Chapter One

Ambiguous Losses

An ambiguous loss may be defined in at least three different ways.

1. The loss is characterized by a lack of clarity or confusion surrounding the loss itself. There is no certainty of exactly what is happening, or when the uncertainty may end. Examples of this type of loss are hostages, MIAs, and kidnappings. The events surrounding this type of loss are often unclear; the status and condition of the person is uncertain (dead or alive, harmed or unharmed); and the return of the person is hoped for, but unknown. Other examples of this type of loss include chronic illness, dementia, Alzheimer’s disease, and coma. In these cases the grievers know that the person will die, but they are uncertain about when and how.

2. The event of the loss is clear, but the perception of the loss is unclear. The loss itself is clear, but the family¹ ignores the facts surrounding the loss event. The family may be unwilling to accept the loss, or may accept the loss too soon. One example of this is the physical absence of a person who remains psychologically present long after the person is clearly physically dead and buried or gone (divorce). Another example is a physically present person who is closed out of a family before he or she is dead (Alzheimer’s disease, addiction, chronic illness, and coma).

3. The loss is unclear because it is not recognized, accepted, supported, validated, or ritualized by society. These types of losses have been renamed “disenfranchised losses” in the recent writings of Kenneth Doka,² and will be addressed in Chapter Two. Examples of this type of loss are prison, miscarriage, stillbirth, and abortion.

In all three types of ambiguous loss, there is no satisfactory resolution to the loss because of the ambiguity surrounding the loss or the perception of the loss, or the lack of recognition and support for the loss. Some ambiguous losses may fit one, two, or even all three categories.

Another way to understand ambiguous losses is to categorize them into two possibilities.

1. The physical presence of the person/psychological absence

• Chronic illness
• Dementia (Alzheimer’s disease)
• Coma
• Addiction
• Preoccupation with something or someone outside the family
• Mental illness

2. The physical absence of the person/psychological presence

• Hostage
• MIA
• Missing child
• Divorce

Naming a loss as ambiguous gives recognition to the fact that a loss has occurred and acknowledges that the ambiguity surrounding the loss may cause complications in the grieving process. Since one of the first tasks of grieving is to acknowledge that a loss has occurred, naming the loss is pivotal. Other tasks of grieving are to let go and reinvest in life tasks that are extremely difficult in ambiguous losses.

Pauline Boss has done much of the research on ambiguous losses, particularly in relation to how families experience ambiguous losses.⁴ According to Boss, the situation in families that results from the stress of ambiguous losses may be referred to as “boundary ambiguity” (Ambiguous Loss 165). Families are always trying to understand and maintain boundaries; this is very difficult, if not impossible, to do with ambiguous losses. Families may be unsure who is in and who is out of the system, and therefore be unable to reorganize themselves as a family. Although the event of the loss itself cannot be changed, it can be clarified. The perception of the loss can also be changed and clarified, thus clarifying who is in and who is out of the family system.

Given the challenge of acknowledging an ambiguous loss and agreeing on a common perception of the loss, what can pastoral ministers do to help families? Pastoral ministers must have an awareness of ambiguous loss in order to accurately identify this type of loss. According to Boss (168–169), we can also:

• Name the ambiguity as a stressor for families;
• Help provide an environment for family meetings to occur where all the various perceptions can be voiced and heard;
• Help provide information about the situation by helping to gather and clarify information surrounding the loss;
• Help provide the families with sources and choices for support besides one pastoral minister; and
• Encourage and help provide families with a format to find meaning in loss.

Pastoral ministers can be especially helpful with this last intervention. We can identify and call on various religious resources and help in facilitating appropriate rituals.

Some ambiguous losses will eventually reach a resolution—the MIA whose remains are found, the kidnapped child who is returned, or the person with Alzheimer’s disease who dies. But the period of ambiguity may be a long one, and the loss may continue to be ambiguous if the family’s perception continues to be that the person has not died. Some ambiguous losses will never have a clear resolution—the MIA or kidnapped child is never found, or the addicted person is continually in and out of recovery. Whether there is resolution or not, individuals and families will need help in learning to live with the uncertainty and will need encouragement and support in their grieving. Rituals will be important here, either in continuing the usual family rituals and finding a way to include the missing family member, or eventually, in ritualizing the death itself, when that finally becomes known or accepted (172).

Because of the difficulties in naming the loss, there are often interferences or difficulties in what Rando refers to as the first “R” process of mourning—recognizing the loss. This will often result in absent or unanticipated grieving. If grief appears to be absent, pastoral ministers may need to look at what is contributing to the absence of grief, in addition to the ambiguity of the loss itself. Factors such as dependency, fear of grieving, and guilt may be contributing to a reluctance to name and recognize the loss (Grief, Dying and Death 109). Because of the difficulties in resolving the loss, there are likely to be problems with the fourth and fifth “R” processes—relinquishing old attachments and readjusting to a new world. This may result in chronic, unending grieving. Again, factors other than the ambiguity of the loss may need to be explored. Is the relationship with the lost person overly dependent or irreplaceable? Is there any motivation to relinquish the ties? Or is the motivation to maintain the ties? Pastoral ministers may need to take an active role in assigning tasks to be completed in the grieving process (109–110). These tasks might include sorting through and giving away the deceased’s possessions, going through photographs, and writing to billing agencies and friends.

Alzheimer’s Disease

Alzheimer’s disease is a degenerative disease that is chronic, irreversible, and progressive. It attacks the brain and results in impairments in memory, thinking, and behavior. In defining Alzheimer’s disease as an ambiguous loss, the emphasis is primarily on the loved ones surrounding the affected person. The person with Alzheimer’s disease is, of course, also grieving as he or she experiences a variety of losses.

According to the three definitions of ambiguous loss given above, Alzheimer’s disease may be assessed as an ambiguous loss under either of the first two definitions: the loss is unclear or the perception of the loss is unclear, depending on the family’s reactions and perceptions. Alzheimer’s disease may also be categorized as an ambiguous loss under the two definitions given above—a physically present, but (eventually) psychologically absent person. Naming the loss as ambiguous can help families and pastoral ministers to work through the loss more effectively.

Howard

Howard was 66 years old, one year into retirement, when his family began to notice that he was becoming forgetful. At first it was little things—forgetting to turn the heat down at night, or to lock the front door when he went out. Eventually the little things became bigger and of more concern—forgetting how to get home after driving somewhere, or forgetting to show up for a family get-together. Even as the number of incidents increased, most of the family was not worried. They attributed the forgetfulness to Howard’s grief over the death of his beloved wife 13 months before. Betty had kept track of most of these details for Howard. Then other changes began to appear. Howard, who was always gentle and accommodating, could now be strong-willed and stubborn.

Howard had three grown children—two married sons, John (45) and Jeff (43), and a single daughter, Jill (38)—who all lived nearby. His daughter was concerned about Howard’s forgetfulness and suggested that he see a doctor. But Howard hadn’t been to a doctor since his family physician had retired 10 years earlier. “I never missed a day of work in my life,” he bragged, “except for Mom’s funeral. I feel fine.” Jill remained concerned and began checking on him on a daily basis. Although her two brothers did not share in her concern, they agreed to keep an eye on Dad.

One day Howard could not be found anywhere. After checking at his home and the Senior Center and with all of his friends, his daughter became worried. Her brothers joined her in the search. When night came and Dad was still nowhere to be found, they called the police. The next day they received a call from the police. Howard had been located at a restaurant a few hours away. He was confused and disoriented, but he knew his name and said he wanted to go home.

After this incident the family was able to convince Howard to go to the doctor—just for a checkup. Some of them now began to fear the worst, yet were unsure what the worst would be. Others remained sure everything would be all right. The diagnosis was Alzheimer’s disease. The doctor suggested that the family meet with a counselor or minister to sort out what this meant and how they would support and care for Howard in the days ahead.

There are a number of issues that need to be acknowledged and addressed here so that grieving can proceed. This case will continue to be explored from the perspective of the pastoral minister⁵ who is called in to help the family sort out what is going on and to help them in their grieving.

Rose, a pastoral associate at Howard’s church, is called in to talk with the family. Before she meets with them, she lays out a genogram⁶ of what she knows of the makeup of the family.

Rose asks to meet with all of the family members, including the four grandchildren. To prepare for this meeting, she reviews what she knows about Alzheimer’s disease, particularly as an ambiguous loss. Rose is aware that she is being asked to come into the picture early on in the grieving process. Most of the family may still be in shock or denial over the diagnosis. Her primary role is to listen as she encourages the family to express all their feelings—whatever they may be, and however different. She will need to let them know that what they are experiencing is normal and part of the beginning of a grieving process.

Rose can also help the family as they gather and try to understand information about Alzheimer’s disease, including treatment and caregiving. She realizes that this may be the start of a very long process and that she needs to be with the family where they are now, even if that is in denial. She needs to be patient, calm, nonjudgmental, and compassionate. She realizes that not only is this family in the first phase of grief, they are in the first stage of caregiving bereavement—the stage that occurs during caregiving. This stage begins with the diagnosis itself and proceeds through deterioration that evokes feelings of powerlessness and loss, when an “empty space” emerges and the caregivers start their long process of detachment. They are at the very beginning of what may be a long, agonizing process. They may feel disoriented and bewildered as each family member struggles to come to terms with a diagnosis that brings an unknown future. The second stage of caregiver bereavement will occur after Howard’s physical death, when grief becomes acute and the empty space enlarges. Caregivers try to fill the empty space as they begin to reconstruct their lives and get on with life without caregiving and without their loved one. Eventually they will experience both relief and recovery (Jones and Martinson 175).

Part of Rose’s first conversation with the family is printed here (see the genogram on page 18 of the printed book for identifying data).

Rose: Thank you for inviting me here today. It is a privilege for me to be with you as you gather together as a family to talk about Howard&3146;s diagnosis and what this means to you as a family. I see my role here today as listener and facilitator. Everyone’s voice is important and I will be asking each one of you for input. Here are the ground rules as I see them:

Each person will have an opportunity to speak, but no one has to speak. You have the right to pass.

No one person or opinion is right or wrong. We are here to listen to each other so that we can better understand where we are coming from as individuals and as a family. We are not here to convince each other of our views.

We are here because of our love for Howard and our concern for his well-being and future care. Any feeling we have is acceptable because we know it originates in our love for Howard.

How does that sound?

Jill: Let’s get started! Even though we all don’t go to church, we agreed it would be good for you to start with a prayer.

Rose: I’d like that. I’ll start. Please join in wherever you like.

Loving God, we are gathered here today—as a family—to talk about our father and grandfather, Howard Jones. Be with us in our conversation as we try to understand and express what is in our hearts. Help us to be patient with each other and to have the courage to say what we are really feeling.

Each of us has special needs that we bring here today, and I now invite any who would like to mention what that need is. I’ll start. I need to be able to hear each of you—wherever you may be. I pray for guidance in listening.

Jill: I tend to talk too much. I pray that I can keep quiet so that others can talk.

John: I pray for a cure so that we don’t have to deal with this.

Brad: I pray that Grandpa will be here to see me graduate from high school and college.

Judy: I don’t know what to pray, but I’m glad we’re praying as a family.

(Silence)

Rose: Anyone else?

Sandra: I need to have some answers. I pray that I can get some today.

(Silence)

Rose: Dear God, we gather these hopes and needs—those we have just expressed and those that remain in our hearts, and give them over to you. We ask your blessing on all that we say and do today. In Christ’s name we pray. Amen.

There are nine family members gathered here today. I’d like to give everyone a chance to speak at least once. Who would like to start?

Jill: I know I said I needed to be quiet so others could talk, but that will be easier for me after I say what I want to say. I just want to say that I can’t believe that I was the only one who saw what was happening with Dad and how sick he was. I can’t help but think that if we had only got him to a doctor sooner ... Jeff (interrupting): There you go again, Jill. You always think only you know what is best. You know the doctor said that wouldn’t have helped.

John: Yeah. And I’m still not sure that Dad is really as sick as you think he is.

Rose: Jill, Jeff, and John, you are all speaking what is in your hearts, and this is good. I wonder if it would be helpful if I kept track of some of the issues and feelings that you are expressing. (Writes on newsprint: Issues/Feelings.)

Rose (writing): Issue Number 1: Need to understand more about Alzheimer’s disease.

Rose: Along with this issue, could you also identify a feeling that you are having?

Jill and Jeff: Anger.

Rose (writing): Feeling Number 1: Anger.

Rose: We’ll come back to that. Let’s see if anyone else wants to say what they are feeling ...

Rose’s purpose is to encourage the family to express their feelings and concerns without having the meeting turn into a blaming session. Doing this means that she will take an active role in keeping the family discussion both open and focused. She needs to affirm, summarize, and draw out emotions. She continues to encourage each person to speak and to keep track of what is being said. She does not add her own opinion or perspective but focuses on understanding and summarizing the various perspectives of the people gathered. At the end of the session Rose has sheets full of emotions and issues. She works with the family to prioritize the issues and helps identify resources: where to get information on Alzheimer’s disease, what support groups exist, and (for those who asked) what religious resources may be helpful (such as particular Scripture passages and prayers). Rose assures them that she will be a supportive presence throughout Howard’s illness. She also reminds them that she is not a professional counselor, and there may come a time when some or all of them will desire professional counseling and she will help in that referral.⁷

Rose is called on a number of times throughout Howard’s seven-year illness, and remains a supportive, pastoral presence in the family. Her ministry includes the following.

Naming the Beast

Helping the family to name and understand Alzheimer’s disease as an ambiguous loss

Taming the Beast

• Using empathy⁸#working with the family to understand their perspective of Howard#s illness
• Gathering information#empowering the family to gather as much information as is needed
• Widening the circle of care#encouraging a broad range of resources, including the parish community
• Providing a continual pastoral presence#as a minister and as a community of faith, including Howard and his family in:
• Community prayers;
• Pastoral visitation to the homebound;
• Greeting cards and notes of support and encouragement;
• Special blessings of those who are ill and their caregivers;
• Church bulletins and newsletters; and
• Rituals for those experiencing loss.

Renaming the Beast, or Dealing with Questions of Faith

Being willing to respond to the thornier theological and moral issues that arise: Why did God do this to Dad? Why doesn’t he die? Why does he have to suffer so long? If he stops eating, should we have a feeding tube inserted?

Rose’s ministry and the ministry of the worshiping community continued on after Howard’s death in many of the same ways. However, much of the grieving and ministry with the person with Alzheimer’s disease occurs before death, in the caregiving period. This unique situation presents caregivers and pastoral ministers with special challenges, some of which have already been noted. Other challenges include:

• The continual change in roles experienced by the person with Alzheimer’s disease and the family;
• The refusal of the affected person and the family to name and acknowledge the losses that continue to occur;
• The long-term uncertainty and ambiguity surrounding the progression of the disease;
• The amounts of physical, emotional, and spiritual strain on the caregivers and pastoral ministers;
• The long-term nature of anticipatory grieving; and
• The tendency to prematurely detach.

These last two points require particular attention.

Anticipatory Grief and Premature Detachment

Anticipatory grief is grief that is experienced before an actual loss occurs. In this case, it is the grief that is experienced before Howard dies. The term was actually coined during World War II by Erich Lindemann, who used the phrase to describe a situation in which a soldier had returned home after being away a long time to find that his wife was no longer in love with him and wanted a divorce. According to Lindemann, the wife had mourned her husband’s absence and had detached herself from him, in anticipation of his not returning. In this case, there was no actual death, but the threat of a death. We may also experience anticipatory loss in relation to the potential loss of social roles (retirement), bodily functions (aging), or a loved possession (selling a home).

In Howard’s case, he and his family experienced anticipatory loss in relation to his future death, and to his ongoing losses in role, functioning, and the ability to relate. For Howard’s loved ones, anticipatory grief was the grief they experienced in the caregiving stage of their bereavement. As Howard became more forgetful, less independent, less communicative, and in need of more care, both he and his family continued to experience anticipatory grief. They grieved:

• The loss of life as they had known it—the past;
• The ongoing and continuing losses—the present; and
• The loss of life as they had envisioned it happening&3151;the future.⁹

Understanding that what they were experiencing had a name—anticipatory grief—was extremely helpful. Learning that it also had a purpose, and an end, helped Howard’s family to feel less anxious and more hopeful. Knowing that with anticipatory grief there is more ambivalence and more denial (Rando, Anticipatory Grief 9) enabled them to be less ashamed of their feelings. As their experience of grief seemed to be increasing with time, they began to worry if they would make it through. They also worried what they would do when Howard died. It was a relief for them to learn that a characteristic of anticipatory grief is that it accelerates as death nears, but ends with death as post-death grief appears. Post-death grief would actually decrease with time, making the most painful time of grieving for them the time they were currently living through (10).

It was also helpful to understand that part of the stress that they were experiencing was because of the length of Howard’s illness. Studies indicate that as the length of an illness progresses beyond 18 months, there is a higher rate of post-death anger and an increase in complicated (abnormal) grief (20). It was also helpful to learn that anticipatory grief had its own stages that they could relate to (Spiegel):

• Shock;
• Attempts at control—busyness;
• Regression—dealing with loss from what was done in the past; and
• Adaptive stage—being ready to face a reintegration with self and others.

As helpful as this was, Howard’s family realized that there were at least two obstacles in anticipatory grief.

1. Experiencing the losses is not the same as grieving the losses; anticipatory grieving requires hard, continuous work over a long time.

2. Because of the length of the illness and grieving, there is a tendency in anticipatory grieving for families to prematurely detach from their loved one, who is still alive.

Three years into Howard’s illness he no longer recognized members of his family. He required around-the-clock care to attend to his physical needs and to maintain his safety. By this time all the members of the family had come to terms with the seriousness of Howard’s illness and the eventual outcome of death. His grandsons—Brad (21), Brian (19), and David (17)—were having a difficult time keeping up a relationship with Grandpa. They dreaded their visits with him when they tried to tell him what was going on in their lives only to find that he didn’t even know who they were. They began to plan events to get out of visiting him, and they no longer talked about having Grandpa at their activities. One day Jill overheard David telling a friend that his grandfather was dead. Jill was outraged and confronted David. He responded, “I know he’s not dead, but it’s like he is. I no longer have the Grandpa I had. He’s not a part of my life. He doesn’t even know I exist. He might as well be dead.”

David (and Brad and Brian) are detaching from their grandfather. Although this is normal and to be expected, it will be unfortunate if they continue to do this while Howard is still alive. Although he can no longer relate to them as before, he still needs to be related to. David, Brad, and Brian need to find new ways to grieve the loss of the grandfather they knew while continuing to relate to the grandfather they now have. They will need their family’s help and Rose’s to learn how to do this.

Once again, Rose’s unique role as pastoral minister was of special help to them in their anticipatory grieving. She was able to bring to the foreground the broader questions of meaning and faith and the value of life, when they got caught up in how things used to be. She was able to work with them to ritualize the passing of certain events in their lives and to include Grandpa in new ways in these rituals. She was able to be present to them in their anger and detachment and to represent and remind them of God’s love and concern for them. Rose was also their link to a community of faith that supported them and held them in their care.

Divorce

Jim and Terry had been married for 12 years and were the parents of two children, Mindy (10) and Michael (8). They had been having trouble in their marriage for a number of years. After six months of marriage counseling they decided to separate. They agreed that it was best for the children to stay at the house with Terry. Jim moved into a small apartment. Since they were still unsure about divorce, they decided on a trial separation of six months. During this time the children stayed with Terry from Monday to Friday and spent every other weekend with Jim. During the week Jim was over at least two to three evenings to help with homework, baby-sit if Terry had to go out, or attend school and sports functions with the kids. Except for every other weekend with only Dad, Mindy and Michael’s life changed very little. They actually saw more of Dad now than they ever had before. They were a bit confused about their mother’s tears and constant talk about Dad being gone.

At the end of six months, Terry was ready to have Jim move back in and try to work on the marriage. She had seen the separation as temporary, a time apart so they could come back together. Jim, however, liked the new arrangement and wanted to proceed with a legal separation and divorce.

Terry talked about Jim all the time, even though he came over less often during the week and preferred seeing the children without Terry being there. Jim also started dating, which upset Terry. One day in religion class Mindy was sharing that she had two homes. When one of the other children asked if her parents were divorced Mindy replied, “Oh, no—at least I don’t think so. Mom still sets Dad’s place at dinner every night, and Dad’s tools are still in the garage.”

This situation represents another type of ambiguous loss—a physical absence, but psychological presence. The children are not sure whether Dad is in or out of the family system, and Terry adds to the confusion by setting Jim’s place at dinner and talking about his return. This is a critical and very difficult time in the grieving process—a time when only Jim seems ready to acknowledge that separation and loss have occurred. Mindy and Michael are caught between Dad talking about a future without Mom and Mom talking about a future with Dad. Even in this confusion and ambiguity, grieving can and actually needs to begin.

At the very least, the family can name the ambiguity of the loss and the differing perceptions and expectations surrounding that ambiguity. They can also name what they have lost.

• What was—being together as a family, doing things with all four members of the family
• What is—Dad’s absence during the week—at meals, at bedtime, and at homework; weekends at their own house
• What would have been—a sense of security about the future as a family; holidays as they have always known them

Terry and Jim could add to this list:

• Companionship;
• Income;
• Parenting as a couple;
• Someone to argue with; and
• Someone to share household chores with.

The future will probably continue to hold additional losses, whether Jim and Terry divorce or reconcile. But it is the present losses that need clarification and a discussion of the differences in perceptions and hopes for the future. Naming the ambiguity of the loss (separation), listing other concrete losses, and expressing differing perceptions and hopes will help give the family some clarity to their grief and initial permission to grieve the losses that are occurring. Since Terry is trying to deny or downplay much of the actual loss of the separation, this process may be most difficult for her, but it is necessary for the health and well-being of the family.

One year later Terry and Jim do divorce. Terry no longer sets a place for Jim and his tools (and other items) have all been moved out. The loss seems less ambiguous and more definite, but certainly still painful. The children continue to talk about Dad almost every day and Terry continues to talk about the way life used to be before the divorce, remembering mostly the good times. She says such things as, “Remember how much fun we had when we all went camping?”

Though now definitely, physically absent from the home, Jim remains a strong psychological presence. When Mindy is asked about her parents she reports, “Oh yeah, they’re divorced, but I think they’ll be getting back together sometime soon.”

The loss remains ambiguous and the grieving remains complicated. Certain factors continue to enhance complications in grieving, but other factors help the family in their grief. Frank, the deacon at their church, sits down with Terry—at her request—to help her list what is helping and what continues to hinder her in her grieving.

What Is Helping

1. Good social and faith resources, lots of friends and a supportive church community

2. A supportive and open family (Mom and Dad) who can talk about the divorce without blaming each other

3. A stable financial situation

4. Children who are not taking sides

What Is Hurting

1. Ambiguity of the loss

2. Other losses (secondary losses¹⁰):

• Self-esteem
• Identity
• Belief that marriage is forever
• Co-parent, mechanic, chauffeur, gardener, friend, companion, and lover

3. Unresolved anger in marriage relationship (intense feelings)

4. Belief that divorce was preventable

Terry was also able to see that a number of potentially complicating factors were not present.

• The children were not so young they couldn’t understand.
• There were no other major stressors or losses in the family.
• The family system was not inflexible or condemning.
• There was no known generational legacy of unresolved loss.

Terry realized that although the loss was complicated, there were a number of factors present that could help her in her grieving. Terry was also able to see how she contributed to the ambiguity of the loss, and therefore the complications, by her constant talk about what was and what might be. She began to limit her talk about a glorified past and her hopes for a reconciled future—at least in front of the children.

As the ambiguity became less dominant, the loss became clearer and the children were able to talk more about their own hopes and fears and to grieve the loss of life as they had known it and as they had imagined it would always be. In doing so, they could more honestly see that their new life had some disadvantages, but it also had some advantages—less fighting, more one-on-one time with Dad, and a new calmness in family outings.

Resourcing the Spiritual

For Terry, Jim, Mindy, and Michael Peters it was important to somehow ritualize the changes that had occurred in their family. They believed that doing so would help them let go of the past and look forward to the future with a new sense of hope. Frank (their deacon) explained some possible reasons for enacting a ritual—to help with and symbolize understanding, forgiveness, transition, healing, or meaning. He also talked about the difference between a mythic ritual that conveys the sense that everything is going to be all right; and a parabolic ritual that embraces the discordant and admits the pain (Anderson and Foley 33). This second type of ritual—the parabolic—may be especially effective in ambiguous losses like divorce, and it was this type of ritual that the Peters family chose.

Pastoral ministers of any denomination can work with divorcing families to come up with rituals that will help in the transition, the healing, and the search for meaning in their grieving. The rituals may be simple and nonreligious—lighting a candle, or planting a tree—or more elaborate and more overtly religious—doing services of hope and healing, or writing or reciting prayers of lament. The Peters family devised a simple ritual of letting go in which each family member wrote down on a piece of paper what was most painful in the divorce. They then shared this hurt with everyone in the family. Each person was invited to let go of that hurt in whatever way was appropriate for them. Michael chose to place his hurts in a balloon, blow it up, and watch it drift away. Mindy chose to throw hers in a river and watch it float away. Jim chose to rip his up and to bury the pieces. Terry had the most trouble letting go of the hurt and asked to keep hers in her jewelry box. With Frank’s encouragement, she was able to decorate her hurt, so although she could not let it go, she could see that it was being transformed. Terry, Jim, Mindy, and Michael ended their ritual with Frank leading them in a prayer for healing, health, and growth. They also planted two new trees at their separate homes, symbolizing the hope for new life and new growth.

Study Questions

1. What is an ambiguous loss? In what three ways can it be defined?

2. Name three things a pastoral minister can do to help families experiencing ambiguous loss.

3. What type of unresolved grief is associated with ambiguous loss? What factors may be contributing to the ambiguity?

4. What are the two stages of caregiving bereavement?

5. What are some of the particular challenges for the family of a person with Alzheimer’s disease?

6. What is anticipatory grief? What are its three foci? What are its stages? How do anticipatory grief and premature detachment contribute to complicated grief for the family of a person with Alzheimer’s disease?

7. What are some of the secondary losses involved in divorce?

Practicums

1. Break up the larger group into groups of three to four. Have each small group develop a ritual for Howard’s family (Alzheimer’s disease case) or for the Peters family (divorce).

2. Have the small groups (three to four) discuss how they would respond to the following questions that Howard’s family raised.

• Why did God do this to Dad? Grandpa?
• Why does he have to suffer so much?
• Should we have a feeding tube inserted if he stops eating?

3. Have one person take the role of one member of Howard’s family who is struggling with one of these questions. Have another person play pastoral minister. Let the two talk for a few minutes. (The other two persons should serve as silent observers.) After 10 minutes have the observers give feedback.

• What issues emerged?
• What was most difficult? Why?
• What was most helpful? Why?
• What skills were used? (See the Appendix.)

In giving feedback, make sure the observers focus on strengths, and also comment on what was missing. Give the persons in the role-play sufficient time to debrief.

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