Ambiguous Loss:Ambiguous Loss:Concepts and Clinical Concepts and Clinical PracticePractice

Rose Collins, PhDRose Collins, PhDMinneapolis VA Health Care SystemMinneapolis VA Health Care System

Ambiguous LossAmbiguous Loss

A loss that is unclear and thus has no A loss that is unclear and thus has no closureclosure

A situation or problem that has no A situation or problem that has no answer and thus no resolutionanswer and thus no resolution

Thus, ambiguous loss can traumatize and Thus, ambiguous loss can traumatize and immobilize grief and coping processesimmobilize grief and coping processes

Due to ambiguity, individuals & families Due to ambiguity, individuals & families can’t move forward with their lives.can’t move forward with their lives.

Two Types of Two Types of Ambiguous LossAmbiguous Loss Type I: Physical absence with Type I: Physical absence with

psychological presence (e.g., psychological presence (e.g., missing, disappeared, missing, disappeared, kidnapped, military deployment)kidnapped, military deployment)

Type II: Psychological absence Type II: Psychological absence with physical presence (e.g., with physical presence (e.g., TBI, coma, dementia, addiction, TBI, coma, dementia, addiction, autism, depression etc)autism, depression etc)

Types of Ambiguous Types of Ambiguous LossLoss

Type I and Type II often overlap in Type I and Type II often overlap in the same person or familythe same person or family

Effects of Ambiguous Effects of Ambiguous LossLoss ConfusionConfusion ImmobilizationImmobilization No validationNo validation No closureNo closure ExhaustionExhaustion

Effects of Ambiguous Effects of Ambiguous LossLoss ConfusionConfusion ImmobilizationImmobilization No validationNo validation No closureNo closure ExhaustionExhaustion

Guidelines for Helping Guidelines for Helping Families Live with Families Live with Ambiguous LossAmbiguous Loss

Guidelines for Helping Guidelines for Helping Families Live with Families Live with Ambiguous LossAmbiguous Loss

Finding MeaningFinding Meaning Tempering MasteryTempering Mastery Reconstructing IdentityReconstructing Identity Normalizing AmbivalenceNormalizing Ambivalence Revising AttachmentRevising Attachment Discovering HopeDiscovering Hope

Boss, P. (2006). Loss, Trauma, and Resilience. NY: Norton

Finding MeaningFinding Meaning

Tempering MasteryTempering Mastery

Reconstructing IdentityReconstructing Identity

Normalizing AmbivalenceNormalizing Ambivalence

Revising AttachmentRevising Attachment

Discovering HopeDiscovering Hope

Boss, P. (2006). Loss, Trauma, and Resilience. NY: Norton

Guidelines for Helping Guidelines for Helping Families Live with Families Live with Ambiguous LossAmbiguous Loss

Finding MeaningFinding Meaning Tempering MasteryTempering Mastery Reconstructing IdentityReconstructing Identity Normalizing AmbivalenceNormalizing Ambivalence Revising AttachmentRevising Attachment Discovering HopeDiscovering Hope

Finding Meaning: Finding Meaning: What HelpsWhat Helps Naming the problemNaming the problem Dialectical thinkingDialectical thinking Religion and spiritualityReligion and spirituality ForgivenessForgiveness Small good worksSmall good works RitualsRituals Positive attributionPositive attribution Sacrifice for a greater good or loveSacrifice for a greater good or love Perceiving suffering as inevitable Perceiving suffering as inevitable HopeHope

Finding Meaning: Finding Meaning: What HelpsWhat Helps Naming the problemNaming the problem Dialectical thinkingDialectical thinking Religion and spiritualityReligion and spirituality ForgivenessForgiveness Small good worksSmall good works RitualsRituals Positive attributionPositive attribution Sacrifice for a greater good or loveSacrifice for a greater good or love Perceiving suffering as inevitable Perceiving suffering as inevitable HopeHope

Finding Meaning: Finding Meaning: What HindersWhat Hinders Hate and revengeHate and revenge SecretsSecrets Violent and sudden lossViolent and sudden loss DisillusionmentDisillusionment

Tempering Mastery: Tempering Mastery: What HelpsWhat Helps Recognizing the world is not always Recognizing the world is not always

just and fairjust and fair Recognizing where views of mastery Recognizing where views of mastery

originateoriginate Externalizing the blameExternalizing the blame Decreasing self-blameDecreasing self-blame Managing and making decisionsManaging and making decisions

Tempering Mastery: Tempering Mastery: What HindersWhat Hinders Too much masteryToo much mastery Too little masteryToo little mastery Ill-timed use of masteryIll-timed use of mastery Belief that one’s efforts will always Belief that one’s efforts will always

result in desired outcomeresult in desired outcome Belief that bad things can’t happen to Belief that bad things can’t happen to

good peoplegood people Blaming oneself or others for not being Blaming oneself or others for not being

able to solve the problem.able to solve the problem.

Reconstructing Reconstructing Identity: Identity: What HelpsWhat Helps Define family boundariesDefine family boundaries Select major developmental themesSelect major developmental themes Develop shared values and viewsDevelop shared values and views

Reconstructing Reconstructing Identity: Identity: What HindersWhat Hinders Discrimination and stigmaDiscrimination and stigma Forced uprootingForced uprooting Isolation and disconnectionIsolation and disconnection Hanging on to one absolute identityHanging on to one absolute identity Resisting changeResisting change

Normalizing Normalizing Ambivalence: Ambivalence: What HelpsWhat Helps Normalizing guilt & negative feelings, but Normalizing guilt & negative feelings, but

not harmful actionsnot harmful actions Using the arts to increase understanding Using the arts to increase understanding

of ambivalenceof ambivalence Regaining personal agencyRegaining personal agency Reassessing & reconstructing the Reassessing & reconstructing the

psychological familypsychological family Seeing the community as familySeeing the community as family Reassigning everyday roles and tasksReassigning everyday roles and tasks Asking questions about context & Asking questions about context &

situationsituation Bringing ambivalent feelings into the openBringing ambivalent feelings into the open

Normalizing Normalizing Ambivalence: Ambivalence: What HelpsWhat Helps Uncovering latent or unconscious Uncovering latent or unconscious

ambivalenceambivalence Managing the ambivalence, once Managing the ambivalence, once

aware of itaware of it Seeing conflict as positiveSeeing conflict as positive Valuing diverse ways of managing Valuing diverse ways of managing

ambivalenceambivalence Knowing that closure does not lower Knowing that closure does not lower

ambivalenceambivalence Developing tolerance to tensionDeveloping tolerance to tension Using cognitive coping strategiesUsing cognitive coping strategies

Normalizing Normalizing Ambivalence: Ambivalence: What HindersWhat Hinders Using only a symptom focusUsing only a symptom focus Expecting typical coping and Expecting typical coping and

adaptationsadaptations

Revising Attachment: Revising Attachment: What HelpsWhat Helps Thinking dialecticallyThinking dialectically Moving from despair to protestMoving from despair to protest Thinking systemically, but not seeing Thinking systemically, but not seeing

maladaptations as bilateral pathologymaladaptations as bilateral pathology Developing memorial ceremonies and Developing memorial ceremonies and

farewell ritualsfarewell rituals Knowing that fantasies of a missing Knowing that fantasies of a missing

person are commonperson are common Watching out for no-talk rulesWatching out for no-talk rules Paying attention to developmental Paying attention to developmental

stages that exacerbate anxietystages that exacerbate anxiety

Revising Attachment: Revising Attachment: What HelpsWhat Helps Including children & adolescents in Including children & adolescents in

therapy when parents or siblings therapy when parents or siblings disappeardisappear

Using multiple-family and couple Using multiple-family and couple groups to build new connectionsgroups to build new connections

Encouraging the use of the artsEncouraging the use of the arts

Revising Attachment: Revising Attachment: What HindersWhat Hinders An overemphasis on individuationAn overemphasis on individuation Expecting closureExpecting closure

Discovering Hope:Discovering Hope:What HelpsWhat Helps Finding spiritualityFinding spirituality Imagining optionsImagining options Laughing at absurdityLaughing at absurdity Developing more patienceDeveloping more patience Redefining justiceRedefining justice Finding forgivenessFinding forgiveness Creating rituals for ambiguous lossCreating rituals for ambiguous loss Rethinking terminationRethinking termination Revising the psychological familyRevising the psychological family

When Hope HindersWhen Hope Hinders

Persistent hope for closurePersistent hope for closure Continued longing for life as it Continued longing for life as it

used to beused to be