1. Ambiguous Loss: Concepts and Clinical Practice Rose Collins, PhD Minneapolis VA Health Care System

2. Ambiguous Loss A loss that is unclear and thus has no closure A loss that is unclear and thus has no closure A situation or problem that has no answer and thus no resolution A situation or problem that has no answer and thus no resolution Thus, ambiguous loss can traumatize and immobilize grief and coping processes Thus, ambiguous loss can traumatize and immobilize grief and coping processes Due to ambiguity, individuals & families can’t move forward with their lives. Due to ambiguity, individuals & families can’t move forward with their lives.

3. Two Types of Ambiguous Loss Type I: Physical absence with psychological presence (e.g., missing, disappeared, kidnapped, military deployment) Type I: Physical absence with psychological presence (e.g., missing, disappeared, kidnapped, military deployment) Type II: Psychological absence with physical presence (e.g., TBI, coma, dementia, addiction, autism, depression etc) Type II: Psychological absence with physical presence (e.g., TBI, coma, dementia, addiction, autism, depression etc)

4. Types of Ambiguous Loss Type I and Type II often overlap in the same person or family Type I and Type II often overlap in the same person or family

5. Effects of Ambiguous Loss Confusion Confusion Immobilization Immobilization No validation No validation No closure No closure Exhaustion Exhaustion

6. Effects of Ambiguous Loss Confusion Confusion Immobilization Immobilization No validation No validation No closure No closure Exhaustion Exhaustion

7. Guidelines for Helping Families Live with Ambiguous Loss

8. Finding Meaning Finding Meaning Tempering Mastery Tempering Mastery Reconstructing Identity Reconstructing Identity Normalizing Ambivalence Normalizing Ambivalence Revising Attachment Revising Attachment Discovering Hope Discovering Hope Boss, P. (2006). Loss, Trauma, and Resilience. NY: Norton

9. Finding Meaning Tempering Mastery Reconstructing Identity Normalizing Ambivalence Revising Attachment Discovering Hope Boss, P. (2006). Loss, Trauma, and Resilience. NY: Norton

10. Guidelines for Helping Families Live with Ambiguous Loss Finding Meaning Finding Meaning Tempering Mastery Tempering Mastery Reconstructing Identity Reconstructing Identity Normalizing Ambivalence Normalizing Ambivalence Revising Attachment Revising Attachment Discovering Hope Discovering Hope

11. Finding Meaning: What Helps Naming the problem Naming the problem Dialectical thinking Dialectical thinking Religion and spirituality Religion and spirituality Forgiveness Forgiveness Small good works Small good works Rituals Rituals Positive attribution Positive attribution Sacrifice for a greater good or love Sacrifice for a greater good or love Perceiving suffering as inevitable Perceiving suffering as inevitable Hope Hope

12. Finding Meaning: What Helps Naming the problem Naming the problem Dialectical thinking Dialectical thinking Religion and spirituality Religion and spirituality Forgiveness Forgiveness Small good works Small good works Rituals Rituals Positive attribution Positive attribution Sacrifice for a greater good or love Sacrifice for a greater good or love Perceiving suffering as inevitable Perceiving suffering as inevitable Hope Hope

13. Finding Meaning: What Hinders Hate and revenge Hate and revenge Secrets Secrets Violent and sudden loss Violent and sudden loss Disillusionment Disillusionment

14. Tempering Mastery: What Helps Recognizing the world is not always just and fair Recognizing the world is not always just and fair Recognizing where views of mastery originate Recognizing where views of mastery originate Externalizing the blame Externalizing the blame Decreasing self-blame Decreasing self-blame Managing and making decisions Managing and making decisions

15. Tempering Mastery: What Hinders Too much mastery Too much mastery Too little mastery Too little mastery Ill-timed use of mastery Ill-timed use of mastery Belief that one’s efforts will always result in desired outcome Belief that one’s efforts will always result in desired outcome Belief that bad things can’t happen to good people Belief that bad things can’t happen to good people Blaming oneself or others for not being able to solve the problem. Blaming oneself or others for not being able to solve the problem.

16. Reconstructing Identity: What Helps Define family boundaries Define family boundaries Select major developmental themes Select major developmental themes Develop shared values and views Develop shared values and views

17. Reconstructing Identity: What Hinders Discrimination and stigma Discrimination and stigma Forced uprooting Forced uprooting Isolation and disconnection Isolation and disconnection Hanging on to one absolute identity Hanging on to one absolute identity Resisting change Resisting change

18. Normalizing Ambivalence: What Helps Normalizing guilt & negative feelings, but not harmful actions Normalizing guilt & negative feelings, but not harmful actions Using the arts to increase understanding of ambivalence Using the arts to increase understanding of ambivalence Regaining personal agency Regaining personal agency Reassessing & reconstructing the psychological family Reassessing & reconstructing the psychological family Seeing the community as family Seeing the community as family Reassigning everyday roles and tasks Reassigning everyday roles and tasks Asking questions about context & situation Asking questions about context & situation Bringing ambivalent feelings into the open Bringing ambivalent feelings into the open

19. Normalizing Ambivalence: What Helps Uncovering latent or unconscious ambivalence Uncovering latent or unconscious ambivalence Managing the ambivalence, once aware of it Managing the ambivalence, once aware of it Seeing conflict as positive Seeing conflict as positive Valuing diverse ways of managing ambivalence Valuing diverse ways of managing ambivalence Knowing that closure does not lower ambivalence Knowing that closure does not lower ambivalence Developing tolerance to tension Developing tolerance to tension Using cognitive coping strategies Using cognitive coping strategies

20. Normalizing Ambivalence: What Hinders Using only a symptom focus Using only a symptom focus Expecting typical coping and adaptations Expecting typical coping and adaptations

21. Revising Attachment: What Helps Thinking dialectically Thinking dialectically Moving from despair to protest Moving from despair to protest Thinking systemically, but not seeing maladaptations as bilateral pathology Thinking systemically, but not seeing maladaptations as bilateral pathology Developing memorial ceremonies and farewell rituals Developing memorial ceremonies and farewell rituals Knowing that fantasies of a missing person are common Knowing that fantasies of a missing person are common Watching out for no-talk rules Watching out for no-talk rules Paying attention to developmental stages that exacerbate anxiety Paying attention to developmental stages that exacerbate anxiety

22. Revising Attachment: What Helps Including children & adolescents in therapy when parents or siblings disappear Including children & adolescents in therapy when parents or siblings disappear Using multiple-family and couple groups to build new connections Using multiple-family and couple groups to build new connections Encouraging the use of the arts Encouraging the use of the arts

23. Revising Attachment: What Hinders An overemphasis on individuation An overemphasis on individuation Expecting closure Expecting closure

24. Discovering Hope: What Helps Finding spirituality Finding spirituality Imagining options Imagining options Laughing at absurdity Laughing at absurdity Developing more patience Developing more patience Redefining justice Redefining justice Finding forgiveness Finding forgiveness Creating rituals for ambiguous loss Creating rituals for ambiguous loss Rethinking termination Rethinking termination Revising the psychological family Revising the psychological family

25. When Hope Hinders Persistent hope for closure Persistent hope for closure Continued longing for life as it used to be Continued longing for life as it used to be