Situation: Bryan Ludlow is a 27-year-old man who regularly smokes cannabis. He is self-employed as a joiner. He recently split acrimoniously with Julianne, his long-term partner – the only intimate relationship of his life. He currently lives with his parents.
Problem: Bryan’s aggressive nature and brusque manner has meant he has found it difficult to make relationships with people generally. He has tended to smoke cannabis to help him to calm down. However, following his split-up, his parents have been worried about his behaviour. They sometimes found him talking to somebody who clearly wasn’t there. He was hearing voices and showing poor concentration and memory. However, he refused to admit a problem and wouldn’t take his parents’ advice to see the GP as he’d “just be given drugs to zonk him out”. Recently, while working on a roof, Bryan fell and damaged his shoulder, arm and knee. Having to visit a doctor, he admitted his problems. The GP, nearing retirement age and having little truck with recreational drug-users, prescribed chlorpromazine – an antipsychotic drug – saying this would stop him seeing and hearing things. This, as Bryan feared, sedated him and he put weight on. He also started experiencing uncontrolled body movements – which potentially made his work unsafe. This heightened his depression, not least because his physical injuries meant he had no income. He has now stopped the prescribed drugs and has gone back to cannabis.
Bryan seems to be a loner. He has problems engaging with people and is experiencing disruptive and debilitating phenomena. He has lost the one person in his life who gave him meaning and purpose and is now dependent on his own coping strategies. He has returned to his parents, further accentuating his feelings of failure. He seeks solace through cannabis, which further isolates him as it dulls the emotional pain and projects him into confusion. Cannabis is often seen as a sociable drug, elevating mood and loosening inhibitions. For Bryan, it will provide a temporary respite from his pain, but heighten its potency when the artificial calm dissipates.
His use of cannabis has probably increased as he seeks to counter his feelings of stress and pressure. This in turn, will have an adverse affect on his cognitive abilities as a negative behavioural loop is established. He will feel more pressure, have difficulty coping with everyday demands and become more withdrawn, heightening his vulnerability.
As a man, he is likely to receive little sympathy for his situation and could succumb to the patient role, losing further grip on his limited social network. Understandably, Bryan is resistant to the side effect-inducing medication, preferring his own form of sedation.
The chances are that he will not come into contact with mental health services unless his GP chooses to refer him on. Many people such as Bryan are held in primary health care, with little specialist input from secondary mental health services. Even if Bryan is referred, he might scorn the idea, with negative conceptions holding sway in his mind.
There has to be much closer working between specialist mental health professionals and primary care colleagues. Bryan’s GP would benefit from exposure to contemporary thinking on mental health.
Ideally, a mental health worker located in Bryan’s GP practice could help to educate his parents and make them aware of how to obtain help for him. Perhaps over time, the worker could make contact with Bryan and build up a rapport based on practical advice and encouragement. Similarly, Bryan’s confidence could be built up, enabling him to address his social needs and lessening the impact of his mental health problems.
It would be best to attempt to enable Bryan to access support from a local (voluntary) drug agency. Outreach workers, for example, try to work closely with primary health care staff and could encourage the GP to “signpost” Bryan or his parents in the direction of a substance misuse support service.
Much will depend on Bryan’s willingness to engage with services, but he could greatly benefit from a structured day care programme to look at his needs holistically. For example, in Buckinghamshire a local project has its own premises and works daily with adults through groupwork, individual counselling and alternative holistic therapies, such as reiki (a system of natural healing) and auricular (ear) acupuncture. Alongside this there are practical components to the day including computer skills, preparation for the return to the workplace, and interview training. The group prepares a healthy lunch each day and takes some form of exercise, be it a walk along the river or a game of football in the park.
A programme such as this could benefit Bryan by raising his self-esteem. Support from a peer group, with experiences of similar difficulties but with evidence of “having moved on”, could be a motivating factor in his recovery. He might particularly benefit from contact with other men who have begun to address their emotional and psychological needs, providing him with positive role models. Such a programme also takes the pressure off his family and imposes structure to his week, facilitating the return to work.
The voluntary agencies often work in tandem with the statutory services, and in Bryan’s case they would need to liaise closely to ensure an accurate assessment of his needs is undertaken. Dual diagnosis is a possibility. It appears that Bryan has been self-medicating with cannabis for some time before this episode, and an underlying mental health problem may have been masked by his long-term cannabis use. However, it is clear that the medication prescribed by his GP was not appropriate, and left a profound social and psychological impact on him. Bryan needs a sensitive and insightful approach to his situation, and requires a holistic approach to his needs in order to start the healing process.
This response was written with Catrin Vaughan, outreach worker, Addiction Counselling Trust, Buckinghamshire.
There is a need to be open-minded here, not just about Bryan’s use of cannabis, but whether there is a link between his cannabis use and his mental health symptoms, writes Kay Sheldon. Cannabis could be having a more therapeutic effect on Bryan’s psychological state than chlorpromazine, the prescribed medication. Cannabis could also be contributing to his mental health problems, but this shouldn’t be assumed.
There should be a coherent and systematic approach to helping Bryan. He has been let down by his GP’s prejudices and less-than-helpful prescribing habits, so I don’t think this doctor is the person to co-ordinate Bryan’s help. Perhaps a more sympathetic and forward-thinking GP could be obtained, a referral made to a more specialist mental health team, or both. Any referral should ideally be to a primary care service if available, but otherwise a short-term referral to secondary mental health services might be beneficial.
A strategy should be worked out in partnership with Bryan. It is important to find out what his preferences and priorities are, especially in relation to his cannabis use. Initially, he could be helped to stay off cannabis for, say, six months to see what effect this has on his mental health. There might be no need for prescription medication.
If medication is used, it should be a drug that is acceptable to him. He should be given full information about it, including potential side-effects and what to do if he experiences them. His care and treatment strategy should be regularly reviewed and there should be a dialogue with him, so he feels in control of what is happening.
Bryan might benefit from help to improve his relationships. One-to-one sessions with a clinical psychologist might help him to look at how he relates to others and to develop different ways of interacting with people. Other possibilities might be art therapy, group therapy or anger-management sessions.
Bryan seems to be keen to go back to work, and this should be facilitated as soon as possible. It concerns me that he has no income, and he should be helped to apply for benefits. Physiotherapy or keep-fit sessions might interest him and help him to get back to work.
Also, as Bryan is now living with his parents, he might value some help in finding accommodation of his own.
Kay Sheldon is a mental health service user.