"Are you mourning the loss of your addictive behaviors? Do you have a support team in place to offer shared experiences, counsel, guidance, and an open heart? Have you considered that sobriety is more than the cessation of abusing a substance, person, or experience; that there is a loss of pleasurable components associated with the addictive behaviors? Do you accept that counting days, weeks, and time, does not entirely remedy the loss or related feelings?
Perhaps it is time to consider incorporating the bereavement process into our overall sober healing. What is no longer a focus of bereavement therapy is the idea that 'time heals all wounds' or that the relationship the patient experienced during their active addiction is immediately wiped from their minds.
Instead, maintaining and continuing a bond with those who have also battled addiction as well as with a support team allows the patient to undertake the developmental process away from addiction and toward sobriety and abstinence that will traverse the patient’s entire lifetime." - Dr. Natalie D'Annibale
(complete article below)
By Natalie D’Annibale, PsyD LMFT
Sobriety, or lack of intoxication, is the first step toward a lifetime of abstinence from substance and alcohol use and abuse, but what happens to the patient who gives up their chosen coping mechanism; does the patient grieve the loss of their addiction and fall into a period of sustained and complicated bereavement?
Bereavement is a series of reactions to the loss of something or someone significant like a loved one, an occupation, a physical ability, prized possessions, or an addiction. Prolonged bereavement that significantly overwhelms and impairs the patient’s ability to maintain healthy functioning and coping becomes complicated bereavement.
Ainslie (2013) states that, “Addiction is sometimes identified with physiological patterns such as intoxication, tolerance, and withdrawal, regardless of how the person values them (np).” But when the patient is removed from their pattern of intoxication, tolerance, and withdrawal and becomes sober and abstinent, a period of mourning followed by the normal reactions of grief and loss do result in bereavement (Medline Plus, 2016, np).
The duration of bereavement depends on a variety of factors including the depth of the relationship the patient had with their drugs or alcohol of choice, the social interactions associated with obtaining and using the drugs and alcohol, with the people in their lives that they must leave due to shared drug use, whether or not sobriety was expected (for example, criminal activity that leads to instant sobriety like drug busts or car accidents), and if there is family, friend, therapeutic, and / or spiritual, faith-based support.
When a patient begins the process of detoxification toward sobriety and abstinence from illicit substance and alcohol use or abuse, the experience of grief and loss that follows should be assessed, evaluated, and considered to assist the patient in understanding that they are entering a period of bereavement; bereavement resulting from the loss of their relationship with drugs and alcohol.
Understanding the effects and complications associated with bereavement may also benefit the family, support system, friends, and loved ones in the patient’s life. These people (friends, family, spouses, children, co-workers, support system) may not personally be challenged by addiction, but they may have experienced symptoms of bereavement due to grief and loss in other ways that would provide insight into the patient’s experience in sobriety.
The cessation of a patient’s relationship to alcohol and drugs in the early days of sobriety removes their preferred coping mechanism, their “liquid courage… Not to mention the loss of [their] perceived identity… ‘as the outgoing partier’ (Health In Recovery, 2016, np).”
As with Kubler-Ross’ Five Stages of Grief: 1. Denial, 2. Anger, 3. Bargaining, 4. Depression, and 5. Acceptance (Help Guide, 2016, np), grief in recovery follows a similar pattern related to the loss of the relationship with drugs and alcohol. Every patient will not experience each of the five stages of grief, nor must they remain in the above order, but Kubler-Ross provides a generalized picture of what a patient may go through when experiencing the grief and loss associated with the process of bereavement.
Denial begins the process of recovery for many patients; a precontemplative period when the patient has yet to decide that action must be taken to deal with their problems associated with drug and alcohol use or abuse. The patient will initially question whether or not they have an addiction and may believe those around them are exaggerating their concerns around the patient’s substance or alcohol use / abuse.
Many patients entering detoxification programs (following major tragedies and difficulties related to their addiction) will deny that they have a problem. Patients may be uncomfortable accepting that they are addicts with the disease of addiction. ASAM (2016) describes addiction as:
[A] primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by [the] inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (np)
According to Steinberg (2014), “Internal acceptance of their chemical dependency is required to overcome (np)” addiction as well as the need for ongoing sobriety with the assistance of a 12-step program or team of support including drug counselors, therapists, psychiatrists, friends, and family.
Following addiction denial, a patient will enter the stage of grief and loss demonstrated by acts and emotions associated with anger. The anger may be seen as venting, raging, refusals to comply, shutting people out, feelings of victimization, cravings, deception, projection, isolation, and withdrawal. Patients may demand to leave treatment, blame others for their plight, or even act out emotionally and physically to procure their alcohol and drug of choice during a relapse.
Anger is most typically displayed cognitively, behaviorally, physically or in combination with each other. The patient may have angry thoughts toward themselves or others related to the loss of their drug of choice, they may act out by damaging property, and they may choose to respond physically as in the fight or flight response.
The anger may be displayed passively or aggressively. Passive anger would include manipulation, failure, sulking, and being secretive (Alcohol Rehab, 2016, np). Aggressive anger would be seen as starting fights and acting out violently against themselves or others. Anger may also be the source of a relapse, triggering emotion dysregulation, fear, and a lack of control.
Patients challenged by addiction bargain by promising to stop using drugs and alcohol in exchange for future desires like happiness, financial success, improved relationship, but they are unlikely to keep their promises (np). The bargaining is rarely successful due to the nature of addiction. The patient’s lack of impulse control results in something called temporal discounting, which discounts future or far-off goals in lieu of immediate gratification, making “normative responsibility in addiction… elusive (Ainslie, 2013, np).”
The next step in the stages of grief and loss that result in bereavement is depression. For many patients, depression is the unexpected, underlying cause of their addiction and certainly a symptom related to the grief and loss of entering sobriety and abstinence. The patient no longer creates drama and problems in their life, but the patient is left to deal with the mess they made due to addiction and out of control behaviors. Stacks of unpaid bills, destroyed finances, bad relationships, poor parenting, the loss of an occupation or place to live, may all cause depression that may no longer be numbed out or ameliorated by substance and alcohol abuse.
Acceptance of addiction may be found in the Big Book of Alcoholics Anonymous on page 417 where serenity and surrender are encouraged during 12-step support meetings and with the help of 12-step sponsors who offer step-work (CBT homework) as a part of the 12-step program of recovery. Malkinson (2010), reports that “inner relationships with the [addiction] often continue throughout one’s life… Grieving, based on this conceptualization, often includes the act of reconstructing a world of meaning that was challenged by the loss (p. 290).”
Acceptance in bereavement is also a time of continued growth and development. This is the time for the patient to create a new-normal and to become calm as they surrender and accept what cannot be changed; their addiction must end to foster healthy sobriety and abstinence.
Individuality in bereavement eliminates a “single predictable pathway through grief (Malkinson, 2010, p. 290)” and the therapeutic emphasis is placed on constructing and establishing new meanings to life. This acceptance is an ongoing work in progress with the alleviation of depression and an understanding that their lives have forever changed.
Cognitive-Behavioral Therapy is an effective method for treating patients reporting symptoms of bereavement. To begin, the therapist will take the patient’s personal history and relationship to the social, physiological, biological, relational, coping, and enjoyment aspects of their addiction to explore and uncover meaning while finding ways to understand the patient’s resultant emotional pain, anger, sadness, and grief associated with the loss of their addiction.
The Centre for Cognitive-Behavioural Therapy (2016) suggests six important steps in the treatment of patients, including: 1. Accepting the reality of the loss of their addiction, 2. Working through the guilt, pain, and anger related to the loss of their addiction, 3. Finding a new normal, 3. Creating and rebuilding relationships as substitutes for the lost relationship with alcohol and drugs, 4. Creating living memories through experiences and symbolism like 30-day chips at 12-step meetings, and 6. Including a spiritual component / focus on a Higher Power (np).
What is no longer a focus of bereavement therapy is the idea that “time heals all wounds” or that the relationship the patient experienced during their active addiction is immediately wiped from their minds. Instead, maintaining and continuing a bond with those who have also battled addiction as well as with a support team allows the patient to undertake the developmental process away from addiction and toward sobriety and abstinence that will traverse the patient’s entire lifetime.
Ainslie, G. (2013). Intertemporal Bargaining in Addiction. Frontiers in Psychiatry, 4(63). Retrieved from: http://doi.org/10.3389/fpsyt.2013.00063
Alcohol Rehab. (2016). Anger in Recovery: Everyone Gets Angry. AlcoholRehab.com. Retrieved from: http://alcoholrehab.com/addiction-recovery/anger-in-recovery/
American Society of Addiction Medicine (ASAM). (2016). Definition of Addiction. Retrieved from: http://www.asam.org/for-the-public/definition-of-addiction
Health In Recovery. (2016). Dealing With Grief. HealthInRecovery.com. Retrived from: http://www.healthinrecovery.com/physical/59.html
Help Guide. (2016). Coping With Grief and Loss. HelpGuide.org. Retrieved from: http://www.helpguide.org/articles/grief-loss/coping-with-grief-and-loss.htm
Malkinson, R. (2010). Cognitive-Behavioral Grief Therapy: The ABC Model of Rational-Emotion Behavior Therapy. School of Social Work. Israel: Tel Aviv University.
Medline Plus. 2016. Bereavement. Retrieved from: https://www.nlm.nih.gov/medlineplus/bereavement.html
Steinberg, C. (2014). The Three Stages of Addiction Denial and How to Overcome Them. Palm Partners Recovery Center. Retrieved from: http://blog.palmpartners.com/the-three-stages-of-addiction-denial-and-how-to-overcome-them/
The Centre for Cognitive Behavioural Therapy. (2016). Bereavement. Retrived from: http://www.centreforcbtcounselling.co.uk/bereavement.php