Ambiguous Loss and Complicated Grief
By Holly J. Bean, Ph.D., LCPC, CRC, CTRS
COVID-19 has increased the feelings of loss, grief, and confusion for many. This is the first pandemic that we have lived through and although we may have experienced short bouts of needing to quarantine, rarely have we needed to quarantine for months at a time. This is unknown territory with unknown outcomes.
The pandemic has brought with it a change of normalcy. We are experiencing many aspects of loss, grief, and confusion. Some have lost loved ones to the pandemic while others have experienced loss in other ways, such as physical and social distancing and the ability to be with loved ones. We have lost our previous way of life due to the pandemic and are in uncharted territory. This loss brings with it complicated grieving. In complicated grief, painful emotions are so long lasting and severe that you have trouble recovering from the loss and resuming your own life (Mayo Clinic, n.d.).
Dr. Pauline Boss has done extensive research on loss and the unresolved emotions created. She coined the term ambiguous loss. Her early studies focused on Veterans who were missing in action (MIA) and the families that were dealing with not knowing what happened to their loved one. Ambiguous loss can be described as having loss without closure. Closure, such as a funeral, has the ability to bring resolution. Although we may still be grieving, we know that our loved one has passed on. In our culture a funeral typifies this ritual designed for closure. Dr. Boss notes in her book Ambiguous Loss: Learning to Live with Unresolved Grief, that ambiguous loss is the most stressful type of loss. Ambiguous loss creates a breeding ground of uncertainty that has the potential to rock our foundation. Our view of what had been our reality is shattered and brings with it complicated grieving.
The two types of ambiguous loss, as described by Dr. Boss, are physical loss and psychological loss. Physical loss is the physical absence of a loved one although they are in our thoughts, we do not know where they are or if they are alive or not. Physical loss is painful with little ability for closure. Psychological loss is where the person may still be present yet is not cognitively or physically able to participate in their previous familiar role. A loved one with dementia who is still present, yet may not be the person the family used to know would be considered psychological loss (Boss, 1999).
What experts agree on is that ambiguous loss creates uncertainty and stress (Mendoza, 2017; Boss, 1999). We may not have control over the situation caused by ambiguous loss, but we can learn to take control over our reaction to the situation. Dr. Boss notes that certain cultures have coping strategies that provide hopefulness and healthy adaptation to ambiguous loss. In the Buddhist philosophy it is considered accepting what is, without judging the situation as good or bad. In the Christian doctrine, we would consider the phrase, “let go and let God”.
Dr. Elizabeth Kubler-Ross noted the five stages of grief in her ground breaking book On Death and Dying (1969): denial, anger, depression, bargaining, and finally, acceptance. These cyclical stages are not linear and have no prescribed order. Could ambiguous loss consist of being stuck in one or more of these stages due to a lack of resolution?
Returning once again to the cultures who adapt to ambiguous loss with healthy coping strategies, it should be noted that they celebrate their loved ones. The ambiguous loss is shared by the community, with all participating in the grief and moving forward into the new situation.
Working with persons with dementia, healthy adapting techniques would include allowing the grief process of acknowledging the loss of the person we used to know while learning to find new treasures in who the person is now. In other words, letting go of the concept of the role our loved one used to play and learning to love the new role being taken on. A family that I worked with would not visit their mother, who was in advance stage dementia (Alzheimer’s type). They could not let go of their concept of who their mother was: an RN, an avid reader, an admired hostess, a volunteer with the historical society, and a life-long learner. Sadly, they never were able to learn to love who their mother is now: active, funny, intelligent (she could still recite Longfellow’s poem Hiawatha), and a joy to be with. Family members have a difficult time when faced with a loved one who no longer recognizes them. I have seen the hurt from the adult children whose parent no longer knows them. I have witnessed the hurt from a spouse that is no longer recognized. Our first reaction is typically to say, “Don’t you know me? I’m your (fill in the blank – son, daughter, wife, husband, sister, brother, aunt, uncle, neighbor, etc.). Our hurt cannot be contained. Yet, I wonder what would happen if we could accept where our love one cognitively is now? Could we be curious enough to learn more about the place our loved one resides in now, due to dementia? Perhaps, if only we could find a way out of ourselves and our own hurt.
We accept, albeit begrudgingly at times, when entertainers reinvent themselves. Could we imagine that our loved one is reinventing themselves? Could we meet them where they are instead of working to bring them back to where we are?
When we realize the final stage of Dr. Kubler-Ross’s stages of grief (acceptance) we are offered the ability to create a new relationship without our expectations getting in the way. This is a great opportunity afforded to all involved.
Ambiguity is difficult to live with, yet once acceptance is gained, the stress of uncertainty can be eased. How does one accept uncertainty? One step at a time. Acknowledging our loss, feeling the pain of the grief, continuing with our activities of daily living (eating, sleeping, showering, etc.). Therapy may provide some relief, yet how we process ambiguous loss is as individualized as the person experiencing it. Some may prefer yoga, running, hiking, while others may want to meditate or join a support group. Others may find their faith provides the comfort needed. Knowing that there are resources that can help is important. You are not alone. One such resource is: https://www.ncfr.org/resources/resource-collections/ambiguous-loss-resources
Boss, P. (1999). Ambiguous Loss; Learning to Live with Unresolved Grief. MA: Harvard Printing
Kubler-Ross, E. (1969). On Death and Dying. NY: Collier Books
Mayo Clinic. (n.d.). Complicated Grief. Retrieved from
Mendoza, M. (2017). Ambiguous Loss: How to Live with the Pain of Uncertainty. Retrieved
And finally, “…be patient toward all that is unsolved in your heart and try to love the questions themselves like locked rooms and like books that are written in a very foreign tongue…And the point is, to live everything. Live the questions now… Perhaps you will then gradually, without noticing it, live along someday into the answer” Rilke