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

Cognitive Behavioral Therapy

The next three sessions of MET/CBT5 primarily employ cognitive behavioral therapy, an approach that focuses on understanding a person’s behavior in the context of his or her environment, thoughts, and feelings. The foundation for the cognitive behavioral group sessions has already been established in the introduction to functional analysis section in session 2. Another key tenet of cognitive behavior therapy is that individuals manifesting maladaptive behaviors may be able to learn coping skills that would allow them to decrease or abstain from the negative behaviors. Thus each of the group sessions focuses on teaching clients a particular skill designed to help them abstain from marijuana and other substance use. The following section provides some recommendations for carrying out the cognitive behavioral group therapy sessions, which are applicable to all the remaining sessions. This section draws heavily on the book Treating Alcohol Dependence: A Coping Skills Training Guide (Monti et al., 1989).

Key Concepts and Session Guidelines

The particular cognitive behavioral treatment approach specified in this manual is based on a social learning model, with a focus on training people in interpersonal and self-management skills. The primary goal of this treatment is for clients to master the skills needed to maintain long-term abstinence from marijuana. An important element in developing these skills is identification of high-risk situations that may increase the likelihood of relapse. These high-risk situations include external precipitants of using, as well as internal events such as cognitions and emotions.

Having identified situations that may create a high risk for relapse, clients must develop skills to cope with them. In the three CBT group sessions, clients are taught basic skill elements for dealing with common high-risk problem areas and are encouraged to engage in roleplaying and real life practice exercises that will enable them to apply these skills to meet their own needs.

Clients must get a chance to build their skills by receiving constructive feedback using relevant (client-centered) problems. Active practice with positive, corrective feedback is the most effective way to modify self-efficacy expectations and create long-lasting behavior change.

Cognitive behavioral treatment for marijuana abuse requires the client’s active participation, as well as his or her assumption of responsibility for using the new self-control skills to prevent future abuse. Through active participation in a training program in which new skills and cognitive strategies are acquired, an individual’s maladaptive habits can be replaced with healthy behaviors regulated by cognitive processes involving awareness and responsible planning. Marlatt and Gordon (1985, p. 12) state:

As the individual undergoes a process of deconditioning, cognitive restructuring, and skills acquisition, he or she can begin to accept greater responsibility for changing the behavior. This is the essence of the self-control or self-management approach: one can learn how to escape from the clutches of the vicious cycle of addiction, regardless of how the habit pattern was originally acquired.

Since behavioral approaches to treatment could be applied inappropriately—without careful consideration of the unique needs of the individual receiving treatment—it is important that therapists be experienced in psychotherapy skills as well as behavioral principles. They must have good interpersonal skills and be familiar with the materials in order to impart skills successfully and serve as credible models. They must be willing to play a very active role in this type of directive therapy.

Prior to each treatment session, therapists are encouraged to reread relevant sections of the manual. To ensure that the main points of each session are covered, we recommend making an outline of them or highlighting them in the text. In presenting the didactic material, we suggest briefly paraphrasing the main points and listing them on a blackboard.

When implementing a therapy based on a manual, it is essential that clinicians do not read the text verbatim. As long as the major points are covered, a natural, free-flowing presentation style is preferred. It is crucial for the clients to think that their treatment issues and concerns are more important than the therapists’ agenda of adhering strictly to the manual.

Indeed, if clients are not routinely involved and encouraged to provide their own material as examples, we have found that treatment becomes boring and the energy level for learning drops off dramatically. Therapists may experience burnout as a result. Effective reinforcement of clients’ active participation can help prevent burnout on the part of both clients and therapists.

The topics covered in each session are intended to teach skills that are highly relevant to the problems in clients’ daily lives. To help clients view treatment as relevant to their daily lives, it is essential that a therapist strive as much as possible to provide examples from material that the clients have previously brought up. Usually this is not difficult, because the skills training sessions cover commonly encountered problems that are likely to have been raised already by the client.

Transitioning From Individual to Group Sessions

In MET/CBT5, therapists transition from working with clients on an individual basis to seeing them as a part of a group. Here are some guidelines for navigating questions of confidentiality and working alliances, which may occur in making this transition. Some therapists may be familiar with this process, having seen clients individually for an initial assessment and then treating them in group therapy. Therapists may question how to handle issues of confidentiality, given that by the time they see clients in the CBT group sessions, they will have quite a bit of personal information about each client. This concern is a particularly sensitive one with adolescents, who are especially concerned about how they are seen by their peers. The idea is to utilize that information while at the same time respecting clients’ confidentiality. A good way to do that is to refer to the general topic and invite clients to share their personal information. For example, if one group member is talking about legal problems associated with his or her substance use, the therapist may say, “There are other people in the group facing this problem. Would anyone else like to say what that’s been like for you?”

In this example, the therapist does not identify any specific group member as being in legal trouble. The therapist can also further broaden the discussion by saying, “Or even if you haven’t been arrested, you might be worried about possible trouble with the law. Do you relate to this?”

The therapist may also invite a particular client to share personal information by referring to the topic in a way that does not reveal sensitive information. For example, “Joe, this reminds me of your situation. Would you be comfortable telling the group about what’s going on with you and your parents?”

If “Joe” declines to do so, don’t pressure him. He may decide to when he feels more comfortable. Of course there is always the risk that “Joe” may be upset even about having the therapist reveal that his situation is similar. In such a case, the therapist is encouraged to apologize without becoming defensive.

The flip side of this issue is that a client may make reference to something he or she and the therapist have discussed, in a way that excludes the rest of the group. When this occurs, the therapist should ask the client to fill the group members in on the story. Here is an example:

Lisa: [looking at the therapist] Remember that problem I was having with my friend Jane? Well I talked to her, and she said. . . .

Therapist: Hold on a second. Could you fill the group in on what was going on?

In general, the therapist acknowledges and makes use of information acquired in the individual sessions, but he or she puts the adolescent in charge of sharing, or not sharing, that information with the group.

In working with adolescents, some therapists have noticed that clients may verbalize their motivation to quit marijuana in the individual sessions and then seem less motivated in the ensuing group sessions. In some cases, the therapist may suspect that this shift is due to the adolescent’s concern that the other group members may not think he or she is cool. The therapist may feel disappointed or frustrated by the client’s seeming lack of cooperation and may feel like confronting the client on this change. Doing so, however, is only likely to cause the client to feel ashamed and, perhaps, intensify his or her antiabstinence position. The following strategies are likely to be more productive.

If the therapist perceives that, overall, the group is communicating the attitude that “using is cool, quitting is not cool,” the therapist can state what he or she observes. Sometimes the group members may acknowledge this position, which may result in some productive dialog about pressures clients may face in their relationships outside of group. Even if the group rejects the therapist’s observation, just having stated it may decrease the likelihood of continued antiabstinence communications.

Another strategy is to acknowledge that a number of group clients may have similar mixed feelings about quitting versus continuing use. The therapist may employ some double-sided reflections that speak to the group as a whole. For example, the therapist could say:

Even though each of you came to this program because of some problems related to your marijuana use, a number of people are saying that you have a lot of good memories about times you’ve smoked, and you’re not sure that you want to give it up now. Obviously, if the group wanted to focus at length on memories of being high, the therapist would need to set limits to avoid romanticizing marijuana use or triggering cravings.

Discussion of Clients’ Recent Problems

[The following recommendations are from the Monti et al. (1989) coping skills training guide for treating alcohol dependence.]

Clients experience numerous problems, cravings, and actual slips as they struggle with abstinence. Although the focus of the sessions must be on the structured program, ignoring clients’ real life problems entails the risk that they will view treatment as peripheral or irrelevant to their current needs. As a compromise between the demands of the protocol and clients’ perceived needs, approximately 15 minutes should be spent at the outset of each session discussing clients’ current problems related to marijuana.

Make efforts to structure these discussions along lines that are consistent with a skills-training approach by using a problem-solving format that involves clearly specifying the problem, brainstorming possible ways of dealing with it, and selecting one way to try out in the situation. The rule is that the opening discussions should be structured along behavioral lines to keep them consistent with the approach of this manual.

If necessary, clearly state to the clients that while skills treatment can help them practice new ways of coping with problems, these problems cannot always be fully discussed to the point of complete resolution. Long-term resolution of specific problems may require additional work after this program is finished.

If serious problems arise repeatedly, consult with your supervisor. It may become necessary to initiate alternative treatment.

Presentation of Skill Guidelines

In each of the cognitive behavioral group sessions, the focus is on teaching a particular skill: (1) marijuana refusal skills, (2) enhancing the social support network, and (3) coping with relapses. Posters focusing on the skill to be taught in each of the sessions are included in appendix 3 of this manual. The poster corresponding to the current session should be hung in the group room where everyone can read it. Only the poster relating to the current session should be displayed, so that the material presented will be novel and, thus, more likely to capture group members’ attention.

In presenting a particular skill, therapists should start by providing a rationale for learning that skill. The main points of the therapeutic rationale are covered on the “why?” part of the poster and will become more meaningful to clients if therapists draw parallels between the rationale and events in group members’ lives. For example, therapists leading session 3 may ask group members if they have noticed a narrowing of their own social circles to include primarily other drug and alcohol users. In describing the session 5 rationale that relapse is an opportunity for learning, a therapist may refer to a relapse story that a client shared earlier in the group and encourage the client and the rest of the group to identify what could be learned from that experience.

Next, therapists review the skill guidelines shown on the posters. Here, again, the key to engaging the group is to make these guidelines come alive by illustrating them with examples and explicitly stating how they are relevant to clients’ lives. Therapists may also engage clients by having them take turns reading the skill guidelines out loud. Be aware that some clients may have deficits in their reading skills or may be uncomfort-able reading aloud in group. Provide them the opportunity to bow out gracefully. For example, you may tell group members that they can just say “pass” if they prefer not to read.

Therapists may be able to make the skill guidelines fun and interesting by using some creativity. For example, the therapist may demonstrate the contrast between making a refusal statement in a voice that is clear and firm rather than vague and hesitant. One group member, for example, might like to try demonstrating the contrast between refusing marijuana with and without making eye contact. In covering the material included for each session, therapists are encouraged to make it lively and fresh. This can be accomplished while staying true to the protocol. Encourage questions and comments about the skill guidelines. If a group member says that a particular skill is not useful, don’t be defensive— instead, focus on listening to the client’s concerns. As in the individual MET sessions, group clients may be more open to the therapist’s input if they do not feel that the therapist is trying to convince them.

Emphasize the importance of real life practice of the skills, as well as practice within the group through roleplaying. The following section contains some guidelines for using roleplay with clients and is based on Monti and colleagues’ (1989) coping skills training guide.

Guidelines for Behavior Rehearsal Roleplay

The main factor that determines the success of cognitive behavioral skills training is the extent to which clients practice and apply the new skills in their lives. Roleplays in the group therapy sessions give clients a chance to test the potentially unfamiliar new skills in a safe environment. Doing so in group increases the likelihood that clients will try new skills in their lives outside therapy. As a result, roleplay in a group provides a valuable practice exercise.

Roleplay is specifically called for in the first group therapy session, in which clients are asked to practice marijuana refusal skills. While roleplay is not built into the remaining two group sessions, if time allows, therapists are encouraged to utilize roleplay when it may enhance learning. For instance, during the review of progress, a client may describe a recent relapse precipitated by an offer of marijuana. The therapist can encourage roleplaying in which the client responds by refusing the offer. Or during a later discussion of requesting help and support, a client could be asked to roleplay asking for help.

Some clients and/or therapists may feel uncomfortable or embarrassed at first about roleplaying. As a result, it may be tempting for the therapist to allow the group simply to talk about the skills rather than practicing them, which would decrease the effectiveness of therapy. Therapists can increase the likelihood that clients will participate in roleplays by taking the lead in the first one. Therapists should acknowledge that feelings of awkwardness are normal when trying a new interpersonal behavior like roleplay. Also, therapists are encouraged to praise clients who volunteer to go first. In general, if therapists establish a safe group environment and follow the suggestions about making group sessions fun and interesting, they are likely to find that clients will readily participate in roleplays. Here are the basic steps for setting up roleplays:

1. Explain what roleplaying is, if you have not already done so. Keep in mind that many clients are likely to be familiar with the idea of roleplay, so it may not require a long explanation. For example, say:
   
   I’d like you to practice turning down an offer to smoke by doing that here in group, as if you were acting. The first time, I’ll pretend to be that guy you told us about.
   
   
2. Briefly review the situation to be roleplayed. What is the problem? What is the skill to be practiced?
   
   Okay, so your friend is driving you to school, and she offers to get high with you. You turn down the offer.
   
   
3. Determine who will play which role. Suggestions for acting the part can be solicited and made.
   
   Who would be willing to play Jason’s mom?
   Jason, should she act mad, sad, or what?

The following strategies are useful in helping clients generate scenes:

• The therapist can ask clients to recall a situation in the recent past where use of the skill being taught would have been desirable.
• The therapist can ask clients to anticipate a difficult situation that may arise in the near future that calls for use of the skill.
• Clients can all be asked to write down scenarios to be roleplayed, fold them up, and place them in the center of the group. Clients then take turns taking one of the written scenarios and roleplaying them.
• The therapist can suggest an appropriate situation based on his or her knowledge of a client’s recent circumstances.

After a roleplay has been set up and enacted, it is essential that it be effectively processed. It is an opportunity for clients to receive praise and recognition for practice and improvement, as well as constructive criticism about the less effective elements of their behavior. Initial attempts may show few elements of the communication skill being taught. During this portion of the session, the therapist’s primary goal is to look for successful elements of the skill being taught and to reinforce those skill elements. The primary emphasis should be on what the client is doing well, in order to gradually shape his or her behavior in a positive direction. A secondary focus is making limited suggestions for improvement. Here are the procedures for delivering this feedback:

1. Immediately after every roleplay, the therapist should give the client reinforcement for participating and for positive aspects of the performance. Both the roleplaying clients should give their reactions to the performance. Examples: How do the protagonists feel about the way they handled the situation? What effect did the interaction have on the partner?
   
   
2. The other group members and the therapist should offer comments about the roleplay. These comments should be both supportive and reinforcing and constructively critical. If there are several deficiencies in a roleplay performance, the therapist should choose only one or two to work on at a time. Both positive and negative feedback should focus on specific aspects of the person’s behavior, since global evaluations do not pinpoint what was particularly effective or ineffective. Finally, the praise and reinforcement provided should always be sincere. However, the therapist should refrain from being unnecessarily effusive, so that the value of positive feedback is not undermined.
   
   
3. The scene should be repeated to give the client an opportunity to try out the feedback he or she received the first time around.

Role reversal is a roleplay strategy in which the therapist models use of the new skill, with the client playing the role of the friend, parent, or teacher. This strategy is particularly useful if a client is having difficulty using a skill or is pessimistic about the effectiveness of a suggested approach. By playing the “other,” he or she has an opportunity to observe and experience firsthand the effects of the suggested skill.

Real Life Practice Exercises

Practice in real life situations is a powerful adjunct to treatment because it enhances the likelihood that these behaviors will be repeated in similar situations (generalization). Practice exercises have been designed for each session of the program. Most require that the client try in a real life sit-uation what has been taught in the session. The real life practice assignment also requires that the client record facts concerning the setting, his or her behavior, the response it evoked, and an evaluation of the adequacy of his or her performance. Practice exercises can be modified to fit the specific details of individual situations.

Using practice exercises often is a problem, and a number of steps can be taken to foster compliance. The assignments are referred to as real life practice to avoid the negative connotations often associated with the term homework. When giving each assignment, provide a careful descrip-tion of the assignment and the rationale for it. Ask clients what problems they can foresee in completing the assignment, and discuss ways to overcome these obstacles. Ask them to identify a specific time that can be set aside to work on the assignment, and try to elicit a commitment from group members to complete the practice exercise by the next session.

To emphasize the importance of practice, therapists should review the preceding session’s exercise at the beginning of each session and make an effort to praise all attempts to comply with the assignment. Although problems that clients have with the exercises should be discussed and understood, the main emphasis should be on reinforcing the positive aspects of performance. If at least two group members have done the real life practice exercise assigned in the previous session, focus on those who have completed the assignment in this portion of the group meeting. To the extent that group members enjoy being the center of attention, this will reinforce completion of written practice exercises. For those who did not do an assignment, discuss ideas for complying with the next assignment. A selection of inexpensive but appealing items should be purchased by the staff, such as items that can be found at a party store or a dollar store (price range 50 cents to $1.25). At the end of the group meeting, let clients who have brought in a completed practice exercise choose one item from the assortment, to reinforce their compliance.

The next section of the treatment manual describes the procedures and content of sessions 3 through 5. Following that section are further recommendations regarding the management of problem behaviors.

Procedural Steps

Phase 1: Introduction to the Group and Brief Review of Progress. The first part of the session is allotted to introducing group members to one another and to reviewing rules, which are posted in the group room. In order to help focus the group, each client is asked to share his or her goal for treatment. The therapist then asks an open-ended question about how the past week has gone regarding the marijuana issues. Because the resulting discussion could probably continue for the rest of the session, the therapist will have to rein it in to allow time for the material in this session to be covered. To facilitate this, the therapist may wish to open the topic with a statement like:

Phase 2: Review of Real Life Practice. Next, the therapist will ask clients who have completed and brought in their self-monitoring records to pick one episode that they wrote about and share it with the group. Group members and the therapist then share their reactions to what was written. Again, the time prohibits getting into detail or an extended discussion of people’s examples.

If none (or only one) of the group members have brought in written comments, give group members blank personal awareness worksheets (Knowledge Is Power) for functional analysis and have them verbally recon-struct one episode of craving or relapse that occurred during the past week. Allow time for feedback about those episodes. If at least two members have brought in written comments, just review their work. To the extent that members like the group attention, this may provide some incentive to complete the exercises. When people create answers on the spot rather than reading what they have written, they may become verbose; the time is better allotted to focusing on clients with written comments.

Phase 3: Marijuana Refusal Skills. Some of the following pointers and skills are included on the marijuana refusal skills poster, which provides visual reinforcement of the material to be covered. The therapist explains the following points regarding marijuana refusal skills:

1. Being offered marijuana or being pressured to use by others is a very common high-risk situation for marijuana users who have decided to stop using. Have you received such offers or pressures? In what situations?
   
   
2. As one’s use increases, there appears to be a “funneling” effect or narrowing of social relationships. The individual begins to eliminate nonusing friends and his or her peer group becomes populated with others who support and encourage continued use. Being with such individuals increases the risk of relapse.
   
   
3. Given the increased risk associated with social pressure, the best initial step is to avoid situations involving marijuana use. As this is not always possible or practical, marijuana refusal skills are necessary.
   
   
4. Being able to turn down marijuana requires more than a sincere decision to stop using. It requires specific assertiveness skills to act on that decision. Practice in refusing marijuana will help you respond more quickly and effectively when real situations arise.
   
   
5. The more rapidly the person is able to say “no” to such requests, the less likely he or she is to relapse. Why is this so? Next, the group should review specific suggestions for the nonverbal and verbal behaviors recommended for marijuana refusal (also shown on the marijuana refusal skills poster). The marijuana refusal skills handout covers this material but adds more detail. Distribute this handout, and review each of the skills. Consider having clients take turns reading the points, in order to keep them all involved. Demonstrate, and then engage the group in demonstrating, the skills described. Group members often enjoy the part of the group in which they see the skills demonstrated effectively rather than ineffectively, and this is a good opportunity to increase their active involve-ment in discussion. Point out that these refusal skills are equally useful in turning down offers to use alcohol or other drugs. Following are the skills to be reviewed with the group. (A handout follows.)

Marijuana Refusal Skills

Nonverbal behaviors:

• Be firm. Speak in a clear and unhesitating voice. Otherwise you invite questions about whether you mean what you say. Demonstrate this skill by making the same refusal statement twice—once in a timid voice and once in a clear, firm voice. Have clients comment on the perceived effectiveness of each style.
  
  
• Make direct eye contact with the other person; it increases the effectiveness of your message. Again, demonstrate (or ask a group member to demonstrate) the same refusal with and without eye contact. Discuss your observations.
  
  
• Stand up for your rights! Don’t feel guilty. You won’t hurt anyone by not using marijuana, so don’t feel guilty. In many social situations, people will not even know whether you are using or not. You have a right not to use. Discuss your reactions.
  
  

Verbal behaviors:

“No” should be the first word out of your mouth. When you hesitate to say “No,” people wonder whether you really mean it. Demonstrate the same statement both with and without the word “No” first. Ask for clients’ reactions.

Besides saying “No,” suggest an alternative, something fun to do instead. Have the group suggest possibilities for alternative activities.

If a person repeatedly pressures you, ask him or her not to offer you marijuana any more. Consider setting up a roleplay to illustrate doing this.

After saying “No,” change the subject to something else to avoid getting drawn into a long discussion or debate about using. Have the group suggest possible changes of subject.

Avoid the use of excuses like “I’m on medication for a cold right now,” and avoid vague answers like “Not tonight.” Discuss the rationale for avoiding excuses; they imply that at some later date you will accept an offer of marijuana.

Nonverbal behaviors:

Be firm. Speak in a clear and unhesitating voice. Otherwise, you invite questions about whether you mean what you say. Make direct eye contact with the other person. It increases the effectiveness of your message.

Stand up for your rights! Don’t feel guilty. You won’t hurt anyone by not using marijuana, so don’t feel guilty. In many social situations, people will not even know whether you are using or not. You have a right not to use.

Verbal behaviors:

“No” should be the first word out of your mouth. When you hesitate to say “No,” people wonder whether you really mean it.

Besides saying “No,” suggest an alternative, something fun to do instead.

If a person repeatedly pressures you, ask him or her not to offer you marijuana any more.

After saying “No,” change the subject to something else to avoid getting drawn into a long discussion or debate about using.

Avoid the use of excuses like “I’m on medication for a cold right now,” and avoid vague answers like “Not tonight.” These imply that at some later date you will accept an offer of marijuana.

The next part of the session involves practice, and clients are generally quite good at generating appropriate scenes to practice. Initially, the therapist will play the person who is being invited to use marijuana and will explain and demonstrate each of the following types of responses:

First, the therapist describes each of the four types of responses listed above, demonstrating an example of each by asking one of the group members to play the person offering the marijuana. The therapist points out the ways that the first three types of responses may not be helpful to clients, highlighting the differences between these styles and the desirable assertive style.

Next, the therapist encourages group members to practice the assertive style of marijuana refusal in roleplays with one another. Group members are encouraged to offer one another support and constructive feedback as they practice these skills. Finally, clients are each given a copy of the marijuana refusal reminders sheet to take home. They are asked to fill in the real life practice exercise at the bottom of the sheet with either: (1) responses they actually make during the week to people who offer marijuana, alcohol, or other drugs; or (2) things they could say to turn down an offer to smoke marijuana. The therapist should attempt to get a verbal commitment from group members to complete this real life practice exercise.

Marijuana Refusal Skills Reminders

When someone asks you to use marijuana, keep the following in mind:

• Say “No” first.
• Make sure your voice is clear, firm, and unhesitating.
• Make direct eye contact.
• Suggest an alternative:
  Something else to do.
  Something to eat or drink.
• Change the subject.
• Avoid vague answers.
• Don’t feel guilty about refusing to use marijuana.
• If necessary, ask the person to stop offering you marijuana and not to do so again.

Listed below are some examples of people who might offer you marijuana in the future. Give some thought to how you will respond to them, and write your responses below each item.

Someone close to you who knows about your marijuana problem:

_________________________________________________________
_________________________________________________________

A school friend:

_________________________________________________________
_________________________________________________________
_________________________________________________________

A coworker (if you have a job):

_________________________________________________________
_________________________________________________________

A new acquaintance:

_________________________________________________________
_________________________________________________________

A person at a party with others present:

_________________________________________________________
_________________________________________________________

A relative at a family gathering:

_________________________________________________________
_________________________________________________________

Procedural Steps

Phase 1: Review of Progress. Prior to formally beginning the group session, clients should be asked to provide urine samples for drug testing. The therapist waits outside the restroom when each client goes in to provide the sample. Clients should not be permitted to bring extra items into the restroom (e.g., coats, purses, etc.). If a multiple-capacity restroom is used, only one client should be allowed into the restroom at a time. When clients bring out their urine samples, the therapist should look at the temperature strip on the outside of the container to see whether the urine was voided recently (i.e., is within the expected temperature range). Clients should be informed that if they do not provide the requested urine sample, or if the sample is invalid, their sample will be considered positive for drugs, meaning that drugs were present in their urine sample. If some clients say that they are unable to urinate prior to the group meeting, ask them to wait until after the meeting to do so. Occasionally a group client may say that he or she must use the restroom during the session and is unable to wait until afterward. In such a case, try to have a support staff person who is outside the group supervise the client providing the urine sample (as described above), rather than interrupting the group to supervise that client yourself.

After obtaining urine samples, begin the group meeting. Following initial greetings and updates (for example, telling the group that a client will not be in that day), the therapist should start with a general question about recent progress. For example:

As you’ve been working on the marijuana issue over the past week, has anyone had any problems or successes that you’d like to share with the group?

Allow sufficient time for discussion, attempt to facilitate members’ feedback and reactions, and offer your own comments, using MET and CBT strategies where possible. Move into the practice exercise review part of the session when the discussion winds down or in 15 minutes, whichever comes first.

Phase 2: Review of Real Life Practice. As in last week’s group ses-sion, keep the focus primarily on those who have done the real life practice exercise, unless fewer than two clients have done so. Have members read their responses to the refusal skills real life practice exercise, with the rest of the group offering feedback. Ask if any group members have had an opportunity to try out their refusal skills in a real life situation. If so, ask them to tell about their experience and reinforce their efforts.

Phase 3: Enhancing the Social Support Network and Increasing Pleasant Activities. This phase of the session starts with the therapist reviewing the rationale for increasing support:

• Social support leads to improved confidence in one’s ability to cope and provides an additional resource.
• Individuals do not often have as much support as they would like.
• There are several potential sources of social support, including one’s family, friends, and acquaintances.

Next, focus on teaching social support skills. Distribute the enhancing social supports reminder sheets (adapted from Monti et al., 1989) to the group. These skill guidelines are summarized on the poster for this session. Review the guidelines with the group and have them come up with examples from their own lives that correspond to some of the items. Here are the areas covered on the reminder sheet, with suggestions for covering them:

Enhancing Social Supports

Who might be able to support you? (Tell the group that “this refers to peo-ple who could help you with the goal you set regarding your marijuana use, as well as with other concerns in your life.”)

• Consider people who usually have been supportive in the past or those with no bias toward you. (Encourage group members to give examples from their own lives.)
  
  
• Consider people who usually have been neutral in the past (who aren’t coming in with a bias against you). (Encourage group mem-bers to give examples from their own lives.)
  
  
• Consider people who usually have not been supportive in the past but who might become supportive when they see your effort. (Encourage group members to give examples from their own lives.)
  
  
• Consider friends, family, acquaintances, or others in your community. (Prompt the group regarding categories that have not already been covered and may apply to group members, for example, teachers, clergy, coaches, extended family, guidance counselors.)

What types of support will be most helpful? (Again, have the group think of examples from their own lives of when they have needed, or when they may need, each of these types of support in the future.)

• Help with problem solving—someone good at thinking of options
• Moral support—someone to offer encouragement and understanding
• Sharing the load—help with getting things done
• Information—about activities, transportation, getting a job, etc.
• Emergency help—for small loans, needed items, a ride, etc.

How can you get the support or help you need?

• Ask for what you need. Be direct and specific.

The therapist should model the following ways of seeking support for the group. You may prefer to substitute a situation described by a group member during the meeting for the example below.

Problem: The client wants a friend to show support by doing things together other than just smoking marijuana.

Ask for group members’ reactions to the situations as they are modeled.

Add new supporters. As you work on something new, like trying to quit marijuana, you may need new or additional supporters. Ask group members who else’s support they could seek.

Lend your support to others. Talk with the group about how giving support allows you to get better at receiving support. Ask them for their reactions to this idea.

Give your supporters feedback. Let them know when something is or isn’t helping. Have the group think of an example of when someone may try to offer support that is not helpful, and how someone could tell them so.

Enhancing Social Supports Reminder Sheet

WHO might be able to support you? Consider people in the past who have been:

• Usually supportive, such as friends, family, acquaintances, or others in your community
• Usually neutral (aren’t coming in with a bias against you)
• Not supportive, but might become supportive when they see your effort

WHAT types of support will be most helpful?

• Help with problem solving—someone good at thinking of options
• Moral support—offers encouragement and understanding
• Sharing the load—help with getting things done
• Information—about activities, transportation, getting a job, etc.
• Emergency help—-for small loans, needed items, a ride, etc.

HOW can you get the support or help you need?

Ask for what you need. Be direct and specific.

• Add new supporters. As you work on something new, like trying to quit marijuana, you may need new or additional supporters.
• Lend your support to others. It allows you to get better at receiving support.
• Give your supporters feedback. Let them know when something is or isn’t helping.

Adapted from Monti et al., 1989

In-Session Exercise: Social Circle Diagraming. Next, group members are asked to diagram their own social circles and to try to determine what support they may be able to obtain from their social circle. They are given pencils and asked to fill in this diagram during the next part of the group meeting.

After 5 to 10 minutes, each group member is asked to share what he or she learned or noticed about his or her own support system. Did group members notice possibilities for asking for and getting more support? They are not asked to share the specifics of their personal support system; there is not enough time for this. Although clients may want to explain every intricacy of their social circle (“Here we have my friend Casey; this is my sort-of friend Joe,” etc.), time will not allow this detail. It will be helpful for the therapist to explain this at the beginning of the discussion to decrease the likelihood that a client will feel cut off later. Please see the social circle diagram on the next page.

Social Circle Diagram

Use the grid below to diagram your own social support circle, focusing on those who could support you in addressing your marijuana issue. Put your name in the center space, then fill in the names of those who do and/or could support you in your goal. Put the people who could be of greatest support to you closest to your space. Fill in as many of the spaces as you can.

Phase 4: Increasing Pleasant Activities. The following exercise is offered as a possible supplement to this session and should be included if there are at least 15 minutes available. Enjoyable activities can be a positive alternative to smoking marijuana. The group is asked to think of pleasant, fun, and safe activities that may serve as an alternative to smoking marijuana.

Tell them that some frequent marijuana smokers forget what it is like to do various things when they are not high and that some fun activities seem normal to them only when they are under the influence. Stopping or reducing marijuana use involves breaking the connection between these activities and being high. Many marijuana smokers may think that these activities will not be fun any more without marijuana, but they are often pleasantly surprised to find that the activities are as much fun, or even more fun, when they are not under the influence. Tell them that you’d like them to think of healthy, fun activities that they may be able to enjoy without, and instead of, marijuana use.

In-Session Exercise. While the group brainstorms possibilities, the therapist writes them down so that they are visible to the whole group. After several minutes, the therapist asks the group to consider if there might be a few activities on the list that they could add to their routine of activities. They are asked to write some of these on the bottom of their social circle diagram.

Next, they are asked to circle any of the listed things they would be willing to do over the next week. Each client is encouraged to tell the group one new thing he or she will do over the next week, including when, with whom, and how they will do it. Remind them that the idea is to do the chosen things without using marijuana, alcohol, or other nonprescribed drugs.

Distribution of Practice Exercises. Before the session concludes, practice exercise sheets (entitled Real Life Practice: Seeking and Giving Support) should be distributed and group members asked to complete them before the next session. Have the clients read the practice exercise sheets in the session so that they can ask any questions they may have at that time. Try to elicit some type of commitment from group members to complete both the written part of the exercise as well as the part where they actually ask for and offer support. This is in addition to trying out the pleasant activity.

Real Life Practice: Seeking and Giving Support

Think of a current problem that you would like help with.

Describe the problem:___________________________________________
_____________________________________________________________

Who might help you with this problem?___________________________
_____________________________________________________________

What might he or she do to give you the support you’d like?
_____________________________________________________________

How can you get this support from him or her? Remember, be direct and specific:_______________________________________________________
_____________________________________________________________

Now, choose the right time and situation, and try to get this person to support you. Describe what happened:_____________________________
_____________________________________________________________

Offer support to someone else.

Name a friend or family member who is currently having a problem and who could use more support from you:____________________________
_____________________________________________________________

Describe what you could do to lend him or her some support:_________
_____________________________________________________________

Now, choose an appropriate time and setting, and give support to this person. Describe what happened:__________________________________
_____________________________________________________________

Procedural Steps

Phase 1: Review of Progress. Like previous group sessions, this session begins with a review of progress. Discussion about progress or problems over the past week is elicited by a general inquiry by the therapist. (See sessions 3 and 4 for further recommendations for conduct-ing the review of progress.) During this phase of the group, the therapist offers to communicate the results of the clients’ urine tests for drugs (from samples obtained at the previous group meeting.) See “The Five Strategies of Motivational Enhancement Therapy” on page 21 for recommendations for discussing these results. The therapist should remind group members that this will be the final therapy session.

Phase 2: Review of Real Life Practice. Have group members read their responses to the seeking and giving support practice exercise. Ask the rest of the group to offer feedback. Reinforce attempts to try out the enhancing social support network skills through real life practice. If some clients have not yet tried out these skills, encourage them to do so soon. Ask them to make a commitment to do this.

If the pleasant activities segment was done in session 4, ask clients about how they did on their plans to increase pleasant activities. Did they do the thing they planned? How did it go? Did they enjoy the activity or not? If they didn’t do it, what got in the way?

Phase 3: Planning for Emergencies and Coping With Relapse. Even if someone avoids situations involving marijuana use, knows how to refuse such offers, increases his or her support system, and plans positive alterna-tive activities, he or she still may encounter unanticipated high-risk (emergency) situations and may relapse.

In-Session Exercise: Group Brainstorming of a Potential Emergency Situation. For individuals attempting to quit marijuana, an emergency situation consists of unanticipated circumstances that place them at increased risk for marijuana use. The group is asked to brainstorm the types of emergencies they may encounter. The therapist writes down the group’s responses in a place that is visible to all group members. After a period of unstructured brainstorming, provide cues to help the group think of types of emergencies they may have missed. Here are some examples of emergencies:

As seen above, emergency situations that can trigger a slip do not just include negative events but can also include positive events (e.g., a new job or a move to a better home). These situations entail the need to adjust to a number of changes in one’s environment and routine, when one’s cop-ing skills may no longer fit the new circumstances. In emergency situations, individuals can increase their likelihood of success by using the problem-solving model described below, an approach developed by D’Zurilla and Goldfried (1971).

Presentation of the Problem-Solving Model. The following brief summary of the problem-solving model is derived from Treating Alcohol Dependence: A Coping Skills Training Guide (Monti et al., 1989), which asks:

1. “Is there a problem?” Recognize that a problem exists. We get clues from our bodies, our thoughts and feelings, our behavior, our reactions to other people, and the ways that other people react to us.
   
   
2. “What is the problem?” Identify the problem. Describe the problem as accurately as you can. Break it down into manageable parts.
   
   
3. “What can I do?” Consider various approaches to solving the problem. Brainstorm to think of as many solutions as you can. Consider acting to change the situation and/or changing the way you think about the situation.
   
   
4. “What will happen if. . . ?” Select the most promising approach. Consider all the positive and negative aspects of each possible approach, and select the one most likely to solve the problem.
   
   
5. “How did it work?” Use the chosen approach. Assess its effectiveness. Having given the approach a fair trial, does it seem to be working out? If not, consider what you can do to beef up the plan, or give it up and try one of the other possible approaches.

Group Practice Exercise: Problem Solving for Emergencies. Have the group select one of the potential emergencies that were generated in the previous brainstorming exercise. Now ask the group to be sure that the problem is clearly identified, and have clients brainstorm various solutions. Write the possible solutions in a place that is visible to the whole group. Now have the group evaluate each of the possible solutions and pick one as the best choice. As this exercise is being done, describe how these brainstorming steps fit in with the problem-solving model.

Group Discussion: Coping With Relapse. Engage the group in discussion about coping with a relapse that may occur in response to an unanticipated high-risk situation. Here are some points to cover:

• Relapse is not uncommon in recovery. The important thing is how one deals with a relapse. Clients may think that after one relapse, the whole recovery plan is ruined, and they might as well give up. Let them know that this does not have to be the case.
  
  
• Clients may learn something from a relapse. Tell them that by looking at the circumstances of the relapse, they may learn situations to avoid, or changes to make in their coping skills.
  
  
• Clients can choose to resume their efforts to live without marijuana after a relapse. Ask the group for ideas about how someone could get back on track. Help the group cover the following suggestions:
  1. Get rid of any leftover marijuana.
  2. Ask for support.
  3. Do other positive things instead of using.
  4. Remind yourself of reasons for wanting to quit.

Individual Practice Exercise: Developing a Personal Emergency Plan. By developing a plan ahead of time, clients will be less likely to be sidetracked by unanticipated emergency situations. Each client is given a blank personal emergency plan worksheet and asked to think about numerous solutions to each of the categories presented on it. Then he or she is to select the one or two he or she thinks may be the best generic plan. Of course, these plans will have to be somewhat general because of the unpredictable nature and circumstances of future emergency situations. Group members begin filling out these sheets in the group, to the extent that there is time available, and they are asked to complete this exercise at home.

Phase 4: Termination. The final 10 minutes of the group are set aside for a discussion of termination of therapy. Group members are asked what it has been like for them to participate in the group. They are given the opportunity to offer feedback to one another and/or to the therapist. Try to keep feedback to peers positive and supportive. Also, ask the clients their goals from this point regarding marijuana. After 10 minutes of termination discussion, the group concludes.

Personal Emergency Plan

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