The continuing confusion and lack of definitive information about the whereabouts of Malaysian Airline MH370 for over two weeks (when this post is written), has focused the world's attention on the suffering of the family and friends of the 239 missing passengers. It is difficult to even imagine what these family members and friends are going through. This article looks at how we can help those coping with an ambiguous loss such as is the case for the family and loved ones of those missing on MH370.

Coping with loss in general

From a psychological point of view, grief is the experience of intense sorrow following a loss. There is a wide range of things whose loss can induce grief. What all these losses have in common is that without them, one's life experience is changed to a stressful degree. The purpose of coping with loss is to reduce this stress and enable the person to gradually re-establish their equilibrium and go on with their life.

Nature of the coping process: Defined loss versus ambiguous loss

In order to help individuals coping with loss, it is essential to recognize that there are two very different categories of loss: defined loss and ambiguous loss. Examples of defined loss are death of a loved one or loss of our job. In these two examples, the loss is well defined, familiar, and explained with most cultures having developed rituals e.g. the funeral and customs, to help a person grieve and move on in their life. There is also psychological help because much research has been carried out on defined loss. For example there is the 5 stages theory of grieving (Denial, Anger, Bargaining, Depression & Acceptance) which is well known and useful in helping persons encountering difficulty in grieving a defined loss (Kubler-Ross, 1970).

The second category of loss is ambiguous loss where the loss is not clearly defined. The term "ambiguous loss" was introduced by Pauline Boss nearly 45 years ago (Boss, 1972) and has proven extremely useful. It arose out of her observation that some families had fathers who were physically present but psychologically and emotionally absent. Boss found that how the family coped with such an ambiguous loss was very different from how it coped with a defined loss such as the death of the father. Boss (2006) wrote "... ambiguous loss is the most stressful kind of loss. It defies resolution and creates the long term confusion ... ". It is the ambiguity of their loss that makes coping so difficult for the family and friends of those on flight MH370. Fortunately strategies for helping those coping with ambiguous loss have been developed (Boss, 1972; 2006; 2013).

Ambiguity and the loss of MH370

The MH370 incident is an example of an ambiguous loss albeit that sooner or later, it is likely the plane will be found and the ambiguity of the loss for the family and friends will disappear. Nevertheless until this happens the family, and friends of those on the plane are in the excruciating situation of not knowing if their loved one is alive or dead; they are coping with an ambiguous loss. They may wake up feeling hopeful only to have this hope dashed by new revelations.

Vice versa they may be feeling sad and hopeless but sees light when new positive news appear e.g. the plane may have been hijacked, giving them the hope that their loved one is still alive. Because of this extreme variation from utter despair one moment to soaring hope the next, their reality may appear to be unravelling. Their perception of their whole life is thrown it into disarray and they feel disoriented and confused.

Another problem specific to ambiguous loss is that the families and even the culture are not familiar with how to cope with such a loss. They do not know whether to mourn or try to keep up their spirits and be hopeful. The same applies to when survivors of the loss try to help each other because they don't know whether they should encourage the other person to be hopeful, or do just the opposite and attempt to help the other person face the terrible reality that their loved one is deceased and will not be coming back home.

What non-professionals can do to help the person coping with ambiguous loss?

In both normal grieving of a well defined loss and in coping with ambiguous loss, social support can be very helpful if done in a sensitive and informed manner. Educating yourself about ambiguous loss is especially important because it is more complex and hence requires more nuanced types of helping behaviour

can be very helpful if done in a sensitive and informed manner. about ambiguous loss is especially important because it is more complex and hence requires more nuanced types of helping behaviour One particular difficulty in case of an ambiguous loss is that family and friends are confused about what to say to the survivor. Where the losses are well defined one can say various appropriate things, depending on the circumstances, for example "At least their suffering is over". However with ambiguous loss, thinking out supportive statements is more difficult although it can be done if one becomes familiar with ambiguous loss concepts. For example you can say, "Just take it one day at a time."

It also is important not to avoid those coping with ambiguous loss because one doesn't know quite what to say and do. It is enough just to be physically and emotionally present and available to listen.

and available to listen. Allow the person coping with ambiguous loss to work through their process in their own way. In the case of defined loss, some benefit by talking or even writing about their loss while others do not (Stroebe et al, 2002; Stroebe et al, 2006). This likely holds even more for ambiguous loss where there might be even a greater tendency to push the survivor into a position of deciding one way or the other the fate of their loved one. It is a tendency that must be resisted.

while others do not (Stroebe et al, 2002; Stroebe et al, 2006). This likely holds even more for ambiguous loss where there might be even a greater tendency to push the survivor into a position of deciding one way or the other the fate of their loved one. It is a tendency that must be resisted. Allow the person coping with ambiguous loss to cope at their own speed. Unfortunately in modern society with its emphasis on speed and efficiency, some well-intentioned individuals who otherwise sympathize with the grieving person, may unconsciously put pressure on the griever to "get on with life" and put "closure" on the loss within an unrealistic time frame. However the reality is that grieving is a natural process which cannot be rushed : the griever has to grieve at their own pace. Grieving is a necessarily painful, lingering, and messy process and those supporting survivors of a ambiguous loss must learn to tolerate this messiness.

: the griever has to grieve at their own pace. Grieving is a necessarily painful, lingering, and messy process and those supporting survivors of a ambiguous loss must learn to tolerate this messiness. However if you feel that a family member or indeed an entire family is experiencing an unusual difficulty, then gently and calmly suggest that they get assistance from a mental health professional. If they refuse initially, as they probably will, gently bring it up later perhaps giving them the name and telephone of a therapist experienced in grieving for them to call.

If they refuse initially, as they probably will, gently bring it up later perhaps giving them the name and telephone of a therapist experienced in grieving for them to call. Whether it is defined loss or ambiguous loss, it is important for those providing emotional support to be vigilant about their own level of emotional distress.

For Mental Health Professionals: What can you do to help the person coping with ambiguous loss

All of the suggestions given above for family and friends hopefully will be useful to professionals as well.

Educate yourself about ambiguous loss theory by reading the literature of Pauline Boss, in particular her 2006 book "Loss, Trauma and Resilience: Therapeutic Work with Ambiguous Loss" . One of the main therapeutic goals in ambiguous loss therapy is to increase the survivors' tolerance for ambiguity . This contrasts to the goal of defined loss therapy where closure and acceptance are the goals.

. One of the main therapeutic goals in ambiguous loss therapy is to increase the survivors' . This contrasts to the goal of defined loss therapy where closure and acceptance are the goals. Because of their different goals, therapists should not attempt to use the stage theory of Kubler-Ross developed for defined loss in the case of ambiguous loss. Therapists should be constantly aware that survivors are in a state of flux concerning their beliefs about whether their loved one is alive or dead. Application of the stage theory to them would likely confuse them even more than they are. Moreover, use of the stage theory presupposes that their loved one is deceased and imposition of this view may only increase the anger of family and friends of those on MH 370. That anger is not to be confused with the anger stage of grieving a defined loss. Rather their anger may be directed at the therapist for pressuring on them the conclusion that their loved one is deceased while the survivor may be clinging however precariously to the belief they are alive.

Recent research indicates that attachment style (the habitual way a person orients to intimate others) influences the kinds of support that are useful for ambiguous loss (Boss, 2006). It seems likely that attachment style, specifically insecure attachment might influence the person's ability to cope with uncertainty. Hence, attachment style is an individual characteristic that should be taken into consideration when designing the treatment plan for an individual.

(the habitual way a person orients to intimate others) influences the kinds of support that are useful for ambiguous loss (Boss, 2006). It seems likely that attachment style, specifically insecure attachment might influence the person's ability to cope with uncertainty. Hence, attachment style is an individual characteristic that should be taken into consideration when designing the treatment plan for an individual. Boss suggests a variety of specific topics to be discussed in cases of ambiguous loss such as the meaning of the loss, modifying the need for certainty, normalizing ambiguity , and discovering hope.

, and discovering hope. The coping process for ambiguous loss can be especially stressful and prolonged and mental health professionals must take care of their own stress by having a good social support system and by daily practice of their own stress management program.

Concluding Remarks

Loss is inevitable in life whether it be defined or ambiguous. As Queen Elizabeth II said "Grief is the price we pay for love." If we attempted to avoid loss by never forming loving or intimate relationships whether it be love of people, love of pets, love of our careers, and even self-love, what kind of life would we have? It is our deep sense of being connected that makes us human. Ambiguous loss theory and therapy helps us all develop a deeper tolerance for the inherent ambiguities in such valuable connections and cope better with their disruption.

References

Boss, P. (1972). Father absence in intact families. Presentation at the annual meeting of the National Council on Family Relations, Research and Theory Session. Toronto, Canada.

Boss, P. (2006). Loss, Trauma and Resilience. New York: W. W. Norton.

Boss, P. (2013). Resilience as tolerance for ambiguity. In D. S. Becvar (Ed.), Handbook of family resilience (pp. 285-297).

Kübler-Ross, E. (1970). On death and dying. New York: Collier Books/Macmillan.

Stroebe, M., Stroebe, W., Schut, H., Zech, E., & van den Bout, J. (2002). Does disclosure of emotions facilitate recovery from bereavement? Evidence from two prospective studies. Journal of Consulting and Clinical Psychology, 70(1), 169-178.

Stroebe, M., Schut, H., & Stroebe, W. (2006). Who benefits from disclosure? Exploration of attachment style differences in the effects of expressing emotions. Clinical Psychology Review, 26(1), 66-85.