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Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions

Background of the
MET/CB5 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).

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 mainte-nance). 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 sub-stance 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).

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 problemat-ic 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 situa-tions 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 self-management 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 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 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 adoles-cents’ 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 1½ to 2 full days of initial live training in MET/CBT5, with the amount of time needed depending on therapist and 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 thera-pists 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.

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.

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