Ambiguous Loss

Watch our presentation on coping with ambiguous loss here: 

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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, grief, and sometimes guilt. Developing a strategy for coping starts by naming this complex experience: It’s called ambiguous loss.  

Pauline Boss, PhD, professor emeritus of family social science at the University of Minnesota, coined the term “ambiguous loss,” which describes a loss that often goes unrecognized because it lacks clarity. Coping begins through acknowledgment of the loss and recognition that closure isn’t possible when circumstances are not resolvable. “An ambiguous loss is a situational disorder beyond human expectation.” says Boss. 

For example, a person with SMI may feel like they’ve lost the life they planned. They might lose friendships or housing, educational, and job opportunities. 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.  

Those who love a person with SMI may feel as though they’ve lost someone without clear evidence of losing them. While struggling to protect and support a new version of the person they love, family and friends may feel guilty for grieving the loss of someone who is still alive. All of that contradictory confusion worsens the emotional distress. Similar complicated feelings can accompany an SMI-related death from homicide, suicide, victimization, or exposure related to untreated or under-treated symptoms. 

Further complicating this experience is society’s fairly narrow depiction of grief support as something to offer when there’s a death certificate and the cause of death is typically understood (illness, accident, old age). Grieving someone who is “gone but not gone” doesn’t fit, leaving those in pain feeling unsupported. Those mourning an SMI-related death also might feel bereft of support when outsiders shy away from circumstances that make them uncomfortable or afraid. Unacknowledged grief is called “disenfranchised grief,” a concept developed by Kenneth J. Doka, PhD, a colleague of Pauline Boss who also has written many books based on his research.  

What does ambiguous loss look like? 

There are two general types of ambiguous loss: 

1. Physical presence with psychological absence: When a person is alive and nearby but not who they were before SMI or another condition changed their cognitive abilities, behavior, and/or personality. A person who is emotionally distant also can represent this type of ambiguous loss. 
2. Psychological presence with physical absence: When memories are present, but a person is missing, incarcerated, kidnapped, estranged, or deceased from an unresolvable cause such as suicide, murder, abuse, neglect, or terrorism. 

Families impacted by SMI may experience both kinds of ambiguous loss at once. For example, a person in psychosis may seem like an entirely different person (psychological absence) at the same time they are homeless, missing or incarcerated (physical absence). The grief families feel in these complex experiences is often muted by the crisis itself. Who has time to mourn when you’re trying to find a person or navigate the criminal legal system? 

Why is it important to acknowledge loss and grief? 

Over time, a person experiencing ambiguous loss but not paying any attention to it can feel stuck, frozen, isolated, anxious, insecure, and confused about who they even are anymore. Family conflict is a natural result. A shift happens when grief is seen and named, and the person feeling it opens up to accept that ambiguous losses aren’t fixable but can be survivable. 

If this rings true for you, start here: What you feel may be profound grief caused by ambiguous loss. Call out the cause of your distress. Name it ambiguous loss without blaming yourself. What has happened has interrupted your life and caused a whole host of emotions and complications, but does not represent a personal failure of will or skill. “Ambiguous loss is the most stressful kind of loss because there isn’t resolution,” Boss says. “It’s not your fault.”  

Below are six guidelines for moving onward, with three inquiry questions to help you explore each. 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.  

Find meaning 

Naming ambiguous losses and describing what each loss means to you personally is vital. What also helps is adapting an attitude of “both, and…” to allow multiple and even conflictual emotions to exist at once. For example, a mother can be deeply troubled by an adult son’s current behavior (anger, fear, resentment) while feeling deep love for him (compassion, hopefulness, empathy). One collection of emotions doesn’t have to move aside to make room for the others. It may help to journal and/or talk through these questions with trusted people. You may face setbacks in pursuing the answers, but articulating your thoughts and feelings enables a shift away from grief that feels frozen or unseen. 

• • What have I lost? 

• • What does this loss mean to me? 

• • Are there “both, and . . .” emotions? 

Adjust mastery 

When unbelievable, untenable circumstances roar into your life, a normal and healthy response is to feel betrayed, confused, grief-stricken — 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 you cannot “fix” the ambiguity. When faced with a predicament beyond your control, seek other places to direct your agency, including through mental health advocacy if it renews your sense of empowerment. Be extra compassionate with yourself on these points: Adjusting to lack of mastery or control is very difficult for most people, especially if the very thing you want to control is a confusing relationship.  

• • When do I struggle for control? 

• • What can I do instead to foster feelings of strength/resilience? 

• • What helps me let go of idealized relationships? 

Reconstruct identity 

If your family has been rearranged by ambiguous losses, everyone may be struggling to figure out their new role. Former rituals—holiday events, for example—might not work like they used to. Becoming angry and resentful is common but gets in the way of healing. Instead, each person can rethink who they are and where their talents best meet the needs of the family, community, and world. New ways of gathering and connecting can be organized. Begin by allowing yourself to see how you might re-envision your sense of self so you might emerge as a new version of you.  

• • Who am I now that I have experienced these losses? 

• • Where do I belong and find purpose? 

• • Can I let go of wanting or needing an absolute identity? 

Revise attachment 

Perhaps the world used to feel like a fair and rational place but doesn’t now? It’s easy to want things to be like they were, but desperately clinging to something that isn’t realistic anymore is exhausting. Letting go doesn’t mean you stop problem-solving and seeking justice, but it does mean that you stop clinging to how things “must be.” Acceptance of loss allows you to let yourself off the hook when life doesn’t play out as you originally planned. You also might find that it gives you more space for treasuring memories of what once was. 

• • Can I accept that someone may be gone but not gone? 

• • What helps me accept that what is real may not be ideal? 

• • How do I let go while remembering? 

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 might prevent you from acting out in unplanned ways.  

• • What mixed emotions do I feel? 

• • Can I give myself grace to feel what I feel? 

• • Can I sit with strong emotions to avoid explosive, unintended actions? 

Find new hope 

A meaningful life emerges without a requirement for closure. In other words, your life can move forward with love, joy, value, belonging, and more without the ambiguous loss getting resolved. Ending an uphill climb toward elusive old hopes is a way to save energy and forge a path toward new possibilities, even as grief is ongoing. A way to strengthen your capacity for uncertainty is to “play with ambiguity” by fishing, playing charades, tossing wildflowers into a field, cooking without a recipe, going for a walk to “get lost,” or choosing another activity that will lead to an unclear result. New hopes and dreams can emerge when you increase your tolerance for ambiguity.   

• • Am I ready to let go of old hope? 

• • How can I play with ambiguity to increase my tolerance for it? 

• • What is still possible, despite not getting the outcome I originally wanted? 

Resources:  

• AmbiguousLoss.com, a website developed by Pauline Boss, is now maintained by the University of Minnesota. Videos, research papers, and books by Dr. Boss are accessible through the website.   

• Gone Before Gone: When Mental Illness Steals Someone You Love,” by Jerri Niebaum Clark, TAC resource and advocacy manager. Part memoir, part survivalist toolkit, this self-help book offers practical strategies for people coping with grief caused by ambiguous losses. 

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.