Losing a loved one is a painful event, and the emotions that follow can be debilitating for some. Feelings of anger, sadness, denial and despair are normal during these periods of loss. There is no “right” way to feel and everyone walks through the grieving process in their own way. When drugs or alcohol are used to help numb the emotions, use can lead to addiction. For those who already meet criteria for a substance use disorder, the loss or, more specifically, the inability to process the loss, only compounds the underlying issues.
The emotional stages experienced during grief can make simple life responsibilities hard to manage. The grieving process, which includes experiencing the emotions of denial, anger, sadness and more, takes time. The process is necessary, as we’re literally rewiring some of the neural pathways in our brains. When we use mood-altering substances to numb our emotions, we halt the process, and the brain is unable to move beyond the healing stage it was in when the substances were first introduced. This interruption results in unresolved grief, which, in turn, can set the stage for depression. The underlying characteristic of unresolved grief, in most cases, is a feeling of guilt over the loss.
Seeing the loss as something we have control over—an event we take ownership of—manifests itself in a variety of ways. Some people refuse to acknowledge the loss has occurred and continue to act as though nothing has changed. When asked about the loss, they may quickly change the subject. This avoidant behavior usually results when shame and stigma are attached to the loss, such as with abortion or drug overdose. People who have a hard time talking about the loss may become preoccupied with the person or thing that they lost. This can lead to some strange behaviors, which can be alarming to others.
The desire to hang on to a loved one is normal but not being able to move through that stage can be life threatening. If the obsession to be with the person lost is coupled with depression, the person may believe that the only “true” way to join their loved one is through suicide. In the same manner in which intoxicants lower a person’s inhibitions, compromising the brain’s ability to judge between right and wrong, suicide can quickly become the decision of choice.
The truth about drugs and alcohol (which is a drug) is that they worked perfectly . . . until they stopped working. A common indicator of a substance use disorder is the user’s need to take increasing amounts of the substance to achieve the desired effect. This is due to what is known as tolerance. There comes a point when the substance simply will not produce the results that it once did, but the user is now so enmeshed in her or his relationship with the substance that all other areas of life begin to suffer greatly, including career, relationships, property and finances. Negative consequences are intensified or accelerated due to the drug use, and the drug use is intensified due to the original loss, which cannot be processed while the griever is still using the drugs. We begin to see a pattern that is difficult to escape.
We recommend that anyone with a substance use disorder seek out treatment that matches the level of intensity of their addiction. Not all treatment is equal, and many traditional treatment facilities are not staffed with professionals trained in treating the co-occurrence of grief and addiction. If detox is required, anyone who has significant grief should be aware that the repressed emotions may come back in a dramatic and exaggerated fashion. This period of treatment is when many people drop out and leave. Those same emotions that were too intense to process in the beginning are back, along with all the compounded problems created since the loss.
Grief counseling should be part of the addiction treatment experience, because the chances of relapse due to unresolved grief is extremely high. Learning how to cope with the feelings when they are experienced without drugs or alcohol can be achieved by working with a skilled therapist. Certain pharmaceuticals can be used in concert with therapy, which can help in the process. It is important to find a practice or facility open to discussing this topic and not completely opposed to such recovery-enhancement treatments.
Many treatment options are available, and what is right for some people may not be appropriate for others. If you or a loved one are struggling with substance use and unresolved grief, the most important thing to look for in a treatment provider is experience and the use of evidence-based practices for the treatment of both problems simultaneously. It is also highly recommended that the family become part of the treatment process.
We provide these services on an outpatient basis, and we collaborate with quality residential facilities if a higher level of care is needed. Taking that first step is often the most difficult, but when you’re ready, we are here to help you start on your path to recovery.
The word trauma has gained attention over the past several decades via several dramatic and highly-publicized events, such as the 9/11 World Trade Center and Pentagon terrorist attacks and soldiers returning from combat with Post Traumatic Stress Disorder (PTSD) after being injured by an explosive device. When we speak, or hear of trauma, it is common to associate the word with the term “traumatic event;” often triggering associations with events like 9/11 or the bombing of the Oklahoma Federal Building. Trauma can also result from a series of events, or repeated single event, that has layers upon layers of experiences. Trauma is most often experienced during an unforeseen or unexpected event, but it can also be very much expected such as when a parent repeatedly abuses a child when the parent is drinking. The child becomes very aware of what is to come when their parent begins the day with a bottle of liquor.
Much like the consequences that come from addiction, trauma has “lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being” (SAMHSA, 2012, p. 2). It can overwhelm coping faculties and triggers the “fight, flight, or freeze” reaction. Many people can move past the trauma and live a healthy productive life. Others have long-lasting and sometimes debilitating consequences, such as developing a stress related disorder, anxiety disorder, and/or substance use disorder. A study on the prevalence of trauma histories for people with an alcohol use disorder showed that 71.6 percent of the sample reported witnessing trauma, 30.7 percent experienced a trauma that resulted in injury, and 17.3 percent experienced psychological trauma (El-Gabalawy, 2012). The general public’s prevalence was found to be 61 percent of men and 51 percent women had experienced trauma in their lifetime, and these figures included all forms of trauma (Kessler et al., 1999).
It is of little surprise that substance abuse often predisposes the user to higher rates of trauma. The lifestyle often associated with many street drugs is riddled with traumatic experiences. The effects of the constant exposure to these experiences along with the substance use disorder has been shown to have a strong correlation with homelessness, poverty and incarceration. When discussing trauma and its link to substance use disorders, these extreme (yet common) cases generally fall into the “of course, that makes sense” category. But the consequences of trauma within the entire population of persons with a current or past substance use disorder (1 in 10 people) is equally debilitating when it comes to treatment and recovery. Helping a client in substance abuse treatment gain control over trauma-related symptoms can greatly improve the client’s chances of substance abuse recovery and lower the possibility of relapse (Farley, Golding, Young, Mulligan, & Minkoff, 2004; Ouimette, Ahrens, Moos, & Finney, 1998).
We recommend that anyone seeking help for a substance use disorder to verify the professionals working there understand the relationship between trauma and substance use, and more importantly, know what therapy options to use. The two greatest errors made during treatment for substance use disorders are: a) ignoring the trauma to where it is left untreated and ultimately leading to relapse; or b) exposure of the trauma by an unqualified or undertrained clinician, which can lead to re-traumatization a replication of trauma dynamics.
CBT: Cognitive–behavioral therapies
Most PTSD models involve cognitive–behavioral therapy (CBT) that integrates cognitive and behavioral theories by incorporating two ideas: first, that cognitions (or thoughts) mediate between situational demands and one’s attempts to respond to them effectively, and second, that behavioral change influences acceptance of altered cognitions about oneself or a situation and establishment of newly learned cognitive–behavioral interaction patterns. In practice, CBT uses a wide range of coping strategies. CBT has been shown to be highly effective in the treatment of substance use disorders and trauma comorbidity.
CPT: Cognitive processing therapy Cognitive processing therapy (CPT)
CPT is a manualized 12-session treatment approach that can be administered in a group or individual setting (Resick & Schnicke, 1992, 1993). CPT was developed for rape survivors and combines elements of existing treatments for PTSD, specifically exposure therapy and cognitive therapy. The exposure therapy component of treatment consists of clients writing a detailed account of their trauma, including thoughts, sensations, and emotions that were experienced during the event. The client then reads the narrative aloud during a session and at home. The cognitive therapy aspect of CPT uses six key PTSD themes identified by McCann and Pearlman (1990): safety, trust, power, control, esteem, and intimacy. The client is guided to identify cognitive distortions in these areas, such as maladaptive beliefs.
Exposure therapy for PTSD asks clients to directly describe and explore trauma-related memories, objects, emotions, or places. Intense emotions are evoked (e.g., sadness, anxiety) but eventually decrease, desensitizing clients through repeated encounters with traumatic material. Careful monitoring of the pace and appropriateness of exposure-based interventions is necessary to prevent retraumatization (clients can become conditioned to fear the trauma-related material even more). Clients must have ample time to process their memories and integrate cognition and affect, so some sessions can last for 1.5 hours or more. For simple cases, exposure can work in as few as 9 sessions; more complex cases may require 20 or more sessions (Foa, Hembree, & Rothbaum, 2007). Various techniques can expose the client to traumatic material. Two of the more common methods are exposure through imagery and in vivo (“real life”) exposure.
While exposure therapy is a proven model in the treatment of trauma, use of this modality is increasingly rare due to the potential of adverse reactions, such as exacerbation of symptoms and traumatization.
Eye movement desensitization and reprocessing (EMDR)
EMDR (Shapiro, 2001) is one of the most widely used therapies for trauma and PTSD. The treatment protocols of EMDR have evolved into sophisticated paradigms requiring training and, preferably, clinical supervision. EMDR draws on a variety of theoretical frameworks, including psychoneurology, CBT, information processing, and nonverbal representation of traumatic memories. The goal of this therapy is to process the experiences that are causing problems and distress. It is an effective treatment for PTSD, but it’s effectiveness for people in with a substance use disorder is not yet known. We do have experienced clinicians to perform this modality when appropriate.
The list of therapeutic techniques goes on, and the professionals at HHPC are qualified to provide many of the evidence-based treatments. Through the screening, assessment, placement, treatment planning, aftercare planning, and all other stages of your care, here at HHPC, your input and collaboration is what determines the plan of care. We believe you are the best source of information about you and you are the most important person in your treatment. Our fully-qualified and experience clinical team can help you gain the skills you need to address the trauma, its symptoms, and begin to live the life you have always wanted.