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The client is 28 years of age and living in a share household.

She has been in


and out of relationships for 10 years and has found it difficult to sustain
anything that is satisfyingly long-term. She comes from a family with a
suspected history of personality disorder (maternal side) and so there are
questions around personal boundaries and ego-container. The client has
regularly taken codeine since she was in high school and it has only been
more recently recognized as a chronic issue. She has been experiencing
panic attacks for the last couple of years and has noticed they are getting
worse. She also said that more recently the anxiety doesnt go away after
taking it. It used to make her feel good and would help her through a normal
day but she found that she gradually had to increase the dose to get the same
effect. She has tried to stop taking it several times but has found that to be
impossible without professional intervention. It has reduced her ability to
concentrate on tasks, impacting on her work, and her reclusive behavior has
caused alienation from family and friends. She has found it impossible to
sustain long-term intimate relationships. She displays signs of liver toxicity but
this is probably due to the combined effect of paracetamol.
Psychiatric Model - DSMV
ICD-10-CM F11.188 Opioid abuse with other opioid-induced disorder (anxiety)
ICD-10-CM Z62.820 Parent-child relational problem
Opioid dependence is a chronic, relapsing brain disease that causes major
medical, social and economic problems to both the individual and society.
Symptoms are CNS depression, drowsiness, analgesia, euphoria and
constipation. Withdrawal symptoms include insomnia, restlessness, anxiety,
abdominal cramping, muscular spasms, diarrhea, chills and hot flushes
including night sweats.
Relational problems are not considered to be a mental disorder. They are
clinically significant behavioral or psychological syndromes or patterns that
occur between or among individuals and that are associated with present
distress or disability or with a significant increased risk of suffering death,
pain, disability, or an important loss of freedom. They are listed as Axis 1
disorders. The treatments at Odyssey House include CBT, relaxation
techniques and family therapy. The mother has not been very compliant to
date.
Other health care services managing the clients case:
Odyssey House
(02) 9281 5144 - drug withdrawal and family therapy
Health Space Oatley (02) 9579 5100 - managing liver toxicity and health
She experienced inconsistent mothering as a child but was spoilt by her father
when he was at home, otherwise he would work back most nights and
weekends. Her mother often locked her in the bedroom for long periods of
time when she was young. The mother would exhibit jealous responses in
front of the father and she never allowed her daughter to grow her hair long,
cutting it once it got to a certain length.

The clients addiction was a form of self-medication. The maladaptive


mechanism would have to be gradually dismantled and replaced with
something that would nurture the clients authentic self. It was obvious that
what lay hidden beneath was much more painful than the addiction itself. The
other consideration was that the addiction had penetrated the physical to such
a degree that it also had a biological component. The clients health was being
addressed through natural therapies at Health Space. Odyssey House was
helping her plan a controlled withdrawal over a period of time.
There was a definite cycle to the addiction. It started with the substance
abuse, followed by shame, promising to stop, fantasizing that everything was
under control and she would just take it once more, obsessing over using
again, building frustration while experiencing withdrawal, and finally back to
the start of the cycle.
It would sound something like this:
I cant believe I did it again.
Im never doing that again.
Maybe I could have just one more to feel a little better.
I need it now. I have to get it. No, I can manage this.
What will I do? I cant stand feeling like this for another minute.
I cant believe I did it again.
The client was given the time she needed to stay in her presenting condition.
This helped to reassure her that her broken state was being honored as an
important part of the path to wholeness.
The client was having problems feeling any sense of compassion for her own
predicament. However, the client often referred to a friend whom they
expressed great affection towards. This friend was in an abusive relationship
and would share her distress with the client, sometimes on a daily basis. I felt
that this could be a doorway to the clients own dislocated sense of self-care. I
asked her to make a list of all the attributes she most valued in her friend.
Eventually she began to recognize some of these attributes in herself.
I shared a poem by Emily Dickenson with the client:
Hope is the thing with feathers That perches in the soul And sings the tune without the words And never stops - at all And sweetest - in the Gale - is heard And sore must be the storm That could abash the little Bird
That kept so many warm Ive heard it in the chillest land And on the strangest Sea Yet - never - in Extremity,
It asked a crumb - of me.

After reading the poem I introduced a process for feather-work. The process
involved sticking feathers on to a piece of paper. I had some templates the
client could refer to in order to create a bird out of the feathers. The idea
behind this was for the client to experience softness through touch. It is in this
way she could allow some softness into her life and hopefully begin a routine
of self-care to gradually take the place of self-abuse. The client was instructed
to take the bird home with her and use it as a reminder for when she was
feeling discouraged and inclined to engage in addictive behavior.
Breaking the cycle of addiction was going to involve several stages. I had
these mapped out for the client and we worked with them in a flexible way.
It began with Pre-contemplation, the client not actually ready or prepared to
embark on the process of change. This would move into Contemplation, the
client would consider everything necessary to go through with the process of
withdrawal. Preparation would involve mentally and physically preparing to
stop using. Action would include stopping use of the substance and seeking
treatment. Maintenance was the creation of a new lifestyle as part of the
recovery process. We worked on a medicine wheel with these marked out as
transformational states. At various stages the client would use it to get a
sense of where she really was in the process. After this the client would do a
clay process in which she would explore her current state followed by a
metamorphosis into the next one. We would then do an amplification of the
results.
During the Action phase the client was given a process that involved
creating a circle on a sheet of paper. She was asked to fill it with everything
associated with regrets related to past addictive behavior. This was completed
as a collage. Afterwards she was asked to view the rest of the paper as
though it were a windscreen. The client was asked a few questions regarding
this:
Is it clear? or Is it foggy?
What do you hope might be contained in the view of the future?
This was followed by another process working with two interlocking circles
(vesica piscis) as a collage: one representing before addiction, the other
afterwards. I asked the client to keep the vesica pisces empty as a symbol for
letting anything new to emerge. The client then explored what was in the
shared space between the two circles.
A tremendous amount of support was needed to assist the client in
overcoming her addictive behavior. I was always very sensitive to the fact that
it could only be achieved one small step at a time. Fortunately I was able to
get the client to contact family and friends so that she had a reliable network
for checking-in. The clients fragmented sense of self needed to be handled
tactfully without wrapping her in cotton wool.
In order to empower the client there were times I had to make it clear that the
relationship was not about us liking each other. The issue of dependency was
obviously a deeply ingrained pattern and the client would sometimes ask me if
I was their comforter or foe. This was a co-dependency that went back to her
childhood. I had to remind the client that I was not her parent and I was not
about to comfort her in place of the drug. There were several occasions I had
to send the client away because she was clearly under the influence. This

was the one contraindication I was most concerned about in regards to the art
therapy sessions. The other was the need for sensitivity towards the clients
fragile ego-container.
My integrity was preserved through making sure that it was clear to the client
that I was only there for her if she was prepared to put in the work herself.
This also helped preserve our boundaries in relationship to each other. The
client had some difficult times ahead of her in regards to building up her own
personal boundaries but this was recognized as integral to the recovery
process.
Habits help us to manage the routine but essential elements of every day life.
When this includes destructive patterns then the habit begins to exert a
disruptive influence on the course of the day. Routine and ritual make the
unknown or unpredictable elements in life more bearable. Any insecurity
regarding identity and place in society compounds lifes uncertainties. In this
way, habits assume the role of coping mechanism.
The human condition has a tendency towards addiction. Very similar stages
are experienced in the process of coming to terms with addiction as there are
with death these being denial, anger, bargaining, depression, and
acceptance. In recognizing her addictive patterns the client exhibited the
necessary strength to move beyond the mask (persona) of denial. Once she
began working with the anxiety of confronting the void of being that was
masked by the addiction, we were able to make considerable progress. Part
of the clients challenge was to meet the strength that is inherent within her.
She still needs to become conscious of her potential and exercise it,
eventually helping others in her life to do the same thing.
I keep up to date with progress reports from her psychiatrist at Odyssey
House and the naturopath at Health Space. There is ongoing speculation on
the part of the psychiatrist regarding a possible Axis 2 diagnosis relating to
inherited personality disorder.

References: (used for DSMV definitions)


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2654406/

http://www.europad.org/MaterialePDF/Maremmani_et_al_2011.pdf