Living with Grief: Understanding Ambiguous Loss
Photo courtesy of ICRC
Today is World Mental Health Day
“You will not ‘get over’ the loss of a loved one; you will learn to live with it. You will heal and you will rebuild yourself around the loss you have suffered. You will be whole again but you will never be the same. Nor should you be the same, nor would you want to.” (Elizabeth Kübler-Ross & David Kessler).
The literature on grief and loss is extensive and identifies different types of grief, ranging from normal grief, anticipatory grief (the impending loss of a loved one), complicated grief (more intense, affecting ability to function in daily life), chronic grief (when the intensity is prolonged and does not subside), delayed grief (when the grief reaction occurs a long time after the event), to name a few. However, there is less research undertaken on the experience of losing a significant other, where that person is either missing or disappeared. This article focuses on this unique type of grieving known as ambiguous loss.
The term ambiguous loss was first used in the 1970s by Dr Pauline Boss, an American psychologist and family therapist, when she was undertaking research on the families of soldiers who went missing in action (Boss, 2006). Dr Boss later developed a model for working with ambiguous loss which is now used globally by mental health professionals as well as humanitarian workers.
Ambiguous loss describes a unique kind of grief and loss where the loved one is either physically absent but psychologically present or is psychologically absent but physically present (Boss, 2017). An example of the latter is a family member suffering from a degenerative condition such as Alzheimer’s Disease. This article will explore the former where a loved one has disappeared and those left behind do not know whether that individual is alive or dead. Ambiguous loss is especially relevant in the Sri Lankan context where the number of missing persons as a result of armed conflict and past youth insurrections is estimated to be in the thousands, affecting all communities in Sri Lanka (ICRC report, 2016).
When a death occurs, no matter how traumatic and painful, there is both legal and social clarity. There is a death certificate; there are rituals, religious or secular, to honour the deceased and dispose of the mortal remains; there is the opportunity to mourn, both individually and as a community (Boss, 2017). The rituals following a death help give meaning to what has happened and provide a degree of comfort for the bereaved.
When a person disappears and there is no official verification of death, the family members are left struggling at multiple levels. There is no legal proof of death and thus no certainty about the fate of the missing person. The family members’ grief and trauma is compounded by the fact that their loss is not viewed as genuine by the law, by religious institutions or by the wider community, in the way it would be with a body and a verified death. With ambiguous loss, the most fundamental processes that we take for granted in the aftermath of a death are not possible: a funeral, a memorial service, rituals, condolence visits. The very lack of a body makes it much harder for families to accept the loss as permanent and leaves those around them confused as to how to respond. In Sri Lanka, the rituals of mourning form an important part of people’s religious and cultural lives. For those in mourning, these rituals are a part of daily life and are believed to enable the deceased to transition peacefully into the next life or the spiritual realm, and furthermore to allow the living to continue with their lives unhindered (ICRC Report, 2016). There are remembrance rituals for the deceased performed on an annual basis involving family and community. Without a body, none of these essential rituals are possible. There is no solace and family members are often left to cope alone because the wider community also struggles to know what to do or how to help.
In the normal grieving process, people ultimately reach a place where they are able to accept the loss; the overwhelming nature of the grief gradually lessens and while it never disappears entirely, it does become more manageable over time. For family members who are experiencing ambiguous loss, this process is stymied and takes on the characteristics of complicated grief wherein the feelings of loss are so intense that they become debilitating. In complicated grief, painful emotions are severe and long lasting and the person is unable to reach that stage of acceptance of the loss. The grief remains frozen.
For mental health practitioners who are working with ambiguous loss, there is a need to think in a new way about grief and loss where the emphasis is less on closure but far more on increasing a tolerance for unanswered questions. As there is no resolution in ambiguous loss, the goal of interventions, whether for an individual or for family members, is to build resilience for ambiguity. One of the key ideas in Dr Pauline Boss’ ambiguous loss model is that of “both-and” thinking (Boss & Carnes, 2012). “Both-and” thinking is when we hold two opposing ideas in our minds simultaneously. An example would be: “My husband is both gone and still here” or “Our father is both likely dead or maybe not dead”. It is far easier for family members to start thinking in this way if practitioners are also able to recognise that it is not possible to find perfect solutions for people experiencing ambiguous loss. Ambiguous loss is, by its very nature, without an end point. For this reason, it is important for family members to identify some kind of new hope, one which does not have the missing person as its focal point. “Both-and” thinking can also be helpful in this process: hoping for the return of the missing person while at the same time moving forward with new plans, hopes and dreams. While new hope will not bring an end to the grief, it will help forward movement despite the pain of ambiguous loss; understanding this can be an invaluable resource for families.
Another key element in Dr Boss’ model is that of the psychological family; the idea that families do comprise of both physical entities as well as psychological ones, those present as well as those absent; and that we can rely equally on both at different times. In this way, a wife may hold onto her missing husband psychologically and look to him to guide her in her new role as head of the household, imagining what he might have done and then doing the same. For others, this psychological support may be linked to their faith; practitioners need to be open to whatever helps people develop the resilience they need to live with ambiguous loss.
In addition to dealing with trauma and grief, families of missing persons also face a number of other challenges that are consequences of ambiguous loss. The ICRC carried out a Family Needs Assessment (FNA) in Sri Lanka from 2014 to 2015. The FNA found that while the families’ greatest need was to establish what had happened to their loved ones, they also had economic, legal and administrative needs. Furthermore, these needs were linked to mental health issues; families reported emotional struggles as their second biggest problem after economic and financial difficulties. This is indicated in the FNA’s statistics: out of 56% of all families that experienced economic challenges, 86% had symptoms of anxiety and depression (ICRC Report, 2016). Families of the missing often face isolation, and this is not only because they feel unable to talk to friends or neighbours about their issues which they feel are not understood. Another factor is to do with certain prevailing cultural beliefs in South Asian societies in relation to widowhood where the widow is seen as bringing bad luck. This is especially the case in rural areas in Sri Lanka and results in the wives of the missing often being excluded from participating in cultural or religious functions as their very presence is believed to be inauspicious. They are thus stigmatized by their communities.
In many instances, the missing person was the main breadwinner; data indicates that the majority of missing persons are male and just under half were married at the time. Families faced financial hardships and the absence of a death certificate proved to be a barrier in accessing a range of legal and administrative services. The ICRC provided technical support and expertise to the Sri Lankan authorities for the introduction of a “Certificate of Absence” in the Sri Lankan law (in lieu of a death certificate).
The ICRC developed an Accompaniment Programme which had three primary objectives: 1) providing psychosocial support to cope with ambiguous loss and raising awareness among authorities and mental health practitioners about ambiguous loss; 2) referral services for families to help resolve legal, administrative and economic needs; and 3) providing economic support to restart livelihoods.
A study published in 2020 in the Conflict and Health journal looked in detail at how the psychosocial component of the Accompaniment Programme has helped to increase understanding and raise awareness of ambiguous loss both among the families of missing persons as well as among professionals (Andersen et al, 2020). The groupwork with family members, one of the key components of the Accompaniment Programme, has proved to be an effective tool. For family members, naming the issue and understanding that they are not suffering alone, being able to share their experience of loss with others similarly affected, has made a significant difference in their ability to cope, to feel hopeful and to live with ambiguous loss.
References
Living with Uncertainty: Needs of the Families of Missing Persons in Sri Lanka, ICRC Report, July 2016
Living with Absence: Helping the Families of the Missing, ICRC Report, August 2014
Boss, P. (2006). Loss, Trauma and Resilience: Therapeutic Work with Ambiguous Loss, Norton Professional Books.
Boss, P. (2017). Families of the Missing: Psychosocial Effects and Therapeutic Approaches, International Review of the Red Cross, 99 (2), 519-534.
Boss, P. & Carnes, D. (2012). The Myth of Closure, Family Process, Vol. 51.
Andersen et al (2020). Mental Health and psychosocial support for families of missing persons in Sri Lanka: a retrospective cohort study, Conflict and Health.
