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Family Support Network for
Adolescent Cannabis Users

CYT
Cannabis Youth Treatment Series
Volume 3

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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Family Support Network for
Adolescent Cannabis Users

Nancy L. Hamilton, M.P.A., CAP, CCJAP
Laura Bunch Brantley, Ph.D.
Frank M. Tims, Ph.D.
Nancy Angelovich, M.S., LMHC
Barbara McDougall, M.A., CAP

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 3

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Acknowledgments
This is volume three of a series of treatment manuals produced under the Cannabis
Youth Treatment (CYT) Project Cooperative Agreement. The document was written
by the following staff members of Operation Parental Awareness and Responsibility
(PAR), Inc.: Nancy L. Hamilton, M.P.A., CAP, CCJAP; Laura Bunch Brantley, Ph.D.;
Frank M. Tims, Ph.D.; Nancy Angelovich, M.S., LMHC; and Barbara McDougall,
M.A., CAP. 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 the Executive Steering Committee
(Thomas Babor, Michael Dennis, Guy Diamond, Jean Donaldson, Susan H. Godley,
and Frank Tims) and many others including Betty Buchan, Jackie Griffin-Doherty,
Jim Herrell, Jeannie Lewis, Terri Mathis, Janet Titus, Joan Unsicker, Charles Webb,
William White, and Art Woodard.
Disclaimer
This report was developed with support from the Center for Substance Abuse
Treatment (CSAT) to Operation PAR, Inc., through Grant No. TI11317. 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 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 from the Office of Communications,
SAMHSA, DHHS.
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 SAMHSAs National Clearinghouse for Alcohol and Drug
Information at 18007296686 or 18004874889 (TDD).
Recommended Citation
Hamilton NL, Brantley LB, Tims FM, Angelovich N, McDougall B. Family Support
Network for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series,
Volume 3. DHHS Pub. No. (SMA) 013488. 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) 013488
Printed 2001
Cover images  2000 Digital Stock.

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Table of Contents

I. Introduction to and Overview of the Family Support Network 
  Intervention  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Overview  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Treatment Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Service Components: Overview and Objectives  . . . . . . . . . . . . . . . .3

Overview of Cannabis Youth Treatment Research . . . . . . . . . . . . . . .8

Staff Requirements  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Clinical Supervision Requirements  . . . . . . . . . . . . . . . . . . . . . . . .10
II. Parent Education Sessions and Discussion Procedures  . . . . . . . . . .13

Parent Education Session 1: Introduction to the Family Support
  Network, Adolescent Development, and Functional Families  . . .14
Parent Education Session 2: Drugs and Adolescents  . . . . . . . . . . .26

Parent Education Session 3: Relapse Signs and Recovery  . . . . . . . .39

Parent Education Session 4: Boundaries, Limits, Authority, 
and Discipline  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Parent Education Session 5: Communication, Conflict Resolution, 
and Fighting Fair  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

Parent Education Session 6: The Family Context  . . . . . . . . . . . . . .67
III. Home Visit Procedures  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

Introduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

Rationale  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

Review of Procedures  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82

Home Visit 1  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

Home Visit 2  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

Home Visit 3  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

Home Visit 4  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
IV. Case Management Procedures  . . . . . . . . . . . . . . . . . . . . . . . . . . .101

Introduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101

Overview of Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102

Components of Case Management . . . . . . . . . . . . . . . . . . . . . . . .104

Qualifications and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108

Missed Appointment Form  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110

Case Management Service Log  . . . . . . . . . . . . . . . . . . . . . . . . . .111

Referral Form  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112

Case Management Screening Log  . . . . . . . . . . . . . . . . . . . . . . . .113
V. References  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115
VI. Appendixes
1. Quality Assurance   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117
2. Clinical Management of a Multisite Field Trial of Five
Outpatient Treatments for Adolescent Substance Abuse  . . . .129

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I. Introduction to and Overview of the Family
Support Network Intervention

Overview
The development of drug abuse is multidetermined. Henggler (1997) points
out that with rare exception, treatment programs address only a limited
portion of factors contributing to adolescent drug abuse (p. 265). Teaching
life skills, refusal skills, and coping skills may contribute to recovery; however,
family support has been cited repeatedly as an important determinant of
both intreatment and posttreatment outcomes (Barrett, Simpson &
Lehman, 1988; Brown et al., 1994). 
Thus, substance-abusing adolescents experiencing inadequate family structure
and functioning will be at a serious disadvantage with regard to recovery.
Their recovery, however, is likely to be enhanced if family functioning can
be improved. Deficits in family functioning may be related to dimensions of
authority, roles, boundaries, communication, and routines. Parental authority
may be eroded and roles confused; boundaries may be blurred or violated;
communication may be dysfunctional and conflict laden; and family structure
or routine may be lacking. Inadequate parenting skills or poor understanding
of family dynamics may also contribute to a chaotic or otherwise 
dysfunctional family context. 
The family support network (FSN) intervention seeks to extend the focus 
of treatment beyond the world of the adolescent by engaging the family, a
major system in his or her life. Family therapy has been cited as a potentially
valuable tool in the treatment of substance abuse, and a substantial amount
of literature about it exists (Stanton & Shadish, 1997; Liddle & Dakof,
1995; Steinglass, 1994; Kaufman, 1994). Studies have shown that retention
of adolescents in treatment increases dramatically when a family interven-
tion is provided (Henggler et al., 1991; Liddle & Dakof, 1995). Although
the value of family therapy is recognized, providing this intervention is
beyond the resources of many programs, especially in view of the well-
documented erosion of services in community-based treatment programs
(Etheridge et al., 1995). 
Because of declining resources and the restriction of services by managed
care, Operation Parental Awareness and Responsibility (PAR), Inc., devel
oped the FSN approach. The FSN model uses only a limited number of the
more costly inhome therapy sessions coupled with several less costly group
sessions. Designed to increase parental support of a childs recovery, the
FSN approach seeks to engage families in the treatment process, improve
parents competence in supporting their childs recovery, and shift therapy
from time-limited formal treatment to a support group for parents. 
The FSN process is a family intervention designed to be used in conjunction
with any standard adolescent treatment approach. The FSN approach was
followed in two locationsOperation PAR, Inc., and the University of
Connecticut Health Center. It was effective at treating teens for cannabis

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use at both locations. Other approaches may be just as effective. The scope
of the study was not to compare family approaches but rather to test 
treatments for adolescent marijuana users. 
The FSN approach consists of several components, each designed to achieve
specific objectives:
  Case management
  Six parent education (PE) groups
  Three or four inhome family therapy sessions.
Case management includes referrals to community support groups and
other support services for both parents and adolescents. The procedures
presented in this manual combine motivational enhancement and cognitive
behavioral therapies as one possible treatment overlay for the adolescent.
The motivational enhancement therapy (MET) and cognitive behavioral
therapy (CBT) approaches used in the Cannabis Youth Treatment (CYT)
study are presented in Motivational Enhancement Therapy and Cognitive
Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions, Cannabis
Youth Treatment (CYT) Series, Volume 1, by Sampl and Kadden (2001) and
The Motivational Enhancement Therapy and Cognitive Behavioral Therapy
Supplement: 7 Sessions of Cognitive Behavioral Therapy for Adolescent
Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 2, by
Webb, Scudder, Kaminer, and Kadden (in press). Thus, while an adolescent
is receiving a special MET/CBT program for adolescents, the family is
involved in the FSN intervention. This manual guides counselors and thera 
pists, so they can consistently conduct effective case management, PE
groups, and home visits.

Treatment Goals

The FSN approach is a multicomponent intervention aimed at improving
the family context in which adolescent recovery takes place. It is based on
an assumption that the adolescents outcomes will be improved if the family
is involved in the treatment process. Although no short-term treatment can
resolve all problems and heal families completely, the goal of FSN is to
improve an adolescents outcomes by: 
  Including the family in the recovery process
  Enhancing family functioning through communication and 
relationship building
  Improving parental effectiveness in dealing with substance abuse
and the behaviors accompanying drug use
  Assessing the familys commitment to the recovery process and
suggesting changes in the way the family approaches problems.
FSN recognizes that the programs opportunity for influence is of limited
duration and that responsibility for aiding recovery must be transferred

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from the program to the family in a short time. The FSN approach provides
a strategy for effecting that transfer in a systematic and responsible way.        

Service Components: Overview and Objectives

The FSN model is designed to treat youth who meet American Society of
Addiction Medicine (ASAM) Level I (outpatient) or Level II (intensive 
outpatient) criteria and who report marijuana as their primary drug of
choice. Although youth abusers may occasionally use alcohol and other
drugs, such as lysergic acid diethylamide (LSD), polysubstance abusers with
long histories of drug use, especially use of cocaine and heroin, who have
ASAM diagnoses at higher levels or those with serious psychiatric or 
criminal issues may be inappropriate for this level of treatment.
Urban, suburban, and rural youth and families were part of the original
research study as were families with parents who had current or past 
histories of use or abuse of alcohol and drugs. Youth and families of color
also participated in the study. No socioeconomic group prevailed in the
original sample. Most families were from working-class or lower socioeco-
nomic groups. The study involved families of all sizes and situationssingle,
divorced, or separated parents; blended families; and intact families.
Because of limited resources, the study required participants to speak and
understand English, although it need not be their first language. Future
FSN manuals can be developed for use with youth and families who are not
English speakers.
The FSN service components are case management, parent education, and
home visits.

Case Management
Case management engages families in the treatment process by providing 
a means to solve problems and motivate family members. Methods of 
engagement include telephone outreach to remind families of scheduled
meetings, reduction of barriers to treatment participation (e.g., overcoming
difficulties with transportation, scheduling, and child care), and prompt
intervention to reengage any adolescent or parent who has missed a 
treatment session.
Case managers work with families by assisting them in resolving issues that
prevent participation. For example, case managers may provide information
about local bus routes or referrals to local resources that provide assistance
to families in need. Some providers may have resources that allow them to
send vans to the familys home to pick up clients or provide bus tokens.
Case managers work with the family to recognize child care issues that may
prevent participation. Solutions for child care problems include care by a
relative, referral to local child care agencies, or onsite child care services.
Other ways to overcome child care and transportation barriers include 
getting the families to act as a cooperativeone family helps another with
transportation or child care. A good case manager works to assist the 
families in becoming empowered to solve their problems in creative ways.

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Major responsibilities of the FSN case manager are to:
  Contact and engage families in the treatment process
  Assist families in overcoming barriers to active participation
  Identify appropriate service and treatment needs
  Provide links for the families to needed services, including 
community support groups
  Monitor the adolescents and familys progress
  Provide motivational enhancement
  Monitor attendance and act quickly to prevent clients from 
disengaging or dropping out
  Make appropriate referrals (including treatment reentry)
  Engage the family and the adolescent in a community support
group.
An important, but difficult, activity of the FSN case manager is to engage
the family and the adolescent in a community support group. The purpose
of this is to transfer the responsibility of recovery from the FSN program to
the family in the limited time available. The case manager should identify
primary referrals for community support groups (e.g., Alcoholics
Anonymous [AA], Narcotics Anonymous [NA], Al-Anon/Alateen, Children
and Adults with Attention-Deficit/Hyperactivity Disorder [CHADD]) within
the first 6 weeks of the program. Contacts for these types of organizations
can be found in local phone directories and by calling local hotlines. The
case manager should prepare a list that includes addresses, phone numbers,
and meeting times as a handout for families. Parents should be contacted
regularly and encouraged to use the support group as a source of support
after their child completes treatment. 
Case managers should receive special training in techniques of outreach to
and motivation of adolescents and families. Training also should be provided
to increase their cultural competence for engaging families of color and
those with special cultural, religious, or ethnic needs. 

Parent Education 
The PE component is designed to: 
  Build competence among parents that leads to healthy families
  Offer methods for coping with the pressures of parenting

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  Promote ways to establish or restore appropriate authority, roles,
rules, boundaries, communication, and routines.
The six PE sessions, each designed to last 90 minutes, should be scheduled
for the same time and location as the adolescents CBT sessions. Each PE
session has clear objectives and is taught in a didactic manner, and time is
allowed for questions and discussion. 
At the didactic sessions information is presented, and discussion provides
clarification and facilitates assimilation of the information into personal
frames of reference. To build a collaborative learning experience, the
counselor should guide and focus the discussion and invite maximum 
participation by the parents. To prepare for the sessions, the counselor
must also consider the following:
Size. The size of PE groups may vary but should not exceed 10 parents per
session. A larger group may be too impersonal, and groups of fewer than
five parents may deprive the parents of an adequate opportunity for 
discussing and exchanging views with others. To facilitate discussion, the
chairs in the room should be arranged in a circle. 
Objectives. The PE sessions are designed to enhance parental motivation
and increase knowledge of parenting skills, family life, and drug/health
issues. The ultimate goal of the PE component is to improve parenting and
family functioning for a more global improvement of the family environment.
Meeting this goal will in turn allow families to better support the recovery
of the substance-abusing adolescent. 
Manual and handouts. The format of the manual for these six sessions is
content, major lecture points, and discussion topics. Handouts are provided
to participants, and parents are encouraged to review the handouts at home.
Preparation. Before each session, the counselor should review the lesson
plan and have all necessary materials on hand. Each individual should have
a copy of the handouts. Audiovisual equipment (VCR and videotapes, slides
and projector, overhead transparencies and projector), magic markers, and
any other required materials should be available. The counselor should have
a visible watch or clock to time segments of the lecture and discussion.
Sequencing of sessions. Missed sessions and home visit schedules may
mean that not all parents will have attended sessions in the proper
sequence. However, the sessions were designed to be conducted in sequence
and should be held in order when possible. Therefore, the therapist should
coordinate scheduling of PE sessions and home visits and ensure that the
sequence of parent education sessions 1 and 2 is maintained. The FSN
model was pilot tested without rolling admissions. Therefore, if the treatment
calendar can be set, the following schedule or order is preferred:
1. PE session 1
2. PE session 2
3. Home visit 1

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4. PE session 3
5. Home visit 2
6. No session
7. PE session 4
8. Home visit 3
9. PE session 5
10. No session
11. PE session 6
12. Home visit 4.
If rolling admissions are necessary, a proposed method for scheduling is
shown in exhibit I1. Based on the following schedule, clients would enter
treatment only in session 1 or 7. This schedule assumes a 12-week cycle
with three to six incoming participants per week. Two treatment calendars
are scheduled simultaneously during the 12-week cycle. For staffing, this
schedule allows for combining groups when possible (e.g., PE sessions 3 to
6 would include group 1 and group 2 members) and alternate weeks for
home visit/no session schedule for group 1 and group 2.
Exhibit I1: Proposed FSN Schedules
Overview of sessions. Exhibit I2 provides a brief description of the six PE
sessions. Specific procedures for each session are included in Part II of this
manual.
 Treatment Week:
Group 1 (Group 2)

1   (7)start Group 1
2   (8)
3   (9)
4   (10)
5   (11)
6   (12)end Group 2
7   (1)start Group 2
8   (2)
9   (3)
10 (4)
11 (5)
12 (6)end Group 1
Group 1
Schedule

PE Session 1
PE Session 2
PE Session 3
Home Visit 1
No Session
PE Session 4
Home Visit 2
Home Visit 3
PE Session 5 
No Session
Home Visit 4
PE Session 6 
Group 2
Schedule

(Home Visit 2)
(Home Visit 3)
(PE Session 3)
(No Session)
(Home Visit 4)
(PE Session 4)
PE Session 1
PE Session 2
PE Session 5
Home Visit 1
No Session
PE Session 6

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Exhibit I2: Parent Education Sessions
Session  Description
PE Session 1 Introduction to the Family Support Network, Adolescent
Development, and Functional FamiliesThis session 
provides an understanding of the family support network,
adolescent development, and the role of the family in this
development. The session focuses on how healthy family
functioning can make the family a source of strength for its
members. Emphasis is on understanding the individuation
process of developing adolescents and how families can help
make it a positive experience. 
PE Session 2  Drugs and AdolescentsThis session helps parents 
understand drug abuse and dependence and how adolescents
become involved with drugs. It addresses the nature and
objectives of treatment and stresses the importance of 
parents in a childs recovery. 
PE Session 3  Relapse Signs and RecoveryThe issues presented in this
session are the recovery process in the context of a healthy
family, ways parents can help their child avoid relapse and
when to appropriately intervene, how to develop healthy
partnerships within the family, and committing to a 
drug-free life. 
PE Session 4  Boundaries, Limits, Authority, and DisciplineThe concept
of boundaries is introduced in this session as a major issue
in child and adolescent development. Clarification of major
issues in family functioning is provided, and appropriate
approaches to discipline and parental authority are suggested.
This session helps parents understand the sources of
authority in the family and how to maintain that authority
in a healthy way. 
PE Session 5  Communication, Conflict Resolution, and Fighting Fair
This session enhances parents understanding of how and
why conflict inevitably occurs, imparts concepts and 
methods of healthy communication, and teaches techniques
for engaging family members in open and fair resolution of
conflict. Conflict is presented as a learning process, and
ways to prevent conflict from becoming dangerous are 
discussed. 
PE Session 6  The Family ContextThis session helps adolescents and
parents understand the importance of family in the recovery
process and the nature of the family as an interdependent
system. Parents are taught how family functioning has both
a direct and an indirect influence on the childs behavior. 

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Home Visits
The objectives of the home visits are to:
  Assess the family environment
  Individualize the treatment process
  Develop a family commitment to recovery
  Encourage a three-way therapeutic alliance (family, adolescent,
and program), and translate the lessons parents and adolescents
are learning into specific changes in family functioning.
The four home visits are to be scheduled by agreement between the family
therapist and the family. Ideally, to spread out the treatment experience as
much as possible, the home visits should be coordinated so they do not take
place during the same week as parent education and discussion sessions.
However, depending upon the therapists caseload, this coordination may
not be possible. Flexibility in scheduling home visits is necessary when time
is limited. If this is the case, home visits should be scheduled continuously
throughout treatment to ensure that each family receives the full treatment.
Each home visit should last approximately 90 minutes. During the first
home visit, the family therapist assesses the family environment, motivates
the family to actively participate, and obtains a commitment for future 
family meetings. In the second home visit, the therapist helps the family
discuss rules, roles, and routines. The therapist builds therapeutic alliances
with the adolescent and the family and acts as a mediator to clarify issues. 
At the third home visit, the therapist assesses progress and provides feedback
on major family and adolescent issues. Some families may require only
three visits. 
Based on the familys need or request, the final home visit is used to 
reinforce therapeutic alliances and obtain a family commitment to work
together on recovery. The parents also are encouraged to become or remain
involved in a community support group. Home visit guidance is detailed in
Part III of this manual.

Overview of Cannabis Youth Treatment Research
This overview presents the development and research phase of this model.
Appendix 2 includes an overview of the full research design for the CYT
Project Cooperative Agreement. 
Referrals to the CYT program were provided by juvenile assessment center
staff, juvenile addiction receiving facility personnel, community mental
health and substance abuse treatment providers, juvenile justice workers,
school system staff, and family members. A preliminary screening determined
the appropriateness of the level of care provided by this model for an 

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adolescent. During the initial research project, participants were randomly
assigned to one of three treatment groups. Information provided in this
manual is pertinent only to those clients assigned to the FSN treatment
group. Participants were included in the FSN treatment model if they (1)
met the inclusion criteria, (2) did not meet the exclusion criteria, and 
(3) agreed to participate in the research study being conducted. Once 
acceptance criteria were met, full baseline assessments and intake procedures
were initiated. 
Those participating in FSN treatment received services for both the 
adolescent participant and the family. Adolescents in the CYT study
received state-of-the-art treatment that included both MET and CBT.
Adolescents in the study received 2 individual MET sessions and 10 group
CBT sessions (subsequently denoted by MET/CBT5 and CBT7). Separate
manuals were developed for each treatment model (Kaminer et al., 1998;
Sampl & Kadden, 2001; Webb et al., in press). This manual presents the
FSN therapy. 
In addition to the MET/CBT5 and CBT7 treatment for the adolescent, the
family received three or four home therapy sessions, six parent education
sessions, and case management services. As mentioned earlier, the FSN and
MET/CBT interventions were designed for adolescents meeting American
Society of Addiction Medicine Level I (outpatient) or Level II (intensive 
outpatient) criteria and using marijuana as their primary drug of choice.
Exhibit I3 shows the overview of the FSN process.

Staff Requirements

Staff requirements for FSN include case managers, parent education specialists
or counselors, and home visit therapists.
Case managers. A bachelor of arts (B.A.) degree or equivalent and formal
or informal training in addiction and substance abuse treatment are
required (certification as a certified addiction professional [CAP] is helpful).
Specialized training in case management, cultural competence and sensitivity,
and sales/motivational techniques should be provided. Personal qualities of
empathy, assertiveness, and the ability to persuade others effectively are
also valuable. 
Parent education specialists or counselors. B.A. degree or equivalent 
certification (e.g., CAP) or higher certification in psychology, sociology, 
or human development, with specialization in family relations and skill in 
facilitating discussion groups, is required. Training to increase cultural
competence and sensitivity is essential. 

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Exhibit I3: The Family Support Network

Home visit therapists. A masters-level therapist with CAP or a licensed
mental health counselor (LMHC) qualifies; however, a licensed clinical
social worker (LCSW) is preferred. Training in family dynamics, with at
least 1 year of experience in family counseling and intervention, is required.
Training to increase cultural competence and sensitivity is essential.
Clinical Supervision Requirements
Clinical supervision, held on a weekly basis, allows the interdisciplinary
team to better meet the needs of the individuals, families, and therapists
involved in FSN. The clinical supervision staffing allows time to clinically
review each case and discuss the progress of the application of the model.
This review allows both clinical supervision and supervision of adherence to
the FSN model. The original research design called for weekly onsite meet-
ings and cross-site conference calls to ensure adherence to the design.

Staff Meetings
Staff meetings should be held weekly and should last approximately 1 hour.
During a meeting, each familys case should be reviewed, including treatment
goals, progress, further interventions that may be necessary, problems
encountered, recommendations, and any other issues. The case manager
should report on every family. The report should include such issues as
referrals made, difficulty with compliance, and any barriers that might 
prevent a family from successful completion of treatment. 
Family Support
Network

Family Parent(s)

Home Visits
(4)
Adolescent

MET/CBT

Completion
  Case
Management

Community
Support
Parent Education
Sessions (6)

Exit

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Standardization of the FSN model should be reviewed. Discussion should
include:
  Difficulties in complying with the process and procedures
  Problems with recruitment, issues involving retention and census,
recommendations for improvement, and development of an action
plan
  Personal or professional difficulties in treating the adolescents
and their families. 
A clinical supervision log should be kept. Attendance, comments on each
agenda item, recommendations, and action plans should be recorded in the
log. All clinical staff (e.g., therapist, therapist coordinator, parent education
therapist, adolescent counselors, and case manager) should participate in
all staff meetings. 

Adherence and Quality Assurance
Procedures have been developed to monitor adherence to the protocol and
provide a quality assurance check. After each session, the therapist should
use the rating sheets provided in appendix 1 to rate adherence to the 
protocol and the overall effectiveness of the session. These forms are 
completed for each parent education session and home visit. The forms can
be used to assess the progress of the intervention and to improve the protocol.
These rating sheets were developed not to evaluate the therapist but rather
to evaluate the protocol. A low rating does not indicate lack of ability on
the therapists part. Therapists are encouraged to write comments in 
the spaces provided and discuss particular successes or difficulties with 
implementation of FSN with their clinical supervisor and in staff meetings.

11

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II. Parent Education Sessions and 
Discussion Procedures

The six parent education sessions, each designed to last 90 minutes, provide
information that complements the family support network (FSN) home 
visits as well as the education that the adolescent receives in motivational
enhancement therapy (MET) and cognitive behavioral therapy (CBT). These
sessions are interactive and allow parents to discuss and review the following
topics: 
1.  The family support network, adolescent development, and 
functional families
2.  Drugs and adolescents
3.  Relapse signs and recovery
4.  Boundaries, limits, authority, and discipline
5.  Communication, conflict resolution, and fighting fair
6.  The family context.
A brief overview of FSN is presented at the first session, and the importance
of the familys commitment in the adolescents recovery is stressed in all
sessions. The philosophical foundation of the parent classes is strength
based: by increasing the parents understanding of issues that influence
families, the family will grow stronger. One of the overriding goals of FSN is
to help the family members develop lifelong support of one another. In 
addition, the experience of FSN helps families consider attending support
groups. Some tips on conducting the sessions follow:
  Always start the first session with introductions. (Parent
Education Session 1)
  Distribute name tags or provide new ones. (These can be collected
at the end of each session and used in subsequent sessions.) (All
Parent Education Sessions)
  If name tags are not used, be sure you know the parents names
(use a card for reference). (All Parent Education Sessions)
  Invest 15 minutes of the initial session in having participants talk
about why they are attending the group or what they hope to get
out of the group. (Parent Education Session 1)
  In the beginning of the first five sessions, take 5 minutes to develop
rapport and settle in. (Parent Education Sessions 1, 2, 3, 4, and 5) 

13

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  For each session, provide a handout with some essential points for
parents to take with them for reference. Handouts are grouped
together at the end of each session narrative. (All Parent
Education Sessions)
       Parent Education Session 1: 
 Introduction to the Family Support Network, 
Adolescent Development, and Functional Families
General OverviewThe purpose of this session is to provide an 
understanding of adolescent development and the role of the family in
this development. The session focuses on how healthy family functioning
can make the family a source of strength for its members. One emphasis is
understanding the individuation process of normal adolescent development
and how families can help make it a positive experience.
RationaleThe more information parents receive on normal adolescent
development and functional families, the better they can identify family
issues and resolve them. 
Materials
  Overhead equipment
  Handouts: 
u
Productive Group Rules for FSN Parent Education Participants
u
Parent Education Sessions
u
Home Visits
u
Summary of Adolescent Classes
u
Typical Teen Beliefs and Rationalizations and Ways Parents Can
Cope
u
Healthy Versus Troubled Families
u
Effective Parenting Questionnaire
u
Life Stressors and Social Resources Inventory*
  Functional Family Qualities poster (purchased or made by the therapist)
  Treatment calendar (a 12-week calender with parent education and
adolescent education sessions preprinted. Parents can add home visits
as they are scheduled.)

Preparation for the Session

  Review the handouts.
  Purchase or create posters to decorate the family meeting space
that promote positive healthy family behaviors. If you are creating
them, make them big and colorful. Include the following 
information: Healthy families communicate and listen to, affirm,
and support one another; teach respect for others; develop a 

*Available from Psychological Assessment Resources, Inc., 16204 North Florida Avenue,
Lutz, FL 33549, 8139683003, www.parinc.com.

14

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sense of trust; have a sense of play and humor; share responsibility;
teach a sense of right and wrong; have family traditions; have a
balance of interaction; have a shared religious core; respect one
anothers privacy; value service to others; value shared meals and
conversation; share leisure time; and admit to and seek help with
problems.
Goal: To communicate an overview of the FSN model and the importance
of family participation

1. Present the FSN model, and discuss the importance of family 
participation. 
Give a brief description of the course of treatment, including the number 
of meetings, length of time in treatment, and so forth. Explain that families
participate in six parent education (PE) groups. Distribute the Productive
Group Rules for FSN Parent Education Participants and Parent Education
Sessions handouts. Discuss the three or four inhome family therapy sessions.
Distribute the Home Visits handout and the Summary of Adolescent Classes
handout, and briefly describe what the children will be learning and the
plan for family involvement. Talk about how the families are assuming
responsibility by their participation and how the parents can take advantage
of community support groups.
Hand out preprinted 12-week treatment calenders. These can easily be 
created on most computers. Explain that the parent education sessions and
the adolescent education sessions are on the treatment calender. Explain
that the parents can write the dates for the home visits on the calendar
once they schedule them with the therapist or case manager. Encourage
parents to post this calendar in a place where the family can readily see it.
Explain that this will help the family schedule its time and avoid conflicts
that may interfere with successful completion of treatment.
Goals of FSN:
  Include the family in the recovery process. Family participation
will improve an adolescents success in recovery.
  Improve family functioning, primarily by improving communication
and relationships.
  Improve parents effectiveness in dealing with substance abuse
and accompanying behaviors.
  Assess the parents and familys commitment to the recovery
process. Commitment to recovery requires changes in how the
parents and family approach the problem.

15

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Goals of home visits: 
  Reestablish relationships.
  Develop a new contract for rules.
  Improve communication skills.
  Develop a Family Relapse Prevention Plan (which is discussed in
detail in PE Session 3).
2. Present information on typical teen rationalizations.
Define rationalization. Explain to parents that rationalizations are excuses
people use to minimize their responsibility for their behaviors. Say: When
we experience consequences that are unpleasant, we seek excuses for why
we should be exempt from such consequences. Adolescents often fluctuate
between being autonomous one day and dependent the next. When teens
seek to do what they want and experience resistance, they blame adults,
particularly parents, for failing to understand their needs. 
Discussion. Distribute the Typical Teen Beliefs and Rationalizations and
Ways Parents Can Cope handout. Ask parents to interject any recent 
situations at home that are examples of these beliefs (this should be a 
light-hearted discussion). It is important for the therapist to provide 
examples of what is harmful and what is harmless behavior.
3. Present material on functional family qualities.
Discussion. Provide the Healthy Versus Troubled Families handout. 
Discuss the differences between healthy and troubled families regarding
rules, communication, alliances, feelings, self-worth, openness to change,
defense mechanisms, stress, growth, and control. Discuss the handout with
the parents, and allow them to ask questions. 
Show parents the posters of qualities of healthy families that the therapist
purchased or made prior to the session (see Preparation for the Session).
Have the parents discuss the information on the posters. Ask them to add
other qualities. 
Discuss ways that families can enjoy more quality time together (e.g., take
meals together, play together). Have the parents make a list of characteristics
they like about their child or identify at least one good quality in the child.
Discuss with the parents feelings they experience while making the list. 
4. Discuss effective parenting behaviors.
Distribute the Effective Parenting Questionnaire handout, and ask the 
parents to rate themselves.

16

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Discussion. Have parents share where they see themselves today and how
they would like to rate themselves following treatment. 
5. Present material on ineffective parenting behaviors that will help 
parents identify habits that may potentially prove unproductive to
healthy communication.
Discussion. Information on styles that can inhibit effective parenting
include the following:
  Sometimes parents cannot be effective because they are preoccupied
with their own problems. These problems can include chemical
dependence or psychological impairment; however, problems can
also include less complicated situations such as stress from work
or a relationship. It is important for parents to recognize their
own problems and realize that their parenting style will be 
affected by personal factors they deal with daily. 
  Sometimes parents attempt to protect their child by overreacting
to inappropriate behaviors. Parents have a tendency to discount
the opinion of a child, and this can hinder individuation of the
child. In extreme cases, parents may be so angry with a child that
they lose respect for the child and feel they need to be strict dis
ciplinarians. The child is often pronounced guilty without a trial. 
  Some parents may be interested in keeping things well under 
control. When this happens in extreme cases, the child can
become insecure and timid or rebellious.
On occasion, parents may be insecure with their parenting style. As a
result, they may lose the ability to set and enforce limits or rules for their
children. These parents have difficulty seeing how the problem behaviors
affect their family. Sometimes their children will have a difficult time in
school because they are not used to taking direction and cannot accept
authority.
When parents have personal needs that are not being met, they sometimes
look to their children to fulfill those needs. These parents tend not to 
punish but to love their children to extremes. Children of such parents find
it difficult to achieve independence from their parents.
People with strong beliefs are often rigid and strongly opinionated. They
have a tendency to approach all people and all problems in the same manner.
Sometimes, as parents, they are perceived as uncompassionate and unemo
tional parents. They have a difficult time seeing beyond their beliefs to the
individual needs of others. These parents tend to lecture and advise often. 
Summarize by pointing out that we all face many stressorsevery day. It 
is important to be aware of how we relate to others, especially when we 
are feeling pressure and stress. Parents are people, too. With strong 

17

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self-understanding, parents can become aware of factors that keep us from
being effective parents.
6. Process, reflect on, and review information introduced on normal 
adolescent development and functional families. 
Discussion. Open up the discussion by asking for reactions to the material
covered. Ask parents whether they recognize any of the parenting styles 
discussed, and talk about ways to avoid bad habits. Talk about knowing
when a teens behavior is normal (even though its still difficult to deal
with) and when behavior is extreme and should be considered a warning
sign. Ask everyone to look at the Effective Parenting Questionnaire handout.
Ask the group to brainstorm different examples of activities that can be
used to demonstrate each of the 10 categories. 
7. Discuss life stressors with parents.
Introduce the Life Stressors and Social Resources Inventory (LISRES). Give
parents a copy of both the adult and juvenile versions. (LISRESAdult
Version 1994 and LISRESYouth Version 1984, revised in 1994, are
available from Psychological Assessment Resources. Visit www.parinc.com.).
It is not necessary to use this particular inventory. Similar assessment tools
exist that will provide parents and adolescents with insights into the stres
sors that affect their lives (Butcher et al., 1992; Achenback & Edelbrock,
1987; Kaminer et al., 1997; Meyers et al., 1995; Miller 1985; Winters &
Henly, 1989; Dennis, 1999). 
Explain that this inventory will be scored and placed on a graph. Explain
that understanding the types and degrees of stressors helps people develop
strategies to decrease stressors and lessen the effects of them.
Ask parents and adolescents to fill out the questionnaires.
Ask that they return these forms before the first home visit to ensure that
the instrument can be scored. 
Tell them that during the first or second home visit, the therapist will
review the results and discuss strategies with the parents and youth for
reducing stress.

18

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 PRODUCTIVE GROUP RULES
FOR FSN PARENT EDUCATION
PARTICIPANTS

  I have made a commitment to attend this
group on a regular basis, and it is my
responsibility to inform the case 
manager or family therapist if I am unable
to attend a session.
  By participating, I will be support
ing other group members while
gaining support from them.
  It is my responsibility to keep
what others say and do in the
group meetings confidential, that
is, Whats said in the group stays
in the group!
  I should be myself and accept responsibility
for my behavior.
  I will listen with an open mind and not be
judgmental.
  I will respect others ideas and suggestions
discussed in the group.

-----------------------------------------------
PARENT EDUCATION SESSIONS
PE Session 1: Introduction to Adolescent Development, and Functional
Families. This session provides 
an understanding of adolescent 
development and the role of the family in
this development. The session focuses on
how healthy family functioning can provide
a source of strength for the 
family members. Ways families can 
help a child make the journey from 
adolescence to adulthood a positive 
experience are presented. 
PE Session 2: Drugs and Adolescents.
This session helps parents understand the
nature of drug abuse and addiction and
how adolescents become involved with drugs. The nature and objectives of
treatment are addressed, and the importance of the parents motivation to
be part of their childs recovery is stressed. 
PE Session 3: Relapse Signs and Recovery. The issues presented in this
session are how to understand the recovery process in the context of a
healthy family, ways parents can be effective in helping their child avoid
relapse (a return to substance abuse), and how they can know when to
appropriately step in to assist their child. Developing a healthy partnership
within the family and making a commitment to a drug-free life are discussed.

PE Session 4: Boundaries, Limits, Authority, and Discipline. The concept
of boundaries is introduced as a major issue in adolescent development and
family life. Clarification of major issues in family functioning is provided, and
appropriate approaches to discipline and parental authority are suggested. The
session materials help parents understand the sources of family 
authority and healthy ways to maintain it.
PE Session 5: Communication, Conflict Resolution, and Fighting Fair.
This session enhances parents understanding of how and why conflict
inevitably happens in families, provides concepts and methods of healthy
communication for families, and presents techniques for engaging family
members in open and fair resolution of conflict. Conflict is presented as a
learning process, and ways to prevent conflict from becoming dangerous to
the individual and family are discussed. 

PE Session 6: The Family Context. This session helps adolescents and 
parents understand the importance of family in the recovery process and the
nature of the family as an interdependent system. Parents learn how family
functioning has both a direct and an indirect influence on a childs behavior.  

-----------------------------------------------
HOME VISITS
Goals of FSN:
  Include the family in the recovery process.
  Improve family functioning, primarily by improving communication
and relationships. 
  Improve your effectiveness as parents in dealing with substance abuse
and accompanying behaviors.
  Assess your commitment to the recovery process because commitment
to recovery requires changes in how you and your family approach
the problem.

Goals of Home Visits:
  Reestablish relationships.
  Develop a new contract for rules.
  Improve communication skills.
  Develop a Family Relapse Prevention Plan.

First Home Visit:
  Discuss the adolescents progress in treatment and urinalysis (UA)
results.
  Develop family treatment goals and a treatment contract.
  Discuss the adolescents treatment issues.
  Conduct the family sculpting exercise.

Second Home Visit: 
  Discuss the adolescents progress in treatment and UA results.
  Discuss family rules, fair fighting, and conflict resolution.
  Develop the family mission statement.

Third Home Visit:
  Discuss the adolescents progress in treatment and UA results.
  Practice problem solving and improving communication.
  Develop the Family Relapse Prevention Plan.

Fourth Home Visit: (conducted when indicated by treatment progress or
requested by family)
  Discuss the adolescents and familys progress in treatment and the
adolescents UA results.
  Address any family-specific treatment issues, and seek closure.

-----------------------------------------------
SUMMARY OF ADOLESCENT CLASSES

Modality  Main Topics To Be Covered
Session   1 Individual  Motivation building, CYT Volume 1
(Sampl & Kadden, 2001)
Session   2 Individual  Goal setting, introduction to functional 
analysis, and preparation for group, CYT 
Volume 1 

(Sampl & Kadden, 2001)
Session   3 Group  Marijuana refusal skills, CYT Volume 1
(Sampl & Kadden, 2001)
Session   4 Group  Enhancing the social support network and 
increasing pleasant activities, CYT Volume 1
(Sampl & Kadden, 2001)
Session   5 Group  Planning for emergencies and coping with 
relapse, CYT Volume 1
(Sampl & Kadden, 2001)
Session   6 Group  Problem solving, CYT Volume 2
(Webb et al., in press)
Session   7 Group  Anger awareness, CYT Volume 2
(Webb et al., in press) 
Session   8 Group  Anger management, CYT Volume 2
(Webb et al., in press)
Session   9  Group  Effective communication, CYT Volume 2
(Webb et al., in press)
Session 10 Group  Coping with cravings and urges to use 
marijuana, CYT Volume 2
(Webb et al., in press)
Session 11 Group  Depression management, CYT Volume 2
(Webb et al., in press)
Session 12 Group  Managing thoughts about marijuana, 
CYT Volume 2
(Webb et al., in press) 

-----------------------------------------------
TYPICAL TEEN BELIEFS AND RATIONALIZATIONS 
AND WAYS PARENTS CAN COPE

Everything is great. Teens can be on top of the world one minute and
depressed and disagreeable the next. Remember that rapid and frequent
changes in feelings are normal for teens.
Privatestay out! This refers not just to teens physical space (e.g., their 
bedroom) but also to their thoughts and feelings. They may be so confused by
their feelings that they dont know how to express them. Let your teen know
that you are willing to listen.
Adults dont know anything. Teens are in the process of deciding what they
believe in and what they value. It is normal for them to rebelat least 
temporarilyagainst what they have been told by parents. By ignoring harmless
rebellions about food and clothes, you give your teen a safety valve to express
himself or herself. This may prevent your teen from getting into self-destructive
rebellions such as drug abuse.
Theyre my friends. Teens want the acceptance and approval of people their
own age, just as adults do. The more teens feel accepted and supported at
home, the less likely they are to be negatively influenced by their peers. 
Sometimes I hate myself. Nearly all teens have periods of low self-esteem.
They need your encouragement. Look for honest ways to boost your teens 
self-esteem. 
No one else has to be in by 11 p.m. Teens often test the boundaries their
parents set for them. They need to know that you are going to prevent them
from harming themselves. Establishing some basic ground rules about chores,
dating, driving, and curfew gives teens something to fall back on as they develop
their own decisionmaking abilities. Rules should be few, arrived at by negotiation
between you and your teen, and clear to everyone involved. Writing them down
is a good idea. 
But everyone drinks and tries pot! Sooner or later teens find themselves in 
a situation in which they must decide whether to use drugs. You can help by 
modeling infrequent use of alcohol and prescription or over-the-counter drugs. 
If you overuse alcohol or drugs, it is likely that your teen will as well. Plan with
your teen, ahead of time, how he or she can handle a drug-using situation, and
specify ways you can help. 

Note: The above behaviors are exhibited by nondrug-using teens as well as
drug-using teens. It is important to learn when your teen is using these beliefs
to manipulate you or to cover up inappropriate behavior. Unfortunately, there
is no certain way of knowing which is the case.

-----------------------------------------------
HEALTHY VERSUS TROUBLED FAMILIES
Remember, there is no right or wrong, good or bad, black or white. If emotional pain exists, we have a choice to
stay in the pain or make changes to remove the pain.
Healthy Families Troubled Families
1. Rules  Few rules exist, and they are clear 
and specific. Rules are respected, 
consistently enforced, fair, and 
negotiable. Rules lead to a 
predictable environment.   

2. Commu- Clear responsibility is taken for 
nication statements, which are open and 
considerate of others. People take 
risks to express feelings, ideas, 
and beliefs. If a problem exists, 
the family discusses it and seeks 
outside help if necessary. 

3. Alliances Members take time with one 
another individually and together.
There is a strong parental 
relationship. 

4. Feelings  Members allow and respect feel
ings. There is an honest expression
of vulnerable feelings.  
5. Self-worth High self-worth exists. Persons are
separated from their behavior.
Members listen with interest and
respect. Members respect others
views.  

6. Change Members are open to change.  

7. Defenses Members display defenses that are
functional and appropriate to the
situation.  

8. Stress Members know how to deal with
stress. They can see when others
are in pain and can nurture and
comfort.  
9. Growth Members accept and welcome life
stages.   

10. Control There is less need to control.
Parents are in charge but can 
negotiate. They respect childrens
opinions.  
Some rules are occasionally enforced, but others are
not. Often no discussion is allowed on changing or
modifying rules. In some cases rules are completely
absent, making members feel uncertain or anxious
because they do not know what is OK and what is not.

Communication is almost nonexistent. There is a lot of
talking about the person instead of to the person.
Double messages, secrets, and a lot of shoulds and
ought tos are frequent. Family secrets are protected
at all costs, and there is fear of seeking outside help. 

Family members take sides and reject other members.
They form hidden relationships (even across genera-
tions). The parental relationship is weak or nonexistent,
or one parent may dominate. 

Members do not discuss or allow feelings. There is
fear of feelings; people try to hurt one another. Some
feelings are OK, whereas others are not.

Individuals are treated without respect (this includes
adults and children). Children are seen but not heard.
A person is condemned, not his or her behavior.
Shame is used for punishment. Blaming is common.
Cynicism and negative attitudes exist.

Members are rigid, fixed, and not open to change.
Nothing can be done; what is the use.
Problems and feelings are denied. Pain is hidden.
Strange or unusual behavior is ignored. There is a no
talk ruleeven about serious problems.
Members avoid pain in themselves and others. They
deny stress and often feel they cant cope.

Parents may compete with children, growth is painful,
and change is feared.

There is rigid control or shifting patterns of domination,
possible upside-down family (children running the 
family).

-----------------------------------------------
EFFECTIVE PARENTING 
QUESTIONNAIRE

Rate yourself in the following categories on a scale of 1 to 10. A rating
of 10 is the highest score.
1.  Listening without judging ______
2.  Showing love and affection ______
3.  Developing regular family times ______
4.  Asking questions about your teens daily and weekly activities ______
5.  Criticizing behaviornot the person ______
6.  Supporting your teens problem-solving efforts ______
7.  Being courteous ______
8.  Praising your teen ______
9.  Spending time with your teen ______
10.  Delaying some gratifications ______

-----------------------------------------------
Parent Education Session 2:
Drugs and Adolescents
General OverviewThis session helps parents understand the nature of
drug abuse and dependence and how adolescents become involved with
them. It presents the nature and objectives of treatment and the 
importance of parents motivation to be part of their childs recovery. 
RationaleThe more information parents receive about adolescence,
drug use, and its signs and symptoms, the better able they are to 
intervene and help their children.
Materials
  The National Institute on Drug Abuse video Drug Abuse and the
Brain*
  Markers and whiteboard
  Handouts:
u
Disease Progression Chart
u
Drug Category Information and Consequences of Use
u
Drugs of Abuse Detection Times
u
Developmental Changes for Adolescents
  Overheads
u
Developmental Changes for Adolescents
u
Questions About Drug Issues

Goal: To provide parents a better understanding of adolescent drug abuse

1. Discuss the disease concept of addiction and what it means in the
process of recovery.
Discussion. Share with parents that their children may be at different
stages of drug use. Some may be in the experimental stage. This means that
they are just now trying substances and have not established a regular pattern
of use. However, some may have established a regular pattern of use, meaning
that they regularly use and look forward to using. This pattern could be
monthly, weekly, or daily.
Explain that if their child uses in a regular pattern, this means that the
adolescent is abusing drugs. Most of the time, but not always, establishing 
a pattern takes time. But for some people, a regular pattern of use can 
develop quickly. They try a substance, and in a short time they can be using
daily. Explain, Once anyone, youth or adult, has established a pattern of
use, we need to examine whether the process of addiction has begun. Not
everyone who uses becomes addicted. We will talk about all the factors that
influence a youths desire to pick up and maintain continued use.  

*Information on ordering the video is available from the National Institute on Drug Abuse
online publication catalog. Visit www.nida.nih.gov/PubCat/PubsIndex.html.

26

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Distribute the Disease Progression Chart handout. Discuss addiction and
how a persons body responds to drugs and alcohol. Explain that a video will
be shown that will explain how drugs affect the brain. Tell parents that
there is a real physical basis for addiction, including addiction to marijuana.
Addiction ultimately means that the substance, whether it is alcohol or a
drug, takes over the persons life. Remember to take time to answer any
questions on this issue. 

2. Distribute the Drug Category Information and Consequences of Use
and Drugs of Abuse Detection Times handouts.
Discussion. Discuss the urinalysis (UA) for drug screening and how it
works, explaining what it means and what it does not mean. Briefly cover 
information on the handouts, stressing the following points:
  A negative UA, or one that indicates that marijuana is not present,
does not prove that the child is not using but only that the
child has not used within the window of detection for testing 
or that the amount is below the level needed for identification. 
  Testing for tetrahydrocannabinol (THC) is not 100-percent accurate.
It is possible to obtain a positive result, or a result that indicates
that marijuana is present, even if the child has not recently used
because THC is stored in fat cells. If the child changes his or her
exercise pattern or diet and loses weight rapidly, a positive result
can be obtained without the child recently using the drug.
Subsequent UAs should result in lower levels of THC if the child 
is no longer using.
Answer any questions.
3. Initiate a discussion based on essential points.
Discussion. Initiate a discussion with the group on the following points:
  Parental ambivalence. Research has shown that an important 
protective factor for adolescent drug use is parental attitudes.
Adolescents perceive parental ambivalence the same as parental
acceptance of drug use. This is particularly true for baby boomer
parents. Not saying anything to your kids is the same as telling
them it is OK.
  Parental use. Some parents use alcohol and drugs. If adolescents
are aware of their use, it will be very difficult to motivate them to
quit. Parents who do not currently use drugs but used them when
they were younger may feel guilty when talking about not using
drugs to their children and will often avoid the discussion.
Parents in this situation should not let the child know about past
drug use. The parents admission usually only gives the teen 
permission to use drugs. If children know about their parents
drug use, parents should do the best they can to explain the 

27

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negative consequences they experienced. If children ask about
parents past drug use, parents should avoid the topic by saying,
Lets stay on track; this conversation is about you, not me.
  Other life problems. Children often turn to substance abuse to
meet a need. Therefore, substance abuse is often a symptom of
another problem. The problem could have a multitude of factors.
It may be beneficial to explore what a child might be experiencing
that caused him or her to turn to drugs by asking the following
questions:

u
Were there any recent events that might have been a trigger to
use?

u
What personality characteristics or tendencies does the teen
have that may lead him or her to use?

u
Has the teen experienced any difficulties in relationships,
either inside or outside the family?

u
How does the teen cope with stressful life events? 

u
How does the teen cope with feelings?

u
How is the teens self-esteem? What can parents do to help
boost the teens self-esteem?
  Substitution of one drug for another. It is important to be aware
that, as adolescents progress through treatment, they will often
switch drugs. Therefore, it is important to watch for signs and
symptoms of all the drugs discussed earlier, not just the ones the
teen is currently using. Often alcohol use will increase as a substi
tute for the drug of choice, especially if the youths urine is being
tested regularly.
  Negative consequences of marijuana use. Adolescents believe that
marijuana is not harmful. It is a difficult battle to convince them
that marijuana has negative consequences. Parents should share
with their child any information they have that would change the
childs perception. Let the child know the following:

u
Continued marijuana use in early years interferes with the 
ability to learn and remember.

u
Childhood and adolescent learning provides the foundation for
the years to come. 

u
Marijuana affects the ability to be responsible. (Remind children
that parents believe they desire to be mature and responsible.)

4. Introduce, show, and discuss the Drug Abuse and the Brain video.

28

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Discussion. Before showing the video, ask participants to look for two or
three key messages in the video. Show the 25-minute video. Initiate a
discussion about the video.
5. Introduce the stages of adolescent development.
Point out that there are special issues to consider when dealing with adoles-
cent substance abuse. Teens are going through developmental stages that
can be affected by drug use. Introduce the effects drugs have on an adoles-
cents developmental stages.
Distribute the Developmental Changes for Adolescents handout. This 
handout provides a comparison of normal development with developmental
changes due to chemical dependence. Make an overhead of the handout if
appropriate.
Discussion. Direct parents to the first grid that describes normal adolescent
development for early and late teen years. Explain that some adolescent
behaviors, although less than desirable, are normal and are part of growing
up. Direct parents to the second grid that compares normal and chemically
dependent phases. Make sure parents understand the terminology and the
difference between normal development and inappropriate developmental
changes associated with drug use. Finally, mention the last grid that gives
some reasons why adolescents may turn to drug use. Have the parents
relate the characteristics listed in the grid to their own children and try to
understand why their children may have started using drugs. Have parents
openly discuss the possible reasons their children may have turned to drugs.
6. Initiate a wrapup discussion using probing questions to reinforce the
valuable information introduced in this session.
Discussion. Show an overhead of the following questions:
  How do drugs create problems for families?
  Why do children use drugs?
  Are families powerless in helping their children?
  What do you expect from treatment?
The purpose of this overhead is to generate group interaction and encourage
participants to share responses. There are no right or wrong answers to the
questions. Discuss these questions, and then spend a few moments writing
down additional questions from the group and sharing some answers.
Responses should be general feelings rather than personal answers.
Reinforce positive responses, and write essential observations on the board.
7. Obtain a commitment from parents to continue attending the group
sessions.

29

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Discussion. Ask for a commitment from the parents, for the sake of their
child and other group members, to continue with the group. Close the session
by stating the topic of the next meeting and encouraging parents to do 
a family activity before that meeting. Suggestions for a family activity
should be simple, short in duration, and cost no money. These suggestions
should provide the family with some guidance but should not be an 
unnecessary strain on their functioning in the beginning of treatment.
Examples include having at least one family meal at which everyone agrees
to discuss only an interesting event they observed that week. Explain that
the family can agree that during this meal no one will be allowed to criti-
cize or make fun of others at the table. Another event could be watching an
appropriate television show or movie that everyone would like to see. Tell
parents that they will be asked to share how the event went with the other
members of the group at the next session.
Thank everyone for attending and being supportive parents, and remind
them how important their attendance and commitment are to their teens.

30

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DISEASE PROGRESSION CHART

1. Sneaks drinks/drugs
2. Is preoccupied with alcohol/drugs
3. Gulps drinks
4. Avoids reference to alcohol/drug use
5. Has memory blackouts
6. Has increased alcohol/drug tolerance
7. Drinks/uses before and after social occasions
8. Begins relief drinking/using
9. Is uncomfortable in situations without alcohol/drugs
10. Experiences loss of control
11. Is dishonest about alcohol/drug use 
12. Has increased frequency of relief drinking/using
13. Hides and protects supply
14. Experiences urgent need for first drink/drug
15. Tries periods of forced abstinence
16. Receives disapproval from others for drinking/drug use
17. Rationalizes drinking/drug use
18. Experiences flashes of aggressiveness
19. Exhibits grandiose behavior
20. Has guilt about drinking/drug use
21. Neglects eating
22. Builds unreasonable resentments
23. Devalues personal relationships
24. Considers geographic escapes or geographic cures
25. Has decreases in sexual drive
26. Quits or loses job
27. Exhibits unreasonable jealousy
28. Drinks/uses alone
29. Tries to control drinking/drug use
30. Experiences tremors and shakes
31. Drinks/uses in early morning
32. Has persistent remorse
33. Participates in lengthy drinking/drug binges 
34. Experiences impaired thinking
35. Drinks/uses with inferiors
36. Loses tolerance for alcohol/drugs
37. Has indefinable fears
38. Is unable to work
39. Has deteriorating physical state 
40. Has deteriorating moral standards
41. Is admitted to hospital
42. Feels persistent remorse  
43. Loses family and friends
44. Exhausts all alibis
Early
Stage

Middle
Stage

Late
Stage

-----------------------------------------------
DRUG CATEGORY INFORMATION 
AND CONSEQUENCES OF USE

ALCOHOLAlcohol is the substance most commonly abused by Americans. It is 
a potent depressant, quickly assimilated into the bloodstream. On reaching the
brain, it acts on the central nervous system to depress brain activity on all levels
and reduce coordination.
Slang Names: booze, brew, spirits
Effects: relaxation, decreased alertness, impaired coordi
nation, repression of normal fears and inhibitions
Duration of Physical Effect: one drink lasts between 1 hour and 2 hours 
(maximum)
Symptoms: flushed face, vessel dilation, loss of motor control
Symptoms of Overdose: blue clammy skin, shallow respiration, weak pulse,
arrested cardiac functioning
Chronic Use: heart, brain, liver, circulatory system, and intestinal
damage; also, damage to the fetus of a pregnant
woman 
Dependence: moderate to high
Method of Ingestion: oral

NICOTINETobacco is the leading drug problem today in terms of health 
consequences. There are an estimated 56 million users in the United States alone.
Slang Names: coffin nails, butts, smokes
Effects: relaxation and easing of tension, appetite suppression
Duration of Physical Effect: 1 to 6 hours
Symptoms: smell of tobacco, stained teeth, increased blood
pressure and heart rate
Chronic Use: cancers of the lung, throat, mouth, esophagus;
bronchitis; stomach ulcers; lowered immunity;
heart disease; emphysema
Dependence: high

Method of Ingestion: smoked, chewed

(Continued on next page)

-----------------------------------------------
MARIJUANAMarijuana comes from the hemp plant, Cannabis sativa, which
grows in many parts of the world. The dried flowers and leaves are usually smoked
in a cigarette, or joint, or a pipe. Marijuana can also be eaten. Marijuana contains
hundreds of different chemicals that produce diverse effects on the mind and
body. The most significant of these chemicals is THC, the major psychoactive (i.e.,
mind-altering) ingredient. The average joint contains 2 to 7 percent THC; however,
stronger strains with a THC level of 13 to 14 percent are now available on the
street, posing a significant risk to users.
Slang Names: pot, reefer, Mary Jane, hash, loco weed, hemp, blunt
Effects: relaxation, euphoria, alteration of inhibitions
Duration of Physical Effects: euphoria lasts 2 to 4 hours; heavy use lasts 24
hours; drug may be detected in urine and blood for
several weeks
Symptoms: drowsiness; impaired coordination; confused
speech; eyes red, but pupils appear normal;
coughing; dry mouth and throat
Chronic Use: memory distortions, reproductive system effects,
lung and lung function damage, psychosis
Dependence: moderate to high
Method of Ingestion: smoked, eaten

STIMULANTSThese drugs stimulate the central nervous system and include
cocaine, amphetamines, caffeine, nicotine, Ritalin, and methylenedioxymetham
phetemine (MDMA also know as ecstasy). Stimulants were once known as the drug
of the rich and famous, but they are now used by individuals at all economic and
social levels. Cocaine is the most reinforcing drug used by people to produce pleasure.
Slang Names: coke, snow, toot, white lady, happy dust, speed,
uppers, pep pills, bennies, dexies, meth, crystal,
crank, ice, black beauties, hearts, co-pilots, 
cartwheels, greenies, browns, whites, diet pills
Effects: loss of appetite, indifference to pain, feelings of
intense sexuality, exhilaration, increased alertness,
anxiety, irritability
Duration of Physical Effects: from a few minutes to 2 to 4 hours; smoked ice
can last up to 24 hours
Symptoms: restlessness, intense short-term high, dilated pupils,
excess activity, mood swings, needle marks, burn
marks on lips or fingertips, burned holes in clothing

Chronic Use: nausea, deterioration of the lining of the nose,
stomach disorders, paranoia and formication
(the feeling that insects are crawling beneath the
skin), death occurring from overdose, psychosis,
hallucinations, convulsions, coma

(Continued on next page)

-----------------------------------------------
Dependence: high
Method of Ingestion: snorted, injected, oral; ice can be smoked, snorted,
or injected

INHALANTSInhalants are legal products abused by sniffing (e.g., spray paint,
hairspray, gasoline, lighter fluid, airplane glue, paint thinner, nail polish remover,
typewriter correction liquid).
Slang Names: poppers, laughing gas, rush, white-out
Effects: euphoria, relaxation, violent behavior, 
hallucinations, alcohol-like high
Duration of Physical Effects: a few seconds to several hours
Symptoms: numbness, confusion, nausea, vomiting, tremors,
memory loss, visual impairment, possible 
respiratory arrest, coma, death
Chronic Use: lung, kidney, bone marrow, and brain damage
Dependence: high
Method of Ingestion: inhaled

HALLUCINOGENSHallucinogens are drugs that alter perceptions of reality,
including phencyclidine (PCP), lysergic acid diethylamide (LSD), mescaline, and
psilocybin.
Slang Names: angel dust, killer weed, supergrass, hog, peace pill,
LSD, acid, trips, cubes, sunshine, windowpane,
purple haze
Effects: varies from relaxation and euphoria to vivid 
distortions; paranoia; psychosis; visual, tactile,
auditory, and olfactory hallucinations; altered 
perceptions; breakdown of inhibitions; dilated
pupils; mood swings
Duration of Physical Effects: PCP lasts 2 to 4 hours, PCP-related psychosis may
last for weeks; LSD lasts 8 to 12 hours, flashbacks
may last for weeks or up to 1 year
Symptoms: users are physically anesthetized and may appear
to possess superhuman strength; respiratory
depression, seizures
Chronic Use: memory disturbances, speech problems, anxiety,
extremely violent behavior, paralysis, death 
occurring from both accidents and overdose,
increased delusions, panic, psychosis, emotional
breakdown, brain damage
(Continued on next page)

-----------------------------------------------
Dependence: moderate to high
Method of Ingestion: oral, smoked, snorted; acid can also be placed on
mucous membrane areaseyes, anus, etc.

DEPRESSANTSDepressants are drugs that relax the body muscles, temporarily
relieve feelings of tension and worry, and bring on sleep. Low doses produce mild
sedation; high doses induce euphoria. Depressant overdose is the leading cause of
suicide among American women. These drugs are extremely dangerous when
consumed with alcohol. Types of depressants are barbiturates, tranquilizers,
Rohypnol, benzodiazepines, and methaqualone. All are easily available by medical
prescription.
Slang Names: downers, reds, pinks, yellow jackets, bluedevils,
Christmas trees, barbs, Xanax, Valium, roofies,
Ativan, Quaaludes, black beauties, goof balls
Effects: depresses central nervous system and respiration
system, slows heartbeat rate, and relaxes muscles
Duration of Physical Effects: 3 to 24 hours
Symptoms: drowsiness, confusion, slurred speech, impaired
judgment, belligerent behavior, needle marks in
people who are severely addicted
Chronic Use: rapid physical and psychological dependence,
addiction with severe withdrawal symptoms, loss
of appetite, death from overdose
Dependence: high

Method of Ingestion: oral, injected

-----------------------------------------------
Drugs of Abuse Detection Times

Substance  How Used        Possible Dangers  Approximate 
Detection Time 
in Urine
Alcohol Orally    Liver disease, respiratory failure, anxiety, depression,      310 hours
coma, psychological or physical addiction, death     
Uppers/Stimulants   Orally, injected,  High blood pressure, loss of appetite, stroke, fever,         24 days
(amphetamines,        or inhaled          heart failure, psychosis, death
speed, dexedrine,      
ice, Ritalin, ecstasy)     
Downers/ Orally Respiratory failure, depression, anxiety, convulsions,    Short-acting or   
Depressants or  insomnia, coma, psychosis, psychological or physical      immediate:
Sedatives addiction, death 24 days
(barbiturates, black  Long-acting:
beauties, goof balls,  up to 24 
nembies, seccies)       weeks

Tranquilizers Orally Respiratory failure, depression, anxiety, convulsions,       15 days or 
(benzodiazepines,  insomnia, coma, psychological/physical addiction, death      up to 2 weeks
roofies, Xanax,  following 
Valium)       heavy abuse

Marijuana, Hashish   Smoked or Damage to short-term memory and lungs, psychosis,  Infrequent 
(cannabinoids,           eaten psychological dependence, birth defects user:
reefers, grass,  up to 10 days
blunts)      Chronic user:
30 days or
more
Cocaine Inhaled, Damage to nasal passages, weight loss, high blood 24 days 
(coke, crack, blow,     injected, or        pressure, heart attacks, strokes, convulsions,
nose candy)              smoked  psychological or physical addiction, death
Hallucinogens Orally or in High blood pressure, loss of appetite, sleeplessness, 12 days
(LSD, white  eye drops anxiety, flashbacks, tremors, psychological disorders
lightening, acid, 
microdot)        
Heroin, Morphine     Orally, inject-  Loss of appetite, nausea, vomiting, respiratory failure,     23 days
(opioids, smack,        ed, inhaled, or   convulsions, coma, psychological or physical 
china white, brown     smoked            dependence, death
sugar, percs)          
PCP       Orally, Dulled coordination and senses, anxiety, depression,       38 days
(phencyclidine, angel injected, or       high blood pressure, convulsions, violent behavior,
dust, rocket, fuel,       inhaled             heart failure, stroke, coma, death
hog) 
Synthetic Narcotics Orally,  Nausea, vomiting, respiratory failure, infections from        14 days
(Demerol, Dilaudid,    injected, or needles, convulsions, psychological/physical addiction,
Darvon, methadone) inhaled death  

-----------------------------------------------
DEVELOPMENTAL CHANGES 
FOR ADOLESCENTS

Normal Development in Adolescents

Characteristics of Early
Teen Years
Often has extreme emotions
Begins to assert himself or herself; is
no longer a child
Shifts back and forth from relatively
mature to childish
Is concerned about appearance to
others
Searches for self-understanding
Is often happy and outgoing
Relates successfully to adults and
peers
Can be sensitive
Likes developing his or her own ideas
Has more worries than fears
Likes showing individuality 
Characteristics of Late
Teen Years
Has somber, quiet demeanor
Establishes his or her own beliefs
Wants to know where adults stand on
issues
Is relatively uncommunicative
Resents infringements on his or her
freedom
Divorces himself or herself from 
family activities
Has group friendships
Is in the first stage of real 
independence        
Has increased interest in sexual 
activities
Is more autonomous with respect to
parents 
(Continued on next page)

-----------------------------------------------
Adolescent Developmental Phases
Normal
Becomes more egocentric and self-
involved 
Anticipates consequences of actions
Looks for fairness; can detect logical
inconsistency
Is preoccupied with his or her own
thoughts
Is somewhat withdrawn and isolated
Is moody
Has intensified feelings
Debates and argues for the sake of
argument
Questions adult decisions and 
authority
Changes previously held values
Questions values and family rituals      

Feels accepted by chemical users
Feels pressured to conform to drug
group
Feels chemicals work first time,
every time to make a person feel
good
Feels more self-accepting
Chemically Dependent
Cannot see reality of his or her own
condition
Confuses what I am with what I
do
Thinks drug is me
Blames others for his or her own 
feelings
Identifies himself or herself as a
druggie; is obsessed with drugs and
drug-using activities
Is socially withdrawn
Becomes excessively moody due to
chemical use
Has inflated image of his or her own
importance
Feels indifferent to criticism
Debates and argues with authority
Rejects previously held values and
authority
Rejects previously respected authority
figures
Remembers selected information

Motivation for Adolescent Drug Use 

Finds it easier to have a relationship
with chemicals than with a person
who can reject him or her
Feels less inhibited when using 
chemicals
Uses drugs to numb bad feelings
about self and others

-----------------------------------------------
Parent Education Session 3: Relapse Signs and Recovery
General OverviewThis session focuses on understanding the recovery
process in the context of a healthy family and presents ways parents can
effectively help their child avoid relapse and how they can know when to
intervene appropriately. It also focuses on developing a healthy partnership
within the family and a commitment to a drug-free life as well.
RationaleThe more information parents have regarding the signs and
symptoms of relapse, the better able they are to intervene.
Materials
  Handouts:
u
Signs and Symptoms of Substance Abuse
u
Relapse Prevention Plan
u
Fire Drill Plan for Staying Drug Free
u
Signs of Recovery
u
Recovery Expectations
u
Plan for Recovery
u
Family Relapse Prevention Plan (in preparation for home visit)

Goal 1: To develop an understanding of the potential problems resulting
from continued use of drugs, including the process of addiction
1. Assist parents in recognizing the difficulties of parenting.
Write on the board: 
Our children are in trouble, and drugs have become a major part of
the trouble; our goal is to set out a new life for them and our families.
Ask a parent to read the statement and share his or her feelings about 
trying to meet this goal, the importance of reaching the goal, and the 
difficulties he or she foresees in reaching the goal.
2. Introduce the topic of recovery, and discuss the importance of family
involvement in the adolescents recovery.
Write on the board: 
The adolescent cant do it alone.
Discussion. Briefly present information on the importance of the familys
involvement in the treatment and recovery processes of the adolescent.
Family involvement helps build mutual responsibility and empathetic 
interactions between the parents and children. For example, say, The 
family is involved, like it or not. Whether children grow up to be healthy or
to be long-term drug abusers may be up to us. That is why we are here. We
care. We want to make a difference in their lives. We want our children to

39

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be healthy and have a good life. This is our chance, but we have to go about
it intelligently.
3. Discuss the signs and symptoms of substance abuse. 
Distribute the Signs and Symptoms of Substance Abuse handout. 
Advise parents that in addressing relapse prevention, they will look at two
issues: (1) signs and symptoms and (2) addiction. 
Remind parents that their children have made progress in their commitment
to treatment and not using substances. 
State that parents must still remain alert. This does not mean that they
should distrust their child. However, they must remember to stay aware
because the child may not be completely out of trouble. Parents should
watch (though not obsessively) for the signs and symptoms of relapse that
are presented in the handout. Review the handout.
Goal 2: To develop an understanding of the recovery process and to learn
that recovery is a long process and that part of this process is relapse 
prevention
1. Discuss the recovery process, ways to prevent relapse, and subtle signs
of relapse.
Discussion. Recovery begins with some type of intervention. This 
intervention means that the person will receive knowledge and tools 
to help maintain abstinence. 
In addition to remaining drug free, it is extremely important that the youth
work on making healthy personal changes and understand relapse preven-
tion. This is where the family can make a difference.
Relapse prevention involves:
  Maintaining health. It is important to develop good health habits
to stay strong. This strength will give the youth the necessary
energy to combat problems and take care of himself or herself.
  Identifying all triggers. Triggers are events or things that 
initiate a desire to use.
  Identifying all danger points. Some days will be exceptionally 
difficult in the process of recovery. These critical times are 
related to the withdrawal of drugs from the body. The process 
of withdrawal is different for different substances. 
  Determining emotional growth issues. The individual must learn
to (1) deal with negative feelings (e.g., anger, guilt, loneliness,
stress, fear), (2) establish or reestablish values (e.g., not

40

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lying/being honest with oneself and the family), and (3) find new 
challenges.
  Addressing environmental or social issues. The affected individual
must find new activities, new friends, and new surroundings.
  Developing support groups. For some people, this is the most
important determinant of recovery. A support group can help 
with all areas of life where triggers to relapse often occur. In this 
intervention, the family is the support group.
2. Discuss and identify potential problems that can lead to relapse.
Discussion. Relapse is a process that starts well before the actual use of
drugs. If the individual is not practicing or using his or her coping tools on
a daily basis, the risk of returning to substance use increases.
Relapse Prevention Guidelines:
  It is important not to let a child deteriorate physically. This will
contribute to feeling poorly and will make it easier for urges to
sneak up on him or her.
  It is important for a child to be aware that old thinking can
return, which includes justifying negative behaviors and denial
(e.g., I can use once in a while). It is important for the person to
talk about the desire to use by letting someone know what is
going on in his or her life to trigger the urge.
  It is important for both parents and their child to be aware of
danger points and to plan to be particularly open and watchful
with one another during these times.
  It is important for a child to share feelings. Feelings are always
eventually expressed, either in a direct, healthy manner or in an
indirect, negative manner. Painful feelings about past events may
need to be discussed. Parents should share with their children
how past events are still affecting the family to begin the healing
process.
  It is important for a child to develop new interests and activities.
Slowly, he or she needs to begin to become involved with new 
people and to explore ways to make new friends. Children should
be aware that even adults have to do this sometimes.
  It is important for your child to identify a support system and
maintain regular contact with that support system. This support
could include a coach, minister, neighbor, and/or a relative.
Distribute the Relapse Prevention Plan and Fire Drill Plan for Staying Drug
Free handouts. Discuss handouts with parents. Explain to parents that their

41

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teens may be filling out forms similar to these during their counseling 
sessions.

3. Present the Signs of Recovery, Recovery Expectations, and Plan for
Recovery handouts. 
Distribute the Signs of Recovery and Recovery Expectations handouts, and
discuss what parents can expect as their adolescent begins the recovery
process. Review the Plan for Recovery, and explain that parents who 
understand the problems that adolescents may encounter during recovery
can develop a plan to cope with situations. Explain that the more prepared
parents are, the more they can help their child deal with potential relapse
issues. Elicit discussion from all parents about the feelings adolescents 
may have during treatment and early recovery and how a parent can react 
effectively.
4. Introduce the importance of a family relapse prevention plan, and
explain the need for the adolescent abusing drugs to have a relapse 
prevention plan.
Discussion. Present the research that shows that relapse prevention plans
increase the chances of recovery and enable individuals and families to 
preplan strategies for troubling times. A good resource for information is
Bell (1992). Bell is a prominent researcher and author on the subject of
adolescent addiction, relapse, and recovery. 
Discuss the essential components of an effective plan (e.g., awareness of the
problem, problem-solving methods, where to get help, necessary changes in
family routines).
Point out that relapse is a process and not an event. Encourage a discussion
that explores the concept that relapse starts long before the return to 
substance abuse or a return of family dysfunction. Refer to the Signs and
Symptoms of Substance Abuse handout discussed earlier. Discussion should
center on the need for awareness of typical signs and symptoms of family
and individual relapse to prevent rapid deterioration.
Distribute the Family Relapse Prevention Plan. Instruct parents that they,
and each member of the family, must briefly answer each item. For
instance, under Previous Signs, ask each member to name a sign or 
symptom that the family displayed that caused problems. An example from
one child might be, There was always a lot of yelling, and no one listened
to anyone. Under the item If the family has a problem, each member
writes down something about the problem that he or she will commit to
doing. For example, the parent might say that if there is a problem, he or
she will bring it to the attention of the whole family immediately. Under
Support Groups and Meetings, each member writes down the name of 
the group he or she will commit to attending.
The importance of this relapse prevention plan is to acknowledge the 
previous signs of problems and commit to doing things differently as 

42

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individuals and as a family unit. The counselor should ask family members
to work on it at home. The inhome therapist will review it with them during
home visit 3. At that visit, all family members will discuss their ideas with
the therapist. The therapist will help them finalize the plan and will ask
each member to sign the final plan.
5. Provide parents with information about community support groups.
Discussion. Share information about Alcoholics Anonymous (AA), Narcotics
Anonymous (NA), and other community support groups. Provide information
about where and when the meetings occur. Discuss the importance of having
a support network after treatment, and note that the recovery process does
not end with this program.
6. Discuss questions regarding relapse and recovery. 
Allow parents to expand this discussion to address their concerns. Ask
group members to share what they expect from treatment. Encourage them
to discuss what they can do and to continue this discussion at home. Ask
the following questions:
  What do you expect from treatment?
  How can you help with this process?
  How long term is the problem?
  What changes will you have to make?
  Are you willing to make changes in the way you do things?

43

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SIGNS AND SYMPTOMS OF 
SUBSTANCE ABUSE

If you notice any of the following, you may want to seek help 
immediately.
  Physical signs of renewed substance use:

u
Peculiar odors of marijuana, alcohol, or solvents on your child, on
his or her clothing, in the house, or in the car

u
Presence of drugs or drug paraphernalia in your childs 
environment or in dirty laundry (e.g., presence of seeds, leaves,
or butts in ashtray or clothing pockets; use of small baggies, 
cigarette papers, or other unusual small containers)

u
Use of eye drops, room deodorizers, or incense

u
Slurred speech or intoxication (Note: Impairment of physical 
function may signal an event requiring immediate medical 
attention. In a medical emergency, call 911.)
  Noticeable change in school performance (e.g., drop in grades or 
attendance, disciplinary reports from the school)
  Sudden change in social pattern (new friends, activities, choice of
music, etc.)
  Secretiveness about friends or activities
  Sudden change in family relations (withdrawal, belligerence, marked
increase in family arguments either with parents or with siblings, 
especially regarding setting limits)
  Noticeable change in personality (lethargy, loss of motivation or interest)
  Sudden changes in mood (e.g., aggressive anger, sullenness, uncaring 
attitude and behavior)
  Deterioration in physical appearance (general unhealthy appearance,
bloodshot eyes, lack of alertness, decrease in neatness or personal
hygiene)
  Involvement in legal problems or delinquent behavior
  Unusual financial problems, repeated pawning or selling of personal
effects
  Extreme dress, language, opinions, or behavior.

-----------------------------------------------
RELAPSE PREVENTION PLAN

Relapse is preventable. By answering these questions, you become aware of 
possible relapse-producing events or causes. This plan can work against your
usual excuses. Please be specific, and, if possible, answer each question with
more than one answer. Remember, the more you put into it, the more you
get out of it!
How many 12-Step (or other self-help) meetings will you attend? Please 
indicate the place, day, and time.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
What times are you most likely to use alcohol or drugs? What will you do
instead? Be specific.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
What actions will you take when you get angry or frustrated? Please indicate
immediate and future actions. 
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
(Continued on next page)

-----------------------------------------------
Describe your plan to handle situations that make you afraid. 
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
What life events or losses could cause you to use drugs or drink?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Make a list of those people who can give you support in times of need.
Indicate how often you will meet with them.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Will you be able to ask these people for help? Write down how you will
ask them for help.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

(Continued on next page)

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How will you start each day? End each day?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
What are some positive actions you can take when you are lonely?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
What are some positive actions you can take when youre not getting along
with friends or family?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
What are some actions you can take if 12-Step meetings begin to feel boring
or unimportant?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

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FIRE DRILL PLAN FOR 
STAYING DRUG FREE

____________________________  ______________________
Name Phone number

_______________________________             ________________________                      
Sponsor, AA, NA Phone number

_______________________________             ________________________
Counselor Phone number

_______________________________             ________________________                      
Other support Phone number

Smoke Plan: If I am in a crisis situation, this is what I will do!

What emotions can trigger 
drinking/drug using? Planned preventive action
_______________________________             _______________________________
_______________________________             _______________________________
_______________________________             _______________________________
_______________________________             _______________________________          
What situations can trigger 
drinking/drug using? Planned preventive action
_______________________________             _______________________________
_______________________________             _______________________________
_______________________________             _______________________________
_______________________________             _______________________________          
If I return to drinking/drug using, this is what I will do!
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________          
This is a plan of actionTOUGH LOVEbecause I want to be part of the solution
and not part of the problem. This fire drill may need to be updated at some time. I
am open to discussing any changes and open to asking an influential person to
help.

Date:_______              Signature of client:______________________________              
Date:_______              Signature of counselor:___________________________             
Date:_______              Signature of parent/guardian:_____________________

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SIGNS OF RECOVERY

The Recovering Person:
  Continues to build a sober lifestyle 
  Respects the boundaries of oneself and othershas
reasonable expectations
  Builds relationships with people who share the same
values and the desire to live responsibly
  Continues to trust others and to gain the trust of others
  Finds being honest and trustworthy gets easier and
easier
  Has a network of support (AA, NA, faith-based
groups, parents, coaches, teachers), and expresses a
sober belief system in word, deed, and thought
  Makes reasonable short- and long-term goals, and
begins to achieve them
  Avoids those who abuse drugs and places where they
are being used.
The Recovering Family:
  Ensures that the family home is a place that becomes
increasingly comfortable and peaceful for its members
(It does not have to be perfect all the timethats
an unrealistic expectation.)
  Remembers to fight fair, respect one another, and give
support when others need it
  Celebrates the accomplishments of each member, and
shares feelings of joy, pain, fear, and excitement
  Continues to grow to form a lifelong FAMILY SUPPORT
NETWORK.

-----------------------------------------------
RECOVERY EXPECTATIONS

1.  It is not necessary to promise sobriety. Slips happen, so plan
to deal with them. Broken promises only increase guilt and
failure.

2.  Watch for unrealistic expectations. At this point in recovery,
it is important to keep feelings of resentment and disap-
pointment to a minimum. These feelings can be used as an
excuse to return to substance use.

3.  Be aware of how the adolescent deals with and expresses
anger, frustration, and depression. Discuss plans to deal with
these emotions as a family.

4.  Physical and emotional pain will be more pronounced 
without substance use. Families need to be aware of this 
and have a plan to deal with emotional pain.

5.  Rebuilding trust will take time for the family. Overcoming 
suspicion and distrust is a slow process.

6.  Often, the early recovery stage includes the pink cloud
effect. During this time, adolescents may feel happy with
themselves and have a sense of power. This usually lasts
between 1 and 4 weeks. Remember, nonusing adolescents
emotions are typically up and down as well.

7.  When quitting substance use, some adolescents experience
a feeling of loss. Grieving the loss of drugs is a healing
process. Try to be patient.

8.  Recovery is a time for adolescents to become honest with 
themselves and with others. This process of honesty can
result in hurt or harm to the family as a whole and to its
individual members. Family members may need to confront
one another, apologize, listen, make amends, and leave the
past behind.

-----------------------------------------------
PLAN FOR RECOVERY

1.  Adolescents need plenty of rest, and they need to eat properly. Sleep patterns
are disturbed during early recovery by nightmares, short sleep periods, and
restlessness. 

2.  The adolescent will have more free time, time that was previously spent
using drugs. A plan needs to be developed to spend free time positively.

3.  Alcohol and drugs need to be removed from the home. Prescriptions must
be secured in a medicine cabinet. Parents need to be aware that other items
around the house can be used to get high. These include gasoline, chemicals
under the sink and in the garage, and whipped cream and other aerosol
cans.

4.  It is important for the adolescent and family to be involved in support
groups.

5.  It is important to keep the concept of sobriety as a priority.

6.  Families need to understand triggers causing the adolescent to slip. (The
relapse plan homework helps in understanding these triggers.)

7.  Rewarding and celebrating are important areas to discuss and plan.
Celebrations are often occasions when the adolescent would likely use
drugs.

8.  Stay focused on the here and now. The idea of never using again is too
overwhelming. It is important to take 1 day at a time.

9.  The adolescent needs to avoid settings where drugs and alcohol are being
used. Relationships with nonusing peers need to be developed and 
encouraged.

10.  Overall, be patient and communicate. Changes in the family, even good
ones, are stressful. Everyone needs to work together. 

-----------------------------------------------
FAMILY RELAPSE PREVENTION PLAN

Instructions: This worksheet will help you and your family think and talk about what each fami
ly member will do to prevent a relapse. Discuss each item with your family at home. To help get
a discussion going, ask the opinions of each child. Remember that each commitment reinforces
that the whole family is making a pledge to recovery. (Use the back of the form if more space is
needed.)
The therapist will discuss the plan with your family during home visit 3. During that visit, the
therapist will review the draft with the family, confirm all members commitments, and ask that
all members sign the plan. A copy will be made for each family member and the therapist.

Commitments  
Mother  Father  Client  Sibling 1  Sibling 2  Sibling 3

(Continued on next page)
Communica
tion: I will
improve my
communications
by always . . .

Fair Fighting:
I will fight fair
by always . . .

Improving
Trust: I agree
to improve trust
and be more
trustworthy by . . .

Healthy
Habits and
Activities: I
believe . . .  are
healthy habits
and activities for
me.

-----------------------------------------------
Commitments  
Mother  Father  Client  Sibling 1  Sibling 2  Sibling 3

Previous
Signs of
Problems:
When . . .  hap 
pened before, it
was a sign that
things were not
going well.

Concerns on
Warning
Signs: I agree
to accept concerns
from all family
members.

If the family
has a prob
lem: I agree to
. . .
Support
Groups and
Meetings: I
agree to attend
support group
meetings.

We agree to do our part in meeting the Family Relapse Prevention Plan. (All members sign below.)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

-----------------------------------------------
      Parent Education Session 4:   
Boundaries, Limits, Authority, and Discipline
General OverviewThis session provides clarification of major issues in
family functioning and appropriate approaches to discipline and parental
authority. It helps parents understand the sources of authority in the 
family and how authority is maintained in a healthy way. The concept of
boundaries is introduced as a major issue in family structure.
RationaleThe more information parents have regarding parental
authority, the better able they are to intervene in their childs behavior.
Materials
  Handouts:
u
Setting Boundaries and Limits
u
Characteristics of People With Unhealthy Boundaries
u
Parent Guidelines
u
Parent/Child Contract

Goal: To teach participants how to set limits and boundaries, establish
appropriate discipline methods for youth, recognize characteristics of
unhealthy boundaries, and develop a parent/child behavioral contract

1. Discuss the process parents undergo in developing discipline.
Discussion. Present the following in narrative form. 
We are different from our children. We know the rules. We know that if you
use your credit card, a bill will come in the mail and the bank will expect
you to pay it. Small children are helpless and they depend on us entirely. 
As they grow and learn, we have to guide them by setting rules and 
expectations. When our children become teenagers, it is a confusing time
for us, but an even more confusing time for them. So rules are important,
even if the reason for the rules is not obvious. We are going to discuss how
to develop a set of age-appropriate rules for your children, how to get their
compliance with those rules, and what to do if the rules are broken.
It is important to realize that drug behavior is associated with rebellion,
risk taking, stress reduction, identity formation, and assertiveness. Parents
must provide structure, limits, and direction for their teenagers. Parents
can build contracts with teenagers allowing them freedom of choice 
(within structured limits) but also defining consequences for failure to
maintain the contract.
Distribute the Setting Boundaries and Limits handout. Allow time for 
parents to read the handout.
Discussion. Answer questions or ask whether parents need clarification on
the concepts before continuing. Ask parents whether they have examples to 

54

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help clarify the guidelines. Ask whether any guidelines are particularly easy
or hard to do.
2. Define boundaries, and explain the need to develop boundaries with
children. Distribute the Characteristics of People With Unhealthy
Boundaries handout.
Discussion. State, Knowing boundaries involves taking care of ourselves,
no matter what happens or with whom it happens.
Write on the board: 
Healthy boundaries are taught and are learned as a result of life 
lessons. Knowing healthy boundaries can be beneficial. 
Boundarysomething that indicates bounds or limits
Boundinseparably connected with.
Boundaries emerge from: 
  Deep decisions about what we believe we deserve and dont
deserve
  What we want and need
  What we like and dislike
  What is important to us
  A deeper sense of our personal rights, especially the right we have
to take care of ourselves (Boundaries emerge as we learn to value,
trust, and listen to ourselves.)
  Deciding what is good for us and for others.
Discussion. Review the characteristics of unhealthy boundaries. Discuss 
the Characteristics of People With Unhealthy Boundaries handout. Ask the 
parents to discuss signs of unhealthy boundaries between parents and their
children. Point out, Unhealthy boundaries lead to resentment, unhappiness,
and a feeling of dissatisfaction and can damage relationships. One person
may be hurt in this kind of relationship and will eventually distance himself
or herself and may leave the relationship.  
3. Introduce the topic of setting limits with children.
Discussion. Distribute the Parent Guidelines handout to the participants
and discuss.

55

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Distribute and discuss the Parent/Child Contract handout. Conduct a 
practice exercise by having parents develop a contract for a 16-year-old 10th
grader. Explain that parents may want to use this contract as a guide when
filling out the Family Contract during home visit 1.
Assignment. Ask parents to practice setting limits and rules for teens by
completing a parent/child contract with their child.
Before they start, ask, What are the difficulties in setting limits and
boundaries when your child is exhibiting rebellious behavior? What are 
reasonable limits and expectations?
Then discuss the following: 
 Feelings of uncertainty and guilt when disciplining teens
 How parents can know their own boundaries and limits of 
tolerating teen behavior 
 How parents can take care of themselves
 Where to draw the line.

56

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SETTING BOUNDARIES AND LIMITS
As a parent it is important that you:

1.  Show confidence in the teens 
ability to make decisions
2.  Support your teen without 
suffocating his or her interests
3.  Allow your teen to experience
the consequences of his or her
behavior
4.  Learn to say no when appropriate
5.  Exercise leadership without giving in and without
fighting
6.  Learn that both coercive and pampering approaches to 
parenting steal initiative and self-confidence from your
teen.

Setting Rules and Limits
1.  Establish and discuss rules and limits with your child
before they need to be enforced. These rules should be
appropriate for the childs age and abilities.
2.  Make sure that the consequences for not abiding by the
rules are clear.
3.  Make only rules you can enforce. A child will test rules
to see whether the consequences are real. It is crucial
that you are consistent in enforcing the rules.
4.  Remain fair but firm with your child.

(Continued on next page)

-----------------------------------------------
5.  If you have a spouse or a significant other involved in
the rearing process, make sure you and that person
work together, that you agree on the set rules, and that
you are consistent in disciplining. Unity of parents
helps discourage the child from playing divide and
conquer and provides a feeling of stability for the
child.
6.  Remember, if the child intentionally, willfully, or 
arrogantly breaks a major rule, the child has made the
choice to be disciplined. Discipline is not something
the parent does to the child but is something that is
done for the child.
7.  When grounding your child, set a realistic time that
can be adhered to (e.g., 6 months is not realistic, but
the weekend is realistic). Make the consequences 
natural and logical (e.g., the child didnt bring the car
back on time so the child cant use the car for 1 week).
8.  Make the rules explicit by forming a verbal or written 
contract with the child. The content of the contract
includes behaviors you want from the child (e.g., 
cleaning his or her room) and behaviors you dont 
want from the child (e.g., staying out past curfew),
rewards for exhibiting positive behaviors, and 
consequences for breaking the rules. 
9.  Let the punishment fit the crime. Consequences
should be natural and logical. Solicit input from your
childwhat does he or she think the consequences
should be? Focus on the most troubling behavior and
not on the little things.

-----------------------------------------------
CHARACTERISTICS OF PEOPLE WITH
UNHEALTHY BOUNDARIES

  We have an overdeveloped sense of responsibility and more concern for
others than for ourselves. This prevents us from looking too closely at our
faults.

  We hide traumatic feelings from childhood, and we lose the ability to feel
or express our feelings because it hurts too much.

  We have isolated ourselves from others and are afraid of people and
authority figures.

  We have become approval-seekers and have lost our identity in the
process.
  We are frightened by angry people and any personal criticism.

  We live from the viewpoint that we are victims and are attracted to 
friendships and love relationships that feed that weakness.
  We judge ourselves harshly and have low self-esteem.

  We have dependent personalities and are terrified of abandonment. We 
will do anything to hold onto a relationship, so we do not experience the
painful feelings of abandonment that we have from caring about people
who were never there for us emotionally.

  We experience guilt feelings when we stand up for ourselves.

  We confuse love and pity and tend to love people we can pity and rescue.

  We have become chemically dependent, married a chemically dependent
person, or found another compulsive personality, such as a workaholic, to
fulfill our own compulsive needs.

  We are addicted to excitement.

  We are reactors in life rather than actors.

-----------------------------------------------
PARENT GUIDELINES
Identify your limits as parents regarding your childs drug abuse problem
and recovery.
Despite concerns, parents:
q Cannot control behaviors and attitudes of a drug-abusing teen
q Cannot prevent all bad things from happening 
q Cannot dwell on guilt over past failures
q Cannot try to rescue teens who get into trouble because of their poor
judgment and bad behavior
q Cannot try to rescue a teen because this will lead to irresponsibility and
resentment in the child (We all learn from mistakes.)
q Cannot give in to unreasonable demands that will encourage more bad
behavior
q Cannot scold, lecture, reason with, or threaten teen.
Parents can work for healthy survival of their family by:
q Managing their home the way they see best
q Practicing patience to become strong and skilled in dealing with drug-
related behavior
q Loving with a firm approach that at times is difficult to implement
q Detaching themselves from the burden of worry and responsibility (The
abuser must take responsibility for his or her behavior.)
q Continuing to care with clear, firm guidelines about what is acceptable
behavior
q Making treatment available to the abuser and realizing parents cannot
force adolescents to benefit from the treatment.
Remember:
q Recovery is a long process and begins with 1 day at a time, so try not 
to become disillusioned too quickly.
q Love, hope, faith, and patience are the cornerstones of recovery, 
especially for parents.

-----------------------------------------------
PARENT/CHILD CONTRACT

RESPONSIBILITIES  S    M    T    W    T    F    S          CONSEQUENCES 

POSITIVE       NEGATIVE

Parents/Guardians Signature:_______________________________________
Childs Signature:__________________________________________________
Date:______________________________________________________________

-----------------------------------------------
         Parent Education Session 5: 
Communication, Conflict Resolution, and Fighting Fair
General OverviewThe purpose of this session is to enhance parents
understanding of how and why conflict inevitably happens in families,
impart concepts and methods of healthy communication, and teach 
techniques for engaging family members in open and fair conflict 
resolution. Conflict is presented as a learning process, and ways to 
prevent it from becoming dangerous to the individual and family are 
discussed. Techniques for dealing with conflict through negotiation are
also presented.
RationaleThe more information parents have about understanding
healthy communication, conflict resolution, and timing negotiations with
teens, the better able they are to improve communication in the home.
Materials
  Whiteboard and markers
  Handouts:
u
Tips for Fighting Fair
u
Ways To Improve Communication With Your Teenager

Goal: To teach parents how to communicate effectively, how to have 
arguments using fair rules, and how to resolve conflicts with adolescents

1. Introduce and encourage discussion on conflict resolution, and 
motivate the participants to learn the information.
Discussion. 
Write on the board: 
When one seeks to win, both lose.
Ask the group to explain this statement. Lead the group to the concept of
conflict resolution. Ask parents to indicate by a show of hands which members
of the group have experienced a recent conflict with their teen. Ask
whether any parents would like to share what the conflict was about.
Encourage other parents to contribute to the discussion or acknowledge
others in the room who are relating to the topic by nodding their heads, etc.
Ask the group to consider the question, Why do conflicts occur between
parents and their children? Write the responses on the board. Examples
could include because children want freedom and parents want to keep a
handle on their children; because family members fight rather than listen
to one another; because each member feels he or she is right.

62

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Ask the group to identify the most important tool for conflict resolution.
Encourage involvement until communication is mentioned. Let the group
know this is the most important tool. 
2. Introduce the topics of mutual respect in communication and effective
communication tools. Identify specific guidelines for fighting fair. 
Discussion. Present the following information in narrative form: What we
want is communication among family members to be based on mutual
respect. Mutual respect is allowing each other to express beliefs and feelings
honestly without fear of rejection. Although one may not agree with the
other, both can demonstrate acceptance of each others feelings. The goal
of this communication technique is to help the person feel understood.
Effective listening may also allow people to clarify their feelings and work
out their own solutions.
Discuss personal qualities that can interfere with communication. Examples
include the following:
  Being impaired or preoccupied with other personal problems
  Being angry
  Being insecure
  Not meeting personal needs
  Being task oriented
  Being too critical  
  Being too busy
  Not accepting problems; wanting a perfect family. 
Allow the group to come up with its own list, but use these ideas to 
stimulate conversation.
Briefly highlight ways to improve communication with teenagers, such as
the following:
  Remembering that effective communication is based on mutual
respect
  Having a willingness to listen
  Remembering to listen to ideas or beliefs that you may not agree
with; you do not have to agree, just listen
  Trying not to criticize the other person
  Providing the opportunity to work through feelings.
Identify specific guidelines for fighting fair.
Discussion. Distribute the Tips for Fighting Fair handout. Review and 
clarify the tips with parents. Ask whether parents have anything to add.

63

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3. Distribute the Ways To Improve Communication With Your Teenager
handout. 
Briefly discuss each point and provide examples when necessary. Ask parents
whether they have questions about the ways to improve communication.
Ask whether anyone needs an example to make any of these ideas clearer.
4. Discuss how to build or rebuild relationships in the family.
Discussion. Explore ways to rebuild relationships in the family. Mention
that the family should: 
  Try to focus on other members positive qualities
  Think about what the relationship would be like if the stress of
substance abuse had not entered the picture
  Strive toward this ideal relationship
  Set time aside to have fun (During this rebuilding time, avoid 
disagreements.)
  Identify opportunities to communicate
  Identify areas of mutual interest
  Set aside time to do something together, even if it is only once
every couple of weeks. 
Discussion/Roleplay. Ask some parents to be volunteers to roleplay a 
scenario that another parent describes. An example may be a teenager
wanting a curfew of 11 p.m. changed to 1 a.m. When the roleplay is over,
discuss the conflict resolution techniques used; ask for other techniques
that could also have been used.
Tell volunteers they should try to use the tips in the Tips for Fighting Fair
handout and the Ways To Improve Communication With Your Teenager
handout.
Wrap up the session by asking for questions and asking parents what 
conflict resolution techniques they could easily begin using at home.

64

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TIPS FOR FIGHTING FAIR

Select a Time: Pick a time that is right for both participants.
Stay on Track: Discuss one issue at a time. If more than one topic/problem
come up, write them down.
Maintain Respect: Do not allow sarcasm, put-downs, or discounts (disrespect
for what another person says). A good way to keep this type of communica
tion under control is to use a buzz word. Pick a word the family will use
to indicate a low blow. When someone says something that is cruel or
uses name-calling or profanity, use the buzz word as a signal. When the
buzz word is used, the person has to restate what he or she said, in an 
appropriate manner.
Use I Statements: Remember that problems begin with any sentence
beginning with you. NEVER START A SENTENCE WITH You always or
You never. Sentences should begin with I like, I dislike, I wish, etc. The
important thing is to focus on the behavior that was disturbing, not the
person.
Listen: When a person is finished with his or her side, encourage him or
her: I will listen now. This is the clue to the other person that he or she
can start assured that there will be no interruptions (unless, of course,
there is a low blow, in which case the buzz word can be used).
Stay out of the Past: Focus on here and now. Refer back to staying on
track, and keep to one issue at a time.
Use Feelings: Dont just state what bothers you; explain how you feel when
this happens. Often the other person will be willing to work on an issue if a
reason is shown to handle the situation differently. 

-----------------------------------------------
WAYS TO IMPROVE COMMUNICATION 
WITH YOUR TEENAGER

1.  Keep talking with the child. Avoid breaking the lines of communication.
2.  Exercise patience. Dont expect overnight miracles. Be ready for setbacks.
3.  Give attention to showing affection. Children of all ages need physical and
emotional contact.
4.  Be a good listener; understand what your child is saying to you.
5.  Be a wise listener; dont be naive, all-believing, or an overly judgmental listener.
6.  Dont be prejudiced.

7.  Demonstrate mutual respect; respect confidentiality.
8.  Dont rush. Rushing gives the teen the impression that you dont have the time
for him or her.

9.  Be supportive, encouraging, and friendly but also firm.
10.  Present your ideas clearly, firmly, and simply. Mean what you say. Say what
you mean. Be consistent and reasonable.

11.  Be a good behavior model for the teen. Avoid double standards.
12.  Avoid being caught in the middle. Dont assume ownership of a problem if the
problem is not yours.

13.  Be yourself. Be honest, sincere, and aware.
14.  Grow up with your teen. Dont wake up to find yourself years behind the 
development of your child.

15.  Encourage the teen to tell you his or her joys and sorrows but do not attempt to
pry, force, tease, or nag.

16.  Seek advice or develop yourself; you are never too old to grow.
17.  Remember that the key to communication is understandingnot who
is right or wrong.

-----------------------------------------------
Parent Education Session 6: 
The Family Context
General OverviewThis session helps adolescents and parents understand
the importance of the family in the recovery process and the nature of the
family as an interdependent system. Parents are educated on how family
functioning has both a direct and an indirect influence on the childs
behavior.
RationaleThe more information parents have on family dynamics, the
better able they are to identify their own strengths and weakness and to
intervene in improving their childs behavior.
Materials
  Whiteboard and markers
  Family mobile (any mobile may be used to illustrate the rigid balance
necessary when families operate in a dysfunctional manner) 
  Handouts:
u
Families as a Dynamic System
u
Family Roles (The Chief Enabler, The Family Hero, The Family
Scapegoat, The Lost Child, and The Family Mascot)
PresentationBuy or borrow a mobile; make overheads of family roles

Goal: To provide an understanding of family dynamics in recovery
1. Introduce the term family. 
Discussion. Present the following in narrative form:
We are participating in the program because our children have gotten into
trouble. We are beginning the journey to make changes for them and our
families.
We have all lived in families, so we know all about them. We are experts.
Right? You might be surprised just how little we all know about some of 
the most important aspects of family life and parenting. When we are 
being trained for a job, we learn things we did not know. When it comes 
to parenting, there is little formal training. There are aspects of parenting
that no one ever taught us. Often we have to learn on the job. Now that our
children have discovered drugs, it is more important than ever that we try
to learn how the family interacts, how one family members actions can
affect the rest of the family, and what families can do to help their children.
The family is not just a group of people living under the same roof, or at
least it should not be. We are related; we care about one another; and we
have obligations to one another. Sometimes, family members are lifelong
friends; sometimes they dont get along at all. But we are in this together, 

67

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and we can perhaps make more sense of our dilemmas if we understand the
concept of family.
2. Introduce the concept of the family as a dynamic system (the family as
a whole).
Discussion. Introduce the mobile by holding it up or hanging it from the
ceiling. Distribute the Families as a Dynamic System handout. Then read
the handout aloud.
Illustrate these points with the mobile. Show how the movement of one part
affects all the other parts. 
Explain how members will adapt their roles within the family to reduce 
family stress. Sometimes the family attempts to survive by repressing or
ignoring the problem behaviors and the resulting pain. The substance-
dependent person develops a unique set of defense mechanisms to hide 
and protect his or her true feelings.
Write on the board:
Substance Abuse = STRESS
Stress Is Uncomfortable
Families Reduce Stress by:
  Ignoring the problem behaviors, conflict, and pain
  Using defense mechanismsboth the chemically dependent and
other family members
  Taking on roles to stabilize the family.
3. Introduce the concept of family roles of individual members. Show
overheads of each role, or distribute the Family Roles handouts to 
participants.
Discussion. Explain that the information about family roles is the work of
many professionals in the field of substance abuse treatment and family
counseling. Information about the roles is presented on the handouts and
below.
Explain that teaching about family roles is not meant to imply that every
family demonstrates every role in the exact manner described in the 
handouts. Learning about the concept is a way for parents to understand
how families with substance-abusing members may experience stress. This
stress often results in the development of these rigid roles. These roles
allow the family to function, albeit painfully. 

68

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The Chief Enabler
Description: This is usually one or both parents. Because of the enduring
love and concern for the using child, the enabler has a difficult time 
allowing the substance-abusing child to experience the consequences of 
his or her actions and thus learn from mistakes.
Benefits for the family (how the chief enabler balances the mobile): The chief
enabler shelters or shields the chemically dependent adolescent from harmful
consequences. Unfortunately, this action can result in more harm than good.
Inner feelings: Feelings of anger, hurt, guilt, and low self-esteem are often
present. 
Examples of this behavior: This person covers up for the substance-abusing
child when he or she breaks promises; blames teachers and schools for the
problems the child is having; and does not report crimes to the police such
as stealing property, money, or the family car, vandalism such as knocking a
hole in the wall in anger, or hitting parents or other family members.
The Family Hero
Description: This person is a high achiever and may excel in school or
extracurricular activities.
Benefits for the family (how the family hero balances the mobile): He or 
she is the child whom the family brags about and who offers a sense of 
accomplishment for the family. Although the family may be having difficulties,
members can still feel that something is going well because of this childs
success.
Inner feelings: Unfortunately, this child is driven by his or her inner feeling
of inadequacy. He or she has a sense of self-blame and hopes that if he or
she is successful enough, the problems of the family will improve. No matter
what the child accomplishes, the child never feels as if he or she is good
enough.
The untreated child: Throughout adulthood, this vicious cycle continues.
This person continues to have an unrealistic sense of control and a need for
control. Many times the untreated hero child becomes a workaholic and an
enabler as an adult and marries a substance abuser.

The Family Scapegoat
Description: This person is the rebel in the family who tests the limits,
breaks the rules, and is usually the one in trouble. The family scapegoat is
often a middle child. 
Benefits for the family (how the scapegoat balances the mobile): This child
offers relief from the other problems in the home. It is easy to blame this
child for the problems in the family. These problems may also serve as a 

69

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reason for the family to stay together because the family needs to work
together to fix this child.
Inner feelings: This child blames himself or herself for the problems in the
family and often has poor coping skills; therefore, using substances provides
an outlet. However, this child usually sees the family more realistically than
other members. This child is often able to identify other family problems
and how he or she is sometimes blamed for them unfairly.
The untreated child: This child usually becomes a substance abuser. This
child experiences problems in school and home. If untreated, this child
chooses an unproductive path with negative results, such as ending up in 
a detention center.

The Lost Child
Description: This child is the quiet one who spends a great deal of time
alone, quietly entertaining himself or herself. This child likes isolating 
activities such as coloring, reading, and setting up elaborate fantasies 
with dolls, toy soldiers, or other toys.                                 
Benefits for the family (how the lost child balances the mobile) : This is the
child who never causes trouble and whom the family never worries about.
Similar to the hero child, the lost child provides a feeling of success in 
parenting because the child lacks problems. This is often a younger sibling.
Inner feelings: Often this child has little understanding of what is happening
in the family. His or her interest in isolating activities allows the child to
avoid the conflict that is going on in the family. This child lacks self-worth
partly due to the little attention he or she seeks or receives.
The untreated child: Depression is highly likely for this person. Interpersonal
relationships are difficult because of needed coping skills the child failed to
master. This person may experience difficulty with his or her sexual identity.
Substance abuse may develop because of an inability to cope with problems.

The Family Mascot
Description: This person is the clown and focus of attention in the home.
He or she enjoys entertaining the family, seeks attention, and is often the
baby of the family.
Benefits for the family (how the mascot balances the mobile): This child 
provides comic relief and a breath of fresh air that the family needs to
escape the pain of other family issues. 
Inner feelings: Self-worth is based on how others react. This child has a 
difficult time identifying his or her own feelings, being too busy trying to
affect others.

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The untreated child: Problems in school and other structured settings may
develop because of the childs need to gain attention from others. This
child has difficulty in intimate relationships because he or she has not
explored the inner self and does not know his or her own needs. The child
may use illicit substances to clown around or fit into the social lifestyle
he or she enjoys.
4. Debrief families about the new and potentially disturbing information.
Discussion/Roleplay. Explain to parents that the information about family
roles is often disturbing and may lead to misunderstandings if used 
inappropriately. As an example of how family roles interact, ask two parents
to volunteer for a roleplay demonstrating a conversation between the chief
enabler and the family hero about the scapegoat family member. Start the
exercise by providing examples of the family heros behavior. For example,
the family hero always gets straight As, is the pride of parents and teachers,
always does his or her chores on time, and may join the enabling parent in
discussing the deficiencies of the other family members, especially the one
causing all the problemsthe scapegoat. Give the following instructions:
You two are talking about how great the family would be if only 'you know
who would straighten up and do things the right way. The scapegoat got in
trouble again at school, and the chief enabler has to take time off, again, to
go to the school. Let them roleplay the conversation for about 3 minutes.
At the end of the roleplay, ask group members to comment on what they
saw.
Wrap up the roleplay by asking parents to share how closely it resembles
their family. Remember, this information is difficult to process because the
parents will begin to see reasons for the problems in their family and how
and why they are occurring. Allowing for time to debrief is important so
parents can share their surprise that much of this information is accurate
and describes their family.
5. Prepare families for upcoming topics that address the family recovery
process. 
Discussion. This step can be presented in narrative form.             
What are the implications of family for the recovery process? The potential
good news is that just as the chemically dependent person affects the family,
the family also greatly affects the teenager. Thus, the healthy functioning of
the family is critical at this point in the teens recovery.
We cant make all changes overnight. We need to concentrate on small 
but important ways to make positive changes. We need to understand that 
children need rules that are applied consistently. We need to understand
that children know we care about them. But we need to hold children
accountable for their own behavior.                                           
Discuss how everyday events in family life can precipitate drug use. Use 
concrete examples.

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Next, present the following information:
Recognition, acceptance, and understanding of each members role in the
family disease of substance abuse are necessary for full family recovery. In
the FSN treatment program, we provide information, teaching skills, and
tools to recognize and address the issues of substance abuse in the family.
When we say 'recovery, we mean a lengthy  process of healing. During this
process, you will increase awareness, address feelings, and learn to forgive.
This process of healing is ongoing and long term.
6. Provide parents with information that will help them choose a new
direction for their families.
Ask families to recommit to the program, and stress the importance of 
continuing with treatment to help the child.
Discussion. The following questions can be provided on a handout, read
aloud, or shown on the board. Encourage answers from the families:
  How can the information presented be of practical use in your
own family?
  What important observations have you made during these sessions
regarding family structure and function?
  Some caregivers are single parents; others are grandparents. How
do these situations affect such aspects as authority and division of
work in the house?
  Does the family have schedules and rituals? Are they strictly
enforced or are they loosely constructed and seldom followed?
How does the lack of either or both affect the recovery of the 
adolescent? How does the lack of either or both affect the 
recovery of the family? How can a family go about developing a
better schedule? Are routines followed at suppertime, on holidays,
or on birthdays? What sorts of rituals can a family develop that
can be longlasting and meaningful and yet not create hardships
on the family and its members?
  Who are the parents and who are the children? Why is it 
inappropriate to regard adolescents as small adults?
  How does the information presented help you understand what
goes on in your family?
  How does your parental behavior affect your family? Discuss the
topic of enabling.
Wrapup. Encourage a wrapup discussion of the six sessions. Ask parents to
think about key points covered in each session and how they can be applied 

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in their homes. Ask families to reaffirm their commitment to helping their
children.

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Families as a Dynamic System

Families operate as a system. Their parts are interdependent. 
A system is a body of parts that work together. They may work
together for peace and harmony. They may work together for
destruction. They may work together for survival. Roles, 
relationships, communication styles, and power distribution 
balance the system. Substance abuse unbalances that system. 
Families react and adjust in a way that will rebalance the system;
they try to achieve stability. In a healthy family (no family is
healthy all of the time), both the system and individual needs are
met. The family system is fluid yet predictable. In a family with
one of the members who is chemically dependent, things are not
stable and predictable. This disruption in the family system affects
everyone in the family, not just the affected teen or the parent.
Substance dependency is a family disease, not just a primary 
disease within the individual family member.

Author Unknown

-----------------------------------------------
The Chief Enabler
Note: May be one or both parents. One or both parents may
have alcohol or drug problems.
BEHAVIORS: Shelters and shields the substance-abusing
family members, makes excuses for and may
lie to protect the substance abuser, minimizes
negative consequences, blames others for the
problems, sometimes sabotages progress
toward recovery
FEELINGS: Anger, hurt, guilt, resentment, anxiety, fear, 
desperation to control everything, helpless,
hopeless, exhausted

Offers the family a sense of stability and protection

-----------------------------------------------
The Family Hero
BEHAVIORS: Is a high achiever, excels, leads, is very busy,
takes on many tasks, almost never says no,
responds to adults, is controlling
FEELINGS: Anxiety, inadequacy, unworthiness, resentfulness,
self-blame, loneliness
AS AN ADULT: Has an unrealistic sense of control and a
need to control, needs approval, feels 
overly responsible or may act irresponsibly
when overwhelmed

Offers the family a sense of being OK

-----------------------------------------------
The Family Scapegoat
BEHAVIORS: Rebels, tests limits, breaks rules, usually gets
in trouble, acts aggressively and angrily; uses
substance abuse as an outlet and relief from
pain; sometimes uses extreme language and
behaves and dresses inappropriately (but 
usually has the most realistic picture of the 
family)
FEELINGS: Anger, confusion, resentment, inadequacy, self-
blame for family problems, feeling of being out
of control
AS AN ADULT: Typically has progressive substance abuse
problems; has many problems throughout
childhood, adolescence, and adulthood;
may have progressive involvement with the
criminal justice system
Offers the family a sense of purpose and provides 
the family with someone to blame for its problems 

-----------------------------------------------
The Lost Child
BEHAVIORS: Is quiet, is a daydreamer, isolates himself or
herself, fantasizes, avoids conflict, is passive
FEELINGS: Loneliness, fear, unworthiness, inadequacy, lack
of fulfillment
AS AN ADULT: May have problems with depression and
difficulty with interpersonal relationships;
may have alcohol or drug problems due to
inability to cope

Offers the family a sense of relief and success 
and is no trouble to the family

-----------------------------------------------
The Family Mascot
BEHAVIORS: Acts as class clown, seeks attention through
humor and acting out, uses humor to keep
people at a distance, is seldom serious
FEELINGS: Anxietymeasures self-worth by how others
see him or her; anger; hurt; loneliness
AS AN ADULT: Has problems in school and at work, seldom
forms intimate relationships, clowns
around or is the life of the party, may
develop substance abuse problems
Offers the family a sense of comic relief from the pain

-----------------------------------------------
III. Home Visit Procedures 
Introduction
Family involvement is essential in this method of treatment. Inhome services
increase the likelihood that families will be involved in the recovery process
of their children. Therapists who are able to view the family in the home
environment are more likely to accurately assess the family dynamics that
affect an adolescents use and abuse of drugs and alcohol.
This manual does not give specific dialogs or examples for the home visits.
To do so might impede the therapists ability to adapt to the cultural, 
ethnic, or individual needs of the family. These sessions were not designed
for counselors with minimal training. The therapist should have the 
experience and education to conduct the family sessions and be familiar
with the familys dynamics. All families are unique. The therapist must be
flexible and adapt to the particular needs of the family while working
toward the goals and objectives of the family sessions.
Each 90-minute session has particular goals. The overall goal of the home
visits is to motivate the family to actively participate in the treatment and
recovery of the adolescent, thereby improving positive outcomes. Generally,
the therapist makes four home visits. Some families, however, make such
progress during the session that they are able to cover more material than
that specified for the visit. In these cases, the therapist should be flexible
and prepared to continue the session with the material scheduled for the
next visit. 
It is important to approach the family from a position of assets rather
than deficits so that the family is hopeful and believes it has the power to 
overcome problems and achieve success. In addition, the therapist must act
as teacher to increase the parents ability to regain control of their family
and establish a nurturing environment that encourages positive development.
The therapist should incorporate effective cultural competence and sensitivity
to the ethnic, religious, and cultural needs of the adolescents and their 
families. At every home visit, attendance at all treatment activities 
(12-session motivational enhancement therapy/cognitive behavioral therapy
[MET/CBT], the parent education sessions, and any additional services
[e.g., parent network support groups, 12-Step community recovery groups])
should be reinforced.

Rationale
Office visits often do not reveal enough information about a family to assist
therapists in encouraging needed changes. By visiting the home and the
neighborhood and by seeing the family function outside a formal office,
therapists are more likely to increase their understanding of how the family
naturally functions, who has the power in the family, and the conditions
under which the family operates.

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Review of Procedures
Appointments should be confirmed 1 week before the visit and reconfirmed
24 hours before the visit. The call that is made 1 week before may be made
by an assistant; however, the 24-hours-prior-to-visit call should always be
made by the therapist. Much care must be taken when confirming the
appointment. If the family is to comply with the visit, it must not change
the appointment or make excuses for why the members cannot participate
at the agreed-on time. 
Tone of voice and the language used during the calls are extremely important.
Any perception by the parents that it is possible to rearrange the appointment
will result in delaying the therapy. It is natural to avoid uncomfortable 
(perceived or real) situations. Nothing should be phrased as a question. The
person making the call 1 week before should state in a clear, friendly manner,
This is ______ to remind you that the therapist will be at your home next
week (state the day, the date, and the time). A closing statement that 
indicates how important this visit is to all concerned should be made, such
as We are looking forward to this important session.
When the therapist calls 24 hours before the appointment, he or she should
use I statements such as Good evening, Mrs. Smith. Ill see you and the
family tomorrow night at 7:30 p.m. Im very excited about tomorrows 
session and meeting your family. The call should be used as an opportunity
to reinforce participation in the treatment project: Your participation in
this project is really going to benefit your child and your family. See you
tomorrow night. It is important that the therapist is trained to overcome
objections and to use proven sales and marketing techniques that
increase the chances for compliance. 

Time
Each visit is scheduled to last 90 minutes. The therapist should be prompt
and try to end the visit on time. There may be a tendency to lengthen 
sessions, especially as the family and the therapist begin to form a 
relationship. This is counterproductive. The goal is to help the family 
function as a system and not become dependent on the therapist. 

Preparation
Some material for the home visits should be specifically adapted for each
family. Examples include items such as the urinalysis (UA) results that the
therapist will discuss with the parents and the adolescent or the family-
generated Mission Statement or Family Relapse Prevention Plan. To ensure
that all information pertinent to the home visit is prepared, thoroughly
review each inhome therapy procedure prior to each visit.

Closure
The end of each home visit should follow the same predictable routine to
signal the family that the session is closing. The therapist should 

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summarize the session, reinforce the progress the family has already
achieved by making the commitment to actively participate in the process,
and market or sell to the family the importance of the next inhome session.
The therapist should ask the family to be aware during the treatment period
of the positive progress as well as any difficulty the family is having. The
therapist should state that at the next session all family members will be
allowed to express their assessment of how the family is doing.

Methods
Therapeutic interaction with the entire family, brief individual discussions
with the siblings, and questions and answers should be used throughout the
sessions. Brief activities should be used that illustrate information and 
provide a dynamic environment. Because people learn in many different
ways, the more variety in the methods, the more likely that each family
member will benefit from the experience.
Therapists should discuss safety issues with the clinical supervisor and the
case manager prior to arranging home visits. In the original research study,
staff members were trained to assess high-risk situations and to follow 
procedures established for dealing with them. For example, therapists were
instructed to consider the neighborhood situation, parking availability, and
family members who would be present during the sessions. Because the
families had already been assessed and had agreed to treatment, few 
situations presented problems, even with parents who were known to have
alcohol or substance abuse issues. The family support network (FSN) model
emphasizes deliberate discussions on agreement of procedures among all
participants, including the parents, the adolescent, and the clinical staff.
Generally, the therapist visited the home alone. Occasionally the case 
manager accompanied the therapist if the situation warranted. On rare
occasions and only with the permission of the supervisors, the family 
sessions were held at the treatment center. This last situation should be
avoided, because the FSN model includes home visits for specific reasons
explained in the overview and introduction of this manual.
Additionally, staff members were advised to check out a mobile phone to
carry for emergencies. They were also instructed in safety precautions, such
as not leaving valuables locked in their cars, not carrying purses or wearing
expensive clothing or jewelry, and ways to confront risky situations. In 
some cases, parents were asked to escort the therapist back to his or her 
automobiles after the sessions. In all cases, sensitivity must be used when
discussing these circumstances with the families. They may see a therapists
fear of coming to their home or neighborhood as snobbery or, worse, based
on some underlying prejudice about color, ethnicity, or poverty. Therapist
safety is critical; however, sensitivity and compassion must guide the 
decision on home visit procedures.

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Home Visit 1
ProcedureThe case manager will set up the initial appointment. This
will allow the family to have an additional contact with the case manager.
Since this is the first visit, the therapist should explore with the parents
the best location in the home for the session. This may be the kitchen,
the living room, or the family room. If there are children who are too
young for the session (usually children who cannot verbalize are 
inappropriate), the therapist should discuss with the parents how those
children will be cared for during the session and help parents identify a
babysitter. 
The therapist must always be aware of his or her own reaction to the 
family, the home environment, and the neighborhood. Some homes 
may be cramped and chaotic. If families suspect that the therapist is 
uncomfortable, judging, or afraid of the environment, the therapeutic
relationship will be impossible to establish. Training in cultural competence
and sensitivity will increase the likelihood that the therapist will not
offend the parents.
General OverviewThe first session should be used to assess the family
members in their home environment, refer them to additional services, if
necessary, and motivate them to actively participate in the treatment 
contract. Every effort should be made to limit the session to 90 minutes.
The therapist should follow the manual and cover the goals and objectives
of each session. Referrals should be made if issues arise that need further
therapeutic attention. At the beginning of the home visit, the therapist
should review what will be covered. 
To help in the assessment, the therapist should discuss the results of the
Life Stressors and Social Resources Inventory (distributed in the first 
parent education [PE] session). This inventory allows the parents and the
therapist to evaluate any life stressors and the need for additional services.
The results of the inventory may also be discussed at the second home
visit. 
RationaleThis session helps the therapist and the family members form
therapeutic alliances that will improve outcomes. Much care must be
taken to make the family feel comfortable with the therapist and the 
sessions. The greater the trust the family places in this therapeutic 
relationship, the greater the likelihood of continued success. Marketing
the methods used in the therapy, congratulating family members on 
their commitment, and helping them overcome barriers will increase 
the likelihood of their success and, thereby, the projects success.
Determining what stressors exist that might impede success will allow 
the professional staff to assist the family in obtaining needed services and
overcoming barriers that might inhibit completion of the program. The
more control people feel they have over their environment, the more 
likely they are to believe that they can change. Self-efficacy improves 
outcomes. 

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Materials
  Scores and charts from the Life Stressors and Social Resources
Inventory.
  Handouts:
u
Family Agreement
u
Treatment Contract
u
Case manager contact information (phone numbers, addresses,
etc.)
  Age-appropriate reading materials, videotapes, games, or other 
distractions for younger children if necessary
  The treatment calendar (e.g., times, dates, and places of the 12-
session MET/CBT, the 6 parent education sessions, the parent 
support groups, and the family home visits) completed prior to the
home visit with the case manager

Goal 1: To increase parental participation in the treatment process by
identifying barriers to successful completion, including misunderstandings
about the treatment process 

1. Review the purpose and the objectives of the home visits in relation to
the goals of substance abuse treatment.
Discussion. Explain the following points: 
  There will be four home visits. Times that are convenient for all
will be determined by the case manager. Sessions will last 90 
minutes. 
  The purpose of a home visit is to improve the adolescents chance
of a successful recovery and to rebuild relationships that have
likely suffered because of drug use. 
Talk to the adolescent. Say, It is likely that you have pulled away from your
family because of your drug use. It is important for your parents to become
involved in your recovery process so they can support you. You and your
family may need to learn new ways of doing some things.   
Give an overview of each session and answer any questions. Reinforce the
importance of the remaining sessions. Market the benefits of the therapy
participation to the family. Stress how much parents and their child will
learn from the information. 
Choose an example from both the parent and the adolescent classes, and
give specific examples of the information to be gained. For instance, The
session on adolescent relapse will really help you identify the warning signs
before your child has a slip. You will also be given ways you can intervene
effectively so that you can help your child stay drug free.

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Explain the success rates for adolescents whose families participate in their
treatment and recovery. Explain that although participation is no guarantee
of success, experience and research indicate that family involvement
increases successful outcomes. Solicit reasons from parents and the 
adolescent about why this may be true.
2. Review the adolescents UA results. 
Discussion. Discuss the results. If the test indicated drugs were present
(positive), discuss what happened and how the use could have been prevented.
The adolescent may become upset or challenge the results. Power struggles
or escalating arguments should be avoided. It is preferable to offer to retest
the adolescent than to continue to argue. A good method is to get the 
adolescent to agree that, if the new test results are positive, he or she will
accept the results and will work through the issue. The therapist should
review the procedures and remind the parents and the adolescent of the
education they received on urinalysis procedures and testing methods. The
therapist should keep in mind that treatment is cumulative and a process
not an event. The FSN model promotes overall results, not a confrontation
over a single event. If the test indicated drugs were not present (negative),
praise the good result and encourage this behavior. Regardless of the
results, stress the importance of abstinence during this treatment program
and in the future.
Sometimes parents will accept reduction of use because they want to
believe that things will get better. Impress on the parents and the adolescent
the need to remain abstinent, especially during the program. Solicit a 
commitment from the adolescent to remain abstinent and from the parents
to require abstinence. The therapist should not be concerned about
whether the commitment is sincere but only that it is made. Acting as 
if is an important therapeutic concept and signals the beginning of 
precontemplation by the adolescent. 
Acting as if is a common term in the lexicon of substance abuse recovery. It
describes the act of allowing the newly recovering individual to take on the
behaviors of a sober person before those behaviors are internalized. As a
result others begin to treat the recovering person differently, and that person
begins to experience the rewards of positive behaviors. By experiencing 
positive regard of society, the newly recovering person not only will continue
to exhibit these behaviors, but will internalize them over time.
Precontemplation refers to a stage in the process of change. In this stage 
a person does not connect his or her substance abuse to the negative 
consequences. As a person becomes aware that many of his or her problems
are a direct result of substance use, he or she may enter into a contempla-
tion of change stage. This is a positive step to deciding to change many
negative behaviors.

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3. Share some of the adolescents reasons for quitting.
Share the reasons provided by the adolescent in his or her motivational
enhancement treatment sessions. Ask for the parents support. Demonstrate
how the parents can support recovery by knowing the motivators for their
child. Review the commitment to abstinence from marijuana and other 
substances. 
4. Encourage the parents to commit to not using illicit drugs and to
being aware of their alcohol use during the treatment period.
Discussion. Discuss how any overt or covert messages about alcohol use 
can have an impact on the adolescents recovery. Explain how heightened 
awareness of the parents substance use patterns can affect their childs 
participation and the likelihood of successful outcomes. This will be a 
delicate process. The therapist must take care not to offend or make the
parents defensive. Using a double-bind technique may prove helpful. For
example: I know that you are very committed to your childs success in the
program and to stopping his or her drug use. That is why I know you will
make every effort to be aware of your alcohol use and the messages you may
send (even without realizing it) to your child, especially during his or her
participation in this program.
5. Explain what the program will and will not do for the adolescent and
the family.
Discussion. Do not overstate the chances for success; say that, if the family
and the adolescent participate and comply with the recommendations, the
chances that they will be successful are great. 
State, This program cannot promise that all family problems will disappear,
but it will improve your familys communication, and it will increase the
chances that your child will modify his or her substance use. It may improve
the chances that your other children may not start abusing substances.
Participating in the program may also help you regain control of the family.
Goal 2: To develop an alliance with the family and begin to establish
knowledge of the family history, environment, and stressors

1. Provide feedback from the Life Stressors and Social Resources
Inventory.
Explain that the inventory assesses the level of stress the parents feel about
their childs behavior and the level of social support available. The youth 
version helps adolescents realize that there are stressors that affect their
functioning.
Discussion. Connect everything observed in the sessions (plus any test or
inventory taken and all activities) to the overall goals of the treatment 
program. It is essential that the family understand how each activity is 
related to the familys and the adolescents chances for success. 

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Solicit questions and discussion by asking open-ended questions. For example:
In what ways do you think stressors affect you and your family? Since this
is the first session, it is important to begin to teach the parents, the 
siblings, and the adolescent how to participate in family sessions. What is
said is not important; what is important is that the members are willing to
explore the questions. Remember, the more family members talk, the easier
the session becomes. 
It is important to create an environment in which all members of the family
are free to speak and participate. This may require gentle redirection if one
member monopolizes all the time. Remember not to offend the power
in the family as this will certainly lead to alienation and an unwillingness to
continue. Much care must be given in identifying the power in the family.
This person is often not the most obvious choice. The power in the family
usually gets his or her way in interactions regardless of his or her status
within the family. The most powerful member may be the father or the
mother, but it is often the substance-abusing adolescent who calls the shots
in the familyespecially in homes with only a mother who may feel guilty
about the youths lack of a father figure. A family member may use subtle
manipulation or a parent may play the role of the injured party, getting the
other parent to come to his or her defense. The adolescent may act out and
intimidate the family into complying with what he or she wants. The thera 
pist must use his or her training and skills to get the person with the power
to believe that it is in his or her best interest to participate in the treatment
sessions.
2. Explain the case managers role, and observe the family in its home
environment. 
Explain how the case manager can assist the parents and the adolescent in
achieving success. Let the family know that the case manager will help
identify support groups in its community and is also available to eliminate
any barrier to participation (e.g., transportation). Before any referrals are
made to the case manager, the referral should first be discussed with the
parents. Explain that the case manager may periodically contact them to
see whether they need any assistance. Tell family members they can call the
case manager directly or inform the therapist of a concern. The therapist
will pass the information along to the case manager. If the therapist has a
concern, he or she will discuss the issue with the parents before asking the
case manager to intervene. 
3. Conduct a brief family sculpting exercise.
Persuade the family to roleplay a family sculpture. This roleplay is not
meant to be a full-blown psychodrama; rather, it is a visual display of how
the members see the family structure. The adolescent, parents, and siblings
should take turns placing the members of the family around themselves in
the sculpture according to the closeness they feel toward each person 
and whom they see as having positions of power and control. If there is 
resistance to participating in the sculpting activity by some members of the
family, pick the most willing or outgoing member of the family to begin the

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process. This exercise need not be dramatic. It can be approached with a
playful attitude. For instance, try asking a member to line the family up
according to some thememost verbal to least verbal or loudest to quietest.
This exercise may get the ball rolling for other types of sculpting activities.
The idea is to allow the family to be aware that each member may see the
family structure in a unique way. There is no right or wrong outcome; this is
an exercise in increasing the family members knowledge of one another. This
exercise will help each family member recognize what role he or she plays in
the family structure and how that role affects his or her life. Remember to:
  Allow all member to place the others as they see the family. 
  Help the family understand that there is no right or wrong 
picture and that negative comments or criticisms are not allowed.
  Act as a facilitator for family members as they make insights into
how each sees the family structure, how helpful or destructive the
structure is, and how the structure affects family dynamics.
4. Initiate a discussion of How you would like your family to be different.
Start by using what was discovered in the family sculpting exercise. Be 
sure to solicit involvement from siblings. Sometimes when one child is 
commanding so much energy from the parents, other children in the 
home begin to feel neglected.

5. Provide the family with copies of the Family Agreement handout.
Have members read it aloud. Always ask small children whether they understand
the meaning of the Family Agreement. Paraphrase it when necessary to
ensure that all members of the family understand the meaning. Have parents
and children sign one copy of the agreement. Explain that one copy will be
made for the file and another copy will be returned at the next family session.

6. Review the Treatment Contract handout. 
This contract should reflect the commitment to the recovery process of 
the parents and the adolescent receiving treatment. Remind parents of the
Parent/Child Contract that they completed during parent education session
4, and instruct the family to use that as a guide for filling out the
Treatment Contract. The therapist and family should discuss only additions
to the contract that the parents or adolescent views as necessary to ensure
a successful treatment experience.
Add additional items to the Treatment Contract as necessary. Explain that
when family members sign the Family Agreement and make commitments 
in writing, they are more likely to honor the contract and follow through.
Have the parents and the adolescent who is receiving the treatment sign
the Treatment Contract. Explain that one copy will be made for the file and
another copy will be returned at the next family session.

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Family Agreement

We have become more aware that substance 
abuse has negatively impacted our family. 
We are now actively involving ourselves in 
the necessary steps to work toward a 
healthy, happy family.
We are aware that we are taking risks and 
will be trying new ways to approach 
problems. We are aware that this may feel 
uncomfortable at times, but we are willing 
to try new ways.
We are excited about these challenges and 
commit to doing our best. At all times we 
will do our best to approach the new ways 
with patience, respect, kindness, and 
understanding.

______________________________________              ___________
Parent/Guardian Signature Date
______________________________________              ___________
Parent/Guardian Signature Date                         
______________________________________              ___________
Child Signature Date
______________________________________              ___________
Child Signature Date  
______________________________________              ___________
Child Signature Date                        
______________________________________              ___________
Therapist Signature Date                         

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Treatment Contract
I agree to attend all my scheduled sessions.
__________________________  __________________________  ___________
Parent/Guardian Signature Child Signature Date
I agree to participate actively and honestly in the home visit sessions.
__________________________  __________________________  ___________
Parent/Guardian Signature Child Signature Date
I agree to complete, to the best of my abilities, all homework assignments
and family assignments given to me as part of the treatment program.
__________________________  __________________________  ___________
Parent/Guardian Signature Child Signature Date
I agree to abstain from substance use while in this treatment program.
__________________________  ___________
Child Signature     Date
I agree to do my best to model appropriate, responsible behavior regarding
medications and other substances.
__________________________  ___________
Parent/Guardian Signature          Date
I will do my best to learn skills necessary to foster a healthy home 
environment and to be more aware of future choices in my behaviors 
and how they impact others.
__________________________  __________________________  ___________
Parent/Guardian Signature Child Signature Date

I agree to these additional items. ____________________________________
_______________________________________________________________________________
_______________________________________________________________________________
__________________________  __________________________  ___________
Parent/Guardian Signature Child Signature Date
__________________________  ___________
Therapist Signature Date

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Home Visit  2
General OverviewThe second home visit allows the family to explore
further its own family dynamics, its communication style, and the rules,
roles, and routines of the family. The overall goal of this session is to
strengthen the familys commitment to the treatment process, to improve
communication, and to provide tools to improve the family structure. 
The Culture-Free Self-Esteem Inventory (30 true/false items for children
and 40 items for adults) is an optional assessment that can be used if the
therapist feels the feedback would benefit the family. (It can be purchased
through PAR, Inc., at www.parinc.com.) The Culture-Free Self-Esteem
Inventories help the therapist assess the individual members level of self-
esteem and to explain to the family the importance of esteem in achieving
success in life. These inventories should be self-administered and returned
to the therapist in the next session. Feedback will then be provided in the
final home visit. 
RationaleThe more family members know about how other members
think, feel, and behave, the greater the likelihood that communication
will improve. Understanding the importance of self-worth and the role it
plays in the adolescents recovery and the family members lives will
increase commitment to the program. Family sculpting exercises showed
members in a visual way how they operate in the family system. Helping
families recognize changes they are making builds on their strengths. A
strength-based approach tends to increase compliance as well as hope
that success can be achieved. Helping family members see setbacks as 
just part of the process and not as failures will increase the motivation 
for continued improvement. 
Materials
  A list of additional community services that, if needed, may assist the
family
  Age-appropriate reading material that will help family members
understand roles, rules, and routines and their importance in the
treatment process
  In reserve, extra copies of the several handouts on family roles and
learning to fight fair without aggression and violence that were 
distributed in the PE sessions 
  A board game

Goal 1: To increase the familys understanding of the adolescents 
urinalysis results and to solve problems, if necessary

1. Review the adolescents and the familys progress, and respond to any
problems or questions.

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Discussion. It is important to avoid allowing the family members to make
unrevealing responses (e.g., fine, great). Ask how each is doing, in
what ways things are improving, and what is different. With these types of 
questions, the therapist not only encourages more participation but helps
the family increase its communication skills. Focus on how each family
member is doing as well as how the family as a unit is doing. 
Review the meaning of urinalysis results. If results showed that drugs were
present (positive), discuss what happened and how the use could have been
prevented. If negative, praise the good results. Stress the importance of
abstinence during this treatment program and in the future. 
Goal 2: To assist the family in preparing a family vision/mission statement
1. Introduce the family to the vision or mission exercise, and assist
members in preparing a statement for the family. 
This exercise helps the family focus on its goals and philosophy and helps
the family visualize and verbalize the successful outcome for all members.
The mission statement pronounces what the family envisions for itself. By
blending ideas from all, the family members design one mission statement
of who they are, what they want to accomplish, and how they will accomplish
this goal.
Discussion. Guide the family in the mission statement/goal exercise.
Provide the family with a method to develop a vision statement. 
Use a large sheet of paper or a posterboard, and write at the top of the
sheet who, what, and how. Ask family members to describe who they are,
what they want to accomplish, and how they want to accomplish their goals.
Have family members complete each section giving descriptive words for
who they are, for what they want to accomplish, and for how they will
accomplish it. Brainstorm ideas for how they will work on accomplishing
the goals. Have parents and siblings of the adolescent verbalize how the
family will be different if the mission statement becomes a reality.
Tell the family members that at the next home visit, you will present them
with a typed and framed family mission statement.
Goal 3: To assist the family in understanding the concept of fair 
fighting and in assessing its current family rules for fighting
1. Discuss how the family fights and in what ways members could change
their interaction to fight fair.
Explain that all families argue at times. Emphasize that families who 
learn to express their disagreement in a less abusive, less hurtful, and 
nonthreatening way, using respect for all members, can actually become
closer following a disagreement. The therapist should be mindful of 
religious and cultural considerations. Reinforce the elimination of 

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name-calling; violence of any kind, including threats and intimidation; 
and other counterproductive behaviors that increase family problems.
2. Determine what rules exist in the family.
Step 1. Ask the family what rules exist in the family and how consistently
they are applied. Ask what the consequences are for following or breaking
the rules in the family. Discuss what would happen if families did not have
rules.
Discussion. Introduce fair-fighting rules and give examples. Discuss why
they are important in a family. A fair rule is developed for the benefit of the
recipient, not the rulemaker. The rule benefits the recipients physical,
emotional, mental, and social development. Adolescents are much more
likely to adhere to fair rules because the rules are rational and in the 
adolescents best interest. Fair rules are flexible in certain, usually rare, 
circumstances (e.g., being allowed to stay up past bedtime because an 
out-of-town grandparent is visiting). Fair rules are in the best interest of
everyone.
Explore family rules that are fair and productive. Ask the members to give
examples. Try to get all members to respond. Younger siblings or those who
have difficulty expressing their opinions may need gentle prompting. Care
must be taken not to be intrusive. Remember, it is essential that the family
begin to talk about its system rationally and productively. 
It is hoped that the family will already have some rules that are fair. Exploit
these, and reinforce the familys strengths.
Step 2. Discuss with the family which rules are unproductive, unnecessary,
or counterproductive. 
Discussion. Explain that some rules are established for the rulegiver with
little consideration for the one who must obey the rule. Point out that
unfair rules usually develop from strong emotion, frustration, or an
urgency to do something. Take extreme care when discussing these issues,
or parental authority can be undermined. Honor cultural considerations. Steer
the discussion to the benefits of eliminating unproductive rules and ways to
accomplish this goal. 
Step 3. Work with the family to develop one or two new productive rules. 
Discussion. Guide the family into correcting unproductive rules and in
developing new, more helpful ones. First, ask the family to write down the
top five rules in the house. Then discuss whether these rules are humane.
Finally, have the family develop one new humane ruleone that is agreed
on and that will work. Quantity is not the object. It is better to help the
family develop one new productive rule than to construct so many that the
family may have a hard time obeying the new rules. Record the rules, and
have each family member sign a commitment to comply with them.

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Step 4. Ask the family to determine the consequences for failing to follow
the rules. 
Try to get all members to verbalize their understanding of the consequences
of rule infraction. 
Discussion. Guide the family members in determining the consequences for
failing to follow productive rules. Record these in the commitment contract.
3. Discuss family commitments to change.
Discussion. Solicit and record members commitment to change specific
behaviors. It is better to get a commitment about changing one behavior
than changing several behaviors. The family members may be overwhelmed
if they are asked to make too many changes at one time.
4. Ask the family to commit to changing family dynamics at least until
the next session. 
Discussion. Introduce or reinforce the concept of acting as if and its
importance in the change process. Use the acting-as-if principle to elicit a
commitment from all members that, at least during the treatment process,
they will adhere to the fighting fair rules (refer to the handout in PE 
session 5).
5. Introduce a board game to improve communication.
Discussion. Ask the family to play a game at least once before the next 
session. The game should be one of chance, so that all players have an equal
chance of winning. Explain that playing as a family allows all members to
appreciate the individuality and talents of each member.

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Home Visit 3 
General OverviewThe third home visit focuses on assessing the
progress of the individuals and the family as a unit and encouraging the
family to reaffirm its commitment to the Family Relapse Prevention Plan
(presented in PE session 3). The parents, identified adolescent, siblings,
and therapist summarize their observations and feelings about the
progress the family is making, including successes and difficulties they
encountered. The family reviews and revises its family vision/mission
statement. The family also reviews its progress in fighting fair, following
new productive rules, and solving problems. If the family and the therapist
have decided that the family is ready to end its treatment, this is the last
session. The therapist should ensure that parents are aware of how to
seek help if the family should relapse. If this is the last session, the 
therapist should bring a treat to help family members celebrate that they
completed their commitment to the home visits. The therapist should
always check with the parents to determine what is an acceptable treat.
RationaleAssessing the progress of the individuals and the family as 
a unit provides positive reinforcement for everyone as well as a chance 
to make necessary changes in the family goals. Getting the family to 
reaffirm its commitment to the Family Relapse Prevention Plan will help
prepare the family if there is a slip in progress. Research shows that
relapse prevention plans actually reduce the chances of relapse because
the individual and, in this case, the family are better prepared to meet 
the inevitable struggles of recovery. Improving the familys ability to self-
assess allows it to adjust its behaviors to increase positive outcomes.
Materials
  A list of additional community services that may, if needed, assist the
family 
  Posterboard and markers for writing a mission statement 
  Treats for the family if this is the last home visit

Goal 1: To provide the family with the typed and framed family vision/
mission statement and to give the family the opportunity to solve any
problems that may have arisen over the past weeks that affect the mission
statement
1. Provide the family with its family vision/mission statement.
Have each family member identify with the family goal and express his or
her individual commitment in the following areas: communication, fighting
fair, trust, healthy habits, healthy activities, and social activities.  
Reaffirm the commitments made by all members of the family in the last
visit regarding who they are, what they want to accomplish, and how they
will accomplish their goals. Then identify any problems that may have aris
en since the last session. Use the opportunity to practice problem solving.

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Have each family member present possible solutions. Explore the practicality
of each solution and determine whether it is in line with the familys goals.
Then discuss any urinalysis results since the last home visit.
Goal 2: To increase the parents and family members ability to self-assess
and adjust their behaviors to increase positive outcomes
1. Explore problems with communication experienced since the last
home visit.
Ask family members how they resolved the problems or what new techniques
were used to improve communication.
Review listening skills and using I statements. Focus on specific commu-
nication problems identified within the family.
2. Review overall progress with parents and family members.
Discussion. Ask the family to describe any disagreements since the last 
session and how the incidents were handled. Identify ways family members
followed the fair-fighting rules and ways in which they did not. Seek 
suggestions from the parents and family members on ways to respond 
to any concerns or questions and methods for improvements.
Goal 3: To reinforce the necessity for all family members to support the
recovery of the identified adolescent and the recovery of the family and 
to provide sources for support if stress or relapse occurs
1. Solicit from family members how they would know whether the family
or the individual is in relapse.
Discussion. Review and discuss the completed Family Relapse Prevention
Plan that was initiated in PE session 3.
Solicit agreement about the signs and symptoms of relapse. Write down
these signals and symptoms for the family. Try to have members agree 
on the signs. Ask the family members to share their views, and solicit 
agreement from all members without allowing criticism.
2. Solicit from family members specific ways they can make one another
aware of problems and agreement issues.
Solicit from all members ways they can make one another aware of problems
and issues before they become overwhelming. Members must agree to help
one another without criticism. Review with all members how they wish to be
approached if they need to be confronted. This is especially important for
younger siblings whose opinions or observations are often dismissed or
ignored in the family. It is important to get parents to agree to listen to
members concerns, especially those of the younger siblings.

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3. Review with each family member the names of the people who will be
able to help and support them in times of stress or relapse.
Each family member should have a list of people (with their phone 
numbers) he or she can turn to for advice, comfort, or encouragement. 
If the family member has been a member of a formal support group, the
phone number of the group contact should be on the list. These people
could be teachers, members of religious organizations, or relatives with
whom the family members or the family as a whole has close, trusting 
relationships.
These lists are important, and each member of the family may have 
different people on the list.

4. Review the Family Relapse Prevention Plan, and have all members sign
it.
Discussion. Reinforce the necessity of the entire familys effort in the 
recovery process. Guide the family in a discussion that restates the individual
and family relapse triggers and how to recognize them. Finally, reinforce
that the parents and adolescents participation in a support group can play
an important role in increasing positive outcomes for the family.
Closure
If this is the last session, congratulate the family on the commitment 
each member showed in following through with treatment, and stress the 
importance of following the Family Relapse Prevention Plan.
Praise the familys efforts, acknowledge its commitment and hard work, and
reinforce that families that work together in recovery have more positive
outcomes. 
Emphasize how following the Family Relapse Prevention Plan will increase
the likelihood of the familys success. Review how family members can seek
help if they recognize relapse triggers.
Reiterate that there is help available to the family and that families who ask
for help are doing the right thing for the entire family unit. (See home visit
4 for additional information on relapse.)

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Home Visit 4
General OverviewThe topics covered in this visit are very important.
This fourth session focuses on assessing the progress of the individuals
and the family as a unit and restating commitment and willingness to 
support the family as a unit. The parents, identified adolescent, siblings,
and therapist summarize their observations and feelings about the
progress the family is making and the successes and difficulties it 
encountered. The family will review its Family Relapse Prevention Plan.
RationaleCompleting commitments is an essential part of individual
and family recovery. Assessing the progress of the individual and the 
family unit provides positive reinforcement and allows the family to make
adjustments to its goals. Reviewing the Family Relapse Prevention Plan
underscores the importance of ongoing recovery and commitment.
Materials
  A drawing pad to illustrate the concept shown in exhibit III1
  A treat for the family to celebrate completing the home visits 

Goal: To assess the progress of the individuals and the family unit during
the treatment process and to gain continued commitment to and support
for the individual and the family

1. Ask each member to evaluate his or her progress, express concerns or
fears for the future, and ask questions.
Reemphasize that the process of recovery includes stops and starts and that
a recovery has setbacks as well as progress. Normalize the stops and
starts of regular recovery. Reinforce that most people in recovery repeatedly
take two steps forward and then one step back over time. Families should
not be discouraged when the person in recovery takes a step back. (Refer to
exhibit III1 below.) 
Exhibit III1: Two Steps Forward and One Step Back

Setback Setback Setback
TIME

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2. Encourage each member to reiterate his or her commitment.
Ask each member to talk about his or her commitment and willingness to
support individuals in the family as well as the family as a unit. 
Restate the commitment to the family, and reiterate that this will be
accomplished by adhering to family rules, structure, and routines; by
respecting each others boundaries; and by fighting fair.
Review the Family Relapse Prevention Plan. The plan is essential for helping
the family remember its commitments made during the treatment process.
3. Individualize the treatment to the family.
Address any special needs or issues that may have arisen during the treatment
process. These may be issues surrounding such things as communication,
problem solving, and relationship building. Use the remainder of the time
with the family to shed light on family-specific issues. Discuss observations
with all family members, and allow them the opportunity to explore 
additional concerns they may have.
See home visit 3 for information on closure.

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IV. Case Management Procedures

Introduction

Operation PAR recognizes that the family plays a major role in adolescent
substance abuse through family dysfunction, enabling, or acceptance. For 
a typical adolescent, recovery is difficult without the active involvement of
and continued support from the family. Research has shown that parental
support can act as a stress-buffering element, allowing adolescents to deal
with negative life events without turning to substance use (Wills & Cleary,
1996) and that family involvement in treatment is associated with improved
outcomes (Stewart & Brown, 1993). 
Family involvement can be greatly increased by a proactive stance from
treatment programs (Morris, Gawinski & Joanning, 1991; Myers, Brown &
Mott, 1993; Richter, Brown & Mott, 1991). To engage and keep the family
of the drug-using adolescent involved in treatment, a case management model
was developed. The model of case management is designed primarily to:
  Engage the family in the treatment process
  Overcome barriers to its active participation
  Identify appropriate service and treatment needs
  Provide links to needed services
  Monitor adolescent and family progress
  Provide motivational enhancement
  Prevent clients from dropping out of the program
  Encourage participation in community family support groups or
initiate a peer-led parent support group.
The case manager, along with the interdisciplinary treatment team 
(counselor, therapist, and clinical supervisor), has primary responsibility for
engaging the adolescent and the family in treatment and preventing the
adolescent and the family from dropping out of treatment. The case manager
addresses a broad and comprehensive array of barriers to treatment and
achievement of treatment goals. As barriers arise, the case manager develops
alternative or creative strategies for achieving desired outcomes. 
Drug abuse treatment programs have unacceptably high dropout rates,
which are a primary concern for case managers. Research findings suggest
that attrition prevention in the early phase of counseling ought to focus on
motivational ambivalence, scheduling conflicts, or financial impediments 
to continued involvement (Roffman et al., 1993). DeLeon and colleagues
(1994) view the risk of dropping out as a function of readiness and motivation

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and suggest that motivation can be enhanced through prompt intervention.
In later stages of treatment, efforts to lessen the possibility that the clients
will drop out should focus on understanding and dealing with the adolescents
dissatisfaction with treatment (Roffman et al., 1993).
Henggler and colleagues (1996) found that dropout rates could be lowered by
increasing the accessibility of treatment services and by placing the respon
sibility for treatment engagement on the service providers. Therefore, a key
responsibility of the case manager is to engage the adolescents family in
treatment and to overcome obstacles to receiving treatment. 
Additional program features that have been found to lower dropout rates
included home visits, short waiting time, frequent contacts with the 
adolescent, the provision of concrete services, and high levels of therapist
commitment to and respect for the adolescent (Henggler et al., 1996). The
case manager, as well as all the professional staff members involved in the
treatment process, should demonstrate respect for the religion and culture
of the adolescent and his or her family. 
In the case management model, services are individualized to meet the 
multiple and fluid needs of adolescents and their families. The case manager
does not obtain services for the adolescent but rather serves as a catalyst
and a source of information. The case manager empowers the adolescent
and the adolescents family to obtain the services they need and to reach
the goals they set for themselves. Family members are viewed as full 
collaborators in the treatment process. 

Overview of Procedures
Case managers should establish and maintain contact with parents of 
adolescents and facilitate their engagement and participation in the treatment
process. Case managers, therefore, should be trained in and use sales or
motivational strategies to overcome the reluctance of parents to participate.
The strategies include eliciting positive decisions, overcoming sales 
resistance (i.e., resistance to participating in treatment), providing trans-
portation, and providing child care and other services to overcome barriers.
Sales skills can be used to encourage and entice families to participate with
their adolescent in treatment at a more intensive level. By breaking down
patterns of denial and resistance to treatment, staff members can bring
reluctant parents into positive participation in treatment. One type of sales
technique generally used in business is effective in substance abuse 
treatmentovercoming barriers or resistance. For example, an excuse by
family members about their inability to attend a particular session is met
with this response by the therapist: No problem. You can make up the 
educational session on this date. Another excuse from the family may be,
We cant find child care that night. The therapist can respond, No 
problem. Lets put our heads together and think of a good alternative or
solution. An even better solution is to establish alternative arrangements
at the time of the intake and actually have the case manager help the 
family arrange backup for transportation or child care in advance. This

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information can then be part of the therapists response: I believe you said
that you had arranged for your sister to watch the other children on therapy
nights. Lets call her and see if she will help you. Sometimes just offering
to help is enough to get the parents to solve the problem themselves.
Breaking down denial can be accomplished by using the parents own 
words gathered during the admission and assessment processes and using 
a double-bind technique. For example, a therapist might say, When you
first came in, you expressed how worried you were about your childs drug
use and that you would do anything to help. It is evident that you really 
love your child. Lets work together to accomplish what you want mosta
healthy child and a happy family. This motivational enhancement technique
is described in detail in the motivational enhancement therapy/cognitive
behavioral therapy (MET/CBT) manual (Scudder & Kaminer, 1998; Sampl &
Kadden, 2001; Webb et al., in press) that is used in conjunction with the 
family support network (FSN) model. To maintain engagement in treatment
and improve outcomes, staff members can use these skills, combined with
an understanding of clinical principles, to reach out to adolescents and
their parents who miss counseling sessions.
Missing a single treatment session should trigger immediate efforts by staff
members to contact the adolescent and his or her family. The staff should
find out the reason the adolescent missed the treatment session and develop
a strategy for keeping him or her in treatment. These efforts significantly
increase the number of adolescents completing the treatment program,
thus enhancing favorable outcomes for both the participant and the program.
An individual service plan should be developed to fit each family. The 
intensity of services the adolescent receives depends on need. For families
with multiple and complex needs, a more intensive service plan, which
evolves into a more supportive service plan as treatment progresses, should
be implemented. To maximize resource allocation, staff members may need
to place some families directly in treatment based on the supportive case
management model upon admission to the treatment program.

Intensive Case Management
Adolescents and families with multiple or complex needs should be treated
with an approach based on an intensive case management model. Case 
management services should be initiated with the case managers first 
contact with the family. The first phase should include:
  Meeting face to face with the adolescent and his or her family
  Explaining case management services
  Establishing a plan of action to meet the immediate needs of the
adolescent and his or her family
  Making an assessment of additional needs not identified in the
adolescents initial assessment and intake processes.

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In the second phase, case managers should maintain frequent contact with
the family, the counselors, and the family therapist and continually assess
needs of the adolescent and family. Case managers should monitor progress
by regularly telephoning the family. This phase may include additional 
face-to-face contact if needed. Contacts with the child and family may be at
the treatment facility, a community center, or the familys home. Using the
results of the assessments, the case manager coordinates links to services
and provides added support to the family in obtaining needed services. Case
managers also actively participate in staff meetings of the adolescents
treatment team and ensure that resources are being used efficiently to
meet the adolescents and familys needs.

Supportive Case Management
During the last month of treatment, the family should be transferred to
treatment based on a less intensive case management model to prepare the
family for discharge. This treatment continues with face-to-face contacts
with both the youth and his or her family, periodic drug testing, and telephone
contacts. However, these services are not delivered as frequently as in the
intensive case management model. 
Case managers should continue to monitor the adolescent and the 
adolescents family throughout the treatment experience. For those families
who begin treatment based on the supportive model, the case manager
should provide services on an as-needed basis. However, the primary counselor
and the family therapist should continually update the case manager about
the adolescents and his or her familys additional needs and progress. 
Components of Case Management 
An overview of the case management model is shown in exhibit IV1. 
This basic model is appropriate for both intensive and supportive case 
management. The services have different levels of intensity. An important
responsibility of the case manager is engagement; the case manager provides
motivational support for the adolescent and helps the youth overcome 
barriers or resistance to treatment participation. 
The case manager should use sales and motivational skills at each stage 
of the process shown in exhibit IV1. The case manager should participate
with the treatment team (clinical supervisor, assessor, therapists, etc.) in
developing a service plan that includes specific needs of the adolescent and
family as they relate to ensuring participation in and completion of treatment.
Once the adolescents needs have been identified, the case manager should
meet with the adolescent and his or her family to prioritize those needs and
objectives. 
Beginning with the adolescents most critical needs, the case manager
should provide links to services. The case manager must also teach families
how to acquire services so they will have that knowledge when the support
of the case manager is no longer available. For the case manager to release
information to the referral agencies in accordance with Federal and State 

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Exhibit IV1: Case Management Model

regulations, the adolescent and family must sign a release form. Once referrals
have been made, the case manager is responsible for monitoring the
progress of the adolescent and his or her family (e.g., checking whether the
family members are keeping their appointments and whether their treatment
plan is effective).
At each stage of the process, the case manager must provide support to
overcome barriers to the successful completion of treatment. The case 
manager must be persistent and assertive to overcome barriers that prevent
the adolescent from receiving treatment or obtaining needed services.
Prompt intervention when obstacles arise (e.g., transportation, child care
issues) helps decrease the dropout rate and increase positive outcomes. The
case manager should also link parents to community support groups or 
initiate a peer-led parent support group. 

Needs Assessment and Treatment Planning  
Clinicians should develop an individual treatment plan based on a complete
psychosocial assessment with the adolescent and the family. Timeframes 
for treatment activities are usually defined in administrative codes and 
regulations based on State statutes. For example, the timeframe for 
providing an individual treatment or service plan may be longer than that
for administering intensive therapy. The initial treatment plan considers 
the adolescents and the familys strengths, areas that need improvement, 
barriers to success, and discharge planning needs. This initial plan defines
short-term, long-term, and deferred goals, as well as objectives and methods
for their achievement. The plan delineates the responsibilities of the 
Case manager Provides links to
parent network
Provides links to
parent network
Assesses needs of
participant/family

 Prioritizes needs
and sets objectives
with family

Provides links to
needed services

Monitors progress

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adolescent, the family, the clinician, and the case manager. The adolescent,
family, clinician, and case manager agree to the plan. Supervisory staff
members then review and sign all treatment plans, treatment evaluations,
and addenda.
For positive outcomes, treatment planning must be a truly collaborative
effort among the clinician, case manager, adolescent, and family. The format
for interdisciplinary treatment teams may vary depending on the organization
providing the services and the resources available. At a minimum, a team
approach should be followed during the initial treatment planning after the
assessment process. Thereafter, there should be regular clinical supervision
and reviews of the progress toward the treatment goals. Reviews must
include the client or the family or both when appropriate. Case managers
should be able to offer special insight into treatment planning because they
see the adolescent and his or her family in their home environment.
Continuous evaluation and assessment of progress should be made as 
the adolescent works on objectives that will help him or her achieve both 
short- and long-term goals. Treatment plans need to be reviewed at least
monthly and updated as objectives and goals are achieved or as other issues
are recognized. When it is a collaboration among clinicians, the adolescent,
and the family, the treatment plan provides a clear roadmap for the 
adolescent to follow. Progress notes continuously document the adolescents
progress. 
Treatment plans should include: 
  Descriptions of the behavioral problems being addressed
  A description of the services or treatment to be provided to the
adolescent and his or her family (including the type of service or
treatment; frequency, duration, and location of services or 
treatment; and names of all accountable providers of services 
or treatment)
  A description of the treatment objectives that will result in 
measurable improvement of the condition of the adolescent.

Linkages  
For case managers to provide effective linkages to community services for
adolescents and their families, they must establish positive working 
relationships with other service providers in the area. Strategies have been
developed for establishing relationships with external referral sources, such
as the Department of Children and Families; diversion and truancy programs;
county schools (dropout prevention programs, Safe & Drug Free Schools
programs); community social services providers (timeout shelters, outpatient
adolescent services); family services planning teams; community providers
of mental health and substance abuse treatment; offices of public assistance;
and law enforcement agencies. Resource lists of help lines or hotlines
should be useful for identifying local service agencies.

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Other useful support services to achieve or maintain successful outcomes
include job placement, counseling, financial planning, independent living
skills training, housing location services, and other continued support. To
develop working relationships with community agencies, case managers
should provide other agencies with information regarding their programs
(e.g., tours of facilities, brochures of services, client eligibility requirements).
The case manager should maintain open communication with each referral
sources point of contact. Open communication should increase collaboration
with each referral agency and increase the case managers knowledge of
each referral agencys service delivery process.
Finally, the case manager is also responsible for referring the family to a
community support group for continuing help after formal treatment has
ended. Parents should be encouraged to use this support group while their
child is in treatment and to remain in contact with the group after their
child has completed therapy. While a child is in treatment, parents should
be contacted regularly and encouraged to attend these groups. 

Monitoring the Adolescents Progress  
The case manager monitors the adolescents and his or her familys
progress. The case manager must follow up on referrals made, ensuring that
the adolescent and family are keeping their appointments and that their
needs are being met. The case manager must also periodically monitor the
treatment plan of the adolescent and his or her family to make sure that
the plan is effective and to make modifications as necessary. 

Preparing for Termination  
The intensity of case management services will decrease gradually over the
treatment period to prepare the family for termination of services. The goal
of the case manager is to empower the family to care for itself. The process
of empowerment requires the case manager to educate the parents, prepare
them to handle future needs, and teach them to remain focused on the
short- and long-term goals they set with their child. 
The process of gradual reductions in case management services should be
explained to the parents in the early stages of treatment. Several weeks
before the end of services, the case manager should begin discussing 
termination. If the parents are not already involved in a community support
group, they should be strongly encouraged to become involved before 
termination. Parents must also be encouraged throughout treatment to
widen their support system in other positive ways (e.g., getting involved
with the Parent Teacher Association or the YMCA), especially ways that
would involve teens as well as parents. 

Availability of the Case Manager
Emergency services should be available 24 hours a day. These services may
be provided by the treatment agency or within the community. The case
manager should be available during business hours. As in many treatment

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programs, business hours should be flexible and extend into the evening on
certain nights. The maximum caseload is 25 adolescents and their families.
The frequency of contact by the case manager varies depending on the
intensity of the service plan developed.
Monitoring and Tracking of Case Management Services
Case management records should capture the frequency, amount, and type
of case management contacts. Documentation should occur as contacts are
made. This will ensure accurate recording of events as well as provide 
information about the family for the treatment teams. Treatment agencies
usually have forms for staff members to use to track activities. Many agencies
use electronic methods that simplify managing data for analysis. Contact
logs should be kept for any direct contact, such as telephone or face-to-face
communication, with adolescents or their families. The frequency, amount,
and type of service referrals also should be tracked, including whether the
adolescent or referred family members kept their appointments. All missed
appointments should be noted either on a form or electronically to facilitate
followup. Examples of forms are provided at the end of this section.
Qualifications and Training
The case manager should have either a bachelors degree or special training
in case management techniques. The individual should have at least 2 years
of experience in case management techniques and possess the abilities to
persuade others and to solve problems creatively. In addition, the case 
manager should receive inhouse training if needed. The following are 
examples of training the case manager should receive as needed. 

Safety Concerns
Case managers must understand that some service areas are high-risk crime
locations, and they should receive training in recognizing these situations.
Case managers should always prepare a daily schedule. Many include the
times they will be traveling to high-risk areas. When necessary, the case
manager should travel with a companion or consider meeting families in a
safe, public place. 

Time Management Techniques
Training on methods for the following will improve the case managers 
performance: prioritizing and planning to maximize use of time, confirming
appointments, using reminder postcards, knowing when a call is as effective
as a face-to-face visit, being prepared to use down time while traveling to
plan or do paperwork, and keeping extra copies of materials available.
Sales and Motivational Techniques
Training in motivational enhancement and other motivational techniques
will improve the skills of staff members and increase their ability to motivate

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participation and overcome barriers, so they can effectively encourage the
adolescent and his or her family to participate fully in the program.

Cultural Competency
Training in cultural competency will help staff members engage the family
throughout the case management procedures. Training should include
understanding ones own cultural perspectives because these cultural biases
affect judgment and clinical decisions.

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Missed Appointment Form 

Participant Name:____________________________________________________
Date of Missed Appointment:___________   Type:_________________________
Case Manager Made Contact on:___________  By: q Phone  q Face to Face

Barriers:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Action Plan:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Results:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Additional Comments:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
_________________________________          ________________
Case Manager Date

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Referral Form

Name:______________________________________________________________
Address:____________________________________________________________
____________________________________________________________
____________________________________________________________
Daytime Phone:______________________________________________________
Evening Phone:______________________________________________________
Referred by:_______________________________________  Date:____________ 
Comments:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Referral Source:_______________________________   Phone:_______________

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V. References
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motivational enhancement therapy and cognitive behavioral therapy 
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Appendix 1. Quality Assurance
Continuous quality improvement requires diligence on the part of treat
ment providers and clinical staff. One method used in the Cannabis Youth
Treatment (CYT) study required that clinical supervisors listen to video
tapes of sessions and home visits. The clinical supervisors then rated the
performance of clinicians using the quality assurance forms found in this
appendix. These forms also provided clinicians the opportunity to rate
themselves. Therefore, the procedure allowed the supervisor and the clinician
to engage in a dialog about the sessions and improve their clinical skills.
During the CYT study, all staff members improved their professional compe
tencies, regardless of their level of experience. The quality improvement
process and use of these forms are optional. However, providers should
either videotape or audiotape all sessions, or randomly selected sessions, to
help supervisors monitor counselors so they can improve their skills and to
ensure adherence to the family support network model. 

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Appendix 2. 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 (PAR) in St. Petersburg, Florida;
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, 2001) (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 
infrastructures 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 inappropriate for the CYT interventions, and 

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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 
working 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 4 CYT sites. Nine staff left the CYT project during

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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 child care 
  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 child care. 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

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manual-based treatments 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 crite-
ria, 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 that the 

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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

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and sustainable in 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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Manuals in the Cannabis Youth Treatment (CYT) Series
Sampl, S., & Kadden, R. Motivational Enhancement Therapy and Cognitive Behavioral
Therapy for Adolescent Cannabis Users: 5 Sessions, Cannabis Youth Treatment (CYT) Series,
Volume 1. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and
Mental Health Services Administration. BKD384
Webb, C., Scudder, M., Kaminer, Y., & Kadden, R. The Motivational Enhancement Therapy
and Cognitive Behavioral Therapy Supplement: 7 Sessions of Cognitive Behavioral Therapy
for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 2. Rockville,
MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services
Administration. BKD385
Hamilton, N. L., Brantley, L. B., Tims, F. M., Angelovich, N., & McDougall, B. Family Support
Network for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 3.
Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health
Services Administration. BKD386
Godley, S. H., Meyers, R. J., Smith, J. E., Karvinen, T., Titus, J. C., Godley, M. D., Dent, G.,
Passetti, L., & Kelberg, P. The Adolescent Community Reinforcement Approach for Adolescent
Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 4. Rockville, MD: Center
for Substance Abuse Treatment, Substance Abuse and Mental Health Services
Administration. BKD387
Liddle, H. A. Multidimensional Family Therapy for Adolescent Cannabis Users, Cannabis
Youth Treatment (CYT) Series, Volume 5. Rockville, MD: Center for Substance Abuse
Treatment, Substance Abuse and Mental Health Services Administration. BKD388

To order copies of this manual or any other manuals in this series, contact the Substance Abuse and Mental
Health Services Administrations (SAMHSAs) National Clearinghouse for Alcohol and Drug Information (NCADI)
at 8007296686, 8004874889 (TDD), or www.samhsa.gov. The manuals will be available to download 
electronically from www.samhsa.gov/centers/csat/csat.html.

DHHS Publication No. (SMA) 013488
Substance Abuse and Mental Health Services Administration
Printed 2001