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SAMHSA News - March/April 2004, Volume 12, Number 2

Manuals Guide Teen Marijuana Use Treatment

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 distributed nationally.

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 continues.

"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 says.

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 their approach."

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 more intense."

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 with parents."

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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