U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

www.samhsa.gov 

Brief COUNSELING for 

MARIJUANA DEPENDENCE 

A Manual for Treating Adults 
Brief COUNSELING for
 

MARIJUANA DEPENDENCE
 

A Manual for Treating Adults
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

1 Choke Cherry Road 

Rockville, MD 20857 
Acknowledgments 

Numerous people contributed to this document, which is part of the Marijuana Treatment Project (MTP) Cooperative 

Agreement. The document was written by Karen L. Steinberg, Ph.D., Roger A. Roffman, D.S.W., Kathleen M. Carroll, 

Ph.D., Bonnie McRee, M.P.H., Thomas F. Babor, Ph.D., M.P.H., Michael Miller, Ph.D., Ronald Kadden, Ph.D., David 

Duresky, M.A., and Robert Stephens, Ph.D. The MTP Research Group provided valuable guidance and support on this 

document. See appendix B for a full list of contributors. 

This publication was developed with support from the Center for Substance Abuse Treatment (CSAT) to the University of 

Connecticut School of Medicine through Grant No. TI1 1323. This study was funded by the Substance Abuse and 

Mental Health Services Administration (SAMHSA), CSAT, U.S. Department of Health and Human Services (DHHS). The 

research was conducted in Farmington, Connecticut (UR4 TI1 1273 and UR4 TI1 1310), Miami, Florida (UR4 TI1 

1274), and Seattle, Washington (UR4 TI1 1270), in cooperation with the following institutions: University of Connecticut 

Health Center, The Village South, Inc., University of Washington, and Evergreen Treatment Services. The publication was 

produced by Johnson, Bassin & Shaw, Inc. (JBS), under the Knowledge Application Program (KAP) contract numbers 

270-99-7072 and 270-04-7049 with SAMHSA, DHHS. Christina Currier served as the CSAT Government Project 

Officer. Andrea Kopstein, Ph.D., M.P.H., served as the Deputy Government Project Officer. Jean Donaldson, M.A., served 

as Government Project Officer for the MTP Cooperative Agreement. Lynne McArthur, M.A., A.M.L.S, served as JBS KAP 

Executive Project Director; Barbara Fink, R.N., M.P.H., served as JBS KAP Managing Director; and Emily Schifrin, M.S., 

and Dennis Burke, M.S., M.A., served as JBS KAP Deputy Directors for Product Development. Other JBS KAP personnel 

included Candace Baker, M.S.W., Senior Writer; Elliott Vanskike, Ph.D., Senior Writer; Wendy Caron, Editorial Quality 

Assurance Manager; Frances Nebesky, M.A., Quality Control Editor; and Pamela Frazier, Document Production Specialist. 

Disclaimer 

The opinions expressed herein are the views of the authors and do not necessarily reflect the official position of CSAT, 

SAMHSA, or DHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS for these opinions or for 

particular instruments, software, or resources described in this document is intended or should be inferred. The 

guidelines in this document should not be considered substitutes for individualized client care and treatment decisions. 

Public Domain Notice 

All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and 

may be reproduced or copied without permission from SAMHSA/CSAT or the authors. Do not reproduce or distribute this 

publication for a fee without specific, written authorization from SAMHSA’s Office of Communications. 

Electronic Access and Copies of Publication 

Copies may be obtained free of charge from SAMHSA’s National Clearinghouse for Alcohol and Drug Information 

(NCADI), 800-729-6686 or 301-468-2600; TDD (for hearing impaired) 800-487-4889; or electronically through the 

following Web site: www.ncadi.samhsa.gov. 

Recommended Citation 

Steinberg, K.L.; Roffman, R.A.; Carroll, K.M.; McRee, B.; Babor, T.F.; Miller, M.; Kadden, R.; Duresky, D.; and Stephens, 

R. Brief Counseling for Marijuana Dependence: A Manual for Treating Adults. DHHS Publication No. (SMA) 05-4022. 

Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 

2005. 

Originating Office 

Practice Improvement Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance 

Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. 

DHHS Publication No. (SMA) 05-4022 

Printed 2005 
TABLE OF CONTENTS
 

I.	 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
 Me? Hooked on Pot? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
 

Case Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
 

Brief Marijuana Dependence Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
 

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
 

Current Findings About Marijuana Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
 

Overview of the Marijuana Treatment Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
 

Who Should Use This Manual? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
 

Organization of This Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
 

II.	 Overview of the Brief Marijuana Dependence 

Counseling Model and Manual . . . . . . . . . . . . . . . . . . . .11
 General Theoretical Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
 

BMDC Therapeutic Tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
 

Target Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
 

Structure of BMDC and the Individual Sessions 13
 

How To Use the Manual . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . .

 . . . . . . . . . . . . . . . . . . . . . . . . .14
 

III.	 Common Treatment Issues . . . . . . . . . . . . . . . . . . . . . . .15
 Client–Counselor Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
 

Orienting the Client and Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
 

Preventing Attrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
 

Practice Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
 

Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
 

Strategies for Addressing Common Clinical Problems . . . . . . . . . . . . . . . . . . . . . . .18
 

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
 

IV.	 Getting Started: Assessment Session . . . . . . . . . . . . . . . .23
 Building Rapport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
 

Assessing Marijuana Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
 

Overview of Assessment Session: Building Rapport and Assessing Marijuana Use . . .25
 

Assessment Session Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
 

Forms for Assessment Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
 

iii 
Brief Counseling for Marijuana Dependence 

V.	 Enhancing Motivation: Sessions 1 and 2 . . . . . . . . . . . . .63
 Key Concepts: Motivational Interviewing Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
 

Tips for the Counselor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
 

Overview of Session 1: Reviewing the PFR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
 

Session 1 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71
 

Overview of Session 2: Change Plan, Treatment Plan, and Supporter Involvement . . .78
 

Session 2 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79
 

Forms for Sessions 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82
 

VI.	 Changing Marijuana Use Through Skill Building: 

Sessions 3 Through 9 . . . . . . . . . . . . . . . . . . . . . . . . . . .97
 Why Focus on Skills? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97
 

What Is Cognitive Behavioral Counseling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98
 

Integrating MET and CBT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98
 

Tips for the Counselor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
 

Overview of Session 3: Skill Topic 1, Coping With Other Life Problems . . . . . . . . . .100
 

Session 3 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
 

Overview of Session 4: Skill Topic 2, Understanding Marijuana Use Patterns . . . . . .107
 

Session 4 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
 

Overview of Session 5: Skill Topic 3, Coping With Cravings and Urges To Use . . . . .111
 

Session 5 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112
 

Overview of Session 6: Skill Topic 4, Managing Thoughts About Marijuana Use . . . .116
 

Session 6 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117
 

Overview of Session 7: Skill Topic 5, Problemsolving . . . . . . . . . . . . . . . . . . . . . .123
 

Session 7 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123
 

Overview of Session 8: Skill Topic 6, Marijuana Refusal Skills . . . . . . . . . . . . . . . .127
 

Session 8 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127
 

Elective Skill Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131
 

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

and Coping With a Lapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132
 

Session 9 Protocol: Elective Skill Topic 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132
 

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

Irrelevant Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134
 

Session 9 Protocol: Elective Skill Topic 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134
 

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

and Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
 

Session 9 Protocol: Elective Skill Topic 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139
 

Overview of Session 9: Elective Skill Topic 4, Demonstrating Assertiveness . . . . . . .142
 

Session 9 Protocol: Elective Skill Topic 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142
 

Forms for Sessions 3 Through 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
 

iv 
Table of Contents 

VII. Supplemental Readings . . . . . . . . . . . . . . . . . . . . . . . .167
 Supplemental Reading A: Who Needs Treatment? The Nature, Prevalence, 

and Consequences of Marijuana Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . .167
 

Supplemental Reading B: How Effective Is Treatment for Marijuana Dependence? 

The Marijuana Treatment Project and Related Studies . . . . . . . . . . . . . . . . . . . . .171
 

Supplemental Reading C: Implementing Brief Marijuana Dependence Counseling . .174
 

Appendix A. Session Rating Form . . . . . . . . . . . . . . . . . . . .179
 

Appendix B. Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . .185
 

Appendix C. Field Reviewers . . . . . . . . . . . . . . . . . . . . . . . . .187
 

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189
 

v 

SECTION I. 

INTRODUCTION 

The Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental 

Health Services Administration, funded three clinical sites and a Coordinating Center (CC) to 

design and implement the Marijuana Treatment Project (MTP) in the late 1990s. A major focus of 

CSAT is rigorous testing of approaches to treat marijuana dependence in both adults and 

adolescents. MTP studied the efficacy of treatments for adults who are dependent on marijuana. 

At the time of funding, MTP was one of the largest Knowledge Development and Applications 

initiatives funded by CSAT. Another was the Cannabis Youth Treatment (CYT) Study, which resulted 

in the CYT Series, a five-volume resource that provides unique perspectives on treating 

adolescents for marijuana use (Godley et al. 2001; Hamilton et al. 2001; Liddle 2002; Sampl 

and Kadden 2001; Webb et al. 2002). 

This manual for Brief Marijuana Dependence Counseling (BMDC) is based on the research 

protocol used by counselors in MTP. The manual provides guidelines for counselors, social workers, 

and psychologists in both public and private settings who treat adults dependent on marijuana. 

The 10 weekly one-on-one sessions in the BMDC manual offer examples of how a counselor can 

help a client understand certain topics, keep his or her determination to change, learn new skills, 

and access needed community supports (exhibit I-1). Stephens and colleagues (2002) describe 

the MTP rationale, design, and participant characteristics. Findings from MTP are presented in 

supplemental reading B of section VII. 

Me? Hooked on Pot? 

Many individuals for whom this intervention was designed often have difficulty accepting that they 

are dependent on marijuana. The topic is controversial, even for those who walk through a 

counselor’s door to talk about their marijuana use. 

People who become clients in BMDC may have 

• Put off actions and decisions to the point of being a burden on family and friends 

• Given up personal aspirations 

• Had nagging health concerns, such as worries about lung damage 

• Made excuses for unfinished tasks or broken promises 

• Experienced disapproval from family and friends 

• Been involved in the criminal justice system. 

1
 
Exhibit I-1. Brief Marijuana Dependence Counseling 

Assessment 

Assessment

•Building 

rapport 

Motivational 

enhancement

therapy (MET)

techniques 

for engaging 

clients 

Overview 

for client 

•

•

Treatment 

Session

1 

Session

2 

•MET 

Review of 

Personal 

Feedback 

Report 

Beginning 

cognitive 

behavioral 

therapy 

•

•

•

Session

3 

Session

4 

Session

5 

Session

6 

Session

7 

Session

8 

Session

9 

Core skill-building topics 

Elective skill-building topics 

Case management as needed 

•

•

Brief Counseling for Marijuana Dependence 

Case Examples 

Doug 

A Caucasian father of two teenagers, Doug was in his early 40s when his wife forced him to talk 

to a counselor about marijuana. He was not happy to be in the counselor’s office. “What’s the big 

deal?” he asked. “It’s just pot.” Doug’s wife had given him an ultimatum: either he quit getting 

high or she would move out. She delivered this ultimatum when their 15-year-old son was 

suspended from school for smoking marijuana. 

When they were younger, Doug and his wife smoked pot together. As their children grew older, 

however, his wife gave it up. For a long time, she tolerated Doug’s continued use, with their 

agreeing that he’d be discreet. Both felt that the children should not know about his using. Doug 

tried to be careful, but a few times his son had walked in on him using marijuana. 

“Why can’t you settle for my promising to try harder to hide it from the kids?” he argued. “It’s not 

as if it’s really a problem. After all, our family benefits from my income.” 

Given what he said in the first several minutes he spent with the counselor, he saw the real issue 

as his wife’s refusal to be reasonable. But Doug also mentioned that he wondered, “What will 

people think if word gets out that I smoke marijuana?” 

2 
Section I. Introduction 

Shirley 

Shirley struggled with thoughts about marijuana and its effects. An African-American mother of 

three girls, Shirley was troubled by what she perceived as a conflict between her personal and 

professional lives. 

Getting high helped her relax and sleep. Shirley had first smoked pot with a favorite uncle, and 

other members of her close-knit family had experienced getting high. No one was critical of her 

smoking. However, Shirley wanted to be an elementary school teacher. While student teaching, 

she was struck by the incongruity of having chosen a profession that called for being a good role 

model for children yet regularly getting stoned. She had thought a lot about quitting. When she 

tried to stop, she felt agitated and had difficulty sleeping. Shirley worried that she might not 

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

Like Doug, Shirley was grappling with a complicated issue. Doug and Shirley perceived aspects of 

their marijuana experiences as positive, yet they were troubled by possible consequences. 

Miguel 

A 36-year-old married Hispanic man, Miguel has known for years that getting high is no longer a 

casual part of his life. When he tried to stop, he got angry at the slightest provocation, could not 

relax, and inevitably returned quickly to frequent use. 

Not too long ago, Miguel made an appointment at a drug treatment agency but never showed up. 

The agency employee who answered the phone asked him, “Is marijuana the only drug you use?” 

He thinks that he needs help but doubts that anyone would understand how he feels. He does not 

want to be treated like an addict. 

Brief Marijuana Dependence Counseling 

These three examples illustrate several important questions commonly asked by people about 

their marijuana use: 

• Is it possible to be dependent on marijuana? 

• Do I want to stop using because of what I’ve experienced? 

• Can I succeed in stopping, given the challenges I’ve faced in the past? 

The counseling approach presented in this manual addresses these issues among others. It 

comprises three key intervention components: motivational enhancement, cognitive behavioral 

skills training, and case management. Each session presents examples of how a counselor might 

introduce certain topics, facilitate the client’s resolution to stop using marijuana, provide skills 

training, and help the client access needed community supports. 

3 
Brief Counseling for Marijuana Dependence 

Background 

Before 1994, no published, controlled trials of treatment for marijuana use disorders existed, 

which is surprising because marijuana long has been the most frequently used illicit substance in 

the United States. Interest in treatment for people who use marijuana may have been lacking 

because of myths that extensive marijuana use did not lead to dependence and that no adverse 

consequences were associated with misuse (Roffman et al. 1988; Stephens and Roffman 1993). 

The relatively mild withdrawal symptoms associated with marijuana use may have led to a belief 

that dependence was unlikely and that people who needed treatment abused other substances 

and their marijuana use was a secondary concern (e.g., Rainone et al. 1987). Similarly, most 

early reviews found few serious negative consequences associated with marijuana use (e.g., 

Hollister 1986; Wert and Raulin 1986a, 1986b). However, recent research shows that a 

significant number of adults are dependent on marijuana and experience negative consequences 

secondary to their use of marijuana. 

Current Findings About Marijuana Use 

Marijuana is the most commonly used illicit substance in the United States (Clark et al. 2002; 

Substance Abuse and Mental Health Services Administration 2003). According to the 2003 

National Survey on Drug Use and Health, 14.6 million people ages 12 and older had smoked 

marijuana in the preceding month (Substance Abuse and Mental Health Services Administration 

2004). It is estimated that approximately 4.3 million people used marijuana at levels consistent 

with abuse or dependence in the past year. Given that it is an illicit substance, any use of 

marijuana carries with it some significant risks. However, this document focuses on people who 

use marijuana heavily or are dependent on it. This treatment manual is directed primarily at these 

persons but may be useful for other persons with substance abuse or substance use disorders. 

Studies have demonstrated that tolerance and withdrawal develop with daily use of large doses of 

marijuana or THC (Haney et al. 1999a; Jones and Benowitz 1976; Kouri and Pope 2000). About 

15 percent of people who acknowledge moderate-to-heavy use reported a withdrawal syndrome 

with symptoms of nervousness, sleep disturbance, and appetite change (Wiesbeck et al. 1996). 

Many adults who are marijuana dependent report affective (i.e., mood) symptoms and craving 

during periods of abstinence when they present for treatment (Budney et al. 1999). The 

contribution of physical dependence to chronic marijuana use is not yet clear, but the existence of 

a dependence syndrome is fairly certain. An Epidemiological Catchment Area study conducted in 

Baltimore found that 6 percent of people who used marijuana met Diagnostic and Statistical 

Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association 1994), 

criteria for dependence and 7 percent met DSM-IV criteria for substance abuse (Rosenberg and 

Anthony 2001). Coffey and colleagues (2002) found that persons who use marijuana more than 

once a week are at significant risk for dependence. In the 1990s, the number of people who 

sought treatment for marijuana dependence more than doubled (Budney et al. 2001). Therefore, 

a large group of adults who smoke marijuana is dependent and may need and benefit from 

treatment. 

Surveys of people using marijuana who are not in treatment consistently show that a majority 

report impairment of memory, concentration, motivation, self-esteem, interpersonal relationships, 

health, employment, or finances related to their heavy marijuana use (Haas and Hendin 1987; 

4 
Section I. Introduction 

Rainone et al. 1987; Roffman and Barnhart 1987; Solowij 1998). Similar marijuana-related 

consequences are seen among those seeking treatment for their marijuana use (Budney et al. 

1998; Stephens et al. 1994b, 2000). People using marijuana who participated in previous 

treatment studies averaged more than 10 years of near-daily use and more than six serious 

attempts to quit (Stephens et al. 1994b, 2000). These individuals had persisted in their use 

despite multiple forms of impairment (i.e., social, psychological, physical), and most perceived 

themselves as unable to stop. 

During the past decade evidence has emerged that a variety of problems are associated with 

chronic marijuana use. Although the severity of these problems appears to be less than that of 

problems caused by other drugs and alcohol, the large number of people using who may have 

these problems raises the possibility of a significant public health problem. Like those who use 

other mood-altering substances, many individuals who use marijuana chronically perceive the 

problems to be severe enough to warrant treatment. 

The results of earlier studies on treatments for marijuana problems indicated that some adults 

who used marijuana responded well to several types of interventions, such as cognitive behavioral, 

motivational enhancement, and voucher-based treatments (Budney et al. 2000; Stephens et al. 

1994b, 2000). Relapse rates following treatment were similar to those for other drugs of abuse 

and, as found with other types of substance abuse treatment, improvements in drug use were 

accompanied by other positive gains, including improvements in dependence symptoms, problems 

related to marijuana use, and anxiety symptoms. However, the generalizability of the treatment 

findings appeared to be limited by the predominantly white, male, and socioeconomically stable 

(i.e., educated and employed) characteristics of the samples. Therefore, the results of these 

studies may be limited to this fairly homogeneous group of people who are marijuana users. 

Overview of the Marijuana Treatment Project1 

CSAT funded MTP to design and conduct a study of the efficacy of treatments for marijuana 

dependence, to extend this line of research, and to broaden the applicability of the approach to a 

more diverse group than that used in earlier trials (Stephens et al. 1994b, 2000). The treatment 

sites were the University of Connecticut School of Medicine, Department of Psychiatry, 

Farmington, Connecticut; The Village South, Miami, Florida; and the University of Washington, 

School of Social Work, Seattle, Washington. The CC was at the University of Connecticut, 

Department of Psychiatry. 

The study examined the efficacy of treatments of different durations for a diverse group of adults who 

were marijuana dependent. Two treatments—one lasting two sessions, the other nine sessions— 

were compared with a delayed treatment control (DTC) condition, in which subjects were offered 

treatment 4 months after their baseline assessment. The same counselors delivered treatments of 

both durations to avoid confounding the mode of treatment, length of treatment, and counselor 

experience. A case management component was incorporated in the longer treatment to help clients 

identify and overcome barriers to successful behavior change in their everyday environments. The 

hypothesis was the nine-session and two-session interventions would produce outcomes superior to 

the DTC in terms of higher abstinence rates and associated negative consequences. Although the 

1The following section is adapted from MTP Research Group (in press). 

5 
Brief Counseling for Marijuana Dependence 

limited prior research suggested no differences between brief and extended treatments, it also was 

hypothesized that the nine-session intervention would yield outcomes superior to the two-session 

intervention when delivered by counselors with the same level of expertise. 

The study improved on the methodology of the previous treatment studies in several other ways. 

Structured diagnostic interviews were used to arrive at formal diagnoses of marijuana 

dependence, and the Addiction Severity Index, a widely used measure of problem severity, was 

included to compare the findings of this study with those of other studies of drug abuse. 

Supplemental reading B in section VII provides a detailed discussion of study methodology. 

As the first well-controlled multisite trial of manual-guided treatments for marijuana dependence, 

this study produced several noteworthy findings: 

•	 The results of the randomized trial suggest that both a two-session motivational 

enhancement therapy (MET) treatment and a nine-session treatment incorporating MET, 

coping skills training, and case management were significantly more effective in reducing 

marijuana use than a DTC condition. 

•	 The more intensive the treatment, the better the outcomes. 

•	 Outcomes of these brief treatments were durable; data from a 1-year followup of the treated 

groups demonstrated treatment’s sustained effect even after treatment termination. 

•	 Reductions in drug use were linked to other positive outcomes (e.g., sustained reductions 

in marijuana-related problems). 

•	 Treatment effects were robust across a number of participant characteristics, including 

gender and ethnicity. 

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

Few studies have evaluated active treatments with respect to a DTC condition. The findings from 

the DTC group are not consistent with the view that marijuana dependence is benign and that 

individuals improve without treatment. Instead, these findings suggest that well-structured 

treatments may be necessary to increase abstinence rates among the chronic marijuana-using 

population. Many subjects reported difficulties finding help for their marijuana-related problems 

through the current substance abuse treatment system. 

The findings are also generally consistent with the results of prior studies of behavioral treatments 

for cannabis-related disorders (Budney et al. 1998; Stephens et al. 1994b, 2000) in suggesting 

that well-defined behavioral treatments for marijuana dependence produce encouraging 

improvement and that treatment is associated with meaningful benefits. These findings support 

other results in the literature pointing to the efficacy of behavioral treatments in producing 

significant and durable improvement for a range of substance-related disorders, particularly 

alcohol and cocaine dependence. 

Findings indicate a robust dose-effect relationship for this study’s treatments and contrast with 

earlier studies of cannabis treatment that have not demonstrated differences in outcome related 

to intensity. The MTP study, one of only a few studies that have focused on treatment intensity, 

6 
Section I. Introduction 

contrasted the brief two-session treatment with the more intensive nine-session treatment; 

treatment participation was high in both conditions. However, further research is needed to 

determine whether treatment outcomes might be improved with more treatment or whether 

different distributions of treatment sessions might help people who use marijuana sustain the 

positive treatment outcomes. 

In addition to the overall reductions observed in the frequency of marijuana smoking, reductions also 

were evident in marijuana dependence symptoms, marijuana-related problems, and anxiety 

symptoms. In each measure, the nine-session treatment group showed the greatest improvements, 

the two-session group showed intermediate reductions, and the DTC group showed little change. 

Finally, countering the historical portrayal of marijuana as a benign drug, the MTP study and 

previous research (Stephens et al. 1993a, 1994b, 2000) suggest that individuals can develop 

recurrent psychological, social, and medical problems with chronic marijuana use. Individuals who 

use marijuana as their primary drug tend not to seek treatment in traditional drug treatment 

settings. Clients in real-life treatment settings, as compared with volunteers in randomized clinical 

trials, tend to present with complex difficulties in addition to substance use disorders. When 

people present for marijuana treatment, they may want and need help with family and other 

relationships, regulating their emotions, employment and financial problems, or addressing health 

worries. These problems may have preceded, resulted from, or co-occurred with the substance 

use difficulties. Increasing evidence suggests that counseling for marijuana dependence is 

effective and accompanied by other positive changes in clients’ lives (Steinberg et al. 2002). 

Who Should Use This Manual? 

The manual is designed for use by experienced clinicians. Counselors should follow the outlined 

procedures and should have the opportunity for regular consultation with clinical supervisors 

familiar with the BMDC approach. Detailed treatment protocols define goals for each session and 

standardize counseling techniques but also permit flexibility. 

All BMDC counselors should meet the following criteria: 

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

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

• Experience in conducting treatment consistent with BMDC 

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

This manual is a blueprint for treatment and is not a substitute for training and supervision. The 

material may not be appropriate for all clients or clinical programs. This manual should be viewed 

as a supplement to careful assessment of each client, appropriate case formulation, monitoring of 

clinical status, and clinical judgment. 

Supplemental reading C in section VII provides detailed information on effectively implementing 

and managing BMDC; appendix A provides a session rating form to guide supervisors. 

7 
Brief Counseling for Marijuana Dependence 

Organization of This Manual 

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

Section II describes the theoretical basis for BMDC treatment. It explains the therapeutic tasks of 

the BMDC approach, describes the target population, and provides an overview and the suggested 

sequencing of BMDC sessions. 

Section III. Common Treatment Issues 

Section III presents potential pitfalls in BMDC and guidelines for handling issues that may arise. 

Some problems identified are not specific to marijuana treatment and may apply generally to 

substance use disorders or clinical counseling. 

Section IV. Getting Started: Assessment Session 

Section IV details the strategies for initiating BMDC treatment with a client dependent on 

marijuana. The assessment session outlines strategies for building rapport, assessment 

procedures, and MET techniques for engaging the client and identifying goals and change 

strategies. Clinical information for assessing and evaluating the client’s status, level of marijuana 

use, problems related to use, and reasons for wanting to change is gathered by the counselor 

during the initial evaluation and is used to develop an individualized treatment plan. The session 

includes assessment and scoring tools for completing a client’s Personal Feedback Report (PFR), 

a critical tool in the implementation of BMDC. 

Section V. Enhancing Motivation: Sessions 1 and 2 

Sessions 1 and 2 of BMDC follow MET principles. During session 1, the counselor uses the 

completed PFR to make the client aware of the effects of marijuana use on critical life areas and to 

increase motivation. Using motivational interviewing strategies, the counselor elicits and reinforces 

the client’s motivation for change. If the client is ready to change, the discussion shifts from 

motivational enhancement to cognitive behavioral strategies, goal setting, and the skills to 

accomplish goals. The guidelines for session 2 instruct the counselor on how to reinforce the client’s 

efforts to initiate change, review goals and plan alternative strategies for behavior change, and 

encourage support from the friend or relative who has been invited to the session by the client. 

Section VI. Changing Marijuana Use Through Skill Building: Sessions 3 Through 9 

Section VI outlines material for the remaining seven sessions of BMDC, including the use of cognitive 

behavioral strategies for building client motivation and maintaining treatment gains. This section 

describes the six core skill topics and four elective skill topics used with clients in BMDC (exhibit I-2). 

8 
Section I. Introduction 

Exhibit I-2. Core and Elective Skill Topics in Brief Marijuana Dependence Counseling 

Core Skill Topics (sessions 3ñ8) 

Session 3: Coping with other life problems 

Session 4: Understanding marijuana use patterns 

Session 5: Coping with cravings and urges to use 

Session 6: Managing thoughts about marijuana use 

Session 7: Problemsolving 

Session 8: Marijuana refusal skills 

Elective Skill Topics (session 9) 

Topic 1: Planning for emergencies and coping with a lapse 

Topic 2: Recognizing seemingly irrelevant decisions 

Topic 3: Managing negative moods and depression 

Topic 4: Demonstrating assertiveness 

The counselor and client jointly select one of the four elective topics that they decide is most 

appropriate. The guidelines for sessions 3 through 9 are twofold: 

•	 The sessions follow detailed protocols for using cognitive behavioral skills to build on client 

strengths and to overcome specific skill deficits associated with substance dependence. 

•	 The sessions identify other problems that can interfere with recovery from marijuana 

dependence and suggest clinical case management interventions. 

Section VII. Supplemental Readings 

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

This section provides a comprehensive review of the literature on the epidemiology of marijuana 

dependence, the significance of the problem, and the rational for developing effective and 

replicable treatments. 

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

Related Studies 

This section presents the design, rationale, and findings from major clinical trials that have 

focused exclusively on marijuana dependence treatment, including MET. 

C. Implementing Brief Marijuana Dependence Counseling 

This section is intended for program developers, administrators, and supervisors who are responsible 

for establishing and maintaining an infrastructure to support clinical implementation of BMDC. These 

guidelines can be used in identifying an appropriate site for BMDC, selecting and supervising 

counselors, easing the transition to marijuana-specific treatment, and monitoring effectiveness. 

9 

SECTION II. 

OVERVIEW OF THE BRIEF MARIJUANA DEPENDENCE COUNSELING 

MODEL AND MANUAL 

The Brief Marijuana Dependence Counseling (BMDC) approach combines elements from previously 

demonstrated treatments for substance use disorders: 

• Motivational enhancement therapy (MET) (CSAT 1999b; Miller and Rollnick 2002) 

• Cognitive behavioral therapy (CBT) (CSAT 1999a; Kadden et al. 1994; Monti et al. 1989) 

• Case management (CSAT 1998). 

MET strategies are perceived as potentially useful with the chronic marijuana-using population 

because of their success in addressing substance use disorders. 

The client-centered engagement approach of MET is a good fit for individuals who, in many cases, 

never have been involved in treatment before and have been frustrated with previous attempts at 

locating marijuana-specific treatment opportunities. MET provides the overall theoretical framework, 

and specified MET strategies are used heavily during sessions 1 and 2. Although the remaining 

seven sessions focus increasingly on skill building rather than motivation, MET concepts and 

strategies are incorporated throughout all treatment sessions. The counselor is encouraged to pay 

attention to the client’s readiness for change and its implications for treatment engagement and 

behavioral and attitudinal changes. 

CBT provides a secondary, but complementary, approach in the BMDC model. The CBT sessions 

focus on building the client’s behavioral, cognitive, and emotional skills necessary to undertake a 

major life change such as stopping marijuana use. 

The case management components are introduced in session 3, which is devoted to identifying life 

problems that are extraneous to or aggravated by the client’s marijuana problems. The counselor 

teaches the client how to access support services to address these additional problems. 

General Theoretical Assumptions 

Clinical Engagement and Therapeutic Alliance 

BMDC fosters the development of a strong working alliance between counselor and client to explore 

marijuana-related problems, identify realistic goals, and initiate change strategies. From the outset 

of treatment, the counselor focuses on engaging the client in the treatment process by establishing 

trust and showing an accurate reflection of the client’s concerns. Throughout treatment, the 

counselor demonstrates respect, warmth, and empathy and shows concern for the client’s needs. 

Any disruptions to the therapeutic relationship are handled carefully and respectfully. 

11
 
Brief Counseling for Marijuana Dependence 

Meeting Clients “Where They Are” 

The counselor develops a clear picture of the client’s past and current marijuana use upon 

admission to treatment, the problems that have been created through continued use, the reasons 

the client has identified for making lifestyle changes related to marijuana, and the goals the client 

wants to achieve. An understanding of where the client is on his or her particular path to 

abstinence helps the counselor guide growth and change. The counselor listens to the client’s core 

concerns about marijuana and his or her treatment goals and provides an environment that 

motivates the client to take steps toward recovery. The counselor does not impose goals or values 

during the treatment process, nor does he or she communicate disapproval or judgment about the 

client’s objectives or readiness to change. Rather, the counselor encourages the client to express 

his or her goals and to participate in developing objectives. This approach presents an apparent 

conundrum: the client’s goal of abstinence will be served by the therapist’s not demanding 

abstinence of the client immediately upon entering treatment. It is important to note that meeting 

clients “where they are” is a therapeutic necessity that is consistent with a goal of abstinence. 

The client-centered aspects of MET and case management allow the counselor to adjust session 

content to a client’s background and culture (Steinberg et al. 2002). Focusing on the individual is 

not meant to preclude the client’s participating in mutual-help or 12-Step programs between 

sessions. If the client shows an interest in attending such groups, the counselor should make 

available a list of local meetings. 

Supporting Client Efficacy and Pointing Out Discrepancies 

As the BMDC counselor engages the client in treatment and establishes a positive working 

relationship with him or her, the counselor looks for opportunities to refine goals and examine 

motivation levels. The counselor achieves this in a variety of ways, including supporting the client’s 

efficacy and pointing out discrepancies. Supporting client efficacy is essential because it 

communicates belief in the client’s inherent wisdom and ability to solve problems effectively. The 

counselor conveys the message that, although treatment entails learning new techniques or skills 

for handling difficult problems, the client possesses the ability to learn, process information, and 

carry out his or her plans. Discrepancies may exist between goals and behaviors, previously stated 

and currently stated concerns, or perceived benefits and actual consequences of marijuana use. By 

pointing out these discrepancies or inconsistencies to the client the counselor can enhance the 

client’s motivation and determination. 

Learning About Marijuana Use Patterns 

The BMDC model is based on the principle that substance use disorders result from learned 

behavior patterns rather than basic character defects. The counselor presents this framework to the 

client as a way of both understanding how the client’s problems developed and thinking about how 

to ameliorate the situation. For example, marijuana dependence can result from repeated use to 

relieve painful emotions or to self-medicate. Therefore, recovery from marijuana dependence 

requires making new choices involving healthier lifestyle patterns. 

12 
Section II. Overview 

BMDC Therapeutic Tasks 

BMDC is a short-term treatment to assist clients. The BMDC counselor engages the client in a 

treatment process that builds on the client’s motivation to change. The approach integrates 

several models and accompanying strategies and is flexible within the general treatment structure. 

The BMDC treatment approach can be tailored to specific clinical situations while retaining its 

specific set of therapeutic tasks. Those tasks include 

•	 Encouraging therapeutic engagement 

•	 Performing a thorough assessment of the client’s marijuana problem, as well as his or her 

strengths and resources 

•	 Facilitating motivation for change 

•	 Addressing psychosocial problems beyond marijuana use 

•	 Building skills to establish and sustain change. 

Client factors such as marijuana problem severity, general acuity, and psychosocial stresses and 

supports determine when activities to address these tasks are initiated. 

Target Population 

BMDC is for people seeking treatment to stop their marijuana use. People with a pattern of longterm marijuana use may have chronic symptoms of physiological and psychological dependence 

as well as impairments in other life areas, such as family relationships, intrapersonal and 

interpersonal capabilities, work, and educational achievement. BMDC has been effective with 

clients who participate voluntarily, but whether it would be effective with individuals who are 

mandated to treatment is not known. BMDC appears to be effective with clients who are 

ambivalent about stopping their marijuana use; in fact, the treatment model helps clients explore 

and resolve such ambivalence (Steinberg et al. 2002). BMDC has been used in outpatient 

treatment settings with individuals who require a low intensity of service. With clients who require 

more intensive services or who have significant co-occurring disorders, BMDC may be used 

adjunctively with other treatments but should not replace needed services. 

Structure of BMDC and the Individual Sessions 

BMDC comprises nine sessions that are organized into three sections: 

•	 Getting Started: Assessment Session 

•	 Enhancing Motivation (sessions 1 and 2) 

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

Each section begins with an introduction that provides an overview of the basic rationale, goals, 

counselor skills, and client activities that are used in the sessions in that section. The introduction 

is followed by an overview and a specific protocol for each session. 

13 
Brief Counseling for Marijuana Dependence 

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

•	 Session Title 

•	 Total Time 

•	 Delivery Method 

•	 Materials 

•	 Goals for This Session 

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

The box is followed by a detailed protocol that walks the counselor through the session content, 

provides session-specific background information and rationale, and offers samples of interactions 

between counselor and client. Italicized text is used to denote a sample script of what a counselor 

might say to a client to illustrate a principle, an example of a possible dialog between a counselor 

and a client, or an example of a role play between a counselor and a client. 

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

•	 Check-in. This includes asking the client about recent events, progress made, and any 

lapses that may have occurred since the last session. The counselor also reviews any 

between-session exercises assigned during the previous session. 

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

the session protocol. 

•	 Summary. The counselor briefly summarizes the session, asks the client whether he or 

she understands major points covered, and provides clarification as necessary. 

How To Use the Manual 

The counselor should read through the entire manual before beginning treatment. Counselors 

should have basic training in both motivational enhancement and cognitive behavioral treatment 

techniques, but the manual provides a solid review of basic principles and information specific to 

working with clients who are marijuana dependent. Supplemental reading C in section VII provides 

details on BMDC-specific training. 

The detailed session protocols are not designed to be taken into a session and followed literally. 

They offer the counselor suggestions on how to transition from one topic to the next during a 

session. The counselor needs to become familiar with the session content before meeting the 

client. However, the boxed overview and outline at the beginning of each session can be pulled 

out of the manual and taken into the session to be used as a cue sheet. 

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

the forms before each session for their clients. 

14 
SECTION III. 

COMMON TREATMENT ISSUES 

This section highlights problems that may arise when working with people who are dependent on 

marijuana. Clients in Brief Marijuana Dependence Counseling (BMDC) may differ from clients with 

mental disorders and from clients who abuse other substances. For example, this may be the 

client’s first experience in any type of treatment setting. Clients may be uncertain about what they 

are supposed to do in therapy. To alleviate feelings of uncertainty, a counselor can provide clients 

with general information about the client–counselor relationship and treatment expectations and 

parameters. 

ClientñCounselor Relationship 

In BMDC the client–counselor relationship is at the core of the change process; a positive 

relationship is the foundation of treatment. Even though BMDC treatment is brief, the quality of 

the relationship is important. 

A strong relationship positively affects compliance and retention. The counselor can promote the 

therapeutic relationship through listening empathically, providing support and encouragement, 

displaying genuine concern, responding to client concerns, addressing disagreements promptly, 

and providing clarifications and explanations. 

The counselor should avoid strategies that may elicit resistance, including aggressive confrontation 

of denial, excessive questioning, interrupting the client, or arguing with the client. The counselor 

should respond to client concerns and complaints while providing a consistent structure for the 

sessions. Clients who have never participated in psychotherapy or psychosocial treatment may 

need extra guidance about the process of treatment to foster therapeutic engagement. 

Orienting the Client and Confidentiality 

As part of the assessment session, the counselor spends time describing the treatment and 

session format and answering questions. The counselor provides an overview at the beginning of 

each session and spends a few minutes at the end summarizing the topics addressed to help the 

client develop a framework for the sessions and retain the material that was discussed. 

The counselor also should discuss confidentiality issues during the assessment session. The client 

may be unfamiliar with the confidentiality of information disclosed in therapy and the limits to 

confidentiality. He or she may need updated information on new rules such as the Health 

Insurance Portability and Accountability Act. Although the client may have signed an informed 

consent or other admissions forms, the counselor should not assume that the client understands 

the issues surrounding confidentiality; it is good clinical practice to discuss them. 

15
 
Brief Counseling for Marijuana Dependence 

Preventing Attrition 

During the assessment session, it is important to anticipate potential obstacles to successful 

treatment, especially factors that can lead to early attrition. The counselor should explore any 

instances in which the client previously dropped out of treatment and urge the client to discuss 

any thoughts of quitting treatment. Open discussion can resolve problems and prevent the client 

from dropping out. Progress in treatment is not steady—there are ups and downs. Most clients 

experience hopelessness, anger, frustration, and other negative feelings at times. Clients should 

be encouraged to discuss their feelings, even if they fear that the discussion might be 

embarrassing or difficult. 

The counselor can point out that prematurely terminating treatment may be one of a series of 

seemingly irrelevant decisions that eventually lead to a relapse. For this reason, any hint that a 

client is considering dropping out should be taken seriously and discussed fully. 

Many clients quit treatment after their first relapse. Clients should be warned that, even with 

efforts to maintain abstinence, some might slip and begin using. They should be encouraged to 

continue attending after a using episode so that they can receive help in regaining abstinence, 

coping with their reaction to the slip, and avoiding future lapses. 

A delicate balance exists between setting the stage for clients to feel they may return after a lapse 

and giving them permission to use. Counselors should ensure that clients understand this 

distinction clearly. 

Recognizing Change Readiness 

Following is a list of questions to assist counselors in determining clients’ readiness to accept, 

continue in, and comply with a change program (Zweben and O’Connell 1988): 

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

•	 If the client was coerced into treatment, have his or her reactions—anger, relief,
 

confusion, acceptance—to this forced attendance been discussed?
 

•	 Is the client hesitant to schedule future sessions? 

•	 Is treatment different from what the client has experienced before? If so, have the
 

differences and the client’s reactions been discussed?
 

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

suggestion is offered? 

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

on life? 

If the answers to these questions suggest a lack of readiness for change, the counselor may 

explore the client’s uncertainties and ambivalence about abstinence and change. This could be an 

opportunity to use motivational enhancement therapy (MET) strategies to enhance client 

determination. 

16 
Section III. Common Treatment Issues 

The counselor should proceed carefully with clients who make a commitment to change too 

quickly or too emphatically. Even when a person seems to enter treatment committed to change, 

his or her motivation should be assessed before beginning treatment. Likewise, the counselor 

should not assume that, once the client has decided to change, he or she will no longer 

experience ambivalence. 

Ambivalence 

If the client is reluctant to commit to making a change in behavior, the counselor should not push 

too hard. If the client commits to a change he or she is not ready to make, he or she may drop 

out of treatment rather than renege on an agreement. Premature commitment evokes resistance 

and undermines the MET process. 

The counselor should not assume that ambivalence has been resolved and commitment is firm. It 

is safer to assume that the client is still ambivalent and to continue using motivation-building and 

commitment-strengthening strategies. 

The counselor should reflect and explore the client’s expressions of uncertainty and ambivalence. 

It can be helpful to “normalize” ambivalence and concerns, for example: 

Counselor (C): What you’re feeling is quite common, especially in these early stages. Of course 

you’re feeling confused. You’re still attached to smoking, and you’re thinking about 

changing a pattern that has developed over many years. Give yourself time. 

The counselor also should reinforce any self-motivational statements and indications of willingness 

to change and provide reassurances that people can change, often with only a few consultations. 

The client may reconsider resistance to change after accepting that the counselor understands his 

or her reasons for being hesitant to change. Alternatively, pushing the client may result in a 

treatment dropout. 

Treatment Dissatisfaction 

A client may say that the treatment is not going to help or may want a different treatment. The 

counselor should first reinforce the client’s honesty. The counselor should confirm that the client 

has the right to quit treatment at any time (unless mandated into treatment), seek help 

elsewhere, or decide to work on the problem in another way. The counselor should explore the 

client’s feelings further. Concerns that arise in the first session are probably reservations about an 

approach the client has not tried. No one can guarantee that a particular treatment will work, but 

the counselor can encourage the client to try it for the planned period. The counselor can add 

that, should the problem continue or worsen, other possible approaches can be discussed. 

Compliance Enhancement Procedures 

A variety of strategies can facilitate compliance and overall client retention in treatment. They 

include devoting time to educating clients about treatment participation, treatment expectations, 

and potential barriers to involvement in treatment, such as transportation or childcare needs and 

work or school conflicts. 

17 
Brief Counseling for Marijuana Dependence 

Didactic Material 

The counselor gives brief presentations of the material in clear and concise language. It is 

important not to overload clients with too much material or use a lot of jargon. At the end of each 

session, the counselor asks whether the client understands major points of the presentation 

rather than assumes that the client comprehends. 

Practice Exercises 

Whenever possible, the counselor encourages the client to complete between-session practice 

exercises. The counselor provides a careful rationale and description of the exercise, gives specific 

instructions, and explains how the task relates to treatment goals. The counselor ensures that the 

client understands each practice exercise, follows up on between-session exercises during the 

next session, and examines obstacles. When the counselor ignores noncompliance with the 

exercise, early dropout may follow. 

Termination 

Termination can be a problem for many clients and can lead to clinical deterioration or some 

emotional dysregulation just before the end of treatment. Several weeks before the last session, 

the counselor should review the treatment timetable to sensitize himself or herself and the client 

to termination issues. Session 6 is a good time to broach the topic of termination. The degree of 

attention to termination can vary according to the client. As the end of treatment nears, it is 

useful to remind the client of the number and the topics of the sessions remaining and respond to 

the client’s reactions. 

The final session explores one of four elective skill topics, but the counselor should ensure that 

enough time is devoted to termination issues. Whatever the structure or content of the final 

session, the counselor must allow sufficient time to process the ending of treatment with the 

client. Processing includes summarizing what happened in treatment, discussing aspects of 

treatment that were most helpful and least helpful from the client’s perspective, eliciting client 

reactions and feelings about treatment, and exploring next steps for the client. 

Strategies for Addressing Common Clinical Problems 

The counselor should respond to common clinical problems in a manner consistent with the 

treatment approach, that is, reflection and reframing that follow the principles of MET and, when 

indicated, a more active problemsolving approach. 

Counselor’s Response to Missed Session 

The counselor should attempt immediately to phone a client who does not show up for a 

scheduled therapy session to find out why the session was missed. Clients sometimes miss 

sessions because they slipped and are embarrassed to admit their failure to the counselor or they 

are ambivalent about making a permanent change. Careful inquiry by the counselor reveals which 

situation is the case. 

18 
Section III. Common Treatment Issues 

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

•	 Clarify the reasons for the missed appointment. 

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

•	 Express eagerness to see the client again. 

•	 Briefly mention serious concerns that have emerged in treatment and express appreciation 

(when appropriate) that the client is exploring them. 

•	 Express optimism about the prospects for change. 

•	 Reschedule the appointment. 

If no reasonable explanation (e.g., illness, lack of transportation) is offered for the missed 

appointment, the counselor can explore with the client whether the missed appointment might 

reflect any of the following: 

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

•	 Ambivalence about making a change. 

•	 Frustration or anger about having to participate in treatment (particularly in clients who 

were mandated to enter the program). 

•	 Embarrassment about a relapse. If client’s absence was because of a slip, the counselor 

should be nonjudgmental and should encourage the client to come to a session clear 

headed and process the experience, noting that both the client and the counselor will 

learn from the discussion. 

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

appreciation. 

Counselor’s Response to Slips 

If a client slips and continues to use episodically, making statements such as “I messed up,” “I’m 

a failure,” or “This isn’t working,” the counselor can commend the client on his or her honesty and 

convey the idea that occasional slips are common in the course of treatment; they do not mean 

that the treatment is not working or that the client is a failure: 

C:	 You may find it hard to stay abstinent. Slips are actually common occurrences and nothing 

to feel ashamed about. You were abstinent for about 3 weeks before the slip. That was 

a significant amount of time! What are some things you can do to remain abstinent and 

not slip? 

Goal of Abstinence From Marijuana 

Marijuana Treatment Project participants were told that their counseling would focus on achieving 

abstinence. It was made clear, however, that individuals who wanted to reduce use would not be 

dropped automatically from the program. People working toward a moderation objective were 

encouraged to learn to be abstinent for several months. The rationale for this suggestion included 

two main points: 

19 
Brief Counseling for Marijuana Dependence 

1.	 Learning refusal skills during a period of abstinence develops many important strengths 

needed to become permanently abstinent. 

2.	 A period of abstinence likely gives the client more information about what it is like not 

being intoxicated on an ongoing basis. 

When following the BMDC approach, the counselor explains that ambivalent feelings about 

accepting abstinence as a goal are common. He or she encourages the client to discuss these 

feelings and any slips that occur. In addition, clients whose initial goals were to reduce use may 

make abstinence their new goal later. 

Handling Marijuana Use or Intoxication 

Before beginning treatment, the client should be told to refrain from using any substances. This 

should be communicated in a nonpunitive way, with the counselor explaining that the client can 

benefit most from the sessions if he or she is not under the influence of marijuana or other 

substances. Clients also might receive a handout with this expectation highlighted. 

If a client comes to a session intoxicated, the counselor can proceed in several ways. The 

counselor should determine during the check-in what the client’s use pattern has been since the 

last session and make a clinical judgment about whether the session should be rescheduled. For 

example, if the client appears to be intoxicated (e.g., has difficulty concentrating on the content of 

the session, seems unusually tangential in speech pattern), the counselor should suggest that 

they reschedule. If the counselor reschedules because of the client’s appearing intoxicated, the 

treatment program should find alternative transportation home so that the client does not drive. 

Anyone asked to leave a session is encouraged to return to the next session abstinent and to 

continue in treatment. If the client smoked marijuana shortly before the appointment, but the 

counselor determines that the client can participate meaningfully in the session, the session can 

proceed as planned. 

The client should be given specific guidelines for handling the immediate aftermath of a using 

episode. He or she should be advised to get rid of the marijuana, leave the setting in which the 

using occurred, and call someone for help (a spouse, a friend, or the supporter identified in 

session 2). The client should be cautioned about the feelings of guilt and self-blame that often 

accompany a slip and warned not to allow such reactions to prompt further drug use. Sessions 4, 

5, 6, and 7 and elective skill topic 1 provide specific guidelines on preventing and handling slips. 

Marijuana Withdrawal 

Some clients report withdrawal symptoms such as flulike symptoms, increased anxiety, or difficulty 

sleeping after they stop using marijuana. These symptoms usually are not severe, start 12 to 24 

hours after the last use, and last less than 2 weeks. In most cases, withdrawal symptoms are 

manageable without medical intervention. Clients can be encouraged to use behavioral strategies 

such as relaxation techniques for anxiety or to decrease caffeine intake for insomnia. However, if a 

client either reports having severe withdrawal symptoms or anticipates having a difficult time 

20 
Section III. Common Treatment Issues 

based on previous experience, the counselor can suggest that the client see a physician for 

assistance and request permission to discuss the problem with the client’s primary care physician. 

In some cases, the client may show more severe problems with anxiety, depression, or cognitive 

functioning than normally expected from a withdrawal syndrome. In these circumstances, the 

counselor can suggest that the client see a psychiatrist for an assessment and possible 

assistance during and after the withdrawal period. 

Use of Alcohol 

Abstinence from alcohol should be determined on a client-by-client basis. The counselor might 

point out that some individuals find that overcoming marijuana dependence is more likely if they 

abstain from drinking alcohol. The client who is concerned about being tempted to substitute 

alcohol for marijuana should stop all use of alcohol. If a counselor determines that a client has 

begun to abuse other drugs or alcohol during this treatment approach, the client should be 

treated appropriately. 

Clients With Special Needs 

It is important to be sensitive to the special needs of clients. For example, clients with children 

may need flexible schedules or assistance with child care. Some clients may be cognitively 

impaired or function at a generally low cognitive level and need adaptations in the treatment 

approach or techniques that increase the likelihood of their absorbing the material. Strategies may 

include additional practice with new behavioral skills and repetition of key concepts. The counselor 

may minimize the use of long and complex sentences or condense the information from cognitive 

behavioral session handouts (forms in sessions 3–9) onto index cards for some clients. The clientcentered aspects of MET allow the counselor to adapt the sessions to the client’s needs. 

Arranging for Additional or Followup Treatment 

The counselor and client should address the need for additional care. For example, some clients 

with a substance use disorder have co-occurring mental disorders, most commonly depression. 

The counselor is encouraged to assess the presence and severity of other problems that might 

require attention. The counselor can explain that the client can continue to make progress after 

treatment ends because the client now has the skills and the ability to continue to improve and 

progress as these skills are used in new situations. If after a careful discussion of these issues, 

the client asks for a referral or information about further substance abuse treatment, the 

counselor can provide this information readily. 

Summary 

The counselor has a complex task that involves relationship building, teaching, supporting, 

encouraging, monitoring progress and setbacks, and recognizing signs that the client may be 

withdrawing from treatment or losing his or her motivation to change. The counselor views these 

common clinical problems as part of the treatment process that can lead to client growth and the 

strengthening of the therapeutic alliance. 

21 

SECTION IV. 

GETTING STARTED: ASSESSMENT SESSION 

This section guides counselors through the assessment session. It outlines strategies for assessing 

individuals who present for Brief Marijuana Dependence Counseling (BMDC) treatment. These 

people have been determined to be appropriate for treatment based on a brief telephone contact 

or an initial triage or evaluation appointment. 

The BMDC assessment session focuses on building rapport with the client while assessing his or 

her marijuana use. This section includes diagnosis and assessment instruments. The assessment 

findings are used to complete the Personal Feedback Report (PFR), which the counselor reviews 

with the client in subsequent sessions. An accurate assessment provides data that can be 

used as 

• A starting point for therapy 

• Motivation and feedback for the client 

• A measure of therapy outcomes over time. 

Building Rapport 

One of the most important aspects of treatment, especially during the assessment session, is 

building rapport; through expressions of warmth, support, and empathy, the counselor gets to know 

the client. Although the assessment session focuses primarily on gathering information, the rapport 

established during this session defines the client–counselor relationship for remaining sessions. 

Assessing Marijuana Use 

BMDC uses the criteria identified in Diagnostic and Statistical Manual of Mental Disorders, 

Fourth Edition (DSM-IV) (American Psychiatric Association 1994), to diagnose marijuana 

dependence (exhibit IV-I) and marijuana abuse (exhibit IV-2). These criteria help the counselor 

determine a client’s level of substance involvement and the associated consequences, as well as 

appropriate level of treatment. These criteria also can be used in later sessions to measure 

treatment effectiveness. 

The symptoms of substance dependence typically are assessed first; substance abuse is 

considered a less severe substance use disorder, and its symptoms are assessed only if the client 

does not meet the criteria for a diagnosis of substance dependence. For this reason, tolerance, 

withdrawal, and symptoms describing impaired control over use are not included in the diagnosis 

of substance abuse. However, it may be useful to complete the assessment of abuse criteria even 

if dependence has been diagnosed to learn more about the nature and extent of negative 

consequences that result from the dependent use pattern. 

23
 
Brief Counseling for Marijuana Dependence 

The guidelines presented here will help the counselor make a diagnosis of marijuana dependence 

or abuse. If the counselor does not have the credentials required for making a diagnosis, he or 

she must receive verification from a State-qualified individual. 

Exhibit IV-I. DSM-IV Substance Dependence Criteria 

1. Tolerance, as defined by either of the following: 

• A need for markedly increased amounts of the substance to achieve intoxication or 

desired effect 

• Markedly diminished effect with continued use of the same amount of the 

substance. 

2. Withdrawal, as manifested by either of the following: 

• The characteristic withdrawal syndrome for the substance 

• The substance is taken to relieve or avoid withdrawal symptoms. 

3. The substance is often taken in larger amounts or over a longer period than was 

intended. 

4. There is a persistent desire or unsuccessful efforts to cut down or control substance 

use. 

5. A great deal of time is spent in activities necessary to obtain the substance, use the 

substance, or recover from its effects. 

6. Important social, occupational, or recreational activities are given up or reduced 

because of substance use. 

7. The substance use is continued despite knowledge of having a persistent or recurrent 

physical or psychological problem that is likely to have been caused by or exacerbated 

by the substance. 

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Copyright 1994. American Psychiatric 

Association (1994). 

Exhibit IV-2. DSM-IV Substance Abuse Criteria 

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, 

school, or home 

2. Recurrent substance use in situations in which it is physically hazardous 

3. Recurrent substance-related legal problems 

4. Continued substance use despite having persistent or recurrent social or interpersonal 

problems caused by the effects of the substance 

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Copyright 1994. American Psychiatric 

Association (1994). 

24 
Section IV. Getting Started 

Overview of Assessment Session: Building Rapport and Assessing Marijuana Use 

Total Time: 1 hour, 30 minutes (1 hour, 20 minutes for session; 10 minutes to prepare PFR) 

Delivery Method: MET-focused individual therapy 

Materials (all forms include instructions and are at the end of this section): 

• Sample Timeline Follow-Back Calendar for past month (form AS1) 

• Timeline Follow-Back Grid (form AS2) 

• Timeline Follow-Back Marijuana Use Summary Sheet (form AS3) 

• Structured Clinical Interview for DSM-IV (form AS4) 

• Marijuana Problem Scale (form AS5) 

• Reasons for Quitting Questionnaire (form AS6) 

• Self-Efficacy Questionnaire (form AS7) 

• Personal Feedback Report and percentage tables (form AS8) 

Goals for This Session: 

• To build rapport with the client, creating a nonthreatening therapeutic environment 

• To collect and document baseline marijuana use information to monitor therapeutic 

outcomes 

Session Outline: 

1.	 Build rapport and give an overview of the assessment process 

2.	 Conduct an overview assessment using open-ended and summary questions 

3.	 Use the timeline follow-back (TLFB) method to assess marijuana use 

• Complete the TLFB Calendar (form AS1) 

• Complete the TLFB Grid (form AS2) 

• Complete the TLFB Marijuana Use Summary Sheet (form AS3) 

4.	 Administer the Structured Clinical Interview for DSM-IV (form AS4) 

• Assess substance dependence 

• Assess substance abuse 

5.	 Explain and ask client to complete the Marijuana Problem Scale (form AS5); evaluate 

consequences of marijuana use 

6.	 Administer Reasons for Quitting Questionnaire (form AS6); evaluate reasons for
 

seeking treatment
 

7. Explain and ask client to complete Self-Efficacy Questionnaire (form AS7); assess 

targets for intervention 

8.	 Conclude the session 

9.	 Prepare the PFR before session 1 

25 
Brief Counseling for Marijuana Dependence 

Assessment Session Protocol 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor assesses the client’s marijuana use while laying the foundation for a positive 

client–counselor relationship. 

Build Rapport and Give an Overview of the Assessment Process 

To build rapport and engage the client during the assessment session, the counselor informs the 

client about the sequence of events for this session and what to expect in the overall treatment 

approach. Introducing session topics, providing information, and responding to client concerns are 

the primary tasks during this part of the session. The counselor could begin the first session of 

BMDC with the following introduction: 

Counselor (C): Let’s talk about what we’d like to accomplish in the assessment session. We need 

a clear description of your marijuana use—how much marijuana you use, how often you 

use it, and what types of problems marijuana might be causing you. I’ll ask you detailed 

questions about your marijuana and other drug and alcohol use, and I’ll also ask you 

questions about how marijuana use has affected your daily life. 

I’ll summarize this information in the Personal Feedback Report that I’ll give you during our 

next session. We’ll use the PFR to compare your marijuana consumption with national 

averages and to get an idea about how to set your treatment goals. The session will take 

about 1 hour and 20 minutes. Some questions may be difficult to answer and a real test 

of your memory; just do your best to be honest and patient! Remember that the 

information is confidential and is used only to help you accomplish your therapy goals. 

Conduct an Overview Assessment Using Open-Ended and Summary Questions 

Most assessment tools, including a few presented later in the session, use closed-ended 

questions (How many days in the past month did you smoke marijuana?), but the counselor starts 

the session by using open-ended questions to engage the client (Tell me about your marijuana 

use pattern over the last month) before transitioning to more detailed tasks. Open-ended 

questions allow the counselor to establish a dialog with the client and build rapport by 

• Showing genuine interest 

• Conveying a nonjudgmental and accepting attitude 

• Demonstrating the ability to track accurately what the client is saying 

• Expressing empathy with the client. 

The dialog might go as follows: 

C:	 How did you hear about this program? 

Shirley (S): I’ve seen the ads in the paper for several weeks. Originally my husband left one on 

the kitchen table for me. 

C:	 You’ve worked with your husband to get here, and the two of you have given this a great 

deal of thought. Have you tried to quit on your own? 

26 
Section IV. Getting Started 

S:	 I try to quit almost every day, or at least I think about it. I’m going to be an elementary 

school teacher; in fact, I’m doing my student teaching now. I feel that quitting is the right 

thing to do—to be a good example to the kids. But nothing ever changes. 

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

S:	 Well, I know someday I will quit, and I’ve been looking at the ad for this program. I never 

thought anyone would offer treatment for pot smokers! 

C:	 This was the opportunity you were waiting for. What would you like to see happen as a 

result of coming to treatment? 

S:	 I guess I thought I’d get help on how to quit. But I realize that ultimately it’s up to me, 

and it’s way past time to do something. 

C:	 You understand that it’s your decision on what to do, but you also think that being here 

might help you. How confident are you at this point that you’ll succeed? 

Use the TLFB Method To Assess Marijuana Use 

The assessment or evaluation component of this session can be a powerful element of treatment. 

Marijuana Treatment Program (MTP) participants reported increased motivation after receiving 

feedback from assessment-related activities. 

During the session the counselor and client complete several forms to assess the client’s 

marijuana use. Quantity of marijuana use is difficult to measure because of varying potency levels 

and smoking methods (e.g., pipe, joint); therefore, frequency of use is the most reliable criterion 

for consumption measures. The TLFB method helps the counselor and client identify patterns and 

possible consequences of use (Sobell and Sobell 2000; Sobell et al. forthcoming). For instance, a 

person who uses heavily on weekends may be at risk of driving an automobile while high. A 

chronic, daily use pattern might indicate that an individual has developed cannabis dependence. 

In addition to providing a precise measure of marijuana consumption, the TLFB method can 

assess changes in a client’s marijuana use and helps the counselor determine treatment 

effectiveness. The counselor begins by asking the client to estimate generally how many days and 

how many times a day he or she smoked marijuana in the past month: 

C:	 In the past month, about how many days did you smoke marijuana? [Waits for client’s 

response before asking the next question.] In the past month, on a typical day when you 

smoked marijuana, about how many times per day did you smoke? 

Once the counselor has a general sense of the client’s use, the formal TLFB assessment process 

begins. The counselor uses the following instruments to assess the pattern, severity, and nature of 

the client’s marijuana use: 

• TLFB Calendar for the past month (form AS1) 

• TLFB Grid (form AS2) 

• TLFB Marijuana Use Summary Sheet (form AS3). 

The counselor uses the TLFB Calendar to help the client recall his or her marijuana use and the 

TLFB Grid to record summary information from the completed calendar. When completed, the 

27 
Brief Counseling for Marijuana Dependence 

TLFB Marijuana Use Summary Sheet provides an overview of basic information about the client’s 

marijuana use, alcohol consumption, and tobacco smoking. (The TLFB Calendar and TLFB 

Marijuana Use Summary Sheet procedures are modified from procedures developed by Sobell and 

Sobell [1992, 2000, 2003] and Sobell and colleagues [forthcoming]. Some administration 

guidelines are adapted from the Form 90 procedure developed by Miller [1996].) 

Complete the TLFB Calendar 

The counselor begins by developing a detailed history of daily marijuana use for a specified period, 

called the assessment window. This manual suggests an assessment window of 1 month. To arrive 

at a diagnosis of dependence or abuse, the DSM-IV advises that symptoms be present for 12 

months. However, assessing symptoms for the last 12 months may tell little about the client’s 

current use, especially if the client’s use pattern has changed significantly over the year prior to 

entering treatment. (If the client had attempted to quit using or cut back usage in preparation for 

treatment, the counselor should ask the client to recall a period of usual marijuana use.) 

Understanding marijuana use at treatment entry is helpful for treatment planning and for 

motivating the client to change. The TLFB method uses memory aids (exhibit IV-3) to help the 

client recall his or her marijuana use. The counselor and client select a month to investigate. The 

counselor fills in the days on the TLFB Calendar (form AS1) and indicates which days in that 

particular month are holidays or other special days for the client (see exhibit IV-4 for a sample). 

Exhibit IV-3. Key Events To Record on the Calendar 

Atypical Events Recurring Events Discrete Events 

• Holidays 

• Birthdays 

• Anniversaries 

• Parties 

• Medical appointments 

• Accidents 

• Court appearances 

• Beginning or termination 

of employment 

• Marital arguments 

• Vacations 

• Separations or 

reconciliations 

• Sporting events 

• Major news events 

• Concerts 

• Paydays 

• Religious services 

• School or classes 

• Standing appointments 

• Child visitations 

• Meetings 

• Work schedule 

• Weekends 

• Jail time 

• Hospitalizations 

• Illness 

• Treatment 

The calendar is used as a memory aid. The counselor asks the client to recall daily consumption of 

marijuana by linking memories to salient life events. The counselor mentions recurring and atypical 

events to help the client recall his or her marijuana use. Recurring events (e.g., work schedule, 

28 
Exhibit IV-4. Sample Completed Calendar 

1 2 3 4 5 6 7 

8 9 10 11 12 13 14 

15 16 17 18 19 20 21 

22 23 24 25 26 27 28 

29 30 31 

Sunday Monday Tuesday Wednesday Thursday Friday Saturday 

Typical Pattern 

X X X X X X X X X X X X X X X X X X X 

X X X X X X X X 

Payday 

Payday 

Church/visit mom 

Church/visit mom 

Church/visit mom 

Church/visit mom 

Funeral - Ohio Ohio 

Ohio Ohio (home) 

Christmas party 

@ work 

Day off 

Day off 

Christmas Eve Christmas 

New Year’s Eve 

party @ house 

A

A

A

December 2002 

X X X X X X X X X X X X X X X 

X X X X X X X X X X X X X X X X X X X X X X 

X X X X X X X X X X X X X X X X X X 

Section IV. Getting Started 

payday) provide a context for describing typical marijuana use patterns (e.g., client always buys 

marijuana on payday and smokes all day on days off). Atypical events (e.g., medical appointment, 

marital argument) provide anchor points for describing exceptions to a regular use pattern (e.g., 

client did not smoke on the day of a medical appointment; smoked more on the day of a marital 

argument). Discrete events (e.g., jail time, hospitalizations) help identify use and nonuse periods: 

C:	 I’d like to start by asking you questions about your marijuana use, other drug use, and 

drinking during the period from about a month ago until yesterday. [Places the calendar in 

front of the client.] We’ll reconstruct this period by using notes on the calendar to help you 

remember things that have happened to you. Then we’ll use these events to help you 

remember when you used marijuana on each day. 

After the counselor and client determine on which days the client smoked, they record the number 

of smoking episodes per day by breaking each calendar day into four quadrants. (As the client 

breaks down daily use into quadrants, it may be helpful for the counselor to have a card that lists 

the quadrants for the client to refer to.) The four boxes on each calendar day in exhibits IV-4 and 

IV-5 correspond to these following quadrants: 

29 
Brief Counseling for Marijuana Dependence 

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

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

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

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

For instance, in the example in exhibit IV-5, the client smoked in the second and third quadrants 

on December 22, in all quadrants on December 23, and in the first quadrant on December 24. 

The counselor explains that this information reveals the context in which marijuana use occurs. 

Exhibit IV-5. Using Quadrants To Determine Use Frequency 

December 22 December 23 December 24 

Church/visit mom Day off Day off 

Christmas Eve 

X X X X X X X 

The counselor records any other drug or alcohol use that occurred during the assessment window. 

By asking questions about alcohol and drug use, the counselor determines whether the client is 

substituting other drugs or alcohol on days when marijuana is not used. 

Once the memorable events have been recorded, the counselor focuses on the client’s longest 

span of invariant or unchanging behavior, such as abstinence, and determines whether a steady 

marijuana use pattern exists: 

C:	 Looking at the calendar and thinking about these events, what is the longest period you 

can remember when you went without smoking at all? 

If the client has had a reasonably consistent pattern of use from week to week, the counselor 

asks him or her to describe a typical week and to identify the weeks during the period that fit the 

steady pattern and record those weeks on the calendar: 

C:	 During this period when you were using marijuana, was your pattern of use similar from 

one week to the next? Although a person’s marijuana use will vary from day to day, I’m 

wondering whether there was any consistency from week to week. 

The counselor starts with weekdays, beginning in one quadrant and moving through the week for 

that quadrant, the second quadrant, and so on: 

C:	 Could you describe a usual or typical week of marijuana use? Thinking about a typical 

week, starting with weekdays, Monday through Friday, did you normally use marijuana in 

the morning, between 6 a.m. and noon? 

This phrasing encourages the client to report use in the morning. The client points out variations in 

day-to-day use (e.g., I smoke before I go to work on 2 mornings a week). The counselor records 

variations on particular days. After constructing the morning quadrants, the counselor proceeds 

until all the appropriate quadrants have been checked to establish the weekday pattern. The 

30 
Section IV. Getting Started 

counselor then asks about weekend use. This exercise reveals the client’s steady use pattern 

during the assessment window. 

The counselor and client now turn to reconstructing the client’s use on days when no pattern 

exists. If the client reports no consistent pattern, the entire assessment window must be 

constructed one day at a time. 

For days not covered by pattern or abstinent days, the counselor focuses on days immediately 

before and after invariant periods (such as periods of abstinence and steady pattern use): 

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

To help the client recall use, the counselor focuses on events that affect the availability of 

marijuana and the client’s marijuana use (e.g., hospitalizations, family outings, work changes). 

The counselor pays close attention to inconsistencies in the client’s descriptions of marijuana use 

and asks questions to ensure that the information is accurate. 

Complete the TLFB Grid 

The TLFB Grid (form AS2) is used to summarize and record calendar data and to monitor changes 

over time. The grid provides spaces for the counselor to total the days of use under various 

categories. When the information is presented on the grid, the counselor and client see use 

patterns emerge (e.g., the client usually smokes late at night or before work). Additional grids can 

be filled out in later sessions and compared with this baseline grid to monitor changes over time 

and help determine causes for slips or relapses. 

Complete the TLFB Marijuana Use Summary Sheet 

The counselor uses the TLFB Marijuana Use Summary Sheet (form AS3) to gather additional 

information about the client’s marijuana consumption prior to entering treatment. The counselor 

asks questions that help the client think about and summarize his or her marijuana use, including 

use in hazardous situations (e.g., taking care of children, driving). The TLFB Marijuana Use 

Summary Sheet increases awareness of the frequency of using marijuana, other drugs, alcohol, 

and tobacco and often elicits concerns from the client. These stated concerns can increase 

motivation to change. 

Administer the Structured Clinical Interview for DSM-IV 

Several self-report scales assess substance dependence and substance abuse symptoms, but 

none assesses specifically for marijuana. Identification of cannabis use disorders is accomplished 

most reliably using a structured interview to assess diagnostic criteria. The Structured Clinical 

Interview for DSM-IV (SCID-IV) (form AS4) used in this manual has been adapted for clients who 

use marijuana (First et al. 1996). A typical structured interview starts with objective questions to 

obtain a brief history of the client’s substance use and proceeds through a series of questions 

that assess for the presence of DSM-IV diagnostic criteria for dependence (questions 1 through 7) 

and abuse (questions 8 through 11). Each objective question can be followed by open-ended 

prompts to elicit information relevant to the symptom being assessed. 

31 
Brief Counseling for Marijuana Dependence 

The counselor asks the client each SCID-IV question and circles the appropriate clinical rating for 

the response. If the counselor is convinced that a particular symptom is present, he or she should 

not allow a client’s denial of the symptom to go unchallenged. In rare cases, an item may be 

rated as present even when the client steadfastly denies it. It is not necessary for the client to 

agree that the symptom is present. The counselor uses all sources of information, including the 

forms completed in the TLFB process, to determine the appropriate rating for the client in 

response to SCID-IV questions. In some cases, the counselor may need to explore discrepancies 

between the client’s account and other sources of information. Form AS4 provides additional 

instructions for completing the SCID-IV. 

Information for Assessing Cannabis Dependence Criteria 

To administer the SCID-IV and assess for the presence of each symptom, it is important to 

understand the intent of substance use disorder criteria and the ways in which symptoms can be 

manifested in people who use marijuana. 

Tolerance. Tolerance refers to needing more or higher quality marijuana to get high than when the 

client first began using it (DSM-IV symptom 1 in exhibit IV-1; SCID-IV question 6, Have you found 

that you need to use a lot more or higher quality marijuana to get high than you did when you 

first started using it regularly?). This symptom reflects the body’s adaptation to or compensation 

for the chronic presence of marijuana, and it may predict the development of withdrawal 

symptoms if use continues. To determine tolerance level, the counselor asks the client to compare 

the current effects of marijuana with past effects. 

According to DSM-IV, the client must use at least 50 percent more marijuana than when he or 

she first started using to meet the tolerance criterion, so it is important to ask the client to 

quantify how much more is used now to achieve the same effect compared with when he or she 

began to smoke regularly. The tolerance criterion can be met if the client reports markedly 

diminished effects from the same amount of marijuana that used to get him or her high. 

Withdrawal. Withdrawal symptoms associated with cessation of cannabis use are another indication 

that the body has made physiological adaptations to the presence of cannabinoids and may motivate 

the person to continue using (DSM-IV symptom 2 in exhibit IV-1; SCID-IV question 7, In the past 

month, have you had withdrawal symptoms? Have you felt sick when you cut down or stopped 

using? Or after not using for a few hours or more, have you smoked to keep from getting sick?). 

Although a cannabis withdrawal syndrome is not described in DSM-IV, symptoms associated with 

marijuana cessation have been documented in several studies. Withdrawal symptoms can include 

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

• Night sweats • Headaches 

• Nausea • Irritability 

• Restlessness 

In general, when withdrawal symptoms occur, they are present for a short period (i.e., a few days 

to 2 weeks). It is not known to what extent these symptoms motivate continued use of marijuana 

or whether they play a clinically meaningful role in the process of modifying marijuana use. 

However, more than half the clients presenting for treatment report experiencing some withdrawal 

32 
Section IV. Getting Started 

symptoms or continuing to use marijuana to avoid withdrawal symptoms. The counselor asks the 

client about the occurrence of withdrawal symptoms when he or she has cut down or stopped 

using and whether he or she used marijuana to avoid withdrawal symptoms. If the client 

acknowledges either experience, then the criterion for this symptom is met. 

Impaired control. To assess impaired control over use, the counselor asks whether the client often 

ended up smoking more than was intended and whether he or she sometimes smoked for a 

longer period than was intended (DSM-IV symptom 3 in exhibit IV-1; SCID-IV question 1, In the 

past month, have you found that, when you started using marijuana, you ended up smoking much 

more of it than you were planning to? or Have you used it over a much longer period than you 

were planning to?; an affirmative answer to either question should lead the counselor to inquire 

about specific instances and the circumstances leading to overuse). The repeated failure to 

terminate marijuana use as planned is evidence of impaired control. 

Impaired control over marijuana use also is assessed by asking whether the client has made 

repeated unsuccessful attempts to quit or reduce use or has had a persistent desire to do so 

(DSM-IV symptom 4 in exhibit IV-1; SCID-IV question 2, In the past month, have you tried to cut 

down or stop using marijuana? or Did you ever stop using altogether?). Typically, these attempts 

include self-imposed rules or other strategies to avoid marijuana entirely or to limit the frequency 

of use. It is useful to ask specifically about the number of times the client has attempted to cut 

down during the period being assessed and whether these attempts were because of concern 

about the extent of use. Resumption of marijuana use after seeking professional help or joining a 

mutual-help group (e.g., Narcotics Anonymous) is evidence of lack of success. These experiences 

suggest impairment in control. If the client denies any attempts at reducing marijuana use, the 

counselor asks specifically whether he or she would like to stop or reduce use but has not done 

so for some reason. Evidence of impaired control includes the client’s wanting to stop or reduce 

use but not making an attempt because he or she knew that the attempt would be unsuccessful. 

Salience. An important aspect of dependence relates to the primacy of the substance in a 

person’s life. The salience of marijuana is investigated by asking the client about how much time 

he or she spends obtaining it, using it, and recovering from its effects (DSM-IV symptom 5 in 

exhibit IV-1; SCID-IV question 3, In the past month, did you spend a lot of time using marijuana 

or doing whatever you had to do to get it?). The phrase “a lot of time” is not defined precisely, but 

it often becomes clear that marijuana-related activities occupy an excessive amount of time. For 

instance, if the client is intoxicated on marijuana most of the day, most days of the week, for a 

month or more, then salience is apparent. At other times, the counselor determines the 

appropriateness of the amount of time given to marijuana-related activities. If marijuana use is 

confined to recreational times of the day or week, this symptom may not be present. 

Another determinant of the salience of marijuana can be when the client reports that he or she 

has given up or reduced involvement in important social, occupational, or recreational activities 

because of marijuana use (DSM-IV symptom 6 in exhibit IV-1; SCID-IV question 4, In the past 

month, did you use marijuana so often that you used it instead of working or spending time on 

hobbies or with your family or friends?; a yes response to this question indicates that marijuana 

use has a higher priority than activities such as work or spending time with friends or family, 

hobbies, or exercising.) This breakdown in the normal processes of social control is an indication 

of dependence on the drug. 

33 
Brief Counseling for Marijuana Dependence 

The persistence of marijuana use despite knowledge that it causes or exacerbates psychological or 

physical problems is an indication of either the salience of the drug or impaired control over its 

use (DSM-IV symptom 7, exhibit IV-1; SCID-IV question 5, Do you forget things or have trouble 

concentrating? Are you anxious or sad a lot? Has marijuana caused you physical problems such 

as difficulty breathing, many colds, or a chronic cough? Has it made a physical problem worse?). 

The counselor assesses whether marijuana use leads to problems with motivation, depression, 

anxiety, concentration, memory, or other psychological problems. Similarly, the client’s awareness 

about the effect of marijuana use on breathing, chronic cough, or other physical conditions is 

ascertained. If the client acknowledges a relationship between marijuana use and any of these 

physical or psychological problems but continues to use anyway, marijuana use may have a higher 

priority than his or her health or the client may be unable to limit use effectively. 

Diagnosing cannabis dependence. To complete the diagnosis, the counselor counts the number of 

dependence symptoms that are present, that is, questions 1 through 7 on the SCID-IV that 

receive a rating of 3. If three or more questions have a rating of 3, the client meets DSM-IV 

criteria for cannabis dependence. In general, the dependence syndrome occurs on a continuum, 

so more symptoms indicate greater severity of dependence. Even when the client does not meet 

the criteria fully, the counselor should discuss symptoms that signal the beginning of a potential 

disorder and the level of impairment associated with the symptoms. 

Information for Assessing Cannabis Abuse Criteria 

In the absence of cannabis dependence, the counselor assesses recurrent negative consequences 

associated with marijuana to diagnose cannabis abuse. The counselor inquires about missed days 

at school or work related to marijuana use and asks whether marijuana has affected the client’s 

abilities at school or on the job (DSM-IV symptom 1 in exhibit IV-2; SCID-IV question 8, In the 

past month, have you missed work or school because you were high or hung over? How often did 

this occur?). It may be appropriate to ask whether marijuana has interfered with keeping the 

house clean or taking care of children. 

Other examples of abuse are driving when feeling high or engaging in other dangerous activities 

when under the influence of marijuana (DSM-IV symptom 2 in exhibit IV-2; SCID-IV question 9, In 

the past month, did you use marijuana in situations in which it might have been dangerous?), 

experiencing legal problems (DMS-IV symptom 3 in exhibit IV-2; SCID-IV question 10, Has your 

use of marijuana gotten you into trouble with the law in the past month), and continuing use 

despite awareness that use causes problems with friends, family, or co-workers (DSM-IV symptom 

4 in exhibit IV-2; SCID-IV question 11, Has your use of marijuana caused you problems with other 

people, such as with family members, friends, or people at work? Have you gotten into physical 

fights or had bad arguments about your marijuana use?). 

Diagnosing cannabis abuse. For a cannabis abuse diagnosis, at least one of the symptoms 

described above must have occurred two or more times during the period being assessed. More 

information is available in First and colleagues (1996, 2000). 

34 
Section IV. Getting Started 

Explain and Ask Client To Complete Marijuana Problem Scale; Evaluate 

Consequences of Marijuana Use 

The Marijuana Problem Scale (MPS) (form AS5), developed by Stephens and colleagues (1994a), 

is a self-report assessment that helps the client identify areas in his or her life affected by 

marijuana use. It contains 19 items that represent potential negative effects of marijuana on 

social relationships, self-esteem, motivation and productivity, work and finances, physical health, 

memory impairment, and legal problems. The items were chosen based on existing self-report 

drug abuse severity measures and on data from people who sought treatment for marijuana use. 

Some questions on the MPS are similar to those in the SCID-IV. However, the MPS is a self-report 

instrument and the counselor should not base diagnostic decisions on the MPS alone. Clinical 

judgment is needed to make a diagnosis of cannabis abuse. 

The counselor gives the form to the client and instructs the client to take a few moments to 

respond to each item by indicating whether he or she experienced a particular problem related to 

marijuana use in the past month. After reading each question, the client circles the corresponding 

number on the questionnaire: 

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

After answering all the questions, the client gives the form back to the counselor who counts the 

number of items identified as either minor or serious problems. Higher scores generally indicate 

more serious problems with marijuana. However, it is important to review the specific problem 

items with clients because the nature of the problems reported may be more important than the 

total score. For instance, although nearly all people who use marijuana and seek treatment report 

feeling bad about their use, a smaller number will indicate serious problems with friends, family, 

work, or finances. Exhibit VII-1 in section VII presents the frequency of problems reported by MTP 

participants. 

The counselor keeps the form and uses the information to complete the client’s PFR, which is 

discussed in the next session. 

Administer Reasons for Quitting Questionnaire; Evaluate Reasons for 

Seeking Treatment 

The Reasons for Quitting Questionnaire (form AS6) is based on earlier work with tobacco 

cessation and has been modified based on initial results with people who use marijuana and seek 

treatment (McBride et al. 1994). The 26 items assess reasons for quitting marijuana in the 

following broad categories: health concerns, desire for self-control, and social and legal 

influences. The counselor gives the client the form and asks him or her to take a few moments to 

indicate the degree to which each reason applies to him or her using a 5-point scale: 

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

35 
Brief Counseling for Marijuana Dependence 

The counselor reviews the items that have been circled 2, 3, or 4. These responses represent the 

client’s motivation for change. The items identified are used in the PFR. Reviewing the items that 

the client endorses stimulates discussion and elicits self-motivational statements during therapy. 

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

The counselor keeps the form and uses the information to complete the client’s PFR, which is 

discussed in the next session. 

Explain and Ask Client To Complete Self-Efficacy Questionnaire; Assess 

Targets for Intervention
 

The Self-Efficacy Questionnaire (form AS7), based on the Situational Confidence Questionnaire 

(Annis 1988), is a measure on which clients rate their ability to resist the temptation to smoke 

marijuana in a variety of different situations. The rating scale has a range of 1 (not at all 

confident) to 7 (extremely confident). The counselor asks the client to take a few moments to rate 

20 statements about situations that might create a temptation to smoke marijuana. 

When the form is completed, the client returns it to the counselor who records in the PFR all 

items coded 1 to 3 (low confidence to resist marijuana). 

Conclude the Session 

To conclude the session, the counselor explains that he or she will use the information from all 

the forms to complete the client’s PFR, which they will review during the next session. The 

counselor asks the client for feedback, responds empathically to his or her comments, and 

troubleshoots any difficulties. 

Prepare the PFR Before Session 1 

The PFR is a therapeutic tool used by the counselor to summarize the results obtained during 

assessment session. The goal of assessment feedback is to point out discrepancies between the 

client’s current behavior and important personal goals identified by the client. 

For the next session with the client, the counselor prepares the PFR by compiling the pertinent 

information from the TLFB process and the SCID-IV. Information also is gathered from the 

questionnaires completed by the client: Marijuana Problem Scale, Reasons for Quitting 

Questionnaire, and Self-Efficacy Questionnaire. All the information from these forms is consolidated 

on the PFR by the counselor. Instructions for preparing the PFR are included in form AS8. 

Forms for Assessment Session 

During the assessment session the counselor and client review or complete eight forms. These 

forms and instructions for completing them are provided on the remaining pages in this section. 

36 
Form AS1 

ollow-Back Calendar Sample Timeline F

Sunday Monday Tuesday Wednesday Thursday Friday Saturday 

1 of 1
 
Form AS2 

1 of 1
 

Timeline Follow-Back Grid 

Start date: ___/___/___ End date: ___/___/___ 

# of days 

used from 

6 a.m.-12 noon 

# of days 

used from 

12 noon-6 p.m. 

# of days 

used from 

6 p.m.-12 mid 

# of days 

used from 

12 mid-6 a.m. 

# of days 

used 

marijuana 

# of days 

used 

alcohol 

# of days 

used other 

drugs 

# of days 

used any 

substance in 

the week 

Week 1 

Week 2 

Week 3 

Week 4 

Total 

(for PFR) 
 

Form AS3 

Timeline Follow-Back Marijuana Use Summary Sheet 

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

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

1.	 During the past month, from _______________to ______________, on average, how much 

marijuana per week do you think you used in ounces? 

Probe by asking the participant how many ounces of marijuana he or she buys (or 

receives) per week. If the client seems uncertain about level of use, the counselor helps 

him or her approximate by using the following types of probes: “Would you say it was more 

like 1/8 ounce or closer to 1 ounce per week?” The counselor continues until the client 

seems comfortable with the estimate and says, “So, you think it was closer to an ounce. 

Was it just an ounce, a little more than that, or a little less?” 

_____<1/16 _____1/16 _____1/8 _____1/4 ____3/8
 

_____1/2 _____5/8 _____3/4 _____7/8 _____1 oz.
 

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

you think you smoked per day? 

____ joints, pipes, or blunts per day 

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

____ hours 

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

____ times
 

5.	 During the past month, did you use marijuana 1 hour before the following activities? If 

yes, would you say (read coding options to client)? 

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

____5a. Driving a vehicle 

____5b. Taking care of children 

____5c. Operating dangerous equipment or heavy machinery 

____5d. Working on a paid job 

6.	 During the past month, how many standard drinks did you have on a typical day? 

One standard drink is a 12-ounce can or bottle of beer, a 5-ounce glass of wine, or a 

1.5-ounce shot of hard liquor straight or in a mixed drink. 

____ drinks per drinking day 

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

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

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

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

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

1 of 1
 
Form AS4 

Structured Clinical Interview for DSM-IV1 

(Non-Alcohol Substance Use Disorders Module Modified for Marijuana Use, Past Month) 

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

week)? ____ 

age of onset of regular use 

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

age of problem use 

Current Marijuana Dependence 

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

since _________________ . 

(give anchor date)
 

Current marijuana dependence is characterized by a maladaptive pattern of marijuana use leading 

to clinically significant impairment or distress, as manifested by three or more of the following 

occurring during the assessment period. The counselor circles the appropriate clinical rating based 

on the chart below. 

Interview Questions Clinical Rating DSM-IV Dependence 

Criteria 

1. In the past month, have you 

often found that, when you 

started using marijuana, you 

ended up using much more 

than you were planning to? 

If no: Have you used it over a 

much longer period than you 

were planning to? 

? 1 2 3 3. Marijuana often is taken in 

larger amounts or over a 

longer period than was 

intended. 

Clinical Rating 

? = Could not determine based on information provided.
 

1 = Absent or false; the symptom described in the criterion clearly is absent
 

or the criterion statement clearly is false. 

2 = Subthreshold; the threshold for the criterion is almost, but not quite, met. 

3 = Threshold or true; the threshold for the criterion is met or the criterion 

statement is true. 

1Source: First et al. 1996. 

1 of 5 
2 of 5
 

Form AS4 

Structured Clinical Interview for DSM-IV (continued) 

(Non-Alcohol Substance Use Disorders Module Modified for Marijuana Use, Past Month) 

DSM-IV Dependence Interview Questions Clinical Rating Criteria 

2. In the past month, have you 

tried to cut down or stop using 

marijuana? 

If yes: In the past month, did you 

ever stop using marijuana? 

(How many times did you try to 

cut down or stop?) 

If no: Did you have a desire to 

stop or cut down? 

If yes: Is this something you worry 

about? 

? 1 2 3 4. There is a persistent desire 

or one or more unsuccessful 

efforts to cut down or 

control marijuana use.

3. In the past month, did you 

spend a lot of time using 

marijuana or doing whatever you

had to do to get it? 

Did it take you a long time to
 

get back to normal? (How much
 

time? As long as several hours?)

? 1 2 3 5. A great deal of time is 

spent in activities necessary 

to obtain marijuana, use 

marijuana, or recover from 

its effects.

4. In the past month, did you use

marijuana so often that you 

used it instead of working or 

spending time on hobbies or 

with your family or friends? 

? 1 2 3 6. Important social, occupational, or recreational 

activities are given up or 

reduced because of 

marijuana use. 

5. Do you forget things? Do you 

have trouble concentrating? 

Are you anxious or sad a lot? 

Do you think this has anything 

to do with marijuana? 

Has marijuana caused you 

physical problems such as 

difficulty breathing, many colds, 

or a chronic cough or made a 

physical problem worse? 

If yes to either: In the past 

month, did you keep on using 

marijuana anyway? 

? 1 2 3 7. Continued marijuana use 

despite knowledge of 

having a persistent or 

recurrent psychological or 

physical problem that is 

likely to have been caused 

or exacerbated by the use 

of the marijuana. 

Clinical Rating

? = Could not determine based on information provided.

1 = Absent or false; the symptom described in the criterion clearly is 

absent or the criterion statement clearly is false. 

2 = Subthreshold; the threshold for the criterion is almost, but not 

quite, met. 

3 = Threshold or true; the threshold for the criterion is met or the 

criterion statement is true. 
Form AS4 

Structured Clinical Interview for DSM-IV (continued) 

(Non-Alcohol Substance Use Disorders Module Modified for Marijuana Use, Past Month) 

Interview Questions Clinical Rating DSM-IV Dependence

Criteria 

6. Have you found that you 

need to use a lot more or 

higher quality marijuana to 

get high than you did when 

you first started using it 

regularly (e.g., three or more 

times a week)? 

If yes: How much more? 

If no: Do you find that, when 

you use the same amount, it 

affects you much less than it 

did before? 

? 1 2 3 1. Tolerance, as defined by 

either of the following: 

(a) A need for markedly 

increased amounts of 

marijuana (at least 50% 

increase) to achieve 

intoxication or desired effect 

or 

(b) Markedly diminished 

effect with continued use 

of the same amount of 

marijuana. 

7. In the past month, have you 

had withdrawal symptoms, 

that is, felt sick when you 

cut down or stopped using? 

If yes: What symptoms did you 

If no: After not using marijuana 

for a few hours or more, 

have you often used it to 

keep yourself from getting 

sick (withdrawal)? 

? 1 2 3 2. Withdrawal, as manifested 

by either of the following: 

(a) The characteristic 

withdrawal syndrome for 

marijuana, e.g., appetite 

have? disturbance, sleep 

disturbance (vivid dreams), 

night sweats, headaches, 

irritability, restlessness 

or 

(b) Marijuana or a closely 

related substance is taken 

to relieve or avoid 

withdrawal symptoms. 

Record the total number of 

items (1–7) coded 3. 

Number of dependence 

criteria met: 

_____ 

If three or more items are 

coded as 3, the client 

meets the DSM-IV 

diagnosis of current 

marijuana dependence. Clinical Rating 

? = Could not determine based on information provided.
 

1 = Absent or false; the symptom described in the criterion clearly is absent
 

or the criterion statement clearly is false. 

2 = Subthreshold; the threshold for the criterion is almost, but not quite, met. 

3 = Threshold or true; the threshold for the criterion is met or the criterion 

statement is true. 

3 of 5
 
Form AS4 

Structured Clinical Interview for DSM-IV (continued) 

(Non-Alcohol Substance Use Disorders Module Modified for Marijuana Use, Past Month) 

Current Marijuana Abuse 

Now I am going to ask you a few more questions about your marijuana use for the past month, 

that is, since _________________ . 

(give anchor date) 

Current marijuana abuse is characterized by a maladaptive pattern of marijuana use leading to 

clinically significant impairment or distress, as manifested by one or more of the following 

occurring during the assessment period. 

Interview Questions Clinical Rating DSM-IV Abuse 

Criteria 

8. In the past month, have you 

missed work or school because 

you were high or hung over? 

Have you done a bad job at work 

or failed courses because of your 

marijuana use? 

If no: Have you not kept your house 

clean or not taken proper care of 

your children because of your 

use of marijuana? 

If yes: How often did this occur? 

? 1 2 3 1. Recurrent (two or more 

times) marijuana use 

resulting in a failure to fulfill 

major obligations at work, 

school, or home (e.g., 

repeated absences or poor 

work performance related to 

marijuana use; marijuanarelated absences, 

suspensions, or expulsions 

from school; neglect of 

household or children). 

9. In the past month, did you use 

marijuana in a situation in which it 

might have been dangerous? (Did 

you drive while you were high?) 

If yes: How often did this occur? 

? 1 2 3 2. Recurrent (two or more times) 

marijuana use in situations in 

which it is physically hazardous 

(e.g., driving a car; operating 

dangerous equipment like a 

lawnmower, chain saw, stove, 

gun, or tractor; or skiing, 

swimming, biking or taking 

care of children when impaired 

by marijuana). 

Clinical Rating 

? = Could not determine based on information provided.
 

1 = Absent or false; the symptom described in the criterion clearly is absent
 

or the criterion statement clearly is false. 

2 = Subthreshold; the threshold for the criterion is almost, but not quite, met. 

3 = Threshold or true; the threshold for the criterion is met or the criterion 

statement is true. 

4 of 5
 
Form AS4 

Structured Clinical Interview for DSM-IV (continued) 

(Non-Alcohol Substance Use Disorders Module Modified for Marijuana Use, Past Month) 

Interview Questions 

10. Has your use of marijuana 

gotten you into trouble with 

the law in the past month? 

If yes: How often did this 

occur? 

11. Has your use of marijuana 

caused you problems with 

other people, such as with 

family members, friends, or 

people at work? Have you 

gotten into physical fights 

or had bad arguments 

about your marijuana use? 

If yes: In the past month, did 

you keep on using 

marijuana anyway? 

Record the total number of If one or more items 

items (8–11) coded 3. 

Clinical Rating 

? 1 2 3 

? 1 2 3 

Number of abuse 

criteria met 

_____ 

DSM-IV Abuse Criteria 

3. Recurrent (two or more 

times) marijuana-related 

legal problems (e.g., 

arrests for marijuanarelated disorderly conduct).

4. Continued use despite 

having persistent or 

recurrent social or 

interpersonal problems 

caused or exacerbated by 

the effects of marijuana 

(e.g., arguments with 

spouse, physical fights). 

(8–11) are coded as 3, 

the client meets the 

DSM-IV diagnosis of 

current marijuana abuse. 

Clinical Rating 

? = Could not determine based on information provided.
 

1 = Absent or false; the symptom described in the criterion clearly is absent
 

or the criterion statement clearly is false. 

2 = Subthreshold; the threshold for the criterion is almost, but not quite, met. 

3 = Threshold or true; the threshold for the criterion is met or the criterion 

statement is true. 

5 of 5
 
Form AS5 

Marijuana Problem Scale 

Following are different types of problems you may have experienced as a result of smoking 

marijuana. Please circle the number that indicates whether each item has been a problem for you 

in the past month. 

Has marijuana use caused you... No 

Problem 

Serious 

Problem 

Minor 

Problem 

1. Problems between you and your partner 0 1 2 

2. Problems in your family 0 1 2 

3. To neglect your family 0 1 2 

4. Problems between you and your friends 0 1 2 

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

6. To lose a job 0 1 2 

7. To have lower productivity 0 1 2 

8. Medical problems 0 1 2 

9. Withdrawal symptoms 0 1 2 

10. Blackouts or flashbacks 0 1 2 

11. Memory loss 0 1 2 

12. Difficulty sleeping 0 1 2 

13. Financial difficulties 0 1 2 

14. Legal problems 0 1 2 

15. To have lower energy level 0 1 2 

16. To feel bad about your use 0 1 2 

17. Lowered self-esteem 0 1 2 

18. To procrastinate 0 1 2 

19. To lack self-confidence 0 1 2 

1 of 2
 
Form AS5 

Marijuana Problem Scale Scoring Instructions 

Marijuana Problem Scale (continued) 

To obtain the Marijuana Problem Scale (MPS) Score, add the number of items reported as either 

a minor problem or serious problem. This score is used in the Personal Feedback Report (form 

AS8) and compared with the scores in table C at the end of the instructions for creating the PFR. 

Items circled as 1 or 2 by the client should be checked on part II of the Personal Feedback Report 

(form AS8). 

For Office Use 

MPS Score: _____ 

2 of 2
 
Form AS6 

Reasons for Quitting Questionnaire 

People who want to stop smoking marijuana may have several reasons for quitting. I am interested 

in finding out your reasons for wanting to quit. 

There are no right or wrong reasons. Any reason is a good one. Below is a list of reasons that a 

person may have. Please read each statement and circle the number that best describes how 

much this reason applies to you at this time. 

Not at 

All 

A Little 

Bit 

Moderately 

Quite 

a Bit 

Very 

Much I want to quit smoking marijuana at this time... 

1. To show myself that I can quit if I want to 0 1 2 3 4 

2. Because I will like myself better if I quit 0 1 2 3 4 

3. Because I won’t have to leave social functions 

or other people’s houses to smoke 0 1 2 3 4 

4. So that I can feel in control of my life 0 1 2 3 4 

5. Because my family and friends will stop 

nagging me if I quit 0 1 2 3 4 

6. To get praise from people I’m close to 0 1 2 3 4 

7. Because smoking marijuana does not fit in 

with my self-image 0 1 2 3 4 

8. Because smoking marijuana is becoming less 

socially acceptable 0 1 2 3 4 

9. Because someone has told me to quit or else 0 1 2 3 4 

10. Because I will receive a special gift if I quit 0 1 2 3 4 

11. Because of potential health problems 0 1 2 3 4 

12. Because people I am close to will be upset 

if I don’t quit 0 1 2 3 4 

13. So that I can get more things done 0 1 2 3 4 

14. Because I have noticed that smoking marijuana 

is hurting my health 0 1 2 3 4 

15. Because I want to save the money I spend 

on marijuana 0 1 2 3 4 

1 of 3
 
Form AS6 

Reasons for Quitting Questionnaire (continued) 

Not at 

All 

A Little 

Bit 

Moderately 

Quite 

a Bit 

Very 

Much I want to quit smoking marijuana at this time... 

16. To prove that I’m not addicted to marijuana 0 1 2 3 4 

17. Because there is a drug-testing policy at work 0 1 2 3 4 

18. Because I know others with health problems 

caused by smoking marijuana 0 1 2 3 4 

19. Because I am concerned that smoking 

marijuana will shorten my life 0 1 2 3 4 

20. Because of legal problems related to marijuana 0 1 2 3 4 

21. Because I don’t want to be a bad example 

for children 0 1 2 3 4 

22. Because I want to have more energy 0 1 2 3 4 

23. So that my hair and clothes won’t smell 

like marijuana 0 1 2 3 4 

24. So that I won’t burn holes in clothes or furniture 0 1 2 3 4 

25. Because my memory will improve 0 1 2 3 4 

26. So that I will be able to think more clearly 0 1 2 3 4 

Use the spaces below to list the three most important reasons for wanting to stop smoking 

marijuana. If any of the statements above are among your most important reasons, list them in 

the spaces below. Otherwise, write your own reasons. 

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

marijuana are: 

1. _______________________________________________________________________ 

2. _______________________________________________________________________ 

3. _______________________________________________________________________ 

2 of 3 
Form AS6 

Reasons for Quitting Questionnaire (continued) 

Please check the box that applies to you. 

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

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

28. If you have not yet quit smoking marijuana, circle the number that indicates how ready you 

are RIGHT NOW to stop smoking marijuana. 

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

ready ready 

to quit to quit 

29. If you have stopped smoking marijuana already, circle the number that indicates how ready 

you are RIGHT NOW to remain abstinent. 

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

ready ready 

to remain abstinent to remain abstinent 

Reasons for Quitting Questionnaire Scoring Instructions 

For a total Reasons for Quitting (RFQ) Score, add the number of items the client reported as a 

reason to quit smoking marijuana. Count only those responses coded as 2, 3, or 4 (moderately, 

quite a bit, or very much). Include any open-ended items in question 27 that are not in the list. 

Items circled as 2, 3, or 4 by the client are his or her most relevant reasons for quitting 

marijuana. These items should be checked on part III of the Personal Feedback Report 

(form AS8). 

For Office Use 

RFQ Score: _____ 

3 of 3
 
Form AS7 

Self-Efficacy Questionnaire2 

Please circle how confident you are that you could resist the temptation to smoke marijuana in 

the following situations. 

Not at all 

Confident 

How confident are you that you could resist the 

temptation to smoke marijuana if you were... 

Extremely 

Confident 

1. Doing monotonous work 1 2 3 4 5 6 7 

2. Wanting to feel more confident 1 2 3 4 5 6 7 

3. Vacationing 1 2 3 4 5 6 7 

4. Seeing someone else smoking marijuana 

and enjoying it 1 2 3 4 5 6 7 

5. Feeling depressed or worried 1 2 3 4 5 6 7 

6. Drinking alcohol 1 2 3 4 5 6 7 

7. Feeling like celebrating good news or 

an accomplishment 1 2 3 4 5 6 7 

8. Feeling frustrated 1 2 3 4 5 6 7 

9. Wanting to feel better about yourself 1 2 3 4 5 6 7 

10. Feeling angry about something or someone 1 2 3 4 5 6 7 

11. Enjoying a pleasant social situation 1 2 3 4 5 6 7 

12. Having time to yourself, free of responsibilities 1 2 3 4 5 6 7 

13. Using other drugs recreationally 1 2 3 4 5 6 7 

14. Being at a party with people who are 

smoking marijuana 1 2 3 4 5 6 7 

15. Feeling embarrassed 1 2 3 4 5 6 7 

16. Being with a spouse or close friend who is 

smoking marijuana 1 2 3 4 5 6 7 

17. Being in an uncomfortable social situation 1 2 3 4 5 6 7 

18. Being offered marijuana by someone 1 2 3 4 5 6 7 

19. Being bored, with nothing to do 1 2 3 4 5 6 7 

20. Feeling stressed out and needing to calm down 1 2 3 4 5 6 7 

2Sources: Stephens et al. 1993a, 1995. 

1 of 2 
Form AS7 

Self-Efficacy Questionnaire Scoring Instructions 

Self-Efficacy Questionnaire (continued) 

To obtain the Self-Efficacy (SE) Score, add the numbers circled for each item and divide by the 

total number answered (the denominator should be 20 unless an item was skipped). 

Items circled as 1, 2, or 3 indicate that the particular situations would be more difficult to resist 

and would affect the client’s ability to remain abstinent. These items should be checked on part IV 

of the Personal Feedback Report (form AS8). 

For Office Use 

SE Score: _____ 

2 of 2
 
Form AS8 

Instructions for Creating the Personal Feedback Report 

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

information is in italics. 

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

• TLFB Grid (summarized from the calendar) (form AS2) 

• TLFB Marijuana Use Summary Sheet (form AS3) 

• SCID-IV (form AS4) 

• Marijuana Problem Scale (form AS5) 

• Reasons for Quitting Questionnaire (form AS6) 

• Self-Efficacy Questionnaire (form AS7). 

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

• Table A. Marijuana Use for Americans Ages 12 and Older 

• Table B. Marijuana Use for Treatment-Seeking Adults 

• Table C. Marijuana Consequences 

• Table D. Confidence in Avoiding Use. 

Part I. Your Marijuana Consumption 

You reported that you have been smoking regularly for ____ years. 

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

In the past month, you smoked marijuana on ____ days. 

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

You said you smoked ____ joints/pipes/blunts per day during that same period. 

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

Relative to other Americans, this places you in the ____th percentile. This means that 

____ percent of other Americans smoke less than you do. 

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

days. Look up the number of days used, and record the percentile. Use the same number in the 

Personal Feedback Report to illustrate the percentage of other Americans who smoke less than 

the client does. 

Relative to other adults who have sought counseling for their marijuana use, you fall in 

the ____th percentile. This means that you smoke more marijuana than ____ percent of 

individuals seeking marijuana treatment. 

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

days. See above. 

1 of 5 
Form AS8 

Instructions for Creating the Personal Feedback Report (continued) 

Part II. Your Problems Related to Marijuana 

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

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

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

You identified ____ problems caused by your marijuana use. 

Insert the MPS Score. 

This places you in the ____th percentile relative to other adults seeking marijuana 

treatment. This means that you experience more problems than ____ percent of people 

seeking treatment for their marijuana use. 

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

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

You also indicated that 

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

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

what else might you add? 

Record any other comments or reflections the client states. 

Part III. Your Reasons for Quitting Marijuana 

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

You listed the following personal reasons for quitting marijuana and said that they applied 

to you moderately, quite a bit, or very much at this time. 

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

You listed these reasons because they have personal significance for you. Do you have 

any other important reasons for quitting that you would like to add? 

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

Record any other reasons the client mentions. 

Your number of personal reasons for quitting marijuana is ______. 

Insert the RFQ Score. 

Part IV. Difficult Situations for Maintaining Abstinence 

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

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

These high-risk situations include 

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

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

2 of 5
 
Form AS8 

Instructions for Creating the Personal Feedback Report (continued) 

Record other comments or tempting situations the client adds. 

Your responses indicate how confident you are that you could avoid smoking marijuana in 

these situations and resulted in an SE Score of ____. 

Insert SE Score. 

This places you in the ____th percentile compared with other adults who have sought 

counseling to help them stop smoking marijuana. 

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

This means that you are more confident that you could resist the temptation to smoke 

marijuana than ____ percent of treatment-seeking individuals. 

Place the same number in this blank. 

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

# Days Used in the Past 30 Days Percentile Ranking 

1 day 94 

2-3 days 95 

4-7 days 96 

8-14 days 97 

15-24 days 98 

>25 days 99 

Source: Substance Abuse and Mental Health Services Administration 2001. 

Table B. Marijuana Use for Treatment-Seeking Adults (Past 30 Days) 

# Days Used 

in the Past 30 Days 

Rounded Percentile 

Ranking 

# Days Used in the 

Past 30 Days 

Rounded Percentile 

Ranking 

0 0 16 11 

1 0 17 12 

2 1 18 13 

3 1 19 14 

4 2 20 19 

5 2 21 20 

6 2 22 21 

7 3 23 26 

8 4 24 27 

9 4 25 32 

10 5 26 34 

11 6 27 44 

12 7 28 53 

13 8 29 64 

14 8 30 100 

15 11 

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

3 of 5 
Form AS8 

Instructions for Creating the Personal Feedback Report (continued) 

Table C. Marijuana Consequences 

Marijuana Problem 

Score 

Rounded Percentile 

Ranking 

Marijuana Problem 

Score 

Rounded Percentile 

Ranking 

0 0 10 57 

1 1 11 68 

2 3 12 77 

3 5 13 85 

4 8 14 91 

5 11 15 95 

6 16 16 98 

7 23 17 99 

8 32 18 100 

9 44 19 100 

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

Table D. Confidence in Avoiding Use 

Self-Efficacy 

Score 

Rounded Percentile 

Ranking 

Self-Efficacy 

Score 

Rounded Percentile 

Ranking 

1.00-1.25 2 2.74-2.79 21 

1.28-1.35 3 2.80-2.80 22 

1.37-1.50 4 2.83-2.84 23 

1.53-1.58 5 2.85-2.89 24 

1.60-1.70 6 2.89-2.94 25 

1.75-1.85 7 2.95-2.95 26 

1.90-2.00 8 3.00-3.00 27 

2.05-2.05 9 3.05-3.05 28 

2.10-2.15 10 3.06-3.11 29 

2.20-2.22 11 3.15-3.16 30 

2.25-2.32 12 3.17-3.20 31 

2.33-2.37 13 3.21-3.21 32 

2.39-2.40 14 3.22-3.25 33 

2.41-2.44 15 3.26-3.28 34 

2.45-2.47 16 3.30-3.33 35 

2.50-2.58 17 3.35-3.35 36 

2.60-2.60 18 3.37-3.39 37 

2.61-2.65 19 3.40-3.40 38 

2.67-2.72 20 3.42-3.45 39 

4 of 5
 
Form AS8 

Instructions for Creating the Personal Feedback Report (continued) 

Table D. Confidence in Avoiding Use (continued) 

Self-Efficacy 

Score 

Rounded Percentile 

Ranking 

Self-Efficacy 

Score 

Rounded Percentile 

Ranking 

3.47-3.47 40 4.47-4.55 72 

3.50-3.50 41 4.56-4.58 73 

3.53-3.53 42 4.60-4.65 74 

3.55-3.56 43 4.67-4.74 75 

3.58-3.58 44 4.75-4.78 76 

3.60-3.60 45 4.79-4.80 77 

3.61-3.63 46 4.83-4.85 78 

3.65-3.68 47 4.89-4.90 79 

3.70-3.70 48 4.94-4.95 80 

3.72-3.76 49 5.00-5.00 81 

3.78-3.79 50 5.05-5.06 82 

3.80-3.80 51 5.11-5.16 83 

3.83-3.84 52 5.17-5.21 84 

3.85-3.89 54 5.22-5.28 85 

3.90-3.90 55 5.30-5.33 86 

3.94-3.95 56 5.37-5.42 87 

4.00-4.05 58 5.44-5.47 88 

4.05-4.05 59 5.50-5.56 89 

4.06-4.06 60 5.58-5.63 90 

4.10-4.11 61 5.65-5.70 91 

4.12-4.16 62 5.72-5.78 92 

4.17-4.20 63 5.79-5.84 93 

4.21-4.22 64 5.89-6.05 94 

4.25-4.26 65 6.06-6.16 95 

4.28-4.28 66 6.17-6.30 96 

4.30-4.32 67 6.33-6.55 97 

4.33-4.35 68 6.56-6.75 98 

4.39-4.40 69 6.83-6.95 99 

4.42-4.42 70 7.00-7.00 100 

4.44-4.45 71 

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

5 of 5
 
Form AS8 

Personal Feedback Report 

This report summarizes information about your marijuana use. The information may be useful in 

developing strategies to resist marijuana. 

Part I. Your Marijuana Consumption 

You reported that you have been smoking regularly for ____ years. 

In the past month, you smoked marijuana on ____ days. 

You said you smoked ____ joints/pipes/blunts per day during that same period. 

Relative to other Americans, this places you in the ____th percentile. This means that 

____ percent of other Americans smoke less than you do. 

Relative to adults who have sought counseling for their marijuana use, you fall in the 

____th percentile. This means that you smoke more marijuana than ____ percent of 

individuals seeking marijuana treatment. 

Part II. Your Problems Related to Marijuana 

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

______ Problems between you and your partner ______ Memory loss 

______ Problems in your family ______ Difficulty sleeping 

______ To neglect your family ______ Financial difficulties 

______ Problems between you and your friends ______ Legal problems 

______ To miss days at work or miss classes ______ To have lower energy level 

______ To lose a job ______ To feel bad about your use 

______ To have lower productivity ______ Lowered self-esteem 

______ Medical problems ______ To procrastinate 

______ Withdrawal symptoms ______ To lack self-confidence 

______ Blackouts or flashbacks 

1 of 5
 
Form AS8 

Personal Feedback Report (continued) 

You identified ____ problems caused by your marijuana use. 

This places you in the ____th percentile relative to other adults seeking marijuana 

treatment. This means that you experience more problems than ____ percent of people 

seeking treatment for their marijuana use. 

You also indicated that 

You often have found that when you start using marijuana, you end up smoking much 

______ more of it than you were planning to. (SCID-IV, question 1) 

You frequently thought about or tried unsuccessfully to cut down or control your use of 

______ marijuana. (SCID-IV, question 2) 

You spent a great deal of time trying to get marijuana, smoking it, or recovering from its 

______ effects. (SCID-IV, question 3) 

You sometimes gave up or did not participate in important occupational, social, or 

______ recreational activities because you were using marijuana. (SCID-IV, question 4) 

You continued using marijuana despite knowing that it was contributing to social, 

______ psychological, or physical problems in your life. (SCID-IV, question 5) 

You needed to smoke more marijuana than you had smoked in the past to get the same 

______ effect. (SCID-IV, question 6) 

You noticed that you were not getting as high as you used to when you smoked the same 

______ amount of marijuana. (SCID-IV, question 6) 

You experienced withdrawal symptoms when you tried to stop using marijuana (e.g., 

______ difficulty sleeping, irritability, excessive perspiration). (SCID-IV, question 7) 

You often used marijuana to relieve or avoid experiencing marijuana-related withdrawal 

______ symptoms. (SCID-IV, question 7) 

You were frequently high or recovering from being high when you were supposed to be 

______ attending to your obligations at work, school, or home. (SCID-IV, question 8) 

You were frequently high or recovering from being high when you were doing something 

______ dangerous like driving a car. (SCID-IV, question 9) 

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

______ question 10) 

2 of 5
 
____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Form AS8 

Personal Feedback Report (continued) 

You have experienced problems with family members, friends, or people at work 

______ because of your marijuana use. (SCID-IV, question 11) 

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

what else might you add? 

Part III. Your Reasons for Quitting Marijuana 

You listed the following personal reasons for quitting marijuana and said that they applied 

to you moderately, quite a bit, or very much at this time. 

______ To show myself that I can quit if I want to 

______ Because I will like myself better if I quit 

______ Because I won’t have to leave social functions or other people’s houses to smoke 

______ So I can feel in control of my life 

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

______ To get praise from people I’m close to 

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

______ Because smoking marijuana is becoming less socially acceptable 

______ Because someone has told me to quit or else 

______ Because I will receive a special gift if I quit 

______ Because of potential health problems 

______ Because people I am close to will be upset if I don’t quit 

______ So that I can get more things done 

______ Because I have noticed that smoking marijuana is hurting my health 

______ Because I want to save the money I spend on marijuana 

______ To prove that I’m not addicted to marijuana 

3 of 5 
____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Form AS8 

Personal Feedback Report (continued) 

______ Because there is a drug-testing policy at work 

______ Because I know others with health problems caused by smoking marijuana 

______ Because I am concerned that smoking marijuana will shorten my life 

______ Because of legal problems related to marijuana 

______ Because I don’t want to be a bad example for children 

______ Because I want to have more energy 

______ So my hair and clothes won’t smell like marijuana 

______ So I won’t burn holes in clothes or furniture 

______ Because my memory will improve 

______ So that I will be able to think more clearly 

You listed these reasons because they have personal significance for you. Do you have 

any other important reasons for quitting that you would like to add? 

Your number of personal reasons for quitting marijuana is ____. 

Part IV. Difficult Situations for Maintaining Abstinence 

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

These high-risk situations include 

______ Doing monotonous work 

______ Wanting to feel more confident 

______ Vacationing 

______ Seeing someone else smoking marijuana and enjoying it 

______ Feeling depressed or worried 

4 of 5
 
______________________________________________________________________________________ 

______________________________________________________________________________________ 

______________________________________________________________________________________ 

Form AS8 

Personal Feedback Report (continued) 

______ Drinking alcohol 

______ Feeling like celebrating good news or an accomplishment 

______ Feeling frustrated 

______ Wanting to feel better about myself 

______ Feeling angry about something or someone 

______ Enjoying a pleasant social situation 

______ Having some time to myself, free of responsibilities 

______ Using other drugs recreationally 

______ Being at a party with people who are smoking marijuana 

______ Feeling embarrassed 

______ Being with a spouse or close friend who is smoking marijuana 

______ Being in an uncomfortable social situation 

______ Being offered marijuana by someone 

______ Being bored, with nothing to do 

______ Feeling stressed out and needing to calm down 

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

Your responses indicate how confident you are that you could avoid smoking marijuana in 

these situations and resulted in an SE Score of ____. 

This places you in the ____th percentile compared with other adults who have sought 

counseling to help them stop smoking marijuana. 

This means that you are more confident that you could resist the temptation to smoke 

marijuana than ____ percent of treatment-seeking individuals. 

5 of 5 

SECTION V. 

ENHANCING MOTIVATION: SESSIONS 1 AND 2 

This section presents the content of sessions 1 and 2. It also presents information on motivational 

interviewing and the stages-of-change concept. The counselor uses this concept throughout the 

remaining sessions to measure the client’s readiness for change and to adjust the sessions to 

accommodate the client’s stage. The section provides examples of motivational interviewing 

strategies, highlighting how to use these techniques in treatment sessions. Finally, it presents 

sessions 1 and 2; these sessions are based primarily on principles of motivational enhancement 

and secondarily on cognitive behavioral skills. 

After completing the initial assessment session, the counselor introduces the client to more 

targeted motivational strategies. Session 1 focuses on 

•	 Reviewing the completed Personal Feedback Report (PFR) 

•	 Exploring the client’s experiences with marijuana 

•	 Eliciting, acknowledging, and reinforcing the client’s expressions of motivation to change 

•	 Building the alliance between the client and counselor 

•	 Integrating the client’s feedback about marijuana use and associated problems 

•	 Setting goals 

•	 Planning treatment. 

The protocol for session 2 guides the counselor in 

•	 Reinforcing successful efforts the client has made at initiating change 

•	 Discussing how and when assistance may be offered by the friend or relative invited 

to the session by the client 

•	 Refining goals 

•	 Reviewing change strategies 

•	 Assessing the client’s social support for initiating changes. 

Key Concepts: Motivational Interviewing Skills 

Identifying the Individual’s Stage of Change 

The stages-of-change model (Prochaska and DiClemente 1982) describes a sequence of stages 

through which individuals progress as they think about and change their behaviors. It gives the 

counselor insight into the client’s thinking so that the counselor can select strategies specific to 

the client’s stage. This model was adapted for the Marijuana Treatment Project and assumes 

63
 
Brief Counseling for Marijuana Dependence 

•	 Progress in overcoming marijuana dependence (e.g., getting ready for the first day of 

abstinence, getting through the first 3 months) depends on the client’s readiness for change. 

•	 Client readiness may shift and evolve and may be influenced by the therapist. 

The model comprises five stages: precontemplation, contemplation, preparation, action, and 

maintenance (exhibit V-1). Individuals move back and forth between the stages and progress through 

the stages at different rates. For example, in the assessment session the client may be committed to 

maintaining abstinence, but in session 2 he or she may be ambivalent. The Center for Substance 

Abuse Treatment’s Treatment Improvement Protocol (TIP) 35, Enhancing Motivation for Change in 

Substance Abuse Treatment (CSAT 1999b), as well as the KAP Keys (CSAT 2001c) and the Quick 

Guide (CSAT 2001d) that accompany TIP 35, provides detailed information about this model. 

Exhibit V-1. Characteristics of the Stages-of-Change Model 

Stages Characteristics 

Precontemplation • Is not considering change 

• May be unwilling to change behaviors 

• Is unaware of adverse consequences from marijuana use, 

although others may believe problems exist 

Contemplation • Becomes aware that problems exist 

• Recognizes causes for concern and reasons to change 

• Typically is ambivalent and continues to use marijuana 

• May seek information and reevaluate marijuana use behavior 

• Weighs the pros and cons of making a change 

• Could remain in this stage for years 

Preparation • Commits to changing 

• Recognizes that advantages of changing outweigh benefits of 

not changing 

• Thinks about capabilities of success (i.e., self-efficacy) 

• Continues using marijuana but intends to stop or cut back soon 

• May have attempted to reduce or stop use 

• Sets goals and may tell others about them 

Action • Chooses and begins to pursue a goal 

• Modifies habits 

• Can last months following termination of marijuana use 

Maintenance • Makes efforts to sustain gains achieved during the action phase 

• Works to prevent recurrence of use 

• Learns how to detect and guard against risky situations 

• Requires prolonged behavior change and continued vigilance for 

6 months to several years 

64 
Section V. Enhancing Motivation 

Using Motivational Interviewing Strategies 

Sessions 1 and 2 rely heavily on the motivational interviewing strategies described in Miller and 

Rollnick (2002). Motivational interviewing is a technique used in motivational enhancement 

therapy (MET). The counselor assesses the client’s motivation by using motivational interviewing 

strategies, which include asking open-ended questions, listening reflectively, affirming the client, 

summarizing the client’s views of change, eliciting self-motivational statements, recognizing and 

addressing resistance, recognizing readiness for change, and identifying discrepancies (see CSAT 

1999b). Once the client’s stage is identified, the counselor uses these strategies to support 

continued progress through the stages. 

Close- Vs. Open-Ended Questions 

Close-ended questions are an efficient way of obtaining information quickly; however, they allow 

the client to be passive, answering each question and quietly waiting for the next. The interviewer 

is in control, and the interviewee responds to each cue. Open-ended questions encourage the 

client to express himself or herself and to adopt an active role in his or her treatment. Exhibit V-2 

presents examples of both types of questions. 

Exhibit V-2. Examples of Close- and Open-Ended Questions 

Close-Ended Questions 

• How old were you when you first 

smoked marijuana? 

• Was it offered to you by a family 

member? 

• How old were you when you began 

using it daily? 

• Have you ever had a bad experience 

with marijuana? 

• When did you first think you had a 

marijuana problem? 

Open-Ended Questions 

• Tell me about your early experiences 

with marijuana. 

• How did your marijuana use change over 

time? 

• Please describe some of your recent 

experiences with marijuana. 

• What was it that made you think you 

had a problem with marijuana? 

Listening Reflectively 

A reflection can take the form of simply repeating the client’s words or paraphrasing his or her 

comments. Sometimes the reflection adds to what the client has said as a way of testing a 

counselor’s hunch. The skilled listener using reflective listening skills can help the client explore 

his or her thoughts and feelings: 

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

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

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

or 

65 
Brief Counseling for Marijuana Dependence 

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

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

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

or 

M:	 My buddies say they’ll support me if I decide to quit, but knowing that they’re getting high 

will make me feel left out. 

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

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

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

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

starts. 

C:	 On the one hand, you don’t want to miss having fun during the summer, but on the other 

hand, you’re thinking that you use too often. 

Affirmation of the Client 

Admitting drug dependence, seeking help by enrolling in a program, summoning the courage to 

change, and undertaking other aspects of overcoming a dependence are tremendously difficult. 

The counselor can be supportive by frequently offering genuine compliments and expressions of 

awareness: 

C:	 You’ve been thinking about quitting for a long time, and now you’re taking the first steps. 

I’m guessing you feel good about that. 

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

difficult. 

C:	 Deciding to give up the extra income that came from selling pot wasn’t a minor decision. It 

requires a real commitment to leave that behind. 

Summarizing the Client’s Views of Change 

As the client reveals facets of his or her thinking about change, the counselor can be supportive 

by summarizing key issues. Hearing the counselor consolidate the client’s statements helps the 

client become aware and ready to resolve his or her mixed motivations: 

C:	 If I understand you correctly, you’re aware of reasons for changing but you’re thinking of 

other reasons not to quit. On the side of quitting are being a good role model for your 

children and overcoming a tendency to procrastinate. On the side of not quitting are your 

fears that you’ll lose friends and won’t make it for long. Have I got it right? What are your 

thoughts about this? 

66 
Section V. Enhancing Motivation 

Eliciting Self-Motivational Statements 

Whereas some clients begin counseling with a strong commitment to stop marijuana use, others have 

considerable ambivalence that may increase over time. Motivational enhancement sessions help the 

ambivalent client strengthen his or her determination to quit. It is hoped that these counseling sessions 

lead the client to recognizing his or her problem (I guess I really have to face that I’m out of control with 

marijuana), becoming concerned about it (I’m worried about whether I can overcome this), expressing 

an intention to change (Now’s the time for me to leave this behind), and feeling positive about the 

prospects of succeeding (I can picture a time when I’ll be clean, and—for once in my life—that seems 

possible). The counselor elicits expressions of motivation from the client with open-ended questions: 

• Recognizing the problem 

C:	 How has your marijuana use gotten in the way of things that are important? 

C:	 What convinces you that marijuana has become a problem? 

• Expressing concern 

C:	 What aspects of your marijuana use have made you, or people close to you, worry? 

C:	 What do you imagine could happen if you continued to smoke marijuana the way 

you have been doing? 

• Encouraging intentions to change 

C:	 When you joined our program, you probably had some hope that things would get 

better. What would improve in your life if your hopes were met? 

C:	 Why should you stop smoking marijuana? Why do you think it’s time to change? 

• Expressing optimism 

C:	 What leads you to think that you could succeed in quitting if you decided to do that? 

C:	 Is there a part of you that feels encouraged about changing? 

With these questions, the counselor helps the client take ownership of the problem and elicit 

expressions of readiness to change. 

Recognizing and Addressing Resistance 

A conventional way of interpreting actions of a client who argues with the counselor, frequently 

interrupts, or denies that a behavior is a problem is that the individual is not motivated to change. 

An alternative view is that the counselor does not understand the client’s thoughts and feelings. 

When the counselor considers these behaviors a signal that he or she needs to understand the 

client’s experience better, a confrontation between counselor and client is less likely to occur. The 

counselor shows that he or she is listening and is not being judgmental. The counselor’s 

reflections can prompt the client to explore his or her thoughts and feelings: 

M:	 I don’t understand why you folks want everyone to quit smoking dope. Maybe I’d be better 

off if I just cut back. 

C:	 I hear you saying that it’s important to you to change your marijuana use, but you’re not 

sure whether stopping completely is best for you right now. I can see that you’re eager to 

find the best goals. 

67 
Brief Counseling for Marijuana Dependence 

In this example, the counselor might have offered a defense of the program’s abstinence 

objectives, listed reasons why the client ought to change, and so forth. Those responses probably 

would have led the client to become even more resistant. The strategy illustrated above is termed 

“rolling with resistance,” an approach that conveys the counselor’s acceptance of the client’s 

point of view and invites the client to be open to a slight variation. In the following examples of 

this approach, the counselor accepts the client’s comments, conveys empathy for the client’s 

feelings, and reframes what has been said: 

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

C: It’s hard to figure out why you’re getting all this pressure. Kind of makes you wonder how 

you could be the only one who is having problems with pot. 

or 

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

C:	 On the one hand, you’d benefit from more energy. On the other hand, you’d need to find 

other ways to relax. 

or 

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

C:	 Slow down. It’s too early to be talking about forever. Let’s talk about what you’re working 

on right now. 

or 

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

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

Recognizing Readiness for Change 

Expressions of motivation take a variety of forms. The counselor needs to listen carefully and 

acknowledge those expressions: 

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

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

or 

M: One thing that I see happening over and over is my promising that I’ll limit how often I get 

high, and then I go right ahead and break every one of these promises. 

C: You’d really like to stop disappointing yourself. 

68 
Section V. Enhancing Motivation 

or 

M:	 I’ve got three beautiful children, and I don’t want my pot smoking to interfere with my 

being a good father. 

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

Identifying Discrepancy 

Clients who are drug dependent have probably seen their reliance on drugs interfere with 

important aspects of their lives. The counselor helps the client focus on the costs of continued 

drug use by pointing them out to the client and seeking the client’s perspectives: 

C:	 I’ve heard you talk about how important it is that your children grow up in a safe and 

happy home. That’s a goal. But you’ve also talked about not wanting anyone, including 

your wife, to dictate what you do, and this is causing tension in your home. Relieving this 

tension is another goal. I wonder what your thoughts are about these two goals. 

C:	 You’ve told me that when you smoke a joint on your lunch break, you have a hard time 

concentrating at work for the rest of the day. You’ve also said that doing your job well is 

important so that you can get promoted. I’m a little confused. 

The Context for Motivational Interviewing and Skills Training 

As the client expresses increasing interest in addressing his or her problems modifying use, the 

counselor carefully supports these efforts to change without prescribing the change. When the 

client expresses a commitment to change, the counselor asks the client about the steps he or she 

will take to make the change. The counselor provides a menu of self-change and assisted-change 

options depending on the client’s inclinations and experience in making changes. 

It is important for the counselor to show genuine interest in the client’s perspectives on and skills 

for making change. For example, if the client has quit smoking tobacco, lost a lot of weight, or left 

a destructive relationship, the counselor explores these experiences to reinforce and highlight the 

client’s capacity and desire for self-development. Self-change advice may be in the form of a brief 

written handout concerning behavioral changes. Sessions 1 and 2 provide several take-home 

handouts that reinforce motivational advice given by the counselor during the sessions. These 

handouts are available at the end of this section. 

Tips for the Counselor 

•	 Review relevant sections of the manual before each session. 

•	 Develop a natural style of conveying the material; avoid reading text to clients. 

•	 Maintain a motivational style; use open-ended questions and reflections; and avoid a 

directive, resistance-building style. 

•	 Encourage involvement and participation by the client. 

•	 Attend to shifts in the client’s motivation and readiness for change. 

•	 Explain practice exercises carefully; probe for the client’s understanding. 

69 
Brief Counseling for Marijuana Dependence 

Overview of Session 1: Reviewing the PFR 

Total Time: 1 hour, 30 minutes 

Delivery Method: MET-focused individual therapy 

Materials (all forms except the PFR are at the end of this section): 

•	 Two copies of client’s completed PFR (form AS8 from the assessment session) 

•	 Learning New Coping Strategies (form 1A) 

•	 A Guide to Quitting Marijuana (form 1B) 

•	 A blank copy of the Quit Agreement (form 1C) 

Goals for This Session: 

•	 To present the data gathered during the assessment session concerning marijuana 

use, its consequences, and the likely benefits and costs of stopping or reducing use 

•	 To facilitate the client’s candid reflection on consequences of marijuana use 

•	 To explore the client’s attitudes about change, including ambivalent attitudes 

•	 To acknowledge the client’s expressions of readiness for change, help set goals, and 

identify change strategies 

Session Outline: 

1.	 Assess the client’s readiness to proceed 

• Ask client for his or her feelings and thoughts about the assessment session 

• Ask whether any changes have occurred since the last meeting 

• Reinforce expressions of motivation 

2.	 Review the PFR 

• Age of onset 

• Comparison of use patterns to the national average 

• Problems caused by use 

• Tolerance level 

• Reasons for quitting 

• Risk factors 

3.	 Summarize the PFR review 

4.	 Elicit and reinforce client’s readiness to change 

5.	 Assist the client in preparing for change 

• Ask him or her to select a stop date (if the client has not already stopped using) 

• Discuss 

— Whether the client will stop “cold turkey” 

— What the client will do with current marijuana supply and paraphernalia 

— How the client will disclose plans to family and friends 

70 
Section V. Enhancing Motivation 

— How the client will address problems in maintaining abstinence 

6. Help the client identify specific behavior change strategies 

• Discuss Learning New Coping Strategies (form 1A) and A Guide to Quitting 

Marijuana (form 1B) 

• Discuss barriers to quitting and vulnerabilities to slipping 

— Managing general stress (HALT) 

— People, situations, and thoughts that increase vulnerability 

— Significant life changes likely to produce stress 

— Supportive people who will provide help 

• Review previous successful experiences at quitting to identify useful strategies 

7. Assign between-session exercises 

• Prepare Quit Agreement (form 1C) 

• Review Learning New Coping Strategies (form 1A) 

• Review A Guide to Quitting Marijuana (form 1B) 

8. Ask client to invite a supporter to next session 

9. Review and conclude session 

Session 1 Protocol 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor uses MET techniques while reviewing the client’s PFR and helping the client prepare for 

change. 

Assess the Client’s Readiness To Proceed 

The counselor asks the client to express his or her thoughts and any major changes that have 

occurred since the assessment session. Some possible responses from the client might be 

• Abstinence since entering treatment 

• A reduction in the client’s marijuana use 

• Seeking additional treatment or attendance at a mutual-help program 

• Conversations about his or her use or about this program with family or friends. 

The counselor responds empathically, uses opportunities to support the client’s self-efficacy for 

change, and reinforces expressions of motivation. 

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

Shirley (S): After answering all those questions about my smoking, I am more aware of it than ever! 

Nothing has changed yet, but I am thinking about it. My husband has been very supportive. 

C: And his support means a lot to you. 

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Brief Counseling for Marijuana Dependence 

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

C: That’s good to hear. Let’s be sure to talk about specific requests you might make of him 

for support in the future. 

or 

C: You arrived a little late for your appointment. Is this a good time for you, or would a 

different time work better? 

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

C: How are things? 

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

C: That sounds like an uncomfortable situation for you. 

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

C: How has this affected your smoking? 

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

C: It’s more of a problem for them. 

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

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

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

Review the PFR 

The PFR review takes approximately 30 minutes. The counselor explains that by reviewing the PFR 

(form AS8), the client will understand reasons for and against changing and what and when 

problems might arise. 

The counselor leads the client through a systematic review of the PFR, giving the client an 

opportunity to explore each point. The counselor avoids simply verifying the information obtained 

during the assessment session. The counselor periodically seeks the client’s thoughts and feelings 

during the review. The counselor listens reflectively to acknowledge expressions of readiness for 

change. Reviewing the PFR provides an ideal opportunity to use motivational interviewing 

techniques, for example, expressing empathy, identifying discrepancy, eliciting self-motivational 

statements, rolling with resistance, and supporting self-efficacy. 

The client may respond to elements in the PFR review with arguments about the validity of the 

items (I didn’t say smoking pot was causing me money problems!). In such cases, the counselor 

maintains a nondefensive tone, acknowledges that the client knows best which areas of his or her 

life have been affected by marijuana use, and moves on to the next item. The counselor may 

make changes to the PFR based on the client’s feedback during this review. 

In keeping with the MET approach, the counselor uses open-ended rather than close-ended 

questions. For example, Did you say you used in unsafe situations? is a close-ended question that 

invites a mere yes or no answer and possible disagreement with the PFR item. Saying instead Tell 

me about using in unsafe situations invites elaboration and discussion. 

72 
Section V. Enhancing Motivation 

The counselor spends more time on the sections that are likely to produce the most constructive 

discussion. The sections on marijuana problems and reasons for quitting are especially conducive 

to motivational interviewing. After reviewing the PFR with the client, the counselor asks the client 

for reactions and responds to them with empathy. Before moving on to the next phase of this 

session, the counselor ensures that the following PFR items are discussed: 

•	 Age of onset (part I of the PFR). The counselor tells the client that substance use 

disorders tend to be more severe when they begin at an early age. This means that the 

earlier the age of onset, the greater the risk of developing severe problems if the 

substance use continues. In the PFR, the age of onset of regular marijuana smoking is the 

age the client began smoking marijuana three or more times a week. 

•	 Comparisons of use patterns (part I of the PFR). When preparing the PFR, the 

counselor uses tables A and B to compare the client’s use with that of others who use 

marijuana. The percentiles indicate the percentage of people in the comparison group who 

scored at or below the client’s score. These comparisons allow the client to compare his 

or her use with that of people who experienced significant problems related to marijuana 

use. The counselor can present the information in the following way: 

C:	 You smoked marijuana on 24 of the past 30 days. That puts you in the top 98 

percentile relative to all Americans. This means that 98 percent of American adults 

smoke less often than you do and about 2 percent smoke more often. 

S:	 Wow! 

C:	 That surprises you. 

S:	 It sounds like a lot. I never thought it was that much! 

C:	 What are you thinking, now that you know that? 

S:	 I don’t like it. I knew I was getting high a lot, but I always thought that a lot of 

other people got loaded as much as I did. This isn’t good news. 

C:	 You’d like this to be different. 

S:	 Yeah. 

•	 Problems caused by marijuana use (part II of the PFR). The counselor tells the client 

where he or she falls, relative to others seeking treatment, based on his or her responses 

to the Marijuana Problem Scale (form AS5) and the data in table C. The counselor reviews 

the criteria listed on the Structured Clinical Interview for DSM-IV (SCID-IV) (form AS4) that 

were coded as 2 or 3. The results provide an overview of the problems and symptoms that 

the client identified as resulting from his or her marijuana use. 

•	 Tolerance level (part II of the PFR). Question 6 of the SCID-IV was used to measure the 

client’s tolerance level. Tolerance is defined as the need for a markedly increased amount 

of marijuana (at least a 50-percent increase) to achieve the desired effect or a markedly 

diminished effect with continued use of the same amount of marijuana. 

•	 Reasons for quitting (part III of the PFR). To reinforce the client’s motivation, the 

counselor reviews the reasons the client gave on the Reasons for Quitting Questionnaire 

(form AS6) and asks the client whether he or she would like to add other reasons to the list. 

•	 Risk factors for relapse (part IV of the PFR). The counselor points out the risky situations 

the client identified on the Self-Efficacy Questionnaire (form AS7) as the client’s risk factors 

73 
Brief Counseling for Marijuana Dependence 

for relapse. The counselor explains that risk factors are warning signs that require the client’s 

attention and indicate a susceptibility to problems associated with marijuana use. A person 

who uses substances besides marijuana is at risk for additional reasons. Decreased use of 

one drug may result in increased use of another, a phenomenon called substance 

substitution. In addition, combining different drugs compounds their effects, sometimes with 

dangerous results. Tolerance for one substance can increase tolerance for another; people 

who take multiple substances simultaneously can develop cross-tolerance for several 

substances and be at risk for injury, arrest, or overdose if severely intoxicated. 

Summarize the PFR Review 

The counselor summarizes the highlights from the PFR, including reactions and modifications 

offered by the client during this session: 

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

S: I’m ready! 

C: Your PFR shows that your smoking has caused several problems including missing work, 

difficulty sleeping, and feeling bad about your use. Is there anything else you want to add? 

S: No; those are the main problems. 

C: You also mentioned reasons for quitting, including so your husband will quit nagging you, 

so you won’t lose the privilege of teaching, and because you have health concerns. 

S: Being a good teacher is really important. 

C: Being a good teacher is important to you, and your smoking gets in the way. You can’t 

properly prepare for class; the kids can find out; you can lose your job. 

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

C: When you talk about being a teacher, you get enthusiastic, but when you talk about your 

smoking, you get discouraged. 

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

C: You also stated that high-risk situations for you would include being with others who 

smoke and seeing them enjoy it. Anything else? 

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

use drugs. 

C: You’ve already identified how difficult it may be, but you’ve also identified some very strong 

reasons for changing your smoking habits. 

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

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

S: I really am. 

Elicit and Reinforce Client’s Readiness To Change 

When the client expresses motivation to change, the counselor acknowledges these expressions, 

seeks elaboration, and offers reinforcement: 

74 
Section V. Enhancing Motivation 

C:	 You said that your smoking has caused problems including feeling that you have lower 

energy. Could you tell me about that? 

Miguel (M): I find I mean to do things, but they never get done. It seems that I’m tired all the 

time. I can’t help but think it’s related to my smoking. 

C:	 Related to your smoking? 

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

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

M:	 I think that’s related to the lower energy. I don’t finish my work at my job, and I’m not as 

creative. I feel that I’m drowning in backed-up work at home, at my job, everywhere. 

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

M:	 Yeah. 

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

M:	 I really would like that. 

Assist Client in Preparing for Change 

The counselor assists the client in preparing to stop using marijuana by discussing several key 

issues. If the client has not stopped already, he or she needs to select a day to stop. The 

counselor helps the client consider several alternative stop dates. 

Topics to consider include what the client will do with his or her marijuana supply and paraphernalia, 

how the client will disclose the plan to stop to family and friends (both supporters and those who 

might sabotage the client’s efforts), and how the client will address possible problems in maintaining 

abstinence (e.g., sleep difficulties, boredom, anxiety, restlessness) in the first week. 

Help Client Identify Specific Behavior Change Strategies 

The counselor discusses specific coping strategies to handle vulnerabilities to slipping. The 

counselor gives the client Learning New Coping Strategies (form 1A) and A Guide to Quitting 

Marijuana (form 1B). If time permits, the counselor reviews these forms with the client, 

highlighting sections that seem particularly relevant to the client. The counselor explains that many 

concepts touched on in the forms are discussed in detail in later sessions and the client should 

bring the forms to the next session (session 2). 

Because managing one’s stress level is important, particularly in the early weeks and months of 

treatment, the counselor advises the client about HALT: 

• Don’t let yourself become too Hungry. 

• Don’t let yourself become too Angry. 

• Don’t let yourself become too Lonely. 

• Don’t let yourself become too Tired. 

The counselor asks the client to think about people, situations (e.g., certain times of day, days of 

the week, places, moods), and thoughts that can increase vulnerability to slipping. Some of these 

75 
Brief Counseling for Marijuana Dependence 

were mentioned on the Self-Efficacy Questionnaire (form AS7). For example, a client may describe 

plans to spend time with a smoking buddy. A client may face significant life changes (e.g., job or 

relationship changes, illness in the family or of a close friend) likely to produce stress that could 

place the client at risk for slipping. The counselor and client identify and discuss coping strategies 

for each situation. 

The counselor helps the client identify people from whom he or she can seek and get support. The 

counselor encourages the client to consider several options rather than only one or two and to 

think creatively. With the counselor, the client can practice making requests and can benefit from 

the counselor’s modeling and feedback. Practicing interactions during treatment sessions can 

lessen the anxiety the client may have about asserting himself or herself with friends and family: 

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

C:	 What concerns do you have? 

M:	 I’ll be at a meeting with several people who smoke. For years we’ve gone out and partied 

after the meetings. I don’t know what I’ll do. 

C:	 You just identified a high-risk situation. 

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

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

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

C:	 That is a difficult situation for you. Maybe if you and I rehearsed a couple of different ways 

to tell them, it would make it easier for you. Would you be willing to try that? 

M:	 Sure, what should we do? 

C:	 Why don’t I play the role of one of your colleagues on this trip, and you try different ways 

you might handle it. Ready? 

Assign Between-Session Exercises 

The counselor gives the client the Quit Agreement (form 1C) and asks the client to bring the 

completed form to the next session. The counselor explains that the agreement summarizes 

1. The client’s date for quitting marijuana use 

2. The client’s reasons for seeking to change 

3. Strategies that the client will use. 

The counselor also asks the client to review Learning New Coping Strategies (form 1A) and 

A Guide to Quitting Marijuana (form 1B) several times before the next session. 

Ask Client To Invite a Supporter to Next Session 

People who are trying to overcome an addiction can benefit greatly from the support of a close 

relative or friend. The counselor asks the client to invite someone to attend the next session and 

to think carefully about the pros and cons of particular people to invite. For example, a friend who 

is dependent on another drug or alcohol is not a good prospect. Factors to consider include 

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Section V. Enhancing Motivation 

closeness to the client, emotional characteristics of the relationship, emotional availability of the 

supporter regarding the client’s desire to quit marijuana use, substance use by the supporter, and 

accessibility during times of stress. The ideal person would be someone who is a good listener, 

cares about the client, and is interested in providing support. This person will be asked to sign the 

Supporter Agreement at session 2. 

Review and Conclude Session 

The counselor reviews the content of the session, asks the client for feedback, responds 

empathically to his or her comments, troubleshoots any difficulties, and reminds the client to 

review the handouts over the next week. 

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Brief Counseling for Marijuana Dependence 

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

Total Time: 1 hour 

Delivery Method: MET-focused individual therapy with case conference elements 

Materials (all forms except the PFR are at the end of this section): 

• Copy of client’s PFR (form AS8) 

• Learning New Coping Strategies (form 1A) 

• Blank copy of the Quit Agreement (form 1C) 

• Supporter Strategies (form 2A) 

• Two blank copies of Supporter Agreement (form 2B) 

Goals for This Session: 

• To specify how a supporter can help the client achieve and maintain change 

• To help the client develop a change plan with coping strategies for high-risk situations 

Session Outline: 

1. Assess client’s progress and readiness to proceed 

• Ask client how he or she feels about continuing therapy 

• Address client comments and questions about session 1 handouts 

• Review the client’s Quit Agreement 

2. Welcome supporter 

• Stress importance of supporter’s participation 

• Provide basic information about intervention 

• Answer questions 

3. Examine client’s recent experiences 

• Did client make an effort to stop? Cut down? 

• Did he or she experience any high-risk or tempting situations? 

• Did the client use any strategies from Learning New Coping Strategies? 

• Were the strategies successful? 

4. Examine client’s experience with supportive and nonsupportive relationships 

5. Discuss ambivalence 

6. Establish a change plan 

• Suggest interim goals if client is not ready for abstinence 

• Encourage client to set general and specific goals 

7. Involve supporter and review Supporter Strategies and Supporter Agreement 

• Elicit supporter’s concerns and hopes for the client 

• Give supporter Supporter Strategies (form 2A) 

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Section V. Enhancing Motivation 

• Complete Supporter Agreement (form 2B) 

• Review Supporter Agreement 

• Help client and supporter decide which items they can agree to 

• Review Supporter Agreement with client, even if no supporter attends, and role play 

asking for support 

8. Assign between-session exercises 

9. Review and conclude session 

Session 2 Protocol 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor helps the client develop a change plan and obtain support from an important person in 

the client’s life. 

Assess Client’s Progress and Readiness To Proceed 

The counselor asks the client how he or she feels about the two previous counseling sessions and 

responds empathically to his or her concerns. The counselor addresses any client comments or 

questions that have arisen since the previous session about the PFR (form AS8), Learning New Coping 

Strategies (form 1A), or the Quit Agreement (form 1C). The counselor reviews the Quit Agreement with 

the client and discusses adjustments (e.g., Is the client setting unrealistically high standards that may 

set him or her up for failure? Has the client identified salient reasons for wanting to make changes in 

marijuana use?). The counselor photocopies the agreement to maintain a record of client goals. 

Welcome Supporter 

If the client has brought a supporter, the counselor welcomes him or her and thanks the individual 

for his or her willingness to participate. The counselor provides general information about the 

intervention and asks whether the supporter has questions. 

In the course of the session, the counselor 

•	 Provides the supporter with information and answers his or her questions about the
 

treatment
 

•	 Fosters motivation by encouraging the supporter and client to discuss the effect of the 

client’s marijuana use on their relationship 

•	 Formulates a change plan 

•	 Identifies how the supporter can help the client with treatment goals and abstinence. 

The counselor emphasizes the importance of the supporter’s participation and indicates that in a 

few minutes the counselor will want to hear more from the supporter but that first the counselor 

will talk with the client about what has been happening recently: 

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Brief Counseling for Marijuana Dependence 

Counselor (C): I want to thank you both for coming today. Shirley has told me how much help 

you’ve been to her. We’ll meet for about an hour today to discuss your role as a 

supporter for Shirley. Does either of you have any questions? 

Husband (H): I want you to know how proud of her I am; I’m willing to do whatever I can to 

help her out. 

C:	 That’s very encouraging to hear. Before we begin, I’d like to take a few minutes to ask 

Shirley how things have been going since we last met. 

Examine Client’s Recent Experiences 

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

•	 Did the client stop use since the previous session? 

•	 Did the client make an effort to stop? 

•	 Was the client confronted with any high-risk or tempting situations? 

•	 What strategies did the client use? Did the client try any of the strategies in Learning 

New Coping Strategies (form 1A)? Were they successful? 

•	 Were there any instances when the client effectively handled a “hot” situation (i.e., 

very high risk)? 

The counselor acknowledges client efficacy and reinforces the strategies that the client found 

useful. The client’s report on the week’s events provides the counselor with an opportunity to 

use motivational interviewing techniques. As the client talks, the counselor’s objective is to 

elicit information and to use that information to provide reflections, express empathy, identify 

discrepancies, elicit self-motivational statements, and roll with resistance: 

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

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

S:	 Right after the last session I kept thinking about how pot has kept me from doing the 

things I want to do. I really want to be a teacher, and I realized that as long as I kept 

smoking, I would always feel bad. So I went home and smoked one last time, then 

flushed the remainder of my stash down the toilet! During the last week I’ve wanted to 

get high several times, but I didn’t. 

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

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

Examine Client’s Experience With Supportive and Nonsupportive Relationships 

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

C:	 Talking to someone else helped. 

S:	 Yes, it did. And I kept cards and notes from my students in my purse and would take 

them out and look at them. Boy, I love those kids! 

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

S:	 You bet! 

80 
Section V. Enhancing Motivation 

or 

Doug (D): My wife chose not to come today. She says this is my problem, and I need to solve it 

or find a new wife. After all these years of me smoking around her, now she wants 

immediate change and doesn’t want to help me! 

C: As you work on making changes, you may not have the support you would like. How are 

things different since we met last? 

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

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

D: I didn’t take pot to work 2 days last week, so I couldn’t smoke. It wasn’t that bad. If I 

didn’t have it in my car, I didn’t leave work on an “errand” to smoke. 

C: You found that you could make changes if you didn’t have marijuana in easy reach, and it 

may have been easier than you thought it might be. Did other things help? 

Discuss Ambivalence 

The client may be reluctant to disclose ambivalence for fear of disapproval. However, strong 

ambivalence may be manifested in nonverbal behavior and possibly in an impaired therapeutic 

alliance (e.g., missed sessions, reluctance to establish treatment goals). The counselor needs to 

be vigilant about maintaining the client’s level of motivation for change and engagement 

in treatment. 

Establish a Change Plan 

The counselor helps the client establish a long-term plan for behavior change, focusing particularly 

on the next 12 months. The counselor summarizes indications of motivation that the client has 

made. If the client has given no indications of a desire to change, he or she may not be ready to 

commit to change, and the counselor points this out. 

The counselor explains that articulating goals increases the likelihood that the counseling will be 

meaningful and useful. For clients whose goal is immediate and permanent abstinence, 

articulating goals is straightforward. However, many clients are not at this stage of change early in 

treatment. If clients say they are not ready to give up marijuana, the counselor suggests setting 

other interim goals such as learning more about the skills that will help them quit or reduce 

marijuana use in the future. Goals may be general, such as quitting marijuana use within the next 

2 weeks or reducing marijuana use to no more than four joints per week. Other goals may be 

more specific. For example, the client may set goals of figuring out how to stay away from 

substance use opportunities, identifying ways to get past cravings, learning new social skills, and 

participating in activities that are incompatible with marijuana use. Although the program’s goal is 

to help clients achieve abstinence, the counselor needs to meet the clients where they are to 

avoid alienating them and to keep the door open for improvement and possible future abstinence. 

Involve Supporter and Review Supporter Strategies and Supporter Agreement 

If a supporter is attending this session, the counselor shifts the focus of the session to the 

relationship between the client and supporter. The counselor asks the supporter why he or she 

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Brief Counseling for Marijuana Dependence 

wants to participate, eliciting the supporter’s concerns and hopes for the client. The counselor 

gives the supporter Supporter Strategies (form 2A) and reviews its contents. 

The counselor introduces the Supporter Agreement (form 2B), and the client and supporter read 

the list to determine which items they will agree to: 

C: We have a list of ideas and strategies that have been helpful for some people. Let’s see 

whether any of these could work for you two. [To husband] As we begin to look at ways 

that you and your wife can work together on this change, what concerns do you have? 

H: Shirley has a habit of getting excited about something and then giving up when things get 

tough. I want to help, but I’m not going to nag her. This is something she’s going to do, 

not me. I’ll help, but I won’t push her. 

C: You recognize that Shirley needs to make her own decisions, and you don’t want to be a 

policeman, is that right? 

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

C: It sounds as if you have some ideas of what you would be willing to do. I’ve given the two 

of you a Supporter Agreement. We’ve listed some ways that Shirley might reach her goals. 

As we look at these together, I’d like you to identify some things you might be willing to 

do. How does that sound? 

Even if the client has not brought a supporter to the session, the counselor reviews the Supporter 

Agreement. The client may choose to identify a supporter later. The counselor and client can role 

play ways of asking for support. 

Assign Between-Session Exercises 

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

week’s session. 

Review and Conclude Session 

The counselor reviews the content of the session, asks the client for feedback, responds 

empathically to his or her comments, and troubleshoots any difficulties. The counselor should also 

discuss with the client the likely scenarios for future treatment sessions. For example: 

C:	 When we meet next time, we’re going to shift gears somewhat. I’m going to talk with you 

about other areas of your life besides your marijuana use—areas in which you may be 

experiencing difficulty. These problems may be directly related to your marijuana use, but 

not necessarily. We’re going to work on these other areas of life because doing so may 

help you be successful in your goal to stop using marijuana. 

Forms for Sessions 1 and 2 

During the enhancing motivation sessions, the counselor and client review or complete five forms. 

These forms are provided on the remaining pages of this section. 

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Form 1A 

Learning New Coping Strategies 

Some Alternatives to Marijuana Use 

You can do many things to stop using marijuana. Some may work better than others. Some help you 

resist the urge to smoke or avoid tempting situations or satisfy your needs in more constructive ways 

than smoking marijuana. Expect to try several and add any that may be helpful. Think about what 

worked when you gave up marijuana before or when you made other changes in your life. 

Be kind to yourself as you begin this change process—you’re doing something to take care of 

yourself, and you deserve all the comfort and self-acceptance you can get! Remind yourself that 

learning and changing inevitably mean giving up old ways and that, in time, you will feel more 

comfortable. Remember the changes your body and mind went through when you learned to drive, 

got to know a new person, started a new job, or learned a new skill. Chances are you felt 

awkward, uncomfortable, silly, dumb, scared, frustrated, impatient, or anxious, in addition to 

hopeful, excited, and challenged. What helped you then? How long did it take you to feel relaxed? 

Did you learn all at once, or were improvement and progress gradual? 

Actions 

Avoid or escape from situations that make you want to smoke marijuana. Sometimes this is the 

easiest and most effective way to resist temptation, especially at the beginning. 

Delay decisions to give in to temptation; for example, you could wait 15 minutes. Take several 

deep breaths. Focus on the fresh air entering your lungs, cleansing and nourishing your body. Let 

out tension with each exhalation. 

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

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

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

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

Thoughts 

Self-talk. Give yourself a pep talk; remind yourself of your reasons for quitting; remind yourself of 

the consequences of using marijuana; challenge any wavering in your commitment to quit. 

Imagery and visualization. Visualize yourself as a nonsmoker, happy, healthy, and in control; 

imagine your lungs getting pink and healthy; or focus on negative imagery and imagine yourself 

with cancer, emphysema, unable to breathe, needing constant care. Visualize yourself in a jail 

made of marijuana cigarettes symbolizing the way marijuana controls your life. 

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

1 of 3
 
Form 1A 

Learning New Coping Strategies (continued) 

Distraction. Focus on something different: the task at hand, a daydream, a fantasy, counting 

backwards from 150 by 3s. 

Lifestyle 

Exercise or take a brisk daily walk. Get your body used to moving; use stairs instead of elevators;
 

park farther away from your destination; walk instead of drive.
 

Practice relaxation or meditation techniques regularly.
 

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

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

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

Change routines associated with smoking marijuana, at least temporarily; for example, don’t turn
 

on the TV when you get home from work; don’t spend time with friends who smoke.
 

Social Interactions and Environment 

Remove smoking paraphernalia (pipes, papers, bongs, ashtrays, matches, lighters, marijuana) 

from your home and car. 

Go to places where it’s difficult to get high, such as a library, theater, swimming pool, sauna, 

steam bath, restaurant, and public gatherings (not rock concerts). 

Spend time with friends who don’t smoke. Enlist support from family and friends. Announce that 

you’ve quit; ask people not to offer you pot, to praise you for stopping, to provide emotional 

support, and not to smoke around you. 

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

Specific Suggestions for Some Common High-Risk Situations 

Below are several high-risk situations that people who use marijuana confront, along with 

suggestions for coping without smoking. 

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

Develop relaxation techniques, exercise, write down your feelings or talk to a friend or counselor, 

do something enjoyable that requires little effort, figure out what you’re feeling and whether you 

can do anything about it. 

2 of 3
 
Form 1A 

Learning New Coping Strategies (continued) 

Anger, Frustration, and Interpersonal Conflict 

Try to handle the situation directly rather than hide your feelings; if appropriate, be assertive; get 

some release by squeezing a rubber ball, pounding a pillow, or doing some physical activity; write 

down your feelings or tell them to someone; take deep breaths. 

Fatigue and Low Energy 

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

Insomnia 

Don’t fight being unable to sleep. Get up and do something constructive or relaxing. Read a book, 

watch TV, or do muscle relaxations until you feel sleepy. Remember that no one dies from losing a 

night’s sleep. 

Timeout 

Read, do a crossword puzzle, prepare a healthy snack, take up a hobby, knit or do other 

needlework (things you can carry with you for easy access). 

Self-Image 

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

Social Pressure 

Be aware when others are smoking. Remember your commitment not to smoke marijuana. Be 

assertive and request that people not offer you pot. If appropriate, ask that they not smoke 

around you for a while. If necessary, be prepared to leave the situation, especially when you’ve 

recently quit. 

Situations Involving Alcohol 

After you’ve quit marijuana, you may continue to associate drinking with smoking pot. Alcohol can 

make you less vigilant about resisting marijuana. It tends to make people less concerned about 

long-term consequences. You might consider not drinking or cutting down during the first few 

weeks after quitting. If you don’t want to do this, be especially careful when you drink. 

Cravings and Urges 

The only way to interrupt cravings is to break the chain of responding to them. That is, don’t give 

in. Eventually they will decrease. Do something to distract yourself; use the techniques listed 

under Thoughts; breathe deeply; call a friend; go for a walk; move around; time the urge, and 

you’ll find that it will disappear like a wave breaking. 

3 of 3 
Form 1B 

A Guide to Quitting Marijuana1 

About Marijuana and How It Affects the Body 

Cannabis is the general name given to a variety of preparations derived from the plant Cannabis 

sativa. The main psychoactive ingredient in cannabis is delta-9-tetrahydrocannabinol or THC. Some 

400 other chemicals also are in the cannabis plant. 

When a person smokes marijuana, THC enters the bloodstream through the walls of the lungs and 

is taken to the brain. THC is stored in fatty tissues and can be detected in urine for days, weeks, 

or sometimes months. The effects of marijuana depend on the person, the environment, the 

potency of the drug, and how long the person has been using the drug. It is possible to become 

addicted to marijuana and feel dependent on it to get through the day. Each year thousands of 

people seek help to stop using marijuana. 

Why Do You Smoke Marijuana? 

You may have many reasons for smoking marijuana: to relax, to help you sleep, to calm down. 

However, meditation or exercise often can accomplish these same results. You may smoke to 

improve social interactions, but many find that after years of smoking, relationships and social life 

in general have deteriorated. Or you may smoke to avoid life’s problems. However, the problems 

don’t go away by themselves. 

Below, identify your specific reasons for smoking. 

Why I Use Marijuana 

1. _________________________________________________________________________________ 

2. _________________________________________________________________________________ 

3. _________________________________________________________________________________ 

Why Do You Want To Give Up Marijuana? 

Researchers, health professionals, and people who smoke marijuana have identified health, social, 

legal, and financial reasons to quit. 

Health Risks 

•	 Respiratory diseases such as chronic bronchitis. 

•	 Changes to cells in the body that may signal the development of cancer. Marijuana smoke 

contains substantially higher levels of cancer-causing chemicals than does tobacco smoke. 

1Adapted from Grenyer et al. 1995. 

1 of 6
 
Form 1B 

A Guide to Quitting Marijuana (continued) 

•	 Problems with attention, concentration, and memory that get worse with continued use of 

marijuana and only partially improve after quitting. 

•	 An increased risk of developing cancers in the mouth, throat, and lungs. 

•	 An increased risk of birth defects or leukemia in children exposed to marijuana during 

pregnancy. Using marijuana also may disrupt sperm production and ovulation. 

•	 Poor educational achievement and difficulties in learning. 

•	 An increase in symptoms for people who suffer from heart disease, asthma, bronchitis, 

emphysema, or schizophrenia. 

Identify the health risks that concern you the most. 

Health Fears 

1. _________________________________________________________________________________ 

2. _________________________________________________________________________________ 

3. _________________________________________________________________________________ 

Social Reasons for Quitting 

Some people give up marijuana because they are tired of their lifestyle and feel they are 

stagnating. Are you 

•	 Worried that your social life is restricted to people who smoke dope? 

•	 Feeling low and avoiding people? 

•	 Worried that some relationships are not going well? 

•	 Arguing with your partner? 

•	 Aware of your partner’s concerns about your smoking? 

•	 Worried about smoking around children? 

Many people use marijuana to avoid problems. Often their problems just continue to get worse. 

Your decision to quit might make some problems seem worse in the short term, but you will feel 

much better in the long run. You will be able to handle problems better, and the problems caused 

by your smoking will diminish. Remember: No pain, no gain. 

2 of 6
 
Form 1B 

A Guide to Quitting Marijuana (continued) 

Financial Costs 

Are you concerned about the amount of money you spend on marijuana? In the blanks below, fill 

in how much you spend on marijuana, and calculate what getting stoned costs you per year. 

$_____________ per week x 52 or $_____________ per month x 12 

TOTAL COST PER YEAR $_____________ 

You might want to include the costs of tobacco, papers, bongs, and munchies as well as days off 

work. It all adds up. 

Other Reasons for Quitting 

What about other hassles? Do you 

• Feel addicted to marijuana or unable to control your marijuana use? 

• Feel anxious and paranoid? 

• Feel as if your thoughts are racing except when you’re stoned? 

• Have trouble sleeping? 

• Feel you are not doing your job properly? 

• Drive when stoned? 

• Waste time trying to get marijuana? 

• Risk getting arrested for growing your own marijuana? 

• Worry about getting arrested for possession? 

• Have arrests, fines, court hearings, a criminal record, or other legal issues to address? 

• Fear going to jail? 

How Do You Give Up Marijuana? 

If you are serious about quitting, the best way is to stop “cold turkey.” You might be surprised that 

it’s easier than you think. Soon after quitting, you’ll find that your thinking becomes clearer. 

To quit using marijuana, you have to confront your desire to get stoned. You will be going into 

battle against a part of yourself that you no longer wish to exist. Giving up marijuana, especially if 

you’ve been using for some time, is a bit like losing an old friend. Quitting may feel like a funeral, 

but it is also the beginning of a new life. 

Think of quitting as a positive step. You must be well prepared and have a plan worked out in 

advance. If you follow the suggestions in this guide, you will find it easier to achieve your goal. If 

you are serious about stopping, it is time to decide when you are going to quit. Review the Quit 

Agreement (form 1C). 

3 of 6 
Form 1B 

A Guide to Quitting Marijuana (continued) 

The Decision 

Designate a day as Quit Day. Remember that the decision is yours, and the commitment you 

make to quit marijuana use is with yourself. Sign and date a contract with yourself now. You might 

want to consider making other changes at this time, such as quitting cigarettes as well. 

Quit Strategies 

The following strategies may prove useful in quitting: 

• Set a date, and stick to it. 

• Replace marijuana use with new activities and interests. 

• Avoid situations where you used to get stoned. 

• Ask a friend for support. You do not have to go it alone. 

• Say to others, “I don’t get stoned anymore.” 

Identify several strategies that will help you quit, and write them down. 

Three Things I Can Do To Give Up Marijuana 

1. _______________________________________________________________________________ 

2. _______________________________________________________________________________ 

3. _______________________________________________________________________________ 

Changing Old Habits 

When you used marijuana, you established a link between the situation in which you used and 

getting stoned. Certain situations, people, and places that you subconsciously associated with 

smoking may trigger a desire to use. Below list the places where you usually used, other persons 

present, and your mood just before using. A final item to include is a substitute for the situation. 

Where With Whom Mood Substitute 

Living room Alone Down Go for a walk 

4 of 6
 
Form 1B 

A Guide to Quitting Marijuana (continued) 

Check Your Feelings 

When you give up using, and for a week or more after, you may feel out of sorts. Several 

“withdrawal symptoms” are caused by stopping use of marijuana. You might experience 

• Anxiety • Moodiness 

• Irritability • Tremors 

• Sweating • Nausea. 

• Sleep disturbances 

These experiences are normal. Your body is flushing out the toxins from the marijuana. Take it 

easy; stay with your determination to quit. These feelings and problems will go away soon. 

How Do You Stay Off? 

When you have taken the initial steps to quit, you will experience times when you want to break 

your contract. Resuming old habits is one reason people fail. Alter your lifestyle to accommodate 

the new you without marijuana. Reread and use the strategies listed on Learning New Coping 

Strategies (form 1A). Write those that will be most helpful in the spaces below. 

Strategies I Can Use To Stay Off Marijuana 

1.________________________________________________________________________________ 

2.________________________________________________________________________________ 

3._________________________________________________________________________________ 

Lapses 

Sometimes you will be unable to fight the urge to use. If you slip, try not to think of it as a failure. 

Think of it as a lapse in concentration, and renew your commitment to quit. Remind yourself that 

you are capable of not smoking. 

Reward Yourself 

Now that you have given up marijuana, reward yourself in new ways. Give yourself a gift at the end 

of each week that you fulfill your contract. Try to match the cost of the gift with the average 

weekly cost of getting stoned. You may like to keep a record of this. 

5 of 6
 
Form 1B 

A Guide to Quitting Marijuana (continued) 

Week Gift Cost 

Week Movie and dinner for two $80 

6 of 6
 
______ _____________________ _____________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Form 1C 

Quit Agreement 

I, _______________________________, am quitting marijuana because (fill in reasons for quitting) 

As of ________________________________, I intend to stop smoking marijuana and to refrain 

from use in the future by (fill in strategies to be used) 

Signatures:

Supporter Participant 

1 of 1
 
Form 2A 

Supporter Strategies2 

Maintaining Motivation 

Help your partner or friend maintain motivation by keeping it from lagging in the first place. Don’t 

wait for a problem to arise. Let him or her know how impressed you are with his or her success in 

quitting marijuana. Tell him or her that you know the change requires much effort and that you can 

see the benefits of the change. Don’t assume the journey away from marijuana is over when he or 

she has been abstinent for 2 or 3 months. 

If you see signs of motivation dwindling, such as your partner’s or friend’s starting to talk about 

using marijuana or wanting to visit friends who still use, ask him or her how he or she is feeling 

about marijuana use. Don’t assume that his or her motivation is decreasing until you’ve talked 

about it. Bring up the topic in a noncritical way; perhaps start with a compliment about his or her 

success. Then ask about his or her motivation for staying away from marijuana. 

If you see that motivation is on the wane, offer to help get it back. Review the list of reasons for 

quitting or the Quit Agreement together. Ask whether he or she is feeling deprived and needs some 

help finding fun things to do. 

Don’t be critical. Motivation is difficult to maintain. Your partner or friend needs support and 

encouragement to increase motivation. Criticizing his or her lack of willpower or threatening with 

ultimatums can provoke a negative mood and lower self-esteem. 

Lifestyle Changes 

Help your partner or friend make the lifestyle changes that will keep him or her from needing pot. 

Talk about your observations of his or her lifestyle. Can stress be reduced? What activities can he 

or she do at those times of the day when he or she might be tempted to use? Can you do any of 

them together, such as an exercise program? It reduces stress, clears out the lungs, and can be 

rewarding in many ways. 

Having a positive, supportive conversation regularly is important. Lifestyles need to be watched so 

that people don’t slip into old ruts. Talking about the upcoming week and discussing how to build 

some fun time into it can become a weekly activity. 

High-Risk Situations 

Help your partner or friend plan for and cope with high-risk situations regularly at least during the 

first year. After a while, coping with the old week-to-week situations that promote use will become 

automatic. However, you still need to be on guard for those unexpected or unusual situations for 

which a coping strategy hasn’t been planned or practiced. Examples might include an upcoming 

vacation, a visit with old friends, unemployment, or an argument with someone. If you see 

something coming up that’s likely to pose a risk for marijuana use, alert your partner or friend. 

Then help plan for coping with the situation if it should occur. 

2Source: Stephens et al. 2000. 

1 of 2
 
Form 2A 

Supporter Strategies (continued) 

If an event occurs without a chance to plan for it, you can go straight to a coping mode, distract 

your partner or friend or offer support depending on the situation. You don’t have to point out that 

you’re doing it to prevent a return to pot smoking unless you think that would be helpful. 

Coping With a Slip 

Chances are a slip will happen. A slip is marijuana use that occurs after a period of abstinence. A 

slip doesn’t mean a person will return to regular marijuana use. That would be a relapse. Slips 

occur when motivation is lagging or when a high-risk situation occurs unexpectedly. Slips do not 

mean that all the success and progress to date have been lost. How your partner or friend 

responds to a slip can mean the difference between returning to abstinence or going into a 

relapse. Here are some things to do if a slip occurs: 

•	 Ask your partner or friend how the slip came about. Did he or she see it coming or was 

it a sudden urge related to a situation? What was the situation? How was your friend feeling 

before smoking? Was he or she feeling down or angry or bored or wanting to celebrate? 

•	 Ask about any attempts at avoiding the situation or coping strategies used in the 

situation. If he or she anticipated the situation and made little effort to avoid or cope with 

it, a motivation problem probably exists. Refer to the ideas in the section above on 

maintaining motivation. 

•	 Ask whether any clues could have warned of a difficult situation. If the urge to use 

came up suddenly or the coping strategies used simply weren’t effective, help your friend 

learn from this slip to prevent more slips in the future. Help him or her find new coping 

strategies to use in the future. Suggest other ways of coping. 

•	 Help your partner or friend regain motivation and learn from what happened. Come 

from a position of support and encouragement. If your friend says things like, “I guess I 

just can’t quit” or “Smoking pot’s not really that bad,” then challenge these statements. 

You know neither is true. 

Your goal is to get your partner or friend back on track, not to punish him or her for slipping. 

Attack the rationalization (I’m only going to smoke this one time) not the person. Say that those 

statements are rationalizations, they’re a symptom of losing motivation, and it’s time to focus on 

getting motivation back. Don’t put the person down, criticize his or her willpower, or say the 

situation is hopeless. Making the person feel bad is likely to promote a return to marijuana use. 

When you show the person how his or her actions are a sign of losing motivation and show how to 

get that motivation back, you can help a slip stay merely a slip. 

Feeling Appreciated 

Does your partner or friend appreciate your efforts? Do you feel that you’re working harder at this 

than he or she is? If so, it’s time to talk to him or her about it. You won’t be any help if you are 

feeling burned out and unrewarded. 

Let your partner or friend know how you feel without accusing him or her of neglecting you. Point out 

that this would be a good time to renegotiate the Supporter Agreement. Start your conversation with 

the words “I feel,” not “You haven’t.” Make sure you ask for what you want—a little acknowledgment, 

a relaxing or fun evening, a chance to talk, or whatever you feel is a reward for your efforts. 

2 of 2
 
Form 2B 

Supporter Agreement3 

In this document, ___________________ will be referred to as the Supporter and 

___________________ will be referred to as the Participant. To maintain ___________________’s 

success in quitting marijuana, we agree to the following arrangements. 

Types of Support. Supporter and Participant initial all conditions that apply 

to the agreement. 

Initials 

___ ___ Supporter will let Participant know how pleased he or she is with the Participant’s 

success at not using marijuana. 

___ ___ Supporter will ask Participant about his or her motivation for remaining abstinent from 

marijuana if Supporter notices that motivation may be decreasing. 

___ ___ Participant will let Supporter know that he or she appreciates the support received. 

___ ___ Supporter will remind Participant of his or her reasons for quitting marijuana and of the 

consequences that marijuana caused, if motivation seems to lag. 

___ ___ Participant will review the Reasons for Quitting Questionnaire or the Quit Agreement with 

the Supporter if they agree that motivation needs a boost. 

___ ___ Supporter will discuss and participate with Participant in lifestyle changes that will reduce 

the need for marijuana. 

___ ___ Supporter will ask Participant about upcoming high-risk situations that Supporter 

anticipates but is not sure whether the Participant anticipates. In addition, Supporter will 

help Participant plan to cope with high-risk situations. 

___ ___ Supporter will help Participant cope with a marijuana use slip and return to abstinence by 

asking about Participant’s motivation and the circumstances of the slip. 

___ ___ Supporter will help restore motivation and develop a coping plan for future situations that 

led to the slip. 

___ ___ Participant will negotiate rewards for Supporter’s continued support and involvement. 

___ ___ Supporter will avoid being critical of Participant in communicating concerns about 

motivation, high-risk situations, and slips. Supporter will focus on questioning 

Participant’s motives and coping plans and on challenging rationalizations for using. 

___ ___ Participant will listen to what Supporter has to say about observations of lagging 

motivation, upcoming high-risk situations, or rationalizations for using marijuana. 

___ ___ Supporter may express disappointment if Participant fails to accept Supporter’s input. 

___ ___ Participant will suggest another time (within 24 hours) to discuss Supporter’s 

observations or concerns if Participant’s current mood or situation does not allow him or 

her to be open to Supporter’s comments at the moment. 

3Source: Stephens et al. 2000. 

1 of 2
 
Form 2B 

Supporter Agreement (continued) 

Specific Conditions or Support Agreements. List additional conditions. 

___ ___ ___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

___ ___ ___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

___ ___ ___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

Signatures: ________________________ __________________________ 

Supporter Participant 

2 of 2
 
SECTION VI. 

CHANGING MARIJUANA USE THROUGH SKILL BUILDING: 

SESSIONS 3 THROUGH 9 

In sessions 3 through 9, the counselor builds on the client’s motivation by encouraging the use of 

specific strategies and skills for accomplishing treatment goals. The counselor offers tools to 

enhance the client’s motivation to change. This approach is based on cognitive behavioral therapy 

(CBT) models for substance abuse treatment, with an emphasis on relapse prevention. The Center 

for Substance Abuse Treatment’s (CSAT’s) Treatment Improvement Protocol (TIP) 34, Brief 

Interventions and Brief Therapies for Substance Abuse (CSAT 1999a), as well as the KAP Keys 

(CSAT 2001a) and the Quick Guide (CSAT 2001b) that accompany TIP 34, provides background 

material on this approach. The CBT sessions follow the approach of Monti and colleagues (1989). 

Why Focus on Skills? 

Motivation Leads to Skills Development 

Once the individual commits to changing his or her behavior, Brief Marijuana Dependence 

Counseling (BMDC) focuses on building and strengthening skills for becoming and remaining 

abstinent. The client’s motivation and commitment may vary during treatment, but the 

motivational enhancement therapy (MET) strategies remain integral to treatment. 

The counselor begins by reexploring the client’s commitment to abstinence and using MET 

strategies (e.g., rolling with resistance, identifying discrepancies) when the client’s motivation 

wavers. In these sessions, the counselor and client work on developing specific skills (e.g., 

refusing offers, coping with cravings). This approach is usually slower and somewhat less 

structured than other CBT approaches, but many individuals who are marijuana dependent find 

this helpful. 

Focusing on the Skills Taught 

After completing the engagement, rapport-building, and goal-setting tasks during the early 

sessions, the client prepares to learn new skills, begins to eliminate problems associated with 

marijuana use, and addresses other life concerns. During this phase, the counselor coaches the 

client to develop supportive social connections and establish links with resources to address 

family, mental, and employment problems. The counselor adjusts the focus, the content of skill 

topics, and the general approach to meet the client’s needs and provides structure and guidance. 

These sessions typically have a more didactic tone than the earlier sections, which are strictly 

MET. However, these sessions should not be delivered as lectures; the counselor maintains a 

balance between guiding and teaching, on the one hand, and the client-centered focus of the 

treatment, on the other. 

97
 
Brief Counseling for Marijuana Dependence 

What Is Cognitive Behavioral Counseling? 

A CBT social learning model focuses on teaching interpersonal and self-management skills (CSAT 

1999a). CBT is a skill-building rather than a deficit-oriented approach. Marijuana dependence is 

considered a learned behavior that developed in response to external (e.g., environmental, 

relational) and internal (e.g., feelings, thoughts) conditions. A CBT perspective suggests that the 

addictive behavior has become a favored strategy because of its repeated associations with 

predictable outcomes. For example, someone uses marijuana when he or she is sad, angry, lonely, 

or upset; he or she feels less bad when smoking and associates marijuana use with feeling better 

(at least in the short term). Over time, marijuana may be selected more often as a strategy to 

escape negative feelings or thoughts. 

CBT views compulsive or addictive behaviors and certain negative moods as learned and not the 

result of a character defect. Because these behaviors are learned, they can be unlearned. The 

unlearning occurs through learning new skills and enhancing the client’s capabilities. 

The client develops skills to identify and cope with high-risk internal states and external situations 

that increase the likelihood of a slip. The counselor assigns the client homework to practice using 

the new skills. The client’s participation and the counselor’s positive feedback enhance client 

confidence in managing situations and create long-lasting behavior change. 

This perspective of addiction as learned is therapeutic because it 

•	 Reduces blame and criticism 

•	 Fosters hope and optimism 

•	 Identifies development and improvement processes. 

CBT differs from other models of treatment because it 

•	 Addresses interpretations of events as important cues for compulsive behavior 

•	 Provides structure (every week the counselor devotes a specific amount of time at a 

specific time in the session to a particular activity) 

•	 Informs and teaches (but is still collaborative). 

Integrating MET and CBT 

Counselors in the Marijuana Treatment Project (MTP) integrated motivational interviewing skills and 

techniques (Stephens et al. 2002) as they moved toward building skills and changing cognitions 

and behavior. Rather than using a traditional cognitive behavioral style of Socratic questioning and 

didactic teaching, the MTP MET/CBT approach used open-ended questions, gradual presentation 

of skills, frequent assessment of the client’s wish to hear more about a particular skill or concept, 

and give-and-take in the didactic portion of the sessions. Counselors frequently assessed the 

client’s level of motivation, renegotiating goals and repeating issues when necessary. 

98 
Section VI. Changing Marijuana Use 

The CBT component of BMDC comprises six core elements and four elective skill topics (see 

exhibit I-2). The sequence of the sessions should be in an order that works best for the counselor 

and client. The six core skill topics represent the fundamental building blocks for CBT and are 

recommended for most clients entering treatment. To meet a particular client’s needs, a different 

group of skill topics may be chosen. For example, a client who has experience in similar 

interventions (e.g., relapse prevention) may not require a review of all the core skill topics. The 

counselor can select some core skills and add relevant elective materials in developing the 

session sequence for the client. Another client may have concerns about depression or difficulty 

regulating moods. The counselor can substitute the elective skill topic on depression in place of a 

core skill. The counselor and client determine whether and how much the treatment deviates from 

the established method (10 sessions including 1 assessment, 2 MET, 6 core CBT, and 1 elective). 

Tips for the Counselor 

•	 Review relevant sections of the manual before each session. 

•	 Develop a natural style of conveying the material; avoid reading text to clients. 

•	 Maintain a motivational style; use open-ended questions and reflections; and avoid a 

directive, resistance-building style. 

•	 Encourage involvement and participation by the client. 

•	 Allow time for role plays and feedback. 

•	 Build self-efficacy; help the client identify and acknowledge skills already in use. 

•	 Avoid overwhelming the client; present only one or two new skills per session. 

•	 Remember to take a few minutes to review the between-session exercises at the start of 

each session. 

•	 Attend to shifts in the client’s motivation and readiness for change. 

•	 Explain practice exercises carefully; probe for the client’s understanding. 

99 
Brief Counseling for Marijuana Dependence 

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

Total Time: 1 hour 

Delivery Method: CBT-focused individual therapy 

Materials (all forms are at the end of this section): 

•	 Problem Checklist (form 3A) 

•	 Support Plan (form 3B) 

•	 Community resource directory (compiled by the program, this should include 

information on community agencies that the client can access to address concerns 

listed on the Problem Checklist) 

Goal for This Session: 

•	 To begin to address the client’s non–substance-related problems that can pose
 

obstacles to abstaining from marijuana
 

Session Outline: 

1.	 Determine whether and when to use psychosocial problemsolving 

2.	 Use the Problem Checklist (form 3A) to identify and prioritize psychosocial problems 

other than substance use 

• Consider information gathered during the assessment 

• Encourage client to be specific about psychosocial problems 

• Have client evaluate the severity of each problem in relation to remaining abstinent 

• Help the client prioritize problems 

3.	 Identify goals and resources 

4.	 Develop a Support Plan (form 3B) 

5.	 Discuss implementation issues 

• Use motivational strategies when client demonstrates ambivalence 

• Convey confidence in the client’s ability to carry out the Support Plan 

• Explore the relationship between the client’s psychosocial problems and his or her 

marijuana use 

• Engage in role plays 

6.	 Help the client identify others who can help with the Support Plan 

7.	 Assign between-session exercise 

8.	 Plan to monitor progress 

9.	 Review and conclude session 

100 
Section VI. Changing Marijuana Use 

Session 3 Protocol 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor uses problemsolving and motivational strategies to teach the client how to use the 

social service system independently. The counselor helps the client identify problem areas and 

develop plans to address them. The client builds self-efficacy in recognizing problems and using 

the social service agencies. The case management model is based on the general model of 

problemsolving described by D’Zurilla and Goldfried (1971). CSAT’s TIP 27, Comprehensive Case 

Management for Substance Abuse Treatment (CSAT 1998), provides more information on the 

case management process. 

Determine Whether and When To Use Psychosocial Problemsolving 

Clients who present for marijuana-dependence treatment often experience problems in other 

areas. They may be depressed or anxious. They may have lost their jobs or feel they are not doing 

work they enjoy. They may have health or relationship worries. These difficulties may be related to 

their long-term marijuana use or may be co-occurring mental disorders. 

Although most clients indicate concerns about other life areas, not all want to focus on these 

problems during treatment. The counselor asks generally about the client’s life problems. The 

counselor and the client decide whether and how much to focus on these other problems, 

depending on their severity and the degree to which the client wants help with them. If no further 

attention is warranted, the counselor proceeds to another skill topic. However, the client who 

indicates significant concerns or who wants help with a non–substance-related problem may 

benefit from one or more problemsolving sessions. 

Use the Problem Checklist To Identify and Prioritize Psychosocial Problems Other 

Than Substance Use 

Problems unrelated to marijuana use that may be a hindrance to the client’s abstinence efforts 

include 

• Lack of housing or financial support 

• Unemployment 

• Chronic or acute medical conditions 

• Legal problems 

• Family or parental pressures 

• Social isolation 

• Need for transportation and child care. 

By reviewing the client’s intake or initial session assessments, including the measures of 

motivation and marijuana-related problems identified on the Personal Feedback Report (PFR) 

(form AS8), the counselor develops a sense of the type and severity of the client’s psychosocial 

problems. Careful assessment requires extensive input from and collaboration with the client. 

101 
Brief Counseling for Marijuana Dependence 

The counselor and client use the Problem Checklist (form 3A) to prioritize problems. The counselor 

asks the client about each category, encouraging the client to identify each problem as specifically 

as possible (I need a job paying at least $9 an hour rather than I have no money), the effect of 

the problem on the client’s abstinence from marijuana, and a realistic and concrete goal for the 

problem (I’ll be attending a trade course at the community college by the end of March rather 

than I’ll get a job next week): 

Counselor (C): You’ve said that although you’re not happy living at your brother’s, you recognize 

that it’s a stable place for you for now. However, you’d like to start saving some money for 

your own place. You mentioned that getting a job is a priority for you; it would keep you 

occupied and help you get your own apartment. That sounds like a good idea because you 

think you might use if you have nothing to do all day. How do you see it? 

Bob (B): That sounds right, but I don’t think I can get a job without a car or driver’s license. 

C: Transportation is another issue, and we should add it to our list. How have you been 

getting to our meetings? 

B: I get a ride from my sister-in-law on her way to work and take the bus home. 

C: That’s pretty resourceful; how did you set that up? 

B: I knew the bus lines because I used to work near here. 

C: It sounds as if you’re good at figuring out how to do what you need to do. As we begin to 

think through how you can reach your goal of getting a job, we’ll need to consider how 

you’ll get there. A lot of jobs and training programs are on bus lines, so it may not be 

difficult. What other difficulties can you foresee that might make it hard for you to reach 

your goals? You’ve told me you don’t have any medical or legal problems; are there any 

problems associated with your former marriage or your kids? 

B: No; I’d like to see the kids more, but that’s okay. I guess that’s all I can think of, for now. 

C: Do you think your relationship with your kids is connected with your marijuana use? 

B: I think I’d be a better dad and see them more often if I wasn’t smoking. 

C: So it sounds as if that’s an important goal for you and another reason for stopping. You 

may become aware of other problems as we go on; we can talk about them and how they 

may be associated with your marijuana use as they come up. 

or 

C: During your initial assessment, you noted housing, transportation, and a family medical 

concern as problems. 

Shirley (S): I’m concerned about my older sister. She has bipolar disorder and whenever she goes 

off her medication, my husband and I spend a couple of hundred dollars to get her back 

to a psychiatrist and on medication. We have only one car, so we argue about who will 

use it. Now that I’ve started student teaching, I need the car every day. It was difficult for 

me to get here today because my husband was late. 

C:	 As you think about these three areas, how would you prioritize them? Which seems more 

pressing for you? 

S:	 Right now transportation is a top priority, then my sister, and then a new house. We’re 

going to see whether I get a teaching job this fall before we start looking for a house. 

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C:	 Let’s start with transportation. What would you like to happen and when? 

S:	 We don’t have the money for a second car right now. 

Identify Goals and Resources 

The counselor and client specify goals for improving the client’s situation. The program’s 

community resource directory should describe services offered, eligibility, and contact personnel at 

community agencies. The directory should include information about housing assistance, 

vocational training, financial assistance, legal services, medical services, mental health services, 

parenting and childcare resources, support groups, homeless shelters, women’s shelters, 

emergency services, food assistance, education and training resources, unemployment 

counseling, rape crisis centers, and transportation resources. 

The counselor and client use the directory to identify relevant resources, determine whether the 

services offered match the client’s goals, and devise a plan for contacting the agency or service 

(e.g., who will do the contacting, what the specific goal of the contact is, when contact will be 

made). Because a major goal of this session is to build client self-efficacy in negotiating the social 

service system, the counselor encourages the client to contact the agency. If the client does not 

have the skills to make initial contacts effectively, the counselor and client role play a contact with 

an agency. If the agency requires that the counselor make the initial contact, he or she makes the 

call during the session to model effective negotiation skills. 

The counselor helps the client transform his or her goals into a plan for obtaining services, and 

together they plan the steps: 

C: So, although you have a problem, you’re not sure of possible solutions? 

S: The solution would be more money, and we don’t have that right now! 

C: Money would help. But did you know the county offers discounted bus fares for students? 

S: No; I was wondering about that because the bus runs right by my school. 

C: I have a book here with the phone number to call for information. Do you want to call? 

Develop a Support Plan 

Once the Problem Checklist is completed, goals have been developed, and the resource list has 

been reviewed, the counselor and client work on the Support Plan (form 3B)—a concrete strategy 

outlining how the client will follow through on reaching goals. For each goal, the Support Plan 

includes whom (or which agency) to contact, when to make the contact, what services or support 

to request, and what the outcome was. The Support Plan is a record of the client’s efforts to 

obtain services and bolsters his or her self-efficacy: 

S:	 I’d like to know how much the bus pass costs and what time the bus runs. I wouldn’t need 

it every day; maybe 2 or 3 days a week. Can we call now? 

C:	 Sure. Let’s write down on the Support Plan what you would like to see happen. First, we 

need to find out how much a bus pass costs with the student discount. Second, we need 

the bus route and schedule between your home and the school. We need to know whether 

the bus schedule fits with your school schedule. Here’s the phone. I’ll read you the number. 

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Discuss Implementation Issues 

The client may be ambivalent about addressing psychosocial problems that are barriers to 

abstinence. He or she may question whether he or she has the skills needed, wonder whether 

change may bring on new challenges, and question changing the status quo. The counselor 

remains alert to signs of client ambivalence. 

The stages-of-change model is applicable to acquiring psychosocial support (see sessions 1 and 

2). For example, some clients may be precontemplators, unaware of barriers affecting their life; 

others may be contemplators, aware of barriers but not sure they are ready to overcome them; 

and others may be ready to engage with resource providers. 

The counselor uses the following motivational strategies to encourage the client to address 

psychosocial problems other than marijuana: 

• Elicit self-motivational statements 

C:	 Tell me how not having a job has affected you. 

C:	 You’ve said it’s tough not having a safe place to live and that it makes it harder to 

stop smoking, but you haven’t convinced me that you’re ready to do something 

about it. Should we go ahead with our plans? 

• Listen with empathy 

C:	 It sounds as if you’re worried about taking all this on at once. 

C:	 You feel not seeing Jerry as much would be an important step forward, but you 

worry about not seeing a friend you’ve been close to for a long time. 

• Roll with resistance 

C:	 You’re not sure you’re ready to spend time finding a new place to live. 

C:	 I think you’re jumping ahead. We’re not talking about moving right now; we’re just 

looking at how living in your current neighborhood may be interfering with your 

goal of quitting marijuana use. 

• Communicate free choice 

C:	 It’s up to you what to do about this. 

C:	 You can take this on now or wait for another time. 

• Review consequences of action and inaction 

C:	 What do you see happening if you don’t see a doctor? 

C: It sounds as if you’re concerned about calling your probation officer right now; 

what do you think will happen if you don’t? 

Throughout the sessions, the counselor praises all the client’s efforts to carry out the Support 

Plan, even small steps. The counselor conveys confidence that the client has the resources and 

skills to carry out the plan and obtain services, during treatment and after treatment: 

C:	 I’m impressed that you arranged a place at Transitional Housing. You questioned whether 

you could handle the steps, but you hung in there. You were persistent when you were put 

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on hold several times, and you kept rescheduling those interviews until you got them. It 

wasn’t easy, but you made it happen. How do you feel about how you handled it? 

B: It wasn’t easy, and once or twice I felt like telling them off, but I just kept telling myself I 

need a drug-free place to live and that I could do it. 

C: You sound proud of yourself, and your pride is well deserved. Knowing how to contact the 

social service system is an important skill, and you’re getting better at it. Have you thought 

about your next step? 

The counselor encourages the client who lacks confidence and communication skills to make 

initial phone calls during the sessions; the counselor provides support and coaching if necessary. 

After each call, the counselor and client talk about the call, and the counselor praises the client’s 

efforts, offers constructive criticism, and reviews the next steps in the client’s change plan. 

A key strategy in this session is exploring the relationship between other life problems and 

marijuana use. What are their roles in the client’s marijuana use, and how are they frustrating his 

or her efforts to become involved in treatment? 

C:	 You’ve told me your concerns about problems you’re having, including not having a place 

of your own or a job, and your probation officer is concerned about these problems, too. 

How do you see these problems making it harder for you to stop smoking? 

B:	 Well, I’m staying at Jerry’s, and he’s always smoking. I don’t have anything to do all day, 

and time moves when you’re partying. I wasn’t smoking as much when I was working. The 

thing is, I don’t know anybody who doesn’t smoke. 

C:	 So it sounds as if finding a place to live where you won’t be with people who smoke and getting 

a job will help you reach your goal of stopping smoking. Meeting some new people who don’t 

smoke might help also. These are important goals. Let’s talk about how you might tackle these 

problems. Are you concerned about other problems that might make it hard to stop? 

If the client lacks assertiveness skills, the counselor engages the client in role plays of contacts 

with agency representatives. To break the ice, the counselor plays the person seeking service and 

the client plays the agency representative. After the initial role play, the counselor comments on 

the skills that were demonstrated (e.g., assertiveness, asking for a specific service, eliciting 

information, avoiding arguments). Then the counselor plays the agency representative and the 

client plays the person requesting service. Afterward, the counselor points out effective behavior 

and provides constructive criticism: 

C:	 [A person requesting services] Hello. My name is Shirley, and I’m calling because I would 

like information about your center and how I might set up an appointment with a family 

counselor for me, my husband, and our children. 

S:	 [As agency representative] Well, we have a long waiting list. You might want to call back 

next month. 

C:	 Okay, I understand that your program is filled, but could you direct me to another family 

counseling center that might have a shorter wait? 

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Help the Client Identify Others Who Can Help With the Support Plan 

Because the counselor’s role is helping the client identify barriers to addressing marijuana use, 

formulating a Support Plan (form 3B), and helping the client implement the plan, it may be useful 

to identify others who can help the client carry out the Support Plan and ways they can help (e.g., 

accompanying the client to appointments, helping with some of the legwork, helping in negotiating 

the system or with transportation or child care, providing financial assistance). The counselor adds 

the names of these people to the Support Plan. 

The client may have withdrawn from friends and family who do not use drugs, reducing his or her 

social circle to only people who use drugs. As the client recognizes the importance of reducing 

contacts with people who use drugs while trying to overcome dependence, he or she may fear social 

isolation when he or she needs others’ support the most. The counselor explores the nature and 

extent of the client’s social network and suggests expansion of that network as a treatment goal. 

Assign Between-Session Exercise 

The counselor asks the client to select a problem to work on during the week. The client should 

complete a Support Plan for the problem and be prepared to discuss his or her efforts to solve the 

problem at the beginning of the next session. 

Plan To Monitor Progress 

Even though the client is responsible for following the Support Plan and obtaining services, the 

counselor monitors all efforts to complete the plan; these efforts should be discussed in every 

session during the check-in phase. The counselor asks about the client’s efforts to implement the 

Support Plan since the preceding session. A portion of the closing of the session should be devoted 

to reviewing what the client will do to implement the Support Plan during the coming week. 

Review and Conclude Session 

The counselor reviews the content of the session, asks the client for feedback, responds 

empathically to his or her comments, and troubleshoots any difficulties. The counselor explains 

that the client will report back on his or her efforts to complete the plan at the next session. 

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

Total Time: 1 hour 

Delivery Method: CBT-focused individual therapy 

Materials (all forms except form 1A, which is in Section V, are at the end of this section): 

• Marijuana Use Self-Awareness Record (form 4A) 

• Learning New Coping Strategies (form 1A) 

• Future-Self Letter (form 4B) 

• Pleasant Activities (form 4C) 

• Relaxation Training (form 4D) 

• Boredom Management (form 4E) 

Goals for This Session: 

• To introduce the client to the reasoning behind coping skills training 

• To examine the client’s high-risk situations and coping strategies 

Session Outline: 

1. Explore the development of addictive patterns 

• Give examples of how marijuana can change how one feels; ask client how these 

examples fit with his or her experience 

• Give examples of environmental triggers for use; ask client for other triggers he or 

she has experienced 

• Give examples of beliefs or automatic thoughts people may have about marijuana; 

use examples provided by the client; and ask the client for more examples 

• Suggest that the client start the process of change by understanding his or her 

behavior; ask, Does this make sense to you? 

2. Assess high-risk situations 

• Ask client about 

— Typical use situations (places, people, activities, time, days) 

— Triggers for use 

— A recent use situation 

— Thoughts and feelings at use times (tense, bored, stressed, etc.) 

• Complete Marijuana Use Self-Awareness Record (form 4A) and summarize the list 

3. Build coping strategies 

• Emphasize the importance of coping strategies 

• Reintroduce Learning New Coping Strategies (form 1A) 

• Ask client to identify strategies he or she has tried and those that might work best 

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4. Assign between-session exercises 

• Give client a blank copy of the Marijuana Use Self-Awareness Record (form 4A) to 

document episodes of craving/desire between sessions 

• Choose additional assignments based on the client’s current needs 

— Writing a Future-Self Letter (form 4B) 

— Pleasant Activities (form 4C) 

— Relaxation Training (form 4D) 

— Boredom Management (form 4E) 

5. Review and conclude session 

Session 4 Protocol 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor draws on information from previous sessions to increase the client’s understanding 

about use patterns. 

Explore the Development of Addictive Patterns 

The counselor asks the client to look closely at his or her behavior, environment, and beliefs to 

identify addictive patterns: 

Counselor (C): We think of repeated marijuana use as learned behavior. When people start to 

use marijuana a lot, they learn that it changes the way they feel. For example, some 

people use it like a tranquilizer to help them cope with stressful situations. Some use it 

when they feel blue. Others expect it to enhance positive feelings. Some think it makes 

them more confident. And some use it to avoid thinking about troublesome things. How 

does that fit with your experience? [Waits for answer.] 

C: After a while, things in the environment can trigger use, sometimes without your even 

realizing it. The environment can trigger cravings. Things in the environment that can 

trigger use include seeing or smelling marijuana, being around people who are smoking, 

or being in stressful situations. During the assessment session, we talked about the 

connection you’ve noticed between getting paid on Fridays and buying pot. Are there other 

connections like that for you? 

C: People often develop beliefs about marijuana and their using. These are ideas or 

“automatic thoughts” you’ve come to believe about you and your marijuana use. I’ve 

heard you say things in previous sessions like, “I can’t be creative or work effectively 

without it,” “I can’t take the way I feel when I’ve tried to quit,” “I need to change, but it’s 

not worth the effort.” What other beliefs do you have about you and marijuana? 

C: Marijuana can change the way a person feels, acts, and thinks. To help you avoid or cope 

with the situations in which you smoke and to help you find things you can do instead of 

smoking, let’s start by working on understanding your behavior. Does this make sense to you? 

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Assess High-Risk Situations 

The counselor explains that marijuana use behavior is learned over time. The client’s understanding 

of his or her use patterns can help the client change those patterns. Understanding high-risk 

situations can help the client avoid or cope with those situations: 

C:	 If using marijuana changes the way a person acts, thinks, and feels, it’s helpful to begin 

by identifying use patterns and habits. Once your patterns are identified, you may find it 

easier to change your behavior. You can find ways to cope with your high-risk situations 

without using. Change involves learning specific skills and strategies. Once you know about 

the situations and problems that contribute to your using marijuana, you can look for 

other ways to handle those situations. What do you think about that? 

The counselor focuses on the client’s behaviors and high-risk situations: 

C:	 In what situations do you use marijuana (e.g., places, people, activities, specific times, days)? 

C:	 What are your triggers for using (e.g., when you’re in a social situation, when you’ve had a 

tense day, when you’re faced with a difficult problem, when you want to feel relaxed)? 

C:	 Can you describe a recent situation when you used (e.g., a relapse story)? 

C:	 Can you remember your thoughts and feelings at the time you used (e.g., tense, bored, 

depressed, stressed, overwhelmed, angry)? 

C:	 What were the consequences of using? 

The counselor asks the client about marijuana use behavior using motivational interviewing 

techniques (e.g., reflection, expressing empathy) while finding out important information about the 

client’s use environment: 

C:	 In what situations do you find yourself smoking? 

Doug (D): When things get hectic at home. Between my wife and my son, it seems as if everyone 

is out to get me. When I smoke, I can cope with them. 

C:	 Smoking helps you cope with stress at home. Are there other situations when you smoke? 

D:	 Not right now. When I go home, I should be able to relax, but with all the nagging, I end 

up smoking to escape. 

C:	 You want your home to be peaceful, but conflicts over your smoking push you to smoke. 

D:	 Yeah; sounds crazy, doesn’t it? 

C:	 Your situation is difficult. Things you identify that lead you to smoke are called triggers. 

You’ve said that conflicts at home trigger you to smoke. What are your thoughts and 

feelings during times of conflict at your house, right before you light up? 

D:	 I’m thinking that if everyone would get off my back, I might be able to quit smoking. But 

they don’t, and it’s the only way I know how to relax. 

C:	 You find yourself in a bind. Let’s use the Marijuana Use Self-Awareness Record [presents 

form 4A] to list the things we’re talking about. You said smoking marijuana helps you 

relax. What else does it do for you? 

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D:	 It helps me sleep. When I don’t get high, it’s hard getting to sleep. I used to enjoy the high 

a lot more than I do now. I keep smoking, but I don’t even get that high anymore. 

C:	 Sounds as if you’re listing the negative parts of smoking. Are there others? 

Together the counselor and client fill out the Marijuana Use Self-Awareness Record (form 4A). 

Build Coping Strategies 

The counselor emphasizes the importance of coping strategies: 

C:	 We’ve talked about your high-risk situations for triggering marijuana use. This is important 

because many people are unaware of how they put themselves at risk for using. Now we’ll 

focus on coping with these situations in ways that will help you resist the urge to smoke. 

You’ve already read the Learning New Coping Strategies [presents form 1A]. Let’s take a 

few moments to go through it and identify the strategies you’ve tried and others that might 

work. Remember, some strategies involve things you can do or specific actions you can 

take, some involve ways of thinking, and some involve other people or your surroundings. 

The counselor records responses on the Marijuana Use Self-Awareness Record (form 4A) and 

summarizes the list. The counselor follows up by asking for other examples. 

Assign Between-Session Exercises 

The counselor gives the client a blank copy of the Marijuana Use Self-Awareness Record and asks 

the client to document episodes of craving or desire for marijuana between this session and the 

next one. In addition, the counselor chooses an appropriate assignment from among the following 

and reviews the instructions with the client: 

• Write a Future-Self Letter (form 4B) 

• Increase your Pleasant Activities (form 4C) 

• Practice Relaxation Training (form 4D). 

If struggling with boredom is a particular problem, the counselor gives the client the Boredom 

Management handout (form 4E). 

Review and Conclude Session 

The counselor reviews the content of the session, asks the client for feedback, responds 

empathically to his or her comments, and troubleshoots any difficulties. The counselor explains 

that the client will report back on his or her efforts to complete the between-session exercises at 

the next session. 

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

Total Time: 1 hour 

Delivery Method: CBT-focused individual therapy 

Materials (all forms are at the end of this section): 

•	 Coping With Cravings and Urges (form 5A) 

•	 Urge Surfing (form 5B) 

•	 Daily Record of Urges To Use Marijuana (form 5C) 

Goals for This Session: 

•	 To enhance the client’s understanding about cravings and urges for marijuana use 

•	 To identify specific triggers or cues for cravings (see Carroll 1998) 

•	 To review and practice specific skills for addressing cravings 

Session Outline: 

1.	 Give reasons for focusing on cravings 

• Provide basic information about the nature of cravings 

— Cravings are experienced most often early in abstinence but can occur weeks, 

months, even years later 

— Cravings may feel very uncomfortable but are a common experience 

— An urge to smoke does not mean something is wrong 

• Give client Coping With Cravings and Urges (form 5A) 

2.	 Identify cues for cravings 

• Give client examples of common cues 

— Exposure to marijuana or paraphernalia 

— Seeing other people using 

— Contact with people, places, times of day, or situations associated with using 

— Particular emotions and physical feelings 

3.	 Discuss strategies for coping with triggers 

• Getting involved in a distracting activity 

• Talking it through 

• Urge surfing (Urge Surfing, form 5B) 

• Delaying decisions 

• Using imagery 

• Challenging and changing thoughts 

• Using self-talk 

4.	 Complete exercises 

• Make a list of craving triggers 

• Make a plan for managing craving 

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5. Assign between-session exercises 

• Encourage client to review material on handouts before the next session 

• Encourage client to practice urge surfing 

• Complete Daily Record of Urges To Use Marijuana (form 5C) 

6. Review and conclude session 

Session 5 Protocol 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor supports the client’s experience and efficacy in making desired changes. 

Give Reasons for Focusing on Cravings 

The counselor gives the client Coping With Cravings and Urges (form 5A) and explains the 

importance of recognizing cravings: 

Counselor (C): Cravings often are experienced when a person first tries to quit, but they may 

occur weeks, months, even years later. Cravings may feel uncomfortable, but they are 

common experiences. An urge to smoke doesn’t mean something’s wrong. Many people 

learn to expect cravings on occasion and how to cope with them. 

Things that remind you of using marijuana can trigger urges or cravings. Physical symptoms 

include tightness in the stomach or feeling nervous throughout the body. Psychological 

symptoms include thoughts about how using marijuana or drugs feels, recollections of 

smoking marijuana, developing plans to get marijuana, or feeling that you need marijuana. 

Cravings and urges usually last only a few minutes or at most a few hours. Rather than 

increase until they become unbearable, they usually peak after a few minutes and then 

die down, like a wave. Urges become less frequent and less intense as you learn more 

methods for coping with them. 

Identify Cues for Cravings 

The counselor talks about triggers or cues: 

C:	 It’s important to learn how to recognize triggers so you can reduce your exposure to them. 

Common triggers include 

• Exposure to marijuana or paraphernalia 

• Seeing other people using 

• Contact with people, places, times of day, and situations associated with using (such 

as people you used with, parties, bars, weekends) 

• Particular emotions (such as frustration, fatigue, feeling stressed), even positive 

emotions (elation, excitement, feelings of accomplishment) 

• Physical feelings (feeling sick, shaky, tense). 

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Some triggers are hard to recognize. Self-monitoring can help you identify them. 

The easiest way to cope with cravings and urges is to minimize their likelihood of 

occurring. You can reduce your exposure to triggers by getting rid of marijuana in the 

house, not going to parties or bars, and limiting contact with friends who use. 

Discuss Strategies for Coping With Triggers 

The counselor presents several coping strategies: 

C:	 Many times cravings can’t be avoided, and it becomes necessary to cope with them. Here 

are some possible strategies for coping with craving: 

Get involved in a distracting activity. Reading, engaging in a hobby, calling a friend, going 

to a movie, and exercising (jogging, biking) are good examples of distracting activities. Once 

you get interested in something else, you’ll find that the urges go away in no time. 

Talk it through. Talking to your supporter or a friend or family member can pinpoint the source 

of the craving and help relieve the feeling. It also can restore honesty in your relationship. 

Urge surfing. [Gives client Urge Surfing handout (form 5B) and reads sheet aloud.] 

Delay the decision to use. Most urges to use are like waves—they build to a peak and 

then dissipate. If you wait 15 minutes, the wave will pass. Try imagining you’re a surfer 

riding the wave of craving until it subsides, or use another image that works for you. 

Use imagery. If you feel as though you are about to be overwhelmed by urges to use, 

imagine scenes that portray those urges as storms that end with calmness, mountains that 

can be climbed, or waves that can be ridden. Everyone can find an image to maintain control 

until the urge peaks and then dissipates. Some people imagine being a warrior who can 

defeat urges as if they were an enemy or an explorer who can slice through tropical 

underbrush and carve out a trail. Images can be made vivid by using relaxation techniques 

and all the senses (e.g., seeing the thick green jungle, hearing the blade swishing through 

the leaves, smelling the tropical plants). Photographs of loved ones also can distract you. 

Challenge and change your thoughts. When experiencing cravings, many remember only 

the good effects of using and forget the negative consequences. You may find it helpful to 

remind yourself of the benefits of not using and the negative consequences of using. Remind 

yourself that you won’t feel better if you just get a little high and that you lose a lot by using. 

It’s helpful to have these benefits and consequences listed on a small card to carry around. 

Self-talk. People constantly think about their actions and things that happen to them. These 

thoughts can influence strongly the way you feel and act. What you tell yourself about your 

urges to use affects how you experience and handle them. Your self-talk can be used to 

strengthen or weaken your urges. Making self-statements is so automatic you may not notice 

it. For example, a self-statement that is automatic for you may be, “I am a skilled 

photographer” or “I have no willpower.” Hidden or automatic self-statements about urges can 

make them hard to handle. (“I want to get high now. I can’t stand this. The urge is going to 

get stronger and stronger until I use. I won’t be able to resist.”) Other types of self-statements 

can make the urge easier to handle. (“Even though my mind is made up to stay clean, my 

body is taking longer to learn this. This urge is uncomfortable, but in 15 minutes or so, I’ll feel 

like myself again.”) We will discuss these automatic thoughts more in the next session. 

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There are two basic steps in using self-talk constructively: 

1.	 Pinpoint the things you tell yourself that make it harder to cope with an urge. One 

way to tell whether you’re on the right track is when you hit on a self-statement 

that increases your discomfort, for example, “I will never be able to withstand this 

urge.” That discomfort-raising self-statement is a leading candidate for challenge. 

2.	 Use self-talk constructively to challenge the statement. An effective challenge 

makes you feel better (less tense, anxious, panicky) even though it may not make 

the feelings disappear entirely. The most effective challenges are ones tailored to 

specific self-statements. Listed below are some challenges that people find useful: 

• What is the evidence? What is the evidence that if I don’t get high in the next 

10 minutes, I’ll die? Has anyone ever died from not using? What’s the evidence 

that people recovering from a marijuana problem don’t have the feelings I’m 

having? What is the evidence that I’ll never improve? 

• What’s so awful about that? What’s so awful about feeling bad? Of course I 

can survive it. Who said that abstinence would be easy? What’s so terrible about 

experiencing an urge? If I hang in, I’ll feel fine. These urges are not like being 

hungry or thirsty; they’re more like a craving for a particular food or an urge to 

talk to a particular person—they’ll pass. 

• I’m a human being and have a right to make mistakes. Maybe I worry about 

being irritable, preoccupied, or hard to get along with. What’s so bad about 

that? We all make mistakes and in a situation that’s complicated, there is no 

“right” or “perfect” way to get along. 

Some of these strategies will be necessary or helpful only initially to distract yourself from 

persistent urges; in the long run, you’ll have an easier time if you replace the thoughts 

with other activities. After a while, abstinence will feel more natural; the urges will diminish 

in intensity and will come less often. You will also know how to cope with them. 

In the example below the counselor and client discuss craving triggers and self-talk strategies: 

C:	 You identified one of your strongest triggers as seeing other people smoking, especially 

family members. Let’s try to pinpoint exactly what’s going on. 

Shirley (S): I feel that if I don’t smoke with some family members, they might think I’m above 

them. They already make fun of me, calling me the college girl, and I want to fit in. 

C:	 You’re sensitive to your family members and concerned that they’ll think you’re trying to be 

better than they are by not smoking. What is the evidence that this will happen? 

S:	 Well, I guess it’s more of a fear than a fact. I really do love them and know that they love 

me. But I don’t know how they would respond. 

C:	 What thoughts have you had about telling them? 

S:	 I almost told my uncle the other day when he lit up. But then I ended up smoking, and I 

just couldn’t. 

C:	 You realize that once you get high, it’s difficult to make changes. 

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S: I’ve been thinking that I need to tell them when there’s no chance that we would be 

smoking. But I dread it! 

C: What are some other ways you might let them know? 

Complete Exercises 

The counselor introduces the following exercises: 

C:	 Make a list of craving triggers. Circle the triggers that you can avoid or to which you 

can reduce your exposure (such as having marijuana in your home). 

Make up a craving plan. Pick two or three of the general strategies that were discussed 

and plan how to put them into practice if you experience an urge. Cravings can come 

when you least expect them! For example, if you think distracting activities would be 

helpful, which activities would you pick? Which are available? Which take preparation? If 

you were feeling a craving, whom would you call? If you haven’t tried urge surfing before, 

practice with me before trying it when facing an urge. 

Assign Between-Session Exercises 

The counselor encourages the client to review the material on the handouts between sessions and 

to practice urge-surfing techniques. The counselor also gives the client a blank Daily Record of 

Urges To Use Marijuana (form 5C), shows the client a completed form (exhibit VI-I) as an example, 

and asks him or her to fill it out during the week. 

Exhibit VI-1. Daily Record of Urges To Use Marijuana (Sample) 

Date Situation (include 

thoughts and feelings) 

Intensity of 

Cravings(1–100) Coping Behaviors Used 

5/16/03 Was feeling stressed. 

Had a disagreement with 

my boss. 

75 Shut myself in office and breathed 

deeply to relax. Felt better after 20 

minutes. 

5/17/03 Restless at bedtime. 

Trouble getting ready for 

bed. 

60 Took a hot shower, listened to 

relaxing music. Shower was better 

than music. 

5/18/03 Went dancing at club 

where I always used to 

get high. 

80 Hung around with “clean friends.” It 

was a close call. Should have 

prepared in advance. 

5/19/03 Payday. Bob wanted to 

party after work. 

65 Suggested we go for coffee instead. 

Bob agreed! Boy—was I surprised! 

Source: Monti et al. 1989. 

Review and Conclude Session 

The counselor reviews the content of the session, asks the client for feedback, responds 

empathically to his or her comments, and troubleshoots any difficulties. The counselor explains 

that the client will report back on his or her efforts to complete the between-session exercises at 

the next session. 

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

Total Time: 1 hour 

Delivery Method: CBT-focused individual therapy 

Material (form is at the end of this section): 

• Managing Thoughts About Marijuana (form 6A) 

Goal for This Session: 

• To identify and learn to cope with automatic thoughts associated with marijuana use 

Session Outline: 

1. Reinforce that thoughts about marijuana use are normal 

2. Identify thought patterns associated with use 

3. Discuss automatic thoughts and strategies for coping 

• Explain situations that may trigger automatic thoughts 

— Nostalgia 

— Testing control 

— Crisis 

— Feeling irritable when abstinent 

— Escape 

— Relaxation 

— Socialization 

— Improved self-image 

— To-hell-with-it thinking 

— No control 

4. Explore conceptual difficulties 

• Review material and probe for client’s understanding of basic concepts 

• Use illustrations and examples 

• Walk client through a using episode to understand thought processes 

5. Develop skills for coping with automatic thoughts 

• Explain three general principles for coping with thoughts about using 

— A commitment to abstinence 

— Recognition of drug-related thoughts 

— Need for time to master automatic thoughts 

• Describe specific strategies for managing thoughts about using; review Managing 

Thoughts About Marijuana (form 6A) 

6. Practice skills for coping with automatic thoughts 

• Demonstrate self-talk 

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— State a using thought and follow it with a challenging statement 

— Make eye contact and speak clearly and confidently 

— Repeat with other examples as necessary 

• Have client practice with one of his or her using thoughts 

— Support client’s phrasing of both thought and challenge 

— Encourage client to be specific 

— Identify any problems in client’s practice and ask client to try again 

7. Assign between-session exercises 

8. Prepare for end of treatment 

9. Review and conclude session 

Session 6 Protocol 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor helps the client manage thoughts about marijuana use. 

Reinforce That Thoughts About Marijuana Use Are Normal 

The counselor discusses the relationships among thoughts, feelings, and using marijuana: 

Counselor (C): For people who have smoked marijuana for a long time, thoughts about using are 

normal; almost anyone who stops using thinks about starting up again. Thinking about 

using is not a problem provided you don’t act on those thoughts. You may feel guilty about 

thoughts, and you may try to get them out of your mind. This skill topic will help you learn 

new ways to manage your thoughts before you slip. Sometimes the thoughts are obvious, 

but sometimes they creep up on you without notice. 

Identify Thought Patterns Associated With Use 

The counselor explains how negative thinking relates to marijuana use: 

C: People who used marijuana need to be aware of a state of mind that predisposes them to 

a relapse. This state of mind is characterized by dangerous attitudes and thought 

processes and is called “negative thinking.” Negative thinking is dangerous because it 

induces people who have used marijuana to let down their guard (decrease vigilance). The 

thought itself isn’t the problem; it’s how people cope with their thoughts. If people learn to 

dismiss this thinking from their minds whenever it appears, recognize it for what it is, or 

counter it with a challenging thought, it need not lead to a relapse. You can learn 

strategies for coping with these thoughts. 

Discuss Automatic Thoughts and Strategies for Coping 

The counselor describes situations that may trigger automatic thoughts or thoughts that could lead 

to a lapse: 

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C:	 Nostalgia. Some people who formerly used marijuana remember using nostalgically, as if 

marijuana were an old friend. For example, “I remember the good old days when I’d go 

out dancing and smoke a few joints.” 

Testing control. After a period of abstinence, people in recovery may become overconfident. 

For example, “I bet I can use tonight and go back on the wagon tomorrow morning.” 

Curiosity also can be a problem: “I wonder what it would be like to get high again?” 

Crisis. A person may respond to stress by saying, “I can handle this only if I’m high” or “I 

went through so much, I deserve to get high” or “When this is over, I’ll stop using again.” 

Feeling irritable when abstinent. Some people find new problems arise after they become 

abstinent and think using will solve these problems. For example, “I’m short-tempered and 

irritable around my family—maybe it’s more important for me to be a good-natured parent 

and spouse than it is to stop using right now” or “I’m no fun to be around when I’m not 

using; I don’t think I should stop because if I do, people won’t like me as much.” 

Escape. Individuals want to avoid unpleasant situations, conflicts, or memories. Failure, 

rejection, disappointment, hurt, humiliation, embarrassment, and sadness tend to demand 

relief. People get tired of feeling hassled, upset, and lousy. They want to get away from it 

all and from themselves. They seek numbness and the perceived absence of problems. 

Relaxation. Thoughts of wanting to unwind are normal, but sometimes people look for a 

shortcut, trying to unwind without doing something relaxing. The individual may choose the 

more immediate route through marijuana. 

Socialization. This overlaps with relaxation but is confined to social situations. Individuals 

who are shy or uncomfortable in social settings may feel they need a social lubricant to 

decrease awkwardness and inhibitions. 

Improved self-image. This situation involves a pervasive negative view of oneself and 

associated low self-esteem. When individuals become unhappy with themselves, feel 

inferior to others, regard themselves as lacking essential qualities, feel unattractive or 

deficient, or doubt their ability to succeed, they begin to think of using marijuana again 

because using previously may have provided immediate, but temporary, relief from these 

painful feelings. 

To-hell-with-it thinking. During the weeks and months of trying to be abstinent, a person 

may become discouraged and think to hell with it. Thinking this way might result from a 

disappointing experience, feeling tired from coping with temptations, or other difficult 

situations. 

No control. The attitude of being unable to control cravings ensures relapse. Individuals 

give up the fight, conceding defeat before attempting to resist marijuana use; they may 

feel out of control in other aspects of their lives as well. Marijuana is considered a viable 

option. This attitude differs from the to-hell-with-it attitude in which individuals do not 

necessarily feel powerless; they just don’t want to continue abstaining. 

Explore Conceptual Difficulties 

A client may have difficulty understanding the concepts of cognitive analysis and restructuring. If a 

concept is not understood, then the benefits of cognitive coping skills are lost. The counselor 

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probes for the client’s understanding before moving on to the next concept. Using illustrations and 

examples helps convey the basic principles. 

Initially a client may be unaware of the thoughts and feelings that precede decisions to use 

marijuana. He or she may be unaware of triggers and state, I just start using, that’s all. The client 

may admit that usually some external force occurs immediately before use but cannot remember 

what it is. The client denies personal responsibility for actions and attributes behavior to forces 

beyond his or her control, making it difficult for the client to initiate appropriate coping skills. 

To help the client grasp cognitive concepts, the idea of “slowing down the action” (as in an instant 

replay or a slow-motion film sequence) of the thought process is useful. The counselor assists the 

client in breaking down the sequence of thoughts and feelings that lead to particular actions. He 

or she learns to observe, for example, that a tense interaction with a colleague may lead to 

feelings of frustration and to thoughts about not being good enough (e.g., smart, competent, or 

skilled enough), which lead to thoughts about wanting to use marijuana. Once the client can 

analyze the series of thoughts that might have led to a previous relapse, the notions of selfmotivating (or self-awareness) and of modifying one’s thoughts (cognitive restructuring) can be 

introduced. The goal is to make the client aware of his or her thought processes and enable the 

client to replace using thoughts with coping thoughts that enhance abstinence: 

C:	 Try to identify your thoughts about resuming marijuana use and rationalizations for using. 

What thoughts preceded your last using episode after a period of abstinence? What 

thoughts about marijuana seem to be the most frequent or strongest? Under what 

circumstances do these resumption thoughts tend to occur? Although this activity may feel 

strange, like most skills, it becomes easier with time. 

Develop Skills for Coping With Automatic Thoughts 

The counselor helps the client identify automatic thoughts and reviews some of the techniques 

used in previous sessions: 

C:	 Everyone trying to stop marijuana use has thoughts about using. It’s not the thought that 

creates the problem but how people cope with it. If you learn to recognize these thoughts 

and counter them with contrary thoughts, they need not lead to a lapse. 

The three general principles for coping effectively with thoughts about using are 

1. It’s easier to choose to remain abstinent and not to give in to persistent thoughts if 

you are committed firmly to quitting. 

2. It’s easier to challenge drug-related thoughts and change them if you are aware 

of them. 

3. This coping skill takes a long time to master; these thoughts can return months 

and years after you stop using. 

The counselor reviews strategies for managing thoughts about using marijuana and shows the 

client Managing Thoughts About Marijuana (form 6A): 

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C:	 Challenge them. Use other thoughts to challenge the resumption thoughts. For example, 

“I cannot get a little high without increasing my risk of using more” or “I don’t have to use 

marijuana to unwind after work; I can use relaxation exercises” or “I can have good times 

without marijuana; it may feel strange at first, but in time I’ll feel more comfortable.” 

An important aspect of challenging thoughts about using (as well as forms of thought 

distraction and substituting behaviors incompatible with using) is to avoid visualizing what 

you are not going to do and instead picture a behavior that you will do. You might try 

developing a mental picture of the new behavior when the old habit pops into mind. 

List and recall benefits of not using. Thoughts about the personal benefits of abstinence 

can weaken excuses for using. Benefits to think about include better physical health, 

improved family life, job stability, more money for recreation and paying bills, increased selfesteem, and self-control. It is important to pay attention to these positive aspects and the 

progress you’re making; don’t focus on what you’re giving up. Carry a card with you listing 

the benefits, add items as you think of them, and review them regularly. 

Recall and list unpleasant using experiences. Recall the pain, fear, embarrassment, 

and negative feelings associated with using marijuana. Make a list of unpleasant 

experiences, such as memory problems, lack of motivation, procrastination, arrests, 

withdrawal, paranoia, and sleep disturbances on the back of the card that lists the 

benefits of abstinence. Read the card regularly. Counteract the positive thoughts you have 

about using with the negative aspects of using and the benefits of abstinence. Visualize 

the possible using episode to the end and include all the detrimental consequences that 

occur with using marijuana. 

Find distractions. Think about something pleasant, like holiday plans, vacation spots, 

loved ones, relaxation, or hobbies. Focus on a task you want to get done. 

Promote self-reinforcement. Remind yourself of your success—for example, 2 weeks of 

abstinence, involvement in treatment, staying in the treatment program. 

Leave or change the situation. Try a different activity, such as a hobby or physical 

exercise. 

Call your supporter or a friend. 

Use self-talk. As mentioned in session 5, self-talk refers to constructive things you can 

say to yourself that replace negative thoughts. We talk to ourselves all the time. Our 

thoughts have a powerful effect on how we feel and act and on our decisions. One way to 

be sure negative thoughts don’t sabotage your effort to quit is to learn how to recognize 

them and challenge them effectively. Self-talk is an effective way of coping with thoughts 

that make staying away from marijuana difficult. 

Practice Skills for Coping With Automatic Thoughts 

The counselor and client practice self-talk: 

C:	 Let’s practice self-talking in response to concerns about quitting. We’ll choose a general 

concern about quitting to work on. Then you’ll do two things: 

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1. State the concern in your own words, using an “I” statement. 

2. After stating the concern, follow it with a challenging statement. Again, use the 

pronoun “I” when making a challenging statement, and say it forcefully. 

The counselor illustrates how to self-talk by focusing on a particular automatic thought that might 

trigger marijuana use (e.g., I guess I wasn’t as dependent on marijuana as I thought). The 

counselor states that thought and follows it with a challenging statement: 

C:	 1. Automatic thought. Quitting marijuana was easier than I thought. I must not have 

been dependent on it in the first place. 

2. Challenge. I must be crazy. What am I saying? Quitting hasn’t been easy. I had the 

urge to smoke all the time until the last few days. If I weren’t dependent on it, I could 

have quit long ago. I’m just missing the feeling of being high and starting to talk myself 

out of quitting. I think I’ll do something else. 

When conducting the demonstration, the counselor makes eye contact, speaks clearly and 

confidently, and repeats the demonstration if necessary. After the counselor gives a few 

demonstrations, the client practices using any concerns he or she has. Other examples of 

automatic thoughts include I’m not feeling that much better now that I’ve quit or I bet I can 

smoke once in a while. 

It is important to support the client’s phrasing of the automatic thoughts and the challenges. The 

counselor encourages the client to be specific (What do you mean by “No one cares whether I 

smoke or not?”), deliver responses as if the situation were real, and use the first person. If the 

client gives an unsatisfactory response, the counselor specifies the problem (e.g., not the first 

person, not specific in the challenge, not said in a forceful tone) and asks the client to try again. 

The counselor gives constructive feedback and avoids judgments or disapproval. 

The following factors contribute to the client’s ability to formulate a positive response although not 

all need to be present all the time: 

•	 Acknowledgment of negative or ambivalent feelings 

•	 Reminder of the positive side (e.g., motivation and commitment, long-term positive 

outcomes, enhanced self-esteem, improved health) 

•	 Specific positive alternatives 

•	 Humor 

•	 Absence of self-condemnation 

•	 Self-reinforcement or self-appreciation. 

Miguel (M): Sometimes, I just want to smoke. It’s easy to forget why I wanted to quit. 

C:	 It gets easier with experience. You are changing a habit that was formed over many years 

and are finding it difficult at times. People need to remind themselves of how hard that can 

be. Let’s go over the skills that may help you and see whether you think they will work. 

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Assign Between-Session Exercises 

At the end of the session, the counselor explains the between-session exercises on Managing 

Thoughts About Marijuana (form 6A). To complete this exercise, the client writes out lists of 

• 5 to 10 benefits of not using 

• 5 to 10 negative consequences associated with using 

• 5 to 10 stumbling blocks or high-risk situations for maintaining abstinence. 

The client uses this information (the benefits of abstinence and the negative consequences of 

using) to rate his or her commitment to quitting. The client’s perceived level of commitment can 

range from 1 (no commitment) to 10 (extremely high level of commitment). 

Prepare for End of Treatment 

Once treatment is halfway completed, the counselor prepares the client for termination: 

C:	 We have three sessions remaining. How do you feel this has been going? What would you 

like to accomplish in our remaining time together? 

Review and Conclude Session 

The counselor reviews the content of the session, asks the client for feedback, responds 

empathically to his or her comments, and troubleshoots any difficulties. The counselor explains 

that the client will report back on his or her efforts to complete the between-session exercises at 

the next session. 

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Overview of Session 7: Skill Topic 5, Problemsolving 

Total Time: 1 hour 

Delivery Method: CBT-focused individual therapy 

Materials (form is at the end of this section): 

• Problemsolving (form 7A) 

• Large paper, posterboard, or dry-erase board to diagram problemsolving steps 

Goals for This Session: 

• To introduce a strategy for solving problems 

• To apply the problemsolving approach to marijuana use and related problems 

• To prepare for termination of treatment 

Session Outline: 

1. Discuss the importance of solving problems 

• Explain that problem situations result in use when people think they have no 

effective coping responses to handle them 

2. Describe problemsolving skills 

• Recognize the problem 

• Identify or elaborate the problem 

• Consider various approaches 

• Select the most promising approach 

• Evaluate effectiveness 

3. Practice problemsolving skills 

• Work through the process, identifying and applying problemsolving skills 

• Role play solutions and evaluate effectiveness 

4. Assign between-session exercise 

5. Review and conclude session 

Session 7 Protocol 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor explains the steps involved in problemsolving. Providing formal training in solving 

problems may accelerate the development of higher order coping strategies that go beyond 

situation-specific skills. This training helps clients act as their own counselors when they are no 

longer engaged in a formal treatment situation. The problemsolving approach used in BMDC is 

adapted from D’Zurilla and Goldfried (1971; see also CSAT 1998). 

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Discuss the Importance of Solving Problems 

The counselor explains the rationale for learning an approach to solving difficult problems: 

Counselor (C): Situations become problems when people think they have no effective coping 

responses to handle them. Individuals can be flooded by emotions when faced with a 

problem and may be unable to manage the problem constructively. People who use 

marijuana and other drugs may encounter the following types of problems: 

• Situations where drug use had occurred 

• Situations that arise after drug use has been stopped (e.g., social pressure to use, 

cravings, slips) 

• Difficulties developing new activities that help maintain abstinence (e.g., new 

recreational habits). 

The counselor describes steps to solve problems and situations where the approach is helpful: 

C:	 Effective problemsolving requires recognizing when you’re confronted with a problem and 

resisting the temptation to respond impulsively or to do nothing. Coming up with an 

effective solution requires that you assess the situation to decide the best action. 

Sometimes the problem involves wanting to use drugs, such as at a party. At other times, 

the problem may be the urge to find a quick and easy solution. The pressure may get to 

you and trigger using. Effective problemsolving strategies must be part of your abstinence 

program because the occurrence of problems can set the stage for a relapse. 

Describe Problemsolving Skills 

The problemsolving approach involves the following phases: 

1. Recognize the problem 

2. Identify or elaborate the problem 

3. Consider various approaches 

4. Select the most promising approach 

5. Evaluate effectiveness. 

The counselor describes the steps involved in solving problems and provides examples: 

C:	 Recognize the problem (adapted from Intagliata 1979). What clues indicate a problem? 

You get clues from your body (e.g., indigestion, craving), your thoughts and feelings (e.g., 

feelings of anxiety, depression, loneliness, fear), your behavior (e.g., have you been 

meeting your own behavioral standards?), the way you respond to others (e.g., anger, lack 

of interest, withdrawal), and the way others respond to you (e.g., they appear to avoid 

you, criticize you). 

Identify or elaborate the problem. What is the problem? Having recognized that 

something is wrong, you identify the problem precisely by gathering as much information 

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as you can. Break the problem down into specific parts; you may find it easier to manage 

several parts than to confront the entire problem all at once. 

Consider various approaches (adapted from Bedell et al. 1980). What are the options? 

Develop several solutions; the first one that comes to mind may not be the best. Use the 

following methods to find a good solution: 

• Brainstorm. Generate ideas without stopping to evaluate how good or bad they are. 

Write down all the ideas you come up with (even impractical ones) so that you can 

review them as you decide which to try. More is better. Don’t judge these ideas. 

• Consider both behavioral and cognitive coping strategies (Sanchez-Craig 1983). 

When the problem involves conflict with others, speak up assertively (behavioral coping) 

to improve the situation. When the problem involves negative emotional reactions to 

uncontrollable events, change the way you think about the situation (cognitive coping). 

Some problems require both behavioral and cognitive coping. 

Select the most promising approach. What will happen if . . . ? Identify probable 

outcomes for each approach; include positive and negative outcomes and long- and shortterm consequences. Consider the resources you’ll need for each solution. Rank the 

possibilities by their consequences and desirability. The solution with the most positive and 

fewest negative consequences is the one to try first. 

Evaluate effectiveness. How did it work? Evaluate the strengths and weaknesses of your 

plan. What difficulties did you encounter? Are you getting the expected results? Can you 

do something to make the approach more effective? Use the same clues as before (e.g., 

from your body, thoughts, feelings, other people) to decide whether your solution is 

effective. If you give the plan a fair chance and it doesn’t solve the problem, move to your 

second choice and follow the same procedure. 

Practice Problemsolving Skills 

The counselor encourages the client to work through the problem-recognition stage: identifying 

problems, describing each, and writing solutions on paper. The counselor asks the client to weigh 

alternatives, select the most promising one, and describe both advantages and disadvantages for 

every alternative. Finally, the client prioritizes the alternatives. The counselor and client role play 

and evaluate the effectiveness of the most promising solutions: 

C: Your upcoming business trip will put you in a tough situation because you’ll be around old 

friends with whom you got high. What is the problem as you see it? 

Miguel (M): I remember the good old times when we would get together and have a great time. 

C: Like nostalgia. 

M: Yeah; I see these colleagues two or three times a year, and we always smoked together. 

C: That’s a good description of the situation, but how do you see the problem? 

M: I’m worried that being out of town, away from my family, I’ll give in and get high. I know 

that if I do, I’ll be upset later. 

C: You want to see these people, but you’re concerned about a possible lapse because you’ll 

want to smoke with them. Have you thought of solutions and how effective they’ll be? 

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Assign Between-Session Exercise 

The counselor presents Problemsolving (form 7A), reviews it, and asks the client to complete the 

practice exercise for the next session. 

Review and Conclude Session 

The counselor reviews the content of the session, asks the client for feedback, responds 

empathically to his or her comments, and troubleshoots any difficulties. The counselor explains that 

the client will report back on his or her efforts to complete the between-session exercise at the next 

session. The counselor might remind the client that treatment will be ending soon and solicit the 

client’s feelings about termination and input on the best way to spend the remaining sessions. 

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

Total Time: 1 hour 

Delivery Method: CBT-focused individual therapy 

Material (form is at the end of this section): 

• Marijuana Refusal Skills (form 8A) 

Goal for This Session: 

• To learn about and practice assertive responses to offers of marijuana use 

Session Outline: 

1. Discuss the effects of social relationships 

• Explain that marijuana use limits one’s social group to those who use; explain that 

this makes it harder to stay abstinent because it increases 

— Direct and indirect pressure to use 

— Cravings associated with people, places, activities, etc. 

— Positive expectancies about the effects of use 

— Access to and availability of marijuana 

2. Discuss social pressures, risky situations, and assertiveness 

• Explain that avoidance of risky social situations is the safest behavior 

• Explain that refusing marijuana requires assertiveness skills 

• Provide guidance for marijuana refusal: nonverbal behavior, oral responses, 

requesting behavior change, changing the subject, avoiding excuses 

3. Rehearse behaviors 

• Role play refusal skills with client 

• Process the role play 

• Reverse roles with client and model a refusal skill 

4. Assign between-session exercise 

5. Review and conclude session 

Session 8 Protocol 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor explains that marijuana-use offers and pressures are common high-risk situations for 

individuals who have stopped using marijuana. The counselor and client role play marijuana 

refusal skills. 

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Discuss the Effects of Social Relationships 

The counselor explains that, as a person’s marijuana use increases, his or her social relationships 

narrow. The individual spends less time with friends who do not use, and his or her peer group 

becomes mostly those who support and reinforce use. Being with such individuals increases the 

risk of relapse through increased 

• Direct and indirect pressure to use 

• Cravings associated with people, places, activities, and emotional states related to using 

• Positive expectancies about the effects of using 

• Access to and availability of substances. 

Counselor (C): People experience two forms of social or peer pressure: direct and indirect. Direct 

social pressure begins with an offer of marijuana. Indirect social pressure comes with a 

return to the same settings, people, and activities that generate feelings associated with 

using. 

Because social pressure increases risk greatly, avoiding risky social situations is the safest 

behavior. However, avoiding social pressure is not always possible or practical. 

Being able to refuse marijuana requires more than a decision to stop using. It requires 

assertiveness to act on that decision. Practicing refusing marijuana will help you respond 

quickly and effectively when real situations arise. 

Discuss Social Pressures, Risky Situations, and Assertiveness 

The counselor describes offers that may occur and with the client devises strategies for avoiding 

such situations. It is best to avoid situations where people are using marijuana or to leave as soon 

as possible. But if the client is unable to avoid certain people and situations, the next level of 

response is to refuse to participate in smoking marijuana. The counselor tells the client that the 

more quickly the person says no, the less likely he or she is to relapse. Being unsure and hesitant 

allows the client to begin rationalizing (e.g., One hit wouldn’t be so bad). The goal is to be ready 

and to say no immediately and convincingly. 

An assertive response to an invitation to use depends on who offers the marijuana and how the 

offer is made. Sometimes a simple No, thank you is sufficient; at other times, additional 

strategies are necessary. Telling the person about prior using problems is useful in eliciting helpful 

support; at other times, it is unnecessary or even detrimental to share that information. 

The counselor provides guidance for marijuana refusal: 

C:	 Nonverbal behaviors. Make direct eye contact with the person to increase the 

effectiveness of your message. Don’t feel guilty. You won’t hurt anyone by not using. In 

many situations, people won’t even know that you’re not using. You have a right not to 

use. Stand up for your rights! 

Oral responses. Speak in a clear, firm, and unhesitating voice. Otherwise you invite 

questions about whether you mean what you say. “No” should be the first word out of 

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your mouth. Suggest something else to do (e.g., go for a walk to talk, go to the movies 

instead of using on a Saturday night). Suggest having something to eat or a cup of coffee. 

Requesting a behavior change. If a person repeatedly pressures you, ask him or her not 

to offer you marijuana any more. For example, if the person says, “Oh, come on, let’s get 

high the way we used to,” an effective response might be, “If you want to be my friend, 

then don’t offer me marijuana.” 

Changing the subject. After saying “No,” change the subject to avoid getting drawn into 

a debate about using. You could say, “No, thanks, I don’t get high. You know, I’m glad I 

came to this party. I haven’t seen a lot of these people in a while, including you. In fact, I 

was wondering what you’ve been up to lately.” 

Avoiding excuses. Avoid excuses (“I’m on medication for a cold right now”) and avoid 

vague responses (“Not tonight”). They imply that at some date you’ll accept an offer. 

Rehearse Behaviors 

The counselor acknowledges that the client may feel uncomfortable at first about role playing and 

that this is a normal reaction. The counselor assures the client that, with practice, the client will 

get into a scene realistically and focus on his or her role. Resistance can take subtle forms such 

as focusing on other issues or asking many questions. 

The counselor develops scenes for role plays that are relevant to the client. Meaningful scenarios 

increase engagement in the role play and the likelihood that the client achieves a sense of 

mastery over the situation. The following strategies are useful in generating scenes: 

•	 Recalling events. The counselor asks the client to recall a recent event in which he or 

she could have used the skill being taught. 

•	 Anticipating future triggers. The counselor asks the client to anticipate a difficult
 

situation that may arise in which the skill can be used.
 

•	 Making suggestions. The counselor suggests an appropriate situation based on his or
 

her knowledge of the client’s circumstances.
 

The counselor and the client anticipate a future trigger in this role play. 

C:	 It might help to practice what you can say to your colleagues when they are socializing 

after your business meeting. 

Miguel (M): Sure, I’m willing to try it. 

C:	 I’ll play one of your colleagues, and you practice some responses. Hey, Miguel! Good to 

see you. Why don’t you come to my room and we’ll burn a few? 

M:	 It’s good to see you too! I hope you won’t be offended, but since I saw you last, I’ve 

stopped smoking. I’d love to spend some time with you though. 

C:	 Aw come on! Just a few tokes for old times’ sake? 

M:	 How about we just sit and talk. I really don’t want to smoke pot anymore. 

C:	 Great job! 

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After completing a role play, the counselor and client must process it effectively. Processing 

provides an opportunity for a client to receive praise and constructive criticism and includes the 

following: 

•	 The counselor and client react to the role play, considering how they felt about the way the 

situation was handled and the effects of the interaction. 

•	 The counselor’s comments provide sincere reinforcing and constructive criticism. Positive 

and negative feedback focuses on specific aspects of the person’s behavior and points out 

what was particularly effective or ineffective. 

•	 The counselor tries a role reversal. The client plays the role of the target person. This 

strategy is useful if a client has difficulty using a skill or is pessimistic about the 

approach’s effectiveness. By playing the other person, the client has an opportunity to 

experience the effects of the skill. 

In another situation, the counselor and client switch roles. The counselor plays a person who is 

offered marijuana at a party. The client plays the person offering marijuana by saying, “Here, help 

us celebrate.” The client ignores the counselor’s refusal and says, “Oh, come on, getting high 

won’t hurt you.” The counselor, in the role of the person being pressured, demonstrates an 

effective and assertive way to handle the situation. 

Some role plays require using more than one partner, such as a group of people sitting around a 

dining room table offering multiple prompts to use. The counselor encourages the client to 

visualize such scenarios even though the individual therapy setting does not provide multiple 

partners. The counselor attempts to rehearse a variety of scenes involving colleagues, parties, 

restaurants, old friends, and new acquaintances. The counselor elicits the client’s suggestions 

about how the person offering marijuana will react to the client’s refusal to use. 

Assign Between-Session Exercise 

The counselor reviews Marijuana Refusal Skills (form 8A) and asks the client to complete the form 

before the next session. 

Review and Conclude Session 

The counselor reviews the content of the session, asks the client for feedback, responds 

empathically to his or her comments, and troubleshoots any difficulties. The counselor explains that 

the client will report back on his or her efforts to complete the between-session exercise at the next 

session. The counselor might remind the client that treatment will be ending soon and solicit the 

client’s feelings about termination and input on the best way to spend the remaining session. 

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Elective Skill Topics 

The four sessions that follow are elective. The counselor and client determine which topic would 

be the most helpful and use that as session 9. Following are the elective skill topics: 

•	 Planning for emergencies and coping with a lapse 

•	 Recognizing seemingly irrelevant decisions 

•	 Managing negative moods and depression 

•	 Demonstrating assertiveness. 

At the end of session 9, the counselor and client discuss termination issues. The following topics 

are suggested: 

•	 The course of treatment. What were the pros and cons? Did the treatment meet the 

client’s expectations? 

•	 Thoughts, feelings, and concerns about terminating from treatment. The counselor 

encourages the client to process feelings about ending, saying goodbye, and moving on. 

•	 Future plans. What does the client anticipate in the upcoming weeks and months 

regarding marijuana use, possible high-risk situations, use of coping strategies, 

involvement in further treatment for marijuana use, or other concerns? 

•	 Continuing care. The counselor offers the client a list of mutual-help resources available 

in the community. 

Note: The counselor stresses that if a client lapses or feels the need for more treatment, he or 

she can return to the facility. 

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Brief Counseling for Marijuana Dependence 

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

Coping With a Lapse 

Total Time: 1 hour 

Delivery Method: CBT-focused individual therapy 

Materials (all forms except forms 1A, 1B, and 1C, which are in section V, are at the end 

of this section): 

•	 Personal Emergency Plan: High-Risk Situation (form 9A) 

•	 Personal Emergency Plan: Lapse (form 9B) 

•	 Learning New Coping Strategies (form 1A) 

•	 A Guide to Quitting Marijuana (form 1B) 

•	 The client’s Quit Agreement (form 1C) 

Goals for This Session: 

•	 To increase preparedness for unexpected triggers and situations likely to promote
 

relapse
 

•	 To learn techniques to manage the aftermath of a lapse or relapse of marijuana use 

•	 To review the client’s treatment 

Session Outline: 

1.	 Explain the effects of major life changes 

2.	 Present Personal Emergency Plan: High-Risk Situation (form 9A) 

3.	 Present Personal Emergency Plan: Lapse (form 9B) 

4.	 Review Previous Skill Topics 

• Review strategies from previous skill topics that the client found helpful 

• Review Learning New Coping Strategies (form 1A), A Guide to Quitting Marijuana 

(form 1B), and the client’s Quit Agreement (form 1C) 

5.	 Terminate treatment 

Session 9 Protocol: Elective Skill Topic 1 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor helps the client develop an emergency plan to follow in high-risk situations. 

Explain the Effects of Major Life Changes 

The counselor explains that life changes, both negative (e.g., health problems, unemployment, 

financial losses) and positive (e.g., a new job, graduating from school, moving to a new home) 

can threaten a client’s efforts to remain abstinent. In these situations, the client needs an 

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emergency plan to cope with stressors. The counselor asks the client to consider possible highrisk situations and ways to address them. 

Present Personal Emergency Plan: High-Risk Situation 

The counselor gives the client Personal Emergency Plan: High-Risk Situation (form 9A), and 

together they review the form. The counselor and client fill out the form with the high-risk 

situations just identified in mind. The client might want to plan alternative enjoyable activities for 

high-risk times; the counselor can help the client with these plans. The counselor encourages the 

client to review compelling reasons for continued abstinence, as noted on the PFR (form AS8; see 

assessment session) or Future-Self Letter (form 4B). 

Present Personal Emergency Plan: Lapse 

The counselor explains that lapses are not uncommon and asks what might help the client leave a 

setting where a lapse occurred and whom he or she can call for immediate support. 

The counselor presents Personal Emergency Plan: Lapse (form 9B) and asks the client to think of 

strategies to cope with a lapse. The counselor helps the client specify how the strategies would be 

carried out, such as how to dispose of the marijuana (e.g., throw it away, flush it down the toilet), 

how to challenge negative thoughts (e.g., I’ll quit again after I finish this stash; My life is just too 

stressful; I was so irritable when I quit last time, I should continue using because I’m nicer to be 

around). The client already should have removed paraphernalia from his or her home, but 

strategies may need to be reviewed. 

Review Previous Skill Topics 

The counselor and client discuss strategies from previous skill topics that the client found helpful 

(e.g., urge surfing, challenging negative thinking) and review Learning New Coping Strategies (form 

1A), A Guide to Quitting Marijuana (form 1B), and the client’s Quit Agreement (form 1C). 

Terminate Treatment 

If this is the final treatment session with this client, the counselor discusses termination issues 

(see pages 18 and 131). 

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Brief Counseling for Marijuana Dependence 

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

Decisions 

Total Time: 1 hour 

Delivery Method: CBT-focused individual therapy 

Material (form is at the end of this section): 

• Seemingly Irrelevant Decisions (form 9C) 

Goals for This Session: 

• To increase awareness of the decisionmaking process 

• To recognize how certain choices increase the likelihood of a return to marijuana use 

Session Outline: 

1. Provide information on effects of seemingly irrelevant decisions 

• Tell George’s story 

2. Help the client anticipate thoughts of himself or herself as a victim 

3. Discuss valuing self-reflection 

• Explain that though people commonly act in an automatic way, it’s important when 

learning new behaviors to be aware of and reflect on decisions and actions 

• Encourage the client to become aware of activities and choices 

• Encourage the client to think about every choice he or she makes 

4. Discuss the role of consciousness in decisionmaking 

5. Introduce topic exercises 

• Ask about the client’s most recent use and trace back the decisionmaking chain 

• Ask about weekend plans and develop a plan to avoid risky situations 

6. Terminate treatment 

Session 9 Protocol: Elective Skill Topic 2 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor helps the client recognize and handle seemingly irrelevant decisions. 

Provide Information on the Effects of Seemingly Irrelevant Decisions 

The counselor helps the client understand that apparently irrelevant decisions can have major 

repercussions (see Marlatt and Gordon 1985): 

Counselor (C): Many ordinary choices seem to have nothing to do with using. Although they may 

not involve choosing directly whether to use, they move you closer to making that choice. 

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Through a series of minor decisions, you come to a point where using becomes likely. 

These seemingly unimportant decisions that put you on a path to resuming marijuana use 

are called seemingly irrelevant decisions. [Refers to form 9C.] 

The counselor tells a story about relapsing (adapted from Carroll 1998): 

C:	 George was driving home from work and decided to take the scenic route. He realized he 

had forgotten to call his wife to say he’d be late. While looking for a pay phone, he 

remembered that his old smoking buddy Ric lived nearby, so he decided to stop at Ric’s to 

use the phone. It was a Friday evening, which he remembered was party night for Ric. 

George noticed several cars parked at Ric’s house. He paused a moment to deliberate, 

deciding that he needed to call his wife and told himself that he would go in for a minute 

to use the phone. Ric answered the door clearly stoned and invited him to reconnect with 

old friends. George entered the smoke-filled house and recognized friends from his using 

days who passed him a blunt. Debating only a second, George took it and began to 

smoke. That was the first of many he had that night. Because George’s marijuana use 

was linked with these friends, his choosing Ric’s house to make his call led to his getting 

high that night. 

You can see that George made several decisions that led up to his final decision to smoke. 

At each point, George could have made a different decision that would have kept him from a 

dangerous situation. Did he have to call his wife? Did he have no alternative but Ric’s 

house? Could he have said no to his friends? Each decision brought George closer to danger. 

Ultimately, George’s decision to have that blunt led to his relapse to marijuana use. 

Help the Client Anticipate Thoughts of Himself or Herself as a Victim 

The counselor helps the client anticipate future thoughts: 

C:	 People often think of themselves as victims (“Things happened, I ended up in a risky 

situation, and I got high; I couldn’t help it”). They don’t recognize that their little decisions 

gradually bring them to their predicament. After the fact, it’s easy to see how you set 

yourself up for relapse, but it’s harder to see what can happen when you’re making the 

decision. So many choices don’t seem to involve using at the time. Each choice may take 

you a little bit closer to making a big choice. When marijuana isn’t on your mind, it’s hard 

to connect using to a minor decision that seems removed from using. 

Discuss Valuing Self-Reflection 

The counselor reminds the client that acting without thinking it through is common. People 

develop automatic processes that allow important tasks to be completed, but in treatment the 

client is encouraged to be aware of activities and choices. During the early phases of learning 

something new and essential to one’s survival or emotional health and well-being, such as 

stopping substance use, the client needs to be aware of his or her choices and decisions. This 

increases the likelihood that each choice moves the person toward his or her goals. 

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The counselor stimulates the client’s ability to be aware of his or her thoughts and choices: 

C:	 Think about every choice you make, no matter how seemingly irrelevant it is to using 

marijuana. By thinking ahead about each option you have and where each choice may 

lead, you can anticipate dangers that may lie along certain paths. 

By paying more attention to the decisionmaking process, you’ll have a greater chance to 

interrupt the chain of decisions that could lead to a relapse. It’s easier to stop the process 

early, before you wind up in a high-risk situation, than later, when you’re in a situation 

that’s hard to handle because you’re exposed to triggers. 

When you pay attention to your decisionmaking process, you can recognize certain 

thoughts that can lead to risky decisions, such as the thought George had to call home. 

Thoughts like you have to go to a party, have to see a certain person you used marijuana 

with, or have to drive by a particular place often occur at the beginning of a seemingly 

irrelevant decision and should be treated as a warning or red flag. Other red flag thoughts 

often start “It doesn’t matter whether I...” or “I can handle...”. 

Discuss the Role of Consciousness in Decisionmaking 

The counselor encourages the client to plan coping approaches: 

C:	 When faced with a decision, you should choose a low-risk option, one that will help you 

avoid a risky situation. However, if you select a high-risk option, you must plan to protect 

yourself. By becoming aware of seemingly irrelevant decisions, you can take action to 

avoid high-risk situations. It is easier to avoid a high-risk situation than it is to resist 

temptation once you’re in it. 

Introduce Topic Exercises 

The counselor introduces several exercises pertinent to this session: 

C:	 Think about your most recent marijuana use. Follow the decisionmaking chain. What was 

the starting point (e.g., exposure to a trigger, certain thoughts)? Can you recognize the 

points where you chose to make a risky decision? 

Have you made plans for this weekend? If no, why not? Is this a seemingly irrelevant 

decision? Sometimes not making any plans means planning to use. What plans can you 

make for this weekend to avoid a risky situation? 

Here are other examples of situations involving seemingly irrelevant decisions that can be 

setups for a relapse. Which ones apply to you? What is a low-risk option for each? 

• Whether to keep marijuana in the house 

• Whether to offer a ride home to a friend you used to smoke with 

• Whether to tell a friend you’ve quit using. 

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In the following dialog the counselor inquires about potential seemingly irrelevant decisions: 

C: You’ve gone several weeks without smoking. That’s quite an accomplishment. 

Doug (D): Yeah, I never thought I could go that long. 

C: What caught your attention during our talk about seemingly irrelevant decisions? 

D: I put a secret stash in the garage several months ago. Sometimes I forget it’s there, but I 

guess I want a way out if things get too tough. 

C: You seem concerned about it. 

D: Yeah, that idea that not making plans may mean planning to smoke hit me right between 

the eyes. As long as I keep pot around, I guess I’m planning to smoke it sooner or later. 

C: What are you thinking about now that you know that? 

Terminate Treatment 

If this is the final treatment session with this client, the counselor discusses termination issues 

(see pages 18 and 131). 

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Brief Counseling for Marijuana Dependence 

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

and Depression 

Total Time: 1 hour 

Delivery Method: CBT-focused individual therapy 

Materials (all forms are at the end of this section): 

• Thinking Errors That Dampen One’s Mood (form 9D) 

• Managing Negative Moods and Depression (form 9E) 

• Pleasant Activities (form 4C) 

Goals for This Session: 

• To become more aware of how moods affect marijuana use 

• To learn strategies to recognize, process, and cope with these emotions 

Session Outline: 

1. Address the possibility of negative moods 

2. Discuss the importance of emotional triggers 

• Review Thinking Errors That Dampen One’s Mood (form 9D) 

• Ask the client to identify which automatic negative thoughts he or she may engage 

in before or during depressed, anxious, or irritable moods 

• Discuss with the client guidelines for evaluating these thoughts 

• Give client Managing Negative Moods and Depression (form 9E) 

• Engage the client in problemsolving to address problems contributing to his or her 

negative moods 

• Give the client Pleasant Activities (form 4C) and help generate a list of appealing 

activities 

• Discuss balancing “have to” activities with “want to” activities 

• With a depressed client, discuss strategies that may help the client start a 

necessary or desirable activity 

3. Link negative moods and marijuana use 

• Explore the relationship between the client’s marijuana smoking and his or her 

experience of negative moods 

• Review Thinking Errors That Dampen One’s Mood (form 9D) 

• Explain “cognitive distortions” 

• Explore automatic thought patterns that appear to lead to negative mood states 

• Explore methods of changing the client’s automatic thoughts 

4. Terminate treatment 

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Session 9 Protocol: Elective Skill Topic 3 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor assesses the client’s level of depression and determines whether additional services are 

required. The client learns to recognize and cope with negative affective states. 

Address the Possibility of Negative Moods 

The counselor explains that negative moods (e.g., anxiety, irritability, depression) are common 

among people overcoming marijuana dependence: 

Counselor (C): Moods may relate to the effects of stopping marijuana use or the losses in one’s 

life (e.g., family, job, finances) resulting from marijuana use. Difficulties with negative 

mood states (e.g., depression) may have started before marijuana use and may serve as a 

trigger for continued use. Abstinence from marijuana usually leads to improved mood 

(especially as clients start to cope effectively with other problems), but some individuals 

experience depression or other moods even after being abstinent for several weeks. 

Because negative moods often pose a risk for relapse, the client should address them directly 

during treatment. The counselor focuses on negative moods through problemsolving and 

increasing pleasant activities. If after session 3 the counselor suspects that the client can benefit 

from additional counseling or psychotropic medications, the counselor explores these possibilities 

with the client, particularly a client who is severely depressed, has an anxiety disorder, or has a 

personal or family history of mental disorders or aggression. 

The counselor discusses the following strategies to help clients with mild to moderate levels of 

depression identify negative feelings: 

• Increase awareness of negative moods and overly negative thinking 

• Challenge negative thoughts 

• Solve problems 

• Change the client’s activity level 

• Decrease negative activities. 

The counselor asks the client whether he or she experiences mood swings, low energy level, 

changes in appetite and sleep, and suicidality. If indicated (e.g., in the case of suicidality) the 

client should be referred for assessment by a mental health professional. He or she encourages 

the client to be aware of possible distorted perceptions that may precede or coincide with 

negative moods. The counselor encourages the client to pay attention to the contexts associated 

with mood changes and to watch for times when confidence level changes. 

Discuss the Importance of Emotional Triggers 

The counselor and client review Thinking Errors That Dampen One’s Mood (form 9D). The 

counselor explains that a connection exists among how people think, feel, and behave and that 

the client can experience fewer negative moods if he or she thinks in realistic, balanced ways 

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rather than in overly negative, self-defeating ways. The client identifies which automatic negative 

thoughts he or she engages in. If the client has difficulty identifying these thoughts, the counselor 

tells the client to slow down the action (as if watching a movie in slow motion) or look at what 

the situation means. Sometimes writing down the most distressing thoughts helps a client 

remember his or her thoughts. 

Once the client identifies his or her automatic negative thoughts, the counselor gives the client 

Managing Negative Moods and Depression (form 9E). The counselor tells the client to fill out the 

form thinking about distressing situations to avoid and recognizing that an event often can be 

interpreted in more than one way (Emery 1981). 

The counselor engages the client in problemsolving to address problems contributing to negative 

moods. The problemsolving steps are reviewed briefly, emphasizing brainstorming and selecting 

the most promising approach. 

The counselor encourages the client to consider increasing involvement in positive activities and 

reducing involvement in negative ones. Increasing positive activities improves mood by 

counteracting fatigue and improving motivation. Pleasant Activities (form 4C) (adapted from 

MacPhillamy and Lewinsohn 1982) or the calendar of events section in the local newspaper may 

help the client generate a list of enjoyable activities. 

The counselor tells the client to consider activities that vary in price and that can be enjoyed 

when a person is abstinent and to balance pleasant activities (e.g., a walk in a park, attending 

the theater) with required activities (e.g., working, cleaning, studying). Engaging in a pleasant 

activity for 30 minutes two or three times a week (e.g., exercising, reading a favorite author) can 

fit easily into the client’s schedule. 

A depressed client may need to schedule fewer activities and record them on a calendar. The 

client may need to be rewarded in some way (unrelated to using substances) for completing 

these activities (e.g., spouse agrees to prepare dinner). 

Decide which activities the client must do and which can be delegated to others. If the activity 

cannot be delegated, the client explores ways to change the context associated with the activity 

(e.g., call a friend only after an hour of studying, combine studying with music that is not 

distracting). If the client reports difficulty starting a necessary activity, he or she might try to do 

the activity for only a short time, perhaps 15 minutes. Some less desirable activities can be 

eliminated by problemsolving, time management (e.g., prioritizing tasks, setting time limits to 

complete tasks), and setting appropriate limits on others’ requests. 

Link Negative Moods and Marijuana Use 

The counselor explores the relationship between marijuana smoking and the experience of 

negative moods and the role of automatic thoughts: 

Shirley (S): I miss smoking pot when I’m overwhelmed by bad feelings. I felt better after 

getting high. 

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C: Smoking helped you cope with your negative mood. 

S: Yeah, but I would get depressed again when I came down from the high. 

C: What works for you in the short term causes other problems later. 

S: Yeah. 

C: Today we’ve reviewed ways to cope with negative thoughts. You said getting up and 

moving around helps. Researchers have found that often the negative feelings don’t just 

happen. That is, they don’t come from nowhere. In fact, negative feelings may be related 

to the way we think about things or the way we interpret situations. Thinking Errors That 

Dampen One’s Mood lists types of thoughts that increase the chances of feeling 

depressed. We call them cognitive distortions because they don’t reflect what’s going on 

but are based on an interpretation of events. Let’s look at automatic thought patterns you 

have that lead to depression. 

Terminate Treatment 

If this is the final treatment session with this client, the counselor discusses termination issues 

(see pages 18 and 131). 

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

Total Time: 1 hour 

Delivery Method: CBT-focused individual therapy 

Materials (all forms are at the end of this section): 

• Assertiveness (form 9F) 

• Assertiveness Practice Exercises (form 9G) 

• Chalkboard or newsprint 

Goal for This Session: 

• To improve the ability to express feelings and needs to others in an effective way 

Session Outline: 

1. Elicit client’s definition of assertiveness 

2. Define aggressive, passive, passive–aggressive, and assertive 

3. Explain benefits of assertiveness 

• Increases chances that a person will meet goals 

• Increases likelihood that a person will feel good about a situation 

4. Introduce skill guidelines 

• Review Assertiveness (form 9F) 

• Discuss handling situations with negative consequences 

5. Model assertiveness 

• Role play passive, aggressive, passive–aggressive, and assertive responses 

• Ask the client to identify each behavior and its influence on preventing a slip 

6. Practice assertive responses to past difficult situations 

• Review Assertiveness Practice Exercises (form 9G) 

7. Terminate treatment 

Session 9 Protocol: Elective Skill Topic 4 

The counselor welcomes the client and provides an overview of the session. In this session, the 

counselor explains and models assertive behavior. The counselor may be surprised about the 

misconceptions a client has about assertiveness. 

Elicit the Client’s Definition of Assertiveness 

The counselor asks the client to define assertiveness, writing this definition on a chalkboard or 

newsprint. The counselor compares the client’s definition with the one presented in this skill topic, 

pointing out differences. The client may give an appropriate definition, but during role plays, it 

may become apparent that his or her behavior is inconsistent with that definition: 

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Counselor (C): Today we’re going to talk about assertiveness. When you hear that word, what do 

you think of? 

Doug (D): People who are pushy, trying to get their way all the time. 

C: We’ll be looking at four styles of interacting: aggressive, passive, passive–aggressive, and 

assertive. [Writes them on the chalkboard.] 

D: I guess I was thinking of the aggressive style, not assertive. 

C: Let’s define each style and see whether you identify with them. We can look at ways to communicate thoughts and feelings without offending other people or compromising your needs. 

Define Aggressive, Passive, Passive–Aggressive, and Assertive 

The counselor helps the client understand the concept: 

C:	 Assertiveness means recognizing your right to decide what to do in a situation rather than 

give in to others. It recognizes and respects the rights of the people. Rights refer to 

• The right to inform others of your opinion 

• The right to inform others of your feelings in a way that is not hurtful 

• The right to ask others to change their behavior that affects you 

• The right to accept or reject what others say to you or request from you. 

We can express our needs to others in several ways: passive, aggressive, passive–aggressive, 

and assertive. 

Passive people give up their rights if a conflict exists between what they want and what 

someone else wants. They usually fail to let others know what they’re thinking or feeling. 

They bottle up their feelings, even when the situation doesn’t require it, and often feel 

anxious or angry. Sometimes they feel depressed by their ineffectiveness or hurt when 

others have not drawn them out or figured out what they wanted. People do not know 

what the passive person wants, and passive people seldom get their needs met. 

Aggressive people protect their rights by running over others’ rights. They may satisfy their 

short-term needs, but the long-term effects are negative. Because they disregard others to 

achieve their goals, they earn the ill will of others, who may seek to get even. 

Passive–aggressive people are indirect. They hint at what they want, make sarcastic 

comments, or mumble, without stating what is on their minds. They may act out by 

slamming doors, giving someone the silent treatment, or being late. They may get what 

they want without interacting directly. Frequently people around them become confused or 

angry, so the passive–aggressive person ends up feeling frustrated or victimized. 

Assertive people decide what they want, plan an appropriate way to involve others, and 

act on the plan. The most effective plan is to state one’s feelings or opinions and request 

the changes one would like from others without making threats, demands, or negative 

statements. Usually assertive people decide in certain circumstances that a passive 

response is safest (e.g., with an insensitive boss) or that an aggressive response is 

necessary (e.g., in confronting a pusher who won’t back off). Assertive people adapt their 

behavior so that it fits the situation; they don’t respond in the same manner to all 

situations. Assertive people feel satisfied with their actions and are well regarded. 

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Explain Benefits of Assertiveness 

The counselor explains the benefits of assertiveness: 

C:	 Assertiveness is the most effective way to let others know what’s going on or what effect 

their behavior has. By expressing themselves, assertive people resolve uncomfortable 

feelings that otherwise build up. Because being assertive often results in correcting a 

source of stress and tension, it can lead to feeling more in control of life. Assertive people 

do not feel like victims of circumstances. However, their goals can’t be met in all 

situations; it isn’t possible to control how another person will respond. Nevertheless, 

behaving assertively has two benefits: it increases the chances that goals will be met, and 

it makes people feel better about their role in the situation. 

Introduce Skill Guidelines 

The counselor explains that the guidelines in Assertiveness (form 9F) can help the client become 

assertive: 

C:	 Take a moment to think before you speak. What did the other person do or say? Try not to 

assume the other person’s intentions. Don’t assume that he or she knows your mind. 

Plan the most effective way to make statements. Be specific and direct. Address the 

problem without bringing in other issues. Be positive. Don’t put others down; blaming 

others makes them defensive and less likely to hear your message. 

Pay attention to your body language: eye contact, posture, gestures, facial expression, and 

tone of voice. Make sure your words and your expression communicate the same 

message. To get your point across, speak firmly and be aware of your appearance. 

Be willing to compromise. Let others know that you’re willing to work things out. No one 

has to leave the situation feeling as if he or she has lost everything. Try to find a way for 

everyone to win. Give others your full attention when they reply, try to understand their 

views, and seek clarification. If you disagree, have a discussion. Don’t dominate or submit 

to others. Strive for equality in the relationship. 

If you feel you’re not being heard, restate your assertion. Persistence and consistency are 

necessary parts of assertiveness. Changing the way you respond requires effort. The first 

step is to become aware of habitual responses and make an effort to change. 

The most difficult situations in which to respond assertively are those that may end with 

negative consequences. Examine the thoughts that prevent you from acting assertively (“My 

boss will fire me if I can’t work overtime because I have my counseling session”). This 

examination uses many skills we discussed under managing thoughts about marijuana: 

• Determine the thought or fear. What am I afraid will happen? What’s the worst that 

could happen? 

• Assess the probabilities. How likely is the negative consequence? 

• Evaluate the catastrophe. What would happen if the worst occurred? Would it really 

be so terrible? 

• Identify the rules. What assumptions and beliefs govern feelings? 

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Model Assertiveness 

The counselor and client role play a situation in which the counselor plays a person refusing to get 

high; the client plays the person offering the marijuana. The counselor models passive, aggressive, 

passive–aggressive, and assertive responses. After each response, the counselor asks the client to 

identify the behavior and determine the success of that approach. 

Practice Assertive Responses to Past Difficult Situations 

The counselor asks the client to list difficult situations he or she has experienced and to role play 

assertive responses. If the client has trouble thinking of situations, the counselor suggests some 

easy ones (e.g., returning an item bought in a store, dismissing a pesky salesperson) and some 

difficult ones (e.g., asking a friend to repay a loan several months old, confronting a supervisor 

who took credit for an idea of the client’s). Following is an example of the counselor 

demonstrating how to assert feelings about being accused of smoking: 

C: You have said that you’ve been both passive and aggressive with your wife and son. 

D: I get annoyed at first; then I get high and don’t talk to them. 

C: Would you like to role play some methods that we reviewed earlier in the skill topic? 

D: Sure, since what I’m doing now isn’t working! 

C: Why don’t you be your wife, and I’ll try some responses we’ve talked about. Ready? 

D: Yeah. Have you been smoking again? I can tell when you’re sneaking around! 

C: I haven’t been smoking, and I don’t appreciate the way you’re confronting me. 

The counselor gives the client Assertiveness Practice Exercises (form 9G) and asks the client to 

practice the exercises at home. 

Terminate Treatment 

If this is the final treatment session with this client, the counselor discusses termination issues 

(see pages 18 and 131). 

Forms for Sessions 3 Through 9 

During the skill-building sessions, the counselor and client review or complete several forms. 

These forms are provided on the remaining pages of this section. 

145 
Form 3A 

Problem Checklist 

Category Describe Problem Severity 

(1–10)* 

Goal 

Housing/shelter 

Childcare 

Transportation 

Financial support 

Job training or 

employment 

Medical problems 

Legal problems 

Family problems 

Social or interpersonal problems 

Social support 

Emotional or psychological problems 

Education 

Other 

* 1 indicates no problem, 10 indicates a very severe problem that is likely to thwart your efforts to remain abstinent if not addressed. 

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__________________________________________ 

__________________________________________ 

__________________________________________ 

_________________________________ 

Form 3B 

Support Plan 

Goal 1 Goal 2 Goal 3 

What are my goals? 

Who is to be contacted? 

(Phone numbers and 

addresses) 

When will the contact 

be made? 

Who is responsible for 

contacting? 

What services will be 

requested? 

Outcome 

Others who can help with the plan: __________________________________________ 

Signature 

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Form 4A 

Marijuana Use Self-Awareness Record 

As a way to increase awareness about your patterns of use, we’ll use this form to identify the 

kinds of situations, thoughts, feelings, and consequences that are associated with your marijuana 

use. It may be difficult initially, but once you get accustomed to paying more attention, you will 

become skilled at discovering the ways in which you typically use marijuana. 

Trigger (What types of events tend to make you want to use? For example, an argument, 

disappointment, loss, or frustration; spending time with friends who use; having marijuana easily 

available to you; recalling positive memories of past use.) 

1. _________________________________________________________________________________ 

2. _________________________________________________________________________________ 

Thoughts and Feelings (What were you thinking or how were you feeling in relation to the 

triggers you have identified? For example, thinking you were incompetent or stupid or that you 

could never achieve a particular goal; feeling angry, sad, frightened, or glad.) 

1. _________________________________________________________________________________ 

2. _________________________________________________________________________________ 

Behavior (What did you actually do when you were thinking and feeling in these ways? For 

example, smoked marijuana, went out to dinner, isolated yourself from people.) 

1. _________________________________________________________________________________ 

2. _________________________________________________________________________________ 

Positive Consequences (What good came out of your response to the situation? For example, I 

felt much better for a short period.) 

1. _________________________________________________________________________________ 

2. _________________________________________________________________________________ 

Negative Consequences (What negative things happened as a result of your response? For 

example, I felt bad about myself for smoking; I couldn’t complete the work I needed to finish.) 

1. _________________________________________________________________________________
 

2. _________________________________________________________________________________
 

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Form 4B 

Future-Self Letter 

Optional Creative Expression Exercise 

Sometime during the next week, imagine that a year has passed and that you haven’t used marijuana 

for a year. Making believe that it’s next year, write a letter to yourself (the old you). Write about your 

life as it has become. Include the reasons why you stopped a year earlier, what your lifestyle is like in 

the new year, and the benefits you enjoy from not smoking. Mention in your letter any problems you 

faced during the past year in giving up marijuana use. Describe yourself without marijuana as clearly 

as you can. As you visualize yourself in the future without marijuana, it may help to think about 

friendships, self-esteem, health, employment, recreational activities, and general lifestyle satisfaction. 

If you prefer, draw, sketch, or paint a picture of this image of yourself in the future, rather than depict 

it in writing. Choose a medium that will allow you to see another possibility for yourself. 

This exercise is extremely useful. It helps you visualize your journey and your goal. Having a clear 

picture of where you’re going, why, and how you’re going to get there will be useful in the months 

ahead. At our next session, we’ll talk about the future you foresee for yourself. 

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Form 4C 

Pleasant Activities1 

Optional Assignment 

In stopping your marijuana use, you are giving up an activity that has taken up a great deal of your 

time. It is important that you identify other activities that bring you pleasure and integrate them into 

your everyday life. Your assignment is to do something nice for yourself every day, something you 

wouldn’t necessarily spend the time, effort, or money to do for yourself otherwise. You may need to 

get your partner’s, supporter’s, or someone else’s cooperation to do this, but don’t hesitate to ask. It 

doesn’t matter whether it’s having dinner out, shopping for something you’ve been wanting, taking a 

hot bath, jogging—something that makes you feel as if you’re treating yourself. You deserve it! If it 

involves spending a little more money than usual, remember that you’ll be saving money by not 

smoking marijuana. You’ll gradually find ways to treat yourself that are less expensive. Keep a record 

of these over the next week, and we’ll discuss them next time. 

Plan for Increasing Pleasant Activities 

(List at least one target for each day) 

Followup (What did you end 

up doing each day?) 

Day 1 

Day 2 

Day 3 

Day 4 

Day 5 

Day 6 

Day 7 

1Source: MacPhillamy and Lewinsohn 1982. 

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Form 4D 

Relaxation Training2 

Optional Assignment 

Deep Muscle Relaxation Practice Exercise 

Arrange to spend some quiet time in a room where you will not be interrupted. Try to practice this 

relaxation technique at least three times during the next week. Proceed through the eight groups 

of muscles in the list below, first tensing each for 5 seconds and then relaxing each for 15 to 20 

seconds. 

Settle back as comfortably as you can, take a deep breath, and exhale very slowly. You may feel 

most comfortable if you close your eyes. Notice the sensations in your body; you will soon be able 

to control those sensations. Begin by focusing your attention on your hands and forearms. 

•	 Squeeze both hands into fists, with arms straight. Then relax hands. 

•	 Flex both arms at the elbows. Then relax arms. 

•	 Shrug shoulders toward head. Tilt chin toward chest. Then relax shoulders and neck. 

•	 Clench jaw, gritting your teeth together. Then relax jaw. 

•	 Close your eyes tightly. Then relax eyes. 

•	 Wrinkle up your forehead and brow. Then relax these muscles. 

•	 Harden your stomach muscles, as if expecting someone to punch you there (continue to 

breathe slowly as you tense your stomach). Then relax stomach. 

•	 Stretch out both legs, point your toes toward your head, and press your legs together. 

Then relax legs. 

Self-Rating Task 

Each day that you engage in this exercise, rate your relaxation level before and after, using the 

following guide: 0=highly tense; 100=fully relaxed. 

Day Time Before After 

2Source: Monti et al. 1989. 

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Form 4E 

Boredom Management 

Optional Exercise 

For many people who use marijuana, boredom is a trigger to smoke. Sometimes it is boredom 

associated with a tedious or uninteresting job. Perhaps it is a way to fill weekday evening hours 

after dinner but before bedtime. At other times, getting stoned is a way to spend a weekend when 

nothing else has been planned. 

Boredom is a complex and interesting emotion. Many different feelings may be associated with it. 

For instance, boredom may be accompanied by anxiety, apathy, irritability, or lethargy. It’s not a 

really strong emotion; it just kind of nags at you. It can sneak up because it’s hard to identify. 

Discussing boredom and how to handle it can make you aware of its influence on your behavior 

and prepare you to cope with it. 

A Boring Story 

Jan was in her mid-30s when she began to think she needed to quit smoking pot. Sometimes she 

enjoyed it, but after 15 years of regular use Jan was unhappy with herself for smoking so much 

marijuana. She began every day with a hit and smoked every hour or two throughout the day. 

Several times in the past few years she had tried to cut back to smoking just in the evenings and 

on weekends. A few times she kept to her limits, but inevitably she’d inch her way back up. When 

she thought about it, she recognized that she slipped back to getting stoned because she couldn’t 

handle the boredom she felt when she was straight. Her job wasn’t stimulating; she was a 

receptionist in a travel agency. When she tried to get through a day without smoking, the tedium 

of her job got to her. 

Now as she thought about quitting pot completely, she couldn’t imagine how she’d cope with 

being bored at work. On top of that, she was sure that the evenings and weekends would be 

miserable if she didn’t get high. Being bored was torture for Jan. Boredom was an endless 

emptiness and an inner void, with unpleasant restlessness and anxiety. She wondered whether 

she had a chance of quitting marijuana. 

Jan lived by herself and liked it that way. She had two close friends and worried about how these 

friendships would be affected if she stopped getting high. She feared that her being straight would 

alienate at least one friend. With fewer friends, boredom would be even worse! 

1. What does boredom feel like to you? 

2. Is it always a miserable experience? 

3. What makes boredom so uncomfortable? 

4. How would you cope with being bored if you were Jan? 

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Form 5A 

Coping With Cravings and Urges3 

•	 Urges are common in the recovery process. Do not regard them as signs of failure.
 

Instead, use your urges to help you understand what triggers your cravings. 

•	 Urges are like ocean waves. They get stronger only to a point; then they start to subside. 

•	 You win every time you defeat an urge to use. Urges get stronger the next time if you give 

in and “feed” them. However, if you don’t feed it, an urge eventually will weaken and die. 

Practice Exercise 

For the next week, make a daily record of urges to use drugs, the intensity of those urges, and the 

coping behaviors you used. 

Fill out the Daily Record of Urges To Use Marijuana (form 5C): 

•	 Date. 

•	 Situation: Include anything about the situation and your thoughts or feelings that seemed 

to trigger the urge to use. 

•	 Intensity of cravings: Rate your craving—1=none at all, 100=worst ever. 

•	 Coping behaviors used: Note how you attempted to cope with the urge to use marijuana. If 

it helps, note the effectiveness of your coping technique. 

3Source: Kadden et al. 1994. 

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Form 5B 

Urge Surfing 

Many people try to cope with their urges by gritting their teeth and toughing it out. Some urges, 

especially when you first return to your old using environment, are too strong to ignore. When this 

happens, it can be useful to stay with your urge to use until it passes. This technique is called 

urge surfing. 

Urges are like ocean waves. They are small when they start, grow in size, and then break up and 

dissipate. You can imagine yourself as a surfer who will ride the wave, staying on top of it until it 

crests, breaks, and turns into less powerful, foamy surf. The basis of urge surfing is similar to that 

of many martial arts. In judo, one overpowers an opponent by first going with the force of the 

attack. By joining with the opponent’s force, one can take control of it and redirect it to one’s 

advantage. This type of technique of gaining control by first going with the opponent allows one to 

take control while expending a minimum of energy. Urge surfing is similar. You can join with an 

urge (rather than meet it with a strong opposing force) as a way of taking control of your urge to 

use. After you have read and become familiar with the instructions for urge surfing, you may find 

this a useful technique when you have a strong urge to use. 

Urge surfing has three basic steps: 

1.	 Take an inventory of how you experience the craving. Do this by sitting in a comfortable 

chair with your feet flat on the floor and your hands in a comfortable position. Take a few 

deep breaths and focus inward. Allow your attention to wander through your body. Notice 

where in your body you experience the craving and what the sensations are like. Notice 

each area where you experience the urge and tell yourself what you are experiencing. For 

example, “Let me see—my craving is in my mouth and nose and in my stomach.” 

2.	 Focus on one area where you are experiencing the urge. Notice the exact sensations in 

that area. For example, do you feel hot, cold, tingly, or numb? Are your muscles tense or 

relaxed? How large an area is involved? Notice the sensations and describe them to 

yourself. Notice the changes that occur in the sensation. “Well, my mouth feels dry and 

parched. There is tension in my lips and tongue. I keep swallowing. As I exhale, I can 

imagine the smell and taste of marijuana.” 

3.	 Refocus on each part of your body that experiences the craving. Pay attention to and 

describe to yourself the changes that occur in the sensations. Notice how the urge comes 

and goes. 

Many people notice that after a few minutes of urge surfing the craving vanishes. The purpose of 

this exercise, however, is not to make the craving go away but to experience the craving in a new 

way. If you practice urge surfing, you will become familiar with your cravings and learn how to ride 

them out until they go away easily. 

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Form 5C 

Daily Record of Urges To Use Marijuana4 

Date Situation (include your Intensity of Cravings Coping Behaviors Used 

thoughts and feelings) (1–100) 

4Source: Kadden et al. 1994. 

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____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Form 6A 

Managing Thoughts About Marijuana5 

Here are several ways of managing thoughts about marijuana: 

•	 Challenge your thought: Do you really need to use? 

•	 Think of the benefits of not using (see Creating Your List below). 

•	 Remember the unpleasant drug experiences and aftereffects (read list on card [see below]). 

•	 Find distractions: Think of something unrelated to marijuana use. 

•	 Think positively: Remind yourself of your successes so far. 

•	 Leave or change the situation. 

•	 Call your supporter or a friend and try to talk it out. 

•	 Use self-talk. 

•	 Use images of riding out the wave of craving until it passes. 

•	 Use images or pictures of loved ones who would be disappointed if you used. 

•	 Use the decision-delay technique: If nothing else is working, then look at your watch and 

put off a decision to use marijuana for 15 minutes or more (use images to tough it out 

until the urge passes). 

Creating Your List 

One way to cope with thoughts about using marijuana is to remind yourself of the benefits of not 

using, the unpleasant consequences of using, and the stumbling blocks or high-risk situations that 

may make it hard to keep your commitment to abstinence. Use this form to make a list of 5 to 10 

reminders in each category, then transfer this list onto an index card. Carry the card with you, and 

read it whenever you start to have thoughts about using marijuana. 

Positive benefits of not using: __________________________________________________________ 

5Source: Monti et al. 1989. 

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____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

 

 

Form 6A 

Managing Thoughts About Marijuana (continued) 

Unpleasant effects or negative consequences of using: ____________________________________ 

Stumbling blocks or high-risk situations that make it difficult to keep commitment to abstinence: 

Overall level of personal commitment to remain abstinent:
 

1 2 3 4 5 6 7 8 9 10
 

None Extremely High 

Overall confidence level in ability to remain abstinent:
 

1 2 3 4 5 6 7 8 9 10
 

None Extremely High 

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____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

Form 7A 

Problemsolving 

Here is a brief list of the steps in the problemsolving process: 

•	 Is there a problem? Recognize that a problem exists. We get clues from our bodies, our 

thoughts and feelings, our behaviors, our responses to other people, and the ways that 

other people respond to us. 

•	 What is the problem? Identify the problem. Describe the problem as accurately as you 

can. Break it into manageable parts. 

•	 What can I do? Consider various approaches to solving the problem. Brainstorm to think of 

as many solutions as you can. Consider acting to change the situation; consider changing 

the way you think about the situation. 

•	 What will happen if . . . ? Select the most promising approach. Consider all the positive 

and negative aspects of each approach, and select the one most likely to solve the 

problem. 

•	 How did it work? Assess the effectiveness of the selected approach. After you have given 

the approach a fair trial, determine whether it worked. If it did not, consider what you can 

do to improve the plan, or give it up and try one of the other approaches. 

Practice Exercise 

Select a problem that does not have an obvious solution. Describe it accurately. Brainstorm a list 

of possible solutions. Evaluate the possibilities, and number them in order of your preference. 

Identify the problem: _________________________________________________________________ 

List brainstorming solutions: ___________________________________________________________ 

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____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

_________________________________________________ 

Form 8A 

Marijuana Refusal Skills6 

When others urge you to use, keep the following in mind: 

• Say no. 

• Speak in a clear, firm, and unhesitating voice. 

• Make direct eye contact. 

• Suggest an alternative: something else to do or something to eat or a cup of coffee. 

• Ask the person to stop offering you marijuana and not to do so again. 

• Change the subject. 

• Avoid using vague answers or excuses. 

• Don’t feel guilty about refusing to use marijuana. 

• Leave if the offerer persists. 

Practice Exercise 

Listed below are some people who might offer you marijuana in the future. Give some thought to 

how you will respond to them, and write your responses after each item. 

Someone close to you who knows about your using problem: _______________________________ 

Colleague: ___________________________________________________________________________ 

Boss: _______________________________________________________________________________ 

New acquaintance: ___________________________________________________________________ 

Someone at a party with others present:

Relative at a family gathering: __________________________________________________________ 

Boyfriend/girlfriend: ___________________________________________________________________ 

6Source: Monti et al. 1989. 

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Form 9A 

Personal Emergency Plan: High-Risk Situation7 

If I encounter a high-risk situation, 

•	 I will leave or change the situation or environment. 

•	 I will put off the decision to use for 15 minutes. I will remember that most cravings are 

time limited and that I can wait it out and not use. 

•	 I will challenge my thoughts about using. Do I really need marijuana? I will remind myself 

that my only true needs are for air, water, food, and shelter. 

•	 I will think of something unrelated to using. 

•	 I will remind myself of my successes to this point. 

•	 I will call people on my list of emergency numbers: 

Names	 Phone Numbers 

1. ________________________________ ________________________________ 

________________________________ ________________________________ 

________________________________ ________________________________ 

________________________________ ________________________________ 

________________________________ ________________________________ 

________________________________ ________________________________ 

2. 

3. 

4. 

5. 

6. 

Remember: Riding out this crisis will strengthen my program. 

7Source: Monti et al. 1989. 

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________________________________________________________________________________ 

________________________________________________________________________________ 

________________________________________________________________________________ 

________________________________________________________________________________ 

________________________________________________________________________________ 

________________________________________________________________________________ 

1.	 ________________________________________________________________________________ 

2.	 ________________________________________________________________________________ 

3.	 ________________________________________________________________________________ 

4.	 ________________________________________________________________________________ 

5.	 ________________________________________________________________________________ 

6. ________________________________________________________________________________
 

Form 9B 

Personal Emergency Plan: Lapse 

A lapse can represent a crisis in recovery. Returning to abstinence requires an all-out effort. Here 

are some things you can do. 

If I do experience a lapse, 

•	 I will get rid of the marijuana and get away from the setting where I lapsed. 

•	 I will realize that a little marijuana or even 1 day of drug use does not have to result in a 

full-blown relapse. I will not give in to feelings of guilt or blame myself because I know 

these feelings will pass in time. 

•	 I will call someone for help. 

Remember: This lapse is only a temporary detour on the road to abstinence. 

Write a detailed emergency plan for coping with high-risk lapse situations. 

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____________________________________________________________________________________ 

_______________

_______________

_____________________________________________________________________ 

_____________________________________________________________________ 

____________________________________________________________________ 

____________________________________________________________________ 

_____________________________________________________________________ 

_____________________________________________________________________ 

_____________________________________________________________________ 

_____________________________________________________________________ 

_____________________________________________________________________ 

_____________________________________________________________________ 

_______________

_______________

_______________

_______________

_______________

_______________

Form 9C 

Seemingly Irrelevant Decisions 

When making any decision, whether large or small, do the following: 

•	 Consider what options you have. 

•	 Think about the possible outcomes of each option. What positive or negative
 

consequences can you anticipate, and what are the risks of relapse?
 

•	 Choose an option that will minimize your relapse risk. If you decide to choose a risky 

option, plan how to protect yourself while in the high-risk situation. 

•	 Watch for “red flag” thinking: thoughts like “I have to . . .” (do something, go somewhere, 

see someone) or “I can handle . . .” (a certain high-risk situation) or “It really doesn’t 

matter whether . . .” (I’ll just have a hit). 

Practice Exercise 

Think about a decision you made recently or are about to make. The decision could involve any 

aspect of your life, such as your job, recreational activities, friends, or family. Identify safe choices 

and choices that might increase your risk of relapsing. 

Decision to be made: ________________________________________________________________ 

Safe alternatives: 

Risky alternatives:

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Form 9D 

Thinking Errors That Dampen Oneís Mood8 

Type of Error Example 

Personalizing Thinking all situations and events revolve around you. Everyone 

was looking at me. 

Magnifying Blowing negative events out of proportion. This is the worst 

thing that could happen to me. 

Minimizing Downplaying the positives. I got the job, but probably no one 

else applied. 

Either/or thinking Not taking into account the full continuum. I’m either a loser or 

a winner. 

Taking events out of context After a successful experience, focusing on one or two rough 

points. I may have gotten the job, but I blew that one question 

in the interview. 

Jumping to conclusions Making a premature conclusion without enough data. I have a 

swollen gland. It must be cancer. 

Overgeneralizing Making a sweeping judgment based on one event. I failed this 

time; I fail at everything I ever try. 

Self-blame Blaming oneself rather than specific behaviors that can be 

changed. I’m no good. 

Mindreading Believing that you know what everyone else is thinking. 

Everyone there thought I was fat and ugly. 

Comparing Comparing yourself unfavorably with someone else. That 

supermodel has a better figure than I do. 

Catastrophizing Focusing on the worst possible outcome or explanation. He 

didn’t call, and I know something terrible has happened to him. 

8Source: Emery 1981. 

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________________________________________________________________________________ 

________________________________________________________________________________ 

________________________________________________________________________________ 

________________________________________________________________________________ 

________________________________________________________________________________ 

________________________________________________________________________________ 

________________________________________________________________________________ 

Form 9E 

Managing Negative Moods and Depression9 

Use the Three As to overcome your depression. 

1.	 Be aware of the symptoms of depression. 

• Be aware of your moods and the situations that influence them. 

• Be aware of your automatic negative thoughts. 

2.	 Answer or respond to these thoughts. 

• Ask questions and challenge the assumptions behind these thoughts. 

• Replace the negative thoughts with positive ones. 

3.	 Act differently. 

• Increase your positive activities. 

• Decrease your involvement in unpleasant activities. 

• Reward yourself for the positive steps you’re taking. 

Practice Exercise 

Use this worksheet to become aware of the issues involved in your depression and the steps you 

can take to change your moods. 

1. What are the ways that I show my depression in my moods, attitudes, and actions? What are 

my symptoms? __________________________________________________________________ 

2. What are the automatic negative thoughts that go along with my depression? What do I think 

about myself, my current situation, and my world in general? __________________________ 

3. What questions can I ask myself to challenge these automatic negative thoughts? ________ 

4. What steps am I going to take to act differently? What problemsolving strategies have I come 

up with to cope with my problems? What pleasant activities might I increase? What 

unpleasant activities might I avoid or minimize? ______________________________________ 

9Source: Kadden et al. 1994. 

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Form 9F 

Assertiveness 

Remember the following points in practicing assertiveness: 

Take a moment to think before you speak.
 

Be specific and direct in what you say. 

Pay attention to your body language (use direct eye contact; 

face the person you’re addressing). 

Be willing to compromise. 

Restate your assertion if you feel that you’re not being heard. 

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_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

Form 9G 

Assertiveness Practice Exercises10 

These exercises will help you become aware of your style of handling various social situations. The 

four common response styles are passive, aggressive, passive–aggressive, and assertive. 

Pick two different social situations. Write brief descriptions of them and of your responses to them. 

Then decide which of the four common response styles best describes each response. 

Situation 1 (describe): _______________________________________________________________ 

Your response: ________________________________________________________________________ 

Circle response style: passive aggressive passive–aggressive assertive
 

If your response was not assertive, think of an assertive response and write it down here: ________
 

Situation 2 (describe): _______________________________________________________________ 

Your response: ________________________________________________________________________ 

Circle response style: passive aggressive passive–aggressive assertive
 

If your response was not assertive, think of an assertive response and write it down here: ________
 

10Source: Monti et al. 1989. 

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SECTION VII. 

SUPPLEMENTAL READINGS 

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

Consequences of Marijuana Dependence 

Brief Marijuana Dependence Counseling (BMDC) is based on findings that show regular marijuana 

use can lead to a drug dependence syndrome characterized by impaired control over marijuana 

use, preoccupation with its use, tolerance of its effects, and recognizable withdrawal symptoms 

following abrupt discontinuation of its use. The syndrome typically develops over the course of 

years rather than months, with daily or near-daily marijuana smoking being the hallmark symptom. 

The Nature of the Syndrome 

A syndrome is a cluster of symptoms that signals the presence of an underlying disorder (see 

section IV of this manual for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition 

[DSM-IV] [American Psychiatric Association 1994] criteria for marijuana dependence). 

The marijuana dependence syndrome includes behavioral, psychological, and physiological 

symptoms that are typically reported by people who chronically smoke marijuana and who have 

difficulty controlling their use (Stephens and Roffman 1993). People who use marijuana daily 

develop tolerance for its subjective effects (e.g., feelings of being high) and cardiovascular effects 

(e.g., increased heart rate) (Compton et al. 1990; Wiesbeck et al. 1996). Some experience such 

difficulty in controlling their marijuana use that they continue to use despite adverse personal 

consequences of use (Stephens and Roffman 1993; Swift et al. 1998a, 1998b). 

The relatively low intensity of physiological withdrawal symptoms resulting from heavy marijuana 

use may have contributed to marijuana’s not being viewed as dependence producing. However, 

studies have documented that people who use marijuana heavily and chronically may develop 

both physiological and psychological dependence and that cessation from use may produce a 

withdrawal syndrome broadly characterized by restlessness, irritability, mild agitation, insomnia, 

decreased appetite, sleep disturbance, anxiety, stomach pain, nausea, runny nose, sweating, and 

cramping (Crowley et al. 1998; Haney et al. 1999b; Wiesbeck et al. 1996). These symptoms 

commonly abate within a few days to 2 weeks of abstinence from marijuana. 

Considerable evidence of a biological basis for marijuana dependence has accumulated since the 

identification of a specific cannabinoid receptor in the brain (Pertwee 1999) and the discovery of 

anandamide, a compound that binds to and activates the same receptor sites in the brain as 

delta-9-tetrahydrocannabinol (THC), the active ingredient in marijuana (Devane et al. 1992). 

Subsequently, researchers discovered a cannabinoid antagonist, a compound that blocks 

anandamide action in the brain (Rinaldi-Carmona et al. 1994). With increased knowledge of the 

neurochemical basis of marijuana’s reinforcing effects on brain systems, the biological basis of 

marijuana dependence is becoming better understood. 

167
 
Brief Counseling for Marijuana Dependence 

Prevalence 

Marijuana is the most widely used illicit substance in the United States and is the third most 

widely used mood-altering substance after alcohol and tobacco. In 2003, more than 75 percent 

of illicit drug users (14.6 million people) smoked marijuana. For nearly 55 percent of illicit drug 

users, marijuana was the only substance they used (Substance Abuse and Mental Health Services 

Administration 2004). The proportion of young adults who use marijuana regularly has increased 

since the 1960s, and the age of initiation has declined (Hall et al. 1999). More risky patterns of 

smoking developed with the increased popularity of waterpipes or bongs, which permit the delivery 

of large doses of THC (Hall and Babor 2000). These conditions, combined with increased social 

tolerance of marijuana use, reduced penalties for possession, and the development of a 

substantial black market industry to distribute marijuana products, likely have increased the 

possibility that a substantial number of persons exposed to marijuana during their youth will 

continue to use the drug regularly into adulthood. 

Epidemiological studies conducted in the last two decades have tracked trends in the prevalence of 

marijuana dependence. In the 1980s, the Epidemiological Catchment Area Study found that 4.4 

percent of adults had been dependent on marijuana at some point in their lives (Anthony and Helzer 

1991). About a decade later, the National Comorbidity Study estimated that 4.2 percent of the U.S. 

population met diagnostic criteria for marijuana dependence (Anthony et al. 1994). Whereas overall 

marijuana use was stable among the adult population in the 1990s, rates of dependence and abuse 

(as classified by the DSM-IV) increased significantly during the same period (Compton et al. 2004). 

These studies indicate that marijuana dependence is one of the most prevalent substance use 

disorders in the United States, exceeded only by nicotine and alcohol dependence. 

The Natural History of Marijuana Dependence 

For those who have used marijuana at least once, the relative probability of ever becoming 

dependent on the substance is estimated to be 9 percent. This level of risk is considerably lower 

than risk estimates of dependence for those who have used tobacco (32%), heroin (23%), 

cocaine (17%), or alcohol (15%) (Anthony et al. 1994). However, the risk of developing marijuana 

dependence may be higher among individuals who have smoked marijuana more frequently. 

Among those who have used marijuana five or more times, the risk of dependence is estimated to 

be 17 percent (Hall et al. 1999). For people who use daily or near daily, the risk may increase to 

33 percent (Kandel and Davies 1992). 

People using marijuana who are recruited into treatment outcome studies averaged more than 10 

years of near-daily use and more than six serious attempts at quitting in the past (Stephens et al. 

1994b, 2000). Their use had persisted in the face of multiple forms of social, psychological, and 

physical impairment, and most clients perceived themselves as unable to stop. In one study of 

450 clients who used marijuana chronically (Stephens et al. 2002), clients had begun smoking in 

early adolescence, had begun regular smoking in their late teens, had begun to experience 

problems by age 27, and had felt they needed treatment by age 36. 

Consequences of Marijuana Use 

A number of potential adverse health and behavioral effects related to both acute intoxication and 

chronic ingestion have been identified in epidemiological studies and clinical research (Hall 1995; 

168 
Section VII. Supplemental Readings 

Hall and Babor 2000). Several surveys of people using marijuana heavily who are not in treatment 

show that a majority report impairment of memory, concentration, motivation, self-esteem, interpersonal relationships, and health related to their marijuana use (Rainone et al. 1987; Roffman and 

Barnhart 1987). A similar profile of marijuana-related consequences is seen in samples of adults 

seeking treatment for marijuana dependence (Budney et al. 1998; Stephens et al. 1994b, 2000). 

Exhibit VII-1 shows the frequency of self-reported problems in a group of 450 people who 

chronically used marijuana participating in the Marijuana Treatment Project (MTP) (Stephens et al. 

2002). The table shows that clients who presented for treatment with primary marijuana 

dependence demonstrated a high prevalence of social, legal, medical, and psychological 

problems, which tend to be directly or indirectly connected with chronic marijuana use and acute 

marijuana intoxication (Hall et al. 1999). 

Exhibit VII-1. Percentage of MTP Participants Who Endorsed 

Each Marijuana Problem Item (N=450) 

Has marijuana caused you % of Sample 

To feel bad about your use 90.2 

To have lower energy level 86.0 

To procrastinate 86.0 

Memory loss 76.4 

To have lower productivity 75.1 

Lowered self-esteem 74.2 

To lack self-confidence 68.4 

Withdrawal symptoms 61.1 

Problems between you and your partner 58.0 

Financial difficulties 48.9 

Difficulty sleeping 46.0 

Problems in your family 44.4 

To neglect your family 38.7 

Medical problems 33.6 

Problems between you and your friends 26.4 

To miss days at work or miss classes 19.8 

To lose a job 8.2 

Blackouts or flashbacks 7.6 

Legal problems 7.1 

Source: Stephens et al. 2002. 

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Brief Counseling for Marijuana Dependence 

Driving performance following marijuana use has been studied in several contexts. Whereas 

marijuana impairs performance in laboratory and simulated driving settings, studies of on-road 

driving performance have found only modest impairments (e.g., Chesher 1995; Robbe 1994). 

Controlled epidemiological studies have not established an increased risk of motor vehicle crashes 

among those who use only marijuana (Smiley 1999). Marijuana’s major public health significance 

for road safety may be to potentiate the adverse effects of alcohol on the performance of drivers 

who combine alcohol and marijuana intoxication (Hall and Babor 2000). 

Reasonable evidence exists that marijuana use may precipitate schizophrenia in vulnerable 

individuals (Andreasson et al. 1987; Thornicroft 1990) and that continued use worsens the 

prognosis of persons with schizophrenia (Hall and Solowij 1998). 

People whose use of marijuana is chronic and heavy report 

•	 Subtle impairment in the ability to focus attention and filter out complex irrelevant auditory 

information (Solowij et al. 1991) 

•	 Reduced verbal and logical reasoning abilities, diminished short- and long-term memory, 

and altered visual spatial ability (Lundqvist 1995) 

•	 Mathematical and verbal expressive skill deficits (Block and Ghoneim 1993) 

•	 Short-term deleterious impairment of executive functions (Pope et al. 1995); impairment 

in these abilities is likely to have an effect on occupational, academic, and interpersonal 

functioning. 

Together, these cognitive impairments may make an individual feel isolated, misunderstood, and 

inadequate. 

Because marijuana is most often smoked, the person who uses heavily may be at greater risk of 

respiratory diseases. Marijuana smoke is similar in composition to tobacco smoke and has been 

shown to increase chronic and acute bronchitis, cause functional alterations in the respiratory 

tracts, and produce morphologic changes in the airways that may precede malignant change (Hall 

and Babor 2000; Tashkin 1999). These adverse effects appear to occur with fewer marijuana 

cigarettes per day and at earlier ages in people who use marijuana than in tobacco smokers. In 

addition, concurrent marijuana use augments many of the effects of tobacco smoking. 

Approximately 50 percent of those who seek treatment for marijuana dependence also smoke 

tobacco (Budney et al. 1998; Stephens et al. 1993a), a rate that is significantly higher than for 

people of comparable age in the general population. The possibility that cancer may be induced by 

chronic marijuana smoking has been raised by case reports, which have described cancers of the 

aerodigestive system in young adults with a history of heavy marijuana use (e.g., Donald 1991; 

Taylor 1988). A recent epidemiological study found that chronic marijuana use may increase the 

risk of head and neck cancer with a strong dose-response pattern (Zhang et al. 1999). 

Some studies have found maternal marijuana use to be related to preterm deliveries, low birth 

weights (Hatch and Bracken 1986; Zuckerman et al. 1989), and signs of neurological distress in 

newborns (Scher et al. 1988). Recent studies suggest subtle forms of cognitive impairment that 

do not become apparent until later in life in children born to mothers who use marijuana (e.g., 

Day et al. 1994; Richardson et al. 1995). 

170 
Section VII. Supplemental Readings 

Conclusion 

Research suggests that individuals can develop a dependence syndrome that is associated with 

recurrent psychological, social, and physical problems. The respiratory, psychological, and 

interpersonal problems often reported by people dependent on marijuana can lead to significant 

impairments in health and the quality of life. 

Supplemental Reading B: How Effective Is Treatment for Marijuana Dependence? 

The Marijuana Treatment Project and Related Studies 

Despite the need for marijuana dependence treatment in the United States, research on how to 

intervene effectively with this problem has been conducted only recently. This section describes 

the results of controlled trials conducted in the last decade to evaluate interventions for adults 

who are marijuana dependent. Special consideration is given to MTP, which is the largest study 

ever conducted of people who smoke marijuana. 

Controlled Studies 

The first controlled trial of marijuana dependence treatment (Stephens et al. 1994b) compared 

the effects of 10 sessions of cognitive behavioral therapy (CBT) with 10 sessions of group 

discussion. The participants were 212 people who had used marijuana daily or almost daily for an 

average of 10 years. Both counseling approaches were modestly effective in helping a significant 

portion of participants achieve either abstinence or improvement. Contrary to predictions, the CBT 

approach was no more effective than social support with adults who were marijuana dependent. 

Higher levels of pretreatment marijuana use predicted higher use levels following treatment. Lower 

socioeconomic status predicted more problems associated with marijuana use after treatment. 

Finally, individuals who before treatment indicated greater self-efficacy for avoiding marijuana use 

had more successful posttreatment outcomes (Stephens et al. 1993b). 

In a related study (Stephens et al. 2000), a brief, 2-session individual treatment was compared 

with 14 sessions of CBT skills training. In this study a delayed treatment control group was 

included to determine the extent to which self-initiated change occurs in this population in the 

absence of formal treatment. This group was placed on a waiting list and asked to come back in 4 

months. The sample consisted of 291 adults who smoked marijuana daily. The 14 CBT skills 

training sessions were delivered in a group setting over a 4-month period. This treatment 

emphasized the learning of coping strategies to deal with situations presenting high risk of 

relapse. It also provided additional time to build group cohesion and support. The second active 

treatment consisted of two motivational enhancement therapy (MET) counseling sessions delivered 

as individual therapy over a 1-month period. 

An important element involved giving participants normative information so they could compare 

their marijuana use with that of the general population and that of other people seeking treatment 

for marijuana dependence. The counselor reviewed with each participant a written personal 

feedback report generated from questions asked during a comprehensive intake assessment. The 

counselor used the client’s reaction to the personal feedback report to promote discussion and 

bolster the client’s motivation to abstain from marijuana use. The information also was used to 

171 
Brief Counseling for Marijuana Dependence 

reinforce clients’ confidence in their ability to end marijuana use and to offer support in goalsetting strategies for behavior change. One month later, the second session reviewed efforts to 

abstain and the coping skills used in the interim period. In both treatment conditions, participants 

had the option of involving a support person. 

The results showed that both active treatments produced substantial reductions in marijuana use 

relative to the delayed treatment control condition. Following treatment, there were no differences 

between the two active treatments in abstinence rates, days of marijuana use, severity of problems, 

or number of dependence symptoms. Similarly, at the 16-month assessment, 29 percent of group 

counseling participants and 28 percent of individual counseling participants reported having been 

abstinent for the past 90 days. The results of this study suggest that minimal interventions 

consisting of as little as two sessions may be more cost-effective than lengthier treatments. 

In another study (Budney et al. 2000), 60 adults who were marijuana dependent were randomly 

assigned to one of three 14-week treatments: (1) MET, (2) MET plus coping skills training, or (3) 

MET plus coping skills training and voucher-based incentives. In the last condition, participants whose 

abstinence from marijuana and other drugs was documented by urinalysis received vouchers that 

were exchangeable for retail items (e.g., movie passes, sports equipment, educational classes). The 

value of each voucher increased with each successive instance of confirmed abstinence. Conversely, 

the occurrence of a cannabinoid-positive urine specimen (or the failure to submit a sample) led to a 

reduction of each voucher’s value to its initial level. The results showed that participants in the 

voucher-based incentive condition were more likely to achieve continuous abstinence from marijuana 

during treatment than were participants in the other two conditions. Moreover, a greater percentage 

of participants in the voucher-based condition (35%) were abstinent at the end of treatment than 

was the case in the skills training (10%) or MET (5%) conditions. 

The results of these studies indicate that a substantial proportion of adults who were marijuana 

dependent and who sought treatment have been aided in either stopping or decreasing their 

marijuana use. However, it is also apparent that not all of those treated achieved the initial goal of 

sustained abstinence from marijuana. Given the evidence of marijuana’s dependence potential 

and adverse health and behavioral consequences, continuing development and testing of 

marijuana dependence interventions are clearly warranted. 

Marijuana Treatment Project 

MTP was funded by the Center for Substance Abuse Treatment in 1997 and conducted in three 

States (Connecticut, Florida, and Washington) over a 3-year period. MTP compared two active 

treatments with a delayed treatment control condition (Stephens et al. 2002). One active 

treatment consisted of nine individual counseling sessions delivered over a 12-week period. The 

initial sessions focused on MET. These were followed by CBT skills training along with additional 

case management if needed. With some minor modifications, the BMDC described in this manual 

was based on the nine-session treatment evaluated in MTP. The other active treatment used in 

MTP consisted of two MET sessions delivered over a 1-month period. 

A total of 450 participants from diverse ethnic and socioeconomic backgrounds was recruited 

through media advertisements and agency referrals. These individuals were primarily male (68%) 

and on average 36 years old. Sixty-nine percent of the group was white, with 12 percent 

172 
Section VII. Supplemental Readings 

African-American, 17 percent Hispanic, and 1 percent other, which included Asian-American, Native 

American, or unknown (1% is accounted for by rounding error). Approximately 60 percent of the 

sample was unmarried. Individuals in this group had, on average, 14 years of education. Sixty-nine 

percent worked full time, 14 percent worked part time, 12 percent were unemployed, and 4 percent 

were students, retired people, or homemakers (1% is accounted for by rounding error). Those who 

worked had been employed at their current jobs for approximately 5 years (Stephens et al. 2002). 

Ninety-two percent of the study participants felt that they were currently dependent on marijuana. 

At the time of the screening, almost the entire sample (99.8%) felt that marijuana was the 

biggest problem for them (relative to other drugs or alcohol). The group reported smoking 

marijuana on 82 of the past 90 days (91% of the days), smoked an average of 3.7 times a day, 

and reported that the number of days since their last smoking episode was 1.2. Use of other 

drugs and alcohol in the past 30 days was infrequent, in part because individuals who were 

concurrently dependent on alcohol or drugs other than marijuana were ineligible. 

The results of MTP showed a consistent pattern of differences between groups. The delayed 

treatment group changed little from baseline to the 4-month followup on almost all outcome 

measures. At each followup point over a 12-month period, both active treatments produced 

outcomes superior to the 4-month delayed treatment control condition. The nine-session 

intervention produced significantly greater reductions in marijuana use and associated 

consequences than the two-session intervention. Abstinence rates at the 4- and 9-month 

followups for the nine-session intervention were 23 percent and 13 percent, respectively. The 

differences between the two active treatments appeared as early as 4 weeks into the treatment 

period and were sustained throughout the first 9 months of followup. 

As was the case in the findings of the studies discussed above, MTP findings demonstrated a 

moderate degree of efficacy of counseling interventions with adults who are marijuana dependent. Outcomes from the two-session MET intervention were less positive than those found in the 

study by Stephens and colleagues (2000), suggesting that the effectiveness of brief and more 

intensive treatment may vary with the population studied, the content of the therapy, and the skills 

of the clinicians. 

The MTP results indicate that even a brief two-session treatment is associated with substantial 

reductions in marijuana use and related problems. Nevertheless, a significant percentage of these 

chronic smokers continue or return to marijuana use, albeit at reduced levels. For example, 

although the nine-session intervention resulted in a 60-percent reduction in marijuana use up to a 

year after the end of therapy, it did not produce sufficient abstinence rates to eliminate completely 

the risk of accidents, injuries, chronic disease, and a return to marijuana dependence. 

Nevertheless, even with reduced levels of use, both treatments were associated with significant 

reductions in anxiety levels, legal problems, and employment problems. 

It is important to note that, although a substantial percentage of clients did not succeed in 

becoming abstinent, many individuals remained motivated to overcome their dependence. At the 9­

month posttreatment assessment, 82 percent had relapsed and 68 percent indicated that they had 

tried to stop using marijuana at some point between their 4- and 9-month assessment interviews. 

These findings suggest that participants who receive a single episode of care remain motivated to 

change and thus should be followed by aggressive community outreach and support services. 

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Brief Counseling for Marijuana Dependence 

Outreach, Access, and Support Groups 

The demonstration of several efficacious treatment interventions for marijuana dependence raises 

additional questions about how best to engage in treatment people who chronically use marijuana 

and how best to maintain improvements following treatment. Unfortunately, little research has 

been conducted in these areas. 

Marijuana Anonymous (MA) groups, a mutual-help fellowship based on the principles and 

traditions of Alcoholics Anonymous (AA), exist in a number of States and internationally. In 

addition to traditional meetings, MA sessions are held on line. (The organization’s Web site 

address is www.marijuana-anonymous.org. Its toll-free telephone number is 800-766-7669.) No 

research has been conducted yet to evaluate the effectiveness of MA, either alone or in 

combination with formal treatment. Nevertheless, research on AA suggests that mutual-help 

organizations can play an important role in recovery, both alone and in combination with formal 

treatment programs (McCrady and Miller 1993). 

Conclusion 

Individuals who use marijuana chronically as their primary drug tend not to seek treatment in 

traditional drug treatment settings, but it appears from MTP and other studies that when given the 

opportunity, they respond to treatment. Given the promising initial research on treatment for 

cannabis dependence and the potential benefits of brief motivational and cognitive behavioral 

relapse prevention therapies, there is now sufficient evidence to support the development of 

focused treatment programs for this population. The manual-guided therapies developed for these 

projects, particularly MTP, should be transferable to specialized outpatient clinics and to behavioral 

health care practitioners. 

Supplemental Reading C: Implementing Brief Marijuana Dependence Counseling 

To be effective, BMDC must be implemented in the context of contemporary substance abuse 

treatment, which has to be integrated with a larger system that takes into account the program 

setting, referral sources, professional staff, program administration, and linkage to and 

coordination with ancillary services and with marketing, recruitment procedures, assessment, 

training, supervision, program administration, and quality assurance. Successful management of a 

population of people who abuse a different substance requires more than simply adding 

interventions to an existing treatment system. Ideally, the implementation of a BMDC component 

to a program will bring with it changes in services, such as recruitment, referrals, case 

management, initial client contact, therapist training, and administration. 

Recruitment 

The majority of participants in clinical trials of marijuana dependence treatment (see Supplemental 

Reading B) contacted the programs in response to newspaper advertising. Advertisements were placed 

in the news and movie sections of major and alternative newspapers. Some treatment participants 

said they had taken the study advertisement from the paper and carried it with them for weeks before 

calling. Other avenues of recruitment included bus advertisements, radio announcements, and 

newspaper stories about the program. Placing small announcements in places appropriate for different 

groups, such as beauty parlors, pharmacies, and supermarkets, also may be effective. 

174 
Section VII. Supplemental Readings 

Many people who chronically use marijuana believe their problems with its use are unique. In a 

study of barriers to formal treatment, Copeland (1997) found that although women in general 

were aware of options for specialized alcohol and drug treatments, this was not true for the 

women who were dependent on marijuana. These women believed that they were the only people 

with such a problem, which may have contributed to their reluctance to seek treatment. It also 

may explain the positive response to the announcements used by MTP, which were gentle and 

nonthreatening and ensured confidentiality. The announcements read, Ready to make a change in 

your marijuana use? Not sure how to go about it? Free, confidential, and nonjudgmental 

marijuana counseling. This communicated that 

• Potential clients were not alone. 

• Experts recognize marijuana use can be a problem and take it seriously. 

• A special program for marijuana use problems existed and was readily accessible. 

The nonauthoritarian nature of the ad appealed to people using marijuana who were experiencing 

problems and were ambivalent about their use. Clients who contacted MTP for treatment often 

commented that the nonjudgmental stance was important in making the offer of assistance 

attractive to them. 

Referrals 

The courts and employee assistance programs (EAPs) are both sources of referrals to BMDC. 

Many communities have drug courts that manage nonviolent drug-related cases. Programs such 

as BMDC provide the courts with alternatives to incarceration for nonviolent offenders. Persons 

convicted of possession or driving under the influence of marijuana also may be referred 

appropriately. EAPs may refer employees who voluntarily present themselves or are identified 

following a job-related accident. Preemployment screening also leads to treatment seeking when 

continued marijuana use is perceived as an obstacle to desired employment. Often these referrals 

result in traditional treatment. However, when EAP counselors are educated about a special 

research-based program for marijuana use, BMDC may be seen as the treatment of choice. 

Court referrals are usually subject to mandatory urine testing for drug use. In Florida between 

1994 and 1999, 63 percent of persons entering treatment and reporting their primary drug 

problem to be marijuana (with no other drug involvement) were involved with the criminal justice 

system. Although court referrals generally are excluded from marijuana clinical trials, there is no 

reason to believe that these individuals would not be appropriate for BMDC. The possibility of 

incarceration is a powerful motivator for change (Hser et al. 1998). 

Similarly, persons who are subject to targeted urine testing because of job-related problems may 

want to enter treatment. Urine testing increases the likelihood that continued use will result in the 

loss of employment. Thus, to the extent continued employment is important, readiness to change 

will be greater and ambivalence less strong. 

Case Management 

Many MTP participants identified case management needs that were nontraditional. Their needs 

were often related to isolation, health, and time management. Referrals to health clubs, 

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Brief Counseling for Marijuana Dependence 

recreational programs, and religious activities were called for. Clients in serious need of medical 

care, housing, or legal counseling were rarely encountered. Programs that implement BMDC 

should develop case management linkages to the community to provide ancillary services, such as 

vocational counseling, medical treatment, and psychiatric care. BMDC uses a problemsolving 

approach to case management. Clients may need assistance in addressing barriers to treatment 

participation and recovery. Case management in the BMDC model provides linkage information 

rather than advocacy. Cooperative agreements for referral should be in place so that the therapist 

knows what services are available in the community and how they can be accessed most easily. 

Initial Contact With Clients 

Receptionists and assessment staff members should be aware of the program’s advertisements, 

public service announcements, or other activities so that they can respond knowledgeably and 

professionally to telephone inquiries. Research participants report that any initial resistance or 

confusion by the treatment facility leads to a breakdown in the initiation process. A friendly, 

empathetic, and understanding atmosphere should begin with the first contact and continue 

throughout treatment and followup. 

If possible, the BMDC component should be assigned its own phone number, and a receptionist 

answering the phone should respond with that component’s name. If an answering system is 

used, the message can distinguish the BMDC program from others offered by the agency. Callers 

may raise questions about BMDC’s specific components and its track record or demonstrated 

effectiveness to determine whether it can help them. They may be concerned about whether they 

will be treated in groups with people who use other drugs (e.g., cocaine) or alcohol. They may be 

relieved that BMDC specializes in treating “people like them” and pleased to know the program is 

based on scientific research. Callers need to know that the program is sensitive to their needs, that 

staff will take them seriously, and that the services are delivered professionally. MTP participants were 

apprehensive initially and wanted a counselor trained to treat marijuana problems. 

Training Staff 

The treatment effort begins with the assessment session. Assessment staff should be 

•	 Knowledgeable about marijuana use and its consequences 

•	 Trained to diagnose marijuana dependence and abuse and to document use patterns and 

related problems 

•	 Sensitive to the ambivalence toward treatment of people who use marijuana 

•	 Trained in MET and how to use the assessment information. 

Counselors should be competent in MET, CBT, and case management. Staff members should be 

selected on the basis of their empathy, warmth, and genuineness, as well as their cognitive style, 

which should include receptiveness to learning new approaches and willingness to consider that 

several ways exist to solve a problem. A counselor who lacks empathy and openness to the 

client’s perspective will be ineffective. 

176 
Section VII. Supplemental Readings 

Training should include at least three elements: 

1.	 Training sessions covering principles and practices of MET. This manual should be 

distributed in advance of training sessions to introduce basic material and create interest 

in the BMDC method. The training should include an introduction to the stages of change 

and the general principles and strategies of MET. A section of the training should be 

dedicated to the unique characteristics of the marijuana-dependent treatment population. 

Incompatible treatment methods need to be identified and discussed. Training can be 

done individually or in a group format. 

2.	 Regular supervision. Counselors in training should be required to provide videotapes of 

themselves using MET, CBT, and case management for trainers and fellow trainees to 

critique. Many counselors are reluctant to allow themselves to be videotaped. To allay their 

concern, counselors first should view tapes of their supervisors conducting sessions and rate 

these tapes. Next, role plays with other counselors can be taped. Finally, counselor–client 

sessions can be taped and discussed. This gradual exposure appears to relieve anxiety 

related to taping. 

Trainers should continue to shape performance until counselors demonstrate competence. 

Training in CBT and case management may take less time and effort than MET training 

because experienced substance abuse treatment practitioners tend to have been exposed 

to the two former treatment procedures. Resistance to MET and a manual-guided approach 

should be expected; opposition sometimes derives from misunderstanding. Many counselors 

believe that motivational interviewing means cheerleading. Also, many professionals in the 

addiction field are committed to their approaches to treatment (traditional approaches often 

are confrontational and directive) and may be reluctant to try a new method, especially if 

the underlying philosophy differs from one they are most familiar with. 

3.	 Ensuring the BMDC approach. Regular supervision is needed to ensure competence. 

Case conferences and periodic session taping are needed to make certain that counselors 

follow the BMDC approach correctly. Chart reviews may be conducted systematically as a 

means of monitoring implementation. In MTP, monthly supervision was sufficient to 

maintain fidelity to the model. Supervision can be done in several ways. The counselor can 

provide a videotape of a session to the supervisor, who rates the treatment elements 

employed (MET, CBT, or case management) using a session rating form similar to the one 

in appendix A. This form provides the counselor with helpful feedback. It also can be 

useful to have counselors rate other counselors’ tapes, comparing their evaluations with 

those of their supervisor and discussing how to implement the model in various situations. 

When rating and scoring taped sessions, counselors’ criticism should be gentle, 

emphasizing what was done right and building on strengths of the counselor being rated. 

Two videotapes were created to accompany this treatment manual. The first tape highlights the 

problem of marijuana dependence in the United States, discusses epidemiology, and contains 

interviews with key figures who have studied this problem. The second tape uses three 

hypothetical clients to provide practical information and demonstrations of BMDC at work. These 

tapes are recommended for counselors, supervisors, and agency administrators who want to use 

177 
Brief Counseling for Marijuana Dependence 

BMDC to treat people who smoke marijuana. To obtain more information about the BMDC training 

tapes, please contact Karen Steinberg, Ph.D., Department of Psychiatry, University of Connecticut 

School of Medicine, 263 Farmington Avenue, Farmington, CT 06030-1410; 860-679-3712. 

Administration 

From an administrative point of view, a sustainable BMDC program requires at least three 

counselors to prevent disruption of service delivery. Administrators should provide uninterrupted 

delivery of BMDC, which may mean training backup personnel in case of resignation, vacation, 

termination, or prolonged illness. 

Sustainability also raises funding issues. Many agencies can use public funding sources to provide 

BMDC, such as block grants or general revenue funds. Any funding source for outpatient 

treatment probably can be used for BMDC. Moreover, many persons with marijuana dependence 

may be willing to pay for treatment out of pocket, especially when weighing the savings that result 

from stopping their marijuana use. 

Another important implementation decision concerns the identity of the program. One option is to 

offer BMDC as one of many services integrated into a variety of treatments that an agency may 

offer. However, use of BMDC may increase when it is promoted as a program with its own identity, 

distinct from other treatment programs, perhaps with its own location, for at least two reasons. 

First, knowing that a special program exists for people who use marijuana is reassuring to 

potential clients. Second, confidentiality often is important. Some clients are more comfortable 

when the program is not identified specifically as a drug treatment center. 

Creating a distinct program identity also has the advantage of minimizing staff resistance. It makes 

it possible to select only those counselors among staff for whom this approach has an appeal or 

to recruit counselors who are eager to join a new, exciting, cutting-edge program. 

178 
APPENDIX A. 

Session Rating Form 

Please answer the following questions based on the session you observed. Do not 

complete this form if this was an emergency session. 

1. What session topic was covered this week? 

1=Motivational enhancement: 

a. Feedback session 

b. Planning session 

2=Cognitive behavioral (if several topics were addressed, indicate the percentage of the 

session devoted to the particular topic; be sure total equals 100 percent): 

a. Introduction/functional analysis ___ g. Planning for emergencies ___ 

b. Coping with cravings ___ h. Seemingly irrelevant decisions ___ 

c. Managing thoughts ___ i. Managing negative moods & depression___ 

d. Problemsolving ___ j. Assertiveness ___ 

e. Refusal skills ___ k. Anger management ___ 

f. Couples/family involvement ___ l. Other (specify): ________________________ 

3=Case management (specify primary target areas): 

a. Housing/shelter ___ g. Emotional/psychological ___ 

b. Childcare/parenting ___ h. Legal ___ 

c. Transportation ___ i. Family problems ___ 

d. Financial support ___ j. Social problems ___ 

e. Job training/employment ___ k. Support groups ___ 

f. Medical ___ l. Other (specify): ________________________ 

2. Did a significant other attend the session? 

1=Yes 

If “Yes,” circle spouse/partner, parent, sibling, friend, other (specify): ______________________ 

2=No 

Motivational Interventions 

3. To what extent did the counselor discuss or address the participant’s current commitment 

to abstinence? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5 

not at all a little somewhat considerably extensively 

179
 
Brief Counseling for Marijuana Dependence 

4. To what extent did the counselor discuss, review, or reformulate the participant’s goals 

for treatment? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

5. To what extent did the counselor encourage the participant to make a commitment to change 

his or her marijuana use? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

6. Eliciting participant concerns about marijuana use: To what extent did the counselor attempt 

to elicit self-motivational statements from the participant? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

7. Ambivalence: To what extent did the counselor attempt to focus on the participant’s 

ambivalence about changing his or her level of marijuana use? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

8. Feedback/negative consequences: To what extent did the counselor provide structured 

feedback about the participant’s level of marijuana use or refer to specific negative 

consequences of marijuana use? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

Cognitive Behavioral Interventions 

9. To what extent did the counselor discuss high-risk situations the participant has encountered 

since the last session and explore coping skills used? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5 

not at all a little somewhat considerably extensively 

10. To what extent did the counselor ask the participant to monitor, report, or evaluate specific 

cognitions associated with marijuana use or related problems? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5 

not at all a little somewhat considerably extensively 

11. To what extent did the counselor attempt to teach, model, rehearse, review, or discuss 

specific skills (e.g., drug refusal, coping with craving, social skills) during the session? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5 

not at all a little somewhat considerably extensively 

180 
Appendix A. Session Rating Form 

12. To what extent did the counselor apply a problemsolving strategy to a problem or issue raised 

during the session (this can include psychosocial problems other than marijuana use, as in 

the case management module)? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

13. Did the counselor do a role play during this session? 

1=Yes 

2=No 

14. To what extent did the counselor encourage the participant to anticipate any high-risk 

situations that might be encountered before the next session and formulate appropriate 

coping strategies for such situations? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

Case Management Interventions 

15. To what extent did the counselor attempt to identify, assess, or prioritize psychosocial 

problems other than marijuana and other substance use? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5 

not at all a little somewhat considerably extensively 

16. To what extent did the counselor review the community resource directory during the session 

or explore what resources are available to the participant to cope with a psychosocial 

problem? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5 

not at all a little somewhat considerably extensively 

17. To what extent did the counselor attempt to develop a support plan with the participant? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5 

not at all a little somewhat considerably extensively 

18. To what extent did the counselor apply motivational strategies to bolster the participant’s 

commitment to access needed services and address other psychosocial problems? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5 

not at all a little somewhat considerably extensively 

19. To what extent did the counselor monitor or review the participant’s progress in implementing 

the support plan? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5 

not at all a little somewhat considerably extensively 

181 
Brief Counseling for Marijuana Dependence 

20. To what extent did the counselor praise participant efforts to carry out the support plan? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5 

not at all a little somewhat considerably extensively 

21. To what extent did the counselor explore the relationship between identified psychosocial 

problems and marijuana use? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5 

not at all a little somewhat considerably extensively 

General 

22. To what extent did the counselor assess the participant’s use of marijuana or other 

substances since the last session? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

23. Assessment of general functioning: To what extent did the counselor assess the participant’s 

general level of functioning in major life spheres (e.g., work, intimate relationships, family life, 

social life)? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

24. Task assignment: Did the counselor develop one or more specific assignments for the 

participant to engage in between sessions? 

1=Yes
 

2=No
 

25. To what extent did the counselor review the participant’s reactions to last session’s assignment, 

explore or address any difficulties encountered in carrying out the assignment, or provide a 

rationale for homework or reinforce the importance of extra-session practice of skills, etc.? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

26. Did the participant do last session’s homework? 

1=No attempt made 

2=Some attempt made 

3=Practice exercise completed adequately 

9=N/A, not assigned 

182 
Appendix A. Session Rating Form 

27. Consistency of problem focus: To what extent did the counselor attempt to keep the session 

focused on prescribed activities (e.g., by redirecting dialog when it strayed off tasks, 

organizing the session so defined tasks were covered)? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

Approximately how many minutes of this session were devoted to discussion of topics outlined 

in the manual? 

______ minutes 

28. Continuity/reference to past sessions: To what extent did the counselor refer to material 

discussed in past sessions as a means of building continuity across sessions? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

29. Reflective listening: To what extent did the counselor communicate understanding of the 

participant’s comments and concerns? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

30. Empathy: To what extent did the counselor respond empathetically to the participant (e.g., 

through a nonjudgmental stance, showing genuine warmth and concern, helping the 

participant feel accepted in the relationship)? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

31. Family support: To what extent did the counselor inquire about or discuss the availability and 

nature of family support for the participant’s involvement in treatment or efforts to become 

abstinent? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

32. Termination: To what extent did the counselor discuss the termination of the therapy (e.g., 

encourage the participant to discuss his or her feelings or thoughts about termination, discuss 

plans for the continuation of treatment after the end of the protocol)? 

1 - - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
 

not at all a little somewhat considerably extensively
 

183 

APPENDIX B. 

CONTRIBUTORS 

Thomas F. Babor, Ph.D., M.P.H 

Department of Community Medicine and 

Health Care 

University of Connecticut School of Medicine 

Farmington, CT 

Writer, sections I and VII 

Kathleen M. Carroll, Ph.D. 

Department of Psychiatry 

Yale University 

New Haven, CT 

Writer, sections II and VI 

Kenneth Christiansen, Psy.D. 

Department of Epidemiology and Public Health 

University of Miami 

Coral Gables, FL 

and 

The Village South 

Miami, FL 

Writer, section IV 

Carol Davidson, M.S.W. 

Evergreen Treatment Services 

Seattle, WA 

Writer, section VI 

David Duresky, M.A. 

Children Services Council of Broward County 

Plantation, FL 

Writer, sections I, V, VI, and VII 

Elise Kabela, Ph.D. 

Department of Psychiatry 

University of Connecticut School of Medicine 

Farmington, CT 

Writer, sections III, IV, V, and VI 

Ronald Kadden, Ph.D. 

Department of Psychiatry 

University of Connecticut School of Medicine 

Farmington, CT 

Writer, sections III, V, and VI 

Sean McParland, M.P.H., M.S.W. 

The Leukemia & Lymphoma Society 

White Plains, NY 

Writer, section VI 

Bonnie McRee, M.P.H.
 

Department of Community Medicine and
 

Health Care 

University of Connecticut School of Medicine 

Farmington, CT 

Writer, sections I and IV 

Michael Miller, Ph.D. 

Department of Epidemiology and Public Health 

University of Miami 

Coral Gables, FL 

and 

The Village South 

Miami, FL 

Writer, sections V, VI, and VII 

185
 
Brief Counseling for Marijuana Dependence 

Roger A. Roffman, D.S.W. 

Innovative Programs Research Group 

University of Washington School of Social 

Work 

Seattle, WA 

Writer, sections I, V, VI, and VII 

Susan Sampl, Ph.D. 

Department of Psychiatry 

University of Connecticut Health Center 

Farmington, CT 

Writer, sections III and VI 

Meleney Scudder, Psy.D.
 

Department of Community Medicine and
 

Health Care 

University of Connecticut School of Medicine 

Farmington, CT 

Writer, sections III and VI 

Karen L. Steinberg, Ph.D. 

Department of Psychiatry 

University of Connecticut School of Medicine 

Farmington, CT 

Writer, sections II, V, and VI 

Robert Stephens, Ph.D. 

Department of Psychology 

Virginia Tech University 

Blacksburg, VA 

Writer, sections I, IV, and VII 

Janice Vendetti, M.P.H.
 

Department of Community Medicine and
 

Health Care 

University of Connecticut School of Medicine 

Farmington, CT 

Writer, section IV 

186 
APPENDIX C. 

Field Reviewers 

Rosie Anderson-Harper, M.A. 

Mental Health Manager 

Missouri Department of Mental Health 

Division of Alcohol and Drug Abuse 

Jefferson City, MO 

Gilberte M. Berry, LADC 

Substance Abuse Counselor and Case 

Manager 

Community Concepts, Inc. 

Auburn, ME 

Jeff Bickford, M.A., LADC 

Manager 

Maine General Medical Center 

Waterville, ME 

Stephen P. Bogan, M.A., NCAC II 

Youth Treatment Services Lead 

Division of Alcohol and Substance Abuse 

OIympia, WA 

Judith A. Booker, LPC, CSAC 

Therapist III 

Alexandria Community Services Board 

Alexandria, VA 

Marty Estrada 

Certified Addiction Specialist 

Human Services Agency 

County of Ventura 

Ventura, CA 

Paul Fergeson, M.A., CSAC 

Counselor III 

Norfolk Community Services Board 

Norfolk, VA 

María del Mar García-Rodriguez, M.S.W., 

M.S.H. 

Continuing Education Coordinator 

Caribbean Basin and Hispanic Addiction 

Technology Transfer Center 

Universidad Central del Caribe 

Bayamon, PR 

Carmen E. Greiner, M.S., LPC, LSATP, MAC 

Mental Health and Substance Abuse Therapist 

Rappahanock Area Community Services Board 

Spotsylvania, VA 

Jaime Henao, CSAC 

Therapist III 

Alexandria Community Services Board 

Alexandria, VA 

Stuart McElfresh, LCSW 

Alexandria Community Services Board 

Alexandria, VA 

Virginia Ochoa, CAC III 

Cultural Services Manager 

Arapahoe House, Inc. 

Commerce City, CO 

187
 
Brief Counseling for Marijuana Dependence 

Karen Redford, CAC, CCS, NCAC II Susan Tatum, LCSW 

Adult Substance Abuse Services Coordinator Substance Abuse Counselor and Case 

Manager Richmond Behavioral Health Authority 

Alexandria Community Services Board Richmond, VA
 

Alexandria, VA
 

188 
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