1. AMBIGUOUS LOSS Prepared by Linda S. Golding MA, BCC
A Spiritual Assessment Tool 1.0
Prepared by Linda S. Golding MA, BCC
NewYork-Presbyterian Hospital
Prepared by Linda Golding MA, BCC,
New York-Presbyterian Hospital.
Linda S Golding, MA, BCC
Patricia Punzalan, MA, RN, NE-BC
New York Presbyterian Hospital, New York

2. “With ambiguous loss, there is no closure; the challenge is to learn to live with the ambiguity.” --Pauline Boss, PhD
Literature (odyssey, opera, divine comedy, the binding of isaac, the raising of lazarus)

3. How many of you work in hospitals – hospices – nursing homes?

4. Ambiguous

5. Ambiguous: doubtful, uncertain;
open to multiple interpretations.

6. Loss

7. diminution of power or control.
Loss: deprivation;
decrease in;
diminution of power or control. .

8. Ambiguous Loss
Can be caused by random, uncontrollable external forces and can be responded to by internal coping processes.
Resilience is key to coping

9. Ambiguous Loss
Can be caused by random, uncontrollable external forces and can be responded to by internal coping processes.
It is a loss that is unclear, without closure.
It is considered a relational and systemic rather than individual loss.

10. How does it differ from ordinary loss?
Ambiguous Loss
How does it differ from ordinary loss?

11. Ambiguous Loss There is no verification of death.
No certainty that the person will return.
The person may not be as he/she used to be.
Think of people who insist on going to the morgue to SEE the dead person.

12. Why does it matter?

13. Ambiguous loss freezes the grief process
Ambiguous loss freezes the grief process. Paralyzes individual and system functioning.

14. Types of Losses
Everyday Losses
Catastrophic Losses

15. Types of Ambiguous Losses
Physically absent and psychologically present.
Physically present and psychologically absent.

16. Physically Present

17. Psychologically Absent
Addiction, Alzheimer’s, dementia, comatose state, brain injury, autism, depression, chronic mental or physical illnesses that take mind or memory away.
Survivors of domestic abuse, genocide, slavery, holocaust, homelessness, poverty.

18. Identifying Ambiguous Loss
What might the individual
and the system be experiencing?

19. Identifying Ambiguous Loss
Loss of how the person used to be.
Loss of relationships.
Loss of identities, sense of self in relation.
Shifting roles and hopes.
Altered socio-economic status, etc.

20. Identifying Ambiguous Loss
Emotionally?

21. Identifying Ambiguous Loss
Exhaustion Confused decision making Trouble coping Immovable grief or sadness Depression Conflict, behavioral issues Substance abuse, etc.

22. Grieving Ambiguous Loss
Until death is confirmed:
Open ended duration of grieving and mourning.
Trying to learn both/and thinking.

23. Grieving Ambiguous Loss
Once actual death is confirmed:
Depending on the mourning work leading up to this time --
Feelings of relief
Guilt
Resentment

24. Grieving Ambiguous Loss
While it is in the holding pattern?
Inexplicable sorrow
Anger
Guilt
Resentment
General uncertainty
Risky behavior

25. Spiritual Assessment Model
Looking for resilience:
Finding Meaning
Adjusting Mastery
Reconstructing Identity
Normalizing Ambivalence
Revising Attachment
Discovering Hope

26. Spiritual Assessment Model
Finding Meaning

27. Spiritual Assessment Model
Finding Meaning
Adjusting Mastery

28. Spiritual Assessment Model
Finding Meaning
Adjusting Mastery
Reconstructing Identity

29. Spiritual Assessment Model
Finding Meaning
Adjusting Mastery
Reconstructing Identity
Normalizing Ambivalence

30. Spiritual Assessment Model
Finding Meaning
Adjusting Mastery
Reconstructing Identity
Normalizing Ambivalence
Revising Attachment

31. Spiritual Assessment Model
Finding Meaning
Adjusting Mastery
Reconstructing Identity
Normalizing Ambivalence
Revising Attachment
Discovering Hope

32. CASE STUDY
Charlie is 25 years old and was diagnosed with Cystic Fibrosis as a baby. He was a stoic boy and is a stoic young man despite the regular bouts of severe illness. He completed college with a degree in the creative arts, lives on his own and is an avid runner, boxer and martial artist. Charlie and his parents lived as though each day was one of Charlie’s last.
 Four weeks ago, Charlie was admitted to the hospital and his parents understood this could be his final hospitalization. Instead, Charlie received a double lung transplant. While recovering from the surgery and stabilizing with the transplant and all its attending medications and complications, Charlie found himself at the lowest emotional and spiritual point in his life: he was not sure it was worth the effort to live, he was without hope that the medical issues would turn around despite the team’s reassurance, he did not understand why he could not find God in this very dark place. His parents were mystified by Charlie’s despondence and by what they called “his whining.” Why now, when life is more assured?

33. Charlie Finding Meaning Adjusting Mastery Reconstructing Identity
Normalizing Ambivalence
Revising Attachment
Discovering Hope

34. Charlie’s Parents Finding Meaning Adjusting Mastery
Reconstructing Identity
Normalizing Ambivalence
Revising Attachment
Discovering Hope

35. And what about the resilience for…

36. The Care Providers Finding Meaning Adjusting Mastery
Reconstructing Identity
Normalizing Ambivalence
Revising Attachment
Discovering Hope

37. Questions?

38. Thank You