Counseling Today, Knowledge Share

Grief, loss and substance use

By Susan Furr and Derrick Johnson December 5, 2017

Andrew’s mother was so happy that he had finally agreed to enter treatment for his drinking problem. He had been an excellent college student until his hard partying began to take over his nights, leading to missed classes and incomplete assignments. He still managed to get a decent job that involved a lot of travel and client dinners. Andrew’s mom thought these responsibilities would help him settle down. What she didn’t realize was that he would begin using stimulants to keep up the hectic pace. When combined with his socially sanctioned business drinking, Andrew’s performance soon suffered.

Andrew managed to cover up the cracks in his professional veneer for several years before finally passing out one evening from a combination of exhaustion and alcohol. Thankfully, his company supported his entry into treatment, a move that encouraged his mother.

During one of the family visiting days, Andrew’s mother was thoroughly confused by his anger over giving up his substance. He had believed that treatment would help him “dry out” and then return to his previous life. “I don’t know why they expect me to give up people, places and things associated with my drinking,” Andrew lamented.

Andrew’s mother wanted to scream that this was such a small price to pay for Andrew to regain his life before it was too late. What she didn’t realize was that she had just encountered the first glimpse of Andrew’s grief related to recovery. Many other layers of grief would need to be uncovered and processed in the weeks and months ahead.

Confronting losses

You do not have to be an addictions counselor to encounter the grief related to substance use. I (Susan) worked for many years in a college counseling center and encountered students struggling with losses related to family members who were addicted. Substance use had taken away the parent they longed for.

For other students, siblings who were addicted created a range of issues, from trying to engage the student in substance use to wanting the student to “cover” for them. In the extreme, counselors may connect with students whose sibling overdosed while they were away at college, adding to their guilt because of a false belief that they could have prevented the act.

Given that college students are engaging in their own developmental issues around identity, they may be in a place to face these issues for the first time. Many college students begin to recognize some of the harmful effects created by the environments in which they lived.

Perhaps the most difficult case I encountered was a young woman who was beginning to address childhood sexual abuse perpetrated by her father. During our work together, her father contacted her to apologize for any harm he might have done, although he professed that his memories were cloudy because of his substance use. He was now in recovery and trying to make amends. Although his confession reaffirmed my client’s own memories, she was left grieving for the father she never had.

Groups such as Adult Children of Alcoholics evolved to support those whose lives have been upended by the addiction of someone else. In examining your client’s history, gathering information on any substance use issues in the family may go a long way toward helping the client understand the evolution of his or her current emotional challenges.

The loss of identity

Grief is often a forgotten aspect of recovery. Out of necessity, the need exists to focus on the physical aspects of addiction to alcohol and other drugs (AOD). These physical aspects of addiction are much more challenging than acknowledged by a “just say no” culture. Think about giving up that first cup of coffee each morning — for the rest of your life. And then multiply that impact manyfold.

Treatment programs have developed protocols to help clients navigate this process on a physical level, and support groups such as Alcoholics Anonymous (AA), Narcotics Anonymous and SMART Recovery help deal with the abstinence aspect of recovery. However, the idea of grieving the loss of one’s substance may seem contradictory to treatment. After all, giving up a destructive substance is a good thing — right? Regardless, any change, no matter how positive, often creates a sense of loss.

One way to think about this issue is to focus on the identity the client forms with the addictive substance rather than just thinking about giving up the substance. Clients often develop a positive view of self in terms of their substance, such as being able to “hold one’s liquor” or a female being able to “drink like a guy.” They gain a positive status for their drinking or drugging prowess; in other words, the user gains a sense of belonging and significance.

As substance use becomes a core value, social networks form around the experience of “using.” For example, one’s knowledge base and interest revolve around being aware of the best microbreweries or having a refined wine palette or even knowing the best place to buy meth. Identity begins to form around using and being with other users. The use of mobile apps that help “connoisseurs” identify and cross off “must-have” finds further increases the social lure of drinking and using substances. These items combine to develop an identity for the user and the onset of a relationship between the substance and the user.

More profound is the discovery of the purpose of substance use. Does it relieve anxiety in social situations or loosen inhibitions with potential relationship partners? How does the substance help the client cope with painful emotions caused by other losses? It is not uncommon for people to cope with a painful situation by going out for a drink, but for some, the substance becomes the go-to solution for any life stressor. I recall a bar that gave out a free drink for every job rejection letter that one of its patrons received. On the surface, this was a way to lighten the mood, but on a deeper level, it was just another way of teaching poor coping strategies — in this instance, managing loss through the use of substances.

Social networks can revolve around a culture of using. Stopping by the neighborhood bar after work may evolve into hanging out with the guys until closing time — dinner missed and a partner outraged. After awhile, users seem to prefer the company of fellow users over that of the distraught family. These gathering places often become part of a ritual, providing a structure that may normalize the damaging behavior. Recall the old TV show Cheers, “where everybody knows your name.” The act of walking in, seeing familiar faces and sharing a favorite drink creates a comforting routine that overshadows the underlying harm caused by abusing substances.

The grief aspects of recovery

To be successful in recovery, the client has to let go of all of the comforting aspects of using. These things must be grieved in order for the client to move forward.

Entering treatment means leaving behind the familiar and facing the unknown. On a cognitive level, giving up immediate gratification for future gains may make sense, but the actual experience of change also results in losses that need to be acknowledged.

Clinicians who understand the role that loss plays in recovery have devised activities, such as writing a goodbye letter to one’s substance, which recognize that even the loss of something that is ultimately negative needs to be grieved. It was through my work in grief and loss counseling that I first became aware of the loss associated with giving up one’s substance. Kathryn Hunsucker, a graduate student at the time, began applying the concept of loss to recovery and found that this concept resonated with her clients. We began working together to use some of the existing grief theories to conceptualize recovery in a way that made sense to clients. Derrick Johnson, an addictions counselor in Charlotte, North Carolina, has teamed with us to extend this approach to families. The theories of both J. William Worden and Therese Rando have been instrumental in helping us conceptualize the grief aspects of recovery.

Grief and loss show up in other phases of recovery too. Clients not only grieve giving up their substance and fellow users, but they also begin to examine losses throughout their lives. Once clients are engaged in ways of maintaining their abstinence and perhaps working through the steps of AA, they begin facing the choices that they made while using. In this phase of recovery, clients may begin to recognize that the consequences of their choices often involved a loss.

The underlying loss may be about the loss of the person the client once was or aspired to be. Some clients lament the loss of meaning in their life and their disconnection from spiritual or existential values. Often, however, there are more concrete losses that may include jobs, family, freedom and home. It is common to see the recognition of these losses emerge as clients address steps No. 8 and No. 9 of the Twelve Steps. Acknowledging those who have been harmed and making amends forces clients to see how they might have created their own losses.

The realization that this time can never be recaptured may trigger new waves of grief that can dampen the sense of hope that treatment initially fosters. Creating space for grieving is necessary to help cushion against relapse. This space is created by the counselor’s willingness to address the issue of loss directly. Clients often are surprised when the counselor asks them about the grief they experience in giving up their substance, but they are typically quite open to sharing what they will miss about using. If we pretend that no sense of loss exists, our clients will continue to avoid facing the losses that they will encounter in recovery.

Throughout the recovery process, clients often fight against memories of painful and traumatic experiences that may initially have contributed to their substance use. Counselors may be drawn to pursuing issues such as childhood sexual abuse early in treatment because the core nature of these events is linked to their clients’ emotional pain. However, until skills to maintain abstinence are developed and more recent losses have been grieved, it may be more productive to focus on the skills needed to contain these feelings. Kathryn Hunsucker, who is now an addictions specialist in Morehead City, North Carolina, suggests “bookmarking” these issues and returning to them at a later date — ideally when clients have formed the strength to encounter the pain associated with these losses.

Metaphors and other creative approaches

Derrick Johnson saw his practice change after adding grief counseling as part of his approach in treating addiction. Of specific interest is his use of “love” as a metaphor.

Derrick has clients think of a romantic love or someone very special to them whom they lost due to the person’s death. Derrick then asks his clients to list both the positive and negative aspects of their relationship with this person. After examining these relational attributes, Derrick next asks, “Did you stop loving that person the moment you said goodbye?” Of course, the reply is “no.” The use of this metaphor creates understanding and generates recognizable feelings and thus becomes a cognitive tool for clients to make the connection to their experience of giving up a substance.

Another example could be the termination of an intimate relationship. Again, although saying goodbye leads to a newly defined relationship status, it does not mean that love immediately stops. Through group discussion, members are able to understand that just because they love someone does not automatically qualify it as a healthy relationship. Similarly, love of or use of a substance does not equal compatibility. This parallels AOD abuse/dependence, which is not compatible with successful life engagements and life fulfillment. Through this metaphor, clients are able to draw parallels between giving up a substance and the loss of a relationship.

Acknowledging that it is OK to grieve the loss of the substance is essential to helping clients move through that initial fear of giving up or losing something. It is no different than acknowledging the passing of a loved one or the end of a relationship. Would counselors take that away from a client who is mourning? Of course not.

Engaging in creative approaches to help clients visualize their losses can also be valuable. Kathryn often uses an activity that starts with a handout, “What Baggage Do You Carry,” illustrated with different types of suitcases. She asks clients to fill the bags with the losses they carry around with them because of their addictions. Clients then explore what it would mean to take items out of their bags to lessen their loads. Emotions related to giving up the items are then examined. This is one concrete way for clients to increase awareness of the losses they may need to grieve.

Another awareness activity Kathryn uses is “Life Event Bingo.” In this activity, group members are given bingo cards featuring different life events in each square. Group members are instructed to mingle to try to find someone who has experienced a particular life event in the past year and to learn what coping techniques worked best for the person in that situation. Group members then record the person’s name and coping strategy in the appropriate box. The goal is to find a different person for each box so that group members make connections with others and explore different ways to deal with life challenges.

It is important to allow clients to discuss and make a list of those things that they miss about using. Though contrary to intuitive treatment protocol, it is important to remember that people use substances to alter their feelings, which means that the complete spectrum of feelings must be explored. This process involves careful one-on-one work between the client and therapist that can uncover a multitude of clues about why a client uses substances.

For example, when Derrick worked at a 90-day intensive outpatient facility, the identification of engagement and belonging was a key factor in uncovering the etiology of one client’s substance dependence. Specifically, this binge drinker identified fall and winter as “just my perfect time.” Upon closer examination, Derrick discovered that attending NFL football games and tailgating prior to the games provided this client with a keen sense of belonging. Thus, giving up drinking also meant saying goodbye to his ritual and way of belonging. This client had to grieve the loss of his ritual and what the loss represented as it related to his identity.

Closing thoughts

Grief and loss issues are essential to explore when working with people living with addictions but, frequently, this focus is left out because of the many competing issues that arise. Although those who are in treatment gain a new understanding of what it means to grieve the loss of their substance of choice, this process may be confusing to those in their support networks. The family just wants the person back whom they lost to addiction. We need to be sensitive to the losses faced by families who have their own grief to explore. They, too, have lost hopes and dreams that were shattered by addiction. Even with effective treatment, the person who returns to them has been changed by the addiction experience and will need to continue to work on personal abstinence.

Families may need additional support as they work to reintegrate their family member returning from treatment. Groups such as Al-Anon can provide needed encouragement and understanding. But as is the case with all losses, grief must be faced and experienced as part of the healing process. Often, the lessons learned from the loss can lead to an enriched way of living, both for the family and the person in recovery.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Susan Furr is a professor in the Department of Counseling at the University of North Carolina at Charlotte (UNC Charlotte). She had 16 years’ experience working at the university’s counseling center before moving to teaching. Her interests include grief and loss counseling, crisis intervention and counselor development. She is an active member of the International Association of Addictions and Offender Counselors (a division of the American Counseling Association), where she is the editor of IAAOC News. Contact her at SusanFurr@uncc.edu.

Derrick Johnson is a doctoral student at UNC Charlotte with research interest in the association of grief, loss and addiction. He is senior clinical addiction therapist at Legacy Freedom Treatment Center and also has a private practice in Charlotte.

 

 

 

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

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