Welcome…

1. Welcome… We learn wisdom from failure much more than from success; We often discover what will do, by finding out what will not do; and probably he who never made a mistake never made a discovery. (Samuel Smiles.)

2. Important Points • Timekeeping. • Mobile Phones. • 17 hours lectures. • 33 hours independent learning. • Working in: small groups/large group. • Contracting.

3. Aims. • Loss and grief are central issues within the dynamic of a person’s recovery from addiction; however, loss and grief are also central experiences for individuals and families who experience addiction. The module will focus on understanding the concepts of grief and loss (including complicated grief), stages of grief, patterns of grief, death and dying – with specific reference to overdose and suicide. To identify the key concepts of grief and loss To review the models of the process of grief To review the models of the tasks of grief To examine how grief and loss might emerge in addiction work To provide the opportunity for students to examine their own experience in relation to grief and loss and recognise how this may influence their working practice

4. Learning outcomes. On successful completion of this module the student will be able to:Discuss the concepts of grief and loss Demonstrate how the tasks of grief can influence the process of working with clients in addiction Summarise the key issues of complicated grief Demonstrate an awareness and understanding of the influence of their own experience

5. SYLLABUS CONTENT. • The process of grief model – Kubler Ross Denial, disbelief, numbness Anger, blaming others Bargaining Depressed mood, sadness, and crying Acceptance, coming to terms The tasks of grief model – William Worden To accept the reality of the loss To work through the pain of grief To adjust to a different type of environment To emotionally relocate the deceased and move on with life.

6. CONTENT. • Grief symptoms and reactions. Grief and loss in addiction, including Death related to addictive behaviour Emergence of latent grief during recovery The mirroring of recovery paths and tasks of grief – such as grieving loss of substance, loss of potential etc Grief in the community and family - acceptable / non-acceptable death

7. Content. • Complicated grief Relational factors Circumstantial factors • Historical factors • Societal factors Suicide overdose • Post Traumatic Stress Disorder

8. Knowledge “There can be no knowledge without emotion. We may be aware of a truth, yet until we have felt its force, it is not ours. To the cognition of the brain must be added the experience of the soul.” Arnold Bennett (1867-1931)

9. Grief and Loss Theory • Theory gives us a conceptual background to help our understanding • It is part of our psychosocial development • We can recognise the face of grief • Helps us engage with loss • Informs clinical and practice approaches

10. Theory. • The psychosocial competence for dealing with loss starts at birth • The interface between our individual experiences and our social world • Erikson’s account of life span development • Maturation is a sequential process • From infantile dependency to adult autonomy

11. Addiction. • What is Addiction ? • In groups of 3 or 4 decide upon a • definition.

12. Definition. • World Health Definition of Drug Addiction • “A state of periodic or chronic intoxication detrimental to the individual or society, produced by the repeated consumption of a drug, characterised by an overpowering desire or need (compulsion) to continue taking the drug, because of either psychological or physical dependence on the effects of the drug, and a tendency to increase the dose or frequency of use.” • Grilly, D, 2002 Drugs and Human Behaviour, Page 119

13. Addiction/Dependency • It is a stage where a person feels a compulsion to drink, take drugs, gamble etc. and believes they cannot cope physically or psychologically without the mood altering substance or activity. • It’s a gradual process, often an individual does not notice their increasing dependence on the substance/habit.

14. Four-Step Cycle Addiction has a four-step cycle which intensifies with each repetition • Pre-occupation: the mood where the person’s mind is completely engrossed with the thoughts of the substance/habit. • Ritualisation: the person will have their own special routines revolving around the addiction, the ritual intensifies the pre-occupation, adding to the excitement.

15. Four-Step Cycle continued. 3. Compulsive using: this is when the addiction has reached the stage where the person is unable to control or stop this behaviour. It is the end result of the first two steps. 4. Despair: the feeling of the utter hopelessness addicts have about the behaviour.

16. Loss. • ı The state of being deprived of, or being without something one has had. • ı Two categories of loss exist • ı Physical • ı Psychological or symbolic • ı All types of change involve loss • ı Developmental - ageing for example • ı Loss from normal change and growth - a couple having a baby (dyad to triad) • ı Competency, finishing school, leaving home

17. Exercise 1 – Loss and addiction • On your own for fifteen minutes list out different addictions. • Choose to focus on one and identify what losses this addiction might cause in a persons life – (1) during the addictive stage and (2) when in recovery? • Identify symptoms/behaviours that you might observe in persons addicted.

18. Loss • Death • Divorce/Separation • Control----External versus Internal Locus • Expectation • Role----- anomie---- Theory of Suicide ( Durkheim) • Job • Respect------ self & others, shame, stigma • Health – physical & psychological • Friends--- anomie

19. Grief – A Definition • An emotional response to loss • Bereaved: The objective event of losing a significant other • Mourning : The manner and action of expressing grief. Relevant Research: Stroebeet al, 1993

20. Bereavement: • Bereavement is the process of losing a close relationship. • ı Bereavement: The period after a loss during which grief is experienced and mourning occurs. The time spent in a period of bereavement depends on how attached the person was to the person who died, and how much time was spent anticipating the loss.

21. ı Complicated grief: Grief that is complicated by adjustment disorders, especially depressed and anxious mood or disturbed emotions and behaviour, major depression, substance abuse, and PTSD. ı Complicated grief is identified by the extended length of time of the symptoms, the interference in normal function caused by the symptoms, or by the intensity of the symptoms (for example, intense suicidal thoughts or acts). Complicated grief

22. Complicated grief may appear as a complete absence of grief and mourning, an ongoing inability to experience normal grief reactions, delayed grief, conflicted grief, or chronic grief. Grief reactions that turn into major depression should be treated with both drug and psychological therapy. One who avoids any reminders of the person who died, who constantly thinks or dreams about the person who died, and who gets scared and panics easily at any reminders of the person who died may be suffering from post-traumatic stress disorder. ı Substance abuse may occur, frequently in an attempt to avoid painful feelings about the loss and symptoms (such as sleeplessness), and can also be treated with drugs and psychological therapy. ı Also called unresolved grief.

23. Types of Grief Normal Traumatic Disenfranchised

24. "Disenfranchised grief" • "Disenfranchised grief" is when your heart is grieving but you can't talk about or share your pain with others because it is considered unacceptable to others. It's when you're sad and miserable and the world doesn't think you should be, either because you're not "entitled" or because it isn't "worth it."

25. Examples. • The way the person died is not as supported as other deaths. • This occurs when the death or the deceased person’s actions while alive are stigmatized by society as with deaths from suicide, a drug overdose, AIDS, a war, violence, or alcoholism. Sometimes a death of a person who had a long life is more discounted than someone younger.

26. Why do people fail to grieve? • Relational Factors: the type of relationship the person had with the deceased e.g. blame, highly dependent, helplessness of ‘survivor’

27. Circumstantial Factors: • Circumstantial Factors: where the loss is uncertain; belief that the person is still alive; multiple losses – air crashes, earthquakes etc or over a short period of time one loses several close relationships. • Historical Factors: if you had complicated grief in the past, you are more likely to have complicated grief in the future

28. Why we fail to grieve. • Personality Factors: ability to cope (emotional distress); one’s self-concept (You’re a strong person but I’m not) • Social Factors: Where the loss is socially unspeakable (e.g. suicide). Where the loss is socially negated (people act as if the loss didn’t happen, e.g. a termination of a pregnancy). Where there is absence of a social network (social isolation by living in a different area to where the loss occurs)

29. Complicated Grief: • Including • Chronic Grief Reactions • Delayed Grief Reactions • Exaggerated Grief Reactions • Masked Grief Reactions

30. Clues to grief being one of the above include: • Person cannot speak of the deceased person without experiencing intense and fresh grief • Minor triggers activate intense grief • Themes of loss come up in reviews of the case • Person refuses to give up material possessions belonging to the deceased • Person starts to develop physical symptoms like those of the deceased • Radical changes are made to their lifestyle like excluding friends/family members who knew the deceased

31. Complicated grief. • Depression, guilt and lowered self-esteem emerge • Imitation of the dead person – e.g. personality characteristics. • Self-destructive impulses • Periodic unaccountable sadness – holidays and anniversaries • Phobia about death and certain illnesses • Avoidance of death-related rituals or visits to the graveside.

32. Handling Grief/Loss Issues in Groups: • My loss is bigger than your loss: • acknowledge all losses are important • The Advice Giver: • Advice is experienced as one of the least helpful interventions when grieving. A statement like ‘we do not give advice unless it is asked for’ is useful • The Moralist: • Advice that is couched in ‘musts’ and ‘shoulds’ and ‘have tos’. Inviting the person to reframe their statements into ‘This is what I would do’ language is sometimes helpful

33. Group. • The non-participant: • This is a common issue in groups and can be interpreted negatively. Directive exercises that invite everybody to share something in the opening sessions is helpful – silence throughout the first session can develop into an unhelpful pattern. • Big issue at the end: • This activity is unhelpful but common; it should be addressed as unhelpful and not left to become a pattern. It should be first thing on the agenda for the next group rather than letting the current group go into overtime. • Sharing with the Facilitator at the end of the Group: • “I think it’s important for everyone to hear this – let’s start the next group by taking about i

34. Elisabeth Kübler-Ross, M.D. (July 8, 1926 – August 24, 2004) was a Swiss-born psychiatrist and the author of the groundbreaking book On Death and Dying.

35. five stages of grief – elisabeth kübler ross • Denial • Anger • Bargaining • Depression/preparatory grieving • Acceptance

36. ı Initial denial was found in almost all patients. • ı Denial or partial denial is used by most patients throughout the illness • ı It is usually temporary and is replaced by partial acceptance. • ı Maintained denial does not always bring increased distress. • ı Denial is a defence and later on most patients use isolation • rather than denial as a form of defence. • ı In our unconscious minds we are all immortal, it is almost • inconceivable for us to acknowledge we have to face death.

37. Anger. When denial fails to work it is replaced by anger, rage, envy and resentment. Very few patients can maintain a make believe world in which they are healthy until they die. • ı This is a difficult stage to cope with as anger can be displaced in all directions, and projected at random. • ı The result of the anger is often grief, shame, guilt and tears which often leads to avoiding people making the person more isolated. • ı The angry demands are to say I am not dead yet.

38. Bargaining. • ı This stage is less well known but of equal importance to the patient. Another approach after denial and anger has not worked. • ı The bargaining is an attempt to postpone it includes a prize offered “ for good behaviour" it also sets a self-imposed deadline and it includes an implicit promise that no more will be asked for. None of the patients kept this promise! ı Often these promises are made to god and kept secret. ı The promise may be associated with guilt.

39. Kübler-Ross, Depression ı At some stage the numbness, stoicism, anger and rage give way to a sense of great loss. This loss may have many facets. Identity, a job, money, but also the preparatory grief for death. ı So Kübler-Ross divides the depression into reactive depression and preparatory depression. ı The first she deals with in terms of increasing self esteem. This she says is vitally important. ı The second is dealing with a future loss - the impending loss of loved people or objects, it is contraindicated to tell a patient too look on the bright side, or not to be sad. Allowing a person to express their sorrow helps with acceptance. ı This second type of depression is a silent one in contrast to the first one. It is necessary and a great assistance in dying with acceptance.

40. ı Acceptance • If given enough time and some help a patient will reach a stage during which he is neither depressed nor angry about his fate‖.' • ı There will be quite expectation. • ı Acceptance is not happy it is void of feelings- as if the pain is gone. Person often not talkative. • ı Acceptance may not be seen positively, and people are often encouraged to fight and be strong. • It is important to distinguish between denial and fighting.

41. The stages are defence mechanisms, they last for varying lengths of time. These stages can exist side by side. Stages,

42. William J. Worden. Professor of Psychology. Ph.D., Boston University ı Tasks of Grief ı The work of William Worden ( in Grief Counselling and Grief Therapy, 1992) conceptualizes the process of grief as a series of tasks‖ that need to be accomplished before mourning is completed. ı These tasks outline the work that needs to be done to resolve a loss.

43. Exercise. • Self awareness exercise – ‘river of life’. • In order for you to work with loss and grief effectively you need an awareness of loss and grief in your own life. In this way you become familiar with what works and doesn’t work for you. • This self awareness combined with knowledge of theoretical concepts will then allow you to listen more effectively and work in collaboration with your client to facilitate them identifying what works for themselves.

44. River of life • On your own think back over your life – from birth to the present moment. • Draw a river or time-line. Mark on the river moments in your life where loss happened. This can be a bereavement; a relationship breaking up; losing a favourite piece of jewellery; a pet; moving from childhood to adolescence; being on this course e.g. less time for…….what ever you remember that touched you/impacted on you. • First just list them, then go back over them and take note of things that helped you during that period, or hindered you. • Then identify what stages/symptoms of the grief process you experienced.

45. Worden’s four tasks in mourning • accept reality of loss • experience and bear the pain or grief • adjust to a world in which the dead person is missing • withdraw and reinvest emotional energy.

46. 1.To Accept the Reality of the Loss ı While the initial reaction to the news of a death may be shock and disbelief, these feelings are usually replaced by a dawning recognition of the reality of what has taken place.

47. To Work through the Pain of Grief • ı For most of us, the normal feelings of grief are sad, uncomfortable ones. From a variety of life experiences, we are all too familiar with the sadness, anger, hurt, emptiness, and loneliness that accompany loss. • ı Homicides bring with them a great deal of fear and concern about the violence and randomness of life in addition to worries about our own safety.

48. Adjust. • To Adjust to an Environment in Which The • Deceased is Missing • ı The rearranging, restructuring and redefining that • takes place as we begin to identify and fill the roles • formerly occupied by the deceased defines this third • task. • ı We may also find it simpler to take care of the • concrete tasks that were part of the deceased's • contribution to our lives than to fill the emotional roles • which can often escape our notice until much later in • the grieving process.

49. Task four. • To Emotionally Relocate the Deceased and Move On with Life • ı The resolution of the major work of grieving takes place when • the fourth task is completed. • ı In simple language, emotionally relocating‖ the deceased • means moving from the feelings of loss and longing that • accompany our awareness that the deceased is really gone • from our lives forever to being able to hold the memory of that • person in our hearts.

50. Worden’s four tasks • As with the other three tasks, completion of this task is also related to the meaning of the deceased in our lives. If we have minimal investment in a relationship, we have little emotion to withdraw, so the process is less complex. If we were extremely invested in the deceased, the loss will have more meaning for us and it will take time to move on.