How do I help clients with psychotic illnesses who report that marijuana (or other substance) is “helpful” or “relaxing”? My client with schizophrenia smokes marijuana whenever he can get it. He says it “relaxes him.” I’m convinced it’s contributing to his continuing psychotic symptoms, and to the fact that his medication doesn’t seem to be effective. He agrees that “many people think marijuana is bad,” but he states: “I’m going to hear voices anyway, and the marijuana helps me to deal with them.” He seems to be in pre-contemplation, and I don’t know what to do.

First, he is not in precontemplation, he is in contemplation, because at least he’s willing to talk with you openly about his marijuana use. If you keep bugging him, however, he may shut down, and that will lead the conversation backwards. The evidence-based stage matched intervention for people in “contemplation” is to engage with them in a motivational partnership and help them work toward the best possible decisions over time. This does not occur in one or two sessions; it may take months or longer, and the outcome is not usually a commitment to stop marijuana, but a willingness to take an initial small step of action to reduce use. To be successful, join him in his discussion of marijuana as beneficial. Avoid arguing, and instead help him tell you how, when, and why it works. Help him to discover the “right amount of marijuana for me” and see how he can stick to that plan and know if it works. Help him to develop his own way of monitoring whether the marijuana is worsening his illness. Build hope so that he may believe in some inspiring goals that would help him get past just short-term relief. Take it slow…these are HIS important decisions. Finally, consider with him whether he might be a candidate for clozapine. Clozapine may help his mental illness significantly improve, even if he continues to use marijuana, and it may independently help him reduce use. For more information, see Implementation Guide: Stage-Matched Interventions for Individuals with Serious Mental Illness (SMI) and Co-Occurring Substance Use.

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