds was recruited through media advertisements and agency
referrals. These individuals were primarily male (68%) and on average 36
years old. Sixty-nine percent of the group was white, with 12 percent
African-American, 17 percent Hispanic, and 1 percent other, which
included Asian-American, Native American, or unknown (1% is accounted
for by rounding error). Approximately 60 percent of the sample was
unmarried. Individuals in this group had, on average, 14 years of
education. Sixty-nine percent worked full time, 14 percent worked part
time, 12 percent were unemployed, and 4 percent were students, retired
people, or homemakers (1% is accounted for by rounding error). Those who
worked had been employed at their current jobs for approximately 5 years
(Stephens et al. 2002).

Ninety-two percent of the study participants felt that they were
currently dependent on marijuana. At the time of the screening, almost
the entire sample (99.8%) felt that marijuana was the biggest problem
for them (relative to other drugs or alcohol). The group reported
smoking marijuana on 82 of the past 90 days (91% of the days), smoked an
average of 3.7 times a day, and reported that the number of days since
their last smoking episode was 1.2. Use of other drugs and alcohol in
the past 30 days was infrequent, in part because individuals who were
concurrently dependent on alcohol or drugs other than marijuana were
ineligible.

The results of MTP showed a consistent pattern of differences between
groups. The delayed treatment group changed little from baseline to the
4-month followup on almost all outcome measures. At each followup point
over a 12-month period, both active treatments produced outcomes
superior to the 4-month delayed treatment control condition. The
nine-session intervention produced significantly greater reductions in
marijuana use and associated consequences than the two-session
intervention. Abstinence rates at the 4- and 9-month followups for the
nine-session intervention were 23 percent and 13 percent, respectively.
The differences between the two active treatments appeared as early as 4
weeks into the treatment period and were sustained throughout the first
9 months of followup.

As was the case in the findings of the studies discussed above, MTP
findings demonstrated a moderate degree of efficacy of counseling
interventions with adults who are marijuana dependent. Outcomes from the
two-session MET intervention were less positive than those found in the
study by Stephens and colleagues (2000), suggesting that the
effectiveness of brief and more intensive treatment may vary with the
population studied, the content of the therapy, and the skills of the
clinicians.

The MTP results indicate that even a brief two-session treatment is
associated with substantial reductions in marijuana use and related
problems. Nevertheless, a significant percentage of these chronic
smokers continue or return to marijuana use, albeit at reduced levels.
For example, although the nine-session intervention resulted in a
60-percent reduction in marijuana use up to a year after the end of
therapy, it did not produce sufficient abstinence rates to eliminate
completely the risk of accidents, injuries, chronic disease, and a
return to marijuana dependence. Nevertheless, even with reduced levels
of use, both treatments were associated with significant reductions in
anxiety levels, legal problems, and employment problems.

It is important to note that, although a substantial percentage of
clients did not succeed in becoming abstinent, many individuals remained
motivated to overcome their dependence. At the 9-month posttreatment
assessment, 82 percent had relapsed and 68 percent indicated that they
had tried to stop using marijuana at some point between their 4- and
9-month assessment interviews. These findings suggest that participants
who receive a single episode of care remain motivated to change and thus
should be followed by aggressive community outreach and support
services.

***Outreach, Access, and Support Groups***

The demonstration of several efficacious treatment interventions for
marijuana dependence raises additional questions about how best to
engage in treatment people who chronically use marijuana and how best to
maintain improvements following treatment. Unfortunately, little
research has been conducted in these areas.

Marijuana Anonymous (MA) groups, a mutual-help fellowship based on the
principles and traditions of Alcoholics Anonymous (AA), exist in a
number of States and internationally. In addition to traditional
meetings, MA sessions are held on line. (The organization's Web site
address is www.marijuana-anonymous.org. Its toll-free telephone number
is 800-766-7669.) No research has been conducted yet to evaluate the
effectiveness of MA, either alone or in combination with formal
treatment. Nevertheless, research on AA suggests that mutual-help
organizations can play an important role in recovery, both alone and in
combination with formal treatment programs (McCrady and Miller 1993).

***Conclusion***

Individuals who use marijuana chronically as their primary drug tend not
to seek treatment in traditional drug treatment settings, but it appears
from MTP and other studies that when given the opportunity, they respond
to treatment. Given the promising initial research on treatment for
cannabis dependence and the potential benefits of brief motivational and
cognitive behavioral relapse prevention therapies, there is now
sufficient evidence to support the development of focused treatment
programs for this population. The manual-guided therapies developed for
these projects, particularly MTP, should be transferable to specialized
outpatient clinics and to behavioral health care practitioners.

**Supplemental Reading C: Implementing Brief Marijuana Dependence
Counseling**

To be effective, BMDC must be implemented in the context of contemporary
substance abuse treatment, which has to be integrated with a larger
system that takes into account the program setting, referral sources,
professional staff, program administration, and linkage to and
coordination with ancillary services and with marketing, recruitment
procedures, assessment, training, supervision, program administration,
and quality assurance. Successful management of a population of people
who abuse a different substance requires more than simply adding
interventions to an existing treatment system. Ideally, the
implementation of a BMDC component to a program will bring with it
changes in services, such as recruitment, referrals, case management,
initial client contact, therapist training, and administration.

***Recruitment***

The majority of participants in clinical trials of marijuana dependence
treatment (see Supplemental Reading B) contacted the programs in
response to newspaper advertising. Advertisements were placed in the
news and movie sections of major and alternative newspapers. Some
treatment participants said they had taken the study advertisement from
the paper and carried it with them for weeks before calling. Other
avenues of recruitment included bus advertisements, radio announcements,
and newspaper stories about the program. Placing small announcements in
places appropriate for different groups, such as beauty parlors,
pharmacies, and supermarkets, also may be effective.

Many people who chronically use marijuana believe their problems with
its use are unique. In a study of barriers to formal treatment, Copeland
(1997) found that although women in general were aware of options for
specialized alcohol and drug treatments, this was not true for the women
who were dependent on marijuana. These women believed that they were the
only people with such a problem, which may have contributed to their
reluctance to seek treatment. It also may explain the positive response
to the announcements used by MTP, which were gentle and nonthreatening
and ensured confidentiality. The announcements read, *Ready to make a
change in your marijuana use? Not sure how to go about it? Free,
confidential, and nonjudgmental marijuana counseling.* This communicated
that

> • Potential clients were not alone.
>
> • Experts recognize marijuana use can be a problem and take it
> seriously.
>
> • A special program for marijuana use problems existed and was readily
> accessible.

The nonauthoritarian nature of the ad appealed to people using marijuana
who were experiencing problems and were ambivalent about their use.
Clients who contacted MTP for treatment often commented that the
nonjudgmental stance was important in making the offer of assistance
attractive to them.

***Referrals***

The courts and employee assistance programs (EAPs) are both sources of
referrals to BMDC. Many communities have drug courts that manage
nonviolent drug-related cases. Programs such as BMDC provide the courts
with alternatives to incarceration for nonviolent offenders. Persons
convicted of possession or driving under the influence of marijuana also
may be referred appropriately. EAPs may refer employees who voluntarily
present themselves or are identified following a job-related accident.
Preemployment screening also leads to treatment seeking when continued
marijuana use is perceived as an obstacle to desired employment. Often
these referrals result in traditional treatment. However, when EAP
counselors are educated about a special research-based program for
marijuana use, BMDC may be seen as the treatment of choice.

Court referrals are usually subject to mandatory urine testing for drug
use. In Florida between 1994 and 1999, 63 percent of persons entering
treatment and reporting their primary drug problem to be marijuana (with
no other drug involvement) were involved with the criminal justice
system. Although court referrals generally are excluded from marijuana
clinical trials, there is no reason to believe that these individuals
would not be appropriate for BMDC. The possibility of incarceration is a
powerful motivator for change (Hser et al. 1998).

Similarly, persons who are subject to targeted urine testing because of
job-related problems may want to enter treatment. Urine testing
increases the likelihood that continued use will result in the loss of
employment. Thus, to the extent continued employment is important,
readiness to change will be greater and ambivalence less strong.

***Case Management***

Many MTP participants identified case management needs that were
nontraditional. Their needs were often related to isolation, health, and
time management. Referrals to health clubs, recreational programs, and
religious activities were called for. Clients in serious need of medical
care, housing, or legal counseling were rarely encountered. Programs
that implement BMDC should develop case management linkages to the
community to provide ancillary services, such as vocational counseling,
medical treatment, and psychiatric care. BMDC uses a problemsolving
approach to case management. Clients may need assistance in addressing
barriers to treatment participation and recovery. Case management in the
BMDC model provides linkage information rather than advocacy.
Cooperative agreements for referral should be in place so that the
therapist knows what services are available in the community and how
they can be accessed most easily.

***Initial Contact With Clients***

Receptionists and assessment staff members should be aware of the
program's advertisements, public service announcements, or other
activities so that they can respond knowledgeably and professionally to
telephone inquiries. Research participants report that any initial
resistance or confusion by the treatment facility leads to a breakdown
in the initiation process. A friendly, empathetic, and understanding
atmosphere should begin with the first contact and continue throughout
treatment and followup.

If possible, the BMDC component should be assigned its own phone number,
and a receptionist answering the phone should respond with that
component's name. If an answering system is used, the message can
distinguish the BMDC program from others offered by the agency. Callers
may raise questions about BMDC's specific components and its track
record or demonstrated effectiveness to determine whether it can help
them. They may be concerned about whether they will be treated in groups
with people who use other drugs (e.g., cocaine) or alcohol. They may be
relieved that BMDC specializes in treating "people like them" and
pleased to know the program is based on scientific research. Callers
need to know that the program is sensitive to their needs, that staff
will take them seriously, and that the services are delivered
professionally. MTP participants were apprehensive initially and wanted
a counselor trained to treat marijuana problems.

***Training Staff***

The treatment effort begins with the assessment session. Assessment
staff should be

> • Knowledgeable about marijuana use and its consequences
>
> • Trained to diagnose marijuana dependence and abuse and to document
> use patterns and related problems
>
> • Sensitive to the ambivalence toward treatment of people who use
> marijuana
>
> • Trained in MET and how to use the assessment information.

Counselors should be competent in MET, CBT, and case management. Staff
members should be selected on the basis of their empathy, warmth, and
genuineness, as well as their cognitive style, which should include
receptiveness to learning new approaches and willingness to consider
that several ways exist to solve a problem. A counselor who lacks
empathy and openness to the client's perspective will be ineffective.

Training should include at least three elements:

> **1. Training sessions covering principles and practices of MET.**
> This manual should be distributed in advance of training sessions to
> introduce basic material and create interest in the BMDC method. The
> training should include an introduction to the stages of change and
> the general principles and strategies of MET. A section of the
> training should be dedicated to the unique characteristics of the
> marijuana-dependent treatment population. Incompatible treatment
> methods need to be identified and discussed. Training can be done
> individually or in a group format.
>
> **2. Regular supervision.** Counselors in training should be required
> to provide videotapes of themselves using MET, CBT, and case
> management for trainers and fellow trainees to critique. Many
> counselors are reluctant to allow themselves to be videotaped. To
> allay their concern, counselors first should view tapes of their
> supervisors conducting sessions and rate these tapes. Next, role plays
> with other counselors can be taped. Finally, counselor--client
> sessions can be taped and discussed. This gradual exposure appears to
> relieve anxiety related to taping.
>
> Trainers should continue to shape performance until counselors
> demonstrate competence. Training in CBT and case management may take
> less time and effort than MET training because experienced substance
> abuse treatment practitioners tend to have been exposed to the two
> former treatment procedures. Resistance to MET and a manual-guided
> approach should be expected; opposition sometimes derives from
> misunderstanding. Many counselors believe that motivational
> interviewing means cheerleading. Also, many professionals in the
> addiction field are committed to their approaches to treatment
> (traditional approaches often are confrontational and directive) and
> may be reluctant to try a new method, especially if the underlying
> philosophy differs from one they are most familiar with.
>
> **3. Ensuring the BMDC approach.** Regular supervision is needed to
> ensure competence. Case conferences and periodic session taping are
> needed to make certain that counselors follow the BMDC approach
> correctly. Chart reviews may be conducted systematically as a means of
> monitoring implementation. In MTP, monthly supervision was sufficient
> to maintain fidelity to the model. Supervision can be done in several
> ways. The counselor can provide a videotape of a session to the
> supervisor, who rates the treatment elements employed (MET, CBT, or
> case management) using a session rating form similar to the one in
> appendix A. This form provides the counselor with helpful feedback. It
> also can be useful to have counselors rate other counselors' tapes,
> comparing their evaluations with those of their supervisor and
> discussing how to implement the model in various situations. When
> rating and scoring taped sessions, counselors' criticism should be
> gentle, emphasizing what was done right and building on strengths of
> the counselor being rated.

Two videotapes were created to accompany this treatment manual. The
first tape highlights the problem of marijuana dependence in the United
States, discusses epidemiology, and contains interviews with key figures
who have studied this problem. The second tape uses three hypothetical
clients to provide practical information and demonstrations of BMDC at
work. These tapes are recommended for counselors, supervisors, and
agency administrators who want to use BMDC to treat people who smoke
marijuana. To obtain more information about the BMDC training tapes,
please contact Karen Steinberg, Ph.D., Department of Psychiatry,
University of Connecticut School of Medicine, 263 Farmington Avenue,
Farmington, CT 06030-1410; 860-679-3712.

***Administration***

From an administrative point of view, a sustainable BMDC program
requires at least three counselors to prevent disruption of service
delivery. Administrators should provide uninterrupted delivery of BMDC,
which may mean training backup personnel in case of resignation,
vacation, termination, or prolonged illness.

Sustainability also raises funding issues. Many agencies can use public
funding sources to provide BMDC, such as block grants or general revenue
funds. Any funding source for outpatient treatment probably can be used
for BMDC. Moreover, many persons with marijuana dependence may be
willing to pay for treatment out of pocket, especially when weighing the
savings that result from stopping their marijuana use.

Another important implementation decision concerns the identity of the
program. One option is to offer BMDC as one of many services integrated
into a variety of treatments that an agency may offer. However, use of
BMDC may increase when it is promoted as a program with its own
identity, distinct from other treatment programs, perhaps with its own
location, for at least two reasons. First, knowing that a special
program exists for people who use marijuana is reassuring to potential
clients. Second, confidentiality often is important. Some clients are
more comfortable when the program is not identified specifically as a
drug treatment center.

Creating a distinct program identity also has the advantage of
minimizing staff resistance. It makes it possible to select only those
counselors among staff for whom this approach has an appeal or to
recruit counselors who are eager to join a new, exciting, cutting-edge
program.

+-----------------------------------------------------------------------+
| **APPENDIX A.**                                                       |
|                                                                       |
| **Session Rating Form**                                               |
+-----------------------------------------------------------------------+

**Please answer the following questions based on the session you
observed. Do not complete this form if this was an emergency session.**

1\. What session topic was covered this week?

> 1 = Motivational enhancement:
>
> a\. Feedback session
>
> b\. Planning session
>
> 2 = Cognitive behavioral (if several topics were addressed, indicate
> the percentage of the session devoted to the particular topic; be sure
> total equals 100 percent):
>
> a\. Introduction/functional analysis\_\_\_
>
> b\. Coping with cravings \_\_\_
>
> c\. Managing thoughts \_\_\_
>
> d\. Problemsolving \_\_\_
>
> e\. Refusal skills \_\_\_
>
> f\. Couples/family involvement \_\_\_

g\. Planning for emergencies \_\_\_

h\. Seemingly irrelevant decisions \_\_\_

i\. Managing negative moods & depression \_\_\_

j\. Assertiveness \_\_\_

k\. Anger management \_\_\_

l\. Other (specify): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> 3 = Case management (specify primary target areas):
>
> a\. Housing/shelter \_\_\_
>
> b\. Childcare/parenting \_\_\_
>
> c\. Transportation \_\_\_
>
> d\. Financial support \_\_\_
>
> e\. Job training/employment \_\_\_
>
> f\. Medical \_\_\_
>
> g\. Emotional/psychological \_\_\_
>
> h\. Legal \_\_\_
>
> i\. Family problems \_\_\_
>
> j\. Social problems \_\_\_
>
> k\. Support groups \_\_\_
>
> l\. Other (specify): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Did a significant other attend the session?

> 1 = Yes
>
> If "Yes," circle spouse/partner, parent, sibling, friend, other
> (specify): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2 = No

**Motivational Interventions**

3\. To what extent did the counselor discuss or address the
participant's current commitment to abstinence?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

4\. To what extent did the counselor discuss, review, or reformulate the
participant's goals for treatment?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

5\. To what extent did the counselor encourage the participant to make a
commitment to change his or her marijuana use?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

6\. Eliciting participant concerns about marijuana use: To what extent
did the counselor attempt to elicit self-motivational statements from
the participant?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

7\. Ambivalence: To what extent did the counselor attempt to focus on
the participant's ambivalence about changing his or her level of
marijuana use?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

8\. Feedback/negative consequences: To what extent did the counselor
provide structured feedback about the participant's level of marijuana
use or refer to specific negative consequences of marijuana use?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

**Cognitive Behavioral Interventions**

9\. To what extent did the counselor discuss high-risk situations the
participant has encountered since the last session and explore coping
skills used?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

10\. To what extent did the counselor ask the participant to monitor,
report, or evaluate specific cognitions associated with marijuana use or
related problems?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

11\. To what extent did the counselor attempt to teach, model, rehearse,
review, or discuss specific skills (e.g., drug refusal, coping with
craving, social skills) during the session?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

12\. To what extent did the counselor apply a problemsolving strategy to
a problem or issue raised during the session (this can include
psychosocial problems other than marijuana use, as in the case
management module)?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

13\. Did the counselor do a role play during this session?

> 1 = Yes
>
> 2 = No

14\. To what extent did the counselor encourage the participant to
anticipate any high-risk situations that might be encountered before the
next session and formulate appropriate coping strategies for such
situations?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

**Case Management Interventions**

15\. To what extent did the counselor attempt to identify, assess, or
prioritize psychosocial problems other than marijuana and other
substance use?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

16\. To what extent did the counselor review the community resource
directory during the session or explore what resources are available to
the participant to cope with a psychosocial problem?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

17\. To what extent did the counselor attempt to develop a support plan
with the participant?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

18\. To what extent did the counselor apply motivational strategies to
bolster the participant's commitment to access needed services and
address other psychosocial problems?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

19\. To what extent did the counselor monitor or review the
participant's progress in implementing the support plan?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

20\. To what extent did the counselor praise participant efforts to
carry out the support plan?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

21\. To what extent did the counselor explore the relationship between
identified psychosocial problems and marijuana use?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

**General**

22\. To what extent did the counselor assess the participant's use of
marijuana or other substances since the last session?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

23\. Assessment of general functioning: To what extent did the counselor
assess the participant's general level of functioning in major life
spheres (e.g., work, intimate relationships, family life, social life)?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

24\. Task assignment: Did the counselor develop one or more specific
assignments for the participant to engage in between sessions?

> 1 = Yes
>
> 2 = No

25\. To what extent did the counselor review the participant's reactions
to last session's assignment, explore or address any difficulties
encountered in carrying out the assignment, or provide a rationale for
homework or reinforce the importance of extra-session practice of
skills, etc.?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

26\. Did the participant do last session's homework?

> 1 = No attempt made
>
> 2 = Some attempt made
>
> 3 = Practice exercise completed adequately
>
> 9 = N/A, not assigned

27\. Consistency of problem focus: To what extent did the counselor
attempt to keep the session focused on prescribed activities (e.g., by
redirecting dialog when it strayed off tasks, organizing the session so
defined tasks were covered)?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

> Approximately how many minutes of this session were devoted to
> discussion of topics outlined in the manual?
>
> \_\_\_\_\_\_ minutes

28\. Continuity/reference to past sessions: To what extent did the
counselor refer to material discussed in past sessions as a means of
building continuity across sessions?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

29\. Reflective listening: To what extent did the counselor communicate
understanding of the participant's comments and concerns?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

30\. Empathy: To what extent did the counselor respond empathetically to
the participant (e.g., through a nonjudgmental stance, showing genuine
warmth and concern, helping the participant feel accepted in the
relationship)?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

31\. Family support: To what extent did the counselor inquire about or
discuss the availability and nature of family support for the
participant's involvement in treatment or efforts to become abstinent?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

32\. Termination: To what extent did the counselor discuss the
termination of the therapy (e.g., encourage the participant to discuss
his or her feelings or thoughts about termination, discuss plans for the
continuation of treatment after the end of the protocol)?

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - -
4 - - - - - - - - - - 5

not at all a little somewhat considerably extensively

+-----------------------------------------------------------------------+
| **APPENDIX B.**                                                       |
|                                                                       |
| **CONTRIBUTORS**                                                      |
+-----------------------------------------------------------------------+

Thomas F. Babor, Ph.D., M.P.H

Department of Community Medicine and

Health Care

University of Connecticut School of Medicine

Farmington, CT

*Writer, sections I and VII*

Kathleen M. Carroll, Ph.D.

Department of Psychiatry

Yale University

New Haven, CT

*Writer, sections II and VI*

Kenneth Christiansen, Psy.D.

Department of Epidemiology and Public Health

University of Miami

Coral Gables, FL

and

The Village South

Miami, FL

*Writer, section IV*

Carol Davidson, M.S.W.

Evergreen Treatment Services

Seattle, WA

*Writer, section VI*

David Duresky, M.A.

Children Services Council of Broward County

Plantation, FL

*Writer, sections I, V, VI, and VII*

Elise Kabela, Ph.D.

Department of Psychiatry

University of Connecticut School of Medicine

Farmington, CT

*Writer, sections III, IV, V, and VI*

Ronald Kadden, Ph.D.

Department of Psychiatry

University of Connecticut School of Medicine

Farmington, CT

*Writer, sections III, V, and VI*

Sean McParland, M.P.H., M.S.W.

The Leukemia & Lymphoma Society

White Plains, NY

*Writer, section VI*

Bonnie McRee, M.P.H.

Department of Community Medicine and

Health Care

University of Connecticut School of Medicine

Farmington, CT

*Writer, sections I and IV*

Michael Miller, Ph.D.

Department of Epidemiology and Public Health

University of Miami

Coral Gables, FL

and

The Village South

Miami, FL

*Writer, sections V, VI, and VII*

Roger A. Roffman, D.S.W.

Innovative Programs Research Group

University of Washington School of Social

Work

Seattle, WA

*Writer, sections I, V, VI, and VII*

Susan Sampl, Ph.D.

Department of Psychiatry

University of Connecticut Health Center

Farmington, CT

*Writer, sections III and VI*

Meleney Scudder, Psy.D.

Department of Community Medicine and

Health Care

University of Connecticut School of Medicine

Farmington, CT

*Writer, sections III and VI*

Karen L. Steinberg, Ph.D.

Department of Psychiatry

University of Connecticut School of Medicine

Farmington, CT

*Writer, sections II, V, and VI*

Robert Stephens, Ph.D.

Department of Psychology

Virginia Tech University

Blacksburg, VA

*Writer, sections I, IV, and VII*

Janice Vendetti, M.P.H.

Department of Community Medicine and

Health Care

University of Connecticut School of Medicine

Farmington, CT

*Writer, section IV*

+-----------------------------------------------------------------------+
| **APPENDIX C.**                                                       |
|                                                                       |
| **Field Reviewers**                                                   |
+-----------------------------------------------------------------------+

Rosie Anderson-Harper, M.A.

Mental Health Manager

Missouri Department of Mental Health

Division of Alcohol and Drug Abuse

Jefferson City, MO

Gilberte M. Berry, LADC

Substance Abuse Counselor and Case

Manager

Community Concepts, Inc.

Auburn, ME

Jeff Bickford, M.A., LADC

Manager

Maine General Medical Center

Waterville, ME

Stephen P. Bogan, M.A., NCAC II

Youth Treatment Services Lead

Division of Alcohol and Substance Abuse

OIympia, WA

Judith A. Booker, LPC, CSAC

Therapist III

Alexandria Community Services Board

Alexandria, VA

Marty Estrada

Certified Addiction Specialist

Human Services Agency

County of Ventura

Ventura, CA

Paul Fergeson, M.A., CSAC

Counselor III

Norfolk Community Services Board

Norfolk, VA

María del Mar García-Rodriguez, M.S.W.,

M.S.H.

Continuing Education Coordinator

Caribbean Basin and Hispanic Addiction

Technology Transfer Center

Universidad Central del Caribe

Bayamon, PR

Carmen E. Greiner, M.S., LPC, LSATP, MAC

Mental Health and Substance Abuse Therapist

Rappahanock Area Community Services Board

Spotsylvania, VA

Jaime Henao, CSAC

Therapist III

Alexandria Community Services Board

Alexandria, VA

Stuart McElfresh, LCSW

Alexandria Community Services Board

Alexandria, VA

Virginia Ochoa, CAC III

Cultural Services Manager

Arapahoe House, Inc.

Commerce City, CO

Karen Redford, CAC, CCS, NCAC II

Adult Substance Abuse Services Coordinator

Richmond Behavioral Health Authority

Richmond, VA

Susan Tatum, LCSW

Substance Abuse Counselor and Case

Manager

Alexandria Community Services Board

Alexandria, VA

  -----------------------------------------------------------------------
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  -----------------------------------------------------------------------

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[^1]: The following section is adapted from MTP Research Group (in
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[^2]: Source: First et al. 1996.

[^3]: Sources: Stephens et al. 1993*a*, 1995.

[^4]: Adapted from Grenyer et al. 1995.

[^5]: Source: Stephens et al. 2000.

[^6]: Source: Stephens et al. 2000.