Manuals Guide Teen Marijuana Use Treatment
By Beryl Lieff Benderly
Everyone who's ever bought a new appliance has used a manual, one
of those indispensable guides to finding out, step-by-step, how
something should be done. But few people associate a book of detailed
instructions with a process as sensitive and complex as substance
abuse treatment. Now, however, service providers throughout the
Nation are using a set of manuals developed and tested in projects
funded by SAMHSA's Center for Substance Abuse Treatment (CSAT) aimed
at developing evidence-based care for adolescents using marijuana.
The five volumes of the Cannabis Youth Treatment (CYT) Series far
exceed the ordinary run of instruction booklets. Each is based on
a treatment approach specifically designed for use with adolescents.
A 3-year study beginning in 1997 found that the methods described
in the manuals produced "statistically significant treatment
outcome results" that were "better than many of the treatments
being used at that time," says Jean Donaldson, M.A., who served
as the CSAT project officer. (See SAMHSA News, Spring 2001.)
A just-completed, 30-month followup study has confirmed "significant
post-treatment improvement" among adolescents, according to
a forthcoming article based on those results in the Journal
of Substance Abuse Treatment.
The CYT manuals are part of SAMHSA's Science to Services Initiative,
which seeks to foster the adoption of effective, evidence-based
interventions gleaned from research into routine clinical practice,
and then strengthen feedback from the services community to inform
research. In keeping with these goals, the CYT manuals are now being
The treatment methods in the CYT manuals depart from former practices
in two important respects. First, each volume details a specific
multi-part intervention and then guides service providers through
its various tasks and sessions (see SAMHSA
News, Cannabis Youth Treatment Series by Volume). Second, the manual-based interventions all build
on a foundation of formal approaches including motivational enhancement
therapy, cognitive behavioral therapy, and other models. Unlike
more eclectic models traditionally used in many agencies, the CYT
interventions specifically focused on equipping adolescents and
their families with methods for stopping and preventing use and
coping with relapse.
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In an informal effort to gauge the effects of the manuals on real-life
practices, SAMHSA News spoke with front-line treatment
providers who use the manuals in a variety of settings. Their comments
cover many aspects of the change to CYT. To begin with, they find
CYT-based approaches less confrontational than much of traditional
substance abuse treatment.
"I hate confronting these kids," says Tina Long, a case
manager at Sojourner Recovery Services in Hamilton, OH. "We
don't counsel anybody else that way. There's no reason to counsel
a person with substance abuse that way."
This change requires that service providers become "convinced
that they don't really have to confront resistance," says psychologist
Win Turner, Ph.D., a project director for the New England Institute
of Addiction Studies. Dr. Turner has trained and helped supervise
the implementation of CYT Volume 1 at community treatment agencies
across Vermont. "When people first do motivational enhancement
therapy, they think that if the client says, ‘I'm not ready
to give this up,' that you have to convince them to change. But
you say, ‘I hear you, you're not ready to quit. Perhaps we
could talk about what brought you here.' The idea is to roll with
resistance and to listen more, so the client feels understood."
Another difference is that cognitive behavioral therapy calls
for "practicing what seem to be rote exercises," Dr. Turner
"That can seem trivial . . . but it becomes very significant"
over time. With experience, service providers learn that "teaching
a skill [needed to prevent or stop use] is just as important as
talking about how I feel," says Julia Hemphill, a counselor
at Operation PAR in St. Petersburg, FL.
The detailed structure laid out in the manuals is also new to
many service providers. "People think that service providers
are going to hate these manuals, but in fact they find that it makes
their working environment a learning environment," Dr. Turner
Ms. Long finds the structure very helpful. "I don't walk
into a session ever feeling unprepared. If any situation arises,
I have got a procedure to deal with it. And it's gone through tests
to know that it's going to work."
Thanks to the manual, Ms. Hemphill adds, "you don't have
to do your own research or put it together yourself."
The detailed progression of topics, however, does more than save
time for service providers and build their confidence. It also gives
them "a way to bring up a subject without pointing the finger,"
says Matt Hassler, M.S.W., another Operation PAR counselor. Sessions
have "a structure that clients don't have to take personally.
That means clients can choose if they want to talk about a topic."
That predetermined structure, however, makes some service providers
"feel like occasionally I lose a little on the creativity side,"
Mr. Hassler says.
At the beginning, "the assumption is that the curriculum
is a rigid entity," Dr. Turner notes. "But that's not
true. It is always advisable to follow along and learn the manual
as it stands. Once you feel you have a sound understanding, you
can then apply it in a different way, as long as the essential components
are left intact."
"You learn the principles, but as to how you implement the
principles, you have a good bit of flexibility," agrees Reginald
Simmons, Ph.D., of the Connecticut Division of Children and Families,
who is coordinating the use of four CYT curricula in Hartford. "You're
not really in lockstep like a robot.
It still takes a skilled clinician who is a good therapist to know
how to implement the principles. There's a great deal of creativity
that can be exercised."
Mr. Hassler agrees. "Even within the boundaries of the manual,
I can be really creative," he says. In fact, he finds creativity
essential because "there has to be some adaptation" of
the manual to each particular case as well as "little tweaks
for personal style."
Service providers agree that the manuals afford plenty of leeway
to meet a client's particular needs. "I find it very flexible,"
says Ms. Long. "It puts you on the right track and shows the
frame of mind you need to be in" to deal with particular situations.
For example, in a rural state like Vermont, Dr. Turner says, "we
don't have big groups of people coming in at one time." Elements
of the program originally designed for groups "can be done
for individuals as well."
Some service providers find the adjustment to this way of working
straightforward. "I'm a manual reader," says Ms. Long.
"I read those VCR manuals. I went through the CYT manual and
read everything. Each of the sections gives you a little synopsis
of how to talk." But, she notes, "Somebody who's been
in the substance abuse field and is used to a confrontational style,
when given this manual, is going to be really challenged to change
For some service providers, learning to do the manual-based treatment
involves "cognitive dissonance," Dr. Turner says. "You're
used to having very fluid conversations, so when you're first learning
manual-based treatment, it seems awkward. The more you work with
the manual, though, you can fit it into your own scripts that you've
had with clients anyway. If you're doing motivational therapy, there
are four or five skills that you need to learn and hone. If you're
doing cognitive-behavioral therapy, you provide an activity, go
over a skill, and then rehearse it. Those foundational elements are not
awkward once you integrate them. But it takes a little while."
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Adjusting to doing manual-based interventions is "really
about practice," Ms. Long agrees. "I've probably done
50 functional analyses of substance abuse as outlined in one of
the manuals, and every time I do it, I learn something new about
a client and I learn something new about the procedure."
The challenge that service providers face in learning a new way
to work is "a parallel process" to what clients experience
trying to break out of behavior patterns, Dr. Turner continues.
For clinical supervision, "that's a beautiful metaphor. Implementing
the manuals and practicing new clinical skills puts clinicians in
the experience of change. This moves them a little closer to the
client" who is attempting a fundamental change that is "much
Manual-based therapy has benefits for the field as a whole as well
as for individual service providers. "It tries to make treatment
consistent," says Dr. Turner. The CYT curricula give a common
"template" to service providers who have "come into
the substance abuse field from all avenues of training."
Historically, the substance abuse field has had "an inadequate
amount of quality assurance," adds Dr. Simmons. "What
are therapists doing? How do they know it even works? You hear therapists
say, ‘Oh, this just feels good.' How do you know?" he
asks. But "a manual-based intervention that has been shown
to be effective . . . allows you to really assess what a therapist
is doing and how that relates to outcome."
In addition, "a manual-based approach really helps you to
think about what you are doing," Dr. Simmons continues. By
forcing service providers "to really plan their work,
it gives a platform to evaluate your work." The CYT manuals
also permit the program in Hartford to use "a treatment-matching
process including comprehensive assessment to help determine what
treatment each kid should receive." The availability of several
"evidence-based interventions that have been shown to work
allows us to really match the treatments to the population."
The CYT manuals are not perfect, however. The treatment providers
suggest several ways in which future manuals could be improved.
These manuals "have to be updated periodically" to match
changing times, Mr. Hassler notes. Ms. Long would like to see some
advice for young therapists like herself on "building rapport
Dr. Turner suggests clinicians need "a short introduction
to the process of adopting a new clinical model" and learning
what helps clients get ready for this experience of change. "Vermont
therapists asked for more examples and strategies for working with
difficult clients," he adds.
In addition, he believes, a separate workbook-like "implementation
binder" containing all the checklists, handouts, and forms
should be provided. Dr. Simmons warns that CYT "may not work
everywhere." An "agency's characteristics" will influence
"whether this model will work for them."
But the benefits of the CYT manuals outweigh their limitations
and the challenge of adjusting to a new method of work, the service
providers interviewed for this article agree. Through structure,
consistency, and research-based techniques, Dr. Turner says,
the manuals have "provided a tighter framework for clinicians
to provide effective treatment for adolescents."
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