Review the PFR

The PFR review takes approximately 30 minutes. The counselor explains that by reviewing the PFR (form AS8), the client will understand reasons for and against changing and what and when problems might arise.

The counselor leads the client through a systematic review of the PFR, giving the client an opportunity to explore each point. The counselor avoids simply verifying the information obtained during the assessment session. The counselor periodically seeks the client’s thoughts and feelings during the review. The counselor listens reflectively to acknowledge expressions of readiness for change. Reviewing the PFR provides an ideal opportunity to use motivational interviewing techniques, for example, expressing empathy, identifying discrepancy, eliciting self-motivational statements, rolling with resistance, and supporting self-efficacy.

The client may respond to elements in the PFR review with arguments about the validity of the items (I didn’t say smoking pot was causing me money problems!). In such cases, the counselor maintains a nondefensive tone, acknowledges that the client knows best which areas of his or her life have been affected by marijuana use, and moves on to the next item. The counselor may make changes to the PFR based on the client’s feedback during this review.

In keeping with the MET approach, the counselor uses open-ended rather than close-ended questions. For example, Did you say you used in unsafe situations? is a close-ended question that invites a mere yes or no answer and possible disagreement with the PFR item. Saying instead Tell me about using in unsafe situations invites elaboration and discussion.

The counselor spends more time on the sections that are likely to produce the most constructive discussion. The sections on marijuana problems and reasons for quitting are especially conducive to motivational interviewing. After reviewing the PFR with the client, the counselor asks the client for reactions and responds to them with empathy. Before moving on to the next phase of this session, the counselor ensures that the following PFR items are discussed:

Age of onset (part I of the PFR). The counselor tells the client that substance use disorders tend to be more severe when they begin at an early age. This means that the earlier the age of onset, the greater the risk of developing severe problems if the substance use continues. In the PFR, the age of onset of regular marijuana smoking is the age the client began smoking marijuana three or more times a week.

Comparisons of use patterns (part I of the PFR). When preparing the PFR, the counselor uses tables A and B to compare the client’s use with that of others who use marijuana.

The percentiles indicate the percentage of people in the comparison group who scored at or below the client’s score. These comparisons allow the client to compare his or her use with that of people who experienced significant problems related to marijuana use. The counselor can present the information in the following way:

C: You smoked marijuana on 24 of the past 30 days. That puts you in the top 98 percentile relative to all Americans. This means that 98 percent of American adults smoke less often than you do and about 2 percent smoke more often.

S: Wow!

C: That surprises you.

S: It sounds like a lot. I never thought it was that much!

C: What are you thinking, now that you know that?

S: I don’t like it. I knew I was getting high a lot, but I always thought that a lot of other people got loaded as much as I did. This isn’t good news.

C: You’d like this to be different.

S: Yeah.

Problems caused by marijuana use (part II of the PFR). The counselor tells the client where he or she falls, relative to others seeking treatment, based on his or her responses to the Marijuana Problem Scale (form AS5) and the data in table C. The counselor reviews the criteria listed on the Structured Clinical Interview for DSM-IV (SCID-IV) (form AS4) that were coded as 2 or 3. The results provide an overview of the problems and symptoms that the client identified as resulting from his or her marijuana use.

• Tolerance level (part II of the PFR). Question 6 of the SCID-IV was used to measure the client’s tolerance level. Tolerance is defined as the need for a markedly increased amount of marijuana (at least a 50-percent increase) to achieve the desired effect or a markedly diminished effect with continued use of the same amount of marijuana.

• Reasons for quitting (part III of the PFR). To reinforce the client’s motivation, the counselor reviews the reasons the client gave on the Reasons for Quitting Questionnaire (form AS6) and asks the client whether he or she would like to add other reasons to the list.

• Risk factors for relapse (part IV of the PFR). The counselor points out the risky situations the client identified on the Self-Efficacy Questionnaire (form AS7) as the client’s risk factors for relapse. The counselor explains that risk factors are warning signs that require the client’s attention and indicate a susceptibility to problems associated with marijuana use. A person who uses substances besides marijuana is at risk for additional reasons. Decreased use of one drug may result in increased use of another, a phenomenon called substance substitution. In addition, combining different drugs compounds their effects, sometimes with dangerous results. Tolerance for one substance can increase tolerance for another; people who take multiple substances simultaneously can develop cross-tolerance for several substances and be at risk for injury, arrest, or overdose if severely intoxicated.