Spring 2025 Issue

Navigating Ambiguous Loss
By Ariella VanHara, LCSW-QS
Social Work Today
Vol. 25 No. 2 P. 18

Referring patients to residential treatment centers may elicit this complex form of grief.

For many individuals, entering residential treatment is filled with a range of mixed emotions, from feeling anxious, sad, angry, happy, hopeful, and many more in between. This experience also elicits another emotion that is often not as apparent; this includes the invisible kind of grief, also known as ambiguous loss. Pauline Boss, PhD, pioneered this concept and described this type of loss as lacking clarity or closure. This is because it is often experienced when a person is physically absent but psychologically present or physically present but psychologically absent. For example, a person in the military may be physically absent from someone in their life, but psychologically present, and a person with dementia may be psychologically absent due to their current cognitive challenges, but physically present. This type of loss and grief is experienced differently because of the uncertainty surrounding the person and circumstance, which makes it difficult to grieve and move forward. What is particularly interesting about ambiguous loss is that it can present in ways people may not always consider. For example, ambiguous loss can manifest for a person entering residential treatment in ways such as experiencing the loss of their identity, loss of autonomy, and loss of relationships. On the contrary, a family member or friend may also experience an ambiguous loss with a loved one entering residential treatment. This can manifest in ways such as the loss of the person they once knew, uncertainty about the future, physical and emotional distance, shifts in family roles, and a range of mixed emotions such as guilt, shame, and relief. Unlike the finality of death, ambiguous loss leaves individuals and families with uncertainty, which can present in the possible ways described, contributing to individuals’ and families’ grappling with how to cope.

A Patient’s Experience
A person may enter residential treatment either voluntarily or involuntarily, depending on their specific circumstances. Entering residential treatment can be a step towards healing for a person, but it can also come with a loss that is challenging to define. This is because they may feel disconnected from their previous life. Change can contribute to feelings of anxiety, and while not all change is bad, it can be difficult when there is a feeling of unknown and uncertainty on the other side. The ambiguous loss a person may experience in residential treatment may include questioning their identity, autonomy, and relationships. In residential treatment, there is often a daily routine structure that is dictated by individual and group therapy, potential medication regimens to follow, facility rules, and specific periods for communication and visitation. This structure may feel like a loss of personal freedom for a person used to independence and the structure of their daily routines. While some may experience the feeling of being “homesick,” there is a feeling of isolation that can occur when a person is removed from the familiar comforts of home and personal connections.

A person’s identity is shaped by a combination of influencing factors such as their family, culture and religion, life experiences, personal values, social interests, education, occupation, and many other contributing aspects. For example, consider the biopsychosocial model in social work practice, which is the framework for understanding humans through the interconnection of biological, psychological, and social factors. This concept may cause conflict and questioning of “who am I now” when faced with the experience of residential treatment, even if the intention is for a positive outcome in receiving treatment. A person may experience a disconnect from their previous self and question where they are now, and how they got there. A person may also experience a personal conflict with their previous identity as a mother, professional, friend, etc, to now, including being a patient. Although a person is still a mother, professional, friend, etc, even as a patient, it can be challenging for a person to see past that addition when there is a new role in their identity that was not anticipated in life. Society’s perception of entering residential treatment has a stigma attached to it that there was a failure somewhere in life, instead of looking at it as a courageous, brave, and empowering moment. Because of this, a person may experience questioning their self-worth, particularly if they associate their identity with achievements and independence.

Handling Loss of Control
The loss of autonomy and adjustment to a controlled environment is a transition that can be challenging and contribute to feelings of grief about previous independence and control. Individuals tend to be creatures of habit, enjoying routine. For example, a person likely gets ready for the day in the same order such as beginning with waking up, brushing their teeth, showering, getting dressed, and eating breakfast. This disruption of scheduled meals and supervision for privileges such as phone use and outings can present as a form of loss. For a person who is used to choosing what to eat for meals out of endless options, changes such as having to ask to use the phone and only during scheduled times can result in feeling like a child asking for permission, despite being an adult. The loss of autonomy and independence stems from the loss of control and self-determination, which can be fundamental to a person’s sense of self. This is because autonomy can be tied to a person’s identity and dignity and losing it can feel like a loss of adulthood.

While residential treatment is intended to be a place for healing, it can also prompt emotional and social isolation for a person. Relationships are fundamental to our personal and social functioning and contribute to our well-being. Entering residential treatment often means less interaction with friends, family, and other support networks. Although there are opportunities for phone calls and visits, there is a sense of emotional detachment and possible fear of missing out. Some individuals fear that relationships may change, weaken, or fade, particularly if family and friends struggle to understand their experience in treatment. There is also a concern about being viewed differently than before, particularly if they feel people are treating them differently. This experience of loss can lead to feelings of resentment and sadness over life and relationships they built with people in their lives, while also contributing to feelings of isolation and loneliness.

Social workers can support patients experiencing ambiguous loss in residential treatment by offering emotional support, therapeutic interventions, empowerment, and advocacy. They are equipped with the skills to help individuals navigate the complexity of these emotions and thoughts. For example, social workers can utilize the strengths-based perspective to help validate and normalize the ambiguous loss experienced by someone in residential treatment. This can be achieved through reflective listening, psychoeducation, and a variety of therapeutic modalities. Utilizing these tools can help patients rebuild a sense of identity and purpose to empower them to redefine themselves outside of their struggles. Social workers can aim to use a trauma-informed care approach to create a safe environment for recovery and work to reduce emotional distress by identifying healthy coping mechanisms. Advocacy is also a core principle of the social work profession and can be used to ensure that patient-centered care is applied. This will help ensure that the person’s voice in their recovery process is included and acknowledged.

A Family’s Experience
Family members often experience a complex form of grief when a loved one enters residential treatment. This grief is ambiguous in the sense that it is characterized by uncertainty, separation, transition in family dynamics, and a range of mixed emotions. While there may be a sense of relief that a loved one is receiving care and improving their condition, there are emotional voids that are experienced. It can be a challenging dynamic to be supportive, but also concerned at the same time, while also learning to navigate through the recovery process collaboratively.

Before entering residential treatment, a person may struggle with mental health or substance use conditions that have impaired their behavior and relationships. This alone can bring up the grief of the person they remember before the current day challenges. For example, a person diagnosed with schizophrenia may have a markedly different appearance and behavior. This lifelong condition of someone who was “fine” previously, can bring upon feelings of grief of a new world filled with concerns and a lot of unknowns. Similarly, a person who has developed an addiction may have behaviors that are foreign to their previous characteristics. This change can bring up feelings of grief regarding a person they knew before the addiction took over. There is also the potential that relationships have been strained. Feelings of hope for a person to improve their condition are desired, but there can also be conflicting thoughts about whether relationships will be the same after treatment.

Recovery is a journey that is often taken with small steps. A challenging piece for families during this process is the uncertainty about the future and the recovery process. For example, family members may ponder questions, such as “Will treatment work, what if they relapse, will our relationship return to normal?” This type of ambiguous loss occurs because there is no clear resolution, and family members are often faced with an unclear and unpredictable path. This is because recovery is different for everyone, and there can often be setbacks and relapses throughout this process. This is truly a “one day at a time” approach.

The uncertainty of the future can also lead to a shift in family dynamics. For example, if a person with addiction enters residential treatment, there may be concern about family gatherings if a person has “wronged” another family member, or if alcohol is served at Thanksgiving dinner. Additionally, if a person has a mental health condition and has struggled with thoughts of self-harm, there are concerns about this person remaining home, along with potentially harmful items in the home. Family members may begin to take on the caretaker role or feel overshadowed by the immense focus on the person in residential treatment. Family members can often grieve the way things used to be. While there is grief and ambiguous loss associated with this change in dynamics, it does not mean the family loves or cares about the person any less.

Emotional Turbulence
Many emotions are present when someone enters residential treatment. As mentioned, the person receiving treatment often experiences a wide range of emotions such as feeling anxious, sad, angry, happy, hopeful, and many more in between. Family members will also experience a range of mixed emotions such as guilt, shame, relief, hope, and many more. Family members may find themselves opposing feelings trying to make sense of them all and how they conflict with each other. The feelings of guilt and shame can present from placing a loved one in treatment and feeling like they should have done more. Relief is a feeling that family members may feel after the previous moments of feeling scared and concerned. The thought of knowing a loved one is in a safe place is peaceful, but also causes conflicting internal questions about whether they should feel bad for experiencing this feeling of relief. A mixed range of feelings can also be present if a family member must legally testify for residential treatment for a loved one. For example, in instances of involuntary commitment, a loved one may have to testify against a family member. A family member testifying may be out of a loved one’s best interest and concern for safety, but it can also be presented with feelings of guilt and relief.

Social workers can support families experiencing ambiguous loss in residential treatment by helping them process and adjust to the treatment and change process, while also identifying ways to maintain connections. Families may often be unfamiliar with the residential treatment process, which can further exacerbate feelings of uncertainty. Social workers can provide psychoeducation, while also providing validation to the families on the feelings and thoughts they experience. Social workers’ specific theoretical concepts of person-in-environment and systems theory allow them to navigate and explore family relationships to help facilitate open conversations about how family members can support recovery, as well as identify and navigate all forms of family dynamics. This can also include the use of guiding family members in establishing healthy communication boundaries by coordinating visits and facilitating sessions, as well as finding a balance of support that meets the needs of the family. During this process, the emotional complexity of the feelings experienced can be processed in a safe space using a nonjudgemental approach. Social workers can also encourage families by providing resources for ongoing support. This may include other outside resources, support groups, therapy, or family sessions. Using a strengths-based approach, social workers can help families adapt and find strength in the recovery process.

Working Through It
It is important to recognize and accept the feelings experienced with ambiguous loss with residential treatment, both from a patient and family perspective. The grief is not about moving on but adjusting and accepting change and learning ways to connect and support the person and family. As previously mentioned, change can contribute to feelings of anxiety, but not all changes are bad. There are positive life changes, and it can be difficult when there is a feeling of unknown and uncertainty on the other side. People often like to be in control and know what is expected and letting go of this control can contribute to feelings of anxiety surrounding the uncertainty of residential treatment, both before, during, and after the experience. Though eliminating ambiguity may be impossible, identifying ways to manage it and navigate through it is not. Some recommendations include seeking supportive services either through therapy or support groups to process emotions and identify a supportive network with similar experiences. Focusing on the present and practicing mindfulness to remain in the present is a strategy to work towards accepting that the ambiguity may remain during this time in life and learning to live with the unknown through acceptance of the treatment process. Learning to let go of control and living in the present can allow us the time to process our emotions. Communication and connection are powerful tools that can be utilized.

As mentioned, while there is grief and ambiguous loss associated with the experience of residential treatment with both the individual and family, it does not mean that there is less love or care for each other through this process. Ambiguous loss can be emotionally challenging for both the person and family, but there are ways to cope and adjust. Recognizing and acknowledging the loss is a key step to validating the experience. This can help towards redefining the identity, goals, and purpose in life. Recovery is a journey and balancing hope with realistic expectations can help to focus on progress rather than perfection. Healthy discussion about family roles, dynamics, and expectations can help to redefine boundaries and roles in the family system. Collaboratively this approach can help to navigate the ambiguous loss in residential treatment.

— Ariella VanHara, LCSW-QS, is a clinical assistant professor at Florida Gulf Coast University, jointly appointed in the social work department and counseling and psychological services. She teaches, provides clinical services, and supervises social work interns. Before academia, she worked in nonprofit community mental health, specializing in crisis stabilization clinical services and acute care leadership. She has served on Florida’s 988 Implementation Task Force and is active in NASW Florida’s Chapter Committee on Nominations and Leadership Identification. She also serves on the board of Project Help, Inc, supporting survivors of sexual assault and violent crimes.