Learning to Live with Ambiguous Loss and Unresolved Grief

Present absence

We all experience losses that seem intangible because there is no body to bury, no death to name. These losses generate grief nonetheless and can impact our ability to function well.

Some examples include:

The psychological absence of a parent consumed by substance use.
A grown child leaving home.
The breakup of a relationship, a divorce.
Not being able to say goodbye to, or hold a loved one, who has died.
No body to bury our beloved dead when pandemic protocols required internment without contact.
The distance of families separated by war, immigration or other social factors and events.
Loving someone with dementia.
Climate change.
Political unrest and the divide of differing political beliefs.
Loss of innocence with experiences of trauma.

The list can seem endless. These past few years have spotlighted civil unrest at home and around the world. We experience what it means to be divided – as a nation, within families and across the globe.

Told to move on

In a culture that idealizes youth, strength and positivity, we are at a loss to name and claim the myriad ways we grieve more ambiguous changes. We’ve all heard the mantras:

Pull yourself up by your bootstraps.
Get over it.
You don’t have it that bad.
It’s time to move on.

Our hearts carry love and concern – and yearn for connection and meaning. It is not about moving on. We know that there is something we have lost – or cannot find. Grief is a natural reaction to any kind of loss, whether we can specifically name it or not.

Pauline Boss, University of Minnesota professor emeritus, calls this “ambiguous loss.” Others may be familiar with the work of Kenneth Doka, who named this state “disenfranchised grief.”

When faced with uncertainty — climate change, political unrest, threat of global war, millions of displaced people, rising inflation — how do we cope with our fear around events that seem far beyond our ability to influence?

Finding hope and learning to live with unresolved grief

Boss and Doka outline ways to live with unresolved grief. It begins with naming our losses, whether that be loss of a sense of order and safety, loss of a sense of security in our future or other intangible emotional costs.

LSS Behavioral Health therapists Kari Duong-Topp and Kay Kinkel speak to the prevalence of loss in recent years and tactics to find hope and build resiliency.

How would you define ambiguous loss? And how do you see it showing up in the people you serve?

Kay: I would define ambiguous loss as a loss that occurs with no clear demarcation of when it begins, and no clear resolution or closure.

I see it most profoundly in work I do in an assisted living/memory care community. People come to live there when enough losses have occurred that they are unable to live independently in the community with safety. Some of them come as middle-aged adults who have always had some level of disability. Others come at varying ages after a stroke or a debilitating diagnosis. Most are older adults who are having increasing difficulty walking, remembering, preparing their own meals, providing their own personal care. Most have experienced the deaths of spouses and friends and are frustrated, angered and scared of their unnamed losses. They fear what their future losses will look like in six months or a year. They come to this community, try to make friends, but then are confronted and overwhelmed by those people’s losses. They become hesitant to make friends and isolate. The pandemic caused them to completely isolate for a year, and they then experienced periods of isolation with outbreaks of the COVID variants, which again increased anxiety and depression.

Kari: Recently, a client shared with me that he heard a podcast in which a mental health expert said something like “all therapy is about loss.” This resonated with him.

While we don’t always name it as such, I see ambiguous loss showing up in many ways:

Marital separation.
The death of a spouse or parent several months or years ago, with grief that interferes with getting back to being able to function.
Loss of a parent to mental illness.
Loss of safety due to an experience of trauma.
Dealing with life after a diagnosis of a terminal illness.
Loss due to children being removed by a child protection agency.

Some people we work with have a shorter list of concerns than others. Some people struggle with mental health concerns their entire life and have multiple traumas; others have a more focused problem that brings them into therapy. Some may have experienced loss a long time ago, but a new experience reopens the old wound that had been healed.

Have you seen an increase in people struggling with grief and loss during the pandemic and the national and global events of the past few years?

Kay: In general, the pandemic intensified emotions, but grief and loss were specifically intensified because early on:

COVID patients in the hospital weren’t allowed to have visitors.
People in long-term care facilities weren’t allowed visitors.
People were isolated and/or tentative about gathering with family and friends.

All this resulted in loss of shared experiences and family events. The divisive political climate also created separations in families.

Many experienced layers of losses that they struggled to reconcile during the pandemic that still resonate today. One client lost a parent to COVID early in the pandemic while her spouse lived in a nursing home with dementia. For many people, dealing with these types of loss were also compounded when family members held vastly different political views. These circumstances changed the way families gathered for holidays and celebrated annual traditions. With so many losses like these, life still isn’t “back on track” for many people. Learning to see life as a cycle of ups and downs can help individuals relearn to experience moments of joy instead of feeling stuck in a never-ending cycle.

Kari: While some people are struggling with loss related to the events of the past few years, I would say that maybe half of the people I see have had many other things that have been difficult. Sure, the pandemic required changes, but other hurts and struggles remained the focus. The events of the past few years changed the coping tools that were available to people – like visiting with others, taking trips for relaxation, going to the gym for exercise.

For those who were experiencing losses related to the pandemic, like the deaths of loved ones, many of our social rituals were unavailable. Being with the person when they were sick or when they passed, having a funeral – these rituals were not available. It left some with a sense of incompleteness – because we couldn’t use our senses to know that an ending has occurred. It was too intangible.

How does this sense of loss that seems intangible manifest itself in symptoms or struggles people encounter? What would someone look for to see if this is part of why they might be struggling now?

Kay: In doing diagnostic assessments with people experiencing depression or anxiety, I frequently hear that those symptoms started with the pandemic, and people sometimes say that the symptoms intensified as the pandemic mandates were lifted. They are still uncertain or fearful of how COVID might continue to be a threat. Now they feel uncertain about wearing masks, going to large events, etc., but also possibly facing family ridicule for the decisions they’re making.

Kari: A lot of what we do in therapy is about naming the hurts and pains of life. Being able to put a name on a feeling can be tremendously helpful as a starting point. There is a saying, “Name it, claim it, tame it.” Claiming it becomes important if a lot of emotional effort or life energy is being spent on avoiding that painful reality. If I can say out loud that something hurts and face it, I can then start to grieve and re-orient to life in a new way. One of my clients has found it helpful to think about a backpack that has been carried around for a long time and that therapy helps to set the backpack down.

Look for evidence of avoidance:

Is something that you used to do and stopped doing?
Do you experience anxiety when you anticipate an upcoming event?
Are you irritated with people in your life who are engaged in the things you are trying to avoid?

Look for evidence of burden:

Are there old topics, roles, hurts that keep coming up and interfering with life today?
Do you experience fatigue or low energy?
Does getting going just seem too hard?
Are usual household responsibilities remaining undone?

This is not a new phenomenon, and yet it is now showing up in public conversations. What would you say to people about the stressors in our current lives and how those stressors might be impacting a general sense of loss that may be difficult to name?

Kay: The continued divisiveness in our culture and the acts of war against the Ukraine are causing people to feel a loss of safety. Help name that. I also think the pervasive intrusion of news in our daily lives — with 24/7 coverage on TV and additional information scrolling across the screen, and notifications on our cell phones — can all contribute to stress and a sense of loss. I now routinely ask people about their screen time, their connections to news sources, and I discuss how to set healthy limits. I do a lot of education on mindfulness and grounding, focusing on what that person has to cope with in the immediate present to help reduce anxiety and depression. I help them identify where can they experience moments of joy. I try to normalize the lack of normalcy, if that makes sense. What we previously knew as “normal” is possibly lost.

Kari: The events of the last few years were unique in that the entire world was affected in a very big way. This topic is appropriate for many people right now. One of the things that is a newer phenomenon for the human family is the 24-hour news cycle that many of us carry in our hands in the form of a smart phone. Being connected to these devices requires discipline if we are going to give ourselves any semblance of a break. The stress-response cycle in our bodies is a physical one designed to help us respond to a crisis and then to rest and relax. If we don’t turn off that stress, then our systems of body, mind and spirit do not get a break.

Pauline Boss started her career researching stress. Our stress response is a normal reaction to an abnormal situation. In her work, she emphasizes that to experience the stress response or to experience a loss is not a pathological problem. We get confused in our culture about what is healthy and what is unhealthy. Allowing yourself to grieve a loss is allowing a normal and natural reaction in the face of something that is difficult. We were designed that way.

Can you speak to the role of guilt for feeling grief when so many people are coping with such extreme circumstances? How do we give ourselves permission to feel our own feelings when so many others are in unimaginable circumstances?

Kay: I talk with clients a lot about feeling competing emotions. It’s okay to live our daily life, acknowledge our sense of loss, and feel sad about the more extreme struggles that others are facing. Feeling gratitude for what we do have is helpful. A reasonable amount of guilt might move us to donate to causes helping others in extreme circumstances, but an inordinate amount of guilt for our feelings of loss for circumstances we can’t change or affect is unhealthy and weighs us down.

Kari: It can be tempting to compare ourselves to others or to choose guilt for grief to avoid what we are really feeling. The thing about feelings is that they are normal human reactions. Just like we feel the sensation of a soft blanket or a cool breeze, there are emotional responses to loss. It is usually the healthiest for us if we can feel our emotions as they are at the time that they come. We can allow ourselves to name and claim our experience and then decide how to deal with the feeling. Whether someone else is experiencing grief does not make our grief any less valid. We both can experience the feelings. Feeling my feelings doesn’t take anything away from you.

We are social creatures. Getting support and grieving in community is an important way to heal. There are some rituals and ceremonies that are considered normal and a part of our culture.

For other types of grief, it may make sense to take care of yourself with a different ritual:

Write about it.
Use art or music to express feelings.
Talk to someone about it.

Many faith communities have had either in-person or virtual online prayer services to pray for peace, for the deceased, for the community. If you look for healing rituals related to loss, you can find them.

What do you do as a therapist – or what advice would you give someone – on how to cope with ambiguous loss?

Kay: Any loss is painful because it represents a loss of meaning in a person’s life. As a therapist, I help clients acknowledge the loss and the loss of meaning that held for them. Then I help them identify other ways they can find similar meaning in their life. One client keenly feels the loss of and isolation from his Native American community, in addition to the loss of his ability to walk and speak and sing due to a stroke. I started burning sage and reading Native American readings with him, which he found very comforting. I used art interventions of making Native American necklaces and dream catchers, following his direction for design since he has very limited use of his hands. While I carried out his ideas, he talked about his childhood trauma and other memories. He got tears in his eyes when we completed one project, and he said, “It makes me feel useful again when my ideas are expressed in a piece of art, and I feel like I can share my Native American culture with other people.”

Kari: Sometimes we need to start by identifying that we have experienced a loss.

Start by naming it.
Once we name it, we can start to sort out how it is affecting our day-to-day lives.
Then claim it. We take responsibility for dealing with the experience and the behavior choices we make.
Tame it using skills for coping with the feelings.

There are many ways that people naturally try to soothe themselves and some are healthier than others. Usually in therapy we look at the unhealthy patterns that are creating problems for people in how they function. The problems might be impacting their relationships, their work, their physical health.

Healthy habits that build resilience include:

Physical activity.
Diet: what are we taking into our body? Eating healthy foods can support our body through stressful times. Some foods and substances add stress that isn’t helpful.
Adequate sleep.
Crying actually helps with the stress response.
Laughter.
Creative self-expression: writing, singing, painting, dancing.
Relaxation exercises – there are many techniques.
Connections: social connection, connection to nature, connection to the Divine.

I encourage people to start small. When you are grieving, it can feel overwhelming to think of adding one more thing. Is there is something that you can take a break from? By giving yourself permission to grieve, you can look at activities that aren’t working for you right now and take a break. Many people know they can take a walk for five minutes. Well, that is something – fresh air and movement for five minutes! Many of us are conditioned to work harder, faster, better. Grieving well involves self-care. Giving yourself permission to get more sleep is a way to take care of yourself. Doing a five-minute relaxation exercise can free you up to be more playful.

We live in a complex world, with minute-by-minute updates on events that can happen half a world away. These past few years we have experienced or witnessed a worldwide pandemic, climate change and political unrest. Americans are experiencing significant increases in mental health concerns.[1]

[1] High rates of depression and anxiety a challenge in Minnesota | MPR News 10/11/22

Resources

If you, or someone you know, could benefit from support by a mental health professional, LSS Behavioral Health therapists are available statewide.

LSS Behavioral Health | [email protected] | 1.888.881.8261

Ambiguousloss.com

The Importance of Mourning Losses (Even When They seem Small). NPR LifeKit 6.4.21. Interview with Kenneth Doka, professor emeritus at the College of New Rochelle in New York, and grief counselor and therapist David Defoe. Hosted by Kavitha Cardoza.

Speaking of Psychology: Ambiguous loss and the “myth of closure,” with Pauline Boss, PhD (apa.org)