Ambiguous Loss
Ambiguous loss is unresolved grief, and grieving someone who is still alive. Ambiguous loss differs from ordinary because there is no verification of death or certainty that the person will come back or return to the way they used to be.
Ambiguous loss has been described as frozen sadness and falls into two categories:
Physically absent but psychologically present
This includes situations where a loved one is physically missing. Those who are grieving may struggle with thoughts around if their person is dead or alive, are they ok, safe etc.
Extreme examples include war, terrorism, missing people and kidnapping; natural disasters including earthquake, flood, tsunami. More common examples include adoption, divorce, immigration (with loss of physical contact with family and friends).
Psychologically absent but physically present
This includes situations where a loved one is psychologically absent; that is, emotionally or cognitively gone or missing.
Examples include dementia, addictions, chronic mental illness, physical illness (medication, brain tumours), acquired brain injury/head trauma. Psychologically ambiguous loss can also result from obsessions or preoccupations with losses that never make sense, e.g., suicide or infant deaths.
Living and caring for family members who are in either of these two categories carries not only the grief response; it can also cause strain on family structures, relationships, finances, social connections, physical health and overall wellbeing.
What to do:
Dr Pauline Boss (2006 “Loss, Trauma and Resilience; Therapeutic Work with Ambiguous Loss” 6 themes to explore for living with ambiguous loss:
Finding Meaning
Gaining Control Over the Unknowns
Reconstructing Identity
Normalising Ambivalence
Revising Attachment
Discovering New Hope
Finding Meaning:
Being able to make sense of an event or situation and eventually finding some logic, coherence or rational reasoning about what has happened.
What helps: Naming the problem, reasoned thinking, faith and spirituality; forgiveness, small acts of kindness and doing things for others and for the greater good, rituals, positive attribution, seeing suffering as inevitable, finding hope.
Gaining Control Over the Unknowns:
How we cope with a situation is influenced by beliefs about mastery (the ability to manage our life) and agency (the ability to exert power when needed to manage our life). Mastery is having a sense of control over our life. Constructive mastery is finding a balance between expectations that are too high or too low.
What helps: recognising that the world is not always just and fair, externalising the blame, decreasing self-blame, identifying past competencies, managing, and making decisions, increasing success experiences, accepting (sometimes) what will not change, knowing the exceptions, reconstructing rituals, mastering our own thoughts and emotions.
Reconstructing Identity
Identity is defined as knowing who one is and what roles one plays in relation to others in family and community. Ambiguous loss can cause loss identity for both the individual and family. It changes our understanding of who we are, the roles we play and where we belong. Some questions that may be asked include: Who am I now? who is really my family now? what roles am I expected to perform now? what community do I now belong? where is home? Redefining our identity after an ambiguous loss is essential for maintaining resilience and overall wellbeing.
What helps: establishing who the family is – who is in and out; reconstructing roles, broadening family rules for problem solving, revising family roles and tasks for rituals and celebrations; identifying positive family themes about resilience, co-constructing rituals without the person who is lost and developing shared values and views.
Normalising Ambivalence Ambiguous loss leads to ambivalent feelings, emotions and behaviours toward the lost person and others in the family. Normalising ambivalence requires acknowledging its existence. Then the ability to cope with the tension it causes, will not be so overwhelming.
What helps: normalising guilt and negative feelings (not harmful actions); using arts to increase understanding of ambivalence, regaining personal agency, seeing the community as family, asking questions about context and situation, valuing diverse ways of managing ambivalence, developing tolerance for tension, using cognitive strategies to cope.
Revising Attachment Revising our attachment to the person lost is essential for resilience. This is a gradual process and requires leaning to live with the possibility of recovery yet, simultaneously, recognising the loss may be permanent. Closure is not possible with ambiguous loss, rather the relationship is different. The goal is to accept the ambiguity and uncertainty of absence and presence i.e. Living with the ambiguity of a close attachment while finding new connections.
What helps: developing memorial ceremonies and farewell rituals, knowing fantasies of the missing person are normal, including children and adolescents in therapy when parents or siblings are lost, using arts.
Discovering New Hope Hope has many definitions; one idea is a belief in a good future. A positive belief with and expectation of fulfilment and that suffering will stop. Where loss remains unclear, extra effort is required to find hope and what one hopes for will need to change over the time the loss remains ambiguous. Unlike the previous 5 guidelines, hope can both benefit and hinder adjustment to ambiguous loss. Hope helps when it is realistic. When sadness is normalised and we let go of an impossible past and shift to a hopeful future, resilience will be strengthened, and healing will progress. Hope can hinder healing when closure and definitive answers are expected, and we hold on to the wish for life as it was.
If you or someone you know is struggling with ambiguous loss, please give us a call to set up an appointment with one of our clinicians, who will walk along side you in your pain. You can contact the clinic on 08 9409 6709.
Written by Kristen Tovey, Senior Social Worker at Masters Psychology in Perth, Western Australia. Registered with AASW as a Mental Health Social Worker.
