Posttraumatic growth following a drug-related death: A family perspective

Abstract

This paper explores the experience of posttraumatic growth in families who have lost a family member to a drug-related death. Seven family units (17 participants) were interviewed, and interviews were analyzed using reflexive thematic analysis. Analyses revealed themes that reflected positive adaptation and growth, including (a) reframing the loss, (b) open dialogue and social support, and (c) reclamation of purpose. Themes are presented in this paper for their pertinence in understanding how best to negotiate adaptation through complicated grief. The paper concludes that posttraumatic growth can occur once families begin a process of acceptance and receive support through the journey.

Introduction

Positive adaptation following the loss of a loved one is a deeply personal journey influenced by diverse personal characteristics and environmental factors (Jordan & Litz, 2014). The grieving experience is inherently complicated, and healing trajectories can be shaped by an individual’s existing or underlying vulnerabilities, relationship to the deceased, gender, age, social supports, spirituality, and the cultural script that guides their society (Kaltman & Bonanno, 2003; Tedeschi & Calhoun, 2004). Research suggests that “normative” grieving patterns begin with intense emotional reactions that begin to reduce after six months (Zisook et al., 2010), but the circumstances surrounding death play a significant role in determining the trajectory of the healing process and, consequently, adaptation strategies.

As the nature of a death can influence adaptation following a loss, traumatic deaths may lead to an increased risk of complicated grief. Traumatic deaths refer to deaths that occur with a degree of suddenness or violence (Feigelman et al., 2012) and may be perceived as preventable (Tay et al., 2016), where the untimely or violent nature of the death may leave the bereaved paralyzed by grief, anxiety, or intrusive flashbacks (Bonanno et al., 2008; Neimeyer, 2006). Such complicated grief does not typically remit over time, preventing a person from accommodating their bereavement (Lambert et al., 2021; Tobin et al., 2020) and placing them at risk for prolonged grief outcomes such as depression, anxiety, and post-traumatic stress (Bonanno et al., 2008; Tedeschi & Calhoun, 2004). Within traumatic death literature, a systematic review by Titlestad et al. (2019) identified families bereaved by a drug-related death as a critically understudied group who are at a considerable risk for complicated grief. Furthermore, this population also reported more severe mental health difficulties than those bereaved by accident or natural deaths.

DRDs (Drug-Related Deaths) are deaths that occur due to the intake of narcotics, or a result of violence, suicide, or infectious disease (Titlestad et al., 2019). These losses are often very abrupt, and the positioning of drug dependence as a criminal activity within many sociocultural contexts can result in a disenfranchized grief that is not socially sanctioned, openly acknowledged, or met with social sympathy (Doka, 1999; Feigelman et al., 2020). Many families struggle to find meaning in such loss as outcomes including stigmatization, guilt, self-blame, and a lack of support from family and peers compound their sense of disenfranchisement (da Silva et al., 2007; Lambert et al., 2021; Neimeyer, 2006). Furthermore, Christiansen et al. (2020) reported that parents bereaved by DRDs have a higher natural cause mortality rate than those bereaved by other causes of death and face an increased risk of death by suicide and substance dependence during the most intense stages of grief. Additionally, Lambert et al. (2021) found that families attributed physical illness outcomes to the combined stress of living with active drug use and navigating the emotional complexities of the loss.

While there is limited literature to date, two studies have engaged with family members bereaved by DRDs to understand their pathways to healing and adjustment. In Norway, a study by Titlestad et al. (2020) examined how parents bereaved by DRDs advanced emotionally following the death of their child. The authors interviewed 14 parents bereaved by DRDs and used reflexive thematic analysis to explore their coping experiences. Participants stated that going back to work, ceasing to blame others, and permitting themselves to grieve facilitated overall positive adaptation. Participants also stated that recognizing and avoiding some triggers (places and things associated with the deceased) was an adaptive coping strategy. Similarly, Feigelman et al. (2020) interviewed 11 family members bereaved by DRDs in the United States where posttraumatic growth occurred following acceptance and open disclosure of the nature of the death to others. However, those who had experienced healing were only able to do so after many years as the complex outcomes associated with DRD bereavement can impede coping strategies.

Recent research efforts exploring bereaved parents who use meaning making as a process to cope with traumatic child loss from chronic illness have shown that meaning reconstruction can facilitate posttraumatic growth (Dutta et al., 2020). Meaning making typically involves understanding the value of one’s life after death, making sense of the loss, and finding purpose (Martela & Steger, 2016). In the context of DRDs, both Titlestad et al. (2020) and Feigelman et al. (2020) identified meaning making as a positive process of adaptive rumination, which assists families in understanding complex emotional reactions. These studies highlight the early intense grief stages as a critical period for intervention, which supports findings by Christiansen et al. (2020) who identified an increased risk of external mortality for families bereaved by DRDs during this period. Social support can buffer against the pathogenic effects of distress, grief, and isolation by promoting feelings of safety, connectedness, and intimacy (Cohen & Wills, 1985; Doka, 2002). In contrast, family members bereaved by DRDs often feel isolated, misunderstood, and disconnected from their community and their family (Lambert et al., 2021; Titlestad et al., 2019).

The findings from Titlestad et al. (2020) in Norway and Feigelman et al. (2020) in the United States have provided an in-depth understanding of the healing trajectories of families bereaved by DRDs with international implications. In 2021, Lambert et al. conducted a study examining DRD bereavement in an Irish context. The study explored the impact of complicated grief on the family system and intra-family dynamics following the DRD of a family member. The authors interviewed multiple members of each family together, and highlighted outcomes such as familial relationship breakdown, the renegotiation of relationships, family shame, and isolation from their community. On an individual level, the study reflected international findings that highlight stigma, helplessness, internalized feelings of shame, guilt, and physical health difficulties as outcomes (Lambert et al., 2021; Titlestad et al., 2019). However, while the Irish study demonstrated the negative social and health implications of a DRD, it did not highlight potential healing trajectories for these families.

The current study aims to examine how the families interviewed by Lambert et al. (2021) engaged in positive adaptation and experienced posttraumatic growth following the DRD of a family member. According to the European Monitoring Center for Drugs and Drug Addiction (EMCDDA, 2021, p. 17), an expert-led network which collects data and analyzes information to provide an evidence-based overview of European drug trends, total DRDs in Ireland are now twice above the European average. Research has highlighted that these families require more robust policies to challenge stigma and provide early intervention for their unique grief (Lambert et al., 2021). Understanding the key facilitators to positive adaptation for families following the loss of a loved one in an Irish context will help inform appropriately targeted family-based interventions and individual supports concerning Irish policy and best practice, while also aiming to inform interventions on an international level.

Materials and methods

Approach

The current research is part of a study by Lambert et al. (2021) which examined the impact of DRD bereavement on families in Ireland. In this paper, we investigated how the families recruited and interviewed by Lambert et al. (2021) experienced posttraumatic growth following a DRD, aiming to provide a phenomenological understanding of potential healing trajectories. In identifying an appropriate qualitative framework, we wanted to ensure that the family unit, at the center of the phenomenon, was the primary focus. Furthermore, we wished to consider the personal nature of bereavement and the individualized impact of disenfranchized grief. As such, reflexive thematic analysis emerged as a tool to explore common patterns and experiences across the data, while also allowing the authors to account for potential biases throughout the process (Braun & Clarke, 2019).

Participants & sampling

As per Lambert et al.’ (2021) recruitment, this study included 17 family members bereaved by DRDs representing seven families across seven interviews (Table 1). As a method of purposive sampling and to ensure transferability of the findings, contact with an independent organization, which supports families affected by drug dependence, facilitated the recruitment process. Staff within the organization approached family members with information leaflets including details of the study’s aims and the professional qualifications of the interviewer. Family members subsequently self-selected to contact the research team by phone, by email, or allowing a staff member to contact the team on their behalf. Those who expressed such interest received a detailed information pack inviting them to participate. These packs outlined the study parameters, potential uses of their anonymized data, the role of the research team in working with the data, and information about their role in the interview process. All who received this information pack decided to participate and invited members of their own family to be involved in a focus group interview. There were no incidents where participants sought to withdraw from the study at any point.

Table 1. Demographic and essential participants’ details.

	Participant	Time (years) since bereavement	Relationship to the deceased
Interview 1	1	1	Mother
	2	1	Brother
Interview 2	3	9	Sister
	4	9	Father
Interview 3	5	27	Father
	6	27	Mother
	7	27	Sister
Interview 4	8	13 and 5	Father
	9	13 and 5	Mother
Interview 5	10	21	Mother
	11	21	Sister
	12	21	Niece
Interview 6	13	9	Mother
Interview 7	14	3	Mother
	15	3	Niece
	16	3	Sister
	17	3	Sister

As primary inclusion criteria, participants had to be active members of a family support organization, and to have experienced the DRD of a family member. In line with the requirements of the ethics committee at the researchers’ home institution, persons who were under 18, recently bereaved (under twelve months), and those who disclosed an active addiction or mental health issue were excluded from the recruitment process. Follow-up support services from the support organization were available to any participants who wished it after taking part in the research.

Participants included four males and thirteen females, (six mothers, three fathers, one brother, five sisters and two nieces). The study investigated the deaths of seven men (two of whom were brothers) and one woman, between the ages of 19 and 46. Four deaths occurred by accidental overdose involving opiates and benzodiazepines and three were suicide by hanging. At the time of interview, time since death ranged from one year to 27 years. One family was from the south of Ireland, two from the southeast, and four from the east.

Data collection

As per the methodology of Lambert et al. (2021), a semi-structured interview schedule guided six focus group interviews alongside one in-depth individual interview with a mother parenting alone. Six interviews took place in the family home, and one occurred in the office of the support network. The semi-structured nature of the interview allowed for the exploration of unanticipated topics while ensuring thematic consistency across cases. The interview schedule contained five open-ended core questions that were supported by general interview protocol such as paraphrasing, follow-up questions, and prompts: (1) “Can you tell me a little about yourselves?,” (2) “What do you think are the impacts on your family of experiencing a drug-related death?,” (3) “Do you think your experiences are the same or different to those who lose a family member in other ways?,” (4) “Have you any recommendations for what is needed to support families who have experienced this loss?” and (5) “On a scale of 1–10, how difficult was this interview for you?.”

Adopting this flexible interview format allowed participants to provide a continuous narrative about their experiences at a comfortable pace. Overall, the interviews provided information about the impact of experiencing a DRD, challenges, supports, and future recommendations. However, a recurring, yet unanticipated, concept that emerged throughout the data was the journey of healing which highlighted how families had adapted in the time since death. Interview lengths ranged from 1 hour and 11 minutes to 2 hours and 40 minutes. The second author conducted all interviews and used a recording device to record the interviews, which were subsequently transcribed verbatim.

Data analysis

The analysis followed Braun and Clarke's (2019) framework for reflexive thematic analysis with findings presented in adherence to O’Brien et al. (2014) standards for reporting qualitative research. All authors have experience in working with marginalized populations and we considered this methodology as the most systematic, yet flexible, tool to bring our skills and values in research to the data. The authors followed six steps as recommended by Braun & Clarke’s protocol: (1) familiarization with the data, (2) coding the transcripts, (3) generating initial themes, (4) reviewing emergent themes, (5) defining the themes, and (6) writing up the findings. At times, there was back-and-forth movement between phases when discussions encouraged revisions of certain emerging concepts. To ensure credibility, transferability, confirmability, and dependability of the results, we followed recommendations cited in the four-dimension criteria for assessing rigor in qualitative research outlined by Forero et al. (2018).

All authors familiarized themselves with the data by reading and re-reading the anonymized transcripts. The first and third author coded the transcripts utilizing NVivo qualitative analysis software and adopted a-priori approach to deconstruct the data and develop nonhierarchical codes, followed by a second round of coding. To ensure dependability and inter-coder reliability, this process was followed by open discussions between the first, second, and third authors about the coding, potential discrepancies, and how to synthesize the codes across the entire data set. As new codes began to decrease in frequency over time, all authors made an informed decision that data saturation had been achieved. The authors moved to initial theme generation with specific focus on any required changes, additions, or biases. Through rigorous reorganization, initial codes from all transcripts transitioned into preliminary themes. All authors reviewed and named the themes, and the first author drafted the report with input and feedback from each coauthor.

Roles and reflexivity

In line with Dodgson’s (2019) recommendations for qualitative research, we adopted a reflexive approach to the analysis to ensure that the process was confirmable, clear, and methodical. Prior to coding the data, all authors met to discuss and reflect on the anonymized transcripts. This discussion encouraged an open dialogue about how our experiences may influence our thoughts, pre-formulated assumptions, and ideas about the content. To reinforce the credibility of the analysis, the authors who coded the data wrote reflective memos and journals to keep a record of emerging thought processes. Each coauthor brought individual experiences to the research team, and to account for potential influences in interpretations, we engaged in reflective practice to minimize the risk of biased analysis.

As drug use is a sensitive topic often associated with criminality, we ensured that the terminology used in the coding and write up was sensitive, appropriate, and non-stigmatizing. The second author conducted all interviews, as they have professional experience working therapeutically with families through addiction services. To augment the credibility of the research process, this individual was considered the most suitable to conduct sensitive interviews while being cognizant of their own prior assumptions. This researcher was the only person present alongside the participants during interviews, and peer debriefing occurred during initial discussions about the data.

To understand bereaved families’ experiences with participating in engaged research, and to continue to develop suitable practices, participants were given an opportunity to provide feedback on the research process. The feedback was exclusively positive as participants spoke appreciatively of the therapeutic value of the interviews: “It was most positive for me as I bottled a lot of anger and resentment over the death of my son, and this was the first time that I ever spoke about his death openly,” and about the opportunity to potentially help other families through their own experience: “The most positive aspect for me was the knowledge that recounting my son’s life and death might in some way help in the future.”

Ethical considerations

The departmental ethics committee within the authors’ home institution granted ethical approval for this research. All components of the research process adhered to the guidelines within the Code of Ethics of the Psychological Society of Ireland (PSI). All participants in this study were briefed, informed how their data would be used, provided informed consent, and offered follow up support the support network. Participation in this study was voluntary, confidential, and family members could withdraw from the study up to 6 weeks post-interview. Once the final report emerged, withdrawal from participation was no longer viable. Data for this research was stored in an encrypted data repository provided by the university.

Results

The analysis revealed varying degrees of individuals’ posttraumatic growth in the aftermath of a DRD and identified three core themes: (a) Reframing the Loss, (b) Dialogue and Social Support, and (c) Reclamation of Purpose. The findings suggest that each of the participants experienced a profound sense of loss and pain following the death of their loved one, but most reported a sense of personal growth and healing. By making sense of the death through various active engagements, bereaved family members expressed that they were able to come to terms with the loss.

Reframing the loss

The period of active addiction before death was tumultuous for families. Years of uncertainty, stigma, and hopelessness permeated throughout the family system and left heavy emotional scarring as they lived in constant fear for the safety of their loved one, and sometimes for themselves. Following the death, this fear alleviated as the unpredictability surrounding the location of loved ones, issues with police, looming threats, and death began to fade. Participant 6 described finding comfort in knowing her son was now safer than he once was:

He could have ended up getting killed on the streets and he didn’t suffer, so I am happy with that…I wouldn’t have liked to have seen him found dead outside somewhere or over a lot of drugs or one thing or another.

Although she initially felt guilty about experiencing relief, all this mother truly wanted for her son was peace. She understood his life in addiction was painful for him and would not provide such comfort. As a mother, she experienced a prevailing sense of helplessness in this role that transformed to solace post-death in knowing her son was no longer suffering:

I am happy with where he is “cos, you know,” if he was here and going on with heroin and the life that he was leading, I’d say he was going to end up in really bad crime and drugs and that. So, if he is where he is and in no pain and happy, sure that’s all a mother wants for their kids.

In the data, there was a distinguishable difference between living one’s life and simply trying to survive chaotic circumstances. Positioning loved ones in “a better place” and references to “God’s will” was commonplace as family members drew on their faith to bring peace to their loved one, make sense of the death, and reach acceptance. Finding meaning in the loss in the context of fate also provided some solace for her husband (Participant 5). They had lost their son 27 years prior, and although the memory of the death remained, he was eventually able to reframe the loss in such a way that helped him transcend the grief:

I have come to accept (son’s) death but maybe it was something that was meant to happen. His life wasn’t going to change, you know? And I think he was happy to go…It was meant to happen or something, that’s what I keep saying to myself.

This family’s experience echoed many of the other participants’ struggles with their loved one’s active addiction. Families spoke about harrowing emotional experiences following the death, but they did find peace in knowing that their loved one’s hardship, and the uncertainty about their health, had ceased. Participant 1’s comments mirrored these sentiments: “I know he didn’t want to die. But to me, I think he’d be happier up there because he wasn’t going to have a good ending.”

One father (Participant 4) only permitted himself to begin healing after a prolonged period of self-blame for his son’s DRD. In holding himself accountable for the loss of his son, this father’s guilt negotiated his healing trajectory, as he did not consider himself within his own right to grieve. Nine years on, he eventually came to understand that his son’s behavior was beyond his direct control. Over time and with the support of his daughter (Participant 3), a greater awareness unfolded that his son’s death ended the associated hardships. This realization facilitated the eventual relief of his guilt and felt that even in his last moments; their son was trying to protect them: “Personally, I think that my son had an insight into where his life was going, and he didn’t want to bring that to us. So, we lost him to the street, there’s no two ways about that.” As an overall family unit, they experienced posttraumatic growth by supporting each other, but the journey to self-acceptance was very much individualized even within the family structure.

Despite the emotional trauma associated with his son’s addiction, Participant 4 managed to absolve himself of guilt and remembered his son with fondness. Such memory reconstruction was challenging for others as some participants struggled with identity fluidity. Conflicting memories of loved ones from life before addiction and the suffering experienced during addiction generated confusion when trying to reframe the loss. Efforts to align these versions of their loved one proved difficult for some, such as Participant 16: “You have to go back and pick out the bits you loved about him and knock out the other bits, that was very confusing.” Emerging from this conflict was the concept of a double loss, where families felt they lost their loved ones to addiction and, consequently, experienced an exacerbated grief following their death. Participant 2 stated: “We always talk about this, she didn’t just grieve for [our brother] when he died, she grieved for [our brother] when he went on drugs.”

Dialogue and social support

Bereavement support groups, where the unique grief associated with a DRD was recognized, offered an empathic space where families could unburden their sense of shame and helplessness. Many found comfort through interaction with others who had experienced this unique loss and sense of seclusion. For Participants 8 and 9, parents who had lost two sons to DRDs, the support groups fostered a deep sense of resiliency, self-preservation, and vitality. This mother (Participant 9) demonstrated that as parents, they moved from prolonged self-blame toward healing after engaging in support groups:

We blamed ourselves for years but then through the family support we got a little bit of learning that it wasn’t our fault at all… And I always say we are the lucky ones, because God knows where we would be today without the support we have gotten from the groups. You know people that have encouraged us to look at things differently, with a different view, and that’s what we do.

Reframing the loss helped the family move toward positive adaptation, but family support groups mediated this journey. Both family members spoke at length about how the clarity and guidance they received helped them to navigate the painful journey of loss: “Dialogue, to us, is the most important thing.” A key outcome of this engagement was that the parents found greater self-compassion, and Participant 8 reflected on recognizing the importance of their own well-being: “I am no good to anyone if I am not well. I can’t do anything for myself if I’m not well, so our whole objective now is to keep ourselves as well as possible, so we keep going to our meetings.” Opening a dialogue with other families created a space of deep reflection where different perspectives, sensitivity, and a culture of mutual understanding fostered posttraumatic growth.

Upon reflection, Participant 14 came to understand that constructing her entire world around intense support provision consumed her quality of life: “If you focus on your children all the time when they are in addiction, you are never going to get well yourself.” However, the parental instinct to care for one’s child took precedence, and many parents experienced a sense of failure, questioning their parental self-efficacy when their loved one passed. As acute stress had already compromised the health of many family members prior to the death, learning the value of prioritizing one’s own health was instrumental to recovery. Engagement with support groups guided families through the process of rebuilding their sense of self-worth and strengthening familial bonds. Open dialogue and reflection facilitated the development of emotional practices to build resilience and maintain wellbeing during daily functioning. In gaining a new perspective and renegotiating their sense of self-worth, families were able to pass on the value of their reflections to others, as shown by Participant 3:

It brings great peace into your life. We often speak to people. We have had a bereavement group here for the last 4 years. We often say to people, when they realize that their children are not able to stay in this world anymore it is better for everybody, you know it’s hard to come to that you know, to that realization but we have come to it. That they are not meant to be there, their time to go you know and prolonging it doesn’t really help.

Speaking to others in the groups who are all at various stages of their recovery cultivated a community of learning where people with similarly complex experiences could establish supportive relationships, validate their grief, and share coping mechanisms. Participant 17, who had lost her older sister three years earlier, described how she found “reassurance from hearing other people’s stories.” Participant 10, whose son passed away 21 years prior to the time of interview, showed considerable posttraumatic growth following engagement with bereavement services and reflected on the value these groups would have had at an early stage: “One good thing is all the work I’ve done on myself through the family support. I probably should have got that done 20 years ago.” This mother still had unprocessed trauma even 20 years post-death and demonstrates that there are benefits to social support that cannot be offered solely by the passing of time.

Although group-based social therapy fostered posttraumatic growth for most families who were in a position to access it, the individualized nature of grief demonstrates that this solution may not work for everyone. Participant 6 expressed her personal discomfort with support groups:

I went but I didn’t like it, for the simple reason I don’t think [group member] should’ve ever mentioned her son’s name. She should have never been telling us stories about her son. But yeah, that kind of group was all about that. When I found I was passing that same person on the street I’d say “Jesus I know all their business.”

Her desire to keep details about the death confidential may reflect the stigma and shame that families burdened by their loved one’s addiction must live with. For those who had not previously engaged with a bereavement group, the thought of having to speak openly about their anguish tempered their orientation toward counseling. Participant 6 mentioned that dealing with the grief was something done internally: “It’s a struggle that a family has to work through themselves, there’s no outsider can help you.” Speaking about her distress magnified her sense of vulnerability and unease, particularly with respect to engaging in open dialogue about personal issues with strangers from the locality. Evident from her concerns, understanding how participants define their own parameters of anonymity is a crucial component of developing individualized support packages for individualized grief processes.

Reclamation of purpose

During their loved one’s active addiction, one constant for family members among the uncertainty was their role as a parent, caregiver, or sibling. Fathers, mothers, and other family members found their identities and roles fractured by a loss that trapped them in cycles of guilt, but many participants demonstrated how they reclaimed and continued these roles in diverse ways. Through self-determination to maintain their identities post-death, many achieved a constructive reorientation of their grief experience to make sense of the loss and find a new purpose in life. Participant 1 spoke about how she continued her role as a mother, taking care of her son even after he had passed away: “I would drive out to the grave, it was like I was making his bed, I would pat the whole thing down and fix it and everything.” As she continued to care for her son while conducting tactile actions to maintain her sense of maternal identity, this role constancy helped her to contend with grief.

While some conducted personal rituals in memory of their loved one, others channeled their energies into loss-inspired activism. Participants 10 and 11 (mother and daughter) cultivated a sense of purpose through advocacy work and drug awareness campaigns, where their new roles as activists served the dual purpose of honoring their loved one while also supporting them to find meaning in the loss. Participant 10 and her daughter reconstructed their lives by becoming proactive in their community, supporting others in similar circumstances, and creating a legacy in honor of their loved one:

I felt that I was doing something, for [my son]. Yeah, I just poured all my life into it…I was doing voluntary work up there for a year, family support up there for a year. I then got the job as [houseworker], and then they got funding for a family support worker, so I was doing that as well.

Over time, participants who attended group support services transitioned their roles and purpose within that framework from solely seeking support to concurrently providing support to others. Participant 8 reflected on how they used their stories and coping efforts as opportunities to support fellow attendees the way others had supported them in the past, developing a communal environment among people who felt isolated from their respective communities:

It reminds us of how important it is to stay well and maybe our story might help people and we might be able to encourage people, but we know ourselves [it’s difficult] when somebody comes in and they are only starting off on their journey.

At the time of the interview, Participant 7 had not engaged in any advocacy work but spoke at length about her experience with her own addiction years prior. She stated that the death of her brother acted as a catalyst for her desire to use her first-hand experience of the different social supports to guide and mentor others through recovery:

I’d like to do that, to let people know that social workers are not there to hurt or harm them. I’ve been through a process. So, if an individual comes in now that’s new, I can sit down and I can guide them the best I can and say try it this way. There is good information coming back from my mouth to them.

Forging a new identity by taking up new active engagements nurtured posttraumatic growth. Participant 5 spoke about the benefits of “breaking the cycle,” where falling into inactivity and languishing made it difficult for him to transcend the loss and overcome his grief. He described intense mental anguish in the early years following his child’s death:

I didn’t handle it very well…I started drinking, not every day drinking that’s not the way it was, but I was drinking more than I was, I felt I couldn’t grieve the way I wanted to.

His family (Participants 6 and 7) emphasized the importance of participating in activities as it alleviated their own sense of helplessness and gave their life a sense of order. This value was pertinent in the case of Participant 6, as while she did not feel comfortable in family therapy, focusing on extracurricular activities provided her with a sense of purpose: “I’ll tell you what I excelled with over the death as well—with crochet, because my whole focus is gone into it.” She encouraged her husband to engage in similar activities, demonstrating an intra-family support network that was vital to recovery. This family experienced posttraumatic growth in diverse ways and at a different pace, but as a family unit they all engaged in other activities that they were passionate about, as Participant 5 highlights:

I nearly used to fish every day [before son’s death]. I got to a stage one time it was like déjà vu. Every day was the same, day in day out, and I was getting depressed about [son’s death], so I got my fishing rod and just threw it in…I did that for a few days to break up the monotony of every day being the same because I was doing everything the exact same every morning.

DRDs can result in the breakdown of family dynamics, but some of the participants in this study spoke about the strengthening of intra-family social bonds. With less emotional distance among family members and a willingness to communicate openly, Participant 3 strengthened her bonds with her parents: “There are a lot of positives that came out of it. Like, I’m very, very close to mom and dad because of (brother’s) passing as well.” When speaking to her father in the interview she noted that he is more empathetic and emotionally available: “I think that a positive thing with you Dad is that you have softened, you are easier to talk to."

Discussion

The process of experiencing positive psychological change following the DRD of a loved one is multifaceted. Healing trajectories are impacted by unique compounding variables such as stigma, the cultural perception of drug use, and the preventable nature of the death (Lambert et al., 2021; Titlestad et al., 2019), and as research suggests that for every DRD, there are at least ten people directly affected (Dyregrov et al., 2020). As total DRDs in Ireland are now twice the European average (EMCDDA, 2021), the current study provided a crucial insight into the healing trajectories of families and aims to inform services about how to support this population at an early intervention stage. The most common tools that facilitated posttraumatic growth, as shown by the thematic analysis, included reframing the loss, opening a dialogue among social supports, and finding purpose following the death.

The amalgamation of acute stress from providing support during life and processing the death yields significant implications for how families cope in the initial grief stages, which Christiansen et al. (2020) identified as a critical period due to a substantial risk of negative health outcomes and increased mortality rates for the bereaved. Services should endeavor to assist families in making sense of the complex and unfamiliar emotional outcomes associated with DRDs. For example, families reported experiencing a sense of relief when their loved one passed, but this relief was initially enveloped in guilt and exacerbated by a sense of remorse for feeling this way. These findings coincide with previous research that reported some families experienced a similar sense of ambivalence in the aftermath of a DRD (da Silva et al., 2007). In struggling to understand and accept the complexities of their own emotions, family members were trapped in cycles of shame. More specifically, in the absence of support to provide guidance and clarity, it was unclear to them at first that this relief was stemming from having their loved one’s peace at heart.

Finding peace for their loved ones was a priority for families. Death offered a stillness from the tumultuous nature of addiction, but families could not begin to process their own grief until they psychologically separated their loved one from chaotic circumstances. Many participants reframed their loss in the context of fate, with spiritual references to God and “a better place.” While their personal sadness did not remit and remained intense, drawing on their faith to position their loved one in a happier place provided a sense of solace with their loved one’s best interests at heart. For those who did not reference religion or spirituality, the fact that their loved one was at peace acted as a form of comfort. Using the various spiritual and emotional tools at their disposal was an essential component of posttraumatic growth and services should aim to support families in drawing from these. Closing this chapter acted as a catalyst for families to finally transition their priorities from their loved ones to themselves. This research was conducted in a predominantly Christian country and future research could examine how spirituality and religion within various cultures may facilitate positive adaptation with reference to how drug use is culturally perceived.

Social support has long been understood to be a protective factor against the negative health outcomes associated with complicated grief (Cohen & Wills, 1985; Doka, 2002), and Feigelman et al. (2020) found evidence of posttraumatic growth following open disclosure about the nature of the death to other people. The current study supports these findings as many families spoke approvingly about the incomparable value of social support. Opening a dialogue amongst other individuals and families bereaved by DRDs cultivated a judgment-free culture of understanding, empathy, and compassion. As family members bereaved by DRDs often feel isolated and disconnected from their community (Lambert et al., 2021; Titlestad et al., 2019), these support groups helped to legitimize their experience and foster a newfound sense of community. As documented by Lambert et al. (2021), some family members in Ireland, who were already experiencing isolation, were met with stigmatization when seeking social and professional support for a DRD. Therefore, it is of pivotal importance that the individual at the first point of contact within a service is cognizant of bereaved families’ emotional complexities, and meets them with compassion, direction, and empathy.

Support between members of the same family proved valuable for participants, but family members within the same unit often grieve in different ways. Lambert et al. (2021) reported that some families experienced a breakdown of relationships following the death. Intra family support that addresses complex needs and emotions in socially excluded populations should aim to be trauma informed with professionals educated in how to navigate the intricacies of family dynamics, assisting them in developing emotional tools to support one another during daily functioning. Within the development of targeted support frameworks, it is important to consider individualized response plans alongside familial projects as some participants felt uncomfortable about disclosing information in a group setting. All families in this study were registered with a family support network at the time of interview, but not at the time of death. National support efforts should consider how to bring practice-based frameworks to those who require it, especially considering some families in the current study reflected on how the knowledge of available supports and their value would have been beneficial to them many years ago.

The current study has also yielded similar findings to recent literature exploring the lived experience of bereaved parents who lost children to chronic illness (Dutta et al., 2020), where parents developed new meaning structures by positively reappraising their trauma through rituals and fostering a new outlook on life. Many of the successful coping strategies in the current study involved reclaiming a sense of what was lost after the death, such as parental/sibling identity, community participation, or emotional connection to the deceased. Reestablishing their identity was vital to positive adaptation, and family members maintained their bonds with their children through religion and physical actions such as candle lighting and grave maintenance. Others engaged in advocacy work to keep their loved one’s memory alive. The value of rituals to empower one’s sense of identity and purpose was a key finding of the current study and coincides with literature from other traumatic deaths (Dutta et al., 2020). Wheeler (2001) found that parents coped with the loss of their child to suicide by preserving memories, conducting rituals, and engaging in reflective processes to maintain bonds with their children.

For DRD bereavement, Titlestad et al. (2020) and Feigelman et al. (2020) specified meaning making as a tool for making sense of the loss. Martela and Steger (2016) suggest that people achieve meaning making when understanding that an individual’s life matters, it has value, and that it has a broader purpose in life. By becoming active members in their own community, engaging in new hobbies, or focusing on their own well-being, the pain of bereavement shifted from paralyzing to transformative as family members in the current study established a newfound sense of purpose. Some family members found their roles within support groups transitioning from simply being supported to providing support and guidance to more recently bereaved families. This new role helped them find meaning and purpose in the loss where they once felt disenfranchized.

Recent meaning focused narrative interventions have shown promise in supporting families living with a child with chronic illness (Dutta et al., 2022). While their research deals with pre-loss interventions for anticipatory grief, the framework has success in implementing a narrative e-writing tool through a therapist facilitated smartphone app to assist meaning-making processes for families. In improving psychological and spiritual wellbeing for families, the tool resulted in increased hopefulness for their own future and the quality of social support available to them. Given some of the similarities between positive adaptation strategies for DRDs and other traumatic deaths, future research could seek to conceptualize a similar support tool for families bereaved by a DRD that incorporates meaning making as a supportive intervention.

Overall, the families in this study found their identities and sense of community shattered by DRDs, and experienced posttraumatic growth through various active engagements that helped them to find purpose and meaning in the loss. Services should aim to support the strengthening of intra-family bonds where possible, while also assisting family members to make sense of unfamiliar and complex grief reactions. Some coping strategies associated with other traumatic deaths are similar, and the development of DRD supports could employ transferable elements of existing frameworks. Furthermore, support efforts must assist the bereaved in reconnecting with themselves and their communities while keeping themselves actively involved in fulfilling engagements. Policy and practice should consider these families in the specialized responses to complicated grief associated with other special deaths. For example, specific services in Ireland support suicide bereavement, but there are currently no extensive formal networks that specifically address DRD bereavement.

Strengths and limitations

A strength of this study lies in its in-depth methodology and approach that allowed participants to voice their experiences, which are seldom heard voices in empirical research. In analyzing the experiences of families of which the members were interviewed together, the analysis allowed for a comprehensive overview of how these participants experienced posttraumatic growth, both individually and as a family unit.

This study included a purposive sample, and all participants were white Irish in a similar urban socio-economic position. Future directions for this research may benefit from a more culturally diverse sample to address any potential differences that were not identified. Future studies could also look to explore intersectionality of experiences with addiction while experiencing social exclusion, considering groups such as the traveler community and other ethnic minority groups. This study included DRDs due to accidental overdose and death by suicide. Researchers should consider the possibility of comparing bereavement experiences and healing trajectories among those who are bereaved from accidental overdose death, intentional overdose death, and other drug-related causes of death, and whether grief and health outcomes differ in a considerable manner. Finally, future research could investigate individuals’ and families’ experiences of posttraumatic growth in more discrete–and narrower–post-death time intervals, as the participants in this study represented a broad range of years since the death of their loved one.

There is a need for targeted supports to help those bereaved by DRDs, not only in the immediate aftermath of the death but as an ongoing support structure to facilitate adjustment. Services could implement bereavement screening to ascertain the specific psychosocial needs of families grieving DRDs. These could be coupled with information sessions where participants are provided with an opportunity to understand the nature of group support and how the sessions are facilitated. Specialized interventions are warranted to help those dealing with complex, disenfranchized grief reactions.

Disclosure statement

With respect to the above-named paper submitted to Death Studies, the authors wish to confirm that the publication has been approved by all coauthors, and authors have no conflicts of interest.