A Cloud of Pain: A Literature Review on the Impact of Ambiguous Loss in the Absent State and Relevant Therapeutic Interventions – Review of the Article by Weiland and Maple

Ambiguous loss is a term coined by Pauline Bosse to describe the experience of people coping with the loss of a missing person. According to Bosse, when a person is missing, the loss is defined by uncertainty, and the ambiguity leaves the bereaved with an endless question about the finality and completeness of the loss. In their article, Weiland and Maple review the research literature on ambiguous loss and the therapeutic interventions that have been studied in this area in the 20 years since Pauline Bosse coined the term.

Research shows that the emotional responses experienced by people whose loved ones are missing are similar to those experienced by people whose loved ones have died suddenly and traumatically, but there are also several characteristics unique to ambiguous loss. For example, people who experience ambiguous loss are forced to deal with both possibilities regarding the fate of their loved one—the possibility that the person is alive and the possibility that they are gone. Research conducted in the field indicates that there is a need to create specific therapeutic interventions for these situations, which do not force the patient to accept the death of their loved one, as is usually required in treatments aimed at coping with loss. The literature review reveals three concepts that can help in working with patients experiencing such loss:
1. Ambiguous loss – a reference to the physical absence of the person, without deciding that the loss is final or that its outcome is known in advance.
2. Anticipatory grief – Anticipatory grief is a grief response that arises in the time before the loss (for example, anticipatory grief can occur in people dealing with a family member who is terminally ill). In people dealing with the absence of a loved one, anticipatory grief can occur at a time of uncertainty regarding the person's fate. It is important to give space to these feelings, and to recognize the complexity that accompanies ambiguous loss.
3. Unjustified grief – Unjustified grief is grief that is not perceived as acceptable by society because it does not fit the mold that people are used to. These social perceptions may create stigma, lack of support, and lack of understanding of grief in situations of ambiguous loss.

The literature review shows that people dealing with ambiguous loss usually experience persistent sadness, confusion, and frustration regarding search or rescue efforts, and are at high risk of developing a pathological grief response, depression, or post-traumatic symptoms. In light of these difficult effects, the researchers list three issues that should be considered when communicating with families experiencing ambiguous loss:
1. Closing the circle – According to Pauline Boss, paradoxically, families who feel pressure from the environment to reach closure are at a higher risk of experiencing negative emotional reactions. The environment is required to demonstrate suffering and respect, and to recognize the emotional complexity that accompanies uncertainty.
2. Acceptance – the environment should convey acceptance, understanding, and openness to the family’s suffering and uncertainty
3. Hope – Hope can change over time as the family deals with a vague loss, but exploring the concept of hope can help with coping and even promote post-traumatic growth.

The researchers also suggest that spiritual or religious rituals can be created to mark the loss, in order to help the family feel that the environment acknowledges their loss, without forcing the conclusion that the person is gone forever (unlike a funeral or farewell ceremony). One such idea could be a “celebration of life,” which could include photographs, stories, customs, and more.
Finally, the researchers mention four therapeutic interventions that can be effective in dealing with a vague loss:
1. Cognitive-behavioral therapy combined with mindfulness (CBT-M) – a treatment that is based on the principles of CBT, and also incorporates meditation and mindfulness exercises. The combination of these tools can be effective in dealing with "thought traps" and help avoid compulsive thoughts about grief and loss.
2. Family therapy for stress reduction - a family model that focuses on creating new family rituals and finding new meaning in the shadow of loss.
3. Acceptance and commitment therapy (ACT) - a therapy that focuses on observing a person's core values and how these values can help them live a full and fulfilling life alongside the loss.
4. Mindfulness and self-compassion therapy - a therapy that focuses on recognizing the difficulty and pain associated with ambiguous loss.
In conclusion, the researchers argue that while research knowledge regarding ambiguous loss has been accumulated over the 20 years since the concept was coined, there is still not a sufficiently good therapeutic understanding of it and ways to cope with it, and further research is still needed. The researchers also emphasize that therapeutic interventions should include special attention to the aspect of uncertainty, which is a central feature in coping with ambiguous loss.