MotivationalEnhancementTherapyand

CognitiveBehavioralTherapy

forAdolescentCannabisUsers: 

5Sessions

Susan Sampl, Ph.D. 

Ronald Kadden, Ph.D. 

University of Connecticut School of Medicine 

CYT
 Cannabis Youth Treatment Series
 

Volume 1
 

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 

www.samhsa.gov
All material appearing in this volume except that taken directly from 

copyrighted sources is in the public domain and may be reproduced or 

copied without permission from the Substance Abuse and Mental Health 

Services Administration’s (SAMHSA’s) Center for Substance Abuse 

Treatment (CSAT) or the authors. Citation of the source is appreciated. 

The material appearing on pages 68 through 76 was adapted from 

copyrighted material and may still be under copyright. The handouts are 

reproduced herein with the permission of the copyright holders. Before 

reprinting, readers are advised to determine copyright status of all such 

materials or to secure permission of the copyright holders. 

The document was written with the support of CSAT through grant 

numbers TI11317, TI11320, TI11321, TI11323, and TI11324. Jean 

Donaldson, M.A., served as the CSAT Project Officer. This document was 

edited and prepared for publication by CSAT’s Knowledge Application 

Program (KAP) under contract number 270-99-7072 with Johnson, Bassin 

& Shaw, Inc. (JBS), and The CDM Group. Karl White, Ed.D., served as the 

CSAT KAP Government Project Officer. Lynne McArthur served as the 

Project Director. Other JBS personnel included Barbara Fink, M.P.H., 

Deputy Director for Product Development; Nancy Hegle, Quality Control 

Manager; and Tonya Young, Graphic Artist. 

The opinions expressed herein are the views of the authors and do not 

represent the official position of CSAT, SAMHSA, or any other part of the 

U.S. Department of Health and Human Services (DHHS). 

DHHS Publication No. (SMA) 01–3486 

Printed 2001 

Cover images © 2000 Digital Stock. 
Acknowledgments, Disclaimer, and Contact Information
 

This document is a product of the Steering Committee for the 

Cannabis Youth Treatment (CYT) Project Cooperative Agreement that was 

funded by the Center for Substance Abuse Treatment (CSAT), Substance 

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

Department of Health and Human Services (DHHS). The document was 

prepared with support from CSAT grants for a coordinating center awarded to 

Chestnut Health Systems, Inc. (TI11320); four sites awarded to the University 

of Connecticut Health Center (TI11324), Operation Parental Awareness and 

Responsibility, Inc. (PAR) (TI11317), Children’s Hospital of Philadelphia 

(CHOP) (TI11323), and Chestnut Health Systems (TI11321) as well as 

Federal staff time from the CSAT collaborators. The authors would like to 

acknowledge that this work builds directly on earlier manuals done for adults 

as part of CSAT’s Marijuana Treatment Project (Steinberg, Carroll, Roffman & 

Kadden, 1997), National Institute on Alcohol Abuse and Alcoholism’s 

(NIAAA) Project MATCH (Kadden, Carroll, Donovan, Cooney, Monti, Abrams, 

Litt & Hester, 1992; Miller, Zweben, DiClemente & Rychtarik, 1992), and an 

earlier manual for treating alcohol dependence through coping skills training 

(Monti, Abrams, Kadden & Cooney, 1989). They would also like to thank the 

staff of the CYT studies and the following people for their assistance in 

preparing and implementing this protocol: Michael Dennis, Guy Diamond, 

Jean Donaldson, Susan Godley, Jim Herrell, Yifrah Kaminer, Kerry Anne 

McGeary, Frank Tims, Janet Titus, and William White. Appreciation is also 

extended to Joan Unsicker of Chestnut Health Systems for the thoughtful 

review she provided of an earlier draft of the manual. Finally, the authors 

would like to thank Barbara Fink of Johnson, Bassin & Shaw, Inc., who 

provided valuable assistance in preparing the manual for publication. 

The opinions expressed in this document are solely those of the 

authors and do not represent official positions of CSAT or any other 

governmental agency. While studies of a combined motivational enhancement therapy and cognitive behavioral therapy (MET/CBT) approach are 

promising, this treatment protocol was tested with adolescents for the first 

time as part of this study. The findings from the CYT study will be made 

public in 2001. Appendix 5 presents a detailed account of the CYT study. 

For further information about this manual, please contact the 

MET/CBT5 work group chair, Dr. Ronald Kadden, at 860–679–4249 

(Kadden@psychiatry.uchc.edu) or Dr. Susan Sampl at 860–679–4715 

(Sampl@psychiatry.uchc.edu). For further information about the Cannabis 

Youth Treatment Project please visit our Web site (www.chestnut.org/CYT) 

or contact the Steering Committee Chair, Dr. Michael Dennis, at 

309–827–6026 (Mdennis@chestnut.org). 

To order copies of this manual or any other manuals in this series, 

contact the National Clearinghouse for Alcohol and Drug Information 

(NCADI) at 800–729–6686, 800–487–4889 (TDD), (www.health.org). 

The manuals also will be available to download from 

http://www.samhsa.gov/csat/csat.htm. 

iii
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 

iv
Table of Contents 

Acknowledgments, Disclaimer, and Contact Information iii
 

I. Introduction and Background 1
 

Introduction and Organization 1
 

Scope and Significance of the Marijuana Problem 1
 

Effects of Marijuana Use 2
 

Patterns of Substance Use 3
 

II. Background on the CYT Cooperative Agreement 5
 

Goals and Objectives 5
 

Overview of Study 5
 

Client and Provider Information 6
 

III. Background of the MET/CBT5 Treatment 9 

Rationale for Brief Treatment 9
 

Basis for MET 9
 

Rationale for CBT Treatment 11
 

Rationale for Group Therapy 11
 

Staff Requirements 12
 

IV. MET/CBT5 Treatment 17
 

Overview of MET/CBT5 Protocol 17
 

V. Motivational Enhancement Therapy 19
 

Key Concepts 19
 

The Five Strategies of Motivational Enhancement Therapy 21
 

Abstinence and Relapse 25
 

Preparation for Individual Sessions 30
 

Session 1: MET1—Motivation-Building Session 32
 

Session 2: MET2—Goal-Setting Session 41
 

VI. Cognitive Behavioral Therapy 53
 

Key Concepts and Session Guidelines 53 

Session 3: CBT3—Marijuana Refusal Skills 61 

Session 4: CBT4—Enhancing the Social Support Network 

and Increasing Pleasant Activities 68 

Session 5: CBT5—Planning for Emergencies and Coping 

With Relapse 77 

v
 

VII. Common Treatment Issues	 83 

Client Issues for Group and Individual Sessions	 83 

Issues in Group Sessions	 85 

Client Participation Problems in Group CBT	 86
 

Monopolizers in Group CBT	 86
 

Working With the Participant With Cognitive or 

Perceptual Impairments	 89
 

Inactive Members in Group CBT	 89
 

VIII. References	 93 

IX. Appendixes 

1. Therapist Session Reports	 99
 

2. Supervisor Session Rating Reports	 109
 

3. Facsimiles of 11- by 17-inch Posters for Sessions 3, 4, and 5 121
 

4. Personalized Feedback Reports	 127
 

5. Clinical Management of a Multisite Field Trial of 

Five Outpatient Treatments for 

Adolescent Substance Abuse 139
 

vi
I. Introduction and Background
 

Introduction and Organization 

This manual is designed to help train substance abuse treatment 

counselors to conduct a brief five-session treatment intervention for 

adolescents with cannabis use disorders presenting for outpatient 

treatment. It combines two sessions of motivational enhancement therapy 

provided individually and three sessions of cognitive behavioral therapy 

provided in a group format. The program is referred to as MET/CBT5. 

Although this will be one of the first applications of these approaches to 

adolescent treatment, related brief intervention approaches with adults 

have proved very effective (Bien, Miller & Tonigan, 1993; Miller et al., 1995; 

Miller & Rollnick, 1991; Siegal, Rapp, Fisher, Cole & Wagner, 1993; Stark & 

Kane, 1985; Stephens, Roffman & Simpson, 1994; Zweben, Pearlman & Li, 

1988). In the CYT study, the approach was also an efficient intervention 

because its personalized feedback report was based on the intake 

assessments already done as part of the research protocol. 

The treatment described in this manual was designed to address the 

problem of marijuana use by adolescents. Section I reviews the scope, 

effects, and patterns of the marijuana problem. Section II provides a brief 

overview of the Cannabis Youth Treatment project for which this manual 

was developed. Section III covers the scientific basis for this intervention. 

Section IV provides step-by-step procedures for actually implementing this 

treatment protocol. 

Scope and Significance of the Marijuana Problem 

Although marijuana use has dropped slightly in the past few years, it 

is still the most widely used and most readily available illicit psychoactive 

substance in the United States (Office of Applied Studies, 2000). In 1998, 

the rate of marijuana use during the month preceding the survey was more 

than twice that of all other drugs combined (8.3 percent vs. 4.0 percent) 

and higher than the rate of getting drunk (7.7 percent). Moreover, the rates 

of marijuana use for 8th graders are twice as high as the rates in 1992. The 

rate of daily use of marijuana is higher than the rate of daily use of alcohol, 

and that rate has not gone down (Monitoring the Future, 1999). 

Furthermore, similar trends in marijuana use are reported in regional 

surveys of junior and senior high school students (Godley et al., 1996; 

Hartwell et al., 1996; Markwood, McDermiet & Godley, 2000). Marijuana 

use has historically been inversely related to an adolescent’s perceived risk 

of using it (Johnson, Hoffman & Gerstein, 1996), and currently this 

perception among 12th graders is at the lowest point since 1982 

(Monitoring the Future, 1999). Unfortunately, these perceptions do not 

match the facts. 

Relative to nonusers, adolescents who used marijuana (and typically 

alcohol) weekly were 3 to 47 times more likely to have a host of problems 

including symptoms of dependence, emergency room admissions, dropping 

1
out of school, behavioral problems, fighting, non-drug-related legal 

problems, other legal problems, and being arrested. Unfortunately, fewer 

than 1 in 10 adolescents with past-year symptoms of dependence received 

treatment (Dennis & McGeary, 1999; Dennis, Godley & Titus, 1999). From 

1992 to 1997, the number of adolescents presenting to publicly funded 

treatment for marijuana problems increased more than 200 percent; in 

1997, 81 percent of adolescents admitted had a primary, secondary, or 

tertiary problem with marijuana (Dennis, Dawud-Noursi & Muck, in press; 

Office of Applied Studies, 1999). Marijuana is also the leading substance 

mentioned in adolescent emergency room admissions and autopsy reports 

and is believed to be one of the major contributing factors to violent deaths 

and accidents among adolescents; it has been reported to be involved in as 

many as 30 percent of adolescent motor vehicle crashes, 20 percent of adolescent homicides, 13 percent of adolescent suicides, and 10 percent of 

other unintentional injuries among adolescents (Centers for Disease 

Control and Prevention, 1997; McKeown, Jackson & Valois, 1997; Office of 

Applied Studies, 1995). 

An additional danger associated with marijuana use and observed in 

adolescents is a sequential pattern of involvement in legal and illegal drugs 

(Kandel, 1982). Marijuana is frequently a stepping stone that bridges the 

gap between cigarette and alcohol use and use of other drugs (e.g., cocaine, 

heroin) (Kandel & Faust, 1975). This stagelike progression of substance 

abuse, known as the gateway phenomenon, is common among youth from 

all socioeconomic and racial backgrounds (Kandel & Yamaguchi, 1993). 

This pattern has also been observed in French and Israeli cohorts (Adler & 

Kandel, 1981) and has been confirmed in a longitudinal cohort followed 

from ages 15 to 35 (Kandel et al., 1992). In sum, adolescent marijuana use 

is intimately linked to future drug involvement. Less serious experimental 

use portends a decline in later use of all drugs, whereas more serious use 

often snowballs into involvement with increasingly addictive and potent 

drugs. 

Effects of Marijuana Use 

The physical effects of marijuana use include fluctuations in blood 

pressure, decreased salivation, mild unsteadiness, impaired coordination, 

hunger, drowsiness, slowed speech, and respiratory difficulties (Cohen, 

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

decrease in the immune response, suppression of testosterone production 

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

The effect of marijuana use during adolescence on central nervous 

system development remains unclear. Adolescents abstaining after chronic 

marijuana use have shown evidence of persistent short-term memory 

impairment on neuropsychological tests (Millsaps et al., 1994). Pope and 

Yurgelun-Todd (1996) have recently demonstrated an indirect association 

between the frequency of marijuana use among college students and cognitive impairment on tests involving card sorting and word learning. These 

effects are likely to have a significant impact on academic functioning. 

Whether neuropsychological deficits preceded the onset of drug use or were 

2
the result of long-term exposure to marijuana is unclear. Clinical studies 

suggest that longer term and/or heavier use of marijuana is directly 

associated with losses of abstract and logical thinking, the ability to focus 

attention and filter out irrelevant information, and the ability to resolve 

normal emotional conflicts, mental confusion, and memory problems 

(Lundvqist, 1995; Solowij, 1995; Solowij et al., 1995). These studies also 

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, 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 the ages of 19 and 21 might actually be due to 

co-occurring depression. Whether amotivational syndrome is a primary or a 

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 

illicit drugs were used almost exclusively by marijuana users, rather than 

those who did not use marijuana, 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 et al., 1992; Hawkins et al., 

1992; Jessor & Jessor, 1977). 

Patterns of Substance Use 

Anecdotal and longitudinal studies have suggested that the age of 

onset for regular marijuana use most frequently occurs during early 

adolescence (before age 15) and is almost always completely intertwined 

with alcohol use (Hops, 1998; Patterson, 1998). Public domain data from 

5,143 adolescents surveyed for the Office of Applied Studies (1996) and 

1995 National Household Survey on Drug Abuse (NHSDA) show that after 

age 15, daily use stabilizes at a rate of about 2 to 3 percent, weekly use at 

about 3 to 4 percent, and monthly use at about 6 to 7 percent. Parallel data 

for alcohol use are consistent with the literature and suggest an early 

pattern of onset. Weekly use increases from less than 1 percent at age 12, 

to 3 percent at age 14, to 10 percent at age 18. Daily use increases from 4 

percent at age 12, to 7 percent at age 14, to 9 percent at age 18. Thus, for 

3
both marijuana and alcohol, adolescence is clearly a significant period both 

for initial use and for increasingly more frequent rates of use. 

With regard to comorbidity, over two-thirds of the monthly and weekly 

marijuana users are drinking alcohol—with a third drinking it daily or weekly. 

Among the daily marijuana users, 27 percent were drinking weekly and 35 

percent were drinking daily. Thus, marijuana and alcohol use is starting at 

similar times, and patterns of their use are largely intertwined. 

4
II. Background on the CYT Cooperative Agreement
 

MET/CBT5 was developed as a brief intervention to be tested at four 

treatment sites within the Cannabis Youth Treatment study. Section III of 

this manual describes the rationale for choosing the elements of the 

MET/CBT5 therapy. The following description illustrates the context in 

which MET/CBT5 was developed. 

Goals and Objectives 

The purpose of the Substance Abuse and Mental Health Services 

Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) 

Cannabis Youth Treatment Cooperative Agreement was to test the relative 

effectiveness and cost-effectiveness of a variety of interventions targeted at 

reducing/eliminating marijuana use and associated problems in adolescents 

and to provide validated models of these interventions to the treatment field. 

The target population was adolescents with cannabis use disorders of abuse or 

dependence, as defined by the American Psychiatric Association (1994), who 

were assessed as appropriate for treatment in outpatient settings. 

Overview of Study 

The study was conducted in collaboration with staff from Chestnut 

Health Systems (CHS–MC) in Bloomington and Madison County, Illinois, 

the University of Connecticut Health Center (UCHC) in Farmington, 

Connecticut, Operation Parental Awareness and Responsibility (PAR) in St. 

Petersburg, Florida, and the Children’s Hospital of Philadelphia (CHOP), 

Pennsylvania. It involved five manual-based, expert-supported treatment 

conditions: 

• MET/CBT5—This is the five-session treatment described in this 

manual. It comprises two individual sessions of motivational 

enhancement therapy (MET) and three group sessions of 

cognitive behavioral therapy (CBT). The MET sessions focus on 

factors that motivate clients to change. In the CBT sessions, 

clients learn skills to cope with problems and meet their 

needs in ways that do not involve turning to marijuana or alcohol. 

• MET/CBT5+CBT7—This treatment is composed of the complete 

MET/CBT5 treatment combined with seven supplemental 

cognitive behavioral sessions covering additional coping skills 

topics. 

• FSN—The Family Support Network (FSN) treatment consists of 

the MET5+CBT7 treatment combined with additional support for 

families (home visits, parent education meetings, parent support 

group), aftercare, and case management. 

• ACRA—The Adolescent Community Reinforcement Approach 

(ACRA) is composed of 12 individual sessions with an adolescent 

5
and the adolescent’s parent, caregiver, or concerned other. The 

focus is on learning alternative skills to cope with problems and 

meet needs with an emphasis on the adolescent’s environment. 

Concerted effort is made to change the environmental contingencies—both positive and negative—related to substance use. 

• MDFT—Multidimensional Family Therapy (MDFT) is a familyfocused treatment that includes 12 weekly sessions to work 

individually with adolescents and their families. MDFT focuses on 

family roles, other problem areas, and their interactions. 

These treatments can also be grouped in three different ways. First, 

they vary by mode, with the first three being combinations of individual and 

group approaches and the last two being purely individual treatment approaches. Second, the MET/CBT and ACRA interventions were based on behavioral 

treatment approaches, while the FSN and MDFT interventions were based on 

family treatment approaches. Third, the treatment conditions were expected 

to vary in terms of resource intensity and cost, with the MET/CBT5 

intervention expected to be the least costly therapy to implement. 

At each site, approximately 150 adolescents were systematically 

assigned to one of three conditions. At ARC and PAR, they were assigned to 

the brief MET/CBT5 or to one of the two other individual/group 

combinations, MET/CBT5+CBT7 or FSN. At CHS–MC and CHOP, adolescents were assigned to the brief MET/CBT5 treatment or one of the two 

individual approaches, ACRA or MDFT. Thus, all five conditions were replicated in two or more sites, with the MET/CBT5 condition implemented at 

all four sites. All clients were assessed at intake and at 3, 6, and 9 months. 

To validate clients’ responses, urine tests and collateral assessments are 

also done at intake and at 3 and 6 months. 

The general research design document prepared by Dennis and 

colleagues describes the overall research plan in greater detail (Dennis, 

Titus, Diamond, Donaldson, Godley, Tims, Webb, Kaminer, Babor, French, 

Godley, Hamilton, Liddle & Scott, under review). The project’s Web site 

(www.chestnut.org/CYT) can be accessed for further information about the 

CYT project. 

Client and Provider Information 

Target Population 

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

ages of 12 and 18 with 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 

• Using marijuana at least weekly for 3 months. 

6
Although this treatment includes suggestions for addressing both 

drug and alcohol use, it is not designed for treating adolescents with polysubstance dependence or those who are heavily using other substances as 

well as marijuana. In the CYT study, adolescents were excluded from the 

study who drank alcohol on 45 or more of the previous 90 days or who used 

another drug on 13 or more of the previous 90 days. 

MET/CBT5 should not be used to treat adolescents 

• Requiring a level of care that is higher than outpatient treatment 

• With a social anxiety disorder severe enough to prevent participation in group therapy sessions 

• With a severe conduct disorder 

• With an acute psychological disorder severe enough to prevent 

full participation in treatment. 

In the CYT study, this treatment was effectively implemented with 

adolescents with mixed demographic characteristics such as race, age, 

socioeconomic group, and gender, as well as from different geographic 

regions. When treating clients, therapists need to be culturally aware of 

and sensitive to the client group so they can provide relevant examples 

and use language that is understood by the clients in the therapy session. 

Likely referral sources of potential MET/CBT5 clients are parents, 

the justice system, school personnel, and medical or mental health care 

providers. Self-referral is infrequent. 

Level of Care 

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

(ASAM level 1) or early intervention (ASAM level 0.5). 

MET/CBT5 can be used by organizations that provide outpatient care, 

including mental health clinics, youth social service agencies, and mental 

health private practice settings. Other organizations such as community 

centers, schools, or general medical settings may appropriately implement 

MET/CBT5 if they have properly trained staff. Medical settings may be particularly well suited for implementation of MET/CBT5 as an early intervention. 

7
III. Background of the MET/CBT5 Treatment 

The MET/CBT5 approach was designed to be an effective brief 

treatment approach for cannabis-abusing adolescents. The course of 

treatment consists of two individual motivational enhancement therapy 

(MET) sessions, followed by participation in three group cognitive 

behavioral therapy (CBT) sessions. The reasons for choosing a brief 

treatment model, as well as the background for the MET and CBT 

treatment models, are described in this section. 

Rationale for Brief Treatment 

Stephens and Roffman (1996) compared an 18-session relapse 

prevention support group approach for the treatment of marijuana 

problems with a 2-session individualized assessment and intervention 

approach. The latter included a feedback report based on data collected in 

pretreatment assessments, discussion of the client’s marijuana use and 

related problems using motivational interviewing principles, and 

development of a plan for change. The results of the study indicated 

substantial reductions in marijuana use for both active treatments and no 

evidence of posttreatment differences between the two approaches in terms 

of abstinence rates, days of marijuana use, severity of problems, or number 

of dependence symptoms. Although conclusions regarding null differences 

must be limited, the large sample sizes and the substantial differences in 

intensity of the treatments argue for an equivalent efficacy of the two 

conditions. The results suggest that a minimal intervention approach may be 

more cost-effective for a marijuana-abusing population than an extended 

group counseling approach. That study, along with others indicating the 

general effectiveness of brief interventions for some psychiatric disorders 

and substance abusers, was an important factor in the decision to test 

relatively brief interventions in large samples of adults (the companion study 

to this one) and adolescents (this study) at diverse locations nationally. 

Basis for MET 

In the addictions field, the search for critical conditions that are 

necessary and sufficient to induce change has led to the identification of six 

critical elements (Miller & Rollnick, 1991): 

• Feedback regarding personal risk or impairment 

• Emphasis on personal responsibility for change 

• Clear advice to change 

• A menu of alternative change options 

• Therapist empathy 

• Facilitation of client self-efficacy or optimism. 

Therapeutic interventions containing some or all of these elements 

have been effective in initiating change and reducing alcohol use (Bien, 

Miller & Tonigan, 1993). 

9
The MET approach is further grounded in research on processes of 

change. Prochaska and DiClemente (1984) describe five stages of change 

that people progress through in modifying problem behaviors (the stages of 

precontemplation, contemplation, determination, action, and maintenance). The MET approach assists clients in moving through the stages 

toward action and maintenance. 

In sum, MET is based on motivational principles and has been 

utilized increasingly in clinical interventions and research, primarily in the 

alcoholism field. Recently it has also been included as a component in the 

study that is a companion to the present one—evaluating brief treatments 

for adult marijuana abusers. 

The MET sessions included in MET/CBT5 are planned as individual 

therapy sessions for a number of reasons. First, motivational enhancement 

therapy is designed to be an individual approach in which the therapist 

works with each client regarding that client’s own specific reasons for 

considering change. Most previous effective demonstrations of motivational 

enhancement therapy have utilized an individual therapy format (Miller et 

al., 1995; Steinberg et al., 1997; Stephens & Roffman, 1996). This individual 

approach in MET/CBT5 is reflected in the use of a personalized feedback 

report, which stimulates discussion of that client’s personal concerns and 

motivations regarding his or her substance use. An individual session is most 

conducive to a personal discussion. In addition, individual MET sessions are 

preferable because clients may feel embarrassed about aspects of their substance abuse and related problems; initially they may feel more comfortable 

discussing these problems individually. Finally, adolescent clients sometimes 

feel apprehensive about verbalizing their motivation to quit marijuana in 

front of their peers, for fear that their peers will think that they are not cool. 

They may have a better chance of contemplating their ambivalence about 

quitting—and firming up their motivation to address their marijuana use— 

by working with the therapist privately at first. 

This MET/CBT5 therapy is an adaptation of adult treatment to 

adolescents. 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 that may help inform therapists using MET/CBT5. Nowinski 

discusses the primary adolescent developmental task of individuation, in 

which adolescents develop identities separate from their parents or 

caregivers. As a part of this individuation process, adolescents are especially 

likely to question what adults tell them. Using MET style minimizes the 

likelihood of provoking resistance, which might occur in a highly directive 

or confrontational therapeutic approach. As a result, the MET approach 

seems particularly promising for adolescent marijuana abusers. 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). 

10
The therapists in MET/CBT5 encourage adolescents to try an 

extended period of abstinence from marijuana to evaluate potential impacts 

on their lives. In keeping with the MET style though, there is a tolerance for 

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

force abstinence, but helps the client to understand the risks associated 

with continued use. It is possible that this aspect of MET may be problematic for others in the adolescent’s life who may take issue with the therapist 

not insisting on absolute abstinence. As a matter of fact, many adolescents 

referred to the treatment may have already been told by other authority 

figures that they need to abstain from marijuana, with little or no impact 

on their behavior. It may be that if the therapist were to echo this unilateral 

message, it too would have little therapeutic impact. It may be useful to 

educate those in supportive roles around the adolescent client about this 

aspect of MET to decrease the likelihood that they will react negatively and 

undermine the therapist’s credibility. 

Rationale for CBT Treatment 

Cognitive behavioral therapy (CBT) is designed to remediate deficits 

in skills for coping with antecedents to marijuana use. Individuals who rely 

primarily on marijuana (or other substances) to cope have little choice but 

to resort to substance use when the need to cope arises. The goal of this 

intervention is to provide some basic alternative skills to cope with situations that might otherwise lead to substance use. Skill deficits are viewed as 

central to the relapse process; therefore, the major focus of the CBT groups 

will be on the development and rehearsal of skills. 

The cognitive-behavioral treatment approach used in this 

intervention is based on that described in Treating Alcohol Dependence: A 

Coping Skills Training Guide (Monti, Abrams, Kadden & Cooney, 1989), a 

treatment manual that focuses on training in interpersonal and selfmanagement skills. It incorporates treatment elements that have 

demonstrated clinical effectiveness with alcoholic clients into a manual of 

interventions aimed at adolescents that can be reliably delivered, monitored, 

and evaluated. 

The focus of CBT treatment is on teaching and practicing overt 

behaviors, while attempting to keep cognitive demands on clients to a 

minimum. Repetition is essential to the learning process in order to develop 

proficiency and to ensure that newly acquired behaviors will be available 

when needed. Therefore, behavioral rehearsal will be emphasized, using 

varied, realistic case examples to enhance generalization to real life 

settings. During the rehearsal periods, clients are asked to identify cues 

that signal high-risk situations, indicating their recognition of when to 

employ newly learned coping skills. 

Rationale for Group Therapy 

Many of the problems or skill deficits associated with substance 

abuse are interpersonal in nature, and the context of a group provides a 

realistic yet “safe” setting for the acquisition or refinement of new skills. A 

11
number of features associated with group approaches to treatment may 

facilitate cognitive, affective, and behavioral changes. These factors include 

the realization that others share similar problems; development of social 

behaviors; opportunity to try out new behaviors in a safe environment; and 

development and enhancement of interpersonal learning and trust. Group 

therapy breaks through clients’ isolation, encouraging development of 

interdependence and identification with other marijuana users, while at the 

same time avoiding overdependence on the therapist. It also provides the 

therapist with an opportunity to observe the interpersonal behavior of each 

group member. 

With respect to social skills training, important aspects of the 

treatment, particularly modeling, rehearsal, and feedback, probably occur 

more powerfully in a group setting. A client model whose skill level is only 

somewhat greater than that of a peer observer is likely to have more impact 

than a skilled therapist is. 

A group-therapy format also provides opportunities for behavioral 

rehearsal and risk taking. Clients benefit from feedback offered by their 

peers, from discussions of anticipated obstacles to implementation of new 

skills, and from the case examples provided by fellow clients. There is also 

the possibility for greater habituation of social anxiety in a group setting. 

Group therapy is the most widely used form of treatment delivery for 

substance abuse rehabilitation. It has a high level of clinical relevance and 

can be utilized across a variety of treatment settings (e.g., inpatient, 

outpatient, day programs). Therefore, the results of any study using group 

therapy are likely to have an impact on current practice. Group therapy is 

also likely to have a bright future in these increasingly cost-conscious times 

because of its favorable client-to-staff ratio. 

Group therapy can be a particularly powerful modality for teen 

clients given the importance of peer influence in adolescence (Nowinski, 

1990). Feedback from a peer is likely to have greater impact on adolescent 

clients than similar feedback from the therapist. In the group CBT sessions, 

therapists encourage adolescent participants to offer other group members 

positive and constructive feedback. At the same time, adolescent clients are 

equally susceptible to the negative influence of peers. As a result, it is 

especially important that the therapist monitor and address any antisocial 

comments and behaviors that occur in group sessions. 

Staff Requirements 

Below are the recommended credentials and prior experience 

requirements for therapists delivering MET/CBT5: 

• Therapists should have completed a graduate program for 

providing clinical mental health services (e.g., M.S.W., Psych.D., 

Ph.D. in psychology) or an addiction counseling certification 

program. Some individuals who have completed a bachelor’s 

degree in an area related to mental health can become effective 

12
providers of MET/CBT5. However, it is likely that they will require 

more intensive training and supervision to achieve competency. 

The more experience bachelor’s level therapists have had in the 

areas listed below, the more likely they will become effective 

MET/CBT5 therapists. 

• Therapists should have a minimum of 1 year’s clinical experience 

working with adolescents. 

• Therapist experience in the following areas is also desirable: 

•	 Working with substance abuse issues 

•	 Providing behavioral and/or cognitive behavior 

interventions 

•	 Providing manual-based therapy. 

Therapists with experience in these areas are likely to learn the 

MET/CBT5 intervention most quickly. 

The following recommended caseloads are considered ideal for 

implementing MET/CBT5 in a clinical setting. One full group of six 

participants is likely to require approximately one-quarter of a full-time staff 

person’s time (approximately 10 hours per week). For a full-time person 

who is only seeing MET/CBT5 participants, it is recommended that the 

caseload be limited to 3 full groups (or 18 participants) rather than 4 full 

groups, because of the demands involved in keeping track of 18 adolescents’ progress and in managing such a caseload. The groups should start 

on a staggered basis, rather than simultaneously. This way, the initial, heavy 

demand on clinicians’ time to see each participant for two individual 

sessions will be spread out. 

Staffing Recommendations 

In the first 2 weeks of the treatment, the therapist sees each 

participant for two individual therapy sessions. Over the following 3 weeks, the 

therapist conducts one group therapy session per week. Additional clinician 

time may be needed to handle emergencies that may occur, to address 

pragmatic issues such as scheduling and communication, or to make referrals. 

Additional staff is needed to conduct and score the initial 

assessments and prepare the personalized feedback reports. During a group 

therapy session, another staff person should be available in reasonable 

proximity to the group therapy room. 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 exhibiting disruptive behavior. 

Training and Certification Procedures 

Therapists should receive 11⁄2 to 2 full days of initial live training in 

MET/CBT5, with the amount of time needed depending on therapist and 

13
 
project/agency characteristics. Longer training is indicated for less-experienced 

trainees and/or when therapists will need orientation to the context in which 

the therapy will be implemented. Also, longer training is indicated when therapists require some extensive training in cultural competence. In the CYT study, 

the therapists participated in 2 full days of training. The first half-day was an 

orientation to the CYT project and some common clinical issues applicable to 

all CYT therapies. The second half of day 1 and all of day 2 focused on teaching 

MET/CBT5. 

The training should be provided by a graduate-level clinician (or a team 

of clinicians) experienced (minimum of 2 years) in providing, supervising, and 

training motivational enhancement and cognitive behavioral therapy for 

substance abusers. The trainer should also have at least 2 years of clinical 

experience with adolescents. The trainer should have extensive knowledge of 

the treatment manual contents. The training should include a variety of 

formats including the following: 

• Instruction of rationale and procedures 

• Observation of live and/or videotaped examples 

• Active practice exercises with feedback. 

By varying the formats and by including engaging visual aids, the 

trainer will be more likely to keep participants actively involved. To increase 

engagement and clarity, the trainer should welcome and encourage 

participants’ questions and comments. 

If MET/CBT5 therapy is to be used in a multisite clinical research 

project, or in a multisite agency where the intent is consistent delivery and 

enhanced cohesiveness, it is recommended that the initial training be 

centralized to one common site and session. This way the therapists at each 

site will have a common foundation from which to work. During the centralized 

training, they will have a chance to hear the comments and questions of 

therapists at other sites and thus will be exposed to a wider range of issues that 

may come up in applying the intervention. Another likely benefit of centralized 

training is the potential for it to generate cohesiveness and enthusiasm, 

whereby participating therapists get the feeling of being a part of the big 

picture. The trainer can help with this by making enthusiastic comments about 

being included among therapists who will implement this new therapy, as well 

as by encouraging participants to interact with those from other sites during 

practice exercises and breaks. 

Supervision and Monitoring Procedures 

The person providing the ongoing supervision may have participated 

as a trainer in the initial training of therapists; however, this in not necessary. 

It is crucial, however, that the clinical supervisor attends the training. The 

clinical supervisor should have at least 2 years’ experience in delivering and 

supervising motivational enhancement and cognitive behavioral therapies for 

substance abusers and in treating adolescents. Experience in supervising 

manual-based therapies is desirable. If the supervisor has not had experience 

supervising manual-based therapies, it is recommended that he or she be 

provided with some related consultation and instruction. 

14
The therapists should receive 1 hour of supervision each week. Prior 

to certification, this supervision should be on an individual basis. All 

therapy sessions should be audiotaped or videotaped (with the consent of 

the adolescent participant and his or her parent/legal guardian). All 

therapists will need to demonstrate their competence in delivering 

MET/CBT5. Prior to certification, the supervisor should review every session 

conducted by the therapist in training and rate each session using the 

supervisor session rating report (see appendix 2). The supervisor provides 

feedback regarding the therapist’s performance on the skills reviewed in 

each session, reinforcing his or her relative strengths and identifying skills 

needing improvement. For those skills needing improvement, the supervisor 

should provide specific examples, present the rationale for changing 

technique, and help the therapist generate alternative responses. The 

therapist is considered certified in providing MET/CBT5 when he or she 

demonstrates an “adequate” or higher skill level on each of the skills. It is 

helpful if the supervisor and therapist review portions of the taped sessions, 

allowing them to discuss the therapist’s skills as they hear them together. 

The therapist also completes a therapist session rating report at the end of 

each session. The supervisor then reviews the reports and notes any 

meaningful differences between the therapist’s and the supervisor’s 

interpretation of the session. Any differences should be discussed. This will 

help the therapist with his or her understanding of MET and CBT skills and 

can improve self-monitoring. 

15
 
 

 

 

 

 

 

IV. MET/CBT5 Treatment
 

Overview of MET/CBT5 Protocol 

The MET/CBT5 treatment, a brief treatment approach for 

adolescents with cannabis use disorders, consists of two individual 

motivational enhancement therapy (MET) sessions, followed by three group 

cognitive behavioral therapy (CBT) sessions. The two initial individual MET 

sessions are primarily intended to enhance adolescents’ motivation to 

address their marijuana use and to prepare the clients for the group 

sessions, with an introduction to functional analysis and the concept of 

triggers. The purpose of the three group sessions is to assist clients in the 

development of skills useful for stopping or reducing marijuana use. The 

CBT sessions focus on the following skills: 

• Learning basic skills for refusing offers of marijuana 

• Developing a plan for pleasant drug-free activities 

• Establishing a social network that will support recovery 

• Coping with high-risk situations 

• Recovering from a relapse, should one occur. 

The table below illustrates the sequence of the five sessions of the 

MET/CBT5 treatment. Note that the first two (individual) sessions are 

expected to last for 60 minutes. The final three (group) sessions are 

scheduled to run for 75 minutes. 

Sequence of MET/CBT5 Treatment 

Session Modality Time 

Period 

Primary 

Approach 

Topics 

Session 1 Individual 60 min. MET Rapport and motivation building 

Review of personalized feedback report 

Session 2 Individual 60 min. MET Goal setting 

Introduction to functional analysis 

Preparation for group sessions 

Session 3 Group 75 min. CBT Marijuana refusal skills, with roleplay 

practice exercises 

Session 4 Group 75 min. CBT Enhancing social support network 

Increasing pleasant activities 

Session 5 Group 75 min. CBT Coping with unanticipated high-risk 

situations and relapses 

While the first two sessions proceed primarily from a motivational 

enhancement therapy plan, and the remaining three sessions focus 

primarily on cognitive-behavioral interventions, it is expected that there will 

be some overlap of each of these approaches in all five sessions. For 

example, it is expected that therapists will make effective use of MET 

interventions, to some extent, across all five treatment sessions. 

17
 
The establishment of rapport between the therapist and the 

adolescent clients is essential. The therapist facilitates this rapport by 

expressing a genuine interest in and nonjudgmental reactions to the 

adolescents’ viewpoints. Therapists are encouraged to use language both 

familiar and similar to that of the clients. In general, it is recommended that 

therapists work in accordance with the MET approach across all five treatment sessions, including the three CBT-focused group sessions. The MET 

approach will be described in detail in the next section. 

Therapists are encouraged to draw from their MET skills throughout 

all five sessions for two important reasons. First, many clients will remain 

ambivalent about abstinence from marijuana beyond the two planned MET 

sessions. If the therapist continues to utilize motivation-enhancing 

reflections and comments, clients will have a greater likelihood of 

developing motivation to quit smoking marijuana. Second, the MET style of 

intervention is recommended because it helps avoid the potential authoritarian power struggle of an adult therapist telling adolescent clients what they 

“must” do. Utilization of the MET style of intervention maximizes the 

chance for a collaborative therapist-client dialog. 

18
V. Motivational Enhancement Therapy 

Motivational enhancement therapy is a therapeutic approach based 

on the premise that clients will best be able to achieve change when 

motivation comes from within themselves, rather than being imposed by the 

therapist. Motivational interviewing, the primary element of MET, was 

developed by William R. Miller and Stephen Rollnick (1991). It is a 

transtheoretical model derived from a number of sources, including stages 

of change theory (Prochaska & DiClemente, 1984), client-centered 

approaches, and research into what clinician behaviors are associated with 

the best client outcomes. 

Key Concepts 

Understanding the following key concepts will assist the clinician in 

learning and utilizing motivational enhancement therapy. 

Ambivalence 

Ambivalence refers to the client’s mixed feelings about change. For 

example, the client feels that quitting marijuana is in part a good idea and 

at the same time, does not want to quit smoking it. MET assumes that 

ambivalence about change is normal and expected. Changing a problematic 

behavior can be difficult and anxiety provoking, and it often involves giving 

up activities and/or relationships that have been enjoyable. So even when 

people see possible benefits to stopping a negative behavior like substance 

abuse, they generally feel that they do in part want to change and do not in 

part want to change. In working with ambivalence, the therapist’s task is to 

help clients acknowledge and discuss these mixed feelings in a way that 

helps tip the balance in favor of change. 

Reflective Listening 

Reflective listening refers to all the statements that the therapist 

makes to clients that express the therapist’s understanding of what the 

client is saying. Reflections can be simple restatements of what the client 

has said, or they can reflect the meaning or feeling implied by the words. 

The following example shows how the therapist can respond to the client 

with any of these types of reflection: 

Client: “My parents are always on my case about getting high. They search 

my room for my supply, they listen in on my phone calls, and they sometimes 

even follow me when I go out.” 

Here are possible therapist responses: 

Using simple reflection (saying what the client has said, but in different 

words): “They bug you about smoking marijuana, and they spy on you about it.” 

or 

19
 
 

Using reflection of meaning (restating the meaning that may be implied by 

the words): “As though they’re always trying to figure out if and when you’re 

getting high.” 

or 

Using reflection of feeling (restating what you perceive to be the feeling 

conveyed in his or her statement): “It sounds like it’s annoying to you, for 

them to get on your case like that.” 

The therapist can use any of the above types of reflections to convey 

his or her understanding. Remember that when trying to reflect the client’s 

meaning or the feeling connected with his or her words, there is an element 

of guessing involved. Try to keep the guess close to what the client has said. 

If the client disagrees with the guess, the therapist should not become 

defensive or attempt to explain the guess. Instead, the therapist should say 

something like “Tell me some more, so I’ll understand it better.” 

Accurate reflection is crucial to facilitating change. If clients feel 

they are truly being understood and accepted by the therapist, they will be 

increasingly open to considering behavior change. Try to accurately reflect 

the client’s mixed feelings about quitting marijuana. The therapist should 

use double-sided reflections (reflections that acknowledge both sides of the 

client’s ambivalence) in empathizing with the client’s mixed feelings. For 

example, 

So you’re saying that you really enjoy getting high, but you’re worried 

that it might be hurting your health. 

or 

You’re not sure that you want to stop smoking marijuana, but, at the 

same time, you don’t want to get into any more trouble with the law. 

Open-Ended Questions 

Open-ended questions invite an elaborative response, while 

closed-ended questions are those that can be answered by a one-word or 

very brief answer. Development of motivation is facilitated by the therapist’s 

use of open-ended questions rather than closed-ended questions. Here are 

some examples of open-ended and closed-ended questions: 

Open-Ended Questions Closed-Ended Questions 

Tell me about your early experiences 

with marijuana. 

How old were you when you first smoked 

marijuana? 

How have your friends reacted to your 

coming to treatment? 

Do you have any friends that 

don’t get high? How many? 

What led to you coming to treatment? Did someone force you to come to 

treatment? 

When the therapist uses open-ended questions, he or she elicits more of the 

client’s thoughts and feelings about his or her marijuana use, which are 

likely to be helpful toward enhancing motivation for change. 

20
The Five Strategies of Motivational Enhancement Therapy 

In their book on the principles of motivational interviewing, Miller 

and Rollnick (1991) have described five main strategies that are used in 

applying this approach: 

1. Express empathy 

2. Develop discrepancy 

3. Avoid argumentation 

4. Roll with resistance 

5. Support self-efficacy. 

The overall MET approach, and these five strategies, were utilized in 

two prior national clinical trials: Project MATCH, a nine-site study of three 

treatments for alcoholism, and the Marijuana Treatment Project, a threesite study of two interventions for marijuana dependence. The following 

descriptions of the MET strategies are drawn from both the Miller and 

Rollnick (1991) book and from the treatment manuals from those two 

studies, respectively: the Motivational Enhancement Therapy Manual (Miller 

et al., 1995) and the Marijuana Treatment Project Therapist Manual 

(Steinberg et al., 1997). They are adapted for use with adolescents. 

In applying all the MET strategies described below, keep in mind that 

good overall therapeutic interviewing skills are the foundation for successful 

MET. It is crucial that the therapist communicate interest in and acceptance 

of what the client is saying, while using good listening skills. The following 

behaviors on the part of the therapist are not good listening and should be 

avoided or minimized: lecturing, criticizing, labeling, ordering, moralizing, or 

distracting (Gordon, 1970). If the therapist finds himself or herself becoming 

extensively involved in those behaviors, he or she should try to put increased 

emphasis on empathic listening and reflection. 

MET Strategy 1: Express Empathy and Acceptance 

The MET therapist seeks to communicate respect for the client. 

Communications that imply a superior/inferior relationship between the 

therapist and client are to be avoided. This treatment approach is not based 

on confrontation. It is important that the therapist not give the impression 

of trying to convince clients of the error of their ways. Rather, the therapist’s role is a blend of supportive listener and knowledgeable consultant. 

Much of MET is listening rather than telling. 

Empathic listening and accurate reflection are crucial to facilitating 

change. If adolescent clients feel that they are truly understood and 

accepted by the therapist, they will be increasingly open to viewing the 

therapist as a valid consultant to their personal change process. 

The MET therapist expresses empathy regarding the client’s 

ambivalence about the possibility of stopping marijuana use. The therapist 

is encouraged to accurately reflect the client’s mixed feelings about 

21
quitting marijuana. The therapist should use double-sided reflections in 

empathizing with the client’s mixed feelings. For example: 

So you’re saying that you really enjoy the feeling you get from smoking 

weed, but you’re worried that it might be hurting your mind. 

or 

You’re not sure that you want to completely stop getting high, but at 

the same time, you don’t want to get into any more legal trouble. 

MET Strategy 2: Develop Discrepancy 

Motivation for change occurs when people perceive a discrepancy 

between where they are and where they want to be. In employing this MET 

strategy, the therapist helps clients recognize the discrepancy between the 

effects of marijuana use on their lives now and how they would like their lives 

to be. Awareness of this discrepancy may well drive the desire for change. 

Here, again, the therapist needs to convey the same respect and 

empathy for clients as described above. In developing discrepancy, the 

therapist is not setting out to convey to the client the impression that “you 

are a loser because you smoke marijuana,” but rather to reflect the client’s 

own stated concerns of how his or her marijuana use is interfering with goal 

attainment. For example: 

You’d like to get a job at that store, but you figure smoking pot would 

make you fail the drug test. 

Therapists may find that many marijuana-smoking adolescents do 

not have many expressed goals, especially beyond the immediate future. 

Therapists, therefore, need to listen for what is important to the adolescent 

in the immediate future. For example: 

On one hand, you want to keep getting high, but you’d also like to get 

your mom off your back. 

Even if they are unable to verbalize any specific goals, some adolescent 

clients may have a vague belief that their lives might be better if they stopped 

using marijuana. In such cases, it is still helpful for the therapist to reflect this 

positive expectation back to the client, as in the following example: 

You want something better from your life than you have now. You’re 

thinking that if you stop smoking weed, your life might start to go 

better. Is that it? 

Notice that in the previous example, the therapist asks the client 

whether the therapist has correctly understood the client. This gives the 

client the chance to correct an inaccurate reflection and, ultimately, may 

allow the client to feel better understood. 

Another type of discrepancy it may be useful to be aware of in 

working with clients is the discrepancy between how they view themselves 

22
currently and how they would like to view themselves. For example, the 

therapist may reflect to the client: 

So you’re saying that you feel like a loser when you get high so often, 

and you don’t like seeing yourself that way. You’d like to feel good 

about yourself. Is that it? 

MET Strategy 3: Avoid Argumentation 

The MET style explicitly avoids direct argumentation, which tends to 

evoke resistance. The therapist does not seek to prove or convince by force 

of argument. When MET is conducted properly, the client and not the 

therapist voices the arguments for change (Miller & Rollnick, 1991). 

If a client becomes increasingly defensive or hostile, the therapist 

should consider the possibility that his or her previous comments may have 

played a role in eliciting this reaction. The therapist may have drifted from 

a MET approach to a confrontational approach. In such a case, the 

therapist will need to resume the motivational interviewing style. 

Another key to avoiding argumentation is to treat ambivalence as 

normal and to explore it openly using double-sided reflections. Here are 

some examples: 

You enjoy partying, but you think it’s messing up your life. 

or 

Part of you wants to quit smoking weed, but you’re worried that 

you’ll miss it too much. 

These double-sided reflections help the client feel understood. This 

feeling of being understood decreases the client’s defensiveness, and also 

decreases the likelihood of further argumentation. 

MET Strategy 4: Roll With Resistance 

The MET strategy does not encourage meeting resistance head on 

but, rather, rolling with it. When a client voices opposition to change, the 

therapist may feel tempted to respond with a counter argument. If the 

therapist does so, however, the client is likely to defend and further 

strengthen the original stated position. The therapist can roll with the 

resistance by empathetically reflecting the client’s hesitancy to change and 

then letting the client know that it will be up to him or her to decide if and 

when to change. Here’s an example: 

Client: I just came here because of the court. I don’t think 

smoking a few joints is a problem. 

Therapist: You had to come here because of the court. You don’t 

want someone else telling you what’s a problem for you. 

Sometimes people find that being in a program like this 

23
helps them get more information to decide for themselves 

whether smoking pot is a problem for them or not. 

In the example above, if the therapist had responded with a lecture 

along the lines of “Smoking pot has already gotten you into trouble with 

the law, so it surely is a problem for you. . .,” the client would likely have 

become more resistant. When clients are genuinely assured that the 

decisions about change are up to them, they often become more open to 

looking at the issue with an open mind. 

In assuring clients that the decision is up to them, the therapist 

need not pretend to ignore contingencies in the environment (e.g., legal 

implications or parental limits) that make the decision seemingly less 

optional. Still, the therapist conveys the message to the client that it is the 

client who decides how these potential consequences will or will not impact 

on his or her marijuana use. 

Sometimes therapists think of resistance as meaning that the client 

is not cooperating with the treatment. In the MET approach, however, 

client resistance is seen as a cue that there may be a problem with the 

therapist’s behavior, and so the therapist should try shifting strategies. 

Similarly, if therapists find themselves in the position of arguing with 

clients to get them to acknowledge and change, something has gone wrong 

in the session. It is time to stop and listen to the client. 

MET Strategy 5: Support Self-Efficacy 

This MET strategy refers to helping develop and support the client’s 

belief that he/she can change. This is important because people who believe 

that they have a serious problem are still unlikely to move toward change 

unless there is hope for success. Even if the adolescent client acknowledges 

that marijuana is a problem, he or she may be disinclined to quit or reduce 

marijuana use without the belief that he or she can be successful in making 

that change. The therapist’s role is to help clients develop and/or strengthen the sense of self-efficacy—that they can, in fact, stop or reduce their 

marijuana use. 

In order to support self-efficacy, the therapist may ask clients about 

previous successful experiences they have had in the following areas: 

• Previous periods of abstinence from or reduced use of marijuana 

• Earlier success in quitting or reducing use of other drugs or 

alcohol 

• Past accomplishment in gaining control over another problematic 

habit 

• Attainment of previous goals that was facilitated once they set 

their minds to it. 

Some clients may not make the connection between these previous 

accomplishments and the likelihood that they will be successful in meeting 

24
their goal regarding marijuana use. They are likely to benefit from the 

therapist’s help in pointing out this relationship. For example: 

So you’re telling me that you were able to stop the bingeing and 

purging. That’s great. Since you were able to stop that problem, 

which many people find a hard habit to break, you may be equally 

successful in breaking the marijuana habit. 

Abstinence and Relapse 

The Goal of Abstinence 

At the same time therapists are maintaining a nonjudgmental 

approach regarding clients’ marijuana use and their current state of 

readiness for change, MET/CBT5 therapists are encouraged to support the 

primary goal of this treatment—abstinence from marijuana use. Therapists 

should be prepared to encourage clients to try abstinence or to work 

toward abstinence. 

Adolescent clients generally vary in their motivation or readiness to 

stop marijuana use completely, and therapists should be prepared to work 

with clients’ varying degrees of commitment as they move through the 

processes of change. MET can be a useful therapeutic approach with clients 

at various stages of motivation and readiness for change. With less motivated clients, the primary therapeutic tasks are helping them recognize 

possible negative consequences of use and identifying and working through 

ambivalence. With highly motivated clients, the therapist’s focus should be 

on helping them to verbalize, and thus strengthen, their own motivation for 

change. The therapist should ask about potential feelings of ambivalence, 

which if left unaddressed could undermine clients’ success. 

The therapist should encourage the adolescent to stop other 

substance use in addition to abstaining from marijuana. The elimination of 

other drug and alcohol use is considered necessary to maximize clients’ 

ability to learn about themselves while substance-free and to prevent the 

substitution of other substance use for marijuana. With adolescent clients 

this position of discouraging other drug and alcohol use also makes the 

most sense from an ethical standpoint. As described in the introduction to 

this document, there is also a high rate of alcohol use among adolescent 

marijuana users. Therapists need to be prepared to address clients’ alcohol 

use in addition to their marijuana use, in order to maximize the chance 

that the treatment will result in more adaptive functioning by clients. 

Finally, by attending to issues regarding all drugs and alcohol, not just 

marijuana, therapists may intervene regarding the gateway phenomenon 

described in section I. Specifically, they will attempt to decrease the chance 

that the client’s marijuana use leads to the use of other drugs. 

Given that some clients may be less than enthusiastic about 

abstaining from drugs and alcohol, therapists should present this idea in a 

25
way that points out the potential benefit to them. Also, clients should be 

given the message that the decision is up to them. Here are some examples 

of ways that this decision can be presented: 

I know you’re not sure about stopping pot smoking completely. Let’s 

spend some time talking some more about what you want to decide. 

There are some good reasons to think about quitting pot completely. 

You mentioned a number of ways that pot is causing you problems, 

like the trouble with your parents and not thinking as clearly as you 

used to. By stopping pot use completely, you’ll have the best chance of 

learning about how your life could be without pot. How does that 

sound to you? 

or 

As you think about what you want to do, I want to encourage you to 

consider stopping all drugs and alcohol, at least for a while. You’d get 

a chance to see what that’s like so that you can decide what you 

want to do in the long run. It also gives you more of a chance to 

learn a lot about yourself—like what sort of things might have been 

keeping you smoking pot. What do you think? 

or 

If you think you might want to quit smoking weed at some point, this 

is a good time to try that out, while you have support from me and 

the other people in your group. What do you think? 

The key to the above interventions is allowing plenty of time to 

listen to the client’s thoughts about the decision, responding with empathy, 

and avoiding argumentation. 

Learning From a Slip or Relapse 

A slip, or a full-blown relapse, should be viewed as a learning 

opportunity. Examine the events prior to the slip, and try to identify the 

trigger(s) and the clients’ reactions to them. Were there expectations that 

marijuana use would change something or meet some need? What events 

followed the slip that might impact the likelihood of further use? 

Help the client develop a plan to cope better with those antecedent 

events when they occur again, as well as with future cravings to use. Can 

any arrangements be made to reduce the likelihood of positive consequences of future use—or to make negative consequences more likely? 

Urine Test Results 

Urine specimens are taken at the fourth session, preferably before 

the session begins. It is only necessary that the test discriminate the 

presence or absence of drugs. In CYT, the urine screen tested for the 

presence of marijuana and alcohol. If a test is used that provides 

quantitative information and/or assesses the presence of additional drugs, 

this additional information should be handled along the same lines as the 

procedures discussed below. 

26
The results of the urine test are discussed with clients at the 

beginning of the fifth session. Since this feedback is given in the context of 

a group therapy session, some clients may feel anxious about having this 

information shared. The therapist may let the group clients know that he or 

she has the results of their urine tests and could give them that feedback in 

the group. The therapist can also offer to convey the test results after the 

group meeting, if a client would rather hear them in private. 

Using this method for feedback is recommended. If the group has 

been conducted in such a way that each client feels that it is safe to be 

honest, the great majority of clients are likely to choose to hear their urine 

test results in the group. This way, clients can receive feedback from other 

group members about their progress in this area. At the same time, by 

offering the option of hearing the results after group, this process is likely 

to proceed with a greater level of safety. Next, try to involve the whole 

group in a discussion about the test results, one specifically focused around 

ideas for coping in the future. 

If the results for substance use are negative (i.e., drugs were not 

present), use these findings as an opportunity to provide strong positive 

reinforcement and support. For example, members may be encouraged to 

congratulate one another. Have group members who were able to abstain 

from substance use describe what they did to achieve that success. When 

applicable, encourage continued development of and involvement in 

activities that are incompatible with drug use, as well as association with 

persons who do not place the client at risk for drug use. Also ask about 

problems encountered during this period of abstinence, particularly 

problems frequently associated with drug use, such as emotional distress or 

cravings for specific drugs. Find out what the client did to cope with these 

problems and, if appropriate, assist him or her in identifying any problemsolving steps that he or she might have used to cope with high-risk 

situations (e.g., identified the existence of a problem, generated a list of 

possible solutions, and implemented one of them). Emphasize the 

importance of continuing to practice problem solving as one method of 

preventing relapse. 

Clients whose urine test results were positive for one or more illicit 

drugs (i.e., drugs were present) should be asked to briefly review the circumstances and context of their drug use. This provides an opportunity to 

identify triggers and enhance coping. Inquire about potential external 

factors (persons, places, things) and internal factors (emotional distress, 

cravings) associated with recent use. Encourage both clients who used 

substances, as well as other group members, to think of other ways to cope 

with the identified trigger situations. Some group members who received 

positive urine results may indicate that they are not motivated to reduce or 

stop substance use and may indicate little motivation to learn alternative 

coping strategies. In such cases, respond using an MET style. For example, 

the therapist may make a brief empathic statement summarizing some 

aspects of that client’s viewpoint: 

27
 
It sounds as if you’re saying that you’re not disappointed that your 

test was positive for marijuana because, so far, you are not trying 

to stop smoking it. You have said that even though marijuana has 

caused some problems for you at your school, you enjoy getting high 

and you do not want to stop smoking at this time. If you decide to 

try to quit sometime in the future, hopefully you’ll have gotten some 

helpful information from this group about how to do it. 

The main point is that the therapist does not have to fight the client 

to become motivated or try to make the client feel badly that his or her 

urine tested positive. 

Sometimes the client may deny recent use when the test results 

are positive. Therapists are advised to discuss such discrepancies in a 

collaborative manner, rather than through confrontation. The amount of 

time that it takes for a person’s body to become free of tetrahydrocannabinol (THC), the active ingredient of cannabis that is assessed in the drug 

screen, varies. As a result, a positive drug screen does not allow the 

clinician to draw a clear conclusion about whether a client has used 

marijuana recently. When a client disagrees with a positive drug screen 

result, the therapist may tell the client that there can be a few different 

reasons for the discrepancy and that it may never be entirely clear which 

applies in this case. Tell the group that the following explanations have 

applied to other clients and seem possible in their case: 

• The positive result may simply mean that previously reported use 

has still left physical traces that are showing up on the test. 

Emphasize that if clients continue to abstain from marijuana and 

other drugs, their drug test results will eventually be negative. 

Obviously this explanation is less likely to be plausible when a 

client reports many weeks of abstinence from marijuana (i.e., 

more than 4 to 6 weeks). 

• For a number of reasons, clients may not believe that it is safe for 

them to be honest about recent use. Consider asking group 

members whether they relate to this, and try to briefly engage 

them in some discussion about why individuals may be reluctant 

to openly disclose their use. Approach the issue in an empathic 

MET style rather than an accusatory style. The idea is to 

recognize that a client may have been dishonest about recent use 

in a way that is likely to keep the dialog open. Even if the client 

in question does not become more open over time, it can be 

reassuring to the rest of the group to know that the therapist is 

not naive about the possibility of dishonesty. 

• Consider mentioning that it may be possible that something has 

gone wrong with the test, but emphasize that this is an 

infrequent occurrence. 

The main point in discussing these possibilities is to acknowledge 

the discrepancy between the test result and the client’s report and to 

28
generate a productive dialog about possible reasons for that discrepancy 

and about the possibility of open disclosure in this setting. For clients who 

seem upset about a positive test result, the therapist may make some 

MET-style statements. For example: 

It sounds as if getting a negative [drugs not present] test result is 

important to you. 

or 

How would getting negative [drugs not present] test results help you? 

or 

You see other group members getting negative drug test results; you 

want that for yourself, but you seem discouraged about being able to 

do that. 

In some treatment settings, clients are referred to treatment by 

legal authorities, and there may be a policy that urine test results are 

shared with the legal system. This kind of policy has a major influence on 

a client’s reaction to his or her test results. When urine test results are to 

be shared with legal authorities, therapy proceeds best if this factor is 

recognized from the very first session, with the therapist reminding the 

client that the results of any urine test will be communicated to the legal 

system. The client needs to provide a related release of information. For all 

cases in which there is legal involvement (whether or not urine test results 

are to be communicated to the legal system), the therapist and client 

should review the various pros and cons of continued use versus abstinence 

together, and the therapist should make sure that the client takes his or 

her legal situation into account. Be explicit about this, as in this example: 

You know that this program has agreed to communicate your drug 

test results to your juvenile justice worker, and you’re thinking that 

your worker will recommend that you go to jail if you keep using. But 

even though you’re pretty worried about that, you are saying that you 

might want to keep smoking weed and take that chance. Is that how 

you see it? 

The purpose of such statements is to help the client see that he or 

she is in charge of the decision and is responsible for its outcome. When 

such legal contingencies have been clear from the start, communicating 

positive urine test results is less likely to result in making the client 

extremely upset. A final recommendation regarding clients who may be 

legally mandated to treatment is to avoid the attitude—on the part of 

either the therapist or the client—that the legal problem is the only 

important influence on the client’s motivation for change. No one wants to 

feel that someone else is forcing him or her to change, and any seemingly 

forced change is unlikely to endure. When faced with serious legal trouble, 

some clients stop using drugs and some continue to use. Clients are 

empowered when they are helped to appreciate that it is their own thought 

process that affects what they do in response to legal trouble. 

29
 
The Safety Net 

Because MET/CBT5 is a brief treatment involving the adolescent 

client individually, without ongoing family participation, procedures have 

been incorporated to monitor the client’s progress or deterioration. This 

safety net is designed to capture clients for whom this treatment may be 

insufficient. At the start of treatment clients’ parents or guardians are given 

a list of signs of clinical deterioration (a problematic decrease in various 

aspects of the client’s functioning). They are made aware that, if the adolescent begins to show these signs, they should contact the therapist for 

assistance. In addition, the therapist should monitor each client’s functioning 

for signs of clinical deterioration, including acute psychological disorder, 

markedly increased use of marijuana, and/or increased polysubstance use. If 

either the client’s parent/guardian or the therapist notices signs of 

deterioration, the therapist should review this information with his or her 

clinical supervisor to determine what course of action should be taken. 

Sometimes the client may benefit from continuing in the MET/CBT5 

treatment with the addition of another intervention. Here are some general 

guidelines for planning a course of action. The therapist and supervisor 

should take the entire clinical picture into account in making a decision 

about a particular client. If only mild difficulties are observed, it may be 

appropriate simply to bring this information into the ongoing therapy and to 

actively monitor the client’s progress. Some of these difficulties may decrease 

as the client makes progress in the MET/CBT5 therapy. When the client 

evidences symptoms of a possible comorbid psychiatric disorder of mild to 

moderate severity, a referral for psychiatric evaluation and possible treatment 

concurrent with MET/CBT5 treatment may be the most appropriate course. 

Finally, in the case of more severe deterioration involving a possible severe 

psychiatric disorder or a marked escalation of substance use, clients will likely 

require a transfer from MET/CBT5 to a higher level of care (e.g., inpatient, 

day treatment, residential, or intensive outpatient care). 

Preparation for Individual Sessions 

Prior to the first contact with a therapist, each client is seen for an 

initial assessment. In that meeting, the client provides background 

information regarding his or her life situation and marijuana problems. 

Data from this meeting are used to prepare a psychosocial report and the 

personalized feedback report (PFR), which is used in session 1. All the data 

that are needed for preparing the PFR can be obtained by completing the 

Global Appraisal of Individual Needs (GAIN) developed by Michael Dennis 

(1999). Appendix 4 shows the directions for using information from GAIN 

to compile the PFR. Please note that the PFR shown in the text consists of 

all possible items, but only a subset of those items are expected to have 

been endorsed by each client. Essentially, GAIN is used to determine which 

PFR items were endorsed by the client, and only those items are placed on 

that client’s PFR. Two identical copies of the PFR are needed for session 1. 

Here are some tips that may be useful in creating PFRs. PFR 

preparation can be made more efficient by creating a word processing file 

30
including the full PFR and then simply deleting the items that do not apply 

when each PFR is created. In addition, there are ways to save time in 

obtaining the necessary GAIN data. Some treatment settings may not have 

the time or resources to administer the full GAIN. When this is the case, a 

subset of the GAIN items may be prepared and administered, including all 

those necessary for preparing the PFR, as well as any others that are of 

particular clinical interest. An additional option is to obtain GAIN 

responses by using a self-report format, rather than through the GAIN 

interview format. Such a self-report format would need to be developed at 

the treatment site. If a self-report format is implemented, clients with 

limited reading and writing skills will need assistance. 

Soon after the assessment interview is conducted and a therapist is 

assigned, the first session should be scheduled. Prior to the session, the 

therapist should review the psychosocial report and PFR. Reminder calls 

should be made to the client prior to each of the therapy sessions to 

confirm the appointment and increase the likelihood of attendance. 

Overview of Two Initial (MET) Sessions 

As described earlier, the first two therapy sessions are individual 

sessions focusing primarily on motivational enhancement. As described 

below, the first session is designed to allow the therapist to get to know the 

client and his or her unique situation, as well as to allow the client to begin 

learning what he or she can expect from treatment. Another task of the 

first session is to provide the client with individual feedback about his or 

her marijuana problem, accompanied by interventions aimed at increasing 

motivation for change. 

The second session, to be scheduled approximately 1 week after the 

first, continues the process of developing motivation for change. Specifically, progress since the first session is reviewed, and an overall goal for 

treatment is developed in a collaborative process involving therapist and 

client. The final parts of this session prepare the client for the remainder of 

treatment: (1) the introduction of the key concept of functional analysis 

and (2) orientation to the group sessions. 

31
Session 1: MET1—Motivation-Building Session 

Key Points: 

• Build rapport with the client. 

• Familiarize the client with what he or she can expect from 

treatment. 

• Begin the process of assessing and building the client’s 

motivation to address his or her marijuana problem. 

• Review the personal feedback report with the client. 

Delivery Method: MET-focused individual therapy 

Session Phases and Times: 

1. Rapport-building and orientation to treatment (20 minutes) 

2. Review of PFR and reactions to it (30 minutes) 

3. Summarization of today’s session and preparation for next 

session (10 minutes) 

Time: 1 hour total 

Handouts: 

• Two copies of the client’s personalized feedback report 

• A Guide to Quitting Marijuana brochure 

• An orientation sheet entitled Welcome! 

Materials: 

• A pocket folder 

Procedural Steps 

Phase 1: Building Rapport. This is an extremely important part of 

the treatment, during which the therapist and client first get to know each 

other. The goal is to create the feeling that the therapy sessions will be safe 

and supportive. 

The therapist should begin by introducing himself or herself and 

then briefly explain the purpose of the first meeting—i.e., to become 

acquainted with the client and to give the client some information and 

feedback. The therapist may indicate that he or she has learned a bit about 

the client from information obtained during the intake or referral process 

or from the research staff but finds it most helpful to hear it directly from 

the client. 

32
Here is the suggested discussion sequence for the rapport-building 

phase of the session: 

1. Start with some casual conversation and a review of 

demographic facts, and attempt to learn a bit more about the 

client. For example, you can talk about whether the client is in 

school and, if so, in what grade; his or her living situation 

(where and with whom); and whether he or she has a job. This 

discussion should be fairly general and brief in order to leave 

enough time for the remainder of the session. 

2. Ask an open-ended question about what led to the client’s 

involvement in marijuana treatment, as this will most likely 

present opportunities to initiate some of the MET strategies 

described earlier in this treatment manual. Try to include 

discussion about the following: 

• How the marijuana use first started 

• The extent of recent use 

• Whether there have been any previous attempts at 

quitting 

• What the client hopes to gain from treatment. 

Phase 2: Orientation to Treatment. Give the client a copy of the 

Welcome! orientation sheet, which introduces the client to the treatment, 

and summarize the main points. You do not need to read it word for word. 

Give the client the Guide to Quitting Marijuana brochure, and 

encourage the client to read the brochure before the next session. The 

Guide to Quitting Marijuana was produced by the Drug and Alcohol 

Research Centre, Sydney, Australia, and is available from Lighthouse 

Publications at: 

702 W. Chestnut Street 

Bloomington, IL 61701 

Telephone: 888–547–8271 

Voice: 309–829–1058, x 3414 

Fax: 309–829–4661 

Web site: www.chestnut.org/li/publications 

E-mail: cschwartz@chestnut.org 

Ask the client to bring the folder to each session because you will be 

providing additional information to add to it. 

33
 
Welcome!
 

What You Can Expect From Us 

Help for your marijuana problem. Treatment consisting of five sessions, 

covering a 5 to 8 week period. First you’ll have two individual sessions, 

then three group sessions. The sessions are designed to give you support 

and information about coping and to help you with marijuana-related 

problems. In the group sessions, you’ll get a chance to practice some 

coping skills and get feedback from other program clients. 

Effective treatment. Delivered by a competent therapist. Your therapist 

is ____________________________________. 

Confidential treatment. What you tell us in treatment is confidential, 

meaning that we cannot tell anyone what you said without your 

permission, with the exception of those people described on the consent 

form. However, if you tell us that you are going to harm yourself or 

another person, or tell us about child abuse or neglect, we are required 

by law to inform those who can obtain help for you or for others. 

What We Ask From You 

Attendance. We ask that you come on time to all of your scheduled 

appointments. If you must cancel, we ask that you call the treatment 

program number (_____-_______) so that your therapist can be notified 

ahead of time and can call you to reschedule. 

A clear head. We ask that you not use any drugs or alcohol on days 

when you have an appointment with your therapist. We believe that you 

will be able to benefit most from this program if you are not under the 

influence during your sessions. 

Completion of treatment. We hope that you will come to all of your 

scheduled sessions. If, however, you ever consider leaving treatment 

early, we ask that you discuss this with your therapist as soon as 

possible. 
Review of the Personalized Feedback Report 

The therapist should give the client a copy of his or her PFR and 

lead the client through a systematic review of it. The therapist and the 

client should have their own copies of the PFR to review together to 

increase the collaborative nature of this process. The PFR included in this 

manual illustrates all possible items that could appear on a PFR. The 

client’s PFR will include some subset of the illustrated items, based on the 

client’s responses during the intake or research assessment. 

The PFR is most useful for developing motivation when the client is 

given the opportunity to elaborate on each point. For example, as the 

therapist and client are reviewing the problem list section of the PFR, the 

therapist might say: 

I know you’ve already told me some of the problems marijuana has 

been causing in your life [during the rapport-building phase of the 

session]. As we go over this list, why don’t you tell me some more 

about each of these problems, like the first problem: In what ways has 

marijuana led to ‘missing work or classes’? 

The main task for the therapist is to listen to the client and respond 

with empathic reflection. Remember that the purpose of the PFR is not to 

do an initial assessment: The client already provided much information 

about his or her background and demographics in the initial assessment. If 

the therapist finds that the focus shifts to asking questions for which the 

solicited response is basic information, the PFR review is not serving the 

intended purpose. Instead, the therapist needs to focus on the MET 

processes described earlier (i.e., expressing empathy, developing 

discrepancy, avoiding argumentation, rolling with resistance, and 

supporting self-efficacy). The PFR provides the raw material for engaging in 

a discussion that employs these techniques. If this therapy session is 

performed as intended, the therapist is likely to find that by the end of the 

session, he or she has a general picture of the client’s current life situation 

and a real understanding of the client’s thoughts and feelings about making 

a change in his or her marijuana use. 

Sometimes clients may respond to the PFR review by attempting to 

argue about the validity of the items on their personal report (e.g., “I didn’t 

say smoking pot was causing me money problems!”). In such cases, do not 

try to debate the client with replies such as, “You must have checked off 

something like that, or it wouldn’t be on the report!” or “Well, you must 

pay for the pot in some way!” Instead, maintain a nondefensive tone, 

acknowledge that the client knows best what areas of his or her life have 

and have not been affected by marijuana use, and move on to the next item. 

In keeping with the general recommendations for using this therapy, 

therapists again are encouraged to use open-ended questions rather than 

closed-ended questions. For example, “Did you say you used marijuana in 

unsafe situations?” is a closed-ended question that invites the potential to 

35
 
disagree with the PFR item. Saying “Tell me about using in unsafe 

situations” invites elaboration and discussion. 

Therapists may find that some sections of the PFR are especially 

conducive to motivational interviewing. For example, with a number of 

clients, the problems and the reasons for quitting sections may be 

especially likely to induce the client to explore his or her ambivalence about 

smoking marijuana. Therapists may adjust the relative emphasis on sections 

of the PFR to accentuate those sections that produce constructive 

discussion for any given client. For example, if a client seems especially 

interested in describing his or her reasons for quitting, the therapist may 

choose to spend extra time focusing on that area. 

Note that the PFR review is expected to take approximately 30 

minutes. This allows for quite a bit of discussion and related comments. 

Use double-sided reflections, develop discrepancy, and employ other MET 

strategies where relevant. Reviewing the PFR provides an excellent 

opportunity to explore the client’s ambivalence and to begin developing 

motivation for change. After reviewing the entire PFR, ask the client about 

his or her reactions to it, and listen with empathy. 

Phase 3: Session Summary. In the final portion of the session, 

summarize the main points that you heard the client saying. Ask the client 

about his or her current readiness for change. Some clients are ready to 

verbalize the goal to change at this point. However, if a particular adolescent is not feeling ready to set a goal for change, the therapist should not 

pressure the client into doing so. 

The following recommendations apply to helping those clients who 

do verbalize the goal to change: 

If the client says that he or she wants to quit or reduce his or her 

marijuana smoking, ask what might help him or her to achieve that goal. 

Many clients may spontaneously come up with some ideas, such as asking 

friends to help them or not buying any more marijuana. Reinforce any such 

statements. If they are unable to come up with any ideas, help them do so. 

For example, say that some people find it helpful to stay away from friends 

who use, and ask if they think this would be helpful for them. Some of these 

ideas may flow directly out of the PFR discussion. Help them develop a plan 

regarding any remaining marijuana they have. Some clients may say that 

they are going to finish smoking the marijuana that they have left in their 

possession, while others may be comfortable disposing of it (giving it away, 

flushing it, etc.). 

Many clients may not yet be willing to make a commitment to 

abstinence. Whether the client plans to quit or reduce use at this point, tell 

him or her that you’ll continue discussing this issue during the next 

session. Ask the client what today’s session has been like for him or her. Set 

up an appointment to meet again next week, and write it down on an 

appointment card. 

36
This example of the PFR contains every possible PFR item. The PFR for any 

given client will contain only the items that the client endorsed during the 

initial assessment. 

Therapist ________________________ 

Client ________________________ 

Personalized Feedback Report (PFR) 

This report summarizes some of the information that you gave us in your 

interview on ___/___/____. 

We want to give you an opportunity to review what you’ve told us and make 

any changes or additions. As you and I work together in reviewing and 

discussing this specific personal information, we can help you develop a 

program and strategies for dealing with marijuana that fit your individual 

needs. 

Primary Substances 

You reported that your favorite substance to use was_____________________ 

and that you needed treatment for ___________________________________. 

You told us you first used alcohol or drugs at age ____ and have been 

smoking marijuana for ____ years. In the past year, you told us you had 

used ______________________. You have been in substance treatment ____ 

times before. 

Extent of Use 

In the past 90 days, you smoked marijuana on _____ of those days, with 

most being ____ hits over a ___hour period. This places you in the _____ 

percentile relative to other adolescents age ___ to ___ in America. 

In the past 90 days, you drank alcohol on _____ of those days, with the 

heaviest drinking episode being ____ drinks over a ___ hour period. This 

places you in the _____ percentile relative to other adolescents ages ___ to 

___ in America. 

In the past 90 days, you reported that you used other drugs, including 

_______________________, on ___ days. In the past week you reported that 

you (had/had not) tried to quit (and that when you did you had the following problems: ______________________________________________). [List 

could include moving and talking much slower than usual; yawning more 

than usual; feeling tired; having bad dreams that seem real; having trouble 

sleeping (sleeping too much or trouble staying asleep); feeling sad, tense, 

or angry; feeling really nervous or tense; fidgeting, wringing your hands, or 

trouble sitting still; having shaky hands; having convulsions or seizures; feeling hungrier than usual; throwing up or feeling like throwing up; having 

diarrhea; having muscle aches; having a runny nose or eyes watering more 

than usual; sweating more than usual; having your heart race or goose 

bumps; having a fever; seeing, feeling, or hearing things that are not real; 
____________________________________________________________________ 

____________________________________________________________________ 

forgetting a list of things or having problems remembering; having withdrawal symptoms that prevented you from doing usual activities; starting to 

use again to avoid withdrawal symptoms, other: ______________________ .] 

Problems 

You indicated that your use of marijuana, alcohol, and/or other substances 

had caused you the following kinds of problems: 

• You did not meet your responsibilities at home, school, or work. 

• You used in situations where it was unsafe for you. 

• Using caused you to have repeated problems with the law. 

• You kept using even though it was causing you to get into fights. 

• You had to use more to get the same high. 

• You had withdrawal symptoms when you tried to stop. 

• You used for longer than you wanted to. 

• You have been unable to cut down or stop using. 

• You spent a lot of time getting or using marijuana, alcohol, or 

other substances. 

• Using led you to give up activities or caused problems at home, 

school, or work. 

• You have kept using despite medical or psychological problems. 

As you reflect on the consequences to your life of smoking marijuana, what 

would you add?______________________________________________________ 

Reasons for Quitting 

You said the main reason you came to treatment was____________________ 

________________________. We showed you a list of personal reasons for 

quitting marijuana, and you said that you wanted to quit: 

• To show myself that I can quit if I really want to. 

• To like myself better. 

• So that I won’t have to leave social functions or other people’s 

houses. 

• To feel in control of my life. 

• So that my parents, girlfriend, boyfriend, or another person I am 

close to will stop nagging me. 

• To get praise from people I am close to. 

• Because smoking marijuana does not fit in with my self-image. 

• Because smoking marijuana is less “cool” or socially acceptable. 

• Because someone has given me an ultimatum. 

• So that I will receive a special gift. 

• Because of potential health problems. 

• Because people I am close to will be upset if I don’t. 

• So that I can get more things done during the day. 

• Because my marijuana use is hurting my health. 

• Because I will save money by quitting. 
___________________________________________________________________ 

___________________________________________________________________ 

• To prove I’m not addicted. 

• Because there is a drug testing policy in detention, probation, 

parole, or school. 

• Because I know others with health problems caused by marijuana. 

• Because I am concerned that smoking marijuana will shorten my 

life. 

• Because of legal problems related to my use. 

• Because I don’t want to embarrass my family. 

• So that I will have more energy. 

• So my hair and clothes won’t smell like marijuana. 

• So I won’t burn holes in clothes or furniture. 

• Because my memory will improve. 

• So that I will be able to think more clearly. 

You listed these because they have personal significance for you. Do you 

have any other important reasons for quitting that you would like to add? 

You also told us about several other problems that might be caused or made 

worse by your marijuana, alcohol, or other drug use. These include: 

• The health problems you reported. 

• The emotional problems you reported. 

• Being bothered by upsetting memories. 

• Having problems paying attention or controlling your behavior. 

• The family problems you reported. 

• Arguments, and problems you had with your temper. 

• Being physically, sexually, or emotionally hurt. 

• Doing things that were illegal. 

• Getting in trouble at school. 

• Getting in trouble at work. 

Pattern of Use 

You told us that the place(s) where you typically use marijuana, alcohol, and 

other drugs is/are: 

• At home 

• At someone else’s home 

• At a party/bar 

• At work 

• At school 

• At a dealer’s house 

• Outdoors 

• In a car 

• Somewhere else (__________________________________________) 
___________________________________________________________________ 

and that you typically use it with: 

• No one else, alone 

• Your romantic/sexual partner 

• Family 

• Friends 

• A club or gang 

• Coworkers 

• Classmates 

• A running partner (someone you regularly do drugs with) 

• A drug dealer/pusher 

• Someone else (____________________________________________) 

As you think about highly tempting situations, are there situations that 

you’d like to add? ___________________________________________________ 

Situational Confidence 

You told us that you thought you could avoid using alcohol or drugs: 

• At home 

• At school or work 

• With your friends 

• When everyone around you was using them 

You also told us that you (had quit and were _______% sure you could stay 

abstinent/you had not quit yet but were _______% sure you could quit). 
Session 2: MET2—Goal-Setting Session 

Key Points: 

• Review progress, thoughts, and reactions since session 1. 

• Collaborate on setting a treatment goal or goals for the 

remaining treatment sessions. 

• Introduce the concept of functional analysis. 

• Prepare for the group therapy sessions. 

Delivery Method: MET-focused individual therapy 

Session Phases and Times: 

1. Review of progress (15 minutes) 

2. Goal-setting (20 minutes) 

3. Functional analysis (20 minutes) 

4. Preparation for group (5 minutes) 

Time: 1 hour total 

Handouts: 

• A personal goal worksheet 

• Blank personal awareness worksheets for functional analysis 

(entitled Knowledge Is Power) 

• A group preparation sheet titled Information and Expectations: 

Group Sessions 

Procedural Steps 

Begin by greeting the client. Notice if the client has brought back 

the folder of information. If so, state that you are glad to see that; if not, 

encourage the client to bring it next time. 

Phase 1: Review of Progress. Begin the review of treatment 

progress by asking the client how he or she has been doing over the past 

week regarding the marijuana issue. The therapist should be prepared to 

listen for possible changes in the client’s behaviors, thoughts, and feelings 

regarding marijuana. Before asking a lot of questions, let the client tell you 

how he or she has been doing regarding his or her marijuana use or 

abstinence first. Respond with reflective comments, and attempt to elicit 

the client’s own motivation-enhancing statements. In order to get a fuller 

picture of the client’s marijuana-related behaviors, thoughts, and feelings, 

you may want to ask questions. Your questions may center on: 

41
Behaviors related to marijuana: 

• How much did you smoke over the past week, if at all? 

• What was going on at the time you smoked (or felt like smoking)? 

• Have you told any of your friends about your plans to stop 

smoking? 

• Did you read the Guide to Quitting Marijuana brochure? What 

are your reactions to that? 

Thoughts about marijuana: 

• It sounds like you’ve given this issue a lot of thought. Tell me 

more about what you’re thinking regarding pot smoking at 

this point. 

• What thoughts have you had about that PFR we went over last 

time? 

Feelings about marijuana: 

• How did you feel after you smoked? 

• It sounds like you have mixed feelings about whether or not you 

want to quit. Tell me some more about that. 

As you listen to the client, be prepared to express empathy, provide 

double-sided reflections as appropriate, reinforce client efficacy, and roll 

with resistance. After approximately 15 minutes of opening discussion, 

move into the goal-setting phase of the session. 

Phase 2: Goal-Setting. Up to this point, you may have been hearing 

the client make statements indicating some motivation for change. If so, 

summarize this; if not, try to accurately reflect the client’s feeling that he 

or she is not yet ready to commit to change. 

Either way, explain to the client that having a written goal increases 

the likelihood that the rest of the therapy will be meaningful and/or useful 

to him or her, and that he or she will be more likely to succeed. When 

working with clients who say they are not willing to give up marijuana, let 

them know that other goals may be useful to them. For example, some may 

decide to start by trying to reduce their marijuana smoking. Others may 

simply like to set the goal of learning more about the skills for quitting or 

reducing marijuana use. 

Give the client a copy of the personal goal worksheet and a pen so 

that he or she can fill it out in the session. It is a good idea to have clients 

verbalize each section of the goal worksheet before writing it down. This 

way, the therapist can offer feedback and suggest modifications before ink 

42
is put to paper, in such a way that the client is less likely to feel criticized. 

If the goal is vague, insufficient, or inappropriate, engage the client in a 

collaborative process to revise it. Offer to help clients with ideas if they get 

stuck. Many clients may be able to come up with some good ideas for steps 

they can take to achieve their goal. If they have trouble with this, here are 

some ways to help them: 

• Tell them that many people find they can be more successful at 

stopping/reducing use by staying away from substance-abuse 

opportunities, and encourage them to write down ways they could 

reduce such situations in their lives. 

• Ask them about ways that they could distract themselves by doing 

something else instead. 

• Let them know that they will be learning more about specific 

strategies for addressing marijuana-related problems in the next 

three sessions. 

When the personal goal worksheet is complete, be sure to have the 

client sign and date it. Ask the client to read it to you, even though you 

may have already heard all the parts of the goal worksheet in progress. You 

can explain to the client that reading it aloud helps reinforce the client’s 

motivation to achieve the goal. Ask permission to make a photocopy of the 

worksheet at the end of the session. Return the original to the client, and 

place the copy in the chart. 

43
 
_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

______________________________________ ___________ 

Personal Goal Worksheet
 

This is my goal regarding my marijuana use: 

Here are some important reasons for my goal: 

The steps I plan to take to achieve my goal are: 

Name Date 
Phase 3: Functional Analysis. After having participated in the 

previous portions of the therapy aimed at improving motivation and 

beginning to resolve ambivalence, clients should now be ready to examine 

the function of marijuana in their lives. Actually, the groundwork for this 

has been laid. This exercise is included at this point to help clients understand that marijuana use doesn’t just happen but is rather a function of 

antecedents and consequences. The aim is to increase clients’ awareness of 

those factors, to provide better focus for the ensuing CBT interventions, 

and to enable better decision making on a daily basis. 

To convey the concept of functional analysis, the therapist may 

begin with a social learning explanation of marijuana abuse. As the 

therapist goes through this explanation, he or she may draw on what the 

client has already described to illustrate the various points. The therapist 

should try to explain the concept in simple language, using concepts that 

the client can understand. Here is an example of such an explanation: 

I want to explain to you how we think about marijuana problems. 

When someone has a marijuana problem, we think of it as a negative 

habit, similar to other habits like biting your nails or eating junk food. 

We try to help the person figure out what has been keeping the habit 

going. This way, if someone wants to stop the habit and knows what 

is keeping it going, he or she can use this information to help stop it. 

Does thinking of it as a habit make sense to you? [Discuss] 

After a while, if someone has often gotten high in certain situations, 

just being in those situations can make that person feel like getting 

high. We call that a trigger. It could be anything about the situation like 

the time of day, whom you’re with, or even something like a type of 

music. You have mentioned some things that sound like triggers for 

you. What do you think some of your triggers are? [Discuss] 

Another type of trigger can be how someone is feeling. Some people 

say that they feel more like smoking marijuana when they are feeling 

badly—like feeling bored, nervous, or angry. They say that smoking is 

a way of trying to cope with the bad feelings. Some people especially 

feel like smoking marijuana when they are happy or excited. Does this 

part of it—someone using to affect how they feel—make sense to you? 

[Discuss] 

Sometimes people develop certain thoughts or ideas about their use, 

like ‘My friends will think I’m boring if I don’t take a few hits,’ or ‘I’ll 

just smoke this one time,’ or other ideas. These thoughts and ideas 

affect whether or not somebody uses. 

The point is that marijuana use doesn’t just suddenly happen. Usually 

there are things going on around a person or in the way someone is 

thinking or feeling that affect whether or not he or she smokes 

marijuana. Knowing what affects your own use gives you more 

power to decide whether or not to use. And looking at both the pros 

and cons of what happens after you use also helps you understand 

45
why you use and helps you make decisions about what you want to 

do in the future. That is why we call this sheet Knowledge Is Power. 

[Give them a blank copy of it; keep one for yourself.] Figuring out 

the factors that lead to your own marijuana use gives you more 

power to decide what to do next, and to break the habit, if you want 

to. That’s the main thing that we are trying to do in this program—to 

give you a lot of different ways to take back control instead of being 

under the control of the habit. 

Having given a rationale for treatment, the therapist should involve 

the client in a functional analysis of his or her own use. The discussion can 

focus on a recent episode(s) of use that the client has reported, or it could 

focus on the client’s use in general. The therapist should fill in some of the 

client’s responses on the personal awareness form while the client follows 

along with a blank copy of his or her own. Here are some ideas for 

discussing the subsections (from row one) of the worksheet: 

Trigger: 

What sorts of things are often going on when you decide to smoke 

marijuana? 

This may include places, people, activities, specific times or 

days, and other situational aspects of use. 

Thoughts and Feelings: 

Can you remember your thoughts and feelings the last time you used? 

Adolescents may be less likely than some adults to be able to 

identify and label their feelings. It may help for the therapist to 

offer some examples of how some adolescents say they have felt 

before they decided to use (e.g., bored, angry, excited, sad). Also, 

some adolescents may have trouble identifying their thoughts. The 

therapist may be able to elicit their thoughts better by asking 

clients what they were saying to themselves at the time. 

Behavior: 

Write down what happened at a recent time that these triggers were 

experienced. 

Often, in the example reviewed in the session, the client will have 

smoked marijuana (possibly along with other substance use, which 

should also be recorded). However, let the client know that this 

analysis can also apply to situations in which the client chose not 

to use. 

46
Positive Results: 

Some clients, when asked what good things resulted from use, may 

try to please the therapist by saying nothing; however this may not 

provide the full picture of a client’s use. The therapist may elicit a 

fuller response by saying something along these lines: 

There have probably been some things that you have liked about 

using, or you wouldn’t have kept doing it. 

Negative Results: 

Ask the client what negative results followed his or her marijuana 

use. If the client has trouble coming up with some of these answers, 

the therapist may prompt him or her by asking about some of the 

areas covered on the PFR problem list, as well as other problems the 

client has mentioned thus far. For example, the therapist may ask 

the client whether the use had any effect on family relationships. 

Show the client how you have recorded his or her responses on the 

personal awareness form, and ask for his or her reactions and questions. The 

therapist should make a photocopy of this example for the client’s chart. The 

original and an additional blank form both are given to the client, who is 

asked to use them to record other episodes of use or craving that occur 

before the next session and to bring these forms to the next session. 

47
 
Knowledge Is Power

Personal Awareness: What Happens Before and After I Use Marijuan

TRIGGER THOUGHTS AND 

FEELINGS 

BEHAVIOR POSITIVE 

RESULTS 

(What sets me up 

to be more likely to 

use marijuana?) 

(What was I thinking? 

What was I feeling? 

What did I tell myself?) 

(What did I do then?) (What good things 

happened?) 

Adapted from Jaffe et al., 1988 
Sample Knowledge Is Power Form

Here is an example of how the self-monitoring record may look after the therapist has helped the client complete it while reviewing a recent episode of use: 

Personal Awareness: What Happens Before and After I Use Mariju

TRIGGER THOUGHTS AND 

FEELINGS 

BEHAVIOR POSITIVE 

RESULTS 

(What sets me up 

to be more likely to 

use marijuana?) 

(What was I thinking? 

What was I feeling? 

What did I tell myself?) 

(What did I do then?) (What good things 

happened?) 

Friend called and 

invited me to smoke 

with him. 

Nothing else to do. 

“I want to reward myself.” 

“I’m bored.” 

“Felt good about going 15 

days w/o smoking, so felt OK 

about smoking today.” 

Went out with friend 

and smoked. 

Had fun. Felt good to ge

high, having gone 15 day

without. 
Phase 4: Preparation for Group. Remind the client that, as explained 

when he or she enrolled in the program, the next three sessions are done 

in a group. The group meetings will be 75 minutes long. Provide an idea of 

how many other clients will be in the group, how many males, how many 

females, and where it will take place. Describe the general format for each 

group session: 

• Review of marijuana-related problems that occurred in the past 

week 

• Discussion of new coping skills and how they relate to client’s 

problems 

• Practice of new coping skills in the group 

• Development of plans to practice the new coping skills at home. 

Next, review the “Information and Expectations: Group Sessions” 

sheet with the client. After discussing it, the client and therapist should 

sign it. Ask the client what else he or she would like to know about the 

group, and also how he or she feels about the upcoming group sessions. 

Clients may express some anxiety about the group sessions. If so, 

reassure them that this feeling of anxiety is normal and is likely to subside 

as they get involved in the group. Remind them that other clients may be 

feeling a similar nervousness. If a client is particularly nervous, help him or 

her think of ways to feel calmer (e.g., sitting next to the therapist, taking 

some deep breaths, telling themselves that it will be okay). 

Tell clients that they are likely to find that the members of the 

group will be at different points regarding their motivation and readiness 

for change. If a client has expressed a good deal of motivation for change, 

talk about ways he or she may preserve that feeling when faced with others 

who may not be motivated for change. If the client feels negatively about 

change, ask how he or she feels about being in a group where some of the 

other clients may be more actively working on quitting. You may point out 

the benefit of staying open to a variety of perspectives. Also let the client 

know that while it will be acceptable to talk about his or her mixed feelings 

(including positive feelings about what the client feels marijuana does for 

him or her), he or she will need to be careful not to talk about it in a way 

that may trigger other members who are trying to quit. Let clients know 

that, regardless of each client’s readiness for change, all perspectives are to 

be treated with respect. Review the group rules for the upcoming sessions. 

Give the client an appointment card with the date and time for the upcoming group session written on it. 

Remember to photocopy the personal goal worksheet and the 

personal-awareness sheet. Conclude the session. 

50
 

 

_______________________________________ ____________________ 

_______________________________________ ____________________ 

Information and Expectations: Group Sessions
 

Group sessions will last 75 minutes. Please arrive on time and attend all 

group meetings. 

If you cannot attend a group meeting, please call ______________ at 

___________________ ahead of time. If you miss a group session, you will 

be asked to make it up before or after the next session. 

Your active participation is important to the whole group. All group members are asked to listen to one another without interrupting, to respect 

the opinions of others, and to offer feedback to other group members. 

Each group member’s confidentiality is to be respected. What is said in 

group stays in group; please do not discuss what is said in group. 

In order to make the group a safe place with a positive focus, the 

following behaviors are not allowed in group: 

• Coming to group under the influence 

• Threatening remarks or gestures 

• Excessive profanity 

• Wearing gang-related clothing 

• Sexually inappropriate comments, gestures, or clothing 

• “War stories,” bragging about drug and alcohol use 

• Exclusive relationships 

The above behaviors could result in a client being asked to leave the 

group. 

I have read this information sheet, and I agree to comply with the expectations for positive participation in group. 

client date 

therapist date 
VI. Cognitive Behavioral Therapy 

The next three sessions of MET/CBT5 primarily employ 

cognitive behavioral therapy, an approach that focuses on understanding a 

person’s behavior in the context of his or her environment, thoughts, and 

feelings. The foundation for the cognitive behavioral group sessions has 

already been established in the introduction to functional analysis section 

in session 2. Another key tenet of cognitive behavior therapy is that 

individuals manifesting maladaptive behaviors may be able to learn coping 

skills that would allow them to decrease or abstain from the negative 

behaviors. Thus each of the group sessions focuses on teaching clients a 

particular skill designed to help them abstain from marijuana and other 

substance use. The following section provides some recommendations for 

carrying out the cognitive behavioral group therapy sessions, which are 

applicable to all the remaining sessions. This section draws heavily on the 

book Treating Alcohol Dependence: A Coping Skills Training Guide (Monti 

et al., 1989). 

Key Concepts and Session Guidelines 

The particular cognitive behavioral treatment approach specified in 

this manual is based on a social learning model, with a focus on training 

people in interpersonal and self-management skills. The primary goal of this 

treatment is for clients to master the skills needed to maintain long-term 

abstinence from marijuana. An important element in developing these skills 

is identification of high-risk situations that may increase the likelihood of 

relapse. These high-risk situations include external precipitants of using, as 

well as internal events such as cognitions and emotions. 

Having identified situations that may create a high risk for relapse, 

clients must develop skills to cope with them. In the three CBT group 

sessions, clients are taught basic skill elements for dealing with common 

high-risk problem areas and are encouraged to engage in roleplaying and 

real life practice exercises that will enable them to apply these skills to 

meet their own needs. 

Clients must get a chance to build their skills by receiving 

constructive feedback using relevant (client-centered) problems. Active 

practice with positive, corrective feedback is the most effective way to 

modify self-efficacy expectations and create long-lasting behavior change. 

Cognitive behavioral treatment for marijuana abuse requires the 

client’s active participation, as well as his or her assumption of responsibility for using the new self-control skills to prevent future abuse. Through 

active participation in a training program in which new skills and cognitive 

strategies are acquired, an individual’s maladaptive habits can be replaced 

with healthy behaviors regulated by cognitive processes involving awareness 

and responsible planning. Marlatt and Gordon (1985, p. 12) state: 

53
 
As the individual undergoes a process of deconditioning, cognitive 

restructuring, and skills acquisition, he or she can begin to accept 

greater responsibility for changing the behavior. This is the essence 

of the self-control or self-management approach: one can learn how 

to escape from the clutches of the vicious cycle of addiction, 

regardless of how the habit pattern was originally acquired. 

Since behavioral approaches to treatment could be applied 

inappropriately—without careful consideration of the unique needs of the 

individual receiving treatment—it is important that therapists be 

experienced in psychotherapy skills as well as behavioral principles. They 

must have good interpersonal skills and be familiar with the materials in 

order to impart skills successfully and serve as credible models. They must 

be willing to play a very active role in this type of directive therapy. 

Prior to each treatment session, therapists are encouraged to reread 

relevant sections of the manual. To ensure that the main points of each 

session are covered, we recommend making an outline of them or 

highlighting them in the text. In presenting the didactic material, we suggest briefly paraphrasing the main points and listing them on a blackboard. 

When implementing a therapy based on a manual, it is essential that 

clinicians do not read the text verbatim. As long as the major points are 

covered, a natural, free-flowing presentation style is preferred. It is crucial 

for the clients to think that their treatment issues and concerns are more 

important than the therapists’ agenda of adhering strictly to the manual. 

Indeed, if clients are not routinely involved and encouraged to 

provide their own material as examples, we have found that treatment 

becomes boring and the energy level for learning drops off dramatically. 

Therapists may experience burnout as a result. Effective reinforcement of 

clients’ active participation can help prevent burnout on the part of both 

clients and therapists. 

The topics covered in each session are intended to teach skills that 

are highly relevant to the problems in clients’ daily lives. To help clients 

view treatment as relevant to their daily lives, it is essential that a therapist 

strive as much as possible to provide examples from material that the 

clients have previously brought up. Usually this is not difficult, because the 

skills training sessions cover commonly encountered problems that are 

likely to have been raised already by the client. 

Transitioning From Individual to Group Sessions 

In MET/CBT5, therapists transition from working with clients on an 

individual basis to seeing them as a part of a group. Here are some 

guidelines for navigating questions of confidentiality and working alliances, 

which may occur in making this transition. Some therapists may be familiar 

with this process, having seen clients individually for an initial assessment 

and then treating them in group therapy. Therapists may question how to 

handle issues of confidentiality, given that by the time they see clients in 

54
the CBT group sessions, they will have quite a bit of personal information 

about each client. This concern is a particularly sensitive one with adolescents, who are especially concerned about how they are seen by their peers. 

The idea is to utilize that information while at the same time respecting 

clients’ confidentiality. A good way to do that is to refer to the general topic 

and invite clients to share their personal information. For example, if one 

group member is talking about legal problems associated with his or her substance use, the therapist may say, “There are other people in the group facing 

this problem. Would anyone else like to say what that’s been like for you?” 

In this example, the therapist does not identify any specific group 

member as being in legal trouble. The therapist can also further broaden 

the discussion by saying, “Or even if you haven’t been arrested, you might 

be worried about possible trouble with the law. Do you relate to this?” 

The therapist may also invite a particular client to share personal 

information by referring to the topic in a way that does not reveal sensitive 

information. For example, “Joe, this reminds me of your situation. Would you be 

comfortable telling the group about what’s going on with you and your parents?” 

If “Joe” declines to do so, don’t pressure him. He may decide to 

when he feels more comfortable. Of course there is always the risk that 

“Joe” may be upset even about having the therapist reveal that his situation 

is similar. In such a case, the therapist is encouraged to apologize without 

becoming defensive. 

The flip side of this issue is that a client may make reference to 

something he or she and the therapist have discussed, in a way that 

excludes the rest of the group. When this occurs, the therapist should ask 

the client to fill the group members in on the story. Here is an example: 

Lisa: [looking at the therapist] Remember that problem I was 

having with my friend Jane? Well I talked to her, and she said. . . . 

Therapist: Hold on a second. Could you fill the group in on what was 

going on? 

In general, the therapist acknowledges and makes use of information 

acquired in the individual sessions, but he or she puts the adolescent in 

charge of sharing, or not sharing, that information with the group. 

In working with adolescents, some therapists have noticed that 

clients may verbalize their motivation to quit marijuana in the individual 

sessions and then seem less motivated in the ensuing group sessions. In 

some cases, the therapist may suspect that this shift is due to the 

adolescent’s concern that the other group members may not think he or 

she is cool. The therapist may feel disappointed or frustrated by the client’s 

seeming lack of cooperation and may feel like confronting the client on this 

change. Doing so, however, is only likely to cause the client to feel ashamed 

and, perhaps, intensify his or her antiabstinence position. The following 

strategies are likely to be more productive. 

55
 
If the therapist perceives that, overall, the group is communicating 

the attitude that “using is cool, quitting is not cool,” the therapist can 

state what he or she observes. Sometimes the group members may 

acknowledge this position, which may result in some productive dialog 

about pressures clients may face in their relationships outside of group. 

Even if the group rejects the therapist’s observation, just having stated it 

may decrease the likelihood of continued antiabstinence communications. 

Another strategy is to acknowledge that a number of group clients 

may have similar mixed feelings about quitting versus continuing use. The 

therapist may employ some double-sided reflections that speak to the group 

as a whole. For example, the therapist could say: 

Even though each of you came to this program because of some 

problems related to your marijuana use, a number of people are 

saying that you have a lot of good memories about times you’ve 

smoked, and you’re not sure that you want to give it up now. 

Obviously, if the group wanted to focus at length on memories of being 

high, the therapist would need to set limits to avoid romanticizing 

marijuana use or triggering cravings. 

Discussion of Clients’ Recent Problems 

[The following recommendations are from the Monti et al. (1989) 

coping skills training guide for treating alcohol dependence.] 

Clients experience numerous problems, cravings, and actual slips as 

they struggle with abstinence. Although the focus of the sessions must be 

on the structured program, ignoring clients’ real life problems entails the 

risk that they will view treatment as peripheral or irrelevant to their current 

needs. As a compromise between the demands of the protocol and clients’ 

perceived needs, approximately 15 minutes should be spent at the outset of 

each session discussing clients’ current problems related to marijuana. 

Make efforts to structure these discussions along lines that are 

consistent with a skills-training approach by using a problem-solving format 

that involves clearly specifying the problem, brainstorming possible ways of 

dealing with it, and selecting one way to try out in the situation. The rule is 

that the opening discussions should be structured along behavioral lines to 

keep them consistent with the approach of this manual. 

If necessary, clearly state to the clients that while skills treatment 

can help them practice new ways of coping with problems, these problems 

cannot always be fully discussed to the point of complete resolution. 

Long-term resolution of specific problems may require additional work after 

this program is finished. 

If serious problems arise repeatedly, consult with your supervisor. 

It may become necessary to initiate alternative treatment. 

56
Presentation of Skill Guidelines 

In each of the cognitive behavioral group sessions, the focus is on 

teaching a particular skill: (1) marijuana refusal skills, (2) enhancing the 

social support network, and (3) coping with relapses. Posters focusing on the 

skill to be taught in each of the sessions are included in appendix 3 of this 

manual. The poster corresponding to the current session should be hung in 

the group room where everyone can read it. Only the poster relating to the 

current session should be displayed, so that the material presented will be 

novel and, thus, more likely to capture group members’ attention. 

In presenting a particular skill, therapists should start by providing a 

rationale for learning that skill. The main points of the therapeutic 

rationale are covered on the “why?” part of the poster and will become 

more meaningful to clients if therapists draw parallels between the 

rationale and events in group members’ lives. For example, therapists 

leading session 3 may ask group members if they have noticed a narrowing 

of their own social circles to include primarily other drug and alcohol users. 

In describing the session 5 rationale that relapse is an opportunity for 

learning, a therapist may refer to a relapse story that a client shared earlier 

in the group and encourage the client and the rest of the group to identify 

what could be learned from that experience. 

Next, therapists review the skill guidelines shown on the posters. 

Here, again, the key to engaging the group is to make these guidelines 

come alive by illustrating them with examples and explicitly stating how 

they are relevant to clients’ lives. Therapists may also engage clients by 

having them take turns reading the skill guidelines out loud. Be aware that 

some clients may have deficits in their reading skills or may be uncomfortable reading aloud in group. Provide them the opportunity to bow out 

gracefully. For example, you may tell group members that they can just say 

“pass” if they prefer not to read. 

Therapists may be able to make the skill guidelines fun and 

interesting by using some creativity. For example, the therapist may 

demonstrate the contrast between making a refusal statement in a voice 

that is clear and firm rather than vague and hesitant. One group member, 

for example, might like to try demonstrating the contrast between refusing 

marijuana with and without making eye contact. In covering the material 

included for each session, therapists are encouraged to make it lively and 

fresh. This can be accomplished while staying true to the protocol. 

Encourage questions and comments about the skill guidelines. If a group 

member says that a particular skill is not useful, don’t be defensive— 

instead, focus on listening to the client’s concerns. As in the individual 

MET sessions, group clients may be more open to the therapist’s input if 

they do not feel that the therapist is trying to convince them. 

Emphasize the importance of real life practice of the skills, as well 

as practice within the group through roleplaying. The following section 

contains some guidelines for using roleplay with clients and is based on 

Monti and colleagues’ (1989) coping skills training guide. 

57
Guidelines for Behavior Rehearsal Roleplay 

The main factor that determines the success of cognitive behavioral 

skills training is the extent to which clients practice and apply the new skills in 

their lives. Roleplays in the group therapy sessions give clients a chance to test 

the potentially unfamiliar new skills in a safe environment. Doing so in group 

increases the likelihood that clients will try new skills in their lives outside 

therapy. As a result, roleplay in a group provides a valuable practice exercise. 

Roleplay is specifically called for in the first group therapy session, 

in which clients are asked to practice marijuana refusal skills. While 

roleplay is not built into the remaining two group sessions, if time allows, 

therapists are encouraged to utilize roleplay when it may enhance learning. 

For instance, during the review of progress, a client may describe a recent 

relapse precipitated by an offer of marijuana. The therapist can encourage 

roleplaying in which the client responds by refusing the offer. Or during a 

later discussion of requesting help and support, a client could be asked to 

roleplay asking for help. 

Some clients and/or therapists may feel uncomfortable or 

embarrassed at first about roleplaying. As a result, it may be tempting for 

the therapist to allow the group simply to talk about the skills rather than 

practicing them, which would decrease the effectiveness of therapy. 

Therapists can increase the likelihood that clients will participate in 

roleplays by taking the lead in the first one. Therapists should acknowledge 

that feelings of awkwardness are normal when trying a new interpersonal 

behavior like roleplay. Also, therapists are encouraged to praise clients who 

volunteer to go first. In general, if therapists establish a safe group 

environment and follow the suggestions about making group sessions fun 

and interesting, they are likely to find that clients will readily participate in 

roleplays. Here are the basic steps for setting up roleplays: 

1. Explain what roleplaying is, if you have not already done so. 

Keep in mind that many clients are likely to be familiar with the 

idea of roleplay, so it may not require a long explanation. For 

example, say: 

I’d like you to practice turning down an offer to smoke by 

doing that here in group, as if you were acting. The first time, 

I’ll pretend to be that guy you told us about. 

2. Briefly review the situation to be roleplayed. What is the 

problem? What is the skill to be practiced? 

Okay, so your friend is driving you to school, and she offers to 

get high with you. You turn down the offer. 

3. Determine who will play which role. Suggestions for acting the 

part can be solicited and made. 

Who would be willing to play Jason’s mom? 

Jason, should she act mad, sad, or what? 

58
The following strategies are useful in helping clients generate scenes: 

• The therapist can ask clients to recall a situation in the recent 

past where use of the skill being taught would have been 

desirable. 

• The therapist can ask clients to anticipate a difficult situation 

that may arise in the near future that calls for use of the skill. 

• Clients can all be asked to write down scenarios to be roleplayed, 

fold them up, and place them in the center of the group. Clients 

then take turns taking one of the written scenarios and 

roleplaying them. 

• The therapist can suggest an appropriate situation based on his 

or her knowledge of a client’s recent circumstances. 

After a roleplay has been set up and enacted, it is essential that it be 

effectively processed. It is an opportunity for clients to receive praise and 

recognition for practice and improvement, as well as constructive criticism 

about the less effective elements of their behavior. Initial attempts may 

show few elements of the communication skill being taught. During this 

portion of the session, the therapist’s primary goal is to look for successful 

elements of the skill being taught and to reinforce those skill elements. The 

primary emphasis should be on what the client is doing well, in order to 

gradually shape his or her behavior in a positive direction. A secondary 

focus is making limited suggestions for improvement. Here are the 

procedures for delivering this feedback: 

1. Immediately after every roleplay, the therapist should give the 

client reinforcement for participating and for positive aspects of 

the performance. Both the roleplaying clients should give their 

reactions to the performance. Examples: How do the protagonists 

feel about the way they handled the situation? What effect did the 

interaction have on the partner? 

2. The other group members and the therapist should offer 

comments about the roleplay. These comments should be both 

supportive and reinforcing and constructively critical. If there are 

several deficiencies in a roleplay performance, the therapist 

should choose only one or two to work on at a time. Both 

positive and negative feedback should focus on specific aspects of 

the person’s behavior, since global evaluations do not pinpoint 

what was particularly effective or ineffective. Finally, the praise 

and reinforcement provided should always be sincere. However, 

the therapist should refrain from being unnecessarily effusive, so 

that the value of the positive feedback is not undermined. 

3. The scene should be repeated to give the client an opportunity to 

try out the feedback he or she received the first time around. 

59
 
Role reversal is a roleplay strategy in which the therapist models use 

of the new skill, with the client playing the role of the friend, parent, or 

teacher. This strategy is particularly useful if a client is having difficulty 

using a skill or is pessimistic about the effectiveness of a suggested 

approach. By playing the “other,” he or she has an opportunity to observe 

and experience firsthand the effects of the suggested skill. 

Real Life Practice Exercises 

Practice in real life situations is a powerful adjunct to treatment 

because it enhances the likelihood that these behaviors will be repeated in 

similar situations (generalization). Practice exercises have been designed for 

each session of the program. Most require that the client try in a real life situation what has been taught in the session. The real life practice assignment 

also requires that the client record facts concerning the setting, his or her 

behavior, the response it evoked, and an evaluation of the adequacy of his or 

her performance. Practice exercises can be modified to fit the specific details 

of individual situations. 

Using practice exercises often is a problem, and a number of steps 

can be taken to foster compliance. The assignments are referred to as real 

life practice to avoid the negative connotations often associated with the 

term homework. When giving each assignment, provide a careful description of the assignment and the rationale for it. Ask clients what problems 

they can foresee in completing the assignment, and discuss ways to 

overcome these obstacles. Ask them to identify a specific time that can be 

set aside to work on the assignment, and try to elicit a commitment from 

group members to complete the practice exercise by the next session. 

To emphasize the importance of practice, therapists should review 

the preceding session’s exercise at the beginning of each session and make 

an effort to praise all attempts to comply with the assignment. Although 

problems that clients have with the exercises should be discussed and 

understood, the main emphasis should be on reinforcing the positive 

aspects of performance. If at least two group members have done the real 

life practice exercise assigned in the previous session, focus on those who 

have completed the assignment in this portion of the group meeting. To the 

extent that group members enjoy being the center of attention, this will 

reinforce completion of written practice exercises. For those who did not do 

an assignment, discuss ideas for complying with the next assignment. A 

selection of inexpensive but appealing items should be purchased by the 

staff, such as items that can be found at a party store or a dollar store 

(price range 50 cents to $1.25). At the end of the group meeting, let 

clients who have brought in a completed practice exercise choose one item 

from the assortment, to reinforce their compliance. 

The next section of the treatment manual describes the procedures 

and content of sessions 3 through 5. Following that section are further 

recommendations regarding the management of problem behaviors. 

60
Session 3: CBT3—Marijuana Refusal Skills 

Key Points: 

• One’s social circle gradually narrows as marijuana use increases. 

Clean friends are avoided and socialization with users increases. 

It is crucial that clients attempting to stop smoking marijuana 

develop refusal skills. 

• It is best to avoid people who put users at high risk, but that is 

not always possible. 

• Clients need to develop refusal skills to handle pressure 

effectively. 

• When being pressured to use marijuana, immediate and effective 

action is needed. 

• Practice will increase the likelihood that clients will use their 

marijuana refusal skills effectively when pressured. 

Delivery Method: Cognitive behavioral group therapy 

Session Phases and Times: 

1. Introduction of group members to one another and a brief review 

of progress (20 minutes) 

2. Review of real life practice (personal awareness forms) 

(10 minutes) 

3. Marijuana refusal skills (45 minutes) 

Time: 75 minutes total 

Handouts: 

• Marijuana refusal skills handout—enough copies for all clients 

and the leader 

• Marijuana refusal skills reminders and real life practice 

handouts—enough copies for all clients and the leader 

• Blank personal awareness forms (homework from session 2) 

Materials: 

• Prizes (for completion of real life practice exercises) 

• Pens or pencils 

• A session 3 poster 

61
Procedural Steps 

Phase 1: Introduction to the Group and Brief Review of Progress. 

The first part of the session is allotted to introducing group members to 

one another and to reviewing rules, which are posted in the group room. In 

order to help focus the group, each client is asked to share his or her goal 

for treatment. The therapist then asks an open-ended question about how 

the past week has gone regarding the marijuana issues. Because the 

resulting discussion could probably continue for the rest of the session, the 

therapist will have to rein it in to allow time for the material in this session 

to be covered. To facilitate this, the therapist may wish to open the topic 

with a statement like: 

Before we get into today’s topic, let’s take about 10 minutes to hear 

how things have been going for all of you this past week regarding the 

marijuana issue. 

Phase 2: Review of Real Life Practice. Next, the therapist will ask 

clients who have completed and brought in their self-monitoring records to 

pick one episode that they wrote about and share it with the group. Group 

members and the therapist then share their reactions to what was written. 

Again, the time prohibits getting into detail or an extended discussion of 

people’s examples. 

If none (or only one) of the group members have brought in written 

comments, give group members blank personal awareness worksheets 

(Knowledge Is Power) for functional analysis and have them verbally reconstruct one episode of craving or relapse that occurred during the past week. 

Allow time for feedback about those episodes. If at least two members have 

brought in written comments, just review their work. To the extent that 

members like the group attention, this may provide some incentive to 

complete the exercises. When people create answers on the spot rather 

than reading what they have written, they may become verbose; the time is 

better allotted to focusing on clients with written comments. 

Phase 3: Marijuana Refusal Skills. Some of the following pointers 

and skills are included on the marijuana refusal skills poster, which provides 

visual reinforcement of the material to be covered. The therapist explains 

the following points regarding marijuana refusal skills: 

1. Being offered marijuana or being pressured to use by others is 

a very common high-risk situation for marijuana users who have 

decided to stop using. Have you received such offers or pressures? 

In what situations? 

2. As one’s use increases, there appears to be a “funneling” effect 

or narrowing of social relationships. The individual begins to 

eliminate nonusing friends and his or her peer group becomes 

populated with others who support and encourage continued use. 

Being with such individuals increases the risk of relapse. 

62
3. Given the increased risk associated with social pressure, the best 

initial step is to avoid situations involving marijuana use. As 

this is not always possible or practical, marijuana refusal skills 

are necessary. 

4. Being able to turn down marijuana requires more than a sincere 

decision to stop using. It requires specific assertiveness skills to 

act on that decision. Practice in refusing marijuana will help you 

respond more quickly and effectively when real situations arise. 

5. The more rapidly the person is able to say “no” to such requests, 

the less likely he or she is to relapse. Why is this so? 

Next, the group should review specific suggestions for the nonverbal 

and verbal behaviors recommended for marijuana refusal (also shown on the 

marijuana refusal skills poster). The marijuana refusal skills handout covers 

this material but adds more detail. Distribute this handout, and review each 

of the skills. Consider having clients take turns reading the points, in order 

to keep them all involved. Demonstrate, and then engage the group in 

demonstrating, the skills described. Group members often enjoy the part of 

the group in which they see the skills demonstrated effectively rather than 

ineffectively, and this is a good opportunity to increase their active involvement in discussion. Point out that these refusal skills are equally useful in 

turning down offers to use alcohol or other drugs. Following are the skills 

to be reviewed with the group. (A handout follows.) 

Marijuana Refusal Skills 

Nonverbal behaviors: 

• Be firm. Speak in a clear and unhesitating voice. Otherwise you 

invite questions about whether you mean what you say. 

Demonstrate this skill by making the same refusal statement 

twice—once in a timid voice and once in a clear, firm voice. Have 

clients comment on the perceived effectiveness of each style. 

• Make direct eye contact with the other person; it increases the 

effectiveness of your message. Again, demonstrate (or ask a group 

member to demonstrate) the same refusal with and without eye 

contact. Discuss your observations. 

• Stand up for your rights! Don’t feel guilty. You won’t hurt anyone 

by not using marijuana, so don’t feel guilty. In many social 

situations, people will not even know whether you are using or 

not. You have a right not to use. Discuss your reactions. 

Verbal behaviors: 

• “No” should be the first word out of your mouth. When you 

hesitate to say “No,” people wonder whether you really mean it. 

Demonstrate the same statement both with and without the word 

“No” first. Ask for clients’ reactions. 

63
• Besides saying “No,” suggest an alternative, something fun to do 

instead. Have the group suggest possibilities for alternative 

activities. 

• If a person repeatedly pressures you, ask him or her not to offer 

you marijuana any more. Consider setting up a roleplay to 

illustrate doing this. 

• After saying “No,” change the subject to something else to avoid 

getting drawn into a long discussion or debate about using. Have 

the group suggest possible changes of subject. 

• Avoid the use of excuses like “I’m on medication for a cold right 

now,” and avoid vague answers like “Not tonight.” Discuss the 

rationale for avoiding excuses; they imply that at some later date 

you will accept an offer of marijuana. 

64
Marijuana Refusal Skills
 

Nonverbal behaviors: 

• Be firm. Speak in a clear and unhesitating voice. Otherwise, 

you invite questions about whether you mean what you say. 

• Make direct eye contact with the other person. It increases 

the effectiveness of your message. 

• Stand up for your rights! Don’t feel guilty. You won’t hurt 

anyone by not using marijuana, so don’t feel guilty. In many 

social situations, people will not even know whether you are 

using or not. You have a right not to use. 

Verbal behaviors: 

• “No” should be the first word out of your mouth. When you 

hesitate to say “No,” people wonder whether you really 

mean it. 

• Besides saying “No,” suggest an alternative, something fun to 

do instead. 

• If a person repeatedly pressures you, ask him or her not to 

offer you marijuana any more. 

• After saying “No,” change the subject to something else to 

avoid getting drawn into a long discussion or debate about 

using. 

• Avoid the use of excuses like “I’m on medication for a cold 

right now,” and avoid vague answers like “Not tonight.” 

These imply that at some later date you will accept an offer 

of marijuana. 
 

 

 

The next part of the session involves practice, and clients are 

generally quite good at generating appropriate scenes to practice. Initially, 

the therapist will play the person who is being invited to use marijuana and 

will explain and demonstrate each of the following types of responses: 

Response 

Type 

This Kind of Person: Response Example 

Passive Tends to give up his or her 

own desire in favor of another 

person’s desire. 

Doesn’t let others know what 

he or she is thinking or feeling. 

“I didn’t want to smoke 

pot tonight, but if you 

want us to, we might as 

well smoke.” 

Aggressive Acts to protect his or her own 

rights but runs over others’ 

rights in the process, which 

can cause others not to like 

him or her. 

“I’m not smoking weed, 

and I don’t want anyone smoking around 

me! I’m throwing 

everyone’s weed 

away!” 

Passive- Is indirect, hints at what he or “Are you all going to 

Aggressive she wants, possibly causing 

confusion and/or resentment 

in others. 

get stoned now? You 

know I’m in the treatment program. . . .” 

Assertive States his or her position and 

makes a direct request. 

“I’ve quit smoking pot, 

and I’d like it if you 

would not ask me to 

smoke with you anymore. I still want to get 

together with you to do 

other things, like shooting some hoops, okay?” 

First, the therapist describes each of the four types of responses 

listed above, demonstrating an example of each by asking one of the group 

members to play the person offering the marijuana. The therapist points out 

the ways that the first three types of responses may not be helpful to 

clients, highlighting the differences between these styles and the desirable 

assertive style. 

Next, the therapist encourages group members to practice the 

assertive style of marijuana refusal in roleplays with one another. Group 

members are encouraged to offer one another support and constructive 

feedback as they practice these skills. Finally, clients are each given a copy 

of the marijuana refusal reminders sheet to take home. They are asked to 

fill in the real life practice exercise at the bottom of the sheet with either: 

(1) responses they actually make during the week to people who offer 

marijuana, alcohol, or other drugs; or (2) things they could say to turn 

down an offer to smoke marijuana. The therapist should attempt to get a 

verbal commitment from group members to complete this real life practice 

exercise. 

66
_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

Marijuana Refusal Skills Reminders
 When someone asks you to use marijuana, keep the 

following in mind: 

• Say “No” first. 

• Make sure your voice is clear, firm, and 

unhesitating.
 

• Make direct eye contact. 

• Suggest an alternative: 

Something else to do.
 

Something to eat or drink.
 

• Change the subject. 

• Avoid vague answers. 

• Don’t feel guilty about refusing to use marijuana. 

• If necessary, ask the person to stop offering you 

marijuana and not to do so again. 

Real Life Practice 

Listed below are some examples of people who might offer you marijuana in the future. Give some thought 

to how you will respond to them, and write your responses below each item. 

Someone close to you who knows about your marijuana problem: 

A school friend: 

A coworker (if you have a job): 

A new acquaintance: 

A person at a party with others present: 

A relative at a family gathering: 
Session 4: CBT4—Enhancing the Social Support Network and 

Increasing Pleasant Activities 

Key Points: 

• Social support leads to improved confidence in one’s ability to 

cope and provides an additional source of help for quitting or 

reducing one’s marijuana use. 

• Often individuals do not have as much support as they would like. 

• There are several potential sources of support, including one’s 

family, friends, and acquaintances. 

Delivery Method: Group cognitive-behavioral therapy 

Session Phases and Times: 

1. Review of progress (15 minutes) 

2. Review of real life practice exercise (10 minutes) 

3. Enhancing support (35 minutes) 

4. Increasing pleasant activities (15 minutes) 

Time: 75 minutes total 

Handouts: 

• A social supports reminder sheet for each group member 

• A social circle worksheet for each member 

• A social support practice exercise sheet (entitled Real Life 

Practice: Seeking and Giving Support) for each member 

Materials: 

• A drug test kit for each client 

• Prizes (for completion of the real life practice exercise) 

• Pens or pencils 

• A blackboard, a “write and wipe” board, or a large poster board 

• A session 4 poster 

Procedural Steps 

Phase 1: Review of Progress. Prior to formally beginning the group 

session, clients should be asked to provide urine samples for drug testing. 

The therapist waits outside the restroom when each client goes in to 

provide the sample. Clients should not be permitted to bring extra items 

into the restroom (e.g., coats, purses, etc.). If a multiple-capacity restroom 

is used, only one client should be allowed into the restroom at a time. 

When clients bring out their urine samples, the therapist should look at the 

temperature strip on the outside of the container to see whether the urine 

was voided recently (i.e., is within the expected temperature range). Clients 

should be informed that if they do not provide the requested urine sample, 

or if the sample is invalid, their sample will be considered positive for drugs, 

68
meaning that drugs were present in their urine sample. If some clients say 

that they are unable to urinate prior to the group meeting, ask them to 

wait until after the meeting to do so. Occasionally a group client may say 

that he or she must use the restroom during the session and is unable to 

wait until afterward. In such a case, try to have a support staff person who 

is outside the group supervise the client providing the urine sample (as 

described above), rather than interrupting the group to supervise that 

client yourself. 

After obtaining urine samples, begin the group meeting. Following 

initial greetings and updates (for example, telling the group that a client 

will not be in that day), the therapist should start with a general question 

about recent progress. For example: 

As you’ve been working on the marijuana issue over the past week, 

has anyone had any problems or successes that you’d like to share 

with the group? 

Allow sufficient time for discussion, attempt to facilitate members’ feedback 

and reactions, and offer your own comments, using MET and CBT strategies 

where possible. Move into the practice exercise review part of the session 

when the discussion winds down or in 15 minutes, whichever comes first. 

Phase 2: Review of Real Life Practice. As in last week’s group session, keep the focus primarily on those who have done the real life practice 

exercise, unless fewer than two clients have done so. Have members read 

their responses to the refusal skills real life practice exercise, with the rest 

of the group offering feedback. Ask if any group members have had an 

opportunity to try out their refusal skills in a real life situation. If so, ask 

them to tell about their experience and reinforce their efforts. 

Phase 3: Enhancing the Social Support Network and Increasing 

Pleasant Activities. This phase of the session starts with the therapist 

reviewing the rationale for increasing support: 

• Social support leads to improved confidence in one’s ability to 

cope and provides an additional resource. 

• Individuals do not often have as much support as they would like. 

• There are several potential sources of social support, including 

one’s family, friends, and acquaintances. 

Next, focus on teaching social support skills. Distribute the 

enhancing social supports reminder sheets (adapted from Monti et al., 

1989) to the group. These skill guidelines are summarized on the poster for 

this session. Review the guidelines with the group and have them come up 

with examples from their own lives that correspond to some of the items. 

Here are the areas covered on the reminder sheet, with suggestions for 

covering them: 

69
Enhancing Social Supports 

Who might be able to support you? (Tell the group that “this refers to people who could help you with the goal you set regarding your marijuana use, 

as well as with other concerns in your life.”) 

Consider people who usually have been supportive in the past or 

those with no bias toward you. (Encourage group members to give 

examples from their own lives.) 

Consider people who usually have been neutral in the past (who 

aren’t coming in with a bias against you). (Encourage group members to give examples from their own lives.) 

Consider people who usually have not been supportive in the past 

but who might become supportive when they see your effort. 

(Encourage group members to give examples from their own lives.) 

Consider friends, family, acquaintances, or others in your community. (Prompt the group regarding categories that have not already 

been covered and may apply to group members, for example, teachers, clergy, coaches, extended family, guidance counselors.) 

What types of support will be most helpful? (Again, have the group think of 

examples from their own lives of when they have needed, or when they may 

need, each of these types of support in the future.) 

Help with problem solving—someone good at thinking of options 

Moral support—someone to offer encouragement and 

understanding
 

Sharing the load—help with getting things done 

Information—about activities, transportation, getting a job, etc. 

Emergency help—for small loans, needed items, a ride, etc. 

How can you get the support or help you need? 

Ask for what you need. Be direct and specific. 

The therapist should model the following ways of seeking support for the 

group. You may prefer to substitute a situation described by a group member during the meeting for the example below. 

70
Problem: The client wants a friend to show support by doing things together 

other than just smoking marijuana. 

Type of Request for Help Response Example 

Indirect The only thing you ever want to do 

with me is smoke pot. 

Direct, but not specific I’d like to spend time with you doing 

stuff other than smoking pot. 

Direct and specific I’d like to spend time with you, but I 

don’t want to smoke pot any more. 

Why don’t we go bowling this Saturday 

night? 

Ask for group members’ reactions to the situations as they are modeled. 

Add new supporters. As you work on something new, like trying to quit 

marijuana, you may need new or additional supporters. Ask group members 

who else’s support they could seek. 

Lend your support to others. Talk with the group about how giving support 

allows you to get better at receiving support. Ask them for their reactions to 

this idea. 

Give your supporters feedback. Let them know when something is or isn’t 

helping. Have the group think of an example of when someone may try to 

offer support that is not helpful, and how someone could tell them so. 

71
Enhancing Social Supports Reminder Sheet
 

WHO might be able to support you? Consider people in the past who have been: 

• Usually supportive, such as friends, family, 

acquaintances, or others in your community 

• Usually neutral (aren’t coming in with a bias 

against you) 

• Not supportive, but might become supportive 

when they see your effort 

WHAT types of support will be most helpful? 

• Help with problem solving—someone good at thinking of options 

• Moral support—offers encouragement and understanding 

• Sharing the load—help with getting things done 

• Information—about activities, transportation, getting a job, etc. 

• Emergency help—-for small loans, needed items, a ride, etc.
 

HOW can you get the support or help you need?
 

Ask for what you need. Be direct and specific.
 

• Add new supporters. As you work on something new, like trying to quit 

marijuana, you may need new or additional supporters. 

• Lend your support to others. It allows you to get better at receiving 

support. 

• Give your supporters feedback. Let them know when something is or isn’t 

helping. 

Adapted from Monti et al., 1989 
In-Session Exercise: Social Circle Diagraming. Next, group 

members are asked to diagram their own social circles and to try to 

determine what support they may be able to obtain from their social 

circle. They are given pencils and asked to fill in this diagram during 

the next part of the group meeting. 

After 5 to 10 minutes, each group member is asked to share what 

he or she learned or noticed about his or her own support system. Did 

group members notice possibilities for asking for and getting more 

support? They are not asked to share the specifics of their personal 

support system; there is not enough time for this. Although clients 

may want to explain every intricacy of their social circle (“Here we 

have my friend Casey; this is my sort-of friend Joe,” etc.), time will 

not allow this detail. It will be helpful for the therapist to explain 

this at the beginning of the discussion to decrease the likelihood 

that a client will feel cut off later. Please see the social circle 

diagram on the next page. 

73
Social Circle Diagram 

Use the grid below to diagram your own social support circle, focusing on those 

who could support you in addressing your marijuana issue. 

Put your name in the center space, then fill in the names of those who do and/or 

could support you in your goal. Put the people who could be of greatest support 

to you closest to your space. Fill in as many of the spaces as you can. 
Phase 4: Increasing Pleasant Activities. The following exercise is 

offered as a possible supplement to this session and should be included if 

there are at least 15 minutes available. Enjoyable activities can be a positive 

alternative to smoking marijuana. The group is asked to think of pleasant, 

fun, and safe activities that may serve as an alternative to smoking marijuana. 

Tell them that some frequent marijuana smokers forget what it is 

like to do various things when they are not high and that some fun 

activities seem normal to them only when they are under the influence. 

Stopping or reducing marijuana use involves breaking the connection 

between these activities and being high. Many marijuana smokers may think 

that these activities will not be fun any more without marijuana, but they 

are often pleasantly surprised to find that the activities are as much fun, or 

even more fun, when they are not under the influence. Tell them that you’d 

like them to think of healthy, fun activities that they may be able to enjoy 

without, and instead of, marijuana use. 

In-Session Exercise. While the group brainstorms possibilities, the 

therapist writes them down so that they are visible to the whole group. 

After several minutes, the therapist asks the group to consider if there 

might be a few activities on the list that they could add to their routine of 

activities. They are asked to write some of these on the bottom of their 

social circle diagram. 

Next, they are asked to circle any of the listed things they would be 

willing to do over the next week. Each client is encouraged to tell the group 

one new thing he or she will do over the next week, including when, with 

whom, and how they will do it. Remind them that the idea is to do the chosen things without using marijuana, alcohol, or other nonprescribed drugs. 

Distribution of Practice Exercises. Before the session concludes, 

practice exercise sheets (entitled Real Life Practice: Seeking and Giving 

Support) should be distributed and group members asked to complete them 

before the next session. Have the clients read the practice exercise sheets in 

the session so that they can ask any questions they may have at that time. 

Try to elicit some type of commitment from group members to complete 

both the written part of the exercise as well as the part where they actually 

ask for and offer support. This is in addition to trying out the pleasant 

activity. 

75
_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

_____________________________________________________________ 

Real Life Practice: Seeking and Giving Support
 

Think of a current problem that you would like help with. 

Describe the problem:___________________________________________ 

Who might help you with this problem?___________________________ 

What might he or she do to give you the support you’d like? 

How can you get this support from him or her? Remember, be direct and 

specific:_______________________________________________________ 

Now, choose the right time and situation, and try to get this person to 

support you. Describe what happened:_____________________________ 

Offer support to someone else. 

Name a friend or family member who is currently having a problem and 

who could use more support from you:____________________________ 

Describe what you could do to lend him or her some support:_________ 

Now, choose an appropriate time and setting, and give support to this 

person. Describe what happened:__________________________________ 

Adapted from Monti et al., 1989 
Session 5: CBT5—Planning for Emergencies and Coping With 

Relapse 

Key Points: 

• Preparation for emergencies (unanticipated high-risk relapse 

situations) will increase the likelihood of effective coping. 

• The group will brainstorm events that could precipitate a relapse. 

• The problem-solving approach will be introduced as a way to cope 

with unforeseen events. 

• A relapse is likely to be accompanied by guilt and shame, which 

exacerbates the problem. 

• Use emergencies and lapses as learning opportunities. 

Delivery Method: Cognitive-behavioral group therapy 

Session Phases and Times: 

1. Review of progress (15 minutes) 

2. Review of real life practice (15 minutes) 

3. Planning for emergencies and coping with relapse (35 minutes) 

4. Termination (10 minutes) 

Time: 75 minutes total 

Handout: 

• A personal emergency plan handout for each client 

Materials: 

• A blackboard, a “write and wipe” board, or a large poster board 

• A session 5 poster 

Procedural Steps 

Phase 1: Review of Progress. Like previous group sessions, this 

session begins with a review of progress. Discussion about progress or 

problems over the past week is elicited by a general inquiry by the 

therapist. (See sessions 3 and 4 for further recommendations for conducting the review of progress.) During this phase of the group, the therapist 

offers to communicate the results of the clients’ urine tests for drugs (from 

samples obtained at the previous group meeting.) See “The Five Strategies 

of Motivational Enhancement Therapy” on page 21 for recommendations 

for discussing these results. The therapist should remind group members 

that this will be the final therapy session. 

Phase 2: Review of Real Life Practice. Have group members read 

their responses to the seeking and giving support practice exercise. Ask the 

rest of the group to offer feedback. Reinforce attempts to try out the 

enhancing social support network skills through real life practice. If some 

77
clients have not yet tried out these skills, encourage them to do so soon. 

Ask them to make a commitment to do this. 

If the pleasant activities segment was done in session 4, ask clients 

about how they did on their plans to increase pleasant activities. Did they 

do the thing they planned? How did it go? Did they enjoy the activity or 

not? If they didn’t do it, what got in the way? 

Phase 3: Planning for Emergencies and Coping With Relapse. Even 

if someone avoids situations involving marijuana use, knows how to refuse 

such offers, increases his or her support system, and plans positive alternative activities, he or she still may encounter unanticipated high-risk 

(emergency) situations and may relapse. 

In-Session Exercise: Group Brainstorming of a Potential 

Emergency Situation. For individuals attempting to quit marijuana, an 

emergency situation consists of unanticipated circumstances that place 

them at increased risk for marijuana use. The group is asked to brainstorm 

the types of emergencies they may encounter. The therapist writes down the 

group’s responses in a place that is visible to all group members. After a 

period of unstructured brainstorming, provide cues to help the group think 

of types of emergencies they may have missed. Here are some examples of 

emergencies: 

Type of Emergency Example of Emergency 

Unanticipated trigger Encountering substance abuse at a 

drug- and alcohol-free dance 

Social separation Friend moves away; breakup with 

boyfriend or girlfriend 

School problem Failing to be promoted; getting 

suspended 

Adjustment to a new situation Move to a new town; parents divorce 

New responsibilities New job; care for a sick family member 

As seen above, emergency situations that can trigger a slip do not 

just include negative events but can also include positive events (e.g., a new 

job or a move to a better home). These situations entail the need to adjust 

to a number of changes in one’s environment and routine, when one’s coping skills may no longer fit the new circumstances. In emergency situations, 

individuals can increase their likelihood of success by using the 

problem-solving model described below, an approach developed by D’Zurilla 

and Goldfried (1971). 

Presentation of the Problem-Solving Model. The following brief 

summary of the problem-solving model is derived from Treating Alcohol 

Dependence: A Coping Skills Training Guide (Monti et al., 1989), which 

asks: 

78
1. “Is there a problem?” Recognize that a problem exists. We get 

clues from our bodies, our thoughts and feelings, our behavior, 

our reactions to other people, and the ways that other people 

react to us. 

2. “What is the problem?” Identify the problem. Describe the 

problem as accurately as you can. Break it down into manageable 

parts. 

3. “What can I do?” Consider various approaches to solving the 

problem. Brainstorm to think of as many solutions as you can. 

Consider acting to change the situation and/or changing the way 

you think about the situation. 

4. “What will happen if. . . ?” Select the most promising approach. 

Consider all the positive and negative aspects of each possible 

approach, and select the one most likely to solve the problem. 

5. “How did it work?” Use the chosen approach. Assess its 

effectiveness. Having given the approach a fair trial, does it seem 

to be working out? If not, consider what you can do to beef up 

the plan, or give it up and try one of the other possible 

approaches. 

Group Practice Exercise: Problem Solving for Emergencies. Have 

the group select one of the potential emergencies that were generated in 

the previous brainstorming exercise. Now ask the group to be sure that the 

problem is clearly identified, and have clients brainstorm various solutions. 

Write the possible solutions in a place that is visible to the whole group. 

Now have the group evaluate each of the possible solutions and pick one as 

the best choice. As this exercise is being done, describe how these 

brainstorming steps fit in with the problem-solving model. 

Group Discussion: Coping With Relapse. Engage the group in 

discussion about coping with a relapse that may occur in response to an 

unanticipated high-risk situation. Here are some points to cover: 

• Relapse is not uncommon in recovery. The important thing is 

how one deals with a relapse. Clients may think that after one 

relapse, the whole recovery plan is ruined, and they might as well 

give up. Let them know that this does not have to be the case. 

• Clients may learn something from a relapse. Tell them that by 

looking at the circumstances of the relapse, they may learn 

situations to avoid, or changes to make in their coping skills. 

• Clients can choose to resume their efforts to live without 

marijuana after a relapse. Ask the group for ideas about how 

someone could get back on track. Help the group cover the 

following suggestions: 

79
1. Get rid of any leftover marijuana. 

2. Ask for support. 

3. Do other positive things instead of using. 

4. Remind yourself of reasons for wanting to quit. 

Individual Practice Exercise: Developing a Personal Emergency Plan. 

By developing a plan ahead of time, clients will be less likely to be sidetracked 

by unanticipated emergency situations. Each client is given a blank personal 

emergency plan worksheet and asked to think about numerous solutions to 

each of the categories presented on it. Then he or she is to select the one or 

two he or she thinks may be the best generic plan. Of course, these plans will 

have to be somewhat general because of the unpredictable nature and 

circumstances of future emergency situations. Group members begin filling 

out these sheets in the group, to the extent that there is time available, and 

they are asked to complete this exercise at home. 

Phase 4: Termination. The final 10 minutes of the group are set 

aside for a discussion of termination of therapy. Group members are asked 

what it has been like for them to participate in the group. They are given 

the opportunity to offer feedback to one another and/or to the therapist. 

Try to keep feedback to peers positive and supportive. Also, ask the clients 

their goals from this point regarding marijuana. After 10 minutes of 

termination discussion, the group concludes. 

80
____________________________________________________________________ 

____________________________________________________________________ 

____________________________________________________________________ 

____________________________________________________________________ 

Personal Emergency Plan
 

Plan for:_________________________ 

Name 

Here are some possible emergencies that I want to be prepared for: 

If one of these emergencies happens, this is how I will help myself cope: 

DO the following: 

___ Think things through.
 

___ Cool down by: ______________________________________
 

___ Distract myself with:
 

___ Physical activity. What kind? ____________________ 

___ Doing something relaxing. What? ________________ 

___ Media (music, book, magazine, TV, movies). 

Which media?_________________________________ 

___ Something creative (writing, art, dance). Which 

one(s)? ____________________________________ _ 

___ Ask or call someone for help 

Helpful People 

Who Phone Number 

DON’T DO the following: 

___ Smoke marijuana, drink alcohol, use drugs. 

___ Act without thinking. 

___ Get overemotional. 

___ Isolate myself and/or stay away from people who care 

about me. 

___ Stay in a high-risk situation. 

If the emergency involves a relapse to marijuana use, the following steps will 

help me stop using: 
VII. Common Treatment Issues
 

Below are some recommendations for handling some common 

treatment issues. In general, most of these issues are managed best by 

skillful screening and assessment and the clear communication of the 

expectations and rules for group participation. When the following 

treatment issues occur, the therapist is advised to consult with his or her 

supervisor to determine the most appropriate response, taking into account 

the unique characteristics of the client and the situation. The first issues 

discussed may be applicable to both individual and group therapy. The final 

issues are relevant to the group sessions. 

Client Issues for Group and Individual Sessions 

Clients Showing up High 

Clients who are under the influence of alcohol, cannabis, or other 

nonprescribed drugs will not be allowed to participate in that therapy 

session. This situation calls for: 

1. An assessment of the need for detoxification 

2. Notification of a parent or guardian (because of potential 

safety/liability issues) 

3. Evaluation of a potential threat to public safety (e.g., a client 

driving an automobile when leaving the treatment site). 

Ideally, clients who are under the influence of drugs or alcohol will be 

identified prior to the start of a group session and prevented from entering 

the group, but this is not always possible. If a client is already in the group 

when the intoxication is noticed or reported, he or she will be asked to leave 

the group. The backup staff person will supervise this individual. 

If a group member is removed from the session due to acute 

substance use, ask the rest of the group members how observing this 

situation has affected them. Encourage them to verbalize their feelings. Ask 

the other group clients if this has been a trigger for them to use as well. If 

so, help them develop a plan to take care of themselves without using drugs 

or alcohol. 

Threats to Harm Oneself or Others 

Clients’ threats to harm themselves or others in individual sessions 

should be evaluated immediately (and just after the session for those occurring in group sessions). Concerns regarding a risk to oneself or others 

should immediately be brought to the clinical supervisor by the therapist. A 

supervisory review will help determine the best clinical response and the 

agency’s ethical/legal duty to warn someone or intervene. Threats of harm 

to oneself or others should bring about an immediate reevaluation of the 

severity of the problem and modality placement. 

83
When a client verbalizes suicidal impulses or impulses to harm a 

person outside the group, the therapist should make it clear to the group 

that he or she will address this concern with the client right after the group 

meeting. It is important for the other clients to know that such statements 

are taken seriously. Check with clients regarding whether they have become 

distressed and/or whether hearing such a statement was a trigger to their 

own problem. 

When a client verbalizes a threat to another group client, the 

therapist should immediately set limits by reminding clients of the group 

rules. The threatening client should be asked to leave the group session. Ask 

him or her to wait until the group is over to speak with a therapist. After the 

group, discuss the seriousness of making such threats and attempt to assess 

the risk they present. The therapist may consider telling the offending client 

that it is not yet clear if he or she will be permitted to return to future 

group meetings. This gives the therapist the opportunity to discuss the 

situation with a supervisor before informing the client of a decision. 

Tardiness 

Clients should not be allowed to enter therapy sessions more than 

15 minutes after the time the session was scheduled to start. The therapist 

may use his or her own judgment regarding exceptions to this policy (that 

is, for clients who have a valid excuse for their tardiness). The therapist 

should also take into account the expected extent of disruption to a group 

session, as well as the likelihood that the client will obtain therapeutic 

benefit from his or her late entry to the session. Therapists should 

document the amount of time missed from the session. 

Missed Sessions 

Because of the brevity of this treatment, clients should complete at 

least 80 percent of the treatment (four sessions) in order to be considered 

treatment completers. As described in earlier sections of this manual, 

attempts are made to increase the likelihood of treatment completion by 

reinforcing the importance of treatment attendance and by making 

telephone calls to confirm appointments. No makeup will be required for 

clients who miss a single session, but clients who miss two or more sessions 

will be provided with the option of makeup sessions. The individual MET 

sessions can be made up simply by rescheduling them. Missed group CBT 

sessions are to be made up by meeting with the client 15 minutes before or 

after another group. If more than one client must make up the same session, these clients can be seen together. It is generally most convenient to 

schedule makeup sessions just prior to or after a regular group session. 

Makeup sessions may be somewhat abbreviated, with the focus on reviewing 

the main points covered in the missed session. A low-level safety net should 

exist whereby an adolescent missing two successive sessions, while 

potentially considered for discharge from the group, should be assessed by 

telephone for possible clinical deterioration. If there is evidence of clinical 

deterioration, this should be reviewed with the supervising therapist/ 

coordinator. 

84
Issues in Group Sessions 

Disruptive Behaviors in Group Sessions 

In general, every effort will be made to manage disruptive behavior 

by having the therapist reassert group rules and by providing therapist and 

peer feedback. To encourage compliance and to reduce the likelihood of 

behavioral problems in group, the therapist should clearly delineate the 

group rules at the beginning of each of the group meetings. Interventions 

(during the group and/or following group) to modify disruptive behavior 

and remotivate a client will be attempted before expulsion from the group. 

If a client continues to violate group rules despite repeated corrective 

feedback, he or she will be asked to leave the group. In preparation for this 

possibility, designate a support staff person prior to each session, and 

always be available in the event of an emergency and/or the removal of a 

member of the group. This staff person either could supervise the client 

removed from the group room and/or call for emergency assistance, if 

needed. Visual supervision should be implemented any time a group 

member leaves the group session due to disruptive behavior and/or 

emotional distress. Any removal of a client from a group session should 

trigger a reevaluation of the type or level of service needed by the client. 

Group members may exhibit a wide range of behaviors that may 

trigger other group members to challenge the authority of the therapist or 

disrupt the group’s focus. One method of disruption is to tell war stories 

(i.e., accounts that present drug and alcohol use in a glorified light). 

Therapists should point out what is happening and divert the discussion. 

This often can be done—with humor yet redirection—in a manner that 

avoids setting up an intense battle for control between the client and the 

therapist. For example, “Okay, okay, we get the point that you like to get 

high. But when you tell it like that, it might make others feel like they 

should start smoking again.” 

Group members may attempt to challenge the therapist’s authority 

and/or make the therapist squirm by asking about his or her experiences 

regarding marijuana. Therapists may choose to answer such questions or 

not, depending on their own preferences about handling personal disclosure. The therapist should remember that such questions generally are not 

so much about needing to know the therapist’s history as they are about 

the clients’ concerns about whether the therapist can understand them. 

Here, again, an expression of empathy will go a long way toward addressing 

this question. 

Other problematic and disruptive behaviors may include 

inappropriate sexual comments, interrupting other group members, side 

conversations, excessive profanity, references to gangs, and threatening 

behaviors. As described above, the focus is on managing these behaviors 

within the group session by reiterating group rules, attempting to shift the 

interaction rather than engage in a control battle, making empathic 

comments where appropriate, and utilizing the feedback of other group 

members. If the behavior continues and escalates, the disruptive group 

85
member(s) should be asked to leave the group. The therapist should use his 

or her clinical judgment to determine if the client will have the opportunity 

to return to that session after the problem behavior has ceased, or if he or 

she will be excluded from the remainder of the session. 

Breach of Confidentiality by Group Members 

The response to this would be similar to those noted above, i.e., the 

therapist reminds the errant client of the group rule regarding confidentiality 

and asks that client to recommit to adhering to that rule. In the case of a 

breach of confidentiality, greater emphasis on peer feedback and pressure is 

made. For example, the client whose confidentiality was breached may tell the 

erring client of the effect of his or her behavior on him or her. Other clients 

may be asked to talk about their own confidentiality concerns. The group 

should be told that further violations of this rule could lead to termination 

from the group. 

Request for Individual Attention Outside Group Sessions 

Individual consultation after completion of the two MET sessions is 

discouraged, other than when it is necessary to address issues of clinical 

deterioration. If a group member asks to discuss a problem with a therapist 

privately, explore the reasons for the request. Usually it will be sufficient to 

reassure the client that the matter is appropriate to discuss in the group. 

Client Participation Problems in Group CBT 

Because of the brevity of the MET/CBT5 therapy, it is particularly 

important that clients be given sufficient time and attention in each of the 

therapy sessions. In group therapy sessions, attending to each group 

member may be hampered by some imbalances in the extent to which each 

member participates. Lewinshohn and colleagues (1984) have suggested 

that some group therapy members can be characterized as either 

“monopolizers,” who dominate the group discussion and seek attention, or 

“nonparticipants,” who show little or no participation in the group. In CYT, 

similar subtypes of clients reflecting either extremely active or inactive 

participation were observed during the CBT groups. The therapist needs to 

balance the time and consideration that each group member receives to 

ensure they all receive sufficient attention in therapy. The two sections 

following describe some strategies for dealing with both monopolizing and 

inactive group members. 

Monopolizers in Group CBT 

Some clients may speak so much in group CBT sessions that they 

monopolize the group’s time and attention. If this situation is not 

addressed, the rest of the clients may not get the therapeutic attention that 

they require. This is a problem because the other members may lose interest in the therapy. Also, the therapist may miss issues of concern regarding 

the other group members. The monopolizer needs to be asked to speak less 

in the group session, but the request must be made in such a way that he 

86
or she is not humiliated or alienated. Remember that adolescents are especially sensitive to being embarrassed in front of their peers. This section 

provides some ideas for dealing with monopolizers in a therapeutic manner. 

It helps to understand some of the reasons adolescents show these 

monopolizing behaviors. Three common reasons are: 

• Neediness 

• Impulsivity or attention problems 

• Antisocial characteristics. 

Here are some ways to identify these types of monopolizers and to tailor 

responses accordingly. 

Needy Monopolizers 

Many adolescents with substance abuse problems also experience 

interpersonal problems, including estrangement from satisfying family and 

peer relationships. As a result, some clients may feel especially lonely and 

neglected. When both a kind therapist and a group of adolescents with 

similar problems listen to them, they may be so pleased to have the group’s 

attention that they get carried away. This needy monopolizer can be 

identified; his or her comments are likely to be task oriented and generally 

prosocial. The key to dealing with these clients is to keep in mind that their 

behavior comes from a desire to be noticed and appreciated. Point out what 

they are doing well, and frame requests that they speak less in the group 

session in terms of helping the rest of the group. For example: 

You are coming up with some great examples. It’s really clear that 

you have thought about this. I’m going to ask you to hold off now a 

bit, to help encourage other folks to do that, too. Okay? 

Some of these clients really enjoy a task like writing the group’s comments 

on the blackboard during a brainstorming exercise. This allows them to 

have a special role in the group, while allowing the other clients to 

participate verbally. 

Impulsive Monopolizers 

Other adolescents frequently may interrupt and/or talk at length in 

the group sessions due to impulsivity or attention problems. These clients 

can be identified because their comments may frequently be off task; i.e., 

they may talk about all sorts of topics that are unrelated, or loosely related, 

to the topic being discussed in the session. Many such clients are also easily 

distracted by extraneous environmental stimuli (e.g., sounds outside the 

group room). Some of their monopolizing comments may relate to these distractions. Often these clients are aware of these attentional problems and 

are generally comfortable with good-natured requests by the therapist that 

they come back to the task at hand. Many of these clients also respond well 

to a combination of both verbal and visual cues; the therapist is encouraged 

to use gestures and hand signals with verbal comments to redirect impulsive 

87
monopolizers. For example, the therapist can smile and hold his or her hand 

up as a stop signal while saying, “Let him finish what he was saying first.” 

Another useful gesture is to make a “T” for time out when encouraging a 

client to wait before speaking. In addition to helping the client contain his 

or her impulsive comments within the group sessions, when a client has 

been demonstrating marked problems with impulsivity and attention, the 

therapist should consider whether a client may benefit from a referral for 

evaluation and possible treatment of this problem. Such questions should be 

addressed in supervision. 

Antisocial Monopolizers 

Another type of monopolizer is a group member who attempts to 

challenge the group leader’s authority and demonstrate power over what 

the group will do and discuss. This type of client often tries to steer the 

discussion away from the task at hand and onto negative topics, such as 

attempting to brag about his or her substance use and related antisocial 

activities, including fighting, criminal activity, and promiscuity. These 

clients may subtly, or not so subtly, pressure and intimidate the rest of the 

group members to follow their lead. For example, if another group member 

tries to change the topic back to something on task, the antisocial monopolizer may look at that member and roll his or her eyes as though that 

member is not cool. These antisocial monopolizers may appear to set up a 

game in which they win by taking control of the group and defeating the 

group therapist. Sometimes these clients may bring up angry feelings in the 

therapist because of their blatant disrespect and their negative effect on 

the attitudes of the other group members. 

The key to dealing with these participants is for the therapist to set 

limits and redirect them without letting his or her own angry feelings come 

out in a counterattack, such as sarcasm or shaming. If the latter occurs and 

the therapist fights fire with fire, the antisocial monopolizer frequently 

escalates the negative behavior. The therapist should say something direct 

and firm and may find it useful to refer to the group rules and/or to the 

impact on other group participants. For example, “I’m going to have to cut 

you off. Remember that we went over the group rule about not telling war 

stories. I don’t want it to trigger other group members.” 

If the therapist sees that a pattern is developing in which group 

members are beginning to feel that it is preferable to follow the lead of the 

antisocial monopolizer lest they do not appear to be cool, it can be useful 

to talk to the group about this. The therapist can say something like, “I 

could be wrong, but it appears to me that a number of group members are 

coming across like it’s only cool to keep using drugs and that it’s not cool 

to stop using. If that’s the case, I’m worried that it could make it hard for 

folks who want to stop.” After such a statement, group members may be 

inclined to disagree with the therapist’s statement, making such statements 

as, “No, that’s not how we feel. It’s cool either way.” It is not necessary to 

get clients to agree with the therapist’s statement in order for it to be 

effective. Often just stating the concern may decrease the likelihood that 

participants will continue to speak in such a manner. If they do, the 

therapist can say (with a smile) something like, “This is the sort of thing I 

was talking about. C’mon, let’s get back on track.” 88
Working With the Participant With Cognitive or Perceptual 

Impairments 

Adolescents with substance use disorders may present with cognitive 

or sensory/perceptual impairments that are due to cumulative toxic effects 

of abused substances, brain injuries, or developmental disorders. As a 

result, the MET/CBT5 therapist needs to be prepared to adapt the approach 

for these clients. The following characteristics are indications of possible 

cognitive or sensory/perceptual impairment: 

• Distractibility and shortened span of attention 

• Difficulty understanding questions and concepts 

• Frequently losing the train of thought in the middle of a sentence 

or idea 

• Getting stuck on one thought and repeating it numerous times 

(perseveration), despite attempts by the therapist to address the 

concern 

• Appearing generally confused 

• Limited ability to generalize (i.e., apply new learning to different 

situations) 

• Difficulty understanding abstract thoughts. 

When such signs are evident, the therapist should consider whether 

the client may benefit from a referral for a neurological or cognitive 

evaluation. If the client appears to have a visual or hearing problem that 

could account for his or her difficulty, ask about this and attempt relevant 

modifications, such as speaking louder, providing enlarged photocopies of 

printed materials, or minimizing background noise. When the problem 

appears to be cognitive rather than sensory, the following therapeutic modifications are recommended in both individual and group therapy sessions 

(these modifications are not intended to replace referral for specialized 

evaluation and remediation): 

• Use simple, short sentences. 

• Simplify ideas and language, and use concrete examples rather 

than abstract concepts. 

• When a new idea is presented, check whether the participant 

understands it. 

• Repeat ideas and information, both within and across sessions. 

• Provide a lot of practice of new learning. 

For those who would like more information or clinical guidance 

regarding this topic, Weinstein and Shaffer (1993) provide a detailed review 

of the neurocognitive deficits likely to be found among substance abusers, 

along with targeted clinical strategies to remediate them. 

Inactive Members in Group CBT 

In contrast to monopolizers, some clients may participate so 

infrequently in the CBT group sessions that they are generally inactive 

group members. This is a problem because these inactive members may get 

89
little out of treatment, and other group members may be uncomfortable 

with their inactivity. The therapist should try to encourage these clients to 

participate more. Because the CBT sessions include some in-session 

exercises in which each client is asked to share his or her response, this 

helps ensure that each participant gets a chance for attention. Make sure 

that each client gets a turn to talk and that the rest of the group members 

pay attention when each member does so. Group members are more likely 

to engage in side conversations when less-well-liked members are presenting. When this occurs, the therapist should set limits through comments 

like, “Please be quiet; Jessica is speaking. Let’s show her some respect. 

Sorry, Jessica; please go on.” 

Again, having a sense of why clients may be inactive helps guide a 

therapist’s response. Three different types of inactive group members are 

discussed below: those who are anxious, angry, or cognitively impaired. 

Anxious Inactive Members 

Some inactive members may be anxious, shy, or frightened, as shown by 

their nervous movements, soft speech, and hesitant responses. Here are some 

things the therapist can do to help these participants feel more comfortable: 

• Directly involve them in the discussion by inviting them by 

name: “Derrick, what do think about that?” Try asking them 

something that is not a difficult, anxiety-provoking question. 

• Involve them by asking them to read some of the skill guidelines 

during the session, unless they have shown impaired reading 

ability during the individual sessions. 

• When members pair up for roleplay exercises, suggest ways to 

pair people up so that these members are not usually the last 

ones to find a partner. 

Angry Inactive Members 

Members may also be inactive because of their resentment and 

anger about being in treatment, especially if they feel they were forced to 

attend against their will. They may communicate their angry feelings 

through nonverbal cues like sighing, folding their arms, or making faces. A 

useful approach with these inactive members is to tell them what you see in 

a nonjudgmental tone and to invite them to talk about their feelings. Here 

is an example that does both: “Hearing you groan like that, it seems like 

you may be angry. Could you talk about what’s going on?” That participant 

may still decline to speak, but such a statement may help increase the likelihood of his or her future participation. In addition, it helps the rest of the 

group to see that the therapist notices what is going on. As a result, they 

are less likely to be anxious and distracted by the angry, inactive participant. It may be useful to normalize such feelings of anger by saying, for 

example, “I know that sometimes people feel that they were forced to be 

here by the legal system or their parents, and understandably that can 

90
make them angry. Does anybody relate to that?” The therapist can express 

some hope that there may be aspects of the sessions that can be helpful or 

at least “acceptable,” despite the fact that some feel pressured to attend. 

Cognitively Impaired Inactive Members 

Finally, some participants may be inactive during group sessions 

because they have cognitive impairments that make it difficult for them to 

keep up with the rest of the group. Their thinking may be more concrete, 

and they may have difficulty following some of the comments made by both 

the group leader and by their fellow participants. The group leader can help 

these participants by doing the following things: 

• Try to keep explanations simple. When difficult ideas are 

expressed, casually repeat them in a simple, translated form to 

the entire group. Obviously, if the simplified explanation is 

directed to only one member, that client could feel humiliated. 

• Create a safe atmosphere for asking questions about concepts 

or words that are not understood. For example, when a client 

says, “What does ‘hesitant’ mean?,” say “I’m glad you asked. 

Sometimes people are afraid to ask and just feel like they have to 

pretend to understand everything.” Then explain it simply. 

• Sometimes these group members may make a comment that is a 

painful demonstration that they are out of it as far as understanding what is being said. The main concern is to prevent them 

from being mocked by the other clients when this occurs. Try 

to look for something that is accurate or relevant in what they 

have said (which generally can be found if the therapist is 

creative). Make a comment reflecting the accurate part of what 

the client has said, and then correct the part that is inaccurate. If 

others do mock the client, set limits on this behavior. 

• Consider whether the participant’s cognitive problem may 

require some type of evaluation and possible treatment. For 

example, it is possible that a client who is having cognitive 

difficulty may be experiencing psychotic or prepsychotic 

symptoms. It is also possible that the client may have a learning 

disorder. Many clients with learning disabilities already have been 

evaluated and already may be receiving help. If it appears, 

however, that an assessment of a client’s cognitive difficulties has 

not been done, the therapist should discuss in supervision the 

possibility of making such a referral. 

If the therapist uses the strategies noted above, inactive participants 

may be helped to particpate more fully in the group sessions. 

91
 
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97
Appendix 1. Therapist Session Reports 

A. Individual Session 

B. Group Session 

99
 
 

 

_________________________________________________________________ 

_________________________________________________________________ 

_________________________________________________________________ 

MET/CBT5: Therapist Session Report—Individual Session 

Site # _______________ 

Client # _____________ 

Therapist # __________ 

Date _________________ 

Session # ____________ 

Date and time of next scheduled session ______________________________ 

1) What topic was covered in this session? 

1 = MET—Motivation-Building Session 

2 = MET—Goal-Setting Session 

2) Other than contacts to schedule appointments, did you have any 

additional contacts with the client (e.g., emergency contacts)? 

1 = Yes 

___# telephone calls ___total # minutes of telephone contact 

___# face-to-face contacts ___total # minutes of face-to-face contact 

2 = No 

3) To what extent did you assess the client’s use of marijuana or other 

substances since the last session (or assessment)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

4) How does the client’s current marijana use (since the previous session) 

compare with his or her use at the initial assessment? 

1 = Client has stopped using marijuana. 

2 = Client has reduced level of marijuana use. 

3 = Client has not changed level of marijuana use. 

4 = Client has increased level of marijuana use. 

5) To what extent does the client report use of other illicit substances 

since the previous session? 

1 = Reports no alcohol or drug (other than marijuana) use. 

2 = Reports other drug use (no alcohol). Type and amount of drug: 

3 = Reports alcohol use (no other drugs). Amount: 

4 = Reports alcohol use and other drug use. What drug? 

9 = Unable to assess. 
 

 

 

 

 

 

6) Compared to the first session (or assessment, if this is the first session), 

how would you describe the client’s clinical status at this contact 

(taking into account his or her current level of substance use, overall 

mental status, social supports, etc.)? 

1 = Poor, deteriorated with respect to treatment inception 

2 = Fair, no improvement 

3 = Good, some improvement 

4 = Very good, significant improvement 

5 = Excellent, greatly improved or recovered 

7) In your opinion, should this client be considered for removal from 

treatment? 

1 = Yes 2 = No 

8) To what extent did you discuss or address the client’s current 

commitment to abstinence? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

9) To what extent did you attempt to focus on the client’s ambivalence 

about changing his or her level of marijuana use? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

10) To what extent did you attempt to elicit self-motivational statements 

from the client? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

11) To what extent did you encourage the client to make a commitment to 

change his or her marijuana use? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

12) To what extent did you discuss high-risk situations the client 

encountered since the last session (or assessment, if this was the first 

session) and explore the coping skills he or she used? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

13) To what extent did you review the client’s reactions to the last 

session’s assignment? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

14) Did the client do the last session’s assignment? 

1 = No, no attempt made. 

2 = Some attempt made. 

3 = Practice exercise completed adequately. 

9 = N/A, not assigned. 
 

 

 

 

 

 

 

 

 

15) 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 

16) Did you do a roleplay? 

1 = Yes 

2 = No 

17) To what extent did you encourage the client to anticipate any highrisk 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 

18) To what extent did you provide one or more specific assignments for 

the client to engage in between sessions? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

19) 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 

20) To what extent was it difficult to engage the client this session? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

21) To what extent did you attempt to keep the session focused on 

prescribed activities (by redirecting dialog when it strayed off task, 

and/or organizing the session so defined activities were covered)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

22) To what extent did you communicate your understanding of the 

client’s concerns through reflective listening and comments? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

23) To what extent did you respond to the client with empathy, warmth, 

and acceptance? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

24) To what extent did the client appear motivated to abstain from 

marijuana? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 
 

 

 

 

____________________________________________________________________ 

____________________________________________________________________ 

____________________________________________________________________ 

____________________________________________________________________ 

____________________________________________________________________ 

_____________________________ ________________ 

25) To what extent did the client appear motivated to reduce his or her 

marijuana use? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

26) To what extent did the client report getting support from others for 

abstinence? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

27) To what extent did you discuss the availability and nature of family 

support for the client’s efforts in treatment? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

28) To what extent did you discuss termination of the therapy (review the 

timing of termination, encourage the client to discuss his or her 

feelings or thoughts about termination)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Additional Note(s)*: 

signature	 date 

* If more space is needed, please continue on the back and note this on the 

line above. 
 

 

 

 

 

MET/CBT5: Therapist Session Report—Group Session 

Site # _______________ 

Client # _____________ 

Therapist # __________ 

Date _________________ 

Session # ____________ 

Date and time of next scheduled session:_______________________________ 

1) What topic was covered in this session? 

3 = CBT3—Marijuana Refusal Skills 

4 = CBT4—Enhancing One’s Social Support Network 

5 = CBT5—Planning for Emergencies and Coping With Relapse 

1b) If this was Session 4 (CBT4), did you also cover the topic 

Increasing Pleasant Activities? 

1 = Yes 

2 = No 

2) To what extent did you assess clients’ use of marijuana or other substances since the last session (or assessment)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

3) In your opinion, should any of the clients be considered for removal 

from treatment due to clinical deterioration? 

1 = Yes If yes, list client #(s): ___________________________________ 

2 = No 

4) To what extent did you discuss or address clients’ 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 clients? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

6) To what extent did you attempt to focus on clients’ 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 clients to make a commitment to 

change their marijuana use? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 
 

 

 

 

 

 

 

 

8) To what extent did you discuss high-risk situations clients encountered 

since the last session (or assessment, if this is the first session) and 

explore the coping skills they used? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

9) To what extent was it difficult to engage the group? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

10) To what extent did you review clients’ reactions to last 

session’s assignment? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

11) 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 

12) Did you do a roleplay? 

1 = Yes 

2 = No 

13) To what extent did you encourage clients to anticipate 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 

14) To what extent did you provide one or more specific assignments for 

clients 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 sessions focused on 

prescribed activities (by redirecting dialog when it strayed off task 

and/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 clients’ 

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 clients 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 clients’ 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 clients to discuss their feelings or 

thoughts about termination)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 
 ________________________________________________________________________________________________________

____________________________ ________________________________ 

Group Report 

Client I.D. 

Number 

Attendance Quantity of 

Participation 

Quality of 

Participation 

Current Marijuana 

Use* 

Other Substance 

Use** 

Clinical Status*** Completio

Assignme

P = Present 

A = Absent 

L = Late 

3 = High 

2 = Medium 

1 = Low 

0 = None 

3 = High 

2 = Medium 

1 = Low 

0 = None 

9 = Unable to assess 

4 = Increased 

3 = Unchanged 

2 = Reduced 

1 = None in the 

past week 

9 = Unable to assess 

4 = Alcohol & 

other drug(s) 

3 = Alcohol only 

2 = Other drug(s) 

1 = None 

5 = Excellent 

4 = Very Good 

3 = Good 

2 = Fair, no 

improvement 

1 = Poor, 

deteriorated 

9 = None 

assign

3 = Comp

2 = Attem

1 = No at

Entire ************ ********************* ******************** ***************** **********

Group ************ ********************* ******************** ***************** **********

*Current Marijuana Use is the level of use since the previous session in comparison to the level of use at the initial assessment.

** Other Substance Use rates whether any use of alcohol and/or any drug (other than marijuana) occurred since previous session.

***Clinical Status takes into account the current level of substance use, mental status, and overall functioning since the previous session.

Additional Comments: ______________________________________________________________________________________________

Signature Date 
Appendix 2. Supervisor Session Rating Reports
 

A. Individual Session 

B. Group Session 

109
 
 

 

___________________________________ 

__________________________________ 

MET/CBT5: Supervisor Session Rating—Individual Session 

Site # ______________ 

Client # ____________ 

Therapist # _________ 

Date ________________ 

Session # ___________ 

1) What topic was covered in this session? 

1 = MET—Motivation-Building Session 

2 = MET—Goal-Setting Session 

2) To what extent did the therapist assess the client’s use of marijuana or 

other substances since the last session (or assessment)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

3) How does the client’s current marijuana use (use since the previous 

session) compare with his or her use at the initial assessment? 

1 = Client has stopped using marijuana. 

2 = Client has reduced his or her level of marijuana use. 

3 = Client has not changed his or her level of marijuana use. 

4 = Client has increased his or her level of marijuana use. 

4) To what extent does the client report use of other illicit substances 

since the previous session? 

1 = Reports no alcohol or drug (other than marijuana) use. 

2 = Reports other drug use (no alcohol). Type and amount of drug: 

3 = Reports alcohol use (no other drugs). 

Amount:___________________________
 

4 = Reports alcohol use and other drug use. What drug? 

9 = Unable to assess. 

5) Compared to the first session (or assessment, if this is the first session), 

how would you describe the client’s clinical status at this contact 

(taking into account his or her current level of substance use, overall 

mental status, social supports, etc.)? 

1 = Poor, deteriorated with respect to treatment inception 

2 = Fair, no improvement 

3 = Good, some improvement 

4 = Very good, significant improvement 

5 = Excellent, greatly improved or recovered 
 

 

 

 

 

 

 

 

 

 

6) In your opinion, should this client be considered for removal from 

treatment? 

1 = Yes 

2 = No 

7) To what extent did the therapist discuss or address the client’s current 

commitment to abstinence? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

8) To what extent did the therapist attempt to focus on the client’s 

ambivalence about changing his or her level of marijuana use? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

9) To what extent did the therapist attempt to elicit self-motivational 

statements from the client? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

10) To what extent did the therapist encourage the client to make a 

commitment to change his or her marijuana use? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

11) To what extent did the therapist discuss high-risk situations the client 

encountered since the last session (or assessment, if this is the first 

session) and explore the coping skills he or she used? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 
 

 

 

 

 

 

 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

12) To what extent did the therapist review the client’s reactions to last 

session’s assignment? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

13) Did the client do the last session’s assignment? 

1 = No, no attempt made. 

2 = Some attempt made. 

3 = Practice exercise completed adequately. 

9 = N/A, not assigned. 

14) To what extent did the therapist 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 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

15) Did the therapist do a roleplay? 

1 = Yes 

2 = No 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

16) To what extent did the therapist encourage the client 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: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

17) To what extent did the therapist provide one or more specific 

assignments for the client to engage in between sessions? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

18) 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: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

19) To what extent was it difficult to engage the client this session? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

20) To what extent did the therapist attempt to keep the session focused 

on prescribed activities (by redirecting dialog when it strayed off task 

and/or organizing the session so defined activities were covered)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

21) To what extent did the therapist communicate understanding of the 

client’s concerns through reflective listening and comments? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

22) To what extent did the therapist respond to the client with empathy, 

warmth, and acceptance? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 
 

 

 

 

 

 

___________________________________________________________________ 

___________________________________________________________________ 

___________________________________________________________________ 

___________________________________________________________________ 

________________________________ ____________________ 

23) To what extent did the client appear motivated to abstain from 

marijuana? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

24) To what extent did the client appear motivated to reduce his or her 

marijuana use? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

25) To what extent did the client report getting support for abstinence 

from others? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

26) To what extent did the therapist discuss the availability and nature of 

family support for the client’s efforts in treatment? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

27) To what extent did the therapist discuss termination of the therapy 

(review the timing of termination, encourage the client to discuss his 

or her feelings or thoughts about termination)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

Additional Note(s)*: ________________________________________________ 

* If more space is needed, please continue on the back and note this on the 

line above. 

Signature	 Date 
 

 

 

 

 

MET/CBT5: Supervisor Session Rating—Group Session 

Site # ______________
 

Client # ____________
 

Therapist # _________
 

Date _______________
 

Session # ___________ 

1) a. What topic was covered in this session? 

3 = CBT3—Marijuana Refusal Skills 

4 = CBT4—Enhancing One’s Social Support Network 

5 = CBT5—Planning for Emergencies, and Coping With Relapse 

b. If this was session 4 (CBT4), did the therapist also cover the topic 

Increasing Pleasant Activities?
 

1 = Yes
 

2 = No
 

2) To what extent did the therapist assess clients’ use of marijuana or 

other substances since the last session (or assessment)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

3) In your opinion, should any of the clients be considered for removal 

from treatment due to clinical deterioration? 

1 = Yes If yes, list client #(s): __________________________________ 

2 = No 

4) To what extent did the therapist discuss or address clients’ current 

commitment to abstinence? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

5) To what extent did the therapist attempt to elicit self-motivational 

statements from the clients? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 
 

 

 

 

 

 

 

 

 

 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

6) To what extent did the therapist attempt to focus on clients’ 

ambivalence about changing their level of marijuana use? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

7) To what extent did the therapist encourage clients to make a 

commitment to change their marijuana use? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

8) To what extent did the therapist discuss any high-risk situations clients 

encountered since the last session (or assessment, if this was the first 

session) and explore any coping skills used? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

9) To what extent did the therapist review clients’ reactions to last 

session’s assignment? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

10) To what extent did the therapist 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 
 

 

 

 

 

 

 

 

 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

11) Did the therapist do a roleplay? 

1 = Yes 

2 = No 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

12) To what extent did the therapist encourage clients 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: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

13) To what extent did the therapist provide one or more specific 

assignments for clients to engage in between sessions? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

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: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

15) To what extent was it difficult to engage the group? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 
 

 

 

 

 

 

 

 

 

16) To what extent did group members present behaviors that were 

disruptive to the group process (e.g., aggression, war stories, 

excessive profanity)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level (of therapist’s management of disruptive behaviors within this 

group): 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

17) To what extent did the therapist attempt to keep the session focused 

on prescribed activities (by redirecting dialog when it strayed off task 

and/or organizing the session so that defined activities were covered)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 

18) To what extent did the therapist communicate understanding of 

clients’ 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 clients 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 clients’ 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 clients to discuss their 

feelings or thoughts about termination)? 

1....................2................ 3....................4.....................5 

not at all a little somewhat considerably extensively 

Skill Level: 

0..........1..............2............3.............4...........5............6............7 

not poor adequate excellent 

done 
___________________________________________________________________ 

___________________________________________________________________ 

___________________________________________________________________ 

___________________________________________________________________ 

________________________________ ____________________ 

• Rate the quantity of participation of this group. 

3 = High 

2 = Medium 

1 = Low 

0 = Silent 

• Rate the quality of participation of this group. 

3 = High 

2 = Medium 

1 = Low 

0 = None 

Additional Note(s)*: ________________________________________________ 

* If more space is needed, please continue on the back and note this on the 

line above. 

Signature	 Date 
Appendix 3. Facsimiles of 11- by 17-inch Posters
 

for Sessions 3, 4, and 5
 

A. Session 3
 

B. Session 4
 

C. Session 5
 

121
 
SESSION 3 

MARIJUANA 

REFUSAL 

SKILLS
 

Why?

• Immediate, effective response is 

needed when someone is pressured 

to use marijuana. 

• One’s social circle narrows with 

increased marijuana use. 

• It’s best, but not always possible, 

to avoid high-risk people and 

situations. 
SKILL GUIDELINES
 

Nonverbal Behaviors: 

• Speak in a clear, firm voice. 

• Make eye contact. 

• Don’t feel guilty about refusing marijuana. 

Verbal Behaviors: 

• “No” should be your first word. 

• Suggest something fun and safe to do 

instead. 

• Change the subject. 

• Avoid excuses or vague answers. 

• If pressure continues, ask him or her to stop 

asking you to use. 
Session 4
 

ENHANCING ONE’S SOCIAL 

SUPPORT NETWORK
 

WHY? 

• When people try to quit marijuana, support helps 

them succeed. 

• People often don’t have as much support as they’d 

like. 

Skill Guidelines
 

WHO might provide good support? 

• Consider family, friends, acquaintances, others in your 

community. 

• Someone who is usually supportive. 

• Someone who is usually neutral. 

• Someone who might become supportive. 

WHAT kinds of support can you ask for? 

• Help with problem solving. 

• Information. 

• Moral support. 

• Sharing the load. 

• Emergency help. 

HOW can you get the support you need? 

• Ask for what you need. 

• Add new supporters. 

• Lend your support to others. 

• Give your supporters feedback. 
SESSION 5 

PLANNING FOR EMERGENCIES 

AND COPING WITH RELAPSE
 

Why? 

• Preparation for an emergency increases good coping 

skills. 

• Problem solving is a way to cope. 

• Emergencies and relapses are learning opportunities. 

SKILL GUIDELINES
 

Types of Possible Emergencies: 

• An unanticipated marijuana trigger. 

• Separation from an important person in your life. 

• School problems. 

• Adjustment to a new life situation or new 

responsibilities. 
Steps for 

Problem
 

Solving
 

Recognize that a problem exists. 

1. Identify the problem. Think: What is the 

problem? 

2. Consider various approaches (brainstorm): 

What can I do? 

3. Think ahead to the good and bad that may 

come out of each possible approach. 

4. Choose one, and do it. Evaluate the 

outcome: Did this work for me? 
Appendix 4. Personalized Feedback Reports 

A. With Instructions for Compiling 

B. Without Instructions (for use in therapy) 

127
 
Therapist ______________ 

Client ______________ 

Personalized Feedback Report (PFR) Instructions 

The personalized feedback report is used to summarize information the client 

reported in the intake assessment for use in a feedback session. Below is a copy 

of the PFR (in regular text) that has been supplemented with instructions on 

how to complete it (in bold italic). A copy of GAIN and the Reasons for 

Quitting Questionnaire (RFQ) from the Supplemental Assessment Form (SAF) 

are available at www.chestnut.org/li/cyt/ or www.chestnut.org/li/cyt/products/ 

index.html. They are followed by tables required for calculating the percentiles 

and a clean copy of the PFR with no instructions. 

This report summarizes some of the information that you gave us in your 

interview on ___/___/____ (record date of baseline interview [XOBSDT,] 

from global appraisal of individual needs-initial (GAIN-I)—bottom of 

cover page). 

We want to give you an opportunity to review what you’ve told us and make 

any changes or additions. As you and I work together in reviewing and 

discussing this specific personal information, we can help you develop 

strategies for dealing with marijuana that fit your individual needs. 

Primary Substances 

You reported that your favorite substance to use was ______ and that you 

needed treatment for _______________________________________ (get from 

GAIN, page 12, S1a and S1b). You told us you first used alcohol or drugs 

at age ____ (use age of first use, GAIN, page 22, S9v) and have been 

smoking marijuana for ____ years (use current age – age of first use, 

GAIN, page 23, Row v, Column 3). In the past year, you told us you had 

used ___________________________________ (record all substances with 

6–2 circled on GAIN, page 13, S2a1–99). You have been in substance 

treatment ____ times before (GAIN, page 18, S7). 

Extent of Use 

In the past 90 days, you smoked marijuana on _____ of those days, with the 

heaviest use being ____ joints/pipes over a ___ hour period (use 

information from GAIN, page 14, questions S2f1–S2f3). This places you in 

the _____ percentile (use Table 1) relative to other adolescents age ____ to 

____ in America (round percentile to nearest integer). 

In the past 90 days, you drank alcohol on _____ of those days, with the 

heaviest drinking episode being ____ drinks over a ___ hour period (use 

information from GAIN, page 14, questions S2e1–S2e3). This places you 

in the _____ percentile (use Table 2) relative to other adolescents age ____ 

to ____ in America (round percentile to nearest integer). 
____________________________________________________________________ 

____________________________________________________________________ 

In the past 90 days, you reported that you used other drugs, including 

_______________________, on ___ days (use GAIN, page14, S2g1). In the 

past week you reported that you (had/had not) tried to quit using drugs 

and/or alcohol (and that when you did you had the following problems: 

_______________________ (use GAIN, page 16, S3). [List only items that 

the client endorsed. List could include moving and talking much slower than 

usual (1); yawning more than usual (2); feeling tired (3); having bad 

dreams that seem real (4); having trouble sleeping (sleeping too much or 

trouble staying asleep) (5); feeling sad, tense, or angry (6); feeling really 

nervous or tense (7); fidgeting, pacing, wringing your hands, or trouble sitting still (8); having shaky hands (9); having convulsions or seizures (10); 

feeling hungrier than usual (11); throwing up or feeling like throwing up 

(12); having diarrhea (13); having muscle aches (14); having a runny nose 

or eyes watering more than usual (15); sweating more than usual, having 

your heart race or goose bumps (16); having a fever (17); seeing, feeling, or 

hearing things that are not real (18); forgetting a list of things or having problems remembering (19); withdrawal symptoms prevented you from doing 

usual activities (20); starting to use again to avoid withdrawal symptoms 

(21); other: _____________________________ (99). 

Problems 

You indicated that your use of marijuana, alcohol, and/or other substances 

had caused you the following kinds of problems (list only problems 

endorsed on GAIN, page 23, S9 or PSF, page 2, PS9): 

You did not meet your responsibilities at home, school, or work (h) 

You used in situations where it was unsafe for you (driving a car, 

using a machine, or where you might have been hurt or forced into 

sex) (j) 

Using caused you to have problems with the law (k) 

You kept using even though it was causing you to get into fights (or 

other kinds of legal trouble) (m) 

You had to use more to get the same high (or found the same 

amount did not get you as high as it used to) (n) 

You had withdrawal symptoms when you tried to stop (or used to 

stop being sick or avoid withdrawal problems) (p) 

You used for longer than you meant to (q) 

You have been unable to cut down or stop using (r) 

You spent a lot of time getting or using marijuana, alcohol, or other 

substances (or feeling the effects of alcohol or drugs—high, sick) (s) 

Using caused you to give up, reduce, or have problems at important 

activities at home, school, work, or social events (t) 

You have kept using despite medical or psychological problems (u) 

As you reflect on the consequences of smoking marijuana on your life, what 

would you add? 
____________________________________________________________________ 

____________________________________________________________________ 

Reasons for Quitting 

You said the main reason you came to treatment was ____________________ 

(use GAIN, Page 6, A4a). We showed you a list of personal reasons for quitting marijuana, and you also said you wanted to quit (list only the items 

below that the client endorsed. Use RFQ questionnaire in SAF, pages 6–8, 

and list items coded 2, 3, or 4. Also add any open-ended items listed by 

the client in question 27 that are not included in the list). 

To show myself that I can quit if I really want to (E1) 

To like myself better (E2) 

So that I won’t have to leave social functions or other people’s 

houses (E3) 

To feel in control of my life (E4) 

So that my parents, girlfriend, boyfriend, or another person I am 

close to will stop nagging me (E5) 

To get praise from people I am close to (E6) 

Because smoking marijuana does not fit in with my self-image (E7) 

Because smoking marijuana is less cool or socially acceptable (E8) 

Because someone has given me an ultimatum (E9) 

So that I will receive a special gift (E10) 

Because of potential health problems (E11) 

Because people I am close to will be upset if I don’t (E12) 

So that I can get more things done during the day (E13) 

Because marijuana use is hurting my health (E14) 

Because I will save money by quitting (E15) 

To prove I’m not addicted (E16) 

Because there is a drug testing policy in detention, probation, 

parole, or school (E17) 

Because I know others with health problems caused by marijuana 

(E18) 

Because I am concerned that smoking marijuana will shorten my life 

(E19) 

Because of legal problems related to my use (E20) 

Because I don’t want to embarrass my family (E21) 

So that I will have more energy (E22) 

So my hair and clothes won’t smell like marijuana (E23) 

So I won’t burn holes in clothes or furniture (E24) 

Because my memory will improve (E25) 

So that I will be able to think more clearly (E26) 

You listed these because they have personal significance for you. Do you 

have any other important reasons for quitting that you would like to add? 
You also told us about several other problems that might be caused or made 

worse by your marijuana, alcohol, or other drug use. These include (list 

only those that apply). 

The health problems you reported (use if 1+ days in GAIN, page 

28, P9a).
 

The emotional problems you reported (use if 1+ days in GAIN, 

page 37, M1f).
 

Being bothered by upsetting memories (use if 1+ days in GAIN, 

page 38, M2q).
 

Having problems paying attention or controlling your behavior (use 

if 1+ days in GAIN, page 40, M3c).
 

The family problems you reported (use if 1+ days in GAIN, page 

46, E3).
 

Arguments and problems you had with your temper (use if 1+ days 

in GAIN, page 50, E8p).
 

Being physically, sexually, or emotionally hurt (use if 1+ days in 

GAIN, page 52, E9u).
 

Doing things that were illegal (use if 1+ days in GAIN, page 58, 

L3v).
 

Getting in trouble at school (use if 1+ days in GAIN, page 64, V3p
 

or V3q).
 

Getting in trouble at work (use if 1+ days in GAIN, page 67, V6p 

or V6q).
 

Pattern of Use 

You told us that the place(s) where you typically use marijuana, alcohol, and 

other drugs is/are (use GAIN, page 15, S2h). 

at home 

at someone else’s home 

at a party/bar 

at work 

at school 

at a dealer’s house 

outdoors 

in a car 

somewhere else (_________________________________________) 

and that you typically use it with (use GAIN, page 15, S2j): 

no one else, alone 

your romantic/sexual partner 

family 

friends 

a club or gang 

coworkers 

classmates 

a running partner (someone you regularly do drugs with) 

drug dealer/pusher 

someone else (____________________________) 
____________________________________________________________________ 

____________________________________________________________________ 

As you think about highly tempting situations, are there situations that 

you’d like to add? 

Situational Confidence 

You told us you thought you could avoid using alcohol or drugs at (use 

GAIN, Page 20, S8m–q). 

home 

school or work 

with your friends 

when everyone around you was using them 

You also told us that you (had quit and were _____% sure you could stay 

abstinent/had not quit yet but were ____% sure you could quit) (use SAF, 

page 8, E28). 
 

 

Table 1: Days of Marijuana Use From Community Sample of 5,143 

Adolescents From the 1995 National Household Survey on Drug Abuse 

Rate 12–13 Years 14–16 Years 17–18 Years 

None 98% 90% 86% 

Monthly 99% 95% 94% 

Weekly 100% 97% 96% 

Daily 100% 100% 100% 

Rate for NHSDA during the past 30 days is defined as follows: None = 0
 

days, Monthly = 1–4 days, Weekly = 5–14 days, Daily = 15–30 days; For
 

CYT, during the past 90 days: None= 0 days, Monthly = 1–12 days, 

Weekly = 13–44 days, Daily = 45–90 days (Office of Applied Studies, 1997). 

Table 2: Days of Alcohol Use From Community Sample of 5,143 

Adolescents From National Household Survey on Drug Abuse 

Rate 12–13 Years 14–16 Years 17–18 Years 

None 92% 75% 58% 

Monthly 96% 89% 83% 

Weekly 97% 93% 92% 

Daily 100% 100% 100% 

Rate for NHSDA during the past 30 days is defined as follows: None = 0
 

days, Monthly = 1–4 days, Weekly = 5–14 days, Daily = 15–30 days; For
 

CYT, during the past 90 days: None= 0 days, Monthly = 1–12 days, 

Weekly = 13–44 days, Daily = 45–90 days (Office of Applied Studies, 1997). 
Therapist _________________ 

Client _________________ 

Personalized Feedback Report (PFR) 

This report summarizes some of the information that you gave us in your 

interview on ____/____/_____. 

We want to give you an opportunity to review what you’ve told us and make 

any changes or additions. As you and I work together in reviewing and 

discussing this specific personal information, we can help you develop a 

program and strategies for dealing with marijuana that fit your individual 

needs. 

Primary Substances 

You reported that your favorite substance to use was ___________________ 

and that you that you needed treatment for ____________________________. 

You told us you first used alcohol or drugs at age ___ and have been smoking marijuana for ____ years. In the past year you told us you had used 

_______________________. You have been in substance treatment ____ times 

before. 

Extent of Use 

In the past 90 days, you smoked marijuana on _____ of those days, with the 

heaviest use being ____ joints/pipes over a ___ hour period. This places you 

in the _____ percentile relative to other adolescents in America age ___ to 

___. 

In the past 90 days, you drank alcohol on _____ of those days, with the 

heaviest drinking episode being ____ drinks over a ___ hour period. This 

places you in the _____ percentile relative to other adolescents in America 

age ___ to ___ . 

In the past 90 days, you reported that you used other drugs, including 

_______________________, on ___ days. In the past week you reported that 

you (had/had not) tried to quit using drugs and/or alcohol (and that when 

you did you had the following problems:_______________________________ 

___________________________________________________________________) 

[List only the items that the client endorsed. List could include moving and 

talking much slower than usual; yawning more than usual; feeling tired; having bad dreams that seem real; having trouble sleeping (sleeping too much or 

trouble staying asleep); feeling sad, tense, or angry; feeling really nervous or 

tense; fidgeting, pacing, wringing your hands, or trouble sitting still; having 

shaky hands; having convulsions or seizures; feeling hungrier than usual; 

throwing up or feeling like throwing up; having diarrhea; having muscle 

aches; having a runny nose or eyes watering more than usual; sweating 

more than usual, having your heart race or goose bumps; having a fever; 

seeing, feeling, or hearing things that are not real; forgetting a list of things or 

having problems remembering; withdrawal symptoms that prevented you 

from doing your usual activities; starting to use again to avoid withdrawal 

symptoms; other: _____________________]. 
____________________________________________________________________ 

____________________________________________________________________ 

Problems 

You indicated that your use of marijuana, alcohol, and/or other substances 

had caused you the following kinds of problems: 

You did not meet your responsibilities at home, school, or work. 

You used in situations where it was unsafe for you (driving a car, 

using a machine, or where you might have been hurt or forced into 

sex). 

Using caused you to have problems with the law. 

You kept using even though it was causing you to get into fights (or 

other kinds of legal trouble). 

You had to use more to get the same high (or found the same 

amount did not get you as high as it used to). 

You had withdrawal symptoms when you tried to stop (or used to 

stop being sick or avoid withdrawal problems). 

You used for longer than you meant to. 

You have been unable to cut down or stop using. 

You spent a lot of time getting or using marijuana, alcohol, or other 

substances (or feeling the effects of alcohol or drugs—high, sick). 

Using caused you to give up, reduce, or have problems at important 

activities at home, school, work, or social events. 

You have kept using despite medical or psychological problems. 

As you reflect on the consequences of smoking marijuana on your life, what 

would you add? 

Reasons for Quitting 

You said the main reason you came to treatment was ___________________. 

We showed you a list of personal reasons for quitting marijuana, and you 

said that you wanted to quit: 

To show myself that I can quit if I really want to. 

To like myself better.
 

So that I won’t have to leave social functions or other people’s 

houses. 

To feel in control of my life. 

So that my parents, girlfriend, boyfriend, or another person I am 

close to will stop nagging me. 

To get praise from people I am close to. 

Because smoking marijuana does not fit in with my self-image. 

Because smoking marijuana is less socially acceptable. 

Because someone has given me an ultimatum. 

So that I will receive a special gift. 

Because of potential health problems. 

Because people I am close to will be upset if I don’t. 

So that I can get more things done during the day. 

Because marijuana use is hurting my health. 

Because I will save money by quitting. 

To prove I’m not addicted. 

Because there is a drug testing policy in detention, probation, 

parole, or school. 

Because I know others with health problems caused by marijuana. 
____________________________________________________________________ 

____________________________________________________________________ 

Because I am concerned that smoking marijuana will shorten my 

life. 

Because of legal problems related to my use. 

Because I don’t want to embarrass my family. 

So that I will have more energy. 

So my hair and clothes won’t smell like marijuana. 

So I won’t burn holes in clothes or furniture. 

Because my memory will improve. 

So that I will be able to think more clearly. 

You listed these because they have personal significance for you. Do you 

have any other important reasons for quitting that you would like to add? 

You also told us about several other problems that might be caused or made 

worse by your marijuana, alcohol, or other drug use. These include: 

The health problems you reported. 

The emotional problems you reported. 

Being bothered by upsetting memories. 

Having problems paying attention or controlling your behavior. 

The family problems you reported. 

Arguments and problems you had with your temper. 

Being physically, sexually, or emotionally hurt. 

Doing things that were illegal. 

Getting in trouble at school. 

Getting in trouble at work. 

Pattern of Use 

You told us that the place(s) where you typically use marijuana, alcohol, and 

other drugs is/are: 

at home 

at someone else’s home 

at a party/bar 

at work 

at school 

at a dealer’s house 

outdoors 

in a car 

somewhere else (______________________________) 

and that you typically use it with: 

no one else, alone 

your romantic/sexual partner 

family 

friends 

a club or gang 

coworkers 

classmates 

a running partner (someone you regularly do drugs with) 
____________________________________________________________________ 

____________________________________________________________________ 

a drug dealer/pusher
 

someone else (_______________________)
 

As you think about highly tempting situations, are there situations that 

you’d like to add? 

Situational Confidence 

You told us you thought you could avoid using alcohol or drugs at: 

home 

school or work 

with your friends 

when everyone around you was using them 

You also told us that you (had quit and were ____% sure you could stay 

abstinent/had not quit yet but were ____% sure you could quit). 
Appendix 5. Clinical Management of a Multisite
 

Field Trial of Five Outpatient Treatments for
 

Adolescent Substance Abuse
 

139
 
The Clinical Management of a Multisite Field Trial of Five 

Outpatient Treatments for Adolescent Substance Abuse 

Nancy Angelovich, M.S.1
 

Tracy Karvinen, M.A.2
 

Suzie Panichelli-Mindel, Ph.D.3
 

Susan Sampl, Ph.D.4
 

Meleney Scudder, Psy.D.4
 

Janet Titus, Ph.D.5
 

William White, M.A.5
 

1 Operation Parental Awareness and Responsibility (PAR), Inc. 

2 Chestnut Health Systems—Madison County (CHS–MC)
 3 Children’s Hospital of Philadelphia (CHOP)/University of Pennsylvania
 

4 University of Connecticut Health Center (UCHC)
 5 Chestnut Health Systems—Coordinating Center (CHS–CC)
 

Acknowledgments: Financial assistance for this study was provided by the Substance Abuse 

and Mental Health Services Administration (SAMHSA) Center for Substance Abuse 

Treatment (CSAT), Grant Nos. TI11317, TI11320, TI11321, TI11323, and TI11324. The 

authors appreciate the valuable comments, suggestions, and support offered by the Cannabis 

Youth Treatment study principal investigators Thomas Babor (UCHC), Michael Dennis 

(CHS–CC), Guy Diamond (CHOP), Susan H. Godley (CHS–MC), and Frank Tims (PAR). 

Correspondence to: William L. White, Sr. Research Coordinator, Chestnut Health Systems, 

720 W. Chestnut St., Bloomington, IL 61701, Phone: 309–829–1058, x3403; Fax: 

309–829–4661; e-mail: bwhite@chestnut.org 

140
 
 

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. 

Carrol and her colleagues (1994) detailed the strategies used to 

implement and to protect the integrity of three manual-based therapies 

evaluated within Project MATCH, a multisite study of adult alcoholism 

treatment (Project MATCH Research Group, 1993). This paper takes a 

similar approach in describing cross-site clinical coordination procedures 

within the Cannabis Youth Treatment study, the largest multisite, randomized field experiment ever conducted of adolescent substance abuse 

treatment. More specifically, the paper details the common clinical 

infrastructure within which these therapies were implemented across 

the treatment sites. 

It is our collective experience that therapies can fail in the 

transition from efficacy (outcomes under ideal circumstances) to effectiveness (outcomes in the real world of adolescent treatment), not because of 

flaws in the interventions themselves, but because of the absence of a sound 

foundation of clinical management upon which empirically validated 

interventions are replicated. The construction of stable clinical 

infrastructures within local treatment programs is as important to the future 

of adolescent treatment as the availability of research-validated therapies. 

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The Cannabis Youth Treatment Study 

After declining in the 1980s, both licit and illicit drug use among 

adolescents rose in the 1990s. In 1996, cannabis use by adolescents (8th, 

10th, and 12th graders) reached its highest peak in 12 years for reported 

lifetime use, past year use, and past month use (ISR, 1997). As cannabis 

abuse/dependence emerged as the leading cause for admission to substance 

abuse treatment (OAS, 1997), demands increased for research-validated 

treatments for cannabis-involved adolescents. In response to this need, the 

Substance Abuse and Mental Health Services Administration (SAMHSA) 

Center for Substance Abuse Treatment (CSAT) of the Department of Health 

and Human Services (DHHS) funded the CYT study. 

The CYT study is a multisite, randomized field experiment designed 

to test the efficacy of five promising outpatient treatment interventions for 

cannabis-abusing and cannabis-dependent adolescents. Its long-range goal 

is to provide validated and cost-effective models of intervention that can be 

widely replicated in local treatment agencies across the country. The study 

sites include Chestnut Health Systems in Madison County, Illinois 

(CHS–MC); the University of Connecticut Health Center (UCHC) in 

Farmington, Connecticut; Operation PAR in St. Petersburg, Florida (PAR); 

and the Children’s Hospital of Philadelphia (CHOP) in Pennsylvania. The 

sites represent both academic, research-oriented clinics (UCHC and CHOP) 

and community-based adolescent treatment programs (CHS–MC and PAR) 

(Dennis, Babor, Diamond, Donaldson, Goldley, Tims, et al., 1998; Herrell, 

Babor, Brantley, Dennis, et. al., 1999). The CYT study provides a test in 

geographically diverse environments of treatments that differ in theoretical 

orientation, delivery format and focus, and dose. 

Between June 1998 and February 1999, 600 adolescents 

(approximately 150 per site) meeting the Diagnostic and Statistical Manual 

of Mental Disorders 4th Edition-Revised (DSM–IV) criteria (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 Treatment/Cognitive Behavior 

Treatment—5 individual/group sessions (MET/CBT5) (Sampl & 

Kadden, 2001) 

• Motivational Enhancement Treatment/Cognitive Behavior 

Treatment—12 individual/group sessions (MET/CBT12) (Webb, 

Scudder, Kaminer, & Kadden, in press) 

• Family Support Network (FSN) (Hamilton, Brantley, Tims, 

Angelovich, N., & McDougall, in press) (FSN includes 

MET/CBT12 plus enhanced family supports: home visits, 

parent education classes, parent support groups) 

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• Adolescent Community Reinforcement Approach (ACRA) (Godley, 

Meyers, Smith, Karvinen, Titus, Godley, Dent, Passetti, & Kelberg, 

in press) 

• 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/CBT12 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, 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 (15 to 25 hours) 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) 

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• Conducted weekly (1-hour onsite or telephone) individual 

supervision and weekly or bimonthly (60 to 90 minute) cross-site 

group supervision for each intervention. 

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 

ensurance 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 druginvolved 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 

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interventions but contextual policies unrelated to the active ingredients of 

each intervention. 

What follows is a synopsis of how common clinical issues were 

managed across the four treatment sites and across the five interventions 

being tested. It is hoped that this discussion will provide researchers and 

treatment practitioners alike with insights into the importance of managing 

such contextual influences. The discussion also represents a snapshot of 

baseline clinical practices in adolescent substance abuse treatment in 1998 

and 1999. 

Issues in Clinical Management and Clinical Care 

A. Clinical Infrastructure. A rather complex clinical infrastructure 

was required to effectively manage clinical activities across the four 

treatment organizations and the five treatments in the CYT study. The care 

taken in constructing this infrastructure was based on the assumption that 

there is a close relationship between the quality of clinical supervision and 

treatment efficacy (Holloway & Neufeldt, 1995). 

There were three levels of clinical coordination and supervision in 

the CYT study. First, local clinical supervisors at each service site 

coordinated cross-intervention clinical issues and day-to-day clinical 

problem solving. Second, a therapist coordinator for each of the five 

interventions used in the CYT study provided onsite and cross-site clinical 

supervision of staff working in their particular intervention. This supervision occurred weekly during the period in which therapists were being 

certified, and bimonthly following staff certification. Third, a TC at the CYT 

coordinating center facilitated cross-site and cross-intervention coordination and problem solving. The centerpiece of this cross-site clinical 

coordination was a monthly meeting at which the respective TCs met with 

the cross-site TC and research coordinator via 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 and 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 Site Visit Protocol, 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 

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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 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 other 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). 

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Staff were paid salaries that were at or slightly above the geographical norm 

for addiction therapists. None of the sites experienced any significant problems recruiting qualified staff. 

In the course of the project, there were a total of 26 full-time and 

part-time clinical positions at the four CYT sites. Nine staff left the CYT 

project during this period—two due to changes in the communities 

selected as service sites and the majority of the others due to either a 

return to school, family relocation, or promotion. The highest turnover rate 

was among the case managers. Several things worked to enhance staff 

morale and retention on the CYT project: a conscious effort to build team 

cohesion, a knowledge of the potential importance of the research being 

conducted, the training and supervision opportunities, the opportunity for 

cross-site contact with peers working on the same intervention, and the 

flexibility of the individual sites regarding scheduling of part-time 

employees on the project. 

Although considerable effort is made to ensure that conditions in 

clinical trials are equivalent to natural conditions in the field, there are 

several characteristics of clinical trials staff that make them somewhat 

different from those in mainstream practice. Staff who seek clinical 

positions in clinical trials are not scared away by the limited timeframe of 

employment on such a project, are often attracted by the intense nature of 

training and supervision such projects afford, and are not put off by the 

rigorous record-keeping generally required in such projects. 

Strategies used for managing clinical continuity in the face of staff 

attrition included replicating the training that was provided to all 

therapists at the beginning of the CYT project, having a built-in 

transition/training period for entering staff, and using videotaped sessions 

of the current therapists to train new therapists. 

The safety of staff working in the field was enhanced by hiring staff 

from the local community; providing inservice training on safety 

management and access to beepers and cellular phones; and the option of 

working in teams to visit areas that posed higher safety threats. 

Office-based safety issues were addressed by ensuring that other staff were 

present while sessions were being conducted and by providing walkie-talkies 

or silent alarms to signal other staff if assistance was needed. There were no 

major safety-related incidents experienced by the CYT project. 

C. Client/Family Recruitment, Engagement, and Retention. The 

major barriers in recruiting, engaging, and retaining adolescents and their 

families were fairly consistent across the CYT project sites: 

• Low adolescent/parent motivation for treatment involvement 

• The perception that other problems in the family were more 

important than the drug experimentation of one child 

• Parental substance abuse 

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• The parental view that smoking marijuana is not that big a deal 

• Failure to attend due to lack of transportation or childcare 

• A marital or relationship breakup during the period of treatment 

involvement 

• 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 (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 fivesession 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 therapists were 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 themselves, 

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begin alliance building, and clarify any questions about treatment participation. All of the CYT interventions begin with an emphasis on empathy and 

skillful rapport building to build a strong therapeutic alliance and work 

through resistance related to the coercive influences that may have brought 

the adolescent to treatment. 

The second strategy was for the therapist to speak for 5 to 10 

minutes with any adolescent who had to wait more than 2 weeks to begin 

service (a delay sometimes caused by randomization and the cycles of starting new groups) to sustain his or her motivation for service involvement. 

The third strategy was to remove as many environmental obstacles 

to treatment participation as possible by using geographically accessible 

service sites, providing assistance with transportation (that is, cab vouchers, 

bus tokens, picking adolescents up in the agency van), and providing or 

arranging childcare. Case management, whether provided by therapists, 

case managers (in the FSN intervention), or even during the screening 

activities of the research staff, was an essential medium of engagement for 

those families whose lives were most chaotic at the point of initial contact 

with the CYT project. Every effort was made to link what could be learned 

in treatment with what could help the immediate crisis presented by the 

family. The CYT interventions shared the message, “We have something that 

could help with some of these problems and improve the quality of life for 

you and your child.” 

The fourth and most important strategy was to actively engage the 

adolescents and families by creating strong therapeutic alliances, 

expressing interest in their participation (e.g., by weekly phone prompts for 

participation), finding a goal that the adolescent/family was 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 

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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 status deteriorated following 

admission, particularly where such deterioration posed the threat of harm 

to themselves or others. Safety net procedures were established at 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/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/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/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 

who were receiving concurrent treatment whose primary focus was the 

problem of substance abuse or who 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 

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adolescents who were treated simultaneously for collateral problems (e.g., 

being medicated for hyperactivity or depression) were allowed to enter and 

remain in the CYT study because the focus of the concurrent services was 

not on substance abuse or dependency. 

F. Session Management. Efforts were made to ensure that issues 

related to the management of sessions that were not unique to the 

particular interventions would be handled in reasonably consistent ways 

across the sites. Where procedures were not the same, they were reviewed 

to ensure the differences would not confound outcomes. These discussions 

included how to respond to lateness, missed sessions (the criteria for 

dropping cases), intoxication, contraband, disruptive behavior, preexisting 

relationships between members, and a group session at which only one 

member is present. 

Lateness was handled by degree, either by ensuring 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 if 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. 

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G. Gender and Cultural Adaptations. While there is significant 

momentum toward the development of standardized, empirically supported, 

and manual-based treatments (Wilson, 1998; Carroll, 1997), there is a 

simultaneous call for the refinement of standardized treatment that 

includes gender and cultural relevance and effectiveness (Orlandi, 1995). 

All of the CYT therapists noted making changes in their delivery of the 

manual-based treatments 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/CBT12, 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 

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(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 drugfree prosocial activities in general than on addiction recovery support group 

involvement. 

J. Ethical Issues. The TC meetings also provided a venue to discuss 

and formulate responses to some of the complex ethical and legal issues 

that can arise in the treatment of adolescent substance abuse (White, 

1993). Considerable time was spent discussing questions such as: 

• What are the boundaries of confidentiality regarding disclosure of 

information about an adolescent to his or her parents? 

• Do parents have a legal/ethical right to the results of their child’s 

urine tests? 

• What circumstances would constitute a duty to report or duty to 

intervene? 

• What obligations, if any, do therapists have in responding to an 

adolescent’s disclosures of past or planned criminal activity? 

• How should therapists respond to reports of abuse of adolescents 

by a parent or to failures by child protection agencies to 

intervene to ensure the safety of the adolescent? 

Discussion 

Carroll and colleagues (1994, 1996, 1997) are to be commended for 

helping transfer the technology model of psychotherapy research to 

addiction treatment outcome studies. The CYT study greatly benefited from 

the earlier experience of Project MATCH in the use of this model. This 

paper has described a structure (the interface between a cross-site and 

cross-intervention TCs 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 

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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 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 would seem 

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 would 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 

154
project remained high, in part because of the near universal belief in the 

historical importance of this study and the climate of excitement and 

discovery that permeated the project. We believe that small field-based 

experiments to answer critical clinical questions, opportunities for 

cross-site sharing, and the opportunity to work on papers and presentations 

can similarly contribute to staff morale within local service organizations. 

We believe this milieu of curiosity, discovery, and contribution is transferable and sustainable in natural clinical settings. Routine outcome 

monitoring and field-based experiments, like the other items in this discussion, must simply be moved from the arena of clinical research to the arena of 

standard clinical practice. This transfer of technology from the research environment to the clinical practice environment, however, will not be simple. 

If there is a single weak link in the current practice of addiction 

treatment that will slow this technology transfer, we believe it is in the 

arena of clinical supervision. Comprehensive assessments, science-guided 

treatment planning, empirically validated and manual-based therapies, 

regular adherence measurement and monitoring, using clients’ response-totreatment data and supervision 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. 

155
 
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