PsychiatryTalk

What Should A Therapist Do in this Situation ?

Posted on January 27th, 2017 by Dr. Blumenfield

What should a therapist do under the following circumstances?

A 40 year old patient male) comes for initial consultation because he is unhappy with his life situation in regard to relationships and his career. There is no evidence of psychosis, severe depression or suicidal ideation. The patient has mild obsessive symptoms and there are various personality traits related to his family experiences. The patient is well motivated for psychotherapy and appears to have capacity for good insight.

The patient has occasional drink on weekends and no drug issues EXCEPT that he smokes marijuana most evenings and enjoys the experience. He also acknowledges that he does “ drive stoned” but he believes he is a good driver and has never had an accident. When this is explored further he acknowledges that he understands that his reaction time might be minutely slowed but he knows he is a better driver than most people. He expects to come for weekly psychotherapy and will drive about ½ hour to my office for an evening appointment. He also drives to work daily for about 45 minutes and sometimes will have joint before he drives home.  search

Questions:

 

1- Would you insist that you cannot treat him if he is engaging in dangerous behavior by driving stoned? Explain

2- Would you make this a high priority issues to work on in therapy whether the patient bring it up or not ? Explain

3-Would you deal with this issue as you would any other topic depending on his associations  and current conflicts as well as transference issues?

4- Would the answer to any of the above question be different if the patient were a moderate drinker and frequently drives while “buzzed“ or intoxicated?

( Please give your opinions in the comments section below )    imgres

6 Responses to “What Should A Therapist Do in this Situation ?”

  1. Doug Ingram says:

    1- I would want to determine how wedded he is to smoking marijuana at these times. Conceivably, he is seeking a nudge to stop what he recognizes is dangerous. I would certainly make a statement that studies show smoking marijuana affects driving and it is unwise to continue this practice. Also, I would explain that for us to work together, he needs to avoid smoking before our therapy sessions. Otherwise, we’d be spinning our wheels. Since he has insight and is generally unhappy, I would hold out privately that as we develop a therapeutic alliance and he is more hopeful about his life that he would avoid smoking and driving. He is coming for help. There is no point in forcing him out of therapy before he even begins.

    2-It is high priority, but his general unhappiness is what demands attention. He is self-medicating. I might put his marijuana use in those terms and suggest that our work together might obviate that need.

    3-No. My eye would be on this more than this than other matters. Associations, current conflicts and transference issues can often point in different directions. When opportunities ocurred for exploring marijuana use, especially when driving, I would make the most of them.

    4- My understanding is that studies of weaving while under the influence of alcohol is shown to be greater than weaving under the influence of marijuana. But the effect of being buzzed with alcohol or some equivalent effect from marijuana is hard to compare. Without further information, yes, I would be more proscriptive re alcohol use when driving.

  2. Philip A. Seibel, MD says:

    #2–I would like to answer this question first because I believe that this patient’s cannibas use is likely having an impact on, and playing a role in, the issues which he cites as his presenting difficulties. While further exploration is warranted in assessing the extent of his cannibas use–how “stoned” does he get, my clinical assessment would include the fact that he seeks escape daily through his marijuana use.

    #1–In working with patients with substance use issues, I consistently emphasize the critical nature of driving while impaired. Of course, this traditionally comes up more frequently regarding alcohol. My specific comments are: “Driving while drinking could cause what is currently a problem in your life to turn into a devastating, life-changing catastrophe.” It is worth noting that I am not aware of the current state of regulations regarding driving following cannibas use.

    #3–To a degree, I would, in individual psychotherapy, address this issue like any other in psychoanalytic psychotherapy. I would first have to determine the extent of the impact of the cannibas use. My approach to this issue would range from stating that I did not believe I can treat this individual without him first addressing his daily marijuana use, to believing that the primary difficulties are in another area and this can be explored within that context.

    #4–Similar assessment with alcohol.

  3. Jane Petro says:

    Love your forum and appreciate you varied subjects.
    Short form answers:
    First, simply ask him to come to his appointments unimpaired…solves two dilemmas at once..driving, and being able to benefit from therapy.

    As for the others, in the absence of clear evidence of harm, other than the potential legal risks of buying a controlled substance, if he is not getting it from a medical pharmacy, working around the other issues he wishes to bring up might bring you closer to the why get stoned issue in due time. This is a simplistic approach, I know, but as a previous regular user (stopped after medical school, so old time, low concentration DTHC, etc) and one who has followed the medical information for some time, I think many of the effects are overblown…Thanks for the chance to enter the random thoughts of the retired surgeon….Jane

  4. I like Drs. Ingram and Seibel’s comments but would like to add a bit about the effects of marijuana. What isn’t generally talked about is the degree to which pot can literally stop emotional growth and development. This effect is most evident in adolescents, who will predictably be smoking a lot more pot as legalization gains momentum. The mechanism is that marijuana has an effect of soothing any discomfort from seeing oneself falling behind in relation to peers and being barraged with the distress of parents and teachers. The result is a cohort of adolescents with a stunted adulthood. They end up with a marginal lifestyle, don’t have a strong sense of identity or values, and are unable to enter into a deep relationship.

    Adults like the patient in this vignette may already have acquired some of those developmental assets. On the other hand, a closer look will often reveal areas of immaturity. For example, one very focused and successful financier could not sustain an emotionally intimate relationship. Faced with a choice, he would not give up his nightly pot smoking and sacrificed any chance at an emotionally intimate relationship. His intelligence and distorted vision from cannabis allowed him to rationalize the sad result.

  5. 1.No. He is not in IMMINENT danger to himself or others. He is a well motivated patient who might flee treatment with such an interdiction.
    2.. Yes, but I would wait a couple of sessions before bringing it up if he fails to do so, lest he be lost to treatment.
    3.Yes.
    4.No.

  6. BILL ROSENTHAL says:

    =when i was younger i took more chances and probably would have investigated further to determine his level of impairment. my experience, jaded perhaps, would assume that no matter what parameters i set up, i.e.
    no weed before our sessions, he would succumb to his addiction. since i would be distgrustful of him, i would not be a very effective therapist. thus, i would tell him i would be glad to treat him if he entered NA,but i could not otherwise.

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