The Bower Place Approach to Working with Codeine Addiction

Introduction

• Codeine is a highly abused prescription medication. 

• It is a narcotic used for treating minor to severe pain, an opiate related to morphine and heroin which is usually prescribed by doctors in the for of pills containing combinations of codeine and over-the-counter anaesthetics, such as aspirin. 

• Codeine can be habit-forming and addictive, and abuse of codeine is increasing. Chronic/long-term use may result in physical dependence.  Some people use codeine to dull emotional and mental pain as well physical pain 

• Addiction to codeine is serious and can devastate a person’s physical, mental, emotional, spiritual, and social life. People who abuse drugs usually have several factors contributing to their addiction; ‘biological’ including genetics and the disruption of normal body mechanisms; ‘psychological’ including unresolved trauma and other experiences not properly addressed, ‘social’ including family and peer influences; and ‘environmental’ including homelessness and the adequacy of food and medical treatment. 

• The signs/symptoms of a codeine problem or addiction include persistent drowsiness, fatigue, itchy skin, loss of appetite, excessive sleeping, bluish tint to lips and fingernails, nausea and dizziness, uncontrolled muscle twitching, withdrawal from social activities; loss of interest in hobbies, repeatedly borrowing or asking for money (to support the addiction). 

• Codeine, as an opiate like morphine, produces an impaired emotional response to pain, and has a long-term impact on the nervous system. The physical consequences include nausea, blurred vision, liver damage, kidney damage, stomach bleeding, tremors, seizures, cardiovascular difficulties, compromised breathing, respiratory depression, and sometimes death.
• The psychological effect includes impaired cognitive function, disorientation, mood swings, irritability, hallucinations, depression and anxiety.
• Socio-relational impact comes in the form of divided and fractured relationships with family and friends, self and other imposed isolation and withdrawal from the ordinary social world and interaction with people.
• Whilst withdrawal of codeine can be an unpleasant experience and most symptoms pass within a few days or weeks, it may take months before a person feels physically ‘normal’ again. Withdrawal can include headaches, muscle pain, insomnia, fever, nausea and vomiting, sweating, dehydration, weakness, and digestive issues. 

The Bower Place Approach

The following information was prepared for a 38 year-old man who presented with an addiction to codeine. It outlines the treatment approach and the rationale behind it. In particular it addresses change to the ‘neural loops inside your head’ as the priority over addressing the past 

 “So the deal with you and me is as follows: 

• Zero secrecy or deception. Secrecy is the glue that binds an addiction together. Without secrecy and deception an addiction finds it difficult to flourish. Addictions largely flourish under the cloak that secrecy and deception provide. Remove secrecy and deception and we have a reasonable chance of dealing with the addiction
• It will take you a full two years to shake this addiction and even then you will need a strong structure of genuine vigilance around you for years to come after this process is done. You will remain hard wired for secrecy, deception and addiction for the rest of your life and you will probably find that very troubling
• We will tackle the secrecy, deception and addiction in four stages over the next two years with the fifth stage being ‘the rest of your life’
  Step 1 is 30 days
  Step 2 is 70 days
  Step 3 is 229 days
  Step 4 is 364 days
  Step 5 is The rest of your life
• You need to accept direction and follow instructions at the start of this process in order to get on top this addiction. That will be hard for you. Understanding the causes of your addiction will not help you significantly at this stage of the process.  Understanding will come later.
• You must understand that an addiction can only be completely broken through the breaking of the secrecy that binds the addiction in place; and that secrecy is on the inside of your head and in the interactions you have with the world and people on the outside of your head. That’s why I put in place a process of twice daily (minimum) messaging. This is not just me making you accountable. It’s you and I creating new loops of cognition, thought and emotions that do not contain secrecy; and new interactional loops on the outside of your head that do not contain secrecy.  
• You must text me first thing in the morning with your stated intention about notusing codeine today; and not putting yourself into a position where you could easily use codeine today. This is about you and codeine today; it’s not about you not using codeine tomorrow. We will deal with tomorrow, tomorrow. 
• This is about you breaking your secrecy about codeine today; it’s not about you breaking your secrecy about codeine  tomorrow. You will break this secrecy and your addiction to codeine one day at a time.  The text you send will be something like this:  e.g. “I will not use codeine or any other drug today under any circumstances; and I will not put myself deliberately or accidentally anywhere near a pharmacy or any other place that will supply codeine (and any other drugs) to me. I will not lie to you about my thoughts and feelings about using codeine or if I actually do use codeine”
• The message must be fully written by you each time and it must be slightly different each time; not just a copy and paste job. I will respond to your message
• It may be useful for you to have an exercise routine in the morning that precedes the sending of that message.
• At night just before you go to bed I want a text from you telling me how you’ve gone today with your undertaking from the morning, irrespective of whether you’ve used codeine or not; and how you’ve handled things through that day.
• Each addiction is different; each substance is different; each person is different. Codeine is pernicious. It’s important to grasp the fact that codeine does something extraordinary for you that nothing else seems to be able to match; and misunderstanding this likely to have a very negative effect on you and this process. It’s not about hunting down a substitute even though that is sometimes helpful. It’s just appreciating the fact that codeine offers you a momentary peace that you can find no other way; solace that has eluded you all these years; and you know this is something we need to address in the process. You will need to find that solace in some other way through this process. 
• The approach I use with addictions emphasizes dealing with the fact of the addiction inside your head; and in the interactions between you and other people in the here and now. Whilst I’m fully across the idea that there may be other casual factors at play in creating this codeine addiction, I’m decidedly of the view that it’s secrecy and deception that binds the codeine addiction in place; in the neural loops inside your head; and in the interactional loops outside your head; in the here and now; not in the past. My view is that we should not force the past to the surface or into the foreground. Whilst the past may have explanatory value in terms of your life and your codeine addiction and how things are in the present, that may help but such an understanding is unlikely to challenge the neural and interactional loops that bind you and your addiction in place in the present.

• By removing codeine and the secrecy that goes with it, we open the emotional, cognitive, behavioural, relational and interactional space for other things to occur, and what often happens is that the person with the codeine addiction spontaneously has revelations, about themselves or their circumstances.”

What happened next?

The client began the first count-down from 30 days and encountered some occasional difficulties in the withdrawal process but was overall successful.

As a direct result of these withdrawal difficulties the practitioner called an urgent face to face consultation with the client. The client lived many hours from the city and the practitioner’s rooms. In this consultation the key issues addressed were the client’s: 

• Withdrawal symptoms from codeine.
• Long standing tendency to behave in an excessively ‘needy’ way in many relationships, including with his new former wife, his father, and his current female partner. He described this behaviour as ‘sooking‘ or sulking and his sense of vulnerability around this. 
• Relationship with his new partner over her five-year-old son’s behaviour. 

 The issues in relation to codeine withdrawal were straightforward and dealt with directly and openly. The removal of secrecy in relation to codeine and everything connected to his codeine use meant that there was a high degree of openness about the withdrawal process. No further intervention was needed at this point in time in relation to his withdrawal from codeine except to reinforce the cessation of secrecy as the first line in the contract between practitioner and client. 

 In relation to being excessively ‘needy‘, ‘sooking‘, it was clear that the client’s long standing anxiety about himself and close intimate, relationships of every type was a significant issue in this withdrawal process and an issue well beyond this time. It was certainly a long-standing issue that had never been addressed with the client in any therapeutic process to date. The critical therapeutic question here was whether unpacking this ‘sooking‘ issue would make a significant difference to the client during this part of the codeine withdrawal process and protect him in the withdrawal process from this anxiety intersecting with the extraordinary anxiety he was experiencing without codeine. 

 The alternative was to devise a strategy for him to manage being excessively ‘needy’ and ‘sooking’ during this part of the withdrawal process and see if it was possible to influence this affect and behaviour and reduce his level of anxiety about the impact of this affect and behaviour on his new relationship. 

The client was provided with a ‘back-brain/front-brain’ summary explanation about the way ‘sooking‘ works neuro-biologically and the reasons why it is difficult to rationally call a halt to ‘sooking‘ in the heat of the ‘hurt’ and emotionally ‘wounded’ moment; how he knows how long it takes for him to settle and calm down; how is not wise for him to do anything in the heat of the ‘hurt’ and ‘wounded’ moment, that he needs to find a way  to calm down and to ensure that he doesn’t do anything unwise during this time (i.e. send his new partner an angry, hurt or wounded text message). What we are removing from the mix, ceasing, is the client’s internal emotions spilling over into humiliating and unwise needy affect and behaviour in the relationship; we are removing his stupidity and resulting humiliation when his hurt and wounded feelings get out of control. 

 The following is the email sent to this client summarizing the discussion in the consultation on “Day 16” about being ‘needy’ and ‘sooking‘ and wanting this to stop. 

Email

“* Bolt the plan for dealing with “sooking” onto the twice daily plan we already have in place for dealing with “secrecy” & “codeine” 

* “Sooking” predates “codeine” so you are probably as or harder wired for “sooking” than you are “codeine” 

* Whilst “sooking” is not directly a physical addiction it functions very much like an addiction 

* “Sooking” makes you appear quite “needy” & diminishes you in your own eyes & the eyes of others & needs to be removed from your life immediately if your relationship with your partner is to last the distance as you would want. You become aroused and distressed by something (an incident, a word, a gesture, the absence of something) & that arousal won’t settle or pass as quickly as you need it to, and your reasoning/logical “front-brain” can’t kick-in & override this state of “back-brain” arousal until the arousal settles down. This is a classic bind or “catch 22” 

* You know the decisions you make, what you do & don’t do, what you say, how you behave, your mood, how you engage or withdraw and what you text are totally different when your “back-brain” is aroused compared to when it’s settled. 

* And that makes a fool of you & you make a fool of yourself & you struggle to get out of that emotional bog-hole even when there is a nagging voice somewhere in the back of your head saying NO!!!! 

* Remove “sooking” from the mix & your life would probably be very different; a great deal of tension would most likely leave you.