Grief is an overpowering emotion that is primarily fueled by feelings of sadness and depression. It is a natural reaction to perceived loss, and nearly every person will experience grief at some point in their lives. The most common reactive associations that fuel grief include the death of a loved one, the dissolution of a romantic or other personal relationship, the loss of a job, perceived personal failures, etc. The drive to understand the process of grief and how it relates to both functional coping and dysfunctional coping has a long history in psychology and psychiatry. As a result, a number of models of the grieving process have been developed.
It is also important to identify the differences in the terms bereavement and grief. Bereavement is typically used to signify a specific type of grieving process related to the loss of a loved one or some important person who has died, whereas grief relates to the emotional state associated with a perceived loss of any kind, including a job, home, relationship, etc. Nonetheless, the clinical literature investigating issues with grief will often use the terms bereavement and grief interchangeably because it is often assumed that grief is always associated with some form of perceived loss. This article will attempt to maintain the above distinction between grief and bereavement.
Models of Grief
There are a number of different models of the grieving process that have been developed by researchers using different approaches. Perhaps the best known approach is the one developed by Elizabeth Kubler-Ross who studied individuals diagnosed with terminal cancer. Her findings regarding how these individuals reacted to learning about their diagnosis resulted in the famous five-stage model of the grieving process:
- Denial: The initial reaction of the grieving person is to deny the facts.
- Anger: The individual then becomes angry over the situation that has produced the stress.
- Bargaining: The individual then seeks to develop some type of deal with some perceived higher power where they can negotiate their way out of the situation that is producing the distress.
- Depression: As the reality of the situation becomes salient, the individual may begin to experience feelings of sadness and bereavement.
- Acceptance: Finally, the individual accepts the situation and prepares to deal with it.
While Kubler-Ross’s model is perhaps the best known to laypeople, and often used as an overall model for the grieving process, there is no significant empirical evidence that suggests that individuals go through the stages in the order that Kubler-Ross outlined or that individuals experience all the stages. In addition, Kubler-Ross looked at a very select group of individuals who were dealing with their own mortality and attempted to generalize her findings. She did not look at or observe individuals experiencing other incidents that often lead to grief (e.g., loss of a loved one). There is no reason to believe that this model has any validity regarding the grieving process in the majority of individuals who experience significant grief.
Research has indicated that the grieving process is highly variable and specific to the individual. This means that theoretical models outlining the grieving process need to identify general consistent trends that occur during grief or bereavement. One of the prominent researchers in the area of grief and bereavement is Dr. Sidney Zasook who has concluded that the most useful models of grief indicate that most individuals experience:
- A period of separation distress that consists of highly variable emotions occurring in individuals, ranging from anger to anxiety to depression
- A period of traumatic distress that consists of feelings of shock, disbelief, confusion, etc.
- Feelings of remorse, guilt, and regret that often result in significant reflection
- A desire to withdraw from, or actual withdrawal from, social activities
- A period of acceptance that consists of the individual recognizing and understanding their feelings, resolving the major issues with their distress, but never being totally free of the issues with separation, sadness, remorse, etc.
Individuals typically “move on” with their lives and often express the notion that they are stronger as a result of the grieving process, but many of the feelings still remain at a much lower level of intensity.
Again, these stages have no specific timetable and may occur simultaneously; someone may experience separation distress and traumatic distress along with remorse at the same time. The actual emotional expression that occurs during the grieving process is highly variable from individual to individual; however, most individuals experience extreme sadness that either meets or is very close to satisfying the criteria for major depressive disorder. However, most clinicians will not diagnose an individual with major depression if it is determined that their presentation of sadness and emotional distress is related to the process of bereavement or grief unless it is prolonged; even so, the formal treatment protocols delivered to individuals who are grieving the loss of a loved one and those who have clinical depression are very similar.
Can Grief Be a Disorder?
Grief can also be classified as acute, meaning that the feelings occur rather rapidly after the event that produces the perceived loss. Grief can also be classified as being prolonged or complex, meaning that the feelings persist for a period of time that is not considered to be within the normal range of the grieving process. Part of the issue with defining exactly what the normal range of grief should be is that individuals are highly variable in their expression of grief. The actual timetable for the grieving process varies from individual to individual and also may differ based on one’s cultural background.
In the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association (APA) has proposed diagnostic criteria for persistent complex bereavement disorder. This is a condition for further study, indicating that APA is attempting to develop diagnostic criteria for a dysfunctional process of bereavement. This proposed category has resulted in quite a bit of controversy, especially regarding the proposed time period of the bereavement process as being indicative of a type of mental health disorder (lasting at least 12 months in adults and six months in children). A number of sources have condemned this proposed category as a method of pathologizing normal human reactions; however, it has been hypothesized that many of the individuals who express complex grief or bereavement have a history of depression, anxiety, a trauma or stress-related disorder or some other mental health disorder, and the vulnerability to complicated grief reflects a combination of genetic and environmental interactions that drive mental health disorders in general.
Despite the controversy regarding trying to identify complex or prolonged grieving as a type of mental health disorder, it is clear that individuals who display complex grief that persists for significant periods of time are most likely displaying signs very similar to clinical depression. Whether or not individuals who are expressing prolonged or complex grief or bereavement actually have a formal mental health disorder should not limit treating an individual’s distress, especially when there is a complex or prolonged period of distress and dysfunction associated with the grieving process.
It is clear that a number of individuals do suffer from issues with complex grief. It is suggested that the notion of complex grief has a prevalence of 2-3 percent in the general population, and it is as high as 10 percent in individuals who suffer loss of a loved one. Having issues with chronic sadness or depression also leads to increased vulnerability to substance abuse.
Grief and Substance Use Disorders
Complex or complicated grief/bereavement shares a number of associations with the normal grieving process, but it lasts abnormally long, and its presentation may be very intense and even extreme in some people. Even though the exact timeframe related to when a normal reaction to grief or bereavement becomes dysfunctional is in question, it is generally agreed that when an individual’s process of grieving significantly interferes with their functioning for a prolonged period of time (six months to a year), the individual should be treated on some level. Treatment might include counseling, formal therapy, medication, or a combination of these.
One of the repercussions of individuals who suffer from complicated and prolonged grief is vulnerability to develop substance use disorders. While actual figures regarding the prevalence of substance use disorders in individuals who suffer from complex grief are not readily available, the prevalence is most likely very similar to the prevalence of substance use disorders in individuals with major depressive disorder. Research has indicated that individuals with major depressive disorder are nearly five times more likely to also be diagnosed with a substance use disorder than individuals in the general population and that about 20 percent of individuals with major depression have a co-occurring substance use disorder.
It is extremely important to understand the nature and driving forces of an individual’s grief reaction in order to develop an effective personalized treatment approach.
An individual who has co-occurring issues with complex grief and substance abuse will present with a complicated presentation. The most common substance of abuse in these cases is alcohol due to its availability and central nervous system depressant effects. Drinking alcohol does not result in an individual becoming more depressed but instead results in a deadening of emotions and can lead to isolation. Other substances of abuse, such as prescription medications (particularly narcotic medications and benzodiazepines), cannabis, and even stimulant medications, may also be abused.
In most cases, it is believed that individuals suffer periods of grief consisting of extreme sadness, perceived hopelessness, and other depressive symptoms, and use alcohol or other medications/drugs to cope with these feelings. However, the relationship between grief and substance use disorders may be bidirectional. There is research to indicate that, in some cases, individuals with chronic opiate use disorders who are entering recovery may begin to grieve the loss of their relationship with opiates, and this results in significant depression and vulnerability to relapse. In addition, it is well known that individuals with substance use disorders are more vulnerable to developing mental health disorders, such as major depressive disorder, issues with complex grief, etc. Thus, the relationship between grief, depression, and substance abuse is not always clear.
Treatment for Grief and Addiction
Because the grieving process is highly individualized, and people who have co-occurring issues with grief or bereavement and substance use disorders have specific personalized reasons for these interactions, there is no single approach that will work for everyone. However, there are general principles that can be useful in guiding interventions for individuals who suffer from prolonged grief and substance use disorders. The approach to treatment will most often be based on cognitive-behavioral principles.
First, both conditions should be treated concurrently. Research indicates that trying to ignore one set of conditions or one mental health disorder while treating a co-occurring disorder is not a useful approach. The individual’s issues with grief and substance abuse should be addressed at the same time. This approach often results in a multidisciplinary team approach where specialists for treating grief/depression and specialists for treating substance use disorders work together to address the person’s needs.
Any individual who has developed physical dependence on drugs or alcohol should be initially placed in a physician-assisted withdrawal management program in order to assist them in negotiating the effects of the withdrawal syndrome. Treatment can address both their issues with grief and substance abuse while they are undergoing the formal withdrawal process. The approach should include some effort to improve the physical health of the individual and keep them healthy. This can involve getting the person involved in a light exercise program, making sure they are getting plenty of rest, and persuading them to eat a balanced diet. Exercise is often therapeutic in its own right for individuals with substance use disorders and/or who are in the process of grieving.
Therapy should assist the individual in making sense of, or in deriving meaning from, their loss. When individuals can establish meaning as a result of their experiences, they are much better prepared to understand and accept them. However, the approach should not attempt to instill a sense of fate or dogma regarding the individual’s loss. Using phrases like, “It’s all for the best,” or “It was meant to be,” are actually counterproductive. If the individual begins to take this attitude, the therapist can roll with it and ask them to explain what they mean; however, the therapist should not push this attitude on the individual. Doing so can result in exacerbating the individual’s grief and substance use by making them less willing to accept change.
Many times, individuals adjust to grief by honoring a person they have lost. It is extremely common for individuals to maintain some form of connection with a lost loved one, and this should be encouraged. Maintaining a connection with a lost loved one is only a detriment if it fuels excessive avoidance of obligations. Helping the person integrate their life with the loss while honoring their loss is the job of the therapist. Having individuals separate focus on their loss from focus on daily activities can also be helpful.
Developing positive coping strategies for both recovery from substance abuse and recovery from loss is an integral part of the therapeutic process. This can include stress management training and cognitive restructuring where individuals examine any irrational beliefs they have and attempt to alter them to a more functional approach.
Therapists should attempt a nonjudgmental approach regarding their client’s feelings, any resentment, and any substance use. They should assist the individual in understanding the driving forces behind any dysfunctional ramifications of these behaviors and help them to let go of any resentment and guilt as they move through the process. Resentment and guilt are often triggers for relapse.
Within the context of the treatment program, any medications that are needed should be administered. This can include antidepressants, anti-anxiety medications (with discretion), and medications for other physical ailments.