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

Susan Sampl, Ph.D. 
Ronald Kadden, Ph.D.
University of Connecticut School of Medicine



U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane 

Rockville, MD 20857
www.samhsa.gov
CYT
Cannabis Youth Treatment Series
Volume 11

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All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or
copied without permission from the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Substance Abuse
Treatment (CSAT) or the authors. Citation of the source is appreciated. The material appearing on pages 68 through 76 was adapted from 
copyrighted material and may still be under copyright. The handouts are reproduced herein with the permission of the copyright holders. Before
reprinting, readers are advised to determine copyright status of all such materials or to secure permission of the copyright holders.
The document was written with the support of CSAT through grant numbers TI11317, TI11320, TI11321, TI11323, and TI11324. Jean Donaldson, 
M.A., served as the CSAT Project Officer. This document was edited and prepared for publication by CSAT’s Knowledge Application
Program (KAP) under contract number 270-99-7072 with Johnson, Bassin & Shaw, Inc. (JBS), and The CDM Group. Karl White, Ed.D., served as 
the CSAT KAP Government Project Officer. Lynne McArthur served as the Project Director. Other JBS personnel included Barbara Fink, M.P.H.,
Deputy Director for Product Development; Nancy Hegle, Quality Control Manager; and Tonya Young, Graphic Artist. The opinions expressed 
herein are the views of the authors and do not represent the official position of CSAT, SAMHSA, or any other part of the U.S. Department of 
Health and Human Services (DHHS). 
DHHS Publication No. (SMA) 01–3486
Printed 2001
Cover images © 2000 Digital Stock. 

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Acknowledgments, Disclaimer, aand Contact Information

This document is a product of the Steering Committee for the Cannabis Youth Treatment (CYT) Project Cooperative Agreement that was funded 
by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services (DHHS). The document was prepared with support from CSAT grants for a coordinating center 
awarded to Chestnut Health Systems, Inc. (TI11320); four sites awarded to the University of Connecticut Health Center (TI11324), Operation 
Parental Awareness and Responsibility, Inc. (PAR) (TI11317), Children’s Hospital of Philadelphia (CHOP) (TI11323), and Chestnut Health 
Systems (TI11321) as well as Federal staff time from the CSAT collaborators. The authors would like to acknowledge that this work builds 
directly on earlier manuals done for adults as part of CSAT’s Marijuana Treatment Project (Steinberg, Carroll, Roffman & Kadden, 1997), 
National Institute on Alcohol Abuse and Alcoholism’s (NIAAA) Project MATCH (Kadden, Carroll, Donovan, Cooney, Monti, Abrams, Litt & 
Hester, 1992; Miller, Zweben, DiClemente & Rychtarik, 1992), and an earlier manual for treating alcohol dependence through coping skills 
training (Monti, Abrams, Kadden & Cooney, 1989). They would also like to thank the staff of the CYT studies and the following people for their 
assistance in preparing and implementing this protocol: Michael Dennis, Guy Diamond, Jean Donaldson, Susan Godley, Jim Herrell, Yifrah 
Kaminer, Kerry Anne McGeary, Frank Tims, Janet Titus, and William White. Appreciation is also extended to Joan Unsicker of Chestnut Health 
Systems for the thoughtful review she provided of an earlier draft of the manual. Finally, the authors would like to thank Barbara Fink of 
Johnson, Bassin & Shaw, Inc., who provided valuable assistance in preparing the manual for publication.
     
The opinions expressed in this document are solely those of the authors and do not represent official positions of CSAT or any other 
governmental agency. While studies of a combined motivational enhancement therapy and cognitive behavioral therapy (MET/CBT) approach 
are promising, this treatment protocol was tested with adolescents for the first time as part of this study. The findings from the CYT study will be
made public in 2001. Appendix 5 presents a detailed account of the CYT study.
     
For further information about this manual, please contact the MET/CBT5 work group chair, Dr. Ronald Kadden, at 860–679–4249 
(Kadden@psychiatry.uchc.edu) or Dr. Susan Sampl at 860–679–4715 (Sampl@psychiatry.uchc.edu). For further information about the Cannabis
Youth Treatment Project please visit our Web site (www.chestnut.org/CYT) or contact the Steering Committee Chair, Dr. Michael Dennis, at 
309–827–6026 (Mdennis@chestnut.org).
     
To order copies of this manual or any other manuals in this series, contact the National Clearinghouse for Alcohol and Drug Information 
(NCADI) at 800–729–6686, 800–487–4889 (TDD), (www.health.org). The manuals also will be available to download from 
http://www.samhsa.gov/csat/csat.htm.



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Manuals in the Cannabis Youth Treatment (CYT) Series

Sampl, S., & Kadden, R. Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions, 
Cannabis Youth Treatment (CYT) Series, Volume 1. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health
Services Administration. BKD384

Webb, C., Scudder, M., Kaminer, Y., & Kadden, R. The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7
Sessions of Cognitive Behavioral Therapy for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 2. Rockville, MD: 
Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. BKD385

Hamilton, N. L., Brantley, L. B., Tims, F. M., Angelovich, N., & McDougall, B. Family Support Network for Adolescent Cannabis Users, Cannabis 
Youth Treatment (CYT) Series, Volume 3. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services
Administration. BKD386

Godley, S. H., Meyers, R. J., Smith, J. E., Karvinen, T., Titus, J. C., Godley, M. D., Dent, G., Passetti, L., & Kelberg, P. The Adolescent Community
Reinforcement Approach for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 4. Rockville, MD: Center for 
Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. BKD387

Liddle, H. A. Multidimensional Family Therapy for Adolescent Cannabis Users, Cannabis Youth Treatment (CYT) Series, Volume 5. Rockville, 
MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. BKD388



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Table of Contents

Acknowledgments, Disclaimer, and Contact Information iii
I. Introduction and Background 1
Introduction and Organization 1
Scope and Significance of the Marijuana Problem 1
Effects of Marijuana Use 2
Patterns of Substance Use 3

II. Background on the CYT Cooperative Agreement 5
Goals and Objectives 5
Overview of Study 5
Client and Provider Information 6

III. Background of the MET/CBT5 Treatment 9 
Rationale for Brief Treatment 9
Basis for MET 9
Rationale for CBT Treatment 11
Rationale for Group Therapy 11
Staff Requirements 12

IV. MET/CBT5 Treatment 17
Overview of MET/CBT5 Protocol 17

V. Motivational Enhancement Therapy 19
Key Concepts 19
The Five Strategies of Motivational Enhancement Therapy 21
Abstinence and Relapse 25
Preparation for Individual Sessions 30
Session 1: MET1—Motivation-Building Session 32
Session 2: MET2—Goal-Setting Session 41

VI. Cognitive Behavioral Therapy 53
Key Concepts and Session Guidelines 53 
Session 3: CBT3—Marijuana Refusal Skills 61 
Session 4: CBT4—Enhancing the Social Support Network 
and Increasing Pleasant Activities 68 
Session 5: CBT5—Planning for Emergencies and Coping 
With Relapse 77 



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VII. Common Treatment Issues 83   
Client Issues for Group and Individual Sessions 83   
Issues in Group Sessions 85   
Client Participation Problems in Group CBT 86
Monopolizers in Group CBT 86
Working With the Participant With Cognitive or Perceptual Impairments 89
Inactive Members in Group CBT 89

VIII. References 93   
IX. Appendixes
1.  Therapist Session Reports 99
2.  Supervisor Session Rating Reports 109
3.  Facsimiles of 11- by 17-inch Posters for Sessions 3, 4, and 5 121
4.  Personalized Feedback Reports 127
5.  Clinical Management of a Multisite Field Trial of  Five Outpatient Treatments for Adolescent Substance Abuse    139



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I. Introduction and Background

Introduction and Organization
This manual is designed to help train substance abuse treatment counselors to conduct a brief five-session treatment intervention for 
adolescents with cannabis use disorders presenting for outpatient treatment. It combines two sessions of motivational enhancement therapy
provided individually and three sessions of cognitive behavioral therapy provided in a group format. The program is referred to as MET/CBT5.
Although this will be one of the first applications of these approaches to adolescent treatment, related brief intervention approaches with adults
have proved very effective (Bien, Miller & Tonigan, 1993; Miller et al., 1995; Miller & Rollnick, 1991; Siegal, Rapp, Fisher, Cole & Wagner, 1993; 
Stark & Kane, 1985; Stephens, Roffman & Simpson, 1994; Zweben, Pearlman & Li, 1988). In the CYT study, the approach was also an efficient
 intervention because its personalized feedback report was based on the intake assessments already done as part of the research protocol.
     
The treatment described in this manual was designed to address the problem of marijuana use by adolescents. Section I reviews the scope,
effects, and patterns of the marijuana problem. Section II provides a brief overview of the Cannabis Youth Treatment project for which this 
manual was developed. Section III covers the scientific basis for this intervention. Section IV provides step-by-step procedures for actually
implementing this treatment protocol. 

Scope and Significance of the Marijuana Problem

Although marijuana use has dropped slightly in the past few years, it is still the most widely used and most readily available illicit psychoactive
substance in the United States (Office of Applied Studies, 2000). In 1998, the rate of marijuana use during the month preceding the survey was 
more than twice that of all other drugs combined (8.3 percent vs. 4.0 percent) and higher than the rate of getting drunk (7.7 percent). Moreover, 
the rates of marijuana use for 8th graders are twice as high as the rates in 1992. The rate of daily use of marijuana is higher than the rate of daily 
use of alcohol, and that rate has not gone down (Monitoring the Future, 1999). Furthermore, similar trends in marijuana use are reported in 
regional surveys of junior and senior high school students (Godley et al., 1996; Hartwell et al., 1996; Markwood, McDermiet & Godley, 2000). 
Marijuana use has historically been inversely related to an adolescent’s perceived risk of using it (Johnson, Hoffman & Gerstein, 1996), and 
currently this perception among 12th graders is at the lowest point since 1982 (Monitoring the Future, 1999). Unfortunately, these perceptions 
do not match the facts.   
     
Relative to nonusers, adolescents who used marijuana (and typically alcohol) weekly were 3 to 47 times more likely to have a host of problems
including symptoms of dependence, emergency room admissions, dropping



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out of school, behavioral problems, fighting, non-drug-related legal problems, other legal problems, and being arrested. Unfortunately, fewer
than 1 in 10 adolescents with past-year symptoms of dependence received treatment (Dennis & McGeary, 1999; Dennis, Godley & Titus, 1999). 
From 1992 to 1997, the number of adolescents presenting to publicly funded treatment for marijuana problems increased more than 200 percent; 
in 1997, 81 percent of adolescents admitted had a primary, secondary, or tertiary problem with marijuana (Dennis, Dawud-Noursi & Muck, in 
press; Office of Applied Studies, 1999). Marijuana is also the leading substance mentioned in adolescent emergency room admissions and 
autopsy  reports and is believed to be one of the major contributing factors to violent deaths and accidents among adolescents; it has been 
reported to be involved in as many as 30 percent of adolescent motor vehicle crashes, 20 percent of adolescent homicides, 13 percent of 
adolescent suicides, and 10 percent of other unintentional injuries among adolescents (Centers for Disease Control and Prevention, 1997;  
McKeown, Jackson & Valois, 1997; Office of Applied Studies, 1995).
     
An additional danger associated with marijuana use and observed in adolescents is a sequential pattern of involvement in legal and illegal drugs
(Kandel, 1982). Marijuana is frequently a stepping stone that bridges the gap between cigarette and alcohol use and use of other drugs 
(e.g., cocaine, heroin) (Kandel & Faust, 1975). This stagelike progression of substance abuse, known as the gateway phenomenon, is common 
among youth from all socioeconomic and racial backgrounds (Kandel & Yamaguchi, 1993). This pattern has also been observed in French and 
Israeli cohorts (Adler & Kandel, 1981) and has been confirmed in a longitudinal cohort followed from ages 15 to 35 (Kandel et al., 1992). In sum, 
adolescent marijuana use is intimately linked to future drug involvement. Less serious experimental use portends a decline in later use of all 
drugs, whereas more serious use often snowballs into involvement with increasingly addictive and potent drugs.

Effects of Marijuana Use 

The physical effects of marijuana use include fluctuations in blood pressure, decreased salivation, mild unsteadiness, impaired coordination,
hunger, drowsiness, slowed speech, and respiratory difficulties (Cohen, 1979; Hall, 1995; National Institute on Drug Abuse, August 1986), a
decrease in the immune response, suppression of testosterone production in males (Cohen, 1979), and a decrease in respiratory vital capacity. 
     
The effect of marijuana use during adolescence on central nervous system development remains unclear. Adolescents abstaining after chronic
marijuana use have shown evidence of persistent short-term memory impairment on neuropsychological tests (Millsaps et al., 1994). Pope and
Yurgelun-Todd (1996) have recently demonstrated an indirect association between the frequency of marijuana use among college students and 
cognitive impairment on tests involving card sorting and word learning. These effects are likely to have a significant impact on academic 
functioning. Whether neuropsychological deficits preceded the onset of drug use or were



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the result of long-term exposure to marijuana is unclear. Clinical studies suggest that longer term and/or heavier use of marijuana is directly 
associated with losses of abstract and logical thinking, the ability to focus attention and filter out irrelevant information, and the ability to 
resolve normal emotional conflicts, mental confusion, and memory problems (Lundvqist, 1995; Solowij, 1995; Solowij et al., 1995). These studies 
also suggest that it may take 6 to 12 weeks for even partial recovery of cognitive functioning to occur and that this process is prolonged when 
there is any interim use.
     
A commonly noted effect of chronic marijuana use is amotivational syndrome, characterized by apathy, decreased attention span, poor  
judgment, diminished capacity to carry out long-term plans, social withdrawal, and a preoccupation with acquiring marijuana (Cohen, 1980, 1981;
Schwartz, 1987). Amotivational syndrome is attributed to heavy cannabis use and has been observed in adolescents (Schwartz, 1987). However, 
Musty and Kaback (1995) reported that amotivational symptoms in heavy marijuana users between the ages of 19 and 21 might actually be due 
to co-occurring depression. Whether amotivational syndrome is a primary or a secondary diagnosis in subpopulations of marijuana abusers has 
not yet been resolved. 
     
Marijuana use has also been associated with a wide variety of social-psychological problems. Rob and colleagues (1990) compared adolescent 
marijuana users and nonusers on a number of psychosocial factors. Marijuana use was associated with poorer family relationships, poorer 
school performance, and higher levels of school absenteeism. Other illicit drugs were used almost exclusively by marijuana users, rather than
those who did not use marijuana, and marijuana users were more than three times as likely as nonusers to be sexually active, to drink alcohol
three or more times per week, and to smoke cigarettes. Serious marijuana use is associated with a multitude of behavioral, developmental, and 
family problems (Kleinman et al., 1988), including conduct disorder, crime and delinquency, school failure, unwanted pregnancy, and escalating 
drug involvement (Donovan & Jessor, 1985; Farrell et al., 1992; Hawkins et al., 1992; Jessor & Jessor, 1977). 

Patterns of Substance Use

Anecdotal and longitudinal studies have suggested that the age of onset for regular marijuana use most frequently occurs during early 
adolescence (before age 15) and is almost always completely intertwined with alcohol use (Hops, 1998; Patterson, 1998). Public domain data from
5,143 adolescents surveyed for the Office of Applied Studies (1996) and 1995 National Household Survey on Drug Abuse (NHSDA) show that 
after age 15, daily use stabilizes at a rate of about 2 to 3 percent, weekly use at about 3 to 4 percent, and monthly use at about 6 to 7 percent. 
Parallel data for alcohol use are consistent with the literature and suggest an early pattern of onset. Weekly use increases from less than 1 
percent at age 12, to 3 percent at age 14, to 10 percent at age 18. Daily use increases from 4 percent at age 12, to 7 percent at age 14, to 9 percent 
at age 18. Thus, for 



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both marijuana and alcohol, adolescence is clearly a significant period both for initial use and for increasingly more frequent rates of use.
     
With regard to comorbidity, over two-thirds of the monthly and weekly marijuana users are drinking alcohol—with a third drinking it daily or 
weekly. Among the daily marijuana users, 27 percent were drinking weekly and 35 percent were drinking daily. Thus, marijuana and alcohol use 
is starting at similar times, and patterns of their use are largely intertwined.



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II. Background on the CYT Cooperative Agreement

MET/CBT5 was developed as a brief intervention to be tested at four treatment sites within the Cannabis Youth Treatment study. Section III of
this manual describes the rationale for choosing the elements of the MET/CBT5 therapy. The following description illustrates the context in
which MET/CBT5 was developed.

Goals and Objectives
The purpose of the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT)
Cannabis Youth Treatment Cooperative Agreement was to test the relative effectiveness and cost-effectiveness of a variety of interventions 
targeted at reducing/eliminating marijuana use and associated problems in adolescents and to provide validated models of these interventions 
to the treatment field. The target population was adolescents with cannabis use disorders of abuse or dependence, as defined by the American 
Psychiatric Association (1994), who were assessed as appropriate for treatment in outpatient settings.



Overview of Study 
The study was conducted in collaboration with staff from Chestnut Health Systems (CHS–MC) in Bloomington and Madison County, Illinois,
the University of Connecticut Health Center (UCHC) in Farmington, Connecticut, Operation Parental Awareness and Responsibility (PAR) in St.
Petersburg, Florida, and the Children’s Hospital of Philadelphia (CHOP), Pennsylvania. It involved five manual-based, expert-supported 
treatment conditions:
•  MET/CBT5—This is the five-session treatment described in this manual. It comprises two individual sessions of motivational enhancement 
   therapy (MET) and three group sessions of cognitive behavioral therapy (CBT). The MET sessions focus on  factors that motivate clients to 
   change. In the CBT sessions, clients learn skills to cope with problems and meet their needs in ways that do not involve turning to marijuana 
   or alcohol.
•  MET/CBT5+CBT7—This treatment is composed of the complete MET/CBT5 treatment combined with seven supplemental cognitive 
   behavioral sessions covering additional coping skills topics. 
•  FSN—The Family Support Network (FSN) treatment consists of the MET5+CBT7 treatment combined with additional support for families
   (home visits, parent education meetings, parent support group), aftercare, and case management.
•  ACRA—The Adolescent Community Reinforcement Approach (ACRA) is composed of 12 individual sessions with an adolescent 


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and the adolescent’s parent, caregiver, or concerned other. The focus is on learning alternative skills to cope with problems and meet needs with 
an emphasis on the adolescent’s environment. Concerted effort is made to change the environmental contingencies—both positive and 
negative—related to substance use.

•  MDFT—Multidimensional Family Therapy (MDFT) is a family-focused treatment that includes 12 weekly sessions to work individually with 
adolescents and their families. MDFT focuses on family roles, other problem areas, and their interactions.
     
These treatments can also be grouped in three different ways. First, they vary by mode, with the first three being combinations of individual and
group approaches and the last two being purely individual treatment approaches. Second, the MET/CBT and ACRA interventions were based 
on behavioral treatment approaches, while the FSN and MDFT interventions were based on family treatment approaches. Third, the treatment \
conditions were expected to vary in terms of resource intensity and cost, with the MET/CBT5 intervention expected to be the least costly 
therapy to implement.
     
At each site, approximately 150 adolescents were systematically assigned to one of three conditions. At ARC and PAR, they were assigned to
the brief MET/CBT5 or to one of the two other individual/group combinations, MET/CBT5+CBT7 or FSN. At CHS–MC and CHOP, 
adolescents were assigned to the brief MET/CBT5 treatment or one of the two individual approaches, ACRA or MDFT. Thus, all five conditions 
were replicated in two or more sites, with the MET/CBT5 condition implemented at all four sites. All clients were assessed at intake and at 3, 6, 
and 9 months. To validate clients’ responses, urine tests and collateral assessments are also done at intake and at 3 and 6 months.
     
The general research design document prepared by Dennis and colleagues describes the overall research plan in greater detail (Dennis, Titus, 
Diamond, Donaldson, Godley, Tims, Webb, Kaminer, Babor, French, Godley, Hamilton, Liddle & Scott, under review). The project’s Web site
(www.chestnut.org/CYT) can be accessed for further information about the CYT project.

Client and Provider Information
Target Population
     
MET/CBT5 is designed for the treatment of adolescents between the ages of 12 and 18 with problems related to marijuana use, as indicated by
one of the following: 
•  Meeting criteria for cannabis abuse or dependence 
•  Experiencing problems (including emotional, physical, legal, social, or academic problems) associated with marijuana use
•  Using marijuana at least weekly for 3 months.


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Although this treatment includes suggestions for addressing both drug and alcohol use, it is not designed for treating adolescents with poly-
substance dependence or those who are heavily using other substances as well as marijuana. In the CYT study, adolescents were excluded from 
the study who drank alcohol on 45 or more of the previous 90 days or who used another drug on 13 or more of the previous 90 days. MET/CBT5 
should not be used to treat adolescents
•  Requiring a level of care that is higher than outpatient treatment
•  With a social anxiety disorder severe enough to prevent participation in group therapy sessions
•  With a severe conduct disorder
•  With an acute psychological disorder severe enough to prevent full participation in treatment.
     
In the CYT study, this treatment was effectively implemented with adolescents with mixed demographic characteristics such as race, age,
socioeconomic group, and gender, as well as from different geographic regions. When treating clients, therapists need to be culturally aware of 
and sensitive to the client group so they can provide relevant examples and use language that is understood by the clients in the therapy 
session.
     
Likely referral sources of potential MET/CBT5 clients are parents, the justice system, school personnel, and medical or mental health care
providers. Self-referral is infrequent.
Level of Care
     
MET/CBT5 is appropriate for use as either an outpatient treatment (ASAM level 1) or early intervention (ASAM level 0.5).  
    
MET/CBT5 can be used by organizations that provide outpatient care, including mental health clinics, youth social service agencies, and mental
health private practice settings. Other organizations such as community centers, schools, or general medical settings may appropriately
implement MET/CBT5 if they have properly trained staff. Medical settings may be particularly well suited for implementation of MET/CBT5 as 
an early intervention.



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III. Background of the MET/CBT5 Treatment

The MET/CBT5 approach was designed to be an effective brief treatment approach for cannabis-abusing adolescents. The course of 
treatment consists of two individual motivational enhancement therapy (MET) sessions, followed by participation in three group cognitive
behavioral therapy (CBT) sessions. The reasons for choosing a brief treatment model, as well as the background for the MET and CBT 
treatment models, are described in this section.

Rationale for Brief Treatment

Stephens and Roffman (1996) compared an 18-session relapse prevention support group approach for the treatment of marijuana 
problems with a 2-session individualized assessment and intervention approach. The latter included a feedback report based on data collected in
pretreatment assessments, discussion of the client’s marijuana use and related problems using motivational interviewing principles, and 
development of a plan for change. The results of the study indicated substantial reductions in marijuana use for both active treatments and no
evidence of posttreatment differences between the two approaches in terms of abstinence rates, days of marijuana use, severity of problems, or 
number of dependence symptoms. Although conclusions regarding null differences must be limited, the large sample sizes and the substantial 
differences in intensity of the treatments argue for an equivalent efficacy of the two conditions. The results suggest that a minimal intervention 
approach may be more cost-effective for a marijuana-abusing population than an extended group counseling approach. That study, along with 
others indicating the general effectiveness of brief interventions for some psychiatric disorders and substance abusers, was an important factor 
in the decision to test relatively brief interventions in large samples of adults (the companion study to this one) and adolescents (this study) 
at diverse locations nationally.



Basis for MET

In the addictions field, the search for critical conditions that are necessary and sufficient to induce change has led to the identification of six
critical elements (Miller & Rollnick, 1991):
•  Feedback regarding personal risk or impairment
•  Emphasis on personal responsibility for change
•  Clear advice to change
•  A menu of alternative change options
•  Therapist empathy
•  Facilitation of client self-efficacy or optimism.
     
Therapeutic interventions containing some or all of these elements have been effective in initiating change and reducing alcohol use (Bien,
Miller & Tonigan, 1993). 



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The MET approach is further grounded in research on processes of change. Prochaska and DiClemente (1984) describe five stages of change
that people progress through in modifying problem behaviors (the stages of precontemplation, contemplation, determination, action, and 
maintenance). The MET approach assists clients in moving through the stages toward action and maintenance.
    
In sum, MET is based on motivational principles and has been utilized increasingly in clinical interventions and research, primarily in the
alcoholism field. Recently it has also been included as a component in the study that is a companion to the present one—evaluating brief 
treatments for adult marijuana abusers. 
     
The MET sessions included in MET/CBT5 are planned as individual therapy sessions for a number of reasons. First, motivational enhancement
therapy is designed to be an individual approach in which the therapist works with each client regarding that client’s own specific reasons for 
considering change. Most previous effective demonstrations of motivational enhancement therapy have utilized an individual therapy format
(Miller et al., 1995; Steinberg et al., 1997; Stephens & Roffman, 1996). This individual approach in MET/CBT5 is reflected in the use of a 
personalized feedback report, which stimulates discussion of that client’s personal concerns and motivations regarding his or her substance use. 
An individual session is most conducive to a personal discussion. In addition, individual MET sessions are preferable because clients may feel 
embarrassed about aspects of their substance abuse and related problems; initially they may feel more comfortable discussing these problems 
individually. Finally, adolescent clients sometimes feel apprehensive about verbalizing their motivation to quit marijuana in front of their peers, 
for fear that their peers will think that they are not cool. They may have a better chance of contemplating their ambivalence about quitting—and 
firming up their motivation to address their marijuana use—by working with the therapist privately at first.
     
This MET/CBT5 therapy is an adaptation of adult treatment to adolescents. The unique developmental tasks of adolescence play a role in 
substance use disorders and their treatment. Nowinski’s 1990 book, Substance Abuse in Adolescents and Young Adults: A Guide to Treatment,
provides a useful discussion of substance abuse in relation to adolescent development that may help inform therapists using MET/CBT5. 
Nowinski discusses the primary adolescent developmental task of individuation, in which adolescents develop identities separate from their 
parents or caregivers. As a part of this individuation process, adolescents are especially likely to question what adults tell them. Using MET 
style minimizes the likelihood of provoking resistance, which might occur in a highly directive or confrontational therapeutic approach. As a 
result, the MET approach seems particularly promising for adolescent marijuana abusers. In MET the therapist works with the client’s own 
marijuana use goal, helping to evaluate the benefits and disadvantages of abstinence versus continued use. This process supports the 
development of self-control, another key developmental task of adolescence (Nowinski, 1990).



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The therapists in MET/CBT5 encourage adolescents to try an extended period of abstinence from marijuana to evaluate potential impacts on 
their lives. In keeping with the MET style though, there is a tolerance for the adolescent’s ambivalence about change. The therapist does not try 
to force abstinence, but helps the client to understand the risks associated with continued use. It is possible that this aspect of MET may be 
problematic for others in the adolescent’s life who may take issue with the therapist not insisting on absolute abstinence. As a matter of fact, 
many adolescents referred to the treatment may have already been told by other authority figures that they need to abstain from marijuana, with 
little or no impact on their behavior. It may be that if the therapist were to echo this unilateral message, it too would have little therapeutic impact. 
It may be useful to educate those in supportive roles around the adolescent client about this aspect of MET to decrease the likelihood that they 
will react negatively and undermine the therapist’s credibility.

Rationale for CBT Treatment

Cognitive behavioral therapy (CBT) is designed to remediate deficits in skills for coping with antecedents to marijuana use. Individuals who rely
primarily on marijuana (or other substances) to cope have little choice but to resort to substance use when the need to cope arises. The goal of 
this intervention is to provide some basic alternative skills to cope with situations that might otherwise lead to substance use. Skill deficits are 
viewed as central to the relapse process; therefore, the major focus of the CBT groups will be on the development and rehearsal of skills.
     
The cognitive-behavioral treatment approach used in this intervention is based on that described in Treating Alcohol Dependence: A Coping 
Skills Training Guide (Monti, Abrams, Kadden & Cooney, 1989), a treatment manual that focuses on training in interpersonal and self-
management skills. It incorporates treatment elements that have demonstrated clinical effectiveness with alcoholic clients into a manual of
interventions aimed at adolescents that can be reliably delivered, monitored, and evaluated.
     
The focus of CBT treatment is on teaching and practicing overt behaviors, while attempting to keep cognitive demands on clients to a 
minimum. Repetition is essential to the learning process in order to develop proficiency and to ensure that newly acquired behaviors will be 
available when needed. Therefore, behavioral rehearsal will be emphasized, using varied, realistic case examples to enhance generalization to real 
life settings. During the rehearsal periods, clients are asked to identify cues that signal high-risk situations, indicating their recognition of when 
to employ newly learned coping skills.

Rationale for Group Therapy 

Many of the problems or skill deficits associated with substance abuse are interpersonal in nature, and the context of a group provides a
realistic yet “safe” setting for the acquisition or refinement of new skills. A



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number of features associated with group approaches to treatment may facilitate cognitive, affective, and behavioral changes. These factors 
include the realization that others share similar problems; development of social behaviors; opportunity to try out new behaviors in a safe 
environment; and development and enhancement of interpersonal learning and trust. Group therapy breaks through clients’ isolation, 
encouraging development of interdependence and identification with other marijuana users, while at the same time avoiding overdependence on 
the therapist. It also provides the therapist with an opportunity to observe the interpersonal behavior of each group member. 
     
With respect to social skills training, important aspects of the treatment, particularly modeling, rehearsal, and feedback, probably occur more 
powerfully in a group setting. A client model whose skill level is only somewhat greater than that of a peer observer is likely to have more impact
than a skilled therapist is. 
     
A group-therapy format also provides opportunities for behavioral rehearsal and risk taking. Clients benefit from feedback offered by their peers, 
from discussions of anticipated obstacles to implementation of new skills, and from the case examples provided by fellow clients. There is also
the possibility for greater habituation of social anxiety in a group setting.
     
Group therapy is the most widely used form of treatment delivery for substance abuse rehabilitation. It has a high level of clinical relevance and
can be utilized across a variety of treatment settings (e.g., inpatient, outpatient, day programs). Therefore, the results of any study using group
therapy are likely to have an impact on current practice. Group therapy is also likely to have a bright future in these increasingly cost-conscious 
times because of its favorable client-to-staff ratio.
     
Group therapy can be a particularly powerful modality for teen clients given the importance of peer influence in adolescence (Nowinski, 1990). 
Feedback from a peer is likely to have greater impact on adolescent clients than similar feedback from the therapist. In the group CBT sessions,
therapists encourage adolescent participants to offer other group members positive and constructive feedback. At the same time, adolescent 
clients are equally susceptible to the negative influence of peers. As a result, it is especially important that the therapist monitor and address 
any antisocial comments and behaviors that occur in group sessions.



Staff Requirements
     
Below are the recommended credentials and prior experience requirements for therapists delivering MET/CBT5:
•  Therapists should have completed a graduate program for providing clinical mental health services (e.g., M.S.W., Psych.D.,  Ph.D. in 
    psychology) or an addiction counseling certification program. Some individuals who have completed a bachelor’s degree in an area related to 
    mental health can become effective 



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providers of MET/CBT5. However, it is likely that they will require more intensive training and supervision to achieve competency. The more 
experience bachelor’s level therapists have had in the areas listed below, the more likely they will become effective MET/CBT5 therapists.
•  Therapists should have a minimum of 1 year’s clinical experience working with adolescents.
•  Therapist experience in the following areas is also desirable:

	•  Working with substance abuse issues
	•  Providing behavioral and/or cognitive behavior interventions
	•  Providing manual-based therapy.
     
Therapists with experience in these areas are likely to learn the MET/CBT5 intervention most quickly.
     
The following recommended caseloads are considered ideal for implementing MET/CBT5 in a clinical setting. One full group of six participants is 
likely to require approximately one-quarter of a full-time staff person’s time (approximately 10 hours per week). For a full-time person who is only 
seeing MET/CBT5 participants, it is recommended that the caseload be limited to 3 full groups (or 18 participants) rather than 4 full groups, 
because of the demands involved in keeping track of 18 adolescents’ progress and in managing such a caseload. The groups should start on a 
staggered basis, rather than simultaneously. This way, the initial, heavy demand on clinicians’ time to see each participant for two individual 
sessions will be spread out.

Staffing Recommendations
     
In the first 2 weeks of the treatment, the therapist sees each participant for two individual therapy sessions. Over the following 3 weeks, the
therapist conducts one group therapy session per week. Additional clinician time may be needed to handle emergencies that may occur, to 
address pragmatic issues such as scheduling and communication, or to make referrals.
     
Additional staff is needed to conduct and score the initial assessments and prepare the personalized feedback reports. During a group therapy 
session, another staff person should be available in reasonable proximity to the group therapy room. This staff person (who may be doing other 
work) could assist in dealing with emergencies or supervising a client who has been asked to leave a group session because he or she is under 
the influence of drugs or exhibiting disruptive behavior.

Training and Certification Procedures

Therapists should receive 1½ to 2 full days of initial live training in MET/CBT5, with the amount of time needed depending on therapist and


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project/agency characteristics. Longer training is indicated for less-experienced trainees and/or when therapists will need orientation to the 
context in which the therapy will be implemented. Also, longer training is indicated when therapists require some extensive training in cultural 
competence. In the CYT study, the therapists participated in 2 full days of training. The first half-day was an orientation to the CYT project and 
some common clinical issues applicable to all CYT therapies. The second half of day 1 and all of day 2 focused on teaching MET/CBT5.
     
The training should be provided by a graduate-level clinician (or a team of clinicians) experienced (minimum of 2 years) in providing, supervising, 
and training motivational enhancement and cognitive behavioral therapy for substance abusers. The trainer should also have at least 2 years of 
clinical experience with adolescents. The trainer should have extensive knowledge of the treatment manual contents. The training should include 
a variety of formats including the following:
•  Instruction of rationale and procedures
•  Observation of live and/or videotaped examples
•  Active practice exercises with feedback.

By varying the formats and by including engaging visual aids, the trainer will be more likely to keep participants actively involved. To increase 
engagement and clarity, the trainer should welcome and encourage participants’ questions and comments.
    
If MET/CBT5 therapy is to be used in a multisite clinical research project, or in a multisite agency where the intent is consistent delivery and
enhanced cohesiveness, it is recommended that the initial training be centralized to one common site and session. This way the therapists at 
each site will have a common foundation from which to work. During the centralized training, they will have a chance to hear the comments and 
questions of therapists at other sites and thus will be exposed to a wider range of issues that may come up in applying the intervention. Another 
likely benefit of centralized training is the potential for it to generate cohesiveness and enthusiasm, whereby participating therapists get the 
feeling of being a part of the big picture. The trainer can help with this by making enthusiastic comments about being included among therapists 
who will implement this new therapy, as well as by encouraging participants to interact with those from other sites during practice exercises 
and breaks.

Supervision and Monitoring Procedures

The person providing the ongoing supervision may have participated as a trainer in the initial training of therapists; however, this in not 
necessary. It is crucial, however, that the clinical supervisor attends the training. The clinical supervisor should have at least 2 years’ experience 
in delivering and supervising motivational enhancement and cognitive behavioral therapies for substance abusers and in treating adolescents. 
Experience in supervising manual-based therapies is desirable. If the supervisor has not had experience supervising manual-based therapies, it is 
recommended that he or she be provided with some related consultation and instruction.



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The therapists should receive 1 hour of supervision each week. Prior to certification, this supervision should be on an individual basis. All 
therapy sessions should be audiotaped or videotaped (with the consent of the adolescent participant and his or her parent/legal guardian). All 
therapists will need to demonstrate their competence in delivering MET/CBT5. Prior to certification, the supervisor should review every session
conducted by the therapist in training and rate each session using the supervisor session rating report (see appendix 2). The supervisor 
provides feedback regarding the therapist’s performance on the skills reviewed in each session, reinforcing his or her relative strengths and 
identifying skills needing improvement. For those skills needing improvement, the supervisor should provide specific examples, present the 
rationale for changing technique, and help the therapist generate alternative responses. The therapist is considered certified in providing 
MET/CBT5 when he or she demonstrates an “adequate” or higher skill level on each of the skills. It is helpful if the supervisor and therapist 
review portions of the taped sessions, allowing them to discuss the therapist’s skills as they hear them together. The therapist also completes 
a therapist session rating report at the end of each session. The supervisor then reviews the reports and notes any meaningful differences 
between the therapist’s and the supervisor’s interpretation of the session. Any differences should be discussed. This will help the therapist 
with his or her understanding of MET and CBT skills and can improve self-monitoring. 



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IV. MET/CBT5 Treatment Overview of MET/CBT5 Protocol

The MET/CBT5 treatment, a brief treatment approach for adolescents with cannabis use disorders, consists of two individual motivational 
enhancement therapy (MET) sessions, followed by three group cognitive behavioral therapy (CBT) sessions. The two initial individual MET
sessions are primarily intended to enhance adolescents’ motivation to address their marijuana use and to prepare the clients for the group 
sessions, with an introduction to functional analysis and the concept of  triggers. The purpose of the three group sessions is to assist clients in 
the development of skills useful for stopping or reducing marijuana use. The CBT sessions focus on the following skills:
•  Learning basic skills for refusing offers of marijuana
•  Developing a plan for pleasant drug-free activities
•  Establishing a social network that will support recovery
•  Coping with high-risk situations
•  Recovering from a relapse, should one occur.
     
The table below illustrates the sequence of the five sessions of the MET/CBT5 treatment. Note that the first two (individual) sessions are
expected to last for 60 minutes. The final three (group) sessions are scheduled to run for 75 minutes.

Sequence of MET/CBT5 Treatment

While the first two sessions proceed primarily from a motivational enhancement therapy plan, and the remaining three sessions focus primarily 
on cognitive-behavioral interventions, it is expected that there will be some overlap of each of these approaches in all five sessions. For 
example, it is expected that therapists will make effective use of MET interventions, to some extent, across all five treatment sessions. 
Session   	Modality    	Time    	Primary   	Topics 				Period Approach
Session 1  	Individual  	60 min.    MET        	Rapport and motivation building	Review of personalized feedback report
Session 2  	Individual   	60 min.    MET        	Goal setting 			Introduction to functional analysis
                            										Preparation for group sessions
Session 3    	Group      	75 min.    CBT         	Marijuana refusal skills, with roleplay practice exercises
Session 4    	Group      	75 min.    CBT         	Enhancing social support network 	Increasing pleasant activities
Session 5   	Group      	75 min.    CBT         	Coping with unanticipated high-risk situations and relapses 



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The establishment of rapport between the therapist and the adolescent clients is essential. The therapist facilitates this rapport by expressing a 
genuine interest in and nonjudgmental reactions to the adolescents’ viewpoints. Therapists are encouraged to use language both familiar and 
similar to that of the clients. In general, it is recommended that therapists work in accordance with the MET approach across all five treatment 
sessions, including the three CBT-focused group sessions. The MET approach will be described in detail in the next section.
     
Therapists are encouraged to draw from their MET skills throughout all five sessions for two important reasons. First, many clients will remain
ambivalent about abstinence from marijuana beyond the two planned MET sessions. If the therapist continues to utilize motivation-enhancing 
reflections and comments, clients will have a greater likelihood of  developing motivation to quit smoking marijuana. Second, the MET style of
intervention is recommended because it helps avoid the potential authoritarian power struggle of an adult therapist telling adolescent clients 
what they “must” do. Utilization of the MET style of intervention maximizes the chance for a collaborative therapist-client dialog. 



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V. Motivational Enhancement Therapy

Motivational enhancement therapy is a therapeutic approach based on the premise that clients will best be able to achieve change when 
motivation comes from within themselves, rather than being imposed by the therapist. Motivational interviewing, the primary element of MET, 
was developed by William R. Miller and Stephen Rollnick (1991). It is a transtheoretical model derived from a number of sources, including 
stages of change theory (Prochaska & DiClemente, 1984), client-centered approaches, and research into what clinician behaviors are associated 
with the best client outcomes.



Key Concepts

Understanding the following key concepts will assist the clinician in learning and utilizing motivational enhancement therapy. 

Ambivalence

Ambivalence refers to the client’s mixed feelings about change. For example, the client feels that quitting marijuana is in part a good idea and
at the same time, does not want to quit smoking it. MET assumes that ambivalence about change is normal and expected. Changing a 
problematic behavior can be difficult and anxiety provoking, and it often involves giving up activities and/or relationships that have been 
enjoyable. So even when people see possible benefits to stopping a negative behavior like substance abuse, they generally feel that they do in 
part want to change and do not in part want to change. In working with ambivalence, the therapist’s task is to help clients acknowledge and 
discuss these mixed feelings in a way that helps tip the balance in favor of change.

Reflective Listening

Reflective listening refers to all the statements that the therapist makes to clients that express the therapist’s understanding of what the client is 
saying. Reflections can be simple restatements of what the client has said, or they can reflect the meaning or feeling implied by the words. The 
following example shows how the therapist can respond to the client with any of these types of reflection: Client: “My parents are always on my 
case about getting high. They search my room for my supply, they listen in on my phone calls, and they sometimes even follow me when I 
go out.” Here are possible therapist responses: Using simple reflection (saying what the client has said, but in different words): “They bug you 
about smoking marijuana, and they spy on you about it.” 

or



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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.

Open-Ended Questions  						Closed-Ended Questions 
Tell me about your early experiences with marijuana.      		How old were you when you first smoked marijuana?
How have your friends reacted to your coming to treatment?      	Do you have any friends that don’t get high? How many?
What led to you coming to treatment?      				Did someone force you to come to treatment?



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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 therapist’s role is a blend of supportive listener and knowledgeable 
consultant. Much of MET is listening rather than telling.
     
Empathic listening and accurate reflection are crucial to facilitating change. If adolescent clients feel that they are truly understood and accepted 
by the therapist, they will be increasingly open to viewing the therapist as a valid consultant to their personal change process. 
     
The MET therapist expresses empathy regarding the client’s ambivalence about the possibility of stopping marijuana use. The therapist
is encouraged to accurately reflect the client’s mixed feelings about 



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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 


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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 



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helps them get more information to decide for themselves whether smoking pot is a problem for them or not.
     
In the example above, if the therapist had responded with a lecture along the lines of “Smoking pot has already gotten you into trouble with
the law, so it surely is a problem for you. . .,” the client would likely have become more resistant. When clients are genuinely assured that the 
decisions about change are up to them, they often become more open to looking at the issue with an open mind.
     
In assuring clients that the decision is up to them, the therapist need not pretend to ignore contingencies in the environment (e.g., legal
implications or parental limits) that make the decision seemingly less optional. Still, the therapist conveys the message to the client that it is the
client who decides how these potential consequences will or will not impact on his or her marijuana use. 
     
Sometimes therapists think of resistance as meaning that the client is not cooperating with the treatment. In the MET approach, however,
client resistance is seen as a cue that there may be a problem with the therapist’s behavior, and so the therapist should try shifting strategies.
Similarly, if therapists find themselves in the position of arguing with clients to get them to acknowledge and change, something has gone 
wrong in the session. It is time to stop and listen to the client.

MET Strategy 5: Support Self-Efficacy
     
This MET strategy refers to helping develop and support the client’s belief that he/she can change. This is important because people who 
believe that they have a serious problem are still unlikely to move toward change unless there is hope for success. Even if the adolescent client 
acknowledges that marijuana is a problem, he or she may be disinclined to quit or reduce marijuana use without the belief that he or she can be 
successful in making that change. The therapist’s role is to help clients develop and/or strengthen the sense of self-efficacy—that they can, in 
fact, stop or reduce their marijuana use. 
     
In order to support self-efficacy, the therapist may ask clients about previous successful experiences they have had in the following areas:
•  Previous periods of abstinence from or reduced use of marijuana
•  Earlier success in quitting or reducing use of other drugs or alcohol
•  Past accomplishment in gaining control over another problematic habit
•  Attainment of previous goals that was facilitated once they set their minds to it.
     
Some clients may not make the connection between these previous accomplishments and the likelihood that they will be successful in meeting 



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their goal regarding marijuana use. They are likely to benefit from the therapist’s help in pointing out this relationship. For example:

So you’re telling me that you were able to stop the bingeing and purging. That’s great. Since you were able to stop that problem, which many 
people find a hard habit to break, you may be equally successful in breaking the marijuana habit.

Abstinence and Relapse
The Goal of Abstinence

At the same time therapists are maintaining a nonjudgmental approach regarding clients’ marijuana use and their current state of readiness for 
change, MET/CBT5 therapists are encouraged to support the primary goal of this treatment—abstinence from marijuana use. Therapists should 
be prepared to encourage clients to try abstinence or to work toward abstinence.
     
Adolescent clients generally vary in their motivation or readiness to stop marijuana use completely, and therapists should be prepared to work
with clients’ varying degrees of commitment as they move through the processes of change. MET can be a useful therapeutic approach with 
clients at various stages of motivation and readiness for change. With less motivated clients, the primary therapeutic tasks are helping them 
recognize possible negative consequences of use and identifying and working through ambivalence. With highly motivated clients, the 
therapist’s focus should be on helping them to verbalize, and thus strengthen, their own motivation for change. The therapist should ask about 
potential feelings of ambivalence, which if left unaddressed could undermine clients’ success.
     
The therapist should encourage the adolescent to stop other substance use in addition to abstaining from marijuana. The elimination of other 
drug and alcohol use is considered necessary to maximize clients’ ability to learn about themselves while substance-free and to prevent the
substitution of other substance use for marijuana. With adolescent clients this position of discouraging other drug and alcohol use also makes 
the most sense from an ethical standpoint. As described in the introduction to this document, there is also a high rate of alcohol use among 
adolescent marijuana users. Therapists need to be prepared to address clients’ alcohol use in addition to their marijuana use, in order to 
maximize the chance that the treatment will result in more adaptive functioning by clients. Finally, by attending to issues regarding all drugs 
and alcohol, not just marijuana, therapists may intervene regarding the gateway phenomenon described in section I. Specifically, they will 
attempt to decrease the chance that the client’s marijuana use leads to the use of other drugs. 
     
Given that some clients may be less than enthusiastic about abstaining from drugs and alcohol, therapists should present this idea in a



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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.



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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 
circumstances and context of their drug use. This provides an opportunity to identify triggers and enhance coping. Inquire about potential 
external factors (persons, places, things) and internal factors (emotional distress, cravings) associated with recent use. Encourage both clients 
who used substances, as well as other group members, to think of other ways to cope with the identified trigger situations. Some group members 
who received positive urine results may indicate that they are not motivated to reduce or stop substance use and may indicate little motivation 
to learn alternative coping strategies. In such cases, respond using an MET style. For example, the therapist may make a brief empathic 
statement summarizing some aspects of that client’s viewpoint:



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It sounds as if you’re saying that you’re not disappointed that your test was positive for marijuana because, so far, you are not trying to stop 
smoking it. You have said that even though marijuana has caused some problems for you at your school, you enjoy getting high and you do not 
want to stop smoking at this time. If you decide to try to quit sometime in the future, hopefully you’ll have gotten some helpful information from 
this group about how to do it.
     
The main point is that the therapist does not have to fight the client to become motivated or try to make the client feel badly that his or her
urine tested positive.
     
Sometimes the client may deny recent use when the test results are positive. Therapists are advised to discuss such discrepancies in a 
collaborative manner, rather than through confrontation. The amount of time that it takes for a person’s body to become free of 
tetrahydrocannabinol (THC), the active ingredient of cannabis that is assessed in the drug screen, varies. As a result, a positive drug screen 
does not allow the clinician to draw a clear conclusion about whether a client has used marijuana recently. When a client disagrees with a 
positive drug screen result, the therapist may tell the client that there can be a few different reasons for the discrepancy and that it may never 
be entirely clear which applies in this case. Tell the group that the following explanations have applied to other clients and seem possible in 
their case:
•  The positive result may simply mean that previously reported use has still left physical traces that are showing up on the test. Emphasize that 
   if clients continue to abstain from marijuana and other drugs, their drug test results will eventually be negative. Obviously this explanation is 
   less likely to be plausible when a client reports 
   many weeks of abstinence from marijuana (i.e., more than 4 to 6 weeks).
•  For a number of reasons, clients may not believe that it is safe for them to be honest about recent use. Consider asking group members 
   whethe 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 


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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.



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The Safety Net
     
Because MET/CBT5 is a brief treatment involving the adolescent client individually, without ongoing family participation, procedures have
been incorporated to monitor the client’s progress or deterioration. This safety net is designed to capture clients for whom this treatment may be
insufficient. At the start of treatment clients’ parents or guardians are given a list of signs of clinical deterioration (a problematic decrease in 
various aspects of the client’s functioning). They are made aware that, if the adolescent begins to show these signs, they should contact the 
therapist for assistance. In addition, the therapist should monitor each client’s functioning for signs of clinical deterioration, including acute 
psychological disorder, markedly increased use of marijuana, and/or increased polysubstance use. If either the client’s parent/guardian or the 
therapist notices signs of deterioration, the therapist should review this information with his or her clinical supervisor to determine what course 
of action should be taken.
     
Sometimes the client may benefit from continuing in the MET/CBT5 treatment with the addition of another intervention. Here are some general
guidelines for planning a course of action. The therapist and supervisor should take the entire clinical picture into account in making a decision
about a particular client. If only mild difficulties are observed, it may be appropriate simply to bring this information into the ongoing therapy 
and to actively monitor the client’s progress. Some of these difficulties may decrease as the client makes progress in the MET/CBT5 therapy. 
When the client evidences symptoms of a possible comorbid psychiatric disorder of mild to moderate severity, a referral for psychiatric 
evaluation and possible treatment concurrent with MET/CBT5 treatment may be the most appropriate course. Finally, in the case of more severe 
deterioration involving a possible severe psychiatric disorder or a marked escalation of substance use, clients will likely require a transfer from 
MET/CBT5 to a higher level of care (e.g., inpatient, day treatment, residential, or intensive outpatient care).

Preparation for Individual Sessions
     
Prior to the first contact with a therapist, each client is seen for an initial assessment. In that meeting, the client provides background 
information regarding his or her life situation and marijuana problems. Data from this meeting are used to prepare a psychosocial report and the
personalized feedback report (PFR), which is used in session 1. All the data that are needed for preparing the PFR can be obtained by completing 
the Global Appraisal of Individual Needs (GAIN) developed by Michael Dennis (1999). Appendix 4 shows the directions for using information 
from GAIN to compile the PFR. Please note that the PFR shown in the text consists of all possible items, but only a subset of those items are 
expected to have been endorsed by each client. Essentially, GAIN is used to determine which PFR items were endorsed by the client, and only 
those items are placed on that client’s PFR. Two identical copies of the PFR are needed for session 1.
     
Here are some tips that may be useful in creating PFRs. PFR preparation can be made more efficient by creating a word processing file


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including the full PFR and then simply deleting the items that do not apply when each PFR is created. In addition, there are ways to save time in
obtaining the necessary GAIN data. Some treatment settings may not have the time or resources to administer the full GAIN. When this is the 
case, a subset of the GAIN items may be prepared and administered, including all those necessary for preparing the PFR, as well as any others 
that are of particular clinical interest. An additional option is to obtain GAIN responses by using a self-report format, rather than through the 
GAIN interview format. Such a self-report format would need to be developed at the treatment site. If a self-report format is implemented, clients 
with limited reading and writing skills will need assistance.
     
Soon after the assessment interview is conducted and a therapist is assigned, the first session should be scheduled. Prior to the session, the
therapist should review the psychosocial report and PFR. Reminder calls should be made to the client prior to each of the therapy sessions to 
confirm the appointment and increase the likelihood of attendance.

Overview of Two Initial (MET) Sessions
     
As described earlier, the first two therapy sessions are individual  sessions focusing primarily on motivational enhancement. As described
below, the first session is designed to allow the therapist to get to know the client and his or her unique situation, as well as to allow the client to 
begin learning what he or she can expect from treatment. Another task of the first session is to provide the client with individual feedback about 
his or her marijuana problem, accompanied by interventions aimed at increasing motivation for change.
     
The second session, to be scheduled approximately 1 week after the first, continues the process of developing motivation for change. 
Specifically, progress since the first session is reviewed, and an overall goal for treatment is developed in a collaborative process involving 
therapist and client. The final parts of this session prepare the client for the remainder of treatment: (1) the introduction of the key concept of 
functional analysis and (2) orientation to the group sessions. 



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Session 1: MET1—Motivation-Building Session

Key Points:
•  Build rapport with the client.
•  Familiarize the client with what he or she can expect from treatment.
•  Begin the process of assessing and building the client’s motivation to address his or her marijuana problem.
•  Review the personal feedback report with the client.

Delivery Method: MET-focused individual therapy

Session Phases and Times:
1. Rapport-building and orientation to treatment (20 minutes)
2. Review of PFR and reactions to it (30 minutes)
3. Summarization of today’s session and preparation for next session (10 minutes)
Time: 1 hour total

Handouts:
•  Two copies of the client’s personalized feedback report
•  A Guide to Quitting Marijuana brochure
•  An orientation sheet entitled Welcome!

Materials:
•  A pocket folder

Procedural Steps
Phase 1: Building Rapport. 
This is an extremely important part of the treatment, during which the therapist and client first get to know each
other. The goal is to create the feeling that the therapy sessions will be safe and supportive.
     
The therapist should begin by introducing himself or herself and then briefly explain the purpose of the first meeting—i.e., to become
acquainted with the client and to give the client some information and feedback. The therapist may indicate that he or she has learned a bit about
the client from information obtained during the intake or referral process or from the research staff but finds it most helpful to hear it directly from
the client.



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Here is the suggested discussion sequence for the rapport-building phase of the session:
1.  Start with some casual conversation and a review of demographic facts, and attempt to learn a bit more about the client. For example, you can 
talk about whether the client is in school and, if so, in what grade; his or her living situation (where and with whom); and whether he or she has 
a job. This discussion should be fairly general and brief in order to leave enough time for the remainder of the session.
2.  Ask an open-ended question about what led to the client’s involvement in marijuana treatment, as this will most likely present opportunities 
to initiate some of the MET strategies described earlier in this treatment manual. Try to include discussion about the following:
•  How the marijuana use first started
•  The extent of recent use
•  Whether there have been any previous attempts at quitting
•  What the client hopes to gain from treatment.
     
Phase 2: Orientation to Treatment. 
Give the client a copy of the Welcome! orientation sheet, which introduces the client to the treatment, and 
summarize the main points. You do not need to read it word for word.
     
Give the client the Guide to Quitting Marijuana brochure, and encourage the client to read the brochure before the next session. The Guide to 
Quitting Marijuana was produced by the Drug and Alcohol Research Centre, Sydney, Australia, and is available from Lighthouse Publications 
at:
702 W. Chestnut Street
Bloomington, IL 61701
Telephone: 888–547–8271 
Voice: 309–829–1058, x 3414
Fax: 309–829–4661 
Web site: www.chestnut.org/li/publications
E-mail: cschwartz@chestnut.org
     
Ask the client to bring the folder to each session because you will be providing additional information to add to it. 



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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 situationand 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 



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disagree with the PFR item. Saying “Tell me about using in unsafe situations” invites elaboration and discussion.
     
Therapists may find that some sections of the PFR are especially conducive to motivational interviewing. For example, with a number of
clients, the problems and the reasons for quitting sections may be especially likely to induce the client to explore his or her ambivalence about 
smoking marijuana. Therapists may adjust the relative emphasis on sections of the PFR to accentuate those sections that produce constructive 
discussion for any given client. For example, if a client seems especially interested in describing his or her reasons for quitting, the therapist may
choose to spend extra time focusing on that area.
     
Note that the PFR review is expected to take approximately 30 minutes. This allows for quite a bit of discussion and related comments. Use 
double-sided reflections, develop discrepancy, and employ other MET strategies where relevant. Reviewing the PFR provides an excellent 
opportunity to explore the client’s ambivalence and to begin developing motivation for change. After reviewing the entire PFR, ask the client 
about his or her reactions to it, and listen with empathy.
     
Phase 3: Session Summary. 
In the final portion of the session, summarize the main points that you heard the client saying. Ask the client about 
his or her current readiness for change. Some clients are ready to verbalize the goal to change at this point. However, if a particular adolescent is 
not feeling ready to set a goal for change, the therapist should not pressure the client into doing so. 
     
The following recommendations apply to helping those clients who do verbalize the goal to change:
     
If the client says that he or she wants to quit or reduce his or her marijuana smoking, ask what might help him or her to achieve that goal. Many 
clients may spontaneously come up with some ideas, such as asking friends to help them or not buying any more marijuana. Reinforce any such
statements. If they are unable to come up with any ideas, help them do so. For example, say that some people find it helpful to stay away from 
friends who use, and ask if they think this would be helpful for them. Some of these ideas may flow directly out of the PFR discussion. Help them 
develop a plan regarding any remaining marijuana they have. Some clients may say that they are going to finish smoking the marijuana that they 
have left in their possession, while others may be comfortable disposing of it (giving it away, flushing it, etc.). 
     
Many clients may not yet be willing to make a commitment to abstinence. Whether the client plans to quit or reduce use at this point, tell him or 
her that you’ll continue discussing this issue during the next session. Ask the client what today’s session has been like for him or her. Set up an 
appointment to meet again next week, and write it down on an appointment card. 



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This example of the PFR contains every possible PFR item. The PFR for any given client will contain only the items that the client endorsed 
during the initial assessment.

Therapist ________________________					Client ________________________

Personalized Feedback Report (PFR) 
This report summarizes some of the information that you gave us in your interview on ___/___/____.  We want to give you an opportunity to 
review what you’ve told us and make any changes or additions. As you and I work together in reviewing and  discussing this specific personal 
information, we can help you develop a program and strategies for dealing with marijuana that fit your individual needs.

Primary Substances
You reported that your favorite substance to use was_____________________ and that you needed treatment 
for ___________________________________.

You told us you first used alcohol or drugs at age ____ and have been smoking marijuana for ____ years. In the past year, you told us you had
used ______________________. You have been in substance treatment ____ times before. 

Extent of Use
In the past 90 days, you smoked marijuana on _____ of those days, with most being ____ hits over a ___hour period. This places you in 
the _____ percentile relative to other adolescents age ___ to ___ in America. 
In the past 90 days, you drank alcohol on _____ of those days, 
with the heaviest drinking episode being ____ drinks over a ___ hour period. This places you in the _____ percentile relative to other 
adolescents ages ___ to ___ in America.
In the past 90 days, you reported that you used other drugs, including _______________________, on ___ days. In the past week you 
reported that you (had/had not) tried to quit (and that when you did you had the following problems: _______________________________). 
[List could include moving and talking much slower than usual; yawning more than usual; feeling tired; having bad dreams that seem real; 
having trouble sleeping (sleeping too much or trouble staying asleep); feeling sad, tense, or angry; feeling really nervous or tense; fidgeting, 
wringing your hands, or trouble sitting still; having shaky hands; having convulsions or seizures; feeling hungrier than usual; throwing up or 
feeling like throwing up; having diarrhea; having muscle aches; having a runny nose or eyes watering more than usual; sweating more than 
usual; having your heart race or goose bumps; having a fever; seeing, feeling, or hearing things that are not real;




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forgetting a list of things or having problems remembering; having withdrawal symptoms that prevented you from doing usual activities; 
starting to use again to avoid withdrawal symptoms, other: ______________________ .]

Problems
You indicated that your use of marijuana, alcohol, and/or other substances had caused you the following kinds of problems:
•  You did not meet your responsibilities at home, school, or work.
•  You used in situations where it was unsafe for you.
•  Using caused you to have repeated problems with the law.
•  You kept using even though it was causing you to get into fights.
•  You had to use more to get the same high.
•  You had withdrawal symptoms when you tried to stop.
•  You used for longer than you wanted to.
•  You have been unable to cut down or stop using.
•  You spent a lot of time getting or using marijuana, alcohol, or other substances.
•  Using led you to give up activities or caused problems at home, school, or work.
•  You have kept using despite medical or psychological problems.

As you reflect on the consequences to your life of smoking marijuana, what would you add?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Reasons for Quitting
You said the main reason you came to treatment was____________________________________________. 

We showed you a list of personal reasons for quitting marijuana, and you said that you wanted to quit:
•  To show myself that I can quit if I really want to. 
•  To like myself better.
•  So that I won’t have to leave social functions or other people’s houses. 
•  To feel in control of my life. 
•  So that my parents, girlfriend, boyfriend, or another person I am close to will stop nagging me.
•  To get praise from people I am close to. 
•  Because smoking marijuana does not fit in with my self-image. 
•  Because smoking marijuana is less “cool” or socially acceptable. 
•  Because someone has given me an ultimatum.
•  So that I will receive a special gift. 
•  Because of potential health problems. 
•  Because people I am close to will be upset if I don’t. 
•  So that I can get more things done during the day. 
•  Because my marijuana use is hurting my health. 
•  Because I will save money by quitting. 




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•  To prove I’m not addicted. 
•  Because there is a drug testing policy in detention, probation, parole, or school. 
•  Because I know others with health problems caused by marijuana. 
•  Because I am concerned that smoking marijuana will shorten my life. 
•  Because of legal problems related to my use. 
•  Because I don’t want to embarrass my family. 
•  So that I will have more energy. 
•  So my hair and clothes won’t smell like marijuana. 
•  So I won’t burn holes in clothes or furniture. 
•  Because my memory will improve.
•  So that I will be able to think more clearly. 

You listed these because they have personal significance for you. Do you have any other important reasons for quitting that you would like 
to add?
______________________________________________________________________________________________________
______________________________________________________________________________________________________

You also told us about several other problems that might be caused or made worse by your marijuana, alcohol, or other drug use. These include:
•  The health problems you reported. 
•  The emotional problems you reported.
•  Being bothered by upsetting memories.
•  Having problems paying attention or controlling your behavior.
•  The family problems you reported.
•  Arguments, and problems you had with your temper.
•  Being physically, sexually, or emotionally hurt.
•  Doing things that were illegal. 
•  Getting in trouble at school. 
•  Getting in trouble at work. 

Pattern of Use
You told us that the place(s) where you typically use marijuana, alcohol, and other drugs is/are:
•  At home
•  At someone else’s home
•  At a party/bar
•  At work
•  At school
•  At a dealer’s house
•  Outdoors
•  In a car
•  Somewhere else (__________________________________________) 




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and that you typically use it with:
•  No one else, alone
•  Your romantic/sexual partner
•  Family
•  Friends
•  A club or gang
•  Coworkers
•  Classmates
•  A running partner (someone you regularly do drugs with)
•  A drug dealer/pusher
•  Someone else (____________________________________________)

As you think about highly tempting situations, are there situations that you’d like to add?
 ______________________________________________________________________________________________________
______________________________________________________________________________________________________

Situational Confidence
You told us that you thought you could avoid using alcohol or drugs:
•  At home
•  At school or work
•  With your friends
•  When everyone around you was using them 
You also told us that you (had quit and were _______% sure you could stay abstinent/you had not quit yet but were _______% sure you 
could quit).




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Session 2: MET2—Goal-Setting Session

Key Points:
•  Review progress, thoughts, and reactions since session 1.
•  Collaborate on setting a treatment goal or goals for the remaining treatment sessions.
•  Introduce the concept of functional analysis.
•  Prepare for the group therapy sessions.

Delivery Method: MET-focused individual therapy

Session Phases and Times:
1. Review of progress (15 minutes)      
2. Goal-setting (20 minutes)             
3. Functional analysis (20 minutes)
4. Preparation for group (5 minutes)
Time: 1 hour total

Handouts:
•  A personal goal worksheet
•  Blank personal awareness worksheets for functional analysis (entitled Knowledge Is Power)
•  A group preparation sheet titled Information and Expectations: Group Sessions

Procedural Steps
Begin by greeting the client. Notice if the client has brought back the folder of information. If so, state that you are glad to see that; if not,
encourage the client to bring it next time.
     
Phase 1: Review of Progress. 
Begin the review of treatment progress by asking the client how he or she has been doing over the past week 
regarding the marijuana issue. The therapist should be prepared to listen for possible changes in the client’s behaviors, thoughts, and feelings
regarding marijuana. Before asking a lot of questions, let the client tell you how he or she has been doing regarding his or her marijuana use or 
abstinence first. Respond with reflective comments, and attempt to elicit the client’s own motivation-enhancing statements. In order to get a 
fuller picture of the client’s marijuana-related behaviors, thoughts, and feelings, you may want to ask questions. Your questions may center on:



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Behaviors related to marijuana:
•  How much did you smoke over the past week, if at all?
•  What was going on at the time you smoked (or felt like smoking)?
•  Have you told any of your friends about your plans to stop smoking?
•  Did you read the Guide to Quitting Marijuana brochure? What are your reactions to that?

Thoughts about marijuana:
•  It sounds like you’ve given this issue a lot of thought. Tell me more about what you’re thinking regarding pot smoking at this point.
•  What thoughts have you had about that PFR we went over last time?

Feelings about marijuana:
•  How did you feel after you smoked?
•  It sounds like you have mixed feelings about whether or not you want to quit. Tell me some more about that.
     
As you listen to the client, be prepared to express empathy, provide double-sided reflections as appropriate, reinforce client efficacy, and roll
with resistance. After approximately 15 minutes of opening discussion, move into the goal-setting phase of the session.
     
Phase 2: Goal-Setting. 
Up to this point, you may have been hearing the client make statements indicating some motivation for change. If so,
summarize this; if not, try to accurately reflect the client’s feeling that he or she is not yet ready to commit to change.
     
Either way, explain to the client that having a written goal increases the likelihood that the rest of the therapy will be meaningful and/or useful
to him or her, and that he or she will be more likely to succeed. When working with clients who say they are not willing to give up marijuana, let
them know that other goals may be useful to them. For example, some may decide to start by trying to reduce their marijuana smoking. Others 
may simply like to set the goal of learning more about the skills for quitting or reducing marijuana use. 
     
Give the client a copy of the personal goal worksheet and a pen so that he or she can fill it out in the session. It is a good idea to have clients
verbalize each section of the goal worksheet before writing it down. This way, the therapist can offer feedback and suggest modifications 
before ink



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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. 



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Personal Goal Worksheet


This is my goal regarding my marijuana use:
______________________________________________________________________________________________________
______________________________________________________________________________________________________


Here are some important reasons for my goal:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________


The steps I plan to take to achieve my goal are:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________


______________________________________       ___________
Name Date



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 Phase 3: Functional Analysis. 
After having participated in the previous portions of the therapy aimed at improving motivation and beginning to 
resolve ambivalence, clients should now be ready to examine the function of marijuana in their lives. Actually, the groundwork for this has been 
laid. This exercise is included at this point to help clients understand that marijuana use doesn’t just happen but is rather a function of
antecedents and consequences. The aim is to increase clients’ awareness of those factors, to provide better focus for the ensuing CBT 
interventions, and to enable better decision making on a daily basis.
     
To convey the concept of functional analysis, the therapist may begin with a social learning explanation of marijuana abuse. As the therapist 
goes through this explanation, he or she may draw on what the client has already described to illustrate the various points. The therapist
should try to explain the concept in simple language, using concepts that the client can understand. Here is an example of such an explanation:
I want to explain to you how we think about marijuana problems. When someone has a marijuana problem, we think of it as a negative habit, 
similar to other habits like biting your nails or eating junk food. We try to help the person figure out what has been keeping the habit going. 
This way, if someone wants to stop the habit and knows what is keeping it going, he or she can use this information to help stop it. Does 
thinking of it as a habit make sense to you? [Discuss] 

After a while, if someone has often gotten high in certain situations, just being in those 
situations can make that person feel like getting high. We call that a trigger. It could be anything about the situation like the time of day, whom 
you’re with, or even something like a type of music. You have mentioned some things that sound like triggers for you. What do you think some 
of your triggers are? [Discuss] 

Another type of trigger can be how someone is feeling. Some people say that they feel more like smoking marijuana when they are feeling
badly—like feeling bored, nervous, or angry. They say that smoking is a way of trying to cope with the bad feelings. Some people especially
feel like smoking marijuana when they are happy or excited. Does this part of it—someone using to affect how they feel—make sense to you?
[Discuss]

Sometimes people develop certain thoughts or ideas about their use, like 'My friends will think I’m boring if I don’t take a few hits,’ or 'I’ll just 
smoke this one time,’ or other ideas. These thoughts and ideas affect whether or not somebody uses. The point is that marijuana use doesn’t 
just suddenly happen. Usually there are things going on around a person or in the way someone is thinking or feeling that affect whether or not
he or she smokes marijuana. Knowing what affects your own use gives you more power to decide whether or not to use. And looking at both 
the pros and cons of what happens after you use also helps you understand



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why you use and helps you make decisions about what you want to do in the future. That is why we call this sheet Knowledge Is Power.
[Give them a blank copy of it; keep one for yourself.] 

Figuring out the factors that lead to your own marijuana use gives you more power to decide what to do next, and to break the habit, if you want
to. That’s the main thing that we are trying to do in this program—to give you a lot of different ways to take back control instead of being
under the control of the habit.
     
Having given a rationale for treatment, the therapist should involve the client in a functional analysis of his or her own use. The discussion can
focus on a recent episode(s) of use that the client has reported, or it could focus on the client’s use in general. The therapist should fill in some 
of the client’s responses on the personal awareness form while the client follows along with a blank copy of his or her own. Here are some ideas 
for discussing the subsections (from row one) of the worksheet:

Trigger:
What sorts of things are often going on when you decide to smoke marijuana? This may include places, people, activities, specific times or 
days, and other situational aspects of use.

Thoughts and Feelings:
Can you remember your thoughts and feelings the last time you used? Adolescents may be less likely than some adults to be able to identify and 
label their feelings. It may help for the therapist to offer some examples of how some adolescents say they have felt before they decided to use 
(e.g., bored, angry, excited, sad). Also, some adolescents may have trouble identifying their thoughts. The therapist may be able to elicit their 
thoughts better by asking clients what they were saying to themselves at the time. 

Behavior:
Write down what happened at a recent time that these triggers were experienced. Often, in the example reviewed in the session, the client will 
have smoked marijuana (possibly along with other substance use, which should also be recorded). However, let the client know that this 
analysis can also apply to situations in which the client chose not to use.



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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.



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Knowledge Is Power

Personal Awareness: What Happens Before and After I Use Marijuana?

TRIGGER THOUGHTS AND 	BEHAVIOR         	POSITIVE RESULTS                   	NEGATIVE RESULTS		FEELINGS 
(What sets me up to be more likely
to use marijuana?   

(What was I thinking?            

(What did I do then?)      

(What good things  happened? )       

(What bad things happened?_
            
(What was I feeling?)

What did I tell myself?)

Adapted from Jaffe et al., 1988



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Sample Knowledge Is Power Form
Here is an example of how the self-monitoring record may look after the therapist has helped the client complete it while reviewing a recent 
episode of use:

Personal Awareness: What Happens Before and After I Use Marijuana?

TRIGGER THOUGHTS AND BEHAVIOR         POSITIVE                  NEGATIVE
FEELINGS RESULTS RESULTS
(What sets me up   (What was I thinking?           (What did I do then?)        (What good things            (What bad things
to be more likely to            What was I feeling? happened?) happened?)
use marijuana?)       What did I tell myself?)

 Friend called and  “I want to reward myself.”       Went out with friend  Had fun. Felt good to get     
invited me to smoke  “I’m bored.”                        and smoked. high, having gone 15 days    
with him. “Felt good about going 15  without.                 
Nothing else to do.     days w/o smoking, so felt OK 
about smoking today.”
 Broke the 15-day absti
nence (although wasn’t
too worried about this).
Didn’t get as much done.
Didn’t feel as healthy.



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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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Information and Expectations: Group Sessions

Group sessions will last 75 minutes. Please arrive on time and attend all group meetings. 
If you cannot attend a group meeting, please call ______________ at ___________________ ahead of time. If you miss a group session, you 
will be asked to make it up before or after the next session. Your active participation is important to the whole group. All group members are 
asked to listen to one another without interrupting, to respect the opinions of others, and to offer feedback to other group members. Each group 
member’s confidentiality is to be respected. What is said in group stays in group; please do not discuss what is said in group. 

In order to make the group a safe place with a positive focus, the following behaviors are not allowed in group:
•  Coming to group under the influence
•  Threatening remarks or gestures
•  Excessive profanity
•  Wearing gang-related clothing
•  Sexually inappropriate comments, gestures, or clothing
• “War stories,” bragging about drug and alcohol use
•  Exclusive relationships

The above behaviors could result in a client being asked to leave the group.

I have read this information sheet, and I agree to comply with the expectations for positive participation in group.

_______________________________________              ____________________
client date
_______________________________________              ____________________
therapist date



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VI. Cognitive Behavioral Therapy

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

Key Concepts and Session Guidelines
     
The particular cognitive behavioral treatment approach specified in this manual is based on a social learning model, with a focus on training
people in interpersonal and self-management skills. The primary goal of this treatment is for clients to master the skills needed to maintain 
long-term abstinence from marijuana. An important element in developing these skills is identification of high-risk situations that may increase 
the likelihood of relapse. These high-risk situations include external precipitants of using, as well as internal events such as cognitions and 
emotions.
     
Having identified situations that may create a high risk for relapse, clients must develop skills to cope with them. In the three CBT group 
sessions, clients are taught basic skill elements for dealing with common high-risk problem areas and are encouraged to engage in roleplaying 
and real life practice exercises that will enable them to apply these skills to meet their own needs.
     
Clients must get a chance to build their skills by receiving  constructive feedback using relevant (client-centered) problems. Active practice with 
positive, corrective feedback is the most effective way to modify self-efficacy expectations and create long-lasting behavior change.
     
Cognitive behavioral treatment for marijuana abuse requires the client’s active participation, as well as his or her assumption of responsibility for 
using the new self-control skills to prevent future abuse. Through active participation in a training program in which new skills and cognitive
strategies are acquired, an individual’s maladaptive habits can be replaced with healthy behaviors regulated by cognitive processes involving 
awareness and responsible planning. Marlatt and Gordon (1985, p. 12) state:



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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. Effectiv