Resilience in ambiguous loss.

During a conference at the Albert Einstein College of Medicine in September 2000, Pauline Boss presented her concept of ambiguous loss (1), an "incomplete or uncertain loss" (p. 3). Boss recognizes two basic kinds of ambiguous loss. In the first, people are perceived by family members as being physically absent but psychologically present as in cases of soldiers missing in action, children who have been kidnapped, or adopted children and their birth parents. In such situations, grieving may not be completed because the facts surrounding the loss are unclear. Family members may become preoccupied with the lost person and be satisfied only when they receive definitive information about him/her. In the second kind of ambiguous loss, a person is perceived as physically present but psychologically absent or emotionally unavailable, as in substance abuse, infidelity, or preoccupation with work. In the case of Alzheimer's disease, mental illness, or some chronic illnesses, the person is physically present but radically changed in mind or body. "In both types of ambiguous loss, those who suffer the loss have to deal with something very different from ordinary, clear-cut loss." (p. 9) .... Since such losses are ongoing and unacknowledged as losses, the usual rituals for mourning are unavailable. As a result, the mourning process cannot be completed, grief may become frozen; people may become stuck and unable to move on with their lives. In coping with a loss that is definite and permanent, most people are able to complete their grief work. For those individuals and families managing ambiguous loss, complicated grieving or melancholia can be a "normal reaction to a complicated situation" (p. 10). The inability to resolve the loss is engendered by the external situation and the role and boundary confusion about the actual family composition. A factor that frequently complicates the ability to cope is the stigma that accompanies many kinds of ambiguous losses; for example, shame and secrecy often surround mental illness, divorce, and some chronic illnesses. Thus, the individual and/or family become isolated at a time when they most need to rely on their social supports. Boss mainly describes the impact on the family but, in many situations, the affected individual may suffer the consequences of ambiguous loss as well, losing prior capacities or ability to function without clear knowledge of what may come next or of ultimate outcomes. In order to cope with ambiguous loss, individuals and families must first confront the change in their situation; they must be able to hold something meaningful of the past while letting go of that which is not in the present. Boss suggests that mastery and spiritual acceptance of the situation are effective means of coping (p. 116). Those affected by the ambiguous loss can learn that the situation may not change but what they are hoping for can change. In order to resolve loss, people need to be able to make sense of it. However, as Boss says, "In the case of ambiguous loss, gaining meaning is even more difficult than in an ordinary loss, because the grief itself remains unresolved. But if we cannot make sense out of ambiguity, nothing really changes. We merely endure" (p. 118). Central to the ability to make sense out of the loss is the ability to maintain hope, to find some way to change, and to construct a meaningful narrative. These are among the ways in which people are resilient in the face of ambiguous loss. The Random House Dictionary defines resilience, from Latin resilire (to spring back, rebound), as 1. The power or ability to return to the original form, position, etc. after being bent, compressed, or stretched; elasticity or 2. Ability to recover readily from illness, depression, adversity, or the like; buoyancy. Walsh (2) defines resilience in families as the "capacity to rebound from adversity, strengthened and more resourceful" (p. 4). She continues, "We cope with crisis and adversity by making meaning of our experience: linking it to our social world, to our cultural and religious beliefs, to our multigenerational past, and to our hopes and dreams for the future" (p. …