Motivators for Cannabis Use among Young Adults in Outpatient Psychiatric Care: A Qualitative Study

Background

Cannabis use is widespread among young adults and is now the most used recreational drug worldwide. About 45% of 12th graders and 50% of 18- to 25-year-olds have tried cannabis and use among these age groups is steadily increasing. In most Western societies, 15- to 24-year-olds have higher rates of cannabis use than those aged 25 and older. Of current adolescent and young adult users, nearly 25% meet criteria for cannabis use disorder (CUD) (Wu et al., 2014). Many young adults believe cannabis to be “natural” and not as harmful as other substances. However, cannabis use negatively impacts brain functioning, particularly during the transitional and developmental period of young adulthood (National Academies of Sciences, 2017). Tetrahydrocannabinol (THC) in cannabis triggers repeated activation of the endogenous mesolimbic dopaminergic system, which may sensitize this system and increase susceptibility to psychiatric illness (Bagot et al., 2019).

The interaction between psychiatric illness and substance use is complicated for young adults. Psychiatric symptoms can lead to cannabis use as a form of self-medication. Further, cannabis use can cause psychiatric symptoms to develop or worsen (Bagot et al., 2019). Epidemiologic data consistently show that major psychiatric and substance use disorders most commonly begin, and are most prevalent, in young adulthood (Gustavson et al., 2018). The median age of onset for major depressive episode is 24 years; for bipolar disorder, 21 years; for psychotic disorders, 24 years; and for cannabis abuse or dependence, 21 years (Bose et al., 2016). Studies show that although smoking cannabis can temporarily ease symptoms of depression, anxiety, and stress shortly after use, depressive symptoms are likely to worsen with continued use over time (Lev-Ran et al., 2014). In a systematic review and meta-analysis of 11 studies and 23,317 individuals, adolescent cannabis consumption was associated with increased risk of developing depression and suicidal behavior (Gobbi et al., 2019). There is also a large amount of epidemiological evidence suggesting that cannabis use in the general population increases risk of psychosis (Large et al., 2011). Additionally, studies show that cannabis use leads to earlier onset of psychosis, increased symptom severity, premature mortality, higher rates of relapse, longer hospitalizations, as well as poorer prognosis, cognition, and quality of life (Large et al., 2011).

Despite associated negative sequelae, rapidly changing cannabis-related laws and policies have led to the normalization of cannabis use and a decrease in the perception of associated risks (Friese, 2017). False advertisements and misleading marketing by cannabis distributors have caused many youth to believe cannabis is an approved treatment for symptoms of depression, anxiety and attention deficit disorder (Mitchell et al., 2016). A qualitative study by Friese et al. examined themes of cannabis normalization among 47 teens, ages15–18 years, living in California. Teens not only endorsed witnessing widespread cannabis use amongst their social circle but also reported that that the legalization of cannabis for medical and recreational use serves “as evidence that marijuana is not harmful (Friese, 2017).” Lobbana et al. (2010) made a valuable contribution to the literature by describing several themes associated with cannabis use amongst 19 participants, ages 16–35 years, with recent onset-psychosis. The authors found that neighborhood and community beliefs on cannabis use strongly influenced beliefs on the relationship between drugs and mental health issues. However, many participants felt that there was no link between the two(Lobbana et al., 2010). Childs et. al. elucidated, through qualitative analyses, that the initial foray into cannabis use for young adults living with psychosis was strongly influenced by friends, cultural norms, and a desire to belong (Childs et al., 2011).

Less qualitative work is available to guide the development of interventions to reduce cannabis among young adults, and there is no qualitative study that we could find to guide the development of cannabis cessation or reduction interventions for young adults in psychiatric treatment. Amongst a non-clinical sample of cannabis-using adolescents recruited from high schools, qualitative analyses uncovered that youth valued the following intervention strategies: (1) rewards to incentivize the progressive reduction of cannabis use, which included both nontangible rewards that mimic those obtained on social media platforms and prosocial activity-related rewards, (2) self-monitoring of progress, (3) peer social support, (4) privacy and confidentiality, (5) individualizing frequency and content of notifications and reminders (Bagot et al., 2019).

The evidence for efficacious interventions targeting problematic cannabis use among adolescents and young adults is also sparse. In-person behavioral interventions demonstrate short-term decreases in use during active treatment, with less gains seen at follow-up. Specifically, randomized controlled trials (RCTs) utilizing motivational enhancement therapy (MET), cognitive behavioral therapy (CBT), family support therapy, case management, and contingency management (CM) show moderate effect sizes posttreatment, with few adolescents or young adults maintaining abstinence, or decreases in use, over time (Copeland & Swift, 2009; Hall, 2006). Recently, technology-based interventions for young adult cannabis users have shown promise. Web- and computer-based interventions in cannabis-using young adults and adults have demonstrated efficacy in correcting misperceptions about use and increasing knowledge but demonstrate mixed results for cessation outcomes (Budney et al., 2011; Elliott et al., 2014; Gulliver et al., 2015; Kay-Lambkin et al., 2009). Mason et. al conducted an RCT to test the efficacy of a text messaging intervention that utilized Motivational Interviewing (MI) and focused on changing peer interactions. The intervention was tested against a waitlist control group with 30 treatment seeking young adults (ages 18–25) who met DSM-5 criteria for CUD. The group receiving text messages significantly reduced their cannabis use related problems, as well as cannabis cravings, and had a significantly greater percentage of urine samples that tested negative for cannabis metabolites. Results from this pilot trial are promising and warrant further research on text-message based interventions for addressing CUD amongst young adults (Mason et al., 2018).

There are few interventions tailored to persons with comorbid cannabis use and psychiatric disorders. Glasner et. al. 2018 examined the feasibility, acceptability, and preliminary outcomes of a computer-assisted intervention combining CBT and MET techniques for adults with comorbid major depressive disorder (MDD) and CUD presenting for care in a psychiatric setting. This tailored and targeted intervention produced significant reductions in past 30-day cannabis use from baseline (mean percentage of days using = 69%) to follow-up (M=44%, p<0.05, d= 0.79). The intervention also yielded significant reductions in depressive symptom severity (p<0.001, d=1.52). The study shows that addressing comorbid CUD and MDD via electronic, evidence-based treatment strategies is feasible in a psychiatric care setting (Glasner et al., 2018). The study also demonstrates that a tailored intervention, addressing facilitators and barriers to cannabis use for psychiatric patients, can produce significant reductions in cannabis use (Glasner et al., 2018).

Although young adults in psychiatric care are at great risk for negative outcomes due to cannabis use, there is currently a dearth of tailored interventions to reduce cannabis use among this high-risk group. In order to design effective interventions for young adults in psychiatric care, motivators for cannabis use, and facilitators for reduction of use, must be examined (Gates et al., 2012; van der Pol et al., 2013). A qualitative phenomenological approach allows rigorous exploration of idiographic subjective experiences and explores how people ascribe meaning to experiences (Smith et al., 1999). Using the phenomenological qualitative approach, this study gathers young adult psychiatric patients’ own perspectives on cannabis use (Biggerstaff & Thompson, 2008). Specifically, the goal of this qualitative work is to a) examine motivations for cannabis use among young adults in psychiatric treatment b) examine facilitators to decreasing use that could be integrated into a text-based cannabis cessation intervention for young adults in psychiatric care.

Methods

Design

Interviews were conducted with patients recruited from a young adult psychiatric outpatient program in Rhode Island. Sixteen of the 22 patients approached were eligible for the study, and one eligible patient declined. Fifteen participants were enrolled and took part in individual or paired qualitative interviews. One paired interview occurred to accommodate two individuals who finished their appointments and were unable to return to the clinic to participate.

Interview Schedule

The semi-structured interview guide, using a phenomenological approach, was developed as interviews proceeded. Initially, interviews elucidated content around motivations for cannabis use, facilitators to reducing cannabis use, and feedback regarding the development of a text message intervention aiming to decrease cannabis use. Final probes explored the following areas regarding cannabis use: (i) perceived reactions and experiences of parents, partners and friends; (ii) perceived feedback from heath care clinicians; (iii) societal reactions; (iv) effects on mental health symptomatology and life goals; (v) experiences of cannabis as addictive or non-addictive; (vi) experiences with reduction; (vii) knowledge of health effects; (viii) recommendations for an intervention.

Procedure

The study was advertised to potential participants by flyers and/or by research staff who approached patients in the waiting room of the clinic. Participants were eligible to participate if they were: 1) 18–28 years of age, 2) using cannabis two or more times per week per self-report, 3) English speaking, and 4) receiving treatment at the psychiatric outpatient program. All research procedures were approved by the affiliated Institutional Review Boards and a Certificate of Confidentiality was obtained from the National Institutes of Health. All enrolled participants completed a brief demographics questionnaire, including self-reported psychiatric diagnoses. Participants were interviewed by the principal investigator and one research staff member in a private room for 30 to 90 minutes. Interviewers were unknown to participants in the study. All interviews were audio recorded. Each participant received $40 as compensation for participation.

Data analysis

A coding scheme was developed based on the iteratively developed semi-structured interview guide. Codes were added to the coding scheme throughout the interview process. All transcripts were independently coded by two research team members. Discrepancies were identified by a third member and resolved by consensus.

Agreement among the two coders was calculated using an inter-rater reliability test of a random selection of 20% of the interviews. The resulting kappa value was 0.70, indicating relatively strong agreement prior to group meetings. After all transcripts were reviewed, codes were entered into the qualitative data analysis software, NVivo Version 12 (QSR International Pty Ltd., 2018). This facilitated thematic analysis of overarching ideas and patterns.

Results

Participants’ ages ranged from 20 to 26; the mean age was 22.4. The sample was 53.3% female, 92.9% non-Hispanic and 73.3% white. All participants had health insurance and reported using cannabis at least twice a week, with 60.0% endorsing daily use and 26.7% endorsing almost daily use. Additional information on demographics, cannabis use, and self-reported psychiatric diagnoses can be found in Table 1.

Table 1:

Demographics of Participants (N=15)

Age (mean, SD)	22.4 (2.0)
Gender
Male	46.7%
Female	53.3%
Hispanic and/or Latinx Descent
Yes	7.1%
No	92.9%
Race
White	73.3%
Multi-racial	20.0%
Other	6.7%
Highest Level of Education
High school diploma or GED	20.0%
Some college, no degree	53.3%
Associates degree	6.7%
Bachelor’s degree	20.0%
Education Status
Student	46.7%
Non-student	53.3%
Employment Status
Employed	76.9%
Unemployed	15.4%
Unable to work	7.7%
Frequency of Cannabis Use
A couple times a week	13.3%
Almost daily	26.7%
Once daily	20.0%
Multiple times daily	40.0%
Cannabis Provider
Medical dispensary	33.3%
Recreational dispensary	53.3%
Acquaintance	93.3%
Methods of Cannabis Use
Smoking (joint, pipe, blunt, bong)	100.0%
Gravity Bongs	20.0%
Vaping	53.3%
Dabbing	26.7%
Oral ingestion (i.e., edibles)	73.3%
Psychiatric Diagnoses (by self-report)
Anxiety disorder	86.7%
Mood disorder	73.3%
Personality disorder	20.0%
Impulse control disorder	6.7%

Findings were categorized into three foci: motivators for cannabis use, facilitators to reducing use, and recommendations for reduction interventions. Themes corresponding to these foci are listed in Table 2 and described in greater detail below with representative quotes from the participants. Pseudonyms were assigned to protect participant anonymity.

Table 2:

List of Themes by Foci

Foci	Themes
Motivators for cannabis use	• Belief that cannabis improves psychiatric symptoms and is a safer alternative to psychiatric medications • Perception that healthcare providers are unconcerned or indifferent about cannabis use • Feeling that cannabis use is normalized by society and supported by family, friends, and trusted adults
Facilitators to decrease or cease cannabis use	• Belief that cannabis may help with psychiatric symptoms in the short-term, but it is not a viable long- term solution • Acknowledgment of negative psychiatric sequelae of marijuana use through observing friends and family • Belief that using cannabis in moderation is an effective strategy to reducing overall use
Recommendations for Cannabis Use Reduction Intervention	• Avoid using content that is overly critical of cannabis • Provide motivational messages, mindfulness, and behavioral skills to decrease cannabis use

Foci 1: Motivators for cannabis use

Theme 1: Participants believed that cannabis improved their psychiatric symptoms and was a safer alternative to psychiatric medications.

Questions about how cannabis affected psychiatric symptoms evoked the most emotional reactions from participants. Every participant reported using cannabis to self-medicate symptoms associated with anxiety, mood, and/or personality disorders. Cannabis was said to offer short-term relief. Kristina (aged 23) shared, “I don’t cut myself, but sometimes I’ll hit my head on things or punch myself in the face. If I smoke, it helps me not get to that point.”

Most believed that self-medicating was essential to their mental health and believed previous attempts to treat their psychiatric symptoms pharmaceutically were ineffective. Lewis (aged 26) explained, “It keeps my mood stable. I’ve tried different medications and it hasn’t really hit it right…”

Others voiced concerns regarding psychiatric medications’ safety. Aubrey (aged 22) felt that the pills were unnatural, “When I’m freaking out, I think it’s better than taking a benzo. It acts quicker, and it’s more natural than that.” Tyler (aged 24) pondered the long-term effects of anxiety medications.

I guess I can smoke and feel high, but when I come down, I’m not high anymore. I feel if I take the medications [for anxiety] I’ll just progressively change and not be myself. I’m afraid that I don’t know how it’s going to affect me, and I don’t want to need it.

Moreover, participants believed that cannabis was non-addictive due to lack of experienced withdrawal symptoms. Darrell (aged 25) shared, “I think the good thing is though with marijuana is that there is not that physical dependency like with nicotine. So, it’s a lot easier to get people to cut down on that.” Emma (age not reported) described her disbelief that cannabis was an addictive substance.

I haven’t noticed anyone who’s been like only addicted to weed…I would say that I have a few friends that I was concerned about their use, but nobody that I know was unable to stop or cut down when they wanted to.

However, some individuals acknowledged that addiction to cannabis is possible. Alex (aged 20) expressed his fear of being addicted:

I think that that’s the idea that it’s not addictive just because it’s not giving you physical withdrawals or DTs. I think that that’s crazy... When I’m not high, I want to be high. As soon as I get high, I’m like why did I want to get high? I don’t need this. It’s hard. It’s difficult. It’s more of a mental gymnastics thing, than that I’m shaking and sweating.

Theme 2: Participants perceived healthcare clinicians as unconcerned or indifferent to cannabis use.

Most participants mentioned their cannabis use to their clinicians. Some reported that their doctors supported the use of cannabis to alleviate symptoms. Rachel (aged 21) shared that her primary care doctor helped her obtain a medical marijuana card to treat insomnia by saying, “My doctor recommended sleeping pills, but I felt that because I was so young, that I didn’t want to get involved in that, so then he said that pot helps a lot of people with sleep.” Two participants shared that their healthcare clinicians opposed cannabis use. Kristina mused,

I think my psychiatrist didn’t have a good opinion of it, which was kind of annoying. She wrote down in my file that I’m addicted to it. I was like, “no, it just helps me.” Then my therapist is supportive of it. So, it really depends.

However, most participants described indifference from clinicians. Tyler offered, “For all of my friends who’ve told their doctors they smoke, not one of them have told [me] their doctor said not to.” Similarly, Madison (aged 20) described her doctor’s lack of feedback, “[My doctor] knows I smoke, but he doesn’t talk about the risks.” In summary, the vast majority of patients did not perceive that their healthcare clinicians were concerned about their cannabis use.

Theme 3: Participants felt that cannabis use was normalized by society and supported by family, friends, and trusted adults.

Participants also felt surrounded by positive depictions of cannabis use in the media and world around them. Brianna (aged 25) acknowledged many references to cannabis in popular TV shows, “I heard on a show on Netflix that it’s not a drug...There’s no shame in it...” Tyler described cannabis normalization in music, “I can’t really name one rapper that would not talk about getting high. People even talk about getting high in country music.” Jacob (aged 22) felt that society had accepted cannabis use as “normal.” He surmised that his college supported cannabis while opposing alcohol.

I think the discourse on campus is …alcohol is so terrible, it is poison. There’s a CBD shop next to campus. So clearly, one is being championed over the other. I think it’s very chic to say pot’s healthy, it’s natural, it’s from the earth. Alcohol is terrible, it’s going to kill you.

Brianna described the effect of living in a state where cannabis is legal for medicinal purposes, “I hear a lot about how many people in Rhode Island smoke, and try to grow weed as well. I’ve met a lot of people.” Marshal (aged 20) also shared that his parents became more accepting of cannabis after it was legalized for recreation and medicinal use in his home state of Massachusetts. He said, “I live in a state that has legalized it, Massachusetts. So, my parents, my mom, was immediately accepting of it, just because…she sees the benefits of it, she’s a nurse.”

Notably, participants commonly reported using cannabis with their parents and other trusted adults. Darrell revealed that he smoked cannabis with his mother, stating, “my mom smokes too. I’ve smoked with her about a million times.” Some participants suggested that witnessing parental use of cannabis conveyed normalcy. Tyler succinctly described, “If you grew up knowing that your dad or mom smoked, why would you think it was wrong? Those are your parents. Why would they be doing something that you shouldn’t?”

A few participants reported seeking out advice about cannabis from their teachers, which resulted in positive testimonies. Marshal recounted this conversation with a trusted teacher, “One of my professors smoked regularly and I spoke to him because I was having a lot of anxious fits in school… he said that recreational use of marijuana can help in some situations.”

In summary, participants were acutely aware of cultural, familial, and institutional reactions to cannabis use and felt it was ubiquitous. In the words of Brianna, “All my friends smoke. It’s everywhere, all the time… if you don’t smoke, that is kind of weird. “

Foci 2: Facilitators to reducing cannabis use

Theme 1: Despite perceived short-term psychiatric benefits to use, participants felt cannabis was not a viable long-term solution.

Participants frequently reported use of cannabis as a “Band-Aid” for managing stress and psychiatric symptoms. These individuals recognized that long-term cannabis use neither addressed the underlying causes of their psychiatric disorders nor served as an effective treatment. Alex felt that he had been “leaning on [cannabis] for a very long time” and stated that the “pros…don’t last very long.” Participants noted that although cannabis use may help to reduce symptoms in the moment, it can exacerbate mental health problems by not addressing their root causes. Aubrey described,

I think the people who do it all day, every day, they’re definitely escaping from something. They are escaping from their feelings. They’re just covering it like a band-aid. If you’re already depressed, and you smoke, you are just going to be more depressed.

Kristina expressed desire to decrease cannabis use by effectively managing her mental health symptoms: “I do not want to use forever at all. I want to have my borderline personality disorder in check to the point where I don’t have to smoke to have myself not have an episode.”

Many participants described the importance of talking with a therapist or psychiatrist and developing effective coping mechanisms to manage symptoms, as cannabis will not always be available. Brianna shared the unfortunate experience of her friends who used cannabis heavily and did not seek professional help.

I’ve had two friends who committed suicide. I’m not saying that marijuana led up to it, but I am saying that they did smoke a lot, and I noticed that it did bum them out. What led them to suicide was not taking care of their problems and diagnosing it, and all of their friends and family would say so.

While cannabis helped to relieve participants’ symptoms in the short-term, some noted that effective psychiatric medication(s), or changes in their regimen, reduced their frequency of cannabis use. They seemed to recognize that therapy and medications could lead to a longer-term alleviation of symptoms than cannabis use alone. Nigel (aged 21) recalled feeling the need to cut down on cannabis use when addressing his psychiatric symptoms. He described,

That was when I started like [saying], ‘ok, I need to stop everything’, because my medications were changing…It even came to a point where it was months, many months, where I didn’t smoke…and I thought I need to completely just focus on what’s causing these problems.

Theme 2: Observing the negative psychiatric sequelae of cannabis use in friends and family served as motivation for decreasing use.

Many individuals observed negative effects of cannabis use on their friends and family, such as heightened anxiety and paranoia. Rachel described similar adverse experiences shared by her mother and friend.

I know my mom, this was years ago, but she’ll never smoke again. She took a puff, and she was very, very paranoid. I know a lot of my friends who have smoked with paranoid experiences won’t even touch it because of how scary it was.

Another common observation among participants was the negative impact of cannabis use on educational and vocational attainment. Several participants had friends who frequently used cannabis and dropped out of college. Aubrey expressed sadness over her boyfriend’s difficulty.

I think [cannabis] was the reason my boyfriend quit college. He was going to college and he said that his friend would always, after class they’d go and smoke. He’d go and smoke and skip the rest of his classes, and then he dropped out. It’ll take over, the effects. I think people should know.

Participants cited the potential for cannabis use to jeopardize long-term career goals as another motivator for reducing their heavy use. Brianna was considering better employment opportunities but worried that drug testing could be a problem.

I want more serious employment… They said the company really wants women to diversify their portfolio or whatever. But it’s also got full benefits and so many pluses to it, you know what I mean. You can go all over the country if you wanted. That’s what I want; to be able to move and bobble around. One of the things is that you get drug tested.

Larissa (aged 23) gave up an enjoyable job for fear of failing a drug test.

I did work at a job where I had to pass a drug test, and I worked there for two years. I ended up not going back…I didn’t want to have to deal with going through taking the drug test and semi-worrying about it.

Many of the participants were currently in college or early in their careers. Their motivations and career aspirations served as facilitators for both reducing and eventually stopping cannabis use completely.

Theme 3: Practicing moderation was described as an effective cannabis reduction strategy.

One potential strategy identified as helpful in conjunction with psychiatric treatment was using cannabis in moderation. Kristina described her successful efforts to cut back.

I kind of cut down a bit, but was also nervous like “can I go a day without smoking?” From smoking so much, I was worried I would be dependent on it. Then I’d go a couple of days without smoking and think, “ok, I can do that.” Then I’d cut down a bit more.

Brianna also felt empowered by gradually decreasing her cannabis use.

You really got to find moderation and cut back. That’s the thing I tell people, it’s like you don’t have to smoke forever, just cut back. Just smoke when you feel good, not when you feel stressed. I know that’s a real big pill to swallow.

A few participants suggested that replacing cannabis with another rewarding activity could aid moderation and cessation. Nigel shared,

Having some other positive feedback, general motivation like, “yeah, you can do it,” but also like another goal for the day. So, do like a “go to the gym today and then reward yourself” or something else equivalent to going to the gym that someone might feel accomplished by…It’s like reward it, but use moderation. Once you start to feel the positives of that reward, that’s when something better comes up.”

Foci 3: Participant recommendations for cannabis reduction intervention

Theme 1: Participants recommended avoiding content that was overly critical of cannabis.

Many participants warned that beginning an intervention by focusing on the negative consequences of cannabis use could be perceived as patronizing and lead people to not listen or engage with the intervention content. For example, Marshal insisted that a one-sided approach would not be helpful:

When you are trying to help someone stop an addiction, I find that starting with talking about the worst parts of it is going to immediately make them become dismissive and not want to hear the rest of what you are talking about.

This was a common warning across the interviews. All participants recommended a balanced approach that acknowledged both good and bad experiences with cannabis.

Theme 2: Participants recommended using motivational messages, mindfulness practices, and behavioral skills to decrease cannabis use.

When probed for content that would be interesting and engaging without seeming patronizing, participants agreed that motivating messages and behavioral skills would lead people to decrease their cannabis use. The most commonly reported motivator for cannabis cessation was saving money. Brianna described that saving for a special trip or a large purchase could be effective in an intervention motivating young adults to cut back on cannabis use:

Saving money, that’s one of the first things that comes to mind. It’s just like you could either buy an eighth and then another eighth, or you could save your money and buy… a car. Yeah, something better for yourself. So, that’s the first thing I think of. Or like go do something fun like a cruise or something. Look at Instagram, do you want to be the person who is just sitting around smoking weed, or do you want to be the person going on cruises and having a really fun time. Those are the two choices.

Participants also expressed concerns with how reducing cannabis use would affect their daily routine. To address these problems, many suggested the intervention should provide behavioral skills that are also helpful in reducing mental health symptomatology (e.g., meditation, mindfulness, hobbies). Tyler acknowledged the importance of introspection.

I would start with more of an acceptance of yourself and realizing if you are becoming addicted to something. So, a Stop, Look, and Listen type message. If that makes sense. Then the next week, maybe a coping mechanism and information text. Like maybe if he has already quit based off the first text, now we gotta help them find a coping mechanism. Because after a week, you are gonna start to feel the loss of marijuana. So, coping mechanisms are an immediate category to follow.

Emma also stressed that introspection and mindfulness techniques should be used in an intervention to examine reasons for cannabis use and aid cessation.

You should be really mindful about why you’re smoking, and what is motivating you to smoke, so it became helpful for me to know, am I smoking to avoid something or am I smoking because I know I want to feel good. It’s just being aware of that trigger… Another thing we’ve done is to just be in the moment when you are smoking. What does it feel like? Do your lungs hurt? Instead of passively smoking. Through that I’ve noticed that I don’t really like the smoking feeling, as much as I thought. So, just bringing attention to that has been helpful. I think it has helped me cut down.

Participants felt that increasing awareness of simple coping techniques could be effective in reducing cannabis use. Furthermore, Lewis shared that experiencing joy and fulfillment from other sources removes the desire to use cannabis,

I notice a lot of people smoke pot just to be happy, so if you can already put them in that state of mind. Because there are some mornings, I have a playlist in my car for if I have a lot of energy that morning, it’s like a club party is going on in my car. That’s how I won’t even have to smoke in the morning.

When probed, participants identified that the same behavioral skills used to help with mood and anxiety could be applied to cutting back on cannabis. They also felt they could effectively reduce their cannabis use if given easy-to-use coping strategies and other alternatives to cannabis.

Discussion

Although cannabis commonly used recreational drug among young adults with psychiatric symptoms, there are no existing electronic interventions to reduce cannabis use that are tailored to vulnerable young adults in psychiatric care. The aforementioned qualitative data can inform the development of interventions to reduce use among emerging adults living with psychiatric disorders.

Common themes about cannabis use in the context of psychiatric symptoms:

Themes on the motivations of cannabis use included: the beliefs that cannabis improves psychiatric symptoms as a safer, non-addictive alternative to psychiatric medications, healthcare clinicians are unconcerned or indifferent to patients’ cannabis use, and cannabis use is normalized and supported by patients’ family, friends, and community as well as society at large.

Self-medicating psychiatric symptoms with cannabis was prevalent among this cohort. Participants were aware that they were using cannabis to cope with unwanted emotions and avoid problems. These findings align with previous research by Chabrol et al. that showed health (sleep, form, energy, appetite) was the only motive uniquely and positively related to problematic cannabis use among 249 high schoolers (Chabrol et al., 2017). Individuals with psychiatric disorders may be at risk for developing a reliance on cannabis to cope with distress. This concern is particularly evident when psychotropic medications have previously been unsuccessful at treating symptoms, and when cannabis is perceived as less harmful than psychotropic alternatives.

Varying opinions from healthcare clinicians may also lead individuals to believe that there are no negative consequences to cannabis use or that health information about cannabis is inaccurate. Participants also voiced skepticism regarding negative information about cannabis. This may be due to normalization of cannabis use by society and perceived acceptance by family, friends, and community. These results are similar to a qualitative study conducted with older teens, which found that participants’ perception of cannabis normalization was related to its increased use by known individuals, as well as its legalization for medical and recreational purposes (Friese, 2017). This highlights the power of social and peer influence on the perception of cannabis.

Common themes about facilitators to reducing cannabis use:

Themes regarding facilitators to reducing cannabis use included: the belief that cannabis may not be the best long-term treatment option, the observation of negative psychiatric sequelae of cannabis use in friends and family, and the belief that utilizing cannabis more sparingly can be an effective strategy for reducing overall use.

Participants recognized that long-term cannabis use does not serve as an effective mental health treatment and that prolonged use may lead to addiction. Many noted the importance of developing coping mechanisms and partaking in other enriching activities to replace cannabis use. Consistent with social learning theory, a motivator for cannabis reduction was witnessing negative consequences peers faced from chronic use, including heightened anxiety or withdrawal from college. Participants offered several important strategies to consider when creating reduction interventions, the most popular being promoting moderation rather than immediate cessation (Hathaway & Erickson, 2003). Educating users about the potential harmful effects of cannabis and replacing it with other rewarding activities may also help reduce use (Pedersen et al., 2016). Additionally, linking the impact of cannabis use on long-term educational, occupational, and mental health goals of an individual may cultivate a lasting motivation for cannabis reduction.

Common themes regarding intervention development:

The common themes regarding intervention development were to avoid content that is overly critical of cannabis, and provide motivational messages, mindfulness tools, and behavioral skills to decrease cannabis use. Interventions should begin with interesting content unrelated to the negative consequences of cannabis use. Similar to building rapport in a clinical relationship, it is critical to first gain participants’ attention and trust before approaching content related to negative side effects. Intervention content could be introduced through providing motivational messages (e.g., informing the person of how much money they would save or providing words of encouragement) and teaching behavioral skills. Navigating cravings and adjusting a daily routine were among the popular concerns about reducing cannabis consumption. To address these problems, participants suggested that the intervention provide alternative coping mechanisms (e.g., meditation, mindfulness, hobbies).

There are limitations to this study despite its careful design. These limitations include a small sample size (n=15) with all participants recruited from a single outpatient psychiatric clinic specializing in young adult care in Rhode Island. Therefore, this sample may not represent the broader emerging adult population in psychiatric care. Additionally, racial and ethnic diversity was limited in our sample. It is important to note that medical cannabis is legal in Rhode Island and is legal for recreational use in the neighboring state of Massachusetts. Therefore, the present sample may overestimate positive attitudes about cannabis and may not be generalizable to populations in geographic areas where cannabis is not legally available. Since the sample was recruited from a psychiatry outpatient program, all participants were linked to mental health care and most received psychiatric medication(s). Thus, our sample may underestimate the use of cannabis for self-medicating psychiatric symptoms. We also cannot comment on differences in cannabis use and perception by mental health condition given the small sample size and that psychiatric diagnoses were self-reported.

Despite these limitations, the phenomenological qualitative approach allowed us to further probe the complexities of cannabis use for emerging adults living with psychiatric issues and explore possible intervention components to decrease use (Biggerstaff & Thompson, 2008). These findings are informative for intervention development and suggest that there are distinct motivators for cannabis use among young adults in psychiatric care.