Treatment Program for Marijuana-dependent Teens who display symptoms of Schitzophrenia: The We Recover for Life Program
Brandon Bruce Dellario LMSW LASAC
Abstract
In recent years, it has become apparent that many people suffering from the disease of addiction have also been diagnosed with mental illness.
In one study it was found that 23% of people diagnosed with serious mental illness have substance abuse or dependence disorders (Inaba, 2007). Other studies show this number to be closer to 60% or 80%. We term these individuals “Dual Diagnosis” or, with “Co-occurring Disorder.” But, what is the relationship between substance abuse and psychosis? “Cannabis use in particular is widespread, both in the general population but especially so amongst people with serious and enduring mental illness, particularly psychotic illness” (Macleod, 2007).
Sadly, many of the people suffering from dual diagnosis, put themselves into dangerous situations which can be very destructive for a person in such a vulnerable condition. “Substance abuse is associated with an increased risk of motor vehicle crashes, emergency department admissions, and suicide” (Griswald, 2007). Marijuana use in general can impair brain activities. Like short-term memory, judgment, learning ability, coordination, and the ability to follow moving objects are all impacted. It can also decrease testosterone and sperm production or harm the heart, lungs and immune system (Gignac, 2005). The drug buying and selling environment is condusive to high-risk sexual practices, disease, violence and other unsafe conditions. Substance abuse often counteracts and even mixes poorly with psychiatric medications. This population also spends a large amount of their income on drugs, (Inaba, 2007) occasionally stealing or selling themselves for money. These factors result in a poor environment for rehabilitation and an increase of psychotic breakdowns.
The population of people suffering from Dual Diagnosis can be divided into several groups. There are patients in the private system (with upper echelon insurance), and those in the public system who are either compliant or non-compliant with the programs offered by the community. There are high functioning subjects who take an active role in their own recovery, and there are severely dysfunctional patients who have trouble living in or out of the psychiatric hospital. Rich or poor, man or woman, old or young, the reality is, everyone is at a different level of sickness and we must focus on a small cross-section of this large population if we are to find and offer solutions of resolve.
“Earlier treatment potentially could avert lifelong disorders“ (Griswald, 2007). This program will focus on all males age 17-26 who abuse Marijuana and have been diagnosed with schizophrenia. 60% to 75% of adolescents with mental illness also suffer from substance use disorders (Griswald, 2007). This may be explained by environmental factors like poor parenting, parental substance use and childhood mistreatment, “and psychological dysregulation (i.e., delayed development of behavioral, emotional, or cognitive regulation)”(Griswald, 2007). Many studies show that young men who use marijuana have an earlier onset of psychotic disorders. “Male cannabis users were found to have their first psychotic episode a mean of 6.9 years earlier than male nonusers, . . . (and) early onset is associated with a poorer prognosis of the disorder” (Veen, 2004). Since there is only a small number of cannabis-using women with schizophrenia, it’s hard to examine the interaction effect (Veen, 2004). Young male schizophrenics abuse cannabis much more than females and older males with schizophrenia (Veen, 2004).
Research
“While drug use is a concern to the general public, it is of particular concern in adolescents with psychiatric disorders“ (Gignac, 2005). Marijuana is the most popular drug of misuse and abuse in early adulthood (Gignac, 2005). “Recent studies suggest drug abuse and addiction are developmental disorders“ (Griswald, 2007).
The 2 questions raised are: 1) Is schizophrenia and cannabis use related? 2) What can be done to provide prevention and treatment for our current generation of young people?
“The ability of cannabis use to precipitate unusual thoughts or perceptions in users is not, generally, in question. These effects are typically acute, that is they disappear on sustained abstinence from cannabis. However, regular cannabis users excrete detectable drug metabolites for up to a month after abstinence and ‘acute’ (i.e. self-limiting) psychoactive effects may also be apparent over a long period” (Macleod, 2007). In addition, contemporary studies have proved over and again that marijuana abuse is involved in early onset of schizophrenia and other psychosis. Whether cannabis use is a cause or an effect, remains to be determined (Veen, 2005). “It is possible that cannabis makes manifest schizophrenia in young subjects who are genetically at risk for developing the disorder. According to this point of view, which has recently gained support from studies in the Netherlands and Sweden, some of the individuals would never have developed schizophrenia had they not used cannabis (Veen, 2004).
It doesn’t appear that these young schizophrenics are self-medicating when they abuse cannabis. “If such use genuinely reflected self-medication then one might predict that it would increase following periods where users felt worse. Instead, lower (rather than higher) depressive symptom scores at one assessment were associated with higher subsequent use of cannabis. Scales on the psychotic symptom scale showed a similar, albeit weaker relation” (Macleod, 2007).
A German study from Charite-University Medicine, Berlin found that long-term cannabis consumption can cause neurotoxic damage in nerve growth factor serum levels. “Nerve growth factor (NGF) is a apheliotropic neurotrophic protein that is implicated in development, protection and regeneration of NFG-sensitive neurones” (Jockers-Scherubl, 2005). They also found that cannabinoids affect catecholaminergic neurotransmission with exposure in the perinatal period, and reduce dopamine transmission in the frontal cortex. Data suggests that long-term abuse (2 or more years), and early adolescent use are contributing factors to psychosis when measured up to schizophrenics without a chronicle of marijuana abuse (Jockers-Scherubl, 2005).
Schizophrenia
Specifically, schizophrenia is a disease with no etiology which can only be measured in clinical practice (Pull, 2007). The definition of Schizophrenia is: “Any group of psychotic disorders usually characterized by withdrawal from reality, illogical patterns of thinking, delusions, and hallucinations, and accompanied in varying degrees by other emotional, behavioral, or intellectual disturbances. Schizophrenia is associated with dopamine imbalances in the brain and defects of the frontal lobe and is caused by genetic, other biological, and psychosocial factors”(Dictionary, 2000). Some of the distinguishing traits are hallucinations and delusions, disorders of thought, speech, behavior, emotions and affect, cognitive deficits and avolition (Pull, 2007). 80% of schizophrenics experience hallucinations and 90% have delusions (Pull, 2007).
Schizophrenia is anhedonic, which means that patients loose feeling or pleasure from things like enjoying sunsets, eating, drinking, singing, being massaged, or being with friends (Pull, 2007). Some of the cognitive deficits include decreased, “attention, memory and problem solving, …complex conceptual reasoning, psycho motor speed, new learning and incidental memory, and both motor and sensory perceptual abilities” (Pull, 2007). These factors will have to come into play in the treatment of schizophrenics. Avolition, or, the lack of will, may also be a barrier as to involving patients in goal-oriented activities (Pull, 2007).
“There have been many attempts to classify the courses of schizophrenia, but there is no universally accepted classification in this field. . . . studies of the course of schizophrenia indicate that there may be very different types of course, ranging from complete cure to severe disabling chronic forms. Some patients experience only one episode of illness, others have several episodes, and still others suffer from chronic symptoms”(Pull, 2007).
In treating schizophrenia, a “true team approach” (Kaplan, 1989). is crucial. “Members of the team must understand what other clinicians and therapists are attempting to do” (Kaplan, 1989). For instance, if medications are affecting the patients ability to get up early enough for an activity, the prescribing physician should relay that information to the activity coordinator. Or, vice versa, “certain types of environmental effects may necessitate dose adjustment” (Kaplan, 1989). As well as a synergistic relationship between treatment modalities where, “. . . one modality may be indirectly exerted through another, as when family therapy serves to enhance compliance with medication” (Kaplan, 1989).
The recommended length of stay for schizophrenics in acute treatment varies from practitioner to practitioner. They range from 1 week up to 6 months (Pull, 2007). One study suggests that patients who respond well to treatment show, “an amelioration of non-specific symptoms, such as sleep disturbance or anxiety and agitation, but also of positive symptoms within the first two treatment weeks” (Pull, 2007). There are treatment resistant schizophrenics, but those include all patients who do not endure the side effects of pharmacologic interventions (Pull, 2007). The majority of patients show a partial reaction in remittance of one of their symptoms, like fewer hallucinations or delusions, while other symptoms persist (Pull, 2007).
Treatment Program
With these findings in mind, we have devised a treatment program for these young, male schizophrenics. We will provide residential treatment for male schizophrenics, ages 17-26, for the treatment of marijuana dependence. This treatment will last from 2 weeks to 3 months depending on the opinions of our trained staff of psychiatrists, psychologists, counselors and administration.
Our Mission Statement: We wish to help and support addicts with psychosis to find relief of their symptoms through abstinence from all drugs outside of the necessary medications taken as directed. This is the first step toward recovery. Recovery being the recuperation of an individual to an acceptable state of health or well-being. We work to put our patients into activity with the recovering community and public agency programs that will aid them in transition to living on their own.
There are many 12-step programs which aid people in recovery from drug and alcohol addiction, as well as mental illness and every other kind of disorder. Narcotics Anonymous, Alcoholics Anonymous, Cocaine Anonymous, Dual Recovery Anonymous, Schizophrenics Anonymous and Celebrate Recovery. Peer support groups like “Recovery Group” at the Pathways Drop-in Center, 119 W. Vine St. in Kalamazoo, MI USA. This is a meeting specifically for people with mental illness or dual-diagnosis. Depression Bi-polar Support Alliance (DBSA) is an international peer-run organization for groups of mutual supporting peers in mental health recovery. There are many other community-inclusive programs for people in recovery worldwide. Also programs funded and supported through the various branches of Community Mental Health, Recovery Innovations of Arizona (RIAZ), The Appalachian Consulting Group and the Recovery Institute of Kalamazoo, MI (RI), to name a few. RI offers groups for aspiring artists, poets and musicians in recovery, groups for peers who are breaking stigma and improving mental health awareness in the community (such as Power Group), groups for peers who are teaching and learning from computer trainings, groups for those who wish to return or are currently attending high-school/college. Education in recovery tools, Wellness Recovery Action Program (WRAP), peers offering peers person-centered planning, self determination, techniques for self awareness & self monitoring, writing, yoga, exercise and health. Anything that fosters our patients to become part of our community and benefit their own recovery path.
Modalities
Our patients meet with one of our 5 counselors to plan the next weeks daily activities outside of the treatment center. They have the choice in-between ten 12-step meetings per week, or some combination of 12-step meetings and community inclusive programs. This is what we focus on directly after detox, in conjunction with other in-house treatment strategies. “Adolescents who benefit most from mutual help groups generally have severe substance involvement and feel they cannot stop or cut down on their own, . . . Groups counter their feeling of being alone, help them see that recovery is possible, and offer support” (Griswald, 2007). One study showed that, “individuals who attended group meetings 1 or more times a week for the first 6 months had lower rates of substance use 4 years and 6 years later, even after controlling for concurrent participation” (Griswald, 2007).
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines substance abuse as, “. . . regular use or abuse with several and more severe consequences” (Griswald, 2007). Substance use disorders are, “maladaptive patterns of use accompanied by clinically significant impairment or distress” (Griswald, 2007). Although criteria have not yet been established for adolescents, kids who start using before they are 18 are eight times more likely to develop substance dependence as adults (Griswald, 2007). Since substance use, abuse, dependence and induced disorders are all a problem in relation to psychosis, Our program will assess and cater to all substance use issues in our dual-diagnosis patients. We try to determine whether the psychosis or substance use disorder is primary by re-assessing the patient at one month clean (Griswald, 2007). Psychiatric medications are prescribed, reduced or eliminated by our 3 psychiatrists directly following detox whenever appropriate. “Although abstinence from substance use should proceed the use of psychotropic medication, there is a risk that untreated psychiatric illness will impede treatment initiation, precipitate early dropout, or interfere with achievement of abstinence” (Griswald, 2007).
We use cognitive-behavioral therapy techniques with our in-house treatment program. It has received the highest level of evidentiary support (Vaughn, 2004). “. . . cultural factors such as discrimination, acculturation, and ethnic pride influence treatment outcome” (Griswald, 2007). Every patient in our program will have an individualized, diversity-informed plan worked out with their counselors in one-on-one therapy. Our well trained staff who specialize in adolescent rehabilitation, will account for the important factors in developing a confidential individualized treatment plan. We incorporate motivational interviewing while accounting for cultural factors, age, sexual orientation, family history, peer attitudes, involvement with the justice system, lethality assessment, readiness to change, social and psychological functioning, “behavior factors such as verbal or physical aggression, academic difficulties, impulsivity, hyperactivity, depressed mood, and poor social skills” (Griswald, 2007). This helps us listen and encourage adolescents while creating an environment of positive change (Griswald, 2007). We look at the positives and negatives of their drug use, look at consequences, set goals while observing their current situation (Kouimtsidis, 2007).
Our counselors will express empathy, work with resistance instead of against it, and communicate free choice, self-efficacy and personal responsibility (Kouimtsidis, 2007). “Essentially this approach [motivational interviewing] aims to work with the clients perception of substance use rather than imposing the therapist’s external view of reality” (Kouimtsidis, 2007). Our program will involve the patient's voice in their own program, through person-centered planning and self-determination. We will assess and refer them to a case worker in the community while they are a resident. We screen for substance use disorders using the CRAFFT questionnaire (reliable tool for adolescent substance abuse screening) (Griswald, 2007). We will screen for mental illness using the GAIN (Global Appraisal of Individual Needs) assessment tool (Anon., 2006).
In our 50 minute group therapy sessions, we employ the Socratic method of question and answer. In this modality, patients are given the chance to reflect and find their own answers when given a series of questions by our counselors. “It allows clients to develop an awareness of their own beliefs and behaviors. By asking such questions clients develop an insight into their thought processes and how these influence their emotions and behavior. Accordingly the client becomes aware of inappropriate beliefs and is helped to challenge them and change the behavior” (Kouimtsidis, 2007). We use two other methods of therapy in our group sessions. One is the Downward arrow exercise where the client is asked variations of the question, “what does that mean to you,” or “if that were true what would it mean” (Kouimtsidis, 2007). Another is Imagery, where the patient is asked to remember and, in effect, re-live certain problematic experiences, “. . . so as to identify the emotions, thoughts and context associated with the problematic event or experience” (Kouimtsidis, 2007). Some of the topics of discussion in our groups are: Depression; anxiety; self-esteem; anger/aggression; impulse control; relationships; compliance with treatment; risky behaviors; criminal behavior; sleep management; trauma and abuse. (Kouimtsidis, 2007).
Activities that our clients participate in are: Daily journaling (Daily thought record); distraction chores like cleaning the house, laundry, gardening, mowing the lawn, etc.; physical exercise activities like hiking, swimming, lifting weights, yoga and frisbee; relaxation training in breathing and guided meditation. We also have a recreation area for movies, music, board games, ping-pong, billiards, and general socializing on the couches.
Family therapy is a crucial part of our treatment plan. Parents are screened for substance abuse, referred to treatment if needed, and educated about substance abuse and psychosis. We work with parents to keep alcohol and medications locked away in the home if the patient is living with them or spending any amount of time there (Griswald, 2007). Parents will be invited to attend family days in our facility where we have lunch, speakers, information and to spend personal time with their loved one. We use the proven, “emphasis on educating the patient and family members about the nature of schizophrenia and available treatments” (Kaplan, 1989), as well as medication management and substance misuse information. We talk about the common symptoms, signs and prognosis of schizophrenia and the patients relationship with family members, peers, lifestyle, work, school, etc. Our family therapy employs the systems-strategic method of demonstrating the ability of the family to modify it’s rules and reactions, even through direct conflict with the patient. (Kaplan, 1989). Through sessions, our families will learn problem-solving skills, how to cope with stress, rehearsal behaviors, modeling, feedback, social reinforcement, expression of feelings, naming feelings, active listening, requests for behavioral change, and reciprocity of conversation (Kaplan, 1989).
Evaluation
We will evaluate our clients success by keeping track of them by phone and contacting their case workers every 6 months post-treatment. Upon discharge, every patient will fill out a personal evaluation form to assess their own performance, as well as their perceptions of the strengths and weaknesses of our in-house structure.
Conclusion
“Peer groups play a vital role in promoting abstinence as well as abuse” (Griswald, 2007). We work to place our patients in contact with peers who are living a new way of life in recovery. In treatment, they live among other males in their age group. They are also encouraged to seek out more peers in the recovering community, outside of the treatment center, while steering clear of people who use. “Triggers” can be people, places, things, and high risk situations which are conducive to relapse.
Continuing care is what we aim for during our entire program. We aid our patients to be ready to actively pursuit their own recovery in the community. Yifrah Kaminer, M.D., M.B.A., co-director of research in the division of child and adolescent psychiatry at the University of Connecticut Health Center’s Alcohol Research Center, suggests, “Aftercare, more appropriately termed continued care, he said, can help prevent relapse and chronic disease. Unfortunately, he said, responsibility for continued care often is left to unmotivated clients who typically receive only passive referral to mutual help groups” (Griswald, 2007).
The expected outcome of our program for patients is involvement in the recovering community (12 step programs such as Dual Recovery Anonymous, Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous and the like), activity in other community inclusive programs, and with aid from public social service agencies such as Community Mental Health, The Department of Human Services, Social Security Administration . . . Our patients will become aware of their peers and peer groups in the community who support each other, develop friendships and learn how to stay clean together, all while actively participating in these programs offered by the community.
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