Complex Grief & Ambiguous Loss

For about 90 percent of people, experiences of grief gradually lessen over time. Usually within a year or so, most find that, even though life will never be the same as it was, they have adjusted significantly and are putting their life “back on track” following a significant experience of loss, whether the death of a loved one, the devastation wrought by a house fire or other forms of loss. But for others, grief continues, often at an intense level, without especially easing up.

The journey through grief is never “easy,” but for some people, processing and coming to terms with loss is simply more complicated than it is for most. To understand how “complicated” grief differs from more common experiences following loss, you might look at it though one of two different lights:

• Either the grief is particularly prolonged, especially feelings of acute grief lasting longer than six months (although, in truth, there is no appropriate “timeline” for grieving);
• or the circumstances surround the loss are complex, perhaps disturbing or involving ambiguous loss, and because they may provoke confusing, conflictual and maybe even “socially unacceptable” responses in the bereaved, it becomes difficult to arrive at acceptance around the loss

In both cases, the experience of loss may continue to feel like an open, gaping emotional wound. Grief then colors every aspect of life and may interfere with relationships, employment, physical and mental health, and/or a general willingness to be an active participant in life.

A Closer Look

Prolonged grief is characterized by the following traits:

• A severe and persistent feeling of yearning for the deceased
• Significant difficulty accepting the loss, even to the point of an inability to do so
• Prolonged or persistently intense feelings of anger about the loss
• Feelings that in losing the deceased, part of oneself is also fundamentally gone
• An inability to imagine the future without the deceased
• Difficulty forming new relationships or engaging in social activities
• Persistent feelings of guilt or blame related to the loss

When these experiences continue to be significant and troublesome for more than six months or a year following the loss, this may be an indicator that someone is struggling with prolonged grief. It is important to note, however, that individuals, and many cultures, have different ways of dealing with and expressing grief, and the length of grief and mourning in and of itself is not something that can be considered problematic. It is only when the experience causes distress to the bereaved or significant trouble in other life domains that prolonged grief may call for intervention.

Complex losses, on the other hand, may share many of the emotional experiences above, in addition to complicated feelings arising from circumstances that may make it difficult to process feelings grief, such as:

• Loss of someone with whom you had a difficult relationship, including abusive parents or partners, relatives or friends from whom you’ve been “cut-off,” partners who engaged in extramarital affairs, people you may have harmed or others who harmed you and where there had not been reconciliation or forgiveness
• Circumstances where the manner of death was especially troublesome, such as sudden, violent, intentional or traumatic loss
• Situations in which you may have conflictual feelings about having a role in bringing about the death of a loved one, whether through medical intervention and end-of-life decision-making, tragic accident or intentionally causing the death
• Losses that were manifold or accumulative, such as losing several loved ones from different causes in a relatively short period of time, or where multiple losses stem from a single event, such as death of a loved one in a house fire that also claimed all of one’s possessions and mementos, including those of the deceased
• Loss that comes on the tail-end of a period of “ambiguous loss,” such as a loved one being missing for some time prior to discovery of their death or witnessing a beloved make the slow descent into Alzheimer’s or waste away in a persistent vegetative state.

In all of these circumstances, both with prolonged grieving and complicated losses, the main concern is when the grieving process does not gradually improve over time and/or the nature of feelings and the new belief systems that emerge engender long-term isolation, depression and/or anxiety, rather than a return to daily life and healthy relationships.

A Note on Ambiguous Loss

Many times, what we’ve lost is hard to quantify, sometimes because it’s still with us or because we haven’t gotten confirmation that a loved one is, in fact, deceased. Researcher Pauline Boss coined the term “ambiguous loss” to describe two unusual circumstances:

• Loss in which a person remains physically present but psychologically absent, such as living with a love one who has Alzheimer’s, has suffered traumatic brain injury or is in a prolonged coma, is “lost” in addiction or extreme depression, or is otherwise remains alive but with whom psychological connection has been severely disrupted;
• Loss in which a person is physically absent but psychologically present, such as abducted children, missing persons, giving a child up for adoption, losing child custody, absentee parents, people incarcerated “for life” and other circumstances, such as being cut off from family and culture due to immigration issues, where you may continue to feel a strong emotional or psychological bond with someone whose welfare is unknown to you or who is physically inaccessible.

These circumstances often create extremely difficult and afflictive emotions, a feeling of being “suspended” and perhaps incapable of “moving on” in daily life, while awaiting some resolution of the situation. Because the timeline and trajectory of finding “closure” is completely unknown, signifiant symptoms of anxiety or depression can manifest, as well as numerous physical ailments. The challenge becomes learning how to live with not-knowing and with ambivalence, both of which can be difficult skills to master.

Having a good support system and engaging in regular self-care activities is essential to your well-being during these especially stressful circumstances.

What helps

In case of prolonged or complicated grief, as well as ambiguous loss, careful and thoughtful individual assistance from a counselor, wise elder or spiritual guide experienced in these nuances of grief & loss work may be of assistance. Participation in grief support groups can also be helpful. (An up-to-date list of therapy groups, including grief & loss groups, can be found on the Portland Therapy Center website.) There is mounting evidence that the use of antidepressant medication does NOT address the symptoms of grief effectively, and that targeted psychotherapy is the most appropriate and effective treatment of these situations.

Similarly, there are many ways to access and work through grief on your own or with supportive friends and relatives. These include:

• Engaging in rituals designed to bring more reality or finality to the loss
• Marking anniversaries with personal practices and activities that honor the lessons you learned or the beneficial experiences the deceased brought into your life, rather than focusing on what’s gone or what was hurtful
• Engaging in expressive arts, such as writing, collage, painting, music (including making play lists), ceramics, dance, etc., to create alternative ways of representing the effect a deceased person had on you
• Talking with a trusted confidant about the difficult and conflictual feelings that remain
• Engaging in volunteer work or activities that help you honor and respect the role a deceased person played in your life
• Engaging in self-care practices, including regular diet, exercise and sleep practices, to begin focusing on yourself and your own well-being again.