News

The name of the service user and her former partner have been changed

CASE NOTES

PRACTITIONERS: Chris Farrell, stimulant drug worker, and Neil Lloyd-Knapman, quality standards manager, Lighthouse Project (formerly the Merseyside Drugs Council) - an independent drugs agency.
FIELD: Substance misuse.
LOCATION: Liverpool.
CLIENT: Linsey Walker is 23 and was using cocaine, as was her partner. 
CASE HISTORY: Walker had a stable upbringing, but in her mid-teens she developed an eating disorder and an obsessive compulsive disorder (OCD). Last year she lost her job through her growing cocaine use: she started turning up late and was often aggressive. Her employers suspected drug misuse and gave her a final warning. She didn't change and was fired. Through a series of circumstances she took a one-off job as an escort model. She was paid £150 for her services (which did not include sex) and used that money to buy cocaine - all of which she took that same night. She then also took some tablets and overdosed. She was rushed to hospital where her heart stopped, but she was resuscitated. 

DILEMMA: Her partner's cocaine use is not as "problematic" as Walker's, but despite saying he will stop, he hasn't and this may well ultimately prevent Linsey from getting clean.
RISK FACTOR: Walker's suicide attempts may have been a cry for help but her cocaine use really deepens her low self-esteem and could yet have tragic consequences.
OUTCOME: Her relationship is over, Walker is now clean, offering support in groupwork to other users, and wants to move eventually into drugs work.

Drug users who misuse stimulant drugs such as amphetamines and cocaine (the two most common in the UK) are typically under-served by drug services, and anyway often perceive services as being there for opiate users only.

And yet there are known associated mental health problems with stimulant drugs including depression and paranoia. The Advisory Council on the Misuse of Drugs also suggests a link exists between cocaine use and suicide.

Indeed, this link was strong in the case of 23-year-old Linsey Walker. Following an overdose her heart had stopped but fortunately she survived. After her discharge from hospital, her GP diagnosed bi-polar disorder (manic-depressive illness), and prescribed venlafaxine - an anti-depressant drug. However, within a week she overdosed again. "After that her mum begged her to get help. She looked in the Yellow Pages, saw this place and came along," says stimulant drugs worker at the Lighthouse Project, Chris Farrell. "Nearly all stimulant drug users self-refer."

He continues: "Our first session was really for me to gauge where Linsey was at. She was presenting with a complex picture: suicidal thoughts, eating disorder, OCD, anti-depressants, and she had used about three days before. She was very emotional. In my experience quite often how you deal with someone can be quite instinctive. I knew we had to take things quite slowly with Linsey."

Walker's experiences at the hospital were poor. Farrell says: "She sat in a room for six hours waiting for a mental health worker, and then just left. Deep down, I think, she was terrified and wanted someone who she felt really wanted to help her."

Farrell realised he needed to fix a second appointment. "I can be flexible so I booked her in again for a couple days later. I think if I had said that we can fit you in in two weeks' time - we would've lost her."

Linsey wanted to stop using cocaine with her long-term aim to get back to work. "However, she was in a relationship with a guy who also snorted coke. I wanted to get him in so I could meet him, but also if she wanted to get and remain clean something had to give in that relationship," he says.

Walker's partner proved receptive, feeling that while he had a problem it wasn't as bad as hers and he was willing to stop using. Farrell shifted the focus to dependency and craving. Although Walker was OK during the week, she would struggle with craving come the weekend - particularly Saturday evening. "For the first few weeks she would go to her parents' house for tea on Saturdays and stay there until about 10pm. That proved a good short-term measure but it doesn't sort out the cravings. So I worked with her helping her to understand the craving process," says Farrell.

However, having a partner who still used - even only occasionally - was proving difficult. "The risk of his cocaine use may have been very little to him. Her cocaine use, which actually could be less frequent, is much more of a risk to her because of her low self-esteem after she has used: it's a different level of risk together," says former quality standards manager, Neil Lloyd-Knapman, now an independent consultant.

Farrell adds: "I said to her what was she prepared to do to get and keep herself clean? She said she'd do anything. And I said there might be a time that we'll have to call on that."

Walker stayed clean for about five weeks but then relapsed. Farrell continues: "Her partner had come in, had a few drinks and scored some coke: Linsey had about a gram. Next day she kicked him out. She'd been with him for just over a year but she knew what it would take to get clean - and he wasn't part of that."

Despite a relapse on Christmas Day she has been clean ever since and doesn't crave any more. "She attends a group of powder cocaine users on Tuesday evenings and hasn't missed one. She still attends because she wants to keep one eye on her use, but I think she also wants to give a bit back: she's exceptionally supportive of other people," says Farrell.

Importantly, Farrell used cognitive therapy techniques to help Walker with her eating disorder - and she hasn't made herself sick for nearly three months: "Which is pretty good since she's been doing it since she was 16," he says. "I'm delighted with the way she's resolved this - she's worked so hard. She is now interested in voluntary work - which ultimately she would like to do within drugs services. It's a big turnaround."

Arguments for risk

• Despite the complexity of Walker's situation, Farrell was right on how best to proceed. He could work slowly with her, building up trust. She had self-referred which is a signal that somebody wants to do something.
• In this case, Farrell was able to build up a comprehensive, holistic picture of need and risk through The Lighthouse Project's new risk assessment system set up by Lloyd-Knapman. "All new referrals are triaged and risk assessed. We look at, for example, risks of suicide, overdose, violence and aggression, neglect, accommodation, and if children are involved. Each answer scores points and the total indicates whether the risk is low, moderate or high," he says.
• Farrell worked on Walker's low self-esteem and fortunately had a good working knowledge of eating disorders and was thus able to tackle that effectively.
• Thanks to the flexible set-up, Farrell was also able to engage with Walker's partner.

Arguments against risk

• Stimulant drug users are a difficult group to engage with. They are largely in employment and do not perceive drug service agencies to be in existence to help them, but rather for people who misuse opiates, such as heroin.
• By accessing the Lighthouse Project (which may be known for its community services such as the needle and syringe exchange) it is often a stimulant drug user's first port of call and they may have misconceived expectations. Certainly this will have been compounded by Walker's after-care experiences in hospital. It may have been more appropriate to have referred her on to more specialist services.
• Indeed, as Farrell explains: "People have disclosed to us for the first time that they were sexually abused as a child and I'm not going to close them down - that's the worst thing I can do. But I will say at the end of our session there are places where they can go. Thing is, they often are not after a specialist."

Independent Comment

Linsey Walker was really lucky to find Chris Farrell who understood obsessive compulsive disorder and eating disorders and was able to structure support through cognitive therapy techniques, writes Tracey Dann. 

Being able to access appropriate support under one roof is always preferable than being pushed from pillar-to-post to get a range of needs met.  With such a long history of an eating disorder, depression and OCD I did question whether a drug rehabilitation framework was being used to treat what might primarily be a mental health problem but it seems to have worked nonetheless. 

Given the complexity of Walker's needs it was positive to note that there had been a comprehensive risk assessment to inform the response. As Walker had low self-esteem, an eating disorder and a one-off escorting job I wondered if the offer of a same sex worker was made in the first instance. 

In relation to GP support I was particularly concerned to note that a woman with an eating disorder who had previously attempted suicide was offered venlafaxine (which needs to be taken with food) for her depression, given side effects which can include loss of appetite and suicide attempts. 

The lack of appropriate after-care from hospital is frustrating as this young woman obviously needed ongoing mental health support. Fortunately, Farrell was flexible and stepped into the gap.

It's heartening to read that Walker is making such good progress but these are early days and I hope she takes the time she needs before embarking on a career supporting others.    

Tracey Dann is director of London Cyrenians Housing