Bereaved siblings’ stories of drug-related death

Abstract

Background

Deaths caused by problematic substance use are an international concern. In bereavement, meaning-making is an essential activity embedded in social and cultural contexts. There is a lack of knowledge about how sociocultural perceptions and stigma associated with problematic substance use and drug-related deaths influence how bereaved siblings give meaning to the loss of their loved ones.

Methods

This article investigates bereaved siblings’ meaning-making stories about the drug-related death of their brother or sister. The study involves in-depth interviews with 14 bereaved siblings, analysed via a discursive psychologic perspective.

Results

Participants used four groups of sense-making stories about drug-related deaths: ‘death as the only outcome,’ ‘death caused by difficulties in the family,’ ‘death caused by lack of public help’, and ‘stories of uncertainty and doubt.’

Conclusion

By identifying culturally constructed storylines used by participants about their siblings’ deaths, positionings of blame and responsibility are displayed, leading to social consequences that may affect how siblings bereaved by drug-related deaths cope with their loss and adapt to life without their brother or sister.

Keywords:

• Siblings
• problematic substance use (PSU), meaning-making
• sociocultural
• discourse psychology
• storyline
• positioning

Introduction

This article investigates bereaved siblings’ meaning-making stories about the drug-related death of their brother or sister. Bereaved siblings are often referred to as a ‘forgotten group’ (Bowman et al., 2014; Smith-Genthôs et al., 2017) because of the lack of research focusing upon them (Løberg et al., 2022; Templeton et al., 2018). Losing a sibling to sudden or unnatural death is a life crisis that can present an increased risk of early death (Rostila et al., 2012; Yu et al., 2017) and mental health challenges (Bolton et al., 2016; Rostila et al., 2019). Also, existing research on families bereaved after drug-related deaths, shows implications such as high risk of complicated grief reactions (Titlestad et al., 2019) and a higher level of natural cause mortality (Christiansen et al., 2020)

Meaning-making is an essential activity to enable bereaved people to adapt to their loss (Dyregrov et al., 2022; Neimeyer et al., 2014; O’Callaghan et al. 2023; Stroebe & Schut, 2010). Titlestad et al.’s (2019, p. 8) systematic review of experiences of being bereaved by drug-related death highlights ‘making sense of loss’ as essential ‘to be able to live on after the loss of a family member’. Still, many find this difficult, related to such deaths (Lambert et al., 2022). Meaning-making can be described as people’s need for ‘storying’ events and experiences by organizing them using a ‘plot structure’ with a beginning, a middle and an end. Such stories help bereaved people to retain order in a new life situation, giving significance to their loss and validation for their experiences from their social surroundings (Neimeyer et al., 2014). Bereavement is both an internal and a social process, as the bereaved usually adopt ways of understanding available to them in their sociocultural environment (Neimeyer et al., 2014). However, there is a need for more research about sociocultural factors relating to death and bereavement (Thompson et al., 2016).

Deaths caused by problematic substance use (PSU) are an international concern (European Monitoring Centre for Drugs and Drug Addiction, 2022). Sociocultural understandings about drugs, people with PSU and preconceived attitudes towards their families explain why many people bereaved by drug-related deaths experience stigmatization from society and may also stigmatize themselves (Corrigan et al., 2017; Titlestad, et al., 2019). ; Bottomley et al. (2023) shows that bereaved from overdose, especially linked their experiences of stigma, guilt, and shame to circumstances before the occurrence of death, such as the extent of the deceased’s drug use, drug use in the family or conflicts between the bereaved and the deceased. Lambert et al. (2022) and O’Callaghan et al. (2023) studies analyzed focus group interviews with family members, including siblings, bereaved after drug-related deaths. O’Callaghan et al. (2023) show that processes of acceptance of death and receiving help and support can be significant regarding posttraumatic growth for the bereaved. Still, Lamberts et al. (2022) explain their findings of why these bereaved experience stigma and difficulties in navigating support services cause difficulties in processing their grief, as caused by an understanding of drug-related deaths as ‘bad’ and not worthy of public support.

There is, however, a lack of knowledge about how sociocultural perceptions and stigma associated with PSU and drug-related deaths influence how bereaved, and particularly siblings give meaning to the loss of their loved ones. Analyses of meaning-making have provided valuable knowledge on how relatives give meaning to family members’ alcohol or substance use (Almanza-Avendaño et al., 2021; Järvinen, 2015) and how discourses of addiction have consequences for self-identity (Eriksen & Hoeck, 2022; Sibley et al., 2020; 2023; Törrönen, 2023). However, there is a lack of research exploring the meaning-making of drug-related deaths. This is an important knowledge gap, because meaning-making is essential to the grief and coping process (Cruts, 2000; Delaveris et al., 2014; Fraser et al., 2018).

The present article explores how bereaved siblings give meaning to their brother’s or sister’s drug-related death, how they position themselves and the consequences of their positionings. The aim is to develop an understanding of how such meaning-making stories are socially and culturally embedded and how they influence the coping and adjustment of siblings who have lost a brother or sister to drug-related deaths.

Methodology

This study is part of ‘The Drug-Death-Related Bereavement and Recovery Project’ (the END-project), a large Norwegian cross-sectional, mixed-methods study (2017–2024).

Participants

The participants contributing to the present study have all had a sibling who had died caused by their problematic substance use. The study is based on in-depth interviews with 14 bereaved siblings from all parts of Norway. 12 of them were recruited from a total of 79 participants who responded to a survey in the END-project, and two of them by using the ‘Snowball strategy’. The participants were purposely selected to ensure variety in terms of gender and age of both the bereaved and the deceased, place of residence and time since death (Table 1). The deaths were all related to the deceased’s PSU. The cause of death varied from overdose and health issues to murder or unknown causes.

Table 1. Participant information.

Pseudonym	Section	Sex	Age	Deceased sibling	Years since death
Adrian	A + B	male	38	Older brother	9
Betty	A	female	44	Older brother	30
Charlotte	A + B	female	30	Older brother	2
Dora	A + B	female	51	Older sister	17
Emma	A	female	32	Younger brother	5.5
Fiona	A + B	female	36	Older brother	1.5
Gina	A + B	female	35	Older brother	7.5
Hannah	A + B	female	41	Younger brother	4.5
Isabel	A + B	female	45	Younger brother	12
Julian	A + B	male	37	Younger brother	10
Kate	A + B	female	61	Younger brother	18
Lucas	A + B	male	53	Younger brother	12.5
Noah	A	male	43	Older brother	2
Olga	A	female	33	Older brother	12

Interviews

Semi-structured interviews were undertaken in two sections following two different interview guides: section A (time before death) and section B (time after death). Section A was conducted by three researchers from the END-project in 2019 (one of whom is the second author of this article). All 14 participants were involved, and the interviews took an overarching, retrospective focus on the time before death. Section B was conducted by three other researchers from the END-project in 2018 and 2019, involving 10 participants who shared their experiences after the death of their sibling. The four extra participants in section A, were added to enrich the data. Interview topics included the time before and after the sibling’s death, reactions from the person’s social network, the help and social support available, and personal growth. The interviews took place after the participants’ own requests, such as their own homes, their workplaces or hotel rooms rented by the interviewers. All interviews were conducted in Norwegian and transcribed verbatim. Quotes used in the present article have been translated into English by the first author.

Ethical considerations

All participant data is published in a non-identifiable manner by using pseudonyms and changing recognizable details about specific elements within the stories and cause of death. Some quotations have been shortened by removing filler words and digressions; some are abridged with ‘(…)’. Participants provided written, informed consent following the Declaration of Helsinki (World Medical Association, 9 July 2018), during which they were told about the study purpose, method and procedures. Adherent to Dyregrov’s (2004) recommendations regarding research with vulnerable populations, participants were given the opportunity to talk to someone after their interviews. The study was approved by the Norwegian Regional Committees for Medical and Health Research Ethics (reference number …). The transcripts of the interviews were anonymized and stored on a research server.

Analytical framework

The analysis is grounded in discourse psychology and uses concepts from positioning theory first developed by Davies and Harré (1990). From this theoretical angle, discourses are described as a ‘multi-faceted public process through which meanings are progressively and dynamically achieved’ (Davies & Harré, 1990, p. 46). Discourses frame what can be thought, said and done within the different situations people engage in and offer various possibilities for interaction by establishing certain subject positions. Positioning theory proposes a framework for studying the meanings and consequences of speech acts, aiming to understand how daily discursive practices impact the construction of social categories and how people construct themselves and others (Harré, 2015; Harré et al., 2009; Kayi-Aydar, 2021).

The essential concepts used in the analysis of the empirical data in the study are storyline, story and positioning. Participants’ stories about their sibling’s drug-related death are explored to identify storylines. A storyline is socially constructed around cultural resources, such as events, social categories and moral systems (Davies & Harré, 1990). Kayi-Aydar (2021) displays two perspectives on storylines. The first is the broad, culturally and morally constructed, taken-for-granted storyline, built on stereotypical categories that guide people in their everyday lives. The second are those emerging from conversations during the talk, referred to as stories in the present study. Stories are also culturally and morally shaped, but are constructed instinctively and naturally, as the conversation unfolds (Davies & Harré, 1990; Kayi-Aydar, 2021). The stories the participants tell draw on culturally acknowledged storylines. Several stories about their sibling’s death are told in the same interview and more than one storyline may emerge in one story.

Positioning is used to examine how identities are constructed and negotiated in interaction through formulations of talk (Davies & Harré, 1990). Positioning theory focuses on aspects of personal interaction regarding how rights and duties within a storyline are distributed among people as they perform actions. Positionings are distributed by personal actions that ascribe or resist rights and duties, and give meaning to people’s actions. The same person can move between different positions within the same discourse, depending on the context and the interaction in which the speech act occurs (Harré et al., 2009, p. 8).

Analytical procedure

To become familiar with the data, the first author started by reading the transcriptions and listening to audio files of the interviews, and selected larger extracts from the interviews that contained participants’ stories about their sibling’s death used to give meaning to their sibling death. This first step of the analysis showed that even though every story was different, they often drew on culturally acknowledged and taken-for-granted storylines found in many interviews. After sorting the data by patterns of talk and variations of understandings, and marking the meaning-making words and formulations related to understandings of their siblings’ deaths, the storylines were identified by the first, second and fourth authors. In this process significant key words were noted, to get an overview of the different storylines discovered of consistent talk from data during the reading, such as ‘accident or suicide’, talk about ‘the typical drug addict’, ‘a tough childhood’, ‘family and social environment’, ‘failures from the public services’ etc. The next step was for the first, second and fourth author to identify different positionings, in studying how the stories differed from each other by the participants either confirming or rejecting the storylines related to the death of their sibling. All authors continually discussed the analysis, text and findings, guided by the research question and led by the first and third authors. All have contributed to the final writing process of the article.

Results: stories about drug-related deaths

Participants most frequently used four groups of stories in their meaning-making of their siblings’ deaths: ‘death as the only outcome’, ‘death caused by difficulties in the family’, ‘death caused by lack of public help’ and ‘stories of uncertainty and doubt’.

Death as the only outcome

Many participants told stories about how the death of their sibling was an inevitable consequence of their extensive drug use. A storyline here was how the sibling’s death was described as a linear process from when their PSU began, how their lives were led by the strongly addictive power of drugs, resulting in their death. The storyline portrayed drugs as having the ability to take away users’ self-control with no hope for recovery and ending in death. Adrian drew on this storyline when making meaning of his brother’s death:

He had acknowledged that he was a drug addict, that’s how his life was, and then he had to take all the benefits of it, but he also had to take all the shit, with the implications that entailed. (…) By then, he had come to the conclusion that ‘I’m a drug addict, and I’m going to die as a drug addict, I guess I’ll just run the race’.

Adrian’s story showed that his brother identified with the storyline’s construction of addiction and how this made him recognize that his destiny was predicted and that death was the only outcome. Lucas confirmed this storyline, saying ‘I think it takes a miracle to get out’. His statement characterized the strong power of drugs by demonstrating the lack of possibility of escaping predestined death. This group of stories, in which death is the only outcome, produced social norms that assumed that there was limited chance to influence the situation and positioned those who struggle with PSU, and their families, as blameless for the death, giving meaning to why the families’ efforts to help did not prevent the sibling from dying. This story was used by some participants to give meaning to their own problems, or to excuse their siblings by portraying the problems they had as inherited.

Julian, whose brother died following an overdose 10 years before the interview, described his reaction as a shock, saying:

He didn’t fill these stereotypical notions of what a drug addict is. We probably imagined that, at worst, it would be sort of a downward spiral where he eventually would start to use syringes, and then, the classical story of reaching the gutter. Then, there would be a danger to his life.

Julian showed he is familiar with the storyline’s identification of a ‘drug addict’, referred to as the ‘classical story’. His portrayal of the linear process, drawing on expressions such as ‘a downward spiral’ and ‘reaching the gutter’, was related to other expressions used by participants in their descriptions of this process. Later in his story, Julian said, ‘We didn’t think there was any real danger of him taking an overdose. I guess that was related to the fact that he was never a hype’. Julian explained his shock when his brother died as a reaction to not seeing him as the stereotypical ‘hype’ (someone who injects drugs). If his brother had fitted more with the family’s understanding of a ‘drug addict’, Julian perceived that he and his family would have been more aware of his risk of death.

Kate’s younger brother who had used drugs for many years, died 18 years before the interview. Kate drew on the storyline of the power of drugs by referring to how her brother’s actions were beyond his choice. She used descriptions such as, ‘He did what he had to. I don’t think he wanted it to be like that’, ‘He is an addict, he’s never going to stop’ and ‘The high is much stronger than all of us.’ Portraying the drugs as more powerful than ‘all of us’, she showed the limitations of the help and support that the family could have given him in what she illustrates as a fight against his drug use. As such she positions both the family as well as her brother, as blameless for his death, as they all were overwhelmed by the power of drugs.

Death caused by difficulties in the family

The next group of stories showed that siblings’ deaths were caused by personal difficulties arising from family experiences. Participants talked about their own families, drawing on a storyline establishing how PSU results from adverse experiences in childhood. This was exemplified by Hannah’s story about her brother:

There are very few who see that there are very few addicts in this world who have started using drugs without experiencing something completely unbearable at the other end (…) For me, it goes without saying that my brother, he died of an overdose, he couldn’t bear to deal with the fact that he was abused as a kid.

Hannah drew a line from experiencing something unbearable (childhood sexual abuse) to dying from an overdose.

While the first group of stories drew on a storyline about how the power of drugs unburden the family from blame this second group may position the blame for the deaths within the family’s social structure and may affect relationships within the family. This story was used by some participants to give meaning to their own problems, or to excuse their siblings by portraying the problems they had as inherited.

Dora and Betty both portrayed their family members with blame. Dora explained that ‘Mom didn’t take care of us. I’m pretty sure she knew what Dad was doing to us, and that’s why my sister started using drugs and finally died.’ She drew on the storyline in making sense of how her sister’s death was caused by what their parents did (and did not do), and clearly blamed them for her sister’s death. In making meaning of her brother’s death, Betty drew on the same storyline:

It was pretty obvious – in our family there were problems. So, my brother was a symptom of everything (…) I realize that my mother didn’t have the opportunity to grow up herself. When you have a child when you’re 16, of course that’ll go to hell.

Betty also blamed her family and, by portraying her brother as ‘a symptom’, she positioned him with lack of blame for his drug use. She positioned her mother with some blame, drawing on an understanding that having a child at a young age made her unable to provide the upbringing conditions that her brother needed. Yet, concurrently, Betty also excused her mother by portraying her as a ‘teen mom’ with lack of opportunity to grow up herself, thereby positioning her with limited responsibility.

The stories of death caused by difficulties in the family led to blaming the family (or specific members) for causing the sibling’s PSU. Familiarity with this storyline also created experiences of the family being blamed without any reason, as shown by Emma:

He felt guilty that he had done this to our parents. This is not what we have been taught to do. They’ve done everything right. (…) It’s perceived as a family disease, in a way. (…) A lot of people think that ‘this can’t happen to us’, but I think that it can happen to anyone. You can help them as much as you can, but it has no use.

Emma showed that she was familiar with an established understanding of PSU being linked to family problems by relaying how it is perceived as a ‘family disease’. However, she challenged this understanding, pointing out that it did not apply to her family and debating the position of blame that often is attributed to the parents. She went further and defended her parents, stressing that they did ‘everything right’ in raising their children and therefore rendering them blameless for her brother’s PSU. In Emma’s story, her brother positioned himself with blame for what he had inflicted on his parents. Emma therefore argued against the established understanding by drawing on the storyline of ‘death as the only outcome’ and its claims that help is useless. She also exempted her family from blame by arguing that this situation can happen in any family.

Death caused by lack of public help

These stories portrayed siblings’ deaths as caused by shortcomings in the public health system regarding the help offered to people with PSU. Here, participants drew on a storyline of ‘the professionals didn’t do what they should’, which described how the public health system deprioritizes and discriminates against people who use drugs. One such example was provided by Fiona, talking about an event with her brother shortly before he died:

He was drunk and had been smoking heroin and was found on the street. He was just being given an antidote and then sent home. I thought it was horrible treatment from the health care system. This should have triggered an alarm (…) There should have been at least a report of concern to his general practitioner about a possible substance abuse problem, because it’s not normal for people to smoke heroin while drunk. (…) ‘Problem solved’, sort of, and then he dies two months later.

Fiona’s story cited the public health system and its inadequate response to her brother’s PSU as a crucial cause of his death. She drew on a storyline of the system’s responsibility to prevent development of PSU. In her brother’s case, no measures were taken when he was found on the street; rather, he was just given an antidote and sent home. This storyline was used by many participants giving meaning to their siblings’ deaths by identifying faults with the system and suggesting alternative measures. Hannah said, ‘I don’t think you need to be a scientist to understand that half a year in treatment after 17 years of drug addiction doesn’t work. You don’t get a gold medal from that. You’ll rather get a headstone.’ Her claim that you ‘don’t need to be a scientist to understand’ portrayed this as a commonly known fact and exposed a resentment towards a welfare system that had limited the length of treatment.

As in the two earlier groups of stories, this third group distributes positionings of blame, in order to give meaning to the siblings’ deaths. Two examples were found in Charlotte and Emma’s stories. When talking about what caused her brother’s death, Charlotte said that ‘He used something called fentanyl patches. (…) That’s what he died of an overdose from, and he’d been prescribed that by his doctor. (…) Why do they prescribe such things to a drug addict?’ She positioned the doctor with blame, linking the fentanyl patches to her brother’s death. Her question of why doctors ‘prescribe such things to a drug addict’ implied that doctors should know better.

Emma’s story displayed how she gave meaning to her brother’s suicide by drawing on the same storyline about how the health service should have supported her brother differently:

We thought everything was going really well when he died. By then, he had been drug-free at his longest, and was admitted to psychiatric care. He had tried to kill himself there and that’s why he was transferred to a psychiatric ward in the city. But there, they just discharged him. So, he went home and killed himself. (…) If we had known then, we could have done something.

Emma’s use of the storyline and positioning the family with limited responsibility, gave meaning to her brother’s death as out of the family’s control. By portraying psychiatric care as a source of reassurance of her brother’s wellbeing, the psychiatric ward was blamed for not doing what it should have done, which was to take proper care of her brother. Emma’s story also gave meaning to why her family did not attempt to prevent her brother’s death, reasoned by the psychiatric ward not telling them about his state, which they should have done.

Stories of uncertainty and doubt

The last group of stories were told by several participants about their uncertainties and doubts about the cause of death and how they continued to ruminate on this issue. Participants drew on different possible storylines of drug-related deaths in their contemplations about what could have happened. One example was seen in Isabel’s story about the circumstances surrounding her brother’s death:

Exactly what the cause of death was, we don’t really know. (…) Of course, there was a syringe on the table, so it was concluded that there was an overdose death. But with a small footnote, regarding difficulties in concluding, because they didn’t get a proper autopsy of him. But we wanted to know. After all, my father died early of a heart attack; ‘Is there any illness in the family?’ (…) We don’t know. He probably smoked 40 cigarettes a day as well as lots of amphetamines and a lot of other drugs and being up for several days in a row and all such things. So, that’s probably his lifestyle that caused his death.

Isabel’s story displayed how her reflections were triggered by a caveat in the forensic report. She rationalized a possible storyline about death caused by inherited medical causes or by an unhealthy or risky lifestyle, before concluding that her brother’s lifestyle was to blame. This choice of meaning-making positioned the family with limited responsibility.

Many other stories of uncertainty and doubt were activated by a partial autopsy, gaps in forensic reports, or because participants distrusted such reports. Many participants justified their distrust by referring to storylines about how death is considered as a result of a life with PSU. This included reflections on how the public health system treats these people differently to others in life and in death, exemplified by Lucas saying, ‘We know that such deaths are not a very high priority, they are just seen as “a junkie who called it a night”.’ In this group of stories, the positioning of blame was negotiated, as illustrated in Dora’s description of the circumstances surrounding her sister’s death:

She had a cocktail of drugs in her. And then she died that night, with her boyfriend present (…) Whether he is the one who killed her, or whether she couldn’t take it anymore, we don’t know. (…) Her boyfriend was immediately put in custody on suspicion of killing her. But he was quickly released, and an overdose was concluded as cause of death.

Even though Dora displayed uncertainties about what happened, she positioned her sister’s boyfriend as a possible suspect by framing the story in a context with him present at the time of death. However, her doubts about whether he was responsible meant that 17 years on, she continued to struggle to make meaning of her sister’s death.

Kate gave meaning to her brother’s death, saying ‘It’s good for me to believe that he did it on purpose, to protect my father and the rest of us, so that we wouldn’t have to start all over again. I have chosen to believe that.’ She revealed a negotiation about whether her brother died from an accidental or a deliberate overdose. Her story rejected a position of her brother as a victim, as in the story of death as the only outcome. Rather, in her meaning-making of her brother’s death, she portrayed her brother as making a respectful gesture to the family. As such, she portrayed him as caring for his family by ending their worries, meaning that she could find reconciliation with his death. Her story demonstrates how stories are crucial in making sense of experiences and how stories produce characters and feelings.

Discussion

This analysis provides insight into how drug-related deaths can be understood in several ways and how cultural context influences how they are understood by bereaved siblings. Drug-related deaths are complex phenomena that must be understood within their contexts, where several explanations may apply. The stories displayed to make sense of drug-related deaths align with Neimeyer et al.’s (2014, p. 487) description of meaning-making, as the siblings organized their experiences of losing their brother or sister using a ‘plot structure’. The use of storylines creates meaning to their loss by giving it significant validation from the social surroundings, attempting to preserve order in a life situation where they are now bereaved (Neimeyer et al., 2014). The storylines commonly demonstrate positions of blame and limited responsibility for the cause of death. The discussion below expands on how the storylines may construct consequences for the bereaved siblings’ grief processes and their access to bereavement support.

The power of drugs

In the stories about death as the only outcome, the bereaved siblings positioned their families as not to blame for their brothers’ or sisters’ deaths. Furthermore, it resonates with the dominant medical discourse that recognizes PSU as an illness, a leading paradigm in Western industrialized societies’ reactions to high-risk drug use since the early 21^st century (Bobak, 2022; Reinarman, 2005). Several studies have shown how PSU is understood as a pathologic illness, with users portrayed as victims of physiological forces outside their control (Almanza-Avendaño et al., 2021; Järvinen, 2015). The concept of ‘alcoholism as disease’ reflects a belief in the incurability of addiction (Järvinen, 2015, p. 815) and adheres to the storyline in the present study about death as the sole outcome. This medical discourse is also found in the widespread Alcoholics Anonymous (AA) movement. In a study from the late 1990s on how people recovered from alcohol addiction, Hanninen and Koski-Jannes (1999) found what they named as the ‘AA story’, drawing on the AA understanding of addiction as being an individual matter and a lifelong disease. The ‘AA story’ described how increased drinking led to various life problems culminating in the feeling of ‘hitting rock bottom’, with experiences of the impossibility of quitting drinking and the perception that ‘the only way out seemed to be death’ (Hanninen & Koski-Jannes, 1999, p. 1840). Their description of ‘hitting rock bottom’ is close to the present study storyline’s portrayal of ‘reaching the gutter’ as the turning point at which drug use becomes dangerous. The idea of the ‘victimized drug user’, understanding drug use as an individual matter, is supported by other understandings of PSU. Sibley et al. (2020) present a narrative of ‘the addict as victim of circumstance’, in which the addict is portrayed as powerless to resist the temptation of drugs, although they do not relate this to biological explanations.

The participants’ positioning of their siblings as slaves to drugs produces an understanding that death was the only outcome and that their siblings were blameless. This way of making meaning of the death can challenge the understanding that drug-related deaths are self-inflicted (Feigelman et al., 2012; Templeton et al., 2017). Viewing an unnatural death as intentional has been shown to be particularly difficult for bereaved people to adjust to. Deaths that are perceived as self-inflicted often lead to feelings of guilt and blame among the bereaved, and are also difficult for society in general to accept (Doka, 1999) because of the belief in the sanctity of life and the need to preserve it at all costs (Feigelman et al., 2012). Such deaths are often followed by both societal and self-stigma (Titlestad, Mellingen, et al., 2021) and, as consequence, the bereaved can be excluded from seeking or receiving support (Doka, 1999). The understanding of death as self-inflicted and the related stigma seems to be well known to participants in the present study. In their stories about the death being only outcome and the lack of public help, there may be storylines developing in the context of the interviews as alternatives to those in which the sibling and their families are positioned with blame. These are referred to by Holstein et al. (2013) as ‘narrative circumstances’, where the context conflicts with the storylines that are being used. Positioning the public health system with blame, and the siblings and their families as ‘unblameable’, can potentially counteract stigma and reduce the uncertainties among bereaved people that can arise from self-inflicted deaths (Guy & Holloway, 2007).

Others are to blame

The widespread understanding of how adverse childhood experiences may cause development of PSU (Valentine & Fraser, 2008) is also found in this study and is supported by other empirical evidence (Afifi et al., 2020; Dube et al., 2003; Greger et al., 2017; Shin et al., 2010). For example, research has shown a persistent relationship between dysfunctional family life and an increased likelihood of substance use when growing up (Afifi et al., 2020; Dube et al., 2003). The storyline of dysfunctional families seems to be powerful in producing stigma against those in the drug user’s close environment, such as bereaved siblings. It may be one explanation for the lack of societal understanding experienced by people bereaved by drug-related deaths (Titlestad, Lindeman, et al., 2019; Titlestad, Mellingen, et al., 2021). Consequently, the storyline can strengthen the possibility for accepting the death, reduce the blame, shame, and guilt that often follow deaths perceived as self-inflicted, and contribute to facilitating a healthy bereavement process for the bereaved siblings who position members of their own family with blame (Doka, 1999). However, among some siblings, there seems to be a strong need to defend their own family and family history. This may be related to the presence of a storyline presenting PSU as a consequence of family difficulties. Peer support, and social support from family and friends are important in the aftermath of traumatic deaths and have been shown in several studies to have a positive effect on bereavement outcomes (Dyregrov et al., 2022; Lambert et al. 2022; O’Callaghan et al. 2023; Titlestad et al., 2022). However, the influence of the socially constructed storyline about PSU as a consequence of family difficulties may create obstacles to social support for siblings. Stigma relating to association with a dysfunctional family can be a barrier to access to support after death. The concept of associative stigma (Sheehan & Corrigan, 2020) describes situations where family, friends, and relatives become affected because of their relationship to the stigmatized person. A consequence of associative stigma can be withdrawal from others, which has been proven to have a strong association with symptoms of complicated grief (Titlestad & Dyregrov, 2022).

The storyline that relates the person’s death to shortcomings in public services may affect how siblings cope with their loss. Bottomley et al. (2023) suggest underutilization or dropout of the public services an individual with PSU are offered, as one possible reason for why the family might experience feelings of responsibility and guilt. Still, research has found that blaming public services can be a common reaction among the bereaved in cases of drug-related deaths (Titlestad et al., 2020, Lambert et al., 2022) and other unnatural deaths such as suicide (Nelson et al., 2020). In the Norwegian context, this anger and blame must be understood in relation to the extensive welfare state model that is likely to generate high expectations about public services (Lindeman et al., 2023; Titlestad, Lindeman, et al., 2019). Shifting discourses on drug use also produces expectations of public services, such as what support may be offered and who is responsible. It is reasonable to assume that the reinforcement of the medical discourse (Bobak, 2022; Reinarman, 2005) has contributed to understandings of health systems as responsible for the provision of high-quality care and treatment to people with PSU.

One consequence of understanding death as caused by health system failure may be that it impedes siblings from seeking and receiving support from that same health system in their bereavement, because they do not believe in its capacity to help. Similar work has shown that some professionals find it hard to help bereaved people who are agitated and angry because of insecurity and a lack of self-confidence, which can result in professional withdrawal (Reime et al., accepted). Still, if professional help is made more readily available to this group of bereaved, opportunities will also be created to explore and help them with their grief needs and any complicated emotions due to experiences of system failure.

Rumination

In the stories of uncertainty and doubt, there are several possible proposals as to who or what could be held responsible for the death. The different stories used by participants show how they continue to ruminate on the cause of death many years after their sibling died. An autopsy can be carried out to clarify the cause of death and can offer the family important information for their bereavement process. Research from Norway and the United Kingdom has documented inconsistencies and delays in the use of autopsy, which can influence bereaved people’s meaning-making process and make it difficult for them to move on in life (Templeton et al., 2017; Titlestad et al., 2020). Delaveris et al. (2014) confirmed the underlying reasons for these stories, reporting that there are substantial differences within the different regions of Norway about whether or not an autopsy is required. It is only mandatory when death is suspected to be caused by criminal action or in cases where the deceased’s identity is unknown. In other cases, such as accidents, suicide or other sudden and unexpected deaths, the decision to perform an autopsy rests with the head of the district police department.

The issue of closure for bereaved people has been shown to be a predictor of how well they are able to cope with their loss and adapt to life without the deceased (Neimeyer et al., 2014; Stroebe & Schut, 2001). It is reasonable to propose that stories of uncertainty and doubt may have potentially harmful consequences for bereaved people, including struggling to accept the death, wondering whether it could have been avoided and whether someone is to blame. Rumination, anger, agitation and bitterness that continue over time can be signs of complicated grief processes, collectively known as prolonged grief disorder if combined with other diagnostic criteria (WHO, 2022).

Limitations and strengths of the study

Only one of the present authors was part of the interview teams collecting data for this study. Therefore the possibility to ask relevant follow-up questions was limited. The stories and storylines presented were validated by analysing both interview sections. All interviewers followed the same guide, but had different professional backgrounds and interviewing experiences, which contributed to some diversity in the topics they explored. Interviewer’s style may also have affected the length of the interviews, which lasted between 45 minutes and 3 hours. However, length was also affected by requests for breaks and differences in the length and content of their stories. Participants’ perspectives were influenced by the differences in time since death. This retrospective focus may be a strength because participants adapt to the context, saying what comes naturally and drawing on culturally available storylines rather than being primarily affected by the recency of loss.

Conclusion and implications for practice

This article has explored how siblings give meaning to their brother’s or sister’s drug-related death, how they position themselves accordingly, and the consequences of doing so. Four groups of meaning-making stories used by the siblings have been presented. The stories draw on culturally acknowledged storylines and distribute positionings of blame and responsibility.

The article provides a foundation for reflections regarding how such storylines affect how drug-related deaths are explained and understood by siblings bereaved by such deaths. Many of the stories construct meaning to the death, which can help bereaved siblings adapt to their loss. Other stories display storylines with consequences in which the siblings feel a need to defend themselves and their families. A key finding from the study is the impact upon siblings in instances where they ruminate over an unknown cause of death. This affects their meaning-making and their ability to come to terms with the loss. Finally, it is important for practitioners, politicians, and the public to be aware of possible negative consequences of the storylines, such as self-stigmatization or harm to relationships arising from blaming family members. Help to bereaved siblings should be more readily available. Our analysis points to an awareness among practitioners of how the experiences of drug-related death are multifaceted and related to meaning-making. Listening to bereaved siblings’ stories, hearing different threads in their stories and helping them think about what story they want to tell can provide fruitful help.

Disclosure of interest

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Norges Forskningsråd [300732].