Breaking free from the limbo of ambiguous loss

SINGAPORE - Those of us who live long lives are generally considered lucky. But such people are also unlucky in the sense that they suffer the loss of loved ones and grieve in their absence.

The most popular notion about grief comes from Swiss-born psychiatrist Elisabeth Kubler-Ross.

She described five stages of loss, progressing from denial, anger, bargaining, depression to acceptance. However, her work was based on terminally ill patients in a Chicago hospital and not on people who were grieving.

More recent research by Dr George Bonanno from Columbia University revealed that grief can take many different journeys. He also found that most of us come out of it reasonably well.

As he wrote in his book, The Other Side Of Sadness: "As frightening as the pain of loss can be, most of us are resilient. Some of us cope so effectively, in fact, we hardly seem to miss a beat in our day-to-day lives. We may be shocked, even wounded by a loss, but we still manage to regain our equilibrium and move on.

"That there is anguish and sadness during bereavement cannot be denied. But there is much more. Above all, it is a human experience. It is something we are wired for, it is certainly not meant to overwhelm us. Rather, our reactions to grief seem designed to help us accept and accommodate losses relatively quickly so that we can continue to live productive lives".

But there is another sort of grief that is more extraordinary and far more complicated. Indeed, the world has seen it played out almost daily for the past few weeks on television as well as in print and social media. In particular, the world has watched with a strange mixture of pity, compassion, and more latterly, bafflement, impatience and even anger.

To many, the reaction of the relatives of the 153 Chinese passengers on MH370 seems excessive, unreasonable and even atavistic.

But there is another way of looking at this. The behaviour of the relatives is not abnormal. What is abnormal is the situation that they have so suddenly found themselves in, and the fact that they have to continue living through it without any end in sight.

Ambiguous loss

For the relatives of the passengers and crew of MH370, as long as the ongoing search effort turns up nothing, they will continue to have what Professor Pauline Boss, professor emeritus at the University of Minnesota, calls "ambiguous loss".

This refers to a situation in which a family member is physically missing, but psychologically present because it is unclear whether that person is dead or alive.

This, in Prof Boss' view, is the most stressful loss people can face. Prof Boss, who is the author of the classic study, Ambiguous Loss: Learning To Live With Unresolved Grief, notes that it is unlike a well-defined and certain death.

In the case of the latter, mourning can start and bring with it all the attendant rituals and support culminating in a funeral. But with MH370, there is, as yet, no official verification, no definitive proof of death, and hence, no possibility of closure or finality.

In consequence, the relatives in the throes of this ambiguous loss can seem resistant to reasoning, implacable and even dysfunctional.

They are likely to experience a maelstrom of emotions: anxiety, regret ("what ifs"), guilt, depression, and utter helplessness.

And all this is leavened occasionally with some glimmer of hope before the plunge back into despair.

Without reliable information to clarify their loss, without irrefutable evidence of death, they have to cope with the "paradox of absence and presence". They can't even start the normal process of grieving. In the words of Prof Boss, "the grief process is frozen and so is the coping process".

Lessons from 9/11

In the wake of the 9/11 attack, Prof Boss was asked to be part of a team of psychological trauma specialists set up to help the families of those who lost their lives when the twin towers of the World Trade Center came crashing down in New York City in 2001.

Close to 3,000 people were killed, but the remains of many hundreds could not be found.

The approach which Prof Boss and the team took and the lessons learnt could be instructive for the present tragedy, even though there are also obvious differences between the two events.

The families of those who died in the twin towers attack came from 60 different countries and spoke 24 languages.

Realising that the diverse cultural, religious and ethnic backgrounds would also mean a diversity of grieving and coping styles, mental health experts from different cultural backgrounds were brought in to try to match the families as far as possible.

The therapists underwent training to make them not just culturally sensitive but also "culturally competent".

Even within families, there were conflicting views and tensions. Some were also keeping the loss a secret from the children.

So, each family was seen on its own and in a safe setting where each member could share perceptions and interpretations with one another under the facilitation of the therapist.

They were told that their feelings of confusion and helplessness were normal in such an abnormal situation. The word "closure" was scrupulously avoided by the therapists.

Multiple family meetings were then organised. Prof Boss and her team discovered that culture made a difference in the meaning of ambiguity and loss. They found a cultural divide between European American families on the one hand, and families of colour on the other. The former maintained "a stiff upper lip" and avoided public displays of emotion, while African Americans and Latinos, among others, were more overtly expressive.

The therapists also found that being with other compatriots who shared a common language, history and values provided invaluable mutual support and solace for the relatives concerned.

Ways of coping

But there are ways to cope with ambiguous loss and to break from this limbo - even without acceptance.

"No one has to accept even the death of a beloved, elderly grandparent. We don't have to accept it, we don't have to like it. We can recognise it and acknowledge it," Prof Boss said.

"The new term in the grief literature is to learn to live with the loss and grief, not to get over it. There is no need to get over it. My experience is that people get angry if you talk to them about accepting a loss. There's no need for us to bring that up. And with ambiguous loss, of course, it's multiplied by a thousand."

In his 1953 novel, The Unnamable, Samuel Beckett ended the book with this: "Where I am, I don't know, I'll never know, in the silence you don't know, you must go on, I can't go on, I'll go on."

There have been many calls for patience and understanding for the behaviour of the relatives of the missing passengers and crew of MH370.

The actions of the relatives can be understood from the perspective of ambiguous loss, but they need more than that if they are to go on. They need the right kind of specialised mental health help if they are to go on with their lives amid the absence, uncertainty and agony.

The writer is the vice-chairman on the medical board (research) of the Institute of Mental Health.

This article was published on April 4 in The Straits Times.

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