Use the TLFB Method To Assess Marijuana Use
The assessment or evaluation component of this session can be a powerful element of treatment. Marijuana Treatment Program (MTP) participants reported increased motivation after receiving feedback from assessment-related activities.
During the session the counselor and client complete several forms to assess the client’s marijuana use. Quantity of marijuana use is difficult to measure because of varying potency levels and smoking methods (e.g., pipe, joint); therefore, frequency of use is the most reliable criterion for consumption measures. The TLFB method helps the counselor and client identify patterns and possible consequences of use (Sobell and Sobell 2000; Sobell et al. forthcoming). For instance, a person who uses heavily on weekends may be at risk of driving an automobile while high. A chronic, daily use pattern might indicate that an individual has developed cannabis dependence. In addition to providing a precise measure of marijuana consumption, the TLFB method can assess changes in a client’s marijuana use and helps the counselor determine treatment effectiveness. The counselor begins by asking the client to estimate generally how many days and how many times a day he or she smoked marijuana in the past month:
C: In the past month, about how many days did you smoke marijuana? [Waits for client’s response before asking the next question.] In the past month, on a typical day when you smoked marijuana, about how many times per day did you smoke?
Once the counselor has a general sense of the client’s use, the formal TLFB assessment process begins. The counselor uses the following instruments to assess the pattern, severity, and nature of the client’s marijuana use:
• TLFB Calendar for the past month (form AS1)
• TLFB Grid (form AS2)
• TLFB Marijuana Use Summary Sheet (form AS3).
The counselor uses the TLFB Calendar to help the client recall his or her marijuana use and the TLFB Grid to record summary information from the completed calendar. When completed, the TLFB Marijuana Use Summary Sheet provides an overview of basic information about the client’s marijuana use, alcohol consumption, and tobacco smoking. (The TLFB Calendar and TLFB Marijuana Use Summary Sheet procedures are modified from procedures developed by Sobell and Sobell [1992, 2000, 2003] and Sobell and colleagues [forthcoming]. Some administration guidelines are adapted from the Form 90 procedure developed by Miller [1996].)
Complete the TLFB Calendar
The counselor begins by developing a detailed history of daily marijuana use for a specified period, called the assessment window. This manual suggests an assessment window of 1 month. To arrive at a diagnosis of dependence or abuse, the DSM-IV advises that symptoms be present for 12 months. However, assessing symptoms for the last 12 months may tell little about the client’s current use, especially if the client’s use pattern has changed significantly over the year prior to entering treatment. (If the client had attempted to quit using or cut back usage in preparation for treatment, the counselor should ask the client to recall a period of usual marijuana use.)
Understanding marijuana use at treatment entry is helpful for treatment planning and for motivating the client to change. The TLFB method uses memory aids (exhibit IV-3) to help the client recall his or her marijuana use. The counselor and client select a month to investigate. The counselor fills in the days on the TLFB Calendar (form AS1) and indicates which days in that particular month are holidays or other special days for the client (see exhibit IV-4 for a sample).
The calendar is used as a memory aid. The counselor asks the client to recall daily consumption of marijuana by linking memories to salient life events. The counselor mentions recurring and atypical events to help the client recall his or her marijuana use. Recurring events (e.g., work schedule,
payday) provide a context for describing typical marijuana use patterns (e.g., client always buys marijuana on payday and smokes all day on days off). Atypical events (e.g., medical appointment, marital argument) provide anchor points for describing exceptions to a regular use pattern (e.g., client did not smoke on the day of a medical appointment; smoked more on the day of a marital argument). Discrete events (e.g., jail time, hospitalizations) help identify use and nonuse periods:
C: I’d like to start by asking you questions about your marijuana use, other drug use, and drinking during the period from about a month ago until yesterday. [Places the calendar in front of the client.] We’ll reconstruct this period by using notes on the calendar to help you remember things that have happened to you. Then we’ll use these events to help you remember when you used marijuana on each day.
After the counselor and client determine on which days the client smoked, they record the number of smoking episodes per day by breaking each calendar day into four quadrants. (As the client breaks down daily use into quadrants, it may be helpful for the counselor to have a card that lists the quadrants for the client to refer to.) The four boxes on each calendar day in exhibits IV-4 and
IV-5 correspond to these following quadrants:
• Quadrant 1 = 6 a.m. to 12 noon (morning)
• Quadrant 2 = 12 noon to 6 p.m. (daytime)
• Quadrant 3 = 6 p.m. to midnight (evening)
• Quadrant 4 = 12 midnight to 6 a.m. (nighttime).
For instance, in the example in exhibit IV-5, the client smoked in the second and third quadrants on December 22, in all quadrants on December 23, and in the first quadrant on December 24. The counselor explains that this information reveals the context in which marijuana use occurs.
The counselor records any other drug or alcohol use that occurred during the assessment window. By asking questions about alcohol and drug use, the counselor determines whether the client is substituting other drugs or alcohol on days when marijuana is not used.
Once the memorable events have been recorded, the counselor focuses on the client’s longest span of invariant or unchanging behavior, such as abstinence, and determines whether a steady marijuana use pattern exists:
C: Looking at the calendar and thinking about these events, what is the longest period you can remember when you went without smoking at all?
If the client has had a reasonably consistent pattern of use from week to week, the counselor asks him or her to describe a typical week and to identify the weeks during the period that fit the steady pattern and record those weeks on the calendar:
C: During this period when you were using marijuana, was your pattern of use similar from one week to the next? Although a person’s marijuana use will vary from day to day, I’m wondering whether there was any consistency from week to week.
The counselor starts with weekdays, beginning in one quadrant and moving through the week for that quadrant, the second quadrant, and so on:
C: Could you describe a usual or typical week of marijuana use? Thinking about a typical week, starting with weekdays, Monday through Friday, did you normally use marijuana in the morning, between 6 a.m. and noon?
This phrasing encourages the client to report use in the morning. The client points out variations in day-to-day use (e.g., I smoke before I go to work on 2 mornings a week). The counselor records variations on particular days. After constructing the morning quadrants, the counselor proceeds until all the appropriate quadrants have been checked to establish the weekday pattern. The counselor then asks about weekend use. This exercise reveals the client’s steady use pattern during the assessment window.
The counselor and client now turn to reconstructing the client’s use on days when no pattern exists. If the client reports no consistent pattern, the entire assessment window must be constructed one day at a time. For days not covered by pattern or abstinent days, the counselor focuses on days immediately before and after invariant periods (such as periods of abstinence and steady pattern use):
C: What happened at this point? How did your marijuana use change?
To help the client recall use, the counselor focuses on events that affect the availability of marijuana and the client’s marijuana use (e.g., hospitalizations, family outings, work changes). The counselor pays close attention to inconsistencies in the client’s descriptions of marijuana use and asks questions to ensure that the information is accurate.
Complete the TLFB Grid
The TLFB Grid (form AS2) is used to summarize and record calendar data and to monitor changes over time. The grid provides spaces for the counselor to total the days of use under various categories. When the information is presented on the grid, the counselor and client see use patterns emerge (e.g., the client usually smokes late at night or before work). Additional grids can be filled out in later sessions and compared with this baseline grid to monitor changes over time and help determine causes for slips or relapses.
Complete the TLFB Marijuana Use Summary Sheet
The counselor uses the TLFB Marijuana Use Summary Sheet (form AS3) to gather additional information about the client’s marijuana consumption prior to entering treatment. The counselor asks questions that help the client think about and summarize his or her marijuana use, including use in hazardous situations (e.g., taking care of children, driving). The TLFB Marijuana Use Summary Sheet increases awareness of the frequency of using marijuana, other drugs, alcohol, and tobacco and often elicits concerns from the client. These stated concerns can increase motivation to change.