The Marijuana Mentality

People have been puffing the magic dragon for decades, but only recently has it been thrust into the spotlight as it gained acceptance as a medicinal treatment in 1996 and a legalized recreational drug in Washington and Colorado in 2014. It has become so commonplace in the world that many police officers don't even find it worth the paperwork to prosecute cheeky teens caught with the grass and the DEA doesn't really bother the dispensaries around the country, even though it is still technically federally illegal. Probation departments are eliminating marijuana from their scores of drug testing and some companies are not even screening their new hires for it anymore. But mental health services are falling behind and slipping back into the dark ages in terms of how we approach marijuana use with our clients. Are we benefiting our clients by demonizing their vices and making a federal case out of their nearly-legal behaviors? Is it hurting them as much as we believe it is? Can we even utilize marijuana to help alleviate their symptoms?

More and more clients are flooding our facilities with regular marijuana use, demanding that secondary diagnosis of substance use/abuse/dependence, along with that lovely 30xMJ coding for our DMH Dual Diagnosis requirements. Once mentioned, eyes roll, heavy sighs fill the air, judgment clouds the room, and the client is cast in the same group as meth-heads and heroin addicts when their use is revealed in supervision. An admission of bong possession automatically elicits referrals to substance abuse programs, unsolicited psychoeducation, and numerous nagging sessions about how the client needs to stop smoking out. In essence, we waste a lot of resources on drug treatment and drug discussions on clients who don't want it and may not need it. Though they smoke are we genuinely and accurately assessing the impact marijuana has on their disorder and whether it contributes to a functional impairment? And in the long run, the constant chiding can damage the therapeutic relationship when the client gets tired of you acting like their mothers.

Let me note now that I have never smoked/ingested marijuana in my life, and I don't plan to, but I appreciate a good glass of wine/beer and the occasional bit of liquor. This is hardly a concern for my doctor, and no one in my life circle has approached me out of fears for my well-being because I enjoy a drink once in awhile after a hard week at work. Like alcohol, many individuals smoke marijuana socially, to relax, to have fun, to unwind after a tough day without any presenting functional impairment. But for some reason, they get twice the judgment. Ironically, they may suffer half the consequences. Naysayers for marijuana screech about the effects on the lungs, the heart, the brain, but the effects of alcohol on the liver and brain and carries with it a significantly higher risk of death. Marijuana does not have definitive research on the long term health effects, but it has been shown that marijuana does not impact lungs the same way that cigarettes does, and there is virtually no risk of overdose. And beyond the scope of recreational purposes, medical marijuana has been soothing the ill for years.

Much research has been done on the effects of THC on various physical ailments, such as reactions to chemotherapy, glaucoma, pain management, Multiple Sclerosis, and seizures, just to name a few. Unfortunately research into the effects of marijuana on mental illnesses is much more limited, likely in part because there are still so many stigmas they're fighting (organizations like NAMI continue to battle marijuana use, citing increased symptomology, the inevitable opening of the drug gateway, and criminal behaviors). Because of this limited research, many articles and agencies discuss the known side effects of marijuana on emotionally healthy individuals while disregarding the effects of marijuana on the mentally ill and the possibility that it may reduce symptoms of significant emotional disorders.

How many times have we heard about our clients' marijuana use as self-medication? "It helps me sleep," "it calms me down when I'm anxious or stressed," "the voices aren't as loud after I smoke." Many mental health professionals have balked at this because of the research they know about the bud. I vividly remember my client telling her psychiatrist the weed helped reduce her voices and calmed her manic episodes, and he vehemently spat back "No, it doesn't! It does not help you!" as if he had recently taken up residence in her chaotic mind and could dictate to her her own feelings. Here's what these doctors actually know: it has been shown over time that mentally healthy people can, at times, suffer from reactions to marijuana which increase anxiety and paranoia. Mentally healthy people may experience hallucinations and delusions when under the influence. Mentally healthy people may show signs of depression when high. All of which is true. But another fact is certain strains of marijuana are depressants (not 'boo-hoo I'm sad' depressants, but 'chemicals that slow the cognitive processes of the brain' depressants). Depressants can be used to calm the sympathetic nervous system, slow the synaptic firings of the axons, reduce the heart rate, and relax tension in the body (all physiological symptoms of anxiety and mania). One small study at Harvard found that marijuana calmed the brains of bipolar individuals considerably. Adversely, there are strains of marijuana that are stimulants, which activate the brain, increase energy, alertness, and motivation, which could in turn assist with symptoms of depression and ADHD. And considering that we give kids with ADHD amphetamines like it's candy, would it hurt to invest in researching a less harmful and more natural drug?

The reality is there are still side effects to marijuana, and while the research is lagging, some studies have definitely found a link to cognitive difficulties in children and young teens who smoke, mainly because their brains are still developing (these effects were not found in young adults who began smoking after the age of 18). But the harsh truth is also what was briefly alluded to before, that our prescription medications are just as if not more dangerous. The synthetic chemicals we pump into each pressure molded tablet have several concerning side effects that can impact our children for years to come (ask the young males who developed breasts after taking Risperdol). With many popular drugs, we still do not know what long term effects will impact a young child's brain and many of these medications were developed for young adults and older adults before they were haphazardly doled out to our youth. So if we're going to scream about dangerous drugs, let's talk about your medicine cabinet. That is, if your rebellious teenager hasn't sold everything in them to the junkies on the street yet.

But if we let our kids have marijuana, can't that lead to other more intense and dangerous drugs? Here's the thing about the gateway myth: if the drugs are being used recreationally, clients have no greater risk of graduating to crack or heroin than you have of becoming an alcoholic because you had a glass of wine watching Game of Thrones last Sunday. The ironic thing is the risk becomes greater when individuals abuse marijuana as a form of a coping skill or self-medication, to numb themselves. So why the hell am I advocating for marijuana in mental illness, you ask? Because prescribed and controlled, it is no longer self-medicating; you are under the care of a physician, which is no more dangerous than taking Zoloft or Adderall as prescribed. And if you teach your clients appropriate coping skills in addition to their new medication and assist them in processing their illness, as we do with therapy and psychotropic treatments, the illness should gradually become manageable as it would any other way. Thus, eliminating the need to bury or numb the suffocating emotions and devastating poisonous thoughts.

So with all this talk of Mary Jane tolerance, what is our role as a mental health provider when our client says they smoke weed? Well, the first step would be to determine if the weed is impacting their mental stability or contributing to their diagnosis (this is hard to do because again, there's no research on it). More importantly, assess for functional impairment, much like you would when you're determining if the client is a social drinker or an alcoholic. If they smoke weed on the weekends but their grades are good or they're going to work on time every day, I'd say the weed's not a big issue at the moment. If they are flunking school because they'd rather stay home and hot box the day away or if they smoke then go drag racing, it's time to grab the drug brochures and write down that 800 number.

In regards to medicinal use, aside from the abundance of studies we still need to wait on, it is crucial to acknowledge that while marijuana may someday be an alternative to prescriptions, many factors need to be considered and reviewed before the client could be advised to keep smoking. The doctor would have to take into consideration the client's diagnosis, mental health history, physical health, and family history. For example, if the client does not have schizophrenia, but there is a strong family history for it, you're not going to want to provide a drug that could trigger their first psychotic break. But with research comes information and precautions: knowing the right type of marijuana strain for which disorder, knowing what the recommended dosage should be, ensuring that the client is getting pure medicinal marijuana and nothing laced or synthetic that they may pick up on the streets, and providing education for safe use and risk reduction.

There are so many unanswered questions, but just because we are unsure of the unknown doesn't mean that we should demonize our clients for doing generally the same thing we do with our drinks, or that we should disregard the potential for a drug that is already helping many people with medical illnesses. As we know, science is a living breathing creature that is always growing and changing. Years ago they said marijuana caused cancer, now they not only use it in cancer treatment, but developing research is showing marijuana can kill certain types of cancer cells. So who knows what we will find in the future. For now, chill. Legalization is coming, and with it will require a whole new approach to drug assessment and treatment, and we should be ready.

The Love Song of the Depressed

Today is World Poetry Day, a day celebrating the penned works of many artists throughout the centuries around the globe, many of whom struggled with their own mental illnesses, emotional disturbances, and deep, personal demons. Much like those who created them, the characters in many of these proses mirror their own existential chaos and provide a fictional window into the minds of our clients and their daily struggles. In The Love Song of J. Alfred Prufrock, by T.S. Eliot, the eternally downtrodden J. Alfred is reflecting back on his somber journey through this world and making a self-appraisal of what he has become today. But in the daily depression and devastation his life had become, Prufrock found comfort in the monotony of it all. In spite of living in misery, it was unvarying, unwavering consistency; though things never got better, they could never get worse. This doesn't mean, however, that he never dared to dream of what could have been. In a moment he asks himself "Do I dare disturb the universe?" Do I dare to break through this carefully arranged mortality of gloom and despair and try to seek out some light, some happiness? Do I dare risk the disappointment and heartache I may find if I am unsuccessful? Do I dare to change my life?

This is a question many of our clients face before they decide to seek mental health services, and some are still grappling with it well into the middle phase of treatment. We typically refer to this as resistance. But the term resistance indicates some underlying tone of opposition or defiance, and can be a very superficial perception of what our clients are truly struggling with. Sometimes it can be frustrating when our "resistant" clients refuse to follow through with our recommendations. Sometimes we want to pull our hair out when they just come to session to vent on a repetitive cycle of grievances rather than to try and work with you to find solutions that can end these daily tribulations. I once had a client who, after two years of treatment with little to no progress, openly admitted that she didn't want help, she did not want to get better, she did not want solutions, she only wanted "someone to complain to." Unfortunately, after verifying once more that she would not willingly work towards her treatment goals and personal betterment, we closed the case and I left her in her dark void.

But this is not often the outcome for clients of county-contracted agencies. In a private practice, if a therapist determines that the individual is not truly ready for treatment, they can recommend that services stop at that time. In fact, it's unethical for a therapist to continue seeing a client and taking their payments knowing that they are not in a frame of mind to benefit from treatment. But in our agencies, we are rarely permitted to close a case simply because they are not ready. We fight and sweat and scream and cry trying to get our clients to that place where they might be ready. And it's rarely an easy task.

Much like our dear Mr. Prufrock, I had a client just last week who is struggling to find her own motivation to disturb her universe. Having been in a depressed state for the better part of 15 years, she was at least insightful enough to recognize that she prefers being on rock bottom. "If I'm at my bottom, there's nowhere to fall. It's steady, it's stable, and I'm okay here. I'm unhappy, but it's safe." She continued "if I get up, if I start climbing that ladder out of my hole, soon I will be above the ground, and then if I slip, I'm going to fall farther down again, and I'm too scared of that. I'd rather just stay here." Another colleague of mine discussed a similar situation with her own client today, finding herself struggling with his refusal to utilize any of the interventions or tools that she provided. And again, this is not outright defiance, this is not him yelling in her face "I don't want your help and I'm not going to use your stupid mind tricks!" This is simply him staring blankly at her with resounding "I don't knows" whenever she asked him questions about how to help himself. They've gone over this multiple times. He knows. He is simply too scared to take the help. You're drowning, but relaxing and sinking to the bottom of the sea is easier than kicking and fighting to keep your head above the surface. Depression is just easier. Not better, but easier.

This is a battle I'm all too familiar with after recovering from a 12 year bout of depression myself. Especially given that I was diagnosed when I was 9 and probably had symptoms much earlier than that, I didn't much recall what it was like to be happy. As I meandered through my teens, as my demons grew larger and my world became darker, it was hard to see any light that may have been shining through that darkness. But this was my life, the only existence I have ever really known, how could I leave it behind? I remember thinking the same thing my client did: at rock bottom, there's nowhere else to fall. When I was 19, after one too many days in Hell, I finally made the choice to disturb my own universe; I finally realized no matter how scary that risk might be, it couldn't have been worse than the fate that awaited me if I stayed in that eternal night. I was 21 by the time I was fully recovered, and even since then I've had a few slips here and there and I've fallen down a few rungs on my own ladder, but one must tighten their grip and climb back up the best they can. As part of the depression game, sometimes the lack of motivation and the hopelessness our clients are enveloped in make it damn near impossible to get them to jump over that abyss and start moving forward in their lives. Sometimes you have to be their tireless cheerleader, sometimes you just have to sit with it, meet them where they're at, and wait until they reach their own awakening, which only they can do alone. Sometimes, they need a little friendly therapeutic push. As I've told my clients, you may fall, but if you try you have a 50% chance at succeeding and finding happiness. If you don't try, you have a 100% chance of failing and feeling this way forever. So let me know when you're finally sick and tired of being sick and tired.

I had been in therapy off and on for a few years in my teens, but with a therapist who never challenged me and me not yet ready to challenge myself, I stayed stuck far longer than I should have or needed to. I will never get that childhood back, but I want to save my clients from the same fate of wasted time. Some clients need that reality check and some clients need a little more empathy and unconditional positive regard to guide them to this final realization. Sometimes we as therapists need to recognize that resistance for what it really is, comfort in familiarity and fear of the unknown; we need to understand it, and we need to address it appropriately. Sometimes I share with my clients this solemn love song and Prufrock's tale of woe. For me, this poem has become my mantra, and I have the famous line tattooed on my shoulder, just in case I need to glance in the mirror and give myself a little reminder to never stay stuck for long, wherever I may find myself. Just because it's comfortable, does not mean it's where I'm meant to be.