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A Brief Clinical Commentary on Prolonged Grief vs. Ambiguous Loss

Grief and loss
September 29, 20223 min read

A Brief Clinical Commentary on Prolonged Grief vs. Ambiguous Loss

Christie Carrera, LCSW, MSW – Vice President of ANWC&P, Clinical Supervisor, and Psychotherapist

‘Grief and loss’ is an umbrella concept within the clinical field pertaining to distress associated with loss. Though grieving and the experience of loss could stem from a multitude of factors, the DSM-5-TR (2022) has only recently addressed the idea that someone could suffer from these symptoms in a long-term capacity, i.e. Prolonged Grief Disorder. Prior to this point, individuals suffering from these symptoms for longer than a 6-month duration were not diagnosed as suffering from grieving symptoms, but were instead shoved into one of the remaining diagnostic boxes, such as major depressive or post-traumatic. 

Too many clients often struggle under misdiagnosis because there isn’t a clear enough diagnostic label to cover the umbrella of grief when pertaining to ambiguous loss. For example, when a psychotherapist sees a client reporting depressive or traumatic symptoms post-loss and perhaps diagnoses an adjustment disorder, that isn't clinically applicable if more than 6 months have passed since the triggering event. Similarly, if a diagnosis of a major depressive disorder episode is given, that isn't exactly right either because it doesn't encompass the overwhelming loss contributor. A diagnosis of post-traumatic stress disorder would also be inaccurate, because it does not cover the experience of longing. In short, there is nothing within the DSM-5-TR that allows for the definitive treatment of the lingering symptoms of ambiguous loss or loss outside of death.

 A Prolonged Grief Disorder diagnosis certainly could be the most viable. DSM-5-TR lists symptoms under Prolonged Grief Disorder unique to grief from loss: intense longing, preoccupation with thoughts/memories, identity disruption, disbelief, avoidance of reminders, intense emotional pain, difficulty reintegrating into one’s relationships/activities, and emotional numbness (American Psychiatric Association, 2022). However, the death-specific loss requirement negates the applicability of the diagnosis to ambiguous loss. It would be spot on for most symptoms that stem from ambiguous loss, yet because it has a requirement that the person must be grieving a death-related loss, the diagnosis is negated in this context. Moreover, this new diagnosis neglects to identify ambiguous loss as something that could cause prolonged grief.

When we force people into categories that may not be the best fit, we not only invalidate the client’s experience of grief and loss, we also seek treatment modalities that are diagnosis-specific and likely not as helpful as they could be. Who is to say that someone suffering from abandonment, tormented by memories of their lost loved one, doesn’t feel a similar pain to someone whose loved one has died? Dr. Pauline Boss wrote extensively on the theory of Ambiguous Loss in her 1999 published book and wrote that ambiguous loss is “…the most devastating [loss] because it remains unclear, indeterminate…” (Boss, 1999, pp. 5-6); she further suggested that “…even sure knowledge of death is more welcome than a continuation of doubt…” (Boss, 1999, p. 6).

Therapeutic healing in this area directly coincides with receiving proper therapeutic intervention from professionals that clearly understand ambiguous loss and how to treat it with the right treatment modality. Boss wrote, “Therapy based on the recognition of the ambiguity of the loss frees people to understand, cope, and move on after the loss, even if it remains unclear. The major theoretical premise underlying therapy is this: the greater the ambiguity surrounding one's loss, the more difficult it is to master it and the greater one's depression [and] anxiety” (Boss, 1999, p. 7). Therapeutic competence in ambiguous loss as a facet of grief and loss is essential for effectively treating clients suffering from this experience.

References


American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association Publishing.

Boss, P. (1999). Ambiguous loss: learning to live with unresolved grief (1st ed.). Harvard University Press.


Christie Carrera, LCSW

Christie is a Licensed Clinical Social Worker, Certified Clinical Supervisor, and Vice President of A New Way Counseling and Psychotherapy. As a clinician she is passionate about helping individuals find their way by using an integrative approach in order to meet the needs of each individual. For more on Christie, visit her page, https://relaxteams.com/products/christie-carrera-licensed-counseling-professional

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