Bereavement following substance misuse: A disenfranchised grief.

Bereavement following a drug and/or alcohol-related death has been largely neglected in research and service provision, despite its global prevalence and potentially devastating consequences for those concerned. Whilst researchers have drawn attention to the suffering experienced by families worldwide in coping with a member’s substance misuse, this article highlights the predicament of families bereaved following a substance misuse death. To this end, it reviews literature drawn from addiction and bereavement research that sheds light on this type of loss. The article also considers how general bereavement theory may illuminate bereavement following a substance misuse death. We argue that available frames of reference reflect not only a lack of focus on this type of loss, but also a tendency to reproduce rather than interrogate normative assumptions of bereavement following ‘bad deaths’. The article concludes by considering how findings from existing literature can guide future research.


Introduction
Early bereavement research focused on prematurely bereaved widows (see, for example, Lindeman, 1944;Marris, 1958;Gorer, 1965), and has since expanded-as have servicesto incorporate bereavement through ever more specific losses, particularly those experienced as traumatic, such as the death of a child, stillbirth, suicide or murder.One such traumatic loss that has received little research is that following a drug and/or alcohol-related death.At a time when substance misuse and associated risks to health and life are of continued and growing global concern (Orford et al., 2012), this paper highlights the consequences for those bereaved as a result of such misuse.By reviewing research literature from the fields of bereavement and addiction, it identifies key issues that have emerged and gaps that remain to be addressed.
While there is substantial research literature on substance misuse in families worldwide (Arcidiacono et al., 2009;Orford et. al., 2005), the experiences of family members in their own right have been largely neglected (Orford et al., 2012).This is even more the case for family members bereaved following a substance misuse death, though there are guidance leaflets and booklets produced by support agencies, as well as personal testimonies published by bereaved individuals.In addition, there has been considerable attention from the popular media, usually in relation to deaths of young people or celebrities. 1There have also been some practice initiatives, though little in the way of evidence-based guidance for providers of either addiction services or bereavement support.Yet, such deaths are often untimely and sudden, accompanied by social and moral censure, with potentially devastating consequences for the well-being of families and individuals emotionally close to the user (Feigelman et al., 2012).
Due to the paucity of research on substance misuse bereavement, the following review is not systematic, but rather also draws on findings from addiction and bereavement research with bearing on this type of loss, as well as bereavement theory more generally.It is organised into two parts.The first part identifies just four studies that focus specifically on bereavement following substance misuse (Da Silva et al., 2007;Feigelman, 2012;Grace, 2012;Guy, 2004), so also examines bereavement studies of other socially censured deaths, such as those resulting from suicide, AIDs, and murder or manslaughter, as well as addiction studies of what it is like for families living with substance misuse.The second part of the review examines general bereavement theory to consider the implications of existing frames of reference for understanding substance misuse bereavement.It argues that these frames have been developed on the basis of what has been considered 'normal' grief, thus tending to reproduce rather than scrutinise grieving norms by which some bereavements, including substance misuse, tend to be marginalised.A concluding section summarises the review's findings and implications for further research.
PART 1: Bereavement following a substance misuse death Deaths relating to alcohol misuse are estimated at 2.5 million globally per year (WHO, 2013), making it the world's third largest risk factor for premature mortality and morbidity.In 2010 there were between 99,000 and 253,000 deaths globally as a result of illicit drug use or between 22 and 56 deaths per million of the population aged 15-64 (UNODC, 2012).Drugrelated deaths are highest in North America and Oceania, accounting for approximately 1 in every 20 deaths among persons aged 15-64.In Asia approximately 1 in 100 deaths are drugrelated, in Europe 1 in 110, in Africa 1 in 150 and in South America approximately 1 in every 200.
Despite these figures, little is known about the impact of such deaths on those who were emotionally close to the drug or alcohol user.Indeed our review has identified only three qualitative studies, two focusing on drug-related deaths: a Brazilian study of six bereaved family members (Da Silva et al., 2007), and an English pilot study of four bereaved family members (Guy, 2004).The third study, which focuses on the parental bereavement of four British teenage girls, aged between 14 and 16 years, also includes alcohol-related deaths (Grace, 2012), which otherwise remain unrepresented.In addition, Feigelman et al., (2012) have conducted an exploratory, comparative survey in the US, which has contrasted parental grief after a drug-related death to other types of death.
Thus, much of what we might expect of the experiences of this group of bereaved people is also based on the application of findings from bereavement studies of other types of problematic death.These include losing a family member to suicide (Simone, 2010;Wertheimer, 2001) or murder or manslaughter (Riches and Dawson, 1998;Rynearson, 1996) and a partner to AIDS (Wright and Coyle, 1996).Drawing on ideas and concepts from across the bereavement literature, these studies have highlighted the difficulties in finding meaning in, and support for, such losses, with considerable consequences for the well-being of families and close others affected by such deaths.Whether similar difficulties affect those bereaved by substance misuse is the focus of a current study in the UK 2 Building on these findings, the three qualitative studies of bereavement following drugrelated deaths (i.e.Da Silva et al., 2007;Grace, 2012;Guy, 2004) have emphasised two main themes, which provide the context for and shape responses to these deaths and their implications for those left behind.The first is the social and moral stigma typically attached to deaths considered to be self-inflicted, which may be transferred to those closely associated with the deceased (Guy, 2004;Feigelman et al., 2011).The other concerns family relationships prior to the death in terms of the pressures associated with living with substance misuse (Da Silva, et al., 2007;Grace, 2012;Guy, 2004).Each of these themes is discussed in more detail.

Stigmatised deaths and devalued grief
Individual, social and cultural responses to death have been found to reflect the extent to which the death is considered 'good' or 'bad' ( Seale and van der Geest, 2004), certain types of 'bad' deaths attracting social and moral condemnation from the wider society.In contemporary Western societies, deaths involving AIDs (Wright and Coyle, 1996), suicide (Simone, 2010;Wertheimer, 2001) and drug or alcohol overdose (Feigelman et al., 2012;Grace, 2012;Guy, 2004) have been particularly implicated.After suicide deaths, Wertheimer has noted the challenges of making sense of something that "outrages our basic assumptions", such as belief in the sanctity of life and the need to preserve it at all costs.With drug-related deaths, in addition to their perceived self-inflicted nature, such outrage is also linked to drug use being illicit and associated with deviant or morally reprehensible life-styles (Feigelman et al., 2012;Guy, 2004).
Thus the experiences of those who are grieving so-called self-inflicted deaths can be obscured by commonly held assumptions and stereotypes.These may devalue or 'disenfranchise' (Doka, 2001) their grief, depriving them of the opportunity to share their experiences with others and, therefore, of social support.In a study of gay men bereaved following the AIDS-related death of a partner (Wright and Coyle, 1996), such lack of support was linked to the stigmatising of homosexuality, including the failure to appreciate the strength of gay relationships.In addition, as one participant reported, 'the media make out gay people deserve what they get because of what they've done' (Wright and Coyle, 1996: 271).Thus, along with the life of the deceased, the grief of those left behind was also devalued due to their being considered in some way complicit in the death.As observed by Worden (2009), the expectation of being judged harshly by others may prompt the bereaved person to lie about the cause of death.
Parents bereaved following the suicide or drug-overdose death of a child have also been found to misrepresent the cause of the death to others, even close family members, in order to protect their child's reputation (Feigelman et al., 2012).Indeed, it has been argued that the intensity of social stigma attracted by suicide and drug-overdose deaths may produce responses over and above what is implied by disenfranchisement, to include active stigmatisation (Feigelman et al., 2012).As such, they may encompass more than empathic failures of close others (Neimeyer and Jordan, 2002), to apportion blame to the mourner, both directly through derogatory comments about their assumed part in the death and indirectly through blaming the deceased for their own death.In both cases, the impact of such blaming was found to increase mourners' distress, particularly the shame, humiliation and self-blame, beyond what it would have been had close others simply avoided or ignored them (Feigelman et al., 2012).
Young people bereaved following a parent's alcohol and/or drug-related were found to be particularly vulnerable to stigma, shame, self-blame and feeling unworthy to grieve (Grace, 2012).Three of the four teenage girls who were interviewed for this study reported having 'gone off the rails', their grief manifesting in disruptive behaviour, something for which they were castigated by teachers, who implied that they were using their parent's death as an excuse.This response from an authority figure, together with the stigma of their parent's substance misuse, left them with a sense of shame and spoiled identity.
The lack of sympathy shown to those bereaved following so-called self-inflicted deaths is also reflected in the way such deaths are reported in the media.A study of parents bereaved through murder or manslaughter (Riches and Dawson, 1998), found that, in cases where murder victims were associated with the lifestyle of their attackers, or portrayed as playing a part in their own death, they too were stigmatised.Instead of encouraging the public to identify with the victim and their families, such media portrayal tended to distance the reader, not only from the self-destructive behaviour, but also from family members who appeared to have condoned or failed to prevent it.As such, it spoiled the mourner's and the deceased's identities, hindering meaning and memory-making (Riches and Dawson, 1998;Rock, 1998).
Similar findings have been reported from a pilot study of four parents, each having lost a child as a result of drug overdose (Guy, 2004).The study found that their grief was compounded by media images of drug culture, including anti-drug messages promoting public outrage at such self-destructive behaviour.As with murder victims, such demonising of drug users, which is likely to be at odds with the family members' experiences, was found to mar the deceased person's identity and memory, at great cost to mourners' well-being.Indeed, the 'spoiled' image of the drug user may be transferred to family members, exacerbating any sense of guilt, shame, regret and failure (Goffman, 1963;Grace, 2012;Guy, 2004:52;Riches and Dawson, 1998).Alternatively, bereaved families may co-operate with the media's anti-drug messages in an attempt to salvage their own identity and make a bad death good by allowing it to serve as a cautionary tale (Guy, 2004:45).As a result family members may compromise their privacy for the sake of a meaning that has been imposed on the situation and focuses on only a part of the deceased's life.This may not do justice to the family's actual experience but instead hinder the negotiation of a shared meaning between those who actually knew the person.
The capacity to create meaning in the death of a significant other has been found to be crucial to regaining control of one's life and rebuilding a shattered identity (Braun and Berg,1994), which can be particularly necessary and challenging after traumatic death (Neimeyer and Sands, 2011).Memory making and post-mortem bonds have been identified as important resources (see, e.g.Klass et al., 1996;Valentine, 2008), though what kind of bonds and memories the person feels are allowable is subject to culture and to worldviews propagated by powerful religious and/or political institutions (Klass and Walter, 2001;Klass and Goss, 2005).In contemporary western democracies, the forging of bonds and memories may take the form of 'conversational remembering' through engaging with others who knew the person (Walter, 1996), talking directly to the deceased person, sensing the person's presence, tending the grave, displaying photos, retaining keepsakes, etc. (Gibson, 2008;Valentine, 2008) and, increasingly, digital social media (Walter et al 2012).However, the opportunity to make use of these resources has been found to depend on a supportive and sympathetic environment in which one's grief is recognised and acknowledged (Simone, 2010).Where this is lacking, due to social censure in the wider environment, and/or disrupted due to lack of communication within the more immediate family, then emotional isolation may result (Grace, 2012;Simone, 2012;Wright and Coyle, 1996).Guy and Holloway (2007) have suggested that the social censuring of such deaths has, in part, to do with their lack of predictability and capacity to be managed, in contrast to most other forms of dying, which are subject to particular procedures and pathways and, as such, capable of being managed (see below).However, with substance misuse deaths, any attempt to construct a coherent and meaningful dying trajectory may be inhibited by popular myths and negative stereotyping of substance misuse, including images and assumptions attached to the user, which take little account of the person behind the image.These stereotypes may set both the deceased and the bereaved apart from the rest of the community.Thus, in spite of media attention through which the family's story is shared with the wider community, such attention is likely to render their grieving a profoundly isolating experience (Guy and Holloway, 2007).In addition, as discussed in the following section, finding meaning may be hampered by circumstances closer to home, within the more immediate family.

Family relationships prior to the death
The stress of living with the person's substance misuse may have already impaired family relationships and ravaged the well-being of family members (Orford et al., 2010).In particular, the breakdown of a relationship in which so much has been invested has been found to involve grief at losing the person they once knew and loved to their addiction.An Australian study (Oreo & Ozgul, 2007), that interviewed 49 parents of living adult substance misusers, reported "...ambiguous, complicated and prolonged grief experiences" (p72).This finding suggests that should the substance misuser die, these parents are likely to experience a 'double-death' in already having 'lost' their child to drugs or alcohol prior to their biological death.
In some cases mental and emotional stress are compounded by economic pressures (see e.g.Barnard, 2007;Orford et al., 2012 ), including being affected financially through supporting the person's habit in order to keep them alive or through the person being unemployed and/ or stealing from family members to support their own habit (Barnard, 2007).While there are no studies focusing specifically on the economic impact on families should the person die as a result of their habit, a few studies have considered the economic pressures of bereavement more generally to suggest that pre-death financial pressure may be exacerbated by funeral costs and needing to withdraw from paid work due to psychological stress (Corden et al. 2008;Woodthorpe et al, 2013).
The ways in which families have sought to cope with such stress has been characterised by Orford et al., (2012) as putting up, withdrawing or standing up.Thus some families may put up with and accommodate the user, for example, supporting their habit as indicated above.Others may withdraw or take action designed to disengage or gain some independence from the person's problems, either temporarily or more long term.Some families find ways of standing up to or confronting the substance misuse and exercising some control in the situation, for example receiving training in overdose management (Strang et al., 2008).Yet, we do not know the implications of these different responses for the way families cope in the event of the person's death as a result of their substance misuse.Since none of them are particularly effective, we might predict post-mortem guilt at not having managed pre-mortem family life well.
It is more often the case that families have little or no knowledge of the nature of drug use and the risks entailed and be unable to respond in any consistent way, so that their attempts to support the user typically fail (Orford et al., 2005).Furthermore, families are often reluctant to seek support outside the family and find the reactions of others to be unhelpful or undermining of their efforts to stand up to the substance misuse.Such lack of social support and the sense of isolation this may bring are likely to continue and, indeed, be exacerbated should the user die and the family be faced with bereavement.For young people who have lived with parental substance misuse, low levels of both familial and social support before death may affect their capacity to access support after death, particularly if their grief manifests through disruptive behaviour (Grace, 2012).
In contrast to alcohol-related deaths, which may result from chronic disease, drug-related deaths are more likely at a younger age, to be sudden and related to overdose or suicide.They may be unexpected in that families were unaware of the substance misuse or all the associated risks (Da Silva et al., 2007;Coleman & Stanton, 1978;Schneider, 2009;Strang et al., 2008).In a Brazilian study of six families, in which a member had died from drug overdose, three were aware of the substance misuse and three were not.Interviews with one member of each of the six families found that those who were aware of the substance misuse had made a "veiled preparation" for a possible death by overdose.Thus, in having lived each day expecting the worst to happen, once it did, their response encompassed ambivalent feelings of grief and relief (Da Silva et al., 2007).In contrast, for those who were unaware, the sudden and unexpected nature of the death was experienced as highly traumatic, haunting them for a long time.
In a British study (Guy and Holloway, 2007) where there had been secrecy about the drug use, the deaths were found to arouse feelings of anger, guilt and helplessness in family members.The discovery of such secrecy left the bereaved person feeling that their relationship with their family member was based on a false premise.Being confronted with not having known the person in the way they thought they did was experienced as undermining their confidence and self-belief (Guy and Holloway, 2007).Indeed, other types of sudden and unexpected deaths have been found to cause 'a shock to the family system' (Handsley, 1996), which may severely shake the family's and the individual's beliefs, and values and undermine their self-esteem, security and trust in life and the future.Even if families are aware of their relative's substance misuse, the death may still be experienced as sudden, unexpected and destabilising.There is an increased risk of death due to overdose after a period of abstinence, which reduces tolerance levels.Studies have demonstrated this risk during the first two weeks after release from prison, the risk remaining elevated up to at least the fourth week (Bird and Hutchinson., 2003;Guy, 2004;Merrall et al., 2010), after residential detoxification treatment programmes (Gossop et al, 2002;Strang et al., 2003), and during and after opiate substitution treatment in primary care (Cornish et. al., 2010).Yet, paradoxically, it is at such times of abstinence or reduced consumption that close others are likely to experience a sense of relief and hope for the person's future, so that death may occur when least expected.

Summary
From both the perspective of societal stigma and prior family relationships, the studies reviewed point to particularly adverse consequences for the well-being of those bereaved following substance misuse.Such consequences may be further compounded where the bereaved are themselves substance users, though none of the existing studies have included or made reference to this group.Yet, as reported with AIDS-related bereavement (Wright and Coyle, 1996: 270), the death of someone close may face the survivor with their own mortality if their own substance misuse is potentially life-threatening.There is also the possibility of being implicated in the death to the extent of being interviewed or even charged as a suspect, as reported in studies of families bereaved by murder or manslaughter (see Riches and Dawson 1996: 147;Rock, 1998), or at least by being perceived as a bad influence on the user.

Part 2: Bereavement theory
In order to further understand the impact of the social pressures identified above, the review now examines how this type of loss has been framed within more general bereavement theory (Cleiren, 1992;Thompson, 2012).It explores the way such theory has largely developed from what are considered 'normal' experiences of grief, arguably contributing to the marginalisation of certain groups at the expense of appreciating the diverse and situated nature of the way people grieve.It argues that, despite increasing attention to the variety of ways in which people grieve, further understanding of how people grieve deaths that fall outside the norm is needed to contribute a more nuanced and culture-specific approach to theorising bereavement and developing services.

Norms about dying and grieving
Literature on dying and bereavement in contemporary western societies has identified some deaths as being especially difficult to grieve due to circumstances and characteristics which place the death beyond the bounds of normal expectation and acceptability (Guy, 2007;Seale, 2004).These include deaths which are considered to be 'out of time' and therefore unpredictable, disruptive and hard to manage.Substance misuse deaths have the additional factor of being considered self-inflicted and may involve illicit activity.As such, they attract social stigma, which may extend to those left behind, and marginalise and isolate them at a time when they most need support.
The concept of 'disenfranchised grief' (Doka, 2002), initially applied to the grief of those whose relationship to the deceased was not publicly recognised or socially sanctioned, has been expanded to refer to grief for deaths considered not to entail a loss, or self-inflicted deaths, including those involving substance misuse (Guy, 2006).Psychologically it has been observed that mourners may disenfranchise their own grief through 'internalising' negative cultural messages (Kaufmann, 2002(Kaufmann, , 2010)).However, as social beings we are also engaged in creating and negotiating these norms, a process of not only perpetuating, but also adapting, revising and even rejecting the conventional line (Seale, 2000;Valentine, 2009).The latter approach is evidenced in the way bereaved individuals have publicly challenged negative cultural messages to influence the way certain groups are treated, for example, the gay community in the US transformed the public's image of the disease (Holst-Warhaft, 2000); and families bereaved through murder or manslaughter in Britain secured better treatment from the police and judicial system (Rock, 1998).
Thus, the status quo is far from static, but subject to variation across cultures and between social groupings within the same culture, as well as change over time.For example, with deaths resulting from murder, suicide and AIDs, the situation has arguably improved (as reviewed in Part 1), which has raised public awareness of and sensitivity towards the grief of the families left behind, as well as the public challenges discussed above.In addition, the online environment may, in some circumstances, enfranchise losses which are otherwise stigmatised (Walter et al., 2012).
However, since to date there has been little research into those affected by deaths linked to substance misuse, existing theoretical perspectives on bereavement fail to reflect their experiences.Thus, any practice initiatives have not been informed by research.Rather, given the largely bad press that tends to accompany these deaths, this group of bereaved people remains particularly vulnerable to a negative response from the wider society.This situation is both distressing for the bereaved individuals affected, as well as limiting for the way we understand and manage death and loss in contemporary societies more generally.With this in mind, we turn to general theories of the psychological reactions of grieving individuals.

Psychological/social psychological theories
Psychoanalytic theories have conceptualised grief following the death of close others as a painful negotiation of the conflict between one's feelings of attachment to the deceased and the need to face the reality of their death in order to re-invest one's energy in a life without that person (Freud, 1917).This intra-psychic approach was further developed through a focus on childhood 'attachment' behaviour, and how such behaviour shapes our attachments later in life (Bowlby, 1980;Parkes, 2006).From this perspective grief is a form of separation anxiety, biologically programmed and shaped by childhood, requiring the bereaved to relinquish their attachment to a close other in the face of the person's death.
As a private, internal condition of the individual, grief has been medicalised and professionalised, with both healthy and pathological forms (Prior, 1989).Thus, various symptoms associated with the 'grief reaction' have been identified (Lindemann, 1944;Engel, 1961) and scales of measurement developed to grade symptoms (Faschingbauer et al. 1977), including those associated with pathological or 'complicated' grief (Prigerson et al., 1995).In the hands of practitioners, the ideas of Freud, Bowlby and Parkes have been recast as stage models and used prescriptively to provide a 'clinical lore' by which recovery involves the emotional working through of these stages in a linear and timely fashion (Wortman and Silver, 1989).
Though some may find support from a symptomology of grief and the notion of working through stages, this 'normalising psychology' (Prior, 1989) may pathologise those who fail to conform to the healthy norm.Such failure, or complicated grief, refers to "grief that is too intense, too long, and impairs functioning" (Walter, 2010:75).Yet, given the limited possibilities for finding support and sharing one's experiences for those bereaved following substance misuse, being overwhelmed by grief is hardly surprising.Indeed, since this group may already feel outside the norm, such models and concepts, which imply that it is mourners not society that are the problem, may further confirm the sense of marginalisation.

Psycho-social and sociological approaches
Some theorists have sought to broaden the emphasis to address the person's social circumstances.Thus, bereavement has been conceptualised as a major psycho-social transition or 'PST' (Parkes, 1993), the pain of which relates to the loss of meaning and sense of identity arising from a severe disruption of one's 'assumptive world' (Parkes, 1993).As such, bereavement involves adapting to a whole host of changes brought about by the death, including relationships, social status, and economic circumstances.In substance misuse bereavement, the assumptive world may already have suffered severe disruption prior to the death (Oreo & Ozgul, 2007).
Combining elements of 'grief work', or the emotional working through of loss and the PST emphasis on transition and adaption, the 'dual process' model or DPM incorporates both 'loss' and 'restoration' (Stroebe and Schut, 1999).Rather than a series of stages, grief is conceptualised as a dynamic experience of moving between the past and grieving what has been lost and the future and adjusting to life without the person, gradually and unevenly becoming more focused on restoration.This perspective, though less prescriptive and more flexible than linear stage models still assumes a progression, in terms of moving towards restoration.However, as with the PST model, for those bereaved following substance misuse, the often disruptive nature of pre-death experiences raises questions about the extent to which the notion of restoration is always appropriate, particularly for those who have been living with another's substance misuse for years or if they themselves are users.
One key resource for managing the disruptive impact of traumatic bereavement on one's assumptive world and adapting to new circumstances has been identified as 'meaning reconstruction' (Neimeyer, 2002), a crucial aspect of which is 'storying' grief.As Kleinman (1988) found with chronic illness, it is through telling one's story that mourners are able to find coherence and meaning in the face of disorder and chaos.Indeed, some of the studies reviewed in Part 1 have identified how the stigma associated with bad deaths may deny mourners the opportunity for telling their story.In addition, they may have to contend with public narratives, such as those produced by the news media and the inquest that do not reflect their own experience (Walter, 2005).These findings should alert support services to the need to provide those concerned with the opportunity to tell their story, which, in some cases, may involve negotiating the impact of public narratives.
A sharper focus on the social and cultural nature of bereavement has drawn attention to the 'continuing bonds' that bereaved people may forge with deceased loved ones.Psychological perspectives have focused on the 'inner representations' of the dead with which bereaved people interact to retain a sense of continuity (Klass, 2006) and the extent to which such representations may foster healthy grieving.Sociologically, post-mortem bonds reflect the way the dead, though physically absent, may remain socially present in the lives of the living via culture-specific forms of memory making, for example, conversational remembering with others who knew the deceased (Walter, 1996) and, more recently, with wider, online social networks, which may include others who did not know the person (Walter et al., 2012).As such, continuing bonds are understood not only as internal and private, but co-constructed (Unruh, 1983).However, for those bereaved following substance misuse memory making through sharing with others may run into social stigma reinforced by media representations, which may spoil both the deceased's and the mourner's identities.Or, does the internet offer a means of enfranchising grief that is problematic in face to face situations and enable the expression of post-mortem bonds?Indeed, such stigma draws attention to how lives as well as deaths are categorised as good or bad (Bailey, 2013: 291-294), the meaning of which remains untheorised.Yet, for those bereaved following substance misuse, it is the deceased's life, which may have involved illicit activity, as much as the way they died, which gives rise to social censure.This raises important questions about how a 'bad' or 'wasted' life may be remembered and memorialised, both publically and privately.In addition to the difficulty of integrating media and inquest narratives, the growing trend towards life-centred funerals, designed to celebrate the life that was lived (Garces-Foley and Holcomb, 2005), may pose challenges for those mourning a life cut short through substance misuse.Studies of funerary and memorialisation trends do not include the experiences of those bereaved through substance misuse, yet this group's experience can shed important light on the extent to which available norms and practices provide resources or pose obstacles to mourning.

Bereavement in Families
People's experiences of grief and mourning will also reflect the interaction between wider socio-cultural norms and those of the more immediate family.Whilst there are fewer studies of bereaved families than individuals, there is inevitably some theoretical overlap, particularly in relation to the impact on family functioning and identity, the importance of communication and 'storying' grief and forming continuing bonds.Bereavement in families has been examined from two main perspectives, one being the family as a system and the other as a network of relationships.A systems approach emphasises the dynamics and functioning of the family unit, which has a life of its own distinct from but connected to individual members (Robinson, 1992).Thus, the death of a family member affects the equilibrium and functioning or life of the family as a whole.In contrast, the relational approach considers the way the meaning of family relationships and events, such as the death of a member, are part of an ongoing social construction of the family.
Drawing on both these approaches, research into bereaved families has demonstrated how, in response to the loss of a family member, surviving members may struggle to negotiate differences in the meanings that each of them gives to that loss (Nadeau, 1998;Riches and Dawson, 2000;Shapiro, 1994).Thus, whilst the family as a system will have its own norms and expectations, individual family members may respond differently to loss, in some cases causing tension (Walter, 2005;Wertheimer, 2001).Also, the changing nature of contemporary family forms, such as reconstituted families following divorce, gay couples and single parents, may cause rifts between family members, for example, a former marriage partner being excluded from those who are considered 'mourners' when their ex-wife or husband dies, with implications for communication, creating shared meanings and continuing bonds (Walter, 1999).
With families bereaved following substance misuse, a system perspective may alert us to this group's predicament in that, when viewed through the lens of the family as a structural unit, a family coping with a member's substance misuse will be seen as a dysfunctional system.In other words this frame of reference is based on assumptions about the 'normal' family from the wider society, which only serve to pathologise and marginalise families which deviate from the idealised norm.In contrast, a relational approach, rather than focusing on how things ought to be, takes a more realistic stance to explore how things are or how people do family, enabling more flexible, sympathetic and supportive ways of understanding family life (Silva and Smart, 1999).As such, it provides a promising lens for further illuminating the experiences of families bereaved through substance misuse, which has the potential to challenge the moral condemnation that is often levelled at them.In turn, this group of bereaved families provide a focus, which has the potential to significantly enhance our understanding of the family.

Conclusion
Studies that have focused on various types of problematic bereavement have identified how mourners' grief may be inhibited by obstacles to making sense of the loss through sharing with others and finding comfort in the deceased person's memory.This reflects a wider social context in which some bad deaths attract condemnation, which may stigmatise and isolate those left behind.For those bereaved following substance misuse deaths, this may involve the deceased being the subject of media interest and public representations that may be at odds with their actual experiences of the person.It may be further compounded by the impact of the substance misuse on family relationships and circumstances, including economic as well as social and psychological pressures prior to the death.Such pressures may be further complicated where those left behind are also drug or alcohol users.
Existing theoretical frames developed from other types of bereavement have highlighted the importance of finding meaning in the face of death, a process which may be more difficult when the death falls outside prevailing expectations.From a psychological perspective, bereavement as a result of a 'bad death' may give rise to 'complicated' grief, as defined by behaviour and symptoms associated with 'normal' grief.However, this approach reproduces rather than interrogates death and grieving norms and fails to address the social and cultural backdrop in which some types of loss, including substance misuse, are set apart.Though a 'continuing bonds' perspective expands conceptualisations of grief, its implications for grieving substance misuse deaths remain unexamined.Indeed, it has arguably become a new norm of healthy grieving.As a result, there are large gaps in understanding how families and individuals experience and grieve such deaths, all of which would merit exploration in future research.Such exploration, including unpacking normative assumptions of grief could, in turn, expand our understanding of death and loss in contemporary societies.