"Ask not for whom the bells toll;
they toll for thee"
Kadmon-Telias, A. (2001). Psychodrama and helplessness in the helper of addicts.
International Journal of Psychosocial Rehabilitation. 5, 111-134
The psychotherapeutic process in general implies situations and interactions in which the transference and countertransference dynamics, have a very deep impact in the "helper", the therapist and in the "helped", the patient. The therapeutic relationship with addicts often brings forth much more powerful feelings of helplessness in countertransference.
Addicts usually are multi-traumatized individuals with unresolved losses in their clinical history, who grew up from dysfunctional families (Triffleman et al, 1995), and they pour into the therapeutic encounters a much more demanding relationship than other types of patients with mental disorders usually do. The addict has frequently suffered from a traumatic event such as processes of immigration and other such existential losses; the death of a parent; the divorce or repeated divorce of a parent or of him/herself; physical, emotional and/or sexual abuse (Jarvis and Copeland, 1997). This distorted development has decreased their adaptive abilities to the stresses of life (Elder, 1990). The losses have been dealt with, unsuccessfully, by using alcohol and other drugs to numb the pain (Nash, 1990).
Another source of worries for the therapists is the fact that the life span of addicts is thought to be shorter than the life span of non-addicts (Risser and Schneider, 1994). The possibility of a fatality occurring while under treatment has been found to be statistically high. The mortality rate of addicts found by Frischer et al, (1997) in a longitudinal study from 1982 to 1994 was 1.8% per year.
Therapists who deal with addicts in the process of weaning and becoming ex-addicts, and with co-dependents family relatives, may be confronted with situations of loss, much more frequently than therapists dealing with neurotics or psychotic patients.
Repeatedly during my professional experience I have been confronted with situations of loss, either of loss of my patients, or the children of my patients, or patients of other therapists. Sometimes my addicted patients would die from overdose, suicide, accident or assassination; sometimes the children of co-dependent parents who were attending my "tough-love" meetings or participating in other kinds of programs aimed at treating family dysfunction, would die, and the question should be raised whether the children did not die as a consequence of the parents applying incorrectly, in a "double message" way, what they learned with me in the therapeutic process of detachment. Sometimes, colleagues who had suffered the loss of a patient, revived once again in me feelings of guilt, shame, rage, helplessness, depression and loss of self esteem.
Grief, mourning and bereavement are the psychological reactions of those who survive a significant loss. Grief is the subjective feeling elicited by the death of a loved one, the term is used interchangeably with mourning, although strictu sensu mourning is the process by which grief is resolved. Bereavement means the state of being deprived of someone by death, and refers to being in the state of mourning (Kaplan and Saddock, 1997).
Many other therapists, like me, have learned to "cope" with death and bereavement in front of the family in mourning, the therapeutic group in grief and the rest of the staff, with scared silence.
- II - The Therapeutic Relationship: Dynamics of Transference and Countertransference in Death and Bereavement.
Transference is the patientís displacement onto the analyst of early wishes and feelings toward other people. Just as patients project transferential attitudes to therapist-patient relationships, therapists themselves also have countertransferential reactions to their patients. Countertransference may take the form of negative feelings that are disruptive to the therapist-patient relationship, but may also encompass disproportionately positive, idealizing or even eroticized reactions (Kaplan and Saddock, 1997). The term countertransference has been given various meanings that may be summarized by the statement that for some authors countertransference includes everything that arises in the analyst as psychological response to the analysand, whereas for others not all this should be called countertransference (Racker, 1996).
As Viney (1994) states, when clients come to psychotherapy they are distressed, this distress usually being expressed in the form of anxiety, hostility, depression and helplessness. In addition to this, addicts come to treatment with a sensation of an "objectal loss" from a psychoanalytic perspective, and tend to believe that it is the function of the therapist to fill the place left by the lost object (Vera Ocampo, 1988).
The substance abuser has a self-destructive behavior (Galanter and Castanceda, 1985). Suicidal (self-destructive) patients place a special burden on the therapist and attack him/her, using the therapist as a "selfobject", an object that regulates the patientís narcissistic equilibrium (Milch, 1990). This tendency to projective identification is part of the transferential process in the addict.
The role addicts thus project onto the therapeutic relationship contributes to the feeling of helplessness often seen in helpers, and specially in therapists who work with addicts.
- III - The Concept of Helplessness: Theoretical Considerations
Helpers, like most people, encounter aversive and stressful events that can have a major impact in the course and direction of their lives. They and those they love may be confronted with a disabling accident, serious illness, death or violent crime. Several authors have recognized the detrimental effects that exposure to stressful life events may have on the individualís mental health, functioning, and adjustment as well as the importance of personality factors that determine the reactions to these events.(Abramson, Garber, & Seligman, 1980; Lazarus & Folkman, 1984; Peterson & Seligman,1984; Bandura, 1986).
After those bad events people tend to ask themselves:" Why did it happen?". "Who is responsible?" "What caused the event?" "Will it always be like this?" Abramson, Seligman and Teasdale (1978) contend that people have fairly habitual ways of explaining the causes of stressful events, which make up their own "attributional/explanatory style" consisting of three dimensions: 1) locus of causality, 2) stability and 3) globality. 1) Locus of causality refers to whether the person assigns an internal or external cause to the event. 2) Stability refers to whether the reason for the event is a transitory or a more or less permanent factor. 3) Globality refers to whether the reason given applies only to the specific event in question or extends to other events as well.
According to this theory, the attributional/explanatory style plays an important role in determining our reactions to negative, aversive uncontrollable life events. Each of the three attributional dimensions has its own impact on the individualís reaction to stress situations and explain how and why do people respond and cope with bad events. Internal attribution for failure ("Itís me") is associated with loss of self-esteem and depressive symptoms (Klein, Fencil-Morse and Seligman, 1976; Beck, 1976; Rizley, 1978; Bowlby, 1982; Weiner, 1986; Higgins, 1987;). The more internal the attribution, the greater the reduction in self-esteem and the stronger the depressive symptoms after failure. Stable attribution ("Itís going to last forever") affects the chronicity (duration) of the depressive symptoms and problems in functioning that may follow failure (Mikulincer,1988). The more stable the explanation, the more persistent the symptoms . Globality ("Itís going to last forever") affects the generalization of the problems in functioning that follow (Mikulincer & Nizan,1988). The more the stressful event is explained by global causes, the broader the impact of the event on the individualís functioning and adjustment.
An attributional style in which bad events are explained by internal, stable and global causes is not only associated with depressive symptoms but also with learned helplessness. This phenomenon has been described as the end result of a process in which an organism learns to believe that outcomes are uncontrollable and independent of its responses (Seligman, 1975). Experiencing uncontrollable bad events has been found, in people with learned helplessness, to cause cognitive, motivational and emotional deficits, which are generalized to new situations even when uncontrollability no longer exists (Abramson, Seligman,& Teasdale,1978; Seligman, Klein, & Miller,1976). The learned helplessness phenomenon has strong parallels with depression in humans. Causal attributions about life events are a risk factor for depression, and the central prediction is that individuals who have an "attributional/explanatory style" that invokes internal, stable and global causes for bad events, tend to become more depressed, have more problems in functioning and more signs of maladjustment when bad events occur than someone who tends to explain the same event by external, unstable and specific causes (Metalsky et al, 1982; Peterson & Seligman,1984).
A research literature review shows that there are at least three means through which explanatory style may be acquired: first, vicariously: one may learn it by imitating parents, particularly the mother, the primary care-giver in our society (Seligman et al, 1984); second, one may learn from the type of criticisms leveled by teachers following failure (Dweck and Licht, 1980); third, the reality of oneís first traumatic loss plays an important role in setting explanatory style: for a young girl the motherís death may represent a stable and global loss which causes an underscored helplessness, which in turn will cause her, as an adult, to impose internal, stable and global explanations on other bad events, rendering her vulnerable to depression (Brown and Harris, 1978).
- IV - Helplessness in the Helper: Needs and Conflicts.
The attribution of personal helplessness in any helper and in the addictís therapist in particular, implies the development of a subjective perception and expectation that nothing he/she can do will help solve the problems of his/her patient/patients. Those who treat the survivors of crisis, trauma and PTSD: social workers, nurses and doctors, not only often develop the helplessness syndrome described above, but also become extremely psychologically vulnerable themselves, and fall victims to secondary traumatic stress disorder (Figley.1995). Although it is a well documented fact that not everybody who undergoes a traumatic event develops a PTSD (March, 1990); direct evidence for the importance of subjective perception is provided by studies demonstrating that cognitive perception of low controllability (Frye and Stockton, 1982; Mikulincer and Solomon, 1988) exacerbate the risk of PTSD or its course.
The planning of a treatment program must take into consideration different needs which provoke conflicts in the helper, in the family, in the therapeutic group and in the staff, keeping in mind that death and loss may suddenly enter the scene.
- Needs and conflicts of the helper.
Close and prolonged work with trauma can have serious psychological consequences for the professionals beside the perception and feeling of helplessness, and can include anxiety, intrusive thoughts, alienation, dissociative episodes, paranoia, hypervigilance, and disrupted personal relationships (Blair and Ramones,1996). Despite this, the therapist has to coordinate the overall intervention in the treatment program and be involved in a controlled fashion with the social service requirements confronting death and trauma. The helper must also take a pragmatic and responsible approach to the case. The fainthearted will find himself in dire straits in this field.
From my professional experience I have learned that the roles of the therapist coping with death and bereavement in general and in the treatment of addictions in particular, are multiple. He/she has to confront the family, the group, the staff, the law, the bureaucratic organization (police, social security, insurance etc.), and, worst of all, has to confront powerful negative countertransference reactions. The therapist must know how to balance the issues of control and affiliation. The helper must feel comfortable with the appropriate use of authority when needed, without losing sight that a therapeutic relationship is essential.
The death of a patient is perceived as a failure by any therapists, from whom there are inner and outer expectations of omnipotence (Menninger, 1958; Greenson, 1972). This kind of failure is difficult to accept by any of us.
- Needs and conflicts of the mourning family.
The direct or indirect impact of trauma on other family members besides the index sufferer is another issue that requires ongoing assessment. Trauma does not occur in a vacuum, and often a number of family members may be similarly traumatized. Even when family members are not directly victimized, the indirect effects on them may be severe (Turnbull and McFarlane, 1996). The treatment of grief and loss needs to be extended to all family members.
As professionals we should be continually interested in the long-term outcome of the family. Sometimes we prefer not to know, because we want to have as little to do with some of these families as possible. However, this type of countertransference negates our therapeutic effectiveness, and maintaining an active and long-term interest may demonstrate our personal interest and responsibility to these families. We cannot let the mourning families drift away no matter how passive or active their aggressiontoward us may be, because we failed to fulfill the expectationsof omnipotence they had from the helper.
-Needs and conflicts of the therapeutic group of addicts.
Addicted patients are characterized by a clinical history of traumatic unresolved losses in their lives. The losses have been dealt with unsuccessfully by using alcohol and other drugs to numb the pain. As they engage in the treatment process, these patients perceive another very important loss: that of their preferred addictive substance. When the group also suffers the loss of some member, and most particularly when the loss is caused by sudden death, the grieving process may become unbearable, and the new situation must be immediately dealt with using a crisis intervention approach (Niekirk, 1987; Elder, 1990).
Discussions on the role of self-disclosure of the group conductor during times of personal crisis have been mostly confined to the theoretical. Little clinical material has been published. This lack contributes further to the sense of loneliness of the therapist facing the therapeutic group, and the helperís uncertainty in terms of how to provide adequate intervention to the group of patients while protecting him/herself at a time of great vulnerability (Kahn, 1987, Vamos, 1993).
- Needs and conflicts of the staff.
Being a helper entails its own particular hazards, and the staff reactions to death and bereavement are exacerbated by administrative incompetence to deal with it, and the staffís own countertransference issues (Cooper, 1995). Crothers (1995), examining the projections of vicarious traumatization on the helpers, found that during the first 6 months of working with survivors of trauma, staff may experience post-traumatic stress disorder, imagery associated with the patientís story, lack of attention, poor work performance, medication errors, sick calls, treatment errors, irreverence, hypervigilance, and somatic complaints. Our fellow therapists often place a heavy burden on us due to their doubts about us having intervened the best we could, or because we intervene differently from what they usually do, or because we are not capable of realizing that there may be some other options in this complex treatment field of addictions. It can result in personal and professional isolation that we should try to avoid.
- V - Helping the Helpless Helper to Cope with Death and Bereavement in the Treatment of Addictions.
The goal of the therapeutic process in general and in the treatment of addictions is to promote change. Change, whether it is good, or bad, is a bit like dying. There is pain in letting go of the familiar. There are feelings of disorientation and confusion experienced by each of us whenever we strike off into the unknown and the unexpected. Experiencing migration, the death of a family member, divorce, losing a job, or any irreversible process elicits mourning reactions. Therapists interventions in the field of addictions are aimed at radically changing the patientís life-style, as in cessation of drug and alcohol use, which trigger the grief and loss response. When the process of change from the slavery of drug addiction toward a future of freedom is halted by the sudden death of a family member, a patient of the therapeutic group or any significant other, the stages of grief and loss follow a predictable pattern: denial, anger, bargaining, depression and acceptance (Kubler-Ross,1969; 1975).
It is difficult to "stay alive" in the area of treatment, when death and bereavement sometimes make us fail and where we are seldom fed by positive outcomes, by the success of our clients, but where we rather have to feed all the time. Preparing a therapist for the possibility of a sudden encounter with death, should be part of the conventional training, but it rarely is.
No matter what therapeutic technique is applied in facing the needs of the helpless helper, we have to give him/her the legitimization that grief is a normal and highly personal reaction to loss. Bereavement care (individual and/or groupal) can assist the family, the group, the staff, and the helper him/herself, in coping with the feelings of grief, thereby reducing the possibility of complicated grief reaction.
The expression of grief encompasses a wide range of emotions, depending on cultural norms and expectations. Some cultures encourage and even demand an intense display of emotions, through acting out (for example Mediterranean cultures), whereas other cultures (for example the most Northern) expect the opposite (acting in, "being cool"). Working with grief is a complex psychological process of withdrawing attachment and working through the pain of death and loss.
Grief may be normal, or it may be pathological (Stoudemire, 1990). Normal (uncomplicated) grief is initially manifested as a state of shock that may be expressed as a feeling of numbness and a sense of bewilderment, feelings of weakness, decreased appetite, difficulty in concentrating and sleep disturbances. Self reproach is common. Survivors guilt occurs in those who are relieved that someone else than themselves has died. Abnormal (pathological) grief can range from inexistent or delayed grief to excessively intense, prolonged grief, or grief associated with suicidal ideation or with psychotic symptoms. For Freud (1917), normal grief results from the withdrawal of the libido from its attachment to the loss object, while in abnormal grief the lost object is not given up but incorporated in the survivorís psyche as an object infused with negative feelings
Identification with the deceased is normal, but overidentification is a pathological process.
Table 1 - Models of grief, mourning and bereavement stages.
|By John Bowlby
(Grief and Bereavement)
|By C.M. Parkes
(Grief and Bereavement)
|By E. Kubler-Ross
Reactions of dying patients)
- Numbness or protest
Characterized by distress, fear
And anger. Shock may last for
moments, days or months.
2 - Yearning and searching
3 - Disorganization and Despair
4 - Reorganization
A stressful state characterized
by physiological changes, e.g.
Rise in blood pressure and heart
rate, similar to Bowlbyís first stage.
2 Ė Numbness
3 - Pining (Searching)
4 Ė Depression
5 - Recovery & Reorganization
- Shock and denial
Patientís initial reaction is shock,
followed by denial that anything
is wrong. Some patients never pass
beyond this state and may go
doctor shopping until they find
one who supports their position.
2 - Anger
3 - Bargaining
4 - Depression
5 - Acceptance
Other theoretical models also exist (Imara, 1983, Speck, 1978) to deal with the bereavement process, the above mentioned are only some of the most useful.
Different kinds of death cause different reactions in the mourners. The context in which death occurs greatly influences the way the family, the group, the staff and helpers experience the process(Devan,1993).
For instance, people may experience death as timely or untimely: timely (anticipatory), when a personís expected survival and actual life span are approximately equal; and untimely, when a personís death is unexpected or premature.
The Kubler-Ross model is more suitable in coping with timely death, while the reactions caused by untimely sudden death are better understood and handled by the models described by Bowlby and by Parkes (see above).
Death can also be thought of as intentional (suicide), unintentional (trauma or disease), and subintentional (substance abuse, alcohol dependence). Death may have multiple psychological meanings for the dying person in a timely terminal illness, or for the related others, or for society in general.
Specific sets of circumstances cause specific grief reactions. For example, a) parentsí reactions after the death of a child. The death of a child is often a more emotionally intense situation than the death of a parent. Feelings of guilt and helplessness in parents may be overwhelming. They may believe that somehow they did not protect their children adequately. The inversion of the natural order of parents dying before their offsprings may manifest in lifetime grief. b) Bereavement in children is similar to adults once the child can understand the irrevocability of death. According to Bowlby (1969), the mourning process, like separation, involves the three phases of: 1) protest; 2) despair; and 3) detachment. In the protest phase the child has a strong desire for the caretaker who died and cries for his/her return; in the despair phase, the child feels hopeless about the return of the caretaker, and becomes withdrawn and apathetic; in the detachment phase, the child relinquishes some of the emotional attachment to the dead caretaker, and shows renewed interest in the surroundings.
Grief sometimes occurs in situations not related to death, and it may be triggered by: 1) the loss of a loved one through separation, divorce or incarceration; 2) the loss of an emotionally charged object or circumstance, e.g., loss of a prized possession or a valued job or position; 3) the loss of a fantasized love object, e.g., death of intrauterine fetus, birth of a malformed infant; and 4) the loss resulting from narcissistic injury, e.g., amputation, mastectomy.
Grief is different from depression in that: 1) as the loss becomes remote, the grief-stricken person usually shows shifts of mood from sadness to a normal state and finds increasing enjoyment in lifeís experiences, while the mood disturbance in depression is pervasive and unremitting; 2) shame and guilt are common in depression. When they occur in grief, it is usually due to not having done enough for the deceased before his/her death, rather than because of a personís fundamental belief that he/she is wicked or worthless, as usually found in depression; 3) the grief-stricken person usually elicits sympathy, support and consolation from others, while the depressed person usually may irritate and annoy listeners; 4) suicide rate of depressed people is higher than that of people in grief (Brown and Stoudemire, 1983).
People who have experienced depression in the past are likely to develop depression instead of grief at the time of a major loss.
Training the helpers: What works in grief therapy in the treatment of addictions.
There is much literature about how to assist mental health professionals to cope with grief and bereavement they find in the course of their professional lives, either when they suffer it by themselves, or when they have to assist others to undergo it. Grief therapy is an increasingly important skill in the treatment of addictions (Nash,1990).
The main "dos" and "doníts" are common to other populations as well, and are different for coping with timely and untimely death (based on Feifel, 1977; Parkes, 1970; Siegel, 1982):
Donít deter the bereaved from crying or getting angry;
Do allow the grieving person to hear other people talking about the deceased;
Donít cope with anxiety by medical prescriptions on a regular basis, but with verbal exchange;
Do visit the bereaved person frequently for short periods instead of few long visits;
Do pay attention to delayed bereavement reactions, which may be particularly
Retention in treatment is the most important single factor in the success of the treatment of addictions, therefore, a therapy which may produce the abandonment of treatment by the addict will have a low success rate(Rounsaville et. al.,1987, Hansen et al., 1990). Long-term psychoanalytic psychotherapy is generally difficult to implement with addicts, because they often lack the necessary constancy to continue in treatment for a long time. Therefore shorter forms of psychotherapy, both individual and groupal, have been advocated for the treatment of addictions, and those forms are also useful to deal with the grief which may accompany those patients.
Specifically the individual grief therapist of the chemically dependent or co- dependent family, must encourage the patient to confront life in an autonomous fashion, without developing a situation of symbiosis. The therapist must dare to treat intense reactions of sorrow, anger, guilt and self-abasement (Richman, 1978).
Among the many forms of individual shorter-term psychotherapies which could be used for the treatment of grief, we are going to mention (Ursano and Silberman, 1988):
2. - Time-limited- psychotherapy (Mann), a psychotherapeutic model based on exactly 12 interviews, focusing on a specified central issue, which could be grief. Mann considered determining a patientís central conflict reasonably correct. He did not determine excluding criteria for his form of therapy, but his exceptions for acceptability include major depressive disorder (grief is not a major depressive disorder), acute psychotic states, and patients who need, but cannot tolerate, object relations.
3. - Short-term Dynamic psychotherapy (Davanloo, McGill University), which, as conducted by Davanloo, encompasses nearly all varieties of brief psychotherapy and crisis intervention. Davanloosí selection criteria emphasize the evaluation of those ego functions of primary importance to psychotherapeutic work: the establishment of a psychotherapeutic focus (for example: psychological reactions to death and loss); the psychotherapeutic formulation of the patientís problems; the ability to have emotional interaction with evaluators; the history of give-and-take relationships with a significant person in patientís life; the ability to experience and tolerate anxiety, guilt, and depression; patientís motivation for change; the patientís ability to respond to interpretation and to link evaluators with people in the present and pass. Those characteristics make this particular form of therapy adequate for the treatment of loss and grief.
4. - Short-Term Anxiety-Provoking psychotherapy (Sifneos, Harvard University). Sifneo established the following criteria for selection: a circumscribed chief complaint (implying a patientís ability to select one of a variety of problems to be given top priority, and the patientís desire to resolve the problem in treatment); one meaningful or give-and-take relationship during early childhood, the ability to interact flexibly with an evaluator and to express feelings appropriately; above-average psychological sophistication (implying not only above-average intelligence, but also an ability to respond to interpretation); a specific psychodynamic formulation; a contract between therapist and patient to work on the specified focus (grief, mourning and bereavement), and the formulation of minimal expectations of outcome, and good-to-excellent motivation for change and not just for symptom relief.
5. - Interpersonal psychotherapy (Myrna Weissman & Gerald Klerman) is specifically used to treat depressive disorders (e.g. pathological grief). Patients are taught to realistically evaluate their interactions with others and to become aware of their deliberate self-isolation, which contributes to or aggravates the depression they complain about. Studies have shown that in selected cases, interpersonal therapy compares favorably with drug therapy that uses antidepressant medication.
Groupal grief therapy has proved to be one of the most effective and important tools we can put at the therapistís disposal, in coping with the needs and conflicts of themselves, the mourning family, the therapeutic group and the staff. Different modalities of group psychotherapy are applied in the treatment of grief, mourning and bereavement. Short-term group psychotherapy; psychoeducational-support groups; and self-help groups, can assist family members in coping with death and losses, thereby reducing the possibility of complicated grief reactions.
Specifically in the treatment of grief, Lieberman and Yalom (1992) tested the hypotheses that 1) brief group psychotherapy during the early stages of loss would facilitate adjustment assessed by measures of mental health, positive psychological states, social role and mourning, and 2) that positive effects would be maximized for subjects who were more distressed psychologically. Although group participants, compared with untreated controls, did over 1 year show modest improvement on role functioning and positive psychological states, overall the study failed to find substantial support for both theories.
When we refer to group psychotherapies, we have to take into consideration that the goals of group psychotherapy are: Alleviation of symptoms, change of interpersonal relationships, and alteration of specific family-couple dynamics. Group psychotherapies can also be used for the treatment of grief and loss.
According to Vinogradov and Yalom (1988), inclusion criteria for group psychotherapy are:
- Ability to perform the group task;
- Problem areas compatible with goals of group;
- Motivation to change;
while exclusion criteria for group psychotherapy are:
- Marked incompatibility with group norms for acceptable behavior;
- Inability to tolerate group setting;
- Severe incompatibility with one or more of the other members;
- Tendency to assume deviant role
Among the groupal forms of psychotherapy which can also be adapted for the treatment of death and loss, we can mention (Kaplan and Saddock, 1997):
2. - Analytically Oriented Group psychotherapy, mostly used for the treatment of anxiety disorders, borderline states and personality disorders, with communication contents aimed at present and past life situations, intra- and extra-group relationships, and with the goal of a moderate reconstruction of personality dynamics after experiencing death and loss ;
3. - Psychoanalysis of Groups, designed for the treatment of anxiety and personality disorders and aiming at the extensive reconstruction of personality dynamics. This form of therapy is usually too long for the treatment of grief;
4. - Transactional Group therapy, aimed at treating anxiety and psychotic disorders, this form of therapy fosters positive relationships and analyzes negative feelings. The end goal of the treatment is alteration of behavior through mechanisms of conscious control which can be achieved, on the one hand, by giving legitimization to the "inner child" in the bereaved, and on the other hand by the acceptance of reality and by empowerment; through the transactions with the "adult" and the "parent" projected in the "here and now", in the intragroup dynamics.
5. - Behavioral Group therapy, although mostly used for the treatment of phobias, passivity, and sexual problems, can also be used to modify the external behavior related to grief. In this form of therapy, the action of the therapist is to create new defenses, active and directive;
6. and other forms of specific interventions for determinate populations, like the Balint groups (Rabinowitz, Kushnir and Ribak, 1994 and 1996), aimed at improving the situation of medical and para-medical staff. Balint groups are aimed at preventing burnout and increase self-efficacy among health professionals. This intervention has shown significant increases in awareness and ability cognitions after the Balint group and reduced emotional exhaustion and cognitive weariness. Balint groups that have helped health professionals to cope with psychosocial stressors in a supporting and accepting group atmosphere should be included in educational programs for social workers in general and substance addiction therapists in particular.
Grief management techniques advocated by other authors include:
2. - Short-term focused interventions, which were found ineffective and misleading, because a sizable proportion of patients with pathologic grief will be unresponsive to treatment (Rynearson, 1987);
3. - Grief counseling for complicated (pathological) grief (Devan, 1993), a combination of intervention techniques which includes grief counseling, brief dynamic psychotherapy, group psychotherapy and family work. The therapist is encouraged to provide empathic approach, active listening, encouragement of verbal expressions of affect, permission to grieve, but to maintain therapeutic neutrality.
4. - Psychodrama, a method of group psychotherapy originated
by the Viennese-born psychiatrist Jacob Moreno in which personality makeup,
interpersonal relationships, conflicts and emotional problems are explored
by means of specific dramatic methods (Moreno, 1947; Kipper, 1992). The
dramatical dimensions of psychotherapy have been explored by several authors
that propose that role playing is in fact the metaphor on which psychotherapy
bases itself. "Believing in make believe", perhaps offers a more appropriate
fit than individual and groupal approaches(MacCormack,1997). Although much
has been written about psychodrama as a therapeutic and educational method
with patients, there is little evidence of itís inclusion in training programs
for professional clinicians. Costa and Walsh (1992) describe how the basic
elements, phases and techniques of psychodrama have been used with groups
of health workers to improve their clinical performance and personal life.
Psychodrama as therapeutic approach, has important applications in helping
staff come to terms with the emotional stresses that characterize the work
of a helper. Didactic psychodrama is a powerful action learning method
that can be successfully employed in the mental health field (Goble,1990).
Among the many approaches in which therapists and helpers could be trained
for dealing with grief in therapy, we are going to concentrate on the psychodramatic
When an addict abandons his/her addiction, a feeling of loss is elicited. If this feeling is accompanied by the death of a significant other, a helper, or a member of the therapeutic group, grief is much more intense. When this process occurs while in treatment, the psychological reactions of grief, mourning and bereavement, are extended to the family, the therapeutic group, the staff and the helper.
The use of psychodramatic techniques for dealing with grief may provide effective and fast relief for everybody involved (the helper, the group, the mourning family, the staff). Psychodrama can also be used to improve the teaching of other skills to helpers: to facilitate information gathering, diagnostic decision-making, and treatment planning and implementation, like in staff training groups designed to teach about the inner world of adolescence. ( Pisa and Lukens,1975; DeCann and Hegarty, 1987Holmes, 1988;),
- A PSYCHODRAMATIC TRAINING MODEL FOR THERAPISTS COPING WITH ADDICTION AND DEATH.
Addiction treatment professionals are a unique blend of recovering and non-recovering, college and "school of hard knocks" graduates. In spite of this diversity, or perhaps because of it, a camaraderie usually develops within the staff in most therapeutic milieus, which creates a basic ground favorable to the implementation of psychodrama. The rationale behind a training seminar is that it can lead addictions programs and helpers to be more effective if a "common language of treatment" is shared; if the staff members come to know each other as individuals and network their own particular expertise; conflicts and needs in general and feelings of helplessness in coping with loss and grief, in particular, in a psychodramatic intervention.
The following proposed model is based on two personal experiences: a training seminar for substance abuse therapists which took place in Pittsburgh, and my participation in the workshop on psychodrama of the course "Death and Bereavement", for which I am writing this paper. This psychodramatic model is aimed to cope with the holistic needs and conflicts linked to the feelings of helplessness in the helper, after death and loss.
At the opening phase of such a seminar, as a "starter," each participant would write two obituaries: the first one as she or he would like it to appear if she or he were to suddenly die that day; the second one announcing the sudden death of a member of the therapeutic group. The following step is sharing the obituaries with the participants, while walking with the director(the trainer, the therapist) around the room (the stage). From my past experience in one such seminar I attended in Pittsburgh, I would expect sharing obituaries with the group to be easier for some than for others. In that occasion one therapist, "P", shared he had suppressed an impulse to write a "bit of fluff" about being remembered for his smile. He instead shared his uncertainty about his lifeís accomplishments and his desire to be remembered through his poetry. His simple yet elegant words touched each of us that day. On the other hand, when he shared the obituary of one of his patients who, in the past, while in treatment, went back to drugs and died from overdose; strong countertransference feelings of guilt, anger, helplessness, and fear of self disclosure aroused, in him. The "starter", writing the obituaries, assisted in the "warm-up" process, and triggered the "act hunger" in the "audience", the group of addiction treatment helpers; while the "barriers" of fear of punishment ,depressed the need for action in "P", "the protagonist". The director suggested him, a psychodramatic exploration of feelings. Reluctantly, he agreed, and the biochemical-psychological process of "warm-up" continued. "P" and the director walked around the stage area, and engaged in a "soliloquy" about his buried feelings of shame, guilt and fear of being thought weak and a failed professional. When the director sensed that the anxiety level and the "barriers" that halted the internal sources in "P," went down, he moved to the second phase of the psychodramatic training model.
The second phase- the "action" stage: The possibility of individuals to act, enables us to express our abilities and feelings, and experience self-control. The psychodramatic enactment permits "spontaneity" and "creativity", basic concepts in Morenoís conception. Psychodrama, by its very action oriented nature, allows a complete therapeutic exploration of issues that characterize the addictionís field: unresolved losses, death, guilt and grief. The treatment process is perceived as a grieving process where the addict loses the drug, the most trusted friend and ally; a social role in the peer group, and a life style (Niekrik,1987). The therapist of addicts is in fact performing grief therapy which is inherent to the change process in which the chemically dependent patient is involved and which triggers the response pattern predicted by Kubler-Ross: D.A.B.D.A.: denial, anger, bargaining, depression, and acceptance. The bereavement process stages sound as follows:
Denial: "This canít be happening" or "Itís just not true". At this initial phase of recovery the addict refuses to give up his\her belief system and a distorted perception of reality. When the family, the group and the staff have to cope with death, they feel this same gut reaction: denial.
Anger: "Why me God?" "Why did this awful thing happen to destroy my life?" The anger is expressed in the recovering addict, by demanding that the staff grants privileges and by acting-out devaluating the program, the staff and the peers. After the death of a patient, the group, the family and the staff may displace their anger onto the helper, whom they blame for the loss; while the helper is also experiencing anger and displacing it on himself.
Bargaining: May express itself as a sudden religious fervor. Bargaining grievers talk to God and promise to "clean up their acts": "Iíll quit heroin forever if you take my craving away", will cry the addict. After the sudden death of an addict, some people eliminates this stage and the grief process lasts longer. Others go through a stage of bargaining by justifying the self-destructive behavior of the deceased who was a victim and undoubtedly will be accepted in Heavens. Others have to be given enough time to get out of the state of denial and anger. The therapist must help the group, the staff and himself /herself to "finish unfinished businesses" before admitting, "This is really happening".
Depression: Once the bargaining stage "dies", the patient experiences sadness, withdrawal, delayed reaction time, hopelessness and suicidal thoughts. The addictís response in this stage of the recovery process, is characterized by emotional, cognitive and behavioral deficits, typical to a reactive depression. The mourning family, after the "unexpected" , will remain in the stage of denial and anger, long before reaching this stage. The group, the staff and the helper, will first mourn past losses; they will experience their own death anxiety; and guilt feelings, that will prepare the ground for depression (Yalom and Lieberman, 1991).
Acceptance: "This is really happening." "It really has happened". Addicts who achieve acceptance of sobriety hold no regrets about the prospect of never using again. The mourning family has to be given indefinite time to accept the sudden death of the loved one; years of working through the grief may be needed. In most therapeutic milieus for addictions, the group, the staff and the helper will fortunately try to reach the acceptance stage, through "The Serenity Prayer:
To accept the things I cannot change;
Courage to change the things I can;
And the wisdom to know the difference."
The role of psychodrama in the training of the helpers to deal with grief in the addicts and in their close vicinity must take into consideration that the process of grief generated by the loss of the preferred addictive substance and the one generated by the loss of a significant other, have a very similar basis and development. Knowing how to deal with one will certainly help to deal with the other. Therefore, it is our contention that teaching psychodramatic technique to therapists is important and should be encouraged.
Psychodrama is a group psychotherapy approach originated by Jacob Moreno, in which personality makeup, interpersonal relationships, conflicts, and emotional problems are explored by means of special dramatic methods. The goal of the technique is to cause a catharsis with the possibility to get rid of our internal conflicts, at the same time transforming them into positive elements through reframing.
The following are the essentials of psychodrama which any therapist treating addicts and grief in addicts should learn in a training seminar:
A) - The basic therapeutic elements required for the dramatization of emotional problems are:
2) -Creativity: which is always linked to spontaneity.
3) -Barriers: which halt our internal sources. Those barriers are called in the professional world "defense mechanisms".
4) - Act hunger: because generally, our barriers do not depress our need for action.
5) - Warm up: a biochemical and psychological process which prepares us to enter in action. This process was attributed great importance by Moreno in the development of spontaneous and creative processes.
6) - Starters: are physical and mental processes, generally related to one another, which assist in the warm-up process. Starters may be physical (walking, breathing, talking, etc..) or mental (psychological, like hopes, initiatives, anxiety, etc.; or social, like social values, social requirements, group criteria, etc.).
7) - Cultural conserve: which is the result of all the creative production of the individual and of the society.
8) - Roles: According to Moreno, each individual interprets, since birth, dozens of different roles. Those roles appear even before the process of individuation, and accompany the individual all through his (her) life. There are three categories of roles: Somatic (related to physical action); Psychodramatic (related to fantasy, imagination and the unconscious); and Social (general roles, not personal, related to social and cultural agreements, like "mother", "son", "the teacher").
9) - Encounter: a dialogue between two persons in which both of them try to accept the other. Those encounters, to be effective, require spontaneity and creativity. According to Moreno, in order to promote encounters, it is important that people can assume the role of the other (role reversal).
10) - Group (or Audience): A group in which participants share at least one common criterion. Topics or problems are open by participants in turn, and the director, and other members of the group, help him/her convert the subject into an experience, assisting him in the development, and creating an atmosphere of warmth and security.
11) - Action: Although action itself is not one of the objectives of the psychodramatic process, "action" had a central role in the interpretation by Moreno of "self" and "society".
12) - Empathy, Tele and Transference - These three linked concepts are an integral part of Morenoís theoretical infrastructure (Rabson, 1979). According to Moreno, there is a difference between empathy and transference and the phenomenon he calls "Tele". He defined "Tele" as a process of feeling in which one, two or more persons may participate. It is the experience of some real factor in the other person and not a subjective fiction. Tele is the basis for intuition and insight. It grows out of person-to-person and person-to-object contacts from the birth level on and gradually develops the sense for interpersonal relationships.
13) - Social atom: This has been defined as "the smallest living social unit". The concept is developed from the telic process, and, according to Moreno, it is the basis for society. According to his conception, society is composed of a network of social atoms, which are activated by positive or negative telic relationships. The social atom inside us is like the "object relations" we internalized from our past experiences with significant others. After death and loss the intra - balance of the social atom is disrupted, and can be regained after the process of grief, mourning and bereavement.
14) - Here and now : The protagonist is asked to experience the past or the future as though it were happening now.
15) - Corrective emotional experience : The term, created by Franz Alexander, refers to the situation in which the analytic situation assist patients to modify the results of traumatic events in their past life. Patients are able to master past traumas and grow from their experiences due to the positive emotional involvement with a supportive and trustworthy therapist, (or a group or audience) (Kaplan and Saddock, 1998).
16) - Catharsis: Morenoís concept of catharsis is integrative
rather than abreactive. In this kind of catharsis the protagonistís own
self has an opportunity to find and reorganize itself, putting together
the elements which may have been left apart by insidious forces, to integrate
them and to attain a sense of power and relief (Rabson, 1979). Catharsis
is the first stage toward transformation.
1. - Acting out : Psychodrama does not encourage the simple acting out of impulses and feelings, it rather aims at a form of controlled acting out.
2. - Search pattern : Is the human tendency to fill the emptiness created inside us after a loss. Each individual has his own "search pattern". The "addictís search pattern" is drug addiction.
4) - Auxiliary ego: It is everybody who participates in psychodrama, except the director, assisting the protagonist to process his case. The auxiliary ego relates simultaneously to the three pillars of psychodrama: the protagonist, the group and the director.
5) - The group (or Audience): In psychodramatic work there are two ways of relating to the group: in one, the group and its problems are at the center; in the other, the group is secondary to the protagonist and his (her) psychodramatic activity.
D) - Some common psychodramatic techniques are (Artzi, 1994):
2) - The mirror : An auxiliary ego who presents the behavior of the protagonist, while he/she steps out of the scene to observe. In this way the protagonist is able to see how he/she appears to others, reflected in the mirror of the perceptions of the group members.
3) - Role reversal (De-role): By this basic technique the participant represents something or somebody not himself. The protagonist represents the characters or objects related to his subject, and the auxiliary egos represent the same characters, or the protagonist.
4) - Soliloquy : This technique is performed by the protagonist, and it is usually used when the protagonist becomes very anxious and falls into a compulsive defensive action.
5) - Empty chair: This is one of the most famous and popular of the psychodramatic techniques. It is related with our natural need for role reversal.
6) -Role playing: This technique relates to non-apparent aspects of behavior or social mechanisms, and has been adopted by many other therapeutic schools.
7) - Non-verbal techniques : May be used in psychodrama for group warm-up, or as part of the activity of the protagonist. They may also be used as a part of the work-up of physical problems.
Since it is estimated that the number of psychodramatic techniques range between 200 and 300, including closure techniques which allow protagonists and group members to enter the sharing phase of the psychodramatic process, we should recommend to refer to Treadwell, Stein and Kumar (1990) for more details on some of the techniques.
We must always remember that the population of our patients, as stated before, suffers from severe loss caused by the disengagement with their favorite substance, and to that loss we must sometimes add the one caused by the untimely decease of some significant one.
The process of grief caused by the disengagement from the drug may cause the patient to rationalize that the second grief he experiences, the one caused by the loss of a significant one, is an excellent reason to return to the drugs. As the patient struggles with feelings of deprivation and grief caused by the loss of the substance, he/she is also feeling other losses: the loss of the addictive drug style, the loss of the peer group, of the pseudo-omnipotent self-image.
The enactment of the conflict, through psychodramatic techniques, allows to achieve a level of spontaneity in which the familiar "story" of the addictive period of his/her life falls apart, and the emotional reality of the loss becomes apparent. Often enough, there is an emotional catharsis, shared by the group, in which the protagonist finally permits him/herself to fully experience the loss, without mood-altering substances.
The process of self-forgiveness, necessary to achieve normal levels of functioning and feeling, after a severe loss with the consequent guilt and shame feelings, may be achieved, or at least started, by the technique of role-reversal. Only an addict who has forgiven him/herself can remain abstinent for a lengthy period.
The final act of the process of grief is usually dramatized by the protagonist "letting go" of the loss object. The physical enactment of the separation, e.g. by the protagonist accompanying the lost object to the tomb, or similar symbolism, opens the way for a more stable recovery from addiction.
Immediately after this dramatization, "the sharing" of the feelings with the group, and the physical warmth with which the group receives the protagonist, is essential to ensure a rapid emotional recovery after the psychodramatic experience. This "sharing" also has the secondary purpose of allowing each group member to relate to the central theme of the dramatization, a theme which, as mentioned before, usually emanates from the group as a whole, and not only from the protagonist.
In my personal experience, having undergone this process with the group in class, I can attest for the importance of offering every therapist, and not only the protagonist, the opportunity to work with his/her own grief and loss.
I came to the group in a difficult moment of my life, both professionally and personally. Just before the beginning of the group activities, I had suffered the loss of a very dear colleague, an ex-addict, who had been my patient. I had also had to accompany the families of two addicts who had died very untimely. Those families had been in my treatment, learning the principles of "Tough Love", and nobody could tell whether the (incorrect) application of Tough Love techniques on the part of the families had been responsible for the deaths of the addicts.
My own son had undergone a serious cardiac problem and had been hospitalized in an emergency cardiac unit, a fact which had elicited in me very intense fear and anticipation of loss.
The moment I started participating in the dramatic studies group, I was suffering from anger in front of the losses, of guilt and of shame, unable to find out what my role had really been in the causation of all those losses. I had already left behind the stage of denial
I was asking myself, as mentioned before about other people with loss, Why me?. I had been trying to bargain with God, promising to do this and that if only things would stop happening to me. I had not (and I am not sure whether I have now) reached the stage of acceptance.
Even after the dramatization of my plights in class, it has taken me more than a year to reach the stage in which I can function more or less normally in relation with those deaths. I have been paralyzed by the grief during all this period.
At the same time, I had to fulfill many roles for the others. I had to be the "good enough mother" for my other patients, their families, and my staff. I had to provide comfort and support for everybody else, but I myself could not even talk about my feelings, due to my fears: fear of having failed to cause in the co-dependent families the change that will permit them the correct application of the "Tough Love" approach ; fear of not having been sufficiently present in the difficult moments; fear of not having done enough for everybody; fear of being accused by others of not having been professionally good enough, or personally good enough; irrational fears, but natural fears.
I also felt helpless, |I could do nothing good enough for the others. I "knew" that everything was my fault, it should always be so, and nothing I did could change the new reality. Having had no resources where to vent my anguish, my grief, my anger, my fears, I was blessed by the opportunity to do that during the course. Other therapists are not so fortunate. The creation of some instrument where helpers could receive the kind of assistance I received is imperative, and I strongly recommend the creation of training seminars to learn how to cope with the needs and conflicts elicited in the helper after a sudden death , through a psychodramatic intervention.
Writing this paper has been a process of personal exploration. I wanted, among others, to explore my internal processing as I work with death, grief and bereavement. Many therapists start their training early in their family of origin. We soon learn how to cope with losses. We learn how to comfort, soothe, listen, hold, accept and direct others in grief. A therapistís effectiveness is not always correlated with previous personal experience with a similar issue. Our personal maturity and resiliency in coping with aversive events has major impact in our personal reaction and therapeutic intervention. Despite all this, all of us helpers share in the negative hallucination of not wanting to believe what is before our eyes. None of us wants to believe that tragedies we see before our eyes, have actually occurred. We find refuge in denial, blame, anger, and depression.
The actions taken to restore the disrupted psychic equilibrium may be viewed within an operational framework, or an intra-psychic one. The operational framework is more readily inferred from observable features, but the intra-psychic one describes what goes on in the mind of the patient and the therapist. If death and loss will cause in the helper the "subjective perception" that leads to the cognition and expectation of low controllability; which characterizes an "attributional/explanatory style", that explains aversive, bad events by: internal, stable and global causes; the "helplessness syndrome", depression and reduction of self esteem, will be elicited in the helper.
Some therapists, as some patients, can restore their equilibrium faster than others (Abrams, 1989) because reality imposes on us a "forced response", but we need the framework to do so, where the therapist must acknowledge and accept the inevitable feeling of hoplessness losses and mourning patients cause, and be able to cope with them (Libbey, 1989).
Groups for the training of professionals support and assistance with their own personal conflicts, already exit (Aveline,1986). Some of the subjects mentioned earlier have been put to test and found useful, like countertransference, used by Szajnberg (1985) to create: 1)a moment of illusion for the patient; 2) an observational frame of reference for the staff, and to 3)clarify certain intra - staff differences about the patientís therapy. The therapist must also be ready to confront the "addiction to negativity" described by Lane, Hull and Foehrenbach (1991), and to solve his/her countertransference reactions, especially induced by feelings of frustration, rage and helplessness.
All this considerations move us to the conclusion, already enunciated, that especial tools must be created to assist therapists with their feelings of helplessness. Psychodrama, a method of human relations training and psychotherapy ,based on concepts of social interaction as encounter, spontaneity, catharsis and role playing, may be one of the best ways to achieve this goal.
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