Catching them young with secret therapy

I’m a primary care physician, but with my young adult patients, I’m secretly a therapist, too. When a new patient between the ages of 18 and 25 arrives at my office, he or she generally has a specific request: a physical exam as clearance for football season, a refill of an asthma inhaler, reassurance that a sore throat isn’t strep.

My job, as I see it, is not only to respond to any requests or questions, but also to ask them about the things 18- to 25-year-olds do: attend college (or consider it), search for employment, separate from (or return to live with) parents, find romantic partners, shrug off one-night stands, run out of money, feel confused or depressed or anxious, experiment with drugs and alcohol. The last topic is of special concern for me.

In my experience, most young adults rarely, if ever, have a personal, 30-minute conversation with an adult. They talk mostly to people their own age. To my patients I’m a curious stranger with whom they’re stuck for a while in a small room. If I do my job well, they might just stumble into telling their story.

Lidia, 22, and soon to graduate college, comes in wearing jeans and a T-shirt that reads OBEY. Some minutes after we’ve discussed the reason for this appointment – eczema – I say: “I’m interested in how you would compare yourself today to your 18-year-old self. Do you feel like you’re moving along into adulthood?” She looks surprised by my question. But to hear about her life, I need to be broadly interested and indirect.

“I’m better at handling problems than I was a few years ago,” she says. “I don’t depend on my parents for everything. In the old days, when I had trouble with a roommate, I might have called my parents and moved home. Now I just wait for the lease to end.” I want to hear a full self-portrait, so I ask, “What things are most important to you at the moment?” “Getting a job, completing school, putting my parents’ minds at ease, making my own happiness even if it feels hard at times...”

By bringing up “happiness,” she has given me an opening to wander into the topic of drugs.“Does marijuana or alcohol play a part in your happiness?” I ask. “I don’t drink much because I don’t like feeling hung over, but I’m smoking more weed than I was last year. I’m flipping between if I should stop and if I’m just gonna have some fun. Back and forth.”

Rather than ask about the specifics – the amount and frequency of use – and put her on the spot, I ask, “It’s hard to think about the next week, but where do you think you’d like your marijuana use to be in a year?”

“I don’t want to stop completely because it would weird out my friends. But I could if I had to, like if my job was going to test me, or if I had to save money.” I’m not overly troubled when she says, “I don’t think marijuana affects me like it does a lot of people.” She may underestimate the effects of marijuana or perhaps marijuana does not affect her negatively at all. But she doesn’t mention that she smokes to forget her troubles, or because she’s sad or nervous, phrases that would suggest there’s a larger problem.

With David – 19, short-haired and big-eared, a part-time community college student – I worry. He informs me that he wants to be “a great decision-maker.” He reports the pride of owning a new laptop, telling me “bills create discipline.” But then, as if the word “discipline” reminds him of something, he says: “My mom is going back to jail. She didn’t make the right decisions in the free world.” He adds: “That makes me push toward drugs. It helps me deal with it.”

Coping with marijuana

As with Lidia, there is no magic number I’m waiting for David to announce so that I can give him a label, and offer him counsel. Here’s what I’m trying to differentiate: Is this person using marijuana for fun or to mitigate negative feelings? Using marijuana “to cope” is often a marker for other pathology – serious mental health problems, anxiety, attention deficit disorder, concurrent alcohol abuse, major depression.

Although I’m concerned about his drug use and his admission of distress, this first visit is an orientation, an introduction. I will ask him to come see me again, and soon. Sometimes people like David never reappear, perhaps embarrassed by what they’ve admitted or upset by my prying.

Life often changes dramatically in a matter of months at their age. New pleasures come along, and also new risks, new forms of distress that are deep and real and need attention. But this is not likely to be revealed unless a young adult is encouraged to find his or her way to a primary care doctor, and unless that doctor tries to understand what’s happening in the full life of a David or a Lidia, a young adult who may have arrived asking simply for a refill.