Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions
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:
An assessment of the need for detoxification
Notification of a parent or guardian (because of potential
safety/liability issues)
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 occur-ring
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.
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 ses-sion,
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.
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 disclo-sure.
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 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 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 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.”
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 modi-fications
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
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 present-ing.
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 like-lihood
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 partici-pant.
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 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.
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