Ambiguous Loss
Watch our presentation on how to cope with ambiguous loss from severe mental illness here:
This article and video offer coping strategies for living with losses connected to SMI
—losses that lack clarity or resolution.
What can I do to help myself with the confusing grief I feel?
When a person has a severe mental illness (SMI), they and their loved ones experience a type of loss that is unique in its ability to cause confusion and complex grief. Developing a strategy for coping starts by naming this complex experience: It’s called ambiguous loss.
Dr. Pauline Boss, professor emeritus of family social science and a family therapist, coined the term. According to Dr. Boss, an ambiguous loss is the most stressful type of loss because resolution is impossible. “An ambiguous loss is a situational disorder beyond human expectation,” Dr. Boss says.
Dr. Boss’s writings and teachings, including from her online course from the University of Minnesota and from her seminal book, “Loss, Trauma, and Resilience: Therapeutic Work with Ambiguous Loss,” are valuable resources for anyone struggling with an ambiguous loss.
Physical presence with psychological absence
Ambiguity describes something that is unclear or can be interpreted in more than one way. In situations of ambiguous loss related to SMI, a loved one may be physically present but so psychologically changed that it feels like they are gone. The loved one may be a missing person or psychologically drift into and away from the family, depending on symptoms. Families might recognize that they have lost someone without clear evidence of losing them. Their loss is ambiguous. If the loss isn’t recognized and supported, grief gets stuck. Effects can include depression/anxiety, hopelessness, a confused identity, ambivalence, insecurity, and lost trust in the world as a fair and rational place. Family conflict is a natural result.
Grief gets stuck in part because there are no cultural rituals and rules for supporting someone experiencing an ambiguous loss. When there is nobody to bury and no typical mourning process to bring friends and family together, grief from an ambiguous loss can be quite isolating. If the loss is not recognized, further isolation can occur due to “disenfranchised grief,” which is a term coined by another researcher, Dr. Kenneth J. Doka. Family members experiencing ambiguous loss often feel this deep pain entirely alone, sometimes wrapped in guilt about whether grief is even an appropriate emotion for the moment.
Mourning what might have been
When a person is diagnosed with SMI, the path of that person’s life changes. While many are able to regain autonomy and stability, the individual and those who love them can feel complex grief for what the future might have been if SMI had not changed their lives.
An individual may feel grief for time lost to treatment or careers that are now out of reach. They may experience a sense of loss related to choices that now are influenced by how something may affect their symptoms, insurance coverage, or disability status. When SMI causes personality changes, loved ones may feel grief for the loss of the person they remember. Many grieve for the relationships they envisioned having with their loved ones over time.
Name your ambiguous loss and don’t expect closure
What you are feeling may be profound grief. With decades of experience in helping people cope, Boss always begins by encouraging people to name the stressor that they are experiencing as an ambiguous loss: “Ambiguous loss is the most stressful kind of loss because there isn’t resolution,” she says. “It’s not your fault.”
Another important realization is that closure is a myth — Boss has written a book about that (see resources below). The ongoing nature of an ambiguous loss means that getting unstuck requires coping and resilience to live well in the presence of a loss and its ambiguity, which are never going to be resolved.
Here are the six primary ways that Boss recommends for moving forward. Keep in mind that developing these skills takes time and patience and is a fluid, non-linear process. There is no “cure,” as this is not a medical disorder. Instead, ambiguous loss results from a situation that is external to the person who is affected and therefore requires ongoing support from family and community. Sharing this information with people you love may be a starting point for shared healing.
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Find meaning
Making sense of a tremendous loss starts with questions that can only be answered by the person who is grieving: “What have I lost, and what does this situation mean to me?” Naming the ambiguous loss is vital, and choosing trusted people to talk through the questions and answers is helpful. What also helps is adapting an attitude of “both, and…” People can adapt to a fluid and frustrating environment by allowing multiple emotions at once. For example, a mother can be deeply saddened by the loss of the son she imagined having at this time of life and, at the same time, feel deep love for the son here now. You may face setbacks in pursuing the answers, but thinking on the questions, discussing them, and writing down answers will enable forward momentum.
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Adjust mastery
Dr. Boss is clear: “The culprit is the ambiguity.” When an unbelievable, untenable circumstance roars into your life, a normal and healthy response is to feel unbelievably sad, confused, angry — and more. How would anyone be able to control all that? Expecting yourself to “get over it and move on” is unrealistic and cruel. Instead, learn to sit in a complex experience of ambiguous loss with acceptance that the loss will be ongoing since you may not be able to “fix” the ambiguity. At the same time, you may find empowerment by joining advocacy work to improve the broken mental healthcare system or get better help for yourself or someone you love. Finding balance between empowered action and honest acceptance about what you cannot change allows for resilience to grow. Be extra patient and compassionate with yourself on these points. Adjusting to lack of mastery or control is very difficult for most people.
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Reconstruct identity
Here’s a question to consider: “Who am I since I’ve experienced this ambiguous loss?” Follow that with: “Where do I belong now?” And then… “How do I find purpose?” Putting life on hold while waiting for an unresolvable problem to resolve is an unhelpful approach. Allowing yourself to emerge as a new version of you can begin to thaw a frozen grief.
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Normalize ambivalence
Ambivalence is a way to describe a sensation of mixed or conflicting emotions. Feelings of ambivalence are a normal response to ambiguous loss but need to be managed so they don’t become debilitating or abusive. When a loved one is gone but not gone due to SMI, for example, it’s normal to be grateful that they have not died from their illness and at the same time experience thoughts that there may be less pain if they had. It is very common to feel anger for the turmoil SMI has brought into your life while also feeling deep sadness for the person experiencing it. Holding space for these mixed feelings is a helpful way to recognize the ambiguity and can actually prevent people from acting out in ways that might be harmful or abusive to themselves or loved ones.
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Revise attachment
How can you let go while remembering? Dr. Boss talks about the dissonance between absence and presence. A person can be physically present but emotionally, cognitively, or psychologically absent. A person also might be physically absent but present in our hearts and minds. A person with SMI is the person they were before the onset of SMI while also being quite different from the memory of who they once were. Allowing for that incongruence creates space for resilience, important relationships, and a meaningful life despite the ongoing grief from ambiguous loss.
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Discover new hope
A meaningful life emerges without a requirement for closure. In other words, life can move forward with love, joy, value, belonging, and more without the ambiguous loss being resolved. Seeing possibilities while experiencing the fluid reality of ongoing grief is part of becoming comfortable with ambiguity. Boss coaches people to “play with ambiguity.” A few activities she recommends are fishing, improvisation exercises, and going for a drive “to get lost.” New hopes and dreams can emerge, she says, when you increase your tolerance for ambiguity.
Resources:
“Loss, Trauma, and Resilience: Therapeutic Work with Ambiguous Loss,” by Pauline Boss
“The Myth of Closure: Ambiguous Loss in a Time of Pandemic and Change,” by Pauline Boss
“Ambiguous Loss: Learning to Live with Unresolved Grief,” by Pauline Boss
Please note that these suggestions are for people who feel ready and able to consider self-care strategies. If moving forward feels impossible, please seek professional help. If you or someone you care for is experiencing thoughts of suicide or self-harm, call 988. Call 911 if there is a threat of violence.