1

Grief and Managing an

Overdose Death

Diane Snyder Cowan, MA, MT-BC, CHPCA

Hospice of the Western Reserve, Inc.

July 27, 2017

2

Diane Snyder Cowan,

Disclosures

• I have no disclosures to report.

3

Planning Committee,

Disclosures AAAP aims to provide educational information that is balanced, independent, objective and free

of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure

information from all planners, faculty and anyone in the position to control content is provided

during the planning process to ensure resolution of any identified conflicts. This disclosure

information is listed below:

The following developers and planning committee members have reported that they have no

commercial relationships relevant to the content of this webinar to disclose: AAAP CME/CPD

Committee Members Dean Krahn, MD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD;

and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, Carol Johnson and Justina Pereira.

All faculty have been advised that any recommendations involving clinical medicine must be

based on evidence that is accepted within the profession of medicine as adequate justification for

their indications and contraindications in the care of patients. All scientific research referred to,

reported, or used in the presentation must conform to the generally accepted standards of

experimental design, data collection, and analysis. The content of this CME activity has been

reviewed and the committee determined the presentation is balanced, independent, and free of

any commercial bias. Speakers must inform the learners if their presentation will include

discussion of unlabeled/investigational use of commercial products.

4

Target Audience

• The overarching goal of PCSS-O is to offer evidence-

based trainings on the safe and effective prescribing of

opioid medications in the treatment of pain and/or opioid

addiction.

• Our focus is to reach providers and/or providers-in-

training from diverse healthcare professions including

physicians, nurses, dentists, physician assistants,

pharmacists, and program administrators.

5

Educational Objectives

• At the conclusion of this activity participants should

be able to:

Define grief, loss and related terms

Discuss common grief reactions resulting from an

overdose death

List three therapeutic approaches for working with

clients grieving a loved one lost to an overdose

death

Discuss self-care strategies to manage cumulative

grief from death of clients

6

“Grieving is as natural as crying when

you are hurt, sleeping when you are tired,

eating when you are hungry, or sneezing

when your nose itches. It is nature’s way

of healing a broken heart.”

- Doug Manning

7

Grief Basics

8

Aspects of Grief

Physical

Cognitive Emotional

Spiritual Behavioral

Social

9

Definitions and Terms

• Grief and mourning

• Anticipatory grief

• Disenfranchised grief

• Cumulative loss

10

Factors Complicating Death

11

Sudden Death

• No opportunity for anticipation

• Unexpected and overwhelming

• Threatens general perceptions of safety

and security

• Emphasis on “WHY”

12

Issues Inherent in

Sudden Death

• Capacity to cope is diminished

• Assumptions about world are violently

shattered

• The loss does not make sense

• No opportunity to say goodbye

13

• Grief symptoms persist

• Obsessively reconstruct events

• Experience profound loss of security

• Secondary losses

• Posttraumatic stress responses

Living With Grief After Sudden Loss Edited by Kenneth J. Doka PhD

Issues Inherent in

Sudden Death

14

Sudden Death

Grief Reactions

• Denial and disbelief

• Disorientation

• Shock

• Confusion and panic

• Struggle to find reason

• Search for answers

15

Grief Reactions with a

Substance Use Disorder Death

• Despair and sadness

• Anger

• Guilt

• Shame

• Blame

• Relief

• Frustration

• Fear and anxiety

• Stigma

• Isolation and loneliness

16

Theories and Approaches

• Four Tasks of Grief (Worden)

• Meaning Making (Niemeyer)

• Dual Process Model (Stroebe and Schut)

• Therapeutic Bereavement Rituals (Rando)

• Trauma Processing Techniques

EFT

EMDR

Breathing techniques

Guided imagery

17

Worden’s Tasks of Grief

Task l - to accept the reality of the loss

(not believing)

Task ll - to process the pain of grief

(not feeling)

Task lll - to adjust to a world without the deceased

(we’ll talk more on this one)

Task lV - to find an enduring connection with the deceased while embarking on a new life

(not moving forward)

(Worden, 2009)

18

Worden’s Task lll

• To adjust to a world without the deceased

External adjustments: living daily without the

person – or not adjusting

Internal adjustments: who am I now? – or not

growing

Spiritual adjustments: reframe assumptive world

– or not understanding

19

Dual Process Model

• Deals with 2 types of stressors

• Loss orientation

• Focuses on the deceased, death events

and losses

• Restoration orientation

• Deals with secondary stressors such as

running a household and finances

(Stroebe and Schut 2008)

20

Loss-

oriented

Intrusion of grief

Breaking bonds

with the deceased

Denial/avoidance

of restoration

changes

Everyday life

experience

Restoration-

oriented

Controlled distraction

Doing new things

Attending to day-to-day

needs

Denial/avoidance

of grief

New roles/identities/

relationships

oscillation

21

“Adaptation to loss involves restoration of

coherence to the narratives of our lives.”

“We construct and reconstruct our identity as

survivors in connection with others.”

“Grieving is the act of affirming or

reconstructing a personal world of meaning that

has

been challenged by loss.”

Meaning Making

- Neimeyer

22

Meaning Making and

Meaning Reconstruction

• Ways to make sense of the death

• Narrative forms: reminiscing, journaling

• Artwork

• Cultural practices, spiritual traditions or

memorials

23

Meaning Making Models

Bereavement Rituals

• Express thoughts and emotions symbolically

• Affirm the death

• Recall the loved one

• Express the mourner’s thoughts and feelings

• Assist in saying good-bye

• Symbolize transition back into life

24

Continuing Bonds

A dynamic bond that shifts and changes over time as

the bereaved adapts to the loss through “negotiating

and renegotiating the meaning of the loss.”

Corr, Nabe & Corr (2009)

This kind of connection, “provided solace, comfort and

support and eased the transition from

the past to the future.”

Klass, Silverman & Nickman (1996)

25

What Can Help Grieving Families

• Accepting the reality of the circumstances of the

death

• Finding healthy ways to acknowledge and

accept feelings

• Not defining the deceased loved one by his or

her addiction

• Educating themselves about addiction

• Finding the right support systems

26

When the Bereaved are

Using or in Treatment

“Addiction is a family disease.”

“One person may use, but the

whole family suffers.”

Shelly Lewis

IdentifyProject.org

12 StepPlant.com

27

Family Issues

• Overprotection

• Enmeshment

• Struggle resolving conflicts

• Extreme rigidness

• Isolation

28

Using to Cope

Emotional Trigger

Use of Substance

“Relief” of emotion

Pain returns

Passage of time

Used with permission from Anna Moreno

29

Options for Support

• When substance use disorder is the

primary condition

• When in treatment/recovery

30

When Healers Grieve

“We cannot heal someone else until we know how to heal ourselves… We start by acknowledging our own woundedness. We enter that woundedness and work through it. By entering that woundedness and working through it, we learn how to heal ourselves and we learn how to assist in the healing of others.”

- Being a Wounded Healer: Douglas Smith

31

Four Essentials

• Rest

• Physical activity

• Healthy eating

• Social connection

32

Self Compassion

• Shift from self judgment to compassion

• Provide active self comfort

• Acknowledge mutual suffering

• Use affirmation

Self Compassion: Kristin Neff

33

Taking Care

Notice tension

Ground yourself

Relaxation techniques

Smile

Breathing exercises

Meditation

Hold position of power

Massage

Yoga

Integrative therapies

34

References

• Corr, C.A., Nabe, C.L. & Corr, D.M. (2009, 6th edition) Death and

Dying, life and living , Belmont, CA: Wadsworth Cengage

Learning.

• Doka, K. (ed) (1996) Hospice Foundation of America. Companion

Books for Annual Teleconference: Living With Grief after Sudden

Loss, Bristol, PA, Taylor & Francis.

• Klass, D., Silver, P.R., Nickman, S. (2014, first published 1996),

Continuing bonds: new understandings of grief, Hoboken: Taylor &

Francis.

• Manning, Doug. (2003, 29th ed) Don’t Take Away my Grief, In-

sight Books, Inc., Oklahoma City

• Neff, K. (2013) Self compassion, London: Hodder& Stoughton.

35

References

• Neimeyer, R. (ed.). (2012) Techniques of Grief Therapy: Creative Practices for Counseling the Bereaved. New York, NY: Taylor& Francis.

• Neimeyer, R (2001) Meaning Reconstruction and the Experience of Loss. Washington DC: American Psychological Association

• Rando, T. (ed.). (2000). Clinical Dimensions of Anticipatory Mourning: Theory and Practice in Working with the Dying, Their Loved ones, and their Caregivers. Champaign, Ill: Research Press.

• Worden, J. (2009). Grief Counseling and Grief Therapy: A Handbook for the Mental Healthy Practitioner, (4th ed). New York: Springer Publishing.

• Smith, D. (1999). Being a Wounded Healer, Psycho-Spiritual Publications (1999).

• Stroebe, M.S., Hansson R.O., Schut, H. & Stroebe,W. (eds). (2008). Handbook of Bereavement Research and Practice. Washington DC, American Psychological Association.

36

PCSS-O Colleague Support Program

and PCSS Discussion Forum • PCSS-O Colleague Support Program is designed to offer general information to health

professionals seeking guidance in their clinical practice in prescribing opioid

medications.

• PCSS-O Mentors comprise a national network of trained providers with expertise in

addiction medicine/psychiatry and pain management.

• Our mentoring approach allows every mentor/mentee relationship to be unique and

catered to the specific needs of both parties.

• The mentoring program is available at no cost to providers.

• PCSS Discussion Forum: A resource that provides an “Expert of the Month” who will

answer questions about educational content that has been presented through PCSS

projects. To join, register here: http://pcss.invisionzone.com/register

For more information on requesting or becoming a mentor visit:

www.pcss-o.org/colleague-support

37

Questions?

38

PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership

with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American

Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of

Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American

Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American

Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and

Southeast Consortium for Substance Abuse Training (SECSAT).

For more information visit: www.pcss-o.org

For questions email: pcss@aaap.org

Twitter: @PCSSProjects

Funding for this initiative was made possible (in part) by grant no. 5H79TI025595-03 from SAMHSA. The views expressed in written conference materials or

publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention

of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.