The intangibleness of ambiguous loss  

by Anne-Kirsten Maclachlan

“It would be easier if he were dead” I heard myself say in a half whisper, looking down at the floor, unable to recognise in those words the love for my husband of more than 20 years.

“It would be easier if he were dead” came the calm response of my therapist. Was it calm, or was it judgment, was it understanding of the excruciating pain I had experienced for over two years?

My life as I knew it was gone and I could not make any sense of any of this. How could this beautiful man change so much and say the things he said and become someone I no longer knew. He sounded the same, looked the same, smelt the same, and yet was not the same, with eyes that had become cold, and soul-less. My stability, my friend, my partner, my life, it was all gone and what was left was terrifying uncertainty. I was experiencing the death of my life, yet I was alive. I was experiencing the death of my marriage, yet he was alive. I was experiencing an unfamiliar empty space, yet he was present in emails and occasional visits. It was like being in an inside out, upside down world where none of the familiar parameters existed. I was airborne and I had no idea how to land.

“It would be easier if he were dead.” The words echoed in my ears, the words of my client, not mine, and with those I was brought back with a jolt to our session. “Can you understand?” I heard her and composed myself. Did I truly understand? This time, it was not my husband of 20-plus-years, it was hers, this devastated 40-year-old woman sitting in front of me was pleading and yes, I did understand.

I sat as I allowed her the space to spit venom, to cry uncontrollably, in turn demonising then forgiving him, looking for an explanation, blaming herself, feeling guilty, and excusing him. The pattern that was so familiar to me repeated in our sessions, week in and week out, going around and around in an endless loop of highs and lows, of hope followed by cruel disappointments, stuck like a needle on an old vinyl. I would breathe a sigh of relief when she would say she had let go, and my heart would sink when she would say: “oh you know he came by for coffee last weekend and we talked, and it felt like him again, not the awful monster of the other day who was shouting at me. Maybe this means he is coming back”.

Had I not experienced the traumatising loss of a marriage breakup and learned what type of loss this was, how would I have been able to understand the emotional lability of my client, and been able to support her adequately? I would have most likely relied on bereavement models, such as the 5-Stage Model of Elizabeth Kübler-Ross (2001) I had learned in college and assumed my client was in the early stage of the process. Maybe I would have switched to the Dual Process Model of Stroebe and Schut (Stroebe & Schut, 1999). Perhaps Worden (2010) would have been remembered, with the focus ultimately being on finding ‘closure’ and move on from the marriage. I would have felt I had failed her, that I had missed something, as she appeared not to improve, not to let go as she professed, and changing her story all the time. I would probably have lost patience having used everything in my toolbox, defeated at the lack of closure that would have signalled the successful end of therapy.

What this client was experiencing was a type of disenfranchised loss called ‘Ambiguous Loss’, a term coined in the 1970s by Dr. Pauline Boss, during her work with the families of the missing to describe the 

concept of a person who could either be “psychologically present while being physically absent” or conversely “physically present while being psychologically absent” (Boss, 2016, p. 270). The first definition can be applied in the case of a missing person when it is not known if they are alive or dead, and it can also be applied in cases of relationship ruptures such as divorce, where a person remains present in the mind of family members, at the same time, is no longer physically part of that family. The second definition can be illustrated in cases of mental impairment, seen in dementia or Alzheimer’s disease, where a person is there physically but is no longer psychologically available to those around them (Boss, 2004, 2010).

The loss can be traumatic, sudden, and incomprehensible, leading clients to cycle in their process and appear stuck in their grief (Boss, 2007). The symptoms can include depression, anxiety, loss of control, even hopelessness, resulting in an inability to cope, move through or grieve a situation as a consequence of the stress of having no clear resolution to said situation (Boss & Couden, 2002). The shock associated with ambiguous loss can be experienced as post-traumatic stress and can present in clients as complicated grief (Boss, 2010).

Boss (2010) wrote:

ambiguous loss is unclear loss; ambiguous loss is traumatic loss; ambiguous loss is a relational disorder; ambiguous loss is externally caused (e.g., illness, war), not by individual pathology; ambiguous loss is an uncanny loss – confusing and incomprehensible (138) and it is found in many life situations (Boss, 2010; Boss & Yeats, 2014; Jackson, 2018).

Sadly, the trauma that may accompany this loss is often not recognised by others (Rycroft & Perlesz, 2001, as cited in Betz & Thorngren, 2006). Ambiguous loss has devastating and exhausting effects physically, cognitively, behaviourally, and often opposing in nature emotionally (Betz & Thorngren, 2006).

Though symptoms are similar to those of bereavement loss, what separates ambiguous loss from bereavement loss is that the absent person is (or may still be) alive, and this ambiguity does not allow for the grief to come to a natural end (Boss, 2010). Moreover, in ambiguous loss, none of the usual societal rituals seen in bereavement are present, making closure elusive (Boss, 2004). In a study carried out, where therapists employed a stage-based bereavement model when counselling clients who were experiencing the loss of a missing person, poor responses were noted in sessions. Clients felt that the missing person was assumed to be dead, and that removed any hope of a return that had been held onto. They could not accept the idea of closure, and therapy was found not to help (Glassock 2006). Boss (2010) put forward the precept that traditional therapies are inadequate in cases of ambiguous loss, as grief work has traditionally been focused on attaining closure (Beckett & Dykeman, 2017), whereas in cases of ambiguous loss, the aim of the work is in supporting clients in their understanding and acceptance of the ambiguity they face, promoting changes in perspectives and coming to terms with the possibility that there may never be a resolution to the situation (Boss & Yeats, 2014).

Boss developed a theory to facilitate this work, which comprises six guidelines, namely “finding meaning, tempering mastery, reconstructing identity, normalising ambivalence, revising attachment and discovering hope” (Boss & Yeats, 2014: 67-68), illustrated by the following diagram:

Contrary to bereavement models which have been at times linear, stage and task-based, this process is circular. Any aspect can be engaged with, in no particular order, with the intention that each would eventually be looked at. The theory encourages dialectical thinking to help find meaning, and advocates an open dialogue regarding the presence of ambiguity (Boss & Couden, 2002; Boss & Yeats, 2014; Jackson, 2018). The cornerstones of the theory are allowing change, redefining roles, identity and attachments in the context of the loss, supporting clients in coming to terms with conflicting feelings and finally, finding hope, with new meaning for a different future (Boss & Yeats, 2014).

One of the most challenging aspects that therapists can encounter when working with ambiguous loss, is witnessing clients holding on to the hope of a return of the missing person, when everything would point to this being an impossibility. Jackson (2018) is a strong proponent that without hope, a person may become more distressed and hopeless and coping with ambiguity may therefore become more difficult. Hope can provide a space for acceptance, and movement through the ambiguity, helping a person withstand the loss more easily, and it can even promote the opportunity for them to re-discover who they were before their experience of ambiguous loss (Wayland, Maple, McKay, & Glassock, 2016).

Further challenges may also arise for those therapists who do not hold similar views regarding faith and spirituality as their clients and for those who may question their professional abilities in front of clients that appear to remain stuck in their grief (Boss, 2004, 2006, 2007, 2010, 2017; Boss & Carnes, 2012, Wayland & Maple, 2020).

Ambiguous loss theory has been conceptualised as a framework for therapeutic interventions in various populations, examples of which are: the loss experienced by adults who remain single (Jackson, 2018), parents experiencing the effect of premature births (Golish & Powell, 2003; Wilson & Cook, 2018), families of an autistic child (Blankenship, 2016; O’Brien, 2007), trans-genderism (McGuire, Catalpa, Lacey, Kuvalanka, 2016) and women seeking support in occurrences of miscarriage (Pettyjohn & Schwerdtfeger Gallus, 2018). Recently, ambiguous loss theory has emerged in relation to newer phenomena such as social media ghosting (LeFebvre & Fan, 2020), and most currently, Covid-19 and its effect on mental health (Bertuccio & Runion, 2020; Zhai & Du, 2020)

Pauline Boss, amongst others, calls for therapists to be trained to meet the demands of ambiguous loss, to recognise their own personal experiences of this loss, to develop patience, tolerance, and manage any frustration when faced with the cyclical process of clients, accepting there may be no answer to situations, and change the focus of therapy away from finding closure, towards acceptance of the presence of ambiguity (Boss & Yeats, 2014).

And as I sat with my client, holding all this information in my head, I relaxed, knowing I could lean on a structure and a framework to work from, seeing her eventually come to terms with the impossible. Once the ambiguity was exposed and accepted, once the symptoms were explained and understood, the real work of healing could begin.

 

Anne-Kirsten MacLachlan is a pre-accredited Humanistic and Integrative psychotherapist, working in private practice in Dublin. She is a former student of Turning Point Institute and holds a MSc degree with UCC. Her master’s thesis (unpublished) on Ambiguous Loss informed this article

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IAHIP 2022 - INSIDE OUT 96 - Spring 2022