Grief is more than sadness after a loss. It encompasses a wide range of emotions that come with losing someone or something meaningful. It can include anger, guilt, relief, numbness, and even the unexpected instinct to reach out to someone who is no longer there. These experiences are deeply personal and can be difficult to process without support. But without working through grief, many people find it takes other forms, including substance abuse.
Unresolved grief is a major driver of addiction, and understanding how the two overlap and how grief therapy supports recovery is essential for anyone who is working through both grief and substance use.
What Is Grief?
Grief is the emotional, psychological, and physical reaction one has to a significant loss.[1] While grief is most commonly associated with the death of a loved one, it can also stem from any loss, including the end of a relationship, loss of identity or role, a disability, miscarriage, estrangement from family members, or a major lifestyle change.[2]
Grieving is not considered a disorder. It is a normal reaction to loss, and for the vast majority of people, it resolves naturally through time and support from others without requiring professional intervention.
However, grief becomes clinically significant and a potential driver of substance use when it gets stuck, and the person experiencing it cannot move forward.[3]
Types of Grief
- Acute grief — The initial, intense wave of emotional pain, cognitive disruption, and physical distress that follows a significant loss. Acute grief is intense and consuming but usually fades over time.
- Normal grief — The overall grieving process through which most people adapt to loss over time, coming to terms with the reality and finality of the loss while rebuilding a functioning life. While therapy can be helpful in this stage, normal grief typically does not require formal treatment.
- Complicated grief — A grief reaction that lasts longer than the normal grieving process and deviates significantly from what is considered a typical response, in terms of intensity, duration, or functional impairment. Complicated grief involves intense, prolonged yearning, difficulty accepting the loss, bitterness or anger that does not fade with time, avoidance of reminders, and significant interference with daily life.
- Prolonged grief disorder (PGD) — A medical disorder recognized in the DSM-5, defined as experiencing intense grief following the death of a loved one with a significant level of impairment lasting more than 12 months after the death. PGD is a distinct clinical condition that responds to specific evidence-based treatment.
- Delayed grief — Grief that does not emerge at the time of loss but arises later, sometimes months or years afterward, often triggered by another loss or a significant life transition, creating space for feelings that were suppressed.
- Traumatic grief — Grief following a sudden, violent, or traumatic loss that can include symptoms of PTSD and requires trauma-informed professional support.
Symptoms of Grief
Grief symptoms extend across emotional, cognitive, physical, and behavioral dimensions. Understanding the full range of grief reactions helps explain why unprocessed grief so often finds expression through substance use.
Emotional symptoms include:
- Intense sadness and longing for the lost person or thing
- Anger, either directed at the deceased, at circumstances around the loss, at oneself, or without direction of any kind
- Guilt and self-blame, often irrational
- Anxiety and fear regarding the future
- Numbness and emotional blunting
- Relief, especially following an uncomfortable death or a relationship that ended poorly; often accompanied by secondary guilt
Physical symptoms of grief include:
- Fatigue and physical exhaustion
- Suppressed immunity and an increased chance of being ill
- Sleep problems, including insomnia or hypersomnia (sleeping too much)
- Changes in appetite leading to weight loss or weight gain
- Increased risk of cardiovascular problems, particularly in the period immediately following a major loss
- Physical soreness and somatic complaints without a clear medical cause
Cognitive symptoms include:
- Difficulty concentrating and mental fog
- Intrusive thoughts about the loss
- Disbelief and difficulty accepting the reality of the loss
- Preoccupation with memories of the deceased or lost relationship
Behavioral symptoms include:
- Social withdrawal and isolation
- Avoiding reminders of the loss
- Loss of interest in previously meaningful activities
- In some cases, substance use as a coping strategy
How Unresolved Grief Leads to Substance Abuse
Unresolved grief often can increase vulnerability to mental health conditions and harmful coping behaviors, including substance abuse.[4]
Many people in substance use disorder treatment have experienced losses, some recently and some years ago, that they are still grieving and have never fully processed. In each of these cases, substance use is not an incidental behavior; rather, it was a way to help cope with pain. At least, initially.
Grieving creates very high levels of emotional pain, and most people do not feel prepared to handle that pain, particularly in cultures where it is not permissible to grieve openly or where support systems are underdeveloped. Turning to substance is a way to cope. Alcohol numbs the pain. Opioids quiet the unbearable yearning. Cannabis takes the edge off the intrusive thoughts. In each case, the substance provides relief from grief reactions that feel intolerable. But in doing so, it interrupts the natural grieving process, preventing the emotional work of adapting to the loss.
Delayed grief is particularly relevant in addiction contexts.[5] Many people suppress their grief at the time of the loss and continue to function, only for their unprocessed grief to manifest later as depression, anxiety, or an intensification of substance abuse that appears to have no link to the initial loss. In early recovery, when substance use is stopped, and the person no longer has their primary physiological or emotional tool to cope with the acute emotional pain of the loss, all of the previously unresolved grief will emerge with significant intensity.
Creating an effective grief treatment plan in early recovery must identify the connection between substance use and grief. If a person does not process their grief while being treated for addiction, there is a strong chance they will return to the same behaviors and continue to use substances.
The Stages of Grief and Beyond
Elisabeth Kübler-Ross’s five stages of grief — denial, anger, bargaining, depression, acceptance — remains one of the most widely recognized frameworks for understanding the grieving process.[6]
However, grief research has moved beyond the stage model, recognizing that grief does not occur linearly; the five stages represent typical behaviors experienced throughout the grieving process rather than a defined sequence.
The dual process model, introduced by Stroebe and Schut, is a more broadly applicable model for working with grieving clients: people in grief move between two coping types — loss-oriented grief (actively dealing with and resolving the grieving process) and restoration-oriented grief (addressing practical needs while creating a new life).[7] Healthy grief requires moving between both rather than staying in one or the other. This model is especially important in addiction treatment, as the client must simultaneously grieve and rebuild a new life in recovery.
Evidence-Based Grief Treatment
Complicated Grief Therapy (CGT): Complicated grief therapy (CGT), developed by Katherine Shear at Columbia University, is the gold standard treatment for complicated grief and prolonged grief disorder.[8] CGT integrates cognitive behavioral therapy and motivational interviewing with techniques specifically designed to treat the symptoms of complicated grief, including imagined conversations with the deceased, revisiting the events surrounding the death, and overcoming the barriers to adaptation that distinguish complicated from normal grief. Multiple clinical trials published in JAMA demonstrate that CGT is significantly more effective than standard interpersonal therapy as a treatment for complicated grief.[9]
Cognitive Behavioral Therapy (CBT): CBT for grief focuses on the negative thoughts, cognitive distortions, and avoidance behaviors that continue to feed complicated grief and depression. Cognitive restructuring addresses the self-blame, feelings of guilt, and catastrophic thinking that many people experience while grieving, while behavioral activation gradually re-engages them in meaningful activities.
Traumatic Grief Therapy: For those whose grief involves a traumatic loss, trauma-focused approaches such as EMDR and prolonged exposure therapy are used in conjunction with grief-specific treatments to address both the traumatic and loss-related components of the experience.
Grief Support Groups: Peer support in grief is one of the most powerful forms of therapeutic intervention available. It provides a shared experience of being heard by others who have also experienced loss, reduces feelings of isolation, and creates a community that grief typically destroys. Grief support groups have been incorporated into group therapy programming at All In Solutions.
