Stigma, Mental Health, Addiction, Cannabis


Mental illnesses and addictive disease are sometimes lumped together under the category “behavioral health.” One thing they have in common, unfortunately, is that both mental illnesses and addictions are highly stigmatized. Among other findings,  researchers have seen that reactions to mental illness include the following:

  1. fear and exclusion: persons with severe mental illness should be feared and, therefore, be kept out of most communities;

  2. authoritarianism: persons with severe mental illness are irresponsible, so life decisions should be made by others;

  3. benevolence: persons with severe mental illness are childlike and need to be cared for.

There are many myths about mental illness including the idea that people with mental illness are dangerous. In fact, they are ten times more likely to be victims of violence the the general population. Another widespread, incorrect belief is that people with mental illness are responsible for their illnesses. This belief is typically not held toward people with other health problems.

Stigma toward people with addictions is even worse. This is despite the widespread acknowledgement by various sources such as the DSM 5  that substance use disorders (SUD’s) are a category of mental disorder. Many myths about addiction continue to be widespread.

Into this already confused field comes the changing role of cannabis in society. Is it a miracle substance that cures otherwise difficult to treat ailments? Is it a deadly drug that is, as past anti-marijuana crusaders claimed, an “assassin of youth?” Fortunately, and National Academies of Science, Engineering, and Medicine have compiled an excellent review of the literature on the effects of cannabis and cannabinoids. What the review shows, not surprisingly, is that a great many claims, pro and con, have no basis in any research. However, from a mental health perspective, there were some key conclusions that anyone might want to note.

There is substantial evidence of a statistical association between cannabis use and the development of schizophrenia or other psychoses, with the highest risk among the most frequent users.

There is moderate evidence of a statistical association between cannabis use and increased incidence of suicidal ideation and suicide attempts with a higher incidence among heavier users, increased incidence of suicide completion and increased incidence of social anxiety disorder (regular cannabis use).

Most importantly for anyone concerned about youth, the report finds that there is substantial evidence that  initiating cannabis use at an earlier age is a risk factor for the development of problem cannabis use and that there is moderate evidence that during adolescence the frequency of cannabis use, oppositional behaviors, a younger age of first alcohol use, nicotine use, parental substance use, poor school performance, antisocial behaviors, and childhood sexual abuse are risk factors for the
development of problem cannabis use.


The short answer is yes. The DSM 5 includes cannabis use disorder. The criteria for a substance use disorder are as follows:

1. Substance is often taken in larger amounts and/or over a longer period than the patient intended.

2. Persistent attempts or one or more unsuccessful efforts made to cut down or control substance use.

3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from effects.

4. Craving or strong desire or urge to use the substance

5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.

6. Continued substance use despite having persistent or recurrent social or interpersonal problem caused or exacerbated by the effects of the substance.

7. Important social, occupational or recreational activities given up or reduced because of substance use.

8. Recurrent substance use in situations in which it is physically hazardous.

9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

10. Tolerance, as defined by either of the following:
a. Markedly increased amounts of the substance in order to achieve intoxication or desired effect;
b. Markedly diminished effect with continued use of the same amount.

11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for the substance;
b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

Depending on how many of the eleven symptoms a person has, the disorder is qualified as mild, moderate, or severe.


How many people are currently using marijuana?

The main reference for this is the National Study of Drug Use and Health (NSDUH)

It found, in part, that:

Aged 12 to 17

In 2017, 6.5 percent of adolescents aged 12 to 17 were current users of marijuana (Figure 13). This means that approximately 1.6 million adolescents used marijuana in the past month. The percentage of adolescents in 2017 who were current marijuana users was lower than the percentages in most years from 2009 to 2014, but it was similar to the percentages in 2015 and 2016.

Aged 18 to 25

In 2017, about 1 in 5 young adults aged 18 to 25 (22.1 percent) were current users of marijuana (Figure 13). This means that 7.6 million young adults used marijuana in the past month. The percentage of young adults who were current marijuana users in 2017 was higher than the percentages between 2002 and 2016.

Aged 26 or Older

In 2017, 7.9 percent of adults aged 26 or older were current users of marijuana (Figure 13), which represents about 16.8 million adults in this age group. The percentage of adults aged 26 or older who were current marijuana users in 2017 was higher than the percentages in 2002 to 2016.


According to the NSDUH:

In 2017, an estimated 1.2 million adolescents aged 12 to 17 used marijuana for the first time in the past year (Figure 28), which translates to approximately 3,300 adolescents each day who initiated marijuana use (Table A.19A). About 1.1 million to 1.4 million adolescents per year in 2002 to 2016 were recent marijuana initiates. The 2017 estimate was similar to the estimates in most years from 2002 to 2016.

In 2017, 1.3 million young adults aged 18 to 25 initiated marijuana use in the past year (Figure 28), or an average of about 3,600 recent initiates per day in this age group (Table A.19A). The 2017 estimate for the number of young adults who initiated marijuana use in the past year was higher than the estimates in all years from 2002 to 2016.

An estimated 525,000 adults aged 26 or older in 2017 initiated marijuana use in the past year, which rounds to the estimate of 0.5 million initiates in this age group in Figure 28. This number averages to about 1,400 recent initiates per day in this age group (Table A.19A). The number of recent marijuana initiates in this age group in 2017 was higher than the numbers of initiates in all years from 2002 to 2014, but it was similar to the numbers in 2015 and 2016. Consistent with the pattern for cigarette and alcohol use, the majority of people in 2017 who initiated marijuana use in the past year were aged 12 to 25.

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Your Sense of Self is Behind the Times

Image result for person looking in the mirror of an older person

I was reminded about this when I saw a post on NPR about insects changing their behavior situationally. It turns out that shy, solitary grasshoppers turn into swarming locusts under stress. Same critter, amazingly different behavior.

I first identified the issue of who you are– and under what circumstances– for us humans when I was working in substance abuse treatment. Someone would start treatment, become abstinent from alcohol and drugs, make a new circle of acquaintance and support in AA or NA, but would still have a self-image as a desperate alcoholic/dope fiend. The new person didn’t drink or use drugs, had a circle of new friends who didn’t and who had never seen them intoxicated, but had not yet grown into the self-concept of being a clean/sober person. Their self-concept was behind the times.

Later, I spotted the same phenomenon with respect to any and all of us with respect to aging. Someone who was middle aged talked about feeling like a seventeen year old whose body had mysteriously gone bad on them. If you’re not old enough to have had this sensation, watch for it. By the same token, people who have changed health habits in middle age (or always had good ones) can be described as biologically younger than their chronological age– something that I think gives great hope to us all. There are a lot of tests like this online. (To do the one I link to, you either need to know your weight in kilos or that fourteen pounds equals one stone (weird British measurement))

But I digress. The point is, we change both by deliberate effort and simply with the passing of time, and we sometimes don’t keep track. Because I have worked with people in treatment modalities that are skills based, such as Dialectical Behavior Therapy or Seeking Safety , I have seen this same process when people develop coping skills and resiliency that they didn’t previously have, but still see themselves as unable to cope with various problems in life. As a therapist I find it exhilarating to point out to someone that they successfully got through some challenge that used to be a huge crisis for them.

While there are tests we can take that show us to be biologically older or younger than our chronological ages, I don’t know of any simple test that can measure whether or not we have wisdom that is greater than or less than our chronological ages. I doubt that could be accomplished, not least because most of us take actions that can be seen as demonstrating a lack of wisdom and at other times we may take actions or say things that seem very wise indeed. Also, there are times when we have had the benefit of clear-eyed and deep wisdom spontaneously from the very young. We can also think of people in our circle of acquaintance who might be labeled as “old souls” or “forever young” regardless of chronological age.

The phenomenon I’m thinking of might, in a sense, be equated with a certain kind of humility– not the sense of eating humble pie or abasing oneself, but the sense of simply knowing oneself and acknowledging it to oneself. I think this is one reason why 12-step recovery has become popular with everyone from alcoholics to procrastinators and everyone in between. Step four has everyone take “a searching and fearless moral inventory” and step ten instructs recovering folk to “continue to take personal inventory” on a daily or even more frequent basis– to keep track of who you are. Many people interpret this as being strictly about what’s wrong with you, but a closer peek at the literature reveals that it includes keeping track of one’s pluses as well as aspects of oneself that just are. Of course, there are other schools of self-improvement that encourage the same kind of activity, including psychotherapy.

The original article on insects and humans has a beautiful phrase in it– “a vocabulary of selves.”  Looking at it this way, my sense of self may be more misplaced geographically than out of date. I may be a confident, expansive tour guide showing people around my home town and be a very shy and retiring person in the temple of a faith that’s new to me. In sports, I may be a bold mountain climber but a very timid sailor. One can multiply examples.

The door to change is that for a healthy sense of self we need to have a flexible sense of self– to be open to the idea that we may be more, or less, or just different from who we believe we are.  And who we are here, or who we were  then, is not who we have been– or might be– in other places or other times.


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Take Good Care of Yourself


5 Tips to peaceful sleepI have had a couple of things I have been working on, don’t have anything I feel ready to publish just yet, but ran across this from Center for Greater Good on how getting enough sleep is good for your relationships.

There are so many places where therapists talk about taking care of your mental health and end up talking about taking care of your physical health. Eating right, getting some exercise, and sleeping are all helpful. We know that the brain, the organ of thought and emotion, depends on proper care to work properly. In addition to the physical and obvious benefits of good nutrition, exercise, and sleep, there’s also the benefits in terms of a sense of self-efficacy– the sense that “I can do something that works.” In the case of self-care, this also dovetails nicely with self-soothing or self-nurturing, take your pick for what you want to call it.

There are times of extreme emergency when we can’t take a time out to self-nurture or self-soothe, but these are relatively rare. Even if I’m freaking out about taxes on April 14, I can still file an extension. I just need to get over my freakout before the extension expires. If I have a lifestyle that depends on the creation of crisis after crisis, that’s another conversation for a different time.

Many years ago, when AIDS was still a death sentence, I learned about some research that found that one group of women who were diagnosed with AIDS lived about six weeks after diagnosis. Given the nature of the disease, this was a shockingly short time, even before there were any medications. What further investigation showed was that these women were so busy taking care of others that they wouldn’t go to the doctor to get any help for themselves until they were nearly dead. The point here is that adequate self-care is also helpful to other people in your life. Taking care of yourself adequately means there’s less strain on others who might otherwise have to care for you, and you also have a greater capacity to help others in your life who you may wish to nurture.

For now, just recognize that when you take good care of yourself, you are also improving your ability to have good relationships and over all health. Self-care is not selfish.

image from

The site from which the image was taken has some good tips on healthy sleep as well.

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The Parable of the Shopping Cart

Have you ever gone to a supermarket, gotten a shopping cart, started to push it up the aisle, and realized that it tended to pull to the right (or left)? It’s like a car that needs the alignment done. At first you don’t think much about it. You just compensate by pushing it a little more to the left (or right) to make it go straight. But if you speed up to get down an aisle where you don’t need anything, you have to push more forcefully to keep it going straight. If you load the cart with a lot of groceries, as it starts to get heavier, you have to push harder to keep it going straight. If you try to go fast while it’s heavily loaded, then you have to push really hard to keep it going straight. It’s easier to just slow down. Of course with a car, you have motivation to get the alignment done– you don’t want to wear out your tires. That’s where the metaphor turns a psychotherapist into the equivalent of your mechanic, but I’m sticking with the shopping cart for now.

Can you relate the shopping cart image to other areas of your life? I’ll bet you can. My clinical experience is that we all have certain tendencies as to how we react to various stressors in life. Specifically, some people will become more anxious when stressed, and some will become more depressed. Some of us may experience both, depending on the stressor. When the shopping cart of my life is too heavily loaded, or going to fast– or both– I have to push harder all the time to keep it going straight.

If we go back 200+ years, the idea that people had basic personality types was well established. There were supposedly four humors, the predominance of one or the other leading to the four temperaments. In more recent times, theories of personality have been reworked in various ways, but most people would agree that we all have characteristic ways of being in the world. So, in shopping cart language, some of us are more likely to pull to the left, some of us to the right when we get overloaded or in a hurry.

For people in therapy, it’s a reminder to take care of ourselves without becoming self-victimizing through “should” statements about how we wish we could perform. To give a physical example, if my doctor has told me that I have a back problem & will aggravate it if I lift more than a certain amount of weight, I’d best follow the advice and not try any heavy lifting. Unfortunately, psychological conditions are not always as clear-cut, and family, friends, and employers are not always understanding.  I’ve heard from so many clients whose friends and family have told them to “Just snap out of it” or “Pull yourself up by your bootstraps” or equivalent, unable or unwilling to accept that a mental disorder can impose limitations on what a person can do. Psychological problems can be disabling, and not taking care of ourselves because the problem is invisible can only make things worse. That’s why it’s good to have some kind of self-care plan already in mind, before things start to go sideways. That’s why we want to take time to think about what can make us feel good, what can get us through a hard time, and have a self-care plan in advance. It’s good to be able to have someone to talk to, but it has to be someone who understands. Otherwise, I may be better off binge watching stand-up comedy on Netflix. I also have to be able to say “no” to people,  especially during the holidays. I may not be able– emotionally– to attend one more holiday gathering, pick up one more kid in the car pool, or bring an additional dish to the potluck. When I feel the cart start to pull, I slow down– before I crash into the shelves. And I don’t overload it, either.

image from:

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Did You Plant Cotton?

Image result for field of cottonSooner or later,  people come to some issue where they may want to go it alone, but they need help. I sometimes confront people, but in a way I hope is gentle. I take hold of my shirt sleeve and ask rhetorically, “When I wanted a shirt, did I go out and plant cotton?”

Depending on how it goes from there, I may go on to point out that when I bought the shirt, I relied on someone to plant the cotton, someone to harvest it, someone else to take the cotton to a place to be spun into thread, someone else to put the thread on a loom to weave cloth, someone else to make the cloth into a garment, and a veritable fleet of truck drivers to transport the intermediate and the final products. Everyday life requires us to be dependent on others for many things. In fact, the division of labor makes life better for us. There are many examples: even the most talented musician is unlikely to be able to play violin, viola, clarinet, oboe, french horn, trumpet, tympani– everything in a symphony orchestra– and even if they could, they couldn’t do all of them at once. It’s the collaboration of the group that makes for the beauty and power of the orchestra.

Why, then, is it so hard to allow ourselves to be helped when it comes to mental/emotional issues? Well, of course, sometimes we are more open to it than others. We may get help from family, friends, a spiritual director or pastor, or see a therapist.  But it is complicated, no question. Perhaps a family member is too involved to be a disinterested helper. Sometimes a friend is too quick to jump to problem solving and has a hard time listening. But the barriers to getting help can be inside us, as well. Maybe we have a hard time talking about it, or don’t trust anyone, or are inhibited for any one of a number of reasons. Perhaps a pastor of spiritual director will direct us to a therapist because the issues are outside of what is considered the scope of a spiritual director.

By the same token, we can get advice from others who have been through similar experiences. We can ask other parents, what did you do when your kid just couldn’t seem to get their homework turned in? Who did you find who was a reliable handyman to fix the front steps? What was it like caring for your elderly relative with Alzheimer’s? And there are, of course the 200+ twelve step programs,  all based on the idea of one sufferer, who has been through a similar experience, helping another. Being networked in to a community, being part of an interdependent group, is likely to help. If you already are a cotton farmer,  go ahead and plant cotton. But I’ll bet that even cotton farmers go to the store to buy their cotton clothing. It’s OK to depend on others.

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The Boy Who Wanted to Be Happy

man beach sea coast sand person people boy vacation male model spring africa child black fish season muscle beauty african network south africa africans photo shoot barechestednessI have found myself recounting this story many times in the course of my professional work, most recently in the week just past. I read it many years ago in a collection of children’s stories, and I associate it with my being in what was then called junior high school, now middle school. In my vague memory, the story was attributed to a West African folk tradition. I have looked for it in various ways a number of times over the years and have never found a version that seemed like the one I remember. Memory is a fallible thing, as we know. If anyone recognizes it & can direct me to a reasonable facsimile, please feel welcome to contact me. I am not going to try to represent the story in its original form; just the bare bones plot details as I remember them.

A boy was fishing at the river, and he caught a magic fish, which promised to grant him a wish– a single wish– in exchange for being released back into the river. The boy wished, “I want to always be happy.” The fish, being a wise as well as magical fish, encouraged him to think about his wish carefully, but the boy persisted. What could be wrong with always being happy? So, poof! the wish was granted and the boy immediately felt very happy, and released the fish back into the river.

On returning to his village, he found that his family’s house had burned down. People were lamenting this unfortunate event, especially the rest of his family, but he was very happy. Everyone thought this was at least odd, if not downright disrespectful, or worse. Then he went into the jungle, where he soon found himself being chased by a lion. As he ran for his life, he noted that he was very happy, and even realized that if he were scared, he might be able to run faster. He then had several other adventures in which happiness was not called for. He finally went back to the river, was able to recapture the fish, and wished to always have the right emotion for whatever befell.

So many times, I have been with someone who bemoaned feeling anxiety, or depression, or another negative emotion. Yet, negative emotions are appropriate to negative events. Depression is not a mental disorder. Anxiety is not a mental disorder. If I have just lost my home to a hurricane, it is a time for depression and sadness. It is also a time for action. If I have anxiety about being able to retire, my worry about the future can lead me to save money today. If I am depressed and anxious about my health, it may lead me to start exercising and to stop having seconds on chocolate cake. A depressive disorder is when my depression impairs my ability to have a life, or is so severe that it immobilizes me, making it impossible to work toward having the life I want. An anxiety disorder is when my anxiety prevents me from living my life, or makes it incredibly distressing.

This also means that when I recover from a mood disorder, I cannot expect to be free from negative emotions. I will still be depressed or sad when bad things happen. I will still be anxious when I worry about the risks and uncertainties of life. What recovery means is that I can still work toward having the life I want, whether it means climbing up out of setbacks to get on level ground again, or setting out to climb the mountains of my goals and aspirations.

image source:


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Resources on Youth, Vaping & Cannabis want to thank all the parents and youth who came to the cannabis forum informational event last Wednesday, October 17 at Manuel F. Cunha Intermediate School.You were very kind to me and to the other presenters. I was told that a link to this post was going to be made available to school parents and I see some people have already visited.

There are a great many sources of information about these sometimes controversial topics, and I have tried to limit myself to sources which I believe to be factual and to the extent possible, not controversial.

One of the things that we talked about at the forum is the fact that there are multi-billion dollar industries which want people to use nicotine and either the whole cannabis or its extract, THC. The purveyors of nicotine drug delivery systems are quick to point out that vaping is safer than smoking (still a somewhat controversial claim), but neglect to point out that breathing pure air is safer than vaping. The purveyors of THC will point out that you won’t suffer respiratory failure from THC overdose the way you do from alcohol overdose, but they won’t go out of the way to say  you are  at still more likely to crash your car if you drive high. Soda manufacturers won’t tell you that sugar rots your teeth, either. That’s life in America.

I have always strongly believed that knowledge is power, and I hope this will empower parents in talking to their kids. As I said at the forum, it’s never too soon to talk to talk to your kids about these risks, but you want to be armed with honest facts, not vague claims of, “it’s bad for you.” As Dr. O said so eloquently at the forum, you want to have the kind of open, loving relationship with your kids where these kinds of conversations can happen honestly.

Here are some web sites that give information on youth & substance use and substance use disorders:

The TEDS Report:  Age of first use of substances among people age 18-30 when admitted to substance abuse treatment programs.

FAQ’s from young people on alcohol/drug use from NCADD, 

Tobacco Prevention Tool Kit from Stanford.

SAMHSA free store of publications on a wide variety of topics.


In my own words, list of diagnostic criteria for substance use disorders:

  1. Had times when you used more, or for longer than you intended?
  2. More than once, wanted to cut down or quit, but you could not?
  3. Spent a lot of time getting it, using, it getting over the effects?
  4. Experienced craving?
  5. Using interfered with fulfilling job, family, or school obligations?
  6. Continued to do it even though it was causing problems with family & friends?
  7. Reduced or quit other activities that were important or interesting?
  8. Got into risky or dangerous situations due to use (for example, driving intoxicated)?
  9. Continued to use even if it made other problems, like depression or anxiety, worse?
  10. Experienced tolerance– having to use more than previously for the same effect?
  11. Experienced withdrawal– got sick from not getting it, or had to use a replacement?

mild= 2 or three symptoms

moderate = 4-5 symptoms

severe = 6+ symptoms

example: I want to vape, and if I don’t get to, I get cranky, irritable, and won’t feel right until I do. This would be criterion # 4, craving, along with #11, withdrawal, so right there I have a mild nicotine use disorder. If I get in trouble with my parents because they don’t want me doing it, and I risk getting busted because I’m using under age, one could say I meet #6 and #8, so that’s a moderate nicotine use disorder. The whole thing is not as clear-cut as this necessarily, but this gives a rough idea of how it works.

For a different view, here is the ASAM addiction definition  from the American Society for Addiction Medicine.

Statistics and studies on youth substance use:

NIDA (National Institute on Drug Abuse) pamphlet on vaping

NIDA teens & e-cigarettes

New Yorker article on JUUL

Centers for Disease Control and Prevention fact sheet on tobacco


Monitoring the future 2017

This is a national survey on youth and a wide variety of drug issues.

With introductory remarks & some additional links to vaping/cannabis info:

National Survey on Drug Use and Health (NSDUH) 2017 This is a summary. The full NSDUH runs hundreds of pages and is a treasure trove for statistics nerds.

California Healthy Kids Survey is a statewide survey on a variety of issues including drugs, alcohol, tobacco, mental health, school safety.

CANNABIS HEALTH EFFECTS SUMMARY  This is the conclusions summary of a committee  from the National Academies of Sciences, Engineering, and Medicine after an extensive review of the literature on the effects of cannabis. Highlights include that the committee found that there is substantial or conclusive evidence that cannabis is effective for chemotherapy-induced nausea and for treatment of chronic pain in adults and other potential benefits of medical use.

On the other hand, the committee also found out that there is substantial evidence for a statistical association between cannabis use and increased risk of motor vehicle crashes, substantial evidence of a statistical association between use and the development of schizophrenia or other psychoses, with the highest risk among the most frequent users, and moderate evidence of a statistical association between use increased incidence of suicidal ideation and suicide attempts with a higher incidence among heavier users.

The committee also found substantial evidence that initiating cannabis use at an earlier age is a risk factor for the development of problem cannabis use.

October 30, 2018 update: article on adolescent cannabis cessation from NPR

Please feel welcome to contact me.




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