This article was published in the January/February issue of Viewpoint, the quarterly newsletter of The Psychotherapy Institute in Berkeley, CA. Although geared toward clinicians, I believe there's a lot here to think about for anyone.
*Clinical material has been disgusied so as to protect the identities of clients.
The Complexities of Working with Cannabis Use and Abuse:
Historical Context, Conflicting Ideologies, and Clinical Practice
By Sara Ouimette, LMFT
As psychotherapists, how do we think about clients who use cannabis? I suspect our opinions vary, based on factors such as race, culture, upbringing, value systems, personal experience, age, education, and so on. According to the National Survey on Drug Use and Health, “cannabis is the most commonly used illicit drug in the country,” and the Bay Area has the highest rate of use in the nation (Hughes, Lipari, & Williams, 2016). I believe that many of our perceptions of cannabis have been shaped by the prohibition and criminalization of this substance in the United States since the beginning of the 20th century. I also believe we have an ethical duty to educate ourselves on this history, as it informs both the collective and the personal unconscious and is largely unknown.
Humans have been using cannabis for thousands of years (DEA Museum, n.d.). In the United States, cannabis was a common medicine and was openly sold in pharmacies in the late 19th century. So how did cannabis come to be prohibited in this country? According to Burnett and Reiman (2014), to understand the current picture, we must go as far back as the Mexican Revolution (1910-1920) and fear of Mexican immigrants in the early 1900s, which ultimately led to the initial “demonization” of cannabis in the United States:
When the media began to play on the fears that the public had about these new citizens by falsely spreading claims about the “disruptive Mexicans” with their dangerous native behaviors including marihuana use, the rest of the nation did not know that this “marihuana” was a plant they already had in their medicine cabinets… The idea was to have an excuse to search, detain and deport Mexican immigrants. That excuse became marijuana. (Burnett & Reiman, 2014, para. 3)
Following a propaganda campaign that included the notorious film Reefer Madness, Congress passed the Marihuana Tax Act of 1937, placing an excise tax on medical and industrial uses of cannabis (hemp), and established punishments for evading the tax. The congressional hearings took only two hours. Ironically, they included medical testimony from Dr. William C. Woodward, Chief Counsel to the American Medical Association, who concluded, "The American Medical Association knows of no evidence that marihuana is a dangerous drug.” One of the Congressmen responded, "Doctor, if you can't say something good about what we are trying to do, why don't you go home?" (Whitebread, 1995, “The Marihuana Tax Act of 1937,” para. 23).
The changing cultural climate of the 1960s made cannabis use more widespread among the White middle class, and in 1970, Congress passed the Controlled Substances Act, establishing official U.S. drug policy. The act categorized cannabis as a Schedule I substance, defined as substances with “no currently accepted medical use and a high potential for abuse” (DEA, n.d.). The act also established the National Commission on Marihuana and Drug Abuse (later known as the Shafer Commission) to look into cannabis use among Americans, potentially in order to re-evaluate the harsh criminalization of marijuana and differentiate marijuana from more harmful drugs. Yet despite an extensive report by this bipartisan, Nixon-appointed commission favoring decriminalization of marijuana possession, the Nixon administration retained the classification of cannabis as a Schedule I substance. Both Nixon’s War on Drugs and Nancy Reagan’s “Just Say No” campaign targeted cannabis, establishing a cultural climate that in large part continues today.
(The Shafer Report, entitled, Marihuana: A Signal of Misunderstanding, is a fascinating, comprehensive, and highly informative read, highlighting some remaining misconceptions about the substance. A copy of the Shafer Report can be found here.)
Why did the Nixon administration ignore the Shafer report? According to Dan Baum, who interviewed Nixon aide John Erlichman in 1994, it was because using marijuana as a tool of oppression and control took precedence (Baum, 2016). Baum reports that Erlichman stated:
The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people. You understand what I'm saying? We knew we couldn't make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders. raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did. (Baum, 2016, para. 2)
Not too long after cannabis was deemed nonmedicinal and highly addictive, the theory that mental illness is caused by chemical imbalances in the brain that can be corrected with the proper drug became widely accepted. In the late 1970s, on the heels of the Controlled Substances Act, psychiatry boomed “by fully embracing the biological model of mental illness and the use of psychoactive drugs to treat it. … By emphasizing drug treatment, psychiatry became the darling of the pharmaceutical industry” (Angell, 2011, para. 5). Many of those drugs—pharmaceuticals like Xanax and Valium—we now know to be highly addictive and to have harmful, dangerous, and potentially lethal effects and consequences.
Big Pharma has also played a role in supporting the prohibition of cannabis. A 2015 clinical review published in the Journal of the American Medical Association found evidence that medical marijuana was effective in treating chronic pain (Hill, 2015). In contrast, the CDC reported that in 2014, “the majority of drug overdose deaths (more than six out of ten) involve an opioid. … 78 Americans die every day from an opioid overdose” (CDC, 2016). When doctors have the option of prescribing medical marijuana for their patients on Medicare, there is a notable drop in prescriptions for other drugs (Bradford & Bradford, 2016). Perhaps not surprisingly, pharmaceutical companies, specifically the ones that make painkillers, made the largest campaign contributions to oppose cannabis legalization efforts in Arizona in 2016 (Sanchez, 2016).
The few research findings about the benefits and/or dangers of cannabis use are mixed. According to a study published by the Clinical Psychology Review, evidence suggests that cannabis has the potential to treat social anxiety, depression, and especially PTSD, but it can be problematic for those with psychotic disorders (Walsh et al., 2017). A study published in JAMA Psychiatry found no significant correlation between cannabis use and anxiety disorders or depression, but it did show a correlation between cannabis use and increased risk for other substance use disorders (Blanco, Hasin, & Wall, 2016). A meta-analysis of longitudinal studies published in Psychological Medicine found a possible association between cannabis use and risk of depression (Lev-Ran, Roerecke, Le Foll, George, McKenzie, & Rehm, 2014). There is controversy around the potential physical dangers of cannabis, including addiction. Physical withdrawal symptoms such as irritability and discomfort have been reported among heavy users, but no cases of death from overdose or withdrawal have been reported (NIH, 2016). Medical cannabis is also currently being used as a less harmful substitute to help treat opioid addition (Villani, 2015).
Have we, as a nation and as clinicians, been propagandized to believe that cannabis is harmful and ineffective by the very same systems that oppress people of color and maintain the status quo of corporate profits in the pharmaceutical industry? Is this an ideology that needs re-evaluation? I believe it is. Now that cannabis has been legalized for recreational use in California and the medical and psychiatric benefits of cannabis are becoming more widely accepted and sought out by patients (including our clients), how do we proceed in working with this substance as clinicians?
I see cannabis as a highly complex substance that lies in a unique category of its own in comparison with other drugs. Nobody has ever died from a cannabis overdose. As far as addiction, dependency seems to be more of a psychological nature than a physical one. Not enough research exists to say definitively just how beneficial cannabis might be for psychiatric conditions, but research on cannabis as a treatment for PTSD is picking up speed. At the same time, cannabis is a mind-altering drug, and therefore responsible and informed use is a critical consideration. The cannabis industry is exploding, and so is an entire “cannabis culture.” Today’s cannabis products are overwhelmingly diverse. They include edibles, flowers, oils, waxes, creams, patches, tinctures, capsules, and more. Different strains of cannabis have drastically different effects, ranging from mentally stimulating to sedating to no mind-altering effect (as in the case of canabidiol, or CBD), and each person’s unique body chemistry may also come into play. Level of THC, method of ingestion, and dosage will dramatically impact a person’s experience on cannabis.
The approach I take with my clients who use cannabis is based on the harm reduction model. One of the underlying principles of this model is that drug use is part of our current societal reality; therefore, reducing the harm associated with this use is the most effective way to protect the public. I believe this to be true of cannabis. Due to the complexity of the substance and the potential medicinal benefits, the goals I form with my clients don’t always include working toward abstinence. The harm reduction model I use is noncoercive, collaborative, and client-centered. I aim to assist my clients in obtaining a quality of inner life that best serves them, and I do this by encouraging my clients to think critically about their use and its benefits and negative consequences. This is basically motivational interviewing. What I often find is that many clients believe that cannabis is a less dangerous substance than benzodiazapines for anxiety or opiates for chronic pain.
Cannabis use can vary from recreational to medicinal to misuse, abuse, and addiction. One of the things I enjoy about working with the use of this substance is the complexity of it. When I know my client uses cannabis, I ask about it. I assess for frequency, method of ingestion, where they use, when they use, how much they use, and how informed they are about the substance. I do have concerns about a relatively recent method of ingesting cannabis called “dabbing.” Dabbing is a way of vaporizing cannabis concentrates at extremely high temperatures that delivers a rush of THC to the brain, resulting in high levels of immediate intoxication (including possible loss of consciousness).
A client of mine who was a frequent, daily cannabis user initially sought treatment for relationship issues and work-related stress. This was a highly driven, intelligent, motivated, and, at times, obsessive individual who was raised in a home marked by domestic violence over many years. For this client, cannabis and work were tools for avoiding emotional pain and numbing his anger, fear, and self-loathing. Deeper exploration revealed that cannabis also functioned as a protective barrier, a solitary way of maintaining distance from others due to a deep sense of shame and fear around his vulnerabilities. As we explored and acknowledged the pain behind his use, childhood traumas, and the importance of addressing and accessing this pain in therapy, he began to become increasingly ambivalent about his lifestyle, including cannabis use/abuse.
There were many times in the earlier phases of treatment that he would come to his session under the influence of cannabis. I agreed to work with him in this state, exploring what may have contributed to his use before coming to therapy as well as what it was like to be with me altered versus unaltered. I noticed that when he came to session after having used cannabis, he seemed significantly calmer, certainly sedated, but not so much so that we couldn’t have a meaningful session. In fact, to my surprise, the only times my client cried in therapy were when he was under the influence of cannabis. This made me wonder about the various ways cannabis functioned for him. Paradoxically, the same tool he used to maintain distance from others also became the route by which he could access deeper feelings and expressions of vulnerability with me. Now the work has become about getting to those feelings, tolerating the pain, and being with me unaltered and at his pace.
In our work, each case is unique. For me, the same goes for working with cannabis use. I approach my clients’ use with genuine curiosity and compassion. I do not try to coerce; I aim to empathize and collaborate, keeping in mind the history, cultural context, and both state and federal laws regarding use of this substance. Although cannabis use is a highly controversial topic, I do not hear much discussion about it in our professional community. With articles like “Medical Marijuana for Psychiatric Disorders” posted in Psychology Today (Spiegel, 2013), clinicians might need to consider taking a closer look at our framework when it comes to approaching this substance. Considering the common use of cannabis, its political history, and the current political and cultural controversy surrounding it, I strongly encourage all therapists to examine their own conscious and unconscious beliefs about this substance and its place in the work we do.
Angell, M. (2011, July 14). The illusions of psychiatry. The New York Review of Books. Retrieved from http://www.nybooks.com/articles/2011/07/14/illusions-of-psychiatry/
Baum, D. (2016, April). Legalize it all: How to win the war on drugs. Harper’s Magazine. Retrieved from http://harpers.org/archive/2016/04/legalize-it-all/
Blanco, C., Hasin, D. S., & Wall, M. D. (2016). Cannabis use and risk of psychiatric disorders: Prospective evidence from a U.S. national longitudinal study. JAMA Psychiatry, 73(4), 388-395.
Bradford, A. C., & Bradford, W. D. (2016). Medical marijuana laws reduce prescription medication use in Medicare Part D. Health Affairs, 3(7), 1230-1236.
Burnett, M., & Reiman, A. (October 9, 2014). How did marijuana become illegal in the first place? Drug Policy Alliance. Retrieved from http://www.drugpolicy.org/blog/how-did-marijuana-become-illegal-first-place
CDC. (2016) Drug overdose deaths in the United States hit record numbers in 2014. Retrieved from http://www.cdc.gov/drugoverdose/epidemic/index.html
DEA. (n.d.). Drug scheduling. Retrieved from https://www.dea.gov/druginfo/ds.shtml
DEA Museum. (n.d.). Cannabis, coca, & poppy: Nature’s addictive plants. Retrieved from https://www.deamuseum.org/ccp/cannabis/history.html
Hill, K. (2015). Medical marijuana for treatment of chronic pain and other medical and psychiatric problems: A clinical review. JAMA, 313(24), 2474-2483.
Hughes, A., Lipari, R. N., & Williams, M.R. (2016, July 26). Marijuana use and perceived risk of harm from marijuana use varies within and across states. The CBHSQ Report. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from http://www.samhsa.gov/data/sites/default/files/report_2404/ShortReport-2404.html
Lev-Ran, S., Roerecke, M., Le Foll, B., George, T. P., McKenzie, M., & Rehm, J. (2014). The association between cannabis use and depression: A systematic review and meta-analysis of longitudinal studies. Psychological Medicine, 44, 797-810.
NIH. (2016). Drug Facts Chat Day: Marijuana. Retrieved from https://teens.drugabuse.gov/national-drug-alcohol-facts-week/drug-facts-chat-day-marijuana
Sanchez, Y.W. (2016, September 8). Anti-marijuana’s biggest campaign donor? Chandler pharma company. AZCetral. Retrieved from http://www.azcentral.com/story/news/politics/elections/2016/09/08/anti-marijuana-campaigns-biggest-donor-chandler-pharma-company/89981456/
Spiegel, J. (2013, March 11). Medical marijuana for psychiatric disorders. Psychology Today. [Transcript from a podcast.] Retrieved from https://www.psychologytoday.com/blog/mind-tapas/201303/medical-marijuana-psychiatric-disorders
Walsh, Z., Gonzalez, R., Crosby, K., Theirssen, M. S., Carroll, C., Bonn-Miller, M. O. (2017). Medical cannabis and mental health: A guided systematic review. Clinical Psychology Review, 51, 15-29.
Whitebread, C. (1995). The history of the non-medical use of drugs in the United States. [Speech to the California Judges Association 1995 Annual Conference]. Schaeffer Library of Drug Policy. Retrieved from http://druglibrary.org/schaffer/history/whiteb1.htm
Villani, C. (2015, Oct. 4). Doctors pioneer pot as an opioid substitute. Boston Herald. Retrieved from http://www.bostonherald.com/news_opinion/local_coverage/2015/10/doctors_pioneer_pot_as_an_opioid_substitute