Understanding and Providing Grief Support to People in Recovery

Life can be complicated, and most of us have dealt, on some level, with grief and loss. Certainly, the global pandemic moved grief into a central role in our global consciousness.

However, people with substance use issues, posttraumatic stress disorder, and mental illness are at greater risk of experiencing unexpected, tragic, and traumatic losses.

What is the function of grief, and how can we learn to experience this natural process without complications of shame, stigma, and guilt?

How can behavioral health professionals provide trauma-informed grief support for people in recovery?

Grief Work and Grief Support

For most humans, life involves love and relationships, which inevitably lead to loss, death, and bereavement. However, our ability to cope with loss is greatly dependent on our ability to emotionally process the loss.

In a recent Connecticut Women’s Consortium training, Supporting Grief “Work” in Recovery, Donald Scherling, PsyD, LADC, CCS, explores theories of bereavement and grief and provides practical tools for grief support for people in active addiction and recovery.

Scherling uses the term “grief work” to describe the process of healing and living one’s life after someone has died. The American Psychological Association’s APA Dictionary of Psychology defines grief work as:

“The theoretical process through which bereaved people gradually reduce or transform their emotional connection to the person who has died and thereby refocus appropriately on their own ongoing lives.”

The term “grief work” first appeared in the writing of pioneering psychiatrist Sigmund Freud. The core concept is transforming the relationship into a symbolic, continuing bond.

Grief in the Pandemic

Grief was already a challenge for many before the COVID-19 pandemic upended life as we knew it in 2020. Now, in addition to the usual obstacles, people needed to stay physically distanced from loved ones and had to grieve without saying goodbye in person.

So many people experienced a sense of incompleteness as they had to forego shared rituals to celebrate life and love.

Grief and Depression

Grief and depression are closely connected. In fact, the DSM-5 includes a diagnosis of prolonged grief disorder for an adult who has lost someone at least a year prior or 6 months for children and adolescents. The diagnosis applies to people experiencing at least three of the following symptoms nearly every day:

• Identity disruption (feeling like something in them has died)
• Marked sense of disbelief about the death
• Avoidance of reminders that the person is dead
• Intense emotional pain (such as anger, bitterness, sorrow) related to the death
• Difficulty with reintegration and reengaging with life and community
• Emotional numbness
• Feeling that life is meaningless
• Intense loneliness

As many as 10% of bereaved adults, children, and adolescents will experience these symptoms, and it is also common to experience sleep problems.

Processing Grief

A number of prominent social scientists have explored theories of mourning and grief. In 1969, pioneering psychologist Dr. Elizabeth Kubler-Ross published On Death and Dying, where she defined five stages of dying: denial, anger, bargaining, depression, and acceptance.

Further scholarship by Bowlby and Parkes emphasized that grief is a messy, nonlinear process. They replaced the term “denial” with “shock and disbelief,” and proposed that attachment styles affect someone’s response to grief. Bowlby and Parkes defined the stages of grief as:

1. Shock and numbness
2. Yearning and searching
3. Disrepair and disorganization
4. Reorganization and recovery

Another influential approach to grief support is William Worden’s Process Model.

Worden believes grief work includes four stages/tasks.

1. Accept the reality of the loss.
2. Experience the pain of grief.
3. Adjust to a world without the deceased.
4. Withdraw the emotional energy and reinvest it. This could also be described as relocating the bond. As Worden puts it, “finding a way to remember the deceased while embarking on the rest of one’s journey through life.”

The Many Faces of Grief

Grief is not just a response to death; it is a response to losses. And while society recognizes our need to grieve the death of a loved one, the path to grieving other types of losses is not as clear-cut. For example, not everyone understands the intense grief we feel when a pet dies. We grieve when a relationship ends, when a marriage ends in divorce, or when someone we love is incarcerated. Exclusion or dismissal can trigger grief, as can an “undetermined loss” — for example, when someone goes missing.

Complicated Grief

Grief is a natural process, and when someone is diagnosed with acute grief, it can be considered uncomplicated as they move through stages of accepting and embracing a new rhythm of life.

Prolonged/complicated grief is when someone’s grief disrupts their life. They don’t feel present, their traumatic responses are activated, and they experience emotional flooding. According to Dr. Scherling, 7% to 10% of the general population experiences complicated grief. However, the percentage is much higher among people with substance use disorders and addiction.

Treatment Options for Complicated Grief

Everyone’s grief is different, and behavioral health professionals can help people address grief in individual treatment plants. When someone is experiencing complicated grief, many clinicians focus on trauma-informed and trauma-specific treatments such as Eye Movement Desensitization and Reprocessing (EMDR), Accelerated Resolution Therapy (ART), and Dialectical Behavior Therapy (DBT). Some clinicians help people process complicated grief with cognitive behavioral therapy (CBT).

Regardless of the diagnosis or situation, paying attention to self-care is critical. Getting good sleep, exercise, nutrition, and social and spiritual support are all a part of integrated treatment plans.

Mindfulness practices such as meditation, prayer, yoga, music, and journaling have all proved useful when providing grief support.

Companioning

In Companioning You!: A Soulful Guide to Caring for Yourself While You Care for the Dying and the Bereaved, Dr. Alan Wolfelt, PhD, champions an approach to self-care called “companioning.” This involves listening with the heart and learning from others’ experiences, bearing witness to another person’s pain. This powerful approach can help clinicians stay grounded and avoid burnout while also helping people heal from grief and trauma.

“Bright Tomorrows”

This quote from the Rev. Martin Luther King, Jr. encapsulates the spirit of this approach to helping people heal from the grief that paralyzes them.

“When our days become dreary with low-hovering clouds of despair, and when our nights become darker than a thousand midnights, let us remember that there is a creative force in this universe, working to pull down the gigantic mountains of evil, a power that is able to make a way out of no way and transform dark yesterdays into bright tomorrows.”