I had the opportunity to suggest y own potential study to look at long-term use of drugs or alcohol as a coping mechanism instead of counseling or support.

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The Use of Alcohol and Drugs in Response to Grief and Loss

I am interested in cognitive psychology and the ways that stress, loss or grief may contribute to, or exacerbate, addictive tendencies or behaviors. Behaviors such as alcoholism, drug addiction, emotional eating and other compulsive or addictive behaviors.

Literature Review

In treatment facility websites and blogs, published writings acknowledge that grief and loss are seen as primary factors people have cited as one of the reasons, they began using controlled substances or alcohol as coping mechanisms. Specifically, where they did not feel other options, such as family support or professional counseling, were available, or accepted by their core community. There seems to be a belief still held in parts of this country that men especially do not seek out support groups of counseling. It can be seen as a sign of weakness and there is social pressure, real or perceived, that those who do are not “real men”.

A 2017 study published in Addiction Research & Theory was conducted with individuals who had experienced a death in their family and also reported increased usage of alcohol or drugs (Masferrer, 361-367). This research used a control group that reported not using substances during grief in order to see what correlations there may be. While the data collected was very interesting there was no follow up over time to determine whether those reporting higher usages changed over time.

A 2017 paper by R. Andrew Chambers reviewed the neurobiological overlap found in the chemical and neuron pathways between grief and addictions. (Psychodyn Psychiatry). This study looked at the similarities between the process of attachment pathways that are disrupted during the grieving process, and how the same pathways appear to be present in those trying to end addictions, acknowledging that letting go of any behavior is similar to the grief process. This opens up questions regarding how to better understand the correlation between the two and facilitate better, and more effective treatments, for them.

The article did not report on their own unique data which may have resulted in different findings. The article is also not focused just on addictive behaviors but attachment disruption as well which may affect interpersonal and romantic relationships. An argument could also be made that the authors had a very personal reason for coming to the conclusions they did. As their acknowledgments include a statement that the paper is dedicated to various family members who died as a result of nicotine addiction.

A Hungarian study of ~4400 people, men and women, between the ages of 18-75 over a three-year period, the authors wanted to understand any correlation between the grief / mourning process and the rate of alcohol misuse (Piling, 2012). The researchers not only measured behavior over this period using the Alcohol Use Disorders Identification Test (AUDIT), but also drew from the Hungarostudy Epidemiological Panel Survey (HEP) conducted in 2006. Data collected was analyzed by gender and time of bereavement, and further broken out to account for educational levels. They found that there was an increase in alcohol abuse in this population, and that men were more likely to experience alcohol related problems than women.

Within the Hungarian study the authors do make note that some data may be skewed against the women sample as they mention that: “When interpreting the results, we also have to consider that women might perform differently on tests that require the estimation of alcohol consumption, and might be more likely to hide their alcohol related problems” It also is noted that the original HEP data was collected as part of a government initiative, and while follow up interviews regarding alcohol use was conducted by nurses, the original population were not specifically selected for, or asked about, their alcohol use.

The Hungarian study was participant driven; such participants were culled from a much larger cross-section of the nation’s population. The data analyzed came from approximately 4,500 questionnaires with follow-up that the participants provided. The authors used an ordinal regression model where each gender was analyzed separately before they were combined into overall findings. The Chambers’ paper focuses more on the biological mechanisms and social interactions as a neurological basis for maladaptive behavior such as addiction. As such the paper does not address the specific statistical methods used or how conclusions were arrived at via data review. I see more statistical value in the Hungarian study as it had direct data collection from the participants. While interesting, and given some references worth following up with, the Chambers’ article would not pass statistical scrutiny, in my opinion.

In neither paper were any Conflicts of Interest noted by the authors (APA Standard 3.06), no identifying participant information that would breach their confidentiality (APA Standard 4.01) and no mention of any inducements offered for their assistance in the research (APA Standard 8.06). The Chambers’ paper had no direct contact with individual participants as the Pilling research did. In the case of the Pilling paper the authors note that they did receive approval by the Ethics Committee of the Semmelweis University in Budapest (APA Standard 8.01) and participants did consent to participate (APA Standard 8.02).

In reviewing various articles and websites dedicated to looking at the correlation between substance abuse and loss as a contributing parameter, there are not as many that follow a subject for an extended period of time to ascertain whether the reliance of a substance decreases as a function of time from the date of the event. Conversely, I have not yet found definitive studies that the use of various substances increased over time. I did locate one European study that looked at the amount of alcohol imbibed over time after the death of a family member. I would like to see if the use of other stimulants/depressants are also linked to a person’s loss/grief as a function of time.

When looking at articles published by others, the Alcohol Use Disorders Identification Test (AUDIT) is cited as a tool used when interviewing participants. When reviewing the work done by the World Health Organization (WHO) team that developed the test however I found the wording of the AUDIT to be judgmental and not what I think would pass muster in a study today, taking into consideration that the test was developed in 1993 I was surprised that in 2006 the Hungarian team would still be using it at all. And that calls into question for me whether the data collected was indeed truly representative or under-reported due to the negative connotation in some of the questions.

The previously mentioned Hungarian study (Piling 2012) culled their initial data from a country/region -wide survey called the Hungarostudy Epidemiological Panel Survey (HEP) conducted in 2002. In looking at references to HEP it appears to be an agency funded regular survey open to all residents in Hungary and surrounding countries. It consists of many focus points for the questions asked such as job security, family dynamics, happiness ratings, use of alcohol, reasons for missing work etc. I have seen articles using this data discussing issues such as worker displacement (Brenner, 2014), Pertussis prevalence (Torza, 2017), early maternal separation (Szilvia, 2011) and premature mortality (Kopp, 2011). All of which leads me to conclude that the initial data collected on the 2002 and subsequent 2006 follow up was “cherry picked” for its relevance to the authors’ intent.

The Piling article is a Retrospective Research Design where they looked at prior research conducted by others, with a cross-sectional component. As the original survey asked about a wide variety of life factors it was not specifically written to address the use of alcohol as a means of coping with grief. The Masferrer article also used Retrospective Design to make their conclusions, but they also did make use of a retrospective cohort where findings were compared between alcohol users and non-user so they were able to draw some comparisons.

The downside of using only Retrospective Data is there is no control the researcher can exercise after the fact to verify that prior analysis done align enough with each other to make secondary analysis as robust as might be wished.

Thesis Statement

People process grief and loss in a variety of ways. The mechanisms a person uses to handle their pain are often influenced by factors such as their social, cultural or religious background. One of these mechanisms can be the over use of alcohol, narcotics or prescription medications as a tool to dull or erase the painful or difficult feelings that they associate with the traumatic event. This study will look at whether the use of such substances decreases over time as the feelings around the loss are managed and processed, and do factors such as age, gender, educational level and support system(s) effect levels of usage.

Method

I would like this study to be presented as a simple fact finding one to ascertain how much a day/week people are using controlled substances or alcohol as a function of time and grief. Without presenting any verbiage that could be construed as disapproving I believe more accurate information can be obtained.

Methodology

Preliminary research has confirmed for me that direct participant data points will provide the most accurate information to look at causality between loss and substance abuse and other addictive behaviors. Collecting data points such as age groups, gender and time since the loss along with amount of alcohol, drugs, food etc. are being used to self-sooth will also provide a more focused collection of data points.

I would structure my study to be Prospective Design which will allow for follow up with the participants over several years, ideally at six-month intervals. The study participants could be stratified based on the substance they use most often, this would allow data to be sliced based on chemical(s) used then rolled up into overall findings based on gender, age or other.

Based on the guidelines of Section 2.06 of the APA Manual the study could be described as:

Participants will be asked to participate based on recommendations from either their personal mental health professional, or supervising medical practitioner during their stay at a substance abuse program. Subjects must be at least 18 years old and include a variety of educational levels along with self-identified gender and ethnic classifications. Initial data collection will be in the form of a written questionnaire regarding their grief/loss experience and use of alcohol, prescription and/or other substances. Follow-up contact will be done at six-month intervals with a target of three years total for each subject. To allow for attrition and drop-out rates an initial sample of 800 people is targeted to assure enough robust data is available for analysis.

Research Participants/Sampling Frame

As the study will be looking primarily at those who not only experienced a significant loss or grief event, but are also may be self-medicating with drugs or alcohol, seeking the cooperation of personal mental health professionals who can refer patients for the study, and are well educated on the safe guards that will be put into place to protect the patients from any prosecution, will be vital. Given that not all such referrals will be using alcohol or drugs the inclusion of non-self-medicating patients will allow the study to have a control group and hopefully provide insight into other coping mechanisms employed and if the subject does begin to self-medicate at a later date.

Working with IRBs and with similar guidelines, staff that work with in, and out, patient treatment facilities would be able to identify those who experienced recent loss/grief and would be appropriate to the study. This population may be harder to follow up with and discussions around confidentiality, non-identifying measures for their responses and best methods of private follow up may be slightly more problematic.

As noted in the prior section an ideal cohort of 800 initial responders will hopefully result in at least 500 follow up subjects for the entire three-year period across age, gender, education and preferred self-medication groups.

An additional source of participants might be physicians who have patients that meet certain pre-determined criteria. Perhaps fluctuations in weight, prescribed medications in the aftermath of loss or other blood test results that could indicate the use, or uptick in use, of alcohol or drugs. This would not only require IRB/EC approval from the practice or affiliate hospitals but could place the physician in a very awkward position by asking if their patient would like to participate. This could potentially cause a rift and in the doctor/patient relationship and could be seen as a conflict of interest for the physician.

Data Collection/Instrumentation

The use of marijuana, opiates and the over-use of alcohol and prescription medications can be a very sensitive issue for many people. While alcohol is legal within the United States, and marijuana has become legal in a few States, there is still a social stigma associated with their use beyond what is considered casual use. Being aware of this, the study has been designed to let the participants self-identify initially in relative anonymity.

The questionnaire has been carefully written to remove any judgmental wording or subjective phrasing that should allow the participants to feel more comfortable responding to inquiries about substance(s), usage amount(s), cause of their loss and if they have other options of processing mechanisms such as a therapist, family, support group etc.

Once the participant has been accepted into the study, trained staff will do follow-up interview contact every six months to ask about current usage, support options etc. The participant will only be known to the interviewer by first name and contact number or e-mail. I prefer this type of structured interview as it can be conducted fairly quickly during the follow-ups, and all participants will have the same response options for the researchers to be able to have consistent data for analysis. This collection of quantitative data will either support or disprove the hypothesis, and perhaps support a more in-depth series of case studies in the future.

Protection of Participants

There are potential issues in identifying participants for such a study. One avenue might be to solicit participation from those entered into in-patient treatment facilities after a specific period of time so to allow them some respite and healing before gathering information. This would involve not only Informed Consent from each person but IRB approval from each facility, and only once both are approved and in hand could data be gathered. It would be made clear to patients that their declining to participate would in no way adversely affect their course of treatment or eligibility for treatment.

The researchers will endure that participant identifying information and other confidential records are stored in a secure area with limited access, and stripped of identifying information, as outlined in Section 1.11 (Rights and Confidentiality of Research Participants) of the APA Ethical Principles of Psychologists. Also, as the study will seek information about potentially illegal substances each participant will be protected with a Certificate of Confidentiality and informed that no information about their usage will be given to any employer, school, or law enforcement agency.

Discussion

When considering the possible findings of this study there appears to be two strong results that are expected. 1) That those participants who have experienced a significant loss or source of grief, and therefore have increased their use of various substances, will over time taper off their usage amounts when availing themselves of various support structures. Such as family, groups, counseling and therapy. Or 2) Usage amounts that rose in response to such an event will not taper back to pre-loss quantities due to the absence of the aforementioned support frameworks.

If this study is able to show that people in crisis and loss fare better overall with support such as groups, individual therapy or other cognitive behavioral treatments (hereafter referred to as “therapy”), then eventually health care companies and insurance corporations will see the overall cost benefit to the patient and medical resources in offering reimbursement for such treatment. The idea being that therapy can prevent far more costly options due to the abuse of alcohol and drugs. A positive correlation between a reduction in usage and support options could be used as part of a proposal to fund additional longitudinal case studies where specific biomarkers and laboratory tests could support the bodies return to a healthier state than if the over-use or abuse of substances continued unabated.

This studies results may also shed insight into trends between the various substances asked about. There is plenty of literature that speaks to the addictive qualities of specific drugs over others and the cost to the public to deal with the fall out (Trends & Statistics, 2017). There is currently little long-term follow up when looking at people’s alcohol and drug usage, specifically as it relates to a primary stressor. Being able to show a direct link between the two can open up avenues for health-care providers to explore regarding how to perhaps recognize the link and then have applicable resources for that patient in order to help them manage the situation in a more constructive manner. A manner that would not only be healthier for the patient, but cost effective for the system as well.

References

Brenner, M. H., Andreeva, E., Theorell, T., Goldberg, M., Westerlund, H., Leineweber, C., Magnusson-Hanson, L. L., Imbernon, E., Bonnaud, S. (19 May 2014). Organizational Downsizing and Depressive Symptoms in the European Recession: The Experience of Workers in France, Hungary, Sweden and the United Kingdom. PLos ONE 9(5). https://doi.org/10.1371/journal.pone.0097063

Chambers, R. A., & Wallingford, S. C. (2017). On Mourning and Recovery: Integrating Stages of Grief and Change Toward a Neuroscience-Based Model of Attachment Adaptation in Addiction Treatment. Psychodynamic psychiatry, 45(4), 451–473. doi:10.1521/pdps.2017.45.4.451

Csóka, S., Simor, P., Szabó, G., Kopp, M. S., & Bódizs, R. (2011) Early maternal separation, nightmares, and bad dreams: Results from the Hungarostudy Epidemiological Panel, Attachment & Human Development, 13:2, 125-140, DOI: 10.1080/14616734.2011.553991

Kopp, M. S., Skrabski, A., László, K.D., and Janszky I. (Mar 2011). Gender patterns of socioeconomic differences in premature mortality: follow-up of the Hungarian Epidemiological Panel. International Journal of Behavioral Medicine. 18(1), 22-34. DOI: 10.1007/s12529-010-9126-5

Masferrer, L., Garre-Olmo, J. & Caparrós, B. (2017) Is complicated grief a risk factor for substance use? A comparison of substance-users and normative grievers. Addiction Research & Theory, 25:5, 361-367, DOI: 10.1080/16066359.2017.1285912

Publication Manual of the American Psychological Association, Sixth Edition. (2010). Publication Manual. Washington, D.C.

Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., Grant, M.
(1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption – II. Addiction, 88, 791-804. Retrieved from: http://www.automesure.com/library/pdf/8329970.pdf