“Grief and Loss in Addiction and Recovery” was presented on September 25, 2012; by Janice Firn, LMSW, Clinical Social Worker, University of Michigan Hospital; Matthew Statman, LLMSW, CADC, Dawn Farm therapist and Education Series Coordinator; and Barb Smith, author of “Brent’s World” (http://compassionhearts.com.) The culture of addiction is rife with experiences of grief and loss for the person with addiction and for family and friends. The nature of these experiences combined with the stigma, shame and general lack of understanding of addiction can make grief and loss associated with addiction exceptionally lonely and difficult to heal from. This program will describe Worden's and Kubler-Ross' theories of grief and grief recovery, losses that the chemically dependent individual and his/her family experience throughout the addiction and recovery processes, and how recovery program tools can help individuals cope with grief and loss. It will include a personal account of addiction-related grief, loss and recovery from a mother who lost her son to addiction-related causes. This program is part of the Dawn Farm Education Series, a FREE, annual workshop series developed to provide accurate, helpful, hopeful, practical, current information about chemical dependency, recovery, family and related issues. The Education Series is organized by Dawn Farm, a non-profit community of programs providing a continuum of chemical dependency services. For information, please see http://www.dawnfarm.org/programs/education-series.
5. Grief is an…
Emotional
Mental
Social
Spiritual
Physical
…response to loss
09/28/12 Janice Firn, L.M.S.W., Clinical 5
Social Worker, UofM Hospital
6. Why talk about Grief?
Change happens!
To live is to experience loss
“Little deaths”
“Change is Inevitable—Growth is Optional.”
- Walt Disney
09/28/12 Janice Firn, L.M.S.W., Clinical 6
Social Worker, UofM Hospital
7. Why do we feel Grief?
Attachment Theory
Types of Attachments
Secure
Avoidant
Anxious
Ambivalent
09/28/12 Janice Firn, L.M.S.W., Clinical 7
Social Worker, UofM Hospital
8. Why talk about Grief?
“Working through our endings
allows us to redefine our
relationships,
to surrender what is dead and to
accept what is alive,
and to be in the world more fully to
face the new situation.
- Stanley Keleman
(from Living Your Dying)
09/28/12 Janice Firn, L.M.S.W., Clinical 8
Social Worker, UofM Hospital
9. Personal Awareness of Grief & Loss
Perception is Key
Individual Response
Frequency of
Exposure
09/28/12 Janice Firn, L.M.S.W., Clinical 9
Social Worker, UofM Hospital
10. Myths About Grief
Myth: The pain of the loss will go away faster
if you ignore it.
Myth: It’s important to be “be strong” in the
face of loss.
Myth: If you don’t cry, it means you aren’t
sorry about the loss.
Myth: Grief should last about a year.
09/28/12 Janice Firn, L.M.S.W., Clinical 10
Social Worker, UofM Hospital
11. Facts About Grief
Fact: Trying to ignore your pain or keep it from
surfacing will only make it worse in the long run.
Fact: Feeling sad, frightened, or lonely is a normal
reaction to loss. Showing your true feelings can help
you and others deal with the grief.
Fact: Crying is a normal response to sadness, but
it’s not the only one.
Fact: There is no right or wrong time frame for
grieving.
09/28/12 Janice Firn, L.M.S.W., Clinical 11
Social Worker, UofM Hospital
12. Kubler-Ross
The five stages of grief:
1. Denial/Shock: “This can’t be happening to me.”
2. Anger: “Why is this happening? Who is to blame?
What should have been done differently…”
3. Bargaining: “Make this not happen, and in return I
will ____.”
4. Depression: “I’m too sad to do anything.”
5. Acceptance: “I’m able to exist with what
happened.”
09/28/12 Janice Firn, L.M.S.W., Clinical 12
Social Worker, UofM Hospital
13. Stroebe & Schut
Dual Process Model
Oscillating between a ‘Loss-
oriented’ state and a
‘Restoration-oriented’ state
Loss-oriented: more
emotional work of grief
Restoration-oriented: more
task-focused grief work
Adaptive denial and distraction
from the emotional work of
grief
09/28/12 Janice Firn, L.M.S.W., Clinical 13
Social Worker, UofM Hospital
14. Martin & Doka
Grieving Styles: contrasting patterns of grieving and
mourning
Patterns which are not related solely to gender, but to ‘style’
of mourning
Intuitive – emphasizing the experiencing and expression
of emotion
Instrumental – focuses on practical matters and problem
solving
These contrasting styles are poles on a spectrum or continuum
Related more to socialization and personality types than to
gender
09/28/12 Janice Firn, L.M.S.W., Clinical 14
Social Worker, UofM Hospital
15. J. William Worden
Physiological healing is needed to bring the
body back into physical health – this type of
healing takes time.
Similarly, after a loss it takes time to return to
an emotional state of well-being.
The 4 tasks of mourning are an essential part
of the healing process.
No specific order, but still must be worked
through during the time of grieving.
09/28/12 Janice Firn, L.M.S.W., Clinical 15
Social Worker, UofM Hospital
16. The 4 Tasks of Mourning
1. Accept the reality of the
loss
2. Experience and work
through the pain of grief
3. Adjust to the new
“normal”; life without what
was lost
4. Emotionally relocate the
loss and move forward in
life
09/28/12 Janice Firn, L.M.S.W., Clinical 16
Social Worker, UofM Hospital
17. Accept the Reality
To come full face with the fact that your loss is real
and will not return, i.e. that immediate reunion or
regaining it is impossible.
Obstacles:
Denying the facts of loss.
Denying the meaning of the loss, e.g. “It wasn’t a
good job anyway”, or “I don’t miss him,” or “I’m just
as healthy as I ever was.”
Minimizing the loss. “It’s not that big of a deal.”
09/28/12 Janice Firn, L.M.S.W., Clinical 17
Social Worker, UofM Hospital
18. Experience & Work
Through the Pain
It is impossible to lose something or someone you
have been deeply attached to without experiencing
some level of pain.
Obstacles:
Not allowing yourself to feel.
Cutting off your feelings and denying that pain is
present.
Avoiding reminders of the loss – e.g., trying to
find a ‘geographic cure’ by moving to another
location, or travelling
09/28/12 Janice Firn, L.M.S.W., Clinical 18
Social Worker, UofM Hospital
19. The New “Normal”
Coming to terms with being without (maybe raising children
alone, facing future unemployment or handicap, redefinition of
self, etc.).
A. External Adjustments : how the loss affects your everyday
functioning in the world
B. Internal Adjustments: how the loss affects your sense of self
C. Spiritual Adjustments: how the loss affects your beliefs,
values and assumptions about the world
Obstacles:
Promoting your own helplessness.
Not developing the skills you need to cope or to function in
new roles.
Withdrawing from the world. Refusing to see yourself or the
world differently.
09/28/12 Janice Firn, L.M.S.W., Clinical 19
Social Worker, UofM Hospital
20. Moving Forward
To find a place for what was lost that will enable us to remain
connected with them/it but in a way that will not keep us from
going on with life.
Obstacles:
Withdrawal from others and life. Unwillingness to love.
Unwillingness to risk; making a vow to never invest
yourself again.
Holding on so tight to the past that you’re unable to form
new relationships or develop new skills.
09/28/12 Janice Firn, L.M.S.W., Clinical 20
Social Worker, UofM Hospital
21. When is Grieving Over?
When a person can think of what was lost without
acute pain.
When the tasks of mourning have been accomplished.
When one can think of the what was lost without
physical manifestations such as crying or feeling
tightness in the chest.
When one can reinvest his/her emotions into life and
the living.
When one can regain an interest in life, feel more
hopeful, experience gratification again, and adapt to
new roles.
Is there a time limit? 1 year? 4 seasons? 2 years? It
depends.
09/28/12 Janice Firn, L.M.S.W., Clinical 21
Social Worker, UofM Hospital
22. Grieving is Necessary!
“Man, when he does
not grieve,
hardly exists.”
- Antonio Porchia
09/28/12 Janice Firn, L.M.S.W., Clinical 22
Social Worker, UofM Hospital
24. Grief vs. Depression
Grief is a roller coaster.
Depression is dead end.
09/28/12 Janice Firn, L.M.S.W., Clinical 24
Social Worker, UofM Hospital
25. Tensions for Families
Hope Despair
Denial Acceptance
Meaninglessness Meaningfulness
Independence Accepting Interdependence
Ambiguity Certainty of Outcome
Making Plans Experiencing Emotions
Holding On Letting Go
Speaking Openly Not Talking
Family as it Was Family as it is Becoming
09/28/12 Janice Firn, L.M.S.W., Clinical 25
Social Worker, UofM Hospital
26. When Grief Isn’t Healing
Relational Factors
Circumstantial Factors
Historical Factors
Personality Factors
Social Factors
09/28/12 Janice Firn, L.M.S.W., Clinical 26
Social Worker, UofM Hospital
28. Grief WORK
Grief therapy: goal is not about forgetting but
remembering with less pain.
Developing adaptive coping mechanisms.
Finding meaning.
AA and Al-Anon, NA and Nar-Anon = grief work
09/28/12 Janice Firn, L.M.S.W., Clinical 28
Social Worker, UofM Hospital
29. Getting Support When
You Are Grieving
Do not grieve alone
Turn to friends and family members
Join a support group
Talk to a therapist or grief counselor
Face your feelings
Express your feelings in a tangible
or creative way.
Look after your physical health.
Plan ahead for grief “triggers”.
09/28/12 Janice Firn, L.M.S.W., Clinical 29
Social Worker, UofM Hospital
30. Helping Someone who is Grieving
Listen
Acknowledge the
uniqueness of grief
Offer practical help
Make contact, write a
personal note
Be aware of holidays
and anniversaries
09/28/12 Janice Firn, L.M.S.W., Clinical 30
Social Worker, UofM Hospital
31. “Grief heals when it is received by
09/28/12 Janice Firn, L.M.S.W., Clinical 31
Social Worker, UofM Hospital
32. Resources
J. William Worden, Grief Counseling & Grief Therapy, 2008.
Judith Viorst, Necessary Losses, 2002.
Holmes-Rahe Social Readjustment Rating Scale. Journal of Psychosomatic Research, (1967).
Vol. 11, pp. 213-218.
Lynn, J. and Harrold, J. (1999). Handbook for Mortals: Guidance for People Facing Serious
Illness, p.41.
Al-Anon Dist. 5, http://www.hvcn.org/info/afg5/griefloss.htm
HelpGuide.org, http://71.6.131.182/mental/grief_loss.htm
Dennis C. Daley & G. Alan Marlatt, Overcoming your Alcohol or Drug Problem, 2006.
Wolfet, A. (2009). The Handbook for Companioning the Mourner. Companion Press:
Colorado.
Abbot, A., Alcohol, Tobacco, and Other Drugs. NASW, 2010.
http://www.hospicenet.org
Maciejewski, Zhang, Block, Prigerson, (2010) “An Empirical Examination of the Stage
Theory of Grief”, JAMA
Stroebe, M., & Schut, H., (1999). The dual process model of coping with bereavement:
rationale and description. Death Studies,197-224.
Doka, K., & Martin, T. (1999). Men Don't Cry, Women Do: Transcending Gender Stereotypes
of Grief.
09/28/12 Janice Firn, L.M.S.W., Clinical 32
Social Worker, UofM Hospital
33. Grief and Loss in
Addiction and Recovery
Matt Statman, LLMSW, CADC
Dawn Farm
Education September
Series 2012
34. "To spare oneself from grief at all
cost can be achieved only at the
price of total detachment, which
excludes the ability to experience
happiness."
Dr. Erich Fromm
35. o Unresolved grief, loss & trauma often
predate use
o Compounded in addiction
o Complicated by use
37. Grief in addiction
o Use AOD to cope
o Lack healthy support
o Medicate / Avoid / Minimize feelings
o Grief not processed
o Losses not fully grieved
38. Examples of Losses in
Addiction
o Experiences and events
o Relationships with family/friends
o Parenting time
o Family milestones
o Deaths
o Time
o Opportunities
o Perinatal
o Spiritual
39. Losses in moving from addiction to
recovery…
“What are you leaving behind?”
43. o Early onset - identity formed around AOD –
You have to give up who you are to become
who you can be
o Addiction forces people to live outside their
values - guilt and shame
o Loss of hopes, plans, aspirations and dreams
o Loss of innocence, dignity, self-esteem,
choice, control of one’s body
45. o Loss over rituals “ The lifestyle”
o Loss of coping mechanisms and
survival techniques
o Loss of culture of addiction
o Loss of using friends / relatives
o Etc…
46. In early recovery people
begin to realize that they
have lost a lot…
47. Barriers to Grieving
o Lack of safety/ trust
o Unable to feel / identify feelings
o Feelings unfreeze - feel
overwhelming
o Seemingly unrelated feelings may
arise (anger, depression, anxiety)
o Complicated by guilt/shame/
stigma/ trauma
48. Feelings - Early Recovery
o Unable to verbalize
o Lack healthy coping skills
o May seek relief through compulsive
behaviors/ other addictions /
relapse
50. “… If you're an addict on the road to
recovery, be prepared to experience
emotions in a new way – the good and
bad; and be sure to have a plan in place
to fight off the cravings while you're in
that vulnerable state.”
–Michael Bloch
51. “The best therapy for grief is
time and community.”
-Michael S. Logan
52. Recovery is a Process
Grief recovery, like addiction
recovery, is not a linear process
53. In recovery people
acknowledge, understand,
and accept losses and move
through grief
54. o Safe and supportive
environment
o Community
o Additional support
55. Some Tasks
o Develop skills to cope with
feelings
o Open up, identify and talk about
losses
o Learn to identify feelings
o Learn to verbalize feelings
o Learn to tolerate “negative”
feelings
56. Grief recovery …
o Healthy grieving enables the
recovering person to confront and
accept the reality of the loss, and
find purpose and meaning for life
o Losses are eventually remembered
with less pain.
Things will get better
57. “Have You A Sufficient
Substitute?”
AA Page 152
63. “The reaction to loss that is widely experienced
by friends and family members of persons who
are addicted to mind altering substances is
profound grief. It has characteristics of flawed
interactional patterns because the loss is
ambiguous. If a person dies, the grief is
unambiguous: the social role the deceased
played is no longer occupied and the
deceased cannot fulfill obligations or promises.
The spouse who becomes addicted to mind
altering substances often ceases to fulfill
obligations or promises, but physically the
social role is still occupied.”
-Vicki Loyer-Carlson, Ph.D., LMFT
64. Losses may include
o Relationships
o Financial security
o Hopes and dreams
o Self-esteem
o Emotional support, “presence”
o Other important tangible and
intangible things
66. Grief feels lonely for family and friends
and circumstances may be especially
challenging - but help, support and
understanding is available, and
healing is possible
67. Grief recovery is hard work
for family and friends too –
but it is worth the effort!
69. Being triggered is normal
and OK
Grief recovery, like
addiction recovery, is
ongoing
70. Triggering Events
o Anniversaries
o National tragedies
o Others having a similar experience
o Holidays
o ___________
o ___________
o ___________
71. Take Action
o Identify sources of support
o Talk about it
o Plan ahead (more meetings, more social
contact, more service work, more
spiritual practice etc…)
73. o A safe placed to be open about feelings
and experiences, without shame
o Step work helps people express grief,
gain perspective and acceptance,
forgive and move on with their lives
o Provides opportunities to give back to
others and make meaning
o Peer grief support groups can be
helpful
75. Helpers
o It’s ok / important to just be there
/ sit / listen
o Avoid trying to fix - It’s ok to say
“This sucks!” or “I am so sorry!”
o If it is out of your league refer to
professionals
76. Grievers
o Let family/friends/coworkers/others
know what you need
o Support dissipates over time - continue
to ask for support
o If family/friends are unavailable or
unsupportive (including well-intentioned
but misguided efforts to be supportive)
–seek support elsewhere
78. o Participation in faith community
activities/rituals
o Faith-based support groups or prayer
groups
o Prayer, mindfulness, meditation
o One’s chosen spiritual practices and
rituals
79. Rituals …
Grief rituals and ceremonies acknowledge the pain
of loss while offering social support and a
reaffirmation of life …
80. Tributes …
o Creating a tribute, legacy
or memorial to honor and
remember a loved one
can provide comfort
o People often find comfort
in donating to a related
cause and/or becoming
involved in volunteer or
service work, or other
ways of helping others
81. Experiential techniques …
- experiential therapies (art, writing,
music) engage areas of the brain
music) engage areas of the brain
involved in grief, memory, healing,
recovery
83. o Participation in mutual aid groups / social
support
o Nutrition
o Exercise
o Adequate rest and sleep
o Activities to engage in that help with healing
and regaining a feeling of purpose
o Internet resources
o Literature
It is how we integrate the losses we experience into our lives, how we adapt to the changes that move us forward into new definitions of ourselves, growth happens from living through the loss and redefining ourselves. Any time there is a change a loss is experienced whether one realizes it or not.
Attachment theory describes the dynamics of long-term relationships between humans. Attachments to people, animals, things, rituals, etc. The more avoidant, anxious, or ambivalent the relationship the more complex and conflicted the grief reaction
The goal of grief work is to more fully engage in life and to be open to the future.
No relationship is like another. How a loss impacts us will depend on the unique relationship we had with what is lost. If one perceives the loss as important or life altering than that is what it is. Additionally, the impact of the loss can be magnified by the number of losses experienced over time, our reserve for coping with the loss can be depleted if there are too many within a short time period. Life Events Scale Handout
Dual processing model addresses the balance between focusing on feelings and focusing on the practical tasks that move you through loss
The type of loss, the situation surrounding the loss, your personality, and the characteristics of the unique relationship with what was lost/how significant the loss is to you, etc. will all impact how grief looks and how long it lasts. For very significant losses the grief may never go away altogether, it may ease for a while only to resurface at key anniversaries or holidays.
Kubler-Ross has said that these are not linear and do not have to be completed in order, one can vacillate between them over time. Often immediately after a loss feelings of denial/shock and depression can surface, over time as denial and shock wear off, acceptance grows. Maciejewski, Zhang, Block, Prigerson, “An Empirical Examination of the Stage Theory of Grief”, JAMA, January 11, 2010
his model identifies two types of stressors, loss- and restoration-oriented, and a dynamic, regulatory coping process of oscillation, whereby the grieving individual at times confronts, at other times avoids, the different tasks of grieving. This model proposes that adaptive coping is composed of confrontation--avoidance of loss and restoration stressors. It also argues the need for dosage of grieving, that is, the need to take respite from dealing with either of these stressors, as an integral part of adaptive coping.
Men Don’t Cry . . . Women Do: Transcending Gender Stereotypes of Grief , by Martin and Doka
Just like after an injury heals we sometimes are reminded of the old injury so too with grief. The would gets better, the grief heals but sometimes there is a twinge. Tasks implies WORK
“ let it be Tuesday” syndrome Substance use can prevent someone from working through this task, prevents one from having to face reality.
Substance abuse numbs the pain and prevents someone from working through this task. Recovery can be a time of facing a number of losses, providing a safe, supportive place to allow you to feel your feelings and work through the pain of the loss – it seems an impossible task but it can be done.
Recovery helps to build new coping skills and to redefine who you are so that you can engage the world differently. Recovery helps you see yourself and the world differently.
Working through recovery allows us to be at peace with the past, to be vulnerable to life in a health way, to form new attachments, to forgive and to ask forgiveness.
Is it ever really over? No. It does get easier though.
The type of life we live depends on how we work through our grieving. Good grieving engages us more fully into life.
Grieving is an Emotional, Mental, Social, Spiritual, and Physical response to a loss. Behavioral – crying, listlessness, sleeplessness, sleepiness Spiritual – wondering about meaning and purpose Emotional – shock, sadness, anger, relief, release, guilt Physical – numbness, empty feeling, tight chest, shortness of breath Cognitive – reviewing what occurred, thinking about what was lost
Grief: the way I am feeling makes sense in light of what happened, these losses are the source for what I am going through, others have validated my losses. I am distracted easily, I wish I looked better – sometimes I feel better than I look, sometimes I look better than I feel. Some people have avoided me or been insensitive since the loss. At times I prefer to be alone and it’s an effort to do things. I am more aware of the fragility of life as a result of what has happened. It’s hard to concentrate but I can if I have to, I’m often preoccupied by thoughts of what I have lost. My heart feels broken. I am very angry, then I am very sad. I yearn to love again. At times I forget and am happy, then I remember again. I pray for strength to get through this. Sometimes I lose sight of my faith but I am sustained by other’s belief in me. I feel comforted when I am with sympathetic people. Depression: I don’t understand why I feel like this. Nothing makes sense. I am preoccupied and lose days or weeks. I don’t care how I look. I am worthless and to blame for this situation. I don’t cry, don’t feel sad. I feel nothing. I have no energy. I am always in a fog. I don’t care about my health. My life is hopeless. I am a broken person. I can find no comfort. I don’t care what happens. I can’t snap out of it. Other’s don’t care. I have nothing to live for.
As we navigate the changes we experience and the sense of loss we have about those changes we move along a continuum, from chaos after the change/loss occurs to a new “normal” or homeostasis. Letting go of what was and accepting what coming into being.
Relationship – if the attachment was complicated or ambivalent then the loss will be more difficult to work through Circumstantial – if the circumstances are not know, suicide, death related to substance use Historical – if you have experienced a number of losses over time or the current loss reminds you of a previous loss Personality – some of us have a greater capacity than others for intense emotions Social – some of us have more extensive support systems, less support is more difficult
Chronic – sometimes when one loss happens after another we do not have time to recover or heal before the next occurs, makes healing harder (ex bone keeps being broken before it has time to heal) Delayed – because of circumstances or personal factors we are not able to experience or work through the loss at the time it occurred, bottling it up and putting it aside for later can complicate our ability to work through it (ex wound has scab over it, hides the infection but it’s still infected) Avoiding – pretending that the loss did not occur, distracting ourselves from grieving, filling the hole left by what was lost in order to avoid the pain (ex pretending the wound doesn’t exist, child’s peek-a-boo game: if I cover my eyes you’re not there).