Grief

Loss, Trauma, and Resilience: Therapeutic Work with Ambiguous Loss by Pauline Boss (W. W. Norton) Whether it is a parent in the grip of Alzheimer's or a spouse missing in a disastrous event, we are all touched by ambiguous losses. Here Pauline Boss, the principal theorist of the concept of ambiguous loss, guides clinicians in the task of building resilience in clients who face the trauma of loss without resolution.

Excerpt: Five years ago, the idea of ambiguous loss—an unclear loss that defies closure—was introduced to the general public (Boss, 1999). I now write about its application.

My basic theoretical premise is that ambiguous loss is the most stressful kind of loss. It defies resolution and creates long-term confusion about who is in or out of a particular couple or family. With death, there is official certification of loss, and mourning rituals allow one to say goodbye. With ambiguous loss, none of these markers exists. The persisting ambiguity blocks cognition, coping, and meaning-making and freezes the grief process (Boss, 1999, 2004a).

The theory of ambiguous loss is based on decades of research and the work of professionals who treat families traumatized by war, terrorism, natural disasters, and chronic illnesses and disabilities. The ideas have also been honed by decades of clinical work with couples and families, as well as from my personal experiences with ambiguous loss. In the early 1970s, through the Center for Prisoner of War Studies at the Naval Health Research Institute in San Diego, I interviewed wives of pilots missing in action (MIA) in Vietnam and Southeast Asia. In 1989, I met with psychologists exhausted by their work in Armenia and Azerbaijan after the Armenia earthquake. In 1997, I met with therapists and community leaders in the aftermath of the flooded Red River Valley in the upper Midwest, and on numerous occasions I have met with military family personnel, rehabilitation counselors, clergy, and healthcare professionals to discuss ambiguous loss and trauma. After the terrorist attacks on 9/11/01, and at the invitation of labor union leaders,

I collaborated with New York therapists to shape interventions for families of the missing. I continue training therapists for that kind of work. At the invitation of the International Committee of the Red Cross (ICRC), I trained professionals and community leaders in Kosovo to work with the nearly 4,000 families with loved ones still missing since the late 1990s from ethnic cleansing. In private practice, I have worked since 1974 with individuals, couples, and families, most of whom had some kind of ambiguous loss—a depressed mate, a parent with Alzheimer's disease, a child with brain injury, a loved one with an addiction or other chronic mental illnesses. From all of this work, I have gained a profound respect for the many who manage to live well despite an ambiguous loss with no resolution. They have taught me what resilience is.

Overall, what has become clear to me is this: Ambiguous loss is a relational disorder, and not an individual pathology. It follows, then, that family- and community-based interventions—as opposed to individual therapy—will be less resisted and thus more effective. It should come as no surprise that when loved ones disappear, the remaining family members yearn to stay together. They resist therapy if it means more separation. Separating family members for individual therapy may only add to the trauma of ambiguous loss.

This book is meant to help professionals learn about the concept of ambiguous loss, its impact on resilience and health, and the guidelines for interventions. Rather than offering a concrete list, however, I provide theoretical ideas and treatment guidelines for each professional's particular need. This allows for tailor-made interventions that fit the culturally diverse people we serve today.

In this book, I merge family-based approaches begun by the pioneers of family therapy (Framo, 1972) with community-based approaches (Landau & Saul, 2004; Speck & Attneave, 1973) and theories from sociology, psychology, and family therapy. Social and systemic relational approaches are useful with catastrophic physical absence and chronic psychological absence—traumatic head injury, Alzheimer's disease, mental illnesses, and addictions. In addition, the family- and community-based interventions can support resiliency with couples and families experiencing the ambiguous losses of immigration, migration, and diasporas, as well as divorce, remarriage, adoption, and the placement of loved ones in institutionalized or foster care. When it comes to the trauma of ambiguous loss, individual therapy is insufficient. Although family therapy and community interventions are not new ideas, they appear to be so in the fields of trauma and resiliency.

Human relationships are often traumatized by ambiguous loss, but this unique kind of loss is just beginning to be discussed in professional texts and training courses. Even veteran therapists may miss it. What I learnedfrom experience is that I could not recognize ambiguous loss in others until I had first recognized my own. For me it was immigration, addiction, divorce, and aging parents. Other family histories may contain more catastrophic ambiguous losses through genocide, slavery, holocaust, mysterious disappearances, Alzheimer's disease, and mental illnesses. Rife with ambiguity, losses that cannot be clarified or verified become traumatic, but they can be discussed in community with others to gain meaning and hope. As a colleague said after reflecting on his own experience, "It's not easy, but an untenable situation can be maintained indefinitely. I can stand not knowing."

HOW TO READ THIS BOOK

There are three sections to this book. The first discusses the developing theory of ambiguous loss. The second offers therapeutic goals and guidelines for treating the trauma of ambiguous loss. The epilogue provides information and support for therapists who are experiencing their own situations of ambiguous loss, personally or professionally. Recognizing one's own ambiguous losses is a necessary adjunct to reading this book.

Part I: The Developing Theory of Ambiguous Loss

In this section, I summarize the developing theory about ambiguous loss. Chapter 1 focuses on the psychological family; Chapter 2, on trauma and stress; and Chapter 3, on resilience and health. This first section lays the groundwork for a stress-based therapeutic model, emphasizing resilience and health more than pathology. What does this mean? Although stress is viewed as a natural part of family life due to maturational transitions, there are times when people experience stress and change that go far beyond normal human experience and expectation. Ambiguous loss is one such example, and it is inevitable in human experience. The ambiguity surrounding a loss of a friend, spouse, partner, coworker, teammate, or relative can traumatize and paralyze individual, dyadic, and family coping processes. It can harden people into a frozen grief drained of resilience (Boss, 1999).

Part II: Therapeutic Goals for Treating Ambiguous Loss

The second section of the book provides therapeutic goals and guidelines for treatment and prevention of trauma by centering on how to gain or maintain resiliency through finding meaning (Chapter 4), tempering mastery (Chapter 5), reconstructing identity (Chapter 6), normalizing ambivalence

(Chapter 7), revising attachment (Chapter 8), and discovering hope (Chapter 9). The first chapter in this part of the book (Chapter 4) launches the circular process of building resilience through finding meaning and sets all the others in motion. The resiliency process is systemic, circular, and sometimes—as with conflicting feelings and actions—a combination of both. Although this process is stressful for clients, it is less so than the trauma of doing nothing in response to ambiguous loss. In essence, this section is about finding resiliency despite an irresolvable loss and no solution to the problem.

Epilogue: The Self of the Therapist

This section of the book addresses the self of the therapist. The end is, paradoxically, the place to begin. That is, having read about how to shape therapies for ambiguous loss, you are now ready to begin with yourself. This means recognizing one's own ambiguous losses and finding some personal understanding before trying to help others. This self-work helps to increase your own tolerance for ambiguity and thus increases your professional resiliency.

Self-reflection is essential, and I have included examples of my own self-reflection throughout this book. I encourage you to use the process of self-reflection as you read the entire book, reflecting on your own experiences and feelings in the light of even the didactic information. Reflective and cognitive processes are, after all, intertwined.

COMING FULL CIRCLE

My work in New York, in Kosovo, and with people affected by the 2004 tsunami has solidified my views about including family- and resiliency-based approaches in treating loss and trauma. The common focus on individual treatment and pathology after loss and trauma must be broadened to include safeguarding natural family and community strengths and rebuilding resiliency. This is the underlying thesis of this book.

Working in New York after 9/11 brought me out of the ivory tower and into the community, and it pushed my thinking and my feelings to the brink. My experiences with the families of workers who vanished on that terrible day tested my assumptions—and me—more rigorously than any research test could have. The challenge was to apply the theory to this catastrophe and to help this immensely diverse group of families. The work was exceedingly difficult during the first few weeks and called for frequent time-outs to reflect. On one of those early days, I looked out of the windowfrom the 21st floor of the union building where we were working with the families. The smoke was still rising from Ground Zero. I hungered for another view, but only later did I find a more comforting one. At a friend's high-rise home in lower Manhattan, in the late afternoon sun, I saw the Statue of Liberty—the same statue that welcomed my father and my maternal grandparents into the New York harbor so long ago. I realized then that I had come full circle, back to where my family had begun life in the United States. I felt a deep calm. Hope and loss had merged for them, and now for me, too. Out of this insight came renewed strength.

Many of the families we worked with had come to this shore, like my elders, hoping for a better life. By uprooting, they, too, had lost contact with parents and siblings. After 9/11, they faced an ambiguous loss even more horrendous. Could they regain their resiliency and strength while being cut off from loved ones in faraway islands or countries? Thankfully, with family-and community-based interventions, many have.

 

The Nature of Grief: The Evolution and Psychology of Reactions to Loss by John Archer (Brunner Routledge) John Archer presents a ground-breaking new synthesis of material from evolutionary psychology, ethology and experimental psychology on the process of grief. He argues that grief is a natural reaction to losses of many sorts; to the death of or separation from a loved one, but also to other aspects of life which are important to the individual. In contrast to much prevailing literature on the topic, The Nature of Grief does not regard grief as an illness to be cured or a psychiatric disorder. Instead, it shows how common an experience it is, throughout all human cultures and clearly present in the animal kingdom.

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