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

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

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:

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.

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 three-site 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 thera-pist’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 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 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 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 strength-en 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 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 motivat-ed 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 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.

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 problem-solving 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 cir-cumstances 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:

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 tetrahydrocannabi-nol (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 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.

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 adoles-cent 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 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. Specif-ically, 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.

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.

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: http://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.

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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.

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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 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 adoles-cent 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.

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:

Behaviors related to marijuana:

Thoughts about marijuana:

Feelings about marijuana:

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 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.

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 under-stand 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 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 outthe 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 tr ying 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 involvethe client in a functional analysis of his or her own use. The discussion canfocus on a recent episode(s) of use that the client has reported, or it couldfocus on the client’s use in general. The therapist should fill in some of theclient’s responses on the personal awareness form while the client followsalong 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 tooffer some examples of how some adolescents say they have feltbefore they decided to use (e.g., bored, angr y, excited, sad). Also, some adolescents may have trouble identif ying 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.

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.

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.

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