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The Adolescent Community 
Reinforcement Approach for 
Adolescent Cannabis Users

CYT
Cannabis Youth Treatment Series
Volume 4

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov

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The Adolescent Community
Reinforcement Approach for 
Adolescent Cannabis Users

Susan Harrington Godley, Rh.D.
Robert J. Meyers, M.S.
Jane Ellen Smith, Ph.D.
Tracy Karvinen, M.A.
Janet C. Titus, Ph.D.
Mark D. Godley, Ph.D.
George Dent, M.S.
Lora Passetti, B.A.
Pamela Kelberg, M.S.W.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane

Rockville, MD 20857
CYT
Cannabis Youth Treatment Series
Volume 4

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Acknowledgments
This is volume four of a series of treatment manuals produced under the Cannabis Youth
Treatment (CYT) Project Cooperative Agreement. The document was written by Susan
Harrington Godley, Rh.D., Mark D. Godley, Ph.D., Tracy Karvinen, M.A., Janet C. Titus, Ph.D.,
Lora Passetti, B.A. (Chestnut Health Systems, Inc.); Robert J. Meyers, M.S. (Center on
Alcoholism, Substance Abuse, and Addictions, University of New Mexico); Jane Ellen Smith,
Ph.D. (Psychology Department, University of New Mexico); George Dent, M.S. (University of
Missouri); and Pamela Kelberg, M.S.W. (Treatment Research Center, University of
Pennsylvania). Field reviews and editorial assistance in producing the manual were provided
by staff from Johnson, Bassin & Shaw, Inc. (Lynne McArthur, Holly Brooks, Barbara Fink,
Nancy Hegle, Wendy Caron, and Tonya Young). The authors also acknowledge input and 
assistance received from members of the Executive Steering Committee (see page 2) and
many others including Angela Carey, Jim Fraser, Rod Funk, Bryan Garner, Russ Hagen,
Aimee Harris, Arlinda Jones, Cliff H. Karvinen, Carolyn Kehr, Jennifer Ladd, Suzie Panichelli-
Mindel, Melissa Siekmann, Laura Slown, Bobbie Smith, Joan Unsicker, William White, and
Caroline Hunter Williams.
Disclaimer
This report was developed with support from the Center for Substance Abuse Treatment
(CSAT) to the Chestnut Health Systems, Inc., through Grant No. TI11321. The report was
produced by Johnson, Bassin & Shaw, Inc., under Contract No. 270997072 with the
Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department 
of Health and Human Services (DHHS). Karl White, Ed.D., served as the CSAT Knowledge
Application Program (KAP) Project Officer; Jean Donaldson, M.A., as CSAT CYT Project
Officer. The content of this publication does not necessarily reflect the views or policies of
CSAT, SAMHSA, or DHHS.
Public Domain Notice
All material appearing in this report except that taken directly from copyrighted sources is
in the public domain and may be reproduced or copied without permission from SAMHSA or
CSAT. Citation of the source is appreciated. However, this publication may not be reproduced
or distributed for a fee without the specific, written authorization of the Office of
Communications, SAMHSA, DHHS. 
This work builds directly on an earlier book about alcohol treatment of adults, Clinical
Guide to Alcohol Treatment: The Community Reinforcement Approach (Meyers & Smith,
1995), published by Guilford Press. Material appearing on pages 207 through 215 was adapt
ed from copyrighted material. The pages are reproduced herein with the permission of the
copyright holders. Before reprinting, readers are advised to secure permission of the copy
right holders. 
Electronic Access and Copies of Publication
This publication can be accessed electronically through the following Internet World Wide
Web connection: www.samhsa.gov. For additional free copies of this document, please call
the National Clearinghouse for Alcohol and Drug Information 18007296686 or
18004874889 (TDD).
Recommended Citation
Godley SH, Meyers RJ, Smith JE, Karvinen T, Titus JC, Godley MD, Dent G, Passetti L,
Kelberg P. The Adolescent Community Reinforcement Approach for Adolescent Cannabis
Users, Cannabis Youth Treatment (CYT) Series, Volume 4. DHHS Pub. No. 013489.
Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health
Services Administration, 2001.
Originating Office
Office of Evaluation, Scientific Analysis and Synthesis, Center for Substance Abuse
Treatment, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane,
Rockville, MD 20857.
DHHS Publication No. (SMA) 013489
Printed 2001
Cover images 2000 Digital Stock.

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Table of Contents

I. Introduction
Background  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Overview of the CYT Study  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Purpose, Development, and Organization of This Manual  . . . . . . . . .5
II.  Overview of the Treatment Model
Adaptation of Procedures From the Community 
  Reinforcement Approach  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

General Theoretical Assumptions of CRA and ACRA  . . . . . . . . . . . .7

ACRA Goals  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

About This Manual  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Target Population  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Overview of ACRA Sessions  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Key Concepts of ACRA  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Requirements for an ACRA Therapist  . . . . . . . . . . . . . . . . . . . . . .24

Clinical Supervision Requirements  . . . . . . . . . . . . . . . . . . . . . . . .25
III. Core Procedures
Procedure   1:  Functional Analysis of Substance Use Behavior . . . .27

Procedure   2:  Functional Analysis of Prosocial Behaviors  . . . . . . .49

Procedure   3:  The Happiness Scale and the Goals of Counseling  .65
Procedure   4:  Increasing Prosocial Recreation  . . . . . . . . . . . . . . .87

Procedure   5:  Relapse Prevention Skills  . . . . . . . . . . . . . . . . . . . .96

Procedure   6:  Communication Skills  . . . . . . . . . . . . . . . . . . . . .107

Procedure   7:  Problem-Solving Skills Training  . . . . . . . . . . . . . .123

Procedure   8:  Urine Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . .134

Procedure   9:  Caregiver Overview, Rapport Building, 
and Motivation  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140

Procedure 10:  Caregiver Communication Skills Training   . . . . . .147

Procedure 11:  CaregiverAdolescent Relationship Skills  . . . . . . .156

Procedure 12:  Treatment Closure . . . . . . . . . . . . . . . . . . . . . . . .176
IV. Optional Procedures
Optional Procedure 1:  Dealing With Failure To Attend  . . . . . . . .193

Optional Procedure 2:  Job-Seeking Skills  . . . . . . . . . . . . . . . . . .199

Optional Procedure 3:  Anger Management  . . . . . . . . . . . . . . . . .207
V. Protocol Monitoring Adherence
Overview of Protocol Monitoring Procedures  . . . . . . . . . . . . . . . .217

ACRA Training  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217

Certification of Therapists  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217

Structure and Process of Supervision  . . . . . . . . . . . . . . . . . . . . .218

iii

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Training Resources  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221

Summary  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221
VI. References  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229
VII. Appendix. The Clinical Management of a Multisite Field Trial of 
Five Outpatient Treatments for Adolescent Substance Abuse  .233

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I. Introduction
Background

This publication was written for therapists and their supervisors who may
want to implement the adolescent community reinforcement approach
intervention, which was one of the five interventions tested by the Center
for Substance Abuse Treatments (CSATs) Cannabis Youth Treatment (CYT)
Project. The CYT Project provided funding to support a study that tested
the effectiveness of five interventions designed to reduce or eliminate 
marijuana use and associated problems in adolescents.
The CYT study was important for several reasons. In 1996, marijuana use
reached a 12-year high among adolescents ages 12 to 18 years (Institute for
Social Research, 1997). Among eighth graders, 23 percent reported lifetime
use, and 11 percent reported use in the past month. Among high school
seniors, 45 percent reported lifetime use, and 22 percent reported use in
the past month. Among 12- to 17-year-olds, marijuana has been the primary
substance of abuse identified at treatment entry and mentioned in emergency
room admission and autopsy reports (Office of Applied Studies, 1995, 1997).
Frequent marijuana use is associated with a syndrome characterized by 
apathy, decreased attention span, poor judgment, diminished capacity to
carry out long-term plans, social withdrawal, and a preoccupation with
acquiring marijuana (Cohen, 1980, 1981; Schwartz, 1987). It is also 
associated with co-occurring problems, including alcohol use, depression,
anxiety, attention deficit/hyperactivity, conduct disorder, illegal activity,
high-risk sexual activity, unwanted pregnancies, and difficulties at school
and home (Donovan & Jessor, 1985; Farrell, Danish & Howard, 1992;
Hawkins, Catalano & Miller, 1992; Jessor & Jessor, 1977; Kaminer, 1995;
Musty & Kaback, 1995; Rob, Reynolds & Finlayson, 1990). 
Seventy-nine percent of admissions for primary marijuana problems are
treated in outpatient ambulatory settings, that is, about 69 percent in 
regular outpatient settings (1 to 9 hours per week) and 10 percent in 
intensive outpatient settings (9 to 15 hours per week). Although 
information is still emerging about adolescent treatment effectiveness, 
there is considerable tension between efforts to develop short, cost-effective 
treatments and findings that 50 percent or more of adolescents relapse to
marijuana or alcohol use within the first 3 months after discharge (Brown &
Vik, 1994; Brown, Vik & Creamer, 1989; Catalano et al., 1991; Kennedy &
Minami, 1993). 
There are, however, several promising options for improving treatment
effectiveness that focus on motivational enhancement, relapse prevention,
problem solving, coping strategies, case management, family support, 
family therapy, and working with adolescents concerned others to change
their environments (Azrin, Donohue, et al., 1994; Azrin, McMahon, et al.,
1994; Brown et al., 1994; Graham et al., 1996; Kadden et al., 1989; Liddle
et al., 1995).

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Overview of the CYT Study
The CYT Study tested the relative effectiveness and cost-effectiveness of a
variety of interventions targeted at reducing or eliminating marijuana use
and its associated problems in adolescents and providing validated models
of these interventions for the treatment field. The appendix provides a
detailed review of the study.
The 3-year study began in October 1997. It was conducted in collaboration
with staff from Chestnut Health Systems (CHSMC) in Bloomington and
Madison Counties, Illinois; the University of Connecticut Health Center
(UCHC) in Farmington, Connecticut; Operation Parental Awareness and
Responsibility (PAR), Inc., in St. Petersburg, Florida; and the Childrens
Hospital of Philadelphia (CHOP) in Pennsylvania. Members of the Executive
Steering Committee of the study were Thomas Babor, Michael Dennis, Guy
Diamond, Jean Donaldson, Susan H. Godley, and Frank Tims. During the
study, adolescent participants were assigned to one of five treatment 
interventions. 
1. MET/CBT5. This was a five-session treatment composed of two 
individual sessions of motivational enhancement therapy (MET) and
three weekly group sessions of cognitive behavioral therapy (CBT).
The MET sessions focused on factors that motivate adolescents 
who abuse substances to change; in the CBT sessions, adolescents
learned skills to cope with problems and meet needs in ways that 
did not involve turning to marijuana or alcohol. This treatment 
was one of three interventions conducted at all four sites and was
designed to be inexpensive and in line with what many parents and
insurers seek as a basic intervention.
2.   MET/CBT5 + CBT7. This treatment was composed of two sessions
of MET and 10 weekly group sessions of CBT. It was designed to 
provide more of the same kind of treatment as MET/CBT5 to test
for dosage effects. It was more in line with the type of treatment
usually provided for adolescents.
3.   FSN. The family support network (FSN) treatment included the
MET/CBT5 + CBT7 group therapy plus engagement-type case 
management, family support groups, and aftercare. This treatment 
was designed to wrap several additional low-cost services around the
MET/CBT5 + CBT7 group therapy and to address family issues and 
services in line with CSAT Treatment Improvement Protocol (TIP)
Series recommendations.
4.   ACRA. The adolescent community reinforcement approach to 
treatment was composed of 10 individual sessions with the 
adolescent, 2 individual sessions with one or more caregivers (e.g., 
a single parent or both parents), and 2 sessions with the adolescent
and caregivers together. The intervention focused on rearranging
environmental contingencies so that abstaining from marijuana was
more rewarding than using it. ACRA therapists taught adolescents

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how to find new reinforcers or enhance existing reinforcers for 
staying substance free, how to use existing community resources
that were believed to support positive change, and how to develop 
a positive support system within the family.
5.   MDFT. Multidimensional family therapy (MDFT) was a 12-week 
treatment, composed of 12 to 15 individual, family-focused sessions
plus telephone and case management contacts. Depending on need
or availability, therapists met with adolescents and family members
individually or together. Sessions focused on roles, problem areas,
and interactions among family members. This treatment used an
integrated approach to family issues and focused on helping 
adolescents build more effective and age-appropriate interpersonal
and conflict-resolution skills, while helping parents establish a more
effective and supportive parenting style. Treatment also focused on
building appropriate social supports with peers, schools, and other
involved service providers.
All five therapies were based on treatment manuals to ensure that each
intervention had a unique approach, was uniformly applied at every site
implementing it, and could be replicated by others after the study had been
completed. In the study, treatment manuals were paired with a strong 
quality assurance component that included reviews of actual taped sessions,
which helped ensure compliance with the manuals. 
These five treatments can be categorized in several different ways. First,
they varied by mode; the first three were combinations of individual sessions
and group approaches (i.e., groups of adolescents or groups of families),
and the last two were approaches in which adolescents and family members
were seen individually or with other family members. Second, the MET/CBT
and ACRA interventions were based on behavioral treatment approaches,
whereas the FSN and MDFT interventions were based on family treatment
approaches. Third, they varied in resource intensity and cost.
In the study, approximately 150 adolescents were randomly assigned to 1 
of 3 conditions at 4 sites. At two sites they were assigned to the brief
MET/CBT5 or one of the other individual/group combinations (MET/CBT5
+ CBT7 or FSN). At two sites, adolescents were assigned to the brief
MET/CBT5 treatment or one of the individual approaches (ACRA or MDFT). 
All conditions were replicated in two or more sites. Treatment was 
standardized by using a treatment manual and relying on support from
expert workgroups. All adolescents were assessed at intake and at 3, 6, 9,
and 12 months. To validate adolescents self-reports, urine tests and 
collateral assessments were collected at intake and at 3 and 6 months. 
To minimize attrition, interviews that could not be completed in person 
at the 9-month interviews were completed by telephone. 
The MET/CBT5 intervention consisted of five sessions provided over 5 to 8
weeks; the combined MET/CBT5 + CBT7, MDFT, and ACRA interventions
lasted 12 to 14 weeks; and the FSN intervention lasted 12 weeks but had a

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limited aftercare component that lasted another 12 weeks. Thus, the 
3-month interview was usually the discharge interview, and the 6- and 
9-month interviews occurred approximately 3 and 6 months after discharge.
Data collection included use of the Global Appraisal of Individual Needs
(GAIN) (Dennis, 1998), an onsite urine test for cannabis and cocaine, and 
a collateral assessment form with questions paralleling those of GAIN and
addressing parenting issues. The full research design is described in Dennis
et al. (under review).
The study began in late 1997. The recruitment and treatment phases of 
the study occurred over 18 months. Adolescents were followed up on a 
flow basis through spring 2000. Analyses were conducted on baseline 
characteristics of study participants, outcomes, and cost-effectiveness and
are currently in the process of being published in peer-reviewed journals.
Additional analyses will be conducted to learn more about the interventions
and their interaction with different types of adolescents.
CYT followup data were based on more than 95 percent of the adolescents
who participated in the study at 3-, 6-, 9-, and 12-month intervals after
their intake date. These data revealed that the average number of days 
of use across conditions dropped from 36 days at intake to 23 days at 3
months and 21 days at 6 months. These results were largely sustained, with
an average of 22 days at both 9 months and 12 months. An examination 
of individual response to the treatments showed that 70 percent of the 
participants reduced their marijuana use from intake to 6 months, including
29 percent who eliminated their use in months 4 through 6 and another 29
percent who cut their use by half or more. At 12 months, 69 percent were
using less than at intake, including 35 percent who had eliminated their
marijuana use in months 10 through 12 and 23 percent who cut their use
by half or more.
Analyses of the effectiveness of the different interventions suggest that the
outcomes for each intervention followed a similar pattern. Although some
statistical differences existed at a given point in time, no one treatment was
consistently better across time. This finding was a major advance over the
mixed results from previous studies of existing models of adolescent 
treatment practice (with results that ranged from reductions in use among
20 percent of participants to increases in 18 percent) and the prevailing
course of substance use (which increases sixfold between ages 12 and 21)
(Dennis et al., in press).
The need for evidence-based treatment is great because the number of 
adolescents presenting for treatment of marijuana use disorders increased
135 percent from 1992 to 1998 and many treatment providers need to 
create adolescent services or expand their outpatient services. Because all
of the CYT treatments worked, the Steering Committee recommended that
service providers base their decisions about which ones to use on their
resources and logistical constraints. For example, some agencies may prefer
an approach that relies primarily on a group modality. Other providers may
prefer an individualized approach because it fits with their agencys treatment
philosophy or because their facility is located in a rural area.

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Purpose, Development, and Organization of This Manual
This manual provides guidance on how to prepare for and conduct the
ACRA intervention sessions with adolescents and caregivers. It also provides
examples of exchanges between therapists and adolescents to illustrate
what happens in actual ACRA sessions. Much of the adolescent community
reinforcement approach is based on previous work using a community 
reinforcement approach (CRA) (Meyers & Smith, 1995). The CRA 
intervention was adapted for use with adolescents who abuse or are 
dependent on marijuana. One modification is the inclusion of urine 
screening for drugs, a procedure commonly used in adolescent substance
abuse treatment. Other modifications of CRA used in this manual include
(1) the addition of specific sessions for a caregiver only and for a caregiver
and an adolescent together, (2) changes in the Happiness Scale and Goals
of Counseling forms so that the categories are relevant to adolescents, (3)
inclusion of urine-screening feedback procedures, (4) inclusion of dialog 
representative of interchanges between adolescents and therapists, and 
(5) requirements that snacks be provided routinely for the adolescents
receiving the intervention. Some CRA procedures were eliminated (e.g., 
use of disulfiram, marital therapy) because they were not relevant for 
adolescents.
Modifications were pilot tested by therapists working with adolescents in
tape-recorded sessions that were then made available to the principal
authors of the manual for review. It is extremely difficult to capture realistic
exchanges between therapists and adolescents in a manual because of the
many extraneous variables that impact behavior during a treatment session.
Nevertheless, the authors attempted to document as accurately as possible
what it is like to conduct ACRA sessions. Therefore, the therapists and
supervisor reviewed initial drafts of the manual and suggested changes to
reflect actual practice.
This manual is organized into seven parts. Part I provides an introduction to
ACRA. Part II provides an overview of the general theoretical underpinnings
of the CRA model and an overview of the ACRA intervention. Part III provides
detailed descriptions of 12 core procedures used in ACRA: 8 of the 
procedures apply to individual work with an adolescent, 2 procedures apply
to individual work with caregivers, and 2 procedures apply to working with a
caregiver and an adolescent together. Part IV provides descriptions of three
optional procedures related to failure to attend, finding jobs, and anger
management. Part V provides details on protocol monitoring procedures,
including clinical supervision. Part VI contains the references. Part VII 
contains additional information on the CYT study. 

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II. Overview of the Treatment Model
Adaptation of Procedures From the Community
Reinforcement Approach
Community reinforcement approach procedures were adapted in developing
the adolescent community reinforcement approach procedures for youth
who use and abuse marijuana, alcohol, and occasionally other substances.
CRA procedures were adapted to meet the developmental needs of 
adolescents. It was also important that the procedures could be replicated
in practice settings. CRA procedures are documented in treatment guides
and manuals (Budney & Higgins, 1998; Meyers & Smith, 1995). These 
CRA procedures vary based on the research groups and target populations
involved. For example, procedures for working with clients with cocaine
addiction have included the use of vouchers as a contingency-management
system in which drug abstinence is reinforced with points that have a 
monetary value that can be exchanged for desired prosocial items or 
activities (Budney and Higgins, 1998). When CRA procedures have been
applied to alcohol abuse treatment, they have included the use of disulfiram
or sobriety sampling (Meyers & Smith, 1997) and did not include the use of
vouchers. 

General Theoretical Assumptions of CRA and ACRA
Meyers and Smith (1995, p. 1) describe the theoretical underpinnings of
CRA in this way:
The Community Reinforcement Approach acknowledges the powerful role
of environmental contingencies in encouraging or discouraging drug use,
and thus attempts to rearrange these contingencies such that sober
behavior is more rewarding than using behavior. CRA blends this operant
model with a social systems approach. The overall philosophy is to use the
community to reward nonusing behavior so that the client makes healthy
lifestyle changes.
CRA procedures use operant techniques and skills training activities to
teach individuals new ways of handling lifes problems without drugs or
alcohol. Traditionally, CRA is provided in an individual, context-specific
approach that focuses on the interaction between individuals and those in
their environments. CRA therapists teach an adolescent when and where to
use the techniques, given the reality of each individuals social environment.
This tailored approach is facilitated by conducting a functional analysis of
the adolescents behavior at the beginning of therapy. CRA therapists then
teach individuals how to build on their reinforcers, how to use existing 
community resources that will support positive change, and how to develop
a positive support system.

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CRA is rooted in early work by Azrin and his colleagues (Azrin et al., 1982;
Hunt & Azrin, 1973). More recently, CRA techniques have been adapted for
use with:
  Concerned others to assist them in dealing with a loved ones
drinking (Meyers, Dominquez & Smith, 1996; Meyers & Smith,
1997)
  Cocaine-addicted individuals (Higgins et al., 1991, 1993, 1994,
1995; Shaner et al., 1997)
  Homeless alcohol-dependent individuals (Smith, Meyers &
Delaney, 1998)
  Adolescents in an assertive aftercare approach following a period
of residential treatment (Godley, Godley & Dennis, in press) 
  Adolescent substance abusers in an approach that integrated a 
community reinforcement plus vouchers (Henggler, unpublished). 
In one of the few randomized field studies of adolescent substance abuse
treatment, Azrin and his colleagues (1994) compared the effectiveness of a
behavioral outpatient treatment program for substance-abusing adolescents
with a supportive counseling program. Although not called a community
reinforcement approach, the behavioral treatment program procedures
appeared to have a common theoretical base. Like CRA, it incorporated 
parent attendance at all treatment sessions. When it was compared with 
the supportive counseling condition, the behavioral condition proved 
superior for reducing drug and alcohol use and improving school and work 
attendance (Azrin, Donohue et al., 1994; Azrin, McMahon et al., 1994).
A set of core procedures central to the CRA intervention includes:
  Using the functional analysis of substance use and the functional
analysis of prosocial behavior
  Developing well-specified treatment goals and practical strategies
to reach the goals, including training in using problem-solving
skills, effective communication skills, and prosocial skills
  Emphasizing developing prosocial behaviors to replace activities
related to substance use.

ACRA Goals

The goals of the individual ACRA sessions with adolescents are to:  
  Promote abstinence from marijuana, other drugs, and alcohol.
ACRA helps promote abstinence by working with adolescents to
modify the conditions that promote substance use. To reach this
goal, therapists use a procedure called the functional analysis of 

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substance use that helps an adolescent identify (1) the
antecedents to marijuana, other drug, and alcohol use, (2) the
actual marijuana- or other drug-using behavior, and (3) the 
positive and negative consequences of their use. 
  Promote positive social activity. ACRA assumes that adolescents
can be more successful at terminating substance use behavior if
they learn how to increase their involvement in positive, 
reinforcing behaviors. A procedure called the functional analysis
of prosocial behavior helps adolescents identify prosocial activities
they enjoy or would enjoy and helps them see the benefits of
being involved in these activities. Therapists then gradually
encourage adolescents to spend more time in these activities.
  Promote positive peer relationships. This goal parallels the goal
on positive social activity. Substance-abusing adolescents often
center activities with friends on substance use. With this goal,
ACRA therapists help adolescents identify attributes of healthy
friendships and help them learn how to find and make new
friends, how to deal with negativity, and how to ask for support.
  Promote improved relationships with family. Adolescence is a
stressful time in the relationship between caregivers and the 
adolescent children in their care. This situation is probably even
more stressful in families in which the adolescent is a substance
abuser. Any distrust that caregivers have for the adolescent is
reinforced by the adolescents involvement in substance use.
ACRA seeks to improve communication among family members 
as a way to enhance relationships.
The goals of the ACRA sessions with the caregivers are to:  
  Motivate their participation in the ACRA process. It is possible
that some caregivers may be reluctant to participate in an 
adolescents treatment process. They may feel that the adolescent
has messed up and the role of the treatment process is to fix
him or her. The ACRA therapists role is to help caregivers 
understand that they have an important role in helping their 
adolescent overcome a problem and to motivate the caregivers 
to participate in the therapy process.
  Promote the adolescents abstinence from marijuana, other
drugs, and alcohol. ACRA procedures teach family members
behavioral skills aimed at discouraging an adolescents drug use.
The goal is to help caregivers understand how their behavior
impacts the adolescents substance use so that the caregivers will
be motivated to change their own behavior to promote the 
adolescents abstinence. 
  Provide information to the caregivers about effective parenting 
practices. The information is based on the research of Catalano

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(1998), Hops (1998), and Bry (1998) and includes measures to
keep the adolescent from relapsing. These important parenting
practices are:

!
Be a role model by refraining from using drugs or alcohol
in front of the adolescents in their care. This is the single
most important parenting practice for caregivers.

!
Increase positive communication with the adolescents in
their care.

!
Monitor adolescents activities, including knowing where
they are and whom they are with. 

!"Become involved in adolescents life outside the home by
encouraging and promoting prosocial activities.

!Teach and practice positive communication and problem-
solving skills in the family. Improving communication and
problem-solving skills within the family promotes a more
positive relationship between adolescents and caregivers
and helps create a familial environment that is more 
conducive to recovery.
The ACRA goals of working with the community are to:
  Improve an adolescents environment. An adolescent may be
interacting with several different systems, such as schools and the
probation department. The therapists role is to serve as the 
adolescents advocate in these settings. There may be times when
the therapist directly interacts with school personnel or helps
teach the caregivers skills so that they can advocate at school for
the adolescent in their care. If the adolescent is on probation, the
therapist can work with him or her and the probation officer to
encourage fulfillment of the probation requirements.
  Teach the adolescent problem-solving skills and appropriate
interactions through the use of roleplaying. 

About This Manual
This manual provides information about ACRA by presenting the sequence
and suggested content of each session and how to implement each 
procedure. Procedures and sessions are not synonymous. The order of 
the procedures can be varied according to the needs of the adolescent 
and the caregiver. 

Target Population

The manual describes an outpatient intervention that has been designed 
to be delivered in weekly sessions. The target population is adolescents 

10

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appropriate for an outpatient or intensive outpatient level of care as defined
by the American Society of Addiction Medicines (1996) patient placement
criteria. It is recommended that, before beginning this or any treatment
program, adolescents first participate in a comprehensive biopsychosocial
assessment to determine the appropriate level of care placement. The
Cannabis Youth Treatment study used GAIN (Dennis, 1998). All the 
adolescents who participated in the testing of this intervention (1) were
between the ages 12 and 18, (2) met criteria for current Diagnostic and
Statistical Manual of Mental Disorders (DSMIV) (American Psychiatric
Association, 1994) diagnosis of cannabis abuse or dependence, and (3) had
used marijuana in the last 90 days (or 90 days before being in a controlled
environment). Adolescents were excluded from the study if the intake
assessment revealed any of the following because they would be more 
appropriately served in a residential treatment program: (1) use of alcohol
45 or more days of the 90 days before intake (or before being in a controlled
environment where relevant), (2) an acute medical condition that required
immediate treatment or was likely to prohibit full participation in treatment
and could not be managed in this level of care, (3) an acute psychological
condition that required immediate treatment and/or was likely to prohibit
full participation in treatment and could not be managed at this level of
care, or (4) a history of violent behavior or severe conduct disorder.
ACRA was tested at two treatment sites. One was a large adolescent substance
abuse treatment provider in Illinois that can provide all levels of care (i.e.,
early intervention, outpatient, intensive outpatient, and residential); the
second was a major medical center affiliated with a university in
Philadelphia. The following data are based on the 100 adolescents who 
participated in the ACRA intervention. The average age of the adolescents
was 16 years, and 20 percent were female. In terms of race or ethnic 
composition, 44 percent of participants were black, 53 percent were white,
1 percent were Hispanic, and 2 percent were from other race or ethnic
groups. Fifty-nine percent were from single-parent homes. In terms of 
education and employment, 86 percent reported being in school in the 
last 90 days, and 39 percent reported working in the last 90 days. Sixty-two 
percent reported current criminal justice involvement, and 66 percent
reported some type of victimization. 
Seventy-eight percent of the adolescents reported they were sexually active,
with 47 percent reporting multiple sex partners in the last 90 days; almost
a quarter said they had had unprotected sex. Sixty-eight percent reported
weekly marijuana use, 43 percent reported symptoms of marijuana 
dependence, and 45 percent reported symptoms of marijuana abuse. Fifteen
percent reported weekly alcohol use, 12 percent reported symptoms of 
alcohol dependence, and 30 percent reported symptoms of alcohol abuse.
None of the adolescents reported weekly use or dependence symptoms of
other drugs. Nine percent reported symptoms of abuse related to drugs
other than alcohol or marijuana.

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Overview of ACRA Sessions
Duration
The ACRA intervention described in this manual lasts for 3 months.
ACRA Therapist/Participants Ratio
During the CYT study, the ratio of therapists to adolescents was 
approximately 1 to 12. Therapists were involved in other activities that 
did not require a regular practice setting, so there was a higher ratio of 
participants to therapists in such a setting.
Contact Frequency
Individual face-to-face contact. Therapists provide approximately 10 
individual sessions with the adolescent and 2 sessions with the adolescent
and caregiver together over a 12- to 14-week period. Sessions usually last
60 minutes. The length of the session can vary according to the needs of
the teen or the caregiver or at the discretion of the therapist. Other 
contacts by telephone or letter may be necessary between the in-person
contacts to provide encouragement or motivation. If either the adolescent
or the caregiver is unwilling to come to treatment, the therapist can offer
the unused appointments to the one willing to come. For example, if the
adolescent attends only five sessions and then refuses further treatment but
the caregiver expresses interest in more than the two individual sessions
allotted for a caregiver, the therapist can offer the caregiver additional sessions.
Caregiver contact. Therapists are expected to meet with caregivers for 
four face-to-face sessions (two with the caregiver alone and two with the 
caregiver and adolescent). If the adolescent lives with both parents, the
therapist attempts to engage both parents in the caregiver sessions. If for
some reason only one parent wants to or is able to attend the sessions, it is
acceptable to work with the caregiver who is willing to attend. The first 
session (procedure 9) provides an opportunity for the therapist to give an
overview of the treatment goals and develop rapport with the caregiver.
During the second session (procedure 10), the therapist and caregiver work
on learning and practicing communication skills. In the remaining two 
sessions, the therapist works with the caregiver and adolescent together to
reinforce and practice caregiveradolescent relationship skills (procedure
11). As noted above, if the adolescent drops out of treatment, it is possible
to provide additional sessions to the caregiver.
Involvement of others in ACRA sessions. It is acceptable to invite other
people to attend ACRA sessions when appropriate. Appropriate people to
involve include a parent or other caregiver, a boyfriend or girlfriend, or
other friends. These other people who play an important role in an adoles
cents life could be involved during most of the procedures. For example, if
an adolescent and his girlfriend usually attend parties together and he is
willing to bring his girlfriend to a session, then it may be appropriate to
work with both teens on the early warning system that is part of relapse

12

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prevention (procedure 5). It might also be appropriate for an adolescent to
bring a friend to a session to work on developing alternative prosocial
behaviors (procedure 4). Whether or not to include someone else in a 
session depends on whether that persons involvement could help the 
adolescent attain his or her counseling goals and whether the adolescent
wants to have that person attend a session.
Contact with community resources. Contact with community resources 
is based on individual need. For example, if an adolescent is in a detention
facility, the ACRA therapist could go to that facility for a session. If the 
adolescent was referred by a school and appropriate releases are in place,
the ACRA therapist could talk to school personnel about the adolescents
progress in treatment and advocate for him or her. The therapist might also
provide monthly progress notes and discharge information to a criminal 
justice system case manager or a probation officer. Although these activities
are acceptable in the intervention, therapists should discuss contacts with
community resources with their clinical supervisors.
Referrals for Other Needed Services
Many adolescents requiring substance abuse treatment services have 
additional problems. It is assumed that ACRA is provided in a clinical 
environment that encourages the therapist to refer the adolescent and 
family members to other service providers for help when the adolescent 
has needs that cannot be addressed by ACRA. For example, if a therapist 
suspects that an adolescent has a mental health problem and might benefit
from medication, the therapist would provide a referral to a family physician,
a pediatrician, or a psychiatrist for a consultation. These referrals should be
made, if possible, after consultation with a clinical supervisor. The therapist
should also seek a signed release of information form from the participant
and parent so he or she can provide background information about the 
adolescent, including that the youth is in treatment for a chemical-
dependence problem, to the referred professional.
As treatment progresses with an adolescent, a more severe problem than
originally thought may become apparent, and this problem may require a
higher level of care (e.g., residential treatment). In this case, the appropriate
referral should be made. There are often waiting lists for these services. If
this is the case, the ACRA therapist should continue to provide treatment
to the adolescent on an outpatient basis until there is an opening in the
higher level treatment program.
Nature of the Intervention and Timing of Procedures
The suggested sequence of procedures, by session, follows. This sequence 
is only suggested because the therapist must always pay attention to 
maintaining a therapeutic alliance and to responding to the clinical needs
of a treatment participant. For example, if the participant raises an issue
that provides an opportunity to teach a procedure, the therapist should
address the need presented by the participant rather than rigidly stay with 
a session plan. Or, if the therapist plans to conduct a functional analysis 

13

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of substance use but the adolescent mentions a significant problem, the 
therapist can introduce the problem-solving procedure. Later, the therapist
can return to the functional analysis of substance use procedure. 
Because ACRA attempts to use the reality of an adolescents social 
environment, the therapist does not follow a didactic format with prescribed
examples but uses real life opportunities for learning when they occur.
Focusing on issues presented by the adolescent enhances engagement, a
primary part of ACRA. Interaction between the therapist and the adolescent
during the presentation and practice of procedures also enhances engagement
and reinforces learning.
ACRA supervisors note that this flexible approach to using procedures can
increase the difficulty of training therapists in ACRA procedures. It is easier
to teach therapists how to deliver individual procedures than how to weave
procedures into sessions as opportunities occur. Quality clinical supervision
incorporating tape reviews is essential to the training process. Clinical
supervision is described in part V.
Materials Needed
Because of the flexible nature of ACRA, the therapist should be prepared to
use a variety of procedures and materials to meet the needs the adolescent
presents during that session. The descriptions of procedures include the
materials such as clipboards, pens, handouts, and copies of clinical forms
(found at the end of each procedure section) appropriate for that procedure.
At the beginning of every session, the therapist offers the adolescent a
snack and a drink. Suggestions for snacks include chips, granola bars, fruit
bars, candy, cookies, and caffeine-free sodas or fruit juices. It is more 
practical to offer snacks packaged as one serving (not a whole bag of chips
or a package of cookies). Offering the snacks serves as a primary reinforcer
to help engage the adolescent.
Sequence and Content of Adolescent Sessions 
Session 1: In the first session, the therapist meets with the adolescent and
caregivers together for the first 15 minutes of the session. The goal is for
the therapist to introduce himself or herself, build rapport, answer questions
and provide information about the ACRA program, and make the family feel
comfortable. The therapist discusses ACRA treatment success and philosophy
and the focus of therapy sessions. He or she provides information about the
length of treatment sessions, number and type of therapy sessions, disclosure
of information policy, urine testing, and video- and audiotaping (if applicable).
The therapist should praise family members for participating in treatment
and try to make them feel comfortable by saying something like, Im really
glad you came to treatment; I look forward to working with you! The 
family is encouraged to ask questions during this initial session and at any
time during treatment. The therapist should involve both the adolescent
and caregivers by talking to or directing questions to everyone in the room. 

14

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Once the therapist reviews the necessary information with the caregiver, he
or she explains that the rest of the session will be spent with the adolescent.
The therapists goal for the rest of the session is to develop rapport with the
adolescent. The therapist can use the happiness scale (procedure 3) as a
basis for conversation and to find out what is important to the adolescent.
If time permits, the therapist and adolescent can begin work on the 
functional analysis of substance use (procedure 1).
Sessions 24: By the end of session 4, the therapist should have completed
a functional analysis of substance use (procedure 1), a functional analysis of
prosocial behavior (procedure 2), and at least one Happiness Scale form
and a Goals of Counseling form (procedure 3). Encouragement of prosocial 
behaviors (procedure 4) also begins during the first four sessions. Other
procedures may be used depending on the needs of the adolescent.
Sessions 510: These sessions follow a similar format but do not require
that skills be taught in a standard sequence. Standard parts of each session
include the following:
  Offering a food reward for session attendance
  Beginning the session with rapport-building interchanges
  Checking on homework completion
  Querying the adolescent about social activities or encouraging
healthy social activities
  Checking on the adolescents progress in completion of goals 
listed on the Goals of Counseling form
  Querying the adolescent about relationships with friends
  Querying the adolescent about relationships with family members
  Querying the adolescent about other problems
  Ending the session with a homework assignment related to the
session content
  Reinforcing attendance at the present session and encouraging 
attendance in the future
  Scheduling the time and place for the next session.
Topics and skills that should be covered in these sessions are:
  Relapse prevention skills (procedure 5)
  Communication skills (procedure 6)
  Problem-solving skills (procedure 7)

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  Urine testing (procedure 8)
  Caregiveradolescent relationship skills (procedure 11).
Session 11: This session focuses on the skills presented in procedure 11.
These skills may have been introduced earlier, but they may need to be
reviewed.
Session 12: This last session includes the review of treatment goals and 
termination of services (procedure 12).
Sequence and Content of Caregiver Sessions 
Sessions 1 and 2: The ACRA therapist meets with the caregiver without the
adolescent present. The therapist:
  Begins the session with rapport-building exchanges
  Describes the goals of ACRA treatment
  Describes four behaviors that research has shown caregivers can
do to help prevent the adolescent from relapsing
  Reinforces positive behaviors of parents or caregivers that support
the adolescent and help prevent relapse
  Uses motivational procedures to encourage parental or caregiver 
participation
  Presents communication principles
  Reinforces attendance at the present session and encourages
futures attendance
  Schedules the time and place for the next session.
Procedures 9 and 10 provide detailed descriptions for conducting the 
sessions with caregivers.
Sessions 3 and 4: The ACRA therapist meets with the caregiver and the
adolescent together. The therapist:
  Reviews the goals of ACRA and the reason the caregiver and 
adolescent attend this session together
  Reinforces attendance at the session and encourages future 
attendance
  Helps the family members identify and talk about the things they
like or appreciate about the other family members

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  Reviews communication and problem-solving skills with the 
adolescent and family members
  Completes and reviews the Relationship Happiness Scale form 
(adolescent and caregiver versions)
  Practices relationship-building and communication techniques
(e.g., how to solve problems, how to ask for things, how to receive
things, how the caregiver can say no by offering alternatives, and
how to remember to be nice).
Procedure 11 provides details about how to present these skills and activities.
Note regarding attendance problems: If the adolescent and caregiver fail
to attend, the therapist must attempt to reengage the adolescent and 
caregiver in treatment. Specific procedures for improving attendance are
described in optional procedure 1.
Weekly Overview of Sessions
This section presents the information on session content by week.
Week 1: 
  The therapist meets with the caregiver and adolescent for 15 
minutes. 
  Adolescent session: The therapist meets with the adolescent 
individually. Suggested procedures include rapport building 
(procedure 1), the functional analysis of substance use 
(procedure 1), the happiness scale (procedure 3), and problem
solving (procedure 7).
  Caregiver session: The therapist meets with the caregiver 
individually for a 60-minute session. Suggested guidelines are 
outlined in procedure 9.
  The therapist contacts community resources if necessary.
Week 2:
  Adolescent session: The therapist meets with the adolescent 
following the session format (the Functional Analysis of Substance
Use form is completed by the end of this session). The therapist 
introduces ways to increase prosocial recreation (procedure 4).
  The therapist contacts community services if necessary.
Weeks 3 to 5:
  Adolescent sessions: The therapist meets with the adolescent 
following the session formats.

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  Caregiver session: The therapist meets with the caregiver for his
or her second session following guidelines outlined in procedure 10.
  The therapist contacts community services if necessary.
Weeks 6 and 7:
  Adolescent sessions: The therapist meets with the adolescent 
following the session format.
  Adolescent and caregiver session: The therapist meets with the 
adolescent and the caregiver following the session format and
guidelines in procedure 11.
  The therapist contacts community resources if necessary.
Weeks 8 to 10:
  Adolescent sessions: The therapist meets with the adolescent 
following the session formats.
  The therapist contacts community resources if necessary.
Week 11:
  Adolescent and caregiver session: The therapist meets with the 
adolescent and the caregiver following the session format and
guidelines for procedure 11.
Week 12:
  Adolescent session: The therapist meets with the adolescent 
following the session format and procedure 12 guidelines for
treatment closure. 
Exhibit II1 presents a weekly timeline of the ACRA sessions. This timeline
should help therapists envision the structure and timing of the approach
and can be used as a quick reference when scheduling sessions. It lists the
procedures and the week each topic is recommended for introduction. It
also provides information on the topic and the session participants.

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         Exhibit II1:
Timeline of ACRA Treatment Sessions,
Treatment Procedures, and Participants

Procedure Topics  Session 
Number Timeframe Covered Participants
1        Weeks 1 to 4   Functional analysis of substance use       Adolescent         
Ongoing         Rapport building                        Caregiver and 
                                         Adolescent 
2  Weeks 2 to 4   Functional analysis of prosocial behavior Adolescent 
3*      Weeks 1 to 4  First happiness scale  Adolescent
          First goal of counseling 
Any session    Subsequent happiness scales Adolescent
                 Subsequent goals of counseling 
   4*      Any session,   Encouragement of prosocial behavior      Adolescent
but should 
begin in 
weeks 1 to 4   
   
5*  Any session     Relapse prevention  Adolescent 
   6*  Any session     Communication skills  Adolescent 
   7*  Any session     Problem-solving skills  Adolescent 
   8  Weeks 5         Urine testing Adolescent
to 10 
   
9  Week 1           Caregivers introduction to ACRA  Caregiver 
  10      Weeks 3 to 5  Caregivers communication skills           Caregiver
training and review 
  
11  Weeks 5         Caregiveradolescent relationship    Caregiver and 
to 11  skills Adolescent  
  12  Week 12         Review of treatment goals and  Adolescent
termination of services  

Optional*  As needed       Dealing with caregivers or the  Caregiver and/or
adolescents failure to attend Adolescent
 Find jobs Adolescent
 Anger management   Adolescent
*The therapist has the flexibility to introduce these procedures as needed based on 
situations presented in the therapeutic session.
Key Concepts of ACRA

Positive and enthusiastic approach. One of the key concepts of ACRA is
that the therapists approach to the adolescent and caregivers is positive

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and enthusiastic. The therapist is always looking for opportunities to
reinforce behaviors that can lead to less substance use. In contrast to some
traditional substance abuse treatment approaches, ACRA therapists are
rarely confrontational. This approach is consistent with the general CRA
philosophy and is a logical approach to use with adolescents who are
attending substance abuse treatment because of coercion (subtle or 
otherwise) from parents, school officials, or the criminal justice system. 
In addition, it is a developmentally appropriate approach with adolescents 
who may be oppositional or have a conduct disorder and whose resistance
increases when confronted. If adolescents believe they have power in the
counseling situation, they may be more willing to work with a therapist.
How ACRA therapists deal with uncooperative clients. Resistance and
compliance issues are usually common and ongoing in a therapeutic 
relationship, especially when treating adolescents. Adolescents will usually
resist change because their present behavior is meeting a need or providing
a payoff they do not want to give up. They will often cling to existing 
behaviors until there is good reason to believe that a substitute behavior
will be equally satisfying or reduce anxiety. Notice in the dialog example
below that the therapist is not confrontational or argumentative. ACRA
therapists never try to meet resistance head on and always try to avoid
power struggles. The way a therapist responds to resistant behaviors is a
critical component of ACRA. Resistance can be influenced or decreased by a
therapists behavior and style. It is difficult to provide step-by-step guidance
on how a therapist approaches resistance because success in this endeavor
is dependent on the total therapeutic approach. The approach should
encompass behaviors that convey the most desirable of therapeutic 
qualities, including listening with empathy; having genuine concern; 
being open-minded, affirming, reflecting; praising and having expectations; 
and being accepting and rolling with the resistance. Compliance 
enhancement strategies begin with the first contact between the therapist
and teenager and continue throughout the therapy episode. 
Most of the examples of dialog provided in this manual use compliant
adolescents to try to illustrate the procedures and their components. Each
adolescent will pose his or her unique challenges. It is impossible to capture
or demonstrate in one manual the wide variety of situations and problems
that a therapist will face and the many possible ways to deal with these
problems. Following is one example of how an ACRA therapist works with an
adolescent who is resistant to coming to treatment; the therapist does not
confront the adolescent about his drug use. Confrontation by the therapist
may aggravate an adolescents resistance. The therapist concentrates on
developing a therapeutic alliance to deal more effectively with substance
use later in therapy. 
In this example, the therapist has already met with the adolescent and 
caregiver for introductions and has provided an overview of the ACRA 
treatment process. The caregiver has left the session, and the therapist 
is now meeting with the adolescent alone.

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Therapist:  How are you doing with this, John?
Adolescent: Okay, I guess.
Therapist: Tell me why you think you are here and how I can help
you.
Adolescent: My mom and parole officer think I need to be here.
Therapist:  Do you think you need to be here?
Adolescent: No, not at all.
Therapist:  Thats okay and I can definitely understand that.
Thanks for being so honest with me. [The therapist
tries to reinforce that the teen can communicate
whatever he feels.] Most people dont want to be here.
[Normalizes feelings.] Tell me why your mom and
parole officer think you need to be here. [Asks 
open-ended questions to try to elicit more detail.]
Adolescent:  I guess because I am on probation, and my parole 
officer says I need to be.
Therapist: What are you on probation for?
Adolescent: I got busted with a joint at school. It wasnt even mine.
Therapist: That sucks. Have you ever been to treatment before?
[Doesnt focus on the drug use yet.]
Adolescent: No, and I dont want to be now!
Therapist: I dont blame you. It can be a scary thing, not knowing
what to expect and having to talk to a stranger. I want
to tell you that you dont have to do anything that you
dont want to do. Im just here to help if I can. I really
appreciate your taking the time and having the courage
to come in here today. [Reinforces attendance.] Im not
here to tell you what to do or what not to do.
[Emphasizes personal choice, freedom, and 
control.] 
Adolescent: So youre not going to be riding me about drugs the
whole time.
Therapist: No, not at all. Do people ride you about your drug use?
[Uses the clients own language, and asks indirectly
whether he is using drugs.]
Adolescent: Yes. It gets on my nerves.

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Therapist:  Who rides you? [The therapist is still not confronting
the adolescent about using. Instead, the therapist is
searching for a source of motivation that can be used
to engage the adolescent in the treatment process.]
Adolescent:  My parents, parole officer, teachers, principal, some
friendsyou name it.
Therapist:  Sounds like that irritates you.
Adolescent:  It does; youd be irritated too!
Therapist: Do they ride you because they think you have a prob
lem with drugs?
Adolescent: Now what do you think?
Therapist:  I dont know. They may think you have a problem, or
they may just not like the fact that you use drugs. Or
do you? I know you said you got busted but that 
doesnt necessarily mean you are using. [The 
therapist is not assuming use or accusing the client 
of using.]
Adolescent:  Yes, they think I have a problem. 
Therapist: Do you think the drugs are a problem for you?
Adolescent: Not really.
Therapist: It sounds as if you arent too concerned about your
drug use but others in your life are; they are getting on
your nerves about it; and that is irritating to you. [The
therapist is reflecting and summarizing.] Because you
are required to come here, lets make the most of our
time together. Would you be willing to work together to
try to get all these people off your case? [Tries to 
create an alliance with the client. Attempts to get 
the client interested in treatment. The objective is 
to identify a complaint that the client is interested 
in changing to get him to participate in treatment.]
Adolescent:  So youre telling me that youre not going to make me
quit? [The client admits to using.]
Therapist: I cant tell you what to do or what is best for you. Only
you know that. You could go through treatment here
and decide that its worth it to you to keep using drugs
as you have been. That will be up to you. So what do
you say about trying to get all these people off your
back? [The therapist is rolling with resistance and not

22

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initially focusing on the problem. The most important
thing is to create an alliance in the beginninggiving
the client a sense of freedom and providing choices
rather than confronting him head on or arguing with
him.]
Adolescent:  And how do you suppose we can do that?
Therapist: Well, thats what I would like to work on together.
Because you know yourself and you know all those
people riding you a lot better than I do.
At the end of this dialog, the therapist is starting to build a relationship
with the adolescent. At this point, the therapist can start working on the
clients compliance through problem solving. The therapist will deal with
the issue of using as it comes up. The goal is to address the adolescents
issues as he or she raises them. This can be accomplished at the same time
the adolescent learns and practices the ACRA skills. The timing of 
implementing the procedures is a key factor in this model.
Other examples of an ACRA therapist handling a resistant client can be
found in the sections that describe developing the ACRA treatment plan
(procedure 3) and communication skills (procedure 6). These two examples
illustrate how an ACRA therapist may attempt to handle resistance while
interweaving the procedures in sessions.
The ACRA triangle. The core of ACRA is the relationship of three key ACRA
procedures: the functional analysis, the happiness scale, and the goals of
counseling. These three procedures are closely related and dependent on
one another. The three key 
procedures join together to make 
up the ACRA triangle presented in 
exhibit II2.
ACRA uses two types of functional
analyses. One explores the
antecedents and consequences of
the adolescents marijuana and 
alcohol use. The other explores 
positive, enjoyable activities that
may serve as motivators for change. 
The happiness scale rates the adoles
cents feelings about several critical areas of life. It helps therapists and
adolescents identify areas of life that adolescents feel happy about and
areas in which they have problems. And, most important, it helps determine
the direction of their discussion and helps them track the progress during
treatment. 
The goals of ACRA counseling are determined from the happiness scale and
the functional analyses. Although these components are completed early in
  Exhibit II2: 
The ACRA Triangle

Goals of Counseling

  ACRA
TRIANGLE

Functional 
Analysis
Happiness
Scale

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treatment, all three components are viewed as works in progress. Therapists
should revisit them often and ask adolescents to complete additional 
happiness scales approximately every 2 weeks.
Simple lay language. ACRA emphasizes the use of lay language. Therapists
are encouraged to use language that is easily understood by adolescents
and their families, hence the use of terms such as the happiness scale and
the goals of counseling. ACRA therapists also are encouraged to engage in a
normal conversational process when completing tasks such as the functional
analysis of substance use behavior, prosocial behavior, and the goals of
counseling. 
Flexibility of ACRA. With a few exceptions, ACRA procedures are not tied
to particular sessions. The approach is flexible, and therapists are trained to
respond to cues provided by the adolescent, react to issues raised by the
adolescent, and implement appropriate procedures in response (e.g., 
problem solving, examination of triggers).
Importance of roleplaying when learning new skills. Roleplaying is a 
critical component of the skills training used in ACRA, particularly for 
communication and problem-solving skills. It is very important that ACRA
therapists become comfortable with encouraging and helping adolescents
roleplay new skills in the protective environment of a session. Repeated
roleplays increase the probability that new skills will be used outside the
session.
Importance of homework. It is important for adolescents to complete
homework between sessions. The homework consists of practicing the new
skills and helps adolescents learn to use the new skills.

Requirements for an ACRA Therapist
Recommended Educational and Experiential Qualifications
An ACRA therapist should have a bachelors degree in a counseling-related
field and 5 years of experience or a masters degree in a counseling-related
field. An ACRA therapist candidate should have a demonstrated orientation
to a behavioral or cognitive behavioral approach. Prior experience with
counseling adolescents or treating substance abuse is preferred. 
Skills and Knowledge 
Besides knowing how to deliver ACRA procedures, the therapist must have
the following:
  Good basic counseling skills
  Knowledge and understanding of the developmental issues of 
adolescence
  Education or experience in interpreting clinical assessments. 

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The therapist needs to be an active listener and able to communicate 
empathy and genuineness during counseling situations with both the 
adolescent and parents. These skills promote engagement and help 
participants feel that they have some power in the therapeutic enterprise.
These skills are not always readily discernible in an interview situation.
Possible ways to assess whether a therapist has these skills are to see
whether the individual has a history of good basic counseling skills, to
review a sample therapy tape, or to obtain references from previous 
supervisors who reviewed his or her therapy tapes. 
Adolescent developmental stages and accompanying behavior are extremely
important for the therapist to know or learn during training. The therapist
should have the ability to interpret clinical assessment information so that
he or she can understand the adolescents background and clinical needs.
Personal Qualities 
Preferred qualities for such a therapist are a nonjudgmental attitude and a
willingness to follow established procedures of the ACRA method. Positive
and enthusiastic interpersonal skills are desired. Therapists who prefer 
analytic, solely didactic, or confrontational approaches probably are not
good candidates.
Travel and Other Special Conditions or Requirements 
Travel to an adolescents home or other locations may be necessary if an
adolescent has problems with transportation, does not attend sessions, or 
is in a controlled environment (e.g., a detention home). ACRA strongly
emphasizes meeting the needs of the adolescent and caregivers through
engagement.

Clinical Supervision Requirements
Weekly individual supervision and, if appropriate, group supervision by a
clinical supervisor are recommended, as well as a weekly administrative
case review meeting. A primary component of supervision is a review of
taped treatment sessions by the clinical supervisor with feedback to the
therapist on his or her ability to implement the ACRA protocol. As the
supervisor reviews tapes, he or she also reviews the ACRA Global Procedure
Checklist and the individual procedure checklists that are completed by
therapists after each session. The ACRA Global Procedure Checklist provides
an opportunity for therapists and supervisors to note what ACRA procedures
were used, as well as which ones could have been used. The ACRA Global
Procedure Checklist can be found in part V of this manual. The procedure
checklists, which follow each procedure section, describe specific steps of
each procedure. The therapist notes whether or not each step of the 
procedure is in progress, is completed, or has not been undertaken. If these
checklists are used consistently after sessions or reviewed prior to sessions,
they provide prompts to therapists to complete all steps in a given procedure.
Clinical supervision and protocol monitoring are discussed in more detail in
part V of this manual.

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Procedure 1: Functional Analysis of Substance Use Behavior
Rationale
Functional analysis procedures provide basic information for therapists to
use while implementing adolescent community reinforcement approach
(ACRA) components during treatment (Meyers & Smith, 1995). They are
based on structured interviews that examine the antecedents and 
consequences of a specific behavior. The specific behavior of interest 
can fall into one of two categories: a substance use behavior, such as the
use of marijuana or the consumption of alcohol; or a prosocial behavior 
or activity that the adolescent enjoys, such as riding a bicycle or playing
hockey. These two types of functional analysis procedures are used in
ACRA. Procedure 1 focuses on the functional analysis of substance use.
Procedure 2 describes the functional analysis of prosocial behaviors.
Purposes of the Procedure and Learning Objectives
The first purpose of this procedure is to uncover information about the 
adolescents substance use behavior. One key purpose for conducting a
functional analysis of substance use is to determine the teenagers 
triggers for marijuana or alcohol use. Triggers are thoughts, feelings, 
or behaviors that precede a using episode and are instrumental in leading
the individual to use. By designating the chain of events that lead to use,
the adolescent is made aware that the use of marijuana or alcohol does
not just happen. Rather, many small decisions lead up to the substance
use behavior and are, therefore, within the adolescents control. 
A second key purpose for conducting a functional analysis of substance
use is to clarify the positive and negative consequences of substance use
that occur immediately and those that the adolescent thinks may occur in
the long term. Once the teenager goes through this process, the goal is
to help him or her realize that motivations exist to stop using and there
are healthier ways to obtain some of the pleasures he or she gets 
from using. Information gleaned from this process is never used in a 
confrontational manner; the goal is to try to help the adolescent verbalize
the consequences of substance use/abuse/dependence.
The learning objectives are to help the adolescent:
  Begin to uncover what is powerful enough to cause the adolescent
to change his or her behavior
  Realize that motivations to stop using already exist
  Identify the triggers for substance use and their associated 
high-risk situations
  Identify and clarify substance use behavior

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  Identify the short-term positive consequences of using
  Identify the long-term negative consequences of using.
Timing, Audience, and Delivery Method
Initially complete this procedure individually with an adolescent in 
sessions 1 and 2; revisit it in later sessions; and consider it a work in
progress as the teenagers behaviors and needs change.
Materials
General materials include snacks (e.g., chips, crackers, granola bars, fruit
bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if
applicable) a videocamera and videotapes or an audiotape recorder and
audiotapes.
Procedure-specific materials include a clipboard, pens, and two Functional
Analysis of Substance Use Behavior forms.

General Notes for the Therapist
At this early point in the relationship and basically throughout the treatment
period, you need to establish and elicit positive expectations for change.
Part of this entails persistently finding even small actions or statements
that can be praised to enhance an adolescents motivation for participating
in the intervention. In addition, you should maintain a positive and 
enthusiastic tone of voice. Be sure to maintain a connection with the 
adolescent. For example, you might say something such as, I can see Im
making you angry, so lets start over.  
The steps outlined below explain how to conduct a functional analysis of
substance use with the teenager at the start of therapy. However, this
process is not a one-shot effort. It may be necessary to revisit the functional
analysis of substance use process throughout therapy, as the adolescents
behaviors and needs change. The functional analysis of substance use, like
the functional analysis of prosocial behavior and the treatment plan, is a
work in progress. The procedures outlined below can be repeated as needed.
Forms are used to help conduct both the functional analysis of substance use
and the functional analysis of prosocial behaviors. Use the forms only as
guides. Although it is important to gather as much of the information as you
can, do not feel as if you must use the exact wording on the forms. Rather,
questions should be phrased in an open-ended manner as much as possible. If
applicable, some of the information may be taken from the adolescents
biopsychosocial assessment that is completed before treatment begins.
Clarify assessment information before starting this procedure so that the
teenager does not feel as if he or she is retelling the story. When talking
with an adolescent, guide the conversation so that the form can be 
completed, but avoid making the form the focal point. 

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It is best to complete the Functional Analysis of Substance Abuse Behavior
form in the presence of the adolescent, but it is not necessary to structure
the session so that the focus is on answering questions. It is better to come
back to the functional analysis of substance use at a later session than to
risk alienating the adolescent by pushing him or her to provide information
that may be difficult to recall.
The goal is for you and the adolescent to begin to determine what is 
powerful enough to help the adolescent change his or her behavior. For
example, a powerful reinforcer can be to avoid going to jail. You can also
begin to assess the teenagers internal or external motivations (e.g., Is he
or she in treatment because of probation or parents/caregivers?). During
this process, you can also learn about his or her using and nonusing friends.
You might ask, Do you have friends who dont smoke pot or get high? What
do they do? Another way to identify reinforcers is to ask whom the adolescent
looks up to or who is the most positive influence in his or her life. For
example, if a teenager talks about an older brother, you might ask, What 
is your brothers name? Keith? So, Keith really doesnt want you to use and
get in trouble again and have to go to jail. Later, in this or a subsequent
session, you may want to refer to his or her desire to please Keith by 
staying away from substance use because the teenager has identified Keith
as someone whose opinion is important to him or her.
If the opportunity presents itself, use praise throughout the functional
analysis of substance use to promote engagement and to move the 
adolescent in the right direction. For example:
Adolescent: Im not getting high as often as I used to.
Therapist: Thats excellent news, Johnny. How do you feel about
that accomplishment?
Adolescent: Good, I guess.
Therapist: Yes, I feel good about it also. Congratulations! What an
accomplishment!
At the end of the first session (and every session), praise the adolescent for
working with you. Communicate that the adolescent has provided useful
information and has worked hard.
Procedural Steps
1. Use strategies for building rapport.
2.  Provide an overview of ACRA.
3.  Emphasize that this approach has been successful with others. 

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4.  Explain the purpose of the functional analysis of substance use,
introduce the Functional Analysis of Substance Use Behavior form,
and gather information by:
  Identifying internal and external use triggers
  Identifying and further clarifying the substance use behavior
  Identifying the short-term positive consequences of using
  Identifying the long-term negative consequences of using.
5.  Summarize functional analysis of substance use information, and
praise the adolescent for participating in the session.
6. Complete the ACRA Procedure 1 ChecklistFunctional Analysis of
Substance Use Behavior immediately after the session.
Detailed Description
The remainder of this section contains a detailed overview for conducting a
functional analysis of substance use with an adolescent. Procedural steps
are in bold type and are followed by further directions and comments.
Sample dialogs between a therapist and teenager are indicated in italic type. 
1. Use strategies for building rapport.
The initial conversation with each teenager is critical in the rapport-building
process. Most adolescents who drop out do so early in treatment. During
the first two sessions, focus on the importance of engagement. Get the 
adolescent excited about working with you and about the treatment. Do not
let filling out forms overshadow the rapport-building process. 
Emphasize to the adolescent that you are glad to see him or her and you
are glad that he or she came. Praise the youth for completing the assess
ment or for participation in previous treatment (e.g., if he or she were in
residential treatment or intensive outpatient treatment before transferring
to regular outpatient treatment). Ask, Why did you decide to come to
treatment?  
Set positive expectations, for example, ACRA is a really good treatment and
has worked for a lot of kids like you. You might say, Im glad we get to
work together. Acknowledge the effort it took to come to treatment that
day: Im glad you came. I want you to get something out of this or You
can learn things that will be helpful for you. Note that it takes a lot of
courage to come to treatment. Tell the teenager, Anybody can get high; it
takes real courage and character to quit! Acknowledge some discomfort on
your part and tell the youth, I feel uncomfortable too at this point. We are
in this together.  
Explain that you will focus on what he or she wants to do in treatment.
Emphasize the adolescents independence. Give the adolescent the power to
pick and choose the focus of sessions. Let the adolescent guide and move in
the direction he or she desires. The goal is to give the teenager some sense

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of control during the therapy session. Tell the adolescent, Im not going to
ask you to do anything you dont want to do. You might also say, How can
I best help you?
Be patient; do not push an adolescent when he or she is resistant. Ask
open-ended questions as opposed to ones that require a short yes-or-no
answer like Do you like your Mom? Rather, you might say, Tell me a little
bit about your relationship with your Mom. Ask open-ended questions
about why he or she came to treatment, and let the teenager talk. Good
examples of open-ended questions or conversation starters are the following:
  Tell me a little bit about yourself.
  Tell me what brought you here today. 
  What do you think about being here?
  How do you hope to benefit from these sessions?
  Tell me more about whats going on in school.
  How would you describe how you are feeling today?
  Whats going on today?
Many adolescents are not very verbal, so be patient as you wait for responses,
and be willing to probe for additional information. Let adolescents know
that you are there because you want to help. You might say, Were going to
teach you skills you need to know; then you wont need me any more. Im just
a guide. This isnt forever. Emphasize that the process is time limited, that
is, We have a limited time to work together, so we need to try to accomplish
our business during the time allotted.  
Try other ways to build rapport. For instance, you could try shooting baskets
with a youth to build rapport. Feel free to provide food and a drink to a
teenager. The snacks are not only potentially reinforcing; they also help
keep energy levels up while the teenager is working on treatment issues.
Use the adolescents language. For example, when you are talking about
whom an adolescent from Philadelphia likes to associate with when using
marijuana, you might say, Who do you like to chill with when you are
smoking weed?
2.  Provide an overview of ACRA.
In the first session, give adolescents an overview of ACRA in simple, lay 
language appropriate for them. Tell the adolescents how many sessions are
involved both for themselves and their parents or caregivers during ACRA.
3.  Emphasize that this approach has been successful with others.
Emphasize that the approach has worked for other people like the 
adolescent and can work for him or her as well.
4.  Explain the purpose of the functional analysis of substance abuse,
introduce the Functional Analysis of Substance Use Behavior
form, and gather information.

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Before you begin this procedure, review and become familiar with the
teenagers assessment information. This will help you comment on and link
any relevant information from the assessment as you complete the items on
the Functional Analysis of Substance Use Behavior form. It also communicates
to a teenager that you are familiar with and understand his or her situation.
Explain the purpose of the functional analysis of substance use, bringing
any relevant assessment information into the conversation. Introduce the
adolescent to the Functional Analysis of Substance Use Behavior form; hand
the youth a copy so he or she can follow along during the process. 
A functional analysis of substance use consists of three basic parts: 
identifying external and internal triggers to the behavior, documenting 
the behavior, and identifying the positive and negative consequences of the
behavior. Point out the connections between the three steps of a functional
analysis of substance use: triggers lead to behaviors that in turn lead to
consequences (this is called the behavioral chain). During the introduction
of the functional analysis of substance use, you will need to explain terms,
such as triggers and consequences. Try to avoid using professional jargon
that could interfere with the rapport-building process.
Information from the functional analysis of substance use is recorded on a
form that can be placed in the clinical record for future reference. This
form reflects the basic steps of the analysis noted above. Use the Functional
Analysis for Substance Use Behavior (Initial Assessment) form. Blank and
sample completed copies of the Functional Analysis of Substance Use
Behavior form are included at the end of this section. 
Deemphasize the act of filling in the form, because many adolescents are
turned off by any activity that resembles school work. A good way to begin
the procedure is to ask an adolescent to tell you about a typical situation 
in which he or she uses marijuana or alcohol. As the teenager recounts a 
typical episode, he or she will provide you with much of the information
needed for the functional analysis of substance use. Later, you can ask 
additional questions to fill in any blanks. 
Here is an example of how a therapist might introduce the functional 
analysis of substance use:
Therapist: Id like to learn more about how you view your drug
use. Id like you to help me understand more about
your use. I have this form called a Functional Analysis
of Substance Use Behavior. Id like to fill it in. Could
you help me? Heres a copy for you. Were going to talk
about the types of things that led you to use marijuana
in the first place. These might be things in your 
environment or things you feel inside yourself. Later,
we will also talk about the positive and negative 
consequences of your marijuana use. Id like for you 
to describe a typical time when you use marijuana or
alcohol. 

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Go through the four steps of completing the Functional Analysis of
Substance Use Behavior form listed below.
Step 1: Identify internal and external use triggers and their associated
high-risk situations.
Triggers are thoughts, feelings, or behaviors that precede a using episode
and are instrumental in leading an individual to use. Reiterate that triggers
lead to behaviors, which in turn lead to consequences. (In fact, you may
want to write this on a board or clipboard before or after completing the
functional analysis of substance use.) External triggers are associated with
an individuals environment (whom they are with when they use, where they
typically use, when they typically use), whereas internal triggers are 
associated with an individuals internal states (what adolescents think
about, feel physically, feel emotionally before they use). Exhibit III1 presents
a sample of the section of the form about triggers.
Exhibit III1: Triggers

Explore with the adolescent the chain of events that set him or her up for
using marijuana and/or alcohol. Ask the teenager to give you an example of
a typical using episode. By addressing a typical, concrete situation, you can
ask specific questions about the event, but the teenagers responses usually
can be applied to many situations. If you need additional information about
external triggers, the following questions can be used:
  Whom are you usually with when you use? (Particular friends,
groups of friends, or relatives may serve as triggers to use.)
  Where do you usually use? (At home? At a friends house? In
the woods behind the school? At school dances? This question
presents a great opportunity to point out high-risk situations.)
  When do you usually use? (Are there particular days or times of
the day that the adolescent uses?)
External  Internal
1.  Whom are you usually with when you 
use?
Friends, sister, sisters boyfriend

2.  Where do you usually use?
Friends house (Sue)

3.  When do you usually use?
Nighttime
1.  What are you usually thinking about
right before you use?
Getting high and hanging out with
friends while everyone gets silly and
laughs a lot
2.  What are you usually feeling
physically right before you use?
Dont know
3.  What are you usually feeling
emotionally right before you use?
Bored

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As you are outlining triggers with a teenager, you may discover more than
one typical using situation. For instance, an adolescent typically may smoke
with a group of friends after school a few times per week, with friends every
weekend at a teen hangout in the woods, and alone in the familys attic 
during the week. The teenager may also typically drink beer with friends at
a party at least 1 weekend night. Each of these typical use situations should
be treated separately, but functional analyses do not need to be completed
for each situation. 
Teenagers are likely to be able to use the procedure for identifying external
triggers to identify other problems. If a problem situation is discussed, have
the adolescent try to identify the triggers for the new situation without 
filling out another form. Start with the situation that is most common for 
a teenager. If the teenager identifies several similar incidents, you may want
to group them together in one functional analysis of substance use. Often,
one analysis for weekday events and one for weekend events suffice. Here is
an example of an exchange about external triggers:
Therapist: Okay, lets talk about triggers. Do you know what a
trigger refers to?
Adolescent: Yes.
Therapist:  Okay, please explain it to me.
Adolescent:  Yeah, its like a thing on a gun.
Therapist:  What do you mean?
Adolescent:  Well, you pull it and it goes off.
Therapist: Okay, a trigger on a gun is like a trigger for drug use.
A trigger is something that leads to a behavior. For
example, a trigger to getting high may be hanging out
with friends who get high. Maybe the smell of marijuana
leads to wanting to get high. Does this make sense?
Adolescent: Yes.
Therapist: What are some of your triggers? What triggers you to
get high?
Adolescent: I dont know. I guess the people Im around, cause
everyone I know smokes weed.
Therapist:  So everyone you know smokes weed?
Adolescent:  Yeah, every day.
Therapist:  Hmmm, every day. What time of the day do you 
usually get high?

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Adolescent: Nighttime.
Therapist: I know you said everyone you know smokes weed.
Whom do you smoke with?
Adolescent:  My friends, my sister, my sisters boyfriend.
Therapist:  Where do you usually go to get high?
Adolescent:  Friends house.
Therapist: Which friends house?
Adolescent: Sues.
Next, ask the adolescent specific questions about his or her internal 
triggers. With a teenager who is having difficulty expressing his or her
thoughts or feelings, you might try using visual imagery, for example, Why
dont you close your eyes and imagine where you usually use marijuana.
Set up the scene where he or she tells you use occurs, and use imagery to
help the teenager finish describing the whole episode. For example, if the
adolescent typically uses in his or her bedroom, you could start by asking
the adolescent to visualize the bedroom. Then go through what happens
next. Another helpful approach with an adolescent (because of his or her 
emotional and cognitive developmental level) is to provide several examples
of the type of information desired. The following are probes that can be
used to identify internal triggers.
  What are you usually thinking about right before you use?
Identifying the thinking process is critical because the teenager
needs to see that, at some point, he or she makes a decision to
useusing is not an automatic process. Thoughts also provide
information on the adolescents defense system and valuable
insight into the feelings associated with using. For example, an
adolescent might say, I usually think about how much fun it
would be to get high with my friends.
  What are you usually feeling physically right before you use?
Bodily sensations can suggest different states of emotional 
arousal. For instance, a tight feeling in the chest, sweaty palms,
and restlessness may suggest anxiety.
  What are you usually feeling emotionally right before you use?
Identify how the teenager feels before using. For instance, it is
important to know whether he or she typically uses out of an
emotional reaction such as anger, frustration, or despair. Then
you can spend more time on teaching adaptive behaviors in
response to stress. Examine both positive and negative emotional
states. What emotional statements trigger using behavior? For
example, an adolescent who uses because of depression is making
a statement about that depression when using. In addition, you

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need to know whether an adolescent is using primarily because of
a need to affiliate with peers. 
Here is an example of a dialog about internal triggers:
Therapist: Okay. Thanks for sharing that information on the
external triggers. Youre doing great. Id like to ask you
more about the internal triggers you may have.
Adolescent:  Okay.
Therapist: Internal triggers are those that involve your thoughts
and feelings about getting high. What are you usually
thinking about right before you use?
Adolescent: I think about getting high and hanging out with friends. 
Therapist: Okay. It sounds as if you like to spend time with
friends. Tell me a little more about the getting high part.
Adolescent: Well, I look forward to us all being together and how
we pass a blunt around and then all get silly and laugh
and have fun.
Therapist:  What are you feeling physically right before you use?
Adolescent: I dont know. [It is acceptable not to get all the 
information initially; some adolescents will be better
able to describe their feelings later in treatment.]
Therapist: Okay. Do you know what youre feeling emotionally
right before you use?
Adolescent:  I feel boredtheres nothing to do.
Therapist:  Oh, you feel bored? I wonder if we could talk about
this more.
Adolescent:  Okay.
Therapist:  Does getting high help you to feel less bored?
Adolescent:  Yes.
Therapist: Okay, youre doing great. This is really helping me get
to know you better. Now I want to talk about what you
use, how much, and typically how long.

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Step 2: Identify and further clarify the substance use behavior.
As you move from the triggers to the using behavior itself, you have another
opportunity to impress on the adolescent the crucial connection between
these triggers and using. Say, Tell me about what goes on when you use.
In addition, as you talk with the adolescent about his or her use, you will
probably gather explicit details on patterns of use.
While focusing on the typical use situation identified above, gather explicit
details on the teenagers use of the substance. The information collected
should be as specific as possible.
  What do you usually use? 
  How much do you usually use? 
  Over how long a period of time do you usually use?
Here are more examples:
Therapist: Okay, youre doing great. Now Id like to ask a few
questions to make sure I clearly understand your use
pattern. Could you tell me what drugs you use most
often.
Adolescent: Marijuana mostly, but sometimes I drink.
Therapist:  Okay. Thanks for telling me. Lets talk about each 
separately starting with your marijuana use. When you
get high, how much weed do you use and how do you
use it (for example, in a joint or blunt)?
Adolescent: One or two blunts.
Therapist: Could you clarify: one or two?
Adolescent: Two.
Therapist: You said that you use at Sues. Do you get high every
day?
Adolescent: Its more like every other day.
Therapist: Okay. How much do you use and over what period of
time?
Adolescent: We smoke two blunts in about 2 hours.
Therapist: Okay. Once again thanks for reviewing this with me;
you are doing great. I appreciate your being open and
honest with me. Thats cool. Now I want to talk
about positive and negative consequences of getting
high.

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Exhibit III2 presents a sample of the section of the functional analysis
form about behavior.
Exhibit III2: Behavior
Step 3: Identify the short-term positive consequences of using.
Although drug abuse leads to long-term negative outcomes, adolescents
certainly must be experiencing short-term positive outcomes to continue
using. For instance, smoking marijuana may make adolescents feel more
relaxed, may make them feel more affiliated with peers, or may help them
temporarily forget their problems. It is important for you to acknowledge
these positive benefits. It is true that these benefits are short lived, but they
are enough to reinforce continued use.
The therapists goal is to help an adolescent find the same reinforcers in
a positive way. It often catches a teenagers attention when a therapist
starts talking to him or her about the positive aspects of marijuana use. The
approach is not judgmental, and, therefore, it can help engage the adolescent
in treatment. You may want to briefly mention that later you will help the
teenager find healthier ways to achieve some of these positive consequences.
While focusing on the typical-use situation, encourage the adolescent to
talk about the positive aspects of using the substance. You can begin this
procedure by saying, Im going to ask you something you may find 
surprising: What are the things you like about using pot? Here are some
additional ways to probe for short-term positive consequences of using:
  What do you like about using with [whom]?
  What do you like about using [where]?
  What do you like about using [when]?
  What are some of the pleasant thoughts you have while you are
using?
  What are some of the pleasant physical feelings you have while
you are using?
Behavior
1. What do you usually use?
Marijuana
2. How much do you usually use?
Two blunts, every other day
3. Over how long a period of time 
do you usually use?
A couple of hours

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  What are some of the pleasant emotional feelings you have while
you are using?
For example:
Therapist: When I say consequence, what do you think I mean?
Adolescent: Well, something that happens afterward.
Therapist: Okay, yes. Its the result of a behavior, right?
Adolescent: Yeah. 
Therapist:  Okay. Well, usually there are both positive and negative
consequences of smoking marijuana. Could you tell me
more about what you think the positive consequences
of getting high are? What are some pleasant thoughts
you have while you are high?
Adolescent: I think about chilling and my future. 
Therapist: Okay. What are some of the pleasant physical feelings
you have while getting high? [Therapist could also try
to probe into what the adolescent is thinking about
his or her future.] 
Adolescent:  I feel relaxed.
Therapist:  Okay. What are some of the pleasant emotional feelings
you have while using?
Adolescent:  I feel mellow. 
Therapist: Tell me, what do you like about getting high with your
friends, your sister, and her boyfriend?
Adolescent: Its cool to hang out with themtheyre older than me.
Therapist: Oh, I see. What do you like about getting high at Sues
house?
Adolescent: Her mother is never around. So its cool there.
Therapist: Is there anything you like about getting high at night?
Adolescent: Its cool to just hang out and chill.
Step 4: Identify the long-term negative consequences of using.
Up to this point, the functional analysis of substance use has served to lay
the groundwork for showing the adolescent the long-term negative 

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consequences that result from the using behavior just outlined. Now turn
your attention specifically to the problems associated with the teenagers
use of marijuana, other drugs or alcohol.
Focusing on the specific situation outlined at the beginning of the process,
explore with the adolescent the problems that are associated with his or her
using behavior. Probe for additional problems under each problem category.
For instance, Can you think of people youve had a problem with because
of your marijuana use? If the adolescent is having difficulty providing an
example, you may want to offer examples, such as those below from the 
adolescents assessment information. You might ask, What are the negative
results of your use regarding each of these?
  Family members
  Friends
  Physical problems
  Emotional problems
  Legal consequences
  School problems
  Job problems
  Financial problems
  Other problems.
The goal is for the teenager to see the connection between substance use
behavior and negative consequences. Although the adolescent may not
always be willing to acknowledge the relationship between substance use
and negative consequence, he or she may see the connection. An adolescent
may mention a problem, and you may want to try to help him or her make
the connection between substance use and this problem. For example, Do
you see that there is a connection between your legal problems and your
use of marijuana?   
Some teenagers may completely resist verbalizing any negative conse
quences of their substance use. It is important for the ACRA therapist to
accept the clients resistance and not to confront the adolescent. The
Functional Analysis of Substance Use Behavior form and requests for specific
information can be revisited at a later session after the relationship
between the therapist and adolescent has had time to develop. 
Here is an example of a dialog about negative consequences:
Therapist: Okay. Now that I understand what the positive 
consequences of using are, Id like to ask you about
some of the negative or bad consequences. For 
example, how does getting high negatively affect 
your relationship with family members?
Adolescent: Well, my mother gets on my back, and my father takes
privileges away.

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Therapist:  It sounds as if getting high causes problems between
you and your parents.
Adolescent:  Yeah, I guess so.
Therapist:  How does getting high affect your friendships?
Adolescent: My girlfriend wants me to stop using.
Therapist: It sounds as if she really cares about you and wants
you to stop using?
Adolescent:  Yeah.
Therapist: How else does smoking affect you negatively? Tell me
about any negative physical effects you have from
using?
Adolescent: Like forgetting things? 
Therapist:  Yes, what else?
Adolescent: I often get dry mouth.
Therapist: Yes, dry mouth and memory problems are associated
with marijuana use. Do you have any other negative
physical feelings?
Adolescent:  Sometimes I get tired.
Therapist: Emotionally or physically tired?
Adolescent: Both, like I want to just lie around the house.
Therapist:  Like you dont want to do much?
Adolescent: Yeah. I dont want to do anything.
Therapist: Do you feel any negative consequences with other
parts of your life like with your school or job, or 
legally?
Adolescent: Yeah. I got suspended from school for smoking outside
the school.
Therapist:  So it sounds as if getting high affects your life in
school.
Adolescent:  Yeah, I got suspended, and now I have to come here.
Therapist:  Do you think getting high has affected you legally?

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Adolescent: What do you mean by legally?
Therapist: I mean getting probation and going to court.
Adolescent: Okay, yeah. Im on probation because I got caught
smoking.
Therapist: Do you spend money on marijuana?
Adolescent: Yeah.
Therapist: How much do you spend a day?
Adolescent: I spend about $5 a day.
Therapist: Okayso thats about five times four [days per week],
which is $20 a week. Lets do the math. So $20 times
four [weeks] is $80 a month . . . and $80 times 12
months is $960 a year. 
Adolescent: Wow, thats a lot of money.
Therapist: It sure is. What do you think you might spend that
money on instead of marijuana (or if you werent 
getting high)?
Adolescent: Clothes, a car, give it to my girlfriend.
Therapist: Oh, okay. So you would have use for that money?
Adolescent: [Laughs.] Yeah.
Therapist: You would! Okay! Well, thats a little confusing to me,
because it seems as if you are spending your money on
things like weed. I wonder if you could explain this to
me?
Adolescent: Well, I spend money to buy weed.
Therapist: I see. So, if you stopped smoking weed, would you
have more money?
Adolescent: I guess so. Yeah.
Therapist: Wow. Thanks for helping me understand this. Let me
see whether Ive got this right. You could save money 
if you didnt buy weed, and if you didnt smoke weed,
you wouldnt buy it. So, not smoking weed would 
actually save you money? Is that correct?
Adolescent: Yeah. I never thought about that.

42

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Therapist: Yes, its pretty cool. Isnt it?
Adolescent: Yeah.
Therapist: Are you interested in saving money?
Adolescent: I guess so.
Therapist: Okay. How do you think you could begin to save
money?
Adolescent: I could smoke less often.
Therapist: Yes, you could. Thats an excellent idea. Id like to help
you. Would that be okay?
Adolescent: Yeah.
Therapist: Good. Im wondering whether we could talk more
about the other things youd spend your money on? Id
also like for you to track the amount of money you
spend each time you get high. Would that be okay?
Adolescent: Yeah.
Therapist: Okay. Good. Lets talk more about how to do this
when we meet next time, but could you start to keep a
log of the amount of money you spend on weed?
Adolescent: Sure.
Exhibit III3 presents a sample section of the functional analysis form about
consequences.
5.  Summarize functional analysis of substance use information, and
praise the adolescent for participating in the session.
After completing the functional analysis of substance use, summarize for
the adolescent the information gathered through the process to ensure that
the functional analysis of substance use is accurate. Do not forget to use
positive reinforcement or to praise the teenager for his or her work and 
participation in the session.
This process provides the adolescent an opportunity to clarify use patterns
and provides insight into the behavioral chain involved in his or her use.
Most important, the information gained from the functional analysis of 
substance use provides the framework for the goals of counseling work that
will follow. As illustrated in the earlier sample dialog, much information can
be gathered that will be useful in later sessions. For example, you can see in 
the positive consequence column that several elements are reinforcing this
adolescents marijuana use. He likes to hang out with older kids and feels 

43

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Exhibit III3: Consequences
Short-Term Positive Consequences  Long-Term Negative Consequences

1. What do you like about using with
friends?

[who]
They are older.
2. What do you like about using at
Sues house?

[where]
Sues mother isnt home.
3. What do you like about using at
night?

[when]
Its cool to hang out and chill.
4. What are some of the pleasant
thoughts you have while you are
using?
Chilling/my future
5. What are some of the pleasant 
physical feelings you have while you
are using?
Feel relaxed
6. What are some of the pleasant 
emotional feelings you have while
you are using?
Feel mellow 
1. What are the negative results of
marijuana use?
(behavior/activity in each of these
areas):
a. Family members 
Mother gets on back; father takes
away privileges.
b. Friends
Girlfriend wants me to stop using.
c. Physical feelings
Forgetting things, tired, dry mouth
d. Emotional feelings
Feel lazy
e. Legal situations
Probation, having to go to court
f. School situations
Suspended from school
g. Job situations
Not working
h. Financial situations
Spending $5 per day, $20 per
week, $80 per month, $960 per
year when using
i.  Other situations

relaxed when using. It also appears that he has provided good information
about his girlfriend that can be used later. It seems clear that he sees her as
reinforcing his not using.
You should already be planning how to use this information in your work
with the teenager to help him or her find ways of achieving desired feelings
in healthier ways. In the example above, part of the process will include (at
some point) asking the teenager why he likes to hang out with older kids. Is
it because it helps boost his feelings of self-esteem or power? It would also
be appropriate for the therapist to mention that she or he will be explaining
later in treatment how the adolescent and therapist will work together to
solve problems and to find healthier ways to relax or hang out with older
kids (or find other ways to feel more powerful or boost the adolescents
confidence).

44

-----------------------------------------------
6. Complete the ACRA Procedure 1 ChecklistFunctional Analysis
of Substance Use Behavior immediately after the session.
A blank copy of this form is included at the end of this section.

45

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Functional Analysis for Substance Use Behavior 
(Initial Assessment)

Triggers     

                                    Short-Term Positive    Long-Term Negative   
External                  Internal                Behavior Consequences  Consequences
1. Whom are you 1. What are you  1. What do you  1. What do you like 1. What are the
usually with     usually thinking usually use? about using with          negative  results
when you use? about right  _____________? of _____________
before you use? (whom)                  (behavior/activity)
regarding each of
these areas:
2. Where do you  2. What are you  2. How much 2. What do you like a. Family 
usually use? usually feeling do you usually about using members
physically right  use? _____________?
before you use? (where) b. Friends
c. Physical
feelings
3. When do you  3. What are you  3. Over how 3. What do you like
usually use? usually feeling long a period       about using                 d. Emotional
emotionally right do you usually  _____________? feelings
before you use? use? (when)
e. Legal
situations
4. What are some of         f.  School
the pleasant     situations
thoughts you have            
while you are using?       g.  Job situations
h. Financial
situations
5. What are some of          
the pleasant                i.  Other    
physical feelings situations
you have while you 
are using?

6. What are some of 
the pleasant 
emotional feelings
you have while you 
are using

-----------------------------------------------
             SAMPLE
Functional Analysis for Substance Use Behavior 
(Initial Assessment)

Triggers     

                                    Short-Term Positive    Long-Term Negative   
External                  Internal                Behavior Consequences  Consequences
1. Whom are you 1. What are you  1. What do you  1. What do you like 1. What are the
usually with     usually thinking usually use? about using with          negative  results
when you use?          about right before       Marijuana Friends? of marijuana use
Everyone I know you use? (whom) (behavior/activity)
smokes weed, Getting high and They are older regarding each of 
friends, sister, hanging out with than I am. these areas:
sisters boyfriend       friends
a. Family members
Mom gets
on my back.  
Dad takes away
my privileges.
2. Where do you  2. What are you  2. How much 2. What do you like
usually use? usually feeling do you usually about using b. Friends
My friends physically right  use? at Sues house? Problems with
(Sues) house before you use? One or two (where) girlfriend. My
I dont know. blunts every Its cool there; girlfriend wants
other day her mom is never me to stop    
around. using.  
c. Physical feelings
3. When do you  3. What are you  3. Over how 3. What do you like Forget things,
usually use? usually feeling long a period       about using dry mouth, and
Nighttime emotionally right      do you usually at night? tired
before you use? use? (when)
Bored Over a couple Its cool to just d. Emotional
of hours hang out and chill feelings
Feel lazy
e. Legal situations
4. What are some             On probation;
of the pleasant                having to go to
thoughts you have            court
while you are 
using? f.  School
Chilling/my future situations
Suspended
from school
5. What are some of     
the pleasant                g. Job situations   
physical feelings Not working
you have while you  
are using? h. Financial          
Feel relaxed situations
Spend all my
money on weed
6. What are some of          i. Other   
the pleasant     situations
emotional feelings
you have while you      
are using?
Feel mellow

-----------------------------------------------
Date_______  Session #_____  Adolescent ID_____  Therapist Init.________
     ACRA Procedure 1 Checklist
Functional Analysis of Substance Use Behavior

                   Check Appropriate Boxes
Activity    In Progress      Yes       No
1.  Did you establish a positive atmosphere 
for change?    
2.  Did you build rapport with the adolescent 
by asking open-ended questions, using the 
adolescents language, and praising the 
adolescent for working with you?    
3.  If this is the first session, did you provide 
an overview of the ACRA intervention 
without using jargon?    
4.  Did you emphasize that this approach
has been successful with many people?    
5.  Did you explain the purpose and process 
behind the functional analysis of        
substance use?    
6.  Did you introduce the Functional Analysis 
of Substance Use Behavior form and go   
through the steps for completing it?    
7.  Did you work with the adolescent to 
identify triggers for substance use and 
associated high-risk situations?    
8.  Did you identify and further clarify the 
substance use behavior?    
9.  Did you identify the short-term positive 
consequences of using and point out that 
these benefits are short lived?    
10.  Did you identify the long-term negative 
consequences of using?    
11.  Did you summarize the information 
provided during the functional analysis of 
substance use and help the adolescent see 
the behavioral chain involved in his or her 
use?    

-----------------------------------------------
Procedure 2: Functional Analysis of Prosocial Behaviors
Rationale
The functional analysis of prosocial behaviors is an important contribution
to the substance abuse treatment field. Unlike many treatment approaches
that focus solely on the negative consequences of substance use to 
motivate an adolescent to change, the ACRA intervention goes beyond
negative consequences and uses positive, enjoyable activities as motivators
to change (Azrin, Donohue, et al., 1994; Azrin, McMahon, et al., 1994;
Meyers & Smith, 1995). However, before pleasurable activities can be 
used as motivators, they have to be behaviorally defined.  
Begin this procedure by asking the adolescent to describe activities he 
or she enjoys that do not involve using alcohol or drugs. Then, as in the 
procedures for the functional analysis of substance use behavior, explore
with the adolescent the triggers and consequences of these prosocial
behaviors or activities that the adolescent enjoys.
Purposes of the Procedure and Learning Objectives
The purposes and learning objectives of this procedure are to help the 
adolescent:
  Identify pleasurable nonusing (prosocial) behavior
  Identify positive triggers for prosocial behavior
  Identify the short-term negative consequences of prosocial behavior
  Identify the long-term positive consequences of  prosocial behavior
  Identify a real life activity related to increasing prosocial activity
and commit to trying it.
Timing, Audience, and Delivery Method
This procedure should be completed within the first three treatment 
sessions and then revisited as needed during treatment. Conduct it 
individually with the adolescent.
Materials
General materials include snacks (e.g., chips, crackers, granola bars, fruit
bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 
applicable) a videocamera and videotapes or an audiotape recorder and
audiotapes.  
Procedure-specific materials include a clipboard, pens, two Functional 
Analysis of Prosocial Behavior forms, activity lists, and the handouts What
Else Can I Do? and Activities That May Interest You.

49

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General Notes for the Therapist
Once again, maintain a positive and enthusiastic tone of voice to establish 
a positive atmosphere for change. Find even small things to praise to keep
the adolescents motivation high for participation in the intervention.
The functional analysis of prosocial behaviors, like the functional analysis 
of substance use behavior and the treatment plan, is a work in progress, 
not a one-shot effort. It may be necessary to revisit the functional analysis
process throughout the treatment episode as the adolescents behaviors and
needs change. The procedures outlined below can be repeated as needed.
Procedural Steps
1. Explain the purpose of the functional analysis of prosocial behavior.
2. Introduce functional analysis, and gather information by:
  Briefly reviewing the Functional Analysis of Prosocial
Behavior form
  Identifying and obtaining details on pleasurable nonusing
behavior
  Identifying positive external and internal triggers for 
prosocial behavior 
  Identifying the short-term negative consequences of the
prosocial behavior
  Identifying the long-term positive consequences of the 
prosocial behavior.
3.  For accuracy, summarize the information discussed for the Functional
Analysis of Prosocial Behavior form, and help the adolescent see the 
overall picture.
4. Assign homework.
5. Complete the ACRA Procedure 2 ChecklistFunctional Analysis of
Prosocial Behaviors immediately after the session.
Detailed Description
The remainder of this section contains a detailed overview for conducting a
functional analysis of prosocial behaviors with an adolescent. Procedural steps
are in bold type and are followed by further directions and comments. Sample
dialogs between a therapist and an adolescent are indicated in italic type.
1. Explain the purpose of the functional analysis of prosocial behavior.
Explain to the adolescent that there are activities that he or she has
enjoyed that did not involve alcohol or drugs. The purpose of this functional
analysis is to discover what those activities are, to discover what the 

50

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triggers for them are, and to work on increasing opportunities to engage 
in these prosocial behaviors.
2.  Introduce the functional analysis, and gather information.
Briefly review the Functional Analysis of Prosocial Behavior form. Copies 
of blank and completed Functional Analysis of Prosocial Behavior forms 
are included at the end of this section. Provide a copy of the form to the 
adolescent to allow him or her to follow along. You can record relevant
information on the form either during or after the session, depending 
on what you think will work best with a particular adolescent.
Identify and obtain details of pleasurable nonusing behavior. The 
information gathered here goes into the middle column of the behavior
chart.
  What is the nonusing behavior/activity? 
  How often do you usually [activity]?
  How long does [activity] last?
As with the functional analysis for substance use, one form is completed 
for a specified activity. For instance, suppose a young woman says that she 
really likes dancing. The teenager attends dance class twice per week and
goes dancing with friends on the weekend. The Functional Analysis of 
Prosocial Behavior form can be filled out by specifying her enjoyment 
of dance class. Then without necessarily filling out another form, you can 
see whether she can generalize from the first process and provide similar 
information for another pleasurable activity (e.g., dancing with friends 
on the weekend).  
Following is an example of explaining the functional analysis of prosocial
behavior process and identifying a pleasurable nonusing behavior:
Therapist: Gina, now were going to look at some of the positive
activities in your life that dont involve using drugs or
alcohol. One of the things we do while working together
is try to help you increase the things in your life that
are positive, the things that make you happy. Tell me a
little bit about how you spend your spare time. Id like
to talk about interests you have other than getting high.
What activities do you really enjoy?
Adolescent: I like pedal biking.
Therapist: Oh, what is pedal biking?
Adolescent: Its like riding a regular bikenot a dirt bike.

51

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Therapist: Oh, I understand. Id like to hear more about pedal
biking. [The therapist gives the adolescent the
Functional Analysis of Prosocial Behavior form.] This
form is called a functional analysis; its very similar to
the form we filled out last time. Id like you to follow
along with me as we go through the questions. Does
that sound okay with you?
Adolescent: Yeah.
Therapist: Okay, good. Lets get started.
If the adolescent has difficulty identifying prosocial behaviors he or she
enjoys, try the following:
Develop lists of activities that are available in the community. Examples of
such lists, called What Else Can I Do? and Activities That May Interest You,
are included at the end of this section. The first one simply lists activities
available in the local area, and the second one provides lists of categories of
fun things to do by the name of businesses and their addresses and phone
numbers. These lists can be developed by working with adolescent groups
wherever they are foundin community centers, schools, or treatment
settings. When adolescents say there is nothing to do besides use drugs or
they just have trouble generating different ideas, present the lists to help
stimulate new thoughts. You can say, This list may give you some ideas of
things you would like to do that maybe you have not thought of doing.   
Another approach is to ask, What is something you really enjoyed doing in
the past that did not involve alcohol or drugs?; What is something that
you have always wanted to do?; or What is something you have seen some
one else try that you thought was pretty cool? Once an activity is selected,
either from an activity list or from activities the adolescent is already
involved in, you can begin working on the functional analysis.
Identify positive external and internal triggers for prosocial behavior. As
you did with the functional analysis of substance use, ask about external
and internal triggers. Start with specific questions about external triggers.
  Whom are you usually with when you [activity]? 
  Where do you usually [activity]? 
  When do you usually [activity]?
Then, move to internal triggers.
  What are you usually thinking about right before you [activity]?
  What are you usually feeling physically right before you [activity]?
  What are you usually feeling emotionally right before you 
[activity]?

52

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It is important to help an adolescent make the distinction between a 
trigger that leads to drug use and a trigger that leads to prosocial behavior.
Certain feelings or events may trigger both using behavior and prosocial
behavior. For instance, feeling tired may prompt a person to smoke marijua
na at one time and to go for a walk at another time. Help the adolescent
discern what other factors influence him or her to use rather than to take 
a walk. Once this is determined, it may be helpful to shift the focus of the
session to refusal skills or problem-solving skills, as appropriate.  
Here is a sample exchange to determine triggers for the pedal biking 
prosocial behavior mentioned in the example above:
Therapist: Who do you usually pedal bike with?
Adolescent: Friends.
Therapist: A group of friends or one friend.
Adolescent: Usually about five friends.
Therapist: Where do you usually pedal bike?
Adolescent: In North Philadelphia, on Broad Street.
Therapist: Okay. What time of the day do you usually pedal bike?
Adolescent: From about 4:30 till 8.
Therapist: Do you mean in the evening?
Adolescent: Yeah!
Therapist: Okay. Thanks for clarifying that. Tell me more about
what you think about right before you go pedal biking.
Adolescent: About where to go and about riding my bike.
Therapist: Tell me more about that.
Adolescent: Well, I think about how I want to get out of my house,
get with my friends, and ride around and see whats
going on.
Therapist: Okay. Do you remember what you feel before you pedal
bike? Do you feel any certain way physically? 
Adolescent: No.
Therapist: Okay, how about emotionally?
Adolescent: Cool, I guess.

53

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Therapist: Okay, great! How often do you pedal bike?
Adolescent: About two times a week.
Therapist: How long do you usually pedal bike?
Adolescent: A few hours.
Therapist: Okay. Youre doing very well! It sounds as if you really
enjoy pedal biking. 
Adolescent: Yeah, its cool.

Identify the short-term negative consequences of the prosocial behavior. 
Sometimes enjoyable activities also have unpleasant aspects to them.
Although the unpleasant aspects of a fun activity are usually immediate and
brief, they can sometimes deter an adolescent from engaging in them at all.
Examples of unpleasant aspects of fun are that the activity costs money or
is a long distance away, that the adolescent does not have any friends to
share the activity with, or that he or she has to get up early to do it or has
difficulty fitting it into his or her day. Listen to any negative aspects of the
intervention and determine how much of an obstacle or threat they are.
How much of a deterrent are they? Are the negative consequences serious
enough to keep an adolescent from engaging in the prosocial behavior?
Problem-solving techniques may need to be used to help the adolescent 
figure out ways to solve problems that present barriers or result in negative
consequences of engaging in the behavior.  
Thus, it is important to acknowledge the negative aspects of the activity
before moving on to the positive consequences. A negative consequence
may be something as simple as lack of access to the reinforcer. Be sure to
brainstorm ways to overcome these obstacles. If, for example, the adolescent
would enjoy going to the library but does not have a library card, help the
adolescent obtain a card. For example, ask, How can we get a library
card? Never assume that the adolescent will make the initial contact 
independently. Encourage the adolescent to take steps toward obtaining
desired reinforcers but be willing to locate and speak to a contact person 
in advance if there is an activity available. Be sure to review the adolescents
experience at such an event at the next session.
If the adolescent cannot think of any negative aspects to the enjoyable
activity, do not push too hard because you want to keep the relationship
positive.
  What do you dislike about [activity] with [whom]?
  What do you dislike about [activity] [where]? 
  What do you dislike about [activity] [when]? 

54

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  What are some of the unpleasant thoughts you have while you
are [activity]?
  What are some of the unpleasant physical feelings you have
while you are [activity]? 
  What are some of the unpleasant emotional feelings you have
while you are [activity]?
The following is an exchange about negative consequences of the prosocial
behavior:
Therapist: Okay, now Id like to ask you about the negative 
consequences of pedal biking. Is there anything that
you dislike about pedal biking?
Adolescent: Yeah, when I catch a flat.
Therapist: Okay, how about biking in North Philadelphia? Is there
anything you dislike about where you pedal bike?
Adolescent: Well, sometimes when Im not in my own neighborhood,
I dont know the people that are around.
Therapist: Okay, thanks for being honest with your answer;
youre doing very well! Is there anything else you 
dislike about when you pedal bike?
Adolescent: No.
Therapist: Okay. When you are pedal biking, do you ever have
unpleasant thoughts?
Adolescent: Yeah, that a car might hit me.
Therapist: So it makes you uncomfortable, maybe a little nervous
about whether you can trust people you dont know or
the drivers in cars?
Adolescent: Yeah, thats right.
Therapist: How about any unpleasant physical feelings you may
have?
Adolescent: Yeah, like being thirsty, hungry, and sweaty!
Therapist: That happens. I understand. Do you have any 
unpleasant emotional feelings?
Adolescent: Yeah, I get scared that a car will hit me.

55

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Therapist: That is scary; have you ever been hit?
Adolescent:  No.
Therapist: Good! Okay, you did a great job with this part!
Identify the long-term positive consequences of the prosocial behavior.
Spend time probing this topic so that there is no question about what the
adolescent finds reinforcing. You might say, It looks as if you are into 
dancing (or whatever activity has been mentioned). What do you like about
dancing? Behaviors or activities that are reinforcing in many different
areas of the adolescents life, such as those listed below, are good 
candidates for behaviors that can compete with using drugs (Meyers &
Smith, 1995, p. 33).
What are the positive results of [activity] in each of these areas? 
  Family members 
  Friends 
  Physical feelings 
  Emotional feelings 
  Legal situations
  School situations
  Job situations
  Financial situations
  Other situations.
The following dialog is an example of probing to find the positive 
consequences of an activity:
Therapist: Do you think there are positive consequences of pedal
biking?
Adolescent: What do you mean?
Therapist: I mean that because you like to pedal bike, do you
think that there are positive parts of pedal biking? For
example, do you think that pedal biking has a positive
effect on your relationship with your mother?
Adolescent: Yeah, shes happy because it keeps me off the corner.
Therapist: Okay, great! Do you think that it has affected your 
relationship with friends?
Adolescent: Yeah, I see more people when I pedal bike.
Therapist: Okay, good. Do you think that there are positive 
physical consequences of pedal biking?
Adolescent: Yeah, I can ride farther now.

56

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Therapist: Oh, so pedal biking seems to have positive consequences
physically. How about emotionally?
Adolescent: I feel as if I have more energy.
Therapist: Energy sounds more like a physical feeling. When I say
emotional, Im thinking about whether you feel happy,
sad, bored, or something like that. What emotion do
you think you feel?
Adolescent: Okay. Well, Im happy because I do it with my friends.
Therapist: Good. How about legally? Has pedal biking had any
positive consequences on your legal situation?
Adolescent: Yeah, it keeps me out of trouble.
Therapist:  Yes, that is a positive consequence!
Adolescent: [Laughs.]
Therapist: Okay, has it had a positive effect on school?
Adolescent: No, I dont think so.
Therapist: Well, you mentioned that you felt as if you had more
energywhat is the connection between that high 
energy and getting homework done?
Adolescent: Well, by the time I get home, Im pretty tired so I dont
always feel like doing my homework then.
Therapist: Oh, I see. How about with a job?
Adolescent:  Well, I could ride my bike to work.
Therapist: Thats right! Good thinking! How about financially?
Would pedal biking have positive financial consequences?
Adolescent: Um, yeah. I could ride it to work and save money.
3.  For accuracy, summarize the information discussed for the
Functional Analysis of Prosocial Behavior form, and help the 
adolescent see the overall picture.
After completing the Functional Analysis of Prosocial Behavior form, 
summarize the information gathered through the process so the adolescent
can ensure that it is correct.
The information gained from the functional analysis of prosocial behavior
provides additional material for the goals of counseling work that will follow

57

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and for subsequent sessions. Work continually with the adolescent to
increase the amount of time he or she is engaged in prosocial activities 
that do not involve substance use.
4. Assign homework.
Work together with the adolescent on a homework assignment, such as
finding information about an activity or sampling a new activity identified
during the session. Another homework option is to increase one or more
pleasurable activities identified through the functional analysis of prosocial
behavior. The homework assignment should specify the number of times or
the amount of time the adolescent will engage in the activity. At the next
session, you should discuss with the adolescent any obstacles he or she
encountered while trying to complete the homework assignment.  
If the adolescent appears unsure of his or her ability to perform these types
of tasks, it would be good idea to make some of the initial steps during the
session (e.g., call to find out when a facility is open or what the cost of
admission is, or talk with a caregiver about helping with transportation).
Do not forget to provide positive reinforcement or praise the adolescent for
his or her work and participation in the session.
5. Complete the ACRA Procedure 2 ChecklistFunctional Analysis
of Prosocial Behaviors immediately after the session.
A blank copy of this form is included at the end of this section. 

58

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Handout
WHAT ELSE CAN I DO?
(SampleMidwest)

skateboard
go out to eat
go to the movies
go shopping
rent a movie
walk around the    
mall
watch TV
go camping
lift weights
do aerobics
ride a motor
cycle
play baseball
jog
go to Six Flags
ride a bike
join a youth  
group
play hockey
barbecue
go on a picnic
play volleyball
play golf
walk
listen to music
go to a sporting 
event 
play football 
skydive
play softball
play cards
attend a play
be in a play
travel
go camping
ride horseback 
rollerblade
bowl
work at a craft
walk the dog
play a video game
use a computer
go to the park
ride a hot air 
balloon 
attend a car show
play pool
box
go bungee 
jumping
take flying 
lessons
talk on the phone
go to a zoo
go to a museum
play a board   
game
make a pizza
go to a concert
learn to cook
go canoeing
write a letter
read a book
find a hobby
go skiing 
visit grandparents
go to a library
mow the lawn
learn something 
new
draw 
paint
write a poem
rearrange your   
room
get a job
help a neighbor
bathe a pet
test drive a car
hike
learn archery
play miniature 
golf
plant flowers
paint your room
go to a science 
center
shovel snow
start a journal
make a snowman
go snow sledding
go to an airshow
watch airplanes
visit caves
write a story
ride Metrolink
learn about 
computers
sing
play soccer
play a musical   
instrument
collect baseball 
cards
write a song
go snowboarding
get a makeover
do your nails
look at stars
play tennis
swing
pick flowers
put up new 
posters
help clean house
learn to take 
pictures
make a scrap 
book
organize your 
closet 
make candles
try new foods
go dancing
try a new dance
go fishing
take an art class
go to batting 
cages
go to a carnival
swim
go to an amuse
ment park 
sunbathe
play Ping-Pong
make/decorate 
pottery 
go to car races
go to driving 
ranges
scuba dive
ride go-carts 
do gymnastics
make stained 
glass
try karate classes
try paintball
go rock climbing
get ice cream
go ice skating
play racquetball
take carriage/
sled rides
go to a waterpark
take a nap
start a collection
get a different 
haircut  
go boating
try jet skiing
exercise
run an errand for 
someone
go hunting
write rap music
take a class
play basketball
join a sports 
team
play laser tag
study for your 
drivers test
go to the YMCA
wash the car

-----------------------------------------------
Handout
WHAT ELSE CAN I DO?
(SampleNortheast Urban Area)

babysit
have your hair treated or 
permed
braid your hair
help your family with 
food shopping
talk to neighbors
train for a triathalon
bake a cake
erase graffiti
play at PAL (police ath
letic league)
speak to a group about 
being drug free
watch the Learning 
 Channel
watch the Discovery 
 Channel
watch MTV or VH1
recite a rhyme
eat Chinese food
make grits
study for your drivers 
permit
go to Dorney Park
go to Great Adventure
go to the mountains
go to the beach
ride a bicycle
ride a unicycle
go to the circus
go to the ballet
be on the student 
council
visit the Statue of 
 Liberty
visit the Liberty Bell
go to Sesame Place
fix a car
surf the Internet
go food shopping for an 
elderly or sick person
shovel snow for an elder
ly or sick person
see a Philadelphia 76ers 
game
see a Phillies game
see an Eagles game
see a Flyers game
go to Dave & Busters
go to family game rooms
ride a dirt bike
attend summer school
attend the youth empow
erment project
go jogging
buy stereo equipment
listen to a Walkman or 
 Discman
learn to swing dance
learn to ballroom dance
deliver newspapers
work on an ice cream 
truck
see a Broadway show
go to New York City
go to Washington, D.C.
go to a gallery
fix a bike
fix a radio
play water polo
play basketball
play baseball
play tennis
play hopscotch
run track
go to a park
go whitewater rafting
join Neighborhood Watch
play Nintendo 64
go to Club Mcdonalds
go to club dances
learn to sew
learn to crochet
learn to knit
learn to read music
learn to play the piano
learn to play the guitar
take a horse and buggy 
ride
run up the art museum 
steps
hug someone
smile
laugh

-----------------------------------------------
SAMPLE
Handout

ACTIVITIES THAT MAY INTEREST YOU

Aircraft Flight Instruction
Metro-East Airport   2070 Triad Rd., St. Jacob 6445411
(Shafer Field) 
Langa Air, Inc. 10 Terminal Dr., East Alton 3148958911
Amusement Places
Aladdins Castle 133 St. Clair Sq., Fairview Hts. 6321027
Family Fun Tyme 8 Gateway Dr., Collinsville 3447747
Family Fun Tyme 1 Schiber Ct., Maryville 2887747
G & B Amusement Co.     6930 W. Main, Belleville 3977609
Games People Play 699 S. Bluff Rd., Collinsville 3450885
Time Out 131 St. Clair Sq., Fairview Heights 6321027
Time Passages Arcade 321 Broadway, Alton 465-1270
Amusement Parks
Six Flags I44 & Allenton Rd. 
Eureka, MO    3149384800
Antiques
Alton Landing Antiques    110 Alton St., Alton 4620443
Antique Emporium 100 E. Warren, Bunker Hill 5853929
Broadway Antiques 217 E. Broadway, Alton 4650423
Belleville Antique Mall      208 E. Main, Belleville 2346255
Richards Antiques 2 N. Main, Wood River 2545793
Maryville Antique Mall      2114 S. Center, Maryville 3455533
MC Antiques and More     126 E. Chain of Rocks, Granite City 7972581
Pywacket Antiques 215 E. Central, Benld 2178352970
Wagon Wheel Antiques     National and Academy, Pocahontas 6692918
Aquariums (Public)
Mid-America Aquacenter  416 Hanley Industrial Ct.      
St. Louis, MO 3146479594
Aquariums
Aqua Pets 5733 Godfrey Rd., Godfrey 4663474
Oceans Windows Pets 2755 E. Broadway, Alton 4626353
The Swamp 2324 Nameoki Rd., Granite City 4511852
Archery Ranges
Bullseye Archery 405 E. U.S. Hwy. 40, Troy 6678616
Town Hall Archery Shop   Hwy. 15 and 59th St., Belleville 2359881

-----------------------------------------------
Functional Analysis of Prosocial Behavior
______________________                              
(behavior/activity)
Triggers
                                      Short-Term Negative Long-Term Positive
External Internal  Behavior Consequences           Consequences

1. Whom are you 
usually with    
when you 
______________?
(behavior/activity)

2. Where do you 
usually
_____________?

3. When do you 
usually 
_____________?
1. What are you    
usually think
ing about right  
before you 
_____________?
(behavior/activity)

2. What are you  
usually feeling
physically right  
before you 
_____________?

3. What are you 
usually feeling
emotionally
right before 
you 
_____________?
1. What is the 
nonusing   
behavior/activity?
_____________

2. How often do   
you usually
_____________?

3. How long does 
_____________
usually last?
1. What are the
positive results
of
______________
(behavior/activity)
in each of these  
areas:

a. Family 
members

b. Friends 

c. Physical 
feelings

d. Emotional 
feelings

e. Legal 
situations

f. School 
situations

g. Job situations

h. Financial 
situations

i. Other 
situations
1. What do you 
dislike about    
______________ 
(behavior/activity)
with_________?
(whom)

2. What do you 
dislike about  
______________
(behavior/activity)
_____________?
(where)

3. What do you 
dislike about       
______________   
(behavior/activity)
_____________?
(when)

4. What are some  
of the unpleas
ant thoughts
you have while 
you are
_____________?
5. What are some  
of the unpleas
ant physical
feelings you  
have while you 
are __________?

6. What are some  
of the unpleas
ant emotional 
feelings you
have while you
are
_____________?

-----------------------------------------------
           SAMPLE 
Functional Analysis of Prosocial Behavior 
  Pedal Biking      
(behavior/activity)
Triggers

                                      Short-Term Negative Long-Term Positive
External Internal  Behavior Consequences            Consequences

1. Whom are you 
usually with    
when you 
pedal bike   ?
(behavior/activity)
Usually about 5
of my friends
2. Where do you 
usually
pedal bike  ?
North Philly

3. When do you
usually 
pedal bike?
From 4:30 till 8
in the evening
1. What are the
positive results
of  
pedal biking  
(behavior/activity)
in each of these  
areas:
a. Family 
members
My mom is
happy
because it
gets me off
the corner.
b. Friends 
I see more
people when
biking.
c. Physical 
feelings
I can ride
longer 
distances.
d. Emotional 
feelings
Im more 
energetic.
e. Legal 
situations
Keeps me out
of trouble.
f.  School 
situations
Keeps me out
of trouble
g. Job situations
Could ride
my bike to
work if I got
a job
h. Financial 
situations
I could save
money by rid
ing my bike
to places.
i. Other 
situations
1. What are you    
usually think
ing about right  
before you 
pedal bike   ?
(behavior/activity)
Where to go
2. What are you  
usually feeling
physically right  
before you 
pedal bike  ?
I dont feel any     
thing physically

3. What are you
usually feeling
emotionally
right before you 
pedal bike ?
Cool
1. What is the 
nonusing 
behavior/activity?
pedal biking 

2. How often do   
you usually
pedal bike ?
2 times per week

3. How long does     
pedal biking
usually last?
A few hours
1. What do you 
dislike about    
pedal biking  
(behavior/activity)
with friends   ?
    (whom)
When I get a flat
2. What do you 
dislike about 
    pedal biking   
(behavior/activity)
in North Philly ?
   (where)
Sometimes I   
dont know the  
people around me.
3. What do you 
dislike about       
  pedal biking   
(behavior/activity)
in the evening ?
  (when)
I cant think of 
anything that I 
dislike about it.
4. What are some
of the unpleas
ant thoughts
you have while
you are
pedal biking ?
I think that I
might get hit by
a car.
5. What are some
of the unpleas
ant physical
feelings you
have while you
are pedal biking?
I get thirsty, hun
gry, and sweaty.
6. What are some
of the unpleas
ant emotional
feelings you
have while you
are pedal biking?
I get scared that
a car might hit
me.

-----------------------------------------------
Date _______  Session # _____  Adolescent ID ______  Therapist Init.______
    ACRA Procedure 2 Checklist
Functional Analysis of Prosocial Behaviors

                   Check Appropriate Boxes
Activity In Progress      Yes       No
1. Did you maintain a positive and enthusiastic 
tone of voice to establish a positive 
atmosphere for change?    
2. Did you explain the purpose of the 
Functional Analysis of Prosocial Behavior
form and introduce the new analysis to the 
adolescent?     
3. Did you help the adolescent identify 
pleasurable nonusing behavior, encouraging 
the adolescent to include details?      
4. Did you help the adolescent identify positive 
triggers for prosocial behavior?     
5. Did you help the adolescent identify the 
short-term negative consequences of the 
prosocial behavior?    
6. Did you help the adolescent identify the 
long-term positive consequences of the 
prosocial behavior?      
7. Did you summarize the information in 
the Functional Analysis of Prosocial Behavior
form to check accuracy and to help the 
adolescent see the overall picture?     
8. Did you help the adolescent come up with a 
homework assignment to sample a new 
activity identified through the functional 
analysis of prosocial behavior?    

-----------------------------------------------
Procedure 3: The Happiness Scale and the Goals of Counseling
Rationale
The happiness scale can be used frequently to assess how happy or satisfied
an adolescent is in multiple life areas. These life areas include his or her
use or nonuse of alcohol or drugs, relationships with friends and
boyfriends or girlfriends, relationships with parents or caregivers, school,
social activities, recreational activities, personal habits, legal issues,
money management, emotional well-being, communication, and general
happiness. When the Happiness Scale form is completed early in treatment,
it shows areas of an adolescents life most in need of attention. Although
the happiness scale can be used as a barometer of progress at any time,
one of its important uses is to gather information to help complete the
Goals of Counseling form.  
The Goals of Counseling form is the ACRA version of a treatment plan. It
allows therapists and adolescents to define treatment goals and activities
related to the same domains that are assessed with the happiness scale. 
Purpose of the Procedure and Learning Objectives
The purpose of this procedure is to help the adolescent understand how 
the happiness scale and goals of counseling assist with development of 
a treatment plan. 
The learning objectives are to:
  Devise a step-by-step intervention with the adolescent to reach his
or her treatment goals 
  Assist the adolescent in selecting and committing to a homework
assignment based on the goals of counseling.
Timing, Audience, and Delivery Method
Both the happiness scale and the goals of counseling procedures are 
conducted with the adolescent individually. A happiness scale should be
completed in sessions 1 and 2, prior to beginning work on the goals of
counseling, because it provides important information for the treatment
process. Revisit the happiness scale every 2 weeks as a way to monitor
adolescents ongoing progress in treatment. Therapists have found the
happiness scale helpful when an adolescent is nonverbal or is providing
very little information because it provides a starting point for discussion
in several areas. 
Complete the Goals of Counseling form during the first two or three 
sessions. Like the happiness scale, the goals of counseling can be revisited
throughout therapy. New issues that the adolescent wants to address may 

65

-----------------------------------------------
emerge, or further clarification of old issues may prompt new goals to
work on. Like the functional analysis of substance use behavior and the
functional analysis for prosocial behavior, the goals of counseling should
be thought of as a work in progress. The Happiness Scale and Goals of
Counseling forms are described together in this section, but remember
that the happiness scale is always an option to be used independently at
any time.  
Materials
General materials include snacks (e.g., chips, crackers, granola bars, fruit
bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 
applicable) a videocamera and videotapes or an audiotape recorder and
audiotapes.
Procedure-specific materials include happiness scale materials, a 
clipboard, pens, and a Happiness Scale form. 
Goals of counseling materials include a clipboard, pens, a Goals of
Counseling form, and a completed Happiness Scale form.

General Notes for the Therapist 
Before beginning to use the happiness scale or work on the goals of 
counseling, review any available assessment information, including the
completed Functional Analysis of Substance Use Behavior and Functional
Analysis of Prosocial Behavior forms. This review will allow you to suggest
goals, activities, and reinforcers, based on information the adolescent has
already provided, to use in completing the Goals of Counseling form. 
As always, maintain a positive approach with the adolescent, finding 
opportunities for reinforcement.
Procedural Steps
1. Provide an overview of the happiness scale and goals of counseling.
2. Ask the adolescent to complete the Happiness Scale form, and
review it with him or her.
3.   Complete the Goals of Counseling form with the adolescent.
  Choose two or three happiness scale categories that the 
adolescent rated as low to work on.  
  Work with the adolescent to devise a step-by-step intervention so
the adolescent can reach his or her goals.

66

-----------------------------------------------
  Decide on a timeframe for completing each intervention or activity.
For interventions requiring skills training, indicate when the skills
will be taught to the adolescent.
4.   Assign homework.  
5. Complete the ACRA Procedure 3 ChecklistDeveloping the
Happiness Scale and the Goals of Counseling immediately after 
the session.
Detailed Description
The remainder of this section contains a detailed overview for using the
happiness scale and the goals of counseling. Procedural steps are in bold
type and are followed by further directions and comments. Sample dialogs
between a therapist and teenager are in italic type.
1.   Provide an overview of the happiness scale and goals of counseling.
The Happiness Scale form covers 16 areas of life that the adolescent rates
on a scale of 1 to 10 indicating how happy or satisfied he or she is with
each area of his or her life. These same life areas are repeated on the Goals
of Counseling form. The 16 areas of life on the happiness scale include the 
following: marijuana use/nonuse, alcohol use/nonuse, other drug
use/nonuse, relationship with boyfriend or girlfriend, relationships with
friends, relationships with parents or caregivers, school, social activities,
recreational activities, personal habits, legal issues, money management,
emotional life, communication, general happiness, and other.  
The adolescent rates each area of life on a 1 (totally unhappy) to 10 (totally
happy) scale to reflect how happy he or she currently is with the particular
area. When completed as part of the treatment plan, the happiness scale
provides a precounseling baseline that indicates which areas of an 
adolescents life are most in need of attention. Blank and sample completed
copies of these forms are located at the end of this section. Help the 
adolescent define specific goals and plans for areas of his or her life in need
of attention and set timeframes in which to meet them. Even if the happiness
scale reveals that the adolescent is unhappy in many areas of his or her life,
it is important not to overwhelm the adolescent by developing too many
goals addressing too many different areas of life at once. It is always possible
to set new goals as the teen is ready to work on them.  
The following dialog is an example of how to introduce the Happiness Scale
form.
Therapist: Today, Jim, we are going to work on coming up with
the best treatment plan for you. To help us do that,
there are two forms we are going to fill out together.
The first one is called the Happiness Scale. The 
purpose of this scale is to help us get a clear idea
about how satisfied you are right now with different

67

-----------------------------------------------
areas of your life. It will also help us pinpoint which
areas of your life you might want to work on. The 
second form is called the Goals of Counseling. On this
form, we will list specific goals that you want to reach
during treatment and then devise a plan for you to
reach those goals.
2.   Ask the adolescent to complete the Happiness Scale form, and
review it with him or her.
Explain the directions for completing the Happiness Scale form. Give the 
adolescent the scale and a pencil as you describe it. 
When rating each area of life, the adolescent should use the current 
timeframethat is, how happy he or she is today with the particular area.
Also, for areas in which an adolescent indicates some unhappiness, gently
suggest, where appropriate, there could be a link between his or her using
behavior and unhappiness.
Therapist: Lets look first at the happiness scale. There are 16 
categories on the happiness scale. The first 14 have to
do with specific parts of your life that wed like to look
at, like number 5, your relationships with your friends,
or number 6, your relationships with parents or 
caregivers. The last two are general categories called
general happiness and other. As you go through each
item on the form, Id like you to rate how happy you
are right now with that part of your life, using a scale
of 1 to 10. A rating of 1 in a life area means you are
totally unhappy with that part of your life nowabout
as unhappy as you could be. A rating of 10 means
you are totally happy with that part of your life right
nowyou are totally satisfied and that part of your life
doesnt need any changes. All the numbers in between
are less extremethe lower numbers (2 through 5)
mean you are more unhappy with that area, and the
higher numbers (6 through 9) mean you are happier
with that area. Lets look at the first one together: 
marijuana use/nonuse. Using the 1 to 10 scale, how
satisfied or happy are you right now with that part 
of your life?
When reviewing the adolescents responses, start with areas of his or her
life that he or she has rated high. This encourages the teenager to talk 
and helps build rapport. It also provides an opportunity to learn about what
is going well in the adolescents life and what strengths he or she has in 
different areas. Later, discuss areas that have been rated low or that are
more emotional (e.g., the relationships with his or her parents or alcohol 
or marijuana use).

68

-----------------------------------------------
In discussing the adolescents ratings, urge him or her to tell more about
why he or she rated areas in certain ways. For example:
Therapist: A 2 rating means youre pretty unhappy with that part
of your life. Tell me a little bit about why you decided
on a 2 rating? What made you decide to rate it a 2?
As mentioned above, it is a good idea to revisit the happiness scale every 2
weeks as a way to monitor the adolescents ongoing progress in therapy.
The goal is to help increase his or her happiness in different aspects of life. 
If an adolescents ratings go up (become more positive), ask the reasons for
the change. Use the change as an opportunity to reinforce something with
the adolescent.
Therapist: It looks as if there are some things you feel good about.
Tell me what has happened in your relationships with
your friends that you feel better about.
If the ratings go down, explore with the adolescent the reasons for the
unhappiness, adding new goals to the Goals of Counseling form if necessary.
Consider, however, that things sometimes get worse at first because the
adolescent begins to think more about the situation.
3.   Complete the Goals of Counseling form with the adolescent.
The same 16 areas of life listed on the Happiness Scale form are repeated
on the Goals of Counseling form. This form has two purposes: to help the
adolescent set specific goals for each of the major problem area and to
develop plans to address each goal. The form is set up to reflect these 
purposes. The first column contains the list of 16 major areas of life listed
on the happiness scale. In this column, an adolescent records specific goals
related to his or her major problem area. The second column, labeled 
intervention, is for recording the specific steps the adolescent needs to 
take to meet each goal. In the third column, timeframe, a specified period
is indicated to carry out the intervention. 
One of the advantages of completing the Goals of Counseling form is that it
does not focus solely on an adolescents use of marijuana and alcohol as a
problem area. As the areas are reviewed with the adolescent, it becomes
clear that you want to help him or her with problems in multiple areas. This
knowledge can help break down the resistance of some adolescents.
When completing the Goals of Counseling form, it is important to teach the
adolescent to adhere to the following basic guidelines:
  Keep statements brief. Goals and plans to reach them should be
in the form of simple statements.
  Always state goals or plans positively. This means the adolescent
should say what he or she wants and will do, rather than what he
or she does not want and will not do.

69

-----------------------------------------------
  Use only specific, measurable behaviors. That is, goals and 
interventions should indicate how often (e.g., once a week, every
day), on what days, or for how long an intervention will be tried.
This way, progress can easily be monitored.
Offer guidance and use modeling techniques to show the adolescent how
goals and interventions can be stated according to these basic guidelines.
To begin with, choose only one or two areas of life to work on. When deciding
whether a particular area needs intervention, consider the adolescents 
rating of each area on the happiness scale as well as his or her other input.
When the therapist and adolescent are ready to begin the process of 
completing the form, they should start with a category from the happiness
scale in which the adolescent indicated at least a fair amount of satisfaction.
Goal setting and devising interventions for a category with some satisfaction
are usually easy for the teen. Give the adolescent several options from
among the higher rated items. The following is an example of giving the
adolescent options and setting goals:    
Therapist: You already mentioned that you are working on getting
better grades at school, and youve rated school low
on the happiness scale. You also rated your relation
ship with your parents as an area you arent too
happy with. Both of these are areas we can set goals
for on the Goals of Counseling form . . . or there might
be another area you have noticed from the happiness
scale that you would like to improve. What is one thing
you would like to work on or improve?
Adolescent: I guess Id like to get better grades.
Therapist: Thats great! What type of grades would you like to get?
Adolescent: Id like to get grades as high as I can.
Therapist: What particular grade: an A, a B, or a C? What would
you be happy with?
Adolescent: Well, Id like to get As and Bs.
Therapist: Okay, lets see whether we can put that goal down as
something we can work on while you are coming here.
Remember, the goal should follow the three guidelines:
It should to be brief, positive, and specific. Go ahead
and try stating your goal for school, making it fit all of
these rules.
Adolescent: All right. I want to get As and Bs at school.

70

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Therapist: That was great, but lets make it even more specific;
tell me when you want to get these grades. By the end
of the quarter, or semester, or what?
Adolescent: I want to get them by the end of the semester.
Therapist: Okay, Jason, lets put this goal down here [points to
problem area/goal section of Goals of Counseling].
You said you would like to get As and Bs in your
classes by the end of the semester. Go ahead and write
that in. That is a good goal because we can measure
it; we can look at your daily work and your report
card and see whether you reach this goal.
Help the adolescent formulate a desired, realistic goal following the 
guidelines for each area in which the adolescent wants to set a goal. One
strategy to help the adolescent devise a goal is to ask him or her to talk
about what he or she is dissatisfied with in the problem areas of life. As he
or she talks, listen carefully. Ask the adolescent to identify a reasonable
goal to work toward that would address the problem area. 
Then help the adolescent turn negative statements into positive goals. For
example:
  I hate school becomes I want to do better in school.
  I dont want to go to jail becomes I want to change my 
behavior so I can enjoy my freedom.
  I get angry all the time becomes Id like to feel happier and
more easy going.
Remember to help the adolescent formulate a goal according to the three
guidelines. Use the adolescents own words and reinforcers.  
It is not uncommon for a goal to be made up of a number of components.
For more complex, potentially overwhelming goals, help the adolescent
break the goal down into several smaller, more manageable goals.   
Examples of good open-ended questions to help the adolescent formulate
these goals include:
  What would make you happier about school?
  What do you want in your relationship with your parents?
  What would you like to have happen with your legal issues?
Remember to steer the adolescent toward reasonable goalsones that 
are attainable. Once a goal has been set and recorded in the first column
on the Goals of Counseling form, work with the adolescent to devise a 
reasonable plan (intervention) for reaching the goal. The same guidelines
used for stating goals should also be used to devise plans: Be brief, be 

71

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positive, and use specific (measurable) behaviors. Some goals may require
more than one intervention. Open-ended questions, such as the following,
can help the adolescent begin to develop appropriate interventions:
  What would make this happen for you?
  What would make your relationship with this person better?
  How do you see that happening?
  What can we do to help you reach this goal?
The following is an example of this discussion with a adolescent:
Therapist: The next thing we can do is fill out the intervention
blank, the types of things we do to reach the goal. Lets
follow the same three guidelines we talked about for
setting a goal so we know exactly how you plan to
improve your grades. What are some things you can
think of that we could do now or you could do later 
to help you get As and Bs in all of your classes?
Adolescent: I dont know. I guess I could study more or something.
Therapist: Thats a good idea! How much would you be willing to
study each week for your classes? Or do you need to
study more for some classes than others?
Adolescent: I dont need to study for my art class or P.E. class, but
I could study about 3 hours each weekend for all of my
other classes.
Therapist: Great! It is usually helpful to get as specific as we can.
Can you tell me when on the weekend you think you
can do the extra 3 hours of studying?
Adolescent: Well, thats a tough one. I usually stay out late Friday
night; so, maybe I could do it on Saturday afternoons.
Therapist: Do you really think that will work?
Adolescent: Yeah, I think so.
Therapist: Okay. Well, it would be good to try it this week, and we
can see how it goes. Lets write that right here. [Point
to the intervention column.]
The next step in completing the Goals of Counseling form is to assign a
timeframe for each intervention in the last column. 

72

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Therapist: Okay. When trying to reach a goal, you will find it 
helpful to set a timeframe, when you will begin working
on it and when you will do a status check to see
whether you are doing what you planned to do. When
would you like to start studying more?
Adolescent: I might as well start this weekend.
Therapist: Go ahead and write down that date as the start date
for studying. When shall we do a status check to see
whether you were able to spend the time on the 
weekend? Can we check on this in your next session?
Adolescent: Okay.
Therapist: Well, lets write this time in the timeframe column too,
so we will remember to check on that. Sometimes, to
help people find options that help in solving problems,
we work on problem-solving techniques. In your case
we would work on problem-solving techniques to find
ways to improve your grades. Would you be willing to
do that? [You and the adolescent work on putting
problem-solving techniques in the plan as well.]
Sometimes, a particular intervention may require skills training. In this
case, indicate a timeframe for teaching the skill to the adolescent. Let 
the adolescent know that you will be teaching the skills needed to meet a
desired goal. For example:
Therapist: Jason, I plan to show you a technique that you can
use to solve that sort of problem, so dont worry yet
about how you are going to reach your goal in the
school area. Right now, its just important that you
have set a goal. I will teach you the technique for
reaching it. When should we plan to go over that 
technique? Next week?
As the Goals of Counseling form is completed, monitor the number of 
intervention assignments the adolescent will be accepting for a given week.
Be careful not to overwhelm the adolescent with too many assignments at
the same time.       
If you and the adolescent are unable to finish the selected categories of the
Goals of Counseling form, and you believe the adolescent has the skills to
do so, assign a few categories for the adolescent to complete at home.
During each session, check with the adolescent and discuss the status 
of the intervention assignments from the previous weekhow did the 
assignments go? Feedback and support for attempted interventions are
essential. If difficulties were encountered, work with the adolescent to 
make adaptations or devise a new plan. Roleplay parts if needed. In addition,

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review with the adolescent any upcoming intervention assignments. Provide
any skills training needed and roleplay anticipated difficulties.  
Before leaving this section, it is worthwhile to review the following common
difficulties encountered when completing the Goals of Counseling form
(Meyers & Smith, 1995, pp. 9394):
  Not applying the three guidelines for developing goals. Most 
people talk about their problems in vague, negative, and 
nonspecific (nonmeasurable) ways. For example, I want to 
have more fun, or I want to get along with my parents.
  Designing goals and interventions that are too complex, thus
making them confusing and difficult to follow. For example, a
goal to make the varsity basketball team as a freshman when the
adolescent does not have outstanding athletic skills would be 
difficult to attain.
  Leaving out important steps that are needed to work toward a
certain goal. For example, to improve his or her grades, a student
would need to increase the amount of studying he or she does
every week, not just for 1 week.
  Including plans that are not really under the control of the ado
lescent. For example, if a teenage boy wants go out with a specific
girl, he cannot control whether she wants to go out with him.
  Placing the adolescent in a high-risk using situation. For example,
if you know from the functional analysis of substance use that a
certain persons house is a trigger for substance use, you would
steer the teenager away from planning to study at that house.
As noted earlier, it is recommended that the happiness scale be revisited
every 2 weeks. Ratings on the scale will probably fluctuate as issues are
resolved and new ones appear in the adolescents life. Thus, it may be 
necessary, or even desirable, to revisit the Goals of Counseling form and 
create new goals as the adolescents life and issues proceed. The Goals of
Counseling form is a work in progress and should reflect an adolescents
needs as they change.   
Working with a resistant adolescent. The following dialog between an 
adolescent and a therapist illustrates how a therapist might approach filling
out the Goals of Counseling form with a resistant adolescent. The adolescent
has completed a Happiness Scale form in this session, and the therapist and
adolescent have already discussed the high and low scores and why the 
adolescent rated areas the way that he did.
Therapist: Thanks, Josh! I appreciate your letting me know how
things are going for you. Now Id like to turn to some
goals that we can work on together while you are here
in treatment. Since you rated school as the area you

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are most dissatisfied with on your happiness scale,
lets talk more about that area. You mentioned that the
reason that you are unhappy is that you wanted to
graduate with all of your friends this year and that you
dont think you are going to be able to. [Therapist pulls
out the Goals of Counseling form and shows it to the
adolescent.]
Adolescent: I aint filling out no damn form, and what makes you
think that I dont already have goals of my own. 
Therapist: Thats cool. We dont need this form. Tell me about the
goals that you have. [Therapist decides not to use the
form. She will conduct the goals of counseling part of
the session verbally.]
Adolescent: I told you! I want to graduate with my friends.
Therapist: What makes you think that you arent going to graduate?
Adolescent: I have been missing a lot of school lately because I 
got suspended for fighting. I definitely cant miss any
more. Or then I will not graduate. My principal
already told me that.
Therapist: How much have you missed?
Adolescent: All together?
Therapist:  Yes.
Adolescent: About 3 weeks total this semester. I was suspended 
for 1 week and missed a couple of days here and there
throughout the year.
Therapist: What was going on the days that you werent 
suspended?
Adolescent: Just slept late and skipping . . . hanging with friends.
Therapist:  What do you think you have to do to graduate with
your friends? What are some of the things that need to
happen? [Therapist tries not to tell client what he
does and does not need to do. She tries to have client
verbalize steps. This increases the probability that the
client will take ownership of or become invested in
the steps needed to accomplish the goals.]
Adolescent: I need to go to school every day for the rest of the year
and make sure that I pass my math class, which I am
failing.

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Therapist: Sounds as if you really know what you need to do to
get there. 
Adolescent: Yeah.
Therapist: Do you think you will be able to get to class daily and
be able to pass math?
Adolescent: I think so.
Therapist: You are doing great. You have goals, know what you
need to do achieve them, and you are a very smart
guy. You seem to have all of this figured out; you know
exactly what needs to be done and can see it. I have
problems trying to keep all of these things you are
telling me straight in my head. It gets overwhelming for
me at times. Do you mind if I take notes on what we
are talking about to see if there is any way that I may
be able to help you with this goal of yours? 
Adolescent:  Yeah, thats okay.
Therapist: Thanks. So your goal is that you dont want to have to
graduate with any other class than your current class.
[Therapist writes notes as if she needs it herself. She
will look at it later with client to illustrate his plans
to work on his goals and refer back to it in future 
sessions.]
Adolescent: Yes. 
Therapist: I like to write goals in a positive way. How would I be
able to say that in a positive way? [Attempts to break
down the steps of goal setting.]
Adolescent: Listen, I dont know what the hell you are talking
about.
Therapist: How would you tell me your goal in a positive way?
[Continues to deal with resistance, not arguing or 
confronting.]
Adolescent: I want to graduate this year with my friends?
Therapist: Yes, great! Thank you! Now tell me again the steps you
are going to take to get there? 
Adolescent: Go to school every day and pass math. Damn, how
many times do I have to tell you?

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Therapist: You seem irritated. Im sorry, I am just trying to get all
of this down so I can remember. I really appreciate
your help. And how are you going to be able to get
there every day?
Adolescent: Just get up and go.
Therapist: You stated you oversleep a lot. What kind of things will
you do to make sure you get up?
Adolescent: I am going to set my alarm, try to go to bed earlier,
and have my buddy come by the house to give me a
ride. And if Im not up, I can have him wake me up.
Therapist: Youve got all of this all figured out, dont you? You are
a good planner. [Gives praise and positive reinforcement
whenever possible.] Thats good because I would really
like to see you graduate with your friends also. So you
will set your alarm, go to bed earlier, and have your
friend help get you up. [Reflects and summarizes.] What
else can you do to make sure you get there?
Adolescent: I guess I can have my mom help me get up too.
Therapist: Sounds as if you have several ways in mind to help
you get there. And what are your plans for improving
your math grades so you wont fail?
Adolescent: I dont know. That teacher just doesnt like me. Shes a
mean piece of work.
Therapist:  Why doesnt she like you?
Adolescent: She just doesnt. She thinks Im a troublemaker. So
shes always on me.
Therapist: So what is it about math that you are having problems
with? Is it just the teacher?
Adolescent:  No. I havent been doing my homework. I hate math
and dont want to do it. At this point I am so far
behind.
Therapist: So you are feeling pretty overwhelmed at this point?
[Encourages reflection.]
Adolescent: Yes.
Therapist: So how can we get that grade up? Lets brainstorm
some possible ideas. Can you think of any right off?

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Adolescent: I could do my work the way I am supposed to.
Therapist: Good. You mentioned that you were far behind and
hate math. What are some ways that we can get you
caught up and back on track?
Adolescent: I can go to class and pay attention.
Therapist: Good. Going to class is the first step, isnt it? When
you go to class, youre not paying attention?
Adolescent: No. Usually writing letters to my friends or sleeping.
Therapist: So paying attention would probably help a lot. What
else would help?
Adolescent: Doing my homework; asking parents, friends, and
teachers for help; and studying the way I should.
Therapist: That is a good plan. Even though you dont get along
with your math teacher, would you being willing to
share your goal with herthat you may have made
mistakes in the past but that you are really ready to
work at it now? Possibly asking her what you could do
to try to catch up?
Adolescent:  I can. But like I told you, shes mean and probably
doesnt even want to hear me.
Therapist:  All we can do is try. That is something that I can help
you with. We can talk about how to get her to hear
you. We could even possibly go to talk to her together if
you would like. Would you be up for that?
Adolescent: Thats cool I guess.
Therapist:  Good. You have a lot of great ideas on how to accom
plish this goal of yours. When thinking about goals,
sometimes it is important to put timeframes on them.
Here, lets take a look at the notes I scribbled down on
how you want to get to where you want to be.
The therapist and client look at the Goals of Counseling form. Together,
they determine timeframes for each step or intervention. The therapist
then summarizes the goal, interventions, and timeframes discussed. 
4. Assign homework.
Help the adolescent decide on a homework assignment related to 
accomplishing the goals listed on the Goals of Counseling form. At the 
next session, review progress toward completion of the goals.

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5.   Complete the ACRA Procedure 3 ChecklistDeveloping the
Happiness Scale and the Goals of Counseling immediately after
the session.
A blank copy of this form is included at the end of this section.

79

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Happiness Scale

Name:_____________________  Adolescent ID:___________  Date:________
This scale is intended to estimate your current happiness with your life in each of 
the 16 areas listed below. You are to circle one of the numbers (1 to 10) beside each 
area. Numbers toward the left side of the 10-unit scale indicate various degrees of 
unhappiness, whereas numbers toward the right side of the scale reflect increasing 
levels of happiness. Ask yourself this question as you rate each area of life: How happy
am I today with this area of my life? In other words, state according to the numerical
scale (1 to 10) exactly how you feel today. Try to exclude yesterdays feelings and 
concentrate only on todays feelings in each of the life areas. Also, try not to allow 
one category to influence the results of the other categories.

Completely Completely
Unhappy Happy

1. Marijuana use/nonuse 1  2  3  4  5  6  7  8  9  10
2. Alcohol use/nonuse  1  2  3  4  5  6  7  8  9  10
3. Other drug use/nonuse  1  2  3  4  5  6  7  8  9  10
4. Relationship with boyfriend or girlfriend 1  2  3  4  5  6  7  8  9  10
5. Relationships with friends 1  2  3  4  5  6  7  8  9  10
6. Relationships with parents or caregivers 1  2  3  4  5  6  7  8  9  10
7. School 1  2  3  4  5  6  7  8  9  10
8. Social activities 1  2  3  4  5  6  7  8  9  10
9. Recreational activities 1  2  3  4  5  6  7  8  9  10
10. Personal habits (e.g., getting up in the morning,
being on time, finishing tasks) 1  2  3  4  5  6  7  8  9  10
11. Legal issues 1  2  3  4  5  6  7  8  9  10
12. Money management 1  2  3  4  5  6  7  8  9  10
13. Emotional life (feelings) 1  2  3  4  5  6  7  8  9  10
14. Communication 1  2  3  4  5  6  7  8  9  10
15. General happiness 1  2  3  4  5  6  7  8  9  10
16. Other 1  2  3  4  5  6  7  8  9  10

-----------------------------------------------
   Sample
Happiness Scale

Name:_____________________  Adolescent ID:___________  Date:________
This scale is intended to estimate your current happiness with your life in each of 
the 16 areas listed below. You are to circle one of the numbers (1 to 10) beside each
area. Numbers toward the left side of the 10-unit scale indicate various degrees of
unhappiness, whereas numbers toward the right side of the scale reflect increasing 
levels of happiness. Ask yourself this question as you rate each area of life: How happy
am I today with this area of my life? In other words, state according to the numerical
scale (1 to 10) exactly how you feel today. Try to exclude yesterdays feelings and 
concentrate only on todays feelings in each of the life areas. Also, try not to allow 
one category to influence the results of the other categories.

Completely Completely
Unhappy Happy

1. Marijuana use/nonuse 1  2  3  4  5  6  7  8  9  10
2. Alcohol use/nonuse  1  2  3  4  5  6  7  8  9  10
3. Other drug use/nonuse  1  2  3  4  5  6  7  8  9  10
4. Relationship with boyfriend or girlfriend 1  2  3  4  5  6  7  8  9  10
5. Relationships with friends 1  2  3  4  5  6  7  8  9  10
6. Relationships with parents or caregivers 1  2  3  4  5  6  7  8  9  10
7. School 1  2  3  4  5  6  7  8  9  10
8. Social activities 1  2  3  4  5  6  7  8  9  10
9. Recreational activities 1  2  3  4  5  6  7  8  9  10
10. Personal habits (e.g., getting up in the morning,
being on time, finishing tasks) 1  2  3  4  5  6  7  8  9  10
11. Legal issues 1  2  3  4  5  6  7  8  9  10
12. Money management 1  2  3  4  5  6  7  8  9  10
13. Emotional life (feelings) 1  2  3  4  5  6  7  8  9  10
14. Communication 1  2  3  4  5  6  7  8  9  10
15. General happiness 1  2  3  4  5  6  7  8  9  10
16. Other 1  2  3  4  5  6  7  8  9  10

-----------------------------------------------
Goals of Counseling

Name:____________________________________________________                             Date:________________

Problem Areas/Goals: In the area of ________ I would like to  Intervention  Timeframe

1.  Marijuana use/nonuse

2.  Alcohol use/nonuse

3.  Other drug use/nonuse 

4.  Relationship with boyfriend or girlfriend

5.  Relationships with friends

6.  Relationships with parents or caregivers

7.  School

8.  Social activities

-----------------------------------------------
Goals of Counseling

Name:____________________________________________________                             Date:________________

Problem Areas/Goals: In the area of ________ I would like to  Intervention  Timeframe
9.  Recreational activities

10.  Personal habits (e.g., getting up in the morning,  
being on time, finishing tasks) 

11.  Legal issues

12. Money management

13. Emotional life (feelings)

14. Communication

15. General happiness

16. Other

(Participants Signature)       (Date)                            (Counselors  Signature)       (Date)

(Guardians SignatureOptional)       (Date) (Supervisors Signature)       (Date)

-----------------------------------------------
Goals of Counseling

Name: John Doe  Date: 31

Problem Areas/Goals: In the area of ________ I would like to  Intervention  Timeframe

1.  Marijuana use/nonuse
To be abstinent for 90 days.

2.  Alcohol use/nonuse

3.  Other drug use/nonuse 

4.  Relationship with boyfriend or girlfriend

5.  Relationships with friends

 Receive communication skills training (practice roleplays with therapist).  3/76/1
6.  Relationships with parents or caregivers  Receive problem-solving training.  3/76/1
I want to improve my relationship with my parents.  Participate in activities with my parents.  Weekly
 Report and discuss progress with my therapist.  Weekly
 Study at least 3 hours each weekend.  Weekly
7.  School  Receive problem-solving training (to figure out ways to attain   3/76/1
I want to get As and Bs in my classes by the end of the semester.                and maintain the grades I want).
 Ask for help from my teachers, parents, friends, or therapist when I    Daily if needed
need it.
 Report and discuss progress with my therapist.  Weekly

8.  Social activities
 Attend weekly therapy sessions, report and discuss progress.
 Receive problem-solving training (to address difficulties with 
staying abstinent as they arise).
 Receive refusal-skill training. 
 Provide random urine sample.
 Weekly
 3/16/1
 3/16/1
 Random during
treatment  

-----------------------------------------------
Goals of Counseling

Name: John Doe  Date: 31

Problem Areas/Goals: In the area of ________ I would like to  Intervention  Timeframe
9.  Recreational activities

10.  Personal habits (e.g., getting up in the morning,  
being on time, finishing tasks) 

11.  Legal issues

12. Money management

13. Emotional life (feelings)

14. Communication

15. General happiness

16. Other

    John Doe                                  31       Betty Smith                               31      
(Participants Signature)       (Date)                            (Counselors  Signature)       (Date)
       Jane Doe                                  3-1       Bill Green                               31       
(Guardians SignatureOptional)       (Date) (Supervisors Signature)       (Date)

-----------------------------------------------
Date _______  Session # _____  Adolescent ID ______  Therapist Init.______
          ACRA Procedure 3 Checklist
Developing the Happiness Scale and the Goals of Counseling

                    Check Appropriate Boxes
Activity In Progress      Yes      No
1. Did you review the adolescents assessment 
and functional analysis information before 
developing the adolescents treatment plan?
2. Did you maintain a positive approach with 
the adolescent, finding opportunities for 
reinforcement?
3. Did you introduce the treatment planning 
session to the adolescent, describing the 
Happiness Scale and Goals of Counseling
forms?
4. Did you assist the adolescent in completing 
the Happiness Scale form and review it by 
asking him or her to explain the ratings?    
5. Did you assist the adolescent in completing 
the Goals of Counseling form, teaching the 
adolescent to adhere to the basic rules of 
completion?    
6. Did you assist the adolescent in coming up 
with a homework assignment based on the 
Goals of Counseling form?

-----------------------------------------------
Procedure 4: Increasing Prosocial Recreation
Rationale
Increasing prosocial recreation is an extremely important part of ACRA, 
and it is important to consider using these procedures in every session. 
The main way to help adolescents increase prosocial activities is to help
them try out or sample new activities. When adolescents do so, they 
experience timeout from using drugs and the sensation of being clean. 
Old habits are disrupted, and there is an opportunity to replace them 
with new, positive coping skills. 
Purpose of the Procedure and Learning Objectives
The purpose of this procedure is to help adolescents learn how to increase
their prosocial recreational activities to involve acquaintances who are not
likely to lead to drug use. This procedure helps adolescents:
  Recognize that being in a situation where they used in the past
puts them at risk for relapse
  Identify prosocial activities to try
  Understand how to make initial contacts for the new activities
  Identify and enlist support persons who can meet them at or
accompany them to the new activity
  Become committed to sample new, prosocial activities
  Select a new activity to try as part of the homework assignment.
Timing, Audience, and Delivery Method
Use these procedures beginning in session 2, and reinforce them with 
the adolescent at every session. This procedure is conducted with the 
adolescent individually. Emphasize using results from the functional 
analysis of substance use to pinpoint high-risk times of the week and/or
occasions when the adolescent is most likely to relapse. Prosocial 
recreational activities should be scheduled at these times. The results 
of the functional analysis of prosocial behavior also provide important 
background to help schedule prosocial activities.
Materials
General materials include snacks (e.g., chips, crackers, granola bars, fruit
bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 
applicable) a videocamera and videotapes or an audiotape recorder and
audiotapes.

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Procedure-specific activity materials include a clipboard, pen, and activity
lists from procedure 2.
Reinforcer-sampling materials include activity lists from procedure 2 and 
a Functional Analysis of Prosocial Behavior form.
Systematic-encouragement materials include telephone, phonebook, and
activity lists from procedure 2.
Reinforcer-access materials include activity lists from procedure 2, 
newspapers, phonebooks, and pamphlets from organizations promoting
activities (e.g., youth groups, health clubs).

General Notes for the Therapist
Treatment participants usually have developed many social and recreational
activities centered on the use of alcohol or drugs. It is therefore normal for
youth to find it difficult to find new drug-free activities or friends. Because
both adults and youth with drug problems have devoted much of their free
time to getting high, they need to sample or reengage in positive leisure
time activities to find a drug-free life rewarding. Emphasize to the adolescent
that everyone wants to have fun but that there are ways other than getting
high to have fun. Encourage the adolescent to believe that together the
therapist and the adolescent can find other ways to have fun. 
In discussions of new prosocial activities with the adolescent, be both 
positive and encouraging. Explain that you understand that he or she will,
at times, miss previous activities but that reverting to old habits may bring
back serious problems or may start the teen on a path toward serious problems.
By using reinforcer sampling (described below), the adolescent learns the
appropriate skills to avoid backsliding after a relapse. Searching for new,
positive recreational outlets that are incompatible with drug use is a key
component of ACRA. In fact, the underlying theory of ACRA is that it helps
adolescents create a drug-free lifestyle that is so rewarding that they would
not want to return to drug use because of the potential to lose all that they
have achieved (e.g., improved family relationships, made new friends, 
discovered fun activities). 
Trying out or sampling new activities provides an opportunity to build 
rapport. It enables adolescents to set goals that are reasonable and attainable.
Meeting these goals promotes their self-efficacy, the belief that they can 
complete certain tasks. When people believe they can follow through with 
one task, they are usually more successful at following through with other
tasks. Self-efficacy can be generalized to the task of staying substance free.
Access to reinforcers. To do these procedures well, continually update 
your knowledge about community resources that provide fun, positive, 
recreational activities (reinforcers). Good sources of information about
these activities are local newspapers, youth groups, and service agencies.

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Procedural Steps
1.   Introduce the topic of increasing prosocial activities.
2.   Help the adolescent identify prosocial activities to sample.
3.   Use systematic encouragement to support a commitment to sample
one or more activities that have been identified.
4.   Decide on a homework assignment together.
5.   Complete the ACRA Procedure 4 ChecklistIncreasing Prosocial
Recreation immediately after the session.
Detailed Description
The remainder of this section contains a detailed overview of procedures 
for increasing prosocial activities. Procedural steps are in bold type and are 
followed by further directions and comments. Sample dialogs between a
therapist and adolescent are indicated in italic type.
1. Introduce the topic of increasing prosocial activities.
The purpose for this session is to help the adolescent identify prosocial 
activities he or she would like to sample or try. It is important to convey to 
the adolescent that you understand that many of his or her previous (or
current) activities have involved the use of alcohol or drugs. You can set a
positive tone by communicating that you will work together to help find
new ways of having fun that do not involve alcohol and drugs, while
acknowledging that you understand that the adolescent will miss the 
activities that were enjoyed while using alcohol and drugs in the past. You
can help the adolescent recognize that being in a situation in which he or
she used in the past puts the teen at risk for relapse behavior.
2.   Help the adolescent identify prosocial activities to sample.
High-risk occasions. The functional analysis of substance use provides
knowledge about an adolescents pattern of drug use (e.g., weekend use).
These times are the high-risk occasions for using; make these times the 
primary targets for new recreational alternatives. Review high-risk situations
(people, places, things) to set the stage for the adolescent to replace these
occasions with positive activities. You might say, You mentioned you dont
want to smoke weed during the next month, and weekends are a high-risk
time. Is there some activity that you can think of that will be fun to do 
during the weekends that does not involve alcohol or drugs? This way you
dont have to worry about being put in detention or about your mom 
getting upset.
Things youth do for fun. Before using this procedure, become familiar with
a wide variety of recreational resources available in your community and
develop lists of potential activities (see What Else Can I Do? and the

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Activities That May Interest You examples at the end of procedure 2). These
lists can be developed by adolescents in youth groups, in health classes in
high schools, in groups of adolescents participating in substance abuse
treatment, or in other groups of adolescents who are easily accessible.
Review the Functional Analysis of Prosocial Behavior form to have a better 
understanding of triggers and consequences of prosocial behavior that 
an adolescent may already be participating in.
Reinforcer sampling. Getting an adolescent to try out a new social or
recreational outlet may be challenging. One way to encourage this is to
frame it as sampling. That is, encourage the adolescent to try it once to see
whether there is any potential for enjoying it. For example, you might say,
You mentioned you liked cars. Would you like to go to a car show to see
what one is like?  
Keep in mind that many adolescents may have little ability to socially interact
with nondrug-using peers. Most of their prior social interactions may have
been centered on the drug culture, and drug use may have been a social
lubricant for them. So you may need to refer to communication training
procedures to help them learn how to make conversation in new groups. 
Encourage the adolescent to engage in several new activities that build 
on each new success. The adolescent is likely to get more out of social 
occasions if he or she engages in them frequently and makes an effort to be
part of the group activities and conversation. For example, if the teen joins
a youth group, he or she is more likely to feel a sense of belonging to the
group and make friends more easily by attending activities weekly rather
than monthly.
It is also helpful if you can work with an adolescent to identify a friend 
or family member who would be willing to accompany him or her to an 
identified activity. The adolescent will be more likely to follow through 
if there is someone with whom he or she can share the planning, 
transportation, and fun of the activity. 
The following is a sample dialog between a therapist and an adolescent
about sampling new behaviors:
Therapist: You didnt mention many activities you like that dont
involve alcohol or drugs. I would like to help you find
some things you might like to do that dont create some
of the negative situations that alcohol or drugs have
created for you but that you will have a good time
doing. To help you with this, I have a list here that is
filled with activities you might like to try or have
thought seemed pretty cool. I would like you to read
through it and circle anything you would like to do or
you already do for fun. [Gives adolescent an activity
list.]

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[Looks at list after the adolescent circles activities
that he or she is interested in.] Of all the activities
you read through, which one would you the most like
to try?
Adolescent: Well, laser tag sounded pretty cool. I have a friend who
went a few times, and he said it was a lot of fun.
3.   Use systematic encouragement to encourage a commitment to
sample one or more activities that have been identified.
If an adolescent says he or she is willing to try a new activity, explore 
possible obstacles to trying it, and present problem-solving techniques 
(procedure 7), if needed. Ask the adolescent to identify a good time to try
the activity, and get him or her to make a commitment to actually carry it
out. Advise the adolescent that structured activities (e.g., a skating party)
may be easier to participate in than a party in which the adolescent is alone
as far as communicating with others and having a good time. Stress that
participation in new activities becomes easier with practice.
An activity list that provides telephone numbers (like the one in procedure
2) is particularly helpful when sampling new behaviors. To encourage the
adolescent to find out more about an activity, you may ask him or her to
make a telephone call using the list during the session. Before doing so, you
should work with the adolescent to develop a list of questions that are
appropriate, and then roleplay a typical information-seeking call. It is also
appropriate to assign additional calls for homework. Provide encouragement
throughout, and praise any successes.
Systematic encouragement. Because it may be difficult for adolescents to
engage in a variety of new prosocial activities, Meyers and Smith (1995)
recommend three steps for encouraging adolescents: brainstorming, 
roleplaying, and providing feedback.
Never assume that an adolescent will make a first contact independently.
Brainstorm, roleplay, and give feedback to the adolescent on making the
initial contact. Brainstorming would center on obtaining information about
how to access an activity. You might say, You said you would like to try rock
climbing; how can we find a place to learn how to do this? You may need to
use a problem-solving procedure to help the adolescent figure out how to
access an activity.
When roleplaying, it is important to encourage the adolescents 
participation. Although roleplaying can be somewhat awkward for some 
people, it is an important part of encouraging the adolescent to try new 
activities because it helps him or her visualize and actually carry out what
you are asking. When possible, observe the adolescent making the initial
phone call. You can observe how well the adolescent does this activity and
provide reinforcement for taking this positive step. 

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  Enlist social support. You might ask, Who are the people who
dont want you to smoke weed? Who will help you stay straight?
Whenever possible, identify a support person who can meet or
accompany the adolescent to the new activity. This should lessen
nervousness about participation and help increase commitment
to attending because the adolescent knows someone is expecting
him or her. 
  Review the experience in the next session to determine its 
reinforcement value. (The activity can serve as a form of homework.)
The following dialog illustrates the use of systematic encouragement.
Therapist: Great! Laser tag sounds as if it would be a good time.
Do you know where your friend went to play laser tag?
Adolescent: No, not really. It might be this place in Belleville.
Therapist: How do you think we could find out more information
to get you set up with laser tag?
Adolescent: I guess I could talk to my friend about playing laser tag
or call the place in Belleville.
Therapist: Sounds good. What type of information would you
need to know to play laser tag?
Adolescent: Well, I would want to know how much it costs and
when they are open.
Therapist: And you might want to get directions to the facility,
too! Are there any other things you might want to ask?
Adolescent: Yeah. How long do you get to play each time?
Therapist: Great. Why dont we write down those questions so
you will have them later. [Adolescent writes down
questions.] Why dont we roleplay this to make sure
you get everything down to ask when you contact the
guy about laser tag. [Begins roleplaying.] Say Im the
guy at the laser tag place and you call. Ring. . . .

Hello. This is George at Orbit Laser Tag. May I help
you?
Adolescent: Yeah. My name is Jason, and I wanted to know how
much it costs to play laser tag.
Therapist: It costs $10 for one game and $15 for two games.
Adolescent: How long are the games?

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Therapist: They last 15 minutes each, and you can play with up
to 20 people.
Adolescent: How late are you open?
Therapist: We are open from 11 a.m. to midnight, Monday
through Saturday, during the summer.
Adolescent: Could you tell me how to get there from Alton?
Therapist: Sure. Go to Highway 255 South and turn toward
Belleville. 
Adolescent: Thank you very much.
Therapist: That was really good. It sounded as if you got all your
questions answered and you were pretty relaxed. How
did you feel?
Adolescent: All right. Ive called places before for stuff, so it was no
problem.
Therapist: Good. Since you did well with that and had no prob
lem, why dont we try calling the laser tag place and
see what kind of information they have about playing
there?
Adolescent: Okay. [Adolescent makes phone call.]
Therapist: That was good. You did a good job of getting the 
information you needed for laser tag. Do you think
your friend who has played laser tag before or Jim [a 
nonusing friend] would like to go to the laser tag place
with you?
Adolescent: Yeah, I think they would both like it. I can see if they
want to do it sometime.
4.   Decide on a homework assignment together.
Sampling prosocial activities will be a frequent homework assignment. Work
with the adolescent to get his or her commitment about what will be 
sampled, with whom, and when.
Therapist: When do you think you would be willing to try playing
laser tag?
Adolescent: I dont know, maybe this weekend.

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Therapist: Okay. Then for homework this week, would you like to
try playing laser tag with a friend, maybe someone like
Jim or your other friend, at least once before next 
session? We will talk about it next time and see how 
it went.
Adolescent: Okay. Ill try.
Therapist: You can do it!
5.   Complete the ACRA Procedure 4 ChecklistIncreasing Prosocial
Recreation immediately after the session.
A blank copy of this form is included at the end of this section.

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Date _______  Session # _____  Adolescent ID ______  Therapist Init.______
ACRA Procedure 4 Checklist 
Increasing Prosocial Recreation

                    Check Appropriate Boxes
Activity In Progress      Yes      No
1. Did you convey to the adolescent your 
understanding of the link between his 
or her previous social and recreational 
activities and the use of alcohol or drugs?     
2. Did you emphasize that you will work with 
the adolescent to help find new ways to 
enjoy free time?    
3. Did you express to the adolescent that you 
recognize it is likely that he or she will miss 
the old using activities but that giving in to 
those feelings may bring back serious 
problems?    
4. Did you use an activity list to help the 
adolescent think of new activities to try?      
5. Did you encourage the adolescent to sample 
new social and recreational outlets?    
6. Using systematic encouragement, did you 
roleplay on how to make an initial contact 
and give feedback to the adolescent?     
7. Using systematic encouragement, did you 
identify a support person to meet 
or to accompany the adolescent to the new 
activity?     
8. Did you and the adolescent agree on a 
homework assignment that included a 
commitment to actually trying an activity?     
9. If the adolescent committed to an activity 
in a previous session, did you review the 
adolescents experiences in carrying out 
that activity?    

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Procedure 5: Relapse Prevention Skills
Rationale
Relapse prevention begins with the functional analysis of substance use 
to understand the antecedents and consequences of using. Throughout 
treatment, therapists need to continue identifying adolescents motivations
for attending treatment and reducing or abstaining from alcohol or drug
use. This will help keep adolescents focused on the overall goals they 
identified early in treatment. Initially, adolescents will have varied success
with abstinence or in reducing their use. 
Purpose of the Procedure and Learning Objectives
By definition, a relapse occurs after a period of abstinence. This procedure
provides information about tools therapists can use when adolescents 
continue to use substances during treatment or when they relapse after 
a period of abstinence. 
The learning objectives for this session are to help adolescents:
  Understand how to use the early warning system to identify 
high-risk situations
  Understand how to interrupt a chain of events leading to a
relapse
  Be able to refuse drugs or alcohol assertively
  Change their maladaptive thought patterns and use adaptive ways
to respond to relapse triggers.
Timing, Audience, and Delivery Method
This procedure is presented to the adolescent individually and is 
appropriate for use after an adolescent has had a relapse. With the 
adolescents permission, some of the information about relapse may be
reviewed with caregivers. This procedure can also be used for relapse 
prevention and may be periodically reviewed with the adolescent who is
putting himself or herself in at-risk situations.
Materials
General materials include snacks (e.g., chips, crackers, granola bars, fruit
bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 
applicable) a videocamera and videotapes or an audiotape recorder and
audiotapes.
Procedure-specific materials include: 

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  Functional analysis of relapse materials may include a clipboard,
pens, and two Functional Analysis of Substance Use Beahavior
forms.
  Early warning system materials may include a completed
Functional Analysis of Substance Use Behavior form.
  Behavioral-chain materials may include a chalkboard; whiteboard;
pens, markers, or chalk; and an easel (optional).
  Cognitive-restructuring materials may include a completed
Functional Analysis of Substance Use Behavior form.
  Use-refusal materials may include a chalkboard; whiteboard; and
chalk, pens, or markers to visually outline use-refusal skills.

Procedural Steps
1. Identify the adolescents early warning system.
2. If a relapse occurs, conduct a functional analysis of substance use
specific to the relapse situation.
3.  Outline the behavioral chain that led to relapse.
4.  Provide refusal training.
5.  Use cognitive restructuring, if it is developmentally appropriate.
6. Complete the ACRA Procedure 5 ChecklistsRelapse Prevention
Skills, Early Warning System, and Cognitive Restructuring
immediately after the session.
Detailed Description
The remainder of this section contains a more detailed overview for 
conducting relapse prevention procedures. Procedural steps are in bold 
type and are followed by further directions and comments. Sample dialogs
between the therapist and the adolescent are indicated in italic type.
1.  Identify the adolescents early warning system.
To help treatment adolescents identify and avoid high-risk situations,
Meyers and Smith (1995) refer to using the triggers section of the 
Functional Analysis of Substance Use Behavior form. Another tool they 
recommend is the early warning system. 
The early warning system consists of steps an adolescent can use to help
identify when he or she is placing himself or herself in a high-risk situation.
It also includes steps to avert a relapse. As part of this procedure, it is
important to find out about the adolescents support systemone or more

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persons who know the adolescent is trying to abstain from drugs who are
willing to help if the adolescent experiences a warning sign of a relapse. 
A caregiver, peers, boyfriends and girlfriends, a school counselor, an
Alcoholics Anonymous sponsor, or others could be part of the support system.
An example of a high-risk situation might be when an adolescent male is
repeatedly breaking curfew and hanging out with friends with whom he 
previously used marijuana. As part of the response to this warning sign, a
girlfriend whom the adolescent and therapist have previously identified
would call the therapist to let him or her know about this warning sign. The
next step in the plan would be for the therapist to see the adolescent as
soon as possible to provide direct assistance. A sample dialog for a therapist
working with an adolescent to develop an early warning system follows:
Therapist: Lets talk about something called the early warning
system that could help you figure out when you might
be doing something that could lead to a relapse. The
first thing we need to do is help you become aware 
of behaviors that may lead to a relapse. The second
thing we need to do is figure out what you need to 
do next if you see yourself starting to do these things.
Another important part of this procedure is to identify
someone else who can help you during these times. 
Are you following me?
Adolescent: Yeah, I think so.
Therapist: Okay, good. What are some triggers or high-risk 
situations weve talked about before?
Adolescent: Well, I used to use when I stayed out late with Jennifer
and Bryan.
Therapist: Yes, thats what Im talking about. Thats what we
found out when we did the functional analysis of sub
stance use. Okay, that is a high-risk situation, and if
you started doing that again, what do you think might
be a way to stop putting yourself in that situation?
Adolescent: Well, maybe I could talk about it with you.
Therapist: Yes, I think I could help you. What we find, however, is
that often teenagers dont necessarily want to call their
therapist when they find themselves in these situations.
It seems to work better if a friend or a parent calls the
therapist at these times. Then the teenager is likely to
follow through with seeing the therapist and talking
about the high-risk behavior. Is there someone you
would like to call me if he or she sees you starting to
stay out late with Jennifer and Bryan again? Your
mother? Your girlfriend, Tracy? This would be someone 

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we would tell all about the plan and ask to notify me if 
he or she saw you doing these things again.
Adolescent: Well, I guess it could be Tracy.
Therapist: Would you be willing to have Tracy come in here so we
can talk about this plan with her and make sure that
we are all on the same page about this?
Adolescent: Yeah, we could do that.
Therapist: Thats great! If you can bring her in next time, we will
explain to her exactly what she needs to do.
2.  If a relapse occurs, conduct a functional analysis of substance use 
specific to the relapse situation.
When a relapse occurs, conduct a functional analysis of substance use for
the relapse episode. This task provides the opportunity to break down the
relapse in detail to determine the behavioral chain preceding the relapse.
The Functional Analysis of Substance Use Behavior form can be used.
3.  Outline the behavioral chain that led to relapse. 
After a relapse occurs, it is important to help an adolescent examine the
chain of events that led to relapse. Perhaps it was an abbreviated chain of
events; for example, when the adolescent attended a party, someone offered
him marijuana, everybody was smoking it, so he did too. Perhaps the relapse
actually started when the adolescent received a bad report card, was 
scolded by a parent or caregiver, and then felt bad. To relieve stress, the
adolescent went out looking for some friends to smoke marijuana with. 
By going over an actual relapse, the therapist outlines the chain that led 
to the relapse.
The purpose of this exercise is for the adolescent to examine steps in the
chain of events so he or she can learn to interrupt the chain as soon as it
begins and before it leads to using alcohol, marijuana, or other drugs.
These steps can be outlined on a whiteboard or chalkboard. 
Exhibit III4 gives an example of the steps in the behavioral chain that 
led to a relapse for an adolescent named Jake. The steps show how Jakes 
decisions led him to relapsing. The therapist can work with Jake to help
him realize alternative actions and at what points he could have taken them
to alter the series of events. For example, when he was angry at his Dad, he
could have called a friend to talk about it or gone outside to play basketball
to dissipate his stress.

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   Exhibit III4:
The Behavioral Chain

Step 1. Jake and his dad had a big fight. They yelled at each other
and even got physical and rolled around on the floor.
Step 2.  Jake felt really angry about the fight and wondered why his
dad had to act that way.
Step 3.  Jake went to his room and shut the door. He started thinking
about how he would get back at his dad. He also thought
that his dad doesnt really care about him.
Step 4.  Jake remembered that some of his friends were getting
together that night at one of their houses and that they
probably would be smoking marijuana.
Step 5.  Jake sneaked out of his bedroom window and went over to
his friends house.
Step 6.  Everybody he expected to see was there. He got a whiff of
marijuana and felt a little uncomfortable about using again,
because it had been a while since he had done so. But he
really wanted to use.
Step 7.  His friends welcomed him in and were glad to see him. 
Step 8.  When the blunt got passed around, he took a hit and 
continued to smoke blunts as long as they were available.

4.  Provide refusal training. 
Refusal training is a component of ACRA behavioral skills training. It is
worth presenting to an adolescent several times during treatment. The
training teaches adolescents to refuse alcohol or drugs assertively. The 
timing of providing this training varies, but it may be provided before a
relapse as part of relapse prevention training or following a relapse. It can
be revisited often to ensure the skills are generalizable or to improve the
adolescents confidence in his or her refusal skills.
Adolescents should first review the positive and negative consequences of
not using alcohol or drugs. Before using the refusal skills, they should be
reminded to think of the rewards of not using alcohol or drugs. When
teaching the five techniques presented below, provide an example of each
and roleplay a situation in which the adolescent can practice the technique.
Roleplaying during the therapy session will increase the likelihood of success
when the adolescent encounters the situation outside therapy. Another way
to reinforce existing refusal skills is to ask the adolescent to demonstrate
how he or she has refused drugs or alcohol in the past. Then ask why he or
she refused in that particular instance. This input can provide additional

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insight into a possible motivation to refrain from using. Refusal training
consists of five techniques, any or all of which can be used, depending on
the adolescent or situation.
  Say, No, thanks, assertively. The adolescent must be firm and 
positive when refusing. If an explanation is needed, then it is 
acceptable to offer one (e.g., No, thanks, Im not feeling well
today.). Casual acquaintances and strangers usually will not ask 
for an explanation. Close friends or family members are more 
likely to ask for an explanation for the refusal. A prepared excuse
(even a false one) may be helpful at this time but may create the
need for the adolescent to refuse again later.
  Watch body language. It is important for adolescents to refuse 
alcohol and drugs using both words and body language that 
indicate that they are serious and confident. Adolescents should
practice standing up straight, facing an individual, and stating
firmly, No, thanks. Not doing this may project the idea that 
the decision to refuse to use alcohol or drugs is not a firm one.
  Suggest alternatives. The adolescent can ask for something other
than alcohol or drugs. For example, he or she could say, No,
thanks, but I would really like a soda or No, thanks, but I would
like something to eat.
  Change the subject. Changing the subject indicates that the ado
lescent is not interested in the offer. For example, he or she could
say, No, thanks. Hey, what do you think of that new CD? or
Have you seen that new movie?
  Confront an aggressor. If someone persists in offering alcohol 
or drugs despite receiving a refusal, the adolescent may need to 
confront the individual. This confrontation should be a last resort
because it may lead to a counterattack or temporary loss of a
friend. He or she can say, What dont you understand about
'no? or Why is it so important to you that I use when I dont
want to?
5.  Use cognitive restructuring, if it is developmentally appropriate. 
Cognitive restructuring is a procedure used to identify and change 
maladaptive thought patterns. It requires a certain level of maturity of 
cognitive development to use this technique. For example, it may not be
appropriate for a 12-year-old, but it may work well for an 18-year-old.
Examples of maladaptive thoughts of an adolescent include:
  Everybody is mad at me anyway; I might as well get high.
  I had a joint at that party last week; I might as well use this 
weekend.

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  I havent smoked a joint for a whole monthusing this weekend
wont matter.
The two steps in cognitive restructuring are (1) showing an adolescent 
how negative thought patterns noted in the internal triggers section of 
the initial functional analysis of substance use have led to use in the past
and (2) teaching the adolescent adaptive ways to respond to these relapse 
triggers. The goal is to restrict negative thoughts. Adolescents need to
learn to use positive self-statements to counteract the negative ones.
Examples of positive self-statements that counteract the negative thoughts
outlined above are:
  Everybody will be happier with me if I dont start using again.
  I really did well up until that one slip, and I felt good that I
could control my behavior.
  If I continue to be abstinent, I will be able to get off probation
and get on with my life.
To help an adolescent generate positive statements, ask questions that
examine the evidence that supports those thoughts. For example, If you
use marijuana, will everyone be less mad at you or will everyone be more
mad at you? or Do you really think you can use two weekends in a row
and not start falling back into old habits?    
Once you help the adolescent examine the evidence behind negative 
statements, the adolescent should be encouraged to substitute new, positive
thoughts that are not associated with using. Encourage him or her to 
consider these thoughts several times and then examine the feelings 
associated with the new thoughts. 
6. Complete the ACRA Procedure 5 ChecklistsRelapse Prevention
Skills, Early Warning System, and Cognitive Restructuring imme
diately after the session.
Blank copies of these forms are included at the end of this section.
Tips for Individualizing or Dealing With Difficult Situations
  If the adolescent never has a relapse or says that he or she does
not have a problem with urges to use: 
Reinforce the need to practice effective coping skills, and then
help identify successful strategies the adolescent is using. When
the adolescent analyzes coping tactics, he or she strengthens
awareness of what works well and can continue using these 
methods. The original functional analysis of substance use can
also be reviewed to help reduce the risk of relapse.
  If there is substance use in the adolescents home environment: 

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Substance use by an adolescents caregivers or siblings is a primary
risk factor for relapse. Educate caregivers about this and attempt
to enlist their cooperation in seeking treatment for themselves or
in refraining from use in the home. As always, encourage attendance
at, and link adolescents to, substance-free recreational and
leisure activities. If caregivers refuse to discontinue use, the 
adolescent can be told about enjoyable activities to participate 
in outside the home when those at home are using. Assist in 
identifying family and friends who provide positive reinforcement
of sobriety maintenance.
  If the adolescent continues to place himself or herself in high-risk
environments: 
Stress the importance of not placing himself or herself in these
environments. Probe for reasons why he or she does this (e.g., 
I dont want to give up my friends.) and address these concerns. 
If he or she persists in spending time in these environments,
emphasize using the skills from refusal training. Train the 
adolescent in using refusal skills or review the skills. Ask the 
adolescent to identify other environments or activities that are
reinforcing but that do not contain some of the risks that he or
she is trying to avoid. 
Another goal is to decrease exposure to risky situations. Try to
get the adolescent to agree to avoid some of these situations. 
One technique is to ask the adolescent to name five risky situations.
Then work toward getting an agreement from him or her to
decrease his or her exposure to them. For example, ask, Could
you avoid all five for a week? If the adolescent responds negatively
to this request, then use a less rigid approach. For example,
Okay, you cant see yourself avoiding all these situations. Which
ones would you be willing to try to avoid?
  If the adolescent continues to associate with users: 
Adolescents have difficulty staying away from their friends.
Usually taking an authoritarian approach about staying away 
from friends is not effective. Rather, begin to help the adolescent 
consider the meaning of a friend or a positive relationship.
Some helpful questions are, Do your friends support your wishes
to stay clean? Do they help you not to use? Have you talked
to them about whether you have to use drugs to hang out with
them? Challenge the definition of a friend if that person (friend)
is behaving in ways that make it difficult for the adolescent to
abstain. Ask what would work best to keep him or her from using,
and have him or her generate two or three options. 
Sometimes it is appropriate to ask the adolescents friend to
attend a session. With the friend present, the therapist and 
adolescent can review all the refusal techniques and ask for the
friends cooperation in supporting the goal of abstinence. 

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Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

ACRA Procedure 5 Checklist
Relapse Prevention Skills

                   Check Appropriate Boxes
Activity In Progress      Yes       No
1.   Did you explain the purpose of relapse 
prevention training to the adolescent?
2.   Did you probe whether the adolescent used 
since the last contact?    
3.   If a relapse occurred, did you conduct a 
functional analysis of substance use?    
4.   Did you base your decision to use the early 
warning system and/or cognitive restruct
uring on the adolescents needs?     
5.   Did you provide refusal training and review 
all five techniques?    
6.   Did you have the adolescent list five risky 
situations and talk about how he or she 
could handle them?    

-----------------------------------------------
Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

ACRA Procedure 5 Checklist
Early Warning System

                   Check Appropriate Boxes
Activity In Progress      Yes       No
1.   Did you choose this intervention to help 
the adolescent identify and avoid high-risk 
situations?    
2.   Did you explain this technique to the 
adolescent and a caregiver, a peer, the 
school counselor, or another concerned 
person?     
3.   Did you arrange to see the adolescent as 
soon as possible once you were informed 
of a problem by the caregiver or peer?      

-----------------------------------------------
Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

ACRA Procedure 5 Checklist
Cognitive Restructuring

                   Check Appropriate Boxes
Activity In Progress      Yes       No
1.   Did you choose this intervention to 
identify and change an adolescents 
maladaptive thought patterns?     
2.   Did you determine that the adolescents 
cognitive development was advanced 
enough to benefit from this technique?     
3.   Did you show the adolescent how the 
negative thought patterns expressed in 
the internal triggers section of his or her 
functional analysis led to use in the past?     
4.   Did you teach the adolescent adaptive 
ways to respond to the relapse triggers?    

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Procedure 6: Communication Skills
Rationale
Adolescents often have difficulty communicating in a positive manner
with a parent or caregiver and other adults in their lives. This difficulty
can spiral into negative communication. Factors other than normal 
adolescence, such as arrested development because of drug and alcohol
use and poor models of communication in the home, may also impact 
their communication skills. Improved communication skills can help the 
adolescent create more positive relationships in the home and elsewhere. 
Purposes of the Procedure and Learning Objectives
The purposes of this procedure are to help the adolescent understand the
rationale for developing good communication skills and to help improve
communications skills. By the end of this session, the adolescent will learn
how the ACRA communication techniques are applied to real life situations.
These techniques include how to give an understanding statement, how
to give a partial responsibility statement, and how to offer to help solve
a problem.
Timing, Audience, and Delivery Method
The adolescent and the caregiver receive communication skills training in
individual sessions. In a later joint session, they practice these skills with
each other (see procedure 11). This allows the adolescent to learn and
practice the skills individually before having to practice together with the
caregiver. This session should take place by session 6 or by week 5 or 6 of
treatment. Training can be scheduled for a particular session, or the topic
can be introduced spontaneously. For example, if an adolescent talks
about a communication problem with a parent or caregiver or someone
else during a session, this is the appropriate time to introduce the 
technique. The procedure should be revisited frequently because this 
is a critical area for most adolescents.
Materials
General materials include snacks (e.g., chips, crackers, granola bars, fruit
bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 
applicable) a videocamera and videotapes or an audiotape recorder and
audiotapes.
Procedure-specific materials include the handout Communication Skills; a
clipboard; chalkboard or whiteboard; pens, markers, or chalk; and an easel
for presentation of material on communications skills.

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General Notes for the Therapist
The skills outlined in this section should be taught in the context of real
communication problems experienced by adolescents with their parents or
caregivers and other people in their lives. That is, although the therapist
teaches the adolescent about effective communication skills, the 
teaching is grounded in the experiences of the adolescent. The adolescent
is not merely a passive recipient but is actively involved in learning. This 
situation makes the procedures more relevant for the adolescent, and he 
or she will be more likely to try them outside therapy.
Emphasize that the skills covered in this section can be used to 
communicate more effectively in real life, not just in a therapeutic setting.
Procedural Steps
1. Introduce the topic of communication, and provide a rationale for
developing good communication skills.
2. Assess the current quality of communication between the adolescent
and other important people in his or her life (e.g., parent or 
caregiver).
3. Using real life examples provided by the adolescent, teach the ACRA
communication techniques. 
4.  Roleplay exchanges between the adolescent and another person
(e.g., a parent or caregiver), inserting ACRA and general 
communication techniques whenever they would be helpful.
5.  Process each exchange with the adolescent from the perspectives 
of content and feelings.
6. Assign homework.
7. Complete the ACRA Procedure 6 ChecklistCommunication Skills
immediately after the session.
Detailed Description
The remainder of this section contains a more detailed overview for 
conducting a communication skills exchange with an adolescent.
Procedural steps are in bold type and are followed by further directions 
and comments. Sample dialogs between the therapist and the adolescent
are indicated in italic type. 
1.  Introduce the topic of communication, and provide a rationale for
developing good communication skills.
Take a few minutes at the beginning to introduce the topic and talk about
the importance of communication skills. Find out what reinforcers would

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motivate an individual to make behavior changes. For example, an 
adolescent might say, Im tired of all the yelling at my house. Try to find
out something from him or her that can be used to encourage a behavior
change. Make the key point that just about everyone can improve his or her
communication skills.
2.  Assess the current quality of communication between the 
adolescent and other important people in his or her life (e.g., 
parent or caregiver).
In this step, both the adolescents relationship with parents or caregivers
and his or her communication skills are rated using the happiness scale.
Use the ratings as a starting place for a discussion of the adolescents 
communication skills. To help the adolescent be specific, ask him or her to
identify a particular person (such as a parent or caregiver) to think about
in relation to his or her communication skills. Next, ask the adolescent
about the quality of communication with this particular person when 
discussing both nonproblem topics (social or typical everyday conversations)
and problem topics (the adolescents drug use, a problem at school or
home). Ask how conversations in each of these categories usually proceed.
Ask how the communication has been in the past 2 years. 
For example, say, Tell me what happens when you try to talk together
about. . . .
For situations that do not go well (e.g., the parent/caregiver or adolescent
gets angry or frustrated or leaves; they get into a fight), listen and observe
carefully to understand the dynamics that typically occur between this 
person and the teenager. To make sure you understand the situation (and
to show the adolescent that you are listening), repeat the situation to the
adolescent and ask clarifying questions. For example:
Therapist: Okay. So when you ask your mom to let you go out 
to do something with your friends, a lot of times she
says,You cant do that because your room isnt clean,
and you havent done any of your other chores. You
then get a little angry because you feel as if you are
helping out around the house and cleaning your room.
So, you say something like, Ive been cleaning! Why
dont you look! Your mom then says,If youre going
to be smart with me, you can just go upstairs because
you arent going out tonight! Then you usually go out
side while your mom is yelling at you to come back in.
Ask the adolescent how satisfied he or she is with the present quality of
communication with the parent or caregiver. If the adolescent is unhappy,
ask what he or she would like to have happen when talking to his or her
parents or caregivers. Listen to the adolescent, and observe carefully to
understand his or her goals. 

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Assure the adolescent that techniques that will help with communication
problems will be taught. Make sure to leave time to roleplay a few situations
during the session to practice the techniques before a real life situation
occurs.
3.  Using real life examples provided by the adolescent, teach ACRA 
communication techniques.
ACRA has three basic parts to effective communication: 
1. Give an understanding statement. 
2. Take partial responsibility. 
3. Offer to help. 
An understanding statement brings feelings of empathy into the 
conversation. It shows others that an adolescent is capable of seeing things
from another persons perspective and helps the other person understand
the adolescents perspective. The effect on the other person is a feeling of
validation, and this will decrease his or her defensiveness. 
A partial responsibility statement indicates that the speaker is willing to
accept responsibility in creating, or a role in solving, a problem. It does not
mean the person is blaming himself or herself or anyone else or that it is 
up to the other person to solve the problem. It acknowledges that the 
adolescent shares responsibility for creating or solving a problem. 
An offer to help is just thatan offer to help solve the problem. Here, the
individual thinks of ways to facilitate cooperation from the other person.
Used together, these three conversation enhancers communicate that one
person wants a change in the others behavior and is willing to be actively
involved and supportive in the process. The outcome is decreased 
defensiveness and more open lines of communication. 
Using an actual situation of poor communication between the teenager and
a parent or caregiver, introduce the three ACRA communication techniques
where they would be helpful. The techniques are generic; they can be used
to discuss virtually any situation more effectively.
Therapist: Okay, Gina, lets look at the situation where your mom
got upset at you after you asked to go out. Lets review
that conversation, break it down, and try to see where
everyone is coming from and how each of you feels. To
help improve things and help you get something closer
to what you want, I would like to talk about some 
different communication skills that may help your 
conversations have a better outcome.
One way to tell that people have good communication
skills is for everyone to get a little of what they want. If
there is something you want, you would like to get it. I
know you dont want your parents to give you a hard

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time. When you negotiate, often at the end, you can get
closer to what you want than you were before. 
The first thing I want to talk about is an understanding
statement. The understanding statement is really a big
part of improving communication because you are
first trying to see where the other person is coming
from. Doing that will open up the possibility that that
person will listen to you. First consider his or her per
spective. Lets use the situation that you talked about
earlier when you have trouble getting home in time for
a curfew. How would your mom be affected by your
wanting a ride home by curfew?
Adolescent: She doesnt want me to get in trouble, but she doesnt
want to go out either.
Therapist: Why doesnt she want to go out to get you?
Adolescent: Because she is already at home and she says I should
have made plans for a ride earlier.
Therapist: She thinks you should have planned getting a ride from
someone before. You could say, I understand that its
late and you may already be relaxing at home, so
going out might be tough. 
What is your perspective? Because you want to tell her
where you are coming from so she understands you
better. So, from your perspective, what would you say?
Adolescent: I need a ride home so I dont get in trouble for 
violating curfew.
Therapist: So we answered all these questions. Why do you want
to come home? Because you dont want to get in 
trouble for being out past curfew. Your perspective is
that you dont have anyone to give you a ride home,
but you need to get home to meet your curfew. What
would you like from her in this situation?
Adolescent: I want her to give me a ride home, but I dont want
her to be seen yelling at me. If I call and she doesnt
want to pick me up, I dont want her to come to the
front door and yell at me.

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Therapist: And you dont want to be yelled at in front of your
friends. Okay. I understand how you feel. Next, when
you make a request, it needs to be brief, positive, and
specific. The reason it needs to follow those rules is
that if you are brief, it will be easier for someone to get
the main thing you want to communicate. If you tell a
person something long and drawn out, the person may
get lost. You want to say it in a positive, nice way so
the person is more likely to listen to what you are 
asking for. You dont want to ask for something in a
negative way because the person may respond in a
negative way. You need to be specific, so everyone
understands where you are coming from. 
For example, when you ask to be picked up and you
arent specific, your mom may think you mean right
now, and you may mean in the next 2 hours. When she
comes by, you may be upset because you wanted more
time to hang out with friends. So a real problem arises.
Okay, following the rules of being brief, positive, and
specific what might you say to your mom?
Adolescent: Would you please come to pick me up, and wait 
outside?
Therapist: At what time would you like to be picked up?
Adolescent: I dont know. In an hour.
Therapist: Okay. Thats really good. So what I might say using 
the understanding statement is, Mom, I understand
its late and you may not want to go out, but I am out
someplace without a ride and I want to be home so 
I dont get in trouble for curfew. So I would really 
appreciate it if you could pick me up at my friend
Julies house in an hour and honk the horn when 
you need me to come out.
Lets try it again. This time, lets pretend that Im your
mom, and you can talk to me using the understanding
statement.
Adolescent: I understand its late and you want me home, and I
really want to be home to beat curfew too, but I am
stuck here without a ride and cant get home. So Id
really like it if you could pick me up at my friends
house in an hour.
Therapist: Great. You did a good job. You came from her 
perspective, then yours, and you made a request 
to get picked up at your friends house in an hour.

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Remember when you are coming from the other 
persons perspective, you want to tell why that may 
be difficult for him or her. So you would want to say
something like, Mom, I understand its late and you
may not want to come out and get me, because that
is why she may not like it, okay? Lets try it again
coming from her perspective, coming from your 
perspective, and then making a request. You did a 
really good job with that part before.
Adolescent: Okay. Mom, I know its really late and you dont want
to come out. And I should have made sure earlier that
someone could take me home, but I am stuck here
without a ride and dont want to be out past curfew.
So, I would really like it if you could pick me up at my
friends house in an hour.
Therapist: Good, you had all the parts of the exercise in that one.
You made sure to come from her perspective to show
that you understand how she is feeling about the whole
situation. You also did something else that was really
cool when you talked about how you should have
made sure there was someone to take you home! This
is called taking partial responsibility. Taking partial
responsibility is when you say how something you did
might have contributed to the problem. When you do
this, it shows you dont blame the other person for the
problem, and he or she is more likely to listen to you.
You want to make sure and say something like this in
any situation where the person you are talking to sees
you as part of the problem. After taking partial 
responsibility, I like to restate the request just to keep
everyone on track about what I am talking about. So,
adding the partial responsibility statement, I might say
something like,Mom, I understand its late and you
are probably tired and dont want to go out, but I am
stuck over at my friends house without a ride and
want to get home before curfew. So I would really like
it if you could pick me up in about an hour. I understand
that I should have gotten a ride and I am sorry about
that, but I would really appreciate it if you could pick
me up in about an hour at my friends house. Do you
understand how I restated the request?
Adolescent: Yeah.
Therapist: Okay, lets try it from the top.
Adolescent: All right. Mom, I know its late and you are tired, but 
I am stuck at my friends house and I need a ride, so 
I would really like it if you could pick me up at my

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friends house in about an hour. I know I should have
made sure someone could take me home before I left,
but I would really like it if you could pick me up at my
friends house in an hour.
Therapist: Great! That was perfect. You told her exactly how you
fit into the problem. The last part is to make an offer to
help. It isnt too tough. Its just figuring out what you
can do to make it more likely to get what you wantto
be picked up by mom late at night. What you want to
do is make sure she is involved in the solution, so she
is more likely to come to a decision that both of you
like. So, for this part, I first want to offer a few 
suggestions such as,If there is anything I can do to
help, maybe give you some gas money for picking me
up or mow the lawn tomorrow, I would be willing to
do it. Or, if there is anything else you can think of, I
would be willing to listen. In that last part, I opened 
it up to her so she could give a few suggestions for
solving the problem to make things easier for her. I also
said I would listen or consider it. That way I am not
saying I will just do whatever she says as a suggestion,
but I will listen to what she says and come to a 
compromise, something that works out for both of you.
So it gives you something closer to what you want.
Lets try the whole thing since you did such a good job
adding in the partial responsibility statement last time.
Remember, first do the understanding statement, then
the partial responsibility statement, and then add the
offer to help.
Adolescent: Okay. Mom, I understand you are tired and may not
want to go out, but I am stuck at a friends house and
I really want to be home before curfew, so I would
really appreciate it if you would pick me up at my
friends house in about an hour. I know I should have
had a ride set up before, but I would really like it if you
could pick me up at my friends house in about an
hour. If I can do something like give you gas money or
anything else, I would be willing to do it or if you can
think of anything else, I would listen. I just would like
it if you could pick me up at my friends house in an
hour. 
Therapist: Good job. You did that just right. First you had a good
understanding statement from your moms perspective
and then your perspective, then you had a good 
statement of partial responsibility, and I really liked
your offer to help.

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4.  Roleplay exchanges between the adolescent and another person
(e.g., a parent or caregiver), inserting ACRA and general 
communication techniques whenever they would be helpful.
When doing the roleplay, insert ACRA and effective communication techniques
whenever they would be helpful. Mention pitfalls (e.g., avoid blaming people
or rehashing old problems) to avoid if they arise. Point out barriers to 
communication when they occur. After that, switch roles. 
To help improve the effectiveness of the adolescents communication 
techniques, the adolescent and therapist should conduct additional 
roleplays followed by the therapists feedback. The adolescent can generalize
these skills to many areas of life, so these roleplays should cover many 
problems and issues. After each roleplay, review it thoroughly and help 
the adolescent reword the conversation to be more effective. Both general 
communication techniques (e.g., use of I statements rather than you
statements as well as active listening) and those used in ACRA should be
introduced whenever they may help.
It is important to provide an opportunity for several roleplays. Roleplaying
can be awkward for some people, but it is important for the therapist to
encourage the adolescent to participate fully. If you ask the adolescent, Do
you want to do a roleplay? the answer will often be, No. So a more subtle
approach may be preferable. One way to reduce the awkwardness might be
to avoid using the word roleplay. Instead, you can say something like,
OK, lets just pretend Im your mother and lets practice some of the ways
of talking about what we were just discussing. Stress to the adolescent
that it is acceptable for him or her to leave the role to ask questions or get
advice. Also remember that it is desirable for the adolescent to have the
experience of playing both rolesthat of the parent and that of the adolescent.
Numerous pitfalls can occur when two people are attempting to communicate
with each other. Two common pitfalls occur when one person blames the
other person and when one person brings up an old transgression or 
behavior. These pitfalls should be pointed out to the adolescent, and 
they should be avoided.
The Communication Skills handout is a helpful teaching device that can be
given to a caregiver or adolescent when reviewing communication skills.
Have a copy for the adolescent to review. (A copy of this handout is at the
end of this section.) 
5.  Process each exchange with the adolescent from the perspectives
of content and feelings. 
Following each roleplay, the therapist and adolescent should discuss the
conversation. Ask the adolescent, How did it go? What was different about
the conversation compared to how it usually feels? How did it feel for you to
play the role of your parent? How do you think your parent would respond
to this style of communicating?

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Working with a resistant adolescent on communication skills. The 
following dialog between an adolescent and a therapist illustrates how a
therapist might approach communication skills training with a resistant
adolescent. In this case, the adolescent has already attended a couple of
sessions, and at the last session he rated school and his relationship with
his parents low on the Happiness Scale form.
Therapist: How was your week?
Adolescent:  Okay, I guess. [Adolescent responds with short
answers, looking down and not wanting to talk.]
Therapist: How is school going?
Adolescent: Okay. [Continues to give short answers.]
Therapist: Tell me how you and your mom are doing. [Therapist
asks open-ended questions.]
Adolescent: Shes getting on my nerves.
Therapist: Tell me more about that.
Adolescent: Shes constantly complaining.
Therapist: What kind of things is she complaining about?
Adolescent:  You name it. 
Therapist: [Therapist sits in silence for a while giving the teen
an opportunity to respond without constant question
ing and then, trying to elicit details, responds.] Give
me an example.
Adolescent:  Well, like last night, she was angry with me because I
didnt get home by curfew.
Therapist: What was her response when you got home? [Trying
to find something that the client would invest time in
to work on, the therapist does not question why the
adolescent was not home by curfew.] 
Adolescent:  She started yelling at me.
Therapist:  Is that her typical response when she is angry?
Adolescent:  Yeah.
Therapist: Then how do you respond? [Tries to assess current
state of communication between adolescent and 
parent.]

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Adolescent: I either yell back or ignore her. She is so controlling.
Always wanting to know my every move.
Therapist:  That sounds as if that is difficult for you. Wonder why
she does that?
Adolescent:  Cuz she doesnt trust me.
Therapist: Why doesnt she trust you?
Adolescent: Cuz I came home drunk about 2 weeks ago. Now she
is threatening to take my car from me.
Therapist: Were you driving when you were drunk?
Adolescent: Yeah, I had to get home. She wouldnt let me stay at
my friends because she doesnt like them and I needed
to get the car back. 
Therapist:  Why do you think that your mom would get angry at
that? [Therapist encourages client to try to verbalize
moms feelings rather than takes sides with the
youths mother.]
Adolescent: Cuz she is concerned and worried about me. I mean I
can understand that. She is just weird about how she
handles everything. 
Therapist: So basically you can understand where your mom is
coming from, but you just arent happy with the way
she communicates with you. [Therapist introduces
reflection.]
Adolescent: Yeah, she is just always yelling at me.
Therapist: And when she starts yelling, you either start yelling
back or walk away?
Adolescent: Yeah.
Therapist:  It sounds as if your car is very important to you and
losing it would be a big deal for you. [Therapist 
continues to try to motivate the client to work on
communication skills.]
Adolescent:  Yeah! I need it to get to school and work and to go out
with my friends.
Therapist: Wow. That wouldnt be good then if she took it. Lets
think about how we can talk to her to get your point
across so she will listen. [Therapist does not mention

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communication skills but nevertheless proceeds to
work on these skills.]
Adolescent: Yeah, okay, like thats going to happen.
Therapist:  We can try. What do we have to lose? I want to be able
to help you have a voice and be able to be heard.
Adolescent:  Whatever.
Therapist: She will be coming in in a couple of weeks with you
and that would be a good time to try to talk about
some issues you have. While both of you are here, I
dont want to have you both yelling at each other the
whole time and not hearing the other. So lets talk
about how we can get your point across. Im your
mom. Talk to me, and tell me why you think I should
not take your car away. [Assesses state of communi
cation further.]
Adolescent: I think she is being unfair, and its bull.
Therapist: Good. But talk to me as if I am your mom.
Adolescent:  That is bull, mom, and you know it.
Therapist:  Good! [Therapist offers praise and positive 
reinforcement even though the response is less than
desired.] Okay. There are a couple of things that I
want you to try. First thing is to try to stay positive.
Sometimes when people feel on the attack, they get
defensive and fight back. And our goal is to try to get
her to hear you. The other thing is to try to understand
where she is coming from and communicate that. You
said earlier that you could understand that she worries
when you drink and drive. So you can start by saying
to her in a calm voice, Mom, I understand that, when
I drink and drive, you worry and are concerned.
[Therapist uses modeling, coaching.] Try it.
Adolescent: Mom, I understand that you are worried about me, but
I dont think you need to take the car away. That is
bull, and I told you I wouldnt do it again. 
Therapist: Great! [Continues praising for effort and participa
tion.] Youre doing a good job. You did the understand
ing statement perfectly. After the understanding state
ment I think it might be helpful to get your point across
if you take partial responsibility for your half of what
is going on. Then make an offer to come to some kind
of agreement or resolution about the car. [Introduces

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shaping.] I am going to be you for a second and you
are your mom. Mom, I understand that you are 
worried when I drink and drive. I made a mistake and
drove that night. I know that was bad judgment on my
part. I was just worried about not having the car
home on time, and I know that I should have probably
just called you but I was scared. Is there anything that
I can do to reassure you that I wont make that same
mistake?
Adolescent: I cant talk like that psychobabble! Thats not me. Man,
please . . . my mom would already be yelling.
Therapist:  That is a good point. Its kind of weird to talk like that,
isnt it? I am going to go over the same stuff with your
mom as well, with the goal of trying to have you be
able to hear each others point of view and trying to
get you both what you want. I know you said that it
was not you, but you sounded great! You made it seem
so easy. Have you done this before? 
Adolescent: They tried to teach us this stuff in residential.
Therapist: I am your mom. [Continues and tries to convince
client to continue.] Talk to me about the issue of 
the car, starting with the understanding statement,
because I think we will have some luck with this and 
I want to help you get what you want. [Reinforces
rationale for working on communication skills.]  
Adolescent: Mom, I understand that you are worried when I drink
and drive. 
Therapist: [Therapist interrupts to help shape.] Great! Keep
going by talking about how you take some responsibility
for the night you drank and drove. 
Adolescent: And I know that I shouldnt be doing that. It was wrong. 
Therapist: Tell her what your car means to you. [Helps client
through communication skills while shaping, coaching,
and encouraging.]
Adolescent: My car is the most important thing to me. I need it to
get around to school, work, and with friends. I dont
want to mess it up by driving drunk, and I really dont
want you to take it away from me.
Therapist:  Fantastic! [Offers praise and positive reinforcement
for any effort no matter how big or small.] Now offer
to help or come to some kind of compromise.

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Adolescent: Since my car is so important to me, how can I get you
to trust me again?
Therapist:  You did great! Did that feel weird?
Adolescent:  Yeah. 
Therapist: But you did such a great job! And I think if your mom
heard you talk like that, she would hear what you had
to say about the issue and would be willing to sit down
and talk about it. And I will be here to help you. I know
it feels weird, but try it in other situations as well.
People are more receptive to hearing what you have to
say if you arent yelling and are trying to understand
where they are coming from. This week, practice what
we went over. 
By the end of the session, the therapist has reviewed the important parts of
communication, has urged the adolescent to practice these skills at home
so that he will learn to generalize skills outside sessions, and has praised
the client for participation and attendance.
6.   Assign homework.
Assign the homework of practicing communication skills. Solicit a 
commitment from the adolescent to try to put the skills into practice. At
the next session, the therapist should review the adolescents use of the
communication skills between sessions. 
7. Complete the ACRA Procedure 6 ChecklistCommunication Skills
immediately after the session.
A blank copy of this form is included at the end of this session. 

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COMMUNICATION SKILLS 

The goal of using communication skills is to be able to get your message across to
another person to help you get what you want. Using these communication skills
should enable individuals to compromise or agree on a solution to a problem. When
everyone agrees on a solution, compliance by both sides and contentment with the
solution are more likely. It is important to stay positive during the communication
skills training and avoid blaming. 
Understanding statement. The goal of the understanding statement is to open up
communication and show that you are aware of another persons thoughts on a 
problem. That is:
! Come from the other persons perspective.
  Example: Mom, I understand you would like my room cleaned because it is a
real mess, and you would like the house to be clean when friends come over.
! Come from your perspective.
Example: But Jimmy is having a birthday party at his house, and I have not
seen Jimmy for a while, so I would really like to go.
! Make a request (a request should be brief, positive, and specific).
Example: I would really appreciate if you would let me clean my room later
tonight, maybe around 8 p.m. when I get home.
Partial responsibility. The goal of the statement of partial responsibility is to avoid 
blaming the other person. Remember to state how you or the other person see 
yourselves fitting into the problem or solution. That is:
! How do you fit into the problem?
Example: I know I made a real mess by not putting my clothes away, and I
have not always followed through with cleaning my room, and I am sorry
about that.
! Repeat the request (optional).
Example: But I would really appreciate if you would let me clean my room
around 8 tonight after I get home from Jimmys party.
Offer to help. The offer to help is used to show that you are willing to work on a 
solution that works for everyone and that you would like input from others on possible
solutions. That is:
! Offer several possible solutions.
Example: If there is anything I can do to help make that happenhelp out
with another chore around the house, help out with dinner, or just do a
quick 10-minute cleaning for now and do the rest laterI would really
appreciate it.
! State your openness to listen to and consider the other persons ideas.
Example: Or if there is anything that you can think of, I would be willing to 
listen.
Following the offer to help, individuals may try to compromise on a solution or do
some problem solving. It may be necessary to go through the communication skills
again to state your point.

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Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

ACRA Procedure 6 Checklist
Communication Skills

                   Check Appropriate Boxes
Activity In Progress    Yes       No
1.   Did you introduce the topic of 
communication by providing a rationale 
for developing good skills in this area?    
2.   Did you assess the present quality of 
communication between the adolescent 
and other important people in his or her 
life (e.g., parents/caregivers)?    
3.   In the context of real life examples 
provided by the adolescent, did you teach 
the adolescent to give an understanding 
statement?    
4.   In the context of real life examples 
provided by the adolescent, did you teach 
the adolescent how to make a partial 
responsibility statement?    
5.   In the context of real life examples 
provided by the adolescent, did you teach 
him or her how to offer to help solve the 
problem?    
6.   Did you roleplay exchanges between the 
adolescent and another significant person 
and insert ACRA and general 
communication techniques whenever they 
would be helpful?     
7.   Did you switch roles with the adolescent?    
8.   Did you process each roleplay exchange 
from the perspectives of content and 
feelings?   
9.   Did you use the Communication Skills
handout when appropriate?    
10.   Did you ask the adolescent to practice 
communication skills for homework?    

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Procedure 7: Problem-Solving Skills Training
Rationale
Problem-solving skills are essential in ACRA. They are general life skills
that are valuable beyond the treatment experience. Training adolescents
in problem-solving skills teaches them how to handle the problems that
come up in life without resorting to the use of marijuana or alcohol to
cope. Problem-solving skills increase the adolescents sense of self-efficacy
and self-esteem. With problem-solving techniques, adolescents realize that
no matter how insurmountable a problem may appear, it can always be
broken down into small steps and conquered.
Purpose of the Procedure and Learning Objectives
The main purpose of this procedure is to improve the adolescents ability
to solve problems in real life situations. The learning objectives are to
help the adolescent:
  Understand and practice the three-step problem-solving technique:
define the problem, generate alternatives, and choose one 
solution
  Become aware of the need to evaluate the effectiveness of the
solution.
Timing, Audience, and Delivery Method
Problem-solving skills training takes place with an adolescent individually. 
It can be scheduled for a particular session, or the topic can be intro
duced naturally when the adolescent brings a problem to the session.
Thereafter, every time the adolescent brings up a problem situation, the
therapist should reintroduce the problem-solving technique and work
through the steps to generate solutions for the adolescent to try out.
Materials
General materials include snacks (e.g., chips, crackers, granola bars, fruit
bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 
applicable) a videocamera and videotapes or an audiotape recorder and
audiotapes.
Procedure-specific materials include clipboard; chalkboard; whiteboard;
pens, markers, or chalk; an easel (optional); and the handouts How Do I
Solve That Problem? and How Can I Solve This Problem? (optional).

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General Notes for the Therapist
Maintain a positive atmosphere for change throughout problem solving.
This positive atmosphere is created by a positive demeanor, an enthusiastic
tone of voice, positive expectations for change (a Yes, you can! attitude),
and praise for the adolescents behaviors and efforts. Because problem-
solving techniques are best learned through practice, listen carefully to 
the adolescent during sessions for opportunities to introduce or reintroduce
problem solving. You can use the adolescents exact words to describe a
problem so that it is apparent that you heard his or her concern.
Problem-solving technique handouts are at the end of this section.
Memorize the steps in the problem-solving technique, and give copies of 
the handouts to the adolescent. The problem-solving technique used in this
manual is an adaptation of the problem-solving approach introduced by
DZurilla and Goldfried (1971). It is taken from Meyers and Smith (1995, p.
106) and used with permission of the copyright holders. A problem-solving
form for use by the adolescent is at the end of this procedure. An example
of a completed form is also provided.
Procedural Steps
1.  Introduce (or reintroduce) the technique to the adolescent.
2. Assist the adolescent in defining the problem clearly and specifically.
3.  Encourage the adolescent to generate alternatives for solving the
problem.
4.  Help the adolescent decide on one solution.
5.  Assign homework based on the chosen solution.
6.  Introduce the concept of evaluating the outcome, and follow up in a
subsequent session by reviewing and evaluating an outcome with the
adolescent.
7. Complete the ACRA Procedure 7 ChecklistProblem-Solving Skills
Training immediately after the session.
Detailed Description
The remainder of this section contains a detailed overview for conducting a
problem-solving exchange with an adolescent. Procedural steps are in bold
type and are followed by further directions and comments. Sample dialogs
between a therapist and an adolescent are indicated in italic type. 
1.  Introduce (or reintroduce) the technique to the adolescent.

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This is an example of how the technique is introduced as a scheduled topic:
Therapist: Today, Jim, we are going to talk about a technique 
you can use to solve problems that come up. Not just 
problems you encounter during the time you are meeting
with me, but problems you will encounter throughout
your life, when youre not going through treatment.
Give the adolescent the handout How Do I Solve That Problem? Review 
the contents with the adolescent. Encourage questions, and praise the 
adolescent for giving examples and making connections. 
Once the technique has been explained, illustrate how to use the technique.
Ask the adolescent to mention some current problems that he or she would
like to address. Then select a few relatively uncomplicated problems and
use the problem-solving technique. Also, the problem-solving technique can
be used when the therapist and adolescent are completing the goals of
counseling to identify interventions for each goal. 
The need for problem-solving training often emerges naturally, for example:
Therapist: Gina, it sounds as if you have a problem. Youre really
concerned about bringing your math grade up. Youve
tried to do it on your own, but its not working. Lets
talk about how you might solve this problem.
Use the first step of the technique to help the adolescent define the problem.
Work with the adolescent step by step through the problem-solving method
outlined below. Be generous with your assistance, but let the adolescent
take the lead. The adolescents responses to each step can be written on
the outline to further define the technique.
When the adolescent is already familiar with the technique, reintroduce the
topic, connect the adolescents problem and the technique, and proceed
through the steps with the adolescent. For example:
Therapist: Okay, Gina, it sounds as if you have a problem.
Remember the problem-solving technique weve used a
few times already? Lets see whether we can come up
with some solutions to your problem. The technique
seemed to work well the previous times. You were so
pleased with the outcomes, remember?
2.  Assist the adolescent in defining the problem clearly and 
specifically.
Give the adolescent a copy of the handout How Can I Solve This Problem?
The adolescent can use the handout to record his or her responses. Help
the adolescent define the problem as specifically as possible. Try to generate
open-minded thinking; encourage the adolescent to think about why a 
problem might exist. 

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Therapist: Gina, tell me more about how youre doing in math. I
know you said you were failing, but tell me more about
how your grade got where it is.
Adolescent: We have had three math tests so far. I got a 48 on the
first one, so I studied really hard for the second. I got a
32. So then I spent even more time on my math. Then I
got a 54. If I fail the next one, I will have to repeat
freshman math.
Separate any secondary or related problems. These are additional problems
that may contribute to the problem at hand. 
Therapist: What are some of the things that might be 
contributing to your difficulty in math class? Can 
you think of any?
Adolescent: Well, when I dont understand something, I dont like to
raise my hand in class. I would rather try to figure it
out on my own. I also like to watch TV, so when I do
my homework, the TV is on; and my brother bothers
me when Im trying to study, and I dont always finish
my work.
Therapist: Okay, I can see how these things could contribute to
having a hard time in math. Lets keep them in mind
when we start to come up with possible solutions to
your problem.
3.  Encourage the adolescent to generate alternatives for solving the
problem.
Use brainstorming to generate as many potential solutions to the problem
as possible. Follow two important rules for brainstorming: 
  Do not criticize any of the potential solutions. It doesnt matter
whether they sound like something the adolescent would never do
or whether theyre something that has already been tried. 
  Go for quantity.
Write all possible solutions on a whiteboard or chalkboard. Do not worry
about specificity at this point; you can help the adolescent narrow the
choice as he or she picks a solution to try. 
Therapist: The next thing to do is to think of as many solutions as
you can without judging them. Remember, we dont
want to eliminate any of the possible solutions yet. One
thing I can think of is to see a tutor for your math.
Whats something you can think of?

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Adolescent: Maybe studying away from the TV or at the library so
my brother doesnt bother me.
Therapist: Good! Maybe studying with someone who is doing well
in class would help.
Adolescent: Or just studying more before tests would help.
[Encourages the adolescent to generate as many 
solutions as possible.]
4.  Help the adolescent decide on one solution.
Help the adolescent narrow down the list of alternatives. First, the adolescent
should eliminate any solutions that he or she does not feel comfortable 
trying. No explanations are necessarytell the adolescent that no 
explanations are required for eliminating any alternatives.
For the remaining solutions, encourage the adolescent to think about how
it would be to carry out each solution. Ask, Do you think you would actually
follow through with the solution? Would it work? This may narrow down
the list even more. 
From the pool of remaining solutions, the adolescent should choose one
solution and describe exactly how it will be carried out. Again, ask, Which
one would be most helpful? and encourage the adolescent to be as specific
as possible (e.g., when? how often? what time of day? with whom?).
Help the adolescent identify any obstacles to carrying out the solution
that is, things that might interfere with the completion of the assignment.
The goal is to identify beforehand any obstacles that could possibly subvert
the adolescents attempts to solve the problem. Ask, What might come up
in the course of a week that would get in the way? As each obstacle is
identified, generate backup plans with the adolescent to circumvent it. If
the adolescent thinks he or she might forget, for example, then ask, What
can you do to make sure you dont forget? Spend time talking about these
obstacles. Homework assignments may be appropriate. If possible, allow the
adolescent to write on the whiteboard or use the computer. Participation in
this process will help the adolescent apply lessons learned.
The adolescent should now have a specifically defined plan for addressing
the problem. The plan should include when the solution will be attempted,
how often, and at what times. The adolescent should agree on the number
of times to try the solution before the next session. To reinforce this action,
ask, Now, what did you decide you will do?
Consider whether additional solutions should be attempted before the next
session. If the adolescent wishes to try additional solutions, repeat the 
decision process for each solution. Evaluate with the adolescent the feasibil
ity of the remaining solutions, choose another solution to try, and describe
exactly how it will be carried out, consider possible obstacles to enacting 

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the solution, and generate a backup plan to overcome the obstacles. A 
sample dialog between a therapist and adolescent follows:
Therapist: If there are any solutions that you dont think you
would try, go ahead and cross those off. You dont
have to explain why; just cross them off if you dont
think you would try them.
Adolescent: I dont think I would go to the library.
Therapist: Okay. Well cross that one off. Are there any other ones
you dont think you would try?
Adolescent: No, I think I would try any of the other ones.
Therapist: Are there any solutions you think would not work?
Adolescent: No, I think they could all work.
Therapist: Which one do you think you would like to try the most?
Adolescent: I think if I studied with my friend Julie, that would help
because she does so well in math.
Therapist: How would you go about doing that?
Adolescent: Well, I would just call her up and ask her to study with
me.
Therapist: Good. When do you think you will study and how long
will it take?
Adolescent: I dont know. Maybe Ill study once during the week
and once on weekends, so Im not having to do it all
on the weekends. Maybe I can study 2 hours each
time.
Therapist: So, twice a week. Are any particular days better than
others for you?
Adolescent: Wednesdays and Sundays could probably work, but I
would really have to ask Julie first.
Therapist: Good thinking. Are there any things that could make it
difficult for you to do this?
Adolescent: Not really. We could study anywhere. I guess if she
couldnt study on a certain day, it could be tough.
Therapist: If that happens, what would you do?

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Adolescent: Ill just pick another day. I mean, I can study almost
any time.
5.  Assign homework based on the chosen solution.
Help the adolescent identify a homework assignment based on the solution
chosen during the problem-solving session. 
Therapist: When would you like to start studying with Julie?
Adolescent: Right away probably. I could start tonight.
Therapist: Great! Why dont we try calling Julie right now and
see whether we can set up your study time? [Gina
makes the call and sets up the study session.]
Therapist: Good job! Ill check how the studying is going when we
meet next week. You are planning on studying twice a
week for 2 hours, right?
Adolescent: Yeah.
6.  Introduce the concept of evaluating the outcome, and follow up in
a subsequent session by reviewing and evaluating an outcome with
the adolescent.
Explain to the adolescent that an important part of problem solving is
checking whether a particular solution worked. This checking is done by
asking the following questions: Was the solution carried out? If not, what
barriers got in the way? What could be done differently next time? If the
solution was carried out, did it help solve the problem? Was the desired 
outcome attained? For example, in the solution for the sample above, did
the adolescents grades improve? The adolescent can do the checking 
himself or herself or during a counseling session.
Review the outcome with the adolescent at the next session. Be sure to 
positively reinforce any efforts by the adolescent to try to carry out a solution.
If solutions did not go well or the adolescent had a difficult time carrying
them out, help him or her modify the solution and encourage another try. 
If an entirely new solution is necessary, repeat the problem-solving steps.
If the adolescent did not attempt the assignment, the lack of followthrough
could be treated as a problem that needs a solution. The problem-solving
technique could be applied in this situation. Once the adolescent appears
to understand the problem-solving technique, he or she should walk the
therapist through the procedure step by step using a new problem.
Attaining this level of skill is recommended before terminating therapy.
7. Complete the ACRA Procedure 7 ChecklistProblem-Solving Skills
Training immediately after the session.
A blank copy of this form is included at the end of this section.

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HOW DO I SOLVE THAT PROBLEM? 

Everyone experiences problems from time to time with things like school, 
parents, caregivers, friends, work, or activities. Using problem-solving techniques
can help us consider every part of a problem to come up with a good solution.
Below is an outline of a problem-solving technique you can use when a problem
arises.
1. Define the problem.
!""Define the problem as specifically as possible (be brief, positive, and 
specific).

!""Make sure you are dealing with one problem at a time.
2. Generate alternatives.
!""Use brainstorming (think of as many things as you can) to generate
possible solutions. 

!""Do not criticize any of the suggestions offered.

!""Go for quantity; the more potential solutions, the better!
3. Decide on a solution.
!""Eliminate any solution you would not feel comfortable trying or you
do not think you would do. No explanations are needed. 

!""Think about the chances that each remaining alternative will work
while checking out its probable consequences.

!""Decide on one solution, and describe exactly how you will carry it
out.

!""Consider obstacles that may come up in trying the solution.

!""Generate backup plans in case you run into an obstacle.

!""Decide with the therapist on the number of times you will try the
solution before the next session.

!""Decide whether to attempt a second solution as well.

!""Go through the problem-solving steps above, starting with the second
step, for any solutions considered.
4. Evaluate the outcome.
!""Review the outcome, and decide how satisfied you are with how it
worked out.

!""Modify the solution if necessary.

!""If an entirely new solution is needed, repeat the problem-solving
steps.

-----------------------------------------------
HOW CAN I SOLVE THIS PROBLEM?

1. What is the problem you are dealing with?

2. What are some ways you might be able to solve the problem? List as many
ideas as you can think of. 

3. Draw a line through any ideas that you dont think you would try.
4. Read each idea that you have not crossed off the list, and pick one idea that
sounds like something you would like to try. Write it down.

5. Try that idea before the next time we get together, and we can talk about
how it went.

-----------------------------------------------
HOW CAN I SOLVE THIS PROBLEM?

(SAMPLE ANSWERS)

1. What is the problem you are dealing with?
I am failing math.

2. What are some ways you might be able to solve the problem? List as many
ideas as you can think of. 
Study away from the TV.
Study at the library so my brother doesnt bother me.
Study with someone who is doing well in class.
Study more before a test.

3. Draw a line through any ideas that you dont think you would try.
Study at the library so my brother doesnt bother me.
4. Read each idea that you have not crossed off the list, and pick one idea that
sounds like something you would like to try. Write it down.
Study with my friend Julie, who is doing well in class.
5. Try that idea before the next time we get together, and we can talk about
how it went.

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Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

ACRA Procedure 7 Checklist
Problem-Solving Skills Training

                   Check Appropriate Boxes
Activity In Progress    Yes       No
1.   Did you maintain a positive atmosphere 
for change throughout problem solving?    
2.   Did you introduce the problem-solving 
technique and go over the outline with the 
adolescent?    
3.   Did you help the adolescent clearly and 
specifically define the problem, separating 
out any secondary or related problems?    
4.   Did you encourage the adolescent to 
generate alternatives for solving the 
problem by following the two rules 
important for brainstorming?    
5.   Did you help the adolescent narrow down 
the list of alternatives and choose one 
solution?    
6.   Did you have the adolescent commit to an 
agreed-on number of times to try the 
solution before the next session?    
7.   Will you evaluate the outcome at the next 
session?

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Procedure 8: Urine Testing
Rationale
The results of a urine test are not the focus of ACRA treatment because
ACRA primarily relies on identifying reinforcers and taking a positive
approach. However, a negative (no drugs found) urine test provides the
opportunity to reinforce abstinence, whereas a positive urine test provides
additional information to the therapist that can be used to prompt 
appropriate ACRA procedures (e.g., relapse prevention).
Purpose of the Procedure and Learning Objectives
The purpose of the procedure is to monitor adolescents abstinence
through a means other than self-reports and to provide appropriate 
feedback to adolescents based on test results. The learning objectives 
are to provide adolescents with:
  Positive reinforcement and support if the urine test indicates no
drugs are present
  Nonjudgmental review of the context of use and triggers if the
results indicate that drugs are present
  Potential solutions if a similar using situation is encountered in
the future.
Timing, Audience, and Delivery Method 
During the CYT study, adolescents were asked to complete urine tests 
on two random occasions during a 6-week or 3-month intervention. In 
general practice, the frequency of urine testing may vary, depending on
treatment facility requirements. Regardless of the frequency of urine 
testing, adolescents should be informed about the frequency and general
procedures for urine testing during an initial session.
When the adolescent is due for a test, the therapist can approach the 
adolescent before the session begins and explain that this is the day that
has been randomly chosen for a urine test. Reiterate the reason and 
procedures for completing the test; direct the adolescent to a lavatory; 
and provide a cup. Read the results and record them in the clinical chart.
The entire procedure should take approximately 10 minutes. When the 
adolescent is not able to provide a sample, ask him or her to give a 
sample at the end of the session.
Materials
Procedure-specific materials include drinks if the adolescent is having 
difficulty providing a urine sample, test kits, screening cups, rubber
gloves, and watch or clock.

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Urine Test Kits
If possible, it is important to use an onsite urine test kit that can be read
almost immediately. Kits are available that can test for the primary drugs
being abused by a target population. Because these tests can be read 
immediately, they allow for immediate (same session) feedback and 
discussion of the results with the participant. Besides the test kits, additional
supplies needed to conduct tests include latex gloves, urine screening cups,
a directions or procedure sheet for the analysis of the test kit results, a 
clock or watch to monitor the time that elapses, and access to a rest room.
There are many different brands of onsite drug tests. Typically, these tests
are economical, with prices based on the number of drugs being tested for.
The tests generally require placing drops of urine on testcards, allowing a
certain amount of time to elapse, and then reading the results by examining
visual markers. Tests do not necessarily have to be observed if (1) there are
procedures built into the test that help detect adulterated samples and 
(2) there is temperature monitoring so that it is possible to detect watered
down samples. Temperature monitoring can be done with specimen cups
that have built-in temperature strips. Staff members who handle the urine
should be trained in the proper procedures for safely handling bodily fluids.
It is also important to study procedures regarding refrigeration of test kits
to optimize shelf life.
Note that onsite drug tests are considered to provide preliminary analytical
results. Gas chromatography/mass spectrometry (GC/MS) is usually pre
ferred for a confirmatory analysis. These tests are typically done in a labora
tory. An onsite test may have limited value in assessing decreasing drug use
(as opposed to total abstinence) and does not provide confirmatory analyses
that may be required by a court or other source. If a teenager denies use
but tests positive with an onsite test, consider sending a second urine sam
ple to a certified laboratory to verify the onsite test using GC/MS.
General Notes for the Therapist
Adolescents should be told in the first session that there will be random
urine tests so they are not surprised when the therapist tells them it is time
for one. When the therapist discusses the urine test during the initial 
session, he or she also needs to explain the reason for the test. If the 
adolescent refuses to submit to a test, it is important for the counselor 
to continue therapy with him or her because the most important goal is to
treat the client. If an adolescent is on probation, the probation officer may
conduct the urine test rather than the therapist.
Treatment programs may not want to do urine testing when a teenager
freely admits to using unless the particular test being used is one that 
provides measures of substance use levels.
Note: If the adolescent is absent the week testing is due, administer the
test during the next treatment session he or she attends.

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If urine testing has been mandated by probation, parole, or another court
agency, obtain appropriate signed disclosures and reveal the test results to
the agency.
Procedural Steps
1. Explain to the adolescent that he or she will need to provide a urine
sample today.
2.  Take the adolescent to a bathroom, provide the necessary materials,
and go over the instructions for providing a sample.
3.  Read the test.
4.  Provide the appropriate feedback based on the results.
5. Complete the ACRA Procedure 8 ChecklistUrine Testing
immediately after the session.
Detailed Description
The remainder of this section contains a more detailed overview for 
conducting a urine test and processing its results. Procedural steps are 
in bold type and are followed by further directions and comments. 
1.  Explain to the adolescent that he or she will need to provide a
urine sample today.
Urine tests should have been discussed in an earlier session so they will not
be a surprise to an adolescent. Tell the adolescent that this session is the
one that has been randomly chosen for a urine test. Explain the purpose of
the urine test and the possible outcomes, and provide some general idea of
what your response will be to each of the outcomes. Also tell the adolescent
about procedures that are in place to assess whether a sample has been
tampered with.
2.  Take the adolescent to a bathroom, provide the necessary materials,
and go over the instructions for providing a sample.
Specific steps for conducting the test and an explanation of how it works
should be available from the company that markets the tests. The therapist
should complete either a company-sponsored or an inhouse training program
and be certified before administering tests.
3.  Read the test.
Follow the manufacturers instructions, and read the test resultspossible
outcomes include negative (drugs are not present), positive (drugs are 
present), or inconclusive. If the test is inconclusive, you may want to test
an additional drop from the same sample. Record the results on the 
urine-testing form.

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4.  Provide the appropriate feedback for the results.
When the test indicates that drugs are not present in the urine, provide
strong positive reinforcement and social support. Review aspects of the 
adolescents living environment that have been conducive to abstinence.
Encourage continued development of drug-free activities. Probe for problems
with cravings or emotional distress during this time. Find out how the 
adolescent coped successfully with these problems. Ask the adolescent,
What is your biggest motivation for not using?
When urine test results indicate that drugs are present, review the context
of the adolescents use. Be nonjudgmental. Examine external and internal
triggers associated with his or her use, and generate potential solutions to
resist use if a similar circumstance is encountered in the future. Talk with
the adolescent about goals for marijuana use and nonuse. Try to get the
teen to commit to changing his or her using behavior, and help the adolescent
identify personal motivators for staying away from alcohol or drugs. Review
triggers, coping methods, and other relapse prevention procedures
described in procedure 5 of this manual. 
5. Complete the ACRA Procedure 8 ChecklistUrine Testing
immediately after the session.
A blank copy of this form is included at the end of this section.
Tips for Individualizing or Dealing With Difficult Situations
To individualize urine test results:
  Stick with the specifics of the adolescents situation. 
  Discuss what the adolescent is doing to maintain his or her 
abstinence. 
  Focus on what can be done to avoid triggers and lapses.
If the adolescent denies using despite positive results:
  Do not criticize the adolescent. Rather than being confrontational,
play detective and ask questions. For example, What do you
make of this discrepancy? or What do you think is going on
here? 
  Point out that perhaps a urine test showing drugs in the urine
could have consequences (e.g., probation problems, losing a job)
even if the adolescent did not use. 
  Ask the adolescent how you can help him or her. 
  Reiterate that being around others who are using alcohol or drugs
is a high-risk situation with negative consequences. 

(Continued on next page)
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  Ask how the urine test results could affect his or her goals. 
Note: You also may want to suggest sending an additional sample to a
laboratory for verification. 

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Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

ACRA Procedure 8 Checklist
Urine Testing

                   Check Appropriate Boxes
Activity In Progress    Yes       No
1.   Did you explain the purpose of urine 
testing?    
2.   Did you record the results in the clinical 
chart?        
3.   If test results were negative, did you 
provide positive reinforcement and social 
support?        
4.   If test results were positive, did you review 
the context of the adolescents use, 
examining external and internal triggers?    
5.   If test results were positive, did you 
generate potential solutions to use if the 
adolescent encounters the circumstances 
again?    
6.   If test results were positive, did you review 
procedures on relapse prevention?         

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Procedure 9: Caregiver Overview, Rapport Building, and
Motivation
Rationale
Caregivers have an important role in helping the adolescent overcome a
drug or alcohol problem. They must therefore be taught the behavioral
skills to discourage the adolescents drug use and the parenting practices
that can keep their adolescent from relapsing.
Purposes of the Procedure and Learning Objectives 
The purposes of the first session with the caregiver are to (1) motivate 
participation in the ACRA treatment process and (2) help the caregiver
understand how his or her behavior impacts the adolescents substance 
use. The learning objectives are to provide caretakers with:
  A more positive attitude about their adolescent that eliminates
blaming anyone for current problems
  An understanding of the ACRA approach and treatment process
and the importance of their role in the treatment
  Motivation to continue working with the ACRA therapist.
Timing, Audience, and Delivery Method  
These procedures are covered during the first session with the caregiver
in the first or second week of treatment. During the first adolescent session,
you should have already met briefly with the caregiver to provide an
overview of the ACRA treatment process and the caregivers involvement
in it. (See the section Sequence and Content of Caregiver Sessions in Part
II, Overview of the Treatment Model.)
Materials
General materials include snacks (e.g., chips, crackers, granola bars, fruit
bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if
applicable) a videocamera and videotapes or audiorecorder and audiotapes.
Procedure-specific materials: none.

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General Notes for the Therapist
A caregiver is not necessarily a parent. A caregiver could be an older sibling,
a grandparent, or another adult who is willing to try to help the adolescent
with recovery. It is usually someone who lives with the adolescent.
Caregivers may be emotional during the first session. They may be either
angry or sad. Some will be very angry with their adolescent and want to talk
about how bad the youth is. Others may feel a sense of failure that this
has happened in their family. It will be important to listen empathically and
then attempt to motivate them to play a positive role in their adolescents
treatment.
During the session, maintain a positive and enthusiastic tone of voice. Your
demeanor can help build a positive atmosphere for change and motivate the
caregiver to follow through with the four sessions.
Procedural Steps
1.  Use rapport-building techniques.
2.  Provide an overview of ACRA.
3.  Motivate or hook the caregiver into continued work with the
ACRA therapist.
4.  Provide information to the caregiver about research findings on the
most important parenting practices for keeping his or her adolescent
from relapsing.
5.  Assess whether problems appear serious enough to warrant other
referrals.
6.  Assign homework (but do not call it that).
7. Complete the ACRA Procedure 9 ChecklistCaregiver Overview,
Rapport Building, and Motivation immediately after the session.
Detailed Description
The remainder of this section contains a more detailed overview for 
conducting the first session with the caregiver. Procedural steps are in 
bold type and are followed by further directions and comments.
1.  Use rapport-building techniques.
Strategies for building rapport include:
  Let the caregiver have the opportunity to discuss his or her 
feelings about the family situation.

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  Empathize with the caregivers concerns. After doing so, begin to
refocus on what needs to be done now, and shape the interaction
in a positive way. (See below.)
  Reinforce that the caretaker must attend the sessions, and let
him or her know that you understand it may be difficult to do so.
  Share general information from your work with other families,
affirming that these sessions can be helpful and that research has
shown that these techniques have helped other families in similar
situations.
Techniques for keeping the discussion positive. These techniques from
Functional Family Therapy (Alexander & Parsons, 1982; Waldron & Slesnick,
1998) can be helpful to therapists as they try to shape a positive discussion:
  Relabel behavior. Change the meaning and value of a negative
behavior by describing positive properties of the behavior or by
explaining that the adolescent is not engaging in it to make the
parent or caregiver miserable or angry. If possible, suggest positive
motives for the behavior, and/or portray family members as victims
rather than perpetrators. For example, the adolescent may be
described as someone who is struggling to become independent
and is trying very hard to be accepted by friends. Relabeling
behavior gives family members another picture or new 
information about behaviors and is most effective if it ascribes
benign or benevolent motives.
  Curtail blaming. Communicate to the caregiver that blaming 
someone for previous problems does not serve any purpose.
Emphasize the future, not what happened in the past.
  Use a positive focus. Emphasize family strengths by repeatedly
reinforcing discussions about aspects of family life that are 
working well, such as pleasant events and family activities. For
example, Tell me something nice that your child has done during
the 15 years he or she has been a part of your family.
  Use exception statements. Try exception statements, another
technique useful in decreasing family blaming statements
(Melidonis & Bry, 1995). To use this technique, ask the caregiver
to describe a situation from the past in which the problem 
behavior was expected to occur but did not. Then probe into 
what was different about this situation.
2.  Provide an overview of ACRA.
  Describe ACRA, including the success, philosophy, and the focus
of ACRA therapy sessions. 

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  Provide information about the length of treatment sessions, the
number and type of ACRA therapy sessions, confidentiality, urine
testing, and videotaping or audiotaping, if appropriate.
  Praise the family for participating in treatment and try to make
the members feel comfortable, stating something such as, I am
really glad you came to treatment; I look forward to working with
you! 
  Encourage the family to ask questions, and let both the caregiver
and the adolescent know that they can ask questions about 
therapy at any time during treatment.
  Describe the purposes of ACRA caregiver sessions. During the 
sessions you hope to (1) help diminish the caregivers pain, 
(2) help improve communication, and (3) help improve the 
relationship between the caregiver and the adolescent.
3.  Motivate or hook the caregiver into continued work with the
ACRA therapist. 
Set positive expectations and try the following procedures.
  Assess the caregivers reinforcers related to the youths stopping
substance abuse, and use these to help motivate the caregiver to
try ACRA.
Sometimes the caregivers reinforcers are revealed through 
conversation, but usually it will take questioning to elicit them.
Ask, What benefits will result if the adolescent stops using?
Most caregivers will be able to articulate the benefits or goals 
for their adolescents. For example, they want their teenagers to
graduate from high school and to avoid incarceration. Other 
caregivers motivation revolves around themselves, such as 
wanting to make their own life easier. For example, a caregiver
may say, I want the school system off my back.
Work with whatever reasons the caregivers offer for wanting their
adolescents to stop using alcohol or marijuana, and try to help
them see how the therapist, caregiver, and teen can work 
together to achieve their goals.
  Reiterate potential benefits of ACRA discussed during the
overview; emphasize that caregiver involvement in treatment
could help improve the relationship between the caregiver and his
or her teenager and could help lead to more success in life for the
teenager.
  If the caregiver is skeptical because of past treatment failure or
because he or she does not believe that the adolescent will quit
using alcohol or drugs, emphasize that recovery is a process. Tell

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the caregiver that you believe this program can work for him or
her. Try to get commitment to attend at least four ACRA sessions.
You might say something like, I know you love your son (daugh
ter). Sometimes parents just dont know what to do when there
are problems with their children, and sometimes it is helpful to
try different things.
4.  Provide information to the caregiver about research findings on
the most important parenting practices for keeping his or her 
adolescent from relapsing (based on the work of Catalano [1998],
Hops [1998], and Bry [1998]). 
According to Catalano, Hops, and Bry, the following are four critical 
practices that parents or caregivers can adopt to help their children 
remain abstinent:
  The single most important parenting practice is for caregivers to
be good role models by refraining from using drugs or alcohol in
front of their teenagers. When discussing this with caregivers, tell
them that you are not accusing them of using but that they
need to know this. Ask them whether they will agree not to use
substances in front of their teenager.
  A second critical parenting practice is to increase positive 
communication with their adolescent. Parents or caregivers
should strive toward decreasing blaming and put downs and
increasing positive talk with and about their teenagers. Explain
that in the next session, you will work with them on communication
skills.
  A third important parenting practice is to monitor the adoles
cents whereabouts, including knowing where they are and whom
they are with. 
  A fourth critical parenting practice is involvement in the 
adolescents life outside the home by encouraging and promoting
prosocial activities.
It is important to maintain a dialog during the session, so it is helpful to
weave a discussion of the four parenting practices into conversation. For
example, you may ask, What are some of the things you do really well as a
caregiver? or What are some things you do to keep your teenager away
from alcohol or drugs? As you review the caregivers responses, look for
opportunities to praise them for positive parenting practices. 
During a discussion of the four practices, caregivers may bring up issues or
problems. If so, you can begin to talk to the caregivers about their issue of
concern but still try to review all four parenting practices. For example, a
parent may say he or she has a problem showing appreciation for his or 
her teen. You may help him or her practice providing praise or showing 
appreciation. Or the caregiver may reveal he or she rarely encourages the 

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teen to attend positive social activities. You may begin helping the caregiver
identify positive social activities.
The caregivers primary role with regard to developing other community
reinforcers is to help the adolescent access them or support his or her
interest in them by spending time with the adolescent as he or she watches
or participates in the activities.
5.  Assess whether problems appear serious enough to warrant other
referrals. 
It is especially important to make referrals if there are other adults or 
adolescents in the home who are presently involved in substance abuse or
who have serious mental health problems. You should report any instances
of possible abuse.
6. Assign homework.
At the end of the discussion, try to get the caregiver to commit to homework
such as providing praise, appreciation, and positive reinforcement to the
teenager at home. You may introduce the assignment this way, Weve found
that the best way to have these new behaviors become part of your normal
behavior is to practice them. Would you be willing to try them a couple of
times before I see you again? (If the answer is yes, help specify what he or
she would do.) Examples of homework might be to praise the teenager at
least twice a day and locate a positive activity and encourage the adolescents
participation in it. At the next session, review the caregivers success with
the homework tasks. You also should review the four critical parenting 
practices to help reinforce these concepts.
7. Complete the ACRA Procedure 9 ChecklistCaregiver Overview,
Rapport Building, and Motivation immediately after the session.
A blank copy of this form is included at the end of this section. 

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Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

        ACRA Procedure 9 Checklist
Caregiver Overview, Rapport Building, and Motivation

                   Check Appropriate Boxes
Activity In Progress     Yes       No
1.   Did you maintain a positive and 
enthusiastic tone of voice?    
2.   Did you employ rapport-building 
techniques with the caregiver?   
3.   To keep the discussion positive, did you 
relabel behavior?    
4.   To keep the discussion positive, did you 
curtail blaming?    
5.   To keep the discussion positive, did you 
constantly reinforce discussion about 
aspects of family life that are working well 
and pleasant events and family activities?    
6.   Were you able to motivate or hook the 
caregiver into continued work?    
7.   Did you talk about the benefits of ACRA?    
8.   Did you provide information to the 
caregiver about what he or she can do to 
keep the adolescent from relapsing?    
9.   Did you assess whether the problem 
appears serious enough to warrant 
another referral?    
10.   Did you get the parent or caregiver to 
commit to some homework (without 
calling it homework)?     

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Procedure 10: Caregiver Communication Skills Training
Rationale
Caregivers and adolescents often have a difficult time communicating in a
positive, effective manner. It is not unusual for caregivers to be frustrated
with their adolescents behavior in a number of areas, and substance
abuse problems can exacerbate an already troubled relationship.
Improving communication skills can help family members develop more
positive relationships.
Purpose of the Procedure and Learning Objectives
The purpose of this session is to improve the communication skills of the
caregiver. The caregiver will learn the importance of good communication
skills in improving relationships; how to use the ACRA communication
techniques such as understanding statements, a partial responsibility 
statement, and offer-to-help statements; and how to use these techniques 
in real life situations.
Timing, Audience, and Delivery Method
This session is conducted individually with the caretaker in weeks 3 to 5
of treatment. The caregiver has the opportunity to practice these skills
during the session and is asked to continue practicing them before the next
session. In a later session, the caregiver and adolescent are brought
together for joint practice.
Materials
General materials include snacks (e.g., chips, crackers, granola bars, 
fruit bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and 
(if applicable) a videocamera and videotapes an audiorecorder and 
audiotapes.
Procedure-specific materials include clipboard; chalkboard or whiteboard;
pens, markers, or chalk; and an easel for presentation of material on 
communications skills.

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General Notes for the Therapist
The skills outlined in this section are taught within the context of real 
communication problems between the caregiver and adolescent. Although
the therapist teaches the caregiver about effective communication skills,
the teaching is grounded in the experiences of the caregiver. The caregiver
is not merely a passive recipient of the learning that takes place but is
actively involved. This approach helps make the procedures more valuable
to the caregiver, who will then be more likely to try them in real life.  
The skills covered in this section can be used to enhance communication
with other people besides the adolescent.
Procedural Steps
1. Introduce the topic of communication, and provide a rationale for
developing good communication skills.
2.  Assess and talk about the present quality of communication between
the caregiver and adolescent. 
3.  Using real life examples provided by the caregiver, teach the caregiver
ACRA communication techniques. 
4.  Roleplay a number of interchanges between the caregiver and 
adolescent, with the therapist taking the role of the adolescent.
Insert ACRA and general communication techniques whenever 
helpful, and mention pitfalls to avoid. Then switch roles with the
caregiver playing the adolescent and the therapist playing the 
caregiver.
5.  Process each exchange from the content and feelings perspectives of
the caregiver. 
6. Assign homework.
7. Complete the ACRA Procedure 10 ChecklistCaregiver
Communication Skills Training immediately after the session.
Detailed Description
The remainder of this section contains a step-by-step description for 
providing communication skills training for caregivers. Procedural steps 
are in bold type, and they are followed by further directions and comments.
Sample dialogs between a therapist and caregiver are indicated in italic
type.
1.  Introduce the topic of communication, and provide a rationale for
developing good communication skills.

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Take a few minutes to introduce the session, and talk about why it is 
important to focus on communication skills. Find out what reinforcers
would motivate the caregiver to make changes in his or her behavior. For
example, a caregiver might say, Im really tired of all the arguing. Key
points to make include the following:
  Communication between the caregiver and the teenager can be 
difficult, especially when the teen has difficulty with substance
abuse.
  The fact that you want to discuss communication skills does not
mean that you think the caregiver does not know how to 
communicate. However, most caregivers would probably agree
that they could use some guidelines to help them when communi
cation becomes difficult or awkward, such as when they try to
solve a problem or talk about a difficult situation with their
teenagers.
2.  Assess and talk about the present quality of communication
between the caregiver and adolescent.
Ask the caregiver about the quality of communication when trying to talk
with the adolescent about (1) nonproblem topics (social or typical everyday-
type conversation) and (2) problem topics (the teenagers substance use, a
problem at school, or a problem at home). How do things tend to go? Has
there been any good communication in the last 2 years? Ask the caregiver
for examples of real life conversations discussing both a nonproblem and a
problem situation. 
Therapist: Tell me what happens when you try to talk together
about. . . .
For those situations that do not go well (e.g., caregiver or teenager gets
angry or frustrated and leaves, or the caregiver and teen get into a fight), 
listen and observe carefully to understand the dynamics that typically
unfold between them. To make sure you understand the situation (and to
show the caregiver you are listening), you may want to repeat the situation
to the caregiver and ask clarifying questions. 
Therapist: Let me see whether I understand this. Gina typically
comes home after curfew 2 or 3 nights per week. She
walks in, and you stand there and say, Youre late.
She responds,Tough, and walks to her room. Her
response makes you angry, and you lose your temper
and say things like, You can move out when youre 18
if you cant follow the rules and Go live with your
father; you can be his problem. She typically locks
herself in her room and says nothing back to you. 
She just shuts down, puts on the radio, calls a friend
on the phone, and shuts you out completely. Is that 
accurate? What do you do after that?

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Ask the caregiver how satisfactory the quality of communication is with the
adolescent. If the caregiver is unhappy with it, ask what he or she would
like to have happen. Listen carefully to try to understand the caregivers
goals. 
Assure the caregiver that you will teach a few techniques that may help with
the communication problems. You will also roleplay a few situations with
the caregiver to give him or her a chance to practice before he or she
encounters a real problem situation with his or her teenager. A goal is to
get the teenager and caregiver to make decisions together. If both persons
are involved in developing a solution to a problem, they are more likely to
follow the agreed-on steps to the solution.
3.  Using real life examples provided by the caregiver, teach the 
caregiver ACRA communication techniques.
ACRA has three basic parts to effective communication: (1) giving an
understanding statement, (2) taking partial responsibility, and (3) offering
to help. An understanding statement brings feelings into the conversation
in particular, empathy. It shows that one person is capable of seeing things
from the other persons perspective. The caregiver can also try to help the
teenager understand the caregivers perspective. The effect on the other
person is a feeling of validation, and this will decrease defensiveness. A 
partial responsibility statement indicates that the caregiver is willing to
accept a role in creating or solving a specific problem. It does not mean 
the caregiver or anyone else is to blame or that it is all up to the caregiver 
to solve the problem. It acknowledges that the caregiver has a shared 
responsibility with the adolescent for creating and solving a problem. An
offer to help is just thatan offer by the caregiver to help solve the problem.
In this instance, the caregiver tries to think of ways that would make it 
easier for the teenager to cooperate. In some cases, it may be necessary to
set up a contingencythat is, the teenager is able to do something he or
she wishes if he or she follows through with an agreed-on behavior.
Taken together, these three communication skills deliver the message 
that the caregiver wants a change in the teenagers behavior but that the 
caregiver is willing to be actively involved and supportive in the process. The
outcome is decreased defensiveness on the part of the adolescent and more
open lines of communication. 
Using a problem situation between the caregiver and adolescent, introduce
each of the three ACRA communication techniques where they would be
helpful. The techniques are generic so they can be used in virtually any
problem situation. For example:
Therapist: Okay, Mrs. Smith, lets go back to that situation
between you and Gina when she comes home late.
Lets replay that conversation, break it down into
pieces, and try to understand where you are coming
from at each point and how you and Gina feel. As we
go through the conversation, Id like to offer three 

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techniques that will help the conversation stay calm
and be more productive. The first technique is to try to
make an understanding statement. An understanding
statement brings empathy into the conversation and
helps decrease defensiveness because you are really
trying to understand the others perspective. So what
do you think Ginas perspective is on this issue? 
Caregiver: I mean, I guess I can understand that she enjoys 
running around with her friends and is reluctant to
come home if they are out having a good time. And 
we have been fighting a lot lately.
Therapist: Thats a great start. Talk to me as if Im her, using an
understanding statement.
Caregiver: Gina, I understand that it is hard to leave your friends
to come home when you are having a good time. I also
understand that you may not enjoy being at home
because we have been arguing a lot lately.
Therapist:  That was perfect! Now the next component is to try to
take partial responsibility for the problem or solution.
Caregiver:  How is it my fault?
Therapist: This technique is not to place blame on anyone. It is
meant to indicate that you are willing to accept a role
in creating or solving the problem. 
Caregiver: One thing that I am probably guilty of is not hearing
the reasons why she is late, encouraging her to call, or
even sitting down to talk to her about solutions to this
problem. I just instantly start yelling, then I get so
angry at her response that I say hurtful things to her
like she can move out when shes 18 or can go live
with her father and be his problem. That isnt right.
That really bothers me.
Therapist: Have you ever shared these feelings with Gina?
Caregiver:  No. Thats the problem. We cant just sit down and talk
without fighting.
Therapist: You have been doing great in here with me. Maybe by
going over some of these helpful techniques you will 
be able to sit down and talk. So talk to me using the
understanding statement and the partial responsibility
component.

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Caregiver:  Okay. Gina, I understand that it is hard for you to come
home on time when you are having a good time with
your friends and to come home to us always arguing.
You just get me so angry that I start yelling and. . . .
Therapist:  You are doing well, but try to use I statements.
Instead of saying you just make me angry, start 
by saying I feel angry when. . . . Good job on the 
understanding statement. Start with the partial 
responsibility again.
Caregiver:  I want to apologize for how I act at times. I get angry
when you are not home when you are supposed to be.
I feel like you dont respect me. I get so worried. When
I get worried or angry, I start yelling and say things
that I dont mean. I would like to change and try to
improve our relationship by trying to improve the way
we talk to each other. I would like to hear what you
think or what you think we can do together to help.
Therapist: Great. You are doing very well. Now the third component
is the offer to help. It is an offer on your part to help
solve the problem. Can you think of something you can
offer to do to help resolve the issue of Ginas breaking
curfew? 
Caregiver: I could offer to give her transportation, be open to 
having her call me if she is going to be late, or discuss
the reasons why she has been breaking curfew.
Therapist:  Now lets review the three components by having you
talk to me as if Im Gina, using all of them together.
Caregiver: Gina, I understand that it is hard for you to come
home on time when you are having a good time with
your friends and you come home to us always arguing.
I want to apologize for how I act sometimes. I get 
worried when you are not home when you are supposed
to be. When I get worried or angry, I start yelling and
say things to you that are hurtful and that I dont
mean. I am really sorry. I would like to try to improve
our relationship by trying to work on how we talk to
each other. I would be open to talking about how you
feel about curfew and some of the reasons why you
have been breaking it and to seeing if we can come up
with some ideas together to solve our problem.
Therapist: Fantastic! How did it feel using these techniques?
Caregiver: Weird at first because I really have to think about what
I am saying. I just hope I can do it. 

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Therapist: Youre off to a good start. If you get angry, you might
try to walk away or take a deep breath then try to use
these techniques. Because when you are angry, you
say things to her that you dont mean. This week
would you be willing to try to use these techniques
when talking with Gina?
Caregiver:  Ill try.
Therapist: How do you think Gina will respond if you try talking
to her using these techniques? 
Caregiver: She will probably think I am crazy, but I really want
our relationship and communication to improve. So,
Im willing to give it a shot. 
Therapist: Good. I like your openness to trying new things. I will
be going over these techniques with Gina as well. So
she might be trying these techniques at home too. Later,
when we all meet together, we will be using these
techniques in our family sessions together. 
The therapist might have the caregiver practice several different versions 
of this roleplay. The purpose of the exercise is to practice and to give the 
therapist an opportunity to help shape the skills being taught. Roles can be
switched; the caregiver can play the adolescent, and the therapist can play
the caregiver. This is helpful for a number of reasons. It helps the caregiver
understand the adolescents point of view, and it gives the therapist a
chance to demonstrate or model the techniques. Assign homework to 
practice the skills outside the session. During the next session, review 
any practice attempts and their outcomes.
4.  Roleplay a number of exchanges between the caregiver and 
adolescent, with the therapist taking the role of the adolescent.
Insert ACRA and general communication techniques whenever
helpful, and mention pitfalls to avoid. Then switch roles with the
caregiver playing the adolescent and the therapist playing the
caregiver.
After completing an initial roleplay and providing feedback about how to
improve the effectiveness, practice again. Ask the caregiver for another
example of a problem situation. Dissect the problem and help the caregiver
reword the conversation using effective communication techniques. Both
general communication techniques (e.g., use of I statements rather than
you statements, active listening) and those in ACRA should be introduced
wherever they can help. 
Encourage the caregiver to roleplay with you conversations with his or her
adolescent. Although roleplaying can be awkward for some people, encourage
the caregiver to participate fully. One way to reduce the awkwardness might
be to avoid using the word roleplay.  Instead, you can say something like,

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Okay . . . lets just pretend Im [insert the name of the adolescent], and
lets practice some of the techniques we were just discussing. Whenever
needed, the caregiver can leave the role to ask questions or for advice. The
caregiver should have the experience of playing both rolesthat of the
caregiver and that of the teenager. Point out any examples of barriers to
communication (e.g., blaming or bringing up old problems) and explain
how they will negatively affect communication. 
5.  Process each exchange from the content and feelings perspectives
of the caregiver.
Following each roleplay, discuss it with the caregiver. Questions to ask are,
How did it go? What was different about the conversation compared to how
a typical one goes? How did it feel for you to play the role of the teenager?
Processing the roleplay is essential to solidify learning. A followup question
for the caregiver is, How do you think your teenager would respond to this
style of communicating?  
6. Assign homework.
At the end of the session, assign practicing communication techniques as
homework. It is important to get a commitment from the caregiver to try
these skills at home. During the next session, review the results of these
attempts. 
7. Complete the ACRA Procedure 10 ChecklistCaregiver
Communication Skills Training immediately after the session.
A blank copy of this form is included at the end of this section.

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Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

   ACRA Procedure 10 Checklist
Caregiver Communication Skills Training

                   Check Appropriate Boxes
Activity In Progress     Yes       No
1.   Did you introduce the topic of 
communication, providing a rationale for 
developing good skills in this area?    
2.   Did you assess the present quality of 
communication between the caregiver 
and the adolescent?    
3.   In the context of real life examples 
provided by the caregiver, did you teach 
the caregiver to give an understanding 
statement?    
4.   In the context of real life examples 
provided by the caregiver, did you teach 
the caregiver to make a partial 
responsibility statement?    
5.   In the context of real life examples 
provided by the caregiver, did you teach 
the caregiver to offer to help the 
adolescent solve the problem?    
6.   Did you roleplay exchanges between the 
caregiver and the adolescent and insert 
ACRA and general communication 
techniques whenever helpful?     
7.   Did you point out any problems (e.g., 
blaming and bringing up old issues)?    
8.   Did you switch roles with the caregiver?    
9.   Did you process each exchange with the 
caregiver, from the content and feelings 
perspective?   
10.   Did you get the caregiver to commit to 
doing some homework?    

-----------------------------------------------
Procedure 11: CaregiverAdolescent Relationship Skills 
Rationale
In previous sessions, both the adolescent and caregiver reviewed and 
roleplayed positive communication skills. The adolescent also has learned
techniques for problem solving. Problem-solving training can help caregivers
and adolescents find more satisfactory solutions to their problems. These
procedures are for use in two sessions to provide ample opportunity for 
the caregiver and the adolescent to practice these skills together with the 
therapists guidance. 
Purpose of the Procedure and Learning Objectives
The main purpose of this procedure is to improve communication
between the caregiver and the adolescent. The learning objectives are 
to help both parties improve their ability to:
  Use problem-solving skills introduced in previous sessions
  Say positive things about each other
  Speak nicer to each other.
Timing, Audience, and Delivery Method
The next two sessions are held with the caregiver and the adolescent
together, in weeks 7 to 11 of treatment. By this time, there should have
been two sessions with the caregiver and enough time to establish rapport
and a working relationship with the adolescent. 
Materials
General materials include snacks (e.g., chips, crackers, granola bars, fruit
bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if
applicable) a videocamera and videotapes and an audiorecorder or 
audiotapes.
Procedure-specific materials include:
  Handout: Relationship Happiness Scale (caregiver and adolescent 
versions), clipboards, and pens
  For problem solving: chalkboard or whiteboard, markers or chalk,
and possibly an easel.
  For communication skills: chalkboard or whiteboard, markers or
chalk, possibly an easel, the handout Daily Reminder To Be Nice.

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General Notes for the Therapist
Emphasize to the caregiver and the adolescent that during these sessions
the focus is on the positive attributes of the other person. Guide them to
face and talk to each other during roleplays because the goal is to improve
communication between them. They may try to talk through you because
they feel awkward in the session or because of their poor communication
history. You can help maintain rapport with both by periodically asking how
they are doing during the session.
It is important for you to maintain an equal amount of eye contact with
both during this session and to avoid siding with one person over the other.
Remember to encourage the caregiver and teenager to talk with each other.
Also, in the beginning emphasize keeping the conversation positive.
Discourage any blaming. You can assist by interpreting, coaching, modeling,
and shaping as needed. 
Shaping is an important principle of operant conditioning (behavior 
modification). It involves reinforcing (e.g., through praise, tangible
rewards) small steps toward achieving a larger goal. It is particularly useful
when mastery of a series of small skills, steps, or procedures is necessary to
achieve a complex goal. For example, in trying to teach problem-solving
skills, the therapist should not criticize poor solutions or tell clients to
choose more effective solutions. Instead, the therapist should use a shaping
process that breaks effective problem solving into small components or
steps. Mastery of each component is shaped through teaching, modeling,
rehearsal, feedback, and praise. As clients master each component, they
learn the skills necessary to solve problems. Once they have mastered all
the steps needed to complete a task, they have completed the skill 
acquisition and should be able to use the problem-solving procedure to 
effectively solve their problems.
Procedural Steps
1. Thank both the adolescent and the caregiver for coming in, praise
their work, and offer snacks and beverages.
2. Provide an overview of what is going to happen during the session.
Be clear from the beginning that the emphasis is on being positive
during the session.
3. Check to see whether there are issues that have arisen since the last
session.
4. Have each person face the other and say three positive things about
the other person.
5. Review communication skill procedures with both parties. (See 
procedures 6 and 10.)

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6. Review problem-solving skill procedures with both parties. (See
procedure 7.) This will be the first time that caregivers are 
introduced to these skills.
7. Have both participants complete the Relationship Happiness Scale
forms. (As you review the completed happiness scales, you may 
discover issues for roleplaying communication and problem-solving
skills.)
8. Have the caregiver and adolescent generate realistic roleplay
situations to practice communication and problem-solving skills. 
9. Assign homework.
10. When time permits (it may not be until the second session), present
information on the Daily Reminder To Be Nice form.
11. Spend a little time on closure with the caregiver. Remind the 
caregiver that this will be the last session with him or her, review
what was covered in previous sessions and how it went, and thank
him or her for participating.
12. Complete the ACRA Procedure 11 ChecklistCaregiverAdolescent
Relationship Skills immediately after the session.
Detailed Description
The remainder of this section contains a more detailed overview on how to
conduct the two sessions on reinforcing and practicing caregiver-adolescent
relationship skills. Procedural steps are in bold type and are followed by 
further directions and comments. Sample dialogs between a therapist and
the caregiver and adolescent are indicated in italic type. 
1.  Thank both the adolescent and caregiver for coming in, praise
their work, and offer snacks and beverages.
As in every other session, praise both parties for meeting with you and 
reinforce their work in treatment. The verbal reinforcers and snacks all
serve to continue engaging the caregiver and teenager in treatment.
2.  Provide an overview of what is going to happen during the session
activities. Be clear from the beginning that the emphasis is on
being positive during the session.
To alleviate any anxiety on the parts of the caregiver and teenager, provide
an overview of the content of the session. Explain that you will (1) review
communication skills, (2) review problem-solving techniques, and (3) have
both complete Relationship Happiness Scale forms. Note that when going
through problem solving, the emphasis will be on finding a solution that
works for everyonea win-win solution.

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Therapist: I want to talk with you about what we are going to be
doing today. Were going to be reviewing communication
skills that I have already gone over with each of you.
Then we are going to go over some problem-solving
techniques. Ive gone over these with Erica before.
Then after that, we will go over something that Erica
has done before that is called the Relationship
Happiness Scale. This one is a little different from the
ones we have done before because this time we will be
looking at how happy you are with your relationship
with the other person.
3.  Check to see whether there are issues that have arisen since the
last session.
Check with the teenager to see whether he or she has any pressing issues.
Acknowledge any issues that are mentioned, but try to steer the teenager
and caregiver to the session topics. One way to do this is to say, That is a
really important issue, and I want to spend some time talking about that.
There are some other things we want to cover first, though. Here is an
example of how this part might go:
Therapist: [Looks at the adolescent.] First, I need to check to see
that everythings okay.
Adolescent: I got suspended from school because I left campus 
during a study hall. I thought that it was okay because
I had finished my exams for the day.
Caregiver: The principal called me and said she wasnt the only
one who got suspended. A lot of the students did the
same thing and a lot got suspended.
Therapist: Well, we should look at that and some options that
could prevent that kind of thing next time. Maybe we
will be able to look at that this session; we want to talk
about some things that affect both of you and maybe
this one did.
4.  Have each person face the other and say three positive things
about the other person.
Positive comments about the other person set the tone for the session.
Have each person use I statements when stating the positive comments.
For example, I appreciate that you are always home when I get home from
school or I think it is neat that you know so much about computers.
Periodically ask the person on the receiving end to repeat back what he or
she heard the other person saying. This ensures that the person hears the
good things that are being said and helps develop listening skills.

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Therapist: Id like to keep things on a positive noteyou never
know what can come out, so lets start by each of you
sharing with the other person three things you 
really appreciate about each other. Id like for each of
you to go ahead and face each other and tell the other
person what you appreciate about her. Mrs. Smith
would you begin. Go ahead and face Erica.
Caregiver: I really, really appreciate ityour attitude, cuz I see a
lot of teens get an attitude. You never have done that.
When you go out, youve never been late, no more than
10 minutes. These are two really important things. I
dont worry as much. I try to tell you in certain ways
and maybe it doesnt come out and you dont hear
what I try to tell you.
Therapist: Erica, what do you hear your mom saying?
Adolescent: Well, it sounds like shes glad that I dont smart talk
her and that I come in on time.
Caregiver: Yes, thats right, because I worry so much about . . .
car accidents. If a car doesnt pull up on time, that is
the first thing I think of.
Therapist: Sounds as if you see Erica as a really responsible 
person. Thats great. Erica, do you want to share
some things you appreciate about your mom.
Adolescent: I appreciate the fact that she like . . . if I need to talk
her, shell be there. Sometimes she gets on my nerves
when she comes to my room, but sometimes I really,
really need to talk to someone and shes there.
I appreciate the fact that she puts up with my girlfriends.
I appreciate the fact that shes here with me now. I
dont know how it is helping, but it is.
Therapist: Erica, you did a great job coming up with positive
comments. You were telling me though, not your 
mother. Can you turn and face your mom and tell 
her those nice things?
[Erica turns to her mom and directs her comments to
her.]
Caregiver: I think we find it easier when we come here to tell each
other that we care about each other. Id like to throw
one more in. I appreciate the fact that youre [directed
at daughter] coming here.

160

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5.  Review communication skill procedures with both parties. (See 
procedures 6 and 10.)
Because both parties have had this training before, try to get them to
remember the three techniques for improved communication. Have a white
board available to write down the techniques as they mention them.
Therapist: Very good. You both did a very good job with coming
up with things you appreciate about each other and
sharing them.
Now, lets review communication skills. Okay, who
wants to tell me one of the three techniques we use to
help with communication?
[Erica gets up out of her chair and goes to the board;
she wants to write on the board. Erica and Mrs. Smith
have difficulty coming up with the three techniques,
although they throw out related concepts like active
listening or staying positive. The therapist reinforces
their attempts and then tells them the name of the
first technique.]
Therapist: The first is an understanding statement. [The therapist
gives an example.]  
The second one is called taking partial responsibility.
Its acknowledging how you might have contributed to
the problem. For example, saying, You know, I realize
I didnt give you a lot of time to do dishes or I 
realize that you didnt have time to hang out with your
friends. So it is saying how you might be a part of
the problemor just making a statement that shows
you dont blame the other person. Mrs. Smith, go
ahead and take a shot at that partial responsibility
statement. Remember that you are more likely to get
what you want if you use one.
[Next they talk about an offer to help.]
Therapist: A new technique I want to tell you about is called
avoiding a no in a response. What Id like you to try
is negotiating without saying a flat out No! Lets say
Erica wants to do something on Friday, but youre
concerned about what she might get involved with
while shes out. A good solution is not always perfect
for everyone, but sometimes you can get closer to what
both people want . . . and the main thing is happiness
in the relationship, right? [Looks at her mom.] There
are probably times when Erica is driving you crazy,
but still you want to have happiness in your relationship.

161

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You want to be able to come to a solution together that
works for both of you.
6.  Review problem-solving skill procedures with both parties. (See 
procedure 7.) This will be the first time that caregivers are 
introduced to these skills.
Ask the teenager to explain the steps because he or she has already been
oriented to and practiced these skills. When practicing problem solving,
both the caregiver and the teenager can brainstorm. Then they each get 
a turn to cross out suggestions, which are often the other persons. Then 
they work toward agreeing on a solution. If they end up crossing off all the 
solutions, then both have to start over. Eventually they will see that they
have to work together; otherwise, they will have to be continually generating
more possible solutions.
7.  Have both parties complete the Relationship Happiness Scale
form. (As you review the completed happiness scales, you may 
discover issues for roleplaying communication and problem-
solving skills.)
This is also a good procedure to have teenagers help explain because 
by this session they have filled out several happiness scales. Because the 
adolescent scale is different from the adult scale, provide an initial 
orientation to the scales. After both the caregiver and the teen have filled
out a form, begin by reviewing those items that each rated high to continue
emphasizing positive interactions. For example say, What are some things
that are going well with____? 
Therapist: Erica, youve filled out happiness scales a lot before.
But these are somewhat different from what you have
filled out. We call these Relationship Happiness
Scales because we want you to rate your happiness
with your relationship with each other in different
areas. Erica, you will notice that the areas are different
on this happiness scale, too. So, would you be willing
to read the directions to us and then explain them in
your own words?
Adolescent: Sure. [Erica reads the directions on one of the
forms.] Basically, it means if you are really happy with
what I do in that area, you circle a 10 and if really
unhappy, then circle a 1.
Therapist: Good job. Another important thing to remember is that
this is for right now. It is what you see right now. Go
ahead and fill it out and put your name at the top.
Then give them to me because I want to look them 
over before we start talking about them.
[Both complete the forms.]

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In general, there are some things that you rate really
high and there are some things that you rate low. Lets
talk about what things are good in the relationship. Its
important to learn what we are doing well, so we can
keep that going.
[Looks at Erica] You rated allowance really high.
Could you explain why you rated allowance so high?
Adolescent: I didnt used to get allowance. I get $20 a week for
doing the dishes.
Therapist: I see that you [looks at the mother] rated affection
very high. Could you explain your rating?
Caregiver: When I go to her room and say good night and give her
a kiss and a hug, Erica always responds and she
always tells me that she loves me before I even say it.
Adolescent: She always comes to my room to give me a kiss and
hug. If Im feeling bad, she gives me a kiss and a hug.
Therapist: Lets see. Looking at thisone thing that there might 
be an issue with is communication. Where do you see
some positives first of all?
Adolescent: One thing that I really noticed big time is that she came
upstairs and told me that she was suspended from
school. She came up and told me this is what 
happened. I appreciated the honesty.
Therapist: [Looks at Erica] What is something positive you like
about talking with your mom?
Adolescent: If I come up to her and talk to her, she listens and stuff.
Usually most of the time if I do something and its not
that big of a deal, instead of yelling at me, shell be like,
what are you going to do to take care of this problem
now?
8.  Have the caregiver and adolescent generate realistic roleplay 
situations to practice communication and problem-solving skills.
It is very important to use roleplaying as part of the training. It may be 
necessary to first work on asking for things and remaining positive. The
caregiver and adolescent should not only talk about how they would 
communicate better or solve problems better; they need to try the techniques.
When they do so with you present, you can help model and shape the 
behaviors.

163

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Therapist: Tell me something that you would like to work on
about communication.
Caregiver: There is only one thing that I have a problem with . . .
that is on the school issue. It is the importance of 
education. I end up getting frustrated. I want her to
understand about education. When it comes to talking
about this with me, the word bunk is used a lot.
Therapist:  What you are telling me is that education is important
and youd like to be able to express that to Erica a 
little better so that she sees your point a little more.
[Provides example of a good reflective statement.]
How do you see this, Erica?
Adolescent: About school . . . 
Therapist: Yeahactually school and communication about
school.
Adolescent: With the school thing . . . I think that school is 
important. I dont show it that much. It is important
because Im going to go to a trade school. I just think
about school at school and then when I get home, I 
just dont want to think about it.
Therapist: Okay, so it is important because you want to go on to
trade school. But at the same time you want to leave
school at school. You, on the other hand, [turns to 
parent] youd like . . .
Caregiver: Maybe its my wording. There have been several 
subjects that she has problems with. When Ive talked
to Erica about this . . . I try to tell her that she needs to
let someone know about that. Id help . . . ask someone
or get a tutor. I know its important because I used to
work in offices but now Im working in a laundry
room because I dont have the office skills they need
now. I worry about her future. Is she going to go to
college? If not, what kind of work is she going to do?
Therapist: One of your goals is for her to finish up high school
and then go to college or trade school.
Caregiver: Yes, because it is hard to make it.
Therapist: Mom, use the communication skills now when you talk
to Erica. Just try it. Maybe you can only do it partially,
but thats fine. If you practice it, then when you really
need it, you will be able to use these skills. Lets go
ahead and try out the communication skills.

164

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[Therapist models what needs to be said.] Erica, I
understand that you like your free time after school
and dont want to think about school work; but I
worry about the type of job you would get if you dont
finish school because I want things to work out for
you. I would really appreciate it if you would bring
your school work home so you can graduate from high
school. I know that I havent always stressed educa
tion and I myself havent gone far in school. If there is
anything I can do to help you get to school or bring
your school work home or anything we can do to find
a particular trade, I would be willing to help. Your job
is not to say something directive like, You have to 
finish up so you can go to college.
Caregiver: I can see a big mistake that I am making. Basically Im
not doing the understanding statement.
Therapist: Erica, can you break down what I just said and tell us
which was the understanding statement, what did I
say for partial responsibility, and what did I say that
was an offer to help?
[This is important to ensure that they both are able
to identify the three skills. Erica does this.]
Go ahead and make an understanding statement. [The
therapist tells the mother to face the adolescent and
encourages her to direct her statement to her and
not to the therapist.]
Caregiver: I understand that it is hard to sit in study hall for 2
hours; youre bored and youve already taken your
finals. Im concerned that since youre suspended now,
you wont be able to make up your school work and
that at the end of the school year you wont get your
credits and graduate on time. If there is anything I can
do to helpget you a tutor or if I can helpIll make
the time to help.
Therapist: That was good. Erica, how did it feel being spoken to
this way by your mother, instead of the old way?
Adolescent: I liked it. My problem with the way you usually talk to
me is that you blow up.
Caregiver: I think I get angry when I get worried for her. Im 
projecting ahead about what is going to happen. If you
miss so many classes or get suspended, you might not
be able to finish school.

165

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Therapist: I think you did some really good things when you were
practicing now. With the understanding statement you
showed you knew where she was coming from. You
finished up with some good offers to help. [Turns to
Erica.] Now why dont you try to use the communication
skills. [Praises the participants for any attempt that
they make by trying to find something that they said
that is on the right track. Remember, it is a shaping
process.]
Adolescent: I understand what you think about school being 
important and stuff. I would like for you to ask me
every single night if I have algebra or American history
homework and, if I do, make me do the homework
because those are the subjects I have trouble with.
Therapist: Is that an issue? That you have trouble getting your
homework done?  
Adolescent: Yes, I have a problem keeping up with my homework.
Therapist: Okay, we are in problem solving here. [Therapist
stands up and writes on board.] Lets start 
brainstorming about possible solutions. Erica, do 
you have any ideas?
Adolescent: Like I said . . . one thing mom could do is remind me
about school work; another option is for me to bring
home algebra and American history books each day.
Therapist: How about you, mom? Is there anything you could 
suggest?
Caregiver: If she needs a tutor, we can get her a tutor.
Therapist: Okay, lets just generate a bunch of ideas.
Caregiver: Or if she needs to read to me or have me ask her 
questions.
Therapist: So you could quiz her? Something I can think of that
might help is to have a friend over to study.
Adolescent: [Names two friends who are good at math.]
Therapist: Are there any other suggestions?
Both Clients: No.
Therapist: First of all, without saying why, look at these possible
solutions and tell usare there any you dont want to

166

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do or dont think you would do? [Allows mother and
Erica to cross suggestions off the list.]
Adolescent: I dont think Id do the tutor thing. I know I can do it . . .
if someone tells me how I can do it. I know Im smart.
Ive had a relapse in my smartness. My smartness is
coming back.
Caregiver: I see a different Erica in the last couple of weeks. I see
more confidence.
Therapist: Mom, is there anything on the list you dont want?
Caregiver: I can help her with American history, but not with the
algebraI stank at that.
Therapist: What is something that you can work on . . . what is a
really good solution?
Adolescent: The really good one is to remind me about the homework
and make sure that I do it. 
Therapist: Anything you think would help? [Directs question to
the mother.]
Caregiver: Have her friend over to study . . . because she has a
friend down the street who she says is good at math.
Therapist: Is there anything you can do to make it easier? [to
Erica]
Adolescent: I can keep my books in my book bag.
Therapist: Is there anything important for you about reminding
her about homework?
Caregiver: Just to remember. I get home at 3:00 every day so I
am there when she gets home from school.
Therapist: You guys did really well, and remember you did it
together. I just wrote things down. But you had to
come to a consensus on something you worked on
together. You are willing to do something about school,
but it is a matter of remembering. [Therapist has the
parent practice using her new communication skills
and asks Erica to give feedback on which ways of
reminding her. Earlier Erica said that she did not
want want her mom talking about school, so this may
be a tricky interaction.]

167

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Therapist: Were getting a little short on time. One thing I want to
do is thank you for your work. Also, remember Im not
going to let you off. We are going to have another session
when we can talk about how things went and how you
used the skills on your own. You guys came up with
some really good solutions. Keep in mind that you also
did a really good job using the communication skills.
Caregiver: You know what is hard for me with these 
communication skills? I grew up in the old school. 
You asked a question and it was Yes or No. The
younger generation has this stuff in schools. It is really
hard to communicate this way.
Therapist: The main thing to look at is whether you are getting
what you want. You wont always get it, but you are
more likely to get what you want if you are both 
working together.
9. Assign homework.
At the end of the session, ask the family members to work on the possible
solutions to the problem identified during the session. Then at the next 
session, review how the solution worked in practice, and, if problems have
arisen, again use the communication skills and problem-solving procedures
to address them.
10.  When time permits, present information on the Daily Reminder To
Be Nice form.
Because of lack of time, this procedure is usually introduced in the second
session with both the caregiver and adolescent. All relationships are more
pleasant when both parties work at being nice to each other.
Acknowledge that for many parents or caregivers and teenagers there is a
tendency not to be nice to each other. There are some types of behaviors
that people can practice daily to help increase the number of pleasant
exchanges, and these can be used with all family members. Following this
section is a form that can be used to help prompt daily reminders to be
nice in several areas. The following is a review of areas listed on the form
with examples of each when needed. Work with the teenager and caregiver
to generate additional examples for each area.
  Express appreciation. For example, the son can thank his mom for 
dinner, rides, etc. Mom can thank her son for keeping a clean
room or coming home on time.
  Compliment the other person. For example, one person can 
compliment the other on his or her appearance, how a chore was
done around the house, or how respectful the adolescent was
when introduced to a new adult.

168

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  Give a pleasant surprise. For example, a parent can bring home
an ice cream treat. The son or daughter can clean up a room
without being asked.
  Express affection. For example, a father could tell his son or
daughter, I love you. A son or daughter could kiss a mother
goodbye before going to school.
  Initiate pleasant conversation.
  Offer to help sometime without being asked. For example, a 
daughter could offer to start dinner or a father could offer to do 
one of his sons chores when he is working on a school project.
The form has space for additional reminders to be added. While in the 
session, have the caregiver and adolescent make a list together of other
nice things each would appreciate from the other. Work with them to 
narrow the list down to a few things, and write them on the form.
Review the rules of using the form with the caregiver and adolescent. First,
they should remember to engage in one or more behaviors daily (even if the
other person does not). Second, the form should be posted in a prominent
place where both will have access to it and they can check off when they
remember to do something nice. The placement of the list can be discussed
during the session. Third, they can add to the list at any time.
For homework, ask the participants to include the entire family in the Daily
Reminder To Be Nice activity and to try the procedure for several weeks.
Review completion of this homework assignment with the adolescent during
the next session, and follow up with the caregiver by telephone.
11.  Spend a little time on closure with the caregiver. Remind the
caregiver that this will be the last session with him or her, review
what was covered in previous sessions and how it went, and thank
him or her for participating.
Although you will usually have one or two more sessions with the adolescent,
this will be the last formal session with the caregiver. See procedure 12 for
the type of information covered in a closure session. Once again, thank the
caregiver for participating in treatment. Briefly summarize the progress
made. This would also be an appropriate time to tell the caregiver when 
and under what circumstances he or she might want to contact a substance
abuse treatment professional.
12.  Complete the ACRA Procedure 11 ChecklistCaregiverAdolescent
Relationship Skills immediately after the session.
A blank copy of this form is included at the end of this section. 

169

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Relationship Happiness Scale 
(Adolescent Version)

Name:_________________________________  ID:   _______  Date: _________

This scale is intended to estimate your current happiness with your relationship with
your parent or caregiver in each of the areas listed below. You are to circle one of the
numbers (1 to 10) beside each area. Numbers toward the left end of the 10-unit scale
indicate various degrees of unhappiness, whereas numbers toward the right end of the
scale reflect increasing levels of happiness. Ask yourself this question as you rate each
life area: How happy am I today with my parent in this area? In other words, indicate
according to the numerical scale (1 to 10) exactly how you feel today. Try to exclude
feelings of yesterday and concentrate only on the feelings of today in each of the life
areas. Also, try not to allow one category influence the results of the other categories.
Completely Completely
Unhappy Happy
1. Time spent with me                1  2  3  4  5  6  7  8  9  10
2. Allowance              1  2  3  4  5  6  7  8  9  10
3. Communication               1  2  3  4  5  6  7  8  9  10
4. Affection 1  2  3  4  5  6  7  8  9  10
5. Support of school/work 1  2  3  4  5  6  7  8  9  10
6. Emotional support 1  2  3  4  5  6  7  8  9  10
7. General happiness 1  2  3  4  5  6  7  8  9  10
8. General home activities 1  2  3  4  5  6  7  8  9  10

-----------------------------------------------
Sample
Relationship Happiness Scale 
(Adolescent Version)

Name: John Doe ID: 1234 Date: 31

This scale is intended to estimate your current happiness with your relationship with
your parent or caregiver in each of the areas listed below. You are to circle one of the
numbers (1 to 10) beside each area. Numbers toward the left end of the 10-unit scale
indicate various degrees of unhappiness, whereas numbers toward the right end of the
scale reflect increasing levels of happiness. Ask yourself this question as you rate each
life area: How happy am I today with my parent in this area? In other words, indicate
according to the numerical scale (1 to 10) exactly how you feel today. Try to exclude
feelings of yesterday and concentrate only on the feelings of today in each of the life
areas. Also, try not to allow one category influence the results of the other categories.
Completely Completely
Unhappy Happy
1. Time spent with me                1  2  3  4  5  6  7  8  9  10
2. Allowance              1  2  3  4  5  6  7  8  9  10
3. Communication               1  2  3  4  5  6  7  8  9  10
4. Affection 1  2  3  4  5  6  7  8  9  10
5. Support of school/work 1  2  3  4  5  6  7  8  9  10
6. Emotional support 1  2  3  4  5  6  7  8  9  10
7. General happiness 1  2  3  4  5  6  7  8  9  10
8. General home activities 1  2  3  4  5  6  7  8  9  10

-----------------------------------------------
Relationship Happiness Scale 
(Caregiver Version)

Name:_________________________________  ID:   _______  Date: _________

This scale is intended to estimate your current happiness with your relationship with
your adolescent in each of the eight areas listed below. You are to circle one of the
numbers (1 to 10) beside each area. Numbers toward the left end of the 10-unit scale
indicate various degrees of unhappiness, whereas numbers toward the right end of the
scale reflect increasing levels of happiness. Ask yourself this question as you rate each
area: How happy am I today with my adolescent in this area? In other words, indicate
according to the numerical scale (1 to 10) exactly how you feel today. Try to exclude
feelings of yesterday and concentrate only on the feelings of today in each of the life
areas. Also, try not to allow one category influence the results of the other categories.
Completely Completely
Unhappy Happy
1. Household responsibilities       1  2  3  4  5  6  7  8  9  10
2. Communication 1  2  3  4  5  6  7  8  9  10
3. Affection 1  2  3  4  5  6  7  8  9  10
4. Job or school 1  2  3  4  5  6  7  8  9  10
5. Emotional support 1  2  3  4  5  6  7  8  9  10
6. General happiness 1  2  3  4  5  6  7  8  9  10
7. Time spent with adolescent     1  2  3  4  5  6  7  8  9  10
8. General home atmosphere     1  2  3  4  5  6  7  8  9  10

-----------------------------------------------
Sample
Relationship Happiness Scale 
(Caregiver Version)

Name: John Doe ID:  1234 Date: 31

This scale is intended to estimate your current happiness with your relationship with
your adolescent in each of the eight areas listed below. You are to circle one of the
numbers (1 to 10) beside each area. Numbers toward the left end of the 10-unit scale
indicate various degrees of unhappiness, whereas numbers toward the right end of the
scale reflect increasing levels of happiness. Ask yourself this question as you rate each
area: How happy am I today with my adolescent in this area? In other words, indicate
according to the numerical scale (1 to 10) exactly how you feel today. Try to exclude
feelings of yesterday and concentrate only on the feelings of today in each of the life
areas. Also, try not to allow one category influence the results of the other categories.
Completely Completely
Unhappy Happy
1. Household responsibilities       1  2  3  4  5  6  7  8  9  10
2. Communication 1  2  3  4  5  6  7  8  9  10
3. Affection 1  2  3  4  5  6  7  8  9  10
4. Job or school 1  2  3  4  5  6  7  8  9  10
5. Emotional support 1  2  3  4  5  6  7  8  9  10
6. General happiness 1  2  3  4  5  6  7  8  9  10
7. Time spent with adolescent     1  2  3  4  5  6  7  8  9  10
8. General home atmosphere     1  2  3  4  5  6  7  8  9  10

-----------------------------------------------
Date _______                   Session # _____                   Adolescent ID____                   Therapist Init. ________

ACRA
Daily Reminder To Be Nice
Name:___________________________________ Week Starting:_________________
Day  

Activity Sun Mon Tue Wed Thu Fri Sat
Did you express appreciation to the other person today?
Did you compliment the other person on something?
Did you give the other person a pleasant surprise?
Did you express affection?
Did you initiate pleasant conversation?
Did you offer to help?

-----------------------------------------------
Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

   ACRA Procedure 11 Checklist
CaregiverAdolescent Relationship Skills

                   Check Appropriate Boxes
Activity In Progress     Yes       No
1.   Did you thank both for coming to the 
session?    
2.   Did you provide an overview for the 
session?    
3.   Did you check to see whether there was 
anything pressing?    
4.   Did you have each say three positive 
things about the other?    
5.   Did you review communication skills?    
6.   Did you discuss the importance of 
limiting Nos?    
7.   Did you review problem-solving skills?    
8.   Did you do some roleplays for both 
problem-solving and communication skills?
9.   Did you have both complete Relationship 
Happiness Scale forms?    
10.  Did you go over the Daily Reminder To Be 
Nice form?    
11.  Did you go over closure with the 
caregiver?    

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Procedure 12: Treatment Closure
Rationale
As the treatment sessions end, the adolescent needs to feel positive about
the treatment and the progress he or she has made. Having the therapist
acknowledge the hard work during the treatment sessions helps the 
adolescent reinforce the skills learned and provides motivation to access
additional services in the future, if they are needed.
Purpose of the Procedure and Learning Objectives
The purpose and learning objectives of this session are to make certain
the adolescent understands and acknowledges the progress he or she has
made during treatment and receives praise for the progress and hard
work. The adolescent must also understand procedures that will continue
to help him or her be substance free.
Timing, Audience, and Delivery Method
The closure session is conducted individually with the adolescent and
should be delivered in the last treatment session. If, however, it becomes
clear that an adolescent is dropping out of treatment early, the thera
pist should make an effort to get the adolescent back for one more ses
sion and implement these closing session procedures.
Materials
General materials include snacks (e.g., chips, crackers, granola bars, fruit
bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if
applicable) a videocamera and videotapes or an audiorecorder and 
audiotapes.
Procedure-specific materials include clipboard, pens, a discharge packet,
Relationship Happiness Scale form, happiness scales completed during
sessions 1 through 11, completed Goals of Counseling forms, completed
Functional Analysis of Substance Use Behavior forms, completed Functional
Analysis of Prosocial Behavior forms, completed functional analysis
(relapse version) forms, personalized resource activity list, and certificate
of completion.

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General Notes for the Therapist
The goal of the discharge session is to review progress made during treatment
by briefly reexamining the functional analyses and Relationship Happiness
Scale and Goals of Counseling forms. The therapist should (1) reinforce
progress made toward goals, (2) discuss with the adolescent whether he or
she would like to set additional goals in areas in which a goal was completed,
and (3) discuss progress made toward achieving unmet goals. The therapist
should provide positive expectations for success for the adolescent with
statements like, You have done a really good job while in treatment, and I
think you will achieve all your goals outside of treatment, too. Ask the
teenager how he or she feels about ending treatment, and discuss any 
concerns. 
Procedural Steps
1. Check with the adolescent, and provide an overview of the session.
2. Review the adolescents progress. 
3. Talk with the adolescent about what he or she has gained from the
treatment experience.
4. Provide the adolescent with reference information on procedures
that have been covered during treatment.
5. Reinforce the adolescents efforts and hard work.
6. Review the status of other referrals made during treatment and the
options for future treatment.
7. Consider other optional activities appropriate for a closing session,
such as joint completion of a discharge form and giving the 
adolescent a completion certificate.
8. Complete the ACRA Procedure 12 ChecklistTreatment Closure
immediately after the session.
Detailed Description
The remainder of this section contains a step-by-step description for 
conducting the closing session. Procedural steps are in bold type, and they
are followed by further directions and comments. Sample dialogs between 
a therapist and an adolescent are indicated in italic type.
1.  Check with the adolescent, and provide an overview of the session.
Take a few minutes at the beginning of the session to check how the
teenager is doing, and provide a framework for what will be covered during
the closing session.

177

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Therapist: Last time when we met, you were going to try using
the Daily Reminder To Be Nice technique. How has that
been going? (See procedure 11 for description of these
procedures.)
Adolescent: Its going pretty well. Ive been telling my mom that I
love her, and she has been making more pasta for me.
Therapist: That sounds good. What I would like to do today is 
for us both to talk about the progress youve made in
treatment. We will talk about what it means to be 
discharged and some of the things that could happen
now. Im going to give you some information that can
help you remember some of the things we did.
2.  Review the adolescents progress.
A good way to review a teenagers progress is to look at previous Goals 
of Counseling forms and talk about what goals have been accomplished.
Another helpful review is to compare Relationship Happiness Scale forms
that were completed over the course of treatment. Often these will reflect 
a pattern of improvement. It would also be important to discuss any unmet
goals from prior Goals of Counseling forms and help clarify plans for 
achieving these goals.
Therapist: First of all, lets discuss your first goal, which was to
get at least a C in all of your classes. How is this
going?
Adolescent: Ive been doing pretty well. Im not doing as well as I
want to do yet.
Therapist: How about algebra?
Adolescent: I had a makeup test. But I dont know what my grade
is in there.
Therapist: You probably want to check on that. Remember that
you can also use those problem-solving procedures to
think of other ways to get help for your difficult 
subjects. That can help you out. Youve done really 
well with thatfiguring out different solutions. That 
is something I really appreciate about you.
Another goal was to stay clean for 50 days to a year.
Making it to 50 days was a first milestone. You have
almost made it this long, and youve done really well.
You had one time that you had a problem, and you
said that you were going to bring in your cousin for the
early warning system. Have you talked to her about
that?

178

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Adolescent: Ive talked to her about that, and she is supposed to
remind me about my goal if she notices me hanging out
with Mike and Mark.
Therapist: One of the other things you did was look at different
activities you could have fun at, while staying away
from drugs and alcohol when you were doing them.
What are some of the things you really enjoyed?
Adolescent: I went and played pool at the universitys bowling and
billiard center, and I thought that was pretty cool.
Therapist: What are some other things that youve done?
Adolescent: I went bowling with a couple of friends. I spent the
night at a friends house after her grandfathers 
retirement party.
Therapist: And you also mentioned that you wanted to play laser
tag. So this is something. The good thing is that you
were having fun and you got to do something and got
your mind off things.
Lets review your functional analysis of substance use
a little. You know, when we talked about your outside
and inside triggers, one of the things that is a little 
different is that you said, if you were bored, you would
get restless and smoke pot. We talked about how a pos
itive thing you got out of using marijuana was that it
kept you from getting bored. But we also talked about
the bad things that happened when you used, including
that your mom and sister would get upset about it and
you were spending your money, which was bad
because you needed your money, and you had some
legal problems. Now when you smoked with Mike, it
was really differentyou were kind of anxious. That
was kind of a different situation. What could you have
said to yourself?
Adolescent: Well, I could have thought about some of the bad things
that happen when I use.
Therapist: Good. And this was one of the things you did a really
good job of when you were meeting with me . . . talking
about ways to keep things from happening. And most
of the time you were successful doing this when you
were out there in your real life. One of the other
things is to find another activity you enjoy doing
instead. We went through a prosocial functional analysis
about taking care of your iguana, and that activity
was good because, when you did it, you didnt have to

179

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worry about getting in trouble as you did when 
smoking marijuana.
3.  Talk with the adolescent about what he or she has gained from
the treatment experience.
When the adolescent verbalizes treatment benefits, it helps reinforce new
behaviors he or she has learned.
Therapist: Weve worked on a lot of things, and youve done really
well with things including problem solving and relapse
prevention. What are some things you think you gained
from being in treatment?
Adolescent: I actually want to go out and do stuff instead of going
out and getting high.
Therapist: And what is something that you like about that?
Adolescent: It gets me out of the house and people dont think Im
ignoring them.
Therapist: So it has improved your relationship with your friends.
Thats not something we really have talked about. Has it
improved your relationship with your friend, Susan? And
how about your friends who were attending AA meetings?
Adolescent: Yeah, she used to smoke pot and I would do it with 
her and we just sat at our house. And even when she
started going out with Jonhe would call to do stuff
and we would just sit around at our house and do
nothing. And then I got arrested and I quit smoking pot
and stuff and quit hanging out with Susan, and the
next thing I know she started coming around again
and she was quitting too.
Therapist: So shes been supportive of what you wanted and
thats helped out tooeven though she was not the
first person you thought of. Now all these people are
really good supports for you. Sounds as if you got
some really positive things coming here . . . problem
solving and figuring out some other things you could
do besides use marijuana.
Is there anything else you gained from coming here?
Adolescent: Knowing how to prevent myself from going out and
doing drugs. Like before I never thought, oh this would
happen if I smoked pot. Now there is a whole thought
process that goes through my head about what will
happen.

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Therapist: It sounds as if  you are looking at the big picture. There
were some things that you liked about smoking pot and
before you tended to concentrate on those, but now
you are seeing the whole picture. This doesnt surprise
me, because you did really well in our sessions talking
about these things.
One thing Id like to do now is have you fill out a 
Happiness Scale form. Lets finish that up and look at
some of the changes in your life.
[Therapist shows the client earlier happiness scales
and points out the differences between earlier ones
and the current one.] 
Therapist: Here is a difference on relationship with caregivers
from a 6 to a 9. 
Adolescent: Now it is just easier to talk with my mom. Like 
yesterday, she started going off on me, and instead 
of blowing up I just said, Do you want me to tell you
what I did with my money? And then we just talked
about things calmly.
Therapist: Thats really great. I bet you are both happier when 
you can do that. I see another difference with 
educationfrom a 6 to a 9.
Adolescent: Yeah, I was failing my classes. Now my grades have
improved.
Therapist: It is good because you set some goals and you have
worked at them. Communication went from an 8 to
10. Can you tell me what happened there?
Adolescent: Well, communication with my friends hasnt changed.
But now with my mom and dad, it is better. She listens
now, and it is easier to talk with her. She listens to
what I have to say. Before shed just say Youre
wrong.
Therapist: Sounds really good. Things are working well for you.
Im wondering whether you have any goals from here
on out?
Adolescent: Id like to graduate with my class. Im thinking of taking
a correspondence course to help do this. I could do
that.
4.  Provide the adolescent with reference information on procedures
that have been covered during treatment.

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Consider providing a discharge packet to each teenager for reference. The
contents of the packet can vary based on the individual teenagers needs.
Sample material can be found at the end of this section. It is titled The
Road Ahead. The discharge packet can include the following:
  Information on positive social activities (e.g., activity lists from 
procedure 2)
  A list of tasks that are a part of each procedure (i.e., goal setting,
decision making, communication skills, problem solving, relapse 
prevention [including use refusal])
  Completed forms including the Functional Analysis of Substance
Use Behavior, Functional Analysis of Prosocial Behavior, and
Goals of Counseling.
Therapist: I want to spend a few minutes showing you what is 
in this packet. These are things we have worked on
together, and you can pull them out periodically to help
you when you might need them. You dont always have
to do them in written form. For example, you can do
something similar to the happiness scale in your head.
You can ask yourself what things are going well and
what things arent going well in your life and think
about what goals you want to set to improve those
things that arent going well.
The therapist can individualize the forms and packet by using the clients
information and input.
5.  Reinforce the adolescents efforts and hard work.
This verbal reinforcement is woven throughout the session as is illustrated
in the sample dialog above.
6.  Review the status of other referrals made during treatment and
the options for future treatment.
If the participant demonstrated needs for additional services during treat
ment (e.g., residential treatment, psychiatric treatment, family counseling),
appropriate referrals should have been made when these needs became
apparent. (See discussion in Part II, Overview of the Treatment Model.)
However, this is the time to review the teenagers progress with these other
services and reinforce continued involvement with them, if needed. Talk
with the adolescent about how to access additional services in the future, if
needed. The discharge packet can include contact information for resources
if the client needs additional services (e.g., mental health treatment) in the
future. Include contact information for substance abuse problems the client
may experience in the future. 

182

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Other options are an open invitation for the teenager to call the therapist if
he or she feels the need to in the future or scheduling a monthly call from
the therapist for a limited time. Consider scheduling a followup appointment
within 2 to 3 months as well.
7.  Consider other optional activities appropriate for a closing ses
sion, such as joint completion of a discharge form and giving the
adolescent a completion certificate.
Optional activities during this session depend on the treatment provider.
For example, if the treatment provider has a standard discharge form that
needs to be completed for the clinical record, then you and the adolescent
can fill it out together so that the teenager is fully aware of what his or 
her discharge recommendations are. Some therapists give adolescents a 
completion certificate or some other symbol to indicate that they have
completed the program.
8. Complete the ACRA Procedure 12 ChecklistTreatment Closure
immediately after the session.
A blank copy of the form is included at the end of this section.

183

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THE ROAD AHEAD
(Sample Discharge Packet)

-----------------------------------------------
WHAT LEADS TO USE?
When evaluating alcohol or drug use, we looked at things 
that happened before you used alcohol or drugs 
and the positive and negative consequences of the 
use. The things leading up to use could include your
being around certain people, your being at a 
particular place, a certain time of day, or some
thoughts or feelings that come to mind. We called
those things triggers, things that make you think about using
alcohol or drugs. Remembering what situations you used alcohol or drugs
in can be important in realizing some high-risk situations for use. Triggers
make the use of alcohol or drugs more likely, which in turn leads to both
positive and negative consequences.

Triggers         Behavior       Consequences

Example   Hanging out with ! smoking ! (-) getting grounded,
Joe before school  marijuana not wanting to do
at his house homework
(+) not thinking of
school.

Is there a way to get some of the things you like, the positive consequences,
without getting some of the things you dont like? Finding activities that
you like can help. An activity like shooting baskets may be something fun
you could do with a friend and could give you time to forget about stress
in school without having to worry about it affecting your grades or your
getting grounded or arrested. You end up getting the things you want
without the negative consequences. You can always review lists of possible
activities to see whether there are some new things you would like to try
(see following page). Of course, just as in the example above, triggers for
a positive activity make the activity more likely and lead to positive and
negative consequences. The difference is that these activities tend to have
more long-term positive consequences and fewer short-term negative
consequences than alcohol or drug use.

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Activities That May Interest You

Aircraft Flight Instruction:
Metro-East Airport   2070 Triad Rd., St. Jacob 6445411
(Shafer Field)
Langa Air, Inc. 10 Terminal Dr., East Alton (314) 8958911

Amusement Places:
Aladdins Castle 133 St. Clair Sq., Fairview Hts. 6321027
Family Fun Tyme 8 Gateway Dr., Collinsville 3447747
Family Fun Tyme 1 Schiber Ct., Maryville 2887747
G & B Amusement Co.     6930 W. Main, Belleville 3977609
Games People Play 699 S. Bluff Rd., Collinsville 3450885
Time Out 131 St. Clair Sq., Fairview Heights 6321027
Time Passages Arcade    321 Broadway, Alton 4651270

Amusement Parks:
Six Flags I-44 & Allenton Rd., Eureka (314) 9384800

Antiques:
Alton Landing Antiques     110 Alton St., Alton 4620443
Antique Emporium 100 E. Warren, Bunker Hill 5853929
Broadway Antiques 217 E. Broadway, Alton 4650423
Belleville Antique Mall 208 E. Main, Belleville 2346255
Richards Antiques 2 N. Main, Wood River 2545793
Maryville Antique Mall 2114 S. Center, Maryville 3455533
MC Antiques and More     126 E. Chain of Rocks, Granite City 7972581
Pywacket Antiques 215 E. Central, Benld (217) 8352970
Wagon Wheel Antiques    National & Academy, Pocahontas 6692918

Aquariums (Public):
Mid-America Aquacenter   416 Hanley Industrial Ct. (314) 6479594

Aquariums:
Aqua Pets 5733 Godfrey Rd., Godfrey 4663474
Oceans Windows Pets      2755 E. Broadway, Alton 4626353
The Swamp 2324 Nameoki Rd., Granite City 4511852

Archery Ranges:
Bullseye Archery 405 E. U.S. Hwy 40, Troy 6678616
Town Hall Archery Shop   Hwy 15 & 59th St., Belleville 2359881
SAMPLE

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RESISTING PRESSURE TO USE
         When you decide to abstain from alcohol or drug use, it can be 
a big change. People will probably still offer you alcohol or drugs. 
       To help you reach your goal, it is important to know how to refuse 
alcohol or drugs. Refusing drugs may be easy or more difficult 
depending on whom you are with, where you are, the time of day, and
so forth (basically any of the triggers). Being prepared by practicing use refusal
skills can help you stay away from drugs and reach your goal. Below are the
basic steps to use for refusing alcohol or drugs.
"#Say, No, Thanks
"#Use Good Body Positioning
"#Suggest an Alternative
"#Change the Subject
"#Confront the Aggressor
$##Say, No, Thanks. Of course, if someone offers you alcohol or drugs, 
saying no, thanks is the first thing you would want to do. To make sure
he or she knows you are serious, be firm. Often strangers or acquaintances
will just accept a no thanks without pressuring you any more. However,
other people such as friends may want to have an explanation. Having a
readymade explanation (No, thanks, Im not feeling too well tonight) can
make it easier. You may decide to just tell them directly that you do not
want to use drugs any more and why.
$##Use Good Body Positioning. Be aware of your posture and body positioning.
To get your point across and show you are serious, it is best to look directly
at the individual when refusing alcohol or drugs.
$##Suggest an Alternative. For example, if someone offers you a beer, you
might say something like, No, thanks. How about a soda?
$##Change the Subject. This shows that you are not really interested in using
drugs. For example, say, No, thanks. What did you think of that new CD?
$##Confront the Aggressor. Use this technique as a last resort. It can strain a
relationship at times. If the individual is persistent you may ask, Why is it
so important to you that I do this? 

-----------------------------------------------
GOALS
           Goals are about what you want in your life. We spent some   
time completing the Relationship Happiness Scales and set 
goals while we were working together. The happiness scales 
helped identify what areas of life were going well and what 
areas needed a little more work. If something was going well 
in a particular area (such as school or family relationships), it
is important to remember what you were doing to help make that area of
your life satisfying. If you felt bad about a particular area, you could ask
yourself, What could make this area of my life better? In the areas that you
rated lower on the happiness scales, we developed some goals. Below are
some tips to remember in the area of goals and goal setting.
1. Evaluate areas of your life. 
  What are some areas of your life that are going well? For example, if you
are doing well in school, examine what is making school satisfying for you. 
  What are some areas of your life that you would like to improve? For
example, if you are unhappy with your relationship with your parents or
caregivers, examine what you would like to see different or changed. 
2. Define your goal.
  Keep goals brief, positive, and specific. A specific goal will allow you to
see whether you have reached your goal. Be specific about exactly what
you would like to see different or changed. 
  Make sure your goal is not too complex. It may take several steps to reach
a long-term goal. For example, it may require going to school, getting
good grades, and getting a good score on the ACT or SAT to get into 
college. Each one of those small steps needs to be tackled first before 
you can reach the long-term goal.
3. Determine how can you reach that goal.
Use problem solving (see problem-solving sheet on the next page) to identify
ways to reach your goal. Decide on how often you will try a plan of action
needed to reach your goal. 
4. Evaluate progress toward your goal.
Periodically, see what progress you are making toward your goal. Check any
changes you think you may need to make or any new things to try to reach
your goal. If desired, record progress toward your goal so you can see how
far youve come.

-----------------------------------------------
PROBLEM SOLVING

You can use this sheet to help you when you have problems to solve.
Just answer the questions the way we did during our sessions to
arrive at a possible solution. Try it out, and then evaluate the 
outcome afterward.
%#What is the problem you are dealing with?

%#What are some ways you might be able to solve the problem? List
as many ideas as you can think of.

%#Draw a line through any ideas that you dont think you would try.

%#Read each idea that you have not crossed off the list, and pick
one idea that sounds like something you would like to try. Write it
down below.

%#Evaluate the outcome. Were you satisfied with how it
worked out? (You can modify or change the solution
or even come up with an entirely new solution if
the old solution did not work as planned.)

-----------------------------------------------
COMMUNICATION
SKILLS

                  The goal of using communication skills is to   
be able to get your message across to
another person to help you get what you want.
Through use of communication skills, individuals should be able to
come to a compromise or agree on a solution to a problem. When
everyone agrees on a solution, compliance by all sides and content
ment with the solution are more likely. It is important to stay positive
while using communication skills and avoid any blaming. 

1. Understanding statement: The goal of the understanding statement
is to open up communication and show that you are aware of the
other persons thoughts on the problem.

  Come from their perspective.
Example: Mom, I understand you would like my room clean
because it is a real mess and you would like the house to be
clean when friends come over.

  Come from your perspective.
Example: But Jimmy is having a party at his house and I
have not seen Jimmy in a while, so I would really like to go.

  Make a request (a request should be brief, positive, and 
specific).
Example: I would really appreciate if you would let me
clean my room later on tonight, maybe around 8 p.m. when
I get home.

2. Partial responsibility: The goal of the statement of partial responsibil
ity is to avoid blaming the other person. Remember to state how
you or the other person sees you fitting into the problem or solution.

  How do you fit in to the problem?
Example: I know I made a real mess by not putting my
clothes away, and I have not always cleaned my room, and
I am sorry about that.

  Repeat the request (optional).
Example: But I would really appreciate if you would let me
clean my room around 8 tonight after I get home from
Jimmys party.

(Continued on next page)

-----------------------------------------------
3. Offer to help: The offer to help is used to show
that you are willing to work on a solution that
works for everyone and that you would like
input on possible solutions.

  Offer several possible solutions.
Example: If there is anything I can do to
help make that happen: help out with
another chore around the house, help
out with dinner, or just do a quick 10-
minute cleaning for now and do the rest
later, I would really appreciate it.

  State your openness to listen and consider the other persons
ideas. Example: If there is anything that you can think of, I would
be willing to listen.

Following the offer to help, individuals may try to compromise with
each other on a solution or do some problem solving. It may be 
necessary to go through the communication skills again to state your
point.

-----------------------------------------------
Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

ACRA Procedure 12 Checklist
Treatment Closure

                   Check Appropriate Boxes
Activity In Progress     Yes       No
1.   Did you check with the adolescent and 
provide an overview of the session?    
2.   Did you review the adolescents progress?    
3.   Did you discuss any unmet goals on the 
Goals of Counseling form and plans for 
achieving them?    
4.   Did you talk with the adolescent about 
what he or she has gained from the 
treatment experience?    
5.   Did you provide and review the discharge 
packet?     
6.   Did you reinforce the adolescents efforts 
and hard work?    
7.   Did you discuss with the adolescent 
options for further contact and/or 
treatment?    

-----------------------------------------------
Optional Procedure 1: Dealing With Failure To Attend
Many of the tasks in this procedure are based on the Motivational
Enhancement Therapy Manual used in Project MATCH (Miller et al.,
1995). As described in detail below, the therapists job is to be aggressive
in his or her efforts to engage both the adolescent and the caregiver in
the ACRA treatment process. This approach includes contacting someone
as soon as possible after a missed session and eliciting from him or her
the motivations for attending treatment and ceasing substance use.
Rationale
For the adolescent to benefit from treatment, he or she has to attend. If
the adolescent quits coming to his or her treatment appointments, it is
critical that you reach out to the adolescent and reengage him or her 
in treatment. It is also important for caregivers to attend the sessions
designed for them and, if they do not, the therapist needs to make 
additional efforts to engage them. Consider this outreach activity as 
part of your job description. 
Purpose of the Procedure and Learning Objectives
The purpose of this procedure is to reschedule the missed appointment 
and to encourage the adolescent or caregiver to reengage or engage in
the treatment sessions. The learning objectives are to provide an 
opportunity to clarify the reasons for the missed appointment, show the
adolescent or caregiver that you are optimistic about the prospects for
change, and express your eagerness to see the individual again.
Timing, Audience, and Delivery Method
The timing for this procedure is as soon as possible after a teenager or 
caregiver misses a scheduled appointment. The target audience is the 
adolescent and his or her caregivers. These procedures may begin with a
telephone contact, but they may also include a home visit, if necessary. If
the adolescent has been required to attend treatment by a probation officer,
school official, or another authority figure, contact with this official to
prompt the adolescent to attend may be warranted.
Materials
None.

193

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Procedural Steps
1. Try to reach the adolescent or caregiver by phone immediately, and
keep trying until you reach him or her.
2. If the adolescent or caregiver does not have a phone, make a home
visit and conduct the procedures there.
3. If the adolescent does not respond to the procedures, consider 
contacting a caregiver and the referral source to see whether they
can help prompt attendance.
4. Complete the ACRA Optional Procedure 1 ChecklistDealing With
Failure To Attend immediately after contacting the adolescent or
caregiver.
Detailed Description
The remainder of this section contains a more detailed overview for dealing
with failure to attend sessions. Procedural steps are in bold type, and they
are followed by further directions and comments. A sample dialog between
a therapist and an adolescent is indicated in italic type.
1.  Try to reach the adolescent or caregiver by phone immediately,
and keep trying until you reach him or her. 
Respond immediately when an adolescent or caregiver misses a scheduled
appointment. Try to reach him or her by telephone, and when you do, cover
these points:
  Clarify the reasons for the missed appointment.
  Affirm the adolescent or caregiver. Provide reinforcement to him
or her for having agreed to participate in treatment.
  Express your eagerness to see the individual again.
  Remind the individual about the reinforcers already discussed for
quitting substance use or, in the case of the caregiver, the reasons
the caregiver wants his or her child to quit using substances.
  Express your optimism about the prospects for change.
  Reschedule the appointment.
Here is an example of a telephone call from a therapist to an adolescent
who has missed treatment:
Therapist: Hello John! How are you doing?
Adolescent: Fine.

194

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Therapist: Good. I was just calling because you missed your
appointment today. Was there anything wrong that led
to your missing the appointment?
Adolescent: Well, my mom wasnt home, and I didnt have a ride,
so I couldnt come.
Therapist: Okay. I know you really wanted to work on your 
relationship with your mom, and I think we can 
work on making things work out between you two 
in therapy. I really look forward to starting back on
this problem during one of our sessions. Is there any
thing I can do to help you out with getting to therapy?
Adolescent: No, not really. My mom just needs to take me.
Therapist: Okay. If you need anything, just ask. How are you 
feeling about therapy now?
Adolescent: I really dont feel like coming all the time.
Therapist: Well, I realize it isnt always easy to come to therapy
and try something like this. I think I might have a hard
time coming to therapy at first. What is something you
dont really like about coming to therapy?
Adolescent: Nothing really. It just takes up a lot of my time.
Therapist: It does take up time. One good thing is that it only
lasts a few more weeks and then we will be done. I
know you had a few reasons why you came here in 
the first place and some problems because of alcohol
and drugs. What are those things?
Adolescent: I went because my probation officer sent me. I got in
trouble with him, and my mom doesnt really like me
smoking weed either.
Therapist: What would you like to see happen differently between
you and your mom or probation officer?
Adolescent: I just want them to stop bothering me.
Therapist: I think we can work on that. I would really like to see
your mom and probation officer off your back, too. Do
you think we could go ahead and reschedule your
appointment?
Adolescent: Okay. How about Monday night?
Therapist: Sounds good. Is 6 still good?

195

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Adolescent: Yeah.
Therapist: Great. I really look forward to seeing you and working
on what to do to get your mom and probation officer
to stop bothering you.
If no reasonable explanation is offered for the missed appointment (e.g., 
illness, transportation breakdown), explore with the teenager or caregiver
whether the missed appointment reflects any of the following:
  Uncertainty about whether treatment is needed (e.g., I got
everything I needed from residential treatment or My child
doesnt really have a problem)
  Ambivalence about making change
  Frustration or anger about having to participate in treatment
(e.g., because the school requires it).
The therapist should not act surprised about the poor attendance or confront
the individual with poor motivation or intent. Instead, suggest that it is 
normal to express reluctance by not showing up or being late, and encourage
him or her to express any concerns about participation. Elicit motivational
statements from the adolescent or caregiver by having him or her review
the negative consequences (with peers, family, school, law enforcement,
etc.) that brought the adolescent to treatment in the first place. Then ask
the individual to review how the therapist can assist in preventing these
things from happening again. If speaking with a caregiver, talk about the
goals the caregiver has for his or her adolescent or the problems the 
adolescents use creates.
2.  If the adolescent or caregiver does not have a phone, make a
home visit and conduct the procedures there.
If you suspect flagging motivation, you may need to offer home visits to
prime attendance. A home visit is an option, particularly if the therapist 
has difficulty making contact by telephone or if the family does not have a
telephone. The purpose of this visit is to show the adolescent and caregivers
that the therapist is genuinely interested and to encourage attendance at 
a session. The therapist can go through the procedures outlined above and
work through any problems with transportation or other obstacles. Some
teenagers prefer to have sessions at their school, and this is another option
to explore.
Another useful technique is to send out greeting cards to motivate attendance
and encourage reengagement in treatment. A handwritten message from
the therapist provides a very personal contact for the teenager.

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3.  If the adolescent does not respond to the procedures, consider 
contacting a caregiver and the referral source to see whether they 
can help prompt attendance.
If the caregiver does not attend sessions, consider contacting the referral
source for help or consider inviting an alternative caregiver.
4. Complete the ACRA Optional Procedure 1 ChecklistDealing With
Failure To Attend immediately after contacting the adolescent or
caregiver.
A blank copy of this form is included at the end of this section.

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Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

ACRA Optional Procedure 1 Checklist
Dealing With Failure To Attend

                   Check Appropriate Boxes
Activity In Progress     Yes       No
1.   Did you respond immediately?    
2.   Did you clarify the reasons for the missed 
appointment?    
3.   Did you express your eagerness to see the 
adolescent or caregiver?    
4.   Did you talk about the reinforcers that the 
adolescent had identified to stay away from 
drug use or in the case of the caregiver 
why it is desirable for his or her child to 
become substance free?    
5.   Did you express your optimism about the 
prospects for change?    
6.   Did you reschedule the appointment?    
7.   Have you sent a greeting card?    
8.   If you were unable to make contact by 
phone, did you try a home visit?    

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Optional Procedure 2: Job-Seeking Skills
Rationale
Because a major tenet of ACRA is to encourage positive activities, an 
activity to consider for many teenagers is employment. The job-finding 
procedure has been an important part of the community reinforcement
approach since its inception. The activities described here have been 
successful in helping people find jobs.
Working is not necessarily appropriate for all adolescents because balancing
school work and other positive prosocial activities during the school year
may be all that some adolescents can handle. If, however, they have a lot
of free time during the school year, they are not attending school in the
summer, or they have dropped out, adolescents may find working to be 
a reasonable prosocial activity. Some work situations have a culture of 
alcohol or drug abuse, and one must evaluate this aspect of a potential
work environment. Unfortunately, these cultural aspects of the work 
setting may not become evident until after the adolescent starts the job.
Purpose of the Procedure and Learning Objectives
The main purpose for this procedure is to teach the adolescent how to be
proactive in his or her job search. The learning objectives are to provide
the adolescent with a realistic, systematic approach to finding a job:
decide which job categories are of interest, develop a list of contacts for
job leads, inquire about job openings and ask for an application, and track
job-finding efforts. 
Timing, Audience, and Delivery Method 
Job-finding-skills training takes place individually with the adolescent.
Schedule the training for a particular session or introduce the topic when
the adolescent talks about his or her desire to find a job.
Materials
General materials include snacks (e.g., chips, crackers, granola bars, fruit
bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if appli
cable), a videocamera and videotapes or an audiorecorder and audiotapes.
Procedure-specific materials include clipboard, chalkboard or whiteboard,
pens, markers or chalk, possibly an easel, and possibly a Finding a Job
handout.
A phone, phone directory, and transportation for job interviews are also
needed. Most teenagers are qualified only for unskilled jobs, and many
may be looking for their first job. If the teenager has work experience or
special skills, you may want to provide assistance with resume development,
so access to a computer and printer would be helpful.

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General Notes for the Therapist
It will not be possible to review all the topics described here in one session.
For example, discussion of how to keep a job will be best addressed after
the teenager has a job. The initial emphasis will be on locating a job.
Procedural Steps
1. Provide the adolescent with an overview of the job-finding approach.
2. Help the adolescent decide which job categories he or she is most
interested in.
3. Develop a list of contacts for job leads.
4. Roleplay how to inquire about job openings and ask for an application.
5. Roleplay a job interview.
6. Teach the adolescent how to track his or her job-finding efforts.
7. Monitor the adolescents performance on the job.
8. Complete the ACRA Optional Procedure 2 ChecklistJob-Seeking
Skills immediately after the session.
Detailed Description
The remainder of this section contains a more detailed overview for 
conducting job-finding activities with an adolescent participant. Procedural
steps are in bold type and are followed by further directions and comments.
Provide a copy of the handout Finding a Job located at the end of this 
procedure. 
1.  Provide the adolescent with an overview of the job-finding
approach.
Important points to state are:
  It may take a lot of effort to get a job. If you really want one, then
you need to make a job out of looking for a job.
  Being rejected is part of the job-finding process. Do not be dis
couraged if this happens. 
  A first step is to generate a list of job areas that interest you. 
  Research shows that the more interviews you have, the better
your chances of finding a job.

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  It is important to make a lot of contacts to generate job leads,
and there are ways to do this.
  You need to learn how to fill out an application.
  You need to practice approaching employers and interviewing.
2.  Help the adolescent decide which job categories he or she is most
interested in.
It is important to help the teenager identify job areas that interest him or
her. As noted, job possibilities will be limited because of age, educational
level, and experience. The following questions can help identify interest
areas:
  What kind of work have you done?
  What job training have you had?
  What type of place would you like to work in?
  What would you like to do?
A few possible job categories are restaurant work, retail jobs, maintenance,
and car repair. Job leads are more easily generated once possible job cate
gories are identified.
3.  Develop a list of contacts for job leads.
Research has shown that the best source of job leads are people one knows,
including friends, acquaintances, and family members. Other important
sources of leads are past employer or coworkers and the Yellow Pages. The
more traditional sources, help-wanted ads in the newspaper and job-wanted
postings, are still important to use, but they are not to be relied on solely.
Provide information about generating a list of leads from each of these
sources. Have the teenager actually make a list of friends and family 
members to contact about job openings. Help the adolescent look through
the Yellow Pages to identify businesses in the job category he or she would
most like to work in and add contact information to the job lead list. The
therapist may want to research job-finding resources available in the 
community and provide this information to the teenager.
4.  Roleplay how to inquire about job openings and ask for an 
application.
Although the approach may vary somewhat depending on the type of job
lead, there are some common aspects to approaching an employer about
work. Azrin and Besalel (1980) recommend the following approach:
  Tell the person you are looking for a job and why.
  State why you are asking that person for help (e.g., he or she has
a job or knows where a lot of other teenagers work).

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  Describe your skills briefly.
  Tell the person the kind of help you want (e.g., ask for information
on any places he or she has heard are hiring or any position 
opening signs).
Here are some steps to take when talking with an employer about a possible
job:
1. Introduce yourself.
Hello, my name is _______.
2.  Ask for the manager or person in charge (head of department).
I would like to speak to the manager. Can you tell me his or
her name, please?
3.  If the person is not available, ask to set up an appointment for the
same day or the day after.
Is there a time today that would be convenient for us to meet?
4.  Once you are able to speak with the manager, get to your main
point.
Im looking for a job in fast food. Im wondering whether I
could come in and talk about a possible job or Id like to speak
with you about possible job openings.
5.  Give a brief summary of experience or show enthusiasm for working
there.
This will be my first job. I really would like to work here and
you will find me a dependable worker.
5.  Roleplay a job interview.
Some adolescents have never had a job interview. You can help them devel
op their skills in this area by roleplaying interviews with them. For example,
you can take the role of the employer, ask typical job interview questions,
and coach them in their answers.
6.  Teach the adolescent how to track his or her job-finding efforts.
It is important to track the job contacts made each day and their results for
several reasons. First, the job seeker may be given specific instructions to
call or come back on a certain day. Second, the job seeker may want to
identify employers to check back with because they did not have a current
opening but anticipated one in the future. Recommend that the teenager
keep information in a spiral-bound notebook by date and include the follow
ing: name of business, phone number or address, name of person contacted,
results of the conversation, and any additional comments. This tracking
information provides great reference information for a future job search.

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7.  Monitor the adolescents performance on the job.
Once a job is obtained, teenagers may need some additional coaching on
how to keep a job. During treatment sessions, the therapist can ask how the
job is going and weave in appropriate procedures (e.g., communication and
problem solving) to help the adolescent address any problems on the job.
8. Complete the ACRA Optional Procedure 2 ChecklistJob-Seeking
Skills immediately after the session.
A blank copy of this form is included at the end of this section.

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Finding a Job

&#Make a list of what youre interested inwhat youd
like to do.
' Think of what kind of work youve done in the past. 
ANY experience youve had matters!
' Think about what youre good at or places youd LIKE to work. 
Examples: computers, retail (mall), maintenance, waiter (restaurant
work), typing, filing.
&#Develop a list of contacts for job leads.
' Talk to:
Family members
Friends
Past bosses.
' Look in the Yellow Pages to locate businesses in the job categories you
want to work in.
' Look for help-wanted ads posted in windows of stores or restaurants.
' Examine help-wanted ads in the newspaper every day.
&#Inquire about job openings, and ask for an application. 
' Introduce yourself.
' Ask for the manager.
' Ask whether you can come in and talk about any openingsask for an
interview.
' Set up a time the same day or the day after.
' Tell the person what work you have done in the past. If he or she is not
currently hiring, ask whether you can turn in an application and come
back in a couple of weeks.
' Ask whether he or she knows of any other businesses that are hiring.
' React in a positive and polite manner.
&#Develop a resume that includes:
' Your name
' Address
' Telephone where you can be reached
' Work youve done in past
' Skills you have
' Names and phone numbers of three people for the employer to call as
references.
&#Set goals when looking for a job.
' Make at least five contacts a day.
' Be motivated.
' Make a lot of appointments.
' Call employers back to check whether a position has opened up.
' Turn in applications to as many places as possible. 

(Continued on next page)

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Sample request for an interview:
Hello, my name is ______. I would like to talk to the manager. Can you tell
me his or her name, please? Im looking for a job in ______ (e.g., restaurant
work), and Im wondering whether I could come in to talk about a possible
job opening. I can make it at 2 this afternoon; would that be convenient for
you? I have experience in ______, and Id like to talk to you about any 
openings now or later. Would you have time this afternoon? (If not) When 
is a good time to come back?

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Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

ACRA Optional Procedure 2 Checklist
Job-Seeking Skills

                   Check Appropriate Boxes
Activity In Progress     Yes       No
1.   Did you provide an overview of the 
job-finding approach?    
2.   Did you help the adolescent identify job 
areas he or she was interested in?    
3.   Did you help the adolescent develop a list 
of contacts for job leads?    
4.   Did you roleplay with the adolescent how 
to inquire about job openings and ask for 
an application?    
5.   Did you roleplay a job interview?    
6.   Did you teach the adolescent how to track 
his or her job-finding efforts. 
7.   Did you evaluate the outcome at the next 
session?    

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Optional Procedure 3: Anger Management
The following material is adapted from McKay, Rogers, and McKay
(1989).1
Rationale
Anger-management skills are taught when adolescents or adults express
anger in ways destructive to themselves or to the people around them.
Managing anger does not guarantee that negative life situations or events
will be resolved, but it will assist adolescents in living healthier lifestyles
and minimizing the risk of adverse consequences of anger-related behavior.
Purpose of the Procedure and Learning Objectives
The purpose is to promote positive methods of communicating anger 
that help adolescents express their needs in a safe, effective manner. 
The learning objectives are to help the adolescent or caregiver:
  Identify reinforcers to manage anger
  Recognize anger
  Take time to cool down
  Try to understand another persons position (be empathetic).
Timing, Audience, and Delivery Method
This optional procedure is used when it is evident from assessment 
information or from what is revealed during treatment that the adolescent
or the caregiver has a problem with anger. The procedure is presented
individually with the adolescent or the caregivers if needed. 
Materials
Procedure-specific material include the Anger Management handout.

General Notes for the Therapist

These procedures are to help adolescents who express anger in unhealthy,
maladaptive ways. Maladaptive ways are acting out frequently in a 
physically or verbally aggressive manner, passive behavior that is followed 
by exploding into rage, altercations at school, or screaming matches with
parents or caregivers. 
One reason that teenagers may be angry is that they have been abused,
abandoned, or exposed to other life circumstances for which anger is clearly
an appropriate response. In these cases, anger may have helped protect 

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.
Oakland, CA: New Harbinger Publications. www.newharbinger.com. 8007486273.

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them from mental or physical harm or alerted them that something in their
environments did not feel right. You can stress to youth, with and without
these backgrounds, that it is okay to feel angry; what counts is how they
express their anger and negative emotions. 
Procedural Steps
1. Identify reinforcers to manage anger.
2.  Assist the adolescent in recognizing anger.
3.  Teach the adolescent to take time to cool down.
4.  Teach the adolescent to foster empathy.
5. Distribute the Anger Management handout.
6. Assign homework.
7. Complete the ACRA Optional Procedure 3 ChecklistAnger
Management immediately after the session.
Detailed Description
The remainder of this section contains a more detailed overview on how to
conduct the optional session on anger management. Procedural steps are in
bold type and are followed by further directions and comments. A sample
dialog between a therapist and an adolescent is indicated in italic type.
1.  Identify reinforcers to manage anger.
Initially, the therapist focuses on prompting the teenager to identify which
anger-related behaviors are interfering with his or her life. Examples might
include physical or verbal fighting that has caused trouble for him or her
with parents or caregivers and friends. Other consequences of expressing
anger in unhealthy ways might include criminal justice involvement or
being suspended from school. 
Ask the adolescent to tell you how his or her anger has negatively affected
goal achievement. Provide an example such as a young mans anger leading
to a blowup with his parents, being grounded, and not being able to attend
a rock concert. Similar to conducting a functional analysis, the adolescent
examines the positive and negative consequences of his or her behavior and
is taught to think that there are other, less damaging ways to express anger.
Once again, the idea is for you to elicit reinforcers from the adolescent and
use these as motivation for change. The following dialog provides an 
example.

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.
Oakland, CA: New Harbinger Publications. www.newharbinger.com. 8007486273.

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Therapist: Tell me how your anger has affected you in your life.
Adolescent: Well, I got into an argument with my friend Jeff one
night, and we ended up getting into a fight. After that
we just didnt spend too much time together.
Therapist: Has anything else happened that you have not liked
because of your anger?
Adolescent: I got suspended from school for 5 days once after I
was in a fight with a kid. My grades ended up being
pretty bad because some of the teachers wouldnt let
me catch up on the homework. Thats pretty much it,
though.
Therapist: So you got suspended from school, your grades got
worse, and you dont spend much time with one of
your friends because of your anger.
Adolescent: Yeah, thats right.
2.  Assist the adolescent in recognizing anger.
The first step in helping teenagers express their anger in healthy ways is to
assist them in recognizing when they are beginning to feel out of control.
This is the point at which they can choose to behave in a damaging or 
constructive manner. Some teenagers may have more skill in this area than
others do, but when adolescents can articulate their warning signals, they
have a better chance of identifying the need to use anger-management 
techniques. It is not enough that they know anger-management techniques;
they also need to know when to use them.
Ask the teenager to describe the physical signs of mounting anger because
physiological changes play a part in the bodys response to increased arous
al. For example, an upset stomach, clenched jaw, sweating, tightened fist,
heavy breathing, and a high pulse rate may serve as red flags for the adolescent
to step back and cool down. Each adolescent will identify a unique set of
physical and behavioral warning signs. Encourage the adolescent to monitor
his or her behavior to learn when he or she needs to intervene to avoid an
angry response.
Therapist: Before you get really angry, do you notice any signs
that you are getting upset? Some people clench their
fists or slam doors or something. Do you notice any
thing like that?
Adolescent: Well, I notice I feel like my face gets really hot, and I
start walking around the house really fast, slamming
doors as I go.

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.
Oakland, CA: New Harbinger Publications. www.newharbinger.com. 8007486273.

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Therapist: Good. Remembering those things can be helpful so
when you feel some of those symptoms that show you
are getting upset, you can do something else to calm
yourself down. That way you dont have to worry
about getting really angry and doing something like 
getting in a fight and getting suspended from school.
What is something positive you have done in the past
that has helped calm you down when you have started
to get angry?
Adolescent: Sometimes walking around helps calm me down. When
I get angry, I just want to leave and try not to think
about things.
Therapist: Thats great. So you are able to calm down by walking
around. What are some of the things you do when you
walk around?
Adolescent: I just walk around and think of how much a jerk the
person was.
Therapist: Okay. Some people like trying to do different things
positive activities like shooting some hoops or going to
the arcadewhen they get angry to help them calm
down and get their minds off things for a little while.
What kind of positive thing do you think you would try
once you started walking around?
Adolescent: Well, I sometimes like just going to the park and relax
ing to get my mind off things. If I am really angry, I
sometimes like to play video games at home.
Therapist: So when you start noticing your face getting hot or
start walking around really fast slamming doors, you
would be willing to walk around and maybe spend
some time relaxing in the park or play video games?
That sounds as if it might work for you, and you dont
have to worry about getting in trouble at school. Would
you be willing to try one of these activities the next
time you feel yourself getting upset?
Adolescent: Sure. If I start getting angry, Ill just walk away and go
to the park to calm down.
Therapist: Thats right. 

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.
Oakland, CA: New Harbinger Publications. www.newharbinger.com. 8007486273.

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3.  Teach the adolescent to take time to cool down.
One technique that has proved useful for anger management is taking the
time to calm down. If a person is in an interpersonal situation during which
he or she feels physical signs of mounting anger, he or she is encouraged to
say, I need to cool down, and to leave for an agreed amount of time (e.g.,
1 hour). Walking out for a specified time does not constitute running away
or punishing the other person, but it allows the individual time to work
through the heat of the moment and clear the head.  
During the time away, the teenager is encouraged to engage in a physical
activity to reduce tension. He or she can go for a walk, play some basketball,
or participate in a pleasurable activity. It is not a time to use substances. The
Functional Analysis of Prosocial Behavior form can serve as an adolescent-
generated guide to the kinds of activities that might appeal to youth. After
the time has passed, the adolescent returns to the situation to talk with 
the other person or decides to take more time to reduce the tension.
Communication skills training is also important to help teenagers learn
how to express their anger more productively (see procedure 6).
When the teenager finds himself or herself growing angry outside a 
conversational context, such as thinking about what someone else did or
said, he or she is once again encouraged to engage in tension-reducing
activity. Explain that this cooling down period prevents him or her from
acting impulsively in damaging ways or returning to substance use.
Problem-solving techniques may be useful in attempting to resolve the 
situations to which an adolescent is reacting. Once again, you will want 
to revisit reasons an adolescent has given to stay clean and manage his or
her anger.
4.  Teach the adolescent to foster empathy.
Many times when people are angry with someone, they do not think about
why the other person has acted in a certain way. Fostering empathy is one
method of helping an adolescent learn how to examine situations from dif
ferent viewpoints and defuse anger with understanding. This ability does not
mean that anger in a given situation becomes unjustified, simply that anger
can be communicated more effectively when the person on the receiving
end feels understood and becomes more receptive to the youths position. 
Particularly with an older adolescent who has reached a higher level of 
cognitive maturity, you can help the teenager learn to walk in someone
elses shoes. This skill can be taught through roleplaying. For example, you
pick a real life situation and play the role of the adolescent. The adolescent
can play the role of the person with whom he or she is angry, attempting to
voice concern from another point of view. 

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.
Oakland, CA: New Harbinger Publications. www.newharbinger.com. 8007486273.

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Following the roleplay, process the experience with the teenager. Ask what
effect the roleplay had on his or her understanding of the other persons
position and how he or she would handle the same situation if it happens
again.
5. Distribute the Anger Management handout.
Explain that this sheet contains reminders that will help the youth identify
anger triggers and ways to deal with anger.
6. Assign homework.
Seek agreement from the teenager that he or she will use the anger-
management techniques when experiencing the physical precursors to
anger. You should review the adolescents success at using the anger-
management techniques in the next session and thereafter when the
teenager reports experiencing anger.
7. Complete the ACRA Optional Procedure 3 ChecklistAnger
Management immediately after the session.
A blank copy of this form is included at the end of this section.

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.
Oakland, CA: New Harbinger Publications. www.newharbinger.com. 8007486273.

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Tips for Individualizing or Dealing With Difficult Situations
  Anger management is individualized. Each adolescent will present
with a unique set of situations to which he or she responds with
anger, as well as different methods of expressing his or her emotions.
Listen to each teenagers needs, and respond with interventions
targeted to specific problems. For example, adolescents with
chronic aggressive behavior may initially require more empathy
training and tension-reduction work than adolescents who bottle
their emotions until they explode. Those teenagers may respond
better to problem-solving and communication skills training.
  Adolescents are a danger to themselves or others. One extreme
form of anger-management problems may involve adolescents
threats to hurt themselves or others in a fit of rage. In these
cases, attempt to fully assess the extent of these intentions and
consult with supervisors about the best course of action.
  Caregivers are aggressive. Some teenagers may live with 
caregivers who are physically or verbally aggressive themselves. 
If you have concerns that the caregivers behavior is abusive, 
consult with your supervisor for the best course of action including
whether the behavior needs to be reported to the State child 
welfare authority. Even if the caregivers behavior does not rise to
the level of reportable abuse, it can create a negative situation.
Teenagers will have difficulty learning how to manage their 
negative emotions in a more constructive manner if they live in
an environment where anger is routinely expressed in unhealthy
ways. Work with the caregiver and the adolescent separately. The
caregiver can be helped to improve his or her communication
skills while you are working with the teenager to improve his or
her anger-management skills. 

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.
Oakland, CA: New Harbinger Publications. www.newharbinger.com. 8007486273.

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 ANGER MANAGEMENT  

Remember, its okay to get angry. What is important is how your 
emotions are expressed. Below are some tips for anger management.

$#How has anger interfered with your life? What would you like to
change?

$#How do you know when you are getting angry? (Typical signs are an
upset stomach, clenched jaw, tightened fist.) If you feel you are begin
ning to get angry, you can do something before the situation becomes
too tense and leads to negative consequences. 

Write your typical signs here:__________________________________________

$#Take time to cool down. Find an activity or spend time away from the
situation so you are able to calm down and handle the situation in a way
that does not have negative consequences.

$#Remember to use communication skills to help express how you
feel, while trying to see how the other person feels. Try to come to a
common solution instead of forcing your decisions on someone else.
See the Communications Skills sheet.

$#Try to come from the other persons perspective. Why does the 
person feel the way he or she does?

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Date_______  Session #_____  Adolescent ID_____  Therapist Init.________

ACRA Optional Procedure 3 Checklist
Anger Management

                   Check Appropriate Boxes
Activity In Progress     Yes       No
1.   Did you explain the purpose of learning 
anger-management skills?    
2.   Did you probe the adolescent for his or her 
reason for learning anger-management 
skills?    
3.   Did you ask the adolescent how anger-
related behaviors have interfered with 
goals?    
4.   Did you prompt the adolescent for specific 
physiological and behavioral warning signs?    
5.   Did you identify activities in which the 
adolescent can engage to cool down after
the warning signals have been recognized?    
6.   Did you conduct roleplays with the 
adolescent to help him or her learn to 
walk in another persons shoes?    
7.   Did you assess the adolescents potential 
danger to himself or herself and, if 
necessary, consult with a supervisor about 
the issue?    

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V. Protocol Monitoring Adherence
Overview of Protocol Monitoring Procedures
A treatment manual is only one of the pieces needed to implement a 
treatment protocol. A number of additional supports help ensure that the
protocol is fully implemented and delivered as outlined in the treatment
manual. The following activities are recommended for protocol monitoring:
(1) staff training by an experienced ACRA trainer, (2) certification of 
therapists, (3) individual supervision, (4) group supervision, and (5) quality
assurance rating scales and checklists (i.e., Therapist Skillfulness Scale,
ACRA Global Procedure Checklist, and ACRA individual procedure checklists). 

ACRA Training

Training should be provided by an experienced ACRA trainer. Initial training
should include a review of the background of CRA and ACRA, an overview of
the model, an extensive review of the treatment manual, review of taped
examples of treatment sessions delivering the model, and roleplay or practice
exercises. Ongoing training can be provided in clinical supervision; however,
the trainer providing the initial training should periodically offer refresher
or booster training to all staff delivering the model.

Certification of Therapists    
A process to certify therapists helps ensure that procedures are being 
delivered as outlined in the manual. The certification process requires that
the therapist videotape and/or audiotape therapy sessions and that all or
randomly selected tapes are reviewed and rated by a clinical supervisor.
Several forms have been developed to aid in the tape review and the clinical
supervision process including (1) the Therapist Skillfulness Scale (TSS), 
(2) the ACRA Global Procedure Checklist form, and (3) the ACRA individual 
procedure checklists. Both consistent ratings of four and five on the TSS 
and a demonstration by the therapist that he or she is implementing 
the treatment interventions in a competent and consistent manner are 
necessary for certification. A more detailed description of the rating scale
and the checklists follows.
Therapist Skillfulness Scale 
A therapists working alliance, adherence to the manual, and competence in
the treatment being delivered can be assessed by using the TSS. The TSS is
used by the ACRA supervisor to rate whether the interventions used in 
sessions consistently reflected the protocol. The TSS measures competence
for a range of skills from nonspecific, basic therapy skills to specific skills
related to the manual. This scale is used to provide direction and feedback
in supervision. It is important to note that adherence and competence are
different constructs. Adherence is how much a therapist uses the procedures,
and competence is how well the procedures are implemented with 
appropriate timing. 

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One of the items rated on this scale relates to self-disclosure. In the model,
self-disclosure would rarely be appropriate. It is included on the scale so
that the supervisor can monitor the amount of self-disclosure that occurs
and provide appropriate feedback to the therapist. These ratings can be
monitored over time to maintain quality of treatment. If ratings decline, it
would warrant an increase in training and/or supervision. This scale provides
a tool to assess the need for further supervision on specific techniques or
interventions. A copy of this scale follows this section.
ACRA Global Procedure Checklist
This form is specific to ACRA procedures and provides an opportunity for
supervisors to note what ACRA procedures were used, as well as which ones
could have been used. ACRA therapists complete one after each session.
The supervisor reviews the completed form and initials it to indicate
whether he or she agrees or disagrees with the therapists designation. 
The checklist is another tool that can be used to monitor the treatment
process. Comparing this information with what exists on the tapes of sessions
provides useful information to the supervisor and therapist. By using the
ACRA Global Procedure Checklist, a therapist can monitor his or her 
adherence to the model. A copy of this checklist follows this section.
ACRA Individual Procedure Checklist 
ACRA therapists complete individual procedure checklists after each session
and after they complete the ACRA Global Procedure Checklist. These 
checklists describe steps specific to each procedure. By completing these
checklists, ACRA therapists should improve their compliance over time. 
The ACRA supervisor should monitor the completion of these checklists 
and ensure that he or she is in agreement with the therapist. The checklists 
can also be completed by the ACRA supervisor to provide feedback to the 
therapist regarding his or her performance during treatment sessions.
Copies of procedure checklists follow their appropriate procedure 
descriptions throughout the manual.

Structure and Process of Supervision
Individual Clinical Supervision
The initial stages of supervision concentrate on establishing an open, 
honest, approachable, and helpful alliance. Supervision should provide a
forum for a therapist to develop and grow. It is very hard for a therapist to
do so if he or she is intimidated. A positive approach to supervision is also 
a form of modeling ACRA treatment. Once a positive working alliance has
been established, the process of supervision is much more productive. The
ACRA supervisor functions as a teacher, skill developer, resource person,
coach, team captain, and motivator. He or she must have skill and 
knowledge in basic counseling tasks and ACRA procedures and be able 
to convey that knowledge to others.

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Individual supervision should take place at least 1 day per week for 60 to 90
minutes. During this time, numerous activities could occur depending on
the needs of the therapist. Typically, this weekly meeting with the therapist
begins with a brief overview of his or her cases. The case review is one
means of providing the supervisor and therapist with information that can
be used to decide how best to use their remaining supervision time for the
week. Other information that helps highlight supervision needs includes 
the supervisors review of therapy tapes and accompanying checklists. The 
therapist is also involved in setting the content and agenda for the clinical
supervisory sessions to ensure their relevance to his or her needs. The most
common focus during a supervision session is discussing the best approach
es for addressing clinical issues presented by treatment participants and
helping therapists improve their skills in the delivery of ACRA procedures.
Typical supervisory activities include reviewing tapes, providing feedback, 
roleplaying exercises, modeling, providing training or instruction, and 
problem solving.
Videotape and/or audiotape reviews. Supervisor and therapist reviews of
tapes from actual sessions provide important information for supervision.
Therapists often initially feel threatened by having their sessions taped, 
but tapes provide the greatest opportunity for improving their skills.
Videotaping also leads to self-supervision; the tape may speak for itself 
with little need for comments by the supervisor. The therapist has the 
opportunity to experience feelings and thoughts from the session while 
listening to the tape, instead of relying on his or her perception of what
transpired in the session. The supervisor and therapist can stop a tape 
frequently to focus on the therapists behavior and thought processes. 
Tape reviews provide an opportunity for corrective feedback or for problem 
solving with the therapist considering what else could have been tried or
done at a particular point in the session. The supervisor may choose to
model a procedure or ask the therapist to roleplay a procedure so that he
or she has the opportunity to improve his or her techniques. 
When a supervisor reviews a tape, either alone or with a therapist, it is
important to look for a number of behaviors. First, it is important to notice
and provide feedback on what the therapist does well. The supervisor can
also point out appropriate procedure options within a session that might
have been overlooked by the therapist. It is also important that the 
supervisor review tapes with an eye toward the most common problems
found in implementing ACRA treatment. If problems are noticed during 
the tape review, the supervisor can provide feedback to the therapist and
model what the therapist might have said in a given situation. The most
common problems in implementing ACRA treatment are listed below.
  Losing sight of an adolescents reinforcers
  Failing to involve a parent or caregiver in the treatment
  Neglecting to emphasize the importance of having a satisfying
social life

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  Not stressing the necessity of participating in meaningful 
activities (school, seeking a general equivalency diploma [GED],
work)
  Inadequately monitoring the adolescents contact with triggers
  Not checking for generalization of skills
  Not using the adolescents or caregivers own words as a motivator
  Not determining what motivates the adolescent to change.
Practice roleplays. Intensive and extensive roleplays are excellent skill
builders. During supervision, it is important not only to talk about how 
procedures should be done but also to practice them. Roleplays provide the
therapist the opportunity to practice procedures in the safety of a training
situation and provide the supervisor the opportunity to give feedback on
the therapists performance. Just like therapy participants, therapists may
be embarrassed or reluctant to practice roleplaying. It is important that the
supervisor does not convey the expectation of perfection but instead provides
support and encouragement. The supervisor can praise the therapist for any
efforts he or she made. Because an ACRA supervisor functions as coach and
motivator, it is not appropriate to be negative and critical. Because the
therapist is expected to use a positive approach with therapy participants,
this approach is modeled during supervision as well. 
Group Clinical Supervision 
If there are multiple therapists providing ACRA treatment, group supervision
in addition to individual supervision can be beneficial. Group supervision is
efficient because all staff receive the same information at the same time.
The group can provide a sense of belonging, group cohesiveness, professional
identity, praise, and aid. With individual supervision, there are only two
points of view, whereas in group supervision, many ideas are brainstormed
and discussed. An optimal approach is a combination of both individual and
group sessions for each therapist. The supervision process flows from 
individual to group, back to individual and so on. 
As with individual supervision, a number of activities are appropriate with
group supervision, including videotape and/or audiotape reviews, case 
presentations, peer feedback, peer interaction, and roleplaying. A more
structured agenda should be used during group supervision because with
multiple therapists involved, it becomes easy to slip into rap sessions or get
away from the task at hand. The supervisor needs to regulate the action,
amend the course of discussion, and maintain group functions. When a 
program begins using ACRA procedures, it would be beneficial to have
group supervision weekly. As the team becomes cohesive and knowledgeable
about the model, these meetings can occur biweekly.
Videotape reviews are an excellent tool for group supervision. Tapes can 
be stopped at significant junctures for the group to discuss how other 

220

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therapists would have handled the situation. Situations encountered by
other therapists and viewed on tape provide a stimulus for therapists to
share similar clinical problems and provide support and encouragement for
one another. However, it is important not to put anyone on the spot. Good
judgment and sensitivity should be used to determine whose tape to use in
group supervision and when it is appropriate. 

Training Resources
For information on training on this approach, contact the following 
individuals:
Robert J. Meyers, M.S.
Center on Alcoholism, Substance Abuse, and Addiction (CASAA)
1650 Yale, SE

Albuquerque, NM 87104

E-mail: bmeyers@unm.edu

Phone: 5057680262
Jane Ellen Smith, Ph.D.
Psychology Department, Logan Hall
University of New Mexico
Albuquerque, NM 871311161
E-mail: janellen@unm.edu
Phone: 5052772650
For consultation on this approach, contact:
Susan H. Godley, Rh.D.
Chestnut Health Systems
720 West Chestnut
Bloomington, IL 61701
E-mail: sgodley@chestnut.org
Phone: 3098276026

Summary

As the process progresses, the ACRA therapist becomes more knowledgeable
about and skilled in the delivery of the ACRA procedures. The use of specific
techniques usually comes more easily to the therapist than knowing when
to use which procedure. Appropriate timing develops along with good 
judgment and increasing competence. Once a therapist has mastered the
techniques, tape reviews are critical to helping the therapist with the timing
of procedures. Some of the ongoing tasks of supervision are to train how to
conceptualize cases, make treatment decisions, and select the timing of
procedures. With tape reviews, rating scales, and checklists, the supervision
process provides a method to measure performance and a feedback 
mechanism to make changes as needed.

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Therapist Skillfulness Scale 

Supervisors Name:____________________________________ Therapist Name:_____________________________________
ID#:_________________________________________________ ID#:_______________________________________________
Subject ID:___________________________________________ Session Date:___________________ Session Number:_______________
Please rate the therapist on the  Not
following items:  Not at all      A little     Somewhat Considerably Extensively   observed                  Comments
To what extent did the therapist 
follow the session format?  1  2 3 4  5
To what extent did the therapist 
use language and interventions  1  2 3 4  5
consistent with the treatment 
type?    
To what extent were the treatment 
goals consistent with the  1  2 3 4  5
treatment type?    
To what extent did the therapist 
demonstrate expertise and  1  2 3  4  5
competence?    
To what extent did the therapist 
engage the client?  1  2 3 4  5
To what extent did the therapist 
use interventions at appropriate 
times (interventions not missed  1  2 3 4  5
when needed, interventions not 
made too early)? 

(Continued on next page)

-----------------------------------------------
Please rate the therapist on the  Not
following items:  Not at all     A little     Somewhat Considerably Extensively observed                 Comments
To what extent did the therapist 
use appropriate self-disclosure?  5  4  3  2  1
To what extent did the therapist 
use an appropriate level of  1  2  3  4  5
activity?    
To what extent did the therapist 
maintain the session focus?  1  2  3  4  5
To what extent did the therapist 
set an appropriate tone and  1  2  3  4  5
structure for the session?    
To what extent did the therapist 
demonstrate warmth, sensitivity,  1  2  3  4  5
and genuine concern?    
To what extent did the therapist 
understand and express the 
participants feelings and  1  2  3               4  5
concerns?  

-----------------------------------------------
ACRA Global Procedure Checklist

Date _____________       Session # _________       Therapist Init. _________       Adolescent ID______       Supervisor Init._________

Procedures  Used  Could Have Used
1.  Rapport building
Used open-ended questions  
Praised client for working   
2.  Increasing motivation
Discussed benefits   
Stated importance of attendance   
Mentioned potential barriers   
3.  Functional analysis
Completed for substance use   
Completed for prosocial behaviors   
4.  Treatment plan
Completed Happiness Scale
Completed Goals of Counseling
5.  Increasing prosocial recreation
Identified interest areas   
Used reinforcer sampling   
Provided systematic encouragement

(Continued on next page)

-----------------------------------------------
Procedures  Used  Could Have Used
6.  Relapse prevention
Identified early warning system   
Used functional analysis   
Outlined the behavioral chain   
Provided refusal training   
Used cognitive restructuring   
7.  Communication skills
Assessed quality of communication   
Taught techniques   
Conducted a roleplay   
8.  Problem solving
Defined problem   
Tried brainstorming   
Chose a solution   
9.  Urine testing
Recorded results   
Reviewed results   
10.  Caregiver overview
Used rapport-building techniques   
Provided overview of ACRA procedures   

Looked for caregiver motivators

(Continued on next page)

-----------------------------------------------
Procedures  Used  Could Have Used

Identified most important things from research   
Assessed need for other referrals   
11.  Caregiver communication
Provided rationale   
Assessed quality of communication   
Roleplayed   
12.  Caregiveradolescent relationship skills
Found positive things about each other   
Reviewed communication skills   
Reviewed problem-solving skills   
Completed Relationship Happiness Scales
Gave a reminder to be nice   
Provided closure with caregiver   
13.  Dealing with failure to attend
Contacted client   
Motivated client   
Rescheduled appointment   
14.  Job finding
Assessed job categories   
Developed job leads
(Continued on next page)

-----------------------------------------------
Procedures  Used  Could Have Used
Roleplayed asking for applications and interviews 
15.  Anger management
Identified reinforcers   
Discussed and practiced techniques   
16.  Treatment closure
Reviewed progress   
Analyzed gains   
Reviewed information   
Reinforced efforts and hard work   
Provided a discharge packet   
17.  Odds and ends
Looked for reinforcers   
Tied in reinforcers   
Used roleplays   
Assigned homework   
18.  Other 

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

-----------------------------------------------
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Appendix. Clinical Management of a Multisite 
Field Trial of Five Outpatient Treatments for
Adolescent Substance Abuse

  Nancy Angelovich, M.S.1
   Tracy Karvinen, M.A.2
Suzie Panichelli-Mindel, Ph.D.3
 Susan Sampl, Ph.D.4
Meleney Scudder, Psy.D.4
 Janet Titus, Ph.D.5
William White, M.A.5

1 Operation Parental Awareness and Responsibility (PAR), Inc. 
2 Chestnut Health SystemsMadison County (CHSMC)
3 Childrens Hospital of Philadelphia (CHOP)/University of Pennsylvania
4 University of Connecticut Health Center (UCHC)
5 Chestnut Health SystemsCoordinating Center (CHSCC)

Acknowledgments: Financial assistance for this study was provided by the Substance Abuse
and Mental Health Services Administration (SAMHSA), Center for Substance Abuse
Treatment (CSAT), Grant Nos. TI11317, TI11320, TI11321, TI11323, and TI11324. The
authors appreciate the valuable comments, suggestions, and support offered by the Cannabis
Youth Treatment study principal investigators: Thomas Babor (UCHC), Michael Dennis
(CHSCC), Guy Diamond (CHOP), Susan H. Godley (CHSMC), and Frank Tims (PAR).
Correspondence to: William L. White, Senior Research Coordinator, Chestnut Health
Systems, 720 West Chestnut Street, Bloomington, IL 61701, Phone: 3098291058, x3403;
Fax: 3098294661; E-mail: bwhite@chestnut.org.

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Abstract  

Bridging the gap between clinical research and clinical practice in the
treatment of adolescent substance abuse requires empirically validated
therapies and technology transfer strategies that reflect an awareness of the
realities and resource constraints of local treatment service providers. This
article describes the management of cross-site and cross-intervention 
clinical issues in the Cannabis Youth Treatment (CYT) study, a multisite,
randomized, clinical trial of five outpatient therapies. The methods used in
the management of such clinical trials could play an important role in 
elevating the quality of adolescent substance abuse treatment as practiced
in the field. This technology involves 1) defining and delineating clinically
relevant subpopulations of clients, 2) developing research-supported 
manuals that define the theory, active ingredients, and procedures of 
treatment, 3) monitoring therapist adherence to manual-based therapy, 
4) monitoring client responses to the procedures as they are implemented,
5) individualizing and refining the delivery of these manual-based therapies
within the context of clinical supervision, and 6) conducting rigorous and
sustained followup to determine the enduring effects of the interventions.  
Carroll and her colleagues (1994) detailed the strategies used to implement
and to protect the integrity of three manual-based therapies evaluated 
within Project MATCH, a multisite study of adult alcoholism treatment
(Project MATCH Research Group, 1993). This paper takes a similar
approach in describing cross-site clinical coordination procedures within 
the Cannabis Youth Treatment study, the largest multisite, randomized field
experiment ever conducted of adolescent substance abuse treatment. More
specifically, the paper details the common clinical infrastructure within
which these therapies were implemented across the treatment sites.
It is our collective experience that therapies can fail in the transition from
efficacy (outcomes under ideal circumstances) to effectiveness (outcomes 
in the real world of adolescent treatment), not because of flaws in the 
interventions themselves, but because of the absence of a sound foundation
of clinical management upon which empirically validated interventions are
replicated. The construction of stable clinical infrastructures within local
treatment programs is as important to the future of adolescent treatment 
as the availability of research-validated therapies.   

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The Cannabis Youth Treatment Study
After declining in the 1980s, both licit and illicit drug use among adolescents
rose in the 1990s. In 1996, cannabis use by adolescents (8th, 10th, and
12th graders) reached its highest peak in 12 years for reported lifetime use,
past year use, and past month use (ISR, 1997). As cannabis abuse/dependence
emerged as the leading cause for admission to substance abuse treatment
(OAS, 1997), demands increased for research-validated treatments for
cannabis-involved adolescents. In response to this need, the Substance
Abuse and Mental Health Services Administrations (SAMHSAs) Center for
Substance Abuse Treatment (CSAT) of the U.S. Department of Health and
Human Services (DHHS) funded the CYT study. 
The CYT study is a multisite, randomized field experiment designed to 
test the efficacy of five promising outpatient treatment interventions for
cannabis-abusing and cannabis-dependent adolescents. Its long-range goal
is to provide validated and cost-effective models of intervention that can be
widely replicated in local treatment agencies across the country. The study
sites include Chestnut Health Systems in Madison County, Illinois
(CHSMC); the University of Connecticut Health Center (UCHC) in
Farmington, Connecticut; Operation PAR in St. Petersburg, Florida (PAR);
and the Childrens Hospital of Philadelphia (CHOP) in Pennsylvania. The
sites represent both academic, research-oriented clinics (UCHC and CHOP)
and community-based adolescent treatment programs (CHSMC and PAR)
(Dennis, Babor, Diamond, Donaldson, Goldley, Tims, et al., 1998; Herrell,
Babor, Brantley, Dennis, et. al., 1999). The CYT study provides a test in 
geographically diverse environments of treatments that differ in theoretical
orientation, delivery format and focus, and dose.
Between June 1998 and February 1999, 600 adolescents (approximately
150 per site) meeting the criteria presented in the Diagnostic and
Statistical Manual of Mental Disorders 4th Edition-Revised (DSMIV)
(American Psychiatric Association, 1994) for cannabis abuse or cannabis
dependence were randomly assigned to one of three conditions, with a total
of five conditions used across the four sites. The five conditions include:
  Motivational Enhancement Therapy/Cognitive Behavioral 
Therapy5 individual/group sessions (MET/CBT5) (Sampl & 
Kadden, 2001)
  Motivational Enhancement Therapy/Cognitive Behavioral 
Therapy7 individual/group sessions (MET/CBT5 + CBT7)
(Webb, Scudder, Kaminer, & Kadden, in press)
  Family Support Network (FSN) (Hamilton, Brantley, Tims,
Angelovich, & McDougall, in press) (FSN includes MET/CBT5 +
CBT7 plus enhanced family supports: home visits, parent 
education classes, parent support groups)

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  Adolescent Community Reinforcement Approach (ACRA) (Godley,
Meyers, Smith, Karvinen, Titus, Godley, Dent, Passetti, & Kelberg,
2001) 
  Multidimensional Family Therapy (MDFT) (Liddle, in press).
At UCHC and PAR, adolescents were assigned to a five-session brief 
intervention (MET/CBT5) or to one of two other interventions that combine
more extensive individual and group sessions (MET/CBT5 + CBT7 or FSN).
At CHSMC and CHOP, adolescents were assigned to the five-session brief
intervention (MET/CBT5) or to one of two individual/family approaches
(ACRA or MDFT). All study participants were assessed at intake and at 3
months, 6 months, 9 months, and 12 months. Treatment completion rates
were in the 70-percent range, and followup rates through 9 months after
treatment exceeded 95 percent (Titus et al., 1999; Godley, Diamond, &
Liddle, 1999). 
Methodological Challenges
There were three important challenges in conducting this multisite field
experiment. The first was to ensure the integrity of each of the interventions
being tested (Moncher & Prinz, 1991). Following what has been referred to
as the technology model (Carroll et al., 1994; Carroll & Nuro, 1996;
Carroll, 1997), workgroups led by a technical expert in interventions and a
therapist coordinator (TC) responsible for cross-site supervision of that
intervention took the following six steps to enhance its integrity: 
  Defined and manualized the active ingredients of each therapy, 
including the frequency, intensity, duration, and sequencing, and 
indicated responses to the most common problems that occur 
during delivery of the intervention
  Conducted 15 to 25 hours of centralized, competency-based 
training for the therapists delivering the interventions and 
followed this by local certification of staff in each intervention
  Developed a therapists skillfulness scale to serve as a cross-site 
measure of general therapeutic competence  
  Developed a service contact log to measure therapists adherence 
to each of the five interventions and to document the dosage and 
types of services provided to each client
  Taped and rated sessions for model fidelity (all tapes were rated 
as part of the cross-site supervision by an expert in the 
intervention until each therapist was certified, after which two 
tapes per therapist, per month, were reviewed and rated) 
  Conducted weekly (1-hour onsite or telephone) individual 
supervision and weekly or bimonthly (60 to 90 minute) cross-site 
group supervision for each intervention.

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These procedures helped enhance treatment differentiability (the delineation
of the ingredients and procedures that distinguished each treatment from
the other treatments) and treatment adherence (the assurance that the
interventions [as delivered] maintained fidelity to the original manual-
defined procedures) (Hoffart, 1994).
A second challenge involved controlling extraneous factors that could 
compromise interpretation of the treatment outcomes. To accomplish this,
every effort was made to ensure that all general clinical procedures, other
than those involved in the specific therapies, would be handled similarly
across sites and interventions. This was done to minimize the ability of
these contextual issues to unduly influence the evaluation of the experimental
interventions and was achieved in two ways. First, staff of the CYT coordinating
center conducted two site visits at each of the four service delivery sites to
ensure that each site met baseline standards related to arenas such as
research protocol compliance, accessibility and appropriateness of clinical
space, clinical supervision structure, recruitment strategies, intake and
service procedures, confidentiality procedures, crisis and safety net 
procedures, clinical documentation, data security and storage, and followup
procedures. Second, the TCs for each intervention coordinated similar
responses to issues that were not part of the specific interventions in
monthly conference calls facilitated by the CYT coordinating center. Details
of this latter process will be described shortly. 
The third challenge was to enhance the external validity of the interventions
(the generalizability of study findings) by ensuring that the interventions
could be implemented as designed within the resource constraints of settings
that currently provide the bulk of services to drug-involved adolescents. It
was the goal of the CYT TCs to do everything possible in the CYT study to
bridge the traditional gap between efficacy research conducted under 
experimental (ideal) conditions and effectiveness research conducted in
field (real) settings. We wanted to document the kind of clinical infrastruc
tures and the management of day-to-day clinical issues that might need to
accompany these unique interventions if they were to achieve comparable
results in the field. 
The monthly conference calls among the TCs for each of the five interventions
and the staff from the CYT coordinating center were particularly helpful in
facing the latter two of these challenges. The purpose of these meetings
was to define how sites would manage common clinical issues that were not
a unique part of the experimental interventions but which, if not identified
and controlled, might corrupt the evaluation of these interventions. We
were concerned, for example, that if therapists in one intervention expelled
adolescents from treatment (and the study) for arriving at a session high,
while another site either allowed such adolescents to participate or 
rescheduled their sessions, differences in completion rates between these
sites would reflect not the power or weakness of the interventions but 
contextual policies unrelated to the active ingredients of each intervention. 
What follows is a synopsis of how common clinical issues were managed
across the four treatment sites and across the five interventions being 

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tested. It is hoped that this discussion will provide researchers and treatment
practitioners alike with insights into the importance of managing such 
contextual influences. The discussion also represents a snapshot of  baseline
clinical practices in adolescent substance abuse treatment in 1998 and 1999.
Issues in Clinical Management and Clinical Care  
A. Clinical Infrastructure. A rather complex clinical infrastructure was
required to effectively manage clinical activities across the four treatment
organizations and the five treatments in the CYT study. The care taken in
constructing this infrastructure was based on the assumption that there is a
close relationship between the quality of clinical supervision and treatment
efficacy (Holloway & Neufeldt, 1995). 
There were three levels of clinical coordination and supervision in the CYT
study. First, local clinical supervisors at each service site coordinated 
cross-intervention clinical issues and day-to-day clinical problem solving.
Second, a therapist coordinator for each of the five interventions used in
the CYT study provided onsite and cross-site clinical supervision of staff
working in their particular intervention. This supervision occurred weekly
during the period in which therapists were being certified and bimonthly
following staff certification. Third, a TC at the CYT coordinating center
facilitated cross-site and cross-intervention coordination and problem 
solving. The centerpiece of this cross-site clinical coordination was a 
monthly meeting at which the respective TCs met with the cross-site TC
and research coordinator via a conference call to discuss cross-site clinical
and research issues. Particular problems or procedural questions emerging
from these discussions were sometimes also referred to the CYT executive
committee (all of the principal investigators, the CSAT project officer, and
other CSAT staff) for consultation or decision making. The CYT coordinating
center validated that the cross-site clinical procedures developed through
these processes were in place by conducting two monitoring visits to each
of the CYT research sites during the course of the study (CYT cooperative
agreement, 1999).
Many problems and issues (administrative, fiscal, research, clinical, ethical,
legal) were addressed in this multitiered supervisory structure, but the
major goals were to meet the methodological challenges noted earlier:
ensuring the integrity of the interventions, controlling factors that could
confound outcomes, and enhancing the generalizability of findings. Several
steps were taken to achieve these goals. 
All sites used the same research and service intake and clinical 
assessment/screening procedures, the same inclusion and exclusion 
criteria, and the same approach to randomization and waiting list 
management. To maximize transferability of findings to the field, exclusion
criteria were limited to adolescents 1) who needed a higher level of care
than outpatient treatment, 2) who presented for treatment with confirmed
histories of drug dealing or violence (particularly predatory behavior 
patterns reflecting a high frequency, high intensity, and long duration), 
3) whose psychiatric comorbidity was so severe as to render them 

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inappropriate for the CYT interventions, and 4) whose primary drug of
choice was not cannabis. Although the study focused on adolescents with a
primary drug choice of cannabis, most adolescents entering the CYT study
reported using other drugs in addition to cannabis. Although abstinence
from all alcohol and drug use was a goal of the treatments in the CYT study,
at admission, adolescents were asked to agree to evaluate their drug use
and its effects on themselves and their families. Therapists across sites and
interventions agreed that many adolescents commitment to abstinence was
something that should emerge out of the treatment process, not something
that should be a precondition for entry into treatment.
Mechanisms to enhance clinical fidelity to the interventions used in the
study included centralized training and booster training of clinical staff
delivering the interventions, the videotaping or audiotaping of all sessions
followed by the use of self- and supervisory-scored adherence measures to
monitor skillful execution of the intervention, formal procedures to certify
each therapist in the intervention, continued postcertification tape reviews
to minimize therapist drift, and regular cross-site group supervision led
by an expert in the intervention. 
A considerable portion of the monthly meeting of the CYT TCs was aimed
at ensuring baseline clinical processes and data collection procedures were
being handled consistently across the four sites. There were discussions of
just about everythingfrom drug testing procedures to appropriate
responses to clinical deterioration of a study participant. The monthly 
agenda included a site-by-site review of particular issues, such as the status
of therapists certifications and the quality of communication between 
sister sites (those delivering the same interventions), and an opportunity 
to discuss the general problems and issues encountered. Below are some 
of the cross-site clinical issues that were of major concern throughout the
course of the study. 
B. Staff Recruitment, Training, and Retention. Most of the therapists
working on the CYT project were trained at the masters degree level or
higher, and most had prior training and experience in addiction treatment.
The research sites, like the practice field, varied in their use of full-time and
part-time staff. Most sites felt there were advantages to having full-time
therapists working on the project because that increased their availability
to clients, provided greater flexibility in scheduling, and created a greater
degree of personal investment in the project. In general, sites looked for
individuals with good clinical skills whose overall clinical orientations were
congruent with the intervention they were going to deliver. A particular
effort was made to find staff who had a good working knowledge of child
and adolescent developmenta qualification not often found in those work
ing with adolescent substance abusers (Kaminer, 1994). Staff were paid
salaries that were at or slightly above the geographical norm for addiction
therapists. None of the sites experienced any significant problems 
recruiting qualified staff.
In the course of the project, there were a total of 26 full-time and part-time
clinical positions at the four CYT sites. Nine staff left the CYT project 

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during this periodtwo due to changes in the communities selected as
service sites and the majority of the others due to a return to school, family
relocation, or promotion. The highest turnover rate was among the case
managers. Several things worked to enhance staff morale and retention on
the CYT project: a conscious effort to build team cohesion, a knowledge of
the potential importance of the research being conducted, the training and
supervision opportunities, the opportunity for cross-site contact with peers
working on the same intervention, and the flexibility of the individual sites
regarding scheduling of part-time employees on the project. 
Although considerable effort is made to ensure that conditions in clinical
trials are equivalent to natural conditions in the field, there are several
characteristics of clinical trials staff that make them somewhat different
from those in mainstream practice. Staff who seek clinical positions in 
clinical trials are not scared away by the limited timeframe of employment
on such a project, are often attracted by the intense nature of training and
supervision such projects afford, and are not put off by the rigorous 
record-keeping generally required in such projects. 
Strategies used for managing clinical continuity in the face of staff attrition
included replicating the training that was provided to all therapists at the
beginning of the CYT project, having a built-in transition/training period
for entering staff, and using videotaped sessions of the current therapists to
train new therapists. 
The safety of staff working in the field was enhanced by hiring staff from the
local community, providing inservice training on safety management and
access to beepers and cellular phones, and the option of working in teams
to visit areas that posed higher safety threats. Office-based safety issues
were addressed by ensuring that other staff were present while sessions
were being conducted and by providing walkie-talkies or silent alarms to
signal other staff if assistance was needed. There were no major safety-
related incidents experienced by the CYT project. 
C. Client/Family Recruitment, Engagement, and Retention. The major
barriers in recruiting, engaging, and retaining adolescents and their 
families were fairly consistent across the CYT project sites:  
  Low adolescent/parent motivation for treatment involvement 
  The perception that other problems in the family were more 
important than the drug experimentation of one child
  Parental substance abuse
  The parental view that smoking marijuana is not that big a deal
  Failure to attend due to lack of transportation or childcare 
  A marital or relationship breakup during the period of treatment 
involvement

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  Inconsistent messages from the parents to the adolescent about 
the importance of involvement in counseling
  Relocation of the child during the course of treatment
  Parents having given up on efforts to change their child 
  A general and pervasive sense of hopelessness about life (felt by
both the parents and the adolescent). 
Study participants were recruited by direct appeals to youth and parents
through newspaper and radio public service announcements and 
strategically placed bulletin board posters. Staff also oriented local youth
service professionals regarding how referrals could be made to the program
and the nature of the various treatments that youth would be receiving.
These visits and mailings included CYT information packets, business cards,
and Rolodex inserts. There was some resistance to referring clients to the
project when referral sources discovered that they could not control which
intervention their clients would receive. Some were concerned that the 
five-session intervention would not provide an adequate level of service.
After some education about the benefits of brief therapy in general, 
however, and the need to test such therapies in the substance abuse 
arena, most were willing to make referrals. 
Of 690 adolescents referred to the CYT sites between May 1, 1998, and May
31, 1999, 38.6 percent were referred by criminal justice-affiliated agencies,
24.8 percent by families (7.6 percent of which came from a media promotion
of the CYT project), and 15.2 percent by educational community health and
human service agencies (Webb & Babor, 1999). An analysis of adolescents
admitted to treatment in the CYT study (Tims, Hamilton, Dennis, & Brantley,
1999) revealed that 84.7 percent were age 15 or older, 38.1 percent were
nonwhite, and 11.9 percent were female. The low rate of female admissions is
attributable to at least two factors. The first involves the use of referral
sources such as juvenile probation departments that serve predominantly
male clients. The second factor is that, of those females referred to the CYT
study, more than one-third presented with comorbid psychiatric disorders
severe enough to exclude their participation in the study.
Client engagement was enhanced through five broad strategies. The first
was to make the transition between the research staff (the equivalent 
of the intake staff in most agencies) and the clinical staff as personal as 
possible. When a therapist was not available to be introduced to the
client/family by the research staff, the assigned therapist called the parents
or the adolescent before the first appointment to introduce himself or 
herself, begin alliance building, and clarify any questions about treatment
participation. All of the CYT interventions begin with an emphasis on 
empathy and skillful rapport building to build a strong therapeutic alliance
and work through resistance related to the coercive influences that may
have brought the adolescent to treatment. 

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The second strategy was for the therapist to speak for 5 to 10 minutes with
any adolescent who had to wait more than 2 weeks to begin service (a delay
sometimes caused by randomization and the cycles of starting new groups) to
sustain his or her motivation for service involvement. 
The third strategy was to remove as many environmental obstacles to 
treatment participation as possible by using geographically accessible 
service sites, providing assistance with transportation (that is, cab vouchers,
bus tokens, picking adolescents up in the agency van), and providing or
arranging childcare. Case management, whether provided by therapists,
case managers (in the FSN intervention), or even during the screening
activities of the research staff, was an essential medium of engagement for
those families whose lives were most chaotic at the point of initial contact
with the CYT project. Every effort was made to link what could be learned
in treatment with what could help the immediate crisis presented by the
family. The CYT interventions shared the message, We have something that
could help with some of these problems and improve the quality of life for
you and your child.
The fourth and most important strategy was to actively engage the 
adolescents and families by creating strong therapeutic alliances, expressing
interest in their participation (e.g., by weekly phone prompts for 
participation), finding a goal that the adolescent and family were interested
in working on, expressing optimism in their capacity to change, and 
persisting in family contacts during the earliest signs of disengagement.
FSN intervention staff felt that home visits were very important in initiating 
and sustaining the involvement of the most treatment-resistant families. 
The fifth strategy was to provide a warm, collaborative, adolescent- and 
parent-friendly environment (with informal but respectful hosting, providing
pizza and sodas as part of the dinner-hour adolescent and parent meetings)
and to provide specific incentives for involvement in treatment (help with
very specific problems, fully subsidized treatment, and token prizes for
homework completion).  
D. Safety Net Procedures. Safety net procedures involve strategies for 
recognizing and responding to adolescents who before or after entering 
outpatient care were thought to be in need of a higher level of care or
allied services. We anticipated and experienced four scenarios that required
such safety net procedures. The first involved emergency situations that
might arise related to an adolescents drug use during the course of the
study. All parents were provided a laminated card listing signs of acute
intoxication and oriented to procedures that could be used to respond to an
emergency. The second scenario occurred when adolescents underreported
the frequency and intensity of their drug use at intake but disclosed it after
they were randomized and admitted to one of the therapies. The third 
scenario involved the frequency and intensity of use escalating after the
adolescent had been admitted to outpatient treatment. The fourth scenario
occurred when an adolescents mental health status deteriorated following 
admission, particularly where such deterioration posed the threat of harm
to himself or herself or others. Safety net procedures were established at 

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all four sites that 1) ensured the periodic reassessment of the status of use 
and the appropriateness of the level of care to which clients were assigned, 
2) ensured the availability and use of supervisory supports to formally 
reevaluate changes in clients status and care needs, and 3) facilitated, when
needed, moving an adolescent to a more structured and intense level of care
or the addition of collateral services. Where alternative or additional services
were thought to compromise evaluation of the effect of the CYT intervention,
the adolescent and family were provided the additional services but the 
adolescent was no longer included in the study. 
E. Concurrent Services. The exclusion of adolescents with severe psychiatric
illness from the CYT study does not mean that all adolescents with psychiatric
comorbidity were excluded from the CYT study. The majority of adolescents
and families admitted to the CYT study presented with multiple problems,
and the rate of psychiatric comorbidity of the adolescents admitted to the
study was quite high. Forty-two percent met the criteria for attention
deficit/hyperactivity disorder, 55 percent met the criteria for conduct 
disorder, and 29 percent presented with multiple symptoms of traumatic
stress (Tims, Hamilton, Dennis, & Brantley, 1999). Those adolescents who
were referred for more intense services prior to randomization and who were
not included in the CYT study were most likely to be excluded because they 
presented a high risk of harm to themselves or others. (These risks were
identified through the participant screening form completed at intake and
through the assessment instrument [GAIN] [Dennis, Webber, White, et al.,
1996] and the interviews that were part of the intake process at all of the
CYT service sites.)  
The multiple problems presented by the CYT adolescents and their families
raised an important clinical and research issue: How to respond to the 
clinical needs they presented without contaminating (through concurrent
service involvement) the evaluation of the particular interventions in the
CYT study. This problem was complicated further by the referral patterns 
of the agencies that linked adolescents with the CYT project. Acutely aware 
of the number and complexity of the problems many of these adolescents 
presented, many of these referral sources used a shotgun approach
simultaneously referring the adolescent and family to multiple treatments, 
hoping that the cumulative dose of services would have some positive effect
on the child and family. These problems diminished through education of
and negotiation with referral sources. It was a policy of the CYT study that
adolescents would not be allowed to remain in the study if they were receiving
concurrent treatment whose primary focus was the problem of substance
abuse or if they were receiving services whose impact was judged by the local
staff to inordinately confound the impact of the CYT intervention being 
provided. However, no adolescent had to be excluded from the study for such
concurrent service involvement. Several adolescents who were treated 
simultaneously for collateral problems (e.g., being medicated for hyperactivity
or depression) were allowed to enter and remain in the CYT study because
the focus of the concurrent services was not on substance abuse or 
dependency.   

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F. Session Management. Efforts were made to ensure that issues related 
to the management of sessions that were not unique to the particular 
interventions would be handled in reasonably consistent ways across the
sites. Where procedures were not the same, they were reviewed to ensure
the differences would not confound outcomes. These discussions included
how to respond to lateness, missed sessions, the criteria for dropping cases,
intoxication, contraband, disruptive behavior, preexisting relationships
between members, and a group session at which only one member is present.
Lateness was handled by degree, by ensuring either that the client got the
minimal dose for that session or that the session was rescheduled. Missed
sessions were rescheduled or, in the case of group interventions, provided as
an abbreviated makeup session prior to the next scheduled session. (All
services across the five modalities were expected to be completed within 14
weeks of the time of the first therapy session, with local TCs reviewing and
approving any exceptions to this rule.)  
All programs made intoxication and possession of contraband grounds for
exclusion from that particular session and a flag for reassessment of the
appropriateness of the current level of care. (While rare episodes of an
intoxicated youth arriving for services did occur, these episodes were 
clinically managed without excluding the adolescent from continued service.)
Only one adolescent per family was included in the CYT study, and preexisting
relationships between participants in the group modalities were reviewed to
determine whether the prior history would undermine or enhance treatment.
A group with only one member present was conducted in a 30- to 45-minute
individual format covering the material that was scheduled for presentation.
If an adolescent failed to appear for a family session, the session was 
conducted without the adolescent.  
The TCs collectively sought and implemented general strategies that could
enhance the effectiveness of sessions for all of the CYT therapies. Strategies
that served to minimize problems and enhance session effectiveness 
included formalizing, posting, and consistently enforcing group/family
norms on such issues as dress (banning drug/gang symbols on clothing)
and language (profanity, drug argot). In the group interventions, the closed
group structure made it particularly important to guard against negative
influences within the peer cultures that evolved. A final issue was the 
appropriate level of contact between therapists and adolescents outside the
intervention. The TCs decided that such contact should be minimized so as
not to contaminate model fidelity by altering dose. More specifically, it was
agreed that all extra-session contact should be responded to within the
therapeutic framework of the particular intervention, channeled into
upcoming sessions, documented, and brought to supervisors for review. 
G. Gender and Cultural Adaptations. While there is significant momentum
toward the development of standardized, empirically supported, and manual-
based treatments (Wilson, 1998; Carroll, 1997), there is a simultaneous call
for the refinement of standardized treatment that includes gender and 
cultural relevance and effectiveness (Orlandi, 1995). All of the CYT therapists
noted making changes in their delivery of the manual-based treatments

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that were based on gender, cultural, and socioeconomic status (SES) 
appropriateness. Therapists in group interventions explicitly noted diversity
issues in the group and incorporated respect for diversity into the ground
rules established at the beginning of each group. The most frequently 
mentioned adaptations included:
  Changing the language of the session to reflect cultural or 
geographical norms
  Adding items to some worksheets to make them more applicable 
to urban youth
  Providing special writing and reading assistance to address 
illiteracy
  Slowing the pace and adding repetitions of key ideas to 
accommodate learning impairments
  Developing examples and illustrations of key points that had 
greater gender, cultural, and SES relevance. 
Therapists emphasized it was not the content of interventions that had
changed; there were subtle changes in the way that content was framed or
delivered. 
H. Case Mix Issues. Therapists involved in the group interventions
(MET/CBT5, MET/CBT5 + CBT7, FSN) also decided to monitor closely
client mix issues according to gender, ethnicity, and other important
dimensions. There was an effort to identify any potential iatrogenic effects
of randomization (e.g., harassment, scapegoating, or other predatory 
targeting of a vulnerable group member by other group members) and to
actively manage potential negative effects of group support for antisocial
behavior (Dision, McCord, & Poulin, 1999). This was managed primarily by
establishing and enforcing norms for group sessions. 
I. Mutual Aid and Peer Support Groups. In contrast to Project MATCH, a
12-step facilitation therapy was not included in the CYT study, and there
was some variation in the philosophies of the 5 interventions related to the
desirability of mutual aid involvement by cannabis-involved adolescents. 
The ACRA, MDFT, and MET/CBT interventions do not directly encourage 
affiliation with addiction recovery support groups, but they do frame such
involvement positively if the adolescent is already involved in such a group
or self-initiates involvement during the course of treatment. FSN, while
strongly encouraging parents to participate in Al-Anon, does not directly
encourage adolescent clients to affiliate with Narcotics Anonymous (NA) or
Alcoholics Anonymous (AA). Information on local mutual support groups is
provided simply as one of many community resources. There was more of an
emphasis in all the CYT interventions on involvement in drug-free prosocial
activities in general than on addiction recovery support group involvement.

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J. Ethical Issues. The TC meetings also provided a venue to discuss and 
formulate responses to some of the complex ethical and legal issues that
can arise in the treatment of adolescent substance abuse (White, 1993).
Considerable time was spent discussing questions such as:      
  What are the boundaries of confidentiality regarding disclosure 
of information about an adolescent to his or her parents?
  Do parents have a legal/ethical right to the results of their childs
urine tests?
  What circumstances would constitute a duty to report or duty to 
intervene?  
  What obligations, if any, do therapists have in responding to an 
adolescents disclosures of past or planned criminal activity?
  How should therapists respond to reports of abuse of adolescents 
by a parent or to failures by child protection agencies to 
intervene to ensure the safety of the adolescent?  
Discussion
Carroll and colleagues (1994, 1996, 1997) are to be commended for 
helping transfer the technology model of psychotherapy research to 
addiction treatment outcome studies. The CYT study greatly benefited 
from the earlier experience of Project MATCH in the use of this model. 
This paper has described a structure (the interface between a cross-site 
and cross-intervention TC group and the CYT executive committee) and a
process (monthly meetings of all the TCs and monitoring visits at each CYT
study site) that were used to control contextual elements surrounding the
experimental interventions. Our goal was to hold these contextual elements
constant across the interventions in order to enhance our ability to measure
the differences the experimental interventions produced on outcome 
measures. We wanted differences in outcomes to reflect differences in the
interventions themselves and not factors incidental to the interventions. 
While there were major research design elements (consistency in clinical
data collection instruments and procedures, inclusion and exclusion 
criteria, and followup procedures) that helped control such variance across
sites and interventions, we also sought to identify more subtle areas of
potential contamination of the study. By generating consistent cross-
intervention procedures to respond to lateness, missed sessions, 
disruptiveness, intoxication, and concurrent participation in other services,
we were able to ensure a consistent and a more precise definition of the
dose and type of services provided in, and collateral to, each intervention.
By developing and monitoring safety net procedures across the sites and
interventions, we were able to ensure timely and appropriate responses to
the placement of a client in an inappropriate outpatient modality who 
needed a higher level of care and to respond to acute episodes of clinical
deterioration that warranted a similar change in the level of care. We found

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that the collaborative work of the TCs helped enhance the methodological
rigor of the CYT study and helped establish a sound clinical infrastructure
upon which each of the interventions was tested. 
There are many aspects of the clinical management of the CYT project
other than the efficacy of the particular interventions used that may have
wide applicability to the field of adolescent substance abuse treatment. It is
our view that many of the procedures to provide overall clinical management
of randomized field trials have great clinical utility and are likely to become
future baseline clinical practices in the treatment of adult and adolescent
substance abuse disorders. 
The technology model that, to date, has been used primarily as a means of
ensuring methodological rigor in multisite field trials seems to us to have
enormous advantages for enhancing the quality of treatment and should be
studied for potential adaptation to mainstream clinical practice. Those
looking for ways to enhance the quality of adolescent substance abuse 
treatment would be well served to explore how the elements of this model
could become part of the future definition of treatment as usual. Parents
seeking help to address the substance abuse-related problems of their son
or daughter ought to be able to expect that the theory behind the treatments
they are offered can be articulated and that their active ingredients can be
defined. They should further be able to expect that these treatments have
some degree of scientific support for their effectiveness and that they will
be delivered in a manner consistent with procedures whose effectiveness has
been validated.  
Increased demands for such accountability and fidelity by parents, policy
makers, and funding agencies will likely make manual-based therapies the
rule in the future, along with the training and adherence measures that
accompany them. The technical aspects of cross-site clinical management
of the CYT project have much to offer the field as a whole. The use of 
standardized assessment instruments that are capable of providing 
comprehensive assessment and treatment planning data should become 
a requirement of all adolescent treatment programs in the next decade. 
We further commend the use of central (and booster) training, videotaping
and adherence ratings as standard practices in supervision, and cross-site
supervision as marvelous tools for training and professional development.
Finally, we believe that rigorous followup (monitoring, feedback, and, where
indicated, early reintervention) should move from the realm of clinical
research to being an expectation, if not a requirement, of mainstream clinical
practice. The idea of providing services without measuring outcomes will be
incomprehensible in the very near future, and the technology to perform
this task is rapidly emerging. Morale among staff working in the CYT project
remained high, in part because of the near universal belief in the historical
importance of this study and the climate of excitement and discovery that
permeated the project. We believe that small field-based experiments to
answer critical clinical questions, opportunities for cross-site sharing, and
the opportunity to work on papers and presentations can similarly contribute
to staff morale within local service organizations. We believe this milieu of
curiosity, discovery, and contribution is transferable and sustainable in 

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natural clinical settings. Routine outcome monitoring and field-based 
experiments, like the other items in this discussion, must simply be moved
from the arena of clinical research to the arena of standard clinical practice.
This transfer of technology from the research environment to the clinical
practice environment, however, will not be simple.
If there is a single weak link in the current practice of addiction treatment
that will slow this technology transfer, we believe it is in the arena of 
clinical supervision. Comprehensive assessments, science-guided treatment
planning, empirically validated and manual-based therapies, regular 
adherence measurement and monitoring, using clients response-to-treatment
data to individualize and refine standard interventions, and rigorous 
posttreatment followup (and early reintervention, where called for) all flow
from the clinical infrastructure at the core of which is a clinical supervisor.
If we can elevate the quality of clinical supervision in the fieldthe 
selection, training, and support of clinical supervisors to do true clinical
supervisionto that of clinical supervision in controlled clinical trials, we
will be able to channel knowledge from clinical research to clinical practice. 
Conclusions
Clearly defining the demographic and clinical characteristics of client 
populations, presenting the active ingredients in a manual format and 
procedures inherent in particular treatments for those populations, 
monitoring therapists adherence to such procedures, controlling contextual
influences that can influence treatment outcomes, and conducting rigorous
and sustained followup to determine clients responses to particular 
interventions collectively hold great promise in moving the treatment of
adolescent substance abuse from the status of a folk art to that of a clinical
science. The technologies used to build this science may themselves offer
great potential in enhancing the quality of adolescent substance abuse
treatment programs if they can be adapted for routine use in the clinical
setting. The CYT study confirms the importance that these new tools can
and will have in the future clinical management of adolescent substance
abuse treatment. 

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