Preferences of Young Adults With Psychosis for Cannabis-Focused Harm Reduction Interventions: A Cross-Sectional Study: Préférences des jeunes adultes souffrant de psychose pour les interventions de réduction des méfaits axées sur le cannabis : une étude transversale

OBJECTIVES

Cannabis use is common in people with early-phase psychosis (EP) and is associated with worse treatment outcomes. Few targeted interventions for cannabis use behaviour in this population exist, most focusing on abstinence, none focusing on harm reduction. Many people with EP will not seek treatment for their cannabis use with current therapeutic options. Understanding preferences for cannabis-focused harm reduction interventions may be key to improving outcomes. This study aimed to determine preferences of young adults with EP who use cannabis for cannabis-focused harm reduction interventions.

METHODS

Eighty-nine young adults across Canada with EP interested in reducing cannabis-related harms were recruited. An online questionnaire combining conventional survey methodology and two unique discrete choice experiments (DCEs) was administered. One DCE focused on attributes of core harm reduction interventions (DCE 1) and the second on attributes of boosters (DCE 2). We analysed these using mixed ranked-ordered logistic regression models. Preference questions using conventional survey methodology were analysed using summary statistics.

RESULTS

Preferred characteristics for cannabis-focused harm reduction interventions (DCE 1) were: shorter sessions (60 min vs. 10 min, odds ratio (OR): 0.72; P < 0.001); less frequent sessions (daily vs. monthly, OR: 0.68; P < 0.001); shorter interventions (3 months vs. 1 month, OR: 0.80; P < 0.01); technology-based interventions (vs. in-person, OR: 1.17; P < 0.05). Preferences for post-intervention boosters (DCE 2) included opting into boosters (vs. opting out, OR: 3.53; P < 0.001) and having shorter boosters (3 months vs. 1 month, OR: 0.79; P < 0.01). Nearly half of the participants preferred to reduce cannabis use as a principal intervention goal (vs. using in less harmful ways or avoiding risky situations).

CONCLUSIONS

Further research is required to see if technology-based harm reduction interventions for cannabis featuring these preferences translate into greater engagement and improved outcomes in EP patients.

[Units for difficult patients]

The ten French units for difficult patients are secure psychiatric services which receive people suffering from mental pathologies who could have committed or have committed dangerous acts. Among the mental health structures presented in this dossier, the units for difficult patients are those which admit prisoners with psychological disorders and problems of dangerousness for the longest period of time. As fully-fledged care facilities, they offer intensive and multi-professional care.

Destructiveness: a 'neglected child' in the theory of analytical psychology

C.G. Jung postulates the child motif as the central symbol of the unfolding self towards wholeness. From the 'abandoned child' and the 'invincibility of the child', Jung derives the 'divine child' as hero. It is about the victory of consciousness over the unconscious, about the 'overcoming of the darkness monster'. But in this ego-psychological approach, there is no 'evil', no destructive child. The author is surprised that there is no concept of destructiveness per se, in the Kantian sense, in either psychoanalysis or analytical psychology. In Jung, 'evil' exists as a shadow dynamic that needs to be integrated. This paper is about destructiveness that cannot be integrated. The author's hypothesis is that some patients have the unconscious belief that they are a discarded child and were born as a 'bad' destructive child or have acquired this unconscious belief in the course of their development. Both possibilities are explored with regard to their treatability using clinical vignettes from the therapy of a child, an adolescent and an adult patient. With regard to collective destructiveness, an attempt is also made to highlight some characteristic beliefs of increasingly radicalized political and social groups.

[The work of mourning, getting through the loss]

Pain, mourning translate, in their indeterminacy of the affective experience, the suffering, the guilt, the anguish when the individuals are confronted with the death, the loss or the separation from the object. It doesn't matter if this object is a loved one or an abstraction... These different experiences each sign in their own way the human way of reacting to the inescapable encounter with this reality. To seize and overcome the experience of the affective experience makes it possible to understand and to put in form the significant mechanisms which underlie the processes of mourning. It also helps to apprehend its necessary and obligatory scope, given the attachment and identification that characterize the link between humans.

[Touch-Massage®, an original approach in psychiatric nursing homes]

The practice of Touch-Massage® in a residential unit for dependent elderly people, specialized in psychiatry, requires an adapted and thoughtful approach. A nursing assistant experienced in this type of care and institutional trainer shares her experience. Beyond the technical nature of the approach, Touch-Massage® is above all an informal approach. The primary goal is to establish a relationship of trust, which is synonymous with well-being for the resident.

[Therapeutic education for patients with schizophrenia]

Schizophrenia is a chronic and complex mental illness with a multifactorial aetiology, resulting from the interaction between neurobiological and environmental factors. Affecting approximately 1% of the world's population, it generally appears slowly and progressively in subjects aged 15 to 25 years. The polymorphic symptomatology is a source of disability and often of social maladjustment, which implies the implementation, if possible at an early stage, of multi-axis support in order to meet the specific needs of these patients and their families. Therapeutic patient education is one of the targeted interventions that have proven to be effective in improving the quality of life and functional prognosis of the subjects with schizophrenic disorders.

[The case of Mrs S., an illustration of the contribution of transculturality in psychiatry]

The recurring failure to accurately account for local realities, by semiology built on the universalist model of evidence-based medicine has made it necessary to theorize culture-bound syndrome. The case of Mrs. S. illustrates how, despite multiple hospitalizations and management, a first symptomatology of psychotic appearance has eclipsed, for years, a recurrent depressive disorder. These diagnostic errors involve people because of their non-Western origins, and lead to an overdiagnostic of schizophrenia. It seems urgent to us to promote awareness of this social inequity of health by sensitizing French psychiatric interns to cross-cultural issues.

[Non-compulsory outpatient care programmes: two clinical illustrations]

The act of 5 July 2011 pertaining to the rights and the protection of persons under psychiatric care presents the possibility for compulsory care, without the need for full hospitalisation. Patients can be cared for through partial hospitalisation (day hospital and part-time therapeutic clinic) or in a medical-psychological centre. Treatments and all care are detailed in a care programme. This programme is sent, like all certificates, to the regional health agency and the prefecture in the case of psychiatric care by decision of the State representative, or to the hospital director for psychiatric care at the request of a third party. We propose two clinical vignettes.

[Temporality and home visits for patients with psychosis]

Patients with psychosis are known to dislike change or being hurried. Their relationship with time must therefore be taken into account, all the more so given that today's society leads us to believe that immediate satisfaction takes priority. Constant switching and addiction upset the stability which supports these patients with difficulty. The case of a patient visited at home shows that the team's decision to adapt to that one time will favour her subjectivation and the consolidation of her equilibrium.

[Melting-Pain Therapy for difficult mental health patients]

The nurses in the unit for difficult patients at Cadillac hospital have developed an innovative art therapy concept: Melting-Pain Therapy. In this workshop patients produce a collective piece of art created through participants' individual sessions with a nurse. These patients are exclusively men, suffering mainly from schizophrenia, who have been or who are potentially dangerous. The photographs accompanying this article show some examples of these art brut creations.

[Build a bridge to the patient experiences psychosis in a context of coercion]

The nursepatient relationship is particularly challenging when the patient experiences psychosis and when he or she is placed in a context of coercion. Psychosis causes relational problems in the patient, which are further complicated in a context of coercion as this practice implies differences of understanding, status and power between the nurse and the patient. The Tidal Model, a care model focused on recovery, comprises ten principles of commitment for caregivers, which help to build a bridge between them and the person experiencing psychosis.

[Cognitive Behavioral Therapies, a co-coconstruction of care]

The decline of the medical paternalism tend to promote the emergence of person centered approaches. Cognitive behavioral therapies allow the enhancement of empowerment and contribute to the expansion of experiential knowledge. Various therapeutic strategies are summarized as well as their benefits and especially their leading role in the generation of experiential knowledge.

[Therapeutic mediation through the self-portrait: examining the self through the eyes of others]

Art is used as a form of mediation in care units. In addition to its benefit as an occupational activity, it is rooted in the tangible which can help combat apragmatism and anxiety.While this practice helps patients give meaning to their existence, the group approach and the help of a therapist form part of personalised care projects. Work around the self-portrait is an illustration of this practice, between the occupational and the therapeutic.

[Admission of a patient with psychosis to a nursing home and continuity of psychiatric care]

The terms 'admission, solution and continuity' are the condensation of useful notions for describing the phenomenon of the referral of patients receiving psychiatric care to nursing homes. The extent of this trend and the concern for quality of life means that, in terms of the institutional, legal and ethical issues involved, the psychotic elderly patient must not remain marginal or invisible.

[Care in an LTC unit: between psychosis, fantasy and challenge]

In nursing homes, residents with psychiatric disorders are cared for alongside other residents. While the clinical presentation is different to that of dementia, the caregivers need to adopt a new approach in order to provide the necessary long-term support. Their social representations of madness must also be questioned. The integration of psychotic residents into a nursing home must be anticipated and prepared through exchanges and interventions overseen jointly by the geriatric and psychiatric teams.

[A specific unit for residents presenting psychiatric disorders]

Faced with the growing number of requests for the admission of patients with chronic psychiatric pathologies, a nursing home in Port-Louis has created the 'Normandie' unit to accomodate these residents. The special feature of the support provided and the organisation of the day-to-day routine requires caregivers to adopt a specific approach.

[Psychiatry and palliative care, collaboration for the benefit of the patient]

As palliative care units continue to develop, the provision of end-of-life care for patients with a chronic mental illness needs to be addressed. Aside from the somatic comorbidities to which these patients are particularly exposed and in view of the specificity of psychiatric treatment, the forms of end-of-life support for a patient with schizophrenia are described here, based on the experience of a psychiatric unit in the Var region.

[Body marking in psychosis]

Patients with psychosis speak of an uneasy relationship with their body. Between feelings of too little and too much, for them it is a matter of trying to suture an image which is not always unified, a body which they are not always sure they have. The attentive clinician will attempt to support the solutions of each psychotic patient to maintain their body, beyond the death drive which pushes them to tear it apart.

[When the psychotic person is an alcoholic: working on acceptance]

Alcohol dependence in a person with psychosis is a complex question. Paradoxically, by trying to stay alive, the person places themselves in serious danger, without consideration for their body or their life. Withdrawal could have worse effects than the continuation of alcohol use. The support within a French service for the medical-social support of mentally disabled adults (SAMSAH) therefore involves going not towards the change that we want for the person, but towards acceptance of what they are, in order to open up the future.

[Severe mental disorders: cure? What an idea!]

The evolution of mental disorders, notably the most severe forms such as schizophrenia, is a constant concern in terms of the necessary assessment of treatments and their efficiency, and to the human and economic cost of the 'chronicity' of the disorders. Many patients experience a positive evolution, evaluated in terms of subjective quality of life. However, the concept of recovery does not seem appropriate. The field of representations which the patient and the caregiver form with regard to the disease and its curability is an important element. The co-construction of the patient's future, in an approach centred on the patient, on their freedom and their autonomy, opens up the way towards recovery.

The seventh penis: towards effective psychoanalytic work with pre-surgical transsexuals

The author reflects on his contrasting analytic work with two transsexual patients. He uses three previous psychoanalytic studies (Stoller, Morel and Lemma) to explore whether effective analytic work with the issues driving a person's determined wish for sex reassignment surgery (SRS) is possible. Particular consideration is given to how such work might navigate a path between traumatizing and pathologizing the patient on the one hand and avoiding important analytic material out of fear of so doing on the other. The author proceeds to ask whether it is possible to tell in advance, with any degree of reliability, who is and who is not likely to benefit from surgery. He considers certain diagnostic issues in relation to these questions. Illustrations are given of how, in practice, countertransference anxieties about psychopathologizing transsexual patients can contribute to significant difficulties in working clinically with them. It is argued that the understanding and containment of such anxieties could eventually lead to more effective analytic work, and that such work might be further facilitated by considering the contribution of mind-body dissociation to transsexualism.

[Is therapeutic deadlock inevitable?]

Many long-term treatments appear to be an expression of therapeutic deadlock. The situation leads to a questioning of the concept of chronicity and the identification of the determining factors of situations which are apparently blocked, marked by the search for solutions taking a back seat to the taking of action. The interaction between patients' mental apparatus and the care apparatus lies at the heart of the question, interpreted from an institutional, collective and individual perspective, supported by the clinical and psychopathological approach, and the return to the prioritisation of the thought.

[Prisoners in units for difficult patients]

Prisoners, on remand or convicted, can be placed for a variable amount of time in a unit for difficult patients if their pathological mental state so requires. For the most part, their therapeutic care does not depend on their status as prisoner. The treatments provided are those indicated for their psychological pathologies and their potential or known dangerousness. However, some administrative measures make a distinction between their treatment and that of non-prisoner patients placed in these secure psychiatric units.

[Supporting people with psychosis with and despite their denial]

Denial is an unconscious defence mechanism. Found in people with psychosis, it can make the task of supporting these patients difficult. The French service for the medical-social support of disabled adults (SAMSAH) is confronted with this defence mechanism. Rather than a therapeutic relationship, the mission of this service is one of psychosocial rehabilitation. Placed in a position of impotence, those supporting the patients need to analyse the notion of the relationship and the feelings which the person makes them experience.

[Recovery]

The historical fatalism of the impossibility of recovering from psychosis eased from the 1970s with the shaping of the idea of a possible recovery. Recovery is today the objective for the patient and caregivers. The key to achieving this lies in the encounter with Others. A collective approach, on the level of the institution, must be established. The aim is to create opportunities for the patient to express their doubts and feelings.

[Languages and the history of psychiatry]

Les historiens datent la naissance de la psychiatrie de l’époque où les médecins renoncent à utiliser le latin comme langue scientifique internationale. A partir de la fin du XVIIIe siècle ils publient désormais leurs travaux sur la pathologie mentale dans une langue européenne moderne comme l’anglais, le français, l’allemand, l’italien ou l’espagnol. Certains de textes publiés dans une de celles-ci d’entre sont traduits plus ou moins rapidement dans une ou plusieurs autres. Mais des textes importants ne le sont pas ou très tardivement; les nouveaux concepts psychopathologiques introduits restent méconnus des médecins qui ne connaissent pas la langue originale. Ils sont oubliés et les termes qui les désignent sont remplacés dans les classifications récentes des troubles mentaux par de nouvelles dénominations sans référence à une conception théorique du trouble initialement décrit. L’histoire de la psychiatrie doit étudier l’évolution dans le temps de ces termes traditionnels depuis leur premier emploi par un auteur dans une de ces langues modernes jusqu’à leur éventuel abandon actuel pour comprendre si celui-ci est justifié.

[Psychotropic drugs in general practice]

The article presents a user-friendly overview of psychotropic drugs which are helpful for the prescription in a primary care practice. The author recommends to get familiar with just a small selection of drugs first and second line. This means to know well about their effectiveness, short-and long-term side effects, interactions with other drugs and the necessary monitoring that should be done.