Clients recovering from substance abuse face many obstacles. Patient barriers often include feeling overwhelmed as unresolved losses emerge once the numbing effect of drugs has been removed. We know clients get high to medicate the pain of current and past losses. However, as addiction treatment professionals, we can best help clients deal with grief by being aware of the types of losses clients grieve. Through awareness, counselors can develop skills to help clients successfully release and cope with their pain.

Losses addicted clients experience include:
* Giving up alcohol and drugs. For most clients, alcohol and other drugs have been their constant companion. Many clients have discovered that spouses will leave you, bosses will fire you, relatives will refuse to accept your phone calls, but the drugs are always there. Many will be unable to let the drugs go until they mourn the loss of the absence of the drug.
* Abortion, miscarriages, and stillborn births. Everyone recognizes the pain that accompanies the loss of a child. Few recognize the pain that accompanies the loss of a fetus or a baby who dies in utero or during childbirth. These tragedies are equally as devastating. In such cases, rarely is there ever a funeral, sympathy, or cards of condolence. There are many women in addiction treatment who have had numerous miscarriages, some exacerbated by their drug use. The shame they suffer is tremendous and often they are left to grieve their loss alone, unbeknownst to their counselors.
* Death of a child. Perhaps the most difficult of all losses to grieve. Most people, including counselors, struggle to address this issue.
* Death of a parent or sibling.
* Losses the client links to his/her drug use. In a group therapy session, a client stated that he owed his drug dealer money. The drug dealer went to his house to collect the debt. The client's younger brother, who physically resembled the client, answered the door and was shot and killed by the drug dealer. As shocking as the client's story was, the most powerful aspect of the group was the fact that four other clients mentioned that they felt their addictions had contributed to the deaths of others. All the clients indicated that they never previously discussed this in treatment and considered this to be a major cause of previous relapses.
* Parental abandonment. Melody Beattie and John Bradshaw established clear links in their writings in the late 1980s between parental abandonment, toxic shame, and addiction (Beattie, 1987; Bradshaw, 1988). More recently, Jean Kinney (2000) shed new light this association. Although the abandonment occurred in childhood, the lingering pain may still need to be worked out in counseling. Bradshaw's writing suggests that many clients drink alcohol to bury the feelings of toxic shame, which are caused by abandonment (Bradshaw, 1987).
* Having children placed in the child welfare system due to parental addiction.
* Separation, divorce, and failed relationships. Many people who have experienced divorce describe it as being closely akin to death. Addiction increases the risk of separation and divorce. According to John Jung, alcoholism increases the rates of divorce. Jung indicates that as per capita consumption increases by an average of one liter, divorce rates increase 20 percent (Jung, 2001). In addition to divorce, many addicted clients have patterns of entering into unhealthy relationships. They often choose partners who are emotionally unavailable or who abandon them. This pattern replicates early childhood abandonment (Sanders, 2001). In the book, Stage II Recovery: Life Beyond Addiction (1985), Earnie Larsen divides recovery into two stages. The goal of stage one is learning to stay sober one day at a time. The primary goal of stage two recovery is learning to make relationships work. It can take our clients many years to learn to have healthy relationships. Many bring a track record of failed relationships, apathy, and unresolved grief around relationships with them into treatment. Many have given up on people and seek companionship with the next pill, fix, hit, or drink. This is an ongoing issue for counselors to be concerned with, as many addicted clients who are married end up getting divorced when they become sober.

* Unspeakable/violent deaths. These are losses that are difficult to discuss and grieve because they carry a great deal of stigma in our society. Clients may have had relatives or friends who have committed suicide, died of drug overdoses, died from AIDS, or were murdered. Because of the stigma, many clients suffer these losses in silence.
* Ambivalent deaths. These are deaths that occur among individuals the client has love for, but also a great deal of anger and rage. Examples include the death of a parent or other relative who abused the client as a child. This type of loss is often difficult to grieve, because of the client's ambivalent feelings about the deceased.
* Death of a pet. This loss may be viewed by many as trivial, however, loss of a pet can be a significant source of pain.
* Sexual abuse. Research reveals that the majority of women who are chemically dependent were either sexually abused as girls or raped as women (Straussner and Brown, 2002). This trauma robs girls and women of innocence, dignity, self-esteem, choice, and control of their bodies. Many will suffer an internal death, although they continue to live externally.
* Loss of job, status, and career.
* Loss of housing/shelter.
* Loss of true friends. Many clients call those whom they spend time with during active addiction "associates." Distant are those whom clients call "true friends." These are relationships that have fallen apart as the addiction progressed. Although rarely expressed, many clients mourn the loss of these relationships.
* Firsthand death experience. Clients who have been in wars or those living in neighborhoods where there is extreme violence have most likely witnessed death firsthand. Others have seen people die of drug overdose or violence in crack houses. Many will have actual or symptoms of PTSD, including flashbacks and nightmares, which may need to be worked through along with their addiction.

An assessment tool
There is a long, unwritten legacy in the field of addiction treatment which suggests that clients should leave all other problems at the door until they have dealt with their addiction first. As the field matures, we are discovering that many clients cannot recover unless they are able to simultaneously address a number of their problems. Grief is often one of these problems, as acute pain around losses seems to resurface as soon as clients stop using.

Chart 1 is a 14-question inventory that counselors can use to identify losses recovering clients have suffered. It is helpful to begin asking these questions after rapport has been established. If the client answers "yes" to any of these questions, ask additional questions for elaboration. Since losses are often difficult to talk about, the questions range from those that are often easiest to discuss to those that are often most difficult.

Healing begins as the questions from the inventory allow individuals to verbalize feelings around their losses (Kolf, 1999). Counselors should recognize the significance of this. For some clients, this may be the first time they openly discuss some of the losses.

The basics
The following is a list of basic general skills addictions counselors should possess in order to assist clients with their grief:

* The ability to cope with personal losses. It is imperative that addiction treatment professionals effectively cope with issues surrounding their own personal losses. A counselor's inability to handle the pain of their own loss often keeps them from effectively addressing their clients' issues.
* An awareness of and ability to explore multiple aspects of a client's life. Many clients have suffered numerous losses, ranging from miscarriages to the death of an elderly parent.
* Knowledge of the fact that each client's grief reaction is uniquely different (James & Friedman, 1998). In the groundbreaking book, On Death and Dying (1969), Elisabeth Kubler-Ross outlines the stages of grief (denial, anger, bargaining, depression, acceptance). It is significant to note that not all clients go through each stage, nor do they all go through the stages in order. Some are simply angry as a result of the loss; others stay depressed. It is important to recognize that grief is individualized. At the same time, it is almost universally true that talking to a nonjudgmental and compassionate person about the loss can be helpful.
* Recognition of the healing power of simply listening. There is no doubt it is tremendously beneficial to have clients tell the stories of their losses (Kolf, 1999).
* Working knowledge of sexual trauma and the skills needed to help clients deal with such losses.
* An understanding of the relationship between relapse and loss. A counselor should possess the ability to make concrete suggestions to help clients strengthen their recovery plans when they experience loss (see sidebar "Specific Interventions for Bereaved Clients").
* Realization that issues surrounding previous losses can resurface at anniversaries. Counselors need to have the ability to process upcoming anniversaries with clients. This can be instrumental in preventing any relapses.
* Recognition that tragedies occurring in society can trigger grief reactions. Counselors should be aware that events such as 9/11, plane crashes, and catastrophic disasters profiled in the media will trigger feelings about past losses for clients in recovery. Counselors should be prepared to discuss their clients' reactions.
* Acknowledgment that grief issues may need to be discussed in individual, group, as well as family therapy.
* The ability to assist clients dealing with the death of a peer in treatment.
* Appreciation of the importance of counselor punctuality in therapy sessions. Many clients have experienced loss in the form of abandonment. Constant counselor tardiness for sessions may be perceived by clients as abandonment.
* Acknowledgment of the importance of a positive counselor/client termination. A positive termination can be the most beneficial aspect of the therapeutic experience for clients. This may be the first time that some clients have had the opportunity to deal with a loss or separation without denial, fleeing, or using drugs. This process can be initiated with the counselor bringing up the issue of termination after treatment goals have been met and asking the client, "How do you think things will be when we are no longer meeting?"

Over the course of the last 20 years, as a counselor to substance abusing clients, I have observed clients passing through a number of phases before totally accepting termination. These phases are denial, anger, sadness, reminiscing, and acceptance. Since the termination process can be difficult for clients, Gerald Corey (Theory and Practice of Counseling and Psychotherapy, 2000) suggests that this phase of therapy be handled with care and that it can often take a great deal of time. The five phases that clients go through include:

1. Denial. If the counseling relationship is significant to the client, the client may not want the relationship to end. A natural tendency may be to deny the ending. Clients do this by changing the subject, laughing, regressing (behaving similarly to the way they behaved in the early stages of treatment). Examples of regression include identifying new problems to be solved, creating new crises, spending time with former drinking associates, missing appointments without calling, arriving late, etc., all in response to the termination (the message to the counselor is, "I can't handle termination"). The counselor needs to be very patient with the client in this phase, as the termination may bring up issues for the client around previous losses. The counselor should periodically bring up the fact that the client will be terminating soon. This can gradually decrease denial. If the counselor sees early signs of regression, he or she should let the client know that this is a normal response to termination by simply stating, "You really made a great deal of progress in therapy, and your current behavior (i.e., regression) often occurs in response to a discussion of termination." This can be instrumental in helping the client stay on track.

2. Anger. As denial decreases, anger emerges naturally. The client may feel that the counselor is terminating because he/she is somehow disappointing the counselor or that the counselor doesn't like him/her. Clients are most vulnerable during this phase of the termination process. Some may decide to relapse or prematurely end the counseling relationship. The message the client sends is, "I will leave the counselor before the counselor leaves me." The counselor should avoid "sugar-coating" the client's feelings and allow the client to openly express his/her anger. It is also helpful for the counselor to normalize the client's feelings by stating, "It is really normal to get upset when it is time for termination."

3. Sadness. As anger subsides, sadness often emerges. Counselors can be most helpful here in allowing the client to express his/her sad feelings.

4. Reminiscing. Similar to what adults do at their high school reunions, a sign that termination is going well is when clients start to reminisce about various phases of their counseling work. They may begin to talk about what they were like when they began treatment, laugh about the past, and express positive feelings about their current circumstances. This leads to acceptance of the termination.

5. Acceptance. During this final phase, the counselor and client say their final good-byes. They often discuss progress the client made in treatment, work yet to be accomplished, the client's plans to maintain recovery in the future, and what it was like to work together in the counseling relationship. It is often helpful for the counselor to let the client know that services are available should he/she need them in the future. It is also helpful for the counselor to let the client know that he/she sincerely believes the client has what it takes to succeed in life (if the counselor believes this). When the termination stage of counseling is handled well, clients leave with the belief that they can build other relationships in the future without fearing the end (loss) of the relationship before it begins.

Remembering with less pain
Many counselors believe that if you discuss losses with clients, you "open up a can of worms." For many of our clients, the can is already open, and unresolved issues around grief make it difficult for many of them to lead sober lives. Other counselors may think, "I will go ahead and discuss the losses with the client, so he or she will get over them and forget about them." There is a saying written by an anonymous author, "Grief is not about forgetting. It is about remembering with less pain." As counselors help clients uncover and discuss their losses, the clients gradually learn to deal with the losses with less pain - freeing them up to lead sober and happier lives.

Chart 1
Assessment Tool for Identifying Losses
1. Have you ever been laid off from a job?
2. Have you ever been fired from a job?
3. Have you ever been evicted from a home or an apartment?
4. Have you ever lost a pet?
5. Has anyone died in your extended family (aunt, uncle, cousin, etc.? Who died? When? What were the circumstances? How did you cope with the death?
6. Has a close friend or significant other died? Who died? When? What were the circumstances of the death? How did you cope with the death?
7. Have you ever had a stillborn baby or a miscarriage? Do you continue to have thoughts about this loss?
8. Were you reared by both parents? How available were they to you while you were growing up? (If the client was not reared by either parent, you can discuss his/her feelings about this. If one parent was absent, it's often helpful to discuss the impact of this loss.)
9. Have you ever witnessed the death of someone?
10. Have you ever experienced divorce, separation, or the break-up of a significant relationship?
11. Have you experienced any other losses that felt almost as powerful as a death (loss of a long-term relationship, loss of a career due to injury, discontinuing associations with long-term drinking associates, etc.)?
12. Do you feel anger, sadness, depression, or guilt over any of the losses you have suffered? If yes, please explain.
13. Have you experienced any losses during active addiction for which you were unable to participate in grief rituals, i.e., funerals, wakes, other services?
14. Of the losses you have suffered, are there some that have been more difficult for you to grieve? Is the pain still with you? How do you cope with the pain?

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