Grief and Depression as Factors in Addiction Counseling

Disclaimer:  nothing in this post should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care. 

In his 1916 article¹ titled “Mourning and Melancholia” Sigmund Freud grappled with clarifying the differences between melancholy and mourning.  In his usage melancholy refers to what we would loosely call “depression” and mourning refers to what we would loosely call “grief”. 

In that article he also grappled with the practical implications that arise from clearly differentiating them. 

I read Freud’s article with interest. 

“But why?”, you might wonder. 

To help identify some reasons that I read that article with interest, I ask rhetorically:

1. Do some patients in addiction treatment settings report a history of depression? 
2. Do patients undergoing addiction treatment sometimes report grief as a barrier to, or a side effect of, their personal change process?
3. And can addiction counselors benefit from carefully considering these topics?

Across the decades of my career addressing chronic, complex, and severe addiction illness I have noticed these phenomena and would say “Yes” to all three of those questions.

And I have noticed addiction counselors:

1. Must sort out the real differences between similar symptoms as representative of depression or grief (such as differentiating major depression from an adjustment disorder with depressed mood, and from bereavement);
2. Often need to help the patient navigate the change process while the patient is experiencing something like grief… …over what they now realize they lost due to their active illness, …as they acknowledge some of the positives of their substance use lifestyle they must depart from, …when they consider losing the chemical itself;
3. Commonly face a history of underlying depression that might be active now.

But what, if anything, can we gain from considering this writing by Freud?

“Various clinical forms”

I found it interesting that over 100 years ago Freud voiced a difficulty that is still a caveat today.    About “melancholia” he wrote,

…whose definition fluctuates even in descriptive psychiatry, takes on various clinical forms the grouping together of which into a single unity does not seem to be established with certainty; and some of these forms suggest somatic rather than psychogenic affectations.

• The same could be said of substance use disorders at least insofar as neither mere use nor mere problematic use are the same as alcoholism or addiction illness.
• Even addiction illness itself seems to take on various forms, like a syndrome, rather than always having the same nature in each person when it is present.
• He wonders if some cases are largely biologically based while others may have other origins; likewise there is a wide variability in factors driving the early course of what does eventually become addiction illness.

“The loss of some abstraction”

But he goes on to contrast that by saying “mourning”: 

…is regularly the reaction to the loss of a loved person or to the loss of some abstraction that has taken the place of one, such as one’s country, liberty, an ideal, and so on.

• This shows us a range of possible emotional barriers to recovery – the losses that moving forward might represent. 
• From this we can consider that the shift forward out of active addiction illness could include various kinds of losses and a resulting emotional price for becoming well. 

“Useless or even harmful”

And he is also careful to identify grief experiences that should not be considered a clinical disorder, don’t require clinical help, and that pass on their own. 

Although it involves grave departures from the normal attitude to life, it never occurs to us to refer to it as a pathological condition and to refer it to medical treatment.  We rely on its being overcome after a certain lapse of time, and we look upon any interference with it as useless or even harmful.

• The same could be said of substance use; not all use is disordered use. 
• What are the indicators of disordered use that are not a “use disorder”?
• But this raises an interesting point.  With today’s ultra-high potency substances, the course of addiction illness might be more survivable than simple use. 
  • In this way the topic of “severity” becomes more complicated. 
  • Mere use might be more threatening to a person’s wellbeing than a longstanding pattern of addictive use, depending on the substance, even when they have no substance use disorder.

“Disturbance of self-regard”

Comparing mourning and melancholia, he states,

 The disturbance of self-regard is absent in mourning; but otherwise the features are the same.

• Across my career, in settings and services helping those with high problem complexity, severity, and chronicity SUD’s, “self-regard” is often harder to address than addiction itself.
• Shame.  Existential shame.  The list goes on.      
• Addiction illness often includes this complication of self-regard and it is often a needed focus in addiction counseling, especially in the context of a relational network or family system. 
• Flipping the idea of “disturbance of self-regard” on its head, I wonder, “What is the ego-syntonic way out of addiction?  What new team or new tribe is a natural and positive/supportive fit for the person?”

“The economics of pain”

Concerning mourning he writes:

We should regard it as an appropriate comparison, too, to call the mood of mourning a ‘painful’ one.  We shall probably see the justification for this when we are in a position to give a characterization of the economics of pain.

• The economics of pain brings much to mind from psychology related to understanding the etiology and course of addiction illness:  homeostatic regulation of emotion², cognitive dissonance, attribution theory, possible selves (both hoped for and feared)³, and the lack of effectiveness in stopping use of what would normally be considered overwhelming punishers⁴. 
• My first clinical supervisor and I used the term “Hedonic calculus” as a concept and as a probe to help us better understand. 
  • We collaborated to identify the raw circuitry within, and resulting logic model for, the movement from normal use, into problematic use, and into and across the course of addiction illness generally.⁴ 
  • And in my clinical supervision I was required to build a unique logic model of the hedonic calculus for each case specifically.

“The loved object no longer exists”

Reality-testing has shown that the loved object no longer exists, and it proceeds to demand that all libido shall be withdrawn from its attachments to that object. 

• Here addiction illness differs from mourning.  In treating addiction illness, the object continues to exist.  How so? 
  • One object is the chemical itself.  It continues to exist in the world.  It is viable and available. 
  • And that object (the chemical) is often internalized in the recollection of the person we help.  In that way it can sometimes be difficult to identify a helpful empty space as a point of grounded primacy from which change can proceed and upon which change can continue.  (In this regard the strengths model can be so helpful; “Tell me when the problem does not happen.”) 
• Given the relative permanency of the object, the emotion of the relationship can remain and sit as a latent force.  Even if it is well grieved. 

“What he has lost in him”

This, indeed, might be so even if the patient is aware of the loss which has given rise to his melancholia, but only in the sense that he knows whom he has lost but not what he has lost in him.

• Believe it or not, this makes me think of the family system and building a genogram.  A typical genogram of the family system might show who is in the system and perhaps their individual standing relative to chemical use.
• But this language shows us one could prepare a genogram of the family system noting “what” has been lost, not just the “whom” of the present.   
  • We could diagram the “what” that has been lost inside each family member, each in their own estimation, concerning themselves, the family, the patient, etc.
  • We could diagram the patient’s estimation of each family system member’s related losses. 
  • Thus, the clinician would apprehend a fuller panorama of meaning⁵, rather than merely know “who” is present and who is important. 

“Which has become poor and empty”

Comparing mourning and melancholia, he states,

The melancholic displays something else besides which is lacking in mourning – an extraordinary diminution in his self-regard, and impoverishment of his ego on a grand scale.  In mourning it is the world which has become poor and empty; in melancholia it is the ego itself.

• Here we see a separation of the alcoholic for whom alcohol is a problem, and the one for whom self is a problem.  And of course, some may tell us for them it is both.    
• The alcoholic seeing alcohol as a problem may be making things simple enough and progress well with our without “recovery”. 
• Alternatively, that person may slip, or even progress in the illness – for the lightness of the effect of their estimation of the problem. 
• And my clinical experience has shown me that the patient seeing self as a problem may, in so doing, be intentionally arranging victory or unintentionally arranging their own defeat. 

“A loss in regard to his ego”

And drawing out some results of those differences he states,

The analogy with mourning led us to conclude that he had suffered a loss in regard to an object; what he tells us points to a loss in regard to his ego.

• In this it is simple enough to say that in his formulation mourning comes from loss of the object, while melancholy involves loss concerning ego.
• Addiction professionals helping people move from severe and complex addiction illness to wellbeing may at times need to determine if either of these losses are present, and coach the person served accordingly in navigating the emotions inherent in the journey.

“An object-loss was transformed into an ego-loss”

He expounds libido (roughly equal to “psychic energy”), the ego (roughly equal to “self”), and object in the context of loss: 

But the free libido was not displaced on to another object; it was withdrawn into the ego.  There, however, it was not employed in any unspecified way, but served to establish an identification of the ego with the abandoned object.  Thus the shadow of the object fell upon the ego, and the latter could henceforth be judged by a special agency, as though it were an object, the forsaken object.  In this way an object-loss was transformed into an ego-loss and the conflict between the ego and the loved person into a cleavage between the critical activity of the ego and the ego as altered by identification.

• Does the lost bottle or drink, or lost role they serve, make a clean break? And is that loss well mourned if and as needed? 
• Or does the shadow of the lost object fall upon the ego of the patient in such a way that is experienced as an ego loss and serve as a barrier to recovery, promoting a drink? 
• Does the patient identify with the bottle and in that way prevent change (e.g. superficially stating “I am an alcoholic, what do you expect?”), or face the reality in such a way that promotes change (e.g. “I’ve stopped drinking so many times, please help me.”)? 

Closing Synthesis

Substance use, misuse, and use disorders might each take “various clinical forms”.  Grief might be present, and the patient may not be well served if the addiction counselor holds “the loss of some abstraction” as a category of consideration without relevance and efforts to overlook it.  Addiction counseling may be “useless or even harmful” if applied in the wrong way to the wrong person.  Some people with clinically significant substance use disorders might have a clinically relevant feature in the “disturbance of self-regard”.  If so, that might be relatively more difficult to identify than the use disorder itself.  “The economics of pain” may promote or confound personal progress.  Thus, the addiction counselor might be best served in this regard to privilege the expertise of the patient and have the patient explain what the costs are – for their condition worsening, remaining the same, or getting better.  Just because “the loved object no longer exists” does not mean it is not recalled with affection or longing, even by the family members.  (The related and various positive affections for and negative affections about the object, as well as the object’s various functions in the system, might need to be considered).  The naïve helper might assume the word, idea, or identity of “recovery” per se as a goal are important and that all improvements relative to that are prognostically positive.  The naïve helper might also fail to consider that the patient arriving for services as a hopeful indicator might conceal what the patient “has lost in” self – that they have “become poor and empty” or experienced “a loss in regard to his ego”.  In this way, the addiction counselor may do well to include the moral dimension in their work and consider if “an object-loss was transformed into an ego-loss” – with two practical extensions.  If such a loss is present and not properly addressed, the possibility of fertile reward might be left on the table, making the return to active illness a relief.  And if such a loss is present, holding the possible utility of a recovery identity (and various related personal pathways within such an identity) might serve as a practically helpful existential option.

References

¹ Freud, S.  (1916).  Mourning and Melancholia.

² Solomon, R.L.  (1980).  The Opponent-Process Theory of Acquired Motivation:  The costs of pleasure and the benefits of pain.  American Psychologist.  35(8):  691-712.

³ Dunkel, C., Kelts, D. & Coon, B. (2006).  Possible Selves as Mechanisms of Change in Therapy, in C. Dunkel & J. Kerpelman (Eds.).  Possible Selves: Theory, Research and Application. (pp. 186-204).  Nova Publishers. 

⁴ Kelts, D. & Coon, B.  (1994).  The Acquired Hedonic-Cost Habituation Syndrome:  Conceptualizing the Process of Addictive Self-Destruction.  Unpublished manuscript. 

⁵ Coon, B.  Rescorla is to Pavlov as Semiotics is to Freud.  May 12, 2022.  Recovery Review.