A life resurrected

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