The ambiguous loss, the impact on the family system and the link with Covid-19

Is it gone forever? Will he come back or will I never see him again? I never saw his body, did he really die? The inability to answer these questions prevents the individual from regrouping in thoughts and emotions. The ambiguous loss in the time of Covid-19.

 

Human beings have always shown the psychological need to somehow sanction the definitive loss of a loved one, thus coming to create ritualistic forms of different nature through which to communicate, to themselves and to others, that change (loss) it is immutable. These forms of social communication not only determine the official nature of death and loss, but allow survivors to embark on the painful, but natural, process of mourning, at the end of which the individual will find himself reorganized in his psychological functions cognitive and emotional and able to still move within the world, even in the absence of the loved one (Boss, 2009).

However, there are situations in which the implementation of the classic rituals of passage is not possible. They are those cases in which the loss of the loved one cannot be declared with certainty or in a clear and defined way. This category includes the abductions, the missing of the war, the deaths without a body, but also all those who despite being physically present are extremely distant cognitively and emotionally. Hence the boundaries of loss become blurred and confused and the loss becomes ambiguous.

The ambiguous loss theory appears in literature thanks to the works of Pauline Boss, and is described as an elusive, confused, unclear loss, somehow suspended in time and space (Boss, 1999).

Being in the presence of an ambiguous loss, according to Boss (1999), freezes the pain processing process, prevents cognitive reflection and therefore adaptive coping strategies, arriving to configure the loss as traumatic, precisely because of the uncertainty that the surrounds. It is this uncertainty which, according to the author, feeds the individual an ambivalent and contradictory position, destined by its nature to be unsolvable. In this sense, it is not only ambiguity that becomes the source of traumatic stress, but also the anguish resulting from the constant search for consistency. Did he go away forever or just for a while? Will he come back or will I never see him again? I never saw his body, did he really die? The impossibility of answering these questions prevents the individual from reorganizing himself in thoughts and emotions,

In the ambiguous loss theory Boss (1999) identifies two types of losses: the physical presence of the person who is psychologically absent (good-bye without leaving) and the psychological presence of the physically absent person (leaving without good-bye). If in the first type of loss the person is physically present, but his cognitive state prevents him from participating fully in family dynamics and maintaining the role he has always held, in the second case the person despite being physically absent, continues to have, on family and friends, a psychological influence so important as to make it alive and present at the same time.

It is striking how both types of losses can often be found within the context of the Covid-19 pandemic, even consequentially in the most severe cases. First the hospitalization, the physical and sudden separation of the loved one, who however remains with us, with his clothes in the closet and his toothbrush next to ours. Then, sometimes, the induced coma, an absent mind within a living body that we cannot approach for our own good. And finally, in the most unfortunate cases, death, which is communicated, but cannot be seen, touched and lived in the mortuary or at the funeral. Only a coffin seen from afar.

The loss of a loved one, however, is a factor that affects not only the surviving individual in his singularity, but also the entire family system. From a systemic perspective, the reorganization of the family life cycle involves not only the nuclear family, but the whole system in trigenerational terms. This is in fact the network that constitutes the roots of the individual and, together with friends, is characterized as an important support resource in the face of loss (Canevaro, 2005).

Each system has strategies, which are declined in a unique and singular way, which it puts in place to overcome the family tasks related to the elaboration of mourning. Ideally, to overcome a mourning, the system involved must first recognize and accept death, create a place where you can communicate emotionally around the loss, give up the missing person, readjust family and extra-family roles, in order to finally reaffirm the sense of belonging to the new family system with the entry into a new phase of the life cycle (Godlberg, 1973; Pereira, 1998).

The coping strategies that each individual possesses and that he learns during childhood, sensing what can be openly discussed or not and which emotional states are acceptable (Betz and Thorngren, 2006), interact with the network made up of members of the system, in a game of relationships that evolves and is transmitted within the transgenerational family history (Moos, 1995). The pain related to loss affects the strategies related to everyone’s attachment, the identity of each member, emotional and relational stability, social and family roles. The system will therefore have to implement methods oriented towards the redefinition of the family identity and the roles of its members, finding a shared meaning with respect to what has happened (Rycroft and Perlesz, 2001).

Faced with an ambiguous loss, however, the family finds itself experiencing a state of immobility and inability to move forward due to the specificity of the situation and the impossibility of attributing meaning to it. The factors that in the case of a mourning support the family in the elaboration process, in this case are missing, making the process more complex.

Referring to the two types of ambiguous losses identified by Boss (1999), the elements that seem to prevent and block the normal, however painful, mourning process are the absence of practices that sanction the loss even in case of uncertainty and partiality (dementias , trauma and brain injury, coma) and the physical lack of the person and the doubts about his fate (is he really dead?). Here therefore, the uncertainty and suspension of death feed the sense of loneliness, powerlessness and stall of those who remain, leading to the crystallization of the dynamics and internal relationships preventing the family and the individual from evolving and adapting.

The changes that involved the rituals around death during the Covid-19 pandemic (Moore, Tulloch, Ripoll, 2020) thus translate into a displeasure without rights, in which the lack of recognition and social and cultural sharing compromise the resources that support the mourning process (Zhai, Du, 2020). The internal narrative freezes and mourning becomes traumatic, marking as an injury that continues to bleed the individual’s intrapsychic history and the transgenerational history of the family nucleus (Paul and Grosser, 1965).

The present situation therefore becomes an opportunity, in the here and now, to reflect on the type of support that the health professional can and must offer to those who are confronted (or confronted) with an ambiguous loss. In a Western society always looking for quick, defined and coherent answers, the ambiguous loss represents clear evidence that not everything is controllable and definable in a clear and precise way.

People, however, need some mastery and control over their lives. The trick is to balance the need for control with the acceptance of an unsolvable loss. We accept ambiguity because there is nothing else we can do. We recognize that the world is not always fair, that things do not always go as we wish and that we can externalize guilt, pointing to ambiguity as being responsible for our suffering. We make choices and decisions where possible and find aspects that we can control, such as the reconstruction of family ties and the emotional sharing of the loss (Boss, 1999, 2010).

In order to move towards hope and good memories, therefore, the family system must integrate the experience lived in its own history, changing the meaning that its members attribute to ambiguous loss.