The development of services for women crack users can be likened to the therapeutic process of Denial-Acceptance-Adaptation. I believe by raising awareness of the issues involved, hopefully this theraputic process will be accelerated and the appropriate services will be developed.
Denial of information
We have seen the American experience, where there was a denial of need for funding and information and instead a 'just say no' campaign led by Nancy Reagan. It was only when the crack-cocaine crisis seeped into America's white suburbia that funding for information and education became available. Is the situation to be the same in this country? There is currently a lack of quality information available to the public as well as drug workers. The media has served only to create a biased picture of a drug crazed menace, that does not reflect most people's experience of crack use, or its users.
The public is dependent on drug services to provide quality information to prevent more destruction occurring, but services are in denial and also lack information alternative to the media hype. For example it is extremely hard to obtain America's quality books here. Newham Drug Advice Project (NDAP) sent staff to Lincoln's Hospital in the South Bronx for information and NDAP's Crack Service is based very much on aspects of their philosophy. In addition, for those who wish to produce the quality information, funding has not been easy to obtain. John Major on 9 September 1994, proposed spend more on providing education around drugs a young people. Lets hope it's not a case of 'too little I late'.
Denial of access to service
Ask many services and they claim they don't have a crx problem. So where are the crack users? Maybe th are users but they don't need services.
What I have found is that crack users are out there I they don't come forward. And when they do they find tl services are inadequate in their current form for deal with their needs, particularly in the case of crack us women. Acceptance can be gained by use of a clier experience, bringing understanding of the woman crs user's plight to the fore.
A case in point
In April 1991 a woman and mother of two approack our service for help. At that time she was using for peris of up to seven days and collapsing with exhaustion the two days that following the binge. She was und weight, reporting hallucinations, feelings of paranoia X an inability to control her crack use. She resisl suggestions of a rehab (drug rehabilitation centre) for f~ of losing her children - she wanted to come off craci the community. Attempts were made to arrange this, she was unable to attend her appointments with acupuncturist (to obtain some calm and reduction craving).
Acceptance that she could not come off in the community took seven months. She returned limping and exhausted. She had been using for seven days, was homeless and hadn't slept. After placing her children in voluntary care, she was unable to stay awake and agreed to enter a rehab, on condition her children would go with her. But due to administration obstacles she was unable to enter a rehab immediately. I attempted crisis intervention, but again she could not enter straight away. I woke her at 5.30pm and she spoke to crisis intervention. They then agreed she could be assessed for emergency access but not before 9pm and she would need to meet them in Euston. Since we are in East London, to give her money would not necessarily result in her getting there. There are a number of open crack dealing sites on route and three hours to kill. I drove her there, she was admitted that evening, but left within a few days as she felt she could not stay there, though she still wished to enter a rehab.
To enter the rehab she needed funding agreed by social services for herself and her children. Her interview for a rehab took place six weeks later, but she was still not admitted. As a result she remained homeless and using. Two months after first requesting a rehab, she returned to us using heroin. When I informed her she could not enter a rehab whiVe she was dependent on heroin she stopped using immediately. A couple of weeks later she rang saying she was trapped in a house and extremely concerned for her sanity; she had tried to leave, but kept returning. I advised her to find a way of getting to my office, which she did. I telephoned the rehab but the funding obstacle still remained. My director requested that they accept a verbal agreement from him that funding would be forthcoming. They accepted her, but not the children.
Funding was finally agreed, taking a total of three months to obtain, but still only for the client; funding for the children was still to be agreed. She stayed for only six weeks, but felt she couldn't remain any longer without her children. Another six weeks later after leaving the rehab my client requested to return, even without her children. The rehab policy was such that if you leave without completing your programme, you cannot return until a full three months had passed. She would therefore need to wait a further six weeks for another assessment. The client, homeless and dependant on crack, had six weeks to fill - with what, where and how? Needless to say I lost contact with her.
Seven months later she collapsed with a heart attack, was five months pregnant and taken to hospital. Two days later she was transferred to crisis intervention followed by entering a rehab. She remained there throughout her pregnancy, not using crack and determined to stay clean. The time restraint (six months) on staying in the rehab had been reached. She had to move on to a third stage rehab. (The baby was now two months old).
She had to enter a mixed-sex rehab, with no facilities for children, thus without her baby. Also this service did not specialise in working with crack cocaine users. She had been clean for eight months and was looking forward to leaving. She went to court to get her children back, which they said she could have, if she obtained appropriate housing. But the housing people said she could only have the requested accommodation if she had her children, a catch 22 that proved too difficult for her to deal with and resulted in her using crack. She informed the rehab that she had used and was told she would have to leave. She had broken a rule, she phoned me and said she was not ready to leave and could I help, that her use was no different than before. I tried to find another form of refuge for her but she had left before I returned with suggestions.
Four months later I received a letter from her pleading for help, in which shefexpressed concern for her mind, body and soul. However I later heard that she had been taken into custody. Though she was prescribed chlorpromazine in prison to deal with her 'cocaine psychosis', I advised her to come off this, for it would prevent her entering a rehab. I telephoned the previously used rehab and when they said space would be available a bail application was made. The following week I contacted them about dealing with her application and they informed me they no longer had a space. I asked them to place her on the waiting list and was told as she had been there twice it was felt they were not succeeding with her and to try somewhere else. They gave me another rehab to approach, but it didn't take children. The client was prepared to go without them this time. I asked them if they had space and they said, they had three spaces, but would need a completed application form. I asked them to fax this to me and after visiting my client in prison, returned it complete to them within two days, only for them to inform me they no longer had spaces. I asked to place her on their waiting list, but a couple of hours later they telephoned to say no, she is too chaotic. I realised at this point that she would need to be on many waiting lists, as spaces are not kept open. One rehab interviewed her and agreed to have her on their waiting list.
Obtaining a rehab place took two months in the end, the funding this time with 'fast-track' in place, took just fifteen minutes. However bail was refused, and a report on the client's motivation was requested. I wrote the report including the fact that she had stayed clean for four months and showed endless commitment and motivation to stay clean.
My client was given the four months rehab requested plus two years probation including an update report to be written by probation every three months throughout the probation period.
This client's experience demonstrates the major difficulties which need to be overcome if we are to succeed in providing an appropriate quality service to these women. Here I will briefly outline ten areas that have shown to be obstacles for women crack users.
Women are not able to enter hostels or a women's refuge as drug users. Crack use results in a inability to keep track of time and therefore users may be unable to keep appointments to arrange housing through the usual means. When women complete rehab, often they return back to their previous home, full of old stimuli, which can trigger relapse behaviour.
2. Drug Companies
The drug companies' search for that potential income is still continuing. Though acupuncture involves no additional chemicals for the body to deal with, proving it a successful tool, it remains unpromoted.
3. Drug Services
The drugs services frequently respond to the problem by prescribing methadone, or tranquillisers which only results in abuse of these drugs (such as a client using a whole week's prescription in one session).
Doctors feeling disempowered by crack users, seeing their severe depression, anxiety and paranoia and often prescribe tranquillisers. These again are only abused, serving to increase the probability of chemical overdose.
Psychiatrists' reaction when presented with 'cocaine psychosis' is often to prescribe chlorpromazine, which often only serves to assist the crack user in continued use, popping out on occasions to smoke crack, then coming back for medication. Even when detained under the 1983 Mental Health Act, there is often fear amongst staff of obstructing a crack user with intrnt to use.
Rehabs are very much designed for the white opiate using male, having hoops for clients to jump through to show commitment. But for a crack user their patience is not as strong as their commitment, and this frustration leads to them lapsing. Women crack users often have children and rehabs rarely provide facilities for women to bring their children with them, which makes many women reluctant to enter rehabs.
7. Age of entry into rehabs
There is also a minimum age limit of 18 and over, thus younger users are unable to access rehab in the usual way. They are required to be referred and assessed by psychiatrists, which they may under-standably fear.
8. Social Services
Social services oMen take long periods of time to reach a decision on funding a client's stay at rehab. Often this is lengthened by the need to gain funding from two different departments if funding is required for a child. Often clients cannot maintain appointments, thus they never enter rehabs. There is also the extreme fear of social services amongst most women crack users, because of the belief that they may take their childtren). This is a major reason why women do not access services.
Prisons have a high number of crack using women. On entry, women are again prescribed chlorprom-azine to sedate them. Crack is available within the prison from other inmates and no drug treatment is given prior to their release.
10. Service Co-ordination
There is no central co-ordinating post or body to take responsibility for facilitating joint networking between service providers.
This client's problems like many other crack users will not go away if we continue in denial.
With acceptance of this situation we need to move forward and find solutions, for adaptation.
The Way Forward
Requirements of services
We could either adapt existing services to meet the needs of women crack users, or develop services specifically for crack users needs. Services will need to recognise the different 'personality' presented amongst crack users i.e. the need for immediate gratification that can be driven by intense fear and paranoia.
Treatment needs to be immediate, for appointment times are often forgotten due to crack users tunnel vision. Remember with these clients there are no equivalents to the methadone carrot, so why should they return? You therefore have to 'sell' them your services on their first visit. In other words having services vou can offer them.
Services need to reflect the community they are working with. Due to crack being a supporter of equal op-portunities, it is available to all, and services need to reflect that reality. A diverse cross-cultural staff team is required, reflecting client groups, plus cross-cultural training should be provided to raise awareness in all staff.
Requirements of users
To be informed about services which are available. To provide them with information ranging from effects of drugs to hypothetical situations involving social services, pregnancy etc.
Support in obtaining their needs with everything from housing to court reports.
Users want to know what you can provide that they can't, as it should be borne in mind that women crack users become very independent women.
Child care needs to be provided within the drug services, and community child care needs to prioritise these women, if they are to build and succeed with new drug-free lifestyles.
Housing organisations also need to recognise these women as priority.
Response to the problem by services
1. Produce quality information that is user friendly/ user led
2. Raise public workers awareness in :
3. Outreach to users to let them know you are there and what you can offer:
4. Create services specifically for crack users, particularly catering for immediate gratification :
Day care rather than rehab
Provide 'day care services
These includes the above, plus :
All on offer seven days a week.
Advantages of day care
Staying in the community, which has to be got to be got used to anyway.
No need for social services involvement, as the child can stay with mother and their stability is maintained
in life and school etc.
If women still need to be away from all stimuli, create safe houses, which also cater for homeless users. They should again be designed specifically for crack users needs and serve as short-term respites before leading to re-house them in the long-term.
Denial Acceptance Adaptation
Louise Clarke is the Women and Crack Development Worker at Newham Drugs Advice Project
Our valuable member Louise Clarke has been with us since Sunday, 19 December 2010.