Journal of Substance Abuse Treatment, Vol. 8, pp. 221-226, 1991 Printed in the USA. All rights reserved.

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ARTICLE

To Surrender Drugs: A Grief Process in Its Own Right

PAMELA S. JENNINGS, PhD

Howard University, Department of Psychology, Washington, DC

Abstract - The basic thesk of this article is that addictive substances, because of their need-gratifying and self-medication value, become so central to the life of the addicted person that their absence is associated with a grief reaction. Painful feelings of loss and helplessness accompany drug sur- render. This view contrasts with formulations that indicate that mourning experiences observed in recovering persons are specific to and determined by unresolved past losses of loved ones. The author discusses the theoretical underpinnings of the drug-loss grief reaction. Also presented are case vignettes that demonstrate the grief aspects of drug surrender. Finally, the role of brief psy- chotherapy as a vehicle for helping clients cope with their grief reactions is discussed.

Keywords- substance abuse; addiction; grief; loss; mourning.

INTRODUCTION

THE FIELD OF DRUG REHABILITATION is characterized by a variety of perceptions about the nature of addiction and the elements of rehabilitation. However, there ap- pears to be a certain lack of attention to the reality that drug surrender creates a significant loss situation. Dynamics of mourning that are specific to the loss of drugs can be observed in the behaviors of recovering persons.

Several authors have cited the occurrence of mourning in alcohol and drug abusers undergoing re- habilitation (Bellwood, 1974; Coleman, 1980; Denny & Lee, 1984; Skolnick, 1979). Curiously, this mourn- ing has not been conceptualized as a consequence of losing drugs. Instead, the common view has been that drug-addicted people grieve the loss of significant oth- ers. Usually, these losses pertain to the early childhood deaths of loved ones.

According to Skolnick (1979), loss plays a central role in the etiology of substance abuse. He asserts that drug-addicted individuals resort to drugs in an attempt to resolve major losses. During rehabilitation these losses reemerge and are grieved. Denny and Lee (1984) discuss the use of a 5-session group therapy program

Requests for reprints should be addressed to Pamela S. Jennings, PhD, Department of Psychology, Howard University, Washington, DC 20059.

for resolving such losses. They advocate the use of grief groups as a major rehabilitation strategy.

However, the connection between loss and sub- stance abuse is ambiguous. While loss appears to be a central factor in the etiology of many drug-addictions, it does not appear to explain addiction in those indi- viduals who have not suffered traumatic losses. Nei- ther does it explain why there are many people who have experienced the death of a significant other who have not resorted to drugs as a means of coping. Also, there is no clarification of the specific influence of age and type of loss (e.g., abandonment versus death) in the etiology of drug abuse.

Spitz (1965), for example, has demonstrated that there is a critical period associated with recovery from early losses. Infants and very young children who ex- perience severe grief reactions to the loss of their mothers can recover if a substitute mother is provided within a certain amount of time. If the substitute mother is able to empathize well with the child and regulate painful feeling states, there is no reason to ex- pect that the child will not internalize mechanisms of coping with pain. Of course, the child can be expected to be vulnerable to loss. But, the circumstances under which such vulnerability leads to substance abuse must be elucidated.

Perhaps the underlying issue is that many substance abusers lack the capacity to cope with any extremely painful affective situation. Loss is just one of the many painful feeling states that drug-addicted individ-

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uals may attempt to manage with drugs (Khantzian and Khantzian, 1984). The large-scale grief reactions observed among them cannot be reduced solely to the etiological role of loss.

The conceptualization of drug surrender as a loss situation is long overdue. Almost 20 years ago, Tame- rin (1972) documented the affective significance of the loss of cigarettes. His patients routinely experienced grief marked by tearfulness and sadness when they contemplated a future without cigarettes. Tamerin also noted that cigarettes played a major role in the psychic equilibrium of the smoker.

Illicit drug substances are at least as emotionally significant to their abusers as cigarettes are to the smoker. Drugs can be viewed as cathexis objects. These are objects that humans invest with psychic en- ergy and therefore form attachments to (Brenner, 1973). Drugs sometimes become so meaningful in the lives of their dependents that they are given priority over human relationships. The alcoholic goes home to his bottle instead of his wife. Marital wishes have been expressed toward crack cocaine (Chatlos, 1987). If people depend on drugs to fulfill needs ordinarily directed at other humans, there must be a powerful sense of loss when they are relinquished. This sense of loss is magnified by the fact that the rehabilitating per- son also loses membership in the addictive commu- nity. Also, they are separated from family and friends who use drugs.

It is critical to identify the role of past psychologi- cal traumas, like loss, in the individual’s addiction. However, when substance abusers focus on past traumas to the exclusion of their current trauma, drug loss, some defensive process involving displacement is occurring. This displacement is partly explained by the reality that treatment experts and society at large view drug loss as something to celebrate, not as something to mourn. When people believe that individuals are better off without someone or something that is per- ceived to be destructive, it is difficult to empathize with a need to grieve the loss. The most important gain of rehabilitation, an abstinent life-style, is a fu- ture event. Drug-addicted individuals who enter a drug treatment program can only anticipate, work to- ward, and hope for a drug-free life. First, they must cope, physically and emotionally with their loss. Fol- lowing is a discussion of the theoretical underpinnings of the idea that drug-addicted individuals mourn the drugs that they surrender. Also presented are three case vignettes that depict this mourning process and show the role of brief psychotherapy in helping the addicted person cope with grief.

Theoretical Background

Psychoanalysis and separation and loss theory and re- search provide support for the conceptualization of re-

P. S. Jennings

habilitation as a loss event. The first psychoanalytic formulations of drug and alcohol abuse were based on the idea that drugs provide drive-related tension re- duction. For example, the good feeling aspects of drugs were understood to gratify pleasure-seeking im- pulses. Or, some drugs were thought to reduce aggres- sive drive tension by providing an escape from feelings of hostility and rage (Khantzian & Khantzian, 1984; Wurmser, 1974).

More recently, psychoanalytic accounts of the eti- ology of drug dependence focus on the concept of homeostasis. It is hypothesized that drugs fulfill a reg- ulatory function for the drug-addicted individual in that they help with the management of painful affect states. It is believed that the drug-addicted individual’s personality structure is inadequate in that it fails to in- tegrate highly unpleasurable affects like rage, shame, loneliness, and dysphoria. Consequently, it is rea- soned that drugs are used for self-medication purposes because they relieve the stress associated with intoler- able psychological states (Khantzian, 1985).

The self-medication hypothesis is offered in lieu of drive-reduction theory (Khantzian, 1985). However, it can be reasonably asserted that drug dependence is motivated by both phenomena. The painful affect states that Khantzian discusses come about in part be- cause of inadequate drive discharge, inadequate defenses against unacceptable drives, overdetermined drive intensity, or faulty channeling of drives. Accord- ing to Brenner (1982), affects are related to the gratifi- cation and frustration of drive derivatives. Brenner describes affects as including sensations of pleasure and/or displeasure that are associated with the gratifi- cation or the lack of gratification of a drive derivative. It appears to be meaningless to separate the painful affects experienced by addicted individuals from drive activity.

Both the drive reduction and self-medication hy- potheses help to explain why drugs are invested with libidinal energy. The person or thing that is cathected represents an important object for instinctual gratifi- cation and psychological homeostasis. Take, for ex- ample, the maternal object, who for the infant is associated with the reduction of all kinds of drive re- lated tension. She is a resource for oral gratification in that she provides the infant with objects for suck- ing and biting. Also, the mother’s role with the infant is largely homeostatic in that, in optimal circum- stances, she regulates states of pleasure and unpleas- ure. For example, when the infant cries in discomfort from a wet and cold diaper, gastric discomfort, phys- ical pain, etc., the maternal object reduces the discom- fort. Thus, the regulatory role of drugs can be likened to the regulatory role of the primary caretaker.

Objects that play a fundamental role in the individ- ual’s sense of gratification and well-being tend to be highly cathected. Hence, the formulation that drugs

Drug Surrender and Grief

are cathexis objects. They can be viewed as carrying tremendous psychological importance for the drug- addicted individual. Weider and Kaplan (1%9) discuss the drug-addicted person’s attribution of the words mother and food to drugs. Mishne (1986) states that the earliest prototypes of druglike experiences proba- bly are of milk, breast, and mother.

The Mourning Process. The loss of a cathexis object entails a bereavement process (Freud, 1957; Parkes, 1972). This mourning process is universal and is not limited to the loss of human objects. For example, universal grief and bereavement reactions have been observed with job loss, limb loss, late adolescent/early adulthood separation from parents, and symbolic pa- rental separations as experienced.in physical and sexual abuse. Even psychological phenomena like attitudes, images, and dreams become familiar attachments which prompt separation reactions (Bloom-Feshbach and Bloom-Feshbach, 1987; Freud, 1957; Piotrkowski dz Gornick, 1987). It is reasonable to think that addictive substances, because of their self-esteem altering, need- gratifying, drive reduction and self-medication value, become so central to the life of an addicted individual that their absence is associated with painful feelings of loss and helplessness.

According to several grief experts, reactions to the kinds of loss cited above are universal and proceed according to specific stages (Bowlby, 1973; Kubler- Ross, 1969; Lindemann, 1944; Parkes, 1972). Bowlby’s research on attachment and loss represents the proto- typical scientific exploration and elaboration of the stages of grief. Parkes used Bowlby’s scheme to inves- tigate and delineate five stages of grief in adult pop- ulations. Since I have used these stages to organize the case presentations that follow, I will review them. Stage 1, alarm, is characterized by a generalized fear response that is sometimes manifested in protest. The individual experiences a pervasive disbelief that the loss has occurred. Stage 2, searching, is marked by acceptance of the loss and episodic pangs of grief that can be rather severe. There remains an inner disbelief that the object is gone and the individual yearns for the object. The individual experiences a sense of inner incompleteness. The self as a part of the loss object no longer exists. To resolve the loss, the individual has to restructure her identity so that it is separate and apart from the loss object. Stage 3, mitigation, is character- ized by the nostalgic feeling that the love object is nearby even though she cannot be seen or heard. The bereaved individual makes an effort to comprehend the loss. Stage 4 is characterized by strong affective re- sponses, for example, anger and guilt. Stage 5, depres- sion, concerns integration of the reality of the loss.

It is unclear to what extent we should expect the process of mourning drug-objects to mirror Parkes’s stages. Even in the case of death, variability character-

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izes movement through the stages of grief (Kubler- Ross, 1969). Only further research can provide the details necessary to differentiate the mourning experi- ences of drug-addicted individuals from those that are typical of other populations.

Grief Versus Depression. Dysphoric feelings have been observed in recovering persons (Extein, Dackis, & Pot- tash, 1986; Khantzian, 1975; Nunes 8c Rosecan, 1987). The interpretations of these feelings have been over- simplified. One widespread assumption is that the sub- stance abuser’s experience of sadness during recovery is not new but that they were drugging to their depres- sive affects all along (Wurmser, 1974). Another view, is that withdrawal from drugs like cocaine is associ- ated with a depressive reaction that is specific to the physiological effects of abstinence (Extein et al., 1986). Yet, it is difficult to differentiate these physio- logical effects from the physiological effects of loss. According to Lindemann (1944) and Bugen (1977) the physiological correlates of mourning include tightness in the throat, shortness of breath, loss of appetite, loss of sleep, emotional waves that may last from a few minutes to an hour, lack of strength, exhaustion, and an altered sensorium (slight sense of unreality). It is reasonable to expect that at least some of the depres- sive feelings observed in rehabilitation programs per- tain specifically to mourning.

Drug Surrender Versus Imposed Inaccessibility of the Object. The nature of drug loss in America varies from losses characterized by the imposed inaccessibil- ity of the object, for example, by death or abandon- ment. Drugs are highly accessible in this culture. This reality is a disservice to the recovering individual’s mourning process. According to Freud (1957), in the case of death, the reality that the love object no lon- ger exists helps the person sever his attachment. When the object is remembered and longed for, reality in- trudes with information that the object is gone. Con- sequently, the attachment to the object breaks down. When the recovering individual longs for drugs, real- ity, in the form of drug pushers, friends, family, and marketing techniques, steps in with information that the object can be recovered. This adds immeasurably to the potential for relapse. Society must recognize its role in the availability of illicit substances and, relat- edly, its role in the failure of drug rehabilitation programs.

CASE VIGNETTES

I have observed the various stages of grief in clients undergoing rehabilitation. The following case exam- ples demonstrate the grief reactions of three recovering persons. They were referred for brief psychotherapy because of treatment adjustment problems associated

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with their grief reactions. They vary with respect to where they are in the grief process.

Example One: Ms. W.

Ms. W. is a 36-year-old black female with a 24-year history of substance abuse. She began drinking alco- hol and using heroin and marijuana at the age of 12. At age 19, she expanded her drug experience to PCP, and at the age of 35 she included cocaine in her reper- toire. According to Ms. W., her “choice of drugs” in- cluded all of the drugs she used. Her first 6 to 8 weeks of treatment were marked by an intense fear that she would soon die a violent death (Stage 1, alarm). There were no realistic reasons for her fear. At night, she repeatedly dreamed that an ominous, gun-wielding, big, faceless figure was chasing her. She usually awoke from her dream drenched in sweat and unable to soothe herself. She remained awake for hours thinking about her unfortunate fate. Drug counselors hoped that brief psychotherapy could reduce the client’s anxiety.

Psychologically, significant parts of this woman were threatened with death. The Ms. W. who lived and enjoyed the drug life was no longer an acceptable person. The client was actively trying to kill off the part of herself that wanted and was identified with drugs. Psychological testing demonstrated that Ms. W. had a narcissistic overinvolvement in herself. She was, to a certain extent, her own love object. The client’s narcissism played an important role in her drug-addic- tion. Part of her self-involvement was a withdrawal of her interest in human objects. Much of the energy normally directed to interpersonal relationships was redirected to drugs, which operated like transitional objects in her psychological world. As transitional ob- jects, drugs symbolize the union between the infant and the optimal maternal object who knows when to minister to the child’s needs (Winnicott, 1971). The client’s loss of this symbolic mother substitute was alarming. The fear that she would not survive makes sense when one recalls that people often feel that they will be destroyed by the loss of a major love object.

In individual psychotherapy, Ms. W. talked inces- santly about her fear of death. She expressed feelings of remorse, anger, and guilt about the way she had lived her life, and she even thought that her antici- pated early demise was well deserved. After about 2 months of expressing her alarm, the client’s fears sub- sided. She often commented about how important psychotherapy was to her because it allowed her to have a place where she could get some relief from her distressing fears. Thus, psychotherapy helped her reg- ulate painful feeling states. She was able to experience the therapist as an optimal mother figure who helped her feel better.

As her alarm decreased, Ms. W. redirected her en- ergies to accepting her loss. She verbalized her com-

mitment to walk away from drugs (Stage 2). She even entertained fantasies of moving so far away from her drug life that she would reside in a mountain and “be by myself.” She knew that old friends would pressure her to resume the use of drugs, and though she missed many of them, she accepted the reality that she had to say goodbye to them.

Accepting life without drugs was not easy. Ms. W. deeply missed the apartment and neighborhood she lived in (Stage 3). Also, she grieved the loss of a romantic partner who had died about a year before she started treatment. She had a powerful attraction to guns and boasted of how well she used them in the robberies that had supported her drug habit. She grew nostalgic for her guns. At times, she reminisced about the actual state of being high (Stage 3).

Throughout the course of her grief reaction, Ms. W. struggled with strong feelings of depression, anger, and rage (Stages 4 and 5). Much of the time these feel- ings were directed at counselors, especially those coun- selors who challenged her commitment to abstinence. Additionally, she was angry about the adjustment she was making to life without drugs. At times, she artic- ulated angry feelings at drugs and saw them as respon- sible for ruining her life. She used therapy to talk about her angry feelings, which helped her avoid act- ing on them in her relationships with staff and clients.

At the end of our work together, Ms. W. was work- ing industriously at developing a new identity (Stage 5). This new identity was founded on values that dif- fered from many of her drug-related values. For ex- ample, she was essentially nonviolent, she believed in making an honest living and had no qualms about working in a kitchen or doing manual labor. Finding a job as a cook significantly contributed to her sense of mastery. She worked on maintaining and strength- ening personality traits that she admired, for example, a belief in not being “phony” in interpersonal relation- ships and a commitment to empathizing with others and recognizing them as “equal” to her. Finally, she directed considerable effort at developing the feminine side of her personality. For the first time, she allowed herself to wear make-up and have styled hair.

It is important to note that Ms. W. had suffered a significant early childhood loss. Her mother aban- doned her when she was about 2 years of age and left her with a friend. Ms. W. had thought that this friend was her mother for most of her childhood. It was clear that this issue would one day have to be explored and resolved in order for the client to be in the best position to remain drug-free. The persistence of inter- nalized images of mother as someone who not only failed to help her regulate painful feeling states, but who, in fact, created such states, made her vulnerable to the psychological effects of drugs. However, sad- ness and rage that was specific to the loss of mother did not dominate her conscious psychological experi-

Drug Surrender and Grief 225

ences during treatment. In fact, it is unreasonable to think that such a complicated parental loss as hers would be resolved during a five-session group therapy program like the one outlined by Denny 8z Lee (1984). The client was highly defended against the rage and helplessness she felt when her mother abandoned her. Her rigid defenses against recovering the full system of memories associated with her loss raises serious questions about whether she would have been able to handle her recollections. In this particular case, reinforcement of the client’s defenses against remem- bering and being overwhelmed by her feelings of deso- lation supported her efforts to work through the loss of drugs. Thus, it is not at all clear that approaches to rehabilitation inclusive of grief counseling should en- courage universal mourning of past losses.

Example 2: Ms. F.

In the case of Ms. F., the grief precipitated by the loss of drugs was displaced onto socially acceptable mourning situations, for example, childhood losses, maternal abandonment, etc. This 35year-old Black female had a 20-year addiction to heroin and alcohol. Also, for 15 years she abused marijuana, cocaine, and hallucinogens. Staff members referred her for a psy- chological evaluation after noticing that she was very sad and withdrawn. During the evaluation, the client had difficulty articulating her thoughts because almost everything that she talked about precipitated sobs. She spoke mostly of family and friends who had died over the last 25 years. These included a sister who commit- ted suicide when the client was 15, a best friend who was killed when she was 18, and a brother who died of cardiac disease about 2 years prior to her recovery from drugs. Most importantly, she had experienced major maternal disappointments. Her mother was se- riously mentally disturbed and had tried to kill herself and her children by setting the house on fire when the client was a child. However, the mother was not hospitalized and the client had never been physically separated from her mother.

The client’s sadness and need to cry was so intense that the initial interview was cathartic in nature. She expressed feelings of shock and surprise about her losses (Stage 1). She behaved as if her sister had just committed suicide. She was angry at the people that she held accountable for her losses, for example, she blamed her father for her sister’s suicide. The intensity of the client’s sadness lasted for the first 8 weeks of her treatment. Suddenly, she stopped crying and no longer needed to talk about her losses. At her last ap- pointment, she stated that she was “fine” and believed she could complete the program.

The idea that the client was displacing grief feelings that were specific to her surrender of drugs onto past loss situations is supported by the shock and the qual-

ity of her grief, “as if” this had just happened to her. Certainly, after 20 years of using drugs she was expe- riencing a certain amount of shock getting used to see- ing the world without drugs. She routinely commented about how “different” life would be without drugs. She was painfully aware of the fact that she had spent most of her life on drugs. The loss of her mother to mental illness as well as the suicide of her sister were unresolved losses, but there is no reason to expect that she should have still been shocked by them. Her old losses were vicariously used to express the profound sense of loss she felt upon giving up the drug-object. As her time without drugs increased, her need to be- moan her old losses decreased. This case speaks to the importance of giving clients space to experience their feelings of grief in the sense that doing so allows them to go forward with rehabilitation.

Example 3: Ms. Z.

Ms. Z. is a 42-year-old Black woman who had been drinking heavily for over 20 years. She was referred for psychological evaluation because staff members were concerned about homicidal ideation concerning her husband. Ms. Z. said that she was very angry at him because he made sexual overtures to her daugh- ter. The client was herself a victim of incest. During the evaluation, it became clear that the client was stuck in the protest stage of grief. She had not ac- cepted the idea that drinking was a problem for her, and she rejected the notion that she had given up al- cohol by admitting herself into a treatment program. She said that she was in treatment only to increase her chances of getting custody of her daughter. She viewed alcohol as a lifetime friend who would always be available.

I decided to follow Ms. Z. in brief psychotherapy designed to confront her denial of having a problem that amounted to alcoholism. Another goal was to in- crease her motivation for maintaining sobriety, for ex- ample, custody of her daughter. Throughout her stay in the treatment center, Ms. Z. protested and resented any attempts to get her to relinquish her affection for alcohol. She insisted that she enjoyed drinking and had a right to drink. She reminisced about her drink- ing days often.

As time passed, Ms. Z. grew to accept the idea that she was an alcoholic, but she continued to protest re- habilitation. Eventually, her longings and wishes for alcohol overwhelmed her and she started smuggling beer into the treatment facility. When this was discov- ered she was discharged.

Ms. Z.‘s failure was largely due to an inability to move from protest (Stage 1) to acceptance of her loss (Stage 2). On hindsight, it was clear to this author that the difficulty the client had relinquishing alcohol was contributed to by my failure to realize that she

226 P. S. Jennings

needed to explore the special fondness for alcohol that she repeatedly owned. Also, her fears about being without alcohol needed to be acknowledged. She was as distressed by the loss of alcohol as the infant is by the loss of mother during the period of separation anxiety. Failure to realize that her protest and anxiety was this profound and basic represents an empathic failure.

CONCLUSIONS

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Brenner, C. (1982). The mind in confhct. Madison, CT: Interna- tional Universities Press,

Bugen, L.-A. (1977). Human grief, a model for prediction and in- tervention. American Journal of Orthopsychiatry, 47, 196-206.

Chatlos, C. (1987). Crack: What you should know about the cocaine epidemic. New York: Perigee Books.

Coleman, S. (1980). Incomplete mourning and addict/family trans- actions. National Institute of Drug Abuse Monograph, 30, 83-89.

Denny, G.M., &Lee, L.J. (1984). Grief work with substance abus- ers. Journal of Substance Abuse Treatment, 1, 249-254.

Extein, I., Dackis, C.A., & Pottash, A.L.C. (1986). Depression in

The three case examples have important implications for the treatment of substance abuse. The mourning experiences of these women influenced their adapta- tion to the treatment center. In two of the cases, brief psychotherapy proved to be very helpful in moving them through the initial stages of their grief reaction. This in turn freed them to advance through the reha- bilitation program. It should be noted that the author observed similar mourning reactions in male clients that were seen for psychological evaluation. However, the males tended not to follow through with brief psy- chotherapy recommendations. Thus, female clients provided the richest data source.

drug addicts and alcoholics. In I. Extein & M.S. Gold (Eds.), Medical mimics of psychiatric disorders (pp. 131-162). Progress in Psychiatry Series. Washington, DC: American Psychiatric Press.

Freud, S. (1957). Mourning and melancholia. In J. Strachey (Ed. and Trans.), The standard edition of the completepsychologi- cal works of Sigmund Freud (Vol. 19, pp. 243-258). London: Hogarth Press. (Original work published 1917.)

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Khantzian, E.J., & Khantzian, N. (1984). Cocaine addiction: Is there a psychological predisposition? Psychiatric Annals, 14, 753-759.

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Mishne, J. (1986). Clinical work with adolescents. New York: The Free Press.

The case vignettes clarify the affective significance of the loss of drugs. Drugs and alcohol played an im- portant role in the clients’ lives. Typically, they started using drugs and drinking when they were in early adolescence. Only one of the clients focused on the loss of loved ones during the mourning process, and she did so to the exclusion of drugs. This was viewed as a displacement in that the features of her mourn- ing, shock, and disbelief are most understandable when one considers that they pertained to a recent loss. The only recent loss that she had experienced was drug surrender. The absence of drugs was alarming, shocking, and, in the case of Ms. F., unacceptable. Understanding the meaning of this loss and the need to grieve it is critical to an effective and empathic psy- chotherapy/counseling relationship with recovering persons.

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Nunes, E., & Rosecan, J. (1987). Human neurobiology of cocaine. In H. Spitz & J. Rosecan (Eds.), Cocaine abuse (pp. 48-94). New York: Brunner/Mazel.

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Skolnick, V. (1979). The addictions as pathological mourning: An attempt at restitution of early losses. American Journal of Psy- chotherapy, 33, 281-289.

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