A way out off fog

1. A way out off fog Thomas Lundqvist and Dan Ericsson Drug Addiction Treatment Centre, University Hospital, S-22185 Lund Sweden. Phone + 46 46 178932, Email thomas.lundqvist@med.lu.se

2. Get a binder • Create 20 sections • 18 sessions + 1 session for information + 1 session for parents • Fill every section with themes, questions to be discussed, illustrations and homework.

3. The 18 sessions manual. Session 1 Illustration of THC elimination and anxiety reactions. Info about physical reaction. Information about cannabis. Test: SOC, SCL-90, BDI scale focusing on relations. Session 2 Assessment feedback Positive and negative attitudes to cannabis use Why do you want to quit now? What kind of help do you need? Session3 Acute effects of cannabis Session 4 Chronic effect of cannabis Session 5 Cognitive function and dysfunction Session 6 Attitudes and patterns of use Session 7 Drug lifeline Session 8 Sociogram Session 9 Lifeline Session 10 (or when it is appropriate) Session together with the parents Session 11 Relaxation Focus on emotions Session 12 Continued focus on emotions Guilt and shame Session 13 Norms and values-behavior-abuse Session 14 Juhariwindow or something more suitable Session 15 The process of relapse Session 16 Continued relapse prevention Test: SOC, SCL-90, BDI scale focusing on relations. Session 17 Assessment feedback Look at the flipchart, repeat select the material to be used at the closing session. Session 18 Closing session Show the flipchart for the family and others. Graduation and Diploma

4. A short presentation of the treatment manual It is presented as a course in quitting • Phase 1: a bio-medical focus lasting until the 12th day after smoking cessation. • Phase 2: a psychological focus lasting until the 21st day after smoking cessation. • Phase 3: a psychosocial focus during the rest of the program. • This phase has no time limits.

5. A treatment manual for chronic cannabis users THC Lundqvist & Ericsson 1988 100 % 50 % Phase 3 Psycho-Social focus Phase 2 Psychological focus Phase 1 Bio-Medical focus Anxiety 3 sessions/week - 2 sessions/week 3 session/week Weeks 1 2 3 4 5 6-8

6. The treatment manual focus on • The chronic influence on the cognitive functions. • The impact of the enhanced subjective perception. • The need of professional guidance in the relearning process. • Critical examination of the drug-related episodic memory. • Promotion of the psychological maturation. • Enhancing the social competence and orientation to life. • The self-regulation use of cannabis. • Depression and phobic reaction following cessation of cannabis. • The need to be given proposals.

7. The therapist is requested to: • have good knowledge of the acute and chronic effects of cannabis. • use a concrete and simple language. • transform abstract reasoning into drawings and metaphors. • be a leading authority in describing the detoxification process. • The therapist is the prefrontal substitute.

8. Each discussion should contain • To make the client notice what is happening. • To make the client compare with earlier experiences. • to make the client reflect and consider the topics of the discussion.

9. The structure is used in The original programme, designing a concept for each individual. A manual based program with 18 sessions in six weeks focusing on 17-24 years old with a regular use more than six months A manual based short program with six sessions in six weeks focusing on younger user or those who have used less than six months regularly . For those who are experimenting, there is a three session course. A guide to quitting Marijuana and hashish

10. Why treatment? • The causes that lie behind the self-medicational use of cannabis. • Depression and phobic reaction following cessation of cannabis. • The need to be given proposals.

11. Step 1 implies • To handle and solve the anxiety reactions. • To help the patient resist the desire to escape • back into the influence of cannabis. • To coach the defective capacity for learning. • To reveal the specific thought pattern of the patient.

12. Topics discussed in step 1 • The pattern of cannabis use. • The patient´s image of himself/herself as cannabis • user related to the seven cognitive abilities. • The concept of time. • The withdrawal symptoms.

13. Step 2 implies • To be negative to the state-dependent ego. • To be able to perceive the between what • they are today and what they want to be. • To be inspired with positive representations • of the future.

14. Topics discussed in step 2 • The home situation. • The process of change. • The patients representations of the future. • ”Good feelings- bad feelings”. • The experience of ”the fog lifting”. • Loneliness and isolation.

15. Step 3 implies • To help the patient understand the components • of a developmental process. • To elucidate the basic conflict. • To help the patient realise the difficulties • in changing identity.

16. Topics discussed in step 3 • Do the patient consider himself as a part of the society. • How does he/she function in daily life without the shelter • of cannabis. • How does he/she handle the vulnerability and sensitivity. • How does he/she plan the future life.

17. A logistic framework of seven cognitive functions 1. Verbal Ability(quantitative and qualitative) 2. Logical-Analytic Ability(to make correct conclusions) 3. Psychomotility(flexibility in thought) 4. Memory(working and long-term memory) 5. Analytic-Synthetic Ability(to synthesis and create an entity from perceived information) 6. Psychospatial Ability(orientation in space and time continuum) 7. Gestalt Memory(to create patterns and pictures of perceived information)

18. Verbal AbilityWeaknesses are observed in the following areas: • Vocabulary appropriate to chronological age. • Finding exact words with which to express oneself. • Understanding what other people mean. • Abstract thinking and engaging in concrete thinking. • These symptoms lead the patient to feel misunderstood and lonely.

19. An illustration of the screened off condition

20. Logical-Analytic Ability • Weaknesses are observed in the following • areas: • Critical and logical self-examination. • Correcting errors and mistakes logically. • Thinking before answering. • Abstract and logical solution of problems e.g., socio-analytic • Understanding of casual relationships. • These symptoms lead the patient to feel inadequate and unsuccessful.

22. Psychomotility • Weaknesses are observed in the following • areas: • Establish a correct focus of attention. • Maintaining attention. • Shifting attention. • Understanding the points of view of others. • Changing opinions. • Changing mental set in problem • solving and social perception.

23. Cannabis and attention I • Basal basic attentional processes appear to be intact • Long-term cannabis users are less efficient when performing complex cognitive tasks • less efficient to resist distraction

24. Cannabis and attention II • Long-term users ability to process information efficiently declines more rapidly under a moderate cognitive load compare to non users and short-term users.

25. Cannabis and attention III • Long-term users are inefficient in: • to perform complex tasks that require cognitive flexibility • to identify of unproductive planning strategies • to learn from experience.

26. Cannabis and attention IV • Long-term users may well cope with everyday routine tasks • difficulties with verbal tasks that are novel and which cannot be solved by automatic application of previous knowledge.

27. Short-Term/Working memory • Weaknesses are observed in the following • areas: • Remembering meetings, promises, and so on. • Estimating of the passage of time. • Imagining long time spans . • Maintaining the theme of a story.

28. Long-Term memory • Weaknesses are observed in the following • areas: • Poor recollection of the past, • which refers to become aware of one's identity • and existence in subjective time. • These symptoms lead the patient • to exhibit a lack of patience.

29. Analytic-Synthetic Ability • Sorting out information. • Synthesising from parts to whole e.g. classifying information in a correct way and understanding shades of meaning. • These symptoms lead the patient to feel different and unique. Weaknesses are observed in the following areas:

31. The sense of coherence • is a global orientation that expresses the extent • to which one has a pervasive, enduring though dynamic feeling of confidence that:

32. Psychospatial Ability • Weaknesses are observed in the following • areas: • Differentiating the time of the year and/or time of day. • Maintaining routines of the day or the week. • Having interest in what is going on. • Being aware of one's social position relative to others. • Having an accurate perception of the immediate environment. • Mental representation of localisation in space. • Structuring the daily life.

33. Gestalt Memory • Creating patterns and pictures of the visual world. • Remembering the relations to others. • Putting names to faces • These symptoms lead patients to feel as if they are living in a world of their own. • Weaknesses are observed in the following • areas:

34. A typical client profile He • has problems finding exact words to describe what he really mean. • has limited ability to enjoy reading, motion picture, theatre, music. • has feelings of boredom and emptiness in daily life, loneliness, being misunderstood. • externalises problems and avoid accepting blame. is certain that he functions adequately. • is not able to examine his own behaviour critically. • has feelings of being incapable and unsuccessful. continues

35. A typical client profile, continued He • is unable to maintain a dialogue. • has difficulties with concentration and attention span. • has fixed opinions and pat answers to questions. • doesn't plans his day. • thinks that he's active because he has many ongoing projects, which are seldom finished. • has no daily or weekly routine.

36. Experimental or Recreational useShort-term The cognitive input process is affected (Hippocampus): • a disturbance in concentration, attention, • and storing and elaborating information. • psychologically the individual will experience • enhanced subjective perception

37. Long-Termuse • may impair the ability to efficiently process complex information, due to a prefrontal dysfunction. • inability to make plans. • difficulties in temporal integration of behaviour. In addition the cognitive process is influenced

38. Long-Termuse • not inclined to interpret opinions • and motives of other people. • hardly any self criticism. • emotional superficiality (apathy, listless)

39. Why treatment? • The chronic influence on the cognitive functions. • The impact of the increased subjective perception as a result of the acute intoxication on the emotional system. • The need of professional guidance in the relearning process, and regaining and stabilisation of the cognitive functioning

40. Why treatment? • Critical examination of the drug-related episodic memory. • Promotion of the psychological maturation. • The need to enhance the social competence and orientation to life. continues