Addiction and the Five Stages of Grief

By Regina Walker 06/19/16

Denial, anger, bargaining, depression and acceptance. Sound familiar?

Addiction and the Five Stages of Grief
Could this model be applicable to substance abuse?

In 1969, Swiss psychiatrist Elisabeth Kübler-Ross introduced a five-stage model of grieving in her book On Death and Dying. Dr. Kübler-Ross asserted that the terminally ill, as well as survivors of the death of a loved one, cycle through a series of emotions until they reach final resolution of the loss. Those five stages included denial, anger, bargaining, depression, and acceptance. 

Though Dr. Kübler-Ross was to say later in her career that she felt she’d allowed her initial theory to be misunderstood, and that the stages did not necessarily follow a linear and predictable progression, she did believe they were common experiences shared by many, whether experiencing an intimate loss of a loved one, or facing a terminal diagnosis.

Denial is identified as the first reaction. Both the individual and the loved one may believe that somehow the diagnosis is wrong. Perhaps they go for second and third opinions in the hope that their suspicion is correct. Anger commences when denial can no longer be sustained. The anger can be directed at anyone including those close, the illness itself, or God.

Bargaining is the stage at which the individual attempts to make changes in the hope that the illness will be lifted. For example, the individual vows to eat healthier or be a kinder person in exchange for the alleviation of the diagnosis. A family member may ask God to spare the loved one and take him/her instead.

Depression follows when it becomes clear that the end is inevitable. The individual despairs and may become withdrawn and deeply sad. Acceptance is considered the final stage, in which the individual or loved one accepts their inevitable fate, and reaches an emotional homeostasis, or balance. Kübler-Ross, notably, believed that it was important for those dying to be able to take care of emotional “unfinished business,” and was an early supporter of the hospice care movement.

These stages are not written in stone, and an individual can return to previous stages or skip over other ones. For all its shortcomings, the five stages theory remains an approximate but useful model for working with the dying and their families.

But could this model be applicable to substance abuse?

Denial is a well-known aspect of addiction. Oftentimes both family and the individual will convince themselves that there is no problem with alcohol or drugs or, at least, the problem is not a significant one and certainly not out of control. Frequently, those around the addict will move past the denial stage prior to the addicted individual.

Anger enters when the addict realizes that he/she has a problem. The anger may manifest because the addict is upset that he can no longer use drugs, or it may be fear (masked as anger) because she wants to stop using but finds herself unable to. Anger for the addict can be self-directed. It can also be directed at loved ones and even at the world at large, as a result of the addict’s increasing inability to deny that a problem exists.

Bargaining often enters the picture when the addict is trying to please someone else or perhaps get out of trouble. The addict may promise loved ones that he will stop using in hopes of gaining some type of needed support (money or a place to live). The addict may bargain to get out of trouble such as agreeing to attend treatment so as to lessen legal consequences. The addict may be fully cognizant that there is a significant problem, but may not be ready or willing to make any changes to resolve the problem directly. Bargaining may also take the form of convincing oneself that it’s possible to use drugs or alcohol moderately—an attempt to see addictive behaviors as harmless or sustainable when they’re not.

Depression sets in when the addict comes to terms with the fact that he/she must now live their life without his or her drug of choice. Depression is common in the withdrawal stage (brain research now provides evidence that in the withdrawal stage and for a period of time afterward, there are physical reasons for the depression and “numbness” many newly sober people experience) and is often exacerbated by the addict’s reflection on, and feelings of guilt or remorse over, all the damage done by his/her substance abuse.

The Acceptance stage is not necessarily when the addict admits to a problem. The admission of a problem can often happen much earlier on—most addicts know they have a problem long before they take assertive action to address it. Acceptance is the time when the addict admits there is a problem and takes action to change the situation. This stage, for the addict, is focused on resolution of the problem and is very much an action stage, in contrast to the common perception that the acceptance stage for the terminally ill is one of passive acceptance.

An addict can go through these stages more than once (after a relapse, for example) or never come to a resolution point at all (many die as a result of their addiction) but these stages offer a useful model in identifying the trajectory of the addiction and assisting the addict and loved ones in understanding the process. 

For example, a sober individual can reenter the Bargaining stage even after many years of abstinence. Thoughts such as “I can control it now,” “Heroin was my real problem so I can have a few drinks now and then,” or “I will never touch vodka again but I can handle beer and wine” can be warning signs to impending relapse. Knowledge of this can be quite useful, so interventions such as reality testing can be employed and relapse averted. 

The stages also can be applicable to those close to the addict. Though the experience is different, many loved ones cycle through similar emotional states while attempting to process the addiction of a loved one. 

Anger at the addict for continuing to use despite negative consequences is common. Also, loved ones may be angry at addiction in general, lack of adequate services, or alcohol advertising, etc. In the case of parents, some may blame (internalized anger) themselves for the addict’s condition. Depression can be the feeling of absolute hopelessness and helplessness over the ability to impact the addict’s condition and despair over what fate lies ahead for the addict. This type of suffering is exacerbated by the lack of control the loved one has over the situation and the inability to provide help.

Acceptance for the loved one can be the understanding that the addict has not made the decision to get clean, and the loved one is able to accept this (let go of the situation) and move on with his/her own life with a sense of resolution—no longer attempting to control or be controlled by the addict.

Finally, addiction often makes addicts absent from their own lives. While actively using, real-life events like deaths, destruction of important relationships, as well as medical issues—both those caused and not caused by the addiction—are left un-dealt with. Once sober, the addict may go through the grieving process over losses, sometime years old, as if they had just occurred. The awareness that unresolved losses need to be addressed—and the ability to accept those losses, as well as the understanding that help can be found in doing so—can be useful for the addict and assist in avoiding relapse.

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