Whys and What Ifs: Writing and Anxiety Reduction in Individuals Bereaved by Addiction

ABSTRACT

Research has shown that writing can help reduce anxiety in individuals who have experienced trauma or complicated grief. This small case study asked if writing could also reduce anxiety in those bereaved by addiction. For this study, thirteen individuals who experienced increased anxiety as a result of bereavement by addiction completed two semi-structured interviews and responded to ten writing prompts over four weeks. Thematic analysis was used to analyze interview transcripts and narrative analysis was used to analyze participants’ writing. Findings from this study suggest that writing decreased anxiety for six participants by helping them to identify intrusive ruminations and by demonstrating the progress they had made since the death of their loved one. However, more research is needed to understand why writing reduced anxiety for only half of these participants and to understand how writing might be more effectively used as a therapeutic intervention for individuals bereaved by addiction.

KEYWORDS:

• Anxiety reduction
• bereavement by addiction
• griefloss
• therapeutic writing
• expressive writing
• creativity in counseling

Introduction

Historically, psychologists have considered grief to be a form of “separation anxiety” which requires “the bereaved to relinquish their attachment to a close other in the face of the person’s death” (Valentine et al., 2016, p. 292). According to Boelen (2013), adult separation anxiety often mirrors childhood separation anxiety in which the individual fears that they will be separated from people close to them. For some individuals, the loss of an attachment figure leads to fear of additional loss, a central tenet of separation anxiety disorder (Boelen, 2013).

In the case of those bereaved by addiction, individuals may also experience residual anxiety which lingers in place of the relationship. Although there is no universally agreed definition for bereavement by addiction, it tends to be the result of a drug-related death (DRD) which includes “accidents, suicides and assaults involving drug poisoning, as well as deaths from drug abuse and drug dependence” (Butt, 2020, para. 37). However, before an individual dies from a DRD, their families and friends can be exposed to years of “anticipatory grief” or “waiting grief” (Dyregrov et al., 2020, p. 418). During this time, those who love the person with an addiction are likely to experience a loss of trust, intimacy or hope as well as feelings of grief prior to the drug-related death (Templeton et al., 2016). This experience can contribute to feelings of anxiety and can make the processing of grief more challenging for those bereaved by addiction (Dyregrov et al., 2020, p. 418).

According to Misouridou and Papadatou (2017) families’ traumatic exposure to addiction “leads to intense feelings of anger, guilt, ambivalence, and unresolved grief, as well as overwhelming anxiety caused by the enormous responsibility of preventing death” (p. 1955). Following a DRD, those who are bereaved may continue to feel anxiety as a result of having to talk to people about what caused the death or prepare for an inquest related to the death. Valentine et al. (2016) also note that the social stigma which families carry as a result of a DRD can increase feelings of self-blame, humiliation, and anxiety in social interactions with others. The bereaved may also feel they have lost control over their own lives and that the world makes less sense or is less safe than they previously thought (Smith, 2019). This lack of felt safety can lead to excessive worrying, panic attacks, social anxiety and more (Bui et al., 2013; Smith, 2019).

According to a meta-analysis of 146 studies conducted by Frattaroli (2006), participants who take part in expressive writing studies demonstrate positive physical and psychological health outcomes following a traumatic bereavement, including lowered anxiety symptoms. Of the 112 studies which examined the impact of writing on psychological health, anxiety reduction – along with the reduction of anger – represented the most significant outcome (Frattaroli, 2006, p. 841).

Many researchers believe that the emotional processing theory is the most plausible explanation for the benefits associated with expressive writing (Sloan & Marx, 2004). Several studies suggest that the expressive writing paradigm may “serve as a context that allows an individual to be exposed to aversive stimuli that have previously avoided” (Sloan & Marx, 2004, p. 124). In other words, asking participants to write repeatedly about a traumatic experience that caused them fear or anxiety could give them an opportunity to process the aversive memories, emotions and thoughts associated with their trauma and account for some of the positive health outcomes seen in expressive writing studies (Hayes et al., 1996; Klein & Boals, 2001; Marx & Sloan, 2002; Schoutrop et al., 2002). Given the psychological benefits participants in other writing studies have experienced, this case study considered if a different population – those bereaved by addiction – might also be able to reduce their anxiety through writing.

A note on terminology

Costa and Abreu (2018) state that most studies which use writing as a therapeutic tool – including many of the studies in Frattaroli’s 2006 meta-analysis – employ the terms “expressive writing”, “creative writing”, or both, without much distinction between them. For the purposes of this study, expressive writing was defined as a “form of therapy in which individuals write about their thoughts and feelings related to a personally stressful or traumatic life experience” (Lepore & Kliewer, 2013, para 1). Creative writing was defined as an act which “draws on the imagination to convey meaning through the use of imagery, narrative, and drama” and can be written in the form of “poetry, fiction, scripts, screenplays, and creative non-fiction” (Duke University, Creative Writing: Writing Studio Handout, 2021, para 1). The term “writing” acknowledges that when one is “engaged in the act of writing they may write expressively, creatively or in another way not described” (Thatcher, 2020b, p. 7). All participants engaged in both expressive and creative writing throughout this study but did not distinguish between them when talking about their writing experience in their interviews. Therefore, for the purposes of this article, the term “writing” will be used to acknowledge the many ways in which an individual might engage in the act of writing for therapeutic purposes and the many styles in which they might write.

Methods and materials

To find out if writing could help reduce symptoms of anxiety in individuals bereaved by addiction, a qualitative study was designed which included two semi-structured interviews and independent writing activities based on the expressive writing paradigm (Pennebaker & Beall, 1986). Thirteen adult participants were recruited including parents, siblings, and spouses of individuals who died because of substance misuse. At the start of the study, each participant was bereaved for six years or less and had accessed, or were accessing, bereavement services in England or Wales.

Interviews

Participants each took part in two, semi-structured interviews: one before writing and one after. In these interviews, all 13 participants discussed their anxiety and its effects – both before and after the death of their loved one – among other topics. Interviews were transcribed using the intelligent verbatim transcription method (Bird, 2005; Lapadat & Lindsay, 1999; McLellan et al., 2003). Thematic analysis was then used to identify themes across the data set (Aronson, 1994; Boyatzis, 1998; Braun & Clarke, 2006; Evans & Lewis, 2018; Huberman & Miles, 2002). Both deductive and inductive coding were used to identify codes which were then reduced to themes relevant to the research questions (Joffe & Yardley, 2003). The following article is focussed on just two primary research questions: 1) How does experiencing bereavement by addiction affect an individual’s anxiety? and 2) How does writing impact the anxiety of individuals bereaved by addiction?

Writing task

Following the first interview, every participant was given a creative writing pack with a set of instructions, 10 writing prompts, a notebook and a pen. Participants were asked to complete two practice writing exercises in the presence of the researcher and then were given four weeks to respond to all 10 prompts on their own. Participants were told to only respond to one prompt per day which offered them the flexibility to respond to all the prompts over 10 days or to spread them out according to their own schedule. Participants were asked to spend 20 minutes responding to each prompt in line with the average response time given in most expressive writing studies (Frattaroli, 2006).

The writing prompts themselves were based on 10 themes which regularly appear in disenfranchised grief and/or bereavement by addiction literature (Corr, 1999; Doka, 1989; Osterweis & Townsend, 1988; Valentine & Walter, 2015; Werner-Beland, 1980; Worden, 2009). These themes included: addiction, anxiety, anger, behavior, others, sadness, loneliness, regret, memory, and grief. The 10 writing prompts for this study were divided into two categories: standard prompts and poetry prompts. There were five of each prompt type. Standard prompts – which covered addiction, anger, others, loneliness, and grief – were semi-directed and each included a title as well as a statement and/or question(s). Unlike expressive writing prompts which are typically very broad, these semi-directed prompts encouraged participants to think about a specific emotional, cognitive, physical, or social experience related to their bereavement. Edgar-Bailey and Kress (2010) note that providing prompts with questions can encourage participants to “write a story which has been shown to deepen the reprocessing of the events” and, potentially, lead to greater health benefits (p. 164).

Like the standard prompts, the poetry prompts also included their own theme as well as a statement and/or question(s) for participants to answer. However, these five prompts – which covered anxiety, behavior, sadness, regret, and memory – also required participants to read a poem first. In his seminal work, Leedy (1969) introduces the concept of the “isoprinciple” which suggests that poems used for therapeutic purposes (i.e., for positive change in their readers) should be chosen to match the mood and emotional experiences of those reading the poems. Poems selected using the “isoprinciple” are typically meant for group settings or workshops and are used in the hopes of eliciting agreement or relatable statements like “I know what that poet meant” (Gillispie, 2003, p. 100). Although participants in this study were writing on their own and not in a workshop setting, poems were selected in the hopes that they would be able to relate to the intellectual or emotional premise of each one. Even though poems were chosen for their accessibility and relatability, it was important that participants felt comfortable reading the poems, regardless of their experience with poetry. Therefore, this note was included in their “Instruction Sheet”:

You do not need to completely understand or relate to the poems

Some of the poems chosen for the poetry prompts will deal with bereavement and others with feelings associated with bereavement. Each poem is meant to evoke a feeling, spark a memory or introduce an idea. However, if you don’t feel like the poem does this that is okay – you can simply write to the prompt.Participants were also asked to respond to these poems and prompts in whatever way felt most comfortable for them.

In addition to including both standard and poetry prompts, a simple definition of anxiety from the Cambridge English Dictionary was included with the writing prompt on anxiety to ensure the term’s meaning was accessible and consistent for all participants. Participants were asked to ensure they understood the term and used it in keeping with this definition when writing about it. This allowed for more consistent conclusions to be drawn about participants’ experiences of anxiety as expressed through their writing.

Notebook submission and narrative analysis

Participants were assured that they could choose to keep their writing confidential; submitting their writing at the end of the study was completely voluntary. A total of 12 out of the 13 participants opted to submit either their entire notebooks or a selection of responses. Narrative analysis was used to analyze participants’ writing (Coffey & Atkinson, 1996; Hiles & Cermák, 2008; Phoenix et al., 2010; Riessman & Speedy, 2007). This approach is uniquely suited to studies which explore disruptive life events (Riessman, 2012, p. 370). Hiles and Cermák (2008) state that narrative analysis allows researchers to “focus on both the what and the how of the re-telling, upon both the story that is being told as well as the way in which it is being retold” (p. 155). In this study, narratives were considered to be both the shorter pieces of text (i.e., the responses to individual prompts) as well as the cumulative narrative begin told across the writing samples and full notebooks (Cronon, 1992; Riessman, 2012).

Narrative analysis of the participants’ writing in this study was focused the “content” across their notebooks – that is what participants said about their anxiety – as well as how they chose to say it (i.e., through the use of literary devices). The narrative analysis primarily considered the presence of “I-statements” (i.e., “I am worried”) to determine what was being said and the use of literary devices to determine how participants chose to discuss their anxiety as it related to bereavement experience. In order to accomplish this, incidences of “I-statements” and literary devices were highlighted across the writing samples to assess whether there was an increase from prompt #1 to prompt #10. In the case of writing sample submissions, these were counted in order. For instance, if a participant only submitted their responses to prompts #1, #3 and #9 then “I-statements” were assessed from prompt #1 to prompt #3 and then from prompt #3 to prompt #9 to determine if there was an increase. All writing samples were then reread using guidance from Earthy and Chapter (2008), who state that narrative analysis should include considerations of “the surface content (What happened? Who was present? How did different parties react?)”; “the underlying content (What were the motives or intentions of participants? What is the meaning and importance of this story for the narrator?)”; as well as the sequence of events and the language used (p. 434).

Ethics and confidentiality

The ethics proposal for this study was granted full approval by Dr. Andrew Edgar at Cardiff University. This study also follows the ICMJE requirements on privacy and informed consent. All participants have given permission for their responses to be published as a part of this research article. All participants, and their deceased loved ones, have been fully anonymized and given pseudonyms as a part of this study.

Results

During the interviews, all 13 participants spoke about the anxiety which accompanies losing someone to an addiction. Every participant stated that their anxiety was made worse following their bereavement. Some participants like Alice, who lost her son to a heroin addiction, felt like they were living in a “perpetual state of anxiety” after the death while others found that their anxiety was triggered specifically by events, thoughts, feelings and more. Previous literature indicates that individuals can feel “separation anxiety” (Valentine et al., 2016, p. 291) following a bereavement by addiction. According to Misouridou and Papadatou (2017), anxiety can also be “residual” which means that, even after a substance misuser dies, the family may still feel the intense feelings associated with trying to prevent a death, such as anger, guilt, and excessive worry (p. 1955).

Both the interviews and writing samples gave an insight into participants’ anxiety and its effects on their lives. Thematic analysis of participants’ interview transcriptions highlighted two themes related to anxiety. These themes have been called: What If? and Worried World. Narrative analysis of participants’ writing samples revealed that participants used literary devices – specifically metaphors and similes – to discuss their anxiety and its effects. These findings are outlined below along with a section that explores the impact that writing had on participants’ anxiety during this study.

Participant interviews: anxiety and its effects following bereavement by addiction

“What If?”

Every participant talked about the challenges they faced dealing with “what if?” questions in relation to their bereavement. All participants discussed how they would replay scenarios in their head from when their loved one was still alive and ask themselves “what if” questions like: “What if I had got to their house on time?”, “What if he had gone to rehab?”, “What if I stayed home from work that day?”, “What if she didn’t pick up her keys and drive that night?” For the purposes of this study, I have considered these questions to be ruminations, which can be defined as “thinking repetitively and recurrently about the causes and consequences of one’s negative emotions and/or negative life-events” (Eisma et al., 2015, p. 85). An example of this theme can be seen from Sarah, who lost her son to alcoholism:

Don did not want to go to the hospital in the end. I know how ill he was and I knew it was going to be the end but he just didn’t want to go. Which, you know, fair enough. It was the hiding in the weeds. And there is always this element of, he wanted to come home, and there is always this element of what if: What if I let him come home? What if? But, what if the sky was orange? I mean, it’s not going to change anything. But there is an element of that. What if, what if, what if.

According to Eisma et al. (2015), bereavement researchers generally consider rumination after bereavement to be similar to “confrontation” (p. 85). Ruminations essentially force the bereaved to look at situations repeatedly from different angles. Therefore, researchers have considered this behavior to be a way of confronting the issue. However, other researchers consider bereavement-induced ruminations to be a type of “avoidance” (Boelen et al., 2006; Stroebe et al., 2007). For instance, Stroebe et al. (2007) proposed the “Rumination as Avoidance Hypothesis (RAH)” which states that “chronic rumination about the loss-event and associated problems serves as an ‘excuse’ not to face up to the most painful aspects of a loss-experience, such as the reality of the loss” (Eisma et al., 2015, p. 85). This hypothesis can be seen in Alice’s explanation of her ruminations after her son’s death:

I think my brain is deliberately blocking my ability to think itself if you know I mean. Because when you think you, I mean is there the time, I’ve got this ticker tape running across the back of the head going: Robert’s dead, Robert’s dead, Robert’s dead, Robert’s dead and, you know, I’m refusing to listen to it. I keep sort of going, I know! Don’t keep telling me. But I’m not sure if I do know, but it’s there.

Alice, who was the most newly bereaved person in the study, also spoke about her “forgetfulness” and her inability to focus due to these intrusive ruminations. In the beginning of the second interview, she stated: “I’ve lost so many of my words in the last four months”. She also regularly forgot the questions I was asking and needed them to be repeated. She acknowledged the ruminative playback of “Robert’s dead” but engaged in a type of denial by “refusing to listen to it”.

In many cases, participants’ anxiety was directly related to their own guilt. Parents, in particular, felt a strong sense of responsibility toward “saving” the child they had lost, which led them to ruminate on all the actions they felt they could or should have done; concepts they wish they had known; and words they said or didn’t say to their lost child. Charlotte, who lost her daughter to alcoholism, discussed this:

I think she was still struggling much more than I realized. I should have realized that it was kind of inevitable that she would drink again. I thought she had had enough of a shock from the child services’ involvement and everything. I should have realized, I should have been more prepared. I should have had the conversation with [her partner] about what we would do if she would drink again. And maybe if I’d have had that conversation I would have stressed the need to not let her drive. It is just so unnecessary, that is what really gets me. She didn’t have to die, she wasn’t suffering. I read posts on forums from mothers whose children have died of cancer and things and it’s almost like those are inevitable deaths whereas Nora’s wasn’t. It was so unnecessary, so preventable.

Charlotte’s discussion of her ruminations uses language nearly all the participants used: “should have”. She repeats this “shoulding” throughout and acknowledges, as many participants did, that this death was preventable.

The inference of this desire to prevent is that these ruminations are ways in which participants can figure out how they can prevent the death, even after the person has died. Laylah acknowledges the oddness of this practice:

I think because, um, it was a preventable death. It wasn’t like a freak accident, like we should have – not we should have because we tried and we couldn’t – but you think we should have been able to prevent it. And everyone else felt really guilty … This doesn’t make any sense now that I’m not like hardcore days following the death, but some of Ethan’s friends came around and one of them was like “Oh yeah I was going to meet him that evening but we cancelled”. And I thought oh that’s fine then let’s just not cancel when he won’t die. That’s weird though, right?

Regardless of whether rumination is classed as “confrontation” or “avoidance”, researchers seem to agree that it is intrusive and can negatively impact bereaved individuals by increasing their feelings of anxiety (Eisma et al., 2015). In particular, Nolen-Hoeksema (2001) states that ruminations have the ability to fuel depression by increasing negative thoughts, disrupting problem solving and positive behaviors and driving away friends and family who might offer support.

Worried world

While every participant asked themselves “what if” questions and engaged in rumination, only four (out of 13) participants talked about their anxiety related the wider world. Although only a small number of participants in this case study discussed this topic, the impact this “worried world” anxiety had on participants’ lives seemed significant and therefore worth including. Losing someone to addiction can lead the bereaved to feel as though they can no longer control their own lives and/or as though the world is less safe than it used to be (Smith, 2019). This concept can be seen in the way Charlotte talks about her changing worries and her new view of the world following her daughter’s death:

I used to worry about things but there was always a kind of underlying “oh, it’ll be alright” or “these things don’t happen to me”, you know that sort of thing. So even if I was really worried about something there was an underlying “oh, it will work out”. But now I worry and there’s no relief to it. I think I’m a lot more obsessive than I used to be. I worry about things not being done. I make long lists of things to do and I have a lot of the time but I don’t do them. And then I worry about the fact that I haven’t done them, stupid really. Because, as I said, I’m not working, I look after my grandson part of the week and then the rest of the week, I don’t really have any pressures like I used to … Life just seems a lot more worrisome and difficult than it used to be … I think it’s almost like I don’t, how can I explain this, I don’t trust the world anymore. I used to travel a lot for work, go into meetings, meet customers all sorts of things, give presentations and never really worried about it too much, even if it didn’t go particularly well. But now, small things kind of make me feel quite apprehensive. It’s almost like losing confidence in the way the world works and losing confidence that things will work out OK. It’s a bit like things will give way underneath me whereas I used to feel like my footing was quite secure (Charlotte).

Charlotte, and three other participants, stated that they felt the world was “less inviting”, “less secure” and “less hopeful”. This worry seemed to undermine their confidence as well as reduce their trust in other people. This lack of trust could lead them to feel even more isolated, alone, and anxious than the other participants (Maccallum et al., 2015).

Participants’ writing: anxiety and its effects

Out of the 13 participants who took part in this study, 12 of them voluntarily submitted either their whole notebooks or a selection of writing samples which included their response to the “Anxiety Prompt”. Eleven of these 12 participants used metaphors and similes in their writing to describe how their anxiety made them feel and the effect it had on them. Goldberg and Stephenson (2016) state that “metaphors and similes are important mediums through which feelings are often communicated, and they can also be used to address the continuum of issues related to loss, ranging from concrete to abstract in nature” (p. 107).

According to Baldwin et al. (2018), when individuals face an experience which they perceive to be “unfamiliar, complex, unstable, or obscure”, these feelings can result in a desire to “restore a sense of understanding” (p. 166). They go on to state that this needed to understand increases individual’s “reliance on available metaphor” to compare their experience to something “concrete and structured” (Baldwin et al., 2018, p. 166). A clear example of this use can be seen from Charlotte:

The anxiety feels like a snake coiled up inside me – it feels like it is always there. Sometimes it is coiled so tightly that it squeezes everything inside me and I can’t eat, or if I have eaten, the food turns to lead inside me. Sometimes it uncoils slowly and moves and then settles deeper inside me. Sometimes it reaches up through my throat like a tape worm and makes it hard for me to breath. Sometimes it slides into my head and fills my thoughts with horrible images. Sometimes it coils around my heart and lives so heavily on it that I fear it will break.

Charlotte repeats “sometimes” in a way which suggests that her anxiety manifests in many forms. She says it is like a snake that “squeezes”, “uncoils slowly”, “moves and then settles deeper”, “reaches up my throat”, “slides into my head”, “coils around my heart”. In the middle of her writing, she transforms the snake – often a symbol of evil – into a tape worm – something parasitic which “takes” from the body. By including this transformation, Charlotte is trying to represent her anxiety as accurately and economically as she can. By using a simile which describes her anxiety as a snake and a tapeworm, she is saying a great deal about her experience in a non-literal way. Stott et al. (2010) state that similes and metaphors act as “a cognitive bridge” for participants, connecting something they find abstract and difficult (e.g., anxiety) to something familiar and concrete (e.g., a snake) (p. 6). According to Neimeyer (1999), the enormousness of grief and the “unique sense of loss” that bereaved people feel is difficult to capture in “literal words” or “standard descriptions” (p. 78). This description demonstrates real self-awareness from Charlotte, and even, a desire to “make sense” of her grief experience (Neimeyer, 1999, p. 79).

Writing and the reduction of anxiety

Although all 13 participants in this study discussed their bereavement-related anxiety, only six participants claimed in their interviews that writing about their bereavement led them to feel “less anxious”. Three of the participants claimed this reduction was because writing about their anxiety made them realize how far they had come in their grief process. For these three participants, writing about their anxiety also seemed to reinforce how unhelpful the “what if” ruminations were to them. Sophie, who lost her son to a heroin overdose, discusses this clearly:

When I was writing, I felt that anxiety I felt when I was trying to save [my son]. I was very hyper anxious. He’d gone off to Tenerife and he hadn’t got enough of whatever he was taking and it was a massive race to get him back to the UK. We got him back and even then it just didn’t work out that he lived. So I was very anxious at that time and very anxious in the weeks leading up to him dying. So by writing I kind of, I relived that. It was hard, it was hard, but it was also it was also really helpful to me because just after he died I lived and lived and lived that, I kept reliving it. And I kept coming up short because in reliving it, part of me believed I could make a difference, I could do something about it and I would suddenly stop and think “oh hang on a minute, there’s no point in thinking what if, what if, what if”. But, I just couldn’t help myself doing it. And actually, almost three years on, it’s been very helpful to go back there because I realize I don’t have that shock. I know that he’s dead. I know it didn’t work and I have that with me now to calm the anxiety, to calm the journey of the reliving. So that’s good.

Sophie demonstrates how far she has come in her grief: from being “hyper anxious” before her son died to, three years on, being able to look back and relive those moments with less shock. She felt that “reliving” this experience in her writing helped to “calm” her anxiety by making her more self-aware of her progress. This process, in some way, could speak to the “emotional processing theory” which suggests that by writing about experiences associated with trauma or loss participants can reduce fear-inducing and intrusive thoughts (Klein & Boals, 2001; Schoutrop et al., 2002).

The other three participants who claimed that writing helped to alleviate the negative effects of anxiety stated that it/the practice offered them a new perspective on their experiences. Laylah demonstrated this difference when discussing her experience of writing to the “Anxiety Prompt”:

I wrote about when [my brother] went missing and worrying that he was dead … It wasn’t like an immediate anxiety about what’s going to happen right now, it was more of like a lingering dread … Yeah, so I was writing that [Sharon Olds (1992), in her poem “The Race”] was lucky because her anxiety was a useful anxiety that propelled her forwards. Like, she got on that plane. Whereas the anxiety that you have when someone is addicted, like it’s got nowhere to go. Like it’s not a useful anxiety, it’s just this horrible fear. You can do nothing with it, it just exists … Writing this prompted me to think about the different types of anxiety and how they’re different which made me reflect more. That fact that the poet’s anxiety is so different from mine. I could juxtapose the two in my writing and it kind of illuminated my anxiety, which helped.

It seems that by writing about her anxiety – as well as comparing it to the experience of the speaker in Sharon Olds’ (1992) poem “The Race” – Laylah was able to “reflect” on the different types of anxiety. She uses the word “illuminated” to describe what seems to be increased self-awareness of her anxiety and how it works. This “illumination” seemed to be positive for Laylah, suggesting that learning something about the nature of her anxiety was in some way valuable. Both Laylah and Sophie also spoke about the benefit of “staying with” their feelings and writing “through” them in order to reach new conclusions.

Discussion

The findings from this case study suggest that writing can help alleviate anxiety in some individuals bereaved by addiction. All 13 participants discussed the negative impact anxiety had on their life and six of them – nearly half – claimed that writing led them to feel “less anxious”. These participants claimed that writing specifically about their anxiety helped them realize how unhelpful their ruminations were and how far they had come in their grief process. However, participant interviews and writing samples did not seem to indicate why this reduction happened for some individuals and not others.

Those who reported less anxiety following the writing activities were bereaved for different amounts of time (between four months and 5 years); were different genders and ages; had different relationships to the deceased (i.e., either a parent or sibling); and had lost their loved ones to a variety of addictions (i.e., heroin, alcohol, Benzodiazepine, etc). Given these differences there was no clear reason why these six felt they were “less anxious” than the other seven participants.

Although six participants in this study felt that writing helped to reduce their anxiety, only two could be linked to the “emotional processing theory” (Hayes et al., 1996; Marx & Sloan, 2002). These two participants claimed that the repeated exposure – or “staying with” their difficult feelings during the 20-minute writing exercises – helped reduce their anxiety. This result suggests that the other four participants’ anxiety was reduced for a reason outside the scope of the emotional processing theory. This result indicates that this theory cannot wholly explain the benefits associated with studies, including this one, which employ writing as a therapeutic intervention for the reduction of anxiety.

Conclusion

This article focusses on two research questions from this case study. The first question posed was: how does experiencing bereavement by addiction affect an individual’s anxiety? Thematic analysis of interviews indicated that all participants felt their anxiety was made worse as a result of their bereavement. In particular, participants experienced increased ruminations and intrusive thoughts in the form of “what if” questions. Four out of the 13 participants also found their worries about the wider world led to an undermined sense of confidence and trust in others.

The second research question posed was: how does writing impact the anxiety of individuals bereaved by addiction? Through thematic analysis of interviews and narrative analysis of writing samples, it was concluded that six out of 13 participants reduced their anxiety as a result of writing. Writing seemed to help alleviate participants’ anxiety by giving them an opportunity to recognize the progress they had made throughout their bereavement journey; reinforce how unhelpful and destructive their “what if” ruminations were; gain a new perspective on their experience of grief and anxiety; and spend time with their anxiety (through 20-minute writing prompts) and therefore emotionally process it.

Although the 13 participants in this study came from a wide range of socio-economic backgrounds and had lost their loved ones to a variety of addictions, this research was limited in size and scope which makes its results difficult to generalize to a wider population. Most participants in this study were white, British females who had lost children to an addiction. Future research should aim for a larger sample size which includes more diversity in gender, ethnicity, religious affiliation, and bereaved relationships to the deceased. It would also be helpful for future research to be conducted over a longer period of time and to ask why some of those bereaved by addiction experience a reduction in anxiety as a result of writing while others do not.

According to Titlestad et al. (2019), following every drug-related death there are “at least ten next of kin who are likely to suffer the effects of bereavement” (p. 1). Despite the growing numbers of those bereaved by addiction, this population remains, largely, under-researched. Further studies are needed to fully understand this disenfranchised group and to develop appropriate therapeutic tools to support them.

Additional information

Funding

There is no grant or funding information to declare.