Running head: INTEGRATING THE TTM AND STAGES OF GRIEF 1 Integrating the Transtheoretical Model and Stages of Grief to the Co-Occurring Population A Literature Review Presented to The Faculty of the Adler Graduate School _________________________________ In Partial Fulfillment of the Requirements for The Degree of Master of Arts in Adlerian Counseling and Psychotherapy _________________________________ By Maria Roche ____________________ Chair: Jill Hubble, MSEd, LPCC, LADC Reader: Rashida Fisher, MS, LPCC, LADC ____________________ January 2017 INTEGRATING THE TTM AND STAGES OF GRIEF 2 Abstract Co-occurring disorders are the co-existence of a mental health disorder and substance use disorder. Often times, individuals with co-occurring disorders are dealing with grief and loss. Unresolved grief is one reason individuals return to substance use. Because of the diverse of application, Adlerian theory can be applied to theoretical concepts regarding grief and loss. The Transtheoretical Model has been used in treatment for health behaviors including, substance use disorders and mental health disorders, as a model for improved wellness. Bowlby’s attachment theory explores the relationship between attachment and grief. Grief happens after a loss of attachment relationship. In this paper, Kübler-Ross’s stages of grief are applied to better understand the feelings of grieving individuals, and conceptualize in conjunction with other theories to better understand grief and loss as change within an individual’s life. It is argued that utilizing Adlerian perceptive, Bowlby’s attachment theory, integrating the transtheoretical model with the stages of grief can help individuals with co-occurring disorder cope with the grief and loss problems more effectively. Effectively treating grief in co-occurring individuals can decrease the risk of relapse. Keywords: co-occurring disorders, grief and loss, mental health disorder, substance use disorder, Transtheoretical Model, attachment theory, stages of grief, stages of change, processes of change, effects of the brain, Adlerian theory, complicated grief INTEGRATING THE TTM AND STAGES OF GRIEF 3 Table of Contents Adlerian Individual Psychology………………………………………………………………… 7 Social Interest and Community……………………………………………………………….. 9 Grief and Loss ………………………………………………………………………………….. 10 Co-Occurring Disorder ................................................................................................................. 13 Grief and Loss and Substance Use Disorders ........................................................................... 14 Losses prior to addiction. ...................................................................................................... 15 Losses while in addiction. ..................................................................................................... 16 Losses upon entering treatment. ........................................................................................... 16 Grief and Loss and Mental Disorders ....................................................................................... 17 Bowlby’s Attachment Theory ................................................................................................... 20 Stages of Grief .............................................................................................................................. 23 Denial ........................................................................................................................................ 23 Anger......................................................................................................................................... 24 Bargaining ................................................................................................................................. 25 Depression................................................................................................................................. 25 Acceptance ................................................................................................................................ 26 Transtheoretical Model ................................................................................................................. 26 Stages of Change....................................................................................................................... 27 Precontemplation. ................................................................................................................. 27 Preparation. ........................................................................................................................... 29 Action. ................................................................................................................................... 29 Maintenance. ......................................................................................................................... 30 Processes of Change ................................................................................................................. 31 Consciousness-raising. .......................................................................................................... 31 Social liberation. ................................................................................................................... 32 Emotional arousal. ................................................................................................................ 32 Self-reevaluation. .................................................................................................................. 33 Environmental reevaluation. ................................................................................................. 33 Commitment. ........................................................................................................................ 34 Countering............................................................................................................................. 34 INTEGRATING THE TTM AND STAGES OF GRIEF 4 Stimulus control. ................................................................................................................... 35 Contingency management. .................................................................................................... 35 Helping relationships. ........................................................................................................... 36 Effects on the Brain ...................................................................................................................... 36 Dopamine .................................................................................................................................. 38 DA and substance use. .......................................................................................................... 38 DA and attachment. .............................................................................................................. 39 DA and grief. ........................................................................................................................ 39 Oxytocin .................................................................................................................................... 40 Oxytocin and Dopamine ........................................................................................................... 41 Integrating the Transtheoretical Model and Stages of Grief ......................................................... 42 Precontemplation ...................................................................................................................... 44 Stages of grief. ...................................................................................................................... 44 Denial. ................................................................................................................................... 44 Anger..................................................................................................................................... 45 Bargaining. ............................................................................................................................ 46 Depression............................................................................................................................. 46 Acceptance. ........................................................................................................................... 47 Processes of change. ............................................................................................................. 47 Helping relationships. ........................................................................................................... 47 Social Liberation. .................................................................................................................. 48 Consciousness-raising. .......................................................................................................... 49 Emotional arousal. ................................................................................................................ 50 Contemplation ........................................................................................................................... 50 Stages of grief. ...................................................................................................................... 50 Denial. 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