What is an Ambiguous Loss?
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An ambiguous loss occurs when a significant relationship or connection to your client ends, without a clear understanding or closure. In this non-death type of loss, the uncertainty or lack of information about the lost loved one can be traumatizing for some clients. It is this not knowing or ambiguity, which prolongs the grieving process.
Clients wonder if they need to hold on or let go. This journey is an individual exploration for each person, which can be supported within the therapeutic relationship.
In the article, “Ambiguous Loss: A complicated type of grief when loved ones disappear,” Boss and Yeats state:
“Ambiguous loss is a loss that remains unclear and without resolution. It has no closure or finality because the loss is ongoing. There are two types of ambiguous loss: The first is physical, a loved one is physically absent but kept psychologically present because there is no validation of whereabouts or status as dead or alive. In such a context of doubt, hope for the return of the lost person continues. The second type of ambiguous loss is psychological: a loved one is physically present but psychologically absent due, for example, to memory loss and cognitive impairment, as a result of dementia from Alzheimer’s disease or one of the over fifty other diseases or injuries that cause dementia.”
Additional examples of ambiguous loss can include lost or missing persons or pets, trauma, mental or physical illness, substance use disorders, disconnection or estrangement from family or friends, moving, divorce, or a loss of employment.
A Disenfranchised Grief
Society as a whole does not acknowledge this type of grief, which further complicates the healing process. Denial of grief can add another layer of pain on top of the existing sorrow. Since this is not a clear-cut type of loss, many in society do not consider these types of “death” as significant.
A disenfranchised grief is unrecognized and undervalued in our society. When grief is not acknowledged, validated, and given the space to air out amongst others, it worsens a person’s mood, functioning, and relationships. For many, the grief remains frozen and stuck inside a person’s mind, body, and spirit. People who experience ambiguous loss and disenfranchised grief often second-guess their feelings, and experience anger, shame, or guilt. These are all normal grief feelings, which once expressed, can be healed.
The research on ambiguous grief is lacking, which puts counselors at a disadvantage when trying to help clients who face these types of losses. It can even put clients at risk from counselors disenfranchising their grief, due to a lack of understanding on their part. Knight and Gitterman (2018) state:
“Ambiguous grief results from a non-death loss and has received minimal attention in the social work literature. This type of loss occurs in situations like missing persons, incarceration, military deployment, adoption, foster care, and chronic conditions like dementia. The reactions of loved ones faced with these situations rarely have been understood as a form of grief. The lack of recognition of ambiguous loss means that it is more likely to be disenfranchised, which undermines bereaved individuals’ resilience and ability to move on with their lives.”
The Covid Pandemic
The Covid pandemic has presented many clients with ambiguous losses, and complicated and disenfranchised grief.
In the beginning of the pandemic, many people could not be physically present with their loved one, who was dying. This lack of closure and ritual led some to experience an ambiguous loss and prolonged grief. Research was conducted on 40 participants from different Italian cities, where the Covid pandemic first spread (Testoni et al., 2021):
“The main themes of emotional experiences were: abandonment, anger and guilt, dehumanization/disappeared, derealization and constant rumination. Grief had a complex profile: on the one hand, it was traumatic and characterized by all the risk factors causing mourners to experience prolonged grief, but on the other, some features were similar to ambiguous loss (that occurs without closure and clear understanding) because of the impossibility to be with their relatives in their final moments.”
According to Kaur-Aujla, Lillie, & Wagstaff (2022):
“In search of reasoning, models and theories that explain the sweeping mass destruction that Covid-19 has caused, key concepts arise in terms of how we should deal with losses and in turn support patients in the health and social care sector, (notwithstanding formal therapeutic services). There is a crucial need to embrace ambiguous loss and disenfranchised grief into everyday terminology and be acquainted with these issues, thereby adapting how services/clinicians now embrace loss and grief work. Integral to this process is to recognize that there has been a disproportionate impact on Black and minority ethnic communities, and we now need to ensure services are ‘seriously culturally competent.’”
How to Best Support Your Clients
When others do not recognize a client’s loss as significant, it is important the counselor does. Since this loss is not acknowledged, the person who grieves does not participate in society’s rituals for those who have died. A part of your therapy work can be finding a way to remember the person or the relationship your client misses and grieves for. This can include normalizing grief reactions and creating rituals. Sometimes, you may participate in a ritual or encourage your client to participate in rituals to assist with the healing process.
Empathic counseling supports the client and offers validation for the loss. Listen and hold the space for your client to express in a nonjudgmental setting. Next, mirror back to the client the meanings expressed. You can check in with the client and ask, Did I get that right? This is done to ensure you are continuing the empathic connection accurately. If the client feels you did not understand correctly, ask for the client to express again and re-check in.
Journaling helps process complicated feelings that accompany an ambiguous loss. Clients can express all the feelings that arise from loss, without judgment. Writing can increase their newfound self-awareness, process feelings, integrate and create a new reality. Some clients may want to keep their journals private to ensure they have a safe place to vent about their difficulties.
As the counselor, it is important to respect how much the client wishes to share in the session. Some clients may want to share what they write in a counseling session, while others do not. Honor whatever your client desires for their healing.
For some types of ambiguous loss, there are support groups. Clients can find some online groups, and others may find groups in person. Support groups can help normalize the feelings your client experiences, be a place where they can express their grief, and receive understanding.
Prolonged, Persistent, or Complex Grief
Some clients can develop symptoms of depression, anxiety, or other mental health issues, during an ambiguous type of loss. It is important for counselors to complete a thorough assessment, including past grief experiences and a mental health diagnostic evaluation.
From the article, “Prolonged Grief Disorder: Diagnostic, Assessment, and Treatment Considerations,” the authors, Jordan and Litz state, “The disruption associated with bereavement can trigger various disorders, including not only prolonged grief disorder (PGD) but also major depression and posttraumatic stress disorder (PTSD).”
Due to the lack of closure or ending with an ambiguous loss, it often leads to complicated grief. When there is no official death, it can prolong and delay the grieving process. Our job as a counselor can help clients express their feelings and find meaning while living within the uncertainty.
Diagnosis
The Diagnostic and Statistical Manual of Mental Disorders has no official diagnosis for ambiguous loss. However, your client’s symptoms may meet the proposed criteria for persistent complex bereavement disorder or prolonged grief disorder.
The National Library of Medicine’s “Grief, Bereavement and Coping with Loss,” states:
“The DSM-5 and ICD-11 include bereavement as a diagnosable code (PDQ Supportive and Palliative Care Editorial Board, 2022): Persistent complex bereavement disorder, when elevated grief continues for 12 months for adults and 6 months for children (DSM-5). Prolonged grief disorder, when elevated grief continues 6 months after the death (ICD-11).”
Prolonged Grief Disorder from The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision, DSM-5-TR
Diagnostic Criteria
A. The death, at least 12 months ago, of a person who was close to the bereaved individual (for children and adolescents, at least 6 months ago)
B. Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinical degree. In addition the symptoms have occurred nearly every day for at least the last month:
- Intense yearning/longing for the deceased person
- Preoccupation with thoughts or memories of the deceased person
C. Since the death, at least three of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month:
- Identity disruption (e.g., feeling as though a part of oneself has died) since the death
- Marked sense of disbelief about the death
- Avoidance of reminders that the person is dead
- Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death
- Difficulty reintegrating into one’s relationships and activities after the death
- Emotional numbness as a result of the death
- Feeling that life is meaningless as a result of the death
- Intense loneliness as a result of the death
Lisa Hutchison, LMHC
Writer & Contributing ExpertLisa Hutchison, LMHC, is a licensed mental health counselor for the Commonwealth of Massachusetts. She works for professionals who want to treat and prevent compassion fatigue. With over 20 years of psychotherapy experience, she helps her clients assert themselves, set boundaries, and increase their coping skills. Her specialty is decreasing stress, anxiety, and depression while increasing realistic methods of self-care for those who help others. Ms. Hutchison’s psychological advice has been featured in Reader’s Digest and the Huffington Post. Her articles have been published in numerous magazines, including Grief Digest and Today’s Caregiver.
Lisa is the bestselling author of I Fill My Cup: A Journal for Compassionate Helpers and a faculty member writer for NetCE. Her latest continuing education unit publication is “Setting Ethical Limits for Caring and Competent Professionals.” She has taught creative writing in colleges and presented on boundaries for the compassionate helper; the use of expressive art to heal grief, anxiety, and depression; inspirational and motivational topics; and creative writing techniques.