The Motivational Enhancement Therapy and

Cognitive Behavioral Therapy Supplement: 

7 Sessions of Cognitive Behavioral Therapy for

Adolescent Cannabis Users

Cannabis 

CYT

Youth Treatment Series

Volume 2

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov
The Motivational Enhancement Therapy and

Cognitive Behavioral Therapy Supplement: 

7 Sessions of Cognitive Behavioral Therapy 

for Adolescent Cannabis Users

Charles Webb, Ph.D.

Meleney Scudder, Psy.D.

Yifrah Kaminer, M.D.

Ron Kadden, Ph.D.

CYT

Cannabis Youth Treatment Series

Volume 2

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
Acknowledgments

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

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

staff members of the University of Connecticut School of Medicine: Charles Webb, Ph.D.;

Meleney Scudder, Psy.D.; Yifrah Kaminer, M.D.; and Ron Kadden, Ph.D. Field reviews and 

editorial assistance in producing the manual were provided by staff from Johnson, Bassin &

Shaw, Inc. (Lynne McArthur, Holly Brooks, Barbara Fink, Nancy Hegle, Wendy Caron, and

Tonya Young). The authors also acknowledge input and assistance received from the

Executive Steering Committee (Thomas Babor, Michael Dennis, Guy Diamond, Jean

Donaldson, Susan H. Godley, and Frank Tims) and many others including Nancy Fidler, Patty

Gaupp, Nancy Hamilton, Julia Hemphill, Jim Herrell, Stephen Kane, Mary McCain, Lydia

Robbins, Melissa Sienna, Zeena Tawfik, Joan Unsicker, and William White.

Disclaimer

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

(CSAT) to the University of Connecticut School of Medicine, through Grant No. TI11324.

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., served as the

CSAT CYT Project Officer. The content of this publication does not necessarily reflect the

views or policies of CSAT, SAMHSA, or DHHS.

Public Domain

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 three earlier manuals developed to serve adults who have alcohol

and marijuana problems: Treating Alcohol Dependence: A Coping Skills Training Guide by

Monti et al. (1989); Cognitive-Behavioral Coping Skills Therapy Manual: A Clinical Research

Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence by Kadden et

al. (1992); and Marijuana Treatment Project: Clinical Manual by Steinberg et al. (unpublished

1997). Materials appearing on page 12 (exhibit 1) and selected materials in the sessions section were adapted from copyrighted sources. Copyright and source information for the 

sessions begin on page 101. All the materials 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 copies of this document, please call

SAMHSA’s National Clearinghouse for Alcohol and Drug Information 1-800-729-6686 or 

1-800-487-4889 (TDD).

Recommended Citation

Webb, C.; Scudder, M.; Kaminer; Y., and Kadden, R. The Motivational Enhancement Therapy

and Cognitive Behavioral Therapy Supplement: 7 Sessions of Cognitive Behavioral Therapy

for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 2. DHHS

Pub. No. (SMA) 02-3659. Rockville, MD: Center for Substance Abuse Treatment, Substance

Abuse and Mental Health Services Administration, 2002.

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) 02-3659

Printed 2002

Cover images © 2000.
Table of Contents

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

Introduction and Organization of the Manual . . . . . . . . . . . . . . . . .1

Client and Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Target Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Level of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Staffing Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Types of Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Staffing and Certification Requirements . . . . . . . . . . . . . . . . . . . .3

Scope and Significance of the Cannabis Problem . . . . . . . . . . . . . .4

Background on Cannabis Youth Treatment Cooperative 

Agreement Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Overview of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

II. The CBT7 Approach to Cannabis Treatment: 

Background and Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Evolution and Purpose of Protocol . . . . . . . . . . . . . . . . . . . . . . . . .9

Previous Applications of Cognitive Behavioral Treatment to 

Relevant Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Overview of Treatment Model/Intervention . . . . . . . . . . . . . . . . .10

Treatment Goals and Objectives . . . . . . . . . . . . . . . . . . . . . . .10

Theoretical Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Treatment Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Overview of Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

D: A Composite Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Key Concepts of CBT7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Problem Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Affective Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Communication Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Relapse Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Tailoring the Treatment to the Client . . . . . . . . . . . . . . . . . . . . .21

Externalizing Versus Internalizing Disorders . . . . . . . . . . . . . .21

Severity of Use and Symptoms of Withdrawal . . . . . . . . . . . . .22

Cognitive Functioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Cultural Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Slips and Relapses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Urine Test Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Missed Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Clinical Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Therapist Self-Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Threats To Harm Oneself or Others . . . . . . . . . . . . . . . . . . . .25

Clinical Deterioration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Administrative Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Extended Waiting Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Preventing Attrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Collateral Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

iii
iv

Relevant Ethical and Legal Issues . . . . . . . . . . . . . . . . . . . . . . . .26

Admission to Treatment: Legal Aspects and Policy . . . . . . . . .26

Duty To Warn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Reports of Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Session Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

III. Overview of Treatment Session Components . . . . . . . . . . . . . . . .29

Manual Adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Review of Client Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Participant Behavior Issues . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Review of Real Life Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Rationale for Coping Skill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Skill Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Group Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Modeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Roleplay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Reminder Sheets and Real Life Practice Exercises . . . . . . . . . . . .33

Session Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Session Length and Time Management . . . . . . . . . . . . . . . . . .34

Preexisting or Concurrent Relationships Between 

Two Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Outside Crises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Request for Individual Attention . . . . . . . . . . . . . . . . . . . . . . .35

IV. Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Session 6: Problem Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Session 7: Anger Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

Session 8: Anger Management . . . . . . . . . . . . . . . . . . . . . . . . . .58

Session 9: Effective Communication . . . . . . . . . . . . . . . . . . . . .64

Session 10: Coping With Cravings and Urges To Use Marijuana . . .72

Session 11: Depression Management . . . . . . . . . . . . . . . . . . . . . .80

Session 12: Managing Thoughts About Marijuana . . . . . . . . . . . . .92

Sources for Sessions 6–12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101

V. Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105

VI. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109

VII. Appendixes 

Appendix 1. Miniatures of 11- by 17-inch Posters for 

CBT7 Sessions 6–12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

Appendix 2. Therapist Forms . . . . . . . . . . . . . . . . . . . . . . . . . . .125

Appendix 3. Supervisory Forms . . . . . . . . . . . . . . . . . . . . . . . . .133

Appendix 4. Clinical Management of a Multisite Field 

Trial of Five Outpatient Treatments for Adolescent 

Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143
I. Introduction and Background

Introduction and Organization of the Manual

This manual, a supplement to Motivational Enhancement Therapy and

Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions,

Cannabis Youth Treatment (CYT) Series, Volume 1, presents a seven-session

cognitive behavioral treatment (CBT7) approach designed especially for

adolescent cannabis users. It addresses the implementation and evaluation

of cognitive behavioral treatment for adolescent marijuana users as part 

of the Cannabis Youth Treatment Project: A Cooperative Agreement for

Evaluating the Efficacy of Five Treatments for Adolescents With Self-Reported

Marijuana Use and Problems Associated With Its Use.

This volume provides instructions for sessions 6 through 12 of the cognitive

behavioral therapy (CBT) for adolescent marijuana users. The first five sessions

(two motivational enhancement therapy [MET] sessions and three CBT 

sessions) are described in Motivational Enhancement Therapy and Cognitive

Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions, CYT Series,

Volume 1.

Research provides convincing evidence of the efficacy of using cognitive

behavioral techniques to help adult substance abusers (Stephens, Roffman

& Simpson, 1994; Bien, Miller & Tonigan, 1993). However, relatively little

has been done to test the effectiveness of cognitive behavioral techniques

with adolescent substance abusers. This manual was developed to apply the

cognitive behavioral approach to treat a specific type of substance abuser:

the adolescent cannabis user. It provides a structured cognitive behavioral

model that can be reliably delivered, monitored, and evaluated.

The three incremental arms of the CYT treatment design (Dennis et al.,

1998) are MET/CBT5, consisting of 5 sessions; the MET/CBT5 supplement

(CBT7), consisting of an additional 7 sessions; and the family support 

network (FSN), consisting of 10 sessions (6 parent education sessions and 

4 home visits). In the CYT study, these three modular components were

linked together in various combinations to produce interventions of varying

length and scope. First, MET/CBT5 served as a stand-alone, brief intervention.

Then, CBT7 was combined with MET/CBT5 to produce MET/CBT5 + CBT7.

Finally, FSN was added to MET/CBT5 + CBT7 to produce a combined

intervention that includes individual sessions, adolescent group sessions,

parent education groups, and therapeutic home visits. Two additional 

treatment interventions were also studied: the adolescent community 

reinforcement approach (ACRA) and multidimensional family therapy (MDFT).

This manual has been adapted for general treatment use. It is divided into

seven sections including appendixes. The first two sections provide background,

an overview of the theoretical model underlying the design of CBT7, and

discussions on supplemental issues. Sections III through VI provide an

overview of session components, step-by-step procedures for implementing

the treatment protocol, a glossary of terms, and the references. The appendixes

1
2

include sample posters, sample forms, and a detailed account of the CYT

study. The manual is equipped with tab pages to facilitate finding individual

sections.

Client and Provider Information

Target Population

MET/CBT5 + CBT7 is designed for the treatment of adolescents between

ages 12 and 18 who are exhibiting problems related to marijuana use, as

indicated by one of the following:

• Meeting criteria for cannabis abuse or dependence

• Experiencing problems (including emotional, physical, legal,

social, or academic problems) associated with marijuana use

• Evidencing frequent (weekly or more often) marijuana use, over 

a 3-month period.

Although this treatment includes suggestions for addressing both drug and

alcohol use, it was not originally designed for treating adolescents with

polysubstance dependence or those who use other substances on a weekly

basis. Adolescents were excluded from the study if they drank alcohol on 45

or more of the previous 90 days or if they used another drug on 13 or more

of the previous 90 days.

This treatment was effectively implemented with adolescents with mixed

demographic characteristics such as race, age, socioeconomic status (SES),

and gender, as well as from different regions. MET/CBT5 + CBT7 therapists

need to be culturally aware of and sensitive to the client group to whom

they provide this treatment so they can provide relevant examples and use

language that is understood by the clients in therapy sessions.

Likely referral sources of the clients include parents, the justice system,

school personnel, and medical or mental health providers. Self-referral is

rare.

Contraindications for MET/CBT5 + CBT7 are the following:

• The need for a higher level of care than outpatient treatment

• Social anxiety disorder so severe that participation in group 

therapy is not viable

• Severe conduct disorder

• Other acute psychological disorders of sufficient severity that they

prohibit full participation in treatment.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Level of Care

MET/CBT5 + CBT7 is appropriate for use as either an outpatient treatment

(American Society of Addiction Medicine [ASAM] Level 1) or an early 

intervention (ASAM Level 0.5).

Staffing Recommendations

The staffing level recommended for implementing MET/CBT5 + CBT7 is

one therapist for six adolescents in a treatment group. In the first weeks of

the treatment, the therapist sees each group participant for two individual

therapy sessions. During the next 10 weeks, the therapist conducts one

group therapy session per week. Additional clinician time may be needed to

deal with emergencies that may occur, to address pragmatic issues such as

scheduling and communication problems, and to make referrals.

Additional staff members may be required to conduct and score the initial

assessments and to prepare personalized feedback reports (PFRs). An 

additional staff person should be available in reasonable proximity to the

group therapy room when group sessions are in progress. This staff person

(who may be doing other work) could assist in dealing with emergencies or

supervising a client who has been asked to leave a group session because he

or she is under the influence of drugs or being disruptive.

Types of Organizations

MET/CBT5 + CBT7 is appropriate for use in several types of organizations

that provide outpatient care, including substance abuse treatment programs,

mental health clinics, youth social service agencies, and private practice

mental health and substance abuse treatment settings. Community centers,

schools, or general medical settings may also be appropriate for implementing

MET/CBT5 + CBT7, provided properly trained staff members are available.

These latter settings may be particularly well suited for implementing

MET/CBT5 + CBT7 as an early intervention.

Staffing and Certification Requirements

The CYT study used therapists who were trained at the master’s degree

level; however, a similar level of training is not necessary for individuals in

the field.

Requirements for therapists administering CBT7 in combination with

MET/CBT5 and FSN are (1) a bachelor of arts or master of arts degree, (2)

certification in addiction counseling, (3) a minimum of 1 year of prior clinical

experience working with adolescents, and (4) previous clinical experience

with behavioral interventions.

Supervisors should have expertise in the core intervention: MET/CBT5 +

CBT7. Certification criteria and procedures are detailed in appendix 3.

3

Part I: Introduction and Background
4

Scope and Significance of the Cannabis Problem

Marijuana remains the most widely used and most readily available illicit

psychoactive substance in the United States, with nearly 76 million individuals

reporting use at least once during their lifetime (Substance Abuse and

Mental Health Services Administration, 2001a). Marijuana use among 

adolescents ages 12 to 18 continues to be a serious problem. According to

results of the Monitoring the Future Survey (Institute for Social Research,

1997), use of marijuana among 10th and 12th graders continues to rise and

is at an all-time high, with steady, but decelerating, increases in lifetime,

yearly, monthly, and daily usages. For the first time since 1991, when data

collection began on 8th graders, marijuana use among 8th graders did not

increase, although rates of usage remain alarmingly high. Lifetime use (at

least once during one’s life) in 1997 was 22.6, 42.3, and 49.6 percent among

8th, 10th, and 12th graders, respectively, while annual use prevalence (use in

the past year) was reported as 17.7, 34.8, and 38.5 percent. From 1992 to

1997, past month usage among high school seniors rose from 11.9 to 23.7

percent; among 10th grade students, monthly use increased from 8.1 to

20.5 percent; among 8th graders, it rose from 3.7 to 10.2 percent. Of particular concern is the continuing rise in daily marijuana use. Among 10th

and 12th graders, the 1997 survey results showed daily use prevalence at

3.7 and 5.8 percent, respectively. Similar trends in marijuana usage have

been observed in regional surveys of junior and senior high school students

(Godley et al., 1996b; Hartwell et al., 1996). The continued increase in 

marijuana use has been attributed to two factors: declines both in the 

disapproval of marijuana use and in the perceived dangers of marijuana

(Johnson, Hoffman & Gerstein, 1996). 

Despite the perception that marijuana is not dangerous, the rate of emergency

department mentions of marijuana more than tripled among adolescents

ages 12 to 17 between 1993 and 2000 (Substance Abuse and Mental Health

Services Administration, 2001b). Conversely, in the 12 to 17 age group,

marijuana now accounts for more than twice the number of hospital 

emergency room cases as cocaine and heroin combined. 

Minority youth represent a particularly vulnerable segment of the population

because of their disenfranchised status (Dryfoos, 1990). Minority students

are relatively less likely to start using illegal drugs, but among those who

have done so, the proportions who use marijuana regularly are higher than

among nonminorities (Kandel & Davies, 1996).

An additional danger associated with marijuana use observed in adolescents

is a sequential pattern of involvement in legal then illegal drugs (Kandel,

1982). That is, marijuana is frequently a stepping stone from cigarette and

alcohol use to use of harder drugs (e.g., cocaine, heroin) (Kandel & Faust,

1975). This stagelike progression of substance use, known as the gateway

phenomenon, is common among youth from all socioeconomic and racial

backgrounds (Kandel & Yamaguchi, 1993). In sum, adolescent marijuana

use is closely linked to future drug involvement. That is, as long as marijuana

use is only experimental, it portends a decline in use of all drugs later. 

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
However, more serious use of marijuana often snowballs to involvement with

increasingly addictive and potent drugs. 

Whatever the pattern of marijuana use, its physical effects include fluctuations

in blood pressure, decreased salivation, mild unsteadiness, impaired 

coordination, hunger, drowsiness, slowed speech, respiratory difficulties

(Cohen, 1979; Hall, 1995; National Institute on Drug Abuse, 1986), a

decrease in the immune response, suppression of testosterone production

in males (Cohen, 1979), and a decrease in respiratory vital capacity. 

Adolescents abstaining after chronic marijuana use showed evidence of

short-term memory impairment, loss of abstract and logical thinking,

inability to focus attention and filter out irrelevant information, inability to

resolve normal emotional conflicts, mental confusion, and memory problems

(Millsaps, Azrin & Mittenberg, 1994; Lundqvist, 1995; Solowij, 1995;

Solowij et al., 1995). Studies suggest that it may take 6 to 12 weeks for

even partial recovery of cognitive functioning to occur and that this process

is prolonged when there is any interim use.

A commonly noted effect of chronic marijuana use is amotivational syndrome.

This syndrome is 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). Amotivational syndrome is attributed to heavy cannabis

use and has been observed in adolescents (Schwartz, 1987). However, Musty

and Kaback (1995) reported that amotivational symptoms in heavy marijuana

users between ages 19 and 21 might actually be due to co-occurring 

depression. Whether amotivational syndrome is a primary or secondary

diagnosis in subpopulations of marijuana abusers has not yet been resolved. 

Marijuana use has also been associated with a wide variety of social-psychological

problems. Rob and colleagues (1990) compared adolescent marijuana users

and nonusers on a number of psychosocial factors. Marijuana use was 

associated with poorer family relationships, poorer school performance, 

and higher levels of school absenteeism. Other illegal drug use was almost

entirely restricted to marijuana users, and marijuana users were more than

three times as likely as nonusers to be sexually active, to drink alcohol

three or more times per week, and to smoke cigarettes. Serious marijuana

use is associated with a multitude of behavioral, developmental, and family

problems (Kleinman et al., 1988), including conduct disorder, crime and

delinquency, school failure, unwanted pregnancy, and escalating drug

involvement (Donovan & Jessor, 1985; Farrell, Danish & Howard, 1992;

Hawkins, Catalano & Miller, 1992; Jessor & Jessor, 1977). 

Background on Cannabis Youth Treatment Cooperative

Agreement Goals

The purpose of the Cannabis Youth Treatment Project Cooperative Agreement

with the Substance Abuse and Mental Health Services Administration’s

(SAMHSA’s) Center for Substance Abuse Treatment (CSAT) was to (1) test

the relative effectiveness and cost-effectiveness of a variety of interventions

5

Part I: Introduction and Background
6

targeted at reducing or eliminating marijuana use and associated problems

in adolescents and (2) provide validated models of these interventions to

the treatment field. The target population was adolescents with the

cannabis use disorders of abuse or dependence as defined by the American

Psychiatric Association (1994). Appendix 4 includes additional information

on the CYT study.

Overview of the Study

The CYT study was conducted in collaboration with staff from organizations

in five different sites across the country: Chestnut Health Systems–

Coordinating Center (CHS–CC) in Bloomington, IL, and Chestnut Health

Systems (CHS–MC) in Madison County, IL; University of Connecticut Health

Center (UCHC) in Farmington, CT; Operation PAR in St. Petersburg, FL;

and Children’s Hospital of Philadelphia (CHOP) in Philadelphia, PA. The

study involved five treatment conditions: motivational enhancement therapy/

cognitive behavioral therapy: 5 sessions (MET/CBT5); motivational

enhancement therapy/cognitive behavioral therapy: 12 sessions (MET/CBT5

+ CBT7); motivational enhancement therapy/cognitive behavioral therapy:

12 sessions plus family support network (MET/CBT5 + CBT7 + FSN); 

ACRA; and MDFT.

These five treatments were grouped in several ways. First, they varied by

mode—the first three combined individual and group interventions, whereas

the last two consisted of individual sessions. Second, they varied by modality—

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 were expected to vary by resource 

intensity and cost.

The following descriptions provide greater detail about the individual 

components of the CYT Project.

MET/CBT5: The primary goals of this treatment are to enhance participants’

motivation to change their marijuana use and to develop basic skills needed

to achieve abstinence or gain control over marijuana use. The first and 

second sessions are held individually with each participant. They are spent

enhancing motivation and identifying high-risk situations that may increase

the likelihood of relapse. The therapist explores the participant’s reasons

for seeking treatment, prior treatment attempts, goals, self-efficacy, readiness

for treatment, and problems associated with marijuana use. A PFR is used

to compare the participant’s marijuana use and related problems with

national norms. The three subsequent CBT sessions are provided in a group

therapy format. Therapists conduct one group therapy session per week,

and the group size is limited to six participants. Participants learn basic

skills for refusing offers of marijuana, establishing a social network supporting

recovery, developing a plan for engaging in pleasant activities that fill free

time formerly occupied with marijuana-related activities, coping with 

unanticipated high-risk situations, problem solving, and recovering from 

a relapse, should one occur.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
CBT7: The goals of this treatment are to enhance participants’ motivation

to change cannabis use, as above. However, this intervention supplements

MET/CBT5 with additional training in the use of coping skills for dealing

with events and personal states that, by past association, have become 

functional cues or reinforcers for cannabis use. CBT7 offers weekly group

sessions that teach coping as an alternative to using cannabis when

responding to interpersonal problems, negative affect, and psychological

dependence. In these groups, participants learn problem solving, anger

awareness, anger management, communication skills, resistance to craving,

depression management, and management of thoughts about marijuana.

Group size is limited to six participants.

FSN: This treatment uses an intensive, family-focused approach designed

to improve parenting skills and to increase family cohesion, closeness, and

parental support. Presumably, improving these skills increases the likelihood

of both initial and sustained change. The intervention consists of case 

management (to promote parent engagement in the treatment process), 

six parent education group meetings (to improve parent knowledge and

skills relevant to adolescent problems and family functioning), four therapeutic

home visits, and referral to self-help support groups. At least one parent or

caregiver is required to attend group meetings. All family members living at

home are invited to participate in home visits.

ACRA: This treatment is composed of 12 individual sessions with the 

adolescent and/or the adolescent’s concerned other. ACRA focuses on

teaching alternative skills to cope with problems and meet needs, with an

emphasis on the adolescent’s environment. A concerted effort is made to

change the environmental contingencies—both positive and negative—

related to substance use. 

MDFT: This treatment is family focused and includes 12 weekly sessions to

work individually with the adolescents and their families. MDFT focuses on

family roles, other problem areas, and their interactions.

The interventions for MET/CBT5 and FSN are detailed in Volume 1 (Sampl

& Kadden, 2001) and Volume 3 (Hamilton et al., 2001), respectively, of 

the CYT Series. This manual for CBT7 occasionally references its partner 

interventions (i.e., MET/CBT5 and FSN), and it explains and provides

details on the sessions unique to CBT7. Like the other CBT manuals, this

manual focuses on the development of interpersonal and self-management

skills for helping to effect and maintain abstinence.

In each site of the CYT study, approximately 150 adolescents were 

systematically assigned to one of three interventions. At UCHC and

Operation PAR they were assigned to the brief MET/CBT5 or one of the two

other individual/group combinations. At CHS–CC, CHS–MC, and CHOP, 

adolescents were systematically assigned to the brief MET/CBT5 treatment

or one of the two individual approaches of ACRA or MDFT. All conditions

were replicated in two or more sites and were manual based with expert

workgroups supporting them. Each group met weekly and consisted of six 

participants. All participants were assessed at intake and at 3, 6, and 9

7

Part I: Introduction and Background
8

months after intake. To validate subject responses to questions about use,

urine tests and collateral assessments were done at intake and at 3 and 6

months after intake.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
II. The CBT7 Approach to Cannabis Treatment:

Background and Overview

Evolution and Purpose of Protocol 

The additional sessions presented in this manual were developed to extend

CYT’s MET/CBT five-session intervention by seven group sessions. This

allowed investigators to test whether adding seven coping skills training 

sessions provided in a group format would result in improved outcomes for

treatment recipients.

Previous Applications of Cognitive Behavioral Treatment to

Relevant Populations

In clinical trials, cognitive behavioral approaches to treatment have been

demonstrably effective with other behavior- and mood-related problems

experienced in childhood and adolescence, as well as for relapse problems

of adult substance abusers.

Cognitive behavioral interventions are helpful to children and adolescents

with behavior or mood problems and those with conduct disorder or 

subclinical delinquency. Cognitive behavioral trials with this population

have yielded improvements in problem solving, self-control, prosocial behaviors,

and positive communication that have been sustained for at least a year

(Kendall et al., 1990; Kazdin et al., 1989; Sarason & Sarason, 1981; Camp,

1977; Sarason & Ganzer, 1973). 

Trials with children and adolescents diagnosed with attention deficit/

hyperactivity disorder (AD/HD) have been less successful. Although these

trials yield temporary improvements for on-task behavior and self-control,

the effects often last less than a year. The treatment effects also do not 

generalize to social situations and do not enhance the effects of medication

(Abikoff & Gittleman, 1985; Brown, Wynne & Medemis, 1985; Hinshaw,

Henker & Whalen, 1984; Kendall & Wilcox, 1980; Douglas et al., 1976;

Meichenbaum & Goodman, 1971). 

With respect to internalizing disorders, cognitive behavioral interventions

appear effective with adolescents who meet the criteria for having depressive

disorders. Not uncommonly, reduced rates of depression and relapse are

sustained within these populations for at least 2 years (Hops & Lewinsohn,

1995).

Another type of client that seems to benefit from cognitive behavioral 

treatment is the adult aftercare recipient in recovery from a substance use

disorder. For this population, the cognitive behavioral paradigm appears to

be a useful educational method for helping to organize and anticipate

stages of relapse. Of particular relevance to this manual is Marlatt and

Gordon’s (1985) cognitive behavioral model of relapse. Marlatt and Gordon

propose that relapse is a sequence of stages that can be arrested when

9
10

appropriate cognitive behavioral techniques are introduced to halt the

progress from one stage to the next. According to their stage model, triggers

that generate cravings for a substance work synergistically with positive

thoughts about a substance’s satisfying effects to undermine resistance. 

By using self-talk and social support to check cravings and by mentally 

challenging the perceived benefits of use, adult aftercare patients can 

effectively prevent relapse and extend periods of abstinence. 

Based on its success rate with children and adolescents with a variety of

behavior or mood problems and with adult substance abusers, CBT was

selected as an appropriate component of treatment for participants in the

CYT study. 

As also noted in the MET/CBT5 manual (Sampl & Kadden, 2001), the

MET/CBT intervention described in this manual is an adaptation of adult

treatment. The unique developmental tasks of adolescence play a role in

substance use disorders and their treatment. Nowinski’s 1990 book,

Substance Abuse in Adolescents and Young Adults: A Guide to Treatment,

provides a useful discussion of substance abuse in relation to adolescent

development. Nowinski discusses the primary adolescent developmental

task of individuation, in which adolescents develop identities separate from

their parents or caregivers. During this individuation process, adolescents

are especially likely to question what adults tell them. Using the MET

approach minimizes the likelihood of provoking resistance, which might

occur in a highly directive or confrontative therapeutic approach. As a

result, the MET approach seems particularly promising for adolescent 

marijuana users. In MET the therapist works with the client’s own 

marijuana use goal, helping to evaluate the benefits and disadvantages of

abstinence versus continued use. This process supports the development of

self-control, another key developmental task of adolescence (Nowinski, 1990).

Overview of Treatment Model/Intervention

Treatment Goals and Objectives

The ultimate goal of CBT7 is abstinence. Toward this end, CBT7 is administered

with two broad treatment objectives in mind: (1) to teach adolescents how

to use a broad spectrum of coping activities to help deal with problems,

interpersonal conflicts, and negative mood states and (2) to teach adolescents

how to anticipate and challenge the thoughts, cravings, and urges that

impel marijuana use as a means to maintaining abstinence. The framework

therapists use to promote these objectives is first to work with clients to

identify a wide range of interpersonal and intrapersonal stressors, triggers,

cravings, and urges that pull for impulsive/self-defeating behavior or for

marijuana use. Therapists also teach coping skills that clients can use to

weather stressful circumstances and maintain abstinence.

These objectives of CBT7 are mutually supportive and synergistic. Marijuana

use can be seen as a maladaptive form of coping. Efforts to develop adaptive

coping skills will have the subsidiary effect of reducing the need for

cannabis as a coping agent. Likewise, by reducing or eliminating marijuana

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
use, adolescents learn alternative approaches to stress management that

have greater potential for long-term benefit. 

The overall goal of abstinence, however, deserves further clarification. In

sessions 10 and 12, adolescents in CBT7 are taught to use cognitive behavioral

strategies, first to abstain from marijuana and then to maintain abstinence

after treatment is over. Declaring abstinence the ultimate goal of treatment,

however, does not mean that it becomes a criterion for receiving treatment

in the first place. Adolescents should not be removed from treatment for

occasional use of marijuana or other substances (unless substance use 

escalates to a point where clinical deterioration is evident). They should be

allowed to continue as long as they commit to working toward renewed

abstinence. At the same time, clients should not be allowed to come to

treatment if they are manifestly high on marijuana or other drugs, especially

if the therapist deems them unlikely to benefit from the group or likely to

tempt others to use. (See Coming to Group Intoxicated, page 30 in Section

III: Overview of Treatment Session Components.)

In CBT7, the participant’s ambivalence about the possibility of stopping

marijuana use is considered normal. The therapist is encouraged to accurately

reflect participants’ mixed feelings about quitting marijuana. Therapists are

encouraged to “normalize” ambivalence and concerns about quitting. They

can provide feedback to participants, such as, “What you’re feeling is not at

all unusual, especially in these early stages. Many people have mixed feelings

about quitting pot.” Also, they can reinforce any self-motivational statements

and indications of willingness to change. Participants may reconsider their

resistance to change if they believe the therapist understands the reasons

for being hesitant to change.

Theoretical Assumptions

The cognitive behavioral paradigm assumes that thinking, feeling, and

doing are separate realms of human process that become associated

through learning. Cannabis use, like any behavior, can be linked with

thoughts, feelings, and other behaviors through direct experience or

through observation. Associations can be strengthened by intense learning

experiences or by placing certain thoughts, feelings, or actions in frequent

proximity to use. When they are strong enough, associations can even serve

as triggers (i.e., antecedents) that effectively cue or reinforce a person’s

desire (i.e., consequences) to use—even when that person is planning to

abstain. From a cognitive behavioral perspective, for individuals to change

their patterns of cannabis use, they should attend to the context in which

they use, as well as to the decisions that lead to using. Taking a broad 

perspective on the context of cannabis use can improve one’s chances for

anticipating and thereby avoiding unintended relapse.

A second theoretical assumption in the cognitive behavioral framework is

that teaching and consulting are appropriate ways of intervening with people

who have mental health problems. As teachers, cognitive behavioral therapists

use a classroom teaching style to help clients comprehend coping skills.

They use experiential teaching methods to help clients internalize coping

11

Part II: The CBT7 Approach to Cannabis Treatment
12

skills that are personally useful. As consultants, therapists tailor session

content to problems raised by an individual or by group members. The 

cognitive behavioral therapist is not perceived as an expert by the client but

rather as an ally who appreciates the difficulty of balancing personal emotions

and ambiguous social demands and who is prepared to share ideas about

how to deal with both.

Treatment Model

CBT posits that, for adolescent cannabis users to abstain from smoking,

they must learn new ways of responding to feelings, states of mind, or situations

that have led to use in the past and the internal dissonance that may arise

as a consequence of using, despite earlier commitments to abstain. 

Exhibit 1 suggests that individuals’ confidence in their ability to abstain

(i.e., their self-efficacy) derives from periodic exposure to high-risk situations

that triggered or mediated use in the past. Using coping skills learned

through CBT in these situations increases the likelihood that the adolescent

will achieve a positive outcome such as a reward, reduced anxiety, abstinence,

or discontinuance of use and, in turn, strengthen his or her perception that

a positive outcome is achievable. The bottom trajectory of exhibit 1 illustrates

the default sequence that occurs if the adolescent lacks coping skills or

fails to use coping skills at the appropriate time. In this case, an ineffective

response to the risky event yields disappointment (i.e., low self-efficacy) and

emergent desire to remedy the situation with marijuana. Desire leads to

use, and use further erodes the perceived ability to abstain.

Exhibit 1. Cognitive Behavioral Model of the Relapse Process

Source: Marlatt & Gordon, 1985. Copyright © 1985 by The Guilford Press.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions

No coping

response

Increased

probability

of relapse

Coping

response

Increased

self-efficacy

Decreased

probability

of relapse

High-risk

situation

Decreased

self-efficacy;

Positive 

outcome

expectancies

(for initial

effects of

substance)

Initial use of

substance

Abstinence 

violation

effect:

Dissonance

conflict 

and selfattribution

(guilt and

perceived

loss of 

control)
In short, CBT is an intervention designed to teach adolescents alternative

ways of coping with circumstances that were previously associated with use.

The purpose is (1) to increase adolescents’ range of coping skills and 

subsequently their perceived ability to abstain and (2) to replace cannabis

use as a default option for coping.

Overview of Sessions 

The MET/CBT5 intervention is described fully in Sampl and Kadden (2001).

Exhibit 2 presents the five sessions of MET/CBT5 that always precede

CBT7. Exhibit 3 presents the seven sessions of CBT7.

Exhibit 2. Five Sessions of MET/CBT5

Group sessions are held weekly and consist of six participants. Content

descriptions of the five MET/CBT5 and seven CBT7 sessions are provided

below.

13

Part II: The CBT7 Approach to Cannabis Treatment

Session Time Primary

Number Modality Period Approach Main Topics

Session 1 Individual 60 min. MET Motivation Building (Sampl & 

Kadden, 2001, pages 32–40)

Session 2 Individual 60 min. MET Goal Setting (Sampl & Kadden, 

2001, pages 41–51)

Session 3 Group 75 min. CBT Marijuana Refusal Skills (Sampl 

& Kadden, 2001, pages 61–67)

Session 4 Group 75 min. CBT Enhancing the Social Support 

Network and Increasing 

Pleasant Activities (Sampl & 

Kadden, 2001, pages 68–76)

Session 5 Group 75 min. CBT Planning for Emergencies and 

Coping With Relapse (Sampl & 

Kadden, 2001, pages 77–81)
14

Exhibit 3. Seven Sessions of CBT7

Session 1 includes motivational interviewing and focuses on establishing

rapport and building motivation. The therapist explores the participant’s

reasons for seeking treatment, prior treatment episodes, previous attempts

to quit, treatment goals, and perceptions of self-efficacy. A personalized

feedback report outlines information provided on intake assessment 

instruments, highlights the adolescent’s problems and concerns related 

to marijuana use, and compares his or her marijuana use with national 

adolescent norms. A sample PFR and instructions for filling it out can be

found in appendix 4 of Motivational Enhancement Therapy and Cognitive

Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions (Sampl &

Kadden, 2001). The therapist reinforces indications of motivation to change

and explores ambivalence, as it may pose a significant barrier to abstinence.

Session 2 reinforces the participant’s motivation to change. The first session

is summarized, and reactions to the material covered in the first session are

discussed. The therapist and the participant collaborate on establishing a

personalized plan for change. The therapist introduces the concepts of 

functional analysis and triggers, provides general information about participation in group therapy and the family support network (if applicable), and

answers questions or discusses the adolescent’s concerns.

Session 3 is the first group session and focuses on developing skills for

refusing offers to buy or use marijuana. Participants discuss social pressure,

the need for immediate and effective action, ways to say “no” quickly and

convincingly, alternative activities, and avoidance of making excuses. The 

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions

Session Time Primary

Number Modality Period Approach Main Topics

Session 6 Group 75 min. CBT Problem Solving (pages 37–44)

Session 7 Group 75 min. CBT Anger Awareness (pages 45–57)

Session 8 Group 75 min. CBT Anger Management (pages 

58–63)

Session 9 Group 75 min. CBT Effective Communication (pages 

64–71)

Session 10 Group 75 min. CBT Coping With Cravings and Urges 

To Use Marijuana (pages 72–79)

Session 11 Group 75 min. CBT Depression Management (pages 

80–91)

Session 12 Group 75 min. CBT Managing Thoughts About 

Marijuana (pages 92–100)
therapist roleplays ineffective (passive, aggressive, passive-aggressive) and

effective (assertive) responses. Roleplaying of risky situations is included.

Session 4 focuses on enhancing participants’ social support network. The

adolescents identify potential supporters, kinds of helpful support, and

methods for improving social relationships and increasing support. The

therapist models appropriate ways to seek support. Group members complete

a social circle diagram and describe the support available from the people

included in their diagram. Ways of increasing participation in appropriate

pleasant activities may also be presented.

Session 5 concentrates on coping with unanticipated high-risk situations

and relapses. The group discusses situations that could precipitate relapse.

Participants are advised that smoking marijuana may produce feelings of

guilt and shame. The adolescents are encouraged to view these situations as

learning experiences that contain information on preventing future marijuana

use. Group members develop a personal emergency plan and identify steps

for dealing with a slip or relapse. 

Session 6 focuses on developing effective problem-solving skills using a 

five-step problem-solving model. The group members use a group exercise

to apply the model and respond to feedback from their peers and the therapist.

Session 7 presents anger awareness and relaxation skills training.

Participants are cued to recognize early indicators of anger and learn the

difference between internal and external events that trigger anger. A verbal

practice exercise helps participants process the session content. Progressive

relaxation techniques are taught.

Session 8 teaches techniques for managing anger and expressing it 

appropriately. Participants are encouraged to use problem-solving skills to

address situations that trigger anger. The therapist models appropriate

expressions of anger, and group members roleplay to help process session

content.

Session 9 introduces components of effective communication: active listening,

assertiveness, and receiving criticism. Adolescents are taught to reflect on

their discussions with others and are encouraged to assert their thoughts,

beliefs, and feelings, while respecting that others may think, believe, or feel

differently. Techniques used include therapist modeling and group roleplays.

Session 10 presents coping options for handling craving and urges for 

marijuana. Participants learn to identify triggers; to use a daily log for 

documenting the intensity, length, and source of urges; and to use techniques

for coping and resisting urges such as self-talk, talking to friends, and

engaging in distracting activities.

Session 11 is concerned with feelings of depression and their management.

Topics include early recognition of feeling down, the effects of automatic

negative thoughts, and techniques used to substitute positive thoughts for 

15

Part II: The CBT7 Approach to Cannabis Treatment
16

negative ones. Participants are encouraged to use problem-solving skills to

resolve situations that contribute to sad feelings.

Session 12 returns to the central issue of managing thoughts about marijuana.

Participants are reassured that these thoughts are common to recovery and

that having thoughts is not the same as acting on them. The therapist proposes

cognitive behavioral techniques for managing thoughts about marijuana

and reviews the 12 most common excuses for relapse (Marlatt & Gordon,

1985). Issues related to termination of therapy are discussed.

D: A Composite Case

In keeping with the MET/CBT5 + CBT7 approach and to introduce the 

concepts for practice in real life settings, the following composite case

portrays the encouragement adolescents receive at sessions to try an

extended period of abstinence from marijuana. The composite case

describes how youth are encouraged to evaluate the potential impacts 

of marijuana use on their lives. In this case the therapist tolerates the 

adolescent’s ambivalence about change. The therapist does not try to

force abstinence but helps the client to understand the risk associated

with continued use.

The CBT7 coping skills therapy is designed to remediate deficits in skills

for coping with antecedents to marijuana use. Individuals who rely primarily

on marijuana use (or other substances) for coping have little choice but

to resort to substance abuse when the need to cope arises. Skill deficits

are viewed as central to the relapse process; therefore, CBT focuses on

the development and rehearsal of skills.

D is a composite of several real cases from the CYT study. This composite

was created to help model typical client responses to the MET/CBT5 +

CBT7 protocol.

D’s grandmother, Mrs. M, brought D to treatment shortly after learning

about the program from a newspaper advertisement. D had recently come

to live with his grandmother after deciding that he could no longer live

with his mother, who, according to Mrs. M, “is a heavy drinker and a hard

woman to make listen.” Shortly after moving in with his grandmother, D

was arrested for possession of marijuana. To keep her grandson out of

detention, Mrs. M brought him to treatment, hoping that the judge would

note their initiative at D’s court date.

D presented to treatment as a verbal, neatly dressed, 16-year-old white

male. At intake, he reported he had first experimented with marijuana at

age 13. He admitted to “smoking a lot” in recent months—almost every

other day in the past 90 days. He endorsed one symptom of past-year

cannabis dependence (i.e., spending a lot of time getting marijuana) and

two symptoms of abuse (i.e., continuing to use despite failing to meet 

his responsibilities at home and school and despite repeatedly getting

involved in fights and with the law). Although D’s endorsement indicated

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
a conduct disorder (i.e., he lied or conned to get the things he wanted,

was truant from school, and stayed out later than allowed), D endorsed no

items indicating a persistent pattern of aggressive behavior toward others.

D reported his school performance as adequate (i.e., mostly C’s) although

he contended that “I can do better than that.”

Prior to CBT7, D attended all his scheduled MET/CBT5 appointments.

During his first MET session, he expressed skepticism when told that he

smoked more marijuana than the average adolescent, saying that he knew

several people his age who smoked more than he did. Nevertheless, he

said that he felt that he had been smoking too much lately and voluntarily

made the connection between smoking a lot and “forgetting stuff.”

Although not ready to abstain, D said that he wanted to cut his use in

half—using mostly on weekends. He planned to abstain during treatment

so that his urine tests for probation would be negative. At the end of the

feedback session, D’s therapist asked D about the 50-percent chance D

had given earlier regarding confidence in his own ability to change his

behavior. D unilaterally chose to improve that rating to an 80-percent

chance.

Session 6: Problem Solving. By the time the CBT7 sessions began, D’s

court date was scheduled, and he was assigned to a probation officer. He

was in the third week of the fall high school semester and was going to

afternoon football practice. During session 6’s review of client status, D

stated he was glad that he was spending time with the football team,

adding “they use a lot less than the guys I was hanging out with this 

summer.” The therapists congratulated D for gathering friendly support 

to help him reach his goal of not using. D appeared attentive during the 

session on problem solving and offered three solutions during the brainstorming exercise to help solve a problem that another participant was

having with her boyfriend. The therapist made sure to write D’s ideas on

the blackboard at the front of the room where he could see them.

Session 7: Anger Awareness. The following week, D reported that he

attended a party the previous Sunday. He did not use despite several

opportunities “because I know I’m going to drop a dirty urine and the

judge is going to send me to detention.” Although not the best example 

of problem solving, the therapist used this as an opportunity to build D’s

confidence. She suggested he had actually solved a problem situation by

considering options just as he had during the previous week’s group exercise.

D accepted the idea and stated, “I’ve been thinking things through a little

more, I guess.” However, during the session, D was unconvinced about the

usefulness of the material on anger awareness, stating, “I just get mad

when I get mad. It’s not because I’m tired or anything.” After D completed

Activity Sheet 2: Conducting a Self-Interview, the therapist asked him

whether he could see possibilities for anticipating anger. He remained

unconvinced. He seemed more receptive to the usefulness of session 7’s

relaxation training. The therapist noticed that after providing a urine

sample, D took his Real Life Practice Exercise: Relaxation Technique

handout but left the materials on anger awareness behind.

17

Part II: The CBT7 Approach to Cannabis Treatment
18

Session 8: Anger Management. Before the start of the session, the therapist

met privately with D to tell him that his urine test indicated the presence

of marijuana. D was surprised and said that he was certain that he had

been abstinent for the prior 3 weeks. Realizing that D was feeling anxious

about pending drug screens at probation, the therapist permitted him to

give a second sample. That evening, during the discussion about anger

management, D again stated that he could not see himself affecting his

own anger. The therapist asked D which of the anger management steps

made the most sense to him. D answered “Step 1: Chill Out” and compared

it with “time out.” After helping D explore how D uses timeouts, the therapist

encouraged him to use the Real Life Practice Exercise for Anger

Management handout to see whether he could recognize his anger 

triggers as they occurred.

Session 9: Effective Communication. Before the start of the session, the

therapist reported to D that his second urine sample did not indicate the

presence of marijuana. D was visibly relieved. He stated during the review

session that he had given his first urine specimen for probation and he

hoped it would test the same. The therapist congratulated D and encouraged

him to stick with the goals he had set for himself. During that evening’s

discussion about effective communication, the therapist noticed that D

was frequently off-topic and talked to other group members during the

session. The therapist partially succeeded in reengaging D during the

roleplay about responding to constructive and destructive criticisms.

Session 10: Coping With Cravings and Urges To Use Marijuana. During

the review session, D reported that he used three times at a party that he

threw at his grandmother’s house while she was away visiting a relative.

When asked by the therapist what had triggered the use, D replied that he

was “feeling kind of bored and being around all those guys and just thinking

‘Well, why not? They’re having fun at least.’ ” The therapist reflected

back to D that boredom and friends using had triggered his use, and the

therapist asked what the positive and negative consequences of using had

been. D reported that he felt good at the time but that now he was afraid

that his probation officer would ask for another urine sample. After probing

further, the therapist learned that D had left a pile of empty beer cans “in

the garage where my grandma found them and she yelled at me.” When

asked about his response to his grandmother’s reaction, D reported that

he sat in his room for an hour. “Like a timeout?” the therapist asked.

“Yes, kind of like that,” D stated. Before turning to the evening’s agenda,

the therapist pointed out to the group that D used the first and most

important step of anger management. She suggested that D learned

about some important triggers for using such as boredom or being with

friends who use. He was now in a position to anticipate and avoid triggers.

Sessions 11 and 12: Depression Management and Managing Thoughts

About Marijuana. In sessions 11 and 12, the therapist noticed D became

increasingly off-topic as he became friendlier with other group members

and as he looked forward to the end of treatment. His urine sample from

session 11 indicated, unsurprisingly, the presence of marijuana.

Nevertheless, D reported that he was paying attention to triggers. He 

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
stated he would not use during the final weeks of treatment so the urine

sample for his probation officer would be free of marijuana.

On his last real life practice exercise, D wrote that the benefits of not

using marijuana were that he did not have to go to detention and that he

had more money in his pocket. His high-risk situations were being with

friends who use and being bored.

During termination, D stated that the most important skills he had

learned were problem-solving and relaxation skills. He encouraged other

members of the group to stick with their goals and restated that his goal

was to complete probation, to use only on weekends, and never to use as

much as he was using when he started treatment.

As part of the therapist’s termination feedback, the therapist told D she

was impressed that he came to all his scheduled sessions (even when he

wasn’t sure he wanted to come). She presented him with a certificate for

finishing treatment. She commended D for abstaining during the past 3

weeks by anticipating social situations that placed him at risk for using.

She added that D seemed more attentive and expressive during that

time—possibly due to abstinence.

Key Concepts of CBT7

The key concepts presented in CBT7 are problem solving, affective 

management, communication skills, and relapse prevention.

Problem Solving

Problem solving is addressed in session 6. This session lays important

groundwork for later sessions by presenting problems as a normal part of

daily living and by reassuring participants that they can solve problems if

they take the time to do it. According to D’Zurilla and Goldfried (1971),

mental health and behavioral problems are often the products of hasty problem

solving. Most people (drug users included) tend to narrowly interpret problem

solving as fixing the problem instantly (e.g., “If I smoke pot, I won’t feel

bored anymore.”). Although this approach may produce immediate 

gratification, it may lead to anticipated negative outcomes. Careful problem

solving may not produce gratification immediately, but it does so eventually.

The benefit of careful problem solving is that one sees things improve 

gradually, without having good consequences canceled out by negative ones.

The session on problem solving follows D’Zurilla and Goldfried’s (1971) 

prescription of breaking problem solving into the following steps: general

orientation, problem identification, generation of alternatives, decision

making, and verification. Adolescents are encouraged to think through one

step before moving to the next. The critical distinction is between the 

linear process of getting the right answer and the creative process of generating

and evaluating options. CBT7’s didactic style may give adolescents the

impression they are in a classroom and are being called on to give the right

19

Part II: The CBT7 Approach to Cannabis Treatment
20

answer. Therapists counter this impression, however, and elicit creative and

even outlandish ideas from the group—especially when generating alternatives.

Affective Management

Affective education, presented in sessions 7, 8, and 11, helps adolescents

regulate negative emotions that intrude on their attempts to solve problems.

The components of affective education are emotional identification and

management. In emotional identification, adolescents learn to recognize

physical reactions and behaviors that signify the presence of latent or 

neglected anger or depression. In emotional management, participants

learn how to check escalating anger or depression and to refocus their

energies on problem solving.

Modeling and roleplay are useful approaches for teaching affective 

management. These forms of communication are more effective than verbal

accounts in conveying the full gestalt of affective experience. These techniques

enable the therapist to add inflection, tone of voice, body language, and

facial expression to emotional portrayal and to exhibit the broad range of

emotional cues that participants must use to tap into their feelings.

Roleplay is a natural counterpart to modeling. Through roleplaying, adolescents

can apply what they learn from the modeling of coping strategies to personally

meaningful events.

Communication Skills

Effective communication skills are the adolescent’s first defense when

attempting to deescalate emerging conflict and move in the direction of

problem solving. In session 9, teenagers learn coping skills (listening,

rephrasing, reflecting) to facilitate communication, and they learn to 

distinguish an assertive posture from less adaptive patterns of relating.

Although the goal of communication skills training is effective communication,

the process by which each teenager reaches that goal depends on the

nature and severity of his or her interpersonal deficits. For aggressive, 

externalizing teenagers, developing a more effective communication style

means enhancing receptive language and raising personal awareness of 

reciprocity and boundaries. For passive, internalizing adolescents, improving

communication means developing an assertive interpersonal style and

attending more deliberately to positive feedback from others.

Relapse Prevention

The approach to relapse prevention embraced in sessions 10 and 12 is 

modeled on Marlatt and Gordon’s (1985) cognitive behavioral approach 

to relapse prevention for adult substance abusers in recovery. This model

breaks the process of relapse into a sequence of events, thereby highlighting

crucial moments when coping skills can be used to help strengthen the

resolve to abstain. Triggers such as a negative emotional state or proximity

to friends who are high are an indication that a coping response is needed.

When faced with a trigger, adolescents can use coping skills such as self-talk,

social support, or distraction to help combat their cravings or urges.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Triggers and cravings are often accompanied by positive beliefs about the

good feelings associated with use or the relief that smoking marijuana 

provides. To help resist these beliefs, participants can use thought changing,

self-distraction, social support, or a simple delay of action.

Tailoring the Treatment to the Client

Adolescents vary in their coping deficits and in their capacities to learn.

Although CBT7’s general objective is to expose participants to the intervention’s core content, the emphasis and style of the presentation should be

tailored to meet the unique needs and capabilities of each participant.

When adapting the intervention for a client, the therapist should consider

four crucial client characteristics: pathological coping, severity of use and

symptoms of withdrawal, cognitive functioning, and cultural factors. These

characteristics are discussed below.

Externalizing Versus Internalizing Disorders

Presumably, adolescents are in CBT7 to learn how to deal more effectively

with life problems, and improved coping is a goal of all participants. Some

clients may have adequate coping skills and need only to enhance strategies

they are currently using or work on a few areas of weakness. However, a 

significant number of adolescents enter treatment with coping styles that

are maladaptive or pathological.

Maladaptive styles can be loosely categorized by their association with two

broad classifications for childhood or adolescent disorders: externalizing

disorders (e.g., oppositional defiance, conduct disorder) and internalizing

disorders (e.g., depression, anxiety, posttraumatic stress disorder). These

two broad classifications of disorders pose unique challenges to the therapist

in his or her efforts to help adolescents develop effective coping skills.

Impulsivity and aggression are signature coping strategies of externalizing

adolescents. Swept away by their own volatile reactivity, externalizers tend

to miss opportunities for reflection or consideration of options before taking

action. If they are to learn to use techniques for problem solving, emotional

sensing, and reflective listening, they must first learn to stop and think

before acting. Therapists must remind them that action is rarely the first

step in any effective coping strategy. Action often is the last step, taken

after sufficient time has been used to think through options.

Internalizing adolescents face different challenges, that is, self-abasement

and social isolation. They tend to harbor low expectations about their ability

to cope and are generally pessimistic about forecasting the consequences of

their efforts. In social relationships, their beliefs in their own worthlessness

override evidence of acceptance by others. To work effectively with such

clients, therapists have to challenge clients’ entrenched perceptions of

fatalism and low self-esteem and positively reinforce acknowledgment of

personal achievement. When asking internalizers to roleplay, therapists

should encourage them to practice an assertive interpersonal style and to 

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Part II: The CBT7 Approach to Cannabis Treatment 
22

balance the attention they pay to criticism with attention to the positive

feedback they receive from others.

Severity of Use and Symptoms of Withdrawal

The length and severity of recent marijuana use moderate the likelihood

that a participant will successfully abstain from using marijuana in the

future. When assessing for client vulnerability to relapse, therapists are

advised to assess the frequency of use during the past 90 days and to note

the diagnostic criteria each client endorses for cannabis disorders. Clients

who report frequent use and who endorse dependence items are more likely

than others to be struggling with multiple triggers, urges, cravings, and

obsessive thoughts about marijuana.

Beyond considering risk factors, therapists should assess how congruently

clients’ perceptions of vulnerability coincide with actual risk. If an adolescent

reports using heavily in the past, reports symptoms of dependence, and

then denies feeling at risk for relapse or loss of control over his or her use,

the participant is doubly at risk for relapse because of his or her lack of

concern or vigilance. To help generate concern for potential relapse, therapists

should follow client use patterns closely during the 2 months of treatment

that take place before relapse training in sessions 10 and 12. By attending

to any reported use and objective screening results, therapists may eventually

be able to direct a client’s attention to discrepancies between his or her

unjustified optimism and continued use.

Participants reporting more severe use may need to discuss withdrawal

symptoms such as flulike symptoms, increased anxiety, or difficulty sleeping.

Therapists can reassure these adolescents that withdrawal symptoms are

common 12 to 24 hours after their last use and that the symptoms usually

last less than 2 weeks. The therapist can encourage adolescents to use

strategies such as relaxation techniques to relieve their anxiety or decrease

caffeine intake to reduce insomnia. If participants anticipate having a very

difficult time based on previous experience, or actually report experiencing

severe withdrawal symptoms, the therapist may request permission to discuss

the problem with their parents, primary care physicians, or psychiatrists.

However, a referral to a primary care physician or psychiatrist should be

made only in extreme circumstances (Steinberg et al., 1997, pages 23–24).

Cognitive Functioning 

Because participants in CBT are expected to verbally and conceptually

mediate their coping responses to interpersonal and intrapsychic stress,

those diagnosed with cognitive deficits (e.g., attention deficit disorder) may

have difficulty comprehending and learning some of the skills described in

this manual. When gauging a participant’s cognitive readiness for treatment,

the therapist should not equate the participant’s cognitive deficits with 

cognitive immaturity or the lingering effects of heavy marijuana use.

Teenagers who are cognitively immature or whose short-term memory is

temporarily compromised by lingering tetrahydrocannabinol (THC) may 

initially struggle with the therapy content but should eventually be able to

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
grasp essential concepts. However, participants with enduring cognitive

deficits may need additional help to understand concepts such as triggers

or problem solving. With these participants, therapists are encouraged to be

more task specific when developing treatment goals, to use additional concrete

and visual examples, to model the desired response more frequently, and to

use rewards for helping clients notice personal successes. 

Cultural Factors 

Ethnic and cultural awareness is important to the competent delivery of

treatment to minority populations. An individual’s ethnic or cultural context

is important to consider when evaluating his or her marijuana dependence

or abuse. “A clinician who is unfamiliar with the nuances of an individual’s

cultural frame of reference may incorrectly judge normative variations in

behavior, belief, or experience as psychopathology” (American Psychiatric

Association, 1994, page xxiv). According to Zweben et al. (1998, pages

12–13), “The clinician needs to be sensitive to ethnic and cultural problems

that may cause problems in the diagnosis and treatment (e.g., difficulty in

communicating in the individual’s first language, in eliciting symptoms or

understanding their cultural significance, in negotiating an appropriate

relationship or level of intimacy, in determining whether a behavior is 

normative or pathological).” Although this manual does not contain cultural

sensitivity training, therapists are encouraged to attend any relevant trainings

available to them.

Compliance

Slips and Relapses

A slip is a brief, time-limited use of marijuana after a period of abstinence

or a brief violation of a plan to cut down on use. A relapse is a longer period

of sustained, and often heavy, use. Therapists can help a participant deal

with slips by examining the events leading up to them and by identifying

triggers and the participant’s reactions to them. The slip can be viewed as a

learning opportunity. Questions for the participant might be: “Did you have

expectations that using marijuana would change something or meet some

need?” and “Did anything happen after you used that might influence your

using again in the future?”

When a participant relapses, his or her immediate response might be “I

messed up, I’m a failure, and this treatment isn’t working.” Therapists are

advised to challenge such self-defeating thoughts by commending the 

participant’s honesty and by stating that occasional relapses are normal;

they are not evidence of treatment failure or that the participant is a 

failure. The therapist might say the following to the participant:

Individuals may find it hard to stay completely abstinent and may

use again after several weeks of abstinence. It’s pretty common and

nothing to feel ashamed about. You were abstinent for about 3 weeks

before that slip. I’d expect with all you have learned, you’ll be able 

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Part II: The CBT7 Approach to Cannabis Treatment
24

to stay clean longer this time. What are some things you can do to

remain abstinent longer?

Some participants quit treatment after a slip or relapse. Participants should

be advised that, even with efforts to maintain their abstinence, some may

slip. Although participants are told never to come to a session high, they

should be strongly encouraged to continue attending after a slip or relapse.

Resuming treatment can prevent additional relapses and serve as a 

reaffirmation of a personal commitment to treatment. In addition, therapists

should take care that participants understand that allowing them to return

to treatment after a relapse does not give them permission to use marijuana.

Urine Test Results

Urine is tested for drugs at sessions 3, 7, and 11 of MET/CBT5 + CBT7,

before sessions begin. Therapists should discuss the test results with clients

individually before or after sessions 4, 8, and 12. If the results are negative

(i.e., drugs are not present), therapists can provide strong positive 

reinforcement and support. Therapists can encourage continued involvement

in activities that are incompatible with drug use, as well as continued 

association with persons who do not place the participant at risk for drug

use. They might also ask about problems encountered during this period of

abstinence, such as cravings for specific drugs. If participants used coping

skills learned in therapy, therapists should encourage continuing use of the

new techniques. 

If the results of the urine test are positive (i.e., drugs are present), the therapist

should review the circumstances and context of the drug use with the 

participant. For example, the therapist and participant can identify external

factors (e.g., persons, places, things) and internal factors (e.g., cravings,

emotional distress) associated with the recent drug use. The therapist can

encourage use of problem-solving techniques and coping skills to manage

factors that contributed to drug use and to develop alternative ways of 

handling them.

Missed Sessions

If a participant misses a session, the therapist should attempt to contact

the person by telephone within 24 hours to determine the reason for the

absence. If the participant cannot be reached by telephone within 7 days,

the therapist should send a brief letter. If there is no response to the letter

within 3 weeks, the therapist should refer the case to a supervisor. 

If all group members but one are absent, the therapist should conduct a 

45-minute individual session with the attendee and cover the material

planned for the group session. When confronting participants who have

missed sessions, therapists should explore obstacles to their treatment or

their possible ambivalence toward treatment. Steinberg et al. (1997, page

20) commented:

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Many participants miss sessions because: (a) they slipped and are

simply too embarrassed to admit their “failure” to the therapist, or

(b) they are ambivalent about complete abstinence. Careful inquiry

by the therapist will reveal which of these situations is the case.

Ambivalence indicates a need to return to a MET focus, that is,

rolling with resistance, reframing, and revisiting treatment goals. If

the participant misses sessions because of fear of admitting failure,

the therapist should reiterate that occasional “slips” are fairly 

common, and often signal a high-risk situation that hasn’t yet been

directly discussed during sessions.

Clinical Issues

Therapist Self-Disclosure

Clients often ask therapists about their own past use of marijuana.

Therapists should consider such questions carefully, as they may originate

from an underlying concern such as, “Will you, the therapist, be able to

understand me, and can I get the kind of help here that I need?” (Steinberg

et al., 1997, page 24). Therapists should not, in fact, disclose their previous

use or nonuse of marijuana. Although self-disclosure may be a matter of

preference in general clinical practice and is often used to build rapport,

the clinical strategies provided in this intervention are considered sufficient

and are not enhanced through self-disclosure. 

Threats To Harm Oneself or Others

Threats to harm oneself or others should be addressed separately from the

group whenever possible and should be brought to the attention of the 

clinical supervisor as soon as possible. A supervisory review will help determine

the best clinical response, the ethical and legal responsibilities, and whom

to warn or how to intervene. It should trigger an immediate reevaluation of

the severity of the problem and modality placement.

Clinical Deterioration 

It is inevitable that some participants will suffer setbacks in their personal

or interpersonal functioning. It is imperative that accommodations be made

to provide support or referral services for medical, psychological, or substance

abuse services when they are needed. Offering referral services when clients

express a need is an informal incentive to participation that seems important

to some individuals (Zweben et al., 1998, page 62).

Therapists should refer adolescents to a clinical supervisor if they observe

either of the following:

• Clinical deterioration in multiple spheres of an adolescent’s life

due to increased marijuana use

• Significant deterioration in a single sphere of a participant’s life

due to comorbid issues.

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Part II: The CBT7 Approach to Cannabis Treatment
26

Administrative Issues 

Extended Waiting Periods

If the waiting period between a participant’s individual meetings with a

therapist and the start of his or her attendance in a CBT group is longer

than 2 weeks, therapists should maintain contact with weekly phone calls to

help prepare the adolescent for the treatment and to assess any changes in

the adolescent’s status that might require immediate face-to-face contact.

If such a change is noted, the therapist should discuss this concern with a

supervisor.

Preventing Attrition

To prevent attrition, therapists should explore any potential obstacles, 

such as transportation problems, child care issues, school schedules, court

involvement, or vacations, and discuss them with participants in the 

introductory meeting or session. Therapists may wish to explore any previous

treatment attempts or failures and should encourage participants to discuss

any present thoughts of leaving treatment. If participants express disillusionment with treatment, therapists can offer reassurance that progress in

treatment is rarely steady and that most participants experience hopelessness,

anger, or frustration at some point in the process.

Collateral Services

Participants receiving concurrent services from other agencies may participate

in CBT7. These additional services should, however, be documented (e.g., in

progress notes).

Relevant Ethical and Legal Issues

Admission to Treatment: Legal Aspects and Policy

Federal statutes regarding underage access to treatment and control of

information give the final authority over these matters to the States.

Practitioners using this manual should consult with representatives of their

local departments of children and families and juvenile court systems to

determine adolescents’ rights regarding accessing treatment and releasing

information with or without the consent of a legal guardian.

Duty To Warn

Many addiction professionals believe they have a professional and ethical

duty to prevent a crime if they learn that an adolescent may pose a serious

risk of violence to someone else. A therapist can be held legally accountable

to warn either the potential victims or the police. The trend is toward 

“taking reasonable steps” to protect a potential victim. Federal and State

laws differ regarding the “duty to warn,” and clinical staff are strongly

encouraged to become familiar with both sets of laws. 

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Reports of Abuse

It is common for clinical staff to learn about physical or sexual abuse, neglect,

or maltreatment of a minor. In all States, therapists are obligated to report

any history, recent event, or imminent danger of physical or sexual abuse,

neglect, or maltreatment of a client under the age of 18. If a therapist

learns of such abuse, the case should immediately be referred to a supervisor.

If a supervisor is not immediately available, the therapist should notify the

person in charge of clinic operations. The consultation will help determine

whether there is justifiable cause for filing a report with the local authorities.

Disclosure of abuse information “increases the likelihood of noncompliance

because disclosure of some facts may result in unwanted social or legal 

consequences (for example, reporting suspected child abuse to protective

services)” (Zweben et al., 1998, page 63). Clients should be told that 

counselors will report certain behaviors (such as plans to hurt themselves

or someone else), and clinical staff should report any problems, complaints,

or concerns that participants voice about this policy. 

Session Documentation 

Appendixes 2 and 3 of this volume include forms (adapted from Steinberg

et al., 1997) to assist therapists in documenting delivery of treatment 

and to assist supervisors in certifying and monitoring therapists in their 

administration of CBT7. The appendixes include the following:

1. A MET/CBT5 + CBT7 Treatment Plan, which is an optional clinical form

kept in the chart

2. A Therapist Self-Rating Form, which is completed by the therapist at the

end of each session, allowing the therapist to document changes in a

participant’s clinical status as well as to rate the adequacy with which

each particular intervention was delivered

3. A Supervisory Rating Form, which is completed by a supervisor after 

his or her review of audiotaped and videotaped sessions as part of the 

certification process for CBT7. (For a complete list of certification 

criteria for CBT7, refer to the Recommended Certification Guidelines 

in appendix 3). The supervisor uses this form to rate the intervention 

components.

27

Part II: The CBT7 Approach to Cannabis Treatment
III. Overview of Treatment Session Components

This section provides a detailed outline of each CBT7 intervention. For each

session, there are a rationale, guidelines for presenting coping skills, and

activities for therapist modeling and client roleplay. The outlines are not

intended as a rigid structure but rather as scaffolding to help shape the

therapy event into a learning opportunity.

The CBT7 interventions follow a basic sequence, as given below.

1. Review of client status

2. Review of real life practice

3. Rationale for coping skill

4. Skill guidelines

5. Group exercise

6. Reminder sheets and real life practice exercises.

Urine testing to ensure clients’ compliance with abstinence is recommended

at sessions 7 and 11. At sessions 6 and 10 clients are told that urine testing

will be conducted at the next sessions. The results can be discussed with

clients at subsequent sessions (i.e., sessions 8 and 12), immediately before

or after the session. Should the therapist feel the need to retest on separate

sessions, urine collection may be done at those times as well.

The session content is presented in a classroom format. The setting and 

session agenda are arranged to remind the six participants that they are

attending a lesson for which their attention is required. The therapy room

should be quiet, free of distractions, and equipped with a blackboard, whiteboard, or large posterboard. At each session, review sheets and homework

assignment handouts are distributed to help reinforce the material.

Each cognitive behavioral group session focuses on a particular coping skill.

A poster of the skill should be hung where all participants can easily read it.

The poster for the current session should be displayed prominently so the

material captures the participants’ attention. Appendix 1 contains miniatures

of the session posters, as well as two general posters: one describing the

mission and assumptions of cognitive behavioral therapy and one listing the

group therapy rules.

The sessions include sample presentations, referred to as “talking points,”

for the therapist. The talking points provide information needed to accomplish

the goals of the session. Group participants may not understand all of the

words and concepts used in the talking points. The therapist is encouraged to

assess the participants’ ability to grasp the terms and concepts introduced

and to paraphrase the talking points as necessary.

Manual Adherence

Therapists should be thoroughly familiar with the contents of a session

before beginning the presentation. While allowing for some degree of individual

29
30

therapeutic style, therapists should cover issues in the manner in which

they are presented.

Review of Client Status

Clients may experience many problems with marijuana and abstinence over

the course of treatment. Although the material in CBT7 is prescribed,

ignoring participants’ real life problems runs the risk that treatment will 

be viewed as peripheral or irrelevant to participants’ real needs. Therefore,

each session should begin with a 10-minute review of the clients’ status.

This component provides a brief period of supportive therapy for participants

to discuss their current problems related to marijuana use or abstinence. It

also provides the therapist with the opportunity to support participants who

are having difficulty and to congratulate those who are achieving success. 

The general rule is that the opening discussions should be structured along

behavioral lines, consistent with a skills-training approach. A problem-solving

format—which involves clearly specifying the problem, brainstorming possible

ways of dealing with it, and selecting possible solutions—is recommended.

Participant Behavior Issues

Disruptive Behaviors. To minimize problems and clarify expectations for

appropriate behavior in the group, therapists are encouraged to (1) define

appropriate norms about language (e.g., profanity, “drugalogs” glorifying

addiction), (2) define appropriate dress standards (prohibition of drug or

gang symbols on clothing), and (3) promote recovery-based language.

Therapists can manage disruptive behavior by (1) restating group rules at

each session, (2) providing constructive criticism, and (3) invoking 

constructive criticism from group peers. Interventions during or immediately

following the group session to modify the disruptive behavior and remotivate

the participant should be attempted before expulsion from the group is 

considered. If a participant repeatedly violates group rules, the therapist

can ask the participant to leave the group for that session. If expulsion from

the group is necessary, the therapist should reevaluate the type and level of

service required by the participant.

Lateness. Therapists should convey the attitude that sessions are too

important to waste by being late and should make reasonable efforts to 

help participants solve whatever problems may be causing them to be late.

Participants should not be allowed to enter group sessions more than 15

minutes past the scheduled start time. If a participant is more than 15 

minutes late, the latecomer will need to make up the session.

Coming to Group Intoxicated. Participants are asked to refrain from smoking

marijuana on the days of the assessment and therapy sessions. This expectation

should not be communicated in a punitive way but from the perspective

that an adolescent has a greater chance of benefiting from the session if he

or she is not under the influence of marijuana or other substances. This 

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
message should be communicated during admission to treatment, during

assessment, and during the first therapy session.

Participants who are under the influence of alcohol, cannabis, or other 

nonprescribed drugs will not be allowed to participate. This situation calls

for (1) a detoxification assessment, (2) notification of a parent or guardian

because of a potential safety or liability issue, and (3) evaluation of the

potential threat to public safety (e.g., a participant driving after the session).

If the therapist reschedules because of a participant’s intoxication, arrangements should be made for safe transportation home (if the participant

drove to the session) with a family member, with a friend, or by arranging

for public transportation (Steinberg et al., 1997, page 22).

If a participant admits to using on the day of a session, the therapist needs

to make a clinical judgment about whether the adolescent should be asked

to leave. For example, if the participant appears to be intoxicated (e.g., is

having difficulty concentrating on the session content, seems to be using

unusually tangential speech patterns, acknowledges not being in a state to

participate, or is openly defiant of abstinence as a treatment goal), the

therapist should escort the participant to a staff member who can make

arrangements for transporting the adolescent home. If the therapist determines

that the participant seems able to participate meaningfully in the session,

then the adolescent may remain. Anyone asked to leave a group is encouraged

to return to the next session sober and continue in treatment (Steinberg et

al., 1997, page 23).

Review of Real Life Practice 

Following review of the clients’ status, therapists spend 10 minutes reviewing

coping skills homework assigned in the previous session. Taking the time to

review assigned exercises helps establish the expectation that homework is

to be completed and that coping skills practiced during sessions are to be

practiced outside treatment. Even in the absence of completed assignments,

review time gives therapists the opportunity to assess clients’ retention of

past material.

Rationale for Coping Skill

When presenting a particular skill, therapists start with the rationale. The

rationale provides an explanation of why a particular coping strategy is 

relevant to maintaining abstinence or managing life problems. The rationale

outlines reasons for learning about the new coping skill and seeks to 

convince the adolescent that the skill is relevant to his or her own life.

Therapists discuss how the skill might be applied directly to deal with 

problems that adolescents have raised in the group.

Skill Guidelines

After presenting the rationale, therapists review skill guidelines. These

guidelines can be used as steps or approaches to implementing a target

coping skill. Participants are encouraged to read the guidelines aloud, as

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Part III: Overview of Treatment Session Components
32

well as question and interpret what they read. Participants who doubt the

usefulness of guidelines are encouraged to be specific about their criticisms

and identify situations in which they may or may not be useful. Therapists

work with participants to identify concrete examples of situations in which

the guidelines can be used. Group exercise and practice are used to reinforce

the new skill.

Group Exercises

Group exercises are prescribed in each treatment session to help participants

internalize and actualize the material being taught. Although not always

stated explicitly in the text, an underlying principle of this component is

that learning can be enhanced if therapists use the techniques of modeling

and roleplaying to engage adolescents in the group exercises. These

techniques provide clients with a more immediate sense of the skill being

applied. Participants then imagine or roleplay scenes based on personal

experience to help ground the skill in real life events. 

Modeling

In addition to teaching clients about coping skills, therapists are encouraged

to model, or act out, effective coping strategies to enhance their verbal

explanations. Clinical trials find that modeling increases teenagers’ 

understanding and appreciation of cognitive behavioral concepts. The key

guidelines of modeling are to (1) stay in full view of participants, (2) think

out loud so that participants can hear you state the logic of a coping strategy,

and (3) avoid conveying the idea that coping leads to immediate results.

The desired message is that coping is not a quick fix or panacea but an

approach that yields benefits when applied persistently and consistently.

Beyond prescribed modeling, serendipitous opportunities to model may

occur. A group disagreement may provide an ideal opportunity to model

effective communication skills. Problems that arise during the session, such

as supply shortages or transportation difficulties, may serve as opportunities

to model problem solving. 

Roleplay

Roleplay is explicitly prescribed in only two of the sessions (i.e., sessions 8

and 9), but therapists are encouraged to use roleplaying whenever there is a

perceived need to facilitate understanding of a coping skill. Roleplay is 

therapeutically significant at two levels. First, it is a learning event. Lowfunctioning or disengaged participants may, at first, exhibit only a superficial

understanding of the coping strategy by parroting what the therapist says.

Roleplaying, however, helps internalize and actualize learning into a practical,

usable skill. Participants who are high functioning or more engaged are

more likely to easily apply coping skills to specific demands of life problems

because of this roleplaying experience. Second, roleplay is therapeutically

significant as a disclosure event. Through roleplaying, teenagers can be

made more aware of life stressors. Therapists are advised not to press for

disclosure but to allow adolescents to disclose stressors at their own pace.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Participants who present as shy or uncomfortable with disclosure at first

may choose to roleplay hypothetical events until they are ready to move to

personal incidents.

Although roleplaying may involve standing in front of a group of people and

acting as if a situation were really occurring, going to such lengths is not

always necessary. Roleplaying, in the present context, can involve as much

as an actual performance of a coping skill or as little as stating out loud

what one might say in a given situation or to a particular person. 

To encourage roleplaying among clients, therapists should start by having

them generate problem situations of moderate difficulty and only later have

them move to more difficult situations. Therapists can use the following

strategies to help participants generate problem situations:

1. Ask participants to recall a recent situation in which use of the new skill

would have been desirable (e.g., a participant wanted to speak up about

something but couldn’t, another screamed at his mother when a simple

request would have worked better).

2. Ask participants to anticipate a difficult situation that may arise in the

near future in which the skill could be used (e.g., a participant’s friend

keeps borrowing clothes without asking and the participant wants to be

able to tell the friend to stop).

3. Suggest an appropriate situation based on knowledge of a participant’s

recent circumstances.

4. Help participants generate details about a given situation by identifying

its location, the key figures involved, and the essential problem being

faced.

In roleplay and group exercises in general, the key to successful teaching is

processing what actually occurs. Participation in an exercise or roleplay

should always be met with the therapist’s praise or recognition for practice

and improvement. Constructive criticism about the less effective elements

of the participants’ behavior is always easier for clients to take once they

have been told that their participation is appreciated.

Reminder Sheets and Real Life Practice Exercises

At the end of each session, participants are given a Reminder Sheet that 

outlines all the elements of the new skills taught that day. They are also

given a Real Life Practice Exercise handout (i.e., homework) and are

encouraged to reward themselves for successfully completing exercises.

Practice in real life situations is the process by which the content of the 

session presented in treatment becomes generalized to the client’s life 

outside of treatment. Reminder Sheet handouts and Real Life Practice

Exercise handouts have been designed for each of the seven sessions in 

this program. Reminder Sheet handouts are single sheets that serve to 

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Part III: Overview of Treatment Session Components
34

summarize and highlight the key points made during each session. Real Life

Practice Exercise handouts require that the participant reflect on or try out

a skill that was discussed or roleplayed during a session. The real life practice

assignment sometimes requires that the participant record facts about a

setting, a chosen behavior, a response to a chosen behavior, or an assessment

of outcome.

Compliance with exercises is often a problem in behavioral therapy. In

CBT7, no contingencies other than social praise or disapproval are used by

the therapists to enhance compliance. Several measures are recommended

to help generate compliance: 

• Refer to the exercises as “real life practice” to avoid negative 

connotations associated with the term “homework.” 

• When giving assignments, provide a careful rationale and description.

• Ask what problems clients can foresee in completing an assignment,

and discuss ways to overcome them. 

• Ask clients to set aside a specific time in the day to work on the

assignment. 

• Review exercises from previous sessions at the beginning of each

session, and praise compliance efforts. 

• For those who did not do an assignment, discuss the benefits of

completing assignments and what could be done to ensure 

compliance the next time. 

Session Management

Session Length and Time Management

Group sessions should be kept to their recommended length of 75 minutes.

Although sessions may run over or under the allotted time, therapists are

responsible for structuring sessions so that deviations are minimal. If time

management is a problem, it may be worthwhile for therapists to present a

timetable at the start of each session so both they and the participants can

monitor the time (Steinberg et al., 1997, page 27).

Preexisting or Concurrent Relationships Between Two Participants

A preexisting relationship between two group members does not automatically

justify exclusion of either party. These relationships are to be judged on a

case-by-case basis. If a preexisting relationship is disrupting treatment, the

therapist should refer the case to a supervisor.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Outside Crises

Because each session has its own agenda, outside crises can be given only

limited time at the beginning of sessions. If acute problems arise during the

week, participants and their parents can contact therapists at their offices.

(In the CYT study, home phone numbers of therapists were not given to

participants or parents. However, for the users of this volume, the policy of

the facility should be followed.) If a participant or parent calls regarding a

serious emergency (i.e., one in which harm is imminent), the therapist

should encourage the family to call 911 or go to the nearest emergency

room. If someone calls with an acute concern (e.g., continued use), the

CBT7 therapist should give the caller an opportunity to air this concern and

recommend that the issue be raised in the next group session.

Request for Individual Attention

Individual consultation after a participant has completed individual treatment

and joined a group is seldom advisable, unless clinical deterioration is 

suspected. If a group member wishes to discuss a problem with a therapist

privately, the need for consultation should be explored. When appropriate,

the therapist should recommend that the participant raise the issue in the

group.

35

Part III: Overview of Treatment Session Components
IV. Sessions

Session 6: Problem Solving 

Overview

Purpose: To help group members develop problem-solving strategies for

handling situations that place them at risk for a “slip” or relapse

Total Time: 75 minutes

Breakdown:

u Review of Client Status (10 minutes)

u Review of Real Life Practice Exercise (10 minutes)

u Rationale for Coping Skill: Problem Solving (15 minutes)

‰ Having problems is normal. Everybody has them.

‰ Solving problems takes time.

‰ The five steps of problem solving are recognizing, identifying,

creating options, making a decision, and evaluating.

u Skill Guidelines (15 minutes)

The Five Steps:

1. Recognize that a problem exists.

2. Identify the problem.

3. Come up with possible solutions.

4. Make a decision and act on it.

5. Evaluate the outcome of your decision.

u Group Exercise (20 minutes)

u Real Life Practice Exercise (5 minutes)

Reminder Sheet for Problem Solving and Real Life Practice Exercise

for Problem Solving

Materials:

u A Reminder Sheet for Problem Solving handout for each group member

u A Real Life Practice Exercise for Problem Solving handout for each

group member

u Writing materials for each group member

u A blackboard, “write and wipe” board, or large posterboard

u A session 6 Problem Solving poster (see appendix 1)

PROCEDURES: PROBLEM SOLVING 

Review of Client Status (10 minutes)

Review with group members their efforts to achieve or maintain abstinence

during the past week and any current problems with marijuana. Reinforce

any coping skills they have successfully used to avoid using marijuana.

37
38

Review of Real Life Practice Exercise (10 minutes)

Review the Personal Emergency Plan handout, which was distributed in the

last MET/CBT5 group session (see Sampl & Kadden, 2001, page 81).

Rationale for Coping Skill: Problem Solving (15 minutes)

Therapist Note: When trying to get teenagers to talk about their problems

with marijuana, use open-ended questions and draw on the personalized

feedback report (Sampl & Kadden, 2001, appendix 4), which was filled

out during the initial assessment, when it may be useful. When

teenagers continue to refuse to acknowledge the existence of marijuana

problems, therapists may try shifting the discussion away from problems

that are a direct result of marijuana use to marijuana’s effect on teens’

problem-solving ability (e.g., “Substance use provides an easy escape

and makes us feel as if we have solved a problem without actually

attempting anything.”). 

Present the following talking points to group participants. Adjust the 

presentation to the participants’ ability to understand the concepts and

terms being introduced.

• All of us have problems. Problems are not for the privileged few;

they are for everyone on the planet. If you are having problems, 

it means you are a human being living with many other human

beings who sometimes see, think, and feel differently than you.

Sometimes it’s going to mean that you and another person will

have a disagreement or that two people, both of whom you like,

will disagree with each other and ask you to agree with both of

them at the same time!

• What makes people different is not whether they have problems

but how they deal with them. Some people accept problems as a

fact of life and try not to be too bothered by them, so they can

start working on solving the problems. Some people accept problems,

but they think they can’t solve their problems. These people have

the ability to problem solve; they just do not realize it. Then there

are some people who think they shouldn’t have problems and that

there’s something weird or abnormal about having them. They

feel weird and abnormal even though they’re just like everyone

else.

• Everyone in this room has a problem with marijuana. You may

have problems that involve or do not involve marijuana directly.

The problem-solving steps can be used with any kind of problem.

But because these steps take time and because you have only so

many hours in a day, you probably don’t need to use these steps

with every problem. Problems such as “What’s 4 x 10?” and “What

am I going to wear on Saturday?” can be answered in seconds.

The problems we will talk about take time and effort to solve and

do not have immediate solutions.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
• The first rule of problem solving: it takes time. The number of

problems a person has in his or her life may have less to do with

how smart that person is than how much time that person spends

thinking problems through. If you don’t stick with problem solving,

then problems will stick to you. But if you do stick with it, you

will have the privilege of watching problems get smaller and

smaller as your confidence grows. If you stick with it long enough,

you might even begin to think of problems as challenges.

Explain to the group that solving problems involves five steps.

• Step #1: The first step is to accept that the problem exists and

not get bent out of shape about it. When you get bent out of

shape, you are likely to do two things you should never do when

making a choice. You either (1) do nothing—which gets you

nowhere—or (2) do the first thing that pops into your head—

which gets you where you did not plan to be. Instead, you want to

go somewhere in particular, and you want to decide carefully

where that somewhere should be. So, the first step is to admit

that the problem exists and get ready to work.

• Step #2: The second step is to identify the problem and flesh it

out. Much of what makes a problem threatening is that it is

unknown. The relief that we experience when we get to know our

problems is the same relief we experience when we get to know

someone who was once a stranger. Don’t let your problem be a

stranger. Notice whether it is similar to problems you’ve had

before. Notice how it is different from other problems, and learn

about the differences. Find out what is critical to you about this

problem. Most important, notice that what you think about the

problem changes the more you learn about it. Soon the problem

isn’t a stranger. It’s familiar and something you can work with.

• Step #3: The third step is to come up with solutions. The key

here is to forget about getting the right answer. Forget about

right answers, and forget about good answers. You’re trying to

solve your problem; this is not about getting a grade. Come up

with a lot of different kinds of solutions. Come up with as many

as you can imagine. Come up with at least four or five (and then

come up with a hundred more)! Pile one on top of another. Make

your solutions simple; make them huge; make them far-fetched!

But just keep coming up with them until you have covered at

least several pages of paper.

• Step #4: The fourth step is decision making. Notice that a lot of

other parts of problem solving had to happen before you could

even get to this point. Most of us think that decision making is 

all there is to problem solving. And that is why many of us have 

problems that keep coming back. But you are not going to make

that mistake. You have fleshed out your problems and have come

up with a lot of solutions, and now you are ready to pick and

39

Part IV: Session 6
40

choose (and even put together) which solutions you want to use.

You want a solution that works and gets you where you want to

go. So now is the time to decide which solutions are really doable

and which of these doable solutions will put you where you want

to be.

• Step #5: The fifth step is called evaluating, or following up. This

is another step, like coming up with solutions, that people tend

to forget about. Following up means testing to see whether your

decision really worked. Remember, problems exist only because

they are problems for you. You are the only one who can decide

whether a solution worked. You need to find out what happened

when you acted on your decision. Did somebody treat you differently? Did you feel stronger, clearer, more comfortable afterward?

Did something happen that you didn’t expect? 

• After you have found what actually happened in the real world,

you can now ask yourself the all-important question: Did your

solution work? If your answer is “Yes,” then it is time to bask in

the glory of your genius. If the answer is “Kind of,” then maybe

your decision needs some tweaking. If your answer is “No,” the

good news is you came up with other solutions in Step 3, so you

have more solutions to try. If you came up with five solutions in

Step 3, you have four more to try. And if you came up with 100,

you have 99 more chances to reach a solution.

Skill Guidelines (15 minutes)

Explain to group members that they will now have an opportunity to apply

the five-step model for solving problems effectively. Use the following 

information in the presentation.

• Step #1: Recognize that a problem exists. First, recognize that a

marijuana problem exists. You have received signs that a problem

exists from several sources.

u Your body (e.g., you have cravings, are restless)

u Your thoughts and feelings (e.g., you feel angry, anxious, 

nervous, depressed, lonely)

u Your behavior (you have not met your standards at school, at

work; you are concerned about your relationship with your 

family, with your friends)

u Your reactions to other people (e.g., you are angry, irritable,

not interested, withdrawn)

u Other people’s reactions to you (e.g., they avoid, criticize

you).

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
• Step #2: Identify the problem. Once you identify the problem,

clarify it. Gather as much information and as many details as you

can. Define the problem in terms of behavior whenever possible.

Break it down into parts—you may find it easier to manage parts

individually than to confront the whole problem at once.

u An example of a problem: Every time you stay out late on

school nights without calling home, your parents get worried

and angry and accuse you of smoking pot with friends, even

when you haven’t.

u Examples of some clarifying questions: Who is affected? How

does each one see the situation? What is the outcome that you

want to change (e.g., arguing reduced)? What do other people

want to see changed? What things have led up to the problem

(e.g., your history of pot smoking, past dishonesty about drug

use, parents not knowing your whereabouts, parents not 

trusting you)? 

• Step #3: Come up with solutions. Brainstorm to generate possible

ways to solve a problem. Key guidelines for generating possible

solutions are the following:

u Remember, more is better. Do not judge solutions! (Judging is

for later.)

u Come up with solutions that include both actions and

thoughts.

• Step #4: Make a decision and act on it. Go through each solution

you have come up with, and ask yourself the following questions:

u What is most likely to happen if I choose this solution?

u What are the good or bad things that might happen?

u How likely is it that the good or bad things are going to happen?

u What will happen immediately after I choose this one?

u What will happen a long time after I choose this one?

u How difficult will this option be to carry out? 

Pick one or more possible options. Also, pick options that are

most likely to have good outcomes in the short and long term

and least likely to have bad outcomes in the short and long term.

41

Part IV: Session 6
42

• Step #5: Evaluate the outcome of your decision. Try out the 

solution you decided on. The solution may not be immediate, and

you may have to wait or keep working at it. As you begin to see

the effects of your decision, evaluate strengths and weaknesses by

asking yourself the following questions:

u What problems am I experiencing?

u Are these the results I expected?

u Can I do something to make this solution work better?

u Do I need to consider a different solution?

Group Exercise (20 minutes)

Tell group members it is time to practice the problem-solving model and

have them volunteer practice problems using the following guidelines:

• Remind group members to work on the problem recognition and

identification stages, with particular emphasis on describing the

problem in as much detail as possible.

• Have the group brainstorm solutions, or choices, and write them

on the blackboard or posterboard.

• Encourage group members to consider both positive and negative

effects and both short- and long-term consequences when weighing

alternatives.

• Ask the group to prioritize alternatives and select the most 

promising one. 

Real Life Practice Exercise (5 minutes)

Give group members the Reminder Sheet for Problem Solving handout 

outlining the model and the Real Life Practice Exercise for Problem Solving

handout to be completed by the next session. Encourage participants to

focus on current or recent problems involving marijuana or problems that

may have been caused by marijuana use. 

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Session 6

Reminder Sheet for Problem Solving

These, in brief, are the steps of the problem-solving model.

X Recognize that a problem exists. “Is there a problem?” We

get information from our bodies, our thoughts and feelings, our

behavior, our reactions to other people, and other people’s 

reactions to us.

X Identify the problem. “What is the problem?” Describe the

problem the best way you can. Break it down into smaller parts if

this is more helpful.

X Come up with possible solutions. “What can I do?” Brainstorm

to think of as many solutions as you can. Think of solutions that

involve your thoughts and your behavior. 

X Make a decision and act on it. “What will happen if . . . ?”

Consider all the positive and negative short- and long-term consequences of each alternative. Choose one option that is likely to

solve the problem with the least amount of hassle to you and others.

X Evaluate the outcome of your decision. “How did it work?”

After you have tried the solution, does it seem to be working? If

not, consider what you can do to make the plan work, or give it up

and try the next best solution.

?
Session 6

Real Life Practice Exercise for Problem Solving

Select a problem that you have now (that was not discussed in group) or one that you may have

a hard time coping with in the future. Follow the steps of the model. Remember to describe the

problem well and brainstorm a list of possible solutions. Think about your choices, then rank them

in the order of which solution you think will work best. When you have decided which solution

you believe is the best one, try it out; then evaluate how well it worked.

AN EXAMPLE

You are going to a keg party where you know people will be drinking and getting high.

YOUR PROBLEM

1. Recognize that a problem exists.

_______________________________________

2. Identify the problem. (Describe what the problem is.)

_______________________________________

_______________________________________

_______________________________________

3. Come up with possible solutions. (Make a list [brainstorm].)

_______________________________________

_______________________________________

_______________________________________

4. Make a decision. (Rank the solutions, and think about the consequences of each.)

_______________________________________

_______________________________________

_______________________________________

5. Evaluate the outcome of your decision. (Consider positive and negative results.)

_______________________________________

_______________________________________

_______________________________________
Session 7: Anger Awareness

Overview

Purpose: 

1. To reinforce group members’ recognition of external situations that

trigger anger and internal reactions that signal anger 

2. To introduce group members to relaxation as a technique for coping

with anger

Total Time: 75 minutes

Breakdown:

u Collection of Urinalysis Specimens (prior to or after session)

u Review of Client Status (10 minutes)

u Review of Real Life Practice Exercise (10 minutes)

u Rationale for Coping Skill: Anger Awareness (5 minutes)

‰ Anger is a normal feeling we all have at times. 

‰ Anger has constructive and destructive effects.

‰ There is a relationship between anger and marijuana or alcohol

use.

u Skill Guidelines (5 minutes)

‰ External situations that trigger anger: direct and indirect

‰ Internal reactions that signal anger: feelings, physical reactions,

sleep problems, helplessness, or sadness

u Group Exercise (10 minutes)

u Activity Sheets (10 minutes)

‰ Activity Sheet 1: Anger Triggers 

‰ Activity Sheet 2: Conducting a Self-Interview

u Real Life Practice Exercise (5 minutes)

‰ Anger Awareness Reminder Sheet and Real Life Practice Exercise

u Rationale for Coping Skill: Relaxation Technique (10 minutes)

u Modeling and Group Exercise (10 minutes)

Materials:

u A drug-test kit for each group member 

u Activity Sheet 1: Anger Triggers handout for each group member

u Activity Sheet 2: Conducting a Self-Interview handout for each group

member

u An Anger Awareness Reminder Sheet and Real Life Practice Exercise

handout for each group member

u A Real Life Practice Exercise: Relaxation Technique handout for each

group member

u Writing materials for each group member

u A blackboard, “write and wipe” board, or large posterboard

u A session 7 Anger Awareness poster (see appendix 1)

45

Part IV: Session 7
46

PROCEDURES: ANGER AWARENESS

Collection of Urinalysis Specimens

Therapist Note: Collect urinalysis specimens at either the beginning or

the end of this session depending on the therapist’s discretion and

group logistics. If a participant is absent, collect a urine specimen at

the next session the participant attends. A discussion of urine specimen

collection procedures can be found on page 24.

Review of Client Status (10 minutes)

Review with group members their efforts to achieve or maintain abstinence

during the past week. Discuss the participants’ attempts to deal with current

problems related to marijuana use. Reinforce any coping skills they have

used successfully to avoid using.

Review of Real Life Practice Exercise (10 minutes)

Review with participants the Real Life Practice Exercise for Problem Solving

handout from session 6.

Rationale for Coping Skill: Anger Awareness (5 minutes)

Therapist Note: The message to convey in this session is that anger is

both a useful and a potentially destructive emotion. Anger can signal

problematic situations and provide energy to solve them. However,

group members may be more familiar with destructive responses to

anger that include impulsive behavior, communication avoidance,

aggressive and violent behavior, and substance use.

Present the following talking points to group participants. Adjust the 

presentation to the participants’ ability to understand the new concepts

and terms being introduced.

• Anger is a normal human emotion. There is a distinction between

anger as a feeling and the actions we take because of anger. We

all experience anger now and then. What makes us different is

how we choose to handle our anger.

• Anger can have different effects depending on what we do with it.

Sometimes we can use it to assert ourselves or get through an

unpleasant task. At other times, we may take it out on something

or someone.

Question: When can anger be used constructively? 

Answer: Anger can energize us to solve problems. For example,

if you hear a classmate criticizing a friend, you may 

be energized to support that friend and to remind 

classmates of that person’s good points. Anger is also

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
like the yellow light on a traffic signal that tells you to

slow down and think about what’s important to you.

Hearing that friend being criticized may make you

think about how much you care about that friend.

Question: When might we use anger destructively?

Answer: Anger is destructive when it prevents you from thinking

clearly. Anger can be expressed in ways that may be

harmful to you or others, such as an aggressive

response. Or it may lead you to stuff your feelings

deep inside. This is a passive response. Aggressive

responses block communication and create distance

between you and others. Passive responses leave you

feeling helpless or depressed, make you appear indifferent

to other people, and may result in an angry explosion

about something unrelated.

• It is important to have a strategy to deal with anger to prevent

acting out behaviors that hurt yourself or others. You have a right

to feel angry, but you have the responsibility to express anger in

ways that are not hurtful to yourself or other people.

• Anger and marijuana or alcohol use are related. Many people

report that they get stoned or drunk when they feel angry or

upset at another person. And people who are angry and drink or

use drugs often get angrier, and sometimes they do things that

they wouldn’t normally do when sober. Because anger makes it

difficult to think straight, sometimes people put themselves in

high-risk situations without realizing it.

Skill Guidelines (5 minutes)

Explain that the first step in dealing with anger is to become aware of the

feeling. Tell group members that increased awareness can help them identify

angry feelings early, before they grow and get out of control.

Remind participants that they have talked several times in the group (during

MET/CBT5) about the concept of a trigger. To learn constructive ways to

deal with anger, it is helpful to understand what kinds of things trigger

anger. Ask members to identify some situations, thoughts, or feelings that

make them angry.

Present the following guidelines about increasing awareness of triggers and

signals for anger:

1. Become more aware of situations that trigger anger.

• Direct triggers: A direct attack on you, whether verbal or nonverbal

(e.g., a power play order, a physical attack, an obscene gesture, unfair 

47

Part IV: Session 7
48

treatment), or a circumstance in which you are unable to get 

something you want

• Indirect triggers: Seeing an attack on someone else or being aware

of your thoughts and feelings about a situation (e.g., feeling that you

are being blamed, thinking that someone is disappointed in you, or

feeling that people are expecting too much of you).

2. Become more aware of internal reactions that signal anger. What are

some of the signs that you are getting angry?

• Feelings: Do you feel frustrated, irritated, annoyed, insulted, or

wired? These less intense feelings often happen before you get angry,

and you should try to deal with them before they build up and

become harder to control.

• Sleeplessness: This may be due to angry thoughts and feelings

stuffed down during the day or continuing anger about something

that happened earlier.

• Feeling tired, helpless, or depressed: It may be that your attempts to

express anger have not worked in the past, and you may feel 

frustrated and helpless to change the situation. You may then have

given up trying and become depressed.

• Physical reactions: Do you experience muscle tension in the jaw,

neck, arms, hands; headaches; pounding heart; sweating; rapid

breathing; or clenched fists?

Write the following table of the emotional and physical signs of anger on

the board for all to see. 

EMOTIONAL PHYSICAL

Frustration Muscle tension in your jaw, neck, arms

Irritation Headache

Indifference (to others) Pounding heart

Agitation (feeling wired) Rapid breathing

Helplessness Sweating

Depression Sleeplessness

Feeling insulted Impulsive behavior (acting without 

thinking)

Explain that many of the physical and emotional signs of anger are the

same symptoms people experience when they are withdrawing from marijuana.

Tell participants that if they have recently stopped smoking marijuana after

smoking it for a long time, they may notice that they are experiencing some

of these signs and symptoms more often than usual. These are temporary

symptoms that usually disappear in a few weeks. Some people are tempted

to get high when they experience these problems. However, getting high

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Part IV: Session 7

again only makes these physical and emotional problems last longer. If 

participants stay abstinent, most of these symptoms will go away or occur

less often. People who have a hard time handling frustration may find these

symptoms harder to handle. Because problems with anger can often set off

a relapse, it is important to practice coping skills between sessions. 

Group Exercise (10 minutes)

Have group members list personal anger triggers and the internal reactions

they invoke. Strive for a variety of situations (e.g., at home, at school, at a

party) with a variety of people (e.g., family, friends, teachers, strangers). In

addition, try to elicit responses on a variety of internal reactions that signal

anger (e.g., feeling insulted or helpless, muscle tension, difficulty sleeping).

Activity Sheets (10 minutes)

Have group members complete the activity sheets for Anger Triggers and

Conducting a Self-Interview. Also notify participants that the activity sheet

for Conducting a Self-Interview will be used again in session 8, so they

should bring it to the next session.

Real Life Practice Exercise (5 minutes)

Give the group members the Anger Awareness Reminder Sheet and Real Life

Practice Exercise, and tell them to complete it before the next group session.

Instruct them to pay attention to situations that make them angry, as well

as to internal reactions such as the thoughts, feelings, behaviors, and physical

signs that signal anger. Again, notify participants that this reminder

sheet/real life practice exercise will be used in session 8, so they should 

be sure to bring it to the next session.

Rationale for Coping Skill: Relaxation Technique (10 minutes)

Therapist Note: Conduct two tension-relaxation cycles for each muscle

group. Start with the face and move to the neck, then to the shoulders,

arms, stomach, back, and finally the legs. Allow 5 seconds of tension

and 15 to 20 seconds of relaxation for each cycle.

In relaxation training, how you say things is as important as what you

say. It is not necessary to talk continuously during the tension or 

relaxation phase. The therapist should begin the session in a 

conversational tone and become a bit louder and more intense during

the 5-second tension instructions. Over the course of the rest of the 

session, the therapist’s voice should show a progressive reduction in 

volume and speed, becoming calm, soft, and rhythmic. The therapist

should model the technique for group members. 

Some adolescents may be apprehensive about the eye-closing aspect of

the activity because of anxiety that can be due to past abuse or they

may feel silly or unsafe about closing their eyes for an extended period.

For these adolescents, the therapist should make this part of the activity

49
The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions

50

optional and instruct them to select a particular point in the room and

focus on it during this period. The therapist should explain that the

objective of the activity is to help adolescents concentrate on relaxing

the muscles in their bodies, not to make them feel anxious or silly.

Each tension-relaxation cycle consists of the following instructions:

• Tense up, hold the tension, and become aware of it (5 seconds).

• Relax and feel the tension flowing out of your body (5 seconds).

• Tune in to the feelings of relaxation, notice the difference

between the tension and relaxation, and enjoy the contrast 

(15 to 20 seconds).

Present the following talking points to the group.

• This part of today’s session focuses on the use of relaxation 

techniques in coping with anger, stress, tension, and anxiety.

Being angry and stressed can lead to difficulty concentrating, bad

decision making, and a lot of unnecessary arguing. Now that we

have discussed how to be aware of anger, we can discuss a way of

dealing with it. One way is to relax. At first, you might think it

odd that relaxing is something that you do. Most of the time, we

think of relaxing as just not doing anything. But just as we 

sometimes have to be aware of our anger, there are times when

we have to actively relax. 

• Relaxation is a useful skill. When? Almost anytime. Uses for 

relaxation include the following: to deal with stressful situations,

to deal with everyday stress, to get ready for sleep, to cope with

urges to smoke pot, or to think more clearly about a situation or

problem.

Modeling and Group Exercise (10 minutes)

Use the following text during the relaxation exercise.

Preparations for Relaxation

• I will guide you through a tension-relaxation exercise, so you can

get a good idea of what it involves and can begin to practice it on

your own. This exercise is often called progressive relaxation or

deep muscle relaxation.

• Progressive relaxation involves taking turns tensing and relaxing

different muscle groups to identify feelings of tension and to

replace them with feelings of relaxation. We will begin with the

face and move to the neck, shoulders, arms, stomach, back, and

finally the legs.
• Relaxing is a skill that usually takes practice to master. You will

be in control and learn how to relax yourself. It is important that

you do not expect too much too soon. You may feel little effect

the first few times, although some people feel deeply relaxed the

first time. 

• I will demonstrate how to tense each muscle group, with you 

imitating my behavior. I will tense different groups of muscles,

for 5 seconds each and then relax each for 15 to 20 seconds.

• Remember:

u During the tensing phase, don’t strain the muscles by tensing

them as hard as possible. It is important only that you feel the

muscle tensing.

u After tensing each muscle group, relax those muscles when I

say the words, “Relax now.”

Relaxation Pretest

• Before we begin, think of a scale from 1 to 10, in which 1 is total

relaxation and 10 is maximum tension. Consider where you would

place yourself on that scale, and remember it. Write it down on a

piece of paper if you need to.

Relaxation Rehearsal

• Now sit back in your chairs. Take a moment to feel the chair

against your back, to feel it holding you up. Notice how your

back, arms, and legs feel in that chair.

• Now I’m going to count backward from five to one. Close your

eyes and gradually let yourself sink into the chair. When I say one,

your eyes will be closed: Five. . . four. . . three. . . two. . . one; eyes

closed.

• Tension: 5 seconds. Remaining in your seats, tense up all the

muscles in your face (and subsequent muscle groups: neck, 

shoulders, arms, stomach, back, and legs). Now hold it. Notice

the tension. Hold it, study it, tight, hard, feel the tension in your

face (and subsequent muscle groups). Concentrate on how it feels

and where it is located.

• Relaxation: 15 to 20 seconds. Now relax. Just let go, further 

and further. Get rid of all the tension. Tune into the feelings of 

relaxation, deeper and deeper. Just enjoy the feelings in the muscles

as they loosen up, smooth out, unwind, and relax, thinking about

nothing but the pleasant feelings of relaxation flowing into your

face (and subsequent muscle groups). See if you can let it go a

little bit more. Even though it seems as if you’ve let go as much

51

Part IV: Session 7
52

as you possibly can, there always seems to be that extra bit of

relaxation to let all the tension go. Notice what it’s like as the

muscles become more and more deeply relaxed, calm, and peaceful.

There’s nothing to do but focus your attention on the pleasant

feelings of relaxation flowing into your face (and subsequent 

muscle groups). Notice the difference between the feelings of 

tension and relaxation. 

Relaxation Posttest

• Think of a scale from 1 to 10, in which 1 is total relaxation and

10 is maximum tension. Consider where you would place yourself

on that scale, and remember it so you can jot it down after you’ve

opened your eyes.

• Now I’m going to count backward from five to one. With each

number you are to become more and more fully awake. When I

say one, you’ll be wide awake, still feeling very comfortable and

relaxed, but fully awake and alert: five. . . four. . . three. . . two. . .

one; eyes open wide and awake. 

Therapist Note:

• Have group members discuss any changes in the level of stress they

are experiencing after the exercise compared with their previous tension

rating.

• Provide the group with positive feedback for doing well on the exercise

(regardless of whether subjective ratings of tension decreased from

before or after the exercise). 

• Respond to any questions or comments by group members about the

relaxation exercise. 

• Give group members the Real Life Practice Exercise: Relaxation

Technique.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Session 7

Activity Sheet 1: Anger Triggers

(Adapted from Auerbach, 1997, page 121)

WHICH OF THE FOLLOWING EVENTS, FEELINGS, AND

THOUGHTS ARE ANGER TRIGGERS FOR YOU?

Place one checkmark next to items that sometimes trigger your anger.

Place two checkmarks next to items that make you angry most of the time.

______Being told what to do

______Being treated in a way you think is unfair

______Being blamed for something you did wrong

______Being blamed for something you didn’t do

______Having someone criticize you

______Finding out that someone said something mean about you

when you weren’t there

______Being asked to do more things than you can handle

______Seeing someone have something that you don’t have and

that you want

______Thinking that someone you care about is angry or upset

with you

______Having to stop doing something that you enjoy

______Not having things happen the way you wanted them to happen
Session 7

Activity Sheet 2: Conducting a Self-Interview

(Adapted from Auerbach, 1997, page 123)

Once you’ve calmed yourself down after being angry, it is time to take a close

look at the situation you are in. Some helpful images to keep in mind are a 

camcorder and a VCR. 

First, imagine that a camcorder recorded the whole situation from start to finish.

You are one of the actors in the video. Second, take the tape out of the camcorder

and put it in the VCR. Now press rewind, or run an instant replay, and watch

what happened again. This will give you a chance to review what happened as

many times as you want, to get a better understanding of what occurred. Your

goal is to see clearly what has happened, now that you are cooled down and are

in control.

Conduct a self-interview. You need to try to be openminded to do this exercise

well. Imagine you are a reporter on the scene. Try interviewing yourself (the

actor in the video) to get a better idea of what happened, how you reacted, and

what you should do next. Try to get just the facts. Ask yourself the following

questions: 

1. What’s getting me angry? What was the TRIGGER?

2. What is my anger rating?

Not Angry Rage

3. What exactly did the people involved say or do?

4. What kinds of different things could they have meant?

5. Is this a personal attack or insult?

6. Are my assumptions about this situation correct? 

7. Am I angry because I’m expecting too much of myself or of someone

else?

8. Is someone trying to get me angry?

9. What are the positives in this situation?

1 2 3 4 5
Session 7

Anger Awareness Reminder Sheet and 

Real Life Practice Exercise

Anger is a normal human emotion. Being aware of anger can help you use it in a

constructive way. Until the next session, pay attention to external situations that

make you angry, and identify the anger triggers. Also, try to recognize internal

reactions that signal anger, and identify what these are. Then pick one instance of

anger before the next session, and put checkmarks by the external events and by

the internal reactions that led to your anger.

Direct Triggers

External Events That Trigger Anger (4 Check)

Direct attack on you (verbal or nonverbal):

Physical attack ______

Unfair treatment ______

Bossy treatment (being told what to do) ______

Blame ______

Criticism ______

Mean statements behind your back ______

Circumstance in which:

You are unable to get something you want ______

Someone else has something that you don’t have,

but that you want ______

You have to stop doing something you enjoy ______

Things don’t happen the way you wanted them 

to happen ______ 

You are unable to reach a goal ______

(continued on next page)
Indirect Triggers

Seeing someone else attacked in some way ______

Being aware of your thoughts and feelings about 

a situation ______

Feeling that too much is being expected of you ______

Feeling that you are being blamed ______

Feeling that you are being criticized ______

Thinking that someone is disappointed, angry, or

upset with you (especially someone you care about) ______

Internal Reactions That Signal Anger (4 Check)

Emotions

Feeling frustrated, annoyed, irritated, agitated 

(feeling wired), insulted ______

Feeling tired, helpless, depressed, indifferent 

(to other people) ______

Physical Reactions

Muscle tension in different parts of the body (jaw, neck, 

shoulders, arms, hands, stomach, back, legs) ______

Headache, pounding heart, sweating, rapid breathing, 

clenched fist ______

Difficulty falling asleep ______

Impulsive behavior (acting without thinking) ______
Session 7

Real Life Practice Exercise: 

Relaxation Technique 

Deep Muscle and Progressive Relaxation Techniques

1. Select a quiet time when you will not be interrupted. Practice at least three times during

the next week.

2. Sit in a chair and settle back as comfortably as you can. Take a deep breath and exhale

slowly. You may feel most comfortable if you close your eyes. Notice the feelings in your

body; you will soon be able to control these feelings.

3. Go through the seven groups of muscles in the directions below, first tensing each muscle

group for 5 seconds and then relaxing each for 15 to 20 seconds.

• Wrinkle up your forehead. Then relax your muscles.

• Close your eyes tightly. Then relax your eyes.

• Clench your jaw, gritting your teeth together. Then relax.

• Shrug your shoulders toward your head. Tilt your chin toward your chest. Then

relax.

• Flex both arms at the elbows. Then relax your arms.

• Squeeze both hands into fists, with your arms straight. Then relax your hands.

• Stretch out both legs, point your toes toward your head, and press your legs

together. Then relax your legs.

4. Before each practice exercise, rate your level of relaxation and tension. Using a scale of 1

to 10, with 1 being very relaxed and 10 being very tense, rate how your body feels after

completing each practice exercise.

Rating (1–10) before Rating (1–10) after

practice exercise practice exercise

________________ ________________

________________ ________________

________________ ________________
58

Session 8: Anger Management

Overview

Purpose: To teach healthy coping skills for dealing with anger

Total Time: 75 minutes

Breakdown: 

u Discussion of Urinalysis Results With Individual Group Members

(prior to group)

u Review of Client Status (10 minutes)

u Review of Real Life Practice Exercise (10 minutes)

u Rationale for Coping Skill: Anger Management (15 minutes)

‰ Review triggers from session 7

‰ Present Model of Anger: Events Ÿ Thoughts Ÿ Feelings

u Skill Guidelines (15 minutes)

The Four Steps:

1. Chill Out: Successful past strategies and self-statements

2. Collect Your Thoughts: Self-interview, anger triggers, options, and 

problem solving

3. Choose the Best Action: Decide and evaluate outcome

4. Change the Way You Think About Anger

u Group Exercise (15 minutes)

u Real Life Practice Exercise (10 minutes)

Reminder Sheet for Anger Management and Real Life Practice Exercise

for Anger Management

Materials:

u A Reminder Sheet for Anger Management handout for each group

member

u A Real Life Practice Exercise for Anger Management handout for each

group member

u Session 7 handouts for each group member: Activity Sheet 2:

Conducting a Self-Interview and Anger Awareness Reminder Sheet and

Real Life Practice Exercise

u Writing materials for each group member

u A blackboard, “write and wipe” board, or large posterboard

u A session 8 Anger Management poster (see appendix 1) 

PROCEDURES: ANGER MANAGEMENT

Discussion of Urinalysis Results

Therapist Note: The results of the urinalysis specimens obtained in the

previous session should be discussed with participants before the group

session. If a participant failed to attend the previous group, obtain a

urine specimen during this group session and review the results before

the next session. Guidelines for the presentation of urinalysis results

can be found on page 24.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Review of Client Status (10 minutes)

Review with group members their efforts to achieve or maintain abstinence

during the past week. Discuss the participants’ attempts to deal with current

problems related to marijuana use. Reinforce any coping skills they have

used successfully to avoid using marijuana.

Review of Real Life Practice Exercise (10 minutes)

Review the Anger Awareness Sheet and Real Life Practice Exercise assigned

in session 7, Anger Awareness.

Rationale for Coping Skills: Anger Management (15 minutes)

Present the following talking points to participants. Adjust the presentation

to the participants’ ability to understand the concepts and terms being 

introduced.

• The last session was devoted to anger awareness and to recognizing

events that trigger anger. (See Anger Awareness Reminder Sheet

and Real Life Practice Exercise handout from session 7.) This session

focuses on techniques for managing anger. Anger is not automatically

triggered by events. Our thoughts and beliefs about events play an

important part in how we react to a situation. Consider this

example. (Write the example below on the blackboard).

Event Ÿ Thoughts Ÿ Feelings

Your mother “I must have done something Apprehension, anxiety,

is quiet when wrong. She’s mad at me fear, dread

you get home. again, and we’re in for a

fight.”

• What other ways might you have thought about this event? How

might these different thoughts have led to different feelings?

Skill Guidelines (15 minutes)

Explain that there are four important steps to help deal with situations that

make you angry. Write the steps on the board or ask a participant to do so.

Step #1 Chill out.

Step #2 Collect your thoughts.

Step #3 Choose the best action.

Step #4 Change the way you think.

Use the following presentation to explain each step.

59

Part IV: Session 8
60

Step #1: Chill out. The first thing to do when you realize you’re angry is to

try to calm down. How you think changes how you feel about events. But

you can’t make good decisions if you don’t stop and think. Here are some

ways to calm down: count to 20, leave the room, close your eyes, or go for a

walk. (Encourage participants to share their ideas.) Another way to chill

out is to think cool thoughts. (Ask participants to compare cool and hot

thoughts. See examples below.)

COOL THOUGHTS HOT THOUGHTS

Slow down. It’s not fair!

Take it easy. I hate when this happens!

Take a deep breath. Why me?!

Cool it. What a jerk!

Chill out. No one cares about me!

Relax. I give up!

Ignore it. This is stupid!

Count backward from 20. It’s all my fault!

Step #2: Collect your thoughts. Once you’ve cooled down, take a closer

look at the situation. (Review Activity Sheet 2: Conducting a Self-Interview

from session 7.) 

Step #3: Choose the best action. Once you have a better understanding of

what’s making you angry, look at your choices. What are some skills you

have learned in our sessions that can help you make better decisions when

you are angry? (Invite discussion about problem-solving techniques from

session 6, such as brainstorming solutions, choosing an option, and evaluating

the outcome of one’s decision.)

Step #4: Change the way you think about your anger. Think thoughts such as:

• “I am still angry, but anger isn’t so awful! After all, I will feel 

better soon.”

• “I can’t waste my time being angry about things I can’t control

right now. It’s better to spend time on things I can change. I’m

going to get my mind off this.”

Group Exercise (15 minutes)

Present the following scenario: A friend of yours took one of your CDs 

without permission. When you asked him or her to give it back, he or she

denied having taken it. You decide to confront your friend.

Appropriately respond to this situation using the four-step model of chill

out, collect your thoughts, choose the best action, and change the way you

think. Guide the group to generate positive thoughts about situations they

wrote about in session 7 for the Anger Awareness Reminder Sheet and Real

Life Practice Exercise. When appropriate, have participants roleplay the 

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
situations and think aloud. Ask volunteers to roleplay different situations

that require the use of anger management techniques.

Real Life Practice Exercise (10 minutes)

Give the group members the Reminder Sheet for Anger Management and

Real Life Practice Exercise for Anger Management to be completed before

the next session. This exercise involves identifying a situation and the

thoughts that provoked anger and then trying to change the reaction.

61

Part IV: Session 8
Session 8 

Reminder Sheet for Anger Management

Anger can result from the way we think about things: 

Events Ÿ Thoughts Ÿ Feelings

There are four important steps to help deal with situations that make you

angry.

Step #1: Chill Out

Use phrases like these to help you calm down:

Slow down. Chill out.

Take it easy. Easy does it.

Take a deep breath. Relax.

Cool it. Count backward from 20.

Step #2: Collect Your Thoughts

Next, think about what’s getting you so angry. Review the situation

point by point.

What’s getting me angry? 

Is this a personal attack or insult? 

Am I expecting too much of myself or of someone else? 

Step #3: Choose the Best Action

Then think about your options.

Anger should be a signal to start problem solving.

What can I do? 

What is in my best interests here? 

What other coping skills may be helpful here?

Step #4: Change the Way You Think About Anger

If the problem won’t go away,

Remember that you can’t fix everything. 

Try to shake it off. 

Don’t let it interfere with your life.

If you solve the problem, congratulate yourself!
Session 8

Real Life Practice Exercise 

for Anger Management

Until the next session, pay attention to your reactions to situations that

make you angry. Try to identify the thoughts that are making you angry

and try to change them. Before the next session, pick one occasion

involving angry feelings (or feelings of annoyance, frustration, or 

irritation) and write down the following:

Trigger situation:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Calm-down phrases used:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Anger-increasing thoughts:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Anger-reducing thoughts:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

What other thoughts might have helped you cope with this situation?

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________
64

Session 9: Effective Communication

Overview

Purpose: To teach effective communication through active listening,

assertiveness, and strategies for responding to criticism

Total Time: 75 minutes

Breakdown: 

u Review of Client Status (10 minutes)

u Review of Real Life Practice Exercise (10 minutes)

u Rationale for Coping Skill 1: Active Listening (5 minutes) 

The Four Steps:

1. Listen 

2. Rephrase 

3. Ask questions 

4. Show you understand 

u Rationale for Coping Skill 2: Assertiveness (10 minutes)

The Four Types of People:

1. Passive

2. Aggressive

3. Passive-aggressive

4. Assertive

u Skill Guidelines (5 minutes) 

u Group Exercise #1 (5 minutes)

u Rationale for Coping Skill 3: Receiving Criticism (10 minutes)

‰ The Two Types of Criticism

1. Constructive

2. Destructive

‰ Relationship between receiving criticism and marijuana use

u Skill Guidelines (5 minutes)

1. Don’t get defensive, don’t argue, and don’t counterattack

2. Ask for clarification

3. Find something in the criticism with which you agree

4. Propose a compromise

5. Reject unfair criticism

u Group Exercise #2 (10 minutes)

u Real Life Practice Exercises (5 minutes)

Materials:

u A Reminder Sheet for Receiving Criticism handout for each group

member

u A Real Life Practice Exercises for Receiving Criticism—Exercises 1

and 2 handout for each group member

u Writing materials for each group member

u A blackboard, “write and wipe” board, or large posterboard

u A session 9 Effective Communication and Receiving Criticism poster

(see appendix 1)

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
PROCEDURES: EFFECTIVE COMMUNICATION

Review of Client Status (10 minutes) 

Review with group members their efforts to achieve or maintain abstinence

during the past week. Discuss the participants’ attempts to deal with 

current problems related to marijuana use. Reinforce any coping skills 

they have used successfully to avoid using marijuana.

Review of Real Life Practice Exercise (10 minutes)

Review the Real Life Practice Exercise for Anger Management handout

assigned in session 8.

Rationale for Coping Skill 1: Active Listening (5 minutes)

Present the following talking points to the participants. Adjust the 

presentation to the participants’ ability to understand the concepts 

and terms being introduced.

• The first thought that comes to mind when we think of 

communication is of someone talking. However, talking is only

half of communicating; the other half is listening. We sometimes

forget about listening, the silent partner of talking. But we do

know when listening is not occurring. Without listening, people

do not communicate.

• Even though we pay less attention to listening, we are attracted

to people who listen. The active listener tells us that we are being

paid attention to and that what we are saying is being heard. Here

are four steps for active listening. (Write the four steps on the

board.)

Active Listening

1. Listen.

2. Rephrase.

3. Ask questions.

4. Show that you understand.

• Step #1: Listen. Pay attention to people when they talk to you.

Repeat their words to yourself. If, after repeating their words in

your head, you find something that you don’t understand, remind

yourself to ask a question later.

• Step #2: Rephrase. To rephrase is to restate out loud what people

are saying to you. This might sound weird, but you will be surprised

how many people appreciate it. Rephrasing is the most direct way

of showing someone that you are paying attention. (The therapist

may wish to demonstrate this skill to the group.)

65

Part IV: Session 9
66

Rephrasing

1. It seems as if you feel. . . .

2. It sounds as if you are. . . .

3. If I am hearing you right, you’re feeling. . . .

4. So you’re feeling like. . . .

5. So you’re saying that. . . .

• Step #3: Ask questions. Asking questions shows other people

that you are paying attention to what they are saying and that 

you want to hear more. 

• Step #4: Show that you understand. There are many different

ways to show that you understand what someone is trying 

communicate to you: rephrasing, summarizing, or even admitting

that you don’t understand everything he or she is saying. Saying

you don’t understand everything shows that you do understand

some of it. Showing someone you understand is not the same

thing as saying that you agree with him or her. You can have a 

different point of view from someone else but still understand his

or her point of view.

Rationale for Coping Skill 2: Assertiveness (10 minutes)

Discuss the following talking points with group members:

• Assertiveness means expressing your opinion without hurting

other people, asking other people to change their behavior, or

rejecting what other people say. The trick is to say what you

mean, while letting others know that you respect what they have

to say. By asserting yourself, you can get your needs expressed

without being passive, aggressive, or passive-aggressive. 

• There are four ways of getting along with others: passive, aggressive,

passive-aggressive, and assertive. (See session 5 of the MET/CBT5

manual [Sampl & Kadden, 2001].)

u Passive people tend to give up their rights as soon as they get

into a conflict with someone else. They don’t stand up for

themselves, and they let other people walk all over them. They

don’t let others know what they are thinking or feeling. They

bottle up their feelings, even when they don’t have to, and feel

anxious or angry inside a lot of the time.

u Aggressive people protect their own rights but run over other

people’s rights. They may actually satisfy their own short-term

needs, but their behavior harms their relationships with other

people who, in the long run, may resent the way they have been

treated.

u Passive-aggressive people are indirect. They hint at what they

want, make sarcastic comments, or mumble something, 

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
without saying what is really on their minds. They won’t say

how they feel, but they will “act it out.” For example, they will

slam doors, give someone the “silent treatment,” be late, or do

a sloppy job.

u Assertive people decide what they want, plan an appropriate

way to involve other people, and then act on the plan. They

state their feelings or opinions clearly and are specific about

what they want from others. They stand up for themselves and

do not fall back on threats, demands, or negative statements to

get what they want.

Skill Guidelines (5 minutes)

Explain to the group that the following points are useful to remember when

practicing assertiveness:

• Think before you speak.

• Be specific and direct in what you say.

• Pay attention to your body language. Use eye contact; face the

person you’re talking to.

• Be ready to compromise. Think about what behaviors you are 

willing to change to get what you want.

• Repeat or rephrase statements if you think you’re not being

heard.

Group Exercise #1 (5 minutes)

Ask a participant to roleplay and take the part of a friend at school who

suggests they should smoke a joint in the rest room during lunch period.

The therapist models passive, aggressive, passive-aggressive, and assertive

responses. After each type of response, ask participants from the whole

group to identify the type of behavior being demonstrated and whether it

was successful.

Have participants generate situations they found difficult in the past and

roleplay assertive responses to those situations. The situations do not have

to relate to marijuana use.

Rationale for Coping Skill 3: Receiving Criticism (10 minutes)

Tell participants that criticism is a part of life. It provides everyone with a

chance to learn more about themselves and about how they affect other

people. Remind participants that everyone has room for improvement.

Listening to and hearing criticism can be hard, but it has its rewards. Other

people grow to respect that we are ready to hear their point of view. This

also helps us avoid conflicts.

67

Part IV: Session 9
68

Explain that there are two types of criticism:

1. Constructive (or assertive) criticism is about what a person does and not

about who a person is. This kind of criticism asks for real changes,

because people can change what they do but not who they are.

2. Destructive (or aggressive) criticism is about who a person is.

Destructive criticism is not really looking for a change but is attempting

to hurt someone or start a fight.

Explain further that constructive criticism can help participants if they can

hear it. It provides a chance to change. Destructive criticism is not worth

worrying about. Sometimes, someone may be feeling bad and taking it 

out on another person. Tell participants that when they hear destructive 

criticism, it is better just to walk away.

Describe how learning to accept criticism can help participants resist using

marijuana. Learning to accept criticism helps things go more smoothly with

other people. If participants are feeling better about getting along with

other people, they don’t need marijuana to feel better. Explain that some

participants may have been criticized for using marijuana. If they pay attention

to the part of that criticism that is “constructive,” they can get some useful

information about how to change. Tell the group members not to worry if

the criticism doesn’t stop when they stop using marijuana. It takes time for

people to begin trusting them again. Others may still be thinking about

their smoking behavior. It takes time for others to notice the good effort

they are making today.

Skill Guidelines (5 minutes)

Explain the following five points about receiving and responding to criticism.

1. Don’t get defensive, don’t argue, and don’t try to get back at people

(counterattack). Doing these things will only make the situation worse

and give you less chance of talking things out.

Consider the following example: A teenager heading out for a rock 

concert is criticized by his or her parent for going to the concert. The

teenager replies, “What do you know about my music? You’re clueless.”

This kind of statement may be offensive and directs attention away from

the feelings leading to the argument.

2. Check in with the other person so that you really understand what

that person is criticizing. This gives you a chance to find out what the

person is really worried or angry about. Then you will be in a better 

position to know whether the criticism is constructive (there’s something I

can change here) or destructive (this person is just trying to get at me

and I am going to ignore it). 

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
To continue with this example: A nondefensive reply, and one that would

help someone understand the criticism, would be: “I don’t understand

why my going to the concert makes you upset. Could you tell me what

you’re upset about?”

3. Always look for something in the criticism that you can agree with,

and let the person know you agree with it. Sometimes, criticism is correct.

Even if you feel angry, admitting that you made a mistake can help.

To continue with the previous example: The person going to the concert

might say, “You’re right, some kids do drugs at concerts, but I don’t do

that anymore.” This approach takes away some of the tension and gives

you and the other person time to think.

4. Propose a compromise. A compromise means meeting somebody

halfway. Suggest something specific you can do to make a change. 

To continue with the previous example: A possible compromise might be

that the person going to the concert goes with friends who do not drink

or do drugs.

5. Reject unfair criticism. Sometimes, criticism is not fair. At these times,

it’s good to be assertive and reject the criticism firmly and politely. Do

not insult the other person. Just let him or her know you do not agree. 

Consider the following example: The lead scorer on a soccer team misses

a shot and is criticized by the coach. “You always choke,” he says. A

good way to respond here is to reject the destructive criticism, look for

something to agree on, and make a compromise: “You’re right, I missed

that shot. I gotta practice it. Maybe if I stay after practice, you’ll show

me how to nail it. What do you say?” 

Group Exercise #2 (10 minutes)

Give group members a chance to roleplay responses to both constructive

and destructive criticism. Scenes should involve recent instances of criticism

or future situations where criticism is likely to take place. Participants may

need some help verbalizing criticisms with enough detail to make the 

roleplay substantive. Roleplays should include different types of people (e.g.,

parents, siblings, friends) and different types of criticism (constructive or

destructive; accurate or unfounded) and should refer to both recent and

past marijuana use.

Real Life Practice Exercise (5 minutes)

Give the group members the Reminder Sheet for Receiving Criticism and

Real Life Practice Exercises for Receiving Criticism to complete before the

next session.

69

Part IV: Session 9
Session 9 

Reminder Sheet for 

Receiving Criticism

When you receive criticism, remember the 

following:

• Don’t get defensive.

• Don’t argue.

• Don’t counterattack.

• Ask questions to get a better understanding of

the criticism.

• Find something to agree with about the 

criticism.

• Propose a compromise.

• Reject unfair criticism.
Session 9

Real Life Practice Exercises for

Receiving Criticism

Exercise 1: Responding to Criticism

Stay alert until our next session for any criticism you may receive.

Try to respond according to the guidelines outlined in today’s 

session. For one criticism that you receive this week, write down 

the following:

Describe the situation:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Describe your response:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Communication Checklist YES NO 

1. Did you behave as if the criticism was nothing 

to get upset about? ____ ____

2. Did you ask questions to understand the 

criticism better? ____ ____

3. Did you find something to agree with in 

the criticism? ____ ____

4. Did you propose a compromise? ____ ____

Exercise 2: Responding Assertively

Imagine the following situation: You come home late from a friend’s

house. You’ve been drug free for about 3 months. However, your eyes

are red, and you’re feeling somewhat down and irritable. Your parent

(or someone you live with) approaches you and says, “You’ve been out

smoking pot again, haven’t you?”

In the space below, write an assertive response:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________
72

Session 10: Coping With Cravings and Urges To Use

Marijuana

Overview

Purpose: To help group members identify triggers for marijuana use and

plan for dealing with social pressure, cravings, and urges to smoke

Total Time: 75 minutes

Breakdown:

u Review of Client Status (10 minutes) 

u Review of Real Life Practice (10 minutes)

u Rationale for Coping Skill: Coping With Cravings and Urges To Use

Marijuana (15 minutes)

‰ Craving is a common experience and may last a long time after

group members stop using marijuana.

‰ Urges or cravings can be triggered by things in the environment

or by certain situations.

‰ Cravings and urges are time limited.

u Skill Guidelines (15 minutes)

‰ Avoid urge triggers

‰ Cope with urge triggers you cannot avoid

‰ Remember the benefits of abstinence and the negative results of

use

u Group Exercises (20 minutes)

‰ Activity Sheet for Coping With Cravings—Craving Triggers,

Craving Plan

‰ Reminder card: Benefits of abstinence and consequences of use

u Real Life Practice Exercises (5 minutes)

Materials:

u An Activity Sheet for Coping With Cravings handout for each group

member 

u A Reminder Sheet for Coping With Cravings and Urges handout for

each group member

u A Learning New Coping Strategies handout for each group member

u A Real Life Practice Exercise for Coping With Cravings handout for

each group member

u Writing materials for each group member

u A blackboard, “write and wipe” board, or large posterboard

u A package of index cards 

u A session 10 Coping With Urges and Cravings To Use Marijuana

poster (see appendix 1)

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
PROCEDURES: COPING WITH CRAVINGS AND URGES TO USE MARIJUANA

Review of Client Status (10 minutes) 

Review with group members their efforts to achieve or maintain abstinence

during the past week. Discuss the participants’ attempts to deal with current

problems related to marijuana use. Reinforce any coping skills they have

used successfully to avoid getting high.

Review of Real Life Practice Exercise (10 minutes)

Review the Real Life Practice Exercises for Receiving Criticism handout

assigned in session 9. 

Rationale for Coping Skill: Coping With Cravings and Urges To Use

Marijuana (15 minutes)

Present the following talking points to group participants. Adjust the 

presentation to the participants’ ability to understand the concepts and

terms being introduced.

• Cravings are common and most often happen early in treatment.

They can keep coming back for weeks, months, and occasionally

years after someone stops using marijuana. Cravings may be

uncomfortable, but they do not necessarily mean that your body

or brain is damaged. You do not need to feel ashamed about

them. You should expect cravings to happen and be ready to 

cope with them.

• An urge, need, or craving to use marijuana can be triggered by

things you see around you or by situations that remind you of

using marijuana. Physical cravings include tightness in your stomach

or feeling nervous. Psychological cravings might include thoughts

of how good it would feel to smoke pot, memories of when you

got high in the past, thoughts about how to get a joint, or just a

desire for it. Be alert to people, places, and things that remind

you of getting high.

• Craving and urges do not last forever. Usually, they come and go

fairly quickly. They ordinarily last only a few minutes or a few

hours at most. They do not grow until they are unbearable. They

usually peak after a few minutes and then die down—like an

ocean wave. As you stay clean, it will become easier to cope with

cravings and urges to smoke marijuana. 

Skill Guidelines (15 minutes)

Discuss the following talking points with participants:

• Learn how to recognize triggers so you can avoid them or deal

with them, so you don’t use. There are two kinds of triggers:

73

Part IV: Session 10
74

those that come from the outside (that is, external triggers) and

those that come from the inside (that is, internal triggers).

• External triggers include being in the presence of marijuana,

alcohol, or drugs; being around other people who are getting

high, drinking, or using drugs; being around people with whom

you used to use marijuana; being in places where you used to get

high; and times of the day when you used to smoke marijuana.

The easiest way to deal with external triggers is to avoid them

(e.g., get rid of marijuana in the house or in your car; do not go

to parties where drugs will be around; have less contact with

friends who smoke pot, drink, or use other drugs).

• Internal triggers include feelings like anger, frustration, and

depression. Even positive feelings, such as excitement, feeling

“awesome,” or the desire to celebrate an accomplishment, can

psyche you up for using. Here are four ways to deal with internal

cravings and urges:

‰ Distract yourself. Listen to music, call a friend, go to a movie,

or get some exercise, such as bike riding or roller blading.

Once you are busy doing something else, the urge will be easier

to handle.

‰ Talk it through. Tell a friend or family member about a craving

when it occurs. You may need to educate or remind the person

that craving is a normal part of giving up marijuana and that

it does not mean you are going to slip back into using.

Sometimes it helps to talk to someone else who has quit

smoking pot, because that person understands what you are

going through and can suggest a helpful alternative.

‰ Challenge and change your thoughts. When experiencing a

craving, people tend to remember only good times connected

with marijuana use and often forget the not-so-good times.

Remind yourself of the bad things connected with marijuana

use and the good things about not using. If it helps, write

down the bad things about using and good things about

abstinence on a card and carry it with you.

‰ Use “self-talk” to challenge urges. Self-talk has two steps.

First, pretend that the urge can talk to you. Turn that urge

into a statement. For example, “I’m really angry; if I don’t get

high, I’m going to lose it.” Second, pretend you are talking to

the urge and turn what you are saying into a statement.

Repeat to yourself: “Yeah, I’m angry, but getting high isn’t

going to change the situation. I haven’t dealt with anger 

without getting high for a long time. But I’m going to have to

learn to deal with anger differently to stay clean.” This may not

make the craving completely disappear, but it will make you

feel better and more in control of dealing with the urge.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Group Exercises (20 minutes)

Have participants complete the first part (Craving Triggers) of the Activity

Sheet for Coping With Cravings handout. Ask them to list craving triggers

that come from both situations and emotions. Have them circle those they

can avoid or stay away from.

Have participants complete the second part (Craving Plan) of the activity

sheet. Ask them to list distractions and people they can talk to who will

help them cope with their cravings. Have them pick out two or three of the

ways that will help them most to deal with cravings and urges.

Show participants the Cravings Log on the Real Life Practice for Coping

With Cravings handout. Explain how they can use it to keep a journal, or

log, of cravings and their efforts to deal with these cravings. Note that the

heading for “Intensity” includes a scale that ranges from low (1) to medium

(5) to high (10). Also point out that they will be using the cravings log 

during the next week in the real life practice exercise.

Give each participant a small card and writing materials. On one side of the

card, have members write down the benefits of not using marijuana. On the

other side, have them write down the negative consequences of marijuana

use.

Real Life Practice Exercise (5 minutes)

Distribute the Reminder Sheet for Coping With Cravings and Urges and

Learning New Coping Strategies handouts. Encourage participants to identify

strategies they have used successfully in the past, as well as those they are

willing to try. Briefly cover major categories in the reminder sheet, and ask

participants to review them between sessions.

Give group members the Real Life Practice Exercise for Coping With

Cravings, and ask them to complete it before the next group session.

75

Part IV: Session 10
Session 10

Activity Sheet for Coping 

With Cravings

Craving Triggers

Situations that have triggered cravings for me:

1.__________________________________________________________________

2.__________________________________________________________________

3.__________________________________________________________________

Emotions that have triggered cravings for me:

1.__________________________________________________________________

2.__________________________________________________________________

3.__________________________________________________________________

Craving Plan

Distractions that will help me cope with cravings:

1.__________________________________________________________________

2.__________________________________________________________________

3.__________________________________________________________________

People to whom I can talk about my cravings:

1.__________________________________________________________________

2.__________________________________________________________________

3.__________________________________________________________________
Session 10

Reminder Sheet for Coping 

With Cravings and Urges

Reminders About Cravings and Urges

v Cravings are common and most often happen soon after you

quit. But episodes of craving may continue for a long time after

you stop using. You should expect cravings to happen and be

prepared to cope with them.

v An urge or craving to use marijuana can be triggered by 

people, places, and things that remind you of getting high.

v Cravings and urges are time limited; they usually peak after a

few minutes and then die down, like a wave. Urges will become

less frequent and less intense with time. 

v Learn how to recognize triggers so you can avoid them.

v Self-monitoring can help you recognize triggers.

v The easiest way to deal with cravings and urges is to try to

avoid them. 

v Sometimes cravings cannot be avoided, and you have to cope

with them. 

v Strategies for coping with cravings.

n Get involved in some distracting activity. 

n Challenge and change your thoughts.

n Talk it through. 

n Use self-talk to challenge urges.

v Self-talk can strengthen or weaken your urges.

n Be aware of statements that feed into the urge (i.e., make

the urge more intense). 

n Use self-talk constructively to challenge or counterattack

those statements. 

v Initially, it may seem easier if you replace the urges with 

distracting activities. 
Session 10

Learning New Coping Strategies 

A List of Alternatives to Marijuana Use

Below is a list of ways to resist smoking marijuana. From this list,

choose ways that you think will work best for you. Expect that you

will have to try out some different strategies before you find the

ones that work best for you.

Actions

• Avoid or escape from the situation. 

• Put off deciding to get high for 30 minutes.

• Do something distracting. 

Thoughts

• Give yourself a pep talk. 

• Remind yourself of your reasons for quitting. 

• Visualize yourself as a nonsmoker—happy, healthy, and in

control of your life. 

• Picture the long-term effects on your body of smoking 

marijuana.

• Tell yourself loudly and sharply, “STOP!” then get up and do

something else.

Lifestyle

• Exercise regularly.

• Practice relaxation or meditation.

• Take up a new hobby or try an old one.

• Do fun stuff. 

• Reward yourself for quitting marijuana.

• Remove all smoking paraphernalia (rolling papers, pipes,

bongs, etc.) from your room, car, and home.

• Spend time in places where it’s difficult to get high.

• Spend time with friends who don’t smoke.

80

Session 11: Depression Management

Overview

Purpose: To teach techniques for being aware of depression and for

managing it by identifying and responding to negative thoughts

Total Time: 75 minutes

Breakdown:

u Collection of Urinalysis Specimens (prior to or after session)

u Review of Client Status (10 minutes)

u Review of Real Life Practice (10 minutes)

u Rationale for Coping Skill: Depression Management (10 minutes) 

‰ Principle: Coping with depression = avoiding relapse

‰ Model of Depression: Events Ÿ Thoughts Ÿ Feelings 

‰ Examples of Coping Skills: Managing negative thoughts, solving

problems, and increasing pleasant activities 

u Skill Guidelines (15 minutes) 

The three A’s:

1. [Become] Aware of body signs, mood changes, and feelings

2. Answer negative thoughts 

3. Act differently

u Activity Sheet (10 minutes) 

u Group Exercise (15 minutes)

u Real Life Practice Exercise (5 minutes)

Reminder Sheet for Depression Management, Reminder Sheet for

Thinking Errors, and Real Life Practice Exercise for Managing

Depression and Negative Thoughts

Materials:

u An Activity Sheet for Thoughts handout for each group member

u A Reminder Sheet for Depression Management handout for each group

member

u A Reminder Sheet for Thinking Errors handout for each group member

u A Real Life Practice Exercise for Managing Depression and Negative

Thought handout for each group member

u Writing materials for each group member

u A blackboard, “write and wipe” board, or large posterboard

u A session 11 Depression Management poster (see appendix 1)

PROCEDURES: DEPRESSION MANAGEMENT

Therapist Note: This intervention is not sufficient for treating clinical

depression. The material covered in this session is designed to reinforce

connections among thoughts, feelings, and actions with respect to 

negative moods and depression. Participants exhibiting signs of major

depression should be referred for further assessment and proper treatment.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Collection of Urinalysis Specimens

Therapist Note: Urinalysis specimens should be collected at the beginning

or the end of the session, depending on the therapist’s discretion and

group logistics. If a participant is absent, obtain a urine specimen at the

next group he or she attends. 

Review of Client Status (10 minutes)

Review with group members their efforts to achieve or maintain abstinence

during the past week. Discuss participants’ attempts to deal with current

problems related to marijuana use. Reinforce any coping skills they have

used successfully to avoid using marijuana.

Review of Real Life Practice Exercise (10 minutes)

Review the Real Life Practice Exercise for Coping With Cravings handout

assigned in session 10.

Rationale for Coping Skill: Depression Management (10 minutes)

Present the following talking points to group participants. Adjust the 

presentation to the participants’ ability to understand the concepts and

terms being introduced.

• The goal of this session is to learn to use cognitive behavioral

techniques for dealing with mild and moderate depression and

negative moods. According to cognitive behavioral theory, these

moods can be partially alleviated by changing how one thinks and

behaves. First, we will review a three-step model for managing

depression and then practice the model through roleplays and

written exercises.

• Negative moods and depression are common among substance

abusers during the recovery process. Often these moods are related

to the actual depressant effects of drugs such as marijuana or

alcohol or to the losses experienced in one’s life (e.g., loss of

friends or self-respect) as a result of substance use. Depression

and negative moods often are ameliorated during treatment 

without any specific attention. However, some people continue 

to experience problems with depression even after they have been

clean and sober for fairly long periods. In such cases, it may be

necessary to focus directly on these negative moods and provide

additional treatment.

• Depression is particularly problematic, because negative mood

states, especially depression, often lead to relapse. Marijuana

smoking does not help with depression and may even intensify it.

Most people who use marijuana to help with depression are just as

depressed when they come down as they were before they got

high. They may even feel more depressed!

81

Part IV: Session 11
82

• Sometimes people feel helpless to change the way they feel. They

say, “Everything is making me feel down! I can’t change anything!”

What they are really saying is that events in their lives are making

or causing them to feel depressed—as in this model (draw the

model on the board):

Events Ÿ Feelings

• However, the model does not tell the whole story because events

are not the only things that cause us to feel a certain way. How we

think about events also influences how we feel—as in this more

complete model (draw the model on the board):

Events Ÿ Thoughts Ÿ Feelings

• It is helpful to remember that our thoughts can change the way

we feel about an event because we often cannot control the event

itself. But we do have control over how we think about an event.

We can manage negative moods by changing the way we think and

act. Many of the skills we have already learned for managing negative thoughts, solving problems, and increasing pleasant activities

can also be used for dealing with depression and its symptoms.

Skill Guidelines (15 minutes)

Present the following talking points to participants.

• Here are three steps you can take to help yourself feel better

when you are sad or depressed. We call them the Three A’s:

(Become) Aware, Answer, and Act. The first step is to become

aware of thoughts that get you down. The second step is to

answer these thoughts with new thoughts that are more positive

and realistic. And the third step is to act on these new thoughts.

It takes practice to use the Three A’s, but once you get into the

habit of using them, you can help yourself feel better.

• Step #1: (Become) Aware. The first step is to recognize when

you are feeling depressed. Some signs that help tell you that you

are depressed include the following (write list below on the

board):

Signs of Depression:

• Inability to concentrate and problems with memory 

• Difficulty getting things done or failing at school or work

• Inability to enjoy things that used to be fun

• Loss of confidence or difficulty making decisions

• Moodiness, crying, moping, talking about sadness, or thinking 

about suicide

• Low energy, feeling tired, or not having much energy

• Sleeping a lot or not being able to sleep

• Changes in weight: poor appetite or overeating.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
These are easy to miss when you are actually feeling depressed, so

it is important to become aware of them early on.

Feelings are not as easy to notice as you might think. Sometimes

people are just too busy or too distracted to notice how they feel.

Here are some good tips for helping you keep track of depressed

feelings:

u Pay attention to your mood changes. When you start to feel

sad, ashamed, bored, lonely, or rejected, tune in to what’s

going on and how you’re feeling. Are you sleeping a lot, moping

around, and eating differently from your normal pattern?

u Own your feelings. Take responsibility for your feelings. Use

“I” statements such as “I feel,” “I think,” etc. If you are having

trouble noticing your feelings, start talking about them. Tell

people how you are really feeling at any given moment.

u Check in with your body. You can tell a lot about your feelings

from your muscle tension, posture, facial expression, and how

you walk and move.

u Notice negative thoughts that you have when you are sad or

depressed. Negative thoughts can be a problem when they get

to be automatic (i.e., like a habit) because much of the time

they are just not true! For example, if a friend tells you that

she does not want to go with you to the movies, a negative tape

may start rolling in your head that says, “Nobody wants to go

out with me.” If that thought is allowed to keep repeating over

and over, you might actually start believing it and start feeling alone and depressed—even though there are other friends

who would go with you to the movies in a minute!

• Step #2: Answer. Once you start having negative thoughts, you

can start answering them. First, you must separate what is really

true from what a negative thought tells you is true. A good way to

do this is to ask and answer some serious questions about yourself

and your automatic thoughts.

u Ask, “What’s the evidence?” If you were a judge in a courtroom,

would you be satisfied that there is enough evidence to prove

that the negative thought is true? For example, your girlfriend

did not call you tonight and now you have negative thoughts:

“She is going to dump me!” The judge asks, “Is the fact that

she didn’t call enough evidence to prove that she is going to

dump you?” (Well, not really. She might have been too busy.

In fact, there could be many reasons why she didn’t call.)

u Substitute a more realistic thought for the old one. If the 

negative thought does not hold up in court, replace it with

one that is more likely to be true, or wait until you can get

83

Part IV: Session 11
84

more evidence. For example, you might think, “Just because

she did not call doesn’t mean we’re breaking up. I’ll wait to

see her in school tomorrow, and then I’ll have a better idea of

what’s going on. In the meantime, I’m going to listen to some

music and take my mind off this.”

• Step #3: Act. Just answering your thoughts won’t be enough to

get over feeling depressed. Act on your new thought or belief. If

you act differently, you can change old thinking habits and

strengthen new ones. You have to do something to challenge your

automatic thoughts. Here are some actions you can take to help

overcome your depressed feelings.

u Make a short list of activities that make you feel good and

another list of activities that make you feel bad. Now make

a plan for today that includes one or two extra feel-good activities and one or two fewer activities that make you feel bad.

u Use problem-solving strategies to take some action. These

can help you feel as if you are taking control of your life. Here

are the steps:

‰ Recognize that there is a problem.

‰ Identify the problem.

‰ Come up with solutions.

‰ Make a decision.

‰ Think about the result of your decision.

Activity Sheet (10 minutes)

This exercise was adapted from Auerbach (1997). Instruct participants to

complete the Activity Sheet for Thoughts; this handout helps people become

aware of negative thoughts. Ask group members to identify errors that 

characterize their thinking styles. 

Group Exercise (15 minutes)

Have participants process the following scenario using the three A’s—

(become) aware, answer, act: 

You are grounded for the next 2 months because you came home high

on marijuana one night and were caught by your parents. It is a long

weekend, and no one is home, and you can’t find anything to do. Your

parents are not home and won’t be back for a couple of hours. What

are you thinking? How can you answer any thoughts you might have

about wanting to get high? What can you do?

Real Life Practice Exercise (5 minutes)

Give group members the Reminder Sheet for Depression Management, the

Reminder Sheet for Thinking Errors, and the Real Life Practice Exercise for

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Managing Depression and Negative Thoughts handouts. Ask participants to

review and complete these before the next session.

85

Part IV: Session 11
Session 11

Activity Sheet for Thoughts

(Adapted from Auerbach, 1997, pages 103 and 104) 

The purpose of this worksheet is to give you practice in identifying automatic negative

thoughts and then answering them. Below, write down one or two examples for each

automatic negative thought that may cause problems for you. Then identify one or two

answers that you can use to challenge your thoughts. A more complete list of these 

negative thoughts is on the Reminder Sheet for Thinking Errors.

1. BELIEVING IN PERFECTIONISM

Thinking that if you’re not perfect, you’re a loser

EXAMPLES:

________________________________________________________________________

________________________________________________________________________

ANSWERS:

________________________________________________________________________

________________________________________________________________________

2. CATASTROPHIZING or “AWFULIZING”

Taking something small that happened and exaggerating it

EXAMPLES:

_________________________________________________________________________

_________________________________________________________________________

ANSWERS:

________________________________________________________________________

________________________________________________________________________

3. OVERGENERALIZING

Thinking that if something happens once, it will happen every time

EXAMPLES:

________________________________________________________________________

________________________________________________________________________

ANSWERS:

________________________________________________________________________

________________________________________________________________________

4. EXPECTING THE WORST

Entering a new situation assuming that things won’t work out

EXAMPLES:

________________________________________________________________________

________________________________________________________________________

(continued on next page)
ANSWERS:

________________________________________________________________________

________________________________________________________________________

5. PUTTING ONESELF DOWN

Thinking things that make you feel bad about yourself

EXAMPLES:

________________________________________________________________________

________________________________________________________________________

ANSWERS:

________________________________________________________________________

________________________________________________________________________

6. USING ALL-OR-NOTHING THINKING

Seeing things in black and white, with no in-between

EXAMPLES: 

________________________________________________________________________

________________________________________________________________________

ANSWERS:

________________________________________________________________________

________________________________________________________________________

7. PERSONALIZING

Thinking all situations and events revolve around you or are about you

EXAMPLES: 

________________________________________________________________________

________________________________________________________________________

ANSWERS:

________________________________________________________________________

________________________________________________________________________

8. MINDREADING

Assuming you know what other people are thinking

EXAMPLES: 

________________________________________________________________________

________________________________________________________________________

ANSWERS:

________________________________________________________________________

________________________________________________________________________
Session 11 

Reminder Sheet for Depression Management

Use the Three A’s to help overcome your depression.

Become AWARE of the symptoms of depression.

- Be aware of your moods and the situations that influence them.

- Be aware of your automatic negative thoughts.

ANSWER these thoughts.

- Ask questions and challenge the assumptions behind these

thoughts.

- Replace the negative thoughts with positive ones.

ACT differently.

- Use your problem-solving skills to deal with issues that worry

you.

- Increase your positive activities.

- Decrease your involvement in negative activities.

- Reward yourself for the positive steps you are making.
Session 11

Reminder Sheet for

Thinking Errors

Is the way you’re seeing it the way it really is?

(continued on next page)
Type of Error Example

Personalizing: Thinking all “Everyone was looking at me and wondering

situations and events are about why I was there. I know they must have

you or revolve around you been talking about me.”

Magnifying: Blowing negative “This is the worst thing that could happen 

events out of proportion to me.”

Minimizing: Ignoring the Ignoring the positive: 

positive factors of a situation “Acing that test was no big deal.” 

or overlooking the negative Overlooking the negative: 

factors of a situation “Copping pot in a dangerous neighborhood

is not a problem because nothing really 

bad happens.”

Either/or thinking: Seeing “Either I’m a loser or I’m a winner; either 

things in black and white, I’m bad or I’m good.” 

with no in-between

Jumping to conclusions: Making “I blew the test; I’m never going to be able 

a false connection between one to get into college.” 

set of circumstances and an “My heart is pounding. I must be having a 

outcome heart attack.” 

Overgeneralizing: Thinking that “I am never going to be able to quit smoking

if something happens once, it pot. I always screw up.” 

will happen every time 

Self-blaming: Blaming yourself “I’m no good.”

rather than identifying specific 

behaviors that you can change

Mindreading: Assuming you “My mom is mad at me because she thinks I 

know what other people are am getting high again.” 

thinking

Catastrophizing or “awfulizing”: “Since I’ve already relapsed twice, I’ll never 

Taking something small that be able to stay clean and sober.”

happened and exaggerating it

Expecting the worst: Entering “I’ll never be able to pass this class. I may as 

a new situation assuming that well drop out.”

things won’t work out, assuming 

you will fail before you even try 

to do something

Putting oneself down: Thinking “I don’t deserve things to get any better.” “I 

things that make you feel bad am no good, just as my father [or mother] 

about yourself said.”

Here’s a list of how people think things are worse than they are. Are you

doing any of these? What can you do differently?
Session 11 

Real Life Practice Exercise for

Managing Depression and Negative Thoughts

1. What are the ways I show my depression in moods, attitudes,

and actions? What are the signs?

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

2. What are the negative thoughts that automatically go along

with my depression? What do I think about my current situation,

my world, and myself in general?

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

3. What questions can I ask myself to challenge these automatic

negative thoughts?

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

4. What steps am I going to take to act differently? What 

problem-solving strategies have I come up with to deal with 

my problems? What pleasant activities might I increase? 

What unpleasant activities might I avoid or do less often?

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________
The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions

92

Session 12: Managing Thoughts About Marijuana

Overview

Purpose: To help participants identify thoughts leading to marijuana

use and manage those thoughts before relapse occurs

Total Time: 75 minutes

Breakdown:

u Discussion of Urinalysis Results With Individual Group Members

(prior to group)

u Review of Client Status (10 minutes)

u Review of Real Life Practice (10 minutes)

u Rationale for Coping Skill: Managing Thoughts About Marijuana

(10 minutes)

‰ Thoughts about marijuana are normal.

‰ It is important to be aware of these thoughts, so you don’t act

on them impulsively.

‰ A risky state of mind can lead to 12 common excuses for relapse.

u Skill Guidelines (10 minutes)

‰ Challenge thoughts about marijuana

‰ List and recall benefits of not using

‰ Recall unpleasant using experiences

‰ Distract yourself with other thoughts

‰ Reinforce your successes in coping with marijuana

‰ Delay your decision to use

‰ Leave or change the situation

‰ Call someone

u Group Exercise (15 minutes)

u Real Life Practice Exercise (5 minutes)

u Termination (15 minutes)

Materials:

u A Reminder Sheet for Managing Thoughts About Marijuana handout

for each group member

u A Real Life Practice Exercise for Managing Thoughts About Marijuana

handout for each group member

u Writing materials for each group member

u A blackboard, “write and wipe” board, or large posterboard

u A session 12 Managing Thoughts About Marijuana poster (see 

appendix 1)

PROCEDURES: MANAGING THOUGHTS ABOUT MARIJUANA

Discussion of Urinalysis Results With Individual Group Members

Therapist Note: The results of the urinalysis specimens obtained in the

last session should be discussed with participants before this group session.

Guidelines for the presentation of urinalysis results can be found on

page 24.
Review of Client Status (10 minutes)

Review with group members their efforts to achieve or maintain abstinence

during the past week. Discuss participants’ attempts to deal with current

problems related to marijuana use. Reinforce any coping skills they have

used successfully to avoid using marijuana.

Review of Real Life Practice (10 minutes)

Review the Real Life Practice Exercise for Managing Depression and Negative

Thoughts handout assigned during session 11.

Rationale for Coping Skill: Managing Thoughts About Marijuana

(10 minutes)

Present the following talking points to group participants. Adjust the 

presentation to the participants’ ability to understand the concepts and

terms being introduced.

• Thoughts about smoking marijuana are normal. Almost anyone

who stops using alcohol and drugs occasionally thinks about getting

high again. There is no problem with these thoughts, as long as

you don’t act on them. You may feel guilty about the thoughts

(even though you have not acted on them), and you may even try

to get them out of your mind. The purpose of this session is to

identify those thoughts or feelings that can lead to relapse and

learn new ways to catch yourself before you actually slip.

Sometimes the thoughts are obvious, but sometimes they can

creep up almost without being noticed.

• Recovering substance abusers need to be aware of the state of

mind that can put them at risk for a relapse. A risky state of mind

is one that tempts them to let down their guard. The negative

thoughts of a risky state of mind can take the form of excuses.

The 12 most common excuses for relapse (adapted from Kadden

et al., 1992) are the following:

1. Happy memories of getting high. Some people who are trying

to stop using marijuana think about pot as they think about a

long-lost friend. For example, “I remember the days when I’d

take a few joints down to a party and get stoned”; “What’s a

weekend without pot and booze?”

2. Testing yourself. Sometimes, after not smoking marijuana for

a while, people get overconfident. For example, “I bet I can

smoke with the guys tonight and still deal with school tomorrow

morning.” Sometimes, overconfidence is mixed with curiosity.

For example, “I wonder what it would be like to have just one

hit.”

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94

3. Crisis. During a crisis, a person may say, “I need a hit,” or “I

can handle this only with a joint.”

4. Feeling uncomfortable about life without marijuana. Some

people find that after they stop smoking pot, they are more

aware of old or new problems in their lives. For example: “I’m

very irritable around my friends. Maybe it’s more important for

me to be a nice person than it is for me to stop smoking right

now,” or “I’m no fun to be around when I’m not smoking pot.”

5. Self-doubts. Some people doubt their ability to succeed at

things. For example, “I just have no willpower,” or “I tried to

quit many times before and it never worked out; why should I

expect this time to be any different?”

6. Escape. Most people want to avoid remembering unpleasant

situations, problems, or past experiences. Failure, rejection,

disappointment, embarrassment, or sadness tend to demand

relief. People get tired of feeling hassled, lousy, and upset. They

just want to get away from it all and away from themselves.

They may not necessarily want to catch a buzz or get high, but

they want instead to feel numb, calm, or at peace.

7. Relaxation. Thoughts of wanting to relax are perfectly normal,

but the thoughts can be a problem if you expect to feel relaxed

immediately without actually doing something relaxing. Rather

than trying to do relaxing activities, the individual may choose

the shortcut of using alcohol or drugs. 

8. Socialization. Many people are shy or uncomfortable around

new people or in social settings and may look to marijuana to

feel more relaxed and confident.

9. Improved self-image. When people have low self-esteem or are

unhappy with themselves, they often begin to think again about

drugs as a way to feel more confident and to get immediate and

temporary relief from feeling unhappy.

10. Romance. Most people enjoy daydreaming or having fantasies.

When people are bored or unhappy with their lives, they want

excitement, romance, and the feeling of being in love.

Fantasizing, carried too far, can lead to using marijuana or

alcohol to make fantasies seem real.

11. To hell with it. Some individuals seem to give up on setting

any goals in their lives. They think that nothing really matters

and that there is no reason to try. Why should they give a

damn? Such an attitude leads these people to relax their

guard and not to care whether they remain clean or not.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
12. No control. This attitude is the opposite of the testing-yourself

excuse. If people believe they can’t control their cravings, they

are setting themselves up for relapse. Those who feel they have

no control may give up the fight before they have even tried to

stop using drugs. This attitude differs from the to-hell-with-it

attitude. In that situation, individuals do not necessarily feel

powerless; they just do not want to make the effort to continue

what they have been doing. No control implies just that—a

feeling of being powerless over their cravings and the ability

not to pick up drugs.

Skill Guidelines (10 minutes)

Explain that everyone who tries to stop smoking marijuana has thoughts

about using it again at one time or another. Provide the following list of

ways to manage these thoughts:

• Challenge the thoughts. For example: “Getting through high

school is more important than getting high right now. I am going

to get that diploma,” “If my friends are real friends, they’re going

to respect that I want to do something else besides smoke pot,”

or “I can date without using and feel good about myself.” An

important aspect of challenging thoughts about substance abuse

is not only to visualize what one is not going to do but to picture

what one is going to do as an alternative to using.

• List the benefits of not smoking pot. The benefits might include

increased self-esteem, greater self-control, staying out of legal

trouble, and/or not disappointing friends and relatives. Paying

more attention to the benefits (e.g., better health, improved

memory, thinking more clearly) than to the losses (e.g., not getting

high) will strengthen your decision not to use. You might also

carry a small index card in your wallet or pack to remind you of

the benefits of staying clean whenever you catch yourself being

tempted to use.

• List unpleasant marijuana experiences. Try to remember the bad

feelings you have had as a result of marijuana use. Make a list of

unpleasant experiences such as arrests, family problems, poor

grades, or paranoia. Try to picture a negative experience you 

have had with marijuana. Add these bad feelings and unpleasant 

experiences to your index card.

• Distract yourself with other thoughts. Think about something

besides marijuana. For example, think about holiday plans, people

you love, or hobbies. Focus on something else you want to get

done.

• Reinforce your successes in coping with marijuana. Remind

yourself of the success you have had so far. For example: 12 weeks

of abstinence, getting involved in treatment, or staying in treatment.

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96

• Delay your decision to use. Put off the decision to use drugs for

30 minutes. Most urges to use are like waves: they build up, peak,

and then fade away. If you wait, the wave will pass.

• Leave or change the situation. If a place or activity makes you

think about using marijuana, go somewhere else or try a different

activity.

• Call someone who is good at helping you talk through a 

problem. That person may be able to help you clarify your

thoughts or distract you.

Group Exercise (15 minutes)

Have participants think of their own excuses for using marijuana and select

ways of coping with these excuses from the list above. For example:

• Excuse: “Quitting pot has really been easier than I thought. I

must not have been all that addicted to it in the first place.”

• Coping strategy: Challenge the thoughts. “I must be crazy. What

am I saying? Quitting hasn’t been easy. I was having the urge to

smoke all the time until the last few days. If I didn’t depend on it,

I could have quit on my own a long time ago. I’m just missing the

feeling of being high and starting to talk myself out of quitting. I

think I’ll do something else.”

Real Life Practice Exercise (5 minutes)

Ask participants to write lists of items under the following three categories.

Each list should consist of at least 5 to 10 items. 

• Positive consequences you expect by not using drugs

• Negative consequences of using drugs

• The most high-risk situations you might run into that will make

quitting or staying clean difficult. 

Ask participants to use this information to rate how committed they are to

stopping their marijuana use and to quitting. Ratings range from 1 (no

commitment) to 10 (extremely high level of commitment).

Termination (15 minutes)

Therapist Note: It is important to address termination before the final

session. Beginning in session 9, therapists should broach the topic of

termination. The first mention of termination may be brief. However,

therapists should note that a limited number of sessions remain, review

how these sessions will be spent, and probe for any questions or reactions from participants.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Termination can be problematic for many participants and can lead to

clinical deterioration or acting out prior to the end of treatment.

Several weeks before the end of treatment, therapists should review the

treatment timetable to sensitize themselves and participants to the

issues involved.

During the final session, devote an adequate amount of time to termination

issues. At a minimum, termination should include reviewing and 

summarizing the course of treatment, eliciting the participant’s reactions

and feelings about treatment, inquiring about the pros and cons of the

treatment for the participant, and discussing the participant’s future

plans. Fifteen to twenty minutes, in most cases, should be adequate for

processing termination.

Therapist’s Feedback to the Group Members

During termination, the therapist should model how to give positive feedback

and how to provide suggestions for continued change. The therapist’s 

feedback to the group members should be brief and nonjudgmental and

should project a positive view of the future. It may include references to

participants’ progress toward stated goals, as well as any contributions

group members may have made to the success of a peer or the group as 

a whole. The therapist may use this as an opportunity to suggest future

changes and identify areas needing further development. Group members

should be urged to build on their accomplishments during group and to

continue making positive changes in their lives.

Feedback Among Group Members

Group members have shared many experiences and discussed intimate

aspects of one another’s lives. They are able to provide valuable feedback on

one another’s progress and areas needing additional attention. This structured

activity for providing feedback is the final opportunity to interact with one

another and is an appropriate conclusion to the group’s work together.

Participants should be encouraged to be supportive and focus on positive

achievements.

Group Feedback to the Therapist

Group members should also be encouraged to provide positive and negative

comments regarding their group experience to the therapist. This feedback

should include recommendations for improving groups, as well as comments

on the therapist’s style. Because participants are less accustomed to this

role, they may need prompting and reminding about using the coping skills

learned in the group (e.g., being assertive rather than aggressive or passive;

giving constructive rather than destructive criticism). The therapist can ask

group members about experiences that were especially helpful or meaningful and can get their reactions to the assigned Real Life Practice Exercises.

The therapist can elicit comments about his or her performance as a group

leader (e.g., the degree to which he or she was helpful, his or her openness

to suggestions). Most participants will use this opportunity to 

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Part IV: Session 12
98

provide appropriate and useful information. In rare instances, a client will

abuse this opportunity. However, prompt, assertive intervention can turn

destructive criticism into an opportunity to model important skills to the

group.

Goodbyes

Allow plenty of time for group members to say goodbye. This process will

undoubtedly have already begun during the feedback phase of this session.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Session 12

Reminder Sheet for Managing Thoughts About Marijuana

Here are some ways to manage thoughts about marijuana use:

• Challenge your thought. Do you really need to get high? Can you have

fun without smoking a joint?

• Think of the benefits of not using drugs. This might include increased

self- esteem, greater self-control, better health, improved memory, thinking

more clearly, staying out of legal trouble, and/or not disappointing friends

and relatives.

• Remember negative drug experiences or problems you have had as a

result of getting high. These might include arrests, family problems, poor

grades, or paranoia.

• Distract yourself with other thoughts. Think of something besides marijuana.

• Reinforce your successes. Think about how long ago you quit, how you

got involved in treatment, and why you have stayed in treatment

• Focus on the positive. Think of the benefits you gain from not using.

• Use photographs of people who will be disappointed if you relapse.

• Delay your decision to use. If nothing else is working, then look at your

watch and put off the decision to use for 30 minutes or more.

• Leave or change the situation. If a place or activity makes you think

about using marijuana, go somewhere else or try a different activity.

• Call someone, and try to talk it out. This person may be able to help you

clarify your thoughts or distract you. 
Session 12

Real Life Practice Exercise for Managing

Thoughts About Marijuana

One way to cope with thoughts about marijuana is to remind yourself of the

benefits of not using and of the negative effects that marijuana has had on

your life. Make a list of these reminders on this sheet. Then copy this list

onto a pocket-sized index card. Read the card whenever you have a craving

to smoke marijuana.

Benefits of not using marijuana:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Negative effects of using marijuana:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

High-risk situations that will tempt me to get high:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________
Sources for Sessions 6–12

Session 6, Problem Solving: Material was adapted from the following sources:

Problem-Solving Approach

• Dennis, M. L., Fairbank, J. A., Bonito, A. J., Rourke, K. M., Karuntzos,

G. T., Roland, E. J., Caddell, J. M., Woods, M. G., Rachal, J. V., Bossert,

K. E., & Burks, M. E. (1995). Individual substance abuse counseling

(ISAC) manual. Bloomington, IL: Chestnut Health Systems, Lighthouse

Institute Publications.

• D’Zurilla, T., & Goldfried, M. (1971). Problem-solving and behavioral

modification. Journal of Abnormal Psychology, 78, 107–126. Copyright ©

1971 by the American Psychological Association. Adapted with permission.

Reminder Sheet for Problem Solving and Real Life Practice Exercise for

Problem Solving handouts

• Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989).

Treating alcohol dependence: A coping skills training guide. New York:

The Guilford Press. Copyright © 1989 by The Guilford Press.

Session 7, Anger Awareness: Material was adapted from the following

sources:

Cognitive-Behavioral Model of Anger

• Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989).

Treating alcohol dependence: A coping skills training guide. New York:

The Guilford Press. Copyright © 1989 by The Guilford Press.

Relaxation Training

• Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989).

Treating alcohol dependence: A coping skills training guide. New York:

The Guilford Press. Copyright © 1989 by The Guilford Press. 

• Steinberg, K., Carroll, K., Roffman, R., & Kadden, R. (1997). Marijuana

treatment project: Clinical manual (unpublished).

Anger Triggers Activity Sheets

• Auerbach, S. (1997). Clean and coping manual (unpublished).

• Clarke, G., Lewinsohn, P., & Hops, H. (1990). Leader’s manual for 

adolescent groups: Adolescent coping with depression course. Eugene,

OR: Castaglia Publishing Company.

101

Part IV: Sources
102

Session 8, Anger Management: Material was adapted from the following

source:

Rationale, Reminder Sheet, and Real Life Practice Exercise

• Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989).

Treating alcohol dependence: A coping skills training guide. New York:

The Guilford Press. Copyright © 1989 by The Guilford Press.

Session 9, Effective Communication: Material was adapted from the 

following sources:

Active Listening

• Clarke, G., Lewinsohn, P., & Hops, H. (1990). Leader’s manual for 

adolescent groups: Adolescent coping with depression course. Eugene,

OR: Castaglia Publishing Company.

• Auerbach, S. (1997). Clean and coping manual (unpublished).

Skill Guidelines, Receiving Criticism Rationale, Types of Criticism, and Real

Life Practice Exercise

• Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989).

Treating alcohol dependence: A coping skills training guide. New York:

Guilford Press. Copyright © 1989 by The Guilford Press.

Session 10, Coping With Cravings and Urges To Use Marijuana: Material

was adapted from the following sources:

Rationale, Reminder Sheet, Coping With Cravings Activity Sheet, and Real

Life Practice Exercise

• Kadden, R. M., Carroll, K., Donovan, D., Cooney, N., Monti, P., Abrams,

D., Litt, M., & Hester, R. (Eds.) (1992). Cognitive-behavioral coping

skills manual: A clinical research guide for therapists treating individuals

with alcohol abuse and dependence. Rockville, MD: National Institute on

Alcohol Abuse and Alcoholism.

Learning New Coping Strategies

• Steinberg, K., Carrol, K., Roffman, R., & Kadden, R. (1997). Marijuana

treatment project: Clinical manual (unpublished).

Session 11, Depression Management: Material was adapted from the 

following sources:

Rationale, Cognitive Thinking Errors, Reminder Sheet, and Real Life

Practice Exercises

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
• Kadden, R. M., Carroll, K., Donovan, D., Cooney, N., Monti, P., Abrams,

D., Litt, M., & Hester, R. (Eds.) (1992). Cognitive-behavioral coping

skills manual: A clinical research guide for therapists treating individuals

with alcohol abuse and dependence. Rockville, MD: National Institute on

Alcohol Abuse and Alcoholism.

Session Activity Sheet and Session Activity

• Auerbach, S. (1997). Clean and coping manual (unpublished).

Session 12, Managing Thoughts About Marijuana: Material was adapted

from the following sources:

Rationale, Skill Guidelines, Reminder Sheet, Real Life Practice, and

Termination

• Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989).

Treating alcohol dependence: A coping skills training guide. New York:

The Guilford Press. Copyright © 1989 by The Guilford Press.

Rationale

• Kadden, R. M., Carroll, K., Donovan, D., Cooney, N., Monti, P., Abrams,

D., Litt, M., & Hester, R. (Eds.) (1992). Cognitive-behavioral coping

skills manual: A clinical research guide for therapists treating individuals

with alcohol abuse and dependence. Rockville, MD: National Institute on

Alcohol Abuse and Alcoholism.

103

Part IV: Sources
V. Glossary of Terms

Adolescent community reinforcement approach: A treatment approach

that includes individual sessions with the adolescent or his or her concerned

others or both. Clients learn alternative skills to cope with problems and

meet needs; the adolescent’s environment is emphasized.

Affective management: The ability to modulate intense emotions by attending

to the thoughts and circumstances that maintain them.

Aggressive: A state or an attitude characterized by aggression or 

aggressiveness; a tendency to press one’s own interests or ideas despite

opposition.

Amotivational syndrome: A condition characterized by apathy, decreased

attention span, poor judgment, diminished capacity to carry out long-term

plans, social withdrawal, and a preoccupation with acquiring marijuana. The

condition is often attributed to heavy cannabis use and has been observed

in adolescents.

Assertive: A state or an attitude characterized by boldness or confidence.

Attention deficit/hyperactivity disorder: A neurologically based disorder

that occurs in both adults and children who have significant problems with

inattention, impulsivity, hyperactivity, and boredom.

Automatic negative thoughts: Ideas or thoughts that are not conducive to

positive change; a symptom of depression.

Awfulizing: Taking something small and exaggerating it.

Catastrophizing: Exaggerating a small event (“Since I’ve already relapsed

twice, I’ll never be able to stay clean or sober.”).

Cognitive behavioral therapy: An approach to treatment that focuses on

the client’s thoughts, feelings, and behaviors associated with substance use.

Counterattack: A challenge to a statement or idea.

Direct triggers: A direct verbal or nonverbal attack (e.g., physical attack,

obscene gesture, unfair treatment) or frustration resulting from being

unable to get something.

Disclosure: Shared information.

Dissonance conflict: The discomfort experienced by an individual when 

confronted with his or her professed desire to abstain from continued 

substance use.

Either/or thinking: Seeing things in black and white, with no in-between

(“I’m either a loser or a winner; I’m either bad or good.”).

105
106

Emotional identification: A subcomponent of affective management; the

act of detecting, interpreting, and feeling cues accurately.

Emotional management: A subcomponent of affective management; the

process of checking escalating anger or depression so that the individual

can focus energy on solving problems.

Family support network: A family-focused treatment approach designed to

improve parenting skills and increase family cohesion, closeness, and

parental support.

Gateway phenomenon: A developmental perspective on substance abuse

that assumes that the use of less harmful substances (e.g., alcohol, marijuana,

tobacco) raises the risk for subsequent use of more harmful substances

(e.g., cocaine, heroin).

Indirect triggers: Seeing an attack on someone else or being aware of one’s

thoughts and feelings about a situation (e.g., feeling that one is being

blamed, thinking that someone is disappointed in you, feeling that people

expect too much from you).

Magnifying: Blowing negative events out of proportion (“This is the worst

thing that could happen to me.”).

Mindreading: Assuming what other people are thinking (“My mom is mad

at me because she thinks I’m getting high again.”).

Minimizing: Ignoring the positive factors (“Acing that test was no big

deal.”) or overlooking the negative factors of a situation (“Copping pot in 

a dangerous neighborhood is not a problem because nothing really bad 

happened.”). 

Motivational enhancement therapy: An approach to treatment that focuses

and builds a client’s intrinsic motivation to abstain from or reduce unwanted

behavior.

Motivational interviewing: An interview technique in which the therapist

reinforces indications of motivation to change and explores ambivalence

that may pose a significant barrier to abstinence. Reinforcement is 

accomplished by exploring a participant’s reasons for seeking treatment,

prior treatment episodes, previous attempts to quit, treatment goals, and

perceptions of self-efficacy.

Multidimensional family therapy: A family-focused treatment that requires

therapists to work individually with adolescents and their families in 12

weekly sessions.

Overgeneralizing: Thinking that if something happens once, it will happen

every time (“I’m never going to be able to quit smoking pot. I always screw

up.”).

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
Passive: A state or an attitude characterized by rest or inactivity. A person

with this attitude makes no effort to control the course of events.

Passive-aggressive: A state or an attitude characterized by a lack of genuine

independence. A person with this attitude reacts to difficulties either by

indecisiveness and clinging to others for help or by irritability, temper

tantrums, and destructiveness or obstructionism.

Personalized feedback report (PFR): A form that presents questions to 

gather client information for intake assessment instruments. A completed

PFR highlights the adolescent’s problems and concerns related to marijuana

use and can be used to compare his or her marijuana use with national 

adolescent norms.

Personalizing: A thinking error characteristic of depressed thoughts, such

as thinking all situations and events revolve around oneself (“Everyone was

looking at me and wondering why I was there. I know they must have been

talking about me.”).

Positive outcome expectancy: A heightened belief in the benefit of using

drugs.

Rephrase: To reword.

Self-attribution: Ascribing an outcome to oneself as opposed to environmental

circumstances. 

Self-blaming: Blaming oneself rather than identifying specific behaviors

that can be changed.

Self-efficacy: An individual’s confidence in his or her ability to abstain from

unwanted behaviors.

Self-talk: A coping response to temporarily distract oneself and check one’s

reactive emotions.

Skill guidelines: Techniques for participants to follow when they need a coping

response to reduce the likelihood of future marijuana use. The key to engaging

adolescents is to make the guidelines “come alive” through examples and

clearly explain their relevance in participants’ lives. The posters in appendix

1 highlight the skill guidelines taught in each group session.

Tension relaxation exercise/progressive relaxation/deep muscle relaxation:

Procedures that involve tensing and relaxing different muscle groups to

identify feelings of tension and replace them with feelings of relaxation.

Thought changing: A relapse prevention technique whereby a participant

can act to resist addictive behavior. 

Triggers: Thoughts, feelings, or events that cause an urge or craving to use

marijuana. 

107

V: Glossary of Terms
VI. References

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Appendix 1. 

Miniatures of 11- by 17-inch Posters 

for CBT7 Sessions 6–12

113
Cognitive Behavioral Therapy

Group Mission: To learn and practice coping skills

that will help you identify triggers and beliefs, manage

moods and emotions, strengthen self-esteem, 

improve relationships, and maintain abstinence 

from substance abuse and other high-risk behaviors.

Assumption #1: We all have problems getting along

with other people and handling our moods and 

feelings. 

Assumption #2: Problems in getting along with other

people and trouble managing feelings often set the

stage for drug use. Marijuana use often occurs in

high-risk situations such as feeling frustrated with

someone, being offered a joint at a party, or feeling

depressed, angry, sad, or lonely.

Therefore: The goal of this group is to teach skills

that you can use to cope with your own high-risk 

situations. We will focus on ways to handle difficult

situations with other people more effectively and

teach ways to handle feelings and moods that may 

be difficult for you.
Group Therapy Ground Rules

1. Do not come to a session if you are high or drunk.

2. Maintain confidentiality—in other words, “What’s said here,

stays here.”

3. Work on maintaining abstinence.

4. Attend every session or cancel in advance.

5. Show up on time. 

6. Do not leave the group without permission.

7. Complete all Real Life Practice Exercises.

8. Do not wear clothing that has symbols of gangs or drugs or

revealing clothing. Do not bring electronic equipment or

other distractions.

9. Listen to one another; one person speaks at a time without

being interrupted.

10. Take responsibility for yourself. Own your behavior. Use “I”

statements.

11. Do not tell war stories about drug use or gang involvement.

12. Do not use verbal abuse, threatening words, or threatening

behavior.

13. Verbalize your commitment to abstinence and sobriety.
Session 6 

Problem Solving

Rationale

• Problems are a part of everyday life. A situation

becomes a problem if there is no immediate 

effective way for a person to handle it.

• Coming up with an effective solution requires

that you slow down and check out the situation

so you can decide what will work best for you.

You have to Stop and Think!

Skill Guidelines

1. Recognize that a problem exists. Is there a 

problem?

2. Identify the problem. Stop and think. What is the

problem?

3. Come up with solutions. What can I do? Think

ahead. What are the consequences of each 

solution?

4. Make a decision. Do it.

5. Evaluate the outcome. Did this work for me?
Session 7 

Anger Awareness

Rationale

Anger is a normal human emotion. However, there is a difference between

anger as a feeling and the negative consequences of anger, such as 

aggression, impulsivity, and passivity.

TRIGGER ANGRY BEHAVIOR

THOUGHTS

Everyone has different ways of communicating his or her anger toward

other people. The way you handle anger can have either constructive or

destructive effects.

Destructive: Aggressive, passive, passive-aggressive

Constructive: Assertive

Skill Guidelines

Become more aware of situations that trigger anger:

- Direct - Indirect

Become more aware of internal reactions to anger:

- Feelings - Sleep problems

- Physical reactions - Fatigue or depression 

- Mix of physical reactions and feelings
Session 8

Anger Management

Rationale

Anger is caused by thoughts and beliefs about a particular 

situation. 

Most people think that: Events Anger

(A) (C)

When really it is: Events Thoughts Anger

(A) (B) (C)

Skill Guidelines

1. Calm down.

Chill out.

2. THINK about the situation.

Collect your thoughts.

3. THINK through your options.

Choose the best action.

4. Let it go (if anger is unresolved).

Change the way you think.

CONGRATULATE YOURSELF!
Session 9

Effective Communication 

and Receiving Criticism

Rationale

• Critical statements are encountered in everyday life. 

• Criticism appropriately provides us with a chance to learn

things about ourselves and about how our behavior affects

other people.

Two Types of Criticism:

1. Constructive: Directed at the behavior, not at the person

People can change their behavior

2. Destructive: Focuses on the person rather than the behavior

Skill Guidelines

• Don’t get defensive, don’t argue, don’t try to get back at the

other person.

• Ask questions if you don’t understand the criticism.

• Find something to agree with about the criticism.

• Propose a compromise.

• Reject unfair criticism.

Criticism Related to Substance Abuse:

• Accusations or inquiries about drug use

• A focus on past events or past negative consequences

• An issue made of other behaviors related to past marijuana use
Session 10

Coping With Urges and Cravings 

To Use Marijuana

Rationale

• A craving may be an uncomfortable experience, but it is

common and does not mean something is wrong.

• Urges and cravings can be triggered by things you see in

the environment or by situations that remind you of using

marijuana.

• Urges and cravings usually last only a few minutes or at

most a few hours; they usually peak and then die down,

like a wave. Learning coping skills helps reduce how often

and how intensely you experience an urge.

Skill Guidelines

• Recognize triggers (seeing someone getting high, drinking,

or using other drugs; being around friends or family who

drink or use drugs; and experiencing negative feelings).

• Avoid/decrease exposure. Limit how often you will have to

be in these high-risk situations.

• Distract yourself. Entertain yourself with another activity. 

• Talk it through with a family member or friend when you

want to get high or drunk.
Session 11

Depression Management

Rationale

• Negative moods and depression are common

during recovery. They may be due to the lingering effects of drugs in your body or because of

problems caused by your drug or alcohol use.

Although depression usually gets better with

abstinence, some people still feel depressed for

a while.

• Depression can lead to relapse if you do not

learn to manage negative feelings in a more

productive way.

Skill Guidelines

Change How You Think! The Three A’s

n (Become) AWARE of negative thinking.

n ANSWER negative thoughts.

n ACT on new thoughts.
Session 12

Managing Thoughts About Marijuana

Rationale

• Learn to identify thoughts and feelings that

lead to marijuana use. 

• Learn how to catch yourself before you slip.

Skill Guidelines

Here are some ways to manage your thoughts:

1. Challenge them.

2. List benefits of NOT using.

3. List negative experiences with using.

4. Distract yourself.

5. Reward yourself.

6. Delay your decision to get high.

7. Leave or change the situation.

8. Call someone.
125

Appendix 2. Therapist Forms

MET/CBT5 + CBT7 Treatment Plan

Therapist Self-Rating Form

MET/CBT5 + CBT7 Therapist Group Session

Report
MET/CBT5 + CBT7 Treatment Plan

Participant____________________ Therapist____________________

Date Session Delivered Clinical Note

Session 1: Motivation 

Building

Session 2: Goal Setting

Session 3: Marijuana 

Refusal Skills

Session 4: Enhancing the 

Social Support Network 

and Increasing Pleasant

Activities

Session 5: Planning for 

Emergencies and Coping 

With Relapse

Session 6: Problem Solving

Session 7: Anger Awareness

Session 8: Anger Management

Session 9: Effective 

Communication

Session 10: Coping With Cravings 

and Urges To Use Marijuana

Session 11: Depression 

Management

Session 12: Managing Thoughts 

About Marijuana
Therapist Self-Rating Form

MET/CBT5 + CBT7 Therapist Group Session Report

Instructions

• Provide identifying information at the beginning of the form.

• For each question, circle the number of the appropriate response and,

when asked, write in a response on the lines provided.

• When responding to specific items, refer to the following response set:

1. not at all: The intervention was not delivered in that session.

2. a little: The intervention was presented but only briefly mentioned

and not covered in depth or with great frequency.

3. somewhat: The intervention was presented with some frequency but

not covered in depth.

4. considerably: The intervention was presented frequently and in depth

and was covered in great detail.

5. extensively: The intervention clearly dominated the session.

In general, most interventions should be rated 2 or 3; ratings of 4 or 5

should be comparatively rare and used only when a particular intervention

truly characterized the bulk of a session. Any significant clinical information

relevant to the session should be documented in the additional notes section.

Intervention used (circle)

1 = MET/CBT5

2 = MET/CBT5 + CBT7 

3 = MET/CBT5 + CBT7 + FSN

____ Makeup Session 

____ Number of Participants 

Date and time of next scheduled session: ____________________________

1) What topic was covered in this session?

6 = CBT6, Problem Solving

7 = CBT7, Anger Awareness

8 = CBT8, Anger Management

9 = CBT9, Effective Communication

10 = CBT10, Coping With Cravings and Urges To Use Marijuana

11 = CBT11, Depression Management

12 = CBT12, Managing Thoughts About Marijuana

A) If this was session 6 (CBT6), did you also cover the topic of problem

recognition?

1 = Yes

2 = No

B) If this was session 7 (CBT7), did you also cover the topic of 

relaxation training?

1 = Yes

2 = No

Participants____________

________________________

Therapist______________

Date __________________

Session #______________
C) If this was session 9 (CBT9), did you roleplay both appropriate and

inappropriate responses to receiving criticism?

1 = Yes

2 = No

D) If this was session 10 (CBT10), did you have participants complete a

small card on which they listed the benefits of not using marijuana

and negative consequences of marijuana use?

1 = Yes

2 = No

E) If this was session 12 (CBT12), did you spend time addressing 

termination issues (i.e., encourage participants to discuss their 

feelings or thoughts about treatment completion)?

1 = Yes

2 = No

2) To what extent did you assess the participants’ use of marijuana or

other substances since the last session?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

3) In your opinion, should any of the participants be considered for removal

from treatment due to clinical deterioration? 

1 = Yes If yes, list participants:__________________________________

2 = No If yes, why?_____________________________________________

4) To what extent did you discuss or address the participants’ current commitment to abstinence?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

5) To what extent did you attempt to elicit self-motivational statements

from the participants?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

6) To what extent did you attempt to focus on the participants’ 

ambivalence about changing their level of marijuana use?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

7) To what extent did you encourage the participants to make a commitment

to changing their marijuana use?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively
8) To what extent did you discuss any high-risk situations the participants

encountered since the last session and explore any coping skills used?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

9) To what extent did you teach, model, rehearse, review, or discuss specific

skills (e.g., marijuana refusal skills, enhancing one’s social support 

network, or planning for emergencies and coping with relapse) during

the session?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

10) Did you do a roleplay?

1 = Yes

2 = No

11) To what extent did you encourage the participants to anticipate any

high-risk situations that might be encountered before the next session

and formulate appropriate coping strategies for such situations?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

12) To what extent did you develop one or more specific assignments for

the participants to engage in between sessions?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

13) To what extent did you review the participants’ reactions to last 

session’s assignment?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

14) To what extent did you provide one or more specific assignments for

the participants to engage in between sessions?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

15) To what extent did you emphasize the importance of real life practice

of skills between sessions?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively
16) To what extent did you attempt to keep the session focused on 

prescribed activities (by redirecting dialog when it strayed off task 

or organizing the session so defined activities were covered)?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

17) To what extent did you communicate understanding of the participants’

concerns through reflective listening and comments?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

18) To what extent did you respond to the participants with empathy,

warmth, and acceptance?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

19) To what extent did you discuss the availability and nature of family 

support for the participants’ efforts in treatment?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

20) To what extent did you discuss termination of the therapy (review the

timing of termination, encourage participants to discuss their feelings

or thoughts about termination)?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Additional Notes:____________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________ _________________________

Signature Date
133

Appendix 3. Supervisory Forms

Recommended Certification Guidelines

Criteria for Certification of CBT7 Therapists

Supervisory Rating Form

MET/CBT5 + CBT7 Supervisory Group Session

Report
Recommended Certification Guidelines

Criteria for Certification of CBT7 Therapists

Prior to being considered for certification of their competency in CBT7

treatment, therapists must have

• Obtained certification in MET/CBT5 

• Competently delivered each of the following sessions:

_____ Session 10: Coping With Cravings and Urges To Use Marijuana 

and

_____ Session 12: Managing Thoughts About Marijuana

• Competently delivered at least one of the following sessions:

_____ Session 6: Problem Solving

or

_____ Session 9: Effective Communication

• Competently delivered at least one of the following sessions:

_____ Session 7: Anger Awareness

or 

_____ Session 8: Anger Management 

or 

_____ Session 11: Depression Management

Sessions should be audiotaped or videotaped and then reviewed by supervisors.

Therapists must have obtained a skill rating of at least four (“adequate”) on

the five-point Likert scale on most (i.e., 75 percent) of the skills assessed in

each of the four sessions delivered. For therapists to obtain certification, no

more than a few skills (i.e., 25 percent) delivered in a particular session

may receive a rating of less than four.

If a therapist is not certified to deliver a particular session, only that session

must be reassessed until the therapist is eligible for certification in CBT7

treatment. After therapists have been certified in MET/CBT5 + CBT7, their

supervisors are encouraged to occasionally review the audiotapes or 

videotapes to ensure continuing quality.
Supervisory Rating Form

MET/CBT5 + CBT7: Supervisory Group Session Report

Instructions

Follow the same instructions as those given for the Therapist Self-Rating

Form. In addition, complete the skill-level section according to the following

rating guidelines:

1. not done: The intervention was not delivered in that session.

2. poor: The intervention was presented but delivered with little therapeutic

skill or competence.

3. fair: The intervention was delivered with some therapeutic skill or 

competence.

4. adequate: The intervention was delivered with reasonable clinical skill or

competence.

5. well: The intervention was delivered well, with sufficient clinical skill or

competence.

1 = MET/CBT5 

2 = MET/CBT5 + CBT7 

3 = MET/CBT5 + CBT7 + FSN

____ Makeup Session 

____ Number of Participants

1) What topic was covered in this session?

6 = CBT6, Problem Solving 

7 = CBT7, Anger Awareness

8 = CBT8, Anger Management

9 = CBT9, Effective Communication

10 = CBT10, Coping With Cravings and Urges To Use Marijuana

11 = CBT11, Depression Management

12 = CBT12, Managing Thoughts About Marijuana

A) If this was session 6 (CBT6), did the therapist also cover the topic of

problem recognition?

1 = Yes

2 = No 

B) If this was session 7 (CBT7), did the therapist cover the topic of

relaxation training with the group participants?

1 = Yes

2 = No

C) If this was session 9 (CBT 9), did the therapist roleplay both 

appropriate and inappropriate responses to receiving criticism?

1 = Yes

2 = No

Participants____________

________________________

Therapist______________

Date __________________

Session #______________
D) If this was session 10 (CBT10), did the therapist have participants

complete a small card on which they listed the benefits of not using

marijuana and negative consequences of marijuana use?

1 = Yes

2 = No

E) If this was session 12 (CBT12), did the therapist spend time processing

termination issues (i.e., encourage participants to discuss their 

feelings or thoughts about treatment completion)?

1 = Yes

2 = No

2) To what extent did the therapist assess the participants’ use of marijuana

or other substances since the last session?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

3) In your opinion, should any of the participants be considered for removal

from treatment due to clinical deterioration?

1 = Yes If yes, list participants:__________________________________

2 = No If yes, why?____________________________________________

4) To what extent did the therapist discuss or address the participants’ 

current commitment to abstinence?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

5) To what extent did the therapist attempt to elicit self-motivational

statements from the participants?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well
6) To what extent did the therapist attempt to focus on the participants’

ambivalence about changing their level of marijuana use?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

7) To what extent did the therapist encourage the participants to make a

commitment to changing their marijuana use?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

8) To what extent did the therapist discuss any high-risk situations the 

participants encountered since the last session and explore any coping

skills used?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

9) To what extent did the therapist teach, model, rehearse, review, or 

discuss specific skills (e.g., marijuana refusal skills, enhancing social

support, or planning for emergencies and coping with relapse) during

the session?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

10) Did the therapist do a roleplay?

1 = Yes

2 = No
Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

11) To what extent did the therapist encourage the participants to anticipate

any high-risk situations that might be encountered before the next

session and formulate appropriate coping strategies for such 

situations?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

12) To what extent did the therapist provide one or more specific 

assignments for the participants to engage in between sessions?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

13) To what extent did the therapist review the participants’ reactions to

last session’s assignment?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

14) To what extent did the therapist emphasize the importance of real life

practice of skills between sessions?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well
15) To what extent was it difficult for the therapist to engage the group?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

16) To what extent did the therapist manage disruptions to the group

process (e.g., using aggression, telling war stories, using excessive 

profanity)?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

17) To what extent did the therapist attempt to keep the session focused

on prescribed activities (by redirecting dialog when it strayed off task

or organizing the session so defined activities were covered)?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

18) To what extent did the therapist communicate understanding of the

participants’ concerns through reflective listening and comments?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

19) To what extent did the therapist respond to the participants with 

empathy, warmth, and acceptance?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

20) To what extent did the therapist discuss the availability and nature of

family support for the participants’ efforts in treatment?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively
21) To what extent did the therapist discuss termination of the therapy

(review the timing of termination, encourage participants to discuss

feelings or thoughts about termination)?

1......................2........................3........................4........................5

not at all a little somewhat considerably extensively

Skill Level:

1......................2........................3........................4........................5

not done poor fair adequate well

22) Rate the quantity of participation of this group.

3 = High

2 = Medium

1 = Low

0 = Silent

23) Rate the quality of participation of this group.

3 = High

2 = Medium

1 = Low

0 = No quality

Additional Notes:____________________________________________________

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Signature Date
Appendix 4.

Clinical Management of a Multisite

Field Trial of Five Outpatient

Treatments for Adolescent Substance Abusers

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.

143
145

Appendix 4

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. 
146

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 (PAR) in St. Petersburg, Florida;

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, 2002)

• Family Support Network (FSN) (Hamilton, Brantley, Tims,

Angelovich, & McDougall, 2001) (FSN includes MET/CBT5 +

CBT7 plus enhanced family supports: home visits, parent 

education classes, parent support groups)

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
147

Appendix 4

• 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.
148

These procedures helped enhance treatment differentiability (the delineation

of the ingredients and procedures that distinguished each treatment from

the other treatments) and treatment adherence (the assurance that the

interventions [as delivered] maintained fidelity to the original manual-defined

procedures) (Hoffart, 1994).

A second challenge involved controlling extraneous factors that could 

compromise interpretation of the treatment outcomes. To accomplish this,

every effort was made to ensure that all general clinical procedures, other

than those involved in the specific therapies, would be handled similarly

across sites and interventions. This was done to minimize the ability of

these contextual issues to unduly influence the evaluation of the experimental

interventions and was achieved in two ways. First, staff of the CYT 

coordinating center conducted two site visits at each of the four service

delivery sites to ensure that each site met baseline standards related to 

arenas such as research protocol compliance, accessibility and appropriateness

of clinical space, clinical supervision structure, recruitment strategies,

intake and service procedures, confidentiality procedures, crisis and safety

net procedures, clinical documentation, data security and storage, and 

followup procedures. Second, the TCs for each intervention coordinated

similar responses to issues that were not part of the specific interventions in

monthly conference calls facilitated by the CYT coordinating center. Details

of this latter process will be described shortly. 

The third challenge was to enhance the external validity of the interventions

(the generalizability of study findings) by ensuring that the interventions

could be implemented as designed within the resource constraints of 

settings that currently provide the bulk of services to drug-involved 

adolescents. It was the goal of the CYT TCs to do everything possible in the

CYT study to bridge the traditional gap between efficacy research conducted

under experimental (ideal) conditions and effectiveness research conducted

in field (real) settings. We wanted to document the kind of clinical 

infrastructures and the management of day-to-day clinical issues that 

might need to accompany these unique interventions if they were to

achieve comparable results in the field. 

The monthly conference calls among the TCs for each of the five interventions

and the staff from the CYT coordinating center were particularly helpful in

facing the latter two of these challenges. The purpose of these meetings

was to define how sites would manage common clinical issues that were not

a unique part of the experimental interventions but which, if not identified

and controlled, might corrupt the evaluation of these interventions. We

were concerned, for example, that if therapists in one intervention expelled

adolescents from treatment (and the study) for arriving at a session high,

while another site either allowed such adolescents to participate or 

rescheduled their sessions, differences in completion rates between these

sites would reflect not the power or weakness of the interventions but 

contextual policies unrelated to the active ingredients of each intervention. 

What follows is a synopsis of how common clinical issues were managed

across the four treatment sites and across the five interventions being 

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
tested. It is hoped that this discussion will provide researchers and treatment

practitioners alike with insights into the importance of managing such 

contextual influences. The discussion also represents a snapshot of baseline

clinical practices in adolescent substance abuse treatment in 1998 and 1999.

Issues in Clinical Management and Clinical Care

A. Clinical Infrastructure. A rather complex clinical infrastructure was

required to effectively manage clinical activities across the four treatment

organizations and the five treatments in the CYT study. The care taken in

constructing this infrastructure was based on the assumption that there is a

close relationship between the quality of clinical supervision and treatment

efficacy (Holloway & Neufeldt, 1995). 

There were three levels of clinical coordination and supervision in the CYT

study. First, local clinical supervisors at each service site coordinated 

cross-intervention clinical issues and day-to-day clinical problem solving.

Second, a therapist coordinator for each of the five interventions used in

the CYT study provided onsite and cross-site clinical supervision of staff

working in their particular intervention. This supervision occurred weekly

during the period in which therapists were being certified and bimonthly

following staff certification. Third, a TC at the CYT coordinating center

facilitated cross-site and cross-intervention coordination and problem solving.

The centerpiece of this cross-site clinical coordination was a monthly 

meeting at which the respective TCs met with the cross-site TC and

research coordinator via a conference call to discuss cross-site clinical and

research issues. Particular problems or procedural questions emerging from

these discussions were sometimes also referred to the CYT executive 

committee (all of the principal investigators, the CSAT project officer, and

other CSAT staff) for consultation or decision making. The CYT coordinating

center validated that the cross-site clinical procedures developed through

these processes were in place by conducting two monitoring visits to each

of the CYT research sites during the course of the study (CYT cooperative

agreement, 1999).

Many problems and issues (administrative, fiscal, research, clinical, ethical,

legal) were addressed in this multitiered supervisory structure, but the

major goals were to meet the methodological challenges noted earlier:

ensuring the integrity of the interventions, controlling factors that could

confound outcomes, and enhancing the generalizability of findings. Several

steps were taken to achieve these goals. 

All sites used the same research and service intake and clinical assessment/

screening procedures, the same inclusion and exclusion criteria, and the

same approach to randomization and waiting list management. To maximize

transferability of findings to the field, exclusion criteria were limited to 

adolescents 1) who needed a higher level of care than outpatient treatment,

2) who presented for treatment with confirmed histories of drug dealing or

violence (particularly predatory behavior patterns reflecting a high frequency,

high intensity, and long duration), 3) whose psychiatric comorbidity was so

severe as to render them inappropriate for the CYT interventions, and 

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150

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 4 CYT sites. Nine staff left the CYT project during

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
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 child care 

• A marital or relationship breakup during the period of treatment 

involvement

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Appendix 4
152

• 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 Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
The second strategy was for the therapist to speak for 5 to 10 minutes with

any adolescent who had to wait more than 2 weeks to begin service (a delay

sometimes caused by randomization and the cycles of starting new groups) to

sustain his or her motivation for service involvement. 

The third strategy was to remove as many environmental obstacles to 

treatment participation as possible by using geographically accessible 

service sites, providing assistance with transportation (that is, cab vouchers,

bus tokens, picking adolescents up in the agency van), and providing or

arranging child care. Case management, whether provided by therapists,

case managers (in the FSN intervention), or even during the screening

activities of the research staff, was an essential medium of engagement for

those families whose lives were most chaotic at the point of initial contact

with the CYT project. Every effort was made to link what could be learned

in treatment with what could help the immediate crisis presented by the

family. The CYT interventions shared the message, “We have something that

could help with some of these problems and improve the quality of life for

you and your child.”

The fourth and most important strategy was to actively engage the adolescents

and families by creating strong therapeutic alliances, expressing interest in

their participation (e.g., by weekly phone prompts for participation), finding

a goal that the adolescent and family were interested in working on,

expressing optimism in their capacity to change, and persisting in family

contacts during the earliest signs of disengagement. FSN intervention staff

felt that home visits were very important in initiating and sustaining the

involvement of the most treatment-resistant families. 

The fifth strategy was to provide a warm, collaborative, adolescent- and 

parent-friendly environment (with informal but respectful hosting, providing

pizza and sodas as part of the dinner-hour adolescent and parent meetings)

and to provide specific incentives for involvement in treatment (help with

very specific problems, fully subsidized treatment, and token prizes for

homework completion). 

D. Safety Net Procedures. Safety net procedures involve strategies for 

recognizing and responding to adolescents who before or after entering 

outpatient care were thought to be in need of a higher level of care or

allied services. We anticipated and experienced four scenarios that required

such safety net procedures. The first involved emergency situations that

might arise related to an 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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Appendix 4
154

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. 

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
F. Session Management. Efforts were made to ensure that issues related 

to the management of sessions that were not unique to the particular 

interventions would be handled in reasonably consistent ways across the

sites. Where procedures were not the same, they were reviewed to ensure

the differences would not confound outcomes. These discussions included

how to respond to lateness, missed sessions, the criteria for dropping cases,

intoxication, contraband, disruptive behavior, preexisting relationships

between members, and a group session at which only one member is present.

Lateness was handled by degree, by ensuring either that the client got the

minimal dose for that session or that the session was rescheduled. Missed

sessions were rescheduled or, in the case of group interventions, provided 

as an abbreviated makeup session prior to the next scheduled session. (All

services across the five modalities were expected to be completed within 14

weeks of the time of the first therapy session, with local TCs reviewing and

approving any exceptions to this rule.) 

All programs made intoxication and possession of contraband grounds for

exclusion from that particular session and a flag for reassessment of the

appropriateness of the current level of care. (While rare episodes of an

intoxicated youth arriving for services did occur, these episodes were 

clinically managed without excluding the adolescent from continued 

service.) Only one adolescent per family was included in the CYT study, 

and preexisting relationships between participants in the group modalities 

were reviewed to determine whether the prior history would undermine or

enhance treatment. A group with only one member present was conducted

in a 30- to 45-minute individual format covering the material that was

scheduled for presentation. If an adolescent failed to appear for a family

session, the session was conducted without the adolescent. 

The TCs collectively sought and implemented general strategies that could

enhance the effectiveness of sessions for all of the CYT therapies. Strategies

that served to minimize problems and enhance session effectiveness included

formalizing, posting, and consistently enforcing group/family norms on

such issues as dress (banning drug/gang symbols on clothing) and language

(profanity, drug argot). In the group interventions, the closed group structure

made it particularly important to guard against negative influences within

the peer cultures that evolved. A final issue was the appropriate level of 

contact between therapists and adolescents outside the intervention. The

TCs decided that such contact should be minimized so as not to contaminate

model fidelity by altering dose. More specifically, it was agreed that all

extra-session contact should be responded to within the therapeutic 

framework of the particular intervention, channeled into upcoming sessions,

documented, and brought to supervisors for review. 

G. Gender and Cultural Adaptations. While there is significant momentum

toward the development of standardized, empirically supported, and 

manual-based treatments (Wilson, 1998; Carroll, 1997), there is a 

simultaneous call for the refinement of standardized treatment that

includes gender and cultural relevance and effectiveness (Orlandi, 1995).

All of the CYT therapists noted making changes in their delivery of the

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156

manual-based treatments that were based on gender, cultural, and 

socioeconomic status (SES) appropriateness. Therapists in group interventions

explicitly noted diversity issues in the group and incorporated respect for

diversity into the ground rules established at the beginning of each group.

The most frequently mentioned adaptations included:

• Changing the language of the session to reflect cultural or 

geographical norms

• Adding items to some worksheets to make them more applicable 

to urban youth

• Providing special writing and reading assistance to address 

illiteracy

• Slowing the pace and adding repetitions of key ideas to 

accommodate learning impairments

• Developing examples and illustrations of key points that had 

greater gender, cultural, and SES relevance. 

Therapists emphasized it was not the content of interventions that had

changed; there were subtle changes in the way that content was framed or

delivered. 

H. Case Mix Issues. Therapists involved in the group interventions

(MET/CBT5, MET/CBT5 + CBT7, FSN) also decided to monitor closely

client mix issues according to gender, ethnicity, and other important

dimensions. There was an effort to identify any potential iatrogenic effects

of randomization (e.g., harassment, scapegoating, or other predatory 

targeting of a vulnerable group member by other group members) and to

actively manage potential negative effects of group support for antisocial

behavior (Dision, McCord, & Poulin, 1999). This was managed primarily by

establishing and enforcing norms for group sessions. 

I. Mutual Aid and Peer Support Groups. In contrast to Project MATCH, a

12-step facilitation therapy was not included in the CYT study, and there

was some variation in the philosophies of the 5 interventions related to the

desirability of mutual aid involvement by cannabis-involved adolescents. The

ACRA, MDFT, and MET/CBT interventions do not directly encourage affiliation

with addiction recovery support groups, but they do frame such involvement

positively if the adolescent is already involved in such a group or self-initiates

involvement during the course of treatment. FSN, while strongly encouraging

parents to participate in Al-Anon, does not directly encourage adolescent

clients to affiliate with Narcotics Anonymous (NA) or Alcoholics Anonymous

(AA). Information on local mutual support groups is provided simply as one

of many community resources. There was more of an emphasis in all the

CYT interventions on involvement in drug-free prosocial activities in general

than on addiction recovery support group involvement.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
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 crossintervention TC group and the CYT executive committee) and a process

(monthly meetings of all the TCs and monitoring visits at each CYT study

site) that were used to control contextual elements surrounding the 

experimental interventions. Our goal was to hold these contextual elements

constant across the interventions in order to enhance our ability to measure

the differences the experimental interventions produced on outcome 

measures. We wanted differences in outcomes to reflect differences in the

interventions themselves and not factors incidental to the interventions. 

While there were major research design elements (consistency in clinical

data collection instruments and procedures, inclusion and exclusion criteria,

and followup procedures) that helped control such variance across sites and

interventions, we also sought to identify more subtle areas of potential 

contamination of the study. By generating consistent cross-intervention 

procedures to respond to lateness, missed sessions, disruptiveness, 

intoxication, and concurrent participation in other services, we were able 

to ensure a consistent and a more precise definition of the dose and type 

of services provided in, and collateral to, each intervention. By developing 

and monitoring safety net procedures across the sites and interventions, we

were able to ensure timely and appropriate responses to the placement of 

a client in an inappropriate outpatient modality who needed a higher level

of care and to respond to acute episodes of clinical deterioration that 

warranted a similar change in the level of care. We found that the 

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collaborative work of the TCs helped enhance the methodological rigor of

the CYT study and helped establish a sound clinical infrastructure upon

which each of the interventions was tested. 

There are many aspects of the clinical management of the CYT project

other than the efficacy of the particular interventions used that may have

wide applicability to the field of adolescent substance abuse treatment. It is

our view that many of the procedures to provide overall clinical management

of randomized field trials have great clinical utility and are likely to become

future baseline clinical practices in the treatment of adult and adolescent

substance abuse disorders. 

The technology model that, to date, has been used primarily as a means of

ensuring methodological rigor in multisite field trials seems to us to have

enormous advantages for enhancing the quality of treatment and should be

studied for potential adaptation to mainstream clinical practice. Those

looking for ways to enhance the quality of adolescent substance abuse 

treatment would be well served to explore how the elements of this model

could become part of the future definition of treatment as usual. Parents

seeking help to address the substance abuse-related problems of their son

or daughter ought to be able to expect that the theory behind the treatments

they are offered can be articulated and that their active ingredients can be

defined. They should further be able to expect that these treatments have

some degree of scientific support for their effectiveness and that they will

be delivered in a manner consistent with procedures whose effectiveness has

been validated. 

Increased demands for such accountability and fidelity by parents, policy

makers, and funding agencies will likely make manual-based therapies the

rule in the future, along with the training and adherence measures that

accompany them. The technical aspects of cross-site clinical management

of the CYT project have much to offer the field as a whole. The use of 

standardized assessment instruments that are capable of providing 

comprehensive assessment and treatment planning data should become a

requirement of all adolescent treatment programs in the next decade. We

further commend the use of central (and booster) training, videotaping and

adherence ratings as standard practices in supervision, and cross-site 

supervision as marvelous tools for training and professional development.

Finally, we believe that rigorous followup (monitoring, feedback, and, where

indicated, early reintervention) should move from the realm of clinical

research to being an expectation, if not a requirement, of mainstream 

clinical practice. The idea of providing services without measuring outcomes

will be incomprehensible in the very near future, and the technology to 

perform this task is rapidly emerging. Morale among staff working in the

CYT project remained high, in part because of the near universal belief in

the historical importance of this study and the climate of excitement and

discovery that permeated the project. We believe that small field-based

experiments to answer critical clinical questions, opportunities for cross-site

sharing, and the opportunity to work on papers and presentations can 

similarly contribute to staff morale within local service organizations. We

believe this milieu of curiosity, discovery, and contribution is transferable

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions
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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Substance Abuse and Mental Health Services Administration

Printed 2002

Manuals in the Cannabis Youth Treatment (CYT) Series

Sampl, S., & Kadden, R. Motivational Enhancement Therapy and Cognitive Behavioral

Therapy for Adolescent Cannabis Users: 5 Sessions, Cannabis Youth Treatment (CYT) Series,

Volume 1. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and

Mental Health Services Administration. BKD384

Webb, C., Scudder, M., Kaminer, Y., & Kadden, R. The Motivational Enhancement Therapy

and Cognitive Behavioral Therapy Supplement: 7 Sessions of Cognitive Behavioral Therapy

for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 2. Rockville,

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

Administration. BKD385

Hamilton, N. L., Brantley, L. B., Tims, F. M., Angelovich, N., & McDougall, B. Family Support

Network for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 3.

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

Services Administration. BKD386

Godley, S. H., Meyers, R. J., Smith, J. E., Karvinen, T., Titus, J. C., Godley, M. D., Dent, G.,

Passetti, L., & Kelberg, P. The Adolescent Community Reinforcement Approach for Adolescent

Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 4. Rockville, MD: Center

for Substance Abuse Treatment, Substance Abuse and Mental Health Services

Administration. BKD387

Liddle, H. A. Multidimensional Family Therapy for Adolescent Cannabis Users, Cannabis

Youth Treatment (CYT) Series, Volume 5. Rockville, MD: Center for Substance Abuse

Treatment, Substance Abuse and Mental Health Services Administration. BKD388

To order copies of this manual or any other manuals in this series, contact the Substance Abuse and Mental

Health Services Administration’s (SAMHSA’s) National Clearinghouse for Alcohol and Drug Information (NCADI)

at 800–729–6686, 800–487–4889 (TDD), or www.samhsa.gov/. The manuals will be available to download electronically from www.samhsa.gov/csat/csat.htm/.