Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Unhappy holidays


During “the most wonderful time of the year,” we can remind patients, loved ones, and ourselves, that grief often sits side by side with joy at the holiday table, and that’s ok.  

Last December, I sat with a patient who’d recently been diagnosed with metastatic cancer. She knew her time was limited. She’d been estranged from her brother and sister for decades; now knowing she would die soon, she was desperate to find them to say she loved them and to ask for forgiveness. But it had been so long that she didn’t know where they lived or if they had functioning phone numbers. I helped her track down a cousin’s phone number, but they didn’t know what had happened to the siblings either. My patient died not knowing where her siblings were or whether they were alive, but she never stopped thinking about them. 


My patient was acutely experiencing what psychotherapist Dr. Pauline Boss calls ambiguous loss. Boss coined this term after studying families of soldiers who went missing in action in Vietnam. She observed these families had difficulty finding closure when their loss remained so uncertain. Ambiguous loss includes both being mentally present but physically absent (e.g. missing persons), and being physically present but mentally absent (e.g. dementia).  


While society might judge someone suffering from an ambiguous loss as “not moving on” quickly enough, Boss argues people experiencing ambiguous loss shouldn’t be pathologized; rather, their grief is a natural result of their circumstances. Complex grieving is often a normal reaction to a complicated situation. 


The holidays are a hard time for people dealing with any type of loss, but ambiguous loss can be particularly tough. Because it isn’t as “official” a loss as death, people experiencing it don’t have the societal validation offered to people experiencing other types of loss. This can feel isolating, sometimes causing people to turn inward. What’s more, because they can’t find closure, they often remain “stuck” in their grief process, which adds to feelings of isolation. 


So, what can clinicians do?  

1. Validate.

First, we have tremendous power to help by validating the difficult situations our patients are in and telling them their losses are real. As we meet with the family of a patient who is intubated and sedated in the ICU, or the spouse of a patient with advanced dementia, we can affirm these difficult experiences as legitimate losses.


2. Teach “both/and thinking.”

Second, we can teach our patients “both/and thinking,” a skill Boss identifies as key to building resilience. Both/and thinking allows for holding two opposing ideas at the same time—for instance, a child of a patient with dementia might think: “Mom is here and she is also gone.” Embracing both/and thinking allows us to stop feeling guilty about not being able to solve the underlying problem. Given that ambiguous loss is particularly traumatic because we cannot resolve it, using both/and thinking alleviates some of this trauma. 


Both/and thinking underlies Boss’ “guidelines for resilience” that she believes are key to coping with ambiguous loss. The guidelines highlight flexibility in adapting to a new identity (for example, being more of a caregiver instead of a spouse), celebrating the parts of the person that remain while grieving what is lost, accepting there are situations we cannot control, understanding that ambiguous loss is ongoing, and redefining hope.  


Learning to live with the reality of ambiguous loss is uncomfortable in a world where we’re accustomed to closure. There may be no resolution to this type of grief, but we can learn to accept it. During “the most wonderful time of the year,” when there’s so much pressure to be cheerful, we can remind our patients, loved ones, and ourselves, that grief often sits side by side with joy at the holiday table, and that’s ok.










This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.