5 Tips for Opening Meaningful Discussion With Cannabis Users

While harm reduction is a term most often used in treating problematic drug use, all therapists strive to reduce the harm done by a wide variety of self-damaging thoughts, feelings, and behaviors. This post describes the harm reduction strategies I developed to open meaningful discussion with cannabis users, some of whom are using too frequently to maintain good brain health, and most of whom are wary of any therapist’s agenda in initiating conversation about their use.

In a previous post, I described why many cannabis users are immediately put off by anyone who begins discussing cannabis by warning of its risks and potential for harm, even when their warnings are based on sound scientific evidence. The objective perspective from which such warnings come is often seen as doing disrespect, and even violence, to the more important subjective perspective held by the cannabis community. For them, cannabis has many meanings and great value that is not understood by a purely scientific approach. As a result, beginning a discussion with the potential risks presented by cannabis immediately increases most users’ defensiveness, thus closing off conversation and reducing any trusting therapeutic alliance therapists need.

Tip number one for therapists trying to open a meaningful conversation with cannabis users is to avoid any mention of risk, warnings of potential harm, and absolutely any use of the words “addiction” and ‘dependence." In the classic words of psychodynamic psychotherapy, “Honor the defense before analyzing the impulse.” This is also the essence of "motivational interviewing," which puts a premium on not activating a patient’s/client’s defenses.

Tip number two is to cultivate the internal attitude necessary to practice motivational interviewing effectively. An authentically nonjudgmental curiosity is essential, and far easier to prescribe than to embody. Not every cannabis user’s experience is the same, and it is the therapist’s first task to explore a detailed description of how each individual experiences being high. Many adolescents are especially not well practiced at putting their internal experience into words, so it is often necessary to suggest possible elements (e.g., relaxation, increased appetite, synesthesia, freshening of perceptions) without putting your words into their mouths. The goal of this exploration is to identify their most valued aspect of being high (e.g., lack of anxiety, sense of novelty, etc.).

Tip number three involves preparation needed before entering conversations with cannabis users. Become science literate about cannabis—and not just knowledgeable about the botany of cannabis, but also knowledgeable about the brain’s endogenous cannabinoid system and the impact of THC on brain function. You might take a look at my post "Test Your Science Literacy About Cannabis" to assess your knowledge about cannabis. I have summarized the important scientific information about cannabis in my two books, From Bud to Brain and Marijuana on My Mind, both published by Cambridge University Press.

The goal of becoming scientifically literate about cannabis is to be able to provide fascinating information to cannabis users about how THC produces the elements of being high they most value. I first ask people what they know about how cannabis produces a high to assess their level of understanding, and if they are open to my telling them a bit more of what I know. For example, I enjoy telling people about how the brain contains THC-like chemistry on its own (anandamide) and receptors (CB1) concentrated in different parts of the brain. If they like "the munchies," I talk about CB1 receptors in the hypothalamus and amygdala that increase appetite for comfort foods when activated and decrease appetite when deactivated. If they like experiencing the world as novel and interesting (e.g., the rainbow on every bubble in soap suds), I talk about how THC-activated CB1 receptors in the amygdala lower the bar for sensations to capture our attention. It is less necessary that patients/clients understand every aspect of my explanation as it is important for my own enthusiasm and fascination for learning how cannabis works to be infectious. At its best, we form a mutual alliance around understanding how cannabis works to produce what they like about being high.

Tip number four involves recognizing when a strong enough therapeutic alliance exists for you to be able to begin introducing some inconvenient truths without breaking the trust that has been developed. This is a judgment call based on each therapist’s experience and intuition. The tip is that most cannabis users are willing to entertain less positive information about cannabis once their personal perspective has been respected. The inconvenient truth is that THC’s strong activation of CB1 receptors, which is so pleasant for many, begins to downregulate the receptors. When used too frequently, cannabis reduces the number of natural cannabinoid receptors by 20-60 percent in different brain areas. To explain the impact of this downregulation, I often tell how rimonabant (a CB1 receptor blocker) was used to reduce appetite in overweight people. It worked, but the side effects of agitation, anxiety, insomnia, and depression were severe enough rimonabant was taken off the market. Bottom line is that our brain needs well-balanced natural cannabinoid chemistry to maintain good mental health.

Tip number five is that most people can use cannabis safely. Populations at highest risk who should avoid cannabis are youth, pregnant women, and individuals with mental health and addiction issues. Safety depends on understanding the five signs of using cannabis too frequently (restlessness, anxiety, boredom, loss of appetite, and insomnia). When working with adolescents, additional information about the impact of THC on brain development, not contained in this post, is necessary. When patients/clients become interested in assessing whether they are using cannabis safely, they can be referred to my post, "20 Questions to Tell if You're Using Cannabis Safely."

It is a rare cannabis user who cannot be engaged in meaningful dialogue about their use when the five tips outlined above are followed with an authentically nonjudgmental attitude.