The Adolescent Community 

Reinforcement Approach for 

Adolescent Cannabis Users

Cannabis 

CYT

Youth Treatment Series

Volume 4

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov
The Adolescent Community

Reinforcement Approach for 

Adolescent Cannabis Users

Susan Harrington Godley, Rh.D.

Robert J. Meyers, M.S.

Jane Ellen Smith, Ph.D.

Tracy Karvinen, M.A.

Janet C. Titus, Ph.D.

Mark D. Godley, Ph.D.

George Dent, M.S.

Lora Passetti, B.A.

Pamela Kelberg, M.S.W.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

Rockwall II, 5600 Fishers Lane

Rockville, MD 20857

CYT

Cannabis Youth Treatment Series

Volume 4
Acknowledgments

This is volume four of a series of treatment manuals produced under the Cannabis Youth

Treatment (CYT) Project Cooperative Agreement. The document was written by Susan

Harrington Godley, Rh.D., Mark D. Godley, Ph.D., Tracy Karvinen, M.A., Janet C. Titus, Ph.D.,

Lora Passetti, B.A. (Chestnut Health Systems, Inc.); Robert J. Meyers, M.S. (Center on

Alcoholism, Substance Abuse, and Addictions, University of New Mexico); Jane Ellen Smith,

Ph.D. (Psychology Department, University of New Mexico); George Dent, M.S. (University of

Missouri); and Pamela Kelberg, M.S.W. (Treatment Research Center, University of

Pennsylvania). Field reviews and editorial assistance in producing the manual were provided

by staff from Johnson, Bassin & Shaw, Inc. (Lynne McArthur, Holly Brooks, Barbara Fink,

Nancy Hegle, Wendy Caron, and Tonya Young). The authors also acknowledge input and 

assistance received from members of the Executive Steering Committee (see page 2) and

many others including Angela Carey, Jim Fraser, Rod Funk, Bryan Garner, Russ Hagen,

Aimee Harris, Arlinda Jones, Cliff H. Karvinen, Carolyn Kehr, Jennifer Ladd, Suzie PanichelliMindel, Melissa Siekmann, Laura Slown, Bobbie Smith, Joan Unsicker, William White, and

Caroline Hunter Williams.

Disclaimer

This report was developed with support from the Center for Substance Abuse Treatment

(CSAT) to the Chestnut Health Systems, Inc., through Grant No. TI11321. The report was

produced by Johnson, Bassin & Shaw, Inc., under Contract No. 270–99–7072 with the

Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department 

of Health and Human Services (DHHS). Karl White, Ed.D., served as the CSAT Knowledge

Application Program (KAP) Project Officer; Jean Donaldson, M.A., as CSAT CYT Project

Officer. The content of this publication does not necessarily reflect the views or policies of

CSAT, SAMHSA, or DHHS.

Public Domain Notice

All material appearing in this report except that taken directly from copyrighted sources is

in the public domain and may be reproduced or copied without permission from SAMHSA or

CSAT. Citation of the source is appreciated. However, this publication may not be reproduced

or distributed for a fee without the specific, written authorization of the Office of

Communications, SAMHSA, DHHS. 

This work builds directly on an earlier book about alcohol treatment of adults, Clinical

Guide to Alcohol Treatment: The Community Reinforcement Approach (Meyers & Smith,

1995), published by Guilford Press. Material appearing on pages 207 through 215 was adapted from copyrighted material. The pages are reproduced herein with the permission of the

copyright holders. Before reprinting, readers are advised to secure permission of the copyright holders. 

Electronic Access and Copies of Publication

This publication can be accessed electronically through the following Internet World Wide

Web connection: www.samhsa.gov. For additional free copies of this document, please call

the National Clearinghouse for Alcohol and Drug Information 1–800–729–6686 or

1–800–487–4889 (TDD).

Recommended Citation

Godley SH, Meyers RJ, Smith JE, Karvinen T, Titus JC, Godley MD, Dent G, Passetti L,

Kelberg P. The Adolescent Community Reinforcement Approach for Adolescent Cannabis

Users, Cannabis Youth Treatment (CYT) Series, Volume 4. DHHS Pub. No. 01–3489.

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

Services Administration, 2001.

Originating Office

Office of Evaluation, Scientific Analysis and Synthesis, Center for Substance Abuse

Treatment, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane,

Rockville, MD 20857.

DHHS Publication No. (SMA) 01–3489

Printed 2001

Cover images ©2000 Digital Stock.
Table of Contents

I. Introduction

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

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

Purpose, Development, and Organization of This Manual . . . . . . . . .5

II. Overview of the Treatment Model

Adaptation of Procedures From the Community 

Reinforcement Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

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

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

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

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

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

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

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

Clinical Supervision Requirements . . . . . . . . . . . . . . . . . . . . . . . .25

III. Core Procedures

Procedure 1: Functional Analysis of Substance Use Behavior . . . .27

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

Procedure 3: The Happiness Scale and the Goals of Counseling .65

Procedure 4: Increasing Prosocial Recreation . . . . . . . . . . . . . . .87

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

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

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

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

Procedure 9: Caregiver Overview, Rapport Building, 

and Motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140

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

Procedure 11: Caregiver–Adolescent Relationship Skills . . . . . . .156

Procedure 12: Treatment Closure . . . . . . . . . . . . . . . . . . . . . . . .176

IV. Optional Procedures

Optional Procedure 1: Dealing With Failure To Attend . . . . . . . .193

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

Optional Procedure 3: Anger Management . . . . . . . . . . . . . . . . .207

V. Protocol Monitoring Adherence

Overview of Protocol Monitoring Procedures . . . . . . . . . . . . . . . .217

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

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

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

iii
iv

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

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221

VI. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229

VII. Appendix. The Clinical Management of a Multisite Field Trial of 

Five Outpatient Treatments for Adolescent Substance Abuse .233
I. Introduction

Background

This publication was written for therapists and their supervisors who may

want to implement the adolescent community reinforcement approach

intervention, which was one of the five interventions tested by the Center

for Substance Abuse Treatment’s (CSAT’s) Cannabis Youth Treatment (CYT)

Project. The CYT Project provided funding to support a study that tested

the effectiveness of five interventions designed to reduce or eliminate 

marijuana use and associated problems in adolescents.

The CYT study was important for several reasons. In 1996, marijuana use

reached a 12-year high among adolescents ages 12 to 18 years (Institute for

Social Research, 1997). Among eighth graders, 23 percent reported lifetime

use, and 11 percent reported use in the past month. Among high school

seniors, 45 percent reported lifetime use, and 22 percent reported use in

the past month. Among 12- to 17-year-olds, marijuana has been the primary

substance of abuse identified at treatment entry and mentioned in emergency

room admission and autopsy reports (Office of Applied Studies, 1995, 1997).

Frequent marijuana use is associated with a syndrome characterized by 

apathy, decreased attention span, poor judgment, diminished capacity to

carry out long-term plans, social withdrawal, and a preoccupation with

acquiring marijuana (Cohen, 1980, 1981; Schwartz, 1987). It is also 

associated with co-occurring problems, including alcohol use, depression,

anxiety, attention deficit/hyperactivity, conduct disorder, illegal activity,

high-risk sexual activity, unwanted pregnancies, and difficulties at school

and home (Donovan & Jessor, 1985; Farrell, Danish & Howard, 1992;

Hawkins, Catalano & Miller, 1992; Jessor & Jessor, 1977; Kaminer, 1995;

Musty & Kaback, 1995; Rob, Reynolds & Finlayson, 1990). 

Seventy-nine percent of admissions for primary marijuana problems are

treated in outpatient ambulatory settings, that is, about 69 percent in 

regular outpatient settings (1 to 9 hours per week) and 10 percent in 

intensive outpatient settings (9 to 15 hours per week). Although 

information is still emerging about adolescent treatment effectiveness, 

there is considerable tension between efforts to develop short, cost-effective 

treatments and findings that 50 percent or more of adolescents relapse to

marijuana or alcohol use within the first 3 months after discharge (Brown &

Vik, 1994; Brown, Vik & Creamer, 1989; Catalano et al., 1991; Kennedy &

Minami, 1993). 

There are, however, several promising options for improving treatment

effectiveness that focus on motivational enhancement, relapse prevention,

problem solving, coping strategies, case management, family support, 

family therapy, and working with adolescents’ concerned others to change

their environments (Azrin, Donohue, et al., 1994; Azrin, McMahon, et al.,

1994; Brown et al., 1994; Graham et al., 1996; Kadden et al., 1989; Liddle

et al., 1995).

1
2

Overview of the CYT Study

The CYT Study tested the relative effectiveness and cost-effectiveness of a

variety of interventions targeted at reducing or eliminating marijuana use

and its associated problems in adolescents and providing validated models

of these interventions for the treatment field. The appendix provides a

detailed review of the study.

The 3-year study began in October 1997. It was conducted in collaboration

with staff from Chestnut Health Systems (CHS–MC) in Bloomington and

Madison Counties, Illinois; the University of Connecticut Health Center

(UCHC) in Farmington, Connecticut; Operation Parental Awareness and

Responsibility (PAR), Inc., in St. Petersburg, Florida; and the Children’s

Hospital of Philadelphia (CHOP) in Pennsylvania. Members of the Executive

Steering Committee of the study were Thomas Babor, Michael Dennis, Guy

Diamond, Jean Donaldson, Susan H. Godley, and Frank Tims. During the

study, adolescent participants were assigned to one of five treatment 

interventions. 

1. MET/CBT5. This was a five-session treatment composed of two 

individual sessions of motivational enhancement therapy (MET) and

three weekly group sessions of cognitive behavioral therapy (CBT).

The MET sessions focused on factors that motivate adolescents 

who abuse substances to change; in the CBT sessions, adolescents

learned skills to cope with problems and meet needs in ways that 

did not involve turning to marijuana or alcohol. This treatment 

was one of three interventions conducted at all four sites and was

designed to be inexpensive and in line with what many parents and

insurers seek as a basic intervention.

2. MET/CBT5 + CBT7. This treatment was composed of two sessions

of MET and 10 weekly group sessions of CBT. It was designed to 

provide more of the same kind of treatment as MET/CBT5 to test

for dosage effects. It was more in line with the type of treatment

usually provided for adolescents.

3. FSN. The family support network (FSN) treatment included the

MET/CBT5 + CBT7 group therapy plus engagement-type case 

management, family support groups, and aftercare. This treatment 

was designed to wrap several additional low-cost services around the

MET/CBT5 + CBT7 group therapy and to address family issues and 

services in line with CSAT Treatment Improvement Protocol (TIP)

Series recommendations.

4. ACRA. The adolescent community reinforcement approach to 

treatment was composed of 10 individual sessions with the 

adolescent, 2 individual sessions with one or more caregivers (e.g., 

a single parent or both parents), and 2 sessions with the adolescent

and caregivers together. The intervention focused on rearranging

environmental contingencies so that abstaining from marijuana was

more rewarding than using it. ACRA therapists taught adolescents
how to find new reinforcers or enhance existing reinforcers for 

staying substance free, how to use existing community resources

that were believed to support positive change, and how to develop 

a positive support system within the family.

5. MDFT. Multidimensional family therapy (MDFT) was a 12-week 

treatment, composed of 12 to 15 individual, family-focused sessions

plus telephone and case management contacts. Depending on need

or availability, therapists met with adolescents and family members

individually or together. Sessions focused on roles, problem areas,

and interactions among family members. This treatment used an

integrated approach to family issues and focused on helping 

adolescents build more effective and age-appropriate interpersonal

and conflict-resolution skills, while helping parents establish a more

effective and supportive parenting style. Treatment also focused on

building appropriate social supports with peers, schools, and other

involved service providers.

All five therapies were based on treatment manuals to ensure that each

intervention had a unique approach, was uniformly applied at every site

implementing it, and could be replicated by others after the study had been

completed. In the study, treatment manuals were paired with a strong 

quality assurance component that included reviews of actual taped sessions,

which helped ensure compliance with the manuals. 

These five treatments can be categorized in several different ways. First,

they varied by mode; the first three were combinations of individual sessions

and group approaches (i.e., groups of adolescents or groups of families),

and the last two were approaches in which adolescents and family members

were seen individually or with other family members. Second, the MET/CBT

and ACRA interventions were based on behavioral treatment approaches,

whereas the FSN and MDFT interventions were based on family treatment

approaches. Third, they varied in resource intensity and cost.

In the study, approximately 150 adolescents were randomly assigned to 1 

of 3 conditions at 4 sites. At two sites they were assigned to the brief

MET/CBT5 or one of the other individual/group combinations (MET/CBT5

+ CBT7 or FSN). At two sites, adolescents were assigned to the brief

MET/CBT5 treatment or one of the individual approaches (ACRA or MDFT). 

All conditions were replicated in two or more sites. Treatment was 

standardized by using a treatment manual and relying on support from

expert workgroups. All adolescents were assessed at intake and at 3, 6, 9,

and 12 months. To validate adolescents’ self-reports, urine tests and 

collateral assessments were collected at intake and at 3 and 6 months. 

To minimize attrition, interviews that could not be completed in person 

at the 9-month interviews were completed by telephone. 

The MET/CBT5 intervention consisted of five sessions provided over 5 to 8

weeks; the combined MET/CBT5 + CBT7, MDFT, and ACRA interventions

lasted 12 to 14 weeks; and the FSN intervention lasted 12 weeks but had a

3
4

limited aftercare component that lasted another 12 weeks. Thus, the 

3-month interview was usually the discharge interview, and the 6- and 

9-month interviews occurred approximately 3 and 6 months after discharge.

Data collection included use of the Global Appraisal of Individual Needs

(GAIN) (Dennis, 1998), an onsite urine test for cannabis and cocaine, and 

a collateral assessment form with questions paralleling those of GAIN and

addressing parenting issues. The full research design is described in Dennis

et al. (under review).

The study began in late 1997. The recruitment and treatment phases of 

the study occurred over 18 months. Adolescents were followed up on a 

flow basis through spring 2000. Analyses were conducted on baseline 

characteristics of study participants, outcomes, and cost-effectiveness and

are currently in the process of being published in peer-reviewed journals.

Additional analyses will be conducted to learn more about the interventions

and their interaction with different types of adolescents.

CYT followup data were based on more than 95 percent of the adolescents

who participated in the study at 3-, 6-, 9-, and 12-month intervals after

their intake date. These data revealed that the average number of days 

of use across conditions dropped from 36 days at intake to 23 days at 3

months and 21 days at 6 months. These results were largely sustained, with

an average of 22 days at both 9 months and 12 months. An examination 

of individual response to the treatments showed that 70 percent of the 

participants reduced their marijuana use from intake to 6 months, including

29 percent who eliminated their use in months 4 through 6 and another 29

percent who cut their use by half or more. At 12 months, 69 percent were

using less than at intake, including 35 percent who had eliminated their

marijuana use in months 10 through 12 and 23 percent who cut their use

by half or more.

Analyses of the effectiveness of the different interventions suggest that the

outcomes for each intervention followed a similar pattern. Although some

statistical differences existed at a given point in time, no one treatment was

consistently better across time. This finding was a major advance over the

mixed results from previous studies of existing models of adolescent 

treatment practice (with results that ranged from reductions in use among

20 percent of participants to increases in 18 percent) and the prevailing

course of substance use (which increases sixfold between ages 12 and 21)

(Dennis et al., in press).

The need for evidence-based treatment is great because the number of 

adolescents presenting for treatment of marijuana use disorders increased

135 percent from 1992 to 1998 and many treatment providers need to 

create adolescent services or expand their outpatient services. Because all

of the CYT treatments worked, the Steering Committee recommended that

service providers base their decisions about which ones to use on their

resources and logistical constraints. For example, some agencies may prefer

an approach that relies primarily on a group modality. Other providers may

prefer an individualized approach because it fits with their agency’s treatment

philosophy or because their facility is located in a rural area.
Purpose, Development, and Organization of This Manual

This manual provides guidance on how to prepare for and conduct the

ACRA intervention sessions with adolescents and caregivers. It also provides

examples of exchanges between therapists and adolescents to illustrate

what happens in actual ACRA sessions. Much of the adolescent community

reinforcement approach is based on previous work using a community 

reinforcement approach (CRA) (Meyers & Smith, 1995). The CRA 

intervention was adapted for use with adolescents who abuse or are 

dependent on marijuana. One modification is the inclusion of urine 

screening for drugs, a procedure commonly used in adolescent substance

abuse treatment. Other modifications of CRA used in this manual include

(1) the addition of specific sessions for a caregiver only and for a caregiver

and an adolescent together, (2) changes in the Happiness Scale and Goals

of Counseling forms so that the categories are relevant to adolescents, (3)

inclusion of urine-screening feedback procedures, (4) inclusion of dialog 

representative of interchanges between adolescents and therapists, and 

(5) requirements that snacks be provided routinely for the adolescents

receiving the intervention. Some CRA procedures were eliminated (e.g., 

use of disulfiram, marital therapy) because they were not relevant for 

adolescents.

Modifications were pilot tested by therapists working with adolescents in

tape-recorded sessions that were then made available to the principal

authors of the manual for review. It is extremely difficult to capture realistic

exchanges between therapists and adolescents in a manual because of the

many extraneous variables that impact behavior during a treatment session.

Nevertheless, the authors attempted to document as accurately as possible

what it is like to conduct ACRA sessions. Therefore, the therapists and

supervisor reviewed initial drafts of the manual and suggested changes to

reflect actual practice.

This manual is organized into seven parts. Part I provides an introduction to

ACRA. Part II provides an overview of the general theoretical underpinnings

of the CRA model and an overview of the ACRA intervention. Part III provides

detailed descriptions of 12 core procedures used in ACRA: 8 of the 

procedures apply to individual work with an adolescent, 2 procedures apply

to individual work with caregivers, and 2 procedures apply to working with a

caregiver and an adolescent together. Part IV provides descriptions of three

optional procedures related to failure to attend, finding jobs, and anger

management. Part V provides details on protocol monitoring procedures,

including clinical supervision. Part VI contains the references. Part VII 

contains additional information on the CYT study. 

5

II. Overview of the Treatment Model

Adaptation of Procedures From the Community

Reinforcement Approach

Community reinforcement approach procedures were adapted in developing

the adolescent community reinforcement approach procedures for youth

who use and abuse marijuana, alcohol, and occasionally other substances.

CRA procedures were adapted to meet the developmental needs of 

adolescents. It was also important that the procedures could be replicated

in practice settings. CRA procedures are documented in treatment guides

and manuals (Budney & Higgins, 1998; Meyers & Smith, 1995). These 

CRA procedures vary based on the research groups and target populations

involved. For example, procedures for working with clients with cocaine

addiction have included the use of vouchers as a contingency-management

system in which drug abstinence is reinforced with points that have a 

monetary value that can be exchanged for desired prosocial items or 

activities (Budney and Higgins, 1998). When CRA procedures have been

applied to alcohol abuse treatment, they have included the use of disulfiram

or sobriety sampling (Meyers & Smith, 1997) and did not include the use of

vouchers. 

General Theoretical Assumptions of CRA and ACRA

Meyers and Smith (1995, p. 1) describe the theoretical underpinnings of

CRA in this way:

The Community Reinforcement Approach acknowledges the powerful role

of environmental contingencies in encouraging or discouraging drug use,

and thus attempts to rearrange these contingencies such that sober

behavior is more rewarding than using behavior. CRA blends this operant

model with a social systems approach. The overall philosophy is to use the

community to reward nonusing behavior so that the client makes healthy

lifestyle changes.

CRA procedures use operant techniques and skills training activities to

teach individuals new ways of handling life’s problems without drugs or

alcohol. Traditionally, CRA is provided in an individual, context-specific

approach that focuses on the interaction between individuals and those in

their environments. CRA therapists teach an adolescent when and where to

use the techniques, given the reality of each individual’s social environment.

This tailored approach is facilitated by conducting a functional analysis of

the adolescent’s behavior at the beginning of therapy. CRA therapists then

teach individuals how to build on their reinforcers, how to use existing 

community resources that will support positive change, and how to develop

a positive support system.

7
8

CRA is rooted in early work by Azrin and his colleagues (Azrin et al., 1982;

Hunt & Azrin, 1973). More recently, CRA techniques have been adapted for

use with:

• Concerned others to assist them in dealing with a loved one’s

drinking (Meyers, Dominquez & Smith, 1996; Meyers & Smith,

1997)

• Cocaine-addicted individuals (Higgins et al., 1991, 1993, 1994,

1995; Shaner et al., 1997)

• Homeless alcohol-dependent individuals (Smith, Meyers &

Delaney, 1998)

• Adolescents in an assertive aftercare approach following a period

of residential treatment (Godley, Godley & Dennis, in press) 

• Adolescent substance abusers in an approach that integrated a 

community reinforcement plus vouchers (Henggler, unpublished). 

In one of the few randomized field studies of adolescent substance abuse

treatment, Azrin and his colleagues (1994) compared the effectiveness of a

behavioral outpatient treatment program for substance-abusing adolescents

with a supportive counseling program. Although not called a community

reinforcement approach, the behavioral treatment program procedures

appeared to have a common theoretical base. Like CRA, it incorporated 

parent attendance at all treatment sessions. When it was compared with 

the supportive counseling condition, the behavioral condition proved 

superior for reducing drug and alcohol use and improving school and work 

attendance (Azrin, Donohue et al., 1994; Azrin, McMahon et al., 1994).

A set of core procedures central to the CRA intervention includes:

• Using the functional analysis of substance use and the functional

analysis of prosocial behavior

• Developing well-specified treatment goals and practical strategies

to reach the goals, including training in using problem-solving

skills, effective communication skills, and prosocial skills

• Emphasizing developing prosocial behaviors to replace activities

related to substance use.

ACRA Goals

The goals of the individual ACRA sessions with adolescents are to: 

• Promote abstinence from marijuana, other drugs, and alcohol.

ACRA helps promote abstinence by working with adolescents to

modify the conditions that promote substance use. To reach this

goal, therapists use a procedure called the functional analysis of 
substance use that helps an adolescent identify (1) the

antecedents to marijuana, other drug, and alcohol use, (2) the

actual marijuana- or other drug-using behavior, and (3) the 

positive and negative consequences of their use. 

• Promote positive social activity. ACRA assumes that adolescents

can be more successful at terminating substance use behavior if

they learn how to increase their involvement in positive, 

reinforcing behaviors. A procedure called the functional analysis

of prosocial behavior helps adolescents identify prosocial activities

they enjoy or would enjoy and helps them see the benefits of

being involved in these activities. Therapists then gradually

encourage adolescents to spend more time in these activities.

• Promote positive peer relationships. This goal parallels the goal

on positive social activity. Substance-abusing adolescents often

center activities with friends on substance use. With this goal,

ACRA therapists help adolescents identify attributes of “healthy”

friendships and help them learn how to find and make new

friends, how to deal with negativity, and how to ask for support.

• Promote improved relationships with family. Adolescence is a

stressful time in the relationship between caregivers and the 

adolescent children in their care. This situation is probably even

more stressful in families in which the adolescent is a substance

abuser. Any distrust that caregivers have for the adolescent is

reinforced by the adolescents’ involvement in substance use.

ACRA seeks to improve communication among family members 

as a way to enhance relationships.

The goals of the ACRA sessions with the caregivers are to: 

• Motivate their participation in the ACRA process. It is possible

that some caregivers may be reluctant to participate in an 

adolescent’s treatment process. They may feel that the adolescent

has “messed up” and the role of the treatment process is to “fix”

him or her. The ACRA therapist’s role is to help caregivers 

understand that they have an important role in helping their 

adolescent overcome a problem and to motivate the caregivers 

to participate in the therapy process.

• Promote the adolescent’s abstinence from marijuana, other

drugs, and alcohol. ACRA procedures teach family members

behavioral skills aimed at discouraging an adolescent’s drug use.

The goal is to help caregivers understand how their behavior

impacts the adolescent’s substance use so that the caregivers will

be motivated to change their own behavior to promote the 

adolescent’s abstinence. 

• Provide information to the caregivers about effective parenting 

practices. The information is based on the research of Catalano

9
10

(1998), Hops (1998), and Bry (1998) and includes measures to

keep the adolescent from relapsing. These important parenting

practices are:

! Be a role model by refraining from using drugs or alcohol

in front of the adolescents in their care. This is the single

most important parenting practice for caregivers.

! Increase positive communication with the adolescents in

their care.

! Monitor adolescents’ activities, including knowing where

they are and whom they are with. 

!" Become involved in adolescents’ life outside the home by

encouraging and promoting prosocial activities.

! Teach and practice positive communication and problemsolving skills in the family. Improving communication and

problem-solving skills within the family promotes a more

positive relationship between adolescents and caregivers

and helps create a familial environment that is more 

conducive to recovery.

The ACRA goals of working with the community are to:

• Improve an adolescent’s environment. An adolescent may be

interacting with several different systems, such as schools and the

probation department. The therapist’s role is to serve as the 

adolescent’s advocate in these settings. There may be times when

the therapist directly interacts with school personnel or helps

teach the caregivers skills so that they can advocate at school for

the adolescent in their care. If the adolescent is on probation, the

therapist can work with him or her and the probation officer to

encourage fulfillment of the probation requirements.

• Teach the adolescent problem-solving skills and appropriate

interactions through the use of roleplaying. 

About This Manual

This manual provides information about ACRA by presenting the sequence

and suggested content of each session and how to implement each 

procedure. Procedures and sessions are not synonymous. The order of 

the procedures can be varied according to the needs of the adolescent 

and the caregiver. 

Target Population

The manual describes an outpatient intervention that has been designed 

to be delivered in weekly sessions. The target population is adolescents 
appropriate for an outpatient or intensive outpatient level of care as defined

by the American Society of Addiction Medicine’s (1996) patient placement

criteria. It is recommended that, before beginning this or any treatment

program, adolescents first participate in a comprehensive biopsychosocial

assessment to determine the appropriate level of care placement. The

Cannabis Youth Treatment study used GAIN (Dennis, 1998). All the 

adolescents who participated in the testing of this intervention (1) were

between the ages 12 and 18, (2) met criteria for current Diagnostic and

Statistical Manual of Mental Disorders (DSM–IV) (American Psychiatric

Association, 1994) diagnosis of cannabis abuse or dependence, and (3) had

used marijuana in the last 90 days (or 90 days before being in a controlled

environment). Adolescents were excluded from the study if the intake

assessment revealed any of the following because they would be more 

appropriately served in a residential treatment program: (1) use of alcohol

45 or more days of the 90 days before intake (or before being in a controlled

environment where relevant), (2) an acute medical condition that required

immediate treatment or was likely to prohibit full participation in treatment

and could not be managed in this level of care, (3) an acute psychological

condition that required immediate treatment and/or was likely to prohibit

full participation in treatment and could not be managed at this level of

care, or (4) a history of violent behavior or severe conduct disorder.

ACRA was tested at two treatment sites. One was a large adolescent substance

abuse treatment provider in Illinois that can provide all levels of care (i.e.,

early intervention, outpatient, intensive outpatient, and residential); the

second was a major medical center affiliated with a university in

Philadelphia. The following data are based on the 100 adolescents who 

participated in the ACRA intervention. The average age of the adolescents

was 16 years, and 20 percent were female. In terms of race or ethnic 

composition, 44 percent of participants were black, 53 percent were white,

1 percent were Hispanic, and 2 percent were from other race or ethnic

groups. Fifty-nine percent were from single-parent homes. In terms of 

education and employment, 86 percent reported being in school in the 

last 90 days, and 39 percent reported working in the last 90 days. Sixty-two 

percent reported current criminal justice involvement, and 66 percent

reported some type of victimization. 

Seventy-eight percent of the adolescents reported they were sexually active,

with 47 percent reporting multiple sex partners in the last 90 days; almost

a quarter said they had had unprotected sex. Sixty-eight percent reported

weekly marijuana use, 43 percent reported symptoms of marijuana 

dependence, and 45 percent reported symptoms of marijuana abuse. Fifteen

percent reported weekly alcohol use, 12 percent reported symptoms of 

alcohol dependence, and 30 percent reported symptoms of alcohol abuse.

None of the adolescents reported weekly use or dependence symptoms of

other drugs. Nine percent reported symptoms of abuse related to drugs

other than alcohol or marijuana.

11
12

Overview of ACRA Sessions

Duration

The ACRA intervention described in this manual lasts for 3 months.

ACRA Therapist/Participants Ratio

During the CYT study, the ratio of therapists to adolescents was 

approximately 1 to 12. Therapists were involved in other activities that 

did not require a regular practice setting, so there was a higher ratio of 

participants to therapists in such a setting.

Contact Frequency

Individual face-to-face contact. Therapists provide approximately 10 

individual sessions with the adolescent and 2 sessions with the adolescent

and caregiver together over a 12- to 14-week period. Sessions usually last

60 minutes. The length of the session can vary according to the needs of

the teen or the caregiver or at the discretion of the therapist. Other 

contacts by telephone or letter may be necessary between the in-person

contacts to provide encouragement or motivation. If either the adolescent

or the caregiver is unwilling to come to treatment, the therapist can offer

the unused appointments to the one willing to come. For example, if the

adolescent attends only five sessions and then refuses further treatment but

the caregiver expresses interest in more than the two individual sessions

allotted for a caregiver, the therapist can offer the caregiver additional sessions.

Caregiver contact. Therapists are expected to meet with caregivers for 

four face-to-face sessions (two with the caregiver alone and two with the 

caregiver and adolescent). If the adolescent lives with both parents, the

therapist attempts to engage both parents in the caregiver sessions. If for

some reason only one parent wants to or is able to attend the sessions, it is

acceptable to work with the caregiver who is willing to attend. The first 

session (procedure 9) provides an opportunity for the therapist to give an

overview of the treatment goals and develop rapport with the caregiver.

During the second session (procedure 10), the therapist and caregiver work

on learning and practicing communication skills. In the remaining two 

sessions, the therapist works with the caregiver and adolescent together to

reinforce and practice caregiver–adolescent relationship skills (procedure

11). As noted above, if the adolescent drops out of treatment, it is possible

to provide additional sessions to the caregiver.

Involvement of others in ACRA sessions. It is acceptable to invite other

people to attend ACRA sessions when appropriate. Appropriate people to

involve include a parent or other caregiver, a boyfriend or girlfriend, or

other friends. These other people who play an important role in an adolescent’s life could be involved during most of the procedures. For example, if

an adolescent and his girlfriend usually attend parties together and he is

willing to bring his girlfriend to a session, then it may be appropriate to

work with both teens on the early warning system that is part of relapse
prevention (procedure 5). It might also be appropriate for an adolescent to

bring a friend to a session to work on developing alternative prosocial

behaviors (procedure 4). Whether or not to include someone else in a 

session depends on whether that person’s involvement could help the 

adolescent attain his or her counseling goals and whether the adolescent

wants to have that person attend a session.

Contact with community resources. Contact with community resources 

is based on individual need. For example, if an adolescent is in a detention

facility, the ACRA therapist could go to that facility for a session. If the 

adolescent was referred by a school and appropriate releases are in place,

the ACRA therapist could talk to school personnel about the adolescent’s

progress in treatment and advocate for him or her. The therapist might also

provide monthly progress notes and discharge information to a criminal 

justice system case manager or a probation officer. Although these activities

are acceptable in the intervention, therapists should discuss contacts with

community resources with their clinical supervisors.

Referrals for Other Needed Services

Many adolescents requiring substance abuse treatment services have 

additional problems. It is assumed that ACRA is provided in a clinical 

environment that encourages the therapist to refer the adolescent and 

family members to other service providers for help when the adolescent 

has needs that cannot be addressed by ACRA. For example, if a therapist 

suspects that an adolescent has a mental health problem and might benefit

from medication, the therapist would provide a referral to a family physician,

a pediatrician, or a psychiatrist for a consultation. These referrals should be

made, if possible, after consultation with a clinical supervisor. The therapist

should also seek a signed release of information form from the participant

and parent so he or she can provide background information about the 

adolescent, including that the youth is in treatment for a chemicaldependence problem, to the referred professional.

As treatment progresses with an adolescent, a more severe problem than

originally thought may become apparent, and this problem may require a

higher level of care (e.g., residential treatment). In this case, the appropriate

referral should be made. There are often waiting lists for these services. If

this is the case, the ACRA therapist should continue to provide treatment

to the adolescent on an outpatient basis until there is an opening in the

higher level treatment program.

Nature of the Intervention and Timing of Procedures

The suggested sequence of procedures, by session, follows. This sequence 

is only suggested because the therapist must always pay attention to 

maintaining a therapeutic alliance and to responding to the clinical needs

of a treatment participant. For example, if the participant raises an issue

that provides an opportunity to teach a procedure, the therapist should

address the need presented by the participant rather than rigidly stay with 

a session plan. Or, if the therapist plans to conduct a functional analysis 

13
14

of substance use but the adolescent mentions a significant problem, the 

therapist can introduce the problem-solving procedure. Later, the therapist

can return to the functional analysis of substance use procedure. 

Because ACRA attempts to use the reality of an adolescent’s social 

environment, the therapist does not follow a didactic format with prescribed

examples but uses real life opportunities for learning when they occur.

Focusing on issues presented by the adolescent enhances engagement, a

primary part of ACRA. Interaction between the therapist and the adolescent

during the presentation and practice of procedures also enhances engagement

and reinforces learning.

ACRA supervisors note that this flexible approach to using procedures can

increase the difficulty of training therapists in ACRA procedures. It is easier

to teach therapists how to deliver individual procedures than how to weave

procedures into sessions as opportunities occur. Quality clinical supervision

incorporating tape reviews is essential to the training process. Clinical

supervision is described in part V.

Materials Needed

Because of the flexible nature of ACRA, the therapist should be prepared to

use a variety of procedures and materials to meet the needs the adolescent

presents during that session. The descriptions of procedures include the

materials such as clipboards, pens, handouts, and copies of clinical forms

(found at the end of each procedure section) appropriate for that procedure.

At the beginning of every session, the therapist offers the adolescent a

snack and a drink. Suggestions for snacks include chips, granola bars, fruit

bars, candy, cookies, and caffeine-free sodas or fruit juices. It is more 

practical to offer snacks packaged as one serving (not a whole bag of chips

or a package of cookies). Offering the snacks serves as a primary reinforcer

to help engage the adolescent.

Sequence and Content of Adolescent Sessions 

Session 1: In the first session, the therapist meets with the adolescent and

caregivers together for the first 15 minutes of the session. The goal is for

the therapist to introduce himself or herself, build rapport, answer questions

and provide information about the ACRA program, and make the family feel

comfortable. The therapist discusses ACRA treatment success and philosophy

and the focus of therapy sessions. He or she provides information about the

length of treatment sessions, number and type of therapy sessions, disclosure

of information policy, urine testing, and video- and audiotaping (if applicable).

The therapist should praise family members for participating in treatment

and try to make them feel comfortable by saying something like, “I’m really

glad you came to treatment; I look forward to working with you!” The 

family is encouraged to ask questions during this initial session and at any

time during treatment. The therapist should involve both the adolescent

and caregivers by talking to or directing questions to everyone in the room. 
Once the therapist reviews the necessary information with the caregiver, he

or she explains that the rest of the session will be spent with the adolescent.

The therapist’s goal for the rest of the session is to develop rapport with the

adolescent. The therapist can use the happiness scale (procedure 3) as a

basis for conversation and to find out what is important to the adolescent.

If time permits, the therapist and adolescent can begin work on the 

functional analysis of substance use (procedure 1).

Sessions 2–4: By the end of session 4, the therapist should have completed

a functional analysis of substance use (procedure 1), a functional analysis of

prosocial behavior (procedure 2), and at least one Happiness Scale form

and a Goals of Counseling form (procedure 3). Encouragement of prosocial 

behaviors (procedure 4) also begins during the first four sessions. Other

procedures may be used depending on the needs of the adolescent.

Sessions 5–10: These sessions follow a similar format but do not require

that skills be taught in a standard sequence. Standard parts of each session

include the following:

• Offering a food reward for session attendance

• Beginning the session with rapport-building interchanges

• Checking on homework completion

• Querying the adolescent about social activities or encouraging

healthy social activities

• Checking on the adolescent’s progress in completion of goals 

listed on the Goals of Counseling form

• Querying the adolescent about relationships with friends

• Querying the adolescent about relationships with family members

• Querying the adolescent about other problems

• Ending the session with a homework assignment related to the

session content

• Reinforcing attendance at the present session and encouraging 

attendance in the future

• Scheduling the time and place for the next session.

Topics and skills that should be covered in these sessions are:

• Relapse prevention skills (procedure 5)

• Communication skills (procedure 6)

• Problem-solving skills (procedure 7)

15
16

• Urine testing (procedure 8)

• Caregiver–adolescent relationship skills (procedure 11).

Session 11: This session focuses on the skills presented in procedure 11.

These skills may have been introduced earlier, but they may need to be

reviewed.

Session 12: This last session includes the review of treatment goals and 

termination of services (procedure 12).

Sequence and Content of Caregiver Sessions 

Sessions 1 and 2: The ACRA therapist meets with the caregiver without the

adolescent present. The therapist:

• Begins the session with rapport-building exchanges

• Describes the goals of ACRA treatment

• Describes four behaviors that research has shown caregivers can

do to help prevent the adolescent from relapsing

• Reinforces positive behaviors of parents or caregivers that support

the adolescent and help prevent relapse

• Uses motivational procedures to encourage parental or caregiver 

participation

• Presents communication principles

• Reinforces attendance at the present session and encourages

futures attendance

• Schedules the time and place for the next session.

Procedures 9 and 10 provide detailed descriptions for conducting the 

sessions with caregivers.

Sessions 3 and 4: The ACRA therapist meets with the caregiver and the

adolescent together. The therapist:

• Reviews the goals of ACRA and the reason the caregiver and 

adolescent attend this session together

• Reinforces attendance at the session and encourages future 

attendance

• Helps the family members identify and talk about the things they

like or appreciate about the other family members
• Reviews communication and problem-solving skills with the 

adolescent and family members

• Completes and reviews the Relationship Happiness Scale form 

(adolescent and caregiver versions)

• Practices relationship-building and communication techniques

(e.g., how to solve problems, how to ask for things, how to receive

things, how the caregiver can say no by offering alternatives, and

how to remember to be nice).

Procedure 11 provides details about how to present these skills and activities.

Note regarding attendance problems: If the adolescent and caregiver fail

to attend, the therapist must attempt to reengage the adolescent and 

caregiver in treatment. Specific procedures for improving attendance are

described in optional procedure 1.

Weekly Overview of Sessions

This section presents the information on session content by week.

Week 1: 

• The therapist meets with the caregiver and adolescent for 15 

minutes. 

• Adolescent session: The therapist meets with the adolescent 

individually. Suggested procedures include rapport building 

(procedure 1), the functional analysis of substance use 

(procedure 1), the happiness scale (procedure 3), and problem

solving (procedure 7).

• Caregiver session: The therapist meets with the caregiver 

individually for a 60-minute session. Suggested guidelines are 

outlined in procedure 9.

• The therapist contacts community resources if necessary.

Week 2:

• Adolescent session: The therapist meets with the adolescent 

following the session format (the Functional Analysis of Substance

Use form is completed by the end of this session). The therapist 

introduces ways to increase prosocial recreation (procedure 4).

• The therapist contacts community services if necessary.

Weeks 3 to 5:

• Adolescent sessions: The therapist meets with the adolescent 

following the session formats.

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18

• Caregiver session: The therapist meets with the caregiver for his

or her second session following guidelines outlined in procedure 10.

• The therapist contacts community services if necessary.

Weeks 6 and 7:

• Adolescent sessions: The therapist meets with the adolescent 

following the session format.

• Adolescent and caregiver session: The therapist meets with the 

adolescent and the caregiver following the session format and

guidelines in procedure 11.

• The therapist contacts community resources if necessary.

Weeks 8 to 10:

• Adolescent sessions: The therapist meets with the adolescent 

following the session formats.

• The therapist contacts community resources if necessary.

Week 11:

• Adolescent and caregiver session: The therapist meets with the 

adolescent and the caregiver following the session format and

guidelines for procedure 11.

Week 12:

• Adolescent session: The therapist meets with the adolescent 

following the session format and procedure 12 guidelines for

treatment closure. 

Exhibit II–1 presents a weekly timeline of the ACRA sessions. This timeline

should help therapists envision the structure and timing of the approach

and can be used as a quick reference when scheduling sessions. It lists the

procedures and the week each topic is recommended for introduction. It

also provides information on the topic and the session participants.
Exhibit II–1:

Timeline of ACRA Treatment Sessions,

Treatment Procedures, and Participants

Procedure Topics Session 

Number Timeframe Covered Participants

1 Weeks 1 to 4 • Functional analysis of substance use Adolescent 

Ongoing • Rapport building Caregiver and 

Adolescent 

2 Weeks 2 to 4 • Functional analysis of prosocial behavior Adolescent 

3* Weeks 1 to 4 • First happiness scale Adolescent

• First goal of counseling 

Any session • Subsequent happiness scales Adolescent

• Subsequent goals of counseling 

4* Any session, • Encouragement of prosocial behavior Adolescent

but should 

begin in 

weeks 1 to 4 

5* Any session • Relapse prevention Adolescent 

6* Any session • Communication skills Adolescent 

7* Any session • Problem-solving skills Adolescent 

8 Weeks 5 • Urine testing Adolescent

to 10 

9 Week 1 • Caregiver’s introduction to ACRA Caregiver 

10 Weeks 3 to 5 • Caregiver’s communication skills Caregiver

training and review 

11 Weeks 5 • Caregiver–adolescent relationship Caregiver and 

to 11 skills Adolescent 

12 Week 12 • Review of treatment goals and Adolescent

termination of services 

Optional* As needed • Dealing with caregiver’s or the Caregiver and/or

adolescent’s failure to attend Adolescent

• Find jobs Adolescent

• Anger management Adolescent

*The therapist has the flexibility to introduce these procedures as needed based on 

situations presented in the therapeutic session.

Key Concepts of ACRA

Positive and enthusiastic approach. One of the key concepts of ACRA is

that the therapist’s approach to the adolescent and caregivers is positive

19
20

and enthusiastic. The therapist is always looking for opportunities to

reinforce behaviors that can lead to less substance use. In contrast to some

traditional substance abuse treatment approaches, ACRA therapists are

rarely confrontational. This approach is consistent with the general CRA

philosophy and is a logical approach to use with adolescents who are

attending substance abuse treatment because of coercion (subtle or 

otherwise) from parents, school officials, or the criminal justice system. 

In addition, it is a developmentally appropriate approach with adolescents 

who may be oppositional or have a conduct disorder and whose resistance

increases when confronted. If adolescents believe they have power in the

counseling situation, they may be more willing to work with a therapist.

How ACRA therapists deal with uncooperative clients. Resistance and

compliance issues are usually common and ongoing in a therapeutic 

relationship, especially when treating adolescents. Adolescents will usually

resist change because their present behavior is meeting a need or providing

a payoff they do not want to give up. They will often cling to existing 

behaviors until there is good reason to believe that a substitute behavior

will be equally satisfying or reduce anxiety. Notice in the dialog example

below that the therapist is not confrontational or argumentative. ACRA

therapists never try to meet resistance head on and always try to avoid

power struggles. The way a therapist responds to resistant behaviors is a

critical component of ACRA. Resistance can be influenced or decreased by a

therapist’s behavior and style. It is difficult to provide step-by-step guidance

on how a therapist approaches resistance because success in this endeavor

is dependent on the total therapeutic approach. The approach should

encompass behaviors that convey the most desirable of therapeutic 

qualities, including listening with empathy; having genuine concern; 

being open-minded, affirming, reflecting; praising and having expectations; 

and being accepting and rolling with the resistance. Compliance 

enhancement strategies begin with the first contact between the therapist

and teenager and continue throughout the therapy episode. 

Most of the examples of dialog provided in this manual use “compliant”

adolescents to try to illustrate the procedures and their components. Each

adolescent will pose his or her unique challenges. It is impossible to capture

or demonstrate in one manual the wide variety of situations and problems

that a therapist will face and the many possible ways to deal with these

problems. Following is one example of how an ACRA therapist works with an

adolescent who is resistant to coming to treatment; the therapist does not

confront the adolescent about his drug use. Confrontation by the therapist

may aggravate an adolescent’s resistance. The therapist concentrates on

developing a therapeutic alliance to deal more effectively with substance

use later in therapy. 

In this example, the therapist has already met with the adolescent and 

caregiver for introductions and has provided an overview of the ACRA 

treatment process. The caregiver has left the session, and the therapist 

is now meeting with the adolescent alone.
Therapist: How are you doing with this, John?

Adolescent: Okay, I guess.

Therapist: Tell me why you think you are here and how I can help

you.

Adolescent: My mom and parole officer think I need to be here.

Therapist: Do you think you need to be here?

Adolescent: No, not at all.

Therapist: That’s okay and I can definitely understand that.

Thanks for being so honest with me. [The therapist

tries to reinforce that the teen can communicate

whatever he feels.] Most people don’t want to be here.

[Normalizes feelings.] Tell me why your mom and

parole officer think you need to be here. [Asks 

open-ended questions to try to elicit more detail.]

Adolescent: I guess because I am on probation, and my parole 

officer says I need to be.

Therapist: What are you on probation for?

Adolescent: I got busted with a joint at school. It wasn’t even mine.

Therapist: That sucks. Have you ever been to treatment before?

[Doesn’t focus on the drug use yet.]

Adolescent: No, and I don’t want to be now!

Therapist: I don’t blame you. It can be a scary thing, not knowing

what to expect and having to talk to a stranger. I want

to tell you that you don’t have to do anything that you

don’t want to do. I’m just here to help if I can. I really

appreciate your taking the time and having the courage

to come in here today. [Reinforces attendance.] I’m not

here to tell you what to do or what not to do.

[Emphasizes personal choice, freedom, and 

control.] 

Adolescent: So you’re not going to be riding me about drugs the

whole time.

Therapist: No, not at all. Do people ride you about your drug use?

[Uses the client’s own language, and asks indirectly

whether he is using drugs.]

Adolescent: Yes. It gets on my nerves.

21
22

Therapist: Who rides you? [The therapist is still not confronting

the adolescent about using. Instead, the therapist is

searching for a source of motivation that can be used

to engage the adolescent in the treatment process.]

Adolescent: My parents, parole officer, teachers, principal, some

friends—you name it.

Therapist: Sounds like that irritates you.

Adolescent: It does; you’d be irritated too!

Therapist: Do they ride you because they think you have a problem with drugs?

Adolescent: Now what do you think?

Therapist: I don’t know. They may think you have a problem, or

they may just not like the fact that you use drugs. Or

do you? I know you said you got busted but that 

doesn’t necessarily mean you are using. [The 

therapist is not assuming use or accusing the client 

of using.]

Adolescent: Yes, they think I have a problem. 

Therapist: Do you think the drugs are a problem for you?

Adolescent: Not really.

Therapist: It sounds as if you aren’t too concerned about your

drug use but others in your life are; they are getting on

your nerves about it; and that is irritating to you. [The

therapist is reflecting and summarizing.] Because you

are required to come here, let’s make the most of our

time together. Would you be willing to work together to

try to get all these people off your case? [Tries to 

create an alliance with the client. Attempts to get 

the client interested in treatment. The objective is 

to identify a complaint that the client is interested 

in changing to get him to participate in treatment.]

Adolescent: So you’re telling me that you’re not going to make me

quit? [The client admits to using.]

Therapist: I can’t tell you what to do or what is best for you. Only

you know that. You could go through treatment here

and decide that it’s worth it to you to keep using drugs

as you have been. That will be up to you. So what do

you say about trying to get all these people off your

back? [The therapist is rolling with resistance and not
initially focusing on the problem. The most important

thing is to create an alliance in the beginning—giving

the client a sense of freedom and providing choices

rather than confronting him head on or arguing with

him.]

Adolescent: And how do you suppose we can do that?

Therapist: Well, that’s what I would like to work on together.

Because you know yourself and you know all those

people riding you a lot better than I do.

At the end of this dialog, the therapist is starting to build a relationship

with the adolescent. At this point, the therapist can start working on the

client’s compliance through problem solving. The therapist will deal with

the issue of using as it comes up. The goal is to address the adolescent’s

issues as he or she raises them. This can be accomplished at the same time

the adolescent learns and practices the ACRA skills. The timing of 

implementing the procedures is a key factor in this model.

Other examples of an ACRA therapist handling a resistant client can be

found in the sections that describe developing the ACRA treatment plan

(procedure 3) and communication skills (procedure 6). These two examples

illustrate how an ACRA therapist may attempt to handle resistance while

interweaving the procedures in sessions.

The ACRA triangle. The core of ACRA is the relationship of three key ACRA

procedures: the functional analysis, the happiness scale, and the goals of

counseling. These three procedures are closely related and dependent on

one another. The three key 

procedures join together to make 

up the ACRA triangle presented in 

exhibit II–2.

ACRA uses two types of functional

analyses. One explores the

antecedents and consequences of

the adolescent’s marijuana and 

alcohol use. The other explores 

positive, enjoyable activities that

may serve as motivators for change. 

The happiness scale rates the adolescent’s feelings about several critical areas of life. It helps therapists and

adolescents identify areas of life that adolescents feel happy about and

areas in which they have problems. And, most important, it helps determine

the direction of their discussion and helps them track the progress during

treatment. 

The goals of ACRA counseling are determined from the happiness scale and

the functional analyses. Although these components are completed early in

23

ACRA

TRIANGLE

Goals of Counseling

Functional 

Analysis

Happiness

Scale

Exhibit II–2: 

The ACRA Triangle
24

treatment, all three components are viewed as works in progress. Therapists

should revisit them often and ask adolescents to complete additional 

happiness scales approximately every 2 weeks.

Simple lay language. ACRA emphasizes the use of lay language. Therapists

are encouraged to use language that is easily understood by adolescents

and their families, hence the use of terms such as the happiness scale and

the goals of counseling. ACRA therapists also are encouraged to engage in a

normal conversational process when completing tasks such as the functional

analysis of substance use behavior, prosocial behavior, and the goals of

counseling. 

Flexibility of ACRA. With a few exceptions, ACRA procedures are not tied

to particular sessions. The approach is flexible, and therapists are trained to

respond to cues provided by the adolescent, react to issues raised by the

adolescent, and implement appropriate procedures in response (e.g., 

problem solving, examination of triggers).

Importance of roleplaying when learning new skills. Roleplaying is a 

critical component of the skills training used in ACRA, particularly for 

communication and problem-solving skills. It is very important that ACRA

therapists become comfortable with encouraging and helping adolescents

roleplay new skills in the protective environment of a session. Repeated

roleplays increase the probability that new skills will be used outside the

session.

Importance of homework. It is important for adolescents to complete

homework between sessions. The homework consists of practicing the new

skills and helps adolescents learn to use the new skills.

Requirements for an ACRA Therapist

Recommended Educational and Experiential Qualifications

An ACRA therapist should have a bachelor’s degree in a counseling-related

field and 5 years of experience or a master’s degree in a counseling-related

field. An ACRA therapist candidate should have a demonstrated orientation

to a behavioral or cognitive behavioral approach. Prior experience with

counseling adolescents or treating substance abuse is preferred. 

Skills and Knowledge 

Besides knowing how to deliver ACRA procedures, the therapist must have

the following:

• Good basic counseling skills

• Knowledge and understanding of the developmental issues of 

adolescence

• Education or experience in interpreting clinical assessments. 
The therapist needs to be an active listener and able to communicate 

empathy and genuineness during counseling situations with both the 

adolescent and parents. These skills promote engagement and help 

participants feel that they have some power in the therapeutic enterprise.

These skills are not always readily discernible in an interview situation.

Possible ways to assess whether a therapist has these skills are to see

whether the individual has a history of good basic counseling skills, to

review a sample therapy tape, or to obtain references from previous 

supervisors who reviewed his or her therapy tapes. 

Adolescent developmental stages and accompanying behavior are extremely

important for the therapist to know or learn during training. The therapist

should have the ability to interpret clinical assessment information so that

he or she can understand the adolescent’s background and clinical needs.

Personal Qualities 

Preferred qualities for such a therapist are a nonjudgmental attitude and a

willingness to follow established procedures of the ACRA method. Positive

and enthusiastic interpersonal skills are desired. Therapists who prefer 

analytic, solely didactic, or confrontational approaches probably are not

good candidates.

Travel and Other Special Conditions or Requirements 

Travel to an adolescent’s home or other locations may be necessary if an

adolescent has problems with transportation, does not attend sessions, or 

is in a controlled environment (e.g., a detention home). ACRA strongly

emphasizes meeting the needs of the adolescent and caregivers through

engagement.

Clinical Supervision Requirements

Weekly individual supervision and, if appropriate, group supervision by a

clinical supervisor are recommended, as well as a weekly administrative

case review meeting. A primary component of supervision is a review of

taped treatment sessions by the clinical supervisor with feedback to the

therapist on his or her ability to implement the ACRA protocol. As the

supervisor reviews tapes, he or she also reviews the ACRA Global Procedure

Checklist and the individual procedure checklists that are completed by

therapists after each session. The ACRA Global Procedure Checklist provides

an opportunity for therapists and supervisors to note what ACRA procedures

were used, as well as which ones could have been used. The ACRA Global

Procedure Checklist can be found in part V of this manual. The procedure

checklists, which follow each procedure section, describe specific steps of

each procedure. The therapist notes whether or not each step of the 

procedure is in progress, is completed, or has not been undertaken. If these

checklists are used consistently after sessions or reviewed prior to sessions,

they provide prompts to therapists to complete all steps in a given procedure.

Clinical supervision and protocol monitoring are discussed in more detail in

part V of this manual.

25

Procedure 1: Functional Analysis of Substance Use Behavior

Rationale

Functional analysis procedures provide basic information for therapists to

use while implementing adolescent community reinforcement approach

(ACRA) components during treatment (Meyers & Smith, 1995). They are

based on structured interviews that examine the antecedents and 

consequences of a specific behavior. The specific behavior of interest 

can fall into one of two categories: a substance use behavior, such as the

use of marijuana or the consumption of alcohol; or a prosocial behavior 

or activity that the adolescent enjoys, such as riding a bicycle or playing

hockey. These two types of functional analysis procedures are used in

ACRA. Procedure 1 focuses on the functional analysis of substance use.

Procedure 2 describes the functional analysis of prosocial behaviors.

Purposes of the Procedure and Learning Objectives

The first purpose of this procedure is to uncover information about the 

adolescent’s substance use behavior. One key purpose for conducting a

functional analysis of substance use is to determine the teenager’s 

“triggers” for marijuana or alcohol use. Triggers are thoughts, feelings, 

or behaviors that precede a using episode and are instrumental in leading

the individual to use. By designating the chain of events that lead to use,

the adolescent is made aware that the use of marijuana or alcohol does

not “just happen.” Rather, many small decisions lead up to the substance

use behavior and are, therefore, within the adolescent’s control. 

A second key purpose for conducting a functional analysis of substance

use is to clarify the positive and negative consequences of substance use

that occur immediately and those that the adolescent thinks may occur in

the long term. Once the teenager goes through this process, the goal is

to help him or her realize that motivations exist to stop using and there

are healthier ways to obtain some of the “pleasures” he or she gets 

from using. Information gleaned from this process is never used in a 

confrontational manner; the goal is to try to help the adolescent verbalize

the consequences of substance use/abuse/dependence.

The learning objectives are to help the adolescent:

• Begin to uncover what is powerful enough to cause the adolescent

to change his or her behavior

• Realize that motivations to stop using already exist

• Identify the triggers for substance use and their associated 

high-risk situations

• Identify and clarify substance use behavior

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• Identify the short-term positive consequences of using

• Identify the long-term negative consequences of using.

Timing, Audience, and Delivery Method

Initially complete this procedure individually with an adolescent in 

sessions 1 and 2; revisit it in later sessions; and consider it a work in

progress as the teenager’s behaviors and needs change.

Materials

General materials include snacks (e.g., chips, crackers, granola bars, fruit

bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if

applicable) a videocamera and videotapes or an audiotape recorder and

audiotapes.

Procedure-specific materials include a clipboard, pens, and two Functional

Analysis of Substance Use Behavior forms.

General Notes for the Therapist

At this early point in the relationship and basically throughout the treatment

period, you need to establish and elicit positive expectations for change.

Part of this entails persistently finding even small actions or statements

that can be praised to enhance an adolescent’s motivation for participating

in the intervention. In addition, you should maintain a positive and 

enthusiastic tone of voice. Be sure to maintain a connection with the 

adolescent. For example, you might say something such as, “I can see I’m

making you angry, so let’s start over.” 

The steps outlined below explain how to conduct a functional analysis of

substance use with the teenager at the start of therapy. However, this

process is not a one-shot effort. It may be necessary to revisit the functional

analysis of substance use process throughout therapy, as the adolescent’s

behaviors and needs change. The functional analysis of substance use, like

the functional analysis of prosocial behavior and the treatment plan, is a

work in progress. The procedures outlined below can be repeated as needed.

Forms are used to help conduct both the functional analysis of substance use

and the functional analysis of prosocial behaviors. Use the forms only as

guides. Although it is important to gather as much of the information as you

can, do not feel as if you must use the exact wording on the forms. Rather,

questions should be phrased in an open-ended manner as much as possible. If

applicable, some of the information may be taken from the adolescent’s

biopsychosocial assessment that is completed before treatment begins.

Clarify assessment information before starting this procedure so that the

teenager does not feel as if he or she is retelling the story. When talking

with an adolescent, guide the conversation so that the form can be 

completed, but avoid making the form the focal point. 
It is best to complete the Functional Analysis of Substance Abuse Behavior

form in the presence of the adolescent, but it is not necessary to structure

the session so that the focus is on answering questions. It is better to come

back to the functional analysis of substance use at a later session than to

risk alienating the adolescent by pushing him or her to provide information

that may be difficult to recall.

The goal is for you and the adolescent to begin to determine what is 

powerful enough to help the adolescent change his or her behavior. For

example, a powerful reinforcer can be to avoid going to jail. You can also

begin to assess the teenager’s internal or external motivations (e.g., Is he

or she in treatment because of probation or parents/caregivers?). During

this process, you can also learn about his or her using and nonusing friends.

You might ask, “Do you have friends who don’t smoke pot or get high? What

do they do?” Another way to identify reinforcers is to ask whom the adolescent

looks up to or who is the most positive influence in his or her life. For

example, if a teenager talks about an older brother, you might ask, “What 

is your brother’s name? Keith? So, Keith really doesn’t want you to use and

get in trouble again and have to go to jail.” Later, in this or a subsequent

session, you may want to refer to his or her desire to please Keith by 

staying away from substance use because the teenager has identified Keith

as someone whose opinion is important to him or her.

If the opportunity presents itself, use praise throughout the functional

analysis of substance use to promote engagement and to move the 

adolescent in the right direction. For example:

Adolescent: I’m not getting high as often as I used to.

Therapist: That’s excellent news, Johnny. How do you feel about

that accomplishment?

Adolescent: Good, I guess.

Therapist: Yes, I feel good about it also. Congratulations! What an

accomplishment!

At the end of the first session (and every session), praise the adolescent for

working with you. Communicate that the adolescent has provided useful

information and has worked hard.

Procedural Steps

1. Use strategies for building rapport.

2. Provide an overview of ACRA.

3. Emphasize that this approach has been successful with others. 

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4. Explain the purpose of the functional analysis of substance use,

introduce the Functional Analysis of Substance Use Behavior form,

and gather information by:

• Identifying internal and external use triggers

• Identifying and further clarifying the substance use behavior

• Identifying the short-term positive consequences of using

• Identifying the long-term negative consequences of using.

5. Summarize functional analysis of substance use information, and

praise the adolescent for participating in the session.

6. Complete the ACRA Procedure 1 Checklist—Functional Analysis of

Substance Use Behavior immediately after the session.

Detailed Description

The remainder of this section contains a detailed overview for conducting a

functional analysis of substance use with an adolescent. Procedural steps

are in bold type and are followed by further directions and comments.

Sample dialogs between a therapist and teenager are indicated in italic type. 

1. Use strategies for building rapport.

The initial conversation with each teenager is critical in the rapport-building

process. Most adolescents who drop out do so early in treatment. During

the first two sessions, focus on the importance of engagement. Get the 

adolescent excited about working with you and about the treatment. Do not

let filling out forms overshadow the rapport-building process. 

Emphasize to the adolescent that you are glad to see him or her and you

are glad that he or she came. Praise the youth for completing the assessment or for participation in previous treatment (e.g., if he or she were in

residential treatment or intensive outpatient treatment before transferring

to regular outpatient treatment). Ask, “Why did you decide to come to

treatment?” 

Set positive expectations, for example, “ACRA is a really good treatment and

has worked for a lot of kids like you.” You might say, “I’m glad we get to

work together.” Acknowledge the effort it took to come to treatment that

day: “I’m glad you came. I want you to get something out of this” or “You

can learn things that will be helpful for you.” Note that it takes a lot of

courage to come to treatment. Tell the teenager, “Anybody can get high; it

takes real courage and character to quit!” Acknowledge some discomfort on

your part and tell the youth, “I feel uncomfortable too at this point. We are

in this together.” 

Explain that you will focus on what he or she wants to do in treatment.

Emphasize the adolescent’s independence. Give the adolescent the power to

pick and choose the focus of sessions. Let the adolescent guide and move in

the direction he or she desires. The goal is to give the teenager some sense
of control during the therapy session. Tell the adolescent, “I’m not going to

ask you to do anything you don’t want to do.” You might also say, “How can

I best help you?”

Be patient; do not push an adolescent when he or she is resistant. Ask

open-ended questions as opposed to ones that require a short yes-or-no

answer like “Do you like your Mom?” Rather, you might say, “Tell me a little

bit about your relationship with your Mom.” Ask open-ended questions

about why he or she came to treatment, and let the teenager talk. Good

examples of open-ended questions or conversation starters are the following:

• Tell me a little bit about yourself.

• Tell me what brought you here today. 

• What do you think about being here?

• How do you hope to benefit from these sessions?

• Tell me more about what’s going on in school.

• How would you describe how you are feeling today?

• What’s going on today?

Many adolescents are not very verbal, so be patient as you wait for responses,

and be willing to probe for additional information. Let adolescents know

that you are there because you want to help. You might say, “We’re going to

teach you skills you need to know; then you won’t need me any more. I’m just

a guide. This isn’t forever.” Emphasize that the process is time limited, that

is, “We have a limited time to work together, so we need to try to accomplish

our business during the time allotted.” 

Try other ways to build rapport. For instance, you could try shooting baskets

with a youth to build rapport. Feel free to provide food and a drink to a

teenager. The snacks are not only potentially reinforcing; they also help

keep energy levels up while the teenager is working on treatment issues.

Use the adolescent’s language. For example, when you are talking about

whom an adolescent from Philadelphia likes to associate with when using

marijuana, you might say, “Who do you like to chill with when you are

smoking weed?”

2. Provide an overview of ACRA.

In the first session, give adolescents an overview of ACRA in simple, lay 

language appropriate for them. Tell the adolescents how many sessions are

involved both for themselves and their parents or caregivers during ACRA.

3. Emphasize that this approach has been successful with others.

Emphasize that the approach has worked for other people like the 

adolescent and can work for him or her as well.

4. Explain the purpose of the functional analysis of substance abuse,

introduce the Functional Analysis of Substance Use Behavior

form, and gather information.

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Before you begin this procedure, review and become familiar with the

teenager’s assessment information. This will help you comment on and link

any relevant information from the assessment as you complete the items on

the Functional Analysis of Substance Use Behavior form. It also communicates

to a teenager that you are familiar with and understand his or her situation.

Explain the purpose of the functional analysis of substance use, bringing

any relevant assessment information into the conversation. Introduce the

adolescent to the Functional Analysis of Substance Use Behavior form; hand

the youth a copy so he or she can follow along during the process. 

A functional analysis of substance use consists of three basic parts: 

identifying external and internal triggers to the behavior, documenting 

the behavior, and identifying the positive and negative consequences of the

behavior. Point out the connections between the three steps of a functional

analysis of substance use: triggers lead to behaviors that in turn lead to

consequences (this is called the behavioral chain). During the introduction

of the functional analysis of substance use, you will need to explain terms,

such as triggers and consequences. Try to avoid using professional jargon

that could interfere with the rapport-building process.

Information from the functional analysis of substance use is recorded on a

form that can be placed in the clinical record for future reference. This

form reflects the basic steps of the analysis noted above. Use the Functional

Analysis for Substance Use Behavior (Initial Assessment) form. Blank and

sample completed copies of the Functional Analysis of Substance Use

Behavior form are included at the end of this section. 

Deemphasize the act of filling in the form, because many adolescents are

turned off by any activity that resembles school work. A good way to begin

the procedure is to ask an adolescent to tell you about a typical situation 

in which he or she uses marijuana or alcohol. As the teenager recounts a 

typical episode, he or she will provide you with much of the information

needed for the functional analysis of substance use. Later, you can ask 

additional questions to fill in any blanks. 

Here is an example of how a therapist might introduce the functional 

analysis of substance use:

Therapist: I’d like to learn more about how you view your drug

use. I’d like you to help me understand more about

your use. I have this form called a Functional Analysis

of Substance Use Behavior. I’d like to fill it in. Could

you help me? Here’s a copy for you. We’re going to talk

about the types of things that led you to use marijuana

in the first place. These might be things in your 

environment or things you feel inside yourself. Later,

we will also talk about the positive and negative 

consequences of your marijuana use. I’d like for you 

to describe a typical time when you use marijuana or

alcohol. 
Go through the four steps of completing the Functional Analysis of

Substance Use Behavior form listed below.

Step 1: Identify internal and external use triggers and their associated

high-risk situations.

Triggers are thoughts, feelings, or behaviors that precede a using episode

and are instrumental in leading an individual to use. Reiterate that triggers

lead to behaviors, which in turn lead to consequences. (In fact, you may

want to write this on a board or clipboard before or after completing the

functional analysis of substance use.) External triggers are associated with

an individual’s environment (whom they are with when they use, where they

typically use, when they typically use), whereas internal triggers are 

associated with an individual’s internal states (what adolescents think

about, feel physically, feel emotionally before they use). Exhibit III–1 presents

a sample of the section of the form about triggers.

Exhibit III–1: Triggers

External Internal

1. Whom are you usually with when you 

use?

Friends, sister, sister’s boyfriend

2. Where do you usually use?

Friend’s house (Sue)

3. When do you usually use?

Nighttime

Explore with the adolescent the chain of events that set him or her up for

using marijuana and/or alcohol. Ask the teenager to give you an example of

a typical using episode. By addressing a typical, concrete situation, you can

ask specific questions about the event, but the teenager’s responses usually

can be applied to many situations. If you need additional information about

external triggers, the following questions can be used:

• “Whom are you usually with when you use?” (Particular friends,

groups of friends, or relatives may serve as triggers to use.)

• “Where do you usually use?” (At home? At a friend’s house? In

the woods behind the school? At school dances? This question

presents a great opportunity to point out high-risk situations.)

• “When do you usually use?” (Are there particular days or times of

the day that the adolescent uses?)

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1. What are you usually thinking about

right before you use?

Getting high and hanging out with

friends while everyone gets silly and

laughs a lot

2. What are you usually feeling

physically right before you use?

Don’t know

3. What are you usually feeling

emotionally right before you use?

Bored
34

As you are outlining triggers with a teenager, you may discover more than

one typical using situation. For instance, an adolescent typically may smoke

with a group of friends after school a few times per week, with friends every

weekend at a teen hangout in the woods, and alone in the family’s attic 

during the week. The teenager may also typically drink beer with friends at

a party at least 1 weekend night. Each of these typical use situations should

be treated separately, but functional analyses do not need to be completed

for each situation. 

Teenagers are likely to be able to use the procedure for identifying external

triggers to identify other problems. If a problem situation is discussed, have

the adolescent try to identify the triggers for the new situation without 

filling out another form. Start with the situation that is most common for 

a teenager. If the teenager identifies several similar incidents, you may want

to group them together in one functional analysis of substance use. Often,

one analysis for weekday events and one for weekend events suffice. Here is

an example of an exchange about external triggers:

Therapist: Okay, let’s talk about triggers. Do you know what a

trigger refers to?

Adolescent: Yes.

Therapist: Okay, please explain it to me.

Adolescent: Yeah, it’s like a thing on a gun.

Therapist: What do you mean?

Adolescent: Well, you pull it and it goes off.

Therapist: Okay, a trigger on a gun is like a trigger for drug use.

A trigger is something that leads to a behavior. For

example, a trigger to getting high may be hanging out

with friends who get high. Maybe the smell of marijuana

leads to wanting to get high. Does this make sense?

Adolescent: Yes.

Therapist: What are some of your triggers? What triggers you to

get high?

Adolescent: I don’t know. I guess the people I’m around, ’cause

everyone I know smokes weed.

Therapist: So everyone you know smokes weed?

Adolescent: Yeah, every day.

Therapist: Hmmm, every day. What time of the day do you 

usually get high?
Adolescent: Nighttime.

Therapist: I know you said everyone you know smokes weed.

Whom do you smoke with?

Adolescent: My friends, my sister, my sister’s boyfriend.

Therapist: Where do you usually go to get high?

Adolescent: Friend’s house.

Therapist: Which friend’s house?

Adolescent: Sue’s.

Next, ask the adolescent specific questions about his or her internal 

triggers. With a teenager who is having difficulty expressing his or her

thoughts or feelings, you might try using visual imagery, for example, “Why

don’t you close your eyes and imagine where you usually use marijuana.”

Set up the scene where he or she tells you use occurs, and use imagery to

help the teenager finish describing the whole episode. For example, if the

adolescent typically uses in his or her bedroom, you could start by asking

the adolescent to visualize the bedroom. Then go through what happens

next. Another helpful approach with an adolescent (because of his or her 

emotional and cognitive developmental level) is to provide several examples

of the type of information desired. The following are probes that can be

used to identify internal triggers.

• “What are you usually thinking about right before you use?”

Identifying the thinking process is critical because the teenager

needs to see that, at some point, he or she makes a decision to

use—using is not an automatic process. Thoughts also provide

information on the adolescent’s defense system and valuable

insight into the feelings associated with using. For example, an

adolescent might say, “I usually think about how much fun it

would be to get high with my friends.”

• “What are you usually feeling physically right before you use?”

Bodily sensations can suggest different states of emotional 

arousal. For instance, a tight feeling in the chest, sweaty palms,

and restlessness may suggest anxiety.

• “What are you usually feeling emotionally right before you use?”

Identify how the teenager feels before using. For instance, it is

important to know whether he or she typically uses out of an

emotional reaction such as anger, frustration, or despair. Then

you can spend more time on teaching adaptive behaviors in

response to stress. Examine both positive and negative emotional

states. What emotional statements trigger using behavior? For

example, an adolescent who uses because of depression is making

a statement about that depression when using. In addition, you

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need to know whether an adolescent is using primarily because of

a need to affiliate with peers. 

Here is an example of a dialog about internal triggers:

Therapist: Okay. Thanks for sharing that information on the

external triggers. You’re doing great. I’d like to ask you

more about the internal triggers you may have.

Adolescent: Okay.

Therapist: Internal triggers are those that involve your thoughts

and feelings about getting high. What are you usually

thinking about right before you use?

Adolescent: I think about getting high and hanging out with friends. 

Therapist: Okay. It sounds as if you like to spend time with

friends. Tell me a little more about the getting high part.

Adolescent: Well, I look forward to us all being together and how

we pass a blunt around and then all get silly and laugh

and have fun.

Therapist: What are you feeling physically right before you use?

Adolescent: I don’t know. [It is acceptable not to get all the 

information initially; some adolescents will be better

able to describe their feelings later in treatment.]

Therapist: Okay. Do you know what you’re feeling emotionally

right before you use?

Adolescent: I feel bored—there’s nothing to do.

Therapist: Oh, you feel bored? I wonder if we could talk about

this more.

Adolescent: Okay.

Therapist: Does getting high help you to feel less bored?

Adolescent: Yes.

Therapist: Okay, you’re doing great. This is really helping me get

to know you better. Now I want to talk about what you

use, how much, and typically how long.
Step 2: Identify and further clarify the substance use behavior.

As you move from the triggers to the using behavior itself, you have another

opportunity to impress on the adolescent the crucial connection between

these triggers and using. Say, “Tell me about what goes on when you use.”

In addition, as you talk with the adolescent about his or her use, you will

probably gather explicit details on patterns of use.

While focusing on the typical use situation identified above, gather explicit

details on the teenager’s use of the substance. The information collected

should be as specific as possible.

• “What do you usually use?” 

• “How much do you usually use?” 

• “Over how long a period of time do you usually use?”

Here are more examples:

Therapist: Okay, you’re doing great. Now I’d like to ask a few

questions to make sure I clearly understand your use

pattern. Could you tell me what drugs you use most

often.

Adolescent: Marijuana mostly, but sometimes I drink.

Therapist: Okay. Thanks for telling me. Let’s talk about each 

separately starting with your marijuana use. When you

get high, how much weed do you use and how do you

use it (for example, in a joint or blunt)?

Adolescent: One or two blunts.

Therapist: Could you clarify: one or two?

Adolescent: Two.

Therapist: You said that you use at Sue’s. Do you get high every

day?

Adolescent: It’s more like every other day.

Therapist: Okay. How much do you use and over what period of

time?

Adolescent: We smoke two blunts in about 2 hours.

Therapist: Okay. Once again thanks for reviewing this with me;

you are doing great. I appreciate your being open and

honest with me. That’s cool. Now I want to talk

about positive and negative consequences of getting

high.

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Exhibit III–2 presents a sample of the section of the functional analysis

form about behavior.

Exhibit III–2: Behavior

Behavior

1. What do you usually use?

Marijuana

2. How much do you usually use?

Two blunts, every other day

3. Over how long a period of time 

do you usually use?

A couple of hours

Step 3: Identify the short-term positive consequences of using.

Although drug abuse leads to long-term negative outcomes, adolescents

certainly must be experiencing short-term positive outcomes to continue

using. For instance, smoking marijuana may make adolescents feel more

relaxed, may make them feel more affiliated with peers, or may help them

temporarily forget their problems. It is important for you to acknowledge

these positive benefits. It is true that these benefits are short lived, but they

are enough to reinforce continued use.

The therapist’s goal is to help an adolescent find the same reinforcers in

a positive way. It often catches a teenager’s attention when a therapist

starts talking to him or her about the positive aspects of marijuana use. The

approach is not judgmental, and, therefore, it can help engage the adolescent

in treatment. You may want to briefly mention that later you will help the

teenager find healthier ways to achieve some of these positive consequences.

While focusing on the typical-use situation, encourage the adolescent to

talk about the positive aspects of using the substance. You can begin this

procedure by saying, “I’m going to ask you something you may find 

surprising: What are the things you like about using pot?” Here are some

additional ways to probe for short-term positive consequences of using:

• What do you like about using with [whom]?

• What do you like about using [where]?

• What do you like about using [when]?

• What are some of the pleasant thoughts you have while you are

using?

• What are some of the pleasant physical feelings you have while

you are using?
• What are some of the pleasant emotional feelings you have while

you are using?

For example:

Therapist: When I say consequence, what do you think I mean?

Adolescent: Well, something that happens afterward.

Therapist: Okay, yes. It’s the result of a behavior, right?

Adolescent: Yeah. 

Therapist: Okay. Well, usually there are both positive and negative

consequences of smoking marijuana. Could you tell me

more about what you think the positive consequences

of getting high are? What are some pleasant thoughts

you have while you are high?

Adolescent: I think about chilling and my future. 

Therapist: Okay. What are some of the pleasant physical feelings

you have while getting high? [Therapist could also try

to probe into what the adolescent is thinking about

his or her future.] 

Adolescent: I feel relaxed.

Therapist: Okay. What are some of the pleasant emotional feelings

you have while using?

Adolescent: I feel mellow. 

Therapist: Tell me, what do you like about getting high with your

friends, your sister, and her boyfriend?

Adolescent: It’s cool to hang out with them—they’re older than me.

Therapist: Oh, I see. What do you like about getting high at Sue’s

house?

Adolescent: Her mother is never around. So it’s cool there.

Therapist: Is there anything you like about getting high at night?

Adolescent: It’s cool to just hang out and chill.

Step 4: Identify the long-term negative consequences of using.

Up to this point, the functional analysis of substance use has served to lay

the groundwork for showing the adolescent the long-term negative 

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consequences that result from the using behavior just outlined. Now turn

your attention specifically to the problems associated with the teenager’s

use of marijuana, other drugs or alcohol.

Focusing on the specific situation outlined at the beginning of the process,

explore with the adolescent the problems that are associated with his or her

using behavior. Probe for additional problems under each problem category.

For instance, “Can you think of people you’ve had a problem with because

of your marijuana use?” If the adolescent is having difficulty providing an

example, you may want to offer examples, such as those below from the 

adolescent’s assessment information. You might ask, “What are the negative

results of your use regarding each of these?”

• Family members

• Friends

• Physical problems

• Emotional problems

• Legal consequences

• School problems

• Job problems

• Financial problems

• Other problems.

The goal is for the teenager to see the connection between substance use

behavior and negative consequences. Although the adolescent may not

always be willing to acknowledge the relationship between substance use

and negative consequence, he or she may see the connection. An adolescent

may mention a problem, and you may want to try to help him or her make

the connection between substance use and this problem. For example, “Do

you see that there is a connection between your legal problems and your

use of marijuana?” 

Some teenagers may completely resist verbalizing any negative consequences of their substance use. It is important for the ACRA therapist to

accept the client’s resistance and not to confront the adolescent. The

Functional Analysis of Substance Use Behavior form and requests for specific

information can be revisited at a later session after the relationship

between the therapist and adolescent has had time to develop. 

Here is an example of a dialog about negative consequences:

Therapist: Okay. Now that I understand what the positive 

consequences of using are, I’d like to ask you about

some of the negative or bad consequences. For 

example, how does getting high negatively affect 

your relationship with family members?

Adolescent: Well, my mother gets on my back, and my father takes

privileges away.
Therapist: It sounds as if getting high causes problems between

you and your parents.

Adolescent: Yeah, I guess so.

Therapist: How does getting high affect your friendships?

Adolescent: My girlfriend wants me to stop using.

Therapist: It sounds as if she really cares about you and wants

you to stop using?

Adolescent: Yeah.

Therapist: How else does smoking affect you negatively? Tell me

about any negative physical effects you have from

using?

Adolescent: Like forgetting things? 

Therapist: Yes, what else?

Adolescent: I often get dry mouth.

Therapist: Yes, dry mouth and memory problems are associated

with marijuana use. Do you have any other negative

physical feelings?

Adolescent: Sometimes I get tired.

Therapist: Emotionally or physically tired?

Adolescent: Both, like I want to just lie around the house.

Therapist: Like you don’t want to do much?

Adolescent: Yeah. I don’t want to do anything.

Therapist: Do you feel any negative consequences with other

parts of your life like with your school or job, or 

legally?

Adolescent: Yeah. I got suspended from school for smoking outside

the school.

Therapist: So it sounds as if getting high affects your life in

school.

Adolescent: Yeah, I got suspended, and now I have to come here.

Therapist: Do you think getting high has affected you legally?

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Adolescent: What do you mean by legally?

Therapist: I mean getting probation and going to court.

Adolescent: Okay, yeah. I’m on probation because I got caught

smoking.

Therapist: Do you spend money on marijuana?

Adolescent: Yeah.

Therapist: How much do you spend a day?

Adolescent: I spend about $5 a day.

Therapist: Okay—so that’s about five times four [days per week],

which is $20 a week. Let’s do the math. So $20 times

four [weeks] is $80 a month . . . and $80 times 12

months is $960 a year. 

Adolescent: Wow, that’s a lot of money.

Therapist: It sure is. What do you think you might spend that

money on instead of marijuana (or if you weren’t 

getting high)?

Adolescent: Clothes, a car, give it to my girlfriend.

Therapist: Oh, okay. So you would have use for that money?

Adolescent: [Laughs.] Yeah.

Therapist: You would! Okay! Well, that’s a little confusing to me,

because it seems as if you are spending your money on

things like weed. I wonder if you could explain this to

me?

Adolescent: Well, I spend money to buy weed.

Therapist: I see. So, if you stopped smoking weed, would you

have more money?

Adolescent: I guess so. Yeah.

Therapist: Wow. Thanks for helping me understand this. Let me

see whether I’ve got this right. You could save money 

if you didn’t buy weed, and if you didn’t smoke weed,

you wouldn’t buy it. So, not smoking weed would 

actually save you money? Is that correct?

Adolescent: Yeah. I never thought about that.
Therapist: Yes, it’s pretty cool. Isn’t it?

Adolescent: Yeah.

Therapist: Are you interested in saving money?

Adolescent: I guess so.

Therapist: Okay. How do you think you could begin to save

money?

Adolescent: I could smoke less often.

Therapist: Yes, you could. That’s an excellent idea. I’d like to help

you. Would that be okay?

Adolescent: Yeah.

Therapist: Good. I’m wondering whether we could talk more

about the other things you’d spend your money on? I’d

also like for you to track the amount of money you

spend each time you get high. Would that be okay?

Adolescent: Yeah.

Therapist: Okay. Good. Let’s talk more about how to do this

when we meet next time, but could you start to keep a

log of the amount of money you spend on weed?

Adolescent: Sure.

Exhibit III–3 presents a sample section of the functional analysis form about

consequences.

5. Summarize functional analysis of substance use information, and

praise the adolescent for participating in the session.

After completing the functional analysis of substance use, summarize for

the adolescent the information gathered through the process to ensure that

the functional analysis of substance use is accurate. Do not forget to use

positive reinforcement or to praise the teenager for his or her work and 

participation in the session.

This process provides the adolescent an opportunity to clarify use patterns

and provides insight into the behavioral chain involved in his or her use.

Most important, the information gained from the functional analysis of 

substance use provides the framework for the goals of counseling work that

will follow. As illustrated in the earlier sample dialog, much information can

be gathered that will be useful in later sessions. For example, you can see in 

the positive consequence column that several elements are reinforcing this

adolescent’s marijuana use. He likes to hang out with older kids and feels 

43
44

Exhibit III–3: Consequences

Short-Term Positive Consequences Long-Term Negative Consequences

relaxed when using. It also appears that he has provided good information

about his girlfriend that can be used later. It seems clear that he sees her as

reinforcing his not using.

You should already be planning how to use this information in your work

with the teenager to help him or her find ways of achieving desired feelings

in healthier ways. In the example above, part of the process will include (at

some point) asking the teenager why he likes to hang out with older kids. Is

it because it helps boost his feelings of self-esteem or power? It would also

be appropriate for the therapist to mention that she or he will be explaining

later in treatment how the adolescent and therapist will work together to

solve problems and to find healthier ways to relax or hang out with older

kids (or find other ways to feel more powerful or boost the adolescent’s

confidence).

1. What do you like about using with

friends?

[who]

They are older.

2. What do you like about using at

Sue’s house?

[where]

Sue’s mother isn’t home.

3. What do you like about using at

night?

[when]

It’s cool to hang out and chill.

4. What are some of the pleasant

thoughts you have while you are

using?

Chilling/my future

5. What are some of the pleasant 

physical feelings you have while you

are using?

Feel relaxed

6. What are some of the pleasant 

emotional feelings you have while

you are using?

Feel mellow 

1. What are the negative results of

marijuana use?

(behavior/activity in each of these

areas):

a. Family members 

Mother gets on back; father takes

away privileges.

b. Friends

Girlfriend wants me to stop using.

c. Physical feelings

Forgetting things, tired, dry mouth

d. Emotional feelings

Feel lazy

e. Legal situations

Probation, having to go to court

f. School situations

Suspended from school

g. Job situations

Not working

h. Financial situations

Spending $5 per day, $20 per

week, $80 per month, $960 per

year when using

i. Other situations
6. Complete the ACRA Procedure 1 Checklist—Functional Analysis

of Substance Use Behavior immediately after the session.

A blank copy of this form is included at the end of this section.

45
Functional Analysis for Substance Use Behavior 

(Initial Assessment)

Triggers 

Short-Term Positive Long-Term Negative 

External Internal Behavior Consequences Consequences

1. Whom are you 1. What are you 1. What do you 1. What do you like 1. What are the

usually with usually thinking usually use? about using with negative results

when you use? about right _____________? of _____________

before you use? (whom) (behavior/activity)

regarding each of

these areas:

2. Where do you 2. What are you 2. How much 2. What do you like a. Family 

usually use? usually feeling do you usually about using members

physically right use? _____________?

before you use? (where) b. Friends

c. Physical

feelings

3. When do you 3. What are you 3. Over how 3. What do you like

usually use? usually feeling long a period about using d. Emotional

emotionally right do you usually _____________? feelings

before you use? use? (when)

e. Legal

situations

4. What are some of f. School

the pleasant situations

thoughts you have 

while you are using? g. Job situations

h. Financial

situations

5. What are some of 

the pleasant i. Other 

physical feelings situations

you have while you 

are using?

6. What are some of 

the pleasant 

emotional feelings

you have while you 

are using
SAMPLE

Functional Analysis for Substance Use Behavior 

(Initial Assessment)

Triggers 

Short-Term Positive Long-Term Negative 

External Internal Behavior Consequences Consequences

1. Whom are you 1. What are you 1. What do you 1. What do you like 1. What are the

usually with usually thinking usually use? about using with negative results

when you use? about right before Marijuana Friends? of marijuana use

Everyone I know you use? (whom) (behavior/activity)

smokes weed, Getting high and They are older regarding each of 

friends, sister, hanging out with than I am. these areas:

sister’s boyfriend friends

a. Family members

Mom gets

on my back. 

Dad takes away

my privileges.

2. Where do you 2. What are you 2. How much 2. What do you like

usually use? usually feeling do you usually about using b. Friends

My friend’s physically right use? at Sue’s house? Problems with

(Sue’s) house before you use? One or two (where) girlfriend. My

I don’t know. blunts every It’s cool there; girlfriend wants

other day her mom is never me to stop 

around. using. 

c. Physical feelings

3. When do you 3. What are you 3. Over how 3. What do you like Forget things,

usually use? usually feeling long a period about using dry mouth, and

Nighttime emotionally right do you usually at night? tired

before you use? use? (when)

Bored Over a couple It’s cool to just d. Emotional

of hours hang out and chill feelings

Feel lazy

e. Legal situations

4. What are some On probation;

of the pleasant having to go to

thoughts you have court

while you are 

using? f. School

Chilling/my future situations

Suspended

from school

5. What are some of 

the pleasant g. Job situations 

physical feelings Not working

you have while you 

are using? h. Financial 

Feel relaxed situations

Spend all my

money on weed

6. What are some of i. Other 

the pleasant situations

emotional feelings

you have while you 

are using?

Feel mellow
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Procedure 1 Checklist—

Functional Analysis of Substance Use Behavior

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you establish a positive atmosphere 

for change? 

2. Did you build rapport with the adolescent 

by asking open-ended questions, using the 

adolescent’s language, and praising the 

adolescent for working with you? 

3. If this is the first session, did you provide 

an overview of the ACRA intervention 

without using jargon? 

4. Did you emphasize that this approach

has been successful with many people? 

5. Did you explain the purpose and process 

behind the functional analysis of 

substance use? 

6. Did you introduce the Functional Analysis 

of Substance Use Behavior form and go 

through the steps for completing it? 

7. Did you work with the adolescent to 

identify triggers for substance use and 

associated high-risk situations? 

8. Did you identify and further clarify the 

substance use behavior? 

9. Did you identify the short-term positive 

consequences of using and point out that 

these benefits are short lived? 

10. Did you identify the long-term negative 

consequences of using? 

11. Did you summarize the information 

provided during the functional analysis of 

substance use and help the adolescent see 

the behavioral chain involved in his or her 

use? 
Procedure 2: Functional Analysis of Prosocial Behaviors

Rationale

The functional analysis of prosocial behaviors is an important contribution

to the substance abuse treatment field. Unlike many treatment approaches

that focus solely on the negative consequences of substance use to 

motivate an adolescent to change, the ACRA intervention goes beyond

negative consequences and uses positive, enjoyable activities as motivators

to change (Azrin, Donohue, et al., 1994; Azrin, McMahon, et al., 1994;

Meyers & Smith, 1995). However, before pleasurable activities can be 

used as motivators, they have to be behaviorally defined. 

Begin this procedure by asking the adolescent to describe activities he 

or she enjoys that do not involve using alcohol or drugs. Then, as in the 

procedures for the functional analysis of substance use behavior, explore

with the adolescent the triggers and consequences of these prosocial

behaviors or activities that the adolescent enjoys.

Purposes of the Procedure and Learning Objectives

The purposes and learning objectives of this procedure are to help the 

adolescent:

• Identify pleasurable nonusing (prosocial) behavior

• Identify positive triggers for prosocial behavior

• Identify the short-term negative consequences of prosocial behavior

• Identify the long-term positive consequences of prosocial behavior

• Identify a real life activity related to increasing prosocial activity

and commit to trying it.

Timing, Audience, and Delivery Method

This procedure should be completed within the first three treatment 

sessions and then revisited as needed during treatment. Conduct it 

individually with the adolescent.

Materials

General materials include snacks (e.g., chips, crackers, granola bars, fruit

bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 

applicable) a videocamera and videotapes or an audiotape recorder and

audiotapes. 

Procedure-specific materials include a clipboard, pens, two Functional 

Analysis of Prosocial Behavior forms, activity lists, and the handouts What

Else Can I Do? and Activities That May Interest You.

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50

General Notes for the Therapist

Once again, maintain a positive and enthusiastic tone of voice to establish 

a positive atmosphere for change. Find even small things to praise to keep

the adolescent’s motivation high for participation in the intervention.

The functional analysis of prosocial behaviors, like the functional analysis 

of substance use behavior and the treatment plan, is a work in progress, 

not a one-shot effort. It may be necessary to revisit the functional analysis

process throughout the treatment episode as the adolescent’s behaviors and

needs change. The procedures outlined below can be repeated as needed.

Procedural Steps

1. Explain the purpose of the functional analysis of prosocial behavior.

2. Introduce functional analysis, and gather information by:

• Briefly reviewing the Functional Analysis of Prosocial

Behavior form

• Identifying and obtaining details on pleasurable nonusing

behavior

• Identifying positive external and internal triggers for 

prosocial behavior 

• Identifying the short-term negative consequences of the

prosocial behavior

• Identifying the long-term positive consequences of the 

prosocial behavior.

3. For accuracy, summarize the information discussed for the Functional

Analysis of Prosocial Behavior form, and help the adolescent see the 

overall picture.

4. Assign homework.

5. Complete the ACRA Procedure 2 Checklist—Functional Analysis of

Prosocial Behaviors immediately after the session.

Detailed Description

The remainder of this section contains a detailed overview for conducting a

functional analysis of prosocial behaviors with an adolescent. Procedural steps

are in bold type and are followed by further directions and comments. Sample

dialogs between a therapist and an adolescent are indicated in italic type.

1. Explain the purpose of the functional analysis of prosocial behavior.

Explain to the adolescent that there are activities that he or she has

enjoyed that did not involve alcohol or drugs. The purpose of this functional

analysis is to discover what those activities are, to discover what the 
triggers for them are, and to work on increasing opportunities to engage 

in these prosocial behaviors.

2. Introduce the functional analysis, and gather information.

Briefly review the Functional Analysis of Prosocial Behavior form. Copies 

of blank and completed Functional Analysis of Prosocial Behavior forms 

are included at the end of this section. Provide a copy of the form to the 

adolescent to allow him or her to follow along. You can record relevant

information on the form either during or after the session, depending 

on what you think will work best with a particular adolescent.

Identify and obtain details of pleasurable nonusing behavior. The 

information gathered here goes into the middle column of the behavior

chart.

• “What is the nonusing behavior/activity?” 

• “How often do you usually [activity]?”

• “How long does [activity] last?”

As with the functional analysis for substance use, one form is completed 

for a specified activity. For instance, suppose a young woman says that she 

really likes dancing. The teenager attends dance class twice per week and

goes dancing with friends on the weekend. The Functional Analysis of 

Prosocial Behavior form can be filled out by specifying her enjoyment 

of dance class. Then without necessarily filling out another form, you can 

see whether she can generalize from the first process and provide similar 

information for another pleasurable activity (e.g., dancing with friends 

on the weekend). 

Following is an example of explaining the functional analysis of prosocial

behavior process and identifying a pleasurable nonusing behavior:

Therapist: Gina, now we’re going to look at some of the positive

activities in your life that don’t involve using drugs or

alcohol. One of the things we do while working together

is try to help you increase the things in your life that

are positive, the things that make you happy. Tell me a

little bit about how you spend your spare time. I’d like

to talk about interests you have other than getting high.

What activities do you really enjoy?

Adolescent: I like pedal biking.

Therapist: Oh, what is pedal biking?

Adolescent: It’s like riding a regular bike—not a dirt bike.

51
52

Therapist: Oh, I understand. I’d like to hear more about pedal

biking. [The therapist gives the adolescent the

Functional Analysis of Prosocial Behavior form.] This

form is called a functional analysis; it’s very similar to

the form we filled out last time. I’d like you to follow

along with me as we go through the questions. Does

that sound okay with you?

Adolescent: Yeah.

Therapist: Okay, good. Let’s get started.

If the adolescent has difficulty identifying prosocial behaviors he or she

enjoys, try the following:

Develop lists of activities that are available in the community. Examples of

such lists, called What Else Can I Do? and Activities That May Interest You,

are included at the end of this section. The first one simply lists activities

available in the local area, and the second one provides lists of categories of

fun things to do by the name of businesses and their addresses and phone

numbers. These lists can be developed by working with adolescent groups

wherever they are found—in community centers, schools, or treatment

settings. When adolescents say there is nothing to do besides use drugs or

they just have trouble generating different ideas, present the lists to help

stimulate new thoughts. You can say, “This list may give you some ideas of

things you would like to do that maybe you have not thought of doing.” 

Another approach is to ask, “What is something you really enjoyed doing in

the past that did not involve alcohol or drugs?”; “What is something that

you have always wanted to do?”; or “What is something you have seen someone else try that you thought was pretty cool?” Once an activity is selected,

either from an activity list or from activities the adolescent is already

involved in, you can begin working on the functional analysis.

Identify positive external and internal triggers for prosocial behavior. As

you did with the functional analysis of substance use, ask about external

and internal triggers. Start with specific questions about external triggers.

• “Whom are you usually with when you [activity]?” 

• “Where do you usually [activity]?” 

• “When do you usually [activity]?”

Then, move to internal triggers.

• “What are you usually thinking about right before you [activity]?”

• “What are you usually feeling physically right before you [activity]?”

• “What are you usually feeling emotionally right before you 

[activity]?”
It is important to help an adolescent make the distinction between a 

trigger that leads to drug use and a trigger that leads to prosocial behavior.

Certain feelings or events may trigger both using behavior and prosocial

behavior. For instance, feeling tired may prompt a person to smoke marijuana at one time and to go for a walk at another time. Help the adolescent

discern what other factors influence him or her to use rather than to take 

a walk. Once this is determined, it may be helpful to shift the focus of the

session to refusal skills or problem-solving skills, as appropriate. 

Here is a sample exchange to determine triggers for the pedal biking 

prosocial behavior mentioned in the example above:

Therapist: Who do you usually pedal bike with?

Adolescent: Friends.

Therapist: A group of friends or one friend.

Adolescent: Usually about five friends.

Therapist: Where do you usually pedal bike?

Adolescent: In North Philadelphia, on Broad Street.

Therapist: Okay. What time of the day do you usually pedal bike?

Adolescent: From about 4:30 till 8.

Therapist: Do you mean in the evening?

Adolescent: Yeah!

Therapist: Okay. Thanks for clarifying that. Tell me more about

what you think about right before you go pedal biking.

Adolescent: About where to go and about riding my bike.

Therapist: Tell me more about that.

Adolescent: Well, I think about how I want to get out of my house,

get with my friends, and ride around and see what’s

going on.

Therapist: Okay. Do you remember what you feel before you pedal

bike? Do you feel any certain way physically? 

Adolescent: No.

Therapist: Okay, how about emotionally?

Adolescent: Cool, I guess.

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54

Therapist: Okay, great! How often do you pedal bike?

Adolescent: About two times a week.

Therapist: How long do you usually pedal bike?

Adolescent: A few hours.

Therapist: Okay. You’re doing very well! It sounds as if you really

enjoy pedal biking. 

Adolescent: Yeah, it’s cool.

Identify the short-term negative consequences of the prosocial behavior. 

Sometimes enjoyable activities also have unpleasant aspects to them.

Although the unpleasant aspects of a fun activity are usually immediate and

brief, they can sometimes deter an adolescent from engaging in them at all.

Examples of unpleasant aspects of fun are that the activity costs money or

is a long distance away, that the adolescent does not have any friends to

share the activity with, or that he or she has to get up early to do it or has

difficulty fitting it into his or her day. Listen to any negative aspects of the

intervention and determine how much of an obstacle or threat they are.

How much of a deterrent are they? Are the negative consequences serious

enough to keep an adolescent from engaging in the prosocial behavior?

Problem-solving techniques may need to be used to help the adolescent 

figure out ways to solve problems that present barriers or result in negative

consequences of engaging in the behavior. 

Thus, it is important to acknowledge the negative aspects of the activity

before moving on to the positive consequences. A negative consequence

may be something as simple as lack of access to the reinforcer. Be sure to

brainstorm ways to overcome these obstacles. If, for example, the adolescent

would enjoy going to the library but does not have a library card, help the

adolescent obtain a card. For example, ask, “How can we get a library

card?” Never assume that the adolescent will make the initial contact 

independently. Encourage the adolescent to take steps toward obtaining

desired reinforcers but be willing to locate and speak to a contact person 

in advance if there is an activity available. Be sure to review the adolescent’s

experience at such an event at the next session.

If the adolescent cannot think of any negative aspects to the enjoyable

activity, do not push too hard because you want to keep the relationship

positive.

• “What do you dislike about [activity] with [whom]?”

• “What do you dislike about [activity] [where]?” 

• “What do you dislike about [activity] [when]?” 
• “What are some of the unpleasant thoughts you have while you

are [activity]?”

• “What are some of the unpleasant physical feelings you have

while you are [activity]?” 

• “What are some of the unpleasant emotional feelings you have

while you are [activity]?”

The following is an exchange about negative consequences of the prosocial

behavior:

Therapist: Okay, now I’d like to ask you about the negative 

consequences of pedal biking. Is there anything that

you dislike about pedal biking?

Adolescent: Yeah, when I catch a flat.

Therapist: Okay, how about biking in North Philadelphia? Is there

anything you dislike about where you pedal bike?

Adolescent: Well, sometimes when I’m not in my own neighborhood,

I don’t know the people that are around.

Therapist: Okay, thanks for being honest with your answer;

you’re doing very well! Is there anything else you 

dislike about when you pedal bike?

Adolescent: No.

Therapist: Okay. When you are pedal biking, do you ever have

unpleasant thoughts?

Adolescent: Yeah, that a car might hit me.

Therapist: So it makes you uncomfortable, maybe a little nervous

about whether you can trust people you don’t know or

the drivers in cars?

Adolescent: Yeah, that’s right.

Therapist: How about any unpleasant physical feelings you may

have?

Adolescent: Yeah, like being thirsty, hungry, and sweaty!

Therapist: That happens. I understand. Do you have any 

unpleasant emotional feelings?

Adolescent: Yeah, I get scared that a car will hit me.

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56

Therapist: That is scary; have you ever been hit?

Adolescent: No.

Therapist: Good! Okay, you did a great job with this part!

Identify the long-term positive consequences of the prosocial behavior.

Spend time probing this topic so that there is no question about what the

adolescent finds reinforcing. You might say, “It looks as if you are into 

dancing (or whatever activity has been mentioned). What do you like about

dancing?” Behaviors or activities that are reinforcing in many different

areas of the adolescent’s life, such as those listed below, are good 

candidates for behaviors that can compete with using drugs (Meyers &

Smith, 1995, p. 33).

“What are the positive results of [activity] in each of these areas?” 

• Family members 

• Friends 

• Physical feelings 

• Emotional feelings 

• Legal situations

• School situations

• Job situations

• Financial situations

• Other situations.

The following dialog is an example of probing to find the positive 

consequences of an activity:

Therapist: Do you think there are positive consequences of pedal

biking?

Adolescent: What do you mean?

Therapist: I mean that because you like to pedal bike, do you

think that there are positive parts of pedal biking? For

example, do you think that pedal biking has a positive

effect on your relationship with your mother?

Adolescent: Yeah, she’s happy because it keeps me off the corner.

Therapist: Okay, great! Do you think that it has affected your 

relationship with friends?

Adolescent: Yeah, I see more people when I pedal bike.

Therapist: Okay, good. Do you think that there are positive 

physical consequences of pedal biking?

Adolescent: Yeah, I can ride farther now.
Therapist: Oh, so pedal biking seems to have positive consequences

physically. How about emotionally?

Adolescent: I feel as if I have more energy.

Therapist: Energy sounds more like a physical feeling. When I say

emotional, I’m thinking about whether you feel happy,

sad, bored, or something like that. What emotion do

you think you feel?

Adolescent: Okay. Well, I’m happy because I do it with my friends.

Therapist: Good. How about legally? Has pedal biking had any

positive consequences on your legal situation?

Adolescent: Yeah, it keeps me out of trouble.

Therapist: Yes, that is a positive consequence!

Adolescent: [Laughs.]

Therapist: Okay, has it had a positive effect on school?

Adolescent: No, I don’t think so.

Therapist: Well, you mentioned that you felt as if you had more

energy—what is the connection between that high 

energy and getting homework done?

Adolescent: Well, by the time I get home, I’m pretty tired so I don’t

always feel like doing my homework then.

Therapist: Oh, I see. How about with a job?

Adolescent: Well, I could ride my bike to work.

Therapist: That’s right! Good thinking! How about financially?

Would pedal biking have positive financial consequences?

Adolescent: Um, yeah. I could ride it to work and save money.

3. For accuracy, summarize the information discussed for the

Functional Analysis of Prosocial Behavior form, and help the 

adolescent see the overall picture.

After completing the Functional Analysis of Prosocial Behavior form, 

summarize the information gathered through the process so the adolescent

can ensure that it is correct.

The information gained from the functional analysis of prosocial behavior

provides additional material for the goals of counseling work that will follow

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58

and for subsequent sessions. Work continually with the adolescent to

increase the amount of time he or she is engaged in prosocial activities 

that do not involve substance use.

4. Assign homework.

Work together with the adolescent on a homework assignment, such as

finding information about an activity or sampling a new activity identified

during the session. Another homework option is to increase one or more

pleasurable activities identified through the functional analysis of prosocial

behavior. The homework assignment should specify the number of times or

the amount of time the adolescent will engage in the activity. At the next

session, you should discuss with the adolescent any obstacles he or she

encountered while trying to complete the homework assignment. 

If the adolescent appears unsure of his or her ability to perform these types

of tasks, it would be good idea to make some of the initial steps during the

session (e.g., call to find out when a facility is open or what the cost of

admission is, or talk with a caregiver about helping with transportation).

Do not forget to provide positive reinforcement or praise the adolescent for

his or her work and participation in the session.

5. Complete the ACRA Procedure 2 Checklist—Functional Analysis

of Prosocial Behaviors immediately after the session.

A blank copy of this form is included at the end of this section. 
skateboard

go out to eat

go to the movies

go shopping

rent a movie

walk around the 

mall

watch TV

go camping

lift weights

do aerobics

ride a motorcycle

play baseball

jog

go to Six Flags

ride a bike

join a youth 

group

play hockey

barbecue

go on a picnic

play volleyball

play golf

walk

listen to music

go to a sporting 

event 

play football 

skydive

play softball

play cards

attend a play

be in a play

travel

go camping

ride horseback 

rollerblade

bowl

work at a craft

walk the dog

play a video game

use a computer

go to the park

ride a hot air 

balloon 

attend a car show

play pool

box

go bungee 

jumping

take flying 

lessons

talk on the phone

go to a zoo

go to a museum

play a board 

game

make a pizza

go to a concert

learn to cook

go canoeing

write a letter

read a book

find a hobby

go skiing 

visit grandparents

go to a library

mow the lawn

learn something 

new

draw 

paint

write a poem

rearrange your 

room

get a job

help a neighbor

bathe a pet

test drive a car

hike

learn archery

play miniature 

golf

plant flowers

paint your room

go to a science 

center

shovel snow

start a journal

make a snowman

go snow sledding

go to an airshow

watch airplanes

visit caves

write a story

ride Metrolink

learn about 

computers

sing

play soccer

play a musical 

instrument

collect baseball 

cards

write a song

go snowboarding

get a makeover

do your nails

look at stars

play tennis

swing

pick flowers

put up new 

posters

help clean house

learn to take 

pictures

make a scrap 

book

organize your 

closet 

make candles

try new foods

go dancing

try a new dance

go fishing

take an art class

go to batting 

cages

go to a carnival

swim

go to an amusement park 

sunbathe

play Ping-Pong

make/decorate 

pottery 

go to car races

go to driving 

ranges

scuba dive

ride go-carts 

do gymnastics

make stained 

glass

try karate classes

try paintball

go rock climbing

get ice cream

go ice skating

play racquetball

take carriage/

sled rides

go to a waterpark

take a nap

start a collection

get a different 

haircut 

go boating

try jet skiing

exercise

run an errand for 

someone

go hunting

write rap music

take a class

play basketball

join a sports 

team

play laser tag

study for your 

driver’s test

go to the YMCA

wash the car

Handout

WHAT ELSE CAN I DO?

(Sample—Midwest)
be on the student 

council

visit the Statue of 

Liberty

visit the Liberty Bell

go to Sesame Place

fix a car

surf the Internet

go food shopping for an 

elderly or sick person

shovel snow for an elderly or sick person

see a Philadelphia 76ers 

game

see a Phillies game

see an Eagles game

see a Flyers game

go to Dave & Busters

go to family game rooms

ride a dirt bike

attend summer school

attend the youth empowerment project

go jogging

buy stereo equipment

listen to a Walkman or 

Discman

learn to swing dance

learn to ballroom dance

deliver newspapers

work on an ice cream 

truck

babysit

have your hair treated or 

permed

braid your hair

help your family with 

food shopping

talk to neighbors

train for a triathalon

bake a cake

erase graffiti

play at PAL (police athletic league)

speak to a group about 

being drug free

watch the Learning 

Channel

watch the Discovery 

Channel

watch MTV or VH1

recite a rhyme

eat Chinese food

make grits

study for your driver’s 

permit

go to Dorney Park

go to Great Adventure

go to the mountains

go to the beach

ride a bicycle

ride a unicycle

go to the circus

go to the ballet

see a Broadway show

go to New York City

go to Washington, D.C.

go to a gallery

fix a bike

fix a radio

play water polo

play basketball

play baseball

play tennis

play hopscotch

run track

go to a park

go whitewater rafting

join Neighborhood Watch

play Nintendo 64

go to Club Mcdonalds

go to club dances

learn to sew

learn to crochet

learn to knit

learn to read music

learn to play the piano

learn to play the guitar

take a horse and buggy 

ride

run up the art museum 

steps

hug someone

smile

laugh

Handout

WHAT ELSE CAN I DO?

(Sample—Northeast Urban Area)
SAMPLE

Handout

ACTIVITIES THAT MAY INTEREST YOU

Aircraft Flight Instruction

Metro-East Airport 2070 Triad Rd., St. Jacob 644–5411

(Shafer Field) 

Langa Air, Inc. 10 Terminal Dr., East Alton 314–895–8911

Amusement Places

Aladdin’s Castle 133 St. Clair Sq., Fairview Hts. 632–1027

Family Fun Tyme 8 Gateway Dr., Collinsville 344–7747

Family Fun Tyme 1 Schiber Ct., Maryville 288–7747

G & B Amusement Co. 6930 W. Main, Belleville 397–7609

Games People Play 699 S. Bluff Rd., Collinsville 345–0885

Time Out 131 St. Clair Sq., Fairview Heights 632–1027

Time Passages Arcade 321 Broadway, Alton 465-1270

Amusement Parks

Six Flags I–44 & Allenton Rd. 

Eureka, MO 314–938–4800

Antiques

Alton Landing Antiques 110 Alton St., Alton 462–0443

Antique Emporium 100 E. Warren, Bunker Hill 585–3929

Broadway Antiques 217 E. Broadway, Alton 465–0423

Belleville Antique Mall 208 E. Main, Belleville 234–6255

Richard’s Antiques 2 N. Main, Wood River 254–5793

Maryville Antique Mall 2114 S. Center, Maryville 345–5533

MC Antiques and More 126 E. Chain of Rocks, Granite City 797–2581

Pywacket Antiques 215 E. Central, Benld 217–835–2970

Wagon Wheel Antiques National and Academy, Pocahontas 669–2918

Aquariums (Public)

Mid-America Aquacenter 416 Hanley Industrial Ct. 

St. Louis, MO 314–647–9594

Aquariums

Aqua Pets 5733 Godfrey Rd., Godfrey 466–3474

Oceans Windows Pets 2755 E. Broadway, Alton 462–6353

The Swamp 2324 Nameoki Rd., Granite City 451–1852

Archery Ranges

Bullseye Archery 405 E. U.S. Hwy. 40, Troy 667–8616

Town Hall Archery Shop Hwy. 15 and 59th St., Belleville 235–9881
Functional Analysis of Prosocial Behavior

______________________ 

(behavior/activity)

Triggers

1. Whom are you 

usually with 

when you 

______________?

(behavior/activity)

2. Where do you 

usually

_____________?

3. When do you 

usually 

_____________?

1. What are you 

usually thinking about right 

before you 

_____________?

(behavior/activity)

2. What are you 

usually feeling

physically right 

before you 

_____________?

3. What are you 

usually feeling

emotionally

right before 

you 

_____________?

1. What is the 

nonusing 

behavior/activity?

_____________

2. How often do 

you usually

_____________?

3. How long does 

_____________

usually last?

1. What do you 

dislike about 

______________ 

(behavior/activity)

with_________?

(whom)

2. What do you 

dislike about 

______________

(behavior/activity)

_____________?

(where)

3. What do you 

dislike about 

______________ 

(behavior/activity)

_____________?

(when)

4. What are some 

of the unpleasant thoughts

you have while 

you are

_____________?

5. What are some 

of the unpleasant physical

feelings you 

have while you 

are __________?

6. What are some 

of the unpleasant emotional 

feelings you

have while you

are

_____________?

1. What are the

positive results

of

______________

(behavior/activity)

in each of these 

areas:

a. Family 

members

b. Friends 

c. Physical 

feelings

d. Emotional 

feelings

e. Legal 

situations

f. School 

situations

g. Job situations

h. Financial 

situations

i. Other 

situations

Short-Term Negative Long-Term Positive

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

External Internal Behavior Consequences Consequences

1. Whom are you 

usually with 

when you 

pedal bike ?

(behavior/activity)

Usually about 5

of my friends

2. Where do you 

usually

pedal bike ?

North Philly

3. When do you

usually 

pedal bike?

From 4:30 till 8

in the evening

1. What are you 

usually thinking about right 

before you 

pedal bike ?

(behavior/activity)

Where to go

2. What are you 

usually feeling

physically right 

before you 

pedal bike ?

I don’t feel any 

thing physically

3. What are you

usually feeling

emotionally

right before you 

pedal bike ?

Cool

1. What is the 

nonusing 

behavior/activity?

pedal biking 

2. How often do 

you usually

pedal bike ?

2 times per week

3. How long does 

pedal biking

usually last?

A few hours

1. What do you 

dislike about 

pedal biking 

(behavior/activity)

with friends ?

(whom)

When I get a flat

2. What do you 

dislike about 

 pedal biking 

(behavior/activity)

in North Philly ?

(where)

Sometimes I 

don’t know the 

people around me.

3. What do you 

dislike about 

 pedal biking 

(behavior/activity)

in the evening ?

(when)

I can’t think of 

anything that I 

dislike about it.

4. What are some

of the unpleasant thoughts

you have while

you are

pedal biking ?

I think that I

might get hit by

a car.

5. What are some

of the unpleasant physical

feelings you

have while you

are pedal biking?

I get thirsty, hungry, and sweaty.

6. What are some

of the unpleasant emotional

feelings you

have while you

are pedal biking?

I get scared that

a car might hit

me.

1. What are the

positive results

of 

pedal biking 

(behavior/activity)

in each of these 

areas:

a. Family 

members

My mom is

happy

because it

gets me off

the corner.

b. Friends 

I see more

people when

biking.

c. Physical 

feelings

I can ride

longer 

distances.

d. Emotional 

feelings

I’m more 

energetic.

e. Legal 

situations

Keeps me out

of trouble.

f. School 

situations

Keeps me out

of trouble

g. Job situations

Could ride

my bike to

work if I got

a job

h. Financial 

situations

I could save

money by riding my bike

to places.

i. Other 

situations

SAMPLE 

Functional Analysis of Prosocial Behavior 

Pedal Biking 

(behavior/activity)

Triggers
Date _______ Session # _____ Adolescent ID ______ Therapist Init.______

ACRA Procedure 2 Checklist—

Functional Analysis of Prosocial Behaviors

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you maintain a positive and enthusiastic 

tone of voice to establish a positive 

atmosphere for change? 

2. Did you explain the purpose of the 

Functional Analysis of Prosocial Behavior

form and introduce the new analysis to the 

adolescent? 

3. Did you help the adolescent identify 

pleasurable nonusing behavior, encouraging 

the adolescent to include details? 

4. Did you help the adolescent identify positive 

triggers for prosocial behavior? 

5. Did you help the adolescent identify the 

short-term negative consequences of the 

prosocial behavior? 

6. Did you help the adolescent identify the 

long-term positive consequences of the 

prosocial behavior? 

7. Did you summarize the information in 

the Functional Analysis of Prosocial Behavior

form to check accuracy and to help the 

adolescent see the overall picture? 

8. Did you help the adolescent come up with a 

homework assignment to sample a new 

activity identified through the functional 

analysis of prosocial behavior? 
Procedure 3: The Happiness Scale and the Goals of Counseling

Rationale

The happiness scale can be used frequently to assess how happy or satisfied

an adolescent is in multiple life areas. These life areas include his or her

use or nonuse of alcohol or drugs, relationships with friends and

boyfriends or girlfriends, relationships with parents or caregivers, school,

social activities, recreational activities, personal habits, legal issues,

money management, emotional well-being, communication, and general

happiness. When the Happiness Scale form is completed early in treatment,

it shows areas of an adolescent’s life most in need of attention. Although

the happiness scale can be used as a barometer of progress at any time,

one of its important uses is to gather information to help complete the

Goals of Counseling form. 

The Goals of Counseling form is the ACRA version of a treatment plan. It

allows therapists and adolescents to define treatment goals and activities

related to the same domains that are assessed with the happiness scale. 

Purpose of the Procedure and Learning Objectives

The purpose of this procedure is to help the adolescent understand how 

the happiness scale and goals of counseling assist with development of 

a treatment plan. 

The learning objectives are to:

• Devise a step-by-step intervention with the adolescent to reach his

or her treatment goals 

• Assist the adolescent in selecting and committing to a homework

assignment based on the goals of counseling.

Timing, Audience, and Delivery Method

Both the happiness scale and the goals of counseling procedures are 

conducted with the adolescent individually. A happiness scale should be

completed in sessions 1 and 2, prior to beginning work on the goals of

counseling, because it provides important information for the treatment

process. Revisit the happiness scale every 2 weeks as a way to monitor

adolescents’ ongoing progress in treatment. Therapists have found the

happiness scale helpful when an adolescent is nonverbal or is providing

very little information because it provides a starting point for discussion

in several areas. 

Complete the Goals of Counseling form during the first two or three 

sessions. Like the happiness scale, the goals of counseling can be revisited

throughout therapy. New issues that the adolescent wants to address may 

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66

emerge, or further clarification of old issues may prompt new goals to

work on. Like the functional analysis of substance use behavior and the

functional analysis for prosocial behavior, the goals of counseling should

be thought of as a work in progress. The Happiness Scale and Goals of

Counseling forms are described together in this section, but remember

that the happiness scale is always an option to be used independently at

any time. 

Materials

General materials include snacks (e.g., chips, crackers, granola bars, fruit

bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 

applicable) a videocamera and videotapes or an audiotape recorder and

audiotapes.

Procedure-specific materials include happiness scale materials, a 

clipboard, pens, and a Happiness Scale form. 

Goals of counseling materials include a clipboard, pens, a Goals of

Counseling form, and a completed Happiness Scale form.

General Notes for the Therapist 

Before beginning to use the happiness scale or work on the goals of 

counseling, review any available assessment information, including the

completed Functional Analysis of Substance Use Behavior and Functional

Analysis of Prosocial Behavior forms. This review will allow you to suggest

goals, activities, and reinforcers, based on information the adolescent has

already provided, to use in completing the Goals of Counseling form. 

As always, maintain a positive approach with the adolescent, finding 

opportunities for reinforcement.

Procedural Steps

1. Provide an overview of the happiness scale and goals of counseling.

2. Ask the adolescent to complete the Happiness Scale form, and

review it with him or her.

3. Complete the Goals of Counseling form with the adolescent.

• Choose two or three happiness scale categories that the 

adolescent rated as low to work on. 

• Work with the adolescent to devise a step-by-step intervention so

the adolescent can reach his or her goals.
• Decide on a timeframe for completing each intervention or activity.

For interventions requiring skills training, indicate when the skills

will be taught to the adolescent.

4. Assign homework. 

5. Complete the ACRA Procedure 3 Checklist—Developing the

Happiness Scale and the Goals of Counseling immediately after 

the session.

Detailed Description

The remainder of this section contains a detailed overview for using the

happiness scale and the goals of counseling. Procedural steps are in bold

type and are followed by further directions and comments. Sample dialogs

between a therapist and teenager are in italic type.

1. Provide an overview of the happiness scale and goals of counseling.

The Happiness Scale form covers 16 areas of life that the adolescent rates

on a scale of 1 to 10 indicating how happy or satisfied he or she is with

each area of his or her life. These same life areas are repeated on the Goals

of Counseling form. The 16 areas of life on the happiness scale include the 

following: marijuana use/nonuse, alcohol use/nonuse, other drug

use/nonuse, relationship with boyfriend or girlfriend, relationships with

friends, relationships with parents or caregivers, school, social activities,

recreational activities, personal habits, legal issues, money management,

emotional life, communication, general happiness, and other. 

The adolescent rates each area of life on a 1 (totally unhappy) to 10 (totally

happy) scale to reflect how happy he or she currently is with the particular

area. When completed as part of the treatment plan, the happiness scale

provides a precounseling baseline that indicates which areas of an 

adolescent’s life are most in need of attention. Blank and sample completed

copies of these forms are located at the end of this section. Help the 

adolescent define specific goals and plans for areas of his or her life in need

of attention and set timeframes in which to meet them. Even if the happiness

scale reveals that the adolescent is unhappy in many areas of his or her life,

it is important not to overwhelm the adolescent by developing too many

goals addressing too many different areas of life at once. It is always possible

to set new goals as the teen is ready to work on them. 

The following dialog is an example of how to introduce the Happiness Scale

form.

Therapist: Today, Jim, we are going to work on coming up with

the best treatment plan for you. To help us do that,

there are two forms we are going to fill out together.

The first one is called the Happiness Scale. The 

purpose of this scale is to help us get a clear idea

about how satisfied you are right now with different

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areas of your life. It will also help us pinpoint which

areas of your life you might want to work on. The 

second form is called the Goals of Counseling. On this

form, we will list specific goals that you want to reach

during treatment and then devise a plan for you to

reach those goals.

2. Ask the adolescent to complete the Happiness Scale form, and

review it with him or her.

Explain the directions for completing the Happiness Scale form. Give the 

adolescent the scale and a pencil as you describe it. 

When rating each area of life, the adolescent should use the current 

timeframe—that is, how happy he or she is today with the particular area.

Also, for areas in which an adolescent indicates some unhappiness, gently

suggest, where appropriate, there could be a link between his or her using

behavior and unhappiness.

Therapist: Let’s look first at the happiness scale. There are 16 

categories on the happiness scale. The first 14 have to

do with specific parts of your life that we’d like to look

at, like number 5, your relationships with your friends,

or number 6, your relationships with parents or 

caregivers. The last two are general categories called

general happiness and other. As you go through each

item on the form, I’d like you to rate how happy you

are right now with that part of your life, using a scale

of 1 to 10. A rating of “1” in a life area means you are

totally unhappy with that part of your life now—about

as unhappy as you could be. A rating of “10” means

you are totally happy with that part of your life right

now—you are totally satisfied and that part of your life

doesn’t need any changes. All the numbers in between

are less extreme—the lower numbers (2 through 5)

mean you are more unhappy with that area, and the

higher numbers (6 through 9) mean you are happier

with that area. Let’s look at the first one together: 

marijuana use/nonuse. Using the 1 to 10 scale, how

satisfied or happy are you right now with that part 

of your life?

When reviewing the adolescent’s responses, start with areas of his or her

life that he or she has rated high. This encourages the teenager to talk 

and helps build rapport. It also provides an opportunity to learn about what

is going well in the adolescent’s life and what strengths he or she has in 

different areas. Later, discuss areas that have been rated low or that are

more emotional (e.g., the relationships with his or her parents or alcohol 

or marijuana use).
In discussing the adolescent’s ratings, urge him or her to tell more about

why he or she rated areas in certain ways. For example:

Therapist: A 2 rating means you’re pretty unhappy with that part

of your life. Tell me a little bit about why you decided

on a 2 rating? What made you decide to rate it a 2?

As mentioned above, it is a good idea to revisit the happiness scale every 2

weeks as a way to monitor the adolescent’s ongoing progress in therapy.

The goal is to help increase his or her happiness in different aspects of life. 

If an adolescent’s ratings go up (become more positive), ask the reasons for

the change. Use the change as an opportunity to reinforce something with

the adolescent.

Therapist: It looks as if there are some things you feel good about.

Tell me what has happened in your relationships with

your friends that you feel better about.

If the ratings go down, explore with the adolescent the reasons for the

unhappiness, adding new goals to the Goals of Counseling form if necessary.

Consider, however, that things sometimes get worse at first because the

adolescent begins to think more about the situation.

3. Complete the Goals of Counseling form with the adolescent.

The same 16 areas of life listed on the Happiness Scale form are repeated

on the Goals of Counseling form. This form has two purposes: to help the

adolescent set specific goals for each of the major problem area and to

develop plans to address each goal. The form is set up to reflect these 

purposes. The first column contains the list of 16 major areas of life listed

on the happiness scale. In this column, an adolescent records specific goals

related to his or her major problem area. The second column, labeled 

intervention, is for recording the specific steps the adolescent needs to 

take to meet each goal. In the third column, timeframe, a specified period

is indicated to carry out the intervention. 

One of the advantages of completing the Goals of Counseling form is that it

does not focus solely on an adolescent’s use of marijuana and alcohol as a

problem area. As the areas are reviewed with the adolescent, it becomes

clear that you want to help him or her with problems in multiple areas. This

knowledge can help break down the resistance of some adolescents.

When completing the Goals of Counseling form, it is important to teach the

adolescent to adhere to the following basic guidelines:

• Keep statements brief. Goals and plans to reach them should be

in the form of simple statements.

• Always state goals or plans positively. This means the adolescent

should say what he or she wants and will do, rather than what he

or she does not want and will not do.

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• Use only specific, measurable behaviors. That is, goals and 

interventions should indicate how often (e.g., once a week, every

day), on what days, or for how long an intervention will be tried.

This way, progress can easily be monitored.

Offer guidance and use modeling techniques to show the adolescent how

goals and interventions can be stated according to these basic guidelines.

To begin with, choose only one or two areas of life to work on. When deciding

whether a particular area needs intervention, consider the adolescent’s 

rating of each area on the happiness scale as well as his or her other input.

When the therapist and adolescent are ready to begin the process of 

completing the form, they should start with a category from the happiness

scale in which the adolescent indicated at least a fair amount of satisfaction.

Goal setting and devising interventions for a category with some satisfaction

are usually easy for the teen. Give the adolescent several options from

among the higher rated items. The following is an example of giving the

adolescent options and setting goals: 

Therapist: You already mentioned that you are working on getting

better grades at school, and you’ve rated school low

on the happiness scale. You also rated your relationship with your parents as an area you aren’t too

happy with. Both of these are areas we can set goals

for on the Goals of Counseling form . . . or there might

be another area you have noticed from the happiness

scale that you would like to improve. What is one thing

you would like to work on or improve?

Adolescent: I guess I’d like to get better grades.

Therapist: That’s great! What type of grades would you like to get?

Adolescent: I’d like to get grades as high as I can.

Therapist: What particular grade: an A, a B, or a C? What would

you be happy with?

Adolescent: Well, I’d like to get A’s and B’s.

Therapist: Okay, let’s see whether we can put that goal down as

something we can work on while you are coming here.

Remember, the goal should follow the three guidelines:

It should to be brief, positive, and specific. Go ahead

and try stating your goal for school, making it fit all of

these rules.

Adolescent: All right. I want to get A’s and B’s at school.
Therapist: That was great, but let’s make it even more specific;

tell me when you want to get these grades. By the end

of the quarter, or semester, or what?

Adolescent: I want to get them by the end of the semester.

Therapist: Okay, Jason, let’s put this goal down here [points to

problem area/goal section of Goals of Counseling].

You said you would like to get A’s and B’s in your

classes by the end of the semester. Go ahead and write

that in. That is a good goal because we can measure

it; we can look at your daily work and your report

card and see whether you reach this goal.

Help the adolescent formulate a desired, realistic goal following the 

guidelines for each area in which the adolescent wants to set a goal. One

strategy to help the adolescent devise a goal is to ask him or her to talk

about what he or she is dissatisfied with in the problem areas of life. As he

or she talks, listen carefully. Ask the adolescent to identify a reasonable

goal to work toward that would address the problem area. 

Then help the adolescent turn negative statements into positive goals. For

example:

• “I hate school” becomes “I want to do better in school.”

• “I don’t want to go to jail” becomes “I want to change my 

behavior so I can enjoy my freedom.”

• “I get angry all the time” becomes “I’d like to feel happier and

more easy going.”

Remember to help the adolescent formulate a goal according to the three

guidelines. Use the adolescent’s own words and reinforcers. 

It is not uncommon for a goal to be made up of a number of components.

For more complex, potentially overwhelming goals, help the adolescent

break the goal down into several smaller, more manageable goals. 

Examples of good open-ended questions to help the adolescent formulate

these goals include:

• “What would make you happier about school?”

• “What do you want in your relationship with your parents?”

• “What would you like to have happen with your legal issues?”

Remember to steer the adolescent toward reasonable goals—ones that 

are attainable. Once a goal has been set and recorded in the first column

on the Goals of Counseling form, work with the adolescent to devise a 

reasonable plan (intervention) for reaching the goal. The same guidelines

used for stating goals should also be used to devise plans: Be brief, be 

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positive, and use specific (measurable) behaviors. Some goals may require

more than one intervention. Open-ended questions, such as the following,

can help the adolescent begin to develop appropriate interventions:

• “What would make this happen for you?”

• “What would make your relationship with this person better?”

• “How do you see that happening?”

• “What can we do to help you reach this goal?”

The following is an example of this discussion with a adolescent:

Therapist: The next thing we can do is fill out the intervention

blank, the types of things we do to reach the goal. Let’s

follow the same three guidelines we talked about for

setting a goal so we know exactly how you plan to

improve your grades. What are some things you can

think of that we could do now or you could do later 

to help you get A’s and B’s in all of your classes?

Adolescent: I don’t know. I guess I could study more or something.

Therapist: That’s a good idea! How much would you be willing to

study each week for your classes? Or do you need to

study more for some classes than others?

Adolescent: I don’t need to study for my art class or P.E. class, but

I could study about 3 hours each weekend for all of my

other classes.

Therapist: Great! It is usually helpful to get as specific as we can.

Can you tell me when on the weekend you think you

can do the extra 3 hours of studying?

Adolescent: Well, that’s a tough one. I usually stay out late Friday

night; so, maybe I could do it on Saturday afternoons.

Therapist: Do you really think that will work?

Adolescent: Yeah, I think so.

Therapist: Okay. Well, it would be good to try it this week, and we

can see how it goes. Let’s write that right here. [Point

to the intervention column.]

The next step in completing the Goals of Counseling form is to assign a

timeframe for each intervention in the last column. 
Therapist: Okay. When trying to reach a goal, you will find it 

helpful to set a timeframe, when you will begin working

on it and when you will do a status check to see

whether you are doing what you planned to do. When

would you like to start studying more?

Adolescent: I might as well start this weekend.

Therapist: Go ahead and write down that date as the start date

for studying. When shall we do a status check to see

whether you were able to spend the time on the 

weekend? Can we check on this in your next session?

Adolescent: Okay.

Therapist: Well, let’s write this time in the timeframe column too,

so we will remember to check on that. Sometimes, to

help people find options that help in solving problems,

we work on problem-solving techniques. In your case

we would work on problem-solving techniques to find

ways to improve your grades. Would you be willing to

do that? [You and the adolescent work on putting

problem-solving techniques in the plan as well.]

Sometimes, a particular intervention may require skills training. In this

case, indicate a timeframe for teaching the skill to the adolescent. Let 

the adolescent know that you will be teaching the skills needed to meet a

desired goal. For example:

Therapist: Jason, I plan to show you a technique that you can

use to solve that sort of problem, so don’t worry yet

about how you are going to reach your goal in the

school area. Right now, it’s just important that you

have set a goal. I will teach you the technique for

reaching it. When should we plan to go over that 

technique? Next week?

As the Goals of Counseling form is completed, monitor the number of 

intervention assignments the adolescent will be accepting for a given week.

Be careful not to overwhelm the adolescent with too many assignments at

the same time. 

If you and the adolescent are unable to finish the selected categories of the

Goals of Counseling form, and you believe the adolescent has the skills to

do so, assign a few categories for the adolescent to complete at home.

During each session, check with the adolescent and discuss the status 

of the intervention assignments from the previous week—how did the 

assignments go? Feedback and support for attempted interventions are

essential. If difficulties were encountered, work with the adolescent to 

make adaptations or devise a new plan. Roleplay parts if needed. In addition,

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review with the adolescent any upcoming intervention assignments. Provide

any skills training needed and roleplay anticipated difficulties. 

Before leaving this section, it is worthwhile to review the following common

difficulties encountered when completing the Goals of Counseling form

(Meyers & Smith, 1995, pp. 93–94):

• Not applying the three guidelines for developing goals. Most 

people talk about their problems in vague, negative, and 

nonspecific (nonmeasurable) ways. For example, “I want to 

have more fun,” or “I want to get along with my parents.”

• Designing goals and interventions that are too complex, thus

making them confusing and difficult to follow. For example, a

goal to make the varsity basketball team as a freshman when the

adolescent does not have outstanding athletic skills would be 

difficult to attain.

• Leaving out important steps that are needed to work toward a

certain goal. For example, to improve his or her grades, a student

would need to increase the amount of studying he or she does

every week, not just for 1 week.

• Including plans that are not really under the control of the adolescent. For example, if a teenage boy wants go out with a specific

girl, he cannot control whether she wants to go out with him.

• Placing the adolescent in a high-risk using situation. For example,

if you know from the functional analysis of substance use that a

certain person’s house is a trigger for substance use, you would

steer the teenager away from planning to study at that house.

As noted earlier, it is recommended that the happiness scale be revisited

every 2 weeks. Ratings on the scale will probably fluctuate as issues are

resolved and new ones appear in the adolescent’s life. Thus, it may be 

necessary, or even desirable, to revisit the Goals of Counseling form and 

create new goals as the adolescent’s life and issues proceed. The Goals of

Counseling form is a work in progress and should reflect an adolescent’s

needs as they change. 

Working with a resistant adolescent. The following dialog between an 

adolescent and a therapist illustrates how a therapist might approach filling

out the Goals of Counseling form with a resistant adolescent. The adolescent

has completed a Happiness Scale form in this session, and the therapist and

adolescent have already discussed the high and low scores and why the 

adolescent rated areas the way that he did.

Therapist: Thanks, Josh! I appreciate your letting me know how

things are going for you. Now I’d like to turn to some

goals that we can work on together while you are here

in treatment. Since you rated school as the area you
are most dissatisfied with on your happiness scale,

let’s talk more about that area. You mentioned that the

reason that you are unhappy is that you wanted to

graduate with all of your friends this year and that you

don’t think you are going to be able to. [Therapist pulls

out the Goals of Counseling form and shows it to the

adolescent.]

Adolescent: I ain’t filling out no damn form, and what makes you

think that I don’t already have goals of my own. 

Therapist: That’s cool. We don’t need this form. Tell me about the

goals that you have. [Therapist decides not to use the

form. She will conduct the goals of counseling part of

the session verbally.]

Adolescent: I told you! I want to graduate with my friends.

Therapist: What makes you think that you aren’t going to graduate?

Adolescent: I have been missing a lot of school lately because I 

got suspended for fighting. I definitely can’t miss any

more. Or then I will not graduate. My principal

already told me that.

Therapist: How much have you missed?

Adolescent: All together?

Therapist: Yes.

Adolescent: About 3 weeks total this semester. I was suspended 

for 1 week and missed a couple of days here and there

throughout the year.

Therapist: What was going on the days that you weren’t 

suspended?

Adolescent: Just slept late and skipping . . . hanging with friends.

Therapist: What do you think you have to do to graduate with

your friends? What are some of the things that need to

happen? [Therapist tries not to tell client what he

does and does not need to do. She tries to have client

verbalize steps. This increases the probability that the

client will take ownership of or become invested in

the steps needed to accomplish the goals.]

Adolescent: I need to go to school every day for the rest of the year

and make sure that I pass my math class, which I am

failing.

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76

Therapist: Sounds as if you really know what you need to do to

get there. 

Adolescent: Yeah.

Therapist: Do you think you will be able to get to class daily and

be able to pass math?

Adolescent: I think so.

Therapist: You are doing great. You have goals, know what you

need to do achieve them, and you are a very smart

guy. You seem to have all of this figured out; you know

exactly what needs to be done and can see it. I have

problems trying to keep all of these things you are

telling me straight in my head. It gets overwhelming for

me at times. Do you mind if I take notes on what we

are talking about to see if there is any way that I may

be able to help you with this goal of yours? 

Adolescent: Yeah, that’s okay.

Therapist: Thanks. So your goal is that you don’t want to have to

graduate with any other class than your current class.

[Therapist writes notes as if she needs it herself. She

will look at it later with client to illustrate his plans

to work on his goals and refer back to it in future 

sessions.]

Adolescent: Yes. 

Therapist: I like to write goals in a positive way. How would I be

able to say that in a positive way? [Attempts to break

down the steps of goal setting.]

Adolescent: Listen, I don’t know what the hell you are talking

about.

Therapist: How would you tell me your goal in a positive way?

[Continues to deal with resistance, not arguing or 

confronting.]

Adolescent: I want to graduate this year with my friends?

Therapist: Yes, great! Thank you! Now tell me again the steps you

are going to take to get there? 

Adolescent: Go to school every day and pass math. Damn, how

many times do I have to tell you?
Therapist: You seem irritated. I’m sorry, I am just trying to get all

of this down so I can remember. I really appreciate

your help. And how are you going to be able to get

there every day?

Adolescent: Just get up and go.

Therapist: You stated you oversleep a lot. What kind of things will

you do to make sure you get up?

Adolescent: I am going to set my alarm, try to go to bed earlier,

and have my buddy come by the house to give me a

ride. And if I’m not up, I can have him wake me up.

Therapist: You’ve got all of this all figured out, don’t you? You are

a good planner. [Gives praise and positive reinforcement

whenever possible.] That’s good because I would really

like to see you graduate with your friends also. So you

will set your alarm, go to bed earlier, and have your

friend help get you up. [Reflects and summarizes.] What

else can you do to make sure you get there?

Adolescent: I guess I can have my mom help me get up too.

Therapist: Sounds as if you have several ways in mind to help

you get there. And what are your plans for improving

your math grades so you won’t fail?

Adolescent: I don’t know. That teacher just doesn’t like me. She’s a

mean piece of work.

Therapist: Why doesn’t she like you?

Adolescent: She just doesn’t. She thinks I’m a troublemaker. So

she’s always on me.

Therapist: So what is it about math that you are having problems

with? Is it just the teacher?

Adolescent: No. I haven’t been doing my homework. I hate math

and don’t want to do it. At this point I am so far

behind.

Therapist: So you are feeling pretty overwhelmed at this point?

[Encourages reflection.]

Adolescent: Yes.

Therapist: So how can we get that grade up? Let’s brainstorm

some possible ideas. Can you think of any right off?

77
78

Adolescent: I could do my work the way I am supposed to.

Therapist: Good. You mentioned that you were far behind and

hate math. What are some ways that we can get you

caught up and back on track?

Adolescent: I can go to class and pay attention.

Therapist: Good. Going to class is the first step, isn’t it? When

you go to class, you’re not paying attention?

Adolescent: No. Usually writing letters to my friends or sleeping.

Therapist: So paying attention would probably help a lot. What

else would help?

Adolescent: Doing my homework; asking parents, friends, and

teachers for help; and studying the way I should.

Therapist: That is a good plan. Even though you don’t get along

with your math teacher, would you being willing to

share your goal with her—that you may have made

mistakes in the past but that you are really ready to

work at it now? Possibly asking her what you could do

to try to catch up?

Adolescent: I can. But like I told you, she’s mean and probably

doesn’t even want to hear me.

Therapist: All we can do is try. That is something that I can help

you with. We can talk about how to get her to hear

you. We could even possibly go to talk to her together if

you would like. Would you be up for that?

Adolescent: That’s cool I guess.

Therapist: Good. You have a lot of great ideas on how to accomplish this goal of yours. When thinking about goals,

sometimes it is important to put timeframes on them.

Here, let’s take a look at the notes I scribbled down on

how you want to get to where you want to be.

The therapist and client look at the Goals of Counseling form. Together,

they determine timeframes for each step or intervention. The therapist

then summarizes the goal, interventions, and timeframes discussed. 

4. Assign homework.

Help the adolescent decide on a homework assignment related to 

accomplishing the goals listed on the Goals of Counseling form. At the 

next session, review progress toward completion of the goals.
79

5. Complete the ACRA Procedure 3 Checklist—Developing the

Happiness Scale and the Goals of Counseling immediately after

the session.

A blank copy of this form is included at the end of this section.
Happiness Scale

Name:_____________________ Adolescent ID:___________ Date:________

This scale is intended to estimate your current happiness with your life in each of 

the 16 areas listed below. You are to circle one of the numbers (1 to 10) beside each 

area. Numbers toward the left side of the 10-unit scale indicate various degrees of 

unhappiness, whereas numbers toward the right side of the scale reflect increasing 

levels of happiness. Ask yourself this question as you rate each area of life: “How happy

am I today with this area of my life?” In other words, state according to the numerical

scale (1 to 10) exactly how you feel today. Try to exclude yesterday’s feelings and 

concentrate only on today’s feelings in each of the life areas. Also, try not to allow 

one category to influence the results of the other categories.

Completely Completely

Unhappy Happy

1. Marijuana use/nonuse 1 2 3 4 5 6 7 8 9 10

2. Alcohol use/nonuse 1 2 3 4 5 6 7 8 9 10

3. Other drug use/nonuse 1 2 3 4 5 6 7 8 9 10

4. Relationship with boyfriend or girlfriend 1 2 3 4 5 6 7 8 9 10

5. Relationships with friends 1 2 3 4 5 6 7 8 9 10

6. Relationships with parents or caregivers 1 2 3 4 5 6 7 8 9 10

7. School 1 2 3 4 5 6 7 8 9 10

8. Social activities 1 2 3 4 5 6 7 8 9 10

9. Recreational activities 1 2 3 4 5 6 7 8 9 10

10. Personal habits (e.g., getting up in the morning,

being on time, finishing tasks) 1 2 3 4 5 6 7 8 9 10

11. Legal issues 1 2 3 4 5 6 7 8 9 10

12. Money management 1 2 3 4 5 6 7 8 9 10

13. Emotional life (feelings) 1 2 3 4 5 6 7 8 9 10

14. Communication 1 2 3 4 5 6 7 8 9 10

15. General happiness 1 2 3 4 5 6 7 8 9 10

16. Other 1 2 3 4 5 6 7 8 9 10
Sample

Happiness Scale

Name:_____________________ Adolescent ID:___________ Date:________

This scale is intended to estimate your current happiness with your life in each of 

the 16 areas listed below. You are to circle one of the numbers (1 to 10) beside each

area. Numbers toward the left side of the 10-unit scale indicate various degrees of

unhappiness, whereas numbers toward the right side of the scale reflect increasing 

levels of happiness. Ask yourself this question as you rate each area of life: “How happy

am I today with this area of my life?” In other words, state according to the numerical

scale (1 to 10) exactly how you feel today. Try to exclude yesterday’s feelings and 

concentrate only on today’s feelings in each of the life areas. Also, try not to allow 

one category to influence the results of the other categories.

Completely Completely

Unhappy Happy

1. Marijuana use/nonuse 1 2 3 4 5 6 7 8 9 10

2. Alcohol use/nonuse 1 2 3 4 5 6 7 8 9 10

3. Other drug use/nonuse 1 2 3 4 5 6 7 8 9 10

4. Relationship with boyfriend or girlfriend 1 2 3 4 5 6 7 8 9 10

5. Relationships with friends 1 2 3 4 5 6 7 8 9 10

6. Relationships with parents or caregivers 1 2 3 4 5 6 7 8 9 10

7. School 1 2 3 4 5 6 7 8 9 10

8. Social activities 1 2 3 4 5 6 7 8 9 10

9. Recreational activities 1 2 3 4 5 6 7 8 9 10

10. Personal habits (e.g., getting up in the morning,

being on time, finishing tasks) 1 2 3 4 5 6 7 8 9 10

11. Legal issues 1 2 3 4 5 6 7 8 9 10

12. Money management 1 2 3 4 5 6 7 8 9 10

13. Emotional life (feelings) 1 2 3 4 5 6 7 8 9 10

14. Communication 1 2 3 4 5 6 7 8 9 10

15. General happiness 1 2 3 4 5 6 7 8 9 10

16. Other 1 2 3 4 5 6 7 8 9 10
Goals of Counseling

Name:____________________________________________________ Date:________________

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

1. Marijuana use/nonuse

2. Alcohol use/nonuse3. Other drug use/nonuse 4. Relationship with boyfriend or girlfriend5. Relationships with friends6. Relationships with parents or caregivers7. School8. Social activities
Goals of Counseling

Name:____________________________________________________ Date:________________

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

9. Recreational activities

10. Personal habits (e.g., getting up in the morning, 

being on time, finishing tasks) 

11. Legal issues12. Money management13. Emotional life (feelings)14. Communication15. General happiness16. Other

(Participant’s Signature) (Date) (Counselor’s Signature) (Date)

(Guardian’s Signature—Optional) (Date) (Supervisor’s Signature) (Date)
Goals of Counseling

Name: John Doe Date: 3–1

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

1. Marijuana use/nonuse

To be abstinent for 90 days.

2. Alcohol use/nonuse3. Other drug use/nonuse 4. Relationship with boyfriend or girlfriend5. Relationships with friends

• Receive communication skills training (practice roleplays with 

6. Relationships with parents or caregivers • Receive problem-solving training. 

I want to improve my relationship with my parents. • Participate in activities with my parents. 

• Report and discuss progress with my therapist. 

• Study at least 3 hours each weekend. 

7. School • Receive problem-solving training (to figure out ways to att

I want to get A’s and B’s in my classes by the end of the semester. and maintain the grades I want).

• Ask for help from my teachers, parents, friends, or therapi

need it.

• Report and discuss progress with my therapist. 

8. Social activities

• Attend weekly therapy sessions, report and discuss progre• Receive problem-solving training (to address difficulties w

staying abstinent as they arise).

• Receive refusal-skill training. • Provide random urine sample.
Goals of Counseling

Name: John Doe Date: 3–1

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

9. Recreational activities

10. Personal habits (e.g., getting up in the morning, 

being on time, finishing tasks) 

11. Legal issues12. Money management13. Emotional life (feelings)14. Communication15. General happiness16. Other

John Doe 3–1 Betty Smith 3–1 

(Participant’s Signature) (Date) (Counselor’s Signature) (Date)

Jane Doe 3-1 Bill Green 3–1 

(Guardian’s Signature—Optional) (Date) (Supervisor’s Signature) (Date)
Date _______ Session # _____ Adolescent ID ______ Therapist Init.______

ACRA Procedure 3 Checklist—

Developing the Happiness Scale and the Goals of Counseling

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you review the adolescent’s assessment 

and functional analysis information before 

developing the adolescent’s treatment plan?

2. Did you maintain a positive approach with 

the adolescent, finding opportunities for 

reinforcement?

3. Did you introduce the treatment planning 

session to the adolescent, describing the 

Happiness Scale and Goals of Counseling

forms?

4. Did you assist the adolescent in completing 

the Happiness Scale form and review it by 

asking him or her to explain the ratings? 

5. Did you assist the adolescent in completing 

the Goals of Counseling form, teaching the 

adolescent to adhere to the basic rules of 

completion? 

6. Did you assist the adolescent in coming up 

with a homework assignment based on the 

Goals of Counseling form?
87

Procedure 4: Increasing Prosocial Recreation

Rationale

Increasing prosocial recreation is an extremely important part of ACRA, 

and it is important to consider using these procedures in every session. 

The main way to help adolescents increase prosocial activities is to help

them try out or sample new activities. When adolescents do so, they 

experience timeout from using drugs and the sensation of being clean. 

Old habits are disrupted, and there is an opportunity to replace them 

with new, positive coping skills. 

Purpose of the Procedure and Learning Objectives

The purpose of this procedure is to help adolescents learn how to increase

their prosocial recreational activities to involve acquaintances who are not

likely to lead to drug use. This procedure helps adolescents:

• Recognize that being in a situation where they used in the past

puts them at risk for relapse

• Identify prosocial activities to try

• Understand how to make initial contacts for the new activities

• Identify and enlist support persons who can meet them at or

accompany them to the new activity

• Become committed to sample new, prosocial activities

• Select a new activity to try as part of the homework assignment.

Timing, Audience, and Delivery Method

Use these procedures beginning in session 2, and reinforce them with 

the adolescent at every session. This procedure is conducted with the 

adolescent individually. Emphasize using results from the functional 

analysis of substance use to pinpoint high-risk times of the week and/or

occasions when the adolescent is most likely to relapse. Prosocial 

recreational activities should be scheduled at these times. The results 

of the functional analysis of prosocial behavior also provide important 

background to help schedule prosocial activities.

Materials

General materials include snacks (e.g., chips, crackers, granola bars, fruit

bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 

applicable) a videocamera and videotapes or an audiotape recorder and

audiotapes.
88

Procedure-specific activity materials include a clipboard, pen, and activity

lists from procedure 2.

Reinforcer-sampling materials include activity lists from procedure 2 and 

a Functional Analysis of Prosocial Behavior form.

Systematic-encouragement materials include telephone, phonebook, and

activity lists from procedure 2.

Reinforcer-access materials include activity lists from procedure 2, 

newspapers, phonebooks, and pamphlets from organizations promoting

activities (e.g., youth groups, health clubs).

General Notes for the Therapist

Treatment participants usually have developed many social and recreational

activities centered on the use of alcohol or drugs. It is therefore normal for

youth to find it difficult to find new drug-free activities or friends. Because

both adults and youth with drug problems have devoted much of their free

time to getting high, they need to sample or reengage in positive leisure

time activities to find a drug-free life rewarding. Emphasize to the adolescent

that everyone wants to have fun but that there are ways other than getting

high to have fun. Encourage the adolescent to believe that together the

therapist and the adolescent can find other ways to have fun. 

In discussions of new prosocial activities with the adolescent, be both 

positive and encouraging. Explain that you understand that he or she will,

at times, miss previous activities but that reverting to old habits may bring

back serious problems or may start the teen on a path toward serious problems.

By using reinforcer sampling (described below), the adolescent learns the

appropriate skills to avoid backsliding after a relapse. Searching for new,

positive recreational outlets that are incompatible with drug use is a key

component of ACRA. In fact, the underlying theory of ACRA is that it helps

adolescents create a drug-free lifestyle that is so rewarding that they would

not want to return to drug use because of the potential to lose all that they

have achieved (e.g., improved family relationships, made new friends, 

discovered fun activities). 

Trying out or sampling new activities provides an opportunity to build 

rapport. It enables adolescents to set goals that are reasonable and attainable.

Meeting these goals promotes their self-efficacy, the belief that they can 

complete certain tasks. When people believe they can follow through with 

one task, they are usually more successful at following through with other

tasks. Self-efficacy can be generalized to the task of staying substance free.

Access to reinforcers. To do these procedures well, continually update 

your knowledge about community resources that provide fun, positive, 

recreational activities (reinforcers). Good sources of information about

these activities are local newspapers, youth groups, and service agencies.
89

Procedural Steps

1. Introduce the topic of increasing prosocial activities.

2. Help the adolescent identify prosocial activities to sample.

3. Use systematic encouragement to support a commitment to sample

one or more activities that have been identified.

4. Decide on a homework assignment together.

5. Complete the ACRA Procedure 4 Checklist—Increasing Prosocial

Recreation immediately after the session.

Detailed Description

The remainder of this section contains a detailed overview of procedures 

for increasing prosocial activities. Procedural steps are in bold type and are 

followed by further directions and comments. Sample dialogs between a

therapist and adolescent are indicated in italic type.

1. Introduce the topic of increasing prosocial activities.

The purpose for this session is to help the adolescent identify prosocial 

activities he or she would like to sample or try. It is important to convey to 

the adolescent that you understand that many of his or her previous (or

current) activities have involved the use of alcohol or drugs. You can set a

positive tone by communicating that you will work together to help find

new ways of having fun that do not involve alcohol and drugs, while

acknowledging that you understand that the adolescent will miss the 

activities that were enjoyed while using alcohol and drugs in the past. You

can help the adolescent recognize that being in a situation in which he or

she used in the past puts the teen at risk for relapse behavior.

2. Help the adolescent identify prosocial activities to sample.

High-risk occasions. The functional analysis of substance use provides

knowledge about an adolescent’s pattern of drug use (e.g., weekend use).

These times are the high-risk occasions for using; make these times the 

primary targets for new recreational alternatives. Review high-risk situations

(people, places, things) to set the stage for the adolescent to replace these

occasions with positive activities. You might say, “You mentioned you don’t

want to smoke weed during the next month, and weekends are a high-risk

time. Is there some activity that you can think of that will be fun to do 

during the weekends that does not involve alcohol or drugs? This way you

don’t have to worry about being put in detention or about your mom 

getting upset.”

Things youth do for fun. Before using this procedure, become familiar with

a wide variety of recreational resources available in your community and

develop lists of potential activities (see What Else Can I Do? and the
90

Activities That May Interest You examples at the end of procedure 2). These

lists can be developed by adolescents in youth groups, in health classes in

high schools, in groups of adolescents participating in substance abuse

treatment, or in other groups of adolescents who are easily accessible.

Review the Functional Analysis of Prosocial Behavior form to have a better 

understanding of triggers and consequences of prosocial behavior that 

an adolescent may already be participating in.

Reinforcer sampling. Getting an adolescent to try out a new social or

recreational outlet may be challenging. One way to encourage this is to

frame it as sampling. That is, encourage the adolescent to try it once to see

whether there is any potential for enjoying it. For example, you might say,

“You mentioned you liked cars. Would you like to go to a car show to see

what one is like?” 

Keep in mind that many adolescents may have little ability to socially interact

with non–drug-using peers. Most of their prior social interactions may have

been centered on the drug culture, and drug use may have been a social

lubricant for them. So you may need to refer to communication training

procedures to help them learn how to make conversation in new groups. 

Encourage the adolescent to engage in several new activities that build 

on each new success. The adolescent is likely to get more out of social 

occasions if he or she engages in them frequently and makes an effort to be

part of the group activities and conversation. For example, if the teen joins

a youth group, he or she is more likely to feel a sense of belonging to the

group and make friends more easily by attending activities weekly rather

than monthly.

It is also helpful if you can work with an adolescent to identify a friend 

or family member who would be willing to accompany him or her to an 

identified activity. The adolescent will be more likely to follow through 

if there is someone with whom he or she can share the planning, 

transportation, and fun of the activity. 

The following is a sample dialog between a therapist and an adolescent

about sampling new behaviors:

Therapist: You didn’t mention many activities you like that don’t

involve alcohol or drugs. I would like to help you find

some things you might like to do that don’t create some

of the negative situations that alcohol or drugs have

created for you but that you will have a good time

doing. To help you with this, I have a list here that is

filled with activities you might like to try or have

thought seemed pretty cool. I would like you to read

through it and circle anything you would like to do or

you already do for fun. [Gives adolescent an activity

list.]
91

[Looks at list after the adolescent circles activities

that he or she is interested in.] Of all the activities

you read through, which one would you the most like

to try?

Adolescent: Well, laser tag sounded pretty cool. I have a friend who

went a few times, and he said it was a lot of fun.

3. Use systematic encouragement to encourage a commitment to

sample one or more activities that have been identified.

If an adolescent says he or she is willing to try a new activity, explore 

possible obstacles to trying it, and present problem-solving techniques 

(procedure 7), if needed. Ask the adolescent to identify a good time to try

the activity, and get him or her to make a commitment to actually carry it

out. Advise the adolescent that structured activities (e.g., a skating party)

may be easier to participate in than a party in which the adolescent is alone

as far as communicating with others and having a good time. Stress that

participation in new activities becomes easier with practice.

An activity list that provides telephone numbers (like the one in procedure

2) is particularly helpful when sampling new behaviors. To encourage the

adolescent to find out more about an activity, you may ask him or her to

make a telephone call using the list during the session. Before doing so, you

should work with the adolescent to develop a list of questions that are

appropriate, and then roleplay a typical information-seeking call. It is also

appropriate to assign additional calls for homework. Provide encouragement

throughout, and praise any successes.

Systematic encouragement. Because it may be difficult for adolescents to

engage in a variety of new prosocial activities, Meyers and Smith (1995)

recommend three steps for encouraging adolescents: brainstorming, 

roleplaying, and providing feedback.

Never assume that an adolescent will make a first contact independently.

Brainstorm, roleplay, and give feedback to the adolescent on making the

initial contact. Brainstorming would center on obtaining information about

how to access an activity. You might say, “You said you would like to try rock

climbing; how can we find a place to learn how to do this?” You may need to

use a problem-solving procedure to help the adolescent figure out how to

access an activity.

When roleplaying, it is important to encourage the adolescent’s 

participation. Although roleplaying can be somewhat awkward for some 

people, it is an important part of encouraging the adolescent to try new 

activities because it helps him or her visualize and actually carry out what

you are asking. When possible, observe the adolescent making the initial

phone call. You can observe how well the adolescent does this activity and

provide reinforcement for taking this positive step. 
92

• Enlist social support. You might ask, “Who are the people who

don’t want you to smoke weed? Who will help you stay straight?”

Whenever possible, identify a support person who can meet or

accompany the adolescent to the new activity. This should lessen

nervousness about participation and help increase commitment

to attending because the adolescent knows someone is expecting

him or her. 

• Review the experience in the next session to determine its 

reinforcement value. (The activity can serve as a form of homework.)

The following dialog illustrates the use of systematic encouragement.

Therapist: Great! Laser tag sounds as if it would be a good time.

Do you know where your friend went to play laser tag?

Adolescent: No, not really. It might be this place in Belleville.

Therapist: How do you think we could find out more information

to get you set up with laser tag?

Adolescent: I guess I could talk to my friend about playing laser tag

or call the place in Belleville.

Therapist: Sounds good. What type of information would you

need to know to play laser tag?

Adolescent: Well, I would want to know how much it costs and

when they are open.

Therapist: And you might want to get directions to the facility,

too! Are there any other things you might want to ask?

Adolescent: Yeah. How long do you get to play each time?

Therapist: Great. Why don’t we write down those questions so

you will have them later. [Adolescent writes down

questions.] Why don’t we roleplay this to make sure

you get everything down to ask when you contact the

guy about laser tag. [Begins roleplaying.] Say I’m the

guy at the laser tag place and you call. “Ring. . . .

Hello. This is George at Orbit Laser Tag. May I help

you?”

Adolescent: Yeah. My name is Jason, and I wanted to know how

much it costs to play laser tag.

Therapist: It costs $10 for one game and $15 for two games.

Adolescent: How long are the games?
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Therapist: They last 15 minutes each, and you can play with up

to 20 people.

Adolescent: How late are you open?

Therapist: We are open from 11 a.m. to midnight, Monday

through Saturday, during the summer.

Adolescent: Could you tell me how to get there from Alton?

Therapist: Sure. Go to Highway 255 South and turn toward

Belleville. 

Adolescent: Thank you very much.

Therapist: That was really good. It sounded as if you got all your

questions answered and you were pretty relaxed. How

did you feel?

Adolescent: All right. I’ve called places before for stuff, so it was no

problem.

Therapist: Good. Since you did well with that and had no problem, why don’t we try calling the laser tag place and

see what kind of information they have about playing

there?

Adolescent: Okay. [Adolescent makes phone call.]

Therapist: That was good. You did a good job of getting the 

information you needed for laser tag. Do you think

your friend who has played laser tag before or Jim [a 

nonusing friend] would like to go to the laser tag place

with you?

Adolescent: Yeah, I think they would both like it. I can see if they

want to do it sometime.

4. Decide on a homework assignment together.

Sampling prosocial activities will be a frequent homework assignment. Work

with the adolescent to get his or her commitment about what will be 

sampled, with whom, and when.

Therapist: When do you think you would be willing to try playing

laser tag?

Adolescent: I don’t know, maybe this weekend.
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Therapist: Okay. Then for homework this week, would you like to

try playing laser tag with a friend, maybe someone like

Jim or your other friend, at least once before next 

session? We will talk about it next time and see how 

it went.

Adolescent: Okay. I’ll try.

Therapist: You can do it!

5. Complete the ACRA Procedure 4 Checklist—Increasing Prosocial

Recreation immediately after the session.

A blank copy of this form is included at the end of this section.
Date _______ Session # _____ Adolescent ID ______ Therapist Init.______

ACRA Procedure 4 Checklist— 

Increasing Prosocial Recreation

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you convey to the adolescent your 

understanding of the link between his 

or her previous social and recreational 

activities and the use of alcohol or drugs? 

2. Did you emphasize that you will work with 

the adolescent to help find new ways to 

enjoy free time? 

3. Did you express to the adolescent that you 

recognize it is likely that he or she will miss 

the old using activities but that giving in to 

those feelings may bring back serious 

problems? 

4. Did you use an activity list to help the 

adolescent think of new activities to try? 

5. Did you encourage the adolescent to sample 

new social and recreational outlets? 

6. Using systematic encouragement, did you 

roleplay on how to make an initial contact 

and give feedback to the adolescent? 

7. Using systematic encouragement, did you 

identify a support person to meet 

or to accompany the adolescent to the new 

activity? 

8. Did you and the adolescent agree on a 

homework assignment that included a 

commitment to actually trying an activity? 

9. If the adolescent committed to an activity 

in a previous session, did you review the 

adolescent’s experiences in carrying out 

that activity? 
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Procedure 5: Relapse Prevention Skills

Rationale

Relapse prevention begins with the functional analysis of substance use 

to understand the antecedents and consequences of using. Throughout 

treatment, therapists need to continue identifying adolescents’ motivations

for attending treatment and reducing or abstaining from alcohol or drug

use. This will help keep adolescents focused on the overall goals they 

identified early in treatment. Initially, adolescents will have varied success

with abstinence or in reducing their use. 

Purpose of the Procedure and Learning Objectives

By definition, a relapse occurs after a period of abstinence. This procedure

provides information about tools therapists can use when adolescents 

continue to use substances during treatment or when they relapse after 

a period of abstinence. 

The learning objectives for this session are to help adolescents:

• Understand how to use the early warning system to identify 

high-risk situations

• Understand how to interrupt a chain of events leading to a

relapse

• Be able to refuse drugs or alcohol assertively

• Change their maladaptive thought patterns and use adaptive ways

to respond to relapse triggers.

Timing, Audience, and Delivery Method

This procedure is presented to the adolescent individually and is 

appropriate for use after an adolescent has had a relapse. With the 

adolescent’s permission, some of the information about relapse may be

reviewed with caregivers. This procedure can also be used for relapse 

prevention and may be periodically reviewed with the adolescent who is

putting himself or herself in at-risk situations.

Materials

General materials include snacks (e.g., chips, crackers, granola bars, fruit

bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 

applicable) a videocamera and videotapes or an audiotape recorder and

audiotapes.

Procedure-specific materials include: 
97

• Functional analysis of relapse materials may include a clipboard,

pens, and two Functional Analysis of Substance Use Beahavior

forms.

• Early warning system materials may include a completed

Functional Analysis of Substance Use Behavior form.

• Behavioral-chain materials may include a chalkboard; whiteboard;

pens, markers, or chalk; and an easel (optional).

• Cognitive-restructuring materials may include a completed

Functional Analysis of Substance Use Behavior form.

• Use-refusal materials may include a chalkboard; whiteboard; and

chalk, pens, or markers to visually outline use-refusal skills.

Procedural Steps

1. Identify the adolescent’s early warning system.

2. If a relapse occurs, conduct a functional analysis of substance use

specific to the relapse situation.

3. Outline the behavioral chain that led to relapse.

4. Provide refusal training.

5. Use cognitive restructuring, if it is developmentally appropriate.

6. Complete the ACRA Procedure 5 Checklists—Relapse Prevention

Skills, Early Warning System, and Cognitive Restructuring

immediately after the session.

Detailed Description

The remainder of this section contains a more detailed overview for 

conducting relapse prevention procedures. Procedural steps are in bold 

type and are followed by further directions and comments. Sample dialogs

between the therapist and the adolescent are indicated in italic type.

1. Identify the adolescent’s early warning system.

To help treatment adolescents identify and avoid high-risk situations,

Meyers and Smith (1995) refer to using the triggers section of the 

Functional Analysis of Substance Use Behavior form. Another tool they 

recommend is the early warning system. 

The early warning system consists of steps an adolescent can use to help

identify when he or she is placing himself or herself in a high-risk situation.

It also includes steps to avert a relapse. As part of this procedure, it is

important to find out about the adolescent’s support system—one or more
98

persons who know the adolescent is trying to abstain from drugs who are

willing to help if the adolescent experiences a warning sign of a relapse. 

A caregiver, peers, boyfriends and girlfriends, a school counselor, an

Alcoholics Anonymous sponsor, or others could be part of the support system.

An example of a high-risk situation might be when an adolescent male is

repeatedly breaking curfew and hanging out with friends with whom he 

previously used marijuana. As part of the response to this warning sign, a

girlfriend whom the adolescent and therapist have previously identified

would call the therapist to let him or her know about this warning sign. The

next step in the plan would be for the therapist to see the adolescent as

soon as possible to provide direct assistance. A sample dialog for a therapist

working with an adolescent to develop an early warning system follows:

Therapist: Let’s talk about something called the early warning

system that could help you figure out when you might

be doing something that could lead to a relapse. The

first thing we need to do is help you become aware 

of behaviors that may lead to a relapse. The second

thing we need to do is figure out what you need to 

do next if you see yourself starting to do these things.

Another important part of this procedure is to identify

someone else who can help you during these times. 

Are you following me?

Adolescent: Yeah, I think so.

Therapist: Okay, good. What are some triggers or high-risk 

situations we’ve talked about before?

Adolescent: Well, I used to use when I stayed out late with Jennifer

and Bryan.

Therapist: Yes, that’s what I’m talking about. That’s what we

found out when we did the functional analysis of substance use. Okay, that is a high-risk situation, and if

you started doing that again, what do you think might

be a way to stop putting yourself in that situation?

Adolescent: Well, maybe I could talk about it with you.

Therapist: Yes, I think I could help you. What we find, however, is

that often teenagers don’t necessarily want to call their

therapist when they find themselves in these situations.

It seems to work better if a friend or a parent calls the

therapist at these times. Then the teenager is likely to

follow through with seeing the therapist and talking

about the high-risk behavior. Is there someone you

would like to call me if he or she sees you starting to

stay out late with Jennifer and Bryan again? Your

mother? Your girlfriend, Tracy? This would be someone 
we would tell all about the plan and ask to notify me if 

he or she saw you doing these things again.

Adolescent: Well, I guess it could be Tracy.

Therapist: Would you be willing to have Tracy come in here so we

can talk about this plan with her and make sure that

we are all on the same page about this?

Adolescent: Yeah, we could do that.

Therapist: That’s great! If you can bring her in next time, we will

explain to her exactly what she needs to do.

2. If a relapse occurs, conduct a functional analysis of substance use 

specific to the relapse situation.

When a relapse occurs, conduct a functional analysis of substance use for

the relapse episode. This task provides the opportunity to break down the

relapse in detail to determine the behavioral chain preceding the relapse.

The Functional Analysis of Substance Use Behavior form can be used.

3. Outline the behavioral chain that led to relapse. 

After a relapse occurs, it is important to help an adolescent examine the

chain of events that led to relapse. Perhaps it was an abbreviated chain of

events; for example, when the adolescent attended a party, someone offered

him marijuana, everybody was smoking it, so he did too. Perhaps the relapse

actually started when the adolescent received a bad report card, was 

scolded by a parent or caregiver, and then felt bad. To relieve stress, the

adolescent went out looking for some friends to smoke marijuana with. 

By going over an actual relapse, the therapist outlines the chain that led 

to the relapse.

The purpose of this exercise is for the adolescent to examine steps in the

chain of events so he or she can learn to interrupt the chain as soon as it

begins and before it leads to using alcohol, marijuana, or other drugs.

These steps can be outlined on a whiteboard or chalkboard. 

Exhibit III–4 gives an example of the steps in the behavioral chain that 

led to a relapse for an adolescent named Jake. The steps show how Jake’s 

decisions led him to relapsing. The therapist can work with Jake to help

him realize alternative actions and at what points he could have taken them

to alter the series of events. For example, when he was angry at his Dad, he

could have called a friend to talk about it or gone outside to play basketball

to dissipate his stress.

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Exhibit III–4:

The Behavioral Chain

Step 1. Jake and his dad had a big fight. They yelled at each other

and even got physical and rolled around on the floor.

Step 2. Jake felt really angry about the fight and wondered why his

dad had to act that way.

Step 3. Jake went to his room and shut the door. He started thinking

about how he would get back at his dad. He also thought

that his dad doesn’t really care about him.

Step 4. Jake remembered that some of his friends were getting

together that night at one of their houses and that they

probably would be smoking marijuana.

Step 5. Jake sneaked out of his bedroom window and went over to

his friend’s house.

Step 6. Everybody he expected to see was there. He got a whiff of

marijuana and felt a little uncomfortable about using again,

because it had been a while since he had done so. But he

really wanted to use.

Step 7. His friends welcomed him in and were glad to see him. 

Step 8. When the blunt got passed around, he took a hit and 

continued to smoke blunts as long as they were available.

4. Provide refusal training. 

Refusal training is a component of ACRA behavioral skills training. It is

worth presenting to an adolescent several times during treatment. The

training teaches adolescents to refuse alcohol or drugs assertively. The 

timing of providing this training varies, but it may be provided before a

relapse as part of relapse prevention training or following a relapse. It can

be revisited often to ensure the skills are generalizable or to improve the

adolescent’s confidence in his or her refusal skills.

Adolescents should first review the positive and negative consequences of

not using alcohol or drugs. Before using the refusal skills, they should be

reminded to think of the rewards of not using alcohol or drugs. When

teaching the five techniques presented below, provide an example of each

and roleplay a situation in which the adolescent can practice the technique.

Roleplaying during the therapy session will increase the likelihood of success

when the adolescent encounters the situation outside therapy. Another way

to reinforce existing refusal skills is to ask the adolescent to demonstrate

how he or she has refused drugs or alcohol in the past. Then ask why he or

she refused in that particular instance. This input can provide additional
insight into a possible motivation to refrain from using. Refusal training

consists of five techniques, any or all of which can be used, depending on

the adolescent or situation.

• Say, “No, thanks,” assertively. The adolescent must be firm and 

positive when refusing. If an explanation is needed, then it is 

acceptable to offer one (e.g., “No, thanks, I’m not feeling well

today.”). Casual acquaintances and strangers usually will not ask 

for an explanation. Close friends or family members are more 

likely to ask for an explanation for the refusal. A prepared excuse

(even a false one) may be helpful at this time but may create the

need for the adolescent to refuse again later.

• Watch body language. It is important for adolescents to refuse 

alcohol and drugs using both words and body language that 

indicate that they are serious and confident. Adolescents should

practice standing up straight, facing an individual, and stating

firmly, “No, thanks.” Not doing this may project the idea that 

the decision to refuse to use alcohol or drugs is not a firm one.

• Suggest alternatives. The adolescent can ask for something other

than alcohol or drugs. For example, he or she could say, “No,

thanks, but I would really like a soda” or “No, thanks, but I would

like something to eat.”

• Change the subject. Changing the subject indicates that the adolescent is not interested in the offer. For example, he or she could

say, “No, thanks. Hey, what do you think of that new CD?” or

“Have you seen that new movie?”

• Confront an aggressor. If someone persists in offering alcohol 

or drugs despite receiving a refusal, the adolescent may need to 

confront the individual. This confrontation should be a last resort

because it may lead to a counterattack or temporary loss of a

friend. He or she can say, “What don’t you understand about

‘no’?” or “Why is it so important to you that I use when I don’t

want to?”

5. Use cognitive restructuring, if it is developmentally appropriate. 

Cognitive restructuring is a procedure used to identify and change 

maladaptive thought patterns. It requires a certain level of maturity of 

cognitive development to use this technique. For example, it may not be

appropriate for a 12-year-old, but it may work well for an 18-year-old.

Examples of maladaptive thoughts of an adolescent include:

• “Everybody is mad at me anyway; I might as well get high.”

• “I had a joint at that party last week; I might as well use this 

weekend.”

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• “I haven’t smoked a joint for a whole month—using this weekend

won’t matter.”

The two steps in cognitive restructuring are (1) showing an adolescent 

how negative thought patterns noted in the internal triggers section of 

the initial functional analysis of substance use have led to use in the past

and (2) teaching the adolescent adaptive ways to respond to these relapse 

triggers. The goal is to restrict negative thoughts. Adolescents need to

learn to use positive self-statements to counteract the negative ones.

Examples of positive self-statements that counteract the negative thoughts

outlined above are:

• “Everybody will be happier with me if I don’t start using again.”

• “I really did well up until that one slip, and I felt good that I

could control my behavior.”

• “If I continue to be abstinent, I will be able to get off probation

and get on with my life.”

To help an adolescent generate positive statements, ask questions that

examine the evidence that supports those thoughts. For example, “If you

use marijuana, will everyone be less mad at you or will everyone be more

mad at you?” or “Do you really think you can use two weekends in a row

and not start falling back into old habits?” 

Once you help the adolescent examine the evidence behind negative 

statements, the adolescent should be encouraged to substitute new, positive

thoughts that are not associated with using. Encourage him or her to 

consider these thoughts several times and then examine the feelings 

associated with the new thoughts. 

6. Complete the ACRA Procedure 5 Checklists—Relapse Prevention

Skills, Early Warning System, and Cognitive Restructuring immediately after the session.

Blank copies of these forms are included at the end of this section.

Tips for Individualizing or Dealing With Difficult Situations

• If the adolescent never has a relapse or says that he or she does

not have a problem with urges to use: 

Reinforce the need to practice effective coping skills, and then

help identify successful strategies the adolescent is using. When

the adolescent analyzes coping tactics, he or she strengthens

awareness of what works well and can continue using these 

methods. The original functional analysis of substance use can

also be reviewed to help reduce the risk of relapse.

• If there is substance use in the adolescent’s home environment: 
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Substance use by an adolescent’s caregivers or siblings is a primary

risk factor for relapse. Educate caregivers about this and attempt

to enlist their cooperation in seeking treatment for themselves or

in refraining from use in the home. As always, encourage attendance

at, and link adolescents to, substance-free recreational and

leisure activities. If caregivers refuse to discontinue use, the 

adolescent can be told about enjoyable activities to participate 

in outside the home when those at home are using. Assist in 

identifying family and friends who provide positive reinforcement

of sobriety maintenance.

• If the adolescent continues to place himself or herself in high-risk

environments: 

Stress the importance of not placing himself or herself in these

environments. Probe for reasons why he or she does this (e.g., 

“I don’t want to give up my friends.”) and address these concerns. 

If he or she persists in spending time in these environments,

emphasize using the skills from refusal training. Train the 

adolescent in using refusal skills or review the skills. Ask the 

adolescent to identify other environments or activities that are

reinforcing but that do not contain some of the risks that he or

she is trying to avoid. 

Another goal is to decrease exposure to risky situations. Try to

get the adolescent to agree to avoid some of these situations. 

One technique is to ask the adolescent to name five risky situations.

Then work toward getting an agreement from him or her to

decrease his or her exposure to them. For example, ask, “Could

you avoid all five for a week?” If the adolescent responds negatively

to this request, then use a less rigid approach. For example,

“Okay, you can’t see yourself avoiding all these situations. Which

ones would you be willing to try to avoid?”

• If the adolescent continues to associate with users: 

Adolescents have difficulty staying away from their friends.

Usually taking an authoritarian approach about staying away 

from friends is not effective. Rather, begin to help the adolescent 

consider the meaning of a “friend” or a positive relationship.

Some helpful questions are, “Do your friends support your wishes

to stay clean?” “Do they help you not to use?” “Have you talked

to them about whether you have to use drugs to hang out with

them?” Challenge the definition of a friend if that person (friend)

is behaving in ways that make it difficult for the adolescent to

abstain. Ask what would work best to keep him or her from using,

and have him or her generate two or three options. 

Sometimes it is appropriate to ask the adolescent’s friend to

attend a session. With the friend present, the therapist and 

adolescent can review all the refusal techniques and ask for the

friend’s cooperation in supporting the goal of abstinence. 
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Procedure 5 Checklist—

Relapse Prevention Skills

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you explain the purpose of relapse 

prevention training to the adolescent?

2. Did you probe whether the adolescent used 

since the last contact? 

3. If a relapse occurred, did you conduct a 

functional analysis of substance use? 

4. Did you base your decision to use the early 

warning system and/or cognitive restructuring on the adolescent’s needs? 

5. Did you provide refusal training and review 

all five techniques? 

6. Did you have the adolescent list five risky 

situations and talk about how he or she 

could handle them? 
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Procedure 5 Checklist—

Early Warning System

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you choose this intervention to help 

the adolescent identify and avoid high-risk 

situations? 

2. Did you explain this technique to the 

adolescent and a caregiver, a peer, the 

school counselor, or another concerned 

person? 

3. Did you arrange to see the adolescent as 

soon as possible once you were informed 

of a problem by the caregiver or peer? 
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Procedure 5 Checklist—

Cognitive Restructuring

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you choose this intervention to 

identify and change an adolescent’s 

maladaptive thought patterns? 

2. Did you determine that the adolescent’s 

cognitive development was advanced 

enough to benefit from this technique? 

3. Did you show the adolescent how the 

negative thought patterns expressed in 

the internal triggers section of his or her 

functional analysis led to use in the past? 

4. Did you teach the adolescent adaptive 

ways to respond to the relapse triggers? 
Procedure 6: Communication Skills

Rationale

Adolescents often have difficulty communicating in a positive manner

with a parent or caregiver and other adults in their lives. This difficulty

can spiral into negative communication. Factors other than normal 

adolescence, such as arrested development because of drug and alcohol

use and poor models of communication in the home, may also impact 

their communication skills. Improved communication skills can help the 

adolescent create more positive relationships in the home and elsewhere. 

Purposes of the Procedure and Learning Objectives

The purposes of this procedure are to help the adolescent understand the

rationale for developing good communication skills and to help improve

communications skills. By the end of this session, the adolescent will learn

how the ACRA communication techniques are applied to real life situations.

These techniques include how to give an understanding statement, how

to give a partial responsibility statement, and how to offer to help solve

a problem.

Timing, Audience, and Delivery Method

The adolescent and the caregiver receive communication skills training in

individual sessions. In a later joint session, they practice these skills with

each other (see procedure 11). This allows the adolescent to learn and

practice the skills individually before having to practice together with the

caregiver. This session should take place by session 6 or by week 5 or 6 of

treatment. Training can be scheduled for a particular session, or the topic

can be introduced spontaneously. For example, if an adolescent talks

about a communication problem with a parent or caregiver or someone

else during a session, this is the appropriate time to introduce the 

technique. The procedure should be revisited frequently because this 

is a critical area for most adolescents.

Materials

General materials include snacks (e.g., chips, crackers, granola bars, fruit

bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 

applicable) a videocamera and videotapes or an audiotape recorder and

audiotapes.

Procedure-specific materials include the handout Communication Skills; a

clipboard; chalkboard or whiteboard; pens, markers, or chalk; and an easel

for presentation of material on communications skills.

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General Notes for the Therapist

The skills outlined in this section should be taught in the context of real

communication problems experienced by adolescents with their parents or

caregivers and other people in their lives. That is, although the therapist

“teaches” the adolescent about effective communication skills, the 

teaching is grounded in the experiences of the adolescent. The adolescent

is not merely a passive recipient but is actively involved in learning. This 

situation makes the procedures more relevant for the adolescent, and he 

or she will be more likely to try them outside therapy.

Emphasize that the skills covered in this section can be used to 

communicate more effectively in real life, not just in a therapeutic setting.

Procedural Steps

1. Introduce the topic of communication, and provide a rationale for

developing good communication skills.

2. Assess the current quality of communication between the adolescent

and other important people in his or her life (e.g., parent or 

caregiver).

3. Using real life examples provided by the adolescent, teach the ACRA

communication techniques. 

4. Roleplay exchanges between the adolescent and another person

(e.g., a parent or caregiver), inserting ACRA and general 

communication techniques whenever they would be helpful.

5. Process each exchange with the adolescent from the perspectives 

of content and feelings.

6. Assign homework.

7. Complete the ACRA Procedure 6 Checklist—Communication Skills

immediately after the session.

Detailed Description

The remainder of this section contains a more detailed overview for 

conducting a communication skills exchange with an adolescent.

Procedural steps are in bold type and are followed by further directions 

and comments. Sample dialogs between the therapist and the adolescent

are indicated in italic type. 

1. Introduce the topic of communication, and provide a rationale for

developing good communication skills.

Take a few minutes at the beginning to introduce the topic and talk about

the importance of communication skills. Find out what reinforcers would
motivate an individual to make behavior changes. For example, an 

adolescent might say, “I’m tired of all the yelling at my house.” Try to find

out something from him or her that can be used to encourage a behavior

change. Make the key point that just about everyone can improve his or her

communication skills.

2. Assess the current quality of communication between the 

adolescent and other important people in his or her life (e.g., 

parent or caregiver).

In this step, both the adolescent’s relationship with parents or caregivers

and his or her communication skills are rated using the happiness scale.

Use the ratings as a starting place for a discussion of the adolescent’s 

communication skills. To help the adolescent be specific, ask him or her to

identify a particular person (such as a parent or caregiver) to think about

in relation to his or her communication skills. Next, ask the adolescent

about the quality of communication with this particular person when 

discussing both nonproblem topics (social or typical everyday conversations)

and problem topics (the adolescent’s drug use, a problem at school or

home). Ask how conversations in each of these categories usually proceed.

Ask how the communication has been in the past 2 years. 

For example, say, “Tell me what happens when you try to talk together

about. . . .”

For situations that do not go well (e.g., the parent/caregiver or adolescent

gets angry or frustrated or leaves; they get into a fight), listen and observe

carefully to understand the dynamics that typically occur between this 

person and the teenager. To make sure you understand the situation (and

to show the adolescent that you are listening), repeat the situation to the

adolescent and ask clarifying questions. For example:

Therapist: Okay. So when you ask your mom to let you go out 

to do something with your friends, a lot of times she

says,“You can’t do that because your room isn’t clean,

and you haven’t done any of your other chores.” You

then get a little angry because you feel as if you are

helping out around the house and cleaning your room.

So, you say something like, “I’ve been cleaning! Why

don’t you look!” Your mom then says,“If you’re going

to be smart with me, you can just go upstairs because

you aren’t going out tonight!” Then you usually go outside while your mom is yelling at you to come back in.

Ask the adolescent how satisfied he or she is with the present quality of

communication with the parent or caregiver. If the adolescent is unhappy,

ask what he or she would like to have happen when talking to his or her

parents or caregivers. Listen to the adolescent, and observe carefully to

understand his or her goals. 

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Assure the adolescent that techniques that will help with communication

problems will be taught. Make sure to leave time to roleplay a few situations

during the session to practice the techniques before a real life situation

occurs.

3. Using real life examples provided by the adolescent, teach ACRA 

communication techniques.

ACRA has three basic parts to effective communication: 

1. Give an understanding statement. 

2. Take partial responsibility. 

3. Offer to help. 

An understanding statement brings feelings of empathy into the 

conversation. It shows others that an adolescent is capable of seeing things

from another person’s perspective and helps the other person understand

the adolescent’s perspective. The effect on the other person is a feeling of

validation, and this will decrease his or her defensiveness. 

A partial responsibility statement indicates that the speaker is willing to

accept responsibility in creating, or a role in solving, a problem. It does not

mean the person is blaming himself or herself or anyone else or that it is 

up to the other person to solve the problem. It acknowledges that the 

adolescent shares responsibility for creating or solving a problem. 

An offer to help is just that—an offer to help solve the problem. Here, the

individual thinks of ways to facilitate cooperation from the other person.

Used together, these three conversation enhancers communicate that one

person wants a change in the other’s behavior and is willing to be actively

involved and supportive in the process. The outcome is decreased 

defensiveness and more open lines of communication. 

Using an actual situation of poor communication between the teenager and

a parent or caregiver, introduce the three ACRA communication techniques

where they would be helpful. The techniques are generic; they can be used

to discuss virtually any situation more effectively.

Therapist: Okay, Gina, let’s look at the situation where your mom

got upset at you after you asked to go out. Let’s review

that conversation, break it down, and try to see where

everyone is coming from and how each of you feels. To

help improve things and help you get something closer

to what you want, I would like to talk about some 

different communication skills that may help your 

conversations have a better outcome.

One way to tell that people have good communication

skills is for everyone to get a little of what they want. If

there is something you want, you would like to get it. I

know you don’t want your parents to give you a hard
time. When you negotiate, often at the end, you can get

closer to what you want than you were before. 

The first thing I want to talk about is an understanding

statement. The understanding statement is really a big

part of improving communication because you are

first trying to see where the other person is coming

from. Doing that will open up the possibility that that

person will listen to you. First consider his or her perspective. Let’s use the situation that you talked about

earlier when you have trouble getting home in time for

a curfew. How would your mom be affected by your

wanting a ride home by curfew?

Adolescent: She doesn’t want me to get in trouble, but she doesn’t

want to go out either.

Therapist: Why doesn’t she want to go out to get you?

Adolescent: Because she is already at home and she says I should

have made plans for a ride earlier.

Therapist: She thinks you should have planned getting a ride from

someone before. You could say, “I understand that it’s

late and you may already be relaxing at home, so

going out might be tough.” 

What is your perspective? Because you want to tell her

where you are coming from so she understands you

better. So, from your perspective, what would you say?

Adolescent: I need a ride home so I don’t get in trouble for 

violating curfew.

Therapist: So we answered all these questions. Why do you want

to come home? Because you don’t want to get in 

trouble for being out past curfew. Your perspective is

that you don’t have anyone to give you a ride home,

but you need to get home to meet your curfew. What

would you like from her in this situation?

Adolescent: I want her to give me a ride home, but I don’t want

her to be seen yelling at me. If I call and she doesn’t

want to pick me up, I don’t want her to come to the

front door and yell at me.

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Therapist: And you don’t want to be yelled at in front of your

friends. Okay. I understand how you feel. Next, when

you make a request, it needs to be brief, positive, and

specific. The reason it needs to follow those rules is

that if you are brief, it will be easier for someone to get

the main thing you want to communicate. If you tell a

person something long and drawn out, the person may

get lost. You want to say it in a positive, nice way so

the person is more likely to listen to what you are 

asking for. You don’t want to ask for something in a

negative way because the person may respond in a

negative way. You need to be specific, so everyone

understands where you are coming from. 

For example, when you ask to be picked up and you

aren’t specific, your mom may think you mean right

now, and you may mean in the next 2 hours. When she

comes by, you may be upset because you wanted more

time to hang out with friends. So a real problem arises.

Okay, following the rules of being brief, positive, and

specific what might you say to your mom?

Adolescent: Would you please come to pick me up, and wait 

outside?

Therapist: At what time would you like to be picked up?

Adolescent: I don’t know. In an hour.

Therapist: Okay. That’s really good. So what I might say using 

the understanding statement is, “Mom, I understand

it’s late and you may not want to go out, but I am out

someplace without a ride and I want to be home so 

I don’t get in trouble for curfew. So I would really 

appreciate it if you could pick me up at my friend

Julie’s house in an hour and honk the horn when 

you need me to come out.”

Let’s try it again. This time, let’s pretend that I’m your

mom, and you can talk to me using the understanding

statement.

Adolescent: I understand it’s late and you want me home, and I

really want to be home to beat curfew too, but I am

stuck here without a ride and can’t get home. So I’d

really like it if you could pick me up at my friend’s

house in an hour.

Therapist: Great. You did a good job. You came from her 

perspective, then yours, and you made a request 

to get picked up at your friend’s house in an hour.
Remember when you are coming from the other 

person’s perspective, you want to tell why that may 

be difficult for him or her. So you would want to say

something like, “Mom, I understand it’s late and you

may not want to come out and get me,” because that

is why she may not like it, okay? Let’s try it again

coming from her perspective, coming from your 

perspective, and then making a request. You did a 

really good job with that part before.

Adolescent: Okay. Mom, I know it’s really late and you don’t want

to come out. And I should have made sure earlier that

someone could take me home, but I am stuck here

without a ride and don’t want to be out past curfew.

So, I would really like it if you could pick me up at my

friend’s house in an hour.

Therapist: Good, you had all the parts of the exercise in that one.

You made sure to come from her perspective to show

that you understand how she is feeling about the whole

situation. You also did something else that was really

cool when you talked about how you should have

made sure there was someone to take you home! This

is called taking partial responsibility. Taking partial

responsibility is when you say how something you did

might have contributed to the problem. When you do

this, it shows you don’t blame the other person for the

problem, and he or she is more likely to listen to you.

You want to make sure and say something like this in

any situation where the person you are talking to sees

you as part of the problem. After taking partial 

responsibility, I like to restate the request just to keep

everyone on track about what I am talking about. So,

adding the partial responsibility statement, I might say

something like,“Mom, I understand it’s late and you

are probably tired and don’t want to go out, but I am

stuck over at my friend’s house without a ride and

want to get home before curfew. So I would really like

it if you could pick me up in about an hour. I understand

that I should have gotten a ride and I am sorry about

that, but I would really appreciate it if you could pick

me up in about an hour at my friend’s house.” Do you

understand how I restated the request?

Adolescent: Yeah.

Therapist: Okay, let’s try it from the top.

Adolescent: All right. Mom, I know it’s late and you are tired, but 

I am stuck at my friend’s house and I need a ride, so 

I would really like it if you could pick me up at my

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friend’s house in about an hour. I know I should have

made sure someone could take me home before I left,

but I would really like it if you could pick me up at my

friend’s house in an hour.

Therapist: Great! That was perfect. You told her exactly how you

fit into the problem. The last part is to make an offer to

help. It isn’t too tough. It’s just figuring out what you

can do to make it more likely to get what you want—to

be picked up by mom late at night. What you want to

do is make sure she is involved in the solution, so she

is more likely to come to a decision that both of you

like. So, for this part, I first want to offer a few 

suggestions such as,“If there is anything I can do to

help, maybe give you some gas money for picking me

up or mow the lawn tomorrow, I would be willing to

do it. Or, if there is anything else you can think of, I

would be willing to listen.” In that last part, I opened 

it up to her so she could give a few suggestions for

solving the problem to make things easier for her. I also

said I would listen or consider it. That way I am not

saying I will just do whatever she says as a suggestion,

but I will listen to what she says and come to a 

compromise, something that works out for both of you.

So it gives you something closer to what you want.

Let’s try the whole thing since you did such a good job

adding in the partial responsibility statement last time.

Remember, first do the understanding statement, then

the partial responsibility statement, and then add the

offer to help.

Adolescent: Okay. Mom, I understand you are tired and may not

want to go out, but I am stuck at a friend’s house and

I really want to be home before curfew, so I would

really appreciate it if you would pick me up at my

friend’s house in about an hour. I know I should have

had a ride set up before, but I would really like it if you

could pick me up at my friend’s house in about an

hour. If I can do something like give you gas money or

anything else, I would be willing to do it or if you can

think of anything else, I would listen. I just would like

it if you could pick me up at my friend’s house in an

hour. 

Therapist: Good job. You did that just right. First you had a good

understanding statement from your mom’s perspective

and then your perspective, then you had a good 

statement of partial responsibility, and I really liked

your offer to help.
4. Roleplay exchanges between the adolescent and another person

(e.g., a parent or caregiver), inserting ACRA and general 

communication techniques whenever they would be helpful.

When doing the roleplay, insert ACRA and effective communication techniques

whenever they would be helpful. Mention pitfalls (e.g., avoid blaming people

or rehashing old problems) to avoid if they arise. Point out barriers to 

communication when they occur. After that, switch roles. 

To help improve the effectiveness of the adolescent’s communication 

techniques, the adolescent and therapist should conduct additional 

roleplays followed by the therapist’s feedback. The adolescent can generalize

these skills to many areas of life, so these roleplays should cover many 

problems and issues. After each roleplay, review it thoroughly and help 

the adolescent reword the conversation to be more effective. Both general 

communication techniques (e.g., use of “I” statements rather than “you”

statements as well as active listening) and those used in ACRA should be

introduced whenever they may help.

It is important to provide an opportunity for several roleplays. Roleplaying

can be awkward for some people, but it is important for the therapist to

encourage the adolescent to participate fully. If you ask the adolescent, “Do

you want to do a roleplay?” the answer will often be, “No.” So a more subtle

approach may be preferable. One way to reduce the awkwardness might be

to avoid using the word “roleplay.” Instead, you can say something like,

“OK, let’s just pretend I’m your mother and let’s practice some of the ways

of talking about what we were just discussing.” Stress to the adolescent

that it is acceptable for him or her to leave the role to ask questions or get

advice. Also remember that it is desirable for the adolescent to have the

experience of playing both roles—that of the parent and that of the adolescent.

Numerous pitfalls can occur when two people are attempting to communicate

with each other. Two common pitfalls occur when one person blames the

other person and when one person brings up an old transgression or 

behavior. These pitfalls should be pointed out to the adolescent, and 

they should be avoided.

The Communication Skills handout is a helpful teaching device that can be

given to a caregiver or adolescent when reviewing communication skills.

Have a copy for the adolescent to review. (A copy of this handout is at the

end of this section.) 

5. Process each exchange with the adolescent from the perspectives

of content and feelings. 

Following each roleplay, the therapist and adolescent should discuss the

conversation. Ask the adolescent, “How did it go? What was different about

the conversation compared to how it usually feels? How did it feel for you to

play the role of your parent? How do you think your parent would respond

to this style of communicating?”

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Working with a resistant adolescent on communication skills. The 

following dialog between an adolescent and a therapist illustrates how a

therapist might approach communication skills training with a resistant

adolescent. In this case, the adolescent has already attended a couple of

sessions, and at the last session he rated school and his relationship with

his parents low on the Happiness Scale form.

Therapist: How was your week?

Adolescent: Okay, I guess. [Adolescent responds with short

answers, looking down and not wanting to talk.]

Therapist: How is school going?

Adolescent: Okay. [Continues to give short answers.]

Therapist: Tell me how you and your mom are doing. [Therapist

asks open-ended questions.]

Adolescent: She’s getting on my nerves.

Therapist: Tell me more about that.

Adolescent: She’s constantly complaining.

Therapist: What kind of things is she complaining about?

Adolescent: You name it. 

Therapist: [Therapist sits in silence for a while giving the teen

an opportunity to respond without constant questioning and then, trying to elicit details, responds.] Give

me an example.

Adolescent: Well, like last night, she was angry with me because I

didn’t get home by curfew.

Therapist: What was her response when you got home? [Trying

to find something that the client would invest time in

to work on, the therapist does not question why the

adolescent was not home by curfew.] 

Adolescent: She started yelling at me.

Therapist: Is that her typical response when she is angry?

Adolescent: Yeah.

Therapist: Then how do you respond? [Tries to assess current

state of communication between adolescent and 

parent.]
Adolescent: I either yell back or ignore her. She is so controlling.

Always wanting to know my every move.

Therapist: That sounds as if that is difficult for you. Wonder why

she does that?

Adolescent: ’Cuz she doesn’t trust me.

Therapist: Why doesn’t she trust you?

Adolescent: ’Cuz I came home drunk about 2 weeks ago. Now she

is threatening to take my car from me.

Therapist: Were you driving when you were drunk?

Adolescent: Yeah, I had to get home. She wouldn’t let me stay at

my friends because she doesn’t like them and I needed

to get the car back. 

Therapist: Why do you think that your mom would get angry at

that? [Therapist encourages client to try to verbalize

mom’s feelings rather than takes sides with the

youth’s mother.]

Adolescent: ’Cuz she is concerned and worried about me. I mean I

can understand that. She is just weird about how she

handles everything. 

Therapist: So basically you can understand where your mom is

coming from, but you just aren’t happy with the way

she communicates with you. [Therapist introduces

reflection.]

Adolescent: Yeah, she is just always yelling at me.

Therapist: And when she starts yelling, you either start yelling

back or walk away?

Adolescent: Yeah.

Therapist: It sounds as if your car is very important to you and

losing it would be a big deal for you. [Therapist 

continues to try to motivate the client to work on

communication skills.]

Adolescent: Yeah! I need it to get to school and work and to go out

with my friends.

Therapist: Wow. That wouldn’t be good then if she took it. Let’s

think about how we can talk to her to get your point

across so she will listen. [Therapist does not mention

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communication skills but nevertheless proceeds to

work on these skills.]

Adolescent: Yeah, okay, like that’s going to happen.

Therapist: We can try. What do we have to lose? I want to be able

to help you have a voice and be able to be heard.

Adolescent: Whatever.

Therapist: She will be coming in in a couple of weeks with you

and that would be a good time to try to talk about

some issues you have. While both of you are here, I

don’t want to have you both yelling at each other the

whole time and not hearing the other. So let’s talk

about how we can get your point across. I’m your

mom. Talk to me, and tell me why you think I should

not take your car away. [Assesses state of communication further.]

Adolescent: I think she is being unfair, and it’s bull.

Therapist: Good. But talk to me as if I am your mom.

Adolescent: That is bull, mom, and you know it.

Therapist: Good! [Therapist offers praise and positive 

reinforcement even though the response is less than

desired.] Okay. There are a couple of things that I

want you to try. First thing is to try to stay positive.

Sometimes when people feel on the attack, they get

defensive and fight back. And our goal is to try to get

her to hear you. The other thing is to try to understand

where she is coming from and communicate that. You

said earlier that you could understand that she worries

when you drink and drive. So you can start by saying

to her in a calm voice, “Mom, I understand that, when

I drink and drive, you worry and are concerned.”

[Therapist uses modeling, coaching.] Try it.

Adolescent: Mom, I understand that you are worried about me, but

I don’t think you need to take the car away. That is

bull, and I told you I wouldn’t do it again. 

Therapist: Great! [Continues praising for effort and participation.] You’re doing a good job. You did the understanding statement perfectly. After the understanding statement I think it might be helpful to get your point across

if you take partial responsibility for your half of what

is going on. Then make an offer to come to some kind

of agreement or resolution about the car. [Introduces
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shaping.] I am going to be you for a second and you

are your mom. “Mom, I understand that you are 

worried when I drink and drive. I made a mistake and

drove that night. I know that was bad judgment on my

part. I was just worried about not having the car

home on time, and I know that I should have probably

just called you but I was scared. Is there anything that

I can do to reassure you that I won’t make that same

mistake?”

Adolescent: I can’t talk like that psychobabble! That’s not me. Man,

please . . . my mom would already be yelling.

Therapist: That is a good point. It’s kind of weird to talk like that,

isn’t it? I am going to go over the same stuff with your

mom as well, with the goal of trying to have you be

able to hear each other’s point of view and trying to

get you both what you want. I know you said that it

was not you, but you sounded great! You made it seem

so easy. Have you done this before? 

Adolescent: They tried to teach us this stuff in residential.

Therapist: I am your mom. [Continues and tries to convince

client to continue.] Talk to me about the issue of 

the car, starting with the understanding statement,

because I think we will have some luck with this and 

I want to help you get what you want. [Reinforces

rationale for working on communication skills.] 

Adolescent: Mom, I understand that you are worried when I drink

and drive. 

Therapist: [Therapist interrupts to help shape.] Great! Keep

going by talking about how you take some responsibility

for the night you drank and drove. 

Adolescent: And I know that I shouldn’t be doing that. It was wrong. 

Therapist: Tell her what your car means to you. [Helps client

through communication skills while shaping, coaching,

and encouraging.]

Adolescent: My car is the most important thing to me. I need it to

get around to school, work, and with friends. I don’t

want to mess it up by driving drunk, and I really don’t

want you to take it away from me.

Therapist: Fantastic! [Offers praise and positive reinforcement

for any effort no matter how big or small.] Now offer

to help or come to some kind of compromise.
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Adolescent: Since my car is so important to me, how can I get you

to trust me again?

Therapist: You did great! Did that feel weird?

Adolescent: Yeah. 

Therapist: But you did such a great job! And I think if your mom

heard you talk like that, she would hear what you had

to say about the issue and would be willing to sit down

and talk about it. And I will be here to help you. I know

it feels weird, but try it in other situations as well.

People are more receptive to hearing what you have to

say if you aren’t yelling and are trying to understand

where they are coming from. This week, practice what

we went over. 

By the end of the session, the therapist has reviewed the important parts of

communication, has urged the adolescent to practice these skills at home

so that he will learn to generalize skills outside sessions, and has praised

the client for participation and attendance.

6. Assign homework.

Assign the homework of practicing communication skills. Solicit a 

commitment from the adolescent to try to put the skills into practice. At

the next session, the therapist should review the adolescent’s use of the

communication skills between sessions. 

7. Complete the ACRA Procedure 6 Checklist—Communication Skills

immediately after the session.

A blank copy of this form is included at the end of this session. 
COMMUNICATION SKILLS 

The goal of using communication skills is to be able to get your message across to

another person to help you get what you want. Using these communication skills

should enable individuals to compromise or agree on a solution to a problem. When

everyone agrees on a solution, compliance by both sides and contentment with the

solution are more likely. It is important to stay positive during the communication

skills training and avoid blaming. 

Understanding statement. The goal of the understanding statement is to open up

communication and show that you are aware of another person’s thoughts on a 

problem. That is:

! Come from the other person’s perspective.

Example: “Mom, I understand you would like my room cleaned because it is a

real mess, and you would like the house to be clean when friends come over.”

! Come from your perspective.

Example: “But Jimmy is having a birthday party at his house, and I have not

seen Jimmy for a while, so I would really like to go.”

! Make a request (a request should be brief, positive, and specific).

Example: “I would really appreciate if you would let me clean my room later

tonight, maybe around 8 p.m. when I get home.”

Partial responsibility. The goal of the statement of partial responsibility is to avoid 

blaming the other person. Remember to state how you or the other person see 

yourselves fitting into the problem or solution. That is:

! How do you fit into the problem?

Example: “I know I made a real mess by not putting my clothes away, and I

have not always followed through with cleaning my room, and I am sorry

about that.”

! Repeat the request (optional).

Example: “But I would really appreciate if you would let me clean my room

around 8 tonight after I get home from Jimmy’s party.”

Offer to help. The offer to help is used to show that you are willing to work on a 

solution that works for everyone and that you would like input from others on possible

solutions. That is:

! Offer several possible solutions.

Example: “If there is anything I can do to help make that happen—help out

with another chore around the house, help out with dinner, or just do a

quick 10-minute cleaning for now and do the rest later—I would really

appreciate it.”

! State your openness to listen to and consider the other person’s ideas.

Example: “Or if there is anything that you can think of, I would be willing to 

listen.”

Following the offer to help, individuals may try to compromise on a solution or do

some problem solving. It may be necessary to go through the communication skills

again to state your point.
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Procedure 6 Checklist—

Communication Skills

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you introduce the topic of 

communication by providing a rationale 

for developing good skills in this area? 

2. Did you assess the present quality of 

communication between the adolescent 

and other important people in his or her 

life (e.g., parents/caregivers)? 

3. In the context of real life examples 

provided by the adolescent, did you teach 

the adolescent to give an understanding 

statement? 

4. In the context of real life examples 

provided by the adolescent, did you teach 

the adolescent how to make a partial 

responsibility statement? 

5. In the context of real life examples 

provided by the adolescent, did you teach 

him or her how to offer to help solve the 

problem? 

6. Did you roleplay exchanges between the 

adolescent and another significant person 

and insert ACRA and general 

communication techniques whenever they 

would be helpful? 

7. Did you switch roles with the adolescent? 

8. Did you process each roleplay exchange 

from the perspectives of content and 

feelings? 

9. Did you use the Communication Skills

handout when appropriate? 

10. Did you ask the adolescent to practice 

communication skills for homework? 
Procedure 7: Problem-Solving Skills Training

Rationale

Problem-solving skills are essential in ACRA. They are general life skills

that are valuable beyond the treatment experience. Training adolescents

in problem-solving skills teaches them how to handle the problems that

come up in life without resorting to the use of marijuana or alcohol to

cope. Problem-solving skills increase the adolescent’s sense of self-efficacy

and self-esteem. With problem-solving techniques, adolescents realize that

no matter how insurmountable a problem may appear, it can always be

broken down into small steps and conquered.

Purpose of the Procedure and Learning Objectives

The main purpose of this procedure is to improve the adolescent’s ability

to solve problems in real life situations. The learning objectives are to

help the adolescent:

• Understand and practice the three-step problem-solving technique:

define the problem, generate alternatives, and choose one 

solution

• Become aware of the need to evaluate the effectiveness of the

solution.

Timing, Audience, and Delivery Method

Problem-solving skills training takes place with an adolescent individually. 

It can be scheduled for a particular session, or the topic can be introduced naturally when the adolescent brings a problem to the session.

Thereafter, every time the adolescent brings up a problem situation, the

therapist should reintroduce the problem-solving technique and work

through the steps to generate solutions for the adolescent to try out.

Materials

General materials include snacks (e.g., chips, crackers, granola bars, fruit

bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if 

applicable) a videocamera and videotapes or an audiotape recorder and

audiotapes.

Procedure-specific materials include clipboard; chalkboard; whiteboard;

pens, markers, or chalk; an easel (optional); and the handouts How Do I

Solve That Problem? and How Can I Solve This Problem? (optional).

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General Notes for the Therapist

Maintain a positive atmosphere for change throughout problem solving.

This positive atmosphere is created by a positive demeanor, an enthusiastic

tone of voice, positive expectations for change (a “Yes, you can!” attitude),

and praise for the adolescent’s behaviors and efforts. Because problemsolving techniques are best learned through practice, listen carefully to 

the adolescent during sessions for opportunities to introduce or reintroduce

problem solving. You can use the adolescent’s exact words to describe a

problem so that it is apparent that you heard his or her concern.

Problem-solving technique handouts are at the end of this section.

Memorize the steps in the problem-solving technique, and give copies of 

the handouts to the adolescent. The problem-solving technique used in this

manual is an adaptation of the problem-solving approach introduced by

D’Zurilla and Goldfried (1971). It is taken from Meyers and Smith (1995, p.

106) and used with permission of the copyright holders. A problem-solving

form for use by the adolescent is at the end of this procedure. An example

of a completed form is also provided.

Procedural Steps

1. Introduce (or reintroduce) the technique to the adolescent.

2. Assist the adolescent in defining the problem clearly and specifically.

3. Encourage the adolescent to generate alternatives for solving the

problem.

4. Help the adolescent decide on one solution.

5. Assign homework based on the chosen solution.

6. Introduce the concept of evaluating the outcome, and follow up in a

subsequent session by reviewing and evaluating an outcome with the

adolescent.

7. Complete the ACRA Procedure 7 Checklist—Problem-Solving Skills

Training immediately after the session.

Detailed Description

The remainder of this section contains a detailed overview for conducting a

problem-solving exchange with an adolescent. Procedural steps are in bold

type and are followed by further directions and comments. Sample dialogs

between a therapist and an adolescent are indicated in italic type. 

1. Introduce (or reintroduce) the technique to the adolescent.
This is an example of how the technique is introduced as a scheduled topic:

Therapist: Today, Jim, we are going to talk about a technique 

you can use to solve problems that come up. Not just 

problems you encounter during the time you are meeting

with me, but problems you will encounter throughout

your life, when you’re not going through treatment.

Give the adolescent the handout How Do I Solve That Problem? Review 

the contents with the adolescent. Encourage questions, and praise the 

adolescent for giving examples and making connections. 

Once the technique has been explained, illustrate how to use the technique.

Ask the adolescent to mention some current problems that he or she would

like to address. Then select a few relatively uncomplicated problems and

use the problem-solving technique. Also, the problem-solving technique can

be used when the therapist and adolescent are completing the goals of

counseling to identify interventions for each goal. 

The need for problem-solving training often emerges naturally, for example:

Therapist: Gina, it sounds as if you have a problem. You’re really

concerned about bringing your math grade up. You’ve

tried to do it on your own, but it’s not working. Let’s

talk about how you might solve this problem.

Use the first step of the technique to help the adolescent define the problem.

Work with the adolescent step by step through the problem-solving method

outlined below. Be generous with your assistance, but let the adolescent

take the lead. The adolescent’s responses to each step can be written on

the outline to further define the technique.

When the adolescent is already familiar with the technique, reintroduce the

topic, connect the adolescent’s problem and the technique, and proceed

through the steps with the adolescent. For example:

Therapist: Okay, Gina, it sounds as if you have a problem.

Remember the problem-solving technique we’ve used a

few times already? Let’s see whether we can come up

with some solutions to your problem. The technique

seemed to work well the previous times. You were so

pleased with the outcomes, remember?

2. Assist the adolescent in defining the problem clearly and 

specifically.

Give the adolescent a copy of the handout How Can I Solve This Problem?

The adolescent can use the handout to record his or her responses. Help

the adolescent define the problem as specifically as possible. Try to generate

open-minded thinking; encourage the adolescent to think about why a 

problem might exist. 

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Therapist: Gina, tell me more about how you’re doing in math. I

know you said you were failing, but tell me more about

how your grade got where it is.

Adolescent: We have had three math tests so far. I got a 48 on the

first one, so I studied really hard for the second. I got a

32. So then I spent even more time on my math. Then I

got a 54. If I fail the next one, I will have to repeat

freshman math.

Separate any secondary or related problems. These are additional problems

that may contribute to the problem at hand. 

Therapist: What are some of the things that might be 

contributing to your difficulty in math class? Can 

you think of any?

Adolescent: Well, when I don’t understand something, I don’t like to

raise my hand in class. I would rather try to figure it

out on my own. I also like to watch TV, so when I do

my homework, the TV is on; and my brother bothers

me when I’m trying to study, and I don’t always finish

my work.

Therapist: Okay, I can see how these things could contribute to

having a hard time in math. Let’s keep them in mind

when we start to come up with possible solutions to

your problem.

3. Encourage the adolescent to generate alternatives for solving the

problem.

Use brainstorming to generate as many potential solutions to the problem

as possible. Follow two important rules for brainstorming: 

• Do not criticize any of the potential solutions. It doesn’t matter

whether they sound like something the adolescent would never do

or whether they’re something that has already been tried. 

• Go for quantity.

Write all possible solutions on a whiteboard or chalkboard. Do not worry

about specificity at this point; you can help the adolescent narrow the

choice as he or she picks a solution to try. 

Therapist: The next thing to do is to think of as many solutions as

you can without judging them. Remember, we don’t

want to eliminate any of the possible solutions yet. One

thing I can think of is to see a tutor for your math.

What’s something you can think of?
Adolescent: Maybe studying away from the TV or at the library so

my brother doesn’t bother me.

Therapist: Good! Maybe studying with someone who is doing well

in class would help.

Adolescent: Or just studying more before tests would help.

[Encourages the adolescent to generate as many 

solutions as possible.]

4. Help the adolescent decide on one solution.

Help the adolescent narrow down the list of alternatives. First, the adolescent

should eliminate any solutions that he or she does not feel comfortable 

trying. No explanations are necessary—tell the adolescent that no 

explanations are required for eliminating any alternatives.

For the remaining solutions, encourage the adolescent to think about how

it would be to carry out each solution. Ask, “Do you think you would actually

follow through with the solution? Would it work?” This may narrow down

the list even more. 

From the pool of remaining solutions, the adolescent should choose one

solution and describe exactly how it will be carried out. Again, ask, “Which

one would be most helpful?” and encourage the adolescent to be as specific

as possible (e.g., when? how often? what time of day? with whom?).

Help the adolescent identify any obstacles to carrying out the solution—

that is, things that might interfere with the completion of the assignment.

The goal is to identify beforehand any obstacles that could possibly subvert

the adolescent’s attempts to solve the problem. Ask, “What might come up

in the course of a week that would get in the way?” As each obstacle is

identified, generate backup plans with the adolescent to circumvent it. If

the adolescent thinks he or she might forget, for example, then ask, “What

can you do to make sure you don’t forget?” Spend time talking about these

obstacles. Homework assignments may be appropriate. If possible, allow the

adolescent to write on the whiteboard or use the computer. Participation in

this process will help the adolescent apply lessons learned.

The adolescent should now have a specifically defined plan for addressing

the problem. The plan should include when the solution will be attempted,

how often, and at what times. The adolescent should agree on the number

of times to try the solution before the next session. To reinforce this action,

ask, “Now, what did you decide you will do?”

Consider whether additional solutions should be attempted before the next

session. If the adolescent wishes to try additional solutions, repeat the 

decision process for each solution. Evaluate with the adolescent the feasibility of the remaining solutions, choose another solution to try, and describe

exactly how it will be carried out, consider possible obstacles to enacting 

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the solution, and generate a backup plan to overcome the obstacles. A 

sample dialog between a therapist and adolescent follows:

Therapist: If there are any solutions that you don’t think you

would try, go ahead and cross those off. You don’t

have to explain why; just cross them off if you don’t

think you would try them.

Adolescent: I don’t think I would go to the library.

Therapist: Okay. We’ll cross that one off. Are there any other ones

you don’t think you would try?

Adolescent: No, I think I would try any of the other ones.

Therapist: Are there any solutions you think would not work?

Adolescent: No, I think they could all work.

Therapist: Which one do you think you would like to try the most?

Adolescent: I think if I studied with my friend Julie, that would help

because she does so well in math.

Therapist: How would you go about doing that?

Adolescent: Well, I would just call her up and ask her to study with

me.

Therapist: Good. When do you think you will study and how long

will it take?

Adolescent: I don’t know. Maybe I’ll study once during the week

and once on weekends, so I’m not having to do it all

on the weekends. Maybe I can study 2 hours each

time.

Therapist: So, twice a week. Are any particular days better than

others for you?

Adolescent: Wednesdays and Sundays could probably work, but I

would really have to ask Julie first.

Therapist: Good thinking. Are there any things that could make it

difficult for you to do this?

Adolescent: Not really. We could study anywhere. I guess if she

couldn’t study on a certain day, it could be tough.

Therapist: If that happens, what would you do?
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Adolescent: I’ll just pick another day. I mean, I can study almost

any time.

5. Assign homework based on the chosen solution.

Help the adolescent identify a homework assignment based on the solution

chosen during the problem-solving session. 

Therapist: When would you like to start studying with Julie?

Adolescent: Right away probably. I could start tonight.

Therapist: Great! Why don’t we try calling Julie right now and

see whether we can set up your study time? [Gina

makes the call and sets up the study session.]

Therapist: Good job! I’ll check how the studying is going when we

meet next week. You are planning on studying twice a

week for 2 hours, right?

Adolescent: Yeah.

6. Introduce the concept of evaluating the outcome, and follow up in

a subsequent session by reviewing and evaluating an outcome with

the adolescent.

Explain to the adolescent that an important part of problem solving is

checking whether a particular solution worked. This checking is done by

asking the following questions: Was the solution carried out? If not, what

barriers got in the way? What could be done differently next time? If the

solution was carried out, did it help solve the problem? Was the desired 

outcome attained? For example, in the solution for the sample above, did

the adolescent’s grades improve? The adolescent can do the checking 

himself or herself or during a counseling session.

Review the outcome with the adolescent at the next session. Be sure to 

positively reinforce any efforts by the adolescent to try to carry out a solution.

If solutions did not go well or the adolescent had a difficult time carrying

them out, help him or her modify the solution and encourage another try. 

If an entirely new solution is necessary, repeat the problem-solving steps.

If the adolescent did not attempt the assignment, the lack of followthrough

could be treated as a problem that needs a solution. The problem-solving

technique could be applied in this situation. Once the adolescent appears

to understand the problem-solving technique, he or she should walk the

therapist through the procedure step by step using a new problem.

Attaining this level of skill is recommended before terminating therapy.

7. Complete the ACRA Procedure 7 Checklist—Problem-Solving Skills

Training immediately after the session.

A blank copy of this form is included at the end of this section.
HOW DO I SOLVE THAT PROBLEM? 

Everyone experiences problems from time to time with things like school, 

parents, caregivers, friends, work, or activities. Using problem-solving techniques

can help us consider every part of a problem to come up with a good solution.

Below is an outline of a problem-solving technique you can use when a problem

arises.

1. Define the problem.

!""Define the problem as specifically as possible (be brief, positive, and 

specific).

!""Make sure you are dealing with one problem at a time.

2. Generate alternatives.

!""Use brainstorming (think of as many things as you can) to generate

possible solutions. 

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

!""Go for quantity; the more potential solutions, the better!

3. Decide on a solution.

!""Eliminate any solution you would not feel comfortable trying or you

do not think you would do. No explanations are needed. 

!""Think about the chances that each remaining alternative will work

while checking out its probable consequences.

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

out.

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

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

!""Decide with the therapist on the number of times you will try the

solution before the next session.

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

!""Go through the problem-solving steps above, starting with the second

step, for any solutions considered.

4. Evaluate the outcome.

!""Review the outcome, and decide how satisfied you are with how it

worked out.

!""Modify the solution if necessary.

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

steps.
HOW CAN I SOLVE THIS PROBLEM?

1. What is the problem you are dealing with?

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

ideas as you can think of. 

3. Draw a line through any ideas that you don’t think you would try.

4. Read each idea that you have not crossed off the list, and pick one idea that

sounds like something you would like to try. Write it down.

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

how it went.
HOW CAN I SOLVE THIS PROBLEM?

(SAMPLE ANSWERS)

1. What is the problem you are dealing with?

I am failing math.

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

ideas as you can think of. 

Study away from the TV.

Study at the library so my brother doesn’t bother me.

Study with someone who is doing well in class.

Study more before a test.

3. Draw a line through any ideas that you don’t think you would try.

Study at the library so my brother doesn’t bother me.

4. Read each idea that you have not crossed off the list, and pick one idea that

sounds like something you would like to try. Write it down.

Study with my friend Julie, who is doing well in class.

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

how it went.
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Procedure 7 Checklist—

Problem-Solving Skills Training

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you maintain a positive atmosphere 

for change throughout problem solving? 

2. Did you introduce the problem-solving 

technique and go over the outline with the 

adolescent? 

3. Did you help the adolescent clearly and 

specifically define the problem, separating 

out any secondary or related problems? 

4. Did you encourage the adolescent to 

generate alternatives for solving the 

problem by following the two rules 

important for brainstorming? 

5. Did you help the adolescent narrow down 

the list of alternatives and choose one 

solution? 

6. Did you have the adolescent commit to an 

agreed-on number of times to try the 

solution before the next session? 

7. Will you evaluate the outcome at the next 

session?
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Procedure 8: Urine Testing

Rationale

The results of a urine test are not the focus of ACRA treatment because

ACRA primarily relies on identifying reinforcers and taking a positive

approach. However, a negative (no drugs found) urine test provides the

opportunity to reinforce abstinence, whereas a positive urine test provides

additional information to the therapist that can be used to prompt 

appropriate ACRA procedures (e.g., relapse prevention).

Purpose of the Procedure and Learning Objectives

The purpose of the procedure is to monitor adolescents’ abstinence

through a means other than self-reports and to provide appropriate 

feedback to adolescents based on test results. The learning objectives 

are to provide adolescents with:

• Positive reinforcement and support if the urine test indicates no

drugs are present

• Nonjudgmental review of the context of use and triggers if the

results indicate that drugs are present

• Potential solutions if a similar using situation is encountered in

the future.

Timing, Audience, and Delivery Method 

During the CYT study, adolescents were asked to complete urine tests 

on two random occasions during a 6-week or 3-month intervention. In 

general practice, the frequency of urine testing may vary, depending on

treatment facility requirements. Regardless of the frequency of urine 

testing, adolescents should be informed about the frequency and general

procedures for urine testing during an initial session.

When the adolescent is due for a test, the therapist can approach the 

adolescent before the session begins and explain that this is the day that

has been randomly chosen for a urine test. Reiterate the reason and 

procedures for completing the test; direct the adolescent to a lavatory; 

and provide a cup. Read the results and record them in the clinical chart.

The entire procedure should take approximately 10 minutes. When the 

adolescent is not able to provide a sample, ask him or her to give a 

sample at the end of the session.

Materials

Procedure-specific materials include drinks if the adolescent is having 

difficulty providing a urine sample, test kits, screening cups, rubber

gloves, and watch or clock.
Urine Test Kits

If possible, it is important to use an onsite urine test kit that can be read

almost immediately. Kits are available that can test for the primary drugs

being abused by a target population. Because these tests can be read 

immediately, they allow for immediate (same session) feedback and 

discussion of the results with the participant. Besides the test kits, additional

supplies needed to conduct tests include latex gloves, urine screening cups,

a directions or procedure sheet for the analysis of the test kit results, a 

clock or watch to monitor the time that elapses, and access to a rest room.

There are many different brands of onsite drug tests. Typically, these tests

are economical, with prices based on the number of drugs being tested for.

The tests generally require placing drops of urine on testcards, allowing a

certain amount of time to elapse, and then reading the results by examining

visual markers. Tests do not necessarily have to be observed if (1) there are

procedures built into the test that help detect adulterated samples and 

(2) there is temperature monitoring so that it is possible to detect watered

down samples. Temperature monitoring can be done with specimen cups

that have built-in temperature strips. Staff members who handle the urine

should be trained in the proper procedures for safely handling bodily fluids.

It is also important to study procedures regarding refrigeration of test kits

to optimize shelf life.

Note that onsite drug tests are considered to provide preliminary analytical

results. Gas chromatography/mass spectrometry (GC/MS) is usually preferred for a confirmatory analysis. These tests are typically done in a laboratory. An onsite test may have limited value in assessing decreasing drug use

(as opposed to total abstinence) and does not provide confirmatory analyses

that may be required by a court or other source. If a teenager denies use

but tests positive with an onsite test, consider sending a second urine sample to a certified laboratory to verify the onsite test using GC/MS.

General Notes for the Therapist

Adolescents should be told in the first session that there will be random

urine tests so they are not surprised when the therapist tells them it is time

for one. When the therapist discusses the urine test during the initial 

session, he or she also needs to explain the reason for the test. If the 

adolescent refuses to submit to a test, it is important for the counselor 

to continue therapy with him or her because the most important goal is to

treat the client. If an adolescent is on probation, the probation officer may

conduct the urine test rather than the therapist.

Treatment programs may not want to do urine testing when a teenager

freely admits to using unless the particular test being used is one that 

provides measures of substance use levels.

Note: If the adolescent is absent the week testing is due, administer the

test during the next treatment session he or she attends.

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If urine testing has been mandated by probation, parole, or another court

agency, obtain appropriate signed disclosures and reveal the test results to

the agency.

Procedural Steps

1. Explain to the adolescent that he or she will need to provide a urine

sample today.

2. Take the adolescent to a bathroom, provide the necessary materials,

and go over the instructions for providing a sample.

3. Read the test.

4. Provide the appropriate feedback based on the results.

5. Complete the ACRA Procedure 8 Checklist—Urine Testing

immediately after the session.

Detailed Description

The remainder of this section contains a more detailed overview for 

conducting a urine test and processing its results. Procedural steps are 

in bold type and are followed by further directions and comments. 

1. Explain to the adolescent that he or she will need to provide a

urine sample today.

Urine tests should have been discussed in an earlier session so they will not

be a surprise to an adolescent. Tell the adolescent that this session is the

one that has been randomly chosen for a urine test. Explain the purpose of

the urine test and the possible outcomes, and provide some general idea of

what your response will be to each of the outcomes. Also tell the adolescent

about procedures that are in place to assess whether a sample has been

tampered with.

2. Take the adolescent to a bathroom, provide the necessary materials,

and go over the instructions for providing a sample.

Specific steps for conducting the test and an explanation of how it works

should be available from the company that markets the tests. The therapist

should complete either a company-sponsored or an inhouse training program

and be certified before administering tests.

3. Read the test.

Follow the manufacturer’s instructions, and read the test results—possible

outcomes include negative (drugs are not present), positive (drugs are 

present), or inconclusive. If the test is inconclusive, you may want to test

an additional drop from the same sample. Record the results on the 

urine-testing form.
4. Provide the appropriate feedback for the results.

When the test indicates that drugs are not present in the urine, provide

strong positive reinforcement and social support. Review aspects of the 

adolescent’s living environment that have been conducive to abstinence.

Encourage continued development of drug-free activities. Probe for problems

with cravings or emotional distress during this time. Find out how the 

adolescent coped successfully with these problems. Ask the adolescent,

“What is your biggest motivation for not using?”

When urine test results indicate that drugs are present, review the context

of the adolescent’s use. Be nonjudgmental. Examine external and internal

triggers associated with his or her use, and generate potential solutions to

resist use if a similar circumstance is encountered in the future. Talk with

the adolescent about goals for marijuana use and nonuse. Try to get the

teen to commit to changing his or her using behavior, and help the adolescent

identify personal motivators for staying away from alcohol or drugs. Review

triggers, coping methods, and other relapse prevention procedures

described in procedure 5 of this manual. 

5. Complete the ACRA Procedure 8 Checklist—Urine Testing

immediately after the session.

A blank copy of this form is included at the end of this section.

Tips for Individualizing or Dealing With Difficult Situations

To individualize urine test results:

• Stick with the specifics of the adolescent’s situation. 

• Discuss what the adolescent is doing to maintain his or her 

abstinence. 

• Focus on what can be done to avoid triggers and lapses.

If the adolescent denies using despite positive results:

• Do not criticize the adolescent. Rather than being confrontational,

play detective and ask questions. For example, “What do you

make of this discrepancy?” or “What do you think is going on

here?” 

• Point out that perhaps a urine test showing drugs in the urine

could have consequences (e.g., probation problems, losing a job)

even if the adolescent did not use. 

• Ask the adolescent how you can help him or her. 

• Reiterate that being around others who are using alcohol or drugs

is a high-risk situation with negative consequences. 

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(Continued on next page)
138

• Ask how the urine test results could affect his or her goals. 

Note: You also may want to suggest sending an additional sample to a

laboratory for verification. 
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Procedure 8 Checklist—

Urine Testing

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you explain the purpose of urine 

testing? 

2. Did you record the results in the clinical 

chart? 

3. If test results were negative, did you 

provide positive reinforcement and social 

support? 

4. If test results were positive, did you review 

the context of the adolescent’s use, 

examining external and internal triggers? 

5. If test results were positive, did you 

generate potential solutions to use if the 

adolescent encounters the circumstances 

again? 

6. If test results were positive, did you review 

procedures on relapse prevention? 
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Procedure 9: Caregiver Overview, Rapport Building, and

Motivation

Rationale

Caregivers have an important role in helping the adolescent overcome a

drug or alcohol problem. They must therefore be taught the behavioral

skills to discourage the adolescent’s drug use and the parenting practices

that can keep their adolescent from relapsing.

Purposes of the Procedure and Learning Objectives 

The purposes of the first session with the caregiver are to (1) motivate 

participation in the ACRA treatment process and (2) help the caregiver

understand how his or her behavior impacts the adolescent’s substance 

use. The learning objectives are to provide caretakers with:

• A more positive attitude about their adolescent that eliminates

blaming anyone for current problems

• An understanding of the ACRA approach and treatment process

and the importance of their role in the treatment

• Motivation to continue working with the ACRA therapist.

Timing, Audience, and Delivery Method 

These procedures are covered during the first session with the caregiver

in the first or second week of treatment. During the first adolescent session,

you should have already met briefly with the caregiver to provide an

overview of the ACRA treatment process and the caregiver’s involvement

in it. (See the section Sequence and Content of Caregiver Sessions in Part

II, Overview of the Treatment Model.)

Materials

General materials include snacks (e.g., chips, crackers, granola bars, fruit

bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if

applicable) a videocamera and videotapes or audiorecorder and audiotapes.

Procedure-specific materials: none.
General Notes for the Therapist

A caregiver is not necessarily a parent. A caregiver could be an older sibling,

a grandparent, or another adult who is willing to try to help the adolescent

with recovery. It is usually someone who lives with the adolescent.

Caregivers may be emotional during the first session. They may be either

angry or sad. Some will be very angry with their adolescent and want to talk

about how “bad” the youth is. Others may feel a sense of failure that this

has happened in their family. It will be important to listen empathically and

then attempt to motivate them to play a positive role in their adolescent’s

treatment.

During the session, maintain a positive and enthusiastic tone of voice. Your

demeanor can help build a positive atmosphere for change and motivate the

caregiver to follow through with the four sessions.

Procedural Steps

1. Use rapport-building techniques.

2. Provide an overview of ACRA.

3. Motivate or “hook” the caregiver into continued work with the

ACRA therapist.

4. Provide information to the caregiver about research findings on the

most important parenting practices for keeping his or her adolescent

from relapsing.

5. Assess whether problems appear serious enough to warrant other

referrals.

6. Assign homework (but do not call it that).

7. Complete the ACRA Procedure 9 Checklist—Caregiver Overview,

Rapport Building, and Motivation immediately after the session.

Detailed Description

The remainder of this section contains a more detailed overview for 

conducting the first session with the caregiver. Procedural steps are in 

bold type and are followed by further directions and comments.

1. Use rapport-building techniques.

Strategies for building rapport include:

• Let the caregiver have the opportunity to discuss his or her 

feelings about the family situation.

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• Empathize with the caregiver’s concerns. After doing so, begin to

refocus on what needs to be done now, and shape the interaction

in a positive way. (See below.)

• Reinforce that the caretaker must attend the sessions, and let

him or her know that you understand it may be difficult to do so.

• Share general information from your work with other families,

affirming that these sessions can be helpful and that research has

shown that these techniques have helped other families in similar

situations.

Techniques for keeping the discussion positive. These techniques from

Functional Family Therapy (Alexander & Parsons, 1982; Waldron & Slesnick,

1998) can be helpful to therapists as they try to shape a positive discussion:

• Relabel behavior. Change the meaning and value of a negative

behavior by describing positive properties of the behavior or by

explaining that the adolescent is not engaging in it to make the

parent or caregiver miserable or angry. If possible, suggest positive

motives for the behavior, and/or portray family members as victims

rather than perpetrators. For example, the adolescent may be

described as someone who is struggling to become independent

and is trying very hard to be accepted by friends. Relabeling

behavior gives family members “another picture” or new 

information about behaviors and is most effective if it ascribes

benign or benevolent motives.

• Curtail blaming. Communicate to the caregiver that blaming 

someone for previous problems does not serve any purpose.

Emphasize the future, not what happened in the past.

• Use a positive focus. Emphasize family strengths by repeatedly

reinforcing discussions about aspects of family life that are 

working well, such as pleasant events and family activities. For

example, “Tell me something nice that your child has done during

the 15 years he or she has been a part of your family.”

• Use exception statements. Try exception statements, another

technique useful in decreasing family blaming statements

(Melidonis & Bry, 1995). To use this technique, ask the caregiver

to describe a situation from the past in which the problem 

behavior was expected to occur but did not. Then probe into 

what was different about this situation.

2. Provide an overview of ACRA.

• Describe ACRA, including the success, philosophy, and the focus

of ACRA therapy sessions. 
• Provide information about the length of treatment sessions, the

number and type of ACRA therapy sessions, confidentiality, urine

testing, and videotaping or audiotaping, if appropriate.

• Praise the family for participating in treatment and try to make

the members feel comfortable, stating something such as, “I am

really glad you came to treatment; I look forward to working with

you!” 

• Encourage the family to ask questions, and let both the caregiver

and the adolescent know that they can ask questions about 

therapy at any time during treatment.

• Describe the purposes of ACRA caregiver sessions. During the 

sessions you hope to (1) help diminish the caregiver’s pain, 

(2) help improve communication, and (3) help improve the 

relationship between the caregiver and the adolescent.

3. Motivate or “hook” the caregiver into continued work with the

ACRA therapist. 

Set positive expectations and try the following procedures.

• Assess the caregiver’s reinforcers related to the youth’s stopping

substance abuse, and use these to help motivate the caregiver to

“try ACRA.”

Sometimes the caregiver’s reinforcers are revealed through 

conversation, but usually it will take questioning to elicit them.

Ask, “What benefits will result if the adolescent stops using?”

Most caregivers will be able to articulate the benefits or goals 

for their adolescents. For example, they want their teenagers to

graduate from high school and to avoid incarceration. Other 

caregivers’ motivation revolves around themselves, such as 

wanting to make their own life easier. For example, a caregiver

may say, “I want the school system off my back.”

Work with whatever reasons the caregivers offer for wanting their

adolescents to stop using alcohol or marijuana, and try to help

them see how the therapist, caregiver, and teen can work 

together to achieve their goals.

• Reiterate potential benefits of ACRA discussed during the

overview; emphasize that caregiver involvement in treatment

could help improve the relationship between the caregiver and his

or her teenager and could help lead to more success in life for the

teenager.

• If the caregiver is skeptical because of past treatment failure or

because he or she does not believe that the adolescent will quit

using alcohol or drugs, emphasize that recovery is a process. Tell

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the caregiver that you believe this program can work for him or

her. Try to get commitment to attend at least four ACRA sessions.

You might say something like, “I know you love your son (daughter). Sometimes parents just don’t know what to do when there

are problems with their children, and sometimes it is helpful to

try different things.”

4. Provide information to the caregiver about research findings on

the most important parenting practices for keeping his or her 

adolescent from relapsing (based on the work of Catalano [1998],

Hops [1998], and Bry [1998]). 

According to Catalano, Hops, and Bry, the following are four critical 

practices that parents or caregivers can adopt to help their children 

remain abstinent:

• The single most important parenting practice is for caregivers to

be good role models by refraining from using drugs or alcohol in

front of their teenagers. When discussing this with caregivers, tell

them that you are not “accusing them of using” but that they

need to know this. Ask them whether they will agree not to use

substances in front of their teenager.

• A second critical parenting practice is to increase positive 

communication with their adolescent. Parents or caregivers

should strive toward decreasing blaming and “put downs” and

increasing positive talk with and about their teenagers. Explain

that in the next session, you will work with them on communication

skills.

• A third important parenting practice is to monitor the adolescent’s whereabouts, including knowing where they are and whom

they are with. 

• A fourth critical parenting practice is involvement in the 

adolescent’s life outside the home by encouraging and promoting

prosocial activities.

It is important to maintain a dialog during the session, so it is helpful to

weave a discussion of the four parenting practices into conversation. For

example, you may ask, “What are some of the things you do really well as a

caregiver?” or “What are some things you do to keep your teenager away

from alcohol or drugs?” As you review the caregivers’ responses, look for

opportunities to praise them for positive parenting practices. 

During a discussion of the four practices, caregivers may bring up issues or

problems. If so, you can begin to talk to the caregivers about their issue of

concern but still try to review all four parenting practices. For example, a

parent may say he or she has a problem showing appreciation for his or 

her teen. You may help him or her practice providing praise or showing 

appreciation. Or the caregiver may reveal he or she rarely encourages the 
teen to attend positive social activities. You may begin helping the caregiver

identify positive social activities.

The caregiver’s primary role with regard to developing other community

reinforcers is to help the adolescent access them or support his or her

interest in them by spending time with the adolescent as he or she watches

or participates in the activities.

5. Assess whether problems appear serious enough to warrant other

referrals. 

It is especially important to make referrals if there are other adults or 

adolescents in the home who are presently involved in substance abuse or

who have serious mental health problems. You should report any instances

of possible abuse.

6. Assign homework.

At the end of the discussion, try to get the caregiver to commit to homework

such as providing praise, appreciation, and positive reinforcement to the

teenager at home. You may introduce the assignment this way, “We’ve found

that the best way to have these new behaviors become part of your normal

behavior is to practice them. Would you be willing to try them a couple of

times before I see you again?” (If the answer is yes, help specify what he or

she would do.) Examples of homework might be to praise the teenager at

least twice a day and locate a positive activity and encourage the adolescent’s

participation in it. At the next session, review the caregiver’s success with

the homework tasks. You also should review the four critical parenting 

practices to help reinforce these concepts.

7. Complete the ACRA Procedure 9 Checklist—Caregiver Overview,

Rapport Building, and Motivation immediately after the session.

A blank copy of this form is included at the end of this section. 

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Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Procedure 9 Checklist—

Caregiver Overview, Rapport Building, and Motivation

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you maintain a positive and 

enthusiastic tone of voice? 

2. Did you employ rapport-building 

techniques with the caregiver? 

3. To keep the discussion positive, did you 

relabel behavior? 

4. To keep the discussion positive, did you 

curtail blaming? 

5. To keep the discussion positive, did you 

constantly reinforce discussion about 

aspects of family life that are working well 

and pleasant events and family activities? 

6. Were you able to motivate or “hook” the 

caregiver into continued work? 

7. Did you talk about the benefits of ACRA? 

8. Did you provide information to the 

caregiver about what he or she can do to 

keep the adolescent from relapsing? 

9. Did you assess whether the problem 

appears serious enough to warrant 

another referral? 

10. Did you get the parent or caregiver to 

commit to some homework (without 

calling it homework)? 
Procedure 10: Caregiver Communication Skills Training

Rationale

Caregivers and adolescents often have a difficult time communicating in a

positive, effective manner. It is not unusual for caregivers to be frustrated

with their adolescents’ behavior in a number of areas, and substance

abuse problems can exacerbate an already troubled relationship.

Improving communication skills can help family members develop more

positive relationships.

Purpose of the Procedure and Learning Objectives

The purpose of this session is to improve the communication skills of the

caregiver. The caregiver will learn the importance of good communication

skills in improving relationships; how to use the ACRA communication

techniques such as understanding statements, a partial responsibility 

statement, and offer-to-help statements; and how to use these techniques 

in real life situations.

Timing, Audience, and Delivery Method

This session is conducted individually with the caretaker in weeks 3 to 5

of treatment. The caregiver has the opportunity to practice these skills

during the session and is asked to continue practicing them before the next

session. In a later session, the caregiver and adolescent are brought

together for joint practice.

Materials

General materials include snacks (e.g., chips, crackers, granola bars, 

fruit bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and 

(if applicable) a videocamera and videotapes an audiorecorder and 

audiotapes.

Procedure-specific materials include clipboard; chalkboard or whiteboard;

pens, markers, or chalk; and an easel for presentation of material on 

communications skills.

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General Notes for the Therapist

The skills outlined in this section are taught within the context of real 

communication problems between the caregiver and adolescent. Although

the therapist “teaches” the caregiver about effective communication skills,

the teaching is grounded in the experiences of the caregiver. The caregiver

is not merely a passive recipient of the learning that takes place but is

actively involved. This approach helps make the procedures more valuable

to the caregiver, who will then be more likely to try them in real life. 

The skills covered in this section can be used to enhance communication

with other people besides the adolescent.

Procedural Steps

1. Introduce the topic of communication, and provide a rationale for

developing good communication skills.

2. Assess and talk about the present quality of communication between

the caregiver and adolescent. 

3. Using real life examples provided by the caregiver, teach the caregiver

ACRA communication techniques. 

4. Roleplay a number of interchanges between the caregiver and 

adolescent, with the therapist taking the role of the adolescent.

Insert ACRA and general communication techniques whenever 

helpful, and mention pitfalls to avoid. Then switch roles with the

caregiver playing the adolescent and the therapist playing the 

caregiver.

5. Process each exchange from the content and feelings perspectives of

the caregiver. 

6. Assign homework.

7. Complete the ACRA Procedure 10 Checklist—Caregiver

Communication Skills Training immediately after the session.

Detailed Description

The remainder of this section contains a step-by-step description for 

providing communication skills training for caregivers. Procedural steps 

are in bold type, and they are followed by further directions and comments.

Sample dialogs between a therapist and caregiver are indicated in italic

type.

1. Introduce the topic of communication, and provide a rationale for

developing good communication skills.
Take a few minutes to introduce the session, and talk about why it is 

important to focus on communication skills. Find out what reinforcers

would motivate the caregiver to make changes in his or her behavior. For

example, a caregiver might say, “I’m really tired of all the arguing.” Key

points to make include the following:

• Communication between the caregiver and the teenager can be 

difficult, especially when the teen has difficulty with substance

abuse.

• The fact that you want to discuss communication skills does not

mean that you think the caregiver does not know how to 

communicate. However, most caregivers would probably agree

that they could use some guidelines to help them when communication becomes difficult or awkward, such as when they try to

solve a problem or talk about a difficult situation with their

teenagers.

2. Assess and talk about the present quality of communication

between the caregiver and adolescent.

Ask the caregiver about the quality of communication when trying to talk

with the adolescent about (1) nonproblem topics (social or typical everydaytype conversation) and (2) problem topics (the teenager’s substance use, a

problem at school, or a problem at home). How do things tend to go? Has

there been any good communication in the last 2 years? Ask the caregiver

for examples of real life conversations discussing both a nonproblem and a

problem situation. 

Therapist: Tell me what happens when you try to talk together

about. . . .

For those situations that do not go well (e.g., caregiver or teenager gets

angry or frustrated and leaves, or the caregiver and teen get into a fight), 

listen and observe carefully to understand the dynamics that typically

unfold between them. To make sure you understand the situation (and to

show the caregiver you are listening), you may want to repeat the situation

to the caregiver and ask clarifying questions. 

Therapist: Let me see whether I understand this. Gina typically

comes home after curfew 2 or 3 nights per week. She

walks in, and you stand there and say, “You’re late.”

She responds,“Tough,” and walks to her room. Her

response makes you angry, and you lose your temper

and say things like, “You can move out when you’re 18

if you can’t follow the rules” and “Go live with your

father; you can be his problem.” She typically locks

herself in her room and says nothing back to you. 

She just shuts down, puts on the radio, calls a friend

on the phone, and shuts you out completely. Is that 

accurate? What do you do after that?

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Ask the caregiver how satisfactory the quality of communication is with the

adolescent. If the caregiver is unhappy with it, ask what he or she would

like to have happen. Listen carefully to try to understand the caregiver’s

goals. 

Assure the caregiver that you will teach a few techniques that may help with

the communication problems. You will also roleplay a few situations with

the caregiver to give him or her a chance to practice before he or she

encounters a real problem situation with his or her teenager. A goal is to

get the teenager and caregiver to make decisions together. If both persons

are involved in developing a solution to a problem, they are more likely to

follow the agreed-on steps to the solution.

3. Using real life examples provided by the caregiver, teach the 

caregiver ACRA communication techniques.

ACRA has three basic parts to effective communication: (1) giving an

understanding statement, (2) taking partial responsibility, and (3) offering

to help. An understanding statement brings feelings into the conversation—

in particular, empathy. It shows that one person is capable of seeing things

from the other person’s perspective. The caregiver can also try to help the

teenager understand the caregiver’s perspective. The effect on the other

person is a feeling of validation, and this will decrease defensiveness. A 

partial responsibility statement indicates that the caregiver is willing to

accept a role in creating or solving a specific problem. It does not mean 

the caregiver or anyone else is to blame or that it is all up to the caregiver 

to solve the problem. It acknowledges that the caregiver has a shared 

responsibility with the adolescent for creating and solving a problem. An

offer to help is just that—an offer by the caregiver to help solve the problem.

In this instance, the caregiver tries to think of ways that would make it 

easier for the teenager to cooperate. In some cases, it may be necessary to

set up a contingency—that is, the teenager is able to do something he or

she wishes if he or she follows through with an agreed-on behavior.

Taken together, these three communication skills deliver the message 

that the caregiver wants a change in the teenager’s behavior but that the 

caregiver is willing to be actively involved and supportive in the process. The

outcome is decreased defensiveness on the part of the adolescent and more

open lines of communication. 

Using a problem situation between the caregiver and adolescent, introduce

each of the three ACRA communication techniques where they would be

helpful. The techniques are generic so they can be used in virtually any

problem situation. For example:

Therapist: Okay, Mrs. Smith, let’s go back to that situation

between you and Gina when she comes home late.

Let’s replay that conversation, break it down into

pieces, and try to understand where you are coming

from at each point and how you and Gina feel. As we

go through the conversation, I’d like to offer three 
techniques that will help the conversation stay calm

and be more productive. The first technique is to try to

make an understanding statement. An understanding

statement brings empathy into the conversation and

helps decrease defensiveness because you are really

trying to understand the other’s perspective. So what

do you think Gina’s perspective is on this issue? 

Caregiver: I mean, I guess I can understand that she enjoys 

running around with her friends and is reluctant to

come home if they are out having a good time. And 

we have been fighting a lot lately.

Therapist: That’s a great start. Talk to me as if I’m her, using an

understanding statement.

Caregiver: Gina, I understand that it is hard to leave your friends

to come home when you are having a good time. I also

understand that you may not enjoy being at home

because we have been arguing a lot lately.

Therapist: That was perfect! Now the next component is to try to

take partial responsibility for the problem or solution.

Caregiver: How is it my fault?

Therapist: This technique is not to place blame on anyone. It is

meant to indicate that you are willing to accept a role

in creating or solving the problem. 

Caregiver: One thing that I am probably guilty of is not hearing

the reasons why she is late, encouraging her to call, or

even sitting down to talk to her about solutions to this

problem. I just instantly start yelling, then I get so

angry at her response that I say hurtful things to her—

like she can move out when she’s 18 or can go live

with her father and be his problem. That isn’t right.

That really bothers me.

Therapist: Have you ever shared these feelings with Gina?

Caregiver: No. That’s the problem. We can’t just sit down and talk

without fighting.

Therapist: You have been doing great in here with me. Maybe by

going over some of these helpful techniques you will 

be able to sit down and talk. So talk to me using the

understanding statement and the partial responsibility

component.

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Caregiver: Okay. Gina, I understand that it is hard for you to come

home on time when you are having a good time with

your friends and to come home to us always arguing.

You just get me so angry that I start yelling and. . . .

Therapist: You are doing well, but try to use “I” statements.

Instead of saying you just make me angry, start 

by saying I feel angry when. . . . Good job on the 

understanding statement. Start with the partial 

responsibility again.

Caregiver: I want to apologize for how I act at times. I get angry

when you are not home when you are supposed to be.

I feel like you don’t respect me. I get so worried. When

I get worried or angry, I start yelling and say things

that I don’t mean. I would like to change and try to

improve our relationship by trying to improve the way

we talk to each other. I would like to hear what you

think or what you think we can do together to help.

Therapist: Great. You are doing very well. Now the third component

is the offer to help. It is an offer on your part to help

solve the problem. Can you think of something you can

offer to do to help resolve the issue of Gina’s breaking

curfew? 

Caregiver: I could offer to give her transportation, be open to 

having her call me if she is going to be late, or discuss

the reasons why she has been breaking curfew.

Therapist: Now let’s review the three components by having you

talk to me as if I’m Gina, using all of them together.

Caregiver: Gina, I understand that it is hard for you to come

home on time when you are having a good time with

your friends and you come home to us always arguing.

I want to apologize for how I act sometimes. I get 

worried when you are not home when you are supposed

to be. When I get worried or angry, I start yelling and

say things to you that are hurtful and that I don’t

mean. I am really sorry. I would like to try to improve

our relationship by trying to work on how we talk to

each other. I would be open to talking about how you

feel about curfew and some of the reasons why you

have been breaking it and to seeing if we can come up

with some ideas together to solve our problem.

Therapist: Fantastic! How did it feel using these techniques?

Caregiver: Weird at first because I really have to think about what

I am saying. I just hope I can do it. 
Therapist: You’re off to a good start. If you get angry, you might

try to walk away or take a deep breath then try to use

these techniques. Because when you are angry, you

say things to her that you don’t mean. This week

would you be willing to try to use these techniques

when talking with Gina?

Caregiver: I’ll try.

Therapist: How do you think Gina will respond if you try talking

to her using these techniques? 

Caregiver: She will probably think I am crazy, but I really want

our relationship and communication to improve. So,

I’m willing to give it a shot. 

Therapist: Good. I like your openness to trying new things. I will

be going over these techniques with Gina as well. So

she might be trying these techniques at home too. Later,

when we all meet together, we will be using these

techniques in our family sessions together. 

The therapist might have the caregiver practice several different versions 

of this roleplay. The purpose of the exercise is to practice and to give the 

therapist an opportunity to help shape the skills being taught. Roles can be

switched; the caregiver can play the adolescent, and the therapist can play

the caregiver. This is helpful for a number of reasons. It helps the caregiver

understand the adolescent’s point of view, and it gives the therapist a

chance to demonstrate or model the techniques. Assign homework to 

practice the skills outside the session. During the next session, review 

any practice attempts and their outcomes.

4. Roleplay a number of exchanges between the caregiver and 

adolescent, with the therapist taking the role of the adolescent.

Insert ACRA and general communication techniques whenever

helpful, and mention pitfalls to avoid. Then switch roles with the

caregiver playing the adolescent and the therapist playing the

caregiver.

After completing an initial roleplay and providing feedback about how to

improve the effectiveness, practice again. Ask the caregiver for another

example of a problem situation. Dissect the problem and help the caregiver

reword the conversation using effective communication techniques. Both

general communication techniques (e.g., use of “I” statements rather than

“you” statements, active listening) and those in ACRA should be introduced

wherever they can help. 

Encourage the caregiver to roleplay with you conversations with his or her

adolescent. Although roleplaying can be awkward for some people, encourage

the caregiver to participate fully. One way to reduce the awkwardness might

be to avoid using the word “roleplay.” Instead, you can say something like,

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“Okay . . . let’s just pretend I’m [insert the name of the adolescent], and

let’s practice some of the techniques we were just discussing.” Whenever

needed, the caregiver can leave the role to ask questions or for advice. The

caregiver should have the experience of playing both roles—that of the

caregiver and that of the teenager. Point out any examples of barriers to

communication (e.g., blaming or bringing up old problems) and explain

how they will negatively affect communication. 

5. Process each exchange from the content and feelings perspectives

of the caregiver.

Following each roleplay, discuss it with the caregiver. Questions to ask are,

How did it go? What was different about the conversation compared to how

a typical one goes? How did it feel for you to play the role of the teenager?

Processing the roleplay is essential to solidify learning. A followup question

for the caregiver is, How do you think your teenager would respond to this

style of communicating? 

6. Assign homework.

At the end of the session, assign practicing communication techniques as

homework. It is important to get a commitment from the caregiver to try

these skills at home. During the next session, review the results of these

attempts. 

7. Complete the ACRA Procedure 10 Checklist—Caregiver

Communication Skills Training immediately after the session.

A blank copy of this form is included at the end of this section.
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Procedure 10 Checklist—

Caregiver Communication Skills Training

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you introduce the topic of 

communication, providing a rationale for 

developing good skills in this area? 

2. Did you assess the present quality of 

communication between the caregiver 

and the adolescent? 

3. In the context of real life examples 

provided by the caregiver, did you teach 

the caregiver to give an understanding 

statement? 

4. In the context of real life examples 

provided by the caregiver, did you teach 

the caregiver to make a partial 

responsibility statement? 

5. In the context of real life examples 

provided by the caregiver, did you teach 

the caregiver to offer to help the 

adolescent solve the problem? 

6. Did you roleplay exchanges between the 

caregiver and the adolescent and insert 

ACRA and general communication 

techniques whenever helpful? 

7. Did you point out any problems (e.g., 

blaming and bringing up old issues)? 

8. Did you switch roles with the caregiver? 

9. Did you process each exchange with the 

caregiver, from the content and feelings 

perspective? 

10. Did you get the caregiver to commit to 

doing some homework? 
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Procedure 11: Caregiver–Adolescent Relationship Skills 

Rationale

In previous sessions, both the adolescent and caregiver reviewed and 

roleplayed positive communication skills. The adolescent also has learned

techniques for problem solving. Problem-solving training can help caregivers

and adolescents find more satisfactory solutions to their problems. These

procedures are for use in two sessions to provide ample opportunity for 

the caregiver and the adolescent to practice these skills together with the 

therapist’s guidance. 

Purpose of the Procedure and Learning Objectives

The main purpose of this procedure is to improve communication

between the caregiver and the adolescent. The learning objectives are 

to help both parties improve their ability to:

• Use problem-solving skills introduced in previous sessions

• Say positive things about each other

• Speak “nicer” to each other.

Timing, Audience, and Delivery Method

The next two sessions are held with the caregiver and the adolescent

together, in weeks 7 to 11 of treatment. By this time, there should have

been two sessions with the caregiver and enough time to establish rapport

and a working relationship with the adolescent. 

Materials

General materials include snacks (e.g., chips, crackers, granola bars, fruit

bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if

applicable) a videocamera and videotapes and an audiorecorder or 

audiotapes.

Procedure-specific materials include:

• Handout: Relationship Happiness Scale (caregiver and adolescent 

versions), clipboards, and pens

• For problem solving: chalkboard or whiteboard, markers or chalk,

and possibly an easel.

• For communication skills: chalkboard or whiteboard, markers or

chalk, possibly an easel, the handout Daily Reminder To Be Nice.
General Notes for the Therapist

Emphasize to the caregiver and the adolescent that during these sessions

the focus is on the positive attributes of the other person. Guide them to

face and talk to each other during roleplays because the goal is to improve

communication between them. They may try to talk through you because

they feel awkward in the session or because of their poor communication

history. You can help maintain rapport with both by periodically asking how

they are doing during the session.

It is important for you to maintain an equal amount of eye contact with

both during this session and to avoid siding with one person over the other.

Remember to encourage the caregiver and teenager to talk with each other.

Also, in the beginning emphasize keeping the conversation positive.

Discourage any blaming. You can assist by interpreting, coaching, modeling,

and shaping as needed. 

Shaping is an important principle of operant conditioning (behavior 

modification). It involves reinforcing (e.g., through praise, tangible

rewards) small steps toward achieving a larger goal. It is particularly useful

when mastery of a series of small skills, steps, or procedures is necessary to

achieve a complex goal. For example, in trying to teach problem-solving

skills, the therapist should not criticize poor solutions or tell clients to

choose more effective solutions. Instead, the therapist should use a shaping

process that breaks effective problem solving into small components or

steps. Mastery of each component is shaped through teaching, modeling,

rehearsal, feedback, and praise. As clients master each component, they

learn the skills necessary to solve problems. Once they have mastered all

the steps needed to complete a task, they have completed the skill 

acquisition and should be able to use the problem-solving procedure to 

effectively solve their problems.

Procedural Steps

1. Thank both the adolescent and the caregiver for coming in, praise

their work, and offer snacks and beverages.

2. Provide an overview of what is going to happen during the session.

Be clear from the beginning that the emphasis is on being positive

during the session.

3. Check to see whether there are issues that have arisen since the last

session.

4. Have each person face the other and say three positive things about

the other person.

5. Review communication skill procedures with both parties. (See 

procedures 6 and 10.)

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6. Review problem-solving skill procedures with both parties. (See

procedure 7.) This will be the first time that caregivers are 

introduced to these skills.

7. Have both participants complete the Relationship Happiness Scale

forms. (As you review the completed happiness scales, you may 

discover issues for roleplaying communication and problem-solving

skills.)

8. Have the caregiver and adolescent generate realistic roleplay

situations to practice communication and problem-solving skills. 

9. Assign homework.

10. When time permits (it may not be until the second session), present

information on the Daily Reminder To Be Nice form.

11. Spend a little time on closure with the caregiver. Remind the 

caregiver that this will be the last session with him or her, review

what was covered in previous sessions and how it went, and thank

him or her for participating.

12. Complete the ACRA Procedure 11 Checklist—Caregiver–Adolescent

Relationship Skills immediately after the session.

Detailed Description

The remainder of this section contains a more detailed overview on how to

conduct the two sessions on reinforcing and practicing caregiver-adolescent

relationship skills. Procedural steps are in bold type and are followed by 

further directions and comments. Sample dialogs between a therapist and

the caregiver and adolescent are indicated in italic type. 

1. Thank both the adolescent and caregiver for coming in, praise

their work, and offer snacks and beverages.

As in every other session, praise both parties for meeting with you and 

reinforce their work in treatment. The verbal reinforcers and snacks all

serve to continue engaging the caregiver and teenager in treatment.

2. Provide an overview of what is going to happen during the session

activities. Be clear from the beginning that the emphasis is on

being positive during the session.

To alleviate any anxiety on the parts of the caregiver and teenager, provide

an overview of the content of the session. Explain that you will (1) review

communication skills, (2) review problem-solving techniques, and (3) have

both complete Relationship Happiness Scale forms. Note that when going

through problem solving, the emphasis will be on finding a solution that

works for everyone—a win-win solution.
Therapist: I want to talk with you about what we are going to be

doing today. We’re going to be reviewing communication

skills that I have already gone over with each of you.

Then we are going to go over some problem-solving

techniques. I’ve gone over these with Erica before.

Then after that, we will go over something that Erica

has done before that is called the Relationship

Happiness Scale. This one is a little different from the

ones we have done before because this time we will be

looking at how happy you are with your relationship

with the other person.

3. Check to see whether there are issues that have arisen since the

last session.

Check with the teenager to see whether he or she has any pressing issues.

Acknowledge any issues that are mentioned, but try to steer the teenager

and caregiver to the session topics. One way to do this is to say, “That is a

really important issue, and I want to spend some time talking about that.

There are some other things we want to cover first, though.” Here is an

example of how this part might go:

Therapist: [Looks at the adolescent.] First, I need to check to see

that everything’s okay.

Adolescent: I got suspended from school because I left campus 

during a study hall. I thought that it was okay because

I had finished my exams for the day.

Caregiver: The principal called me and said she wasn’t the only

one who got suspended. A lot of the students did the

same thing and a lot got suspended.

Therapist: Well, we should look at that and some options that

could prevent that kind of thing next time. Maybe we

will be able to look at that this session; we want to talk

about some things that affect both of you and maybe

this one did.

4. Have each person face the other and say three positive things

about the other person.

Positive comments about the other person set the tone for the session.

Have each person use “I” statements when stating the positive comments.

For example, “I appreciate that you are always home when I get home from

school” or “I think it is neat that you know so much about computers.”

Periodically ask the person on the receiving end to repeat back what he or

she heard the other person saying. This ensures that the person hears the

good things that are being said and helps develop listening skills.

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Therapist: I’d like to keep things on a positive note—you never

know what can come out, so let’s start by each of you

sharing with the other person three things you 

really appreciate about each other. I’d like for each of

you to go ahead and face each other and tell the other

person what you appreciate about her. Mrs. Smith

would you begin. Go ahead and face Erica.

Caregiver: I really, really appreciate it—your attitude, ’cuz I see a

lot of teens get an attitude. You never have done that.

When you go out, you’ve never been late, no more than

10 minutes. These are two really important things. I

don’t worry as much. I try to tell you in certain ways

and maybe it doesn’t come out and you don’t hear

what I try to tell you.

Therapist: Erica, what do you hear your mom saying?

Adolescent: Well, it sounds like she’s glad that I don’t smart talk

her and that I come in on time.

Caregiver: Yes, that’s right, because I worry so much about . . .

car accidents. If a car doesn’t pull up on time, that is

the first thing I think of.

Therapist: Sounds as if you see Erica as a really responsible 

person. That’s great. Erica, do you want to share

some things you appreciate about your mom.

Adolescent: I appreciate the fact that she like . . . if I need to talk

her, she’ll be there. Sometimes she gets on my nerves

when she comes to my room, but sometimes I really,

really need to talk to someone and she’s there.

I appreciate the fact that she puts up with my girlfriends.

I appreciate the fact that she’s here with me now. I

don’t know how it is helping, but it is.

Therapist: Erica, you did a great job coming up with positive

comments. You were telling me though, not your 

mother. Can you turn and face your mom and tell 

her those nice things?

[Erica turns to her mom and directs her comments to

her.]

Caregiver: I think we find it easier when we come here to tell each

other that we care about each other. I’d like to throw

one more in. I appreciate the fact that you’re [directed

at daughter] coming here.
5. Review communication skill procedures with both parties. (See 

procedures 6 and 10.)

Because both parties have had this training before, try to get them to

remember the three techniques for improved communication. Have a white

board available to write down the techniques as they mention them.

Therapist: Very good. You both did a very good job with coming

up with things you appreciate about each other and

sharing them.

Now, let’s review communication skills. Okay, who

wants to tell me one of the three techniques we use to

help with communication?

[Erica gets up out of her chair and goes to the board;

she wants to write on the board. Erica and Mrs. Smith

have difficulty coming up with the three techniques,

although they throw out related concepts like “active

listening” or “staying positive.” The therapist reinforces

their attempts and then tells them the name of the

first technique.]

Therapist: The first is an understanding statement. [The therapist

gives an example.] 

The second one is called taking partial responsibility.

It’s acknowledging how you might have contributed to

the problem. For example, saying, “You know, I realize

I didn’t give you a lot of time to do dishes” or “I 

realize that you didn’t have time to hang out with your

friends.” So it is saying how you might be a part of

the problem—or just making a statement that shows

you don’t blame the other person. Mrs. Smith, go

ahead and take a shot at that partial responsibility

statement. Remember that you are more likely to get

what you want if you use one.

[Next they talk about an offer to help.]

Therapist: A new technique I want to tell you about is called

“avoiding a no” in a response. What I’d like you to try

is negotiating without saying a flat out “No!” Let’s say

Erica wants to do something on Friday, but you’re

concerned about what she might get involved with

while she’s out. A good solution is not always perfect

for everyone, but sometimes you can get closer to what

both people want . . . and the main thing is happiness

in the relationship, right? [Looks at her mom.] There

are probably times when Erica is driving you crazy,

but still you want to have happiness in your relationship.

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You want to be able to come to a solution together that

works for both of you.

6. Review problem-solving skill procedures with both parties. (See 

procedure 7.) This will be the first time that caregivers are 

introduced to these skills.

Ask the teenager to explain the steps because he or she has already been

oriented to and practiced these skills. When practicing problem solving,

both the caregiver and the teenager can brainstorm. Then they each get 

a turn to cross out suggestions, which are often the other person’s. Then 

they work toward agreeing on a solution. If they end up crossing off all the 

solutions, then both have to start over. Eventually they will see that they

have to work together; otherwise, they will have to be continually generating

more possible solutions.

7. Have both parties complete the Relationship Happiness Scale

form. (As you review the completed happiness scales, you may 

discover issues for roleplaying communication and problemsolving skills.)

This is also a good procedure to have teenagers help explain because 

by this session they have filled out several happiness scales. Because the 

adolescent scale is different from the adult scale, provide an initial 

orientation to the scales. After both the caregiver and the teen have filled

out a form, begin by reviewing those items that each rated high to continue

emphasizing positive interactions. For example say, “What are some things

that are going well with____?” 

Therapist: Erica, you’ve filled out happiness scales a lot before.

But these are somewhat different from what you have

filled out. We call these “Relationship Happiness

Scales” because we want you to rate your happiness

with your relationship with each other in different

areas. Erica, you will notice that the areas are different

on this happiness scale, too. So, would you be willing

to read the directions to us and then explain them in

your own words?

Adolescent: Sure. [Erica reads the directions on one of the

forms.] Basically, it means if you are really happy with

what I do in that area, you circle a 10 and if really

unhappy, then circle a 1.

Therapist: Good job. Another important thing to remember is that

this is for right now. It is what you see right now. Go

ahead and fill it out and put your name at the top.

Then give them to me because I want to look them 

over before we start talking about them.

[Both complete the forms.]
In general, there are some things that you rate really

high and there are some things that you rate low. Let’s

talk about what things are good in the relationship. It’s

important to learn what we are doing well, so we can

keep that going.

[Looks at Erica] You rated allowance really high.

Could you explain why you rated allowance so high?

Adolescent: I didn’t used to get allowance. I get $20 a week for

doing the dishes.

Therapist: I see that you [looks at the mother] rated “affection”

very high. Could you explain your rating?

Caregiver: When I go to her room and say good night and give her

a kiss and a hug, Erica always responds and she

always tells me that she loves me before I even say it.

Adolescent: She always comes to my room to give me a kiss and

hug. If I’m feeling bad, she gives me a kiss and a hug.

Therapist: Let’s see. Looking at this—one thing that there might 

be an issue with is communication. Where do you see

some positives first of all?

Adolescent: One thing that I really noticed big time is that she came

upstairs and told me that she was suspended from

school. She came up and told me this is what 

happened. I appreciated the honesty.

Therapist: [Looks at Erica] What is something positive you like

about talking with your mom?

Adolescent: If I come up to her and talk to her, she listens and stuff.

Usually most of the time if I do something and it’s not

that big of a deal, instead of yelling at me, she’ll be like,

what are you going to do to take care of this problem

now?

8. Have the caregiver and adolescent generate realistic roleplay 

situations to practice communication and problem-solving skills.

It is very important to use roleplaying as part of the training. It may be 

necessary to first work on asking for things and remaining positive. The

caregiver and adolescent should not only talk about how they would 

communicate better or solve problems better; they need to try the techniques.

When they do so with you present, you can help model and shape the 

behaviors.

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Therapist: Tell me something that you would like to work on

about communication.

Caregiver: There is only one thing that I have a problem with . . .

that is on the school issue. It is the importance of 

education. I end up getting frustrated. I want her to

understand about education. When it comes to talking

about this with me, the word “bunk” is used a lot.

Therapist: What you are telling me is that education is important

and you’d like to be able to express that to Erica a 

little better so that she sees your point a little more.

[Provides example of a good reflective statement.]

How do you see this, Erica?

Adolescent: About school . . . 

Therapist: Yeah—actually school and communication about

school.

Adolescent: With the school thing . . . I think that school is 

important. I don’t show it that much. It is important

because I’m going to go to a trade school. I just think

about school at school and then when I get home, I 

just don’t want to think about it.

Therapist: Okay, so it is important because you want to go on to

trade school. But at the same time you want to leave

school at school. You, on the other hand, [turns to 

parent] you’d like . . .

Caregiver: Maybe it’s my wording. There have been several 

subjects that she has problems with. When I’ve talked

to Erica about this . . . I try to tell her that she needs to

let someone know about that. I’d help . . . ask someone

or get a tutor. I know it’s important because I used to

work in offices but now I’m working in a laundry

room because I don’t have the office skills they need

now. I worry about her future. Is she going to go to

college? If not, what kind of work is she going to do?

Therapist: One of your goals is for her to finish up high school

and then go to college or trade school.

Caregiver: Yes, because it is hard to make it.

Therapist: Mom, use the communication skills now when you talk

to Erica. Just try it. Maybe you can only do it partially,

but that’s fine. If you practice it, then when you really

need it, you will be able to use these skills. Let’s go

ahead and try out the communication skills.
165

[Therapist models what needs to be said.] “Erica, I

understand that you like your free time after school

and don’t want to think about school work; but I

worry about the type of job you would get if you don’t

finish school because I want things to work out for

you. I would really appreciate it if you would bring

your school work home so you can graduate from high

school. I know that I haven’t always stressed education and I myself haven’t gone far in school. If there is

anything I can do to help you get to school or bring

your school work home or anything we can do to find

a particular trade, I would be willing to help.” Your job

is not to say something directive like, “You have to 

finish up so you can go to college.”

Caregiver: I can see a big mistake that I am making. Basically I’m

not doing the understanding statement.

Therapist: Erica, can you break down what I just said and tell us

which was the understanding statement, what did I

say for partial responsibility, and what did I say that

was an offer to help?

[This is important to ensure that they both are able

to identify the three skills. Erica does this.]

Go ahead and make an understanding statement. [The

therapist tells the mother to face the adolescent and

encourages her to direct her statement to her and

not to the therapist.]

Caregiver: I understand that it is hard to sit in study hall for 2

hours; you’re bored and you’ve already taken your

finals. I’m concerned that since you’re suspended now,

you won’t be able to make up your school work and

that at the end of the school year you won’t get your

credits and graduate on time. If there is anything I can

do to help—get you a tutor or if I can help—I’ll make

the time to help.

Therapist: That was good. Erica, how did it feel being spoken to

this way by your mother, instead of the old way?

Adolescent: I liked it. My problem with the way you usually talk to

me is that you blow up.

Caregiver: I think I get angry when I get worried for her. I’m 

projecting ahead about what is going to happen. If you

miss so many classes or get suspended, you might not

be able to finish school.
166

Therapist: I think you did some really good things when you were

practicing now. With the understanding statement you

showed you knew where she was coming from. You

finished up with some good offers to help. [Turns to

Erica.] Now why don’t you try to use the communication

skills. [Praises the participants for any attempt that

they make by trying to find something that they said

that is on the right track. Remember, it is a shaping

process.]

Adolescent: I understand what you think about school being 

important and stuff. I would like for you to ask me

every single night if I have algebra or American history

homework and, if I do, make me do the homework

because those are the subjects I have trouble with.

Therapist: Is that an issue? That you have trouble getting your

homework done? 

Adolescent: Yes, I have a problem keeping up with my homework.

Therapist: Okay, we are in problem solving here. [Therapist

stands up and writes on board.] Let’s start 

brainstorming about possible solutions. Erica, do 

you have any ideas?

Adolescent: Like I said . . . one thing mom could do is remind me

about school work; another option is for me to bring

home algebra and American history books each day.

Therapist: How about you, mom? Is there anything you could 

suggest?

Caregiver: If she needs a tutor, we can get her a tutor.

Therapist: Okay, let’s just generate a bunch of ideas.

Caregiver: Or if she needs to read to me or have me ask her 

questions.

Therapist: So you could quiz her? Something I can think of that

might help is to have a friend over to study.

Adolescent: [Names two friends who are good at math.]

Therapist: Are there any other suggestions?

Both Clients: No.

Therapist: First of all, without saying why, look at these possible

solutions and tell us—are there any you don’t want to
do or don’t think you would do? [Allows mother and

Erica to cross suggestions off the list.]

Adolescent: I don’t think I’d do the tutor thing. I know I can do it . . .

if someone tells me how I can do it. I know I’m smart.

I’ve had a relapse in my smartness. My smartness is

coming back.

Caregiver: I see a different Erica in the last couple of weeks. I see

more confidence.

Therapist: Mom, is there anything on the list you don’t want?

Caregiver: I can help her with American history, but not with the

algebra—I stank at that.

Therapist: What is something that you can work on . . . what is a

really good solution?

Adolescent: The really good one is to remind me about the homework

and make sure that I do it. 

Therapist: Anything you think would help? [Directs question to

the mother.]

Caregiver: Have her friend over to study . . . because she has a

friend down the street who she says is good at math.

Therapist: Is there anything you can do to make it easier? [to

Erica]

Adolescent: I can keep my books in my book bag.

Therapist: Is there anything important for you about reminding

her about homework?

Caregiver: Just to remember. I get home at 3:00 every day so I

am there when she gets home from school.

Therapist: You guys did really well, and remember you did it

together. I just wrote things down. But you had to

come to a consensus on something you worked on

together. You are willing to do something about school,

but it is a matter of remembering. [Therapist has the

parent practice using her new communication skills

and asks Erica to give feedback on which ways of

reminding her. Earlier Erica said that she did not

want want her mom talking about school, so this may

be a tricky interaction.]

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168

Therapist: We’re getting a little short on time. One thing I want to

do is thank you for your work. Also, remember I’m not

going to let you off. We are going to have another session

when we can talk about how things went and how you

used the skills on your own. You guys came up with

some really good solutions. Keep in mind that you also

did a really good job using the communication skills.

Caregiver: You know what is hard for me with these 

communication skills? I grew up in the old school. 

You asked a question and it was “Yes” or “No.” The

younger generation has this stuff in schools. It is really

hard to communicate this way.

Therapist: The main thing to look at is whether you are getting

what you want. You won’t always get it, but you are

more likely to get what you want if you are both 

working together.

9. Assign homework.

At the end of the session, ask the family members to work on the possible

solutions to the problem identified during the session. Then at the next 

session, review how the solution worked in practice, and, if problems have

arisen, again use the communication skills and problem-solving procedures

to address them.

10. When time permits, present information on the Daily Reminder To

Be Nice form.

Because of lack of time, this procedure is usually introduced in the second

session with both the caregiver and adolescent. All relationships are more

pleasant when both parties work at being “nice” to each other.

Acknowledge that for many parents or caregivers and teenagers there is a

tendency not to be nice to each other. There are some types of behaviors

that people can practice daily to help increase the number of pleasant

exchanges, and these can be used with all family members. Following this

section is a form that can be used to help prompt daily reminders to be

nice in several areas. The following is a review of areas listed on the form

with examples of each when needed. Work with the teenager and caregiver

to generate additional examples for each area.

• Express appreciation. For example, the son can thank his mom for 

dinner, rides, etc. Mom can thank her son for keeping a clean

room or coming home on time.

• Compliment the other person. For example, one person can 

compliment the other on his or her appearance, how a chore was

done around the house, or how respectful the adolescent was

when introduced to a new adult.
• Give a pleasant surprise. For example, a parent can bring home

an ice cream treat. The son or daughter can clean up a room

without being asked.

• Express affection. For example, a father could tell his son or

daughter, “I love you.” A son or daughter could kiss a mother

goodbye before going to school.

• Initiate pleasant conversation.

• Offer to help sometime without being asked. For example, a 

daughter could offer to start dinner or a father could offer to do 

one of his son’s chores when he is working on a school project.

The form has space for additional reminders to be added. While in the 

session, have the caregiver and adolescent make a list together of other

nice things each would appreciate from the other. Work with them to 

narrow the list down to a few things, and write them on the form.

Review the rules of using the form with the caregiver and adolescent. First,

they should remember to engage in one or more behaviors daily (even if the

other person does not). Second, the form should be posted in a prominent

place where both will have access to it and they can check off when they

remember to do something nice. The placement of the list can be discussed

during the session. Third, they can add to the list at any time.

For homework, ask the participants to include the entire family in the Daily

Reminder To Be Nice activity and to try the procedure for several weeks.

Review completion of this homework assignment with the adolescent during

the next session, and follow up with the caregiver by telephone.

11. Spend a little time on closure with the caregiver. Remind the

caregiver that this will be the last session with him or her, review

what was covered in previous sessions and how it went, and thank

him or her for participating.

Although you will usually have one or two more sessions with the adolescent,

this will be the last formal session with the caregiver. See procedure 12 for

the type of information covered in a closure session. Once again, thank the

caregiver for participating in treatment. Briefly summarize the progress

made. This would also be an appropriate time to tell the caregiver when 

and under what circumstances he or she might want to contact a substance

abuse treatment professional.

12. Complete the ACRA Procedure 11 Checklist—Caregiver–Adolescent

Relationship Skills immediately after the session.

A blank copy of this form is included at the end of this section. 

169
Relationship Happiness Scale 

(Adolescent Version)

Name:_________________________________ ID: _______ Date: _________

This scale is intended to estimate your current happiness with your relationship with

your parent or caregiver in each of the areas listed below. You are to circle one of the

numbers (1 to 10) beside each area. Numbers toward the left end of the 10-unit scale

indicate various degrees of unhappiness, whereas numbers toward the right end of the

scale reflect increasing levels of happiness. Ask yourself this question as you rate each

life area: “How happy am I today with my parent in this area?” In other words, indicate

according to the numerical scale (1 to 10) exactly how you feel today. Try to exclude

feelings of yesterday and concentrate only on the feelings of today in each of the life

areas. Also, try not to allow one category influence the results of the other categories.

Completely Completely

Unhappy Happy

1. Time spent with me 1 2 3 4 5 6 7 8 9 10

2. Allowance 1 2 3 4 5 6 7 8 9 10

3. Communication 1 2 3 4 5 6 7 8 9 10

4. Affection 1 2 3 4 5 6 7 8 9 10

5. Support of school/work 1 2 3 4 5 6 7 8 9 10

6. Emotional support 1 2 3 4 5 6 7 8 9 10

7. General happiness 1 2 3 4 5 6 7 8 9 10

8. General home activities 1 2 3 4 5 6 7 8 9 10
Sample

Relationship Happiness Scale 

(Adolescent Version)

Name: John Doe ID: 1234 Date: 3–1

This scale is intended to estimate your current happiness with your relationship with

your parent or caregiver in each of the areas listed below. You are to circle one of the

numbers (1 to 10) beside each area. Numbers toward the left end of the 10-unit scale

indicate various degrees of unhappiness, whereas numbers toward the right end of the

scale reflect increasing levels of happiness. Ask yourself this question as you rate each

life area: “How happy am I today with my parent in this area?” In other words, indicate

according to the numerical scale (1 to 10) exactly how you feel today. Try to exclude

feelings of yesterday and concentrate only on the feelings of today in each of the life

areas. Also, try not to allow one category influence the results of the other categories.

Completely Completely

Unhappy Happy

1. Time spent with me 1 2 3 4 5 6 7 8 9 10

2. Allowance 1 2 3 4 5 6 7 8 9 10

3. Communication 1 2 3 4 5 6 7 8 9 10

4. Affection 1 2 3 4 5 6 7 8 9 10

5. Support of school/work 1 2 3 4 5 6 7 8 9 10

6. Emotional support 1 2 3 4 5 6 7 8 9 10

7. General happiness 1 2 3 4 5 6 7 8 9 10

8. General home activities 1 2 3 4 5 6 7 8 9 10
Relationship Happiness Scale 

(Caregiver Version)

Name:_________________________________ ID: _______ Date: _________

This scale is intended to estimate your current happiness with your relationship with

your adolescent in each of the eight areas listed below. You are to circle one of the

numbers (1 to 10) beside each area. Numbers toward the left end of the 10-unit scale

indicate various degrees of unhappiness, whereas numbers toward the right end of the

scale reflect increasing levels of happiness. Ask yourself this question as you rate each

area: “How happy am I today with my adolescent in this area?” In other words, indicate

according to the numerical scale (1 to 10) exactly how you feel today. Try to exclude

feelings of yesterday and concentrate only on the feelings of today in each of the life

areas. Also, try not to allow one category influence the results of the other categories.

Completely Completely

Unhappy Happy

1. Household responsibilities 1 2 3 4 5 6 7 8 9 10

2. Communication 1 2 3 4 5 6 7 8 9 10

3. Affection 1 2 3 4 5 6 7 8 9 10

4. Job or school 1 2 3 4 5 6 7 8 9 10

5. Emotional support 1 2 3 4 5 6 7 8 9 10

6. General happiness 1 2 3 4 5 6 7 8 9 10

7. Time spent with adolescent 1 2 3 4 5 6 7 8 9 10

8. General home atmosphere 1 2 3 4 5 6 7 8 9 10
Sample

Relationship Happiness Scale 

(Caregiver Version)

Name: John Doe ID: 1234 Date: 3–1

This scale is intended to estimate your current happiness with your relationship with

your adolescent in each of the eight areas listed below. You are to circle one of the

numbers (1 to 10) beside each area. Numbers toward the left end of the 10-unit scale

indicate various degrees of unhappiness, whereas numbers toward the right end of the

scale reflect increasing levels of happiness. Ask yourself this question as you rate each

area: “How happy am I today with my adolescent in this area?” In other words, indicate

according to the numerical scale (1 to 10) exactly how you feel today. Try to exclude

feelings of yesterday and concentrate only on the feelings of today in each of the life

areas. Also, try not to allow one category influence the results of the other categories.

Completely Completely

Unhappy Happy

1. Household responsibilities 1 2 3 4 5 6 7 8 9 10

2. Communication 1 2 3 4 5 6 7 8 9 10

3. Affection 1 2 3 4 5 6 7 8 9 10

4. Job or school 1 2 3 4 5 6 7 8 9 10

5. Emotional support 1 2 3 4 5 6 7 8 9 10

6. General happiness 1 2 3 4 5 6 7 8 9 10

7. Time spent with adolescent 1 2 3 4 5 6 7 8 9 10

8. General home atmosphere 1 2 3 4 5 6 7 8 9 10
Date _______ Session # _____ Adolescent ID____ Therapist Ini

ACRA

Daily Reminder To Be Nice

Name:___________________________________ Week Starting:___________

Day 

Activity Sun Mon Tue Wed Thu Fri 

Did you express appreciation to the other person today?Did you compliment the other person on something?Did you give the other person a pleasant surprise?Did you express affection?Did you initiate pleasant conversation?Did you offer to help?
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Procedure 11 Checklist—

Caregiver–Adolescent Relationship Skills

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you thank both for coming to the 

session? 

2. Did you provide an overview for the 

session? 

3. Did you check to see whether there was 

anything pressing? 

4. Did you have each say three positive 

things about the other? 

5. Did you review communication skills? 

6. Did you discuss the importance of 

limiting “No’s”? 

7. Did you review problem-solving skills? 

8. Did you do some roleplays for both 

problem-solving and communication skills?

9. Did you have both complete Relationship 

Happiness Scale forms? 

10. Did you go over the Daily Reminder To Be 

Nice form? 

11. Did you go over closure with the 

caregiver? 
176

Procedure 12: Treatment Closure

Rationale

As the treatment sessions end, the adolescent needs to feel positive about

the treatment and the progress he or she has made. Having the therapist

acknowledge the hard work during the treatment sessions helps the 

adolescent reinforce the skills learned and provides motivation to access

additional services in the future, if they are needed.

Purpose of the Procedure and Learning Objectives

The purpose and learning objectives of this session are to make certain

the adolescent understands and acknowledges the progress he or she has

made during treatment and receives praise for the progress and hard

work. The adolescent must also understand procedures that will continue

to help him or her be substance free.

Timing, Audience, and Delivery Method

The closure session is conducted individually with the adolescent and

should be delivered in the last treatment session. If, however, it becomes

clear that an adolescent is “dropping out” of treatment early, the therapist should make an effort to get the adolescent back for one more session and implement these closing session procedures.

Materials

General materials include snacks (e.g., chips, crackers, granola bars, fruit

bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if

applicable) a videocamera and videotapes or an audiorecorder and 

audiotapes.

Procedure-specific materials include clipboard, pens, a discharge packet,

Relationship Happiness Scale form, happiness scales completed during

sessions 1 through 11, completed Goals of Counseling forms, completed

Functional Analysis of Substance Use Behavior forms, completed Functional

Analysis of Prosocial Behavior forms, completed functional analysis

(relapse version) forms, personalized resource activity list, and certificate

of completion.
General Notes for the Therapist

The goal of the discharge session is to review progress made during treatment

by briefly reexamining the functional analyses and Relationship Happiness

Scale and Goals of Counseling forms. The therapist should (1) reinforce

progress made toward goals, (2) discuss with the adolescent whether he or

she would like to set additional goals in areas in which a goal was completed,

and (3) discuss progress made toward achieving unmet goals. The therapist

should provide positive expectations for success for the adolescent with

statements like, “You have done a really good job while in treatment, and I

think you will achieve all your goals outside of treatment, too.” Ask the

teenager how he or she feels about ending treatment, and discuss any 

concerns. 

Procedural Steps

1. Check with the adolescent, and provide an overview of the session.

2. Review the adolescent’s progress. 

3. Talk with the adolescent about what he or she has gained from the

treatment experience.

4. Provide the adolescent with reference information on procedures

that have been covered during treatment.

5. Reinforce the adolescent’s efforts and hard work.

6. Review the status of other referrals made during treatment and the

options for future treatment.

7. Consider other optional activities appropriate for a closing session,

such as joint completion of a discharge form and giving the 

adolescent a completion certificate.

8. Complete the ACRA Procedure 12 Checklist—Treatment Closure

immediately after the session.

Detailed Description

The remainder of this section contains a step-by-step description for 

conducting the closing session. Procedural steps are in bold type, and they

are followed by further directions and comments. Sample dialogs between 

a therapist and an adolescent are indicated in italic type.

1. Check with the adolescent, and provide an overview of the session.

Take a few minutes at the beginning of the session to check how the

teenager is doing, and provide a framework for what will be covered during

the closing session.

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178

Therapist: Last time when we met, you were going to try using

the Daily Reminder To Be Nice technique. How has that

been going? (See procedure 11 for description of these

procedures.)

Adolescent: It’s going pretty well. I’ve been telling my mom that I

love her, and she has been making more pasta for me.

Therapist: That sounds good. What I would like to do today is 

for us both to talk about the progress you’ve made in

treatment. We will talk about what it means to be 

“discharged” and some of the things that could happen

now. I’m going to give you some information that can

help you remember some of the things we did.

2. Review the adolescent’s progress.

A good way to review a teenager’s progress is to look at previous Goals 

of Counseling forms and talk about what goals have been accomplished.

Another helpful review is to compare Relationship Happiness Scale forms

that were completed over the course of treatment. Often these will reflect 

a pattern of improvement. It would also be important to discuss any unmet

goals from prior Goals of Counseling forms and help clarify plans for 

achieving these goals.

Therapist: First of all, let’s discuss your first goal, which was to

get at least a “C” in all of your classes. How is this

going?

Adolescent: I’ve been doing pretty well. I’m not doing as well as I

want to do yet.

Therapist: How about algebra?

Adolescent: I had a makeup test. But I don’t know what my grade

is in there.

Therapist: You probably want to check on that. Remember that

you can also use those problem-solving procedures to

think of other ways to get help for your difficult 

subjects. That can help you out. You’ve done really 

well with that—figuring out different solutions. That 

is something I really appreciate about you.

Another goal was to stay clean for 50 days to a year.

Making it to 50 days was a first milestone. You have

almost made it this long, and you’ve done really well.

You had one time that you had a problem, and you

said that you were going to bring in your cousin for the

early warning system. Have you talked to her about

that?
Adolescent: I’ve talked to her about that, and she is supposed to

remind me about my goal if she notices me hanging out

with Mike and Mark.

Therapist: One of the other things you did was look at different

activities you could have fun at, while staying away

from drugs and alcohol when you were doing them.

What are some of the things you really enjoyed?

Adolescent: I went and played pool at the university’s bowling and

billiard center, and I thought that was pretty cool.

Therapist: What are some other things that you’ve done?

Adolescent: I went bowling with a couple of friends. I spent the

night at a friend’s house after her grandfather’s 

retirement party.

Therapist: And you also mentioned that you wanted to play laser

tag. So this is something. The good thing is that you

were having fun and you got to do something and got

your mind off things.

Let’s review your functional analysis of substance use

a little. You know, when we talked about your outside

and inside triggers, one of the things that is a little 

different is that you said, if you were bored, you would

get restless and smoke pot. We talked about how a positive thing you got out of using marijuana was that it

kept you from getting bored. But we also talked about

the bad things that happened when you used, including

that your mom and sister would get upset about it and

you were spending your money, which was bad

because you needed your money, and you had some

legal problems. Now when you smoked with Mike, it

was really different—you were kind of anxious. That

was kind of a different situation. What could you have

said to yourself?

Adolescent: Well, I could have thought about some of the bad things

that happen when I use.

Therapist: Good. And this was one of the things you did a really

good job of when you were meeting with me . . . talking

about ways to keep things from happening. And most

of the time you were successful doing this when you

were out there in your “real life.” One of the other

things is to find another activity you enjoy doing

instead. We went through a prosocial functional analysis

about taking care of your iguana, and that activity

was good because, when you did it, you didn’t have to

179
180

worry about getting in trouble as you did when 

smoking marijuana.

3. Talk with the adolescent about what he or she has gained from

the treatment experience.

When the adolescent verbalizes treatment benefits, it helps reinforce new

behaviors he or she has learned.

Therapist: We’ve worked on a lot of things, and you’ve done really

well with things including problem solving and relapse

prevention. What are some things you think you gained

from being in treatment?

Adolescent: I actually want to go out and do stuff instead of going

out and getting high.

Therapist: And what is something that you like about that?

Adolescent: It gets me out of the house and people don’t think I’m

ignoring them.

Therapist: So it has improved your relationship with your friends.

That’s not something we really have talked about. Has it

improved your relationship with your friend, Susan? And

how about your friends who were attending AA meetings?

Adolescent: Yeah, she used to smoke pot and I would do it with 

her and we just sat at our house. And even when she

started going out with Jon—he would call to do stuff

and we would just sit around at our house and do

nothing. And then I got arrested and I quit smoking pot

and stuff and quit hanging out with Susan, and the

next thing I know she started coming around again

and she was quitting too.

Therapist: So she’s been supportive of what you wanted and

that’s helped out too—even though she was not the

first person you thought of. Now all these people are

really good supports for you. Sounds as if you got

some really positive things coming here . . . problem

solving and figuring out some other things you could

do besides use marijuana.

Is there anything else you gained from coming here?

Adolescent: Knowing how to prevent myself from going out and

doing drugs. Like before I never thought, oh this would

happen if I smoked pot. Now there is a whole thought

process that goes through my head about what will

happen.
Therapist: It sounds as if you are looking at the big picture. There

were some things that you liked about smoking pot and

before you tended to concentrate on those, but now

you are seeing the whole picture. This doesn’t surprise

me, because you did really well in our sessions talking

about these things.

One thing I’d like to do now is have you fill out a 

Happiness Scale form. Let’s finish that up and look at

some of the changes in your life.

[Therapist shows the client earlier happiness scales

and points out the differences between earlier ones

and the current one.] 

Therapist: Here is a difference on relationship with caregivers—

from a 6 to a 9. 

Adolescent: Now it is just easier to talk with my mom. Like 

yesterday, she started going off on me, and instead 

of blowing up I just said, “Do you want me to tell you

what I did with my money?” And then we just talked

about things calmly.

Therapist: That’s really great. I bet you are both happier when 

you can do that. I see another difference with 

education—from a 6 to a 9.

Adolescent: Yeah, I was failing my classes. Now my grades have

improved.

Therapist: It is good because you set some goals and you have

worked at them. Communication went from an 8 to

10. Can you tell me what happened there?

Adolescent: Well, communication with my friends hasn’t changed.

But now with my mom and dad, it is better. She listens

now, and it is easier to talk with her. She listens to

what I have to say. Before she’d just say “You’re

wrong.”

Therapist: Sounds really good. Things are working well for you.

I’m wondering whether you have any goals from here

on out?

Adolescent: I’d like to graduate with my class. I’m thinking of taking

a correspondence course to help do this. I could do

that.

4. Provide the adolescent with reference information on procedures

that have been covered during treatment.

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182

Consider providing a discharge packet to each teenager for reference. The

contents of the packet can vary based on the individual teenager’s needs.

Sample material can be found at the end of this section. It is titled The

Road Ahead. The discharge packet can include the following:

• Information on positive social activities (e.g., activity lists from 

procedure 2)

• A list of tasks that are a part of each procedure (i.e., goal setting,

decision making, communication skills, problem solving, relapse 

prevention [including use refusal])

• Completed forms including the Functional Analysis of Substance

Use Behavior, Functional Analysis of Prosocial Behavior, and

Goals of Counseling.

Therapist: I want to spend a few minutes showing you what is 

in this packet. These are things we have worked on

together, and you can pull them out periodically to help

you when you might need them. You don’t always have

to do them in written form. For example, you can do

something similar to the happiness scale in your head.

You can ask yourself what things are going well and

what things aren’t going well in your life and think

about what goals you want to set to improve those

things that aren’t going well.

The therapist can individualize the forms and packet by using the client’s

information and input.

5. Reinforce the adolescent’s efforts and hard work.

This verbal reinforcement is woven throughout the session as is illustrated

in the sample dialog above.

6. Review the status of other referrals made during treatment and

the options for future treatment.

If the participant demonstrated needs for additional services during treatment (e.g., residential treatment, psychiatric treatment, family counseling),

appropriate referrals should have been made when these needs became

apparent. (See discussion in Part II, Overview of the Treatment Model.)

However, this is the time to review the teenager’s progress with these other

services and reinforce continued involvement with them, if needed. Talk

with the adolescent about how to access additional services in the future, if

needed. The discharge packet can include contact information for resources

if the client needs additional services (e.g., mental health treatment) in the

future. Include contact information for substance abuse problems the client

may experience in the future. 
Other options are an open invitation for the teenager to call the therapist if

he or she feels the need to in the future or scheduling a monthly call from

the therapist for a limited time. Consider scheduling a followup appointment

within 2 to 3 months as well.

7. Consider other optional activities appropriate for a closing session, such as joint completion of a discharge form and giving the

adolescent a completion certificate.

Optional activities during this session depend on the treatment provider.

For example, if the treatment provider has a standard discharge form that

needs to be completed for the clinical record, then you and the adolescent

can fill it out together so that the teenager is fully aware of what his or 

her discharge recommendations are. Some therapists give adolescents a 

completion certificate or some other symbol to indicate that they have

completed the program.

8. Complete the ACRA Procedure 12 Checklist—Treatment Closure

immediately after the session.

A blank copy of the form is included at the end of this section.

183
THE ROAD AHEAD

(Sample Discharge Packet)
WHAT LEADS TO USE? WHAT LEADS TO USE?

When evaluating alcohol or drug use, we looked at things 

that happened before you used alcohol or drugs 

and the positive and negative consequences of the 

use. The things leading up to use could include your

being around certain people, your being at a 

particular place, a certain time of day, or some

thoughts or feelings that come to mind. We called

those things triggers, things that make you think about using

alcohol or drugs. Remembering what situations you used alcohol or drugs

in can be important in realizing some high-risk situations for use. Triggers

make the use of alcohol or drugs more likely, which in turn leads to both

positive and negative consequences.

Triggers Behavior Consequences

Example Hanging out with ! smoking ! (-) getting grounded,

Joe before school marijuana not wanting to do

at his house homework

(+) not thinking of

school.

Is there a way to get some of the things you like, the positive consequences,

without getting some of the things you don’t like? Finding activities that

you like can help. An activity like shooting baskets may be something fun

you could do with a friend and could give you time to forget about stress

in school without having to worry about it affecting your grades or your

getting grounded or arrested. You end up getting the things you want

without the negative consequences. You can always review lists of possible

activities to see whether there are some new things you would like to try

(see following page). Of course, just as in the example above, triggers for

a positive activity make the activity more likely and lead to positive and

negative consequences. The difference is that these activities tend to have

more long-term positive consequences and fewer short-term negative

consequences than alcohol or drug use.
SAMPLE

Activities That May Interest You

Aircraft Flight Instruction:

Metro-East Airport 2070 Triad Rd., St. Jacob 644–5411

(Shafer Field)

Langa Air, Inc. 10 Terminal Dr., East Alton (314) 895–8911

Amusement Places:

Aladdin’s Castle 133 St. Clair Sq., Fairview Hts. 632–1027

Family Fun Tyme 8 Gateway Dr., Collinsville 344–7747

Family Fun Tyme 1 Schiber Ct., Maryville 288–7747

G & B Amusement Co. 6930 W. Main, Belleville 397–7609

Games People Play 699 S. Bluff Rd., Collinsville 345–0885

Time Out 131 St. Clair Sq., Fairview Heights 632–1027

Time Passages Arcade 321 Broadway, Alton 465–1270

Amusement Parks:

Six Flags I-44 & Allenton Rd., Eureka (314) 938–4800

Antiques:

Alton Landing Antiques 110 Alton St., Alton 462–0443

Antique Emporium 100 E. Warren, Bunker Hill 585–3929

Broadway Antiques 217 E. Broadway, Alton 465–0423

Belleville Antique Mall 208 E. Main, Belleville 234–6255

Richard’s Antiques 2 N. Main, Wood River 254–5793

Maryville Antique Mall 2114 S. Center, Maryville 345–5533

MC Antiques and More 126 E. Chain of Rocks, Granite City 797–2581

Pywacket Antiques 215 E. Central, Benld (217) 835–2970

Wagon Wheel Antiques National & Academy, Pocahontas 669–2918

Aquariums (Public):

Mid-America Aquacenter 416 Hanley Industrial Ct. (314) 647–9594

Aquariums:

Aqua Pets 5733 Godfrey Rd., Godfrey 466–3474

Oceans Windows Pets 2755 E. Broadway, Alton 462–6353

The Swamp 2324 Nameoki Rd., Granite City 451–1852

Archery Ranges:

Bullseye Archery 405 E. U.S. Hwy 40, Troy 667–8616

Town Hall Archery Shop Hwy 15 & 59th St., Belleville 235–9881
RESISTING PRESSURE TO USE

When you decide to abstain from alcohol or drug use, it can be 

a big change. People will probably still offer you alcohol or drugs. 

To help you reach your goal, it is important to know how to refuse 

alcohol or drugs. Refusing drugs may be easy or more difficult 

depending on whom you are with, where you are, the time of day, and

so forth (basically any of the triggers). Being prepared by practicing use refusal

skills can help you stay away from drugs and reach your goal. Below are the

basic steps to use for refusing alcohol or drugs.

"#Say, “No, Thanks”

"#Use Good Body Positioning

"#Suggest an Alternative

"#Change the Subject

"#Confront the Aggressor

$##Say, “No, Thanks.” Of course, if someone offers you alcohol or drugs, 

saying “no, thanks” is the first thing you would want to do. To make sure

he or she knows you are serious, be firm. Often strangers or acquaintances

will just accept a “no thanks” without pressuring you any more. However,

other people such as friends may want to have an explanation. Having a

readymade explanation (“No, thanks, I’m not feeling too well tonight”) can

make it easier. You may decide to just tell them directly that you do not

want to use drugs any more and why.

$##Use Good Body Positioning. Be aware of your posture and body positioning.

To get your point across and show you are serious, it is best to look directly

at the individual when refusing alcohol or drugs.

$##Suggest an Alternative. For example, if someone offers you a beer, you

might say something like, “No, thanks. How about a soda?”

$##Change the Subject. This shows that you are not really interested in using

drugs. For example, say, “No, thanks. What did you think of that new CD?”

$##Confront the Aggressor. Use this technique as a last resort. It can strain a

relationship at times. If the individual is persistent you may ask, “Why is it

so important to you that I do this?” 
GOALS

Goals are about what you want in your life. We spent some 

time completing the Relationship Happiness Scales and set 

goals while we were working together. The happiness scales 

helped identify what areas of life were going well and what 

areas needed a little more work. If something was going well 

in a particular area (such as school or family relationships), it

is important to remember what you were doing to help make that area of

your life satisfying. If you felt bad about a particular area, you could ask

yourself, “What could make this area of my life better?” In the areas that you

rated lower on the happiness scales, we developed some goals. Below are

some tips to remember in the area of goals and goal setting.

1. Evaluate areas of your life. 

• What are some areas of your life that are going well? For example, if you

are doing well in school, examine what is making school satisfying for you. 

• What are some areas of your life that you would like to improve? For

example, if you are unhappy with your relationship with your parents or

caregivers, examine what you would like to see different or changed. 

2. Define your goal.

• Keep goals brief, positive, and specific. A specific goal will allow you to

see whether you have reached your goal. Be specific about exactly what

you would like to see different or changed. 

• Make sure your goal is not too complex. It may take several steps to reach

a long-term goal. For example, it may require going to school, getting

good grades, and getting a good score on the ACT or SAT to get into 

college. Each one of those small steps needs to be tackled first before 

you can reach the long-term goal.

3. Determine how can you reach that goal.

Use problem solving (see problem-solving sheet on the next page) to identify

ways to reach your goal. Decide on how often you will try a plan of action

needed to reach your goal. 

4. Evaluate progress toward your goal.

Periodically, see what progress you are making toward your goal. Check any

changes you think you may need to make or any new things to try to reach

your goal. If desired, record progress toward your goal so you can see how

far you’ve come.
PROBLEM SOLVING

You can use this sheet to help you when you have problems to solve.

Just answer the questions the way we did during our sessions to

arrive at a possible solution. Try it out, and then evaluate the 

outcome afterward.

%#What is the problem you are dealing with?

%#What are some ways you might be able to solve the problem? List

as many ideas as you can think of.

%#Draw a line through any ideas that you don’t think you would try.

%#Read each idea that you have not crossed off the list, and pick

one idea that sounds like something you would like to try. Write it

down below.

%#Evaluate the outcome. Were you satisfied with how it

worked out? (You can modify or change the solution

or even come up with an entirely new solution if

the old solution did not work as planned.)
COMMUNICATION

SKILLS

The goal of using communication skills is to 

be able to get your message across to

another person to help you get what you want.

Through use of communication skills, individuals should be able to

come to a compromise or agree on a solution to a problem. When

everyone agrees on a solution, compliance by all sides and contentment with the solution are more likely. It is important to stay positive

while using communication skills and avoid any blaming. 

1. Understanding statement: The goal of the understanding statement

is to open up communication and show that you are aware of the

other person’s thoughts on the problem.

• Come from their perspective.

Example: “Mom, I understand you would like my room clean

because it is a real mess and you would like the house to be

clean when friends come over.”

• Come from your perspective.

Example: “But Jimmy is having a party at his house and I

have not seen Jimmy in a while, so I would really like to go.”

• Make a request (a request should be brief, positive, and 

specific).

Example: “I would really appreciate if you would let me

clean my room later on tonight, maybe around 8 p.m. when

I get home.”

2. Partial responsibility: The goal of the statement of partial responsibility is to avoid blaming the other person. Remember to state how

you or the other person sees you fitting into the problem or solution.

• How do you fit in to the problem?

Example: “I know I made a real mess by not putting my

clothes away, and I have not always cleaned my room, and

I am sorry about that.”

• Repeat the request (optional).

Example: “But I would really appreciate if you would let me

clean my room around 8 tonight after I get home from

Jimmy’s party.”

(Continued on next page)
3. Offer to help: The offer to help is used to show

that you are willing to work on a solution that

works for everyone and that you would like

input on possible solutions.

• Offer several possible solutions.

Example: “If there is anything I can do to

help make that happen: help out with

another chore around the house, help

out with dinner, or just do a quick 10-

minute cleaning for now and do the rest

later, I would really appreciate it.”

• State your openness to listen and consider the other person’s

ideas. Example: “If there is anything that you can think of, I would

be willing to listen.”

Following the offer to help, individuals may try to compromise with

each other on a solution or do some problem solving. It may be 

necessary to go through the communication skills again to state your

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

ACRA Procedure 12 Checklist—

Treatment Closure

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you check with the adolescent and 

provide an overview of the session? 

2. Did you review the adolescent’s progress? 

3. Did you discuss any unmet goals on the 

Goals of Counseling form and plans for 

achieving them? 

4. Did you talk with the adolescent about 

what he or she has gained from the 

treatment experience? 

5. Did you provide and review the discharge 

packet? 

6. Did you reinforce the adolescent’s efforts 

and hard work? 

7. Did you discuss with the adolescent 

options for further contact and/or 

treatment? 
193

Optional Procedure 1: Dealing With Failure To Attend

Many of the tasks in this procedure are based on the Motivational

Enhancement Therapy Manual used in Project MATCH (Miller et al.,

1995). As described in detail below, the therapist’s job is to be aggressive

in his or her efforts to engage both the adolescent and the caregiver in

the ACRA treatment process. This approach includes contacting someone

as soon as possible after a missed session and eliciting from him or her

the motivations for attending treatment and ceasing substance use.

Rationale

For the adolescent to benefit from treatment, he or she has to attend. If

the adolescent quits coming to his or her treatment appointments, it is

critical that you reach out to the adolescent and reengage him or her 

in treatment. It is also important for caregivers to attend the sessions

designed for them and, if they do not, the therapist needs to make 

additional efforts to engage them. Consider this outreach activity as 

part of your job description. 

Purpose of the Procedure and Learning Objectives

The purpose of this procedure is to reschedule the missed appointment 

and to encourage the adolescent or caregiver to reengage or engage in

the treatment sessions. The learning objectives are to provide an 

opportunity to clarify the reasons for the missed appointment, show the

adolescent or caregiver that you are optimistic about the prospects for

change, and express your eagerness to see the individual again.

Timing, Audience, and Delivery Method

The timing for this procedure is as soon as possible after a teenager or 

caregiver misses a scheduled appointment. The target audience is the 

adolescent and his or her caregivers. These procedures may begin with a

telephone contact, but they may also include a home visit, if necessary. If

the adolescent has been required to attend treatment by a probation officer,

school official, or another authority figure, contact with this official to

prompt the adolescent to attend may be warranted.

Materials

None.
194

Procedural Steps

1. Try to reach the adolescent or caregiver by phone immediately, and

keep trying until you reach him or her.

2. If the adolescent or caregiver does not have a phone, make a home

visit and conduct the procedures there.

3. If the adolescent does not respond to the procedures, consider 

contacting a caregiver and the referral source to see whether they

can help prompt attendance.

4. Complete the ACRA Optional Procedure 1 Checklist—Dealing With

Failure To Attend immediately after contacting the adolescent or

caregiver.

Detailed Description

The remainder of this section contains a more detailed overview for dealing

with failure to attend sessions. Procedural steps are in bold type, and they

are followed by further directions and comments. A sample dialog between

a therapist and an adolescent is indicated in italic type.

1. Try to reach the adolescent or caregiver by phone immediately,

and keep trying until you reach him or her. 

Respond immediately when an adolescent or caregiver misses a scheduled

appointment. Try to reach him or her by telephone, and when you do, cover

these points:

• Clarify the reasons for the missed appointment.

• Affirm the adolescent or caregiver. Provide reinforcement to him

or her for having agreed to participate in treatment.

• Express your eagerness to see the individual again.

• Remind the individual about the reinforcers already discussed for

quitting substance use or, in the case of the caregiver, the reasons

the caregiver wants his or her child to quit using substances.

• Express your optimism about the prospects for change.

• Reschedule the appointment.

Here is an example of a telephone call from a therapist to an adolescent

who has missed treatment:

Therapist: Hello John! How are you doing?

Adolescent: Fine.
Therapist: Good. I was just calling because you missed your

appointment today. Was there anything wrong that led

to your missing the appointment?

Adolescent: Well, my mom wasn’t home, and I didn’t have a ride,

so I couldn’t come.

Therapist: Okay. I know you really wanted to work on your 

relationship with your mom, and I think we can 

work on making things work out between you two 

in therapy. I really look forward to starting back on

this problem during one of our sessions. Is there anything I can do to help you out with getting to therapy?

Adolescent: No, not really. My mom just needs to take me.

Therapist: Okay. If you need anything, just ask. How are you 

feeling about therapy now?

Adolescent: I really don’t feel like coming all the time.

Therapist: Well, I realize it isn’t always easy to come to therapy

and try something like this. I think I might have a hard

time coming to therapy at first. What is something you

don’t really like about coming to therapy?

Adolescent: Nothing really. It just takes up a lot of my time.

Therapist: It does take up time. One good thing is that it only

lasts a few more weeks and then we will be done. I

know you had a few reasons why you came here in 

the first place and some problems because of alcohol

and drugs. What are those things?

Adolescent: I went because my probation officer sent me. I got in

trouble with him, and my mom doesn’t really like me

smoking weed either.

Therapist: What would you like to see happen differently between

you and your mom or probation officer?

Adolescent: I just want them to stop bothering me.

Therapist: I think we can work on that. I would really like to see

your mom and probation officer off your back, too. Do

you think we could go ahead and reschedule your

appointment?

Adolescent: Okay. How about Monday night?

Therapist: Sounds good. Is 6 still good?

195
196

Adolescent: Yeah.

Therapist: Great. I really look forward to seeing you and working

on what to do to get your mom and probation officer

to stop bothering you.

If no reasonable explanation is offered for the missed appointment (e.g., 

illness, transportation breakdown), explore with the teenager or caregiver

whether the missed appointment reflects any of the following:

• Uncertainty about whether treatment is needed (e.g., “I got

everything I needed from residential treatment” or “My child

doesn’t really have a problem”)

• Ambivalence about making change

• Frustration or anger about having to participate in treatment

(e.g., because the school requires it).

The therapist should not act surprised about the poor attendance or confront

the individual with poor motivation or intent. Instead, suggest that it is 

normal to express reluctance by not showing up or being late, and encourage

him or her to express any concerns about participation. Elicit motivational

statements from the adolescent or caregiver by having him or her review

the negative consequences (with peers, family, school, law enforcement,

etc.) that brought the adolescent to treatment in the first place. Then ask

the individual to review how the therapist can assist in preventing these

things from happening again. If speaking with a caregiver, talk about the

goals the caregiver has for his or her adolescent or the problems the 

adolescent’s use creates.

2. If the adolescent or caregiver does not have a phone, make a

home visit and conduct the procedures there.

If you suspect flagging motivation, you may need to offer home visits to

prime attendance. A home visit is an option, particularly if the therapist 

has difficulty making contact by telephone or if the family does not have a

telephone. The purpose of this visit is to show the adolescent and caregivers

that the therapist is genuinely interested and to encourage attendance at 

a session. The therapist can go through the procedures outlined above and

work through any problems with transportation or other obstacles. Some

teenagers prefer to have sessions at their school, and this is another option

to explore.

Another useful technique is to send out greeting cards to motivate attendance

and encourage reengagement in treatment. A handwritten message from

the therapist provides a very personal contact for the teenager.
3. If the adolescent does not respond to the procedures, consider 

contacting a caregiver and the referral source to see whether they 

can help prompt attendance.

If the caregiver does not attend sessions, consider contacting the referral

source for help or consider inviting an alternative caregiver.

4. Complete the ACRA Optional Procedure 1 Checklist—Dealing With

Failure To Attend immediately after contacting the adolescent or

caregiver.

A blank copy of this form is included at the end of this section.

197
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Optional Procedure 1 Checklist—

Dealing With Failure To Attend

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you respond immediately? 

2. Did you clarify the reasons for the missed 

appointment? 

3. Did you express your eagerness to see the 

adolescent or caregiver? 

4. Did you talk about the reinforcers that the 

adolescent had identified to stay away from 

drug use or in the case of the caregiver 

why it is desirable for his or her child to 

become substance free? 

5. Did you express your optimism about the 

prospects for change? 

6. Did you reschedule the appointment? 

7. Have you sent a greeting card? 

8. If you were unable to make contact by 

phone, did you try a home visit? 
199

Optional Procedure 2: Job-Seeking Skills

Rationale

Because a major tenet of ACRA is to encourage positive activities, an 

activity to consider for many teenagers is employment. The job-finding 

procedure has been an important part of the community reinforcement

approach since its inception. The activities described here have been 

successful in helping people find jobs.

Working is not necessarily appropriate for all adolescents because balancing

school work and other positive prosocial activities during the school year

may be all that some adolescents can handle. If, however, they have a lot

of free time during the school year, they are not attending school in the

summer, or they have dropped out, adolescents may find working to be 

a reasonable prosocial activity. Some work situations have a culture of 

alcohol or drug abuse, and one must evaluate this aspect of a potential

work environment. Unfortunately, these cultural aspects of the work 

setting may not become evident until after the adolescent starts the job.

Purpose of the Procedure and Learning Objectives

The main purpose for this procedure is to teach the adolescent how to be

proactive in his or her job search. The learning objectives are to provide

the adolescent with a realistic, systematic approach to finding a job:

decide which job categories are of interest, develop a list of contacts for

job leads, inquire about job openings and ask for an application, and track

job-finding efforts. 

Timing, Audience, and Delivery Method 

Job-finding-skills training takes place individually with the adolescent.

Schedule the training for a particular session or introduce the topic when

the adolescent talks about his or her desire to find a job.

Materials

General materials include snacks (e.g., chips, crackers, granola bars, fruit

bars), drinks (e.g., milk, fruit juice, caffeine-free soda), chairs, and (if applicable), a videocamera and videotapes or an audiorecorder and audiotapes.

Procedure-specific materials include clipboard, chalkboard or whiteboard,

pens, markers or chalk, possibly an easel, and possibly a Finding a Job

handout.

A phone, phone directory, and transportation for job interviews are also

needed. Most teenagers are qualified only for unskilled jobs, and many

may be looking for their first job. If the teenager has work experience or

special skills, you may want to provide assistance with resume development,

so access to a computer and printer would be helpful.
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General Notes for the Therapist

It will not be possible to review all the topics described here in one session.

For example, discussion of how to keep a job will be best addressed after

the teenager has a job. The initial emphasis will be on locating a job.

Procedural Steps

1. Provide the adolescent with an overview of the job-finding approach.

2. Help the adolescent decide which job categories he or she is most

interested in.

3. Develop a list of contacts for job leads.

4. Roleplay how to inquire about job openings and ask for an application.

5. Roleplay a job interview.

6. Teach the adolescent how to track his or her job-finding efforts.

7. Monitor the adolescent’s performance on the job.

8. Complete the ACRA Optional Procedure 2 Checklist—Job-Seeking

Skills immediately after the session.

Detailed Description

The remainder of this section contains a more detailed overview for 

conducting job-finding activities with an adolescent participant. Procedural

steps are in bold type and are followed by further directions and comments.

Provide a copy of the handout Finding a Job located at the end of this 

procedure. 

1. Provide the adolescent with an overview of the job-finding

approach.

Important points to state are:

• It may take a lot of effort to get a job. If you really want one, then

you need to make a job out of looking for a job.

• Being rejected is part of the job-finding process. Do not be discouraged if this happens. 

• A first step is to generate a list of job areas that interest you. 

• Research shows that the more interviews you have, the better

your chances of finding a job.
• It is important to make a lot of contacts to generate job leads,

and there are ways to do this.

• You need to learn how to fill out an application.

• You need to practice approaching employers and interviewing.

2. Help the adolescent decide which job categories he or she is most

interested in.

It is important to help the teenager identify job areas that interest him or

her. As noted, job possibilities will be limited because of age, educational

level, and experience. The following questions can help identify interest

areas:

• What kind of work have you done?

• What job training have you had?

• What type of place would you like to work in?

• What would you like to do?

A few possible job categories are restaurant work, retail jobs, maintenance,

and car repair. Job leads are more easily generated once possible job categories are identified.

3. Develop a list of contacts for job leads.

Research has shown that the best source of job leads are people one knows,

including friends, acquaintances, and family members. Other important

sources of leads are past employer or coworkers and the Yellow Pages. The

more traditional sources, help-wanted ads in the newspaper and job-wanted

postings, are still important to use, but they are not to be relied on solely.

Provide information about generating a list of leads from each of these

sources. Have the teenager actually make a list of friends and family 

members to contact about job openings. Help the adolescent look through

the Yellow Pages to identify businesses in the job category he or she would

most like to work in and add contact information to the job lead list. The

therapist may want to research job-finding resources available in the 

community and provide this information to the teenager.

4. Roleplay how to inquire about job openings and ask for an 

application.

Although the approach may vary somewhat depending on the type of job

lead, there are some common aspects to approaching an employer about

work. Azrin and Besalel (1980) recommend the following approach:

• Tell the person you are looking for a job and why.

• State why you are asking that person for help (e.g., he or she has

a job or knows where a lot of other teenagers work).

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202

• Describe your skills briefly.

• Tell the person the kind of help you want (e.g., ask for information

on any places he or she has heard are hiring or any position 

opening signs).

Here are some steps to take when talking with an employer about a possible

job:

1. Introduce yourself.

Hello, my name is _______.

2. Ask for the manager or person in charge (head of department).

I would like to speak to the manager. Can you tell me his or

her name, please?

3. If the person is not available, ask to set up an appointment for the

same day or the day after.

Is there a time today that would be convenient for us to meet?

4. Once you are able to speak with the manager, get to your main

point.

I’m looking for a job in fast food. I’m wondering whether I

could come in and talk about a possible job or I’d like to speak

with you about possible job openings.

5. Give a brief summary of experience or show enthusiasm for working

there.

This will be my first job. I really would like to work here and

you will find me a dependable worker.

5. Roleplay a job interview.

Some adolescents have never had a job interview. You can help them develop their skills in this area by roleplaying interviews with them. For example,

you can take the role of the employer, ask typical job interview questions,

and coach them in their answers.

6. Teach the adolescent how to track his or her job-finding efforts.

It is important to track the job contacts made each day and their results for

several reasons. First, the job seeker may be given specific instructions to

call or come back on a certain day. Second, the job seeker may want to

identify employers to check back with because they did not have a current

opening but anticipated one in the future. Recommend that the teenager

keep information in a spiral-bound notebook by date and include the following: name of business, phone number or address, name of person contacted,

results of the conversation, and any additional comments. This tracking

information provides great reference information for a future job search.
7. Monitor the adolescent’s performance on the job.

Once a job is obtained, teenagers may need some additional coaching on

how to keep a job. During treatment sessions, the therapist can ask how the

job is going and weave in appropriate procedures (e.g., communication and

problem solving) to help the adolescent address any problems on the job.

8. Complete the ACRA Optional Procedure 2 Checklist—Job-Seeking

Skills immediately after the session.

A blank copy of this form is included at the end of this section.

203
Finding a Job

&#Make a list of what you’re interested in—what you’d

like to do.

' Think of what kind of work you’ve done in the past. 

ANY experience you’ve had matters!

' Think about what you’re good at or places you’d LIKE to work. 

Examples: computers, retail (mall), maintenance, waiter (restaurant

work), typing, filing.

&#Develop a list of contacts for job leads.

' Talk to:

Family members

Friends

Past bosses.

' Look in the Yellow Pages to locate businesses in the job categories you

want to work in.

' Look for help-wanted ads posted in windows of stores or restaurants.

' Examine help-wanted ads in the newspaper every day.

&#Inquire about job openings, and ask for an application. 

' Introduce yourself.

' Ask for the manager.

' Ask whether you can come in and talk about any openings—ask for an

interview.

' Set up a time the same day or the day after.

' Tell the person what work you have done in the past. If he or she is not

currently hiring, ask whether you can turn in an application and come

back in a couple of weeks.

' Ask whether he or she knows of any other businesses that are hiring.

' React in a positive and polite manner.

&#Develop a resume that includes:

' Your name

' Address

' Telephone where you can be reached

' Work you’ve done in past

' Skills you have

' Names and phone numbers of three people for the employer to call as

references.

&#Set goals when looking for a job.

' Make at least five contacts a day.

' Be motivated.

' Make a lot of appointments.

' Call employers back to check whether a position has opened up.

' Turn in applications to as many places as possible. 

(Continued on next page)
Sample request for an interview:

Hello, my name is ______. I would like to talk to the manager. Can you tell

me his or her name, please? I’m looking for a job in ______ (e.g., restaurant

work), and I’m wondering whether I could come in to talk about a possible

job opening. I can make it at 2 this afternoon; would that be convenient for

you? I have experience in ______, and I’d like to talk to you about any 

openings now or later. Would you have time this afternoon? (If not) When 

is a good time to come back?
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Optional Procedure 2 Checklist—

Job-Seeking Skills

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you provide an overview of the 

job-finding approach? 

2. Did you help the adolescent identify job 

areas he or she was interested in? 

3. Did you help the adolescent develop a list 

of contacts for job leads? 

4. Did you roleplay with the adolescent how 

to inquire about job openings and ask for 

an application? 

5. Did you roleplay a job interview? 

6. Did you teach the adolescent how to track 

his or her job-finding efforts. 

7. Did you evaluate the outcome at the next 

session? 
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Optional Procedure 3: Anger Management

The following material is adapted from McKay, Rogers, and McKay

(1989).1

Rationale

Anger-management skills are taught when adolescents or adults express

anger in ways destructive to themselves or to the people around them.

Managing anger does not guarantee that negative life situations or events

will be resolved, but it will assist adolescents in living healthier lifestyles

and minimizing the risk of adverse consequences of anger-related behavior.

Purpose of the Procedure and Learning Objectives

The purpose is to promote positive methods of communicating anger 

that help adolescents express their needs in a safe, effective manner. 

The learning objectives are to help the adolescent or caregiver:

• Identify reinforcers to manage anger

• Recognize anger

• Take time to “cool down”

• Try to understand another person’s position (be empathetic).

Timing, Audience, and Delivery Method

This optional procedure is used when it is evident from assessment 

information or from what is revealed during treatment that the adolescent

or the caregiver has a problem with anger. The procedure is presented

individually with the adolescent or the caregivers if needed. 

Materials

Procedure-specific material include the Anger Management handout.

General Notes for the Therapist

These procedures are to help adolescents who express anger in unhealthy,

maladaptive ways. Maladaptive ways are “acting out” frequently in a 

physically or verbally aggressive manner, passive behavior that is followed 

by exploding into rage, altercations at school, or screaming matches with

parents or caregivers. 

One reason that teenagers may be angry is that they have been abused,

abandoned, or exposed to other life circumstances for which anger is clearly

an appropriate response. In these cases, anger may have helped protect 

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.

Oakland, CA: New Harbinger Publications. www.newharbinger.com. 800–748–6273.
208

them from mental or physical harm or alerted them that something in their

environments did not feel “right.” You can stress to youth, with and without

these backgrounds, that it is okay to feel angry; what counts is how they

express their anger and negative emotions. 

Procedural Steps

1. Identify reinforcers to manage anger.

2. Assist the adolescent in recognizing anger.

3. Teach the adolescent to take time to “cool down.”

4. Teach the adolescent to foster empathy.

5. Distribute the Anger Management handout.

6. Assign homework.

7. Complete the ACRA Optional Procedure 3 Checklist—Anger

Management immediately after the session.

Detailed Description

The remainder of this section contains a more detailed overview on how to

conduct the optional session on anger management. Procedural steps are in

bold type and are followed by further directions and comments. A sample

dialog between a therapist and an adolescent is indicated in italic type.

1. Identify reinforcers to manage anger.

Initially, the therapist focuses on prompting the teenager to identify which

anger-related behaviors are interfering with his or her life. Examples might

include physical or verbal fighting that has caused trouble for him or her

with parents or caregivers and friends. Other consequences of expressing

anger in unhealthy ways might include criminal justice involvement or

being suspended from school. 

Ask the adolescent to tell you how his or her anger has negatively affected

goal achievement. Provide an example such as a young man’s anger leading

to a blowup with his parents, being grounded, and not being able to attend

a rock concert. Similar to conducting a functional analysis, the adolescent

examines the positive and negative consequences of his or her behavior and

is taught to think that there are other, less damaging ways to express anger.

Once again, the idea is for you to elicit reinforcers from the adolescent and

use these as motivation for change. The following dialog provides an 

example.

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.

Oakland, CA: New Harbinger Publications. www.newharbinger.com. 800–748–6273.
Therapist: Tell me how your anger has affected you in your life.

Adolescent: Well, I got into an argument with my friend Jeff one

night, and we ended up getting into a fight. After that

we just didn’t spend too much time together.

Therapist: Has anything else happened that you have not liked

because of your anger?

Adolescent: I got suspended from school for 5 days once after I

was in a fight with a kid. My grades ended up being

pretty bad because some of the teachers wouldn’t let

me catch up on the homework. That’s pretty much it,

though.

Therapist: So you got suspended from school, your grades got

worse, and you don’t spend much time with one of

your friends because of your anger.

Adolescent: Yeah, that’s right.

2. Assist the adolescent in recognizing anger.

The first step in helping teenagers express their anger in healthy ways is to

assist them in recognizing when they are beginning to feel out of control.

This is the point at which they can choose to behave in a damaging or 

constructive manner. Some teenagers may have more skill in this area than

others do, but when adolescents can articulate their “warning signals,” they

have a better chance of identifying the need to use anger-management 

techniques. It is not enough that they know anger-management techniques;

they also need to know when to use them.

Ask the teenager to describe the physical signs of mounting anger because

physiological changes play a part in the body’s response to increased arousal. For example, an upset stomach, clenched jaw, sweating, tightened fist,

heavy breathing, and a high pulse rate may serve as red flags for the adolescent

to step back and cool down. Each adolescent will identify a unique set of

physical and behavioral warning signs. Encourage the adolescent to monitor

his or her behavior to learn when he or she needs to intervene to avoid an

angry response.

Therapist: Before you get really angry, do you notice any signs

that you are getting upset? Some people clench their

fists or slam doors or something. Do you notice anything like that?

Adolescent: Well, I notice I feel like my face gets really hot, and I

start walking around the house really fast, slamming

doors as I go.

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1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.

Oakland, CA: New Harbinger Publications. www.newharbinger.com. 800–748–6273.
210

Therapist: Good. Remembering those things can be helpful so

when you feel some of those symptoms that show you

are getting upset, you can do something else to calm

yourself down. That way you don’t have to worry

about getting really angry and doing something like 

getting in a fight and getting suspended from school.

What is something positive you have done in the past

that has helped calm you down when you have started

to get angry?

Adolescent: Sometimes walking around helps calm me down. When

I get angry, I just want to leave and try not to think

about things.

Therapist: That’s great. So you are able to calm down by walking

around. What are some of the things you do when you

walk around?

Adolescent: I just walk around and think of how much a jerk the

person was.

Therapist: Okay. Some people like trying to do different things—

positive activities like shooting some hoops or going to

the arcade—when they get angry to help them calm

down and get their minds off things for a little while.

What kind of positive thing do you think you would try

once you started walking around?

Adolescent: Well, I sometimes like just going to the park and relaxing to get my mind off things. If I am really angry, I

sometimes like to play video games at home.

Therapist: So when you start noticing your face getting hot or

start walking around really fast slamming doors, you

would be willing to walk around and maybe spend

some time relaxing in the park or play video games?

That sounds as if it might work for you, and you don’t

have to worry about getting in trouble at school. Would

you be willing to try one of these activities the next

time you feel yourself getting upset?

Adolescent: Sure. If I start getting angry, I’ll just walk away and go

to the park to calm down.

Therapist: That’s right. 

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.

Oakland, CA: New Harbinger Publications. www.newharbinger.com. 800–748–6273.
3. Teach the adolescent to take time to “cool down.”

One technique that has proved useful for anger management is taking the

time to calm down. If a person is in an interpersonal situation during which

he or she feels physical signs of mounting anger, he or she is encouraged to

say, “I need to cool down,” and to leave for an agreed amount of time (e.g.,

1 hour). Walking out for a specified time does not constitute running away

or punishing the other person, but it allows the individual time to work

through the “heat of the moment” and “clear the head.” 

During the time away, the teenager is encouraged to engage in a physical

activity to reduce tension. He or she can go for a walk, play some basketball,

or participate in a pleasurable activity. It is not a time to use substances. The

Functional Analysis of Prosocial Behavior form can serve as an adolescentgenerated guide to the kinds of activities that might appeal to youth. After

the time has passed, the adolescent returns to the situation to talk with 

the other person or decides to take more time to reduce the tension.

Communication skills training is also important to help teenagers learn

how to express their anger more productively (see procedure 6).

When the teenager finds himself or herself growing angry outside a 

conversational context, such as thinking about what someone else did or

said, he or she is once again encouraged to engage in tension-reducing

activity. Explain that this “cooling down” period prevents him or her from

acting impulsively in damaging ways or returning to substance use.

Problem-solving techniques may be useful in attempting to resolve the 

situations to which an adolescent is reacting. Once again, you will want 

to revisit reasons an adolescent has given to stay clean and manage his or

her anger.

4. Teach the adolescent to foster empathy.

Many times when people are angry with someone, they do not think about

why the other person has acted in a certain way. Fostering empathy is one

method of helping an adolescent learn how to examine situations from different viewpoints and defuse anger with understanding. This ability does not

mean that anger in a given situation becomes unjustified, simply that anger

can be communicated more effectively when the person on the receiving

end feels understood and becomes more receptive to the youth’s position. 

Particularly with an older adolescent who has reached a higher level of 

cognitive maturity, you can help the teenager learn to “walk in someone

else’s shoes.” This skill can be taught through roleplaying. For example, you

pick a real life situation and play the role of the adolescent. The adolescent

can play the role of the person with whom he or she is angry, attempting to

voice concern from another point of view. 

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1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.

Oakland, CA: New Harbinger Publications. www.newharbinger.com. 800–748–6273.
212

Following the roleplay, process the experience with the teenager. Ask what

effect the roleplay had on his or her understanding of the other person’s

position and how he or she would handle the same situation if it happens

again.

5. Distribute the Anger Management handout.

Explain that this sheet contains reminders that will help the youth identify

anger triggers and ways to deal with anger.

6. Assign homework.

Seek agreement from the teenager that he or she will use the angermanagement techniques when experiencing the physical precursors to

anger. You should review the adolescent’s success at using the angermanagement techniques in the next session and thereafter when the

teenager reports experiencing anger.

7. Complete the ACRA Optional Procedure 3 Checklist—Anger

Management immediately after the session.

A blank copy of this form is included at the end of this section.

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.

Oakland, CA: New Harbinger Publications. www.newharbinger.com. 800–748–6273.
213

Tips for Individualizing or Dealing With Difficult Situations

• Anger management is individualized. Each adolescent will present

with a unique set of situations to which he or she responds with

anger, as well as different methods of expressing his or her emotions.

Listen to each teenager’s needs, and respond with interventions

targeted to specific problems. For example, adolescents with

chronic aggressive behavior may initially require more empathy

training and tension-reduction work than adolescents who bottle

their emotions until they explode. Those teenagers may respond

better to problem-solving and communication skills training.

• Adolescents are a danger to themselves or others. One extreme

form of anger-management problems may involve adolescents’

threats to hurt themselves or others in a fit of rage. In these

cases, attempt to fully assess the extent of these intentions and

consult with supervisors about the best course of action.

• Caregivers are aggressive. Some teenagers may live with 

caregivers who are physically or verbally aggressive themselves. 

If you have concerns that the caregiver’s behavior is abusive, 

consult with your supervisor for the best course of action including

whether the behavior needs to be reported to the State child 

welfare authority. Even if the caregiver’s behavior does not rise to

the level of reportable abuse, it can create a negative situation.

Teenagers will have difficulty learning how to manage their 

negative emotions in a more constructive manner if they live in

an environment where anger is routinely expressed in unhealthy

ways. Work with the caregiver and the adolescent separately. The

caregiver can be helped to improve his or her communication

skills while you are working with the teenager to improve his or

her anger-management skills. 

1 M. McKay, P.D. Rogers, and J. McKay (1989). When Anger Hurts: Quieting the Storm Within.

Oakland, CA: New Harbinger Publications. www.newharbinger.com. 800–748–6273.
• ANGER MANAGEMENT • 

Remember, it’s okay to get angry. What is important is how your 

emotions are expressed. Below are some tips for anger management.

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

change?

$#How do you know when you are getting angry? (Typical signs are an

upset stomach, clenched jaw, tightened fist.) If you feel you are beginning to get angry, you can do something before the situation becomes

too tense and leads to negative consequences. 

Write your typical signs here:__________________________________________

$#Take time to cool down. Find an activity or spend time away from the

situation so you are able to calm down and handle the situation in a way

that does not have negative consequences.

$#Remember to use communication skills to help express how you

feel, while trying to see how the other person feels. Try to come to a

common solution instead of forcing your decisions on someone else.

See the Communications Skills sheet.

$#Try to come from the other person’s perspective. Why does the 

person feel the way he or she does?
Date_______ Session #_____ Adolescent ID_____ Therapist Init.________

ACRA Optional Procedure 3 Checklist—

Anger Management

Check Appropriate Boxes

Activity In Progress Yes No

1. Did you explain the purpose of learning 

anger-management skills? 

2. Did you probe the adolescent for his or her 

reason for learning anger-management 

skills? 

3. Did you ask the adolescent how angerrelated behaviors have interfered with 

goals? 

4. Did you prompt the adolescent for specific 

physiological and behavioral warning signs? 

5. Did you identify activities in which the 

adolescent can engage to “cool down” after

the warning signals have been recognized? 

6. Did you conduct roleplays with the 

adolescent to help him or her learn to 

walk in another person’s shoes? 

7. Did you assess the adolescent’s potential 

danger to himself or herself and, if 

necessary, consult with a supervisor about 

the issue? 
V. Protocol Monitoring Adherence

Overview of Protocol Monitoring Procedures

A treatment manual is only one of the pieces needed to implement a 

treatment protocol. A number of additional supports help ensure that the

protocol is fully implemented and delivered as outlined in the treatment

manual. The following activities are recommended for protocol monitoring:

(1) staff training by an experienced ACRA trainer, (2) certification of 

therapists, (3) individual supervision, (4) group supervision, and (5) quality

assurance rating scales and checklists (i.e., Therapist Skillfulness Scale,

ACRA Global Procedure Checklist, and ACRA individual procedure checklists). 

ACRA Training

Training should be provided by an experienced ACRA trainer. Initial training

should include a review of the background of CRA and ACRA, an overview of

the model, an extensive review of the treatment manual, review of taped

examples of treatment sessions delivering the model, and roleplay or practice

exercises. Ongoing training can be provided in clinical supervision; however,

the trainer providing the initial training should periodically offer refresher

or booster training to all staff delivering the model.

Certification of Therapists 

A process to certify therapists helps ensure that procedures are being 

delivered as outlined in the manual. The certification process requires that

the therapist videotape and/or audiotape therapy sessions and that all or

randomly selected tapes are reviewed and rated by a clinical supervisor.

Several forms have been developed to aid in the tape review and the clinical

supervision process including (1) the Therapist Skillfulness Scale (TSS), 

(2) the ACRA Global Procedure Checklist form, and (3) the ACRA individual 

procedure checklists. Both consistent ratings of four and five on the TSS 

and a demonstration by the therapist that he or she is implementing 

the treatment interventions in a competent and consistent manner are 

necessary for certification. A more detailed description of the rating scale

and the checklists follows.

Therapist Skillfulness Scale 

A therapist’s working alliance, adherence to the manual, and competence in

the treatment being delivered can be assessed by using the TSS. The TSS is

used by the ACRA supervisor to rate whether the interventions used in 

sessions consistently reflected the protocol. The TSS measures competence

for a range of skills from nonspecific, basic therapy skills to specific skills

related to the manual. This scale is used to provide direction and feedback

in supervision. It is important to note that adherence and competence are

different constructs. Adherence is how much a therapist uses the procedures,

and competence is how well the procedures are implemented with 

appropriate timing. 

217
218

One of the items rated on this scale relates to self-disclosure. In the model,

self-disclosure would rarely be appropriate. It is included on the scale so

that the supervisor can monitor the amount of self-disclosure that occurs

and provide appropriate feedback to the therapist. These ratings can be

monitored over time to maintain quality of treatment. If ratings decline, it

would warrant an increase in training and/or supervision. This scale provides

a tool to assess the need for further supervision on specific techniques or

interventions. A copy of this scale follows this section.

ACRA Global Procedure Checklist

This form is specific to ACRA procedures and provides an opportunity for

supervisors to note what ACRA procedures were used, as well as which ones

could have been used. ACRA therapists complete one after each session.

The supervisor reviews the completed form and initials it to indicate

whether he or she agrees or disagrees with the therapist’s designation. 

The checklist is another tool that can be used to monitor the treatment

process. Comparing this information with what exists on the tapes of sessions

provides useful information to the supervisor and therapist. By using the

ACRA Global Procedure Checklist, a therapist can monitor his or her 

adherence to the model. A copy of this checklist follows this section.

ACRA Individual Procedure Checklist 

ACRA therapists complete individual procedure checklists after each session

and after they complete the ACRA Global Procedure Checklist. These 

checklists describe steps specific to each procedure. By completing these

checklists, ACRA therapists should improve their compliance over time. 

The ACRA supervisor should monitor the completion of these checklists 

and ensure that he or she is in agreement with the therapist. The checklists 

can also be completed by the ACRA supervisor to provide feedback to the 

therapist regarding his or her performance during treatment sessions.

Copies of procedure checklists follow their appropriate procedure 

descriptions throughout the manual.

Structure and Process of Supervision

Individual Clinical Supervision

The initial stages of supervision concentrate on establishing an open, 

honest, approachable, and helpful alliance. Supervision should provide a

forum for a therapist to develop and grow. It is very hard for a therapist to

do so if he or she is intimidated. A positive approach to supervision is also 

a form of modeling ACRA treatment. Once a positive working alliance has

been established, the process of supervision is much more productive. The

ACRA supervisor functions as a teacher, skill developer, resource person,

coach, team captain, and motivator. He or she must have skill and 

knowledge in basic counseling tasks and ACRA procedures and be able 

to convey that knowledge to others.
Individual supervision should take place at least 1 day per week for 60 to 90

minutes. During this time, numerous activities could occur depending on

the needs of the therapist. Typically, this weekly meeting with the therapist

begins with a brief overview of his or her cases. The case review is one

means of providing the supervisor and therapist with information that can

be used to decide how best to use their remaining supervision time for the

week. Other information that helps highlight supervision needs includes 

the supervisor’s review of therapy tapes and accompanying checklists. The 

therapist is also involved in setting the content and agenda for the clinical

supervisory sessions to ensure their relevance to his or her needs. The most

common focus during a supervision session is discussing the best approaches for addressing clinical issues presented by treatment participants and

helping therapists improve their skills in the delivery of ACRA procedures.

Typical supervisory activities include reviewing tapes, providing feedback, 

roleplaying exercises, modeling, providing training or instruction, and 

problem solving.

Videotape and/or audiotape reviews. Supervisor and therapist reviews of

tapes from actual sessions provide important information for supervision.

Therapists often initially feel threatened by having their sessions taped, 

but tapes provide the greatest opportunity for improving their skills.

Videotaping also leads to self-supervision; the tape may speak for itself 

with little need for comments by the supervisor. The therapist has the 

opportunity to experience feelings and thoughts from the session while 

listening to the tape, instead of relying on his or her perception of what

transpired in the session. The supervisor and therapist can stop a tape 

frequently to focus on the therapist’s behavior and thought processes. 

Tape reviews provide an opportunity for corrective feedback or for problem 

solving with the therapist considering what else could have been tried or

done at a particular point in the session. The supervisor may choose to

model a procedure or ask the therapist to roleplay a procedure so that he

or she has the opportunity to improve his or her techniques. 

When a supervisor reviews a tape, either alone or with a therapist, it is

important to look for a number of behaviors. First, it is important to notice

and provide feedback on what the therapist does well. The supervisor can

also point out appropriate procedure options within a session that might

have been overlooked by the therapist. It is also important that the 

supervisor review tapes with an eye toward the most common problems

found in implementing ACRA treatment. If problems are noticed during 

the tape review, the supervisor can provide feedback to the therapist and

model what the therapist might have said in a given situation. The most

common problems in implementing ACRA treatment are listed below.

• Losing sight of an adolescent’s reinforcers

• Failing to involve a parent or caregiver in the treatment

• Neglecting to emphasize the importance of having a satisfying

social life

219
220

• Not stressing the necessity of participating in meaningful 

activities (school, seeking a general equivalency diploma [GED],

work)

• Inadequately monitoring the adolescent’s contact with triggers

• Not checking for generalization of skills

• Not using the adolescent’s or caregiver’s own words as a motivator

• Not determining what motivates the adolescent to change.

Practice roleplays. Intensive and extensive roleplays are excellent skill

builders. During supervision, it is important not only to talk about how 

procedures should be done but also to practice them. Roleplays provide the

therapist the opportunity to practice procedures in the safety of a training

situation and provide the supervisor the opportunity to give feedback on

the therapist’s performance. Just like therapy participants, therapists may

be embarrassed or reluctant to practice roleplaying. It is important that the

supervisor does not convey the expectation of perfection but instead provides

support and encouragement. The supervisor can praise the therapist for any

efforts he or she made. Because an ACRA supervisor functions as coach and

motivator, it is not appropriate to be negative and critical. Because the

therapist is expected to use a positive approach with therapy participants,

this approach is modeled during supervision as well. 

Group Clinical Supervision 

If there are multiple therapists providing ACRA treatment, group supervision

in addition to individual supervision can be beneficial. Group supervision is

efficient because all staff receive the same information at the same time.

The group can provide a sense of belonging, group cohesiveness, professional

identity, praise, and aid. With individual supervision, there are only two

points of view, whereas in group supervision, many ideas are brainstormed

and discussed. An optimal approach is a combination of both individual and

group sessions for each therapist. The supervision process flows from 

individual to group, back to individual and so on. 

As with individual supervision, a number of activities are appropriate with

group supervision, including videotape and/or audiotape reviews, case 

presentations, peer feedback, peer interaction, and roleplaying. A more

structured agenda should be used during group supervision because with

multiple therapists involved, it becomes easy to slip into rap sessions or get

away from the task at hand. The supervisor needs to regulate the action,

amend the course of discussion, and maintain group functions. When a 

program begins using ACRA procedures, it would be beneficial to have

group supervision weekly. As the team becomes cohesive and knowledgeable

about the model, these meetings can occur biweekly.

Videotape reviews are an excellent tool for group supervision. Tapes can 

be stopped at significant junctures for the group to discuss how other 
therapists would have handled the situation. Situations encountered by

other therapists and viewed on tape provide a stimulus for therapists to

share similar clinical problems and provide support and encouragement for

one another. However, it is important not to put anyone on the spot. Good

judgment and sensitivity should be used to determine whose tape to use in

group supervision and when it is appropriate. 

Training Resources

For information on training on this approach, contact the following 

individuals:

Robert J. Meyers, M.S.

Center on Alcoholism, Substance Abuse, and Addiction (CASAA)

1650 Yale, SE

Albuquerque, NM 87104

E-mail: bmeyers@unm.edu

Phone: 505–768–0262

Jane Ellen Smith, Ph.D.

Psychology Department, Logan Hall

University of New Mexico

Albuquerque, NM 87131–1161

E-mail: janellen@unm.edu

Phone: 505–277–2650

For consultation on this approach, contact:

Susan H. Godley, Rh.D.

Chestnut Health Systems

720 West Chestnut

Bloomington, IL 61701

E-mail: sgodley@chestnut.org

Phone: 309–827–6026

Summary

As the process progresses, the ACRA therapist becomes more knowledgeable

about and skilled in the delivery of the ACRA procedures. The use of specific

techniques usually comes more easily to the therapist than knowing when

to use which procedure. Appropriate timing develops along with good 

judgment and increasing competence. Once a therapist has mastered the

techniques, tape reviews are critical to helping the therapist with the timing

of procedures. Some of the ongoing tasks of supervision are to train how to

conceptualize cases, make treatment decisions, and select the timing of

procedures. With tape reviews, rating scales, and checklists, the supervision

process provides a method to measure performance and a feedback 

mechanism to make changes as needed.

221
Therapist Skillfulness Scale 

Supervisor’s Name:____________________________________ Therapist Name:___________________ID#:_________________________________________________ ID#:_____________________________Subject ID:___________________________________________ Session Date:___________________ Session NumPlease rate the therapist on the Notfollowing items: Not at all A little Somewhat Considerably Extensively observed 

To what extent did the therapist follow the session format? 1 2 3 4 5To what extent did the therapist use language and interventions 1 2 3 4 5consistent with the treatment type? To what extent were the treatment goals consistent with the 1 2 3 4 5treatment type? To what extent did the therapist demonstrate expertise and 1 2 3 4 5competence? To what extent did the therapist engage the client? 1 2 3 4 5To what extent did the therapist use interventions at appropriate times (interventions not missed 1 2 3 4 5when needed, interventions not made too early)? 

(C
Please rate the therapist on the Not

following items: Not at all A little Somewhat Considerably Extensively observed 

To what extent did the therapist use appropriate self-disclosure? 5 4 3 2 1To what extent did the therapist use an appropriate level of 1 2 3 4 5activity? To what extent did the therapist maintain the session focus? 1 2 3 4 5To what extent did the therapist set an appropriate tone and 1 2 3 4 5structure for the session? To what extent did the therapist demonstrate warmth, sensitivity, 1 2 3 4 5and genuine concern? To what extent did the therapist understand and express the participant’s feelings and 1 2 3 4 5concerns? 
ACRA Global Procedure Checklist

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

Procedures Used Co

1. Rapport building

Used open-ended questions Praised client for working 

2. Increasing motivation

Discussed benefits Stated importance of attendance Mentioned potential barriers 

3. Functional analysis

Completed for substance use Completed for prosocial behaviors 

4. Treatment plan

Completed Happiness Scale

Completed Goals of Counseling

5. Increasing prosocial recreation

Identified interest areas Used reinforcer sampling Provided systematic encouragement

(C
Procedures Used Co

6. Relapse prevention

Identified early warning system Used functional analysis Outlined the behavioral chain Provided refusal training Used cognitive restructuring 

7. Communication skills

Assessed quality of communication Taught techniques Conducted a roleplay 

8. Problem solving

Defined problem Tried brainstorming Chose a solution 

9. Urine testing

Recorded results Reviewed results 

10. Caregiver overview

Used rapport-building techniques Provided overview of ACRA procedures Looked for caregiver motivators

(C
Procedures Used Co

Identified most important things from research 

Assessed need for other referrals 

11. Caregiver communication

Provided rationale Assessed quality of communication Roleplayed 

12. Caregiver–adolescent relationship skills

Found positive things about each other Reviewed communication skills Reviewed problem-solving skills Completed Relationship Happiness ScalesGave a reminder to be nice Provided closure with caregiver 

13. Dealing with failure to attend

Contacted client Motivated client Rescheduled appointment 

14. Job finding

Assessed job categories Developed job leads

(C
Procedures Used Co

Roleplayed asking for applications and interviews 

15. Anger management

Identified reinforcers Discussed and practiced techniques 

16. Treatment closure

Reviewed progress Analyzed gains Reviewed information Reinforced efforts and hard work Provided a discharge packet 

17. Odds and ends

Looked for reinforcers Tied in reinforcers Used roleplays Assigned homework 

18. Other 

VI. References

Alexander, J., & Parsons, B. V. (1982). Functional family therapy.

Monterey, CA: Brooks/Cole Publishing Company. 

American Psychiatric Association. (1994). Diagnostic and statistical

manual of mental disorders (4th ed.). Washington, DC: Author.

American Society of Addiction Medicine. (1996). Patient placement

criteria for the treatment of psychoactive substance use disorders (2nd ed.).

Chevy Chase, MD: Author.

Azrin, N. H., & Besalel, V. A. (1980). Job club counselor’s manual.

Baltimore, MD: University Press. 

Azrin, N. H., Donohue, B., Besalel, V. A., Kogan, E. S., & Acierno, R.

(1994). Youth drug abuse treatment: A controlled outcome study. Journal

of Child and Adolescent Substance Abuse, 3, 1–66.

Azrin, N. H., McMahon, P., Donohue, B., Besalel, V., Lapinski, K.,

Kogan, E., Acierno, R., & Galloway, E. (1994). Behavior therapy for drug

abuse: A controlled treatment-outcome study. Behavior Research and

Therapy, 32, 857–866.

Azrin, N. H., Sisson, R. W., Meyers, R., & Godley, M. (1982).

Alcoholism treatment by disulfiram and community reinforcement therapy.

Behavioral Therapy and Experimental Psychiatry, 13(2), 105–122.

Brown, S. A., Myers, M. G., Mott, M. A., & Vik, P. W. (1994).

Correlates of success following treatment for adolescent substance abuse.

Applied and Preventive Psychology, 3, 61–73.

Brown, S. A., & Vik, P. W. (1994). Adolescent functioning four years

after substance abuse treatment. Paper presented at the 1994 Annual

Convention of the American Psychological Association, Los Angeles, CA. 

Brown, S. A., Vik, P. W., & Creamer, V. A. (1989). Characteristics of

relapse following adolescent substance abuse treatment. Addictive

Behaviors, 14, 291–300.

Bry, B. H. (1998, January). The targeted adolescent family and 

multisystems intervention (TAFMI): Prevention intervention with youths at

risk for substance abuse. Workshop presented at the Eighth International

Conference on Treatment of Addictive Behaviors, Santa Fe, NM.

Budney, A. J., & Higgins, S. T. (1998). A community reinforcement

plus vouchers approach: Treating cocaine addiction. (NIH Pub. No.

98–4309). Rockville, MD: National Institute on Drug Abuse.

Catalano, R. F. (1998, January). The importance of the family to the

prevention and treatment of substance abuse. Keynote address presented at

the Eighth International Conference on Treatment of Addictive Behaviors,

Santa Fe, NM.

Catalano, R. F., Hawkins, J. D., Wells, E. A., & Miller, J. (1991).

Evaluation of the effectiveness of adolescent drug abuse treatment, assessment of risks for relapse, and promising approaches for relapse prevention.

International Journal of Addictions, 25, 1085–1140.

Cohen, S. (1980). Cannabis: Impact on motivation, Part I. Drug

Abuse and Alcoholism News. San Diego, CA: Vista Hill Foundation.

Cohen, S. (1981). Cannabis: Impact on motivation, Part II. Drug

Abuse and Alcoholism News. San Diego, CA: Vista Hill Foundation.

229
230

Dennis, M. L. (1998). Global Appraisal of Individual Needs (GAIN).

Bloomington, IL: Chestnut Health Systems (www.chestnut.org/li/cyt/gain).

(accessed 9/5/2000).

Dennis, M. L., Dawud-Noursi, S., Muck, R. D., & McDermeit, M. 

(in press). The need for developing and evaluating adolescent treatment

models. In S. J. Stevens & A. R. Morral (Eds.), Adolescent Substance Abuse

Treatment in the United States: Exemplary Models From a National

Evaluation Study. Binghamton, NY: Haworth Press.

Dennis, M. L., Titus, J. C., Diamond, G., Donaldson, J., Godley, S.

H., Tims, F., Webb, C., Kaminer, Y., Babor, T., French, M., Godley, M. D.,

Hamilton, N., Liddle, H., & Scott, C. (under review). The Cannabis Youth

Treatment (CYT) experiment: A multi-site study of five approaches to outpatient treatment for adolescents. Journal of Substance Abuse Treatment. 

Donovan, J. E., & Jessor, R. (1985). Structure of problem behavior

in adolescence and young adulthood. Journal of Consulting and Clinical

Psychology, 53, 890–904.

D’Zurilla, T., & Goldfried, M. (1971). Problem solving and behavior

modification. Journal of Abnormal Psychology, 78, 107–126. 

Farrell, M., Danish, S. J., & Howard, C. W. (1992). Relationship

between drug use and other problem behaviors in urban adolescents.

Journal of Consulting and Clinical Psychology, 60, 705–712.

Godley, S. H., Godley, M. D., & Dennis, M. L. (in press). The

assertive aftercare protocol for adolescent substance abusers. In E. Wagner

& H. Waldron (Eds.), Innovations in adolescent substance abuse interventions. New York, NY: Elsevier Science, Ltd.

Graham, K., Annis, H. M., Brett, P. J., & Venesoen, P. (1996). A 

controlled field trial of group versus individual cognitive-behavioral training

for relapse prevention. Addiction, 91, 1127–1139.

Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early

adulthood: Implications for substance abuse prevention. Psychological

Bulletin, 122, 64–105.

Henggler, S. W. (unpublished). Integration of community reinforcement plus vouchers approach with MST.

Higgins, S. T., Budney, A. J., Bickel, W. K., & Badger, G. J. (1994).

Participation of significant others in outpatient behavioral treatment predicts greater cocaine abstinence. American Journal of Drug and Alcohol

Abuse, 20, 47–56. 

Higgins, S. T., Budney, A. J., Bickel, W. K., Badger, G. J., Foerg, F. E.,

& Ogden, D. (1995). Outpatient behavioral treatment for cocaine dependence: One-year outcome. Experimental Clinical Psychopharmacology, 3,

205–212.

Higgins, S. T., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F. E.,

& Badger, G. J. (1993). Achieving cocaine abstinence with a behavioral

approach. American Journal of Psychiatry, 150, 763–769.

Higgins, S. T., Delaney, D. D., Budney, A. J., Bickel, W. K., Hughes, J.

R., Foerg, F., & Fenwick, J. W. (1991). A behavioral approach to achieving

initial cocaine abstinence. American Journal of Psychiatry, 148,

1218–1224.
Hops, H. (1998, January). From adolescence to adulthood: A 10-year

family perspective on substance use and abuse. Keynote address presented

at the Eighth International Conference on Treatment of Addictive

Behaviors, Santa Fe, NM.

Hunt, G. M., & Azrin, N. H. (1973). A community reinforcement

approach to alcoholism. Behavior Research and Therapy, 11, 91–104. 

Institute for Social Research. (1997). Monitoring the Future Study,

Data Tables and Figures. (www.isr.umich.edu/src/mtf/). (accessed

9/5/2000).

Jessor, R., & Jessor, S. L. (1977). The social-psychological framework. In R. Jessor & S. L. Jessor (Eds.), Problem behavior & psychosocial

development: A longitudinal study of youth (pp. 17–42). New York, NY:

Academic Press.

Kadden, R. M., Cooney, N. L., Getter, H., & Litt, M. D. (1989).

Matching alcoholics to coping skills or interactional therapies:

Posttreatment results. Journal of Consulting and Clinical Psychology, 57,

698–704.

Kaminer, Y. (1995). Pharmacotherapy for adolescents with 

psychoactive substance use disorders. In E. Rahdert & D. Czechowicz

(Eds.), Adolescent drug abuse: Clinical assessment and therapeutic 

interventions (pp. 291–324). NIDA Research Monograph 156. Rockville, MD:

National Institute on Drug Abuse.

Kennedy, B. P., & Minami, M. (1993). The Beech Hill

Hospital/Outward Bound adolescent chemical dependency treatment 

program. Journal of Substance Abuse Treatment, 10, 395–406.

Liddle, H. A., Dakof, G. A., Parker, K., Barrett, K., Diamond, G. S.,

Garcia, R., & Palmer, R. (1995). Multidimensional family therapy of 

adolescent substance abuse. Submitted for publication.

McKay, M., Rogers, P. D., & McKay, J. (1989). When anger hurts:

Quieting the storm within. Oakland, CA: New Harbinger Publications.

Melidonis, G. G., & Bry, B. H. (1995). Effects of therapist exceptions

questions on blaming and positive statements in families with adolescent

behavior problems. Journal of Family Psychology, 9(4), 451–457.

Meyers, R. J., Dominguez, T. P., & Smith, J. E. (1996). Community

reinforcement training with concerned others. In V. B. Van Hasselt & M.

Hersen (Eds.), Sourcebook of psychological treatment manuals for adult 

disorders (pp. 257–294). New York, NY: Plenum Press.

Meyers, R. J., & Smith, J. E. (1995). Clinical guide to alcohol 

treatment: The community reinforcement approach. New York, NY: Guilford

Press. 

Meyers, R. J., & Smith, J. E. (1997). Getting off the fence:

Procedures to engage treatment-resistant drinkers. Journal of Substance

Abuse Treatment, 14(5), 467–472. 

Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G.

(1995). Motivational enhancement therapy (MET) manual, Project MATCH.

Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

Musty, R. E., & Kaback, L. (1995). Relationships between motivation

and depression in chronic marijuana users. Life Sciences, 56(23/24),

2151–2158.

231
232

Office of Applied Studies (OAS). (1995). Services research outreach

survey. Rockville, MD: Substance Abuse and Mental Health Services

Administration, OAS.

Office of Applied Studies (OAS). (1997). Preliminary results from

the 1996 National Household Survey on Drug Abuse (NHSDA). Rockville,

MD: Substance Abuse and Mental Health Services Administration, OAS.

Rob, M., Reynolds, I., & Finlayson, P. F. (1990). Adolescent marijuana

use: Risk factors and implications. Australian and New Zealand Journal of

Psychiatry, 24, 47–56.

Schwartz, R. H. (1987). Marijuana: An overview. Pediatric Clinics of

North America, 34, 305–317.

Shaner, A., Roberts, L. J., Eckman, T. A., Tucker, D. E., Tsuang, J. W.,

Wilkins, J. N., & Mintz, J. (1997). Monetary reinforcement of abstinence

from cocaine among mentally ill patients with cocaine dependence.

Psychiatric Services, 48, 807–810.

Smith, J. E., Meyers, R. J., & Delaney, H. D. (1998). The community

reinforcement approach with homeless alcohol-dependent individuals.

Journal of Consulting and Clinical Psychology, 66, 541–548. 

Waldron, H. B., & Slesnick, N. (1998). Treating the family. In W. R.

Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of

change (2nd ed.) (pp. 271–285). New York, NY: Plenum Press.
Appendix. Clinical Management of a Multisite 

Field Trial of Five Outpatient Treatments for

Adolescent Substance Abuse

Nancy Angelovich, M.S.1

Tracy Karvinen, M.A.2

Suzie Panichelli-Mindel, Ph.D.3

Susan Sampl, Ph.D.4

Meleney Scudder, Psy.D.4

Janet Titus, Ph.D.5

William White, M.A.5

1 Operation Parental Awareness and Responsibility (PAR), Inc. 

2 Chestnut Health Systems–Madison County (CHS–MC)

3 Children’s Hospital of Philadelphia (CHOP)/University of Pennsylvania

4 University of Connecticut Health Center (UCHC)

5 Chestnut Health Systems–Coordinating Center (CHS–CC)

Acknowledgments: Financial assistance for this study was provided by the Substance Abuse

and Mental Health Services Administration (SAMHSA), Center for Substance Abuse

Treatment (CSAT), Grant Nos. TI11317, TI11320, TI11321, TI11323, and TI11324. The

authors appreciate the valuable comments, suggestions, and support offered by the Cannabis

Youth Treatment study principal investigators: Thomas Babor (UCHC), Michael Dennis

(CHS–CC), Guy Diamond (CHOP), Susan H. Godley (CHS–MC), and Frank Tims (PAR).

Correspondence to: William L. White, Senior Research Coordinator, Chestnut Health

Systems, 720 West Chestnut Street, Bloomington, IL 61701, Phone: 309–829–1058, x3403;

Fax: 309–829–4661; E-mail: bwhite@chestnut.org.

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235

Abstract 

Bridging the gap between clinical research and clinical practice in the

treatment of adolescent substance abuse requires empirically validated

therapies and technology transfer strategies that reflect an awareness of the

realities and resource constraints of local treatment service providers. This

article describes the management of cross-site and cross-intervention 

clinical issues in the Cannabis Youth Treatment (CYT) study, a multisite,

randomized, clinical trial of five outpatient therapies. The methods used in

the management of such clinical trials could play an important role in 

elevating the quality of adolescent substance abuse treatment as practiced

in the field. This technology involves 1) defining and delineating clinically

relevant subpopulations of clients, 2) developing research-supported 

manuals that define the theory, active ingredients, and procedures of 

treatment, 3) monitoring therapist adherence to manual-based therapy, 

4) monitoring client responses to the procedures as they are implemented,

5) individualizing and refining the delivery of these manual-based therapies

within the context of clinical supervision, and 6) conducting rigorous and

sustained followup to determine the enduring effects of the interventions. 

Carroll and her colleagues (1994) detailed the strategies used to implement

and to protect the integrity of three manual-based therapies evaluated 

within Project MATCH, a multisite study of adult alcoholism treatment

(Project MATCH Research Group, 1993). This paper takes a similar

approach in describing cross-site clinical coordination procedures within 

the Cannabis Youth Treatment study, the largest multisite, randomized field

experiment ever conducted of adolescent substance abuse treatment. More

specifically, the paper details the common clinical infrastructure within

which these therapies were implemented across the treatment sites.

It is our collective experience that therapies can fail in the transition from

efficacy (outcomes under ideal circumstances) to effectiveness (outcomes 

in the real world of adolescent treatment), not because of flaws in the 

interventions themselves, but because of the absence of a sound foundation

of clinical management upon which empirically validated interventions are

replicated. The construction of stable clinical infrastructures within local

treatment programs is as important to the future of adolescent treatment 

as the availability of research-validated therapies. 
236

The Cannabis Youth Treatment Study

After declining in the 1980s, both licit and illicit drug use among adolescents

rose in the 1990s. In 1996, cannabis use by adolescents (8th, 10th, and

12th graders) reached its highest peak in 12 years for reported lifetime use,

past year use, and past month use (ISR, 1997). As cannabis abuse/dependence

emerged as the leading cause for admission to substance abuse treatment

(OAS, 1997), demands increased for research-validated treatments for

cannabis-involved adolescents. In response to this need, the Substance

Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for

Substance Abuse Treatment (CSAT) of the U.S. Department of Health and

Human Services (DHHS) funded the CYT study. 

The CYT study is a multisite, randomized field experiment designed to 

test the efficacy of five promising outpatient treatment interventions for

cannabis-abusing and cannabis-dependent adolescents. Its long-range goal

is to provide validated and cost-effective models of intervention that can be

widely replicated in local treatment agencies across the country. The study

sites include Chestnut Health Systems in Madison County, Illinois

(CHS–MC); the University of Connecticut Health Center (UCHC) in

Farmington, Connecticut; Operation PAR in St. Petersburg, Florida (PAR);

and the Children’s Hospital of Philadelphia (CHOP) in Pennsylvania. The

sites represent both academic, research-oriented clinics (UCHC and CHOP)

and community-based adolescent treatment programs (CHS–MC and PAR)

(Dennis, Babor, Diamond, Donaldson, Goldley, Tims, et al., 1998; Herrell,

Babor, Brantley, Dennis, et. al., 1999). The CYT study provides a test in 

geographically diverse environments of treatments that differ in theoretical

orientation, delivery format and focus, and dose.

Between June 1998 and February 1999, 600 adolescents (approximately

150 per site) meeting the criteria presented in the Diagnostic and

Statistical Manual of Mental Disorders 4th Edition-Revised (DSM–IV)

(American Psychiatric Association, 1994) for cannabis abuse or cannabis

dependence were randomly assigned to one of three conditions, with a total

of five conditions used across the four sites. The five conditions include:

• Motivational Enhancement Therapy/Cognitive Behavioral 

Therapy—5 individual/group sessions (MET/CBT5) (Sampl & 

Kadden, 2001)

• Motivational Enhancement Therapy/Cognitive Behavioral 

Therapy—7 individual/group sessions (MET/CBT5 + CBT7)

(Webb, Scudder, Kaminer, & Kadden, in press)

• Family Support Network (FSN) (Hamilton, Brantley, Tims,

Angelovich, & McDougall, in press) (FSN includes MET/CBT5 +

CBT7 plus enhanced family supports: home visits, parent 

education classes, parent support groups)
• Adolescent Community Reinforcement Approach (ACRA) (Godley,

Meyers, Smith, Karvinen, Titus, Godley, Dent, Passetti, & Kelberg,

2001) 

• Multidimensional Family Therapy (MDFT) (Liddle, in press).

At UCHC and PAR, adolescents were assigned to a five-session brief 

intervention (MET/CBT5) or to one of two other interventions that combine

more extensive individual and group sessions (MET/CBT5 + CBT7 or FSN).

At CHS–MC and CHOP, adolescents were assigned to the five-session brief

intervention (MET/CBT5) or to one of two individual/family approaches

(ACRA or MDFT). All study participants were assessed at intake and at 3

months, 6 months, 9 months, and 12 months. Treatment completion rates

were in the 70-percent range, and followup rates through 9 months after

treatment exceeded 95 percent (Titus et al., 1999; Godley, Diamond, &

Liddle, 1999). 

Methodological Challenges

There were three important challenges in conducting this multisite field

experiment. The first was to ensure the integrity of each of the interventions

being tested (Moncher & Prinz, 1991). Following what has been referred to

as the “technology model” (Carroll et al., 1994; Carroll & Nuro, 1996;

Carroll, 1997), workgroups led by a technical expert in interventions and a

therapist coordinator (TC) responsible for cross-site supervision of that

intervention took the following six steps to enhance its integrity: 

• Defined and manualized the active ingredients of each therapy, 

including the frequency, intensity, duration, and sequencing, and 

indicated responses to the most common problems that occur 

during delivery of the intervention

• Conducted 15 to 25 hours of centralized, competency-based 

training for the therapists delivering the interventions and 

followed this by local certification of staff in each intervention

• Developed a therapist’s skillfulness scale to serve as a cross-site 

measure of general therapeutic competence 

• Developed a service contact log to measure therapists’ adherence 

to each of the five interventions and to document the dosage and 

types of services provided to each client

• Taped and rated sessions for model fidelity (all tapes were rated 

as part of the cross-site supervision by an expert in the 

intervention until each therapist was certified, after which two 

tapes per therapist, per month, were reviewed and rated) 

• Conducted weekly (1-hour onsite or telephone) individual 

supervision and weekly or bimonthly (60 to 90 minute) cross-site 

group supervision for each intervention.

237
238

These procedures helped enhance treatment differentiability (the delineation

of the ingredients and procedures that distinguished each treatment from

the other treatments) and treatment adherence (the assurance that the

interventions [as delivered] maintained fidelity to the original manualdefined procedures) (Hoffart, 1994).

A second challenge involved controlling extraneous factors that could 

compromise interpretation of the treatment outcomes. To accomplish this,

every effort was made to ensure that all general clinical procedures, other

than those involved in the specific therapies, would be handled similarly

across sites and interventions. This was done to minimize the ability of

these contextual issues to unduly influence the evaluation of the experimental

interventions and was achieved in two ways. First, staff of the CYT coordinating

center conducted two site visits at each of the four service delivery sites to

ensure that each site met baseline standards related to arenas such as

research protocol compliance, accessibility and appropriateness of clinical

space, clinical supervision structure, recruitment strategies, intake and

service procedures, confidentiality procedures, crisis and safety net 

procedures, clinical documentation, data security and storage, and followup

procedures. Second, the TCs for each intervention coordinated similar

responses to issues that were not part of the specific interventions in

monthly conference calls facilitated by the CYT coordinating center. Details

of this latter process will be described shortly. 

The third challenge was to enhance the external validity of the interventions

(the generalizability of study findings) by ensuring that the interventions

could be implemented as designed within the resource constraints of settings

that currently provide the bulk of services to drug-involved adolescents. It

was the goal of the CYT TCs to do everything possible in the CYT study to

bridge the traditional gap between efficacy research conducted under 

experimental (ideal) conditions and effectiveness research conducted in

field (real) settings. We wanted to document the kind of clinical infrastructures and the management of day-to-day clinical issues that might need to

accompany these unique interventions if they were to achieve comparable

results in the field. 

The monthly conference calls among the TCs for each of the five interventions

and the staff from the CYT coordinating center were particularly helpful in

facing the latter two of these challenges. The purpose of these meetings

was to define how sites would manage common clinical issues that were not

a unique part of the experimental interventions but which, if not identified

and controlled, might corrupt the evaluation of these interventions. We

were concerned, for example, that if therapists in one intervention expelled

adolescents from treatment (and the study) for arriving at a session high,

while another site either allowed such adolescents to participate or 

rescheduled their sessions, differences in completion rates between these

sites would reflect not the power or weakness of the interventions but 

contextual policies unrelated to the active ingredients of each intervention. 

What follows is a synopsis of how common clinical issues were managed

across the four treatment sites and across the five interventions being 
tested. It is hoped that this discussion will provide researchers and treatment

practitioners alike with insights into the importance of managing such 

contextual influences. The discussion also represents a snapshot of baseline

clinical practices in adolescent substance abuse treatment in 1998 and 1999.

Issues in Clinical Management and Clinical Care 

A. Clinical Infrastructure. A rather complex clinical infrastructure was

required to effectively manage clinical activities across the four treatment

organizations and the five treatments in the CYT study. The care taken in

constructing this infrastructure was based on the assumption that there is a

close relationship between the quality of clinical supervision and treatment

efficacy (Holloway & Neufeldt, 1995). 

There were three levels of clinical coordination and supervision in the CYT

study. First, local clinical supervisors at each service site coordinated 

cross-intervention clinical issues and day-to-day clinical problem solving.

Second, a therapist coordinator for each of the five interventions used in

the CYT study provided onsite and cross-site clinical supervision of staff

working in their particular intervention. This supervision occurred weekly

during the period in which therapists were being certified and bimonthly

following staff certification. Third, a TC at the CYT coordinating center

facilitated cross-site and cross-intervention coordination and problem 

solving. The centerpiece of this cross-site clinical coordination was a 

monthly meeting at which the respective TCs met with the cross-site TC

and research coordinator via a conference call to discuss cross-site clinical

and research issues. Particular problems or procedural questions emerging

from these discussions were sometimes also referred to the CYT executive

committee (all of the principal investigators, the CSAT project officer, and

other CSAT staff) for consultation or decision making. The CYT coordinating

center validated that the cross-site clinical procedures developed through

these processes were in place by conducting two monitoring visits to each

of the CYT research sites during the course of the study (CYT cooperative

agreement, 1999).

Many problems and issues (administrative, fiscal, research, clinical, ethical,

legal) were addressed in this multitiered supervisory structure, but the

major goals were to meet the methodological challenges noted earlier:

ensuring the integrity of the interventions, controlling factors that could

confound outcomes, and enhancing the generalizability of findings. Several

steps were taken to achieve these goals. 

All sites used the same research and service intake and clinical 

assessment/screening procedures, the same inclusion and exclusion 

criteria, and the same approach to randomization and waiting list 

management. To maximize transferability of findings to the field, exclusion

criteria were limited to adolescents 1) who needed a higher level of care

than outpatient treatment, 2) who presented for treatment with confirmed

histories of drug dealing or violence (particularly predatory behavior 

patterns reflecting a high frequency, high intensity, and long duration), 

3) whose psychiatric comorbidity was so severe as to render them 

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inappropriate for the CYT interventions, and 4) whose primary drug of

choice was not cannabis. Although the study focused on adolescents with a

primary drug choice of cannabis, most adolescents entering the CYT study

reported using other drugs in addition to cannabis. Although abstinence

from all alcohol and drug use was a goal of the treatments in the CYT study,

at admission, adolescents were asked to agree to evaluate their drug use

and its effects on themselves and their families. Therapists across sites and

interventions agreed that many adolescents’ commitment to abstinence was

something that should emerge out of the treatment process, not something

that should be a precondition for entry into treatment.

Mechanisms to enhance clinical fidelity to the interventions used in the

study included centralized training and booster training of clinical staff

delivering the interventions, the videotaping or audiotaping of all sessions

followed by the use of self- and supervisory-scored adherence measures to

monitor skillful execution of the intervention, formal procedures to certify

each therapist in the intervention, continued postcertification tape reviews

to minimize therapist “drift,” and regular cross-site group supervision led

by an expert in the intervention. 

A considerable portion of the monthly meeting of the CYT TCs was aimed

at ensuring baseline clinical processes and data collection procedures were

being handled consistently across the four sites. There were discussions of

just about everything—from drug testing procedures to appropriate

responses to clinical deterioration of a study participant. The monthly 

agenda included a site-by-site review of particular issues, such as the status

of therapists’ certifications and the quality of communication between 

sister sites (those delivering the same interventions), and an opportunity 

to discuss the general problems and issues encountered. Below are some 

of the cross-site clinical issues that were of major concern throughout the

course of the study. 

B. Staff Recruitment, Training, and Retention. Most of the therapists

working on the CYT project were trained at the master’s degree level or

higher, and most had prior training and experience in addiction treatment.

The research sites, like the practice field, varied in their use of full-time and

part-time staff. Most sites felt there were advantages to having full-time

therapists working on the project because that increased their availability

to clients, provided greater flexibility in scheduling, and created a greater

degree of personal investment in the project. In general, sites looked for

individuals with good clinical skills whose overall clinical orientations were

congruent with the intervention they were going to deliver. A particular

effort was made to find staff who had a good working knowledge of child

and adolescent development—a qualification not often found in those working with adolescent substance abusers (Kaminer, 1994). Staff were paid

salaries that were at or slightly above the geographical norm for addiction

therapists. None of the sites experienced any significant problems 

recruiting qualified staff.

In the course of the project, there were a total of 26 full-time and part-time

clinical positions at the four CYT sites. Nine staff left the CYT project 
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during this period—two due to changes in the communities selected as

service sites and the majority of the others due to a return to school, family

relocation, or promotion. The highest turnover rate was among the case

managers. Several things worked to enhance staff morale and retention on

the CYT project: a conscious effort to build team cohesion, a knowledge of

the potential importance of the research being conducted, the training and

supervision opportunities, the opportunity for cross-site contact with peers

working on the same intervention, and the flexibility of the individual sites

regarding scheduling of part-time employees on the project. 

Although considerable effort is made to ensure that conditions in clinical

trials are equivalent to natural conditions in the field, there are several

characteristics of clinical trials staff that make them somewhat different

from those in mainstream practice. Staff who seek clinical positions in 

clinical trials are not scared away by the limited timeframe of employment

on such a project, are often attracted by the intense nature of training and

supervision such projects afford, and are not put off by the rigorous 

record-keeping generally required in such projects. 

Strategies used for managing clinical continuity in the face of staff attrition

included replicating the training that was provided to all therapists at the

beginning of the CYT project, having a built-in transition/training period

for entering staff, and using videotaped sessions of the current therapists to

train new therapists. 

The safety of staff working in the field was enhanced by hiring staff from the

local community, providing inservice training on safety management and

access to beepers and cellular phones, and the option of working in teams

to visit areas that posed higher safety threats. Office-based safety issues

were addressed by ensuring that other staff were present while sessions

were being conducted and by providing walkie-talkies or silent alarms to

signal other staff if assistance was needed. There were no major safetyrelated incidents experienced by the CYT project. 

C. Client/Family Recruitment, Engagement, and Retention. The major

barriers in recruiting, engaging, and retaining adolescents and their 

families were fairly consistent across the CYT project sites: 

• Low adolescent/parent motivation for treatment involvement 

• The perception that other problems in the family were more 

important than the drug experimentation of one child

• Parental substance abuse

• The parental view that smoking marijuana is not that big a deal

• Failure to attend due to lack of transportation or childcare 

• A marital or relationship breakup during the period of treatment 

involvement
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• Inconsistent messages from the parents to the adolescent about 

the importance of involvement in counseling

• Relocation of the child during the course of treatment

• Parents having given up on efforts to change their child 

• A general and pervasive sense of hopelessness about life (felt by

both the parents and the adolescent). 

Study participants were recruited by direct appeals to youth and parents

through newspaper and radio public service announcements and 

strategically placed bulletin board posters. Staff also oriented local youth

service professionals regarding how referrals could be made to the program

and the nature of the various treatments that youth would be receiving.

These visits and mailings included CYT information packets, business cards,

and Rolodex inserts. There was some resistance to referring clients to the

project when referral sources discovered that they could not control which

intervention their clients would receive. Some were concerned that the 

five-session intervention would not provide an adequate level of service.

After some education about the benefits of brief therapy in general, 

however, and the need to test such therapies in the substance abuse 

arena, most were willing to make referrals. 

Of 690 adolescents referred to the CYT sites between May 1, 1998, and May

31, 1999, 38.6 percent were referred by criminal justice-affiliated agencies,

24.8 percent by families (7.6 percent of which came from a media promotion

of the CYT project), and 15.2 percent by educational community health and

human service agencies (Webb & Babor, 1999). An analysis of adolescents

admitted to treatment in the CYT study (Tims, Hamilton, Dennis, & Brantley,

1999) revealed that 84.7 percent were age 15 or older, 38.1 percent were

nonwhite, and 11.9 percent were female. The low rate of female admissions is

attributable to at least two factors. The first involves the use of referral

sources such as juvenile probation departments that serve predominantly

male clients. The second factor is that, of those females referred to the CYT

study, more than one-third presented with comorbid psychiatric disorders

severe enough to exclude their participation in the study.

Client engagement was enhanced through five broad strategies. The first

was to make the transition between the research staff (the equivalent 

of the intake staff in most agencies) and the clinical staff as personal as 

possible. When a therapist was not available to be introduced to the

client/family by the research staff, the assigned therapist called the parents

or the adolescent before the first appointment to introduce himself or 

herself, begin alliance building, and clarify any questions about treatment

participation. All of the CYT interventions begin with an emphasis on 

empathy and skillful rapport building to build a strong therapeutic alliance

and work through resistance related to the coercive influences that may

have brought the adolescent to treatment. 
The second strategy was for the therapist to speak for 5 to 10 minutes with

any adolescent who had to wait more than 2 weeks to begin service (a delay

sometimes caused by randomization and the cycles of starting new groups) to

sustain his or her motivation for service involvement. 

The third strategy was to remove as many environmental obstacles to 

treatment participation as possible by using geographically accessible 

service sites, providing assistance with transportation (that is, cab vouchers,

bus tokens, picking adolescents up in the agency van), and providing or

arranging childcare. Case management, whether provided by therapists,

case managers (in the FSN intervention), or even during the screening

activities of the research staff, was an essential medium of engagement for

those families whose lives were most chaotic at the point of initial contact

with the CYT project. Every effort was made to link what could be learned

in treatment with what could help the immediate crisis presented by the

family. The CYT interventions shared the message, “We have something that

could help with some of these problems and improve the quality of life for

you and your child.”

The fourth and most important strategy was to actively engage the 

adolescents and families by creating strong therapeutic alliances, expressing

interest in their participation (e.g., by weekly phone prompts for 

participation), finding a goal that the adolescent and family were interested

in working on, expressing optimism in their capacity to change, and 

persisting in family contacts during the earliest signs of disengagement.

FSN intervention staff felt that home visits were very important in initiating 

and sustaining the involvement of the most treatment-resistant families. 

The fifth strategy was to provide a warm, collaborative, adolescent- and 

parent-friendly environment (with informal but respectful hosting, providing

pizza and sodas as part of the dinner-hour adolescent and parent meetings)

and to provide specific incentives for involvement in treatment (help with

very specific problems, fully subsidized treatment, and token prizes for

homework completion). 

D. Safety Net Procedures. Safety net procedures involve strategies for 

recognizing and responding to adolescents who before or after entering 

outpatient care were thought to be in need of a higher level of care or

allied services. We anticipated and experienced four scenarios that required

such safety net procedures. The first involved emergency situations that

might arise related to an adolescent’s drug use during the course of the

study. All parents were provided a laminated card listing signs of acute

intoxication and oriented to procedures that could be used to respond to an

emergency. The second scenario occurred when adolescents underreported

the frequency and intensity of their drug use at intake but disclosed it after

they were randomized and admitted to one of the therapies. The third 

scenario involved the frequency and intensity of use escalating after the

adolescent had been admitted to outpatient treatment. The fourth scenario

occurred when an adolescent’s mental health status deteriorated following 

admission, particularly where such deterioration posed the threat of harm

to himself or herself or others. Safety net procedures were established at 

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all four sites that 1) ensured the periodic reassessment of the status of use 

and the appropriateness of the level of care to which clients were assigned, 

2) ensured the availability and use of supervisory supports to formally 

reevaluate changes in clients’ status and care needs, and 3) facilitated, when

needed, moving an adolescent to a more structured and intense level of care

or the addition of collateral services. Where alternative or additional services

were thought to compromise evaluation of the effect of the CYT intervention,

the adolescent and family were provided the additional services but the 

adolescent was no longer included in the study. 

E. Concurrent Services. The exclusion of adolescents with severe psychiatric

illness from the CYT study does not mean that all adolescents with psychiatric

comorbidity were excluded from the CYT study. The majority of adolescents

and families admitted to the CYT study presented with multiple problems,

and the rate of psychiatric comorbidity of the adolescents admitted to the

study was quite high. Forty-two percent met the criteria for attention

deficit/hyperactivity disorder, 55 percent met the criteria for conduct 

disorder, and 29 percent presented with multiple symptoms of traumatic

stress (Tims, Hamilton, Dennis, & Brantley, 1999). Those adolescents who

were referred for more intense services prior to randomization and who were

not included in the CYT study were most likely to be excluded because they 

presented a high risk of harm to themselves or others. (These risks were

identified through the participant screening form completed at intake and

through the assessment instrument [GAIN] [Dennis, Webber, White, et al.,

1996] and the interviews that were part of the intake process at all of the

CYT service sites.) 

The multiple problems presented by the CYT adolescents and their families

raised an important clinical and research issue: How to respond to the 

clinical needs they presented without contaminating (through concurrent

service involvement) the evaluation of the particular interventions in the

CYT study. This problem was complicated further by the referral patterns 

of the agencies that linked adolescents with the CYT project. Acutely aware 

of the number and complexity of the problems many of these adolescents 

presented, many of these referral sources used a shotgun approach—

simultaneously referring the adolescent and family to multiple treatments, 

hoping that the cumulative dose of services would have some positive effect

on the child and family. These problems diminished through education of

and negotiation with referral sources. It was a policy of the CYT study that

adolescents would not be allowed to remain in the study if they were receiving

concurrent treatment whose primary focus was the problem of substance

abuse or if they were receiving services whose impact was judged by the local

staff to inordinately confound the impact of the CYT intervention being 

provided. However, no adolescent had to be excluded from the study for such

concurrent service involvement. Several adolescents who were treated 

simultaneously for collateral problems (e.g., being medicated for hyperactivity

or depression) were allowed to enter and remain in the CYT study because

the focus of the concurrent services was not on substance abuse or 

dependency. 
F. Session Management. Efforts were made to ensure that issues related 

to the management of sessions that were not unique to the particular 

interventions would be handled in reasonably consistent ways across the

sites. Where procedures were not the same, they were reviewed to ensure

the differences would not confound outcomes. These discussions included

how to respond to lateness, missed sessions, the criteria for dropping cases,

intoxication, contraband, disruptive behavior, preexisting relationships

between members, and a group session at which only one member is present.

Lateness was handled by degree, by ensuring either that the client got the

minimal dose for that session or that the session was rescheduled. Missed

sessions were rescheduled or, in the case of group interventions, provided as

an abbreviated makeup session prior to the next scheduled session. (All

services across the five modalities were expected to be completed within 14

weeks of the time of the first therapy session, with local TCs reviewing and

approving any exceptions to this rule.) 

All programs made intoxication and possession of contraband grounds for

exclusion from that particular session and a flag for reassessment of the

appropriateness of the current level of care. (While rare episodes of an

intoxicated youth arriving for services did occur, these episodes were 

clinically managed without excluding the adolescent from continued service.)

Only one adolescent per family was included in the CYT study, and preexisting

relationships between participants in the group modalities were reviewed to

determine whether the prior history would undermine or enhance treatment.

A group with only one member present was conducted in a 30- to 45-minute

individual format covering the material that was scheduled for presentation.

If an adolescent failed to appear for a family session, the session was 

conducted without the adolescent. 

The TCs collectively sought and implemented general strategies that could

enhance the effectiveness of sessions for all of the CYT therapies. Strategies

that served to minimize problems and enhance session effectiveness 

included formalizing, posting, and consistently enforcing group/family

norms on such issues as dress (banning drug/gang symbols on clothing)

and language (profanity, drug argot). In the group interventions, the closed

group structure made it particularly important to guard against negative

influences within the peer cultures that evolved. A final issue was the 

appropriate level of contact between therapists and adolescents outside the

intervention. The TCs decided that such contact should be minimized so as

not to contaminate model fidelity by altering dose. More specifically, it was

agreed that all extra-session contact should be responded to within the

therapeutic framework of the particular intervention, channeled into

upcoming sessions, documented, and brought to supervisors for review. 

G. Gender and Cultural Adaptations. While there is significant momentum

toward the development of standardized, empirically supported, and manualbased treatments (Wilson, 1998; Carroll, 1997), there is a simultaneous call

for the refinement of standardized treatment that includes gender and 

cultural relevance and effectiveness (Orlandi, 1995). All of the CYT therapists

noted making changes in their delivery of the manual-based treatments

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that were based on gender, cultural, and socioeconomic status (SES) 

appropriateness. Therapists in group interventions explicitly noted diversity

issues in the group and incorporated respect for diversity into the ground

rules established at the beginning of each group. The most frequently 

mentioned adaptations included:

• Changing the language of the session to reflect cultural or 

geographical norms

• Adding items to some worksheets to make them more applicable 

to urban youth

• Providing special writing and reading assistance to address 

illiteracy

• Slowing the pace and adding repetitions of key ideas to 

accommodate learning impairments

• Developing examples and illustrations of key points that had 

greater gender, cultural, and SES relevance. 

Therapists emphasized it was not the content of interventions that had

changed; there were subtle changes in the way that content was framed or

delivered. 

H. Case Mix Issues. Therapists involved in the group interventions

(MET/CBT5, MET/CBT5 + CBT7, FSN) also decided to monitor closely

client mix issues according to gender, ethnicity, and other important

dimensions. There was an effort to identify any potential iatrogenic effects

of randomization (e.g., harassment, scapegoating, or other predatory 

targeting of a vulnerable group member by other group members) and to

actively manage potential negative effects of group support for antisocial

behavior (Dision, McCord, & Poulin, 1999). This was managed primarily by

establishing and enforcing norms for group sessions. 

I. Mutual Aid and Peer Support Groups. In contrast to Project MATCH, a

12-step facilitation therapy was not included in the CYT study, and there

was some variation in the philosophies of the 5 interventions related to the

desirability of mutual aid involvement by cannabis-involved adolescents. 

The ACRA, MDFT, and MET/CBT interventions do not directly encourage 

affiliation with addiction recovery support groups, but they do frame such

involvement positively if the adolescent is already involved in such a group

or self-initiates involvement during the course of treatment. FSN, while

strongly encouraging parents to participate in Al-Anon, does not directly

encourage adolescent clients to affiliate with Narcotics Anonymous (NA) or

Alcoholics Anonymous (AA). Information on local mutual support groups is

provided simply as one of many community resources. There was more of an

emphasis in all the CYT interventions on involvement in drug-free prosocial

activities in general than on addiction recovery support group involvement.
J. Ethical Issues. The TC meetings also provided a venue to discuss and 

formulate responses to some of the complex ethical and legal issues that

can arise in the treatment of adolescent substance abuse (White, 1993).

Considerable time was spent discussing questions such as: 

• What are the boundaries of confidentiality regarding disclosure 

of information about an adolescent to his or her parents?

• Do parents have a legal/ethical right to the results of their child’s

urine tests?

• What circumstances would constitute a duty to report or duty to 

intervene? 

• What obligations, if any, do therapists have in responding to an 

adolescent’s disclosures of past or planned criminal activity?

• How should therapists respond to reports of abuse of adolescents 

by a parent or to failures by child protection agencies to 

intervene to ensure the safety of the adolescent? 

Discussion

Carroll and colleagues (1994, 1996, 1997) are to be commended for 

helping transfer the technology model of psychotherapy research to 

addiction treatment outcome studies. The CYT study greatly benefited 

from the earlier experience of Project MATCH in the use of this model. 

This paper has described a structure (the interface between a cross-site 

and cross-intervention TC group and the CYT executive committee) and a

process (monthly meetings of all the TCs and monitoring visits at each CYT

study site) that were used to control contextual elements surrounding the

experimental interventions. Our goal was to hold these contextual elements

constant across the interventions in order to enhance our ability to measure

the differences the experimental interventions produced on outcome 

measures. We wanted differences in outcomes to reflect differences in the

interventions themselves and not factors incidental to the interventions. 

While there were major research design elements (consistency in clinical

data collection instruments and procedures, inclusion and exclusion 

criteria, and followup procedures) that helped control such variance across

sites and interventions, we also sought to identify more subtle areas of

potential contamination of the study. By generating consistent crossintervention procedures to respond to lateness, missed sessions, 

disruptiveness, intoxication, and concurrent participation in other services,

we were able to ensure a consistent and a more precise definition of the

dose and type of services provided in, and collateral to, each intervention.

By developing and monitoring safety net procedures across the sites and

interventions, we were able to ensure timely and appropriate responses to

the placement of a client in an inappropriate outpatient modality who 

needed a higher level of care and to respond to acute episodes of clinical

deterioration that warranted a similar change in the level of care. We found

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that the collaborative work of the TCs helped enhance the methodological

rigor of the CYT study and helped establish a sound clinical infrastructure

upon which each of the interventions was tested. 

There are many aspects of the clinical management of the CYT project

other than the efficacy of the particular interventions used that may have

wide applicability to the field of adolescent substance abuse treatment. It is

our view that many of the procedures to provide overall clinical management

of randomized field trials have great clinical utility and are likely to become

future baseline clinical practices in the treatment of adult and adolescent

substance abuse disorders. 

The technology model that, to date, has been used primarily as a means of

ensuring methodological rigor in multisite field trials seems to us to have

enormous advantages for enhancing the quality of treatment and should be

studied for potential adaptation to mainstream clinical practice. Those

looking for ways to enhance the quality of adolescent substance abuse 

treatment would be well served to explore how the elements of this model

could become part of the future definition of treatment as usual. Parents

seeking help to address the substance abuse-related problems of their son

or daughter ought to be able to expect that the theory behind the treatments

they are offered can be articulated and that their active ingredients can be

defined. They should further be able to expect that these treatments have

some degree of scientific support for their effectiveness and that they will

be delivered in a manner consistent with procedures whose effectiveness has

been validated. 

Increased demands for such accountability and fidelity by parents, policy

makers, and funding agencies will likely make manual-based therapies the

rule in the future, along with the training and adherence measures that

accompany them. The technical aspects of cross-site clinical management

of the CYT project have much to offer the field as a whole. The use of 

standardized assessment instruments that are capable of providing 

comprehensive assessment and treatment planning data should become 

a requirement of all adolescent treatment programs in the next decade. 

We further commend the use of central (and booster) training, videotaping

and adherence ratings as standard practices in supervision, and cross-site

supervision as marvelous tools for training and professional development.

Finally, we believe that rigorous followup (monitoring, feedback, and, where

indicated, early reintervention) should move from the realm of clinical

research to being an expectation, if not a requirement, of mainstream clinical

practice. The idea of providing services without measuring outcomes will be

incomprehensible in the very near future, and the technology to perform

this task is rapidly emerging. Morale among staff working in the CYT project

remained high, in part because of the near universal belief in the historical

importance of this study and the climate of excitement and discovery that

permeated the project. We believe that small field-based experiments to

answer critical clinical questions, opportunities for cross-site sharing, and

the opportunity to work on papers and presentations can similarly contribute

to staff morale within local service organizations. We believe this milieu of

curiosity, discovery, and contribution is transferable and sustainable in 
natural clinical settings. Routine outcome monitoring and field-based 

experiments, like the other items in this discussion, must simply be moved

from the arena of clinical research to the arena of standard clinical practice.

This transfer of technology from the research environment to the clinical

practice environment, however, will not be simple.

If there is a single weak link in the current practice of addiction treatment

that will slow this technology transfer, we believe it is in the arena of 

clinical supervision. Comprehensive assessments, science-guided treatment

planning, empirically validated and manual-based therapies, regular 

adherence measurement and monitoring, using clients’ response-to-treatment

data to individualize and refine standard interventions, and rigorous 

posttreatment followup (and early reintervention, where called for) all flow

from the clinical infrastructure at the core of which is a clinical supervisor.

If we can elevate the quality of clinical supervision in the field—the 

selection, training, and support of clinical supervisors to do true clinical

supervision—to that of clinical supervision in controlled clinical trials, we

will be able to channel knowledge from clinical research to clinical practice. 

Conclusions

Clearly defining the demographic and clinical characteristics of client 

populations, presenting the active ingredients in a manual format and 

procedures inherent in particular treatments for those populations, 

monitoring therapists’ adherence to such procedures, controlling contextual

influences that can influence treatment outcomes, and conducting rigorous

and sustained followup to determine clients’ responses to particular 

interventions collectively hold great promise in moving the treatment of

adolescent substance abuse from the status of a folk art to that of a clinical

science. The technologies used to build this science may themselves offer

great potential in enhancing the quality of adolescent substance abuse

treatment programs if they can be adapted for routine use in the clinical

setting. The CYT study confirms the importance that these new tools can

and will have in the future clinical management of adolescent substance

abuse treatment. 

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References

American Psychiatric Association. (1994). Diagnostic and statistical

manual of mental disorders (4th ed.). Washington, DC: Author.

Cannabis youth treatment (CYT) cooperative agreement: 1999 site

visit protocol. (1999). Bloomington, IL: Chestnut Health Systems.

Carroll, K. M. (Ed.). (1997). Improving compliance with alcoholism 

treatment. National Institute on Alcohol Abuse and Alcoholism 

Project MATCH Monograph Series. Volume 6. NIH Pub. No. 97–4143. 

Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. 

Carroll, K. M., Kadden, R. M., Donovon, D. M., Zweben, A., &

Rounsaville, B. (1994). Implementing treatment and protecting the validity

of the independent variable in treatment matching studies. Journal of

Studies on Alcohol (Suppl. 12), 149–155.

Carroll, K. M., & Nuro, K. F. (1996). The technology model: An 

introduction to psychotherapy research in substance abuse. Yale University

Psychotherapy Development Center, Training Series No. 1. Sponsored by the

National Institute on Drug Abuse. 

Dennis, M. L., Babor, T., Diamond, G. C., Donaldson, J., Godley, S.,

Tims, F., Chirkos, T., Fraser, J., French, M. T., Glover, F., Godley, M.,

Hamilton, N., Herrell, J., Kadden, R., Kaminer, Y., Lennox, R., Liddle, H., 

McGeary, K. A., Sampl, S., Scott, C., Titus, J., Unsicker, J., Webb, C., &

White, W. L. (1998). Treatment for cannabis use disorders general research

design and protocol for the cannabis youth treatment (CYT) cooperative

agreement. Bloomington, IL: Chestnut Health Systems. 

Dennis, M. L., Webber, R., White, W., Senay, E., Adams, L., Bokos, P., 

Eisenberg, S., Fraser, J., Moran, M., Ravine, E., Rosenfeld, J., & Sodetz, A.

(1996). Global appraisal of individual needs (GAIN), Vol. 1: Administration,

scoring, and interpretation. Bloomington, IL: Chestnut Health Systems.

Dision, T. J., McCord, J., & Poulin, F. (1999). When interventions

harm: Peer groups and problem behavior. American Psychologist, 54(9), 

755–764.

Godley, S. H., Diamond, G., & Liddle, H. (1999, August). Cannabis

youth treatment study treatment models: Principles, interventions, 

mechanisms. Paper presented at the 107th Annual Convention of the

American Psychological Association, Boston. 

Godley, S. H., Meyers, R. J., Smith, J. E., Karvinen, T., Titus, J. C.,

Godley, M. D., Dent, G., Passetti, L., & Kelberg, P. (2001). The adolescent

community reinforcement approach for adolescent cannabis users, Cannabis

Youth Treatment (CYT) Series, Volume 4. DHHS Pub. No. (SMA) 01–3489.

Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse 

and Mental Health Services Administration.

Hamilton, N. L., Brantley, L. B., Tims, F. M., Angelovich, N., &

McDougall, B. (in press). Family support network for adolescent cannabis

users, Cannabis Youth Treatment (CYT) Series, Volume 3. DHHS Pub. No.

(SMA) 01–3488. Rockville, MD: Center for Substance Abuse Treatment,

Substance Abuse and Mental Health Services Administration. 
Herrell, J., Babor, T., Brantley, L., Dennis, M., Diamond, G.,

Donaldson, J., Godley, S., Hamilton, N., Liddle, H., Tims, F., Titus, J., &

Webb, C. (1999, August). Treatment of adolescent marijuana abuse: A 

randomized clinical trial. A cooperative agreement funded by the Center for

Substance Abuse Treatment. Paper presented at the 107th Annual

Convention of the American Psychological Association, Boston.

Hoffart, A. (1994). Use of treatment manuals in comparative outcome research: A schema-based model. Journal of Cognitive Psychotherapy:

An International Quarterly, 8(1), 41–54. 

Holloway, E., & Neufeldt, S. (1995). Supervision: Its contribution to 

treatment efficacy. Journal of Consulting and Clinical Psychology, 63(2),

207–213.

Institute for Social Research (ISR). (1997). Monitoring the Future

Study. Ann Arbor, MI: University of Michigan.

Kaminer, Y. (1994). Adolescent substance abuse: A comprehensive

guide to theory and practice. New York: Plenum Medical Book Company. 

Liddle, H. A (in press). Multidimensional family therapy for adolescent

cannabis users, Cannabis Youth Treatment (CYT) Series, Volume 5. DHHS

Pub. No. (SMA) 01–3490. Rockville, MD: Center for Substance Abuse

Treatment, Substance Abuse and Mental Health Services Administration.

Moncher, F., & Prinz, R. (1991). Treatment fidelity in outcome 

studies. Clinical Psychology Review, 11, 247–266. 

Office of Applied Studies (OAS). (1997). National admissions to 

substance abuse treatment services. The Treatment Episode Data Set (TEDS)

1992–1995. (Advanced Report No. 12, prepared by B. Ray, R. Thoreson, L.

Henderson, & M. Toce). Rockville, MD: OAS, Substance Abuse and Mental

Health Services Administration.

Orlandi, M. A. (Ed.). (1995). Cultural competence for evaluators.

Rockville, MD: Center for Substance Abuse Prevention, Substance Abuse

and Mental Health Services Administration.

Project MATCH Research Group. (1993). Project MATCH: Rationale 

and methods for a multisite clinical trial matching alcoholism patients to

treatment. Alcoholism: Clinical and Experimental Research, 17, 1130–1145.

Sampl, S., & Kadden, R. (2001). Motivational enhancement therapy

and cognitive behavioral therapy for adolescent cannabis users: 5 sessions,

Cannabis Youth Treatment (CYT) Series, Volume 1. DHHS Pub. No. (SMA)

01–3486. Rockville, MD: Center for Substance Abuse Treatment, Substance

Abuse and Mental Health Services Administration.

Tims, F., Hamilton, N., Dennis, M., & Brantley, L. (1999, August). 

Characteristics and problems of adolescent marijuana users in treatment.

Paper presented at the 107th Annual Convention of the American

Psychological Association, Boston.

Titus, J., Dennis, M., Diamond, G., Godley, S., Babor, T., Donaldson,

J., Herrell, J., Tims, F., & Webb, C. (1999, August). Treatment of adolescent

marijuana abuse: A randomized clinical trial. Structure of the cannabis

youth treatment study. Paper presented at the 107th Annual Convention of

the American Psychological Association, Boston.

Webb, C., & Babor, T. (1999, August). Cannabis youth treatment

study: Referral sources. Paper presented at the 107th Annual Convention of

the American Psychological Association, Boston.

251
252

Webb, C., Scudder, M., Kaminer, Y., & Kadden, R. (in press). The

motivational enhancement therapy and cognitive behavioral therapy supplement: 7 sessions of cognitive behavioral therapy for adolescent cannabis

users, Cannabis Youth Treatment (CYT) Series, Volume 2. DHHS Pub. No.

01–3487. Rockville, MD: Center for Substance Abuse Treatment, Substance

Abuse and Mental Health Services Administration.

White, W. (1993). Critical incidents: Ethical issues in substance

abuse prevention and treatment. Bloomington, IL: Chestnut Health Systems.

Wilson, G. T. (1998). Manual-based treatment and clinical practice.

Clinical Psychology: Science and Practice, 5(3), 363–375.