Examples of physical ambiguous loss
Missing from earthquake and tsunami (3/11)
Missing from terrorist explosion (9/11)
Vanished without a trace (lost at sea, lost airplane)
Kidnapped by political or religious terrorists
Forced relocation, uprooting, and loss of home, land, animals, and community
Examples of psychological ambiguous loss
Depression, unresolved grief
Preoccupation with missing person
Addiction to drugs or alcohol, gambling
Obsession with computer games, Internet, TV, etc.
Dementia from Alzheimer’s disease and other cognitive disorders
Chronic mental illness
It is important to note that both types of ambiguous loss can occur simultaneously in one person or one family. For example, in Fukushima, many families are not only experiencing type 1 ambiguous loss with physically missing loved ones, but due to relocation, they have also lost the psychological presence and support of longtime friends and neighbors who were also uprooted and relocated (see Chap. 5, this volume). Multiple ambiguous losses also occurred after 9/11 in New York. Some children with a parent lost in the rubble of the World Trade Center towers told us months later they felt as if they had lost both of their parents. We were puzzled as their mothers were sitting at the other end of the room. However, many of the mothers were so depressed that they apparently were no longer “there” for their children (Boss, Beaulieu, Wieling, Turner, & LaCruz, 2003) . They were now psychologically absent because their husbands were physically missing. Both types of ambiguous loss were impacting the children.
Experiencing both types of ambiguous loss at the same time also impacts adults. For example, after 9/11, a woman we worked with had a physically missing husband and also a psychologically missing mother. That is, her mother suffered from Alzheimer’s disease, a pathological condition characterized by severe deficits in memory and cognition that differ dramatically from normal aging (see Cherry & Smith, 1998) . Understandably, she felt doubly sad and confused. Such situations are likely to be of higher risk and require more attention and support.
Depending on cultural values and beliefs, many family members, however, manage to find a surprising resilience, which helps them to live well despite “not knowing.” For example, people may use religious beliefs or even dreams to create one or multiple endings to their mystery. They symbolically construct an ending to their story that brings them relief (Boss & Carnes, 2012; Robins, 2013, 2014) .
The theory of ambiguous loss provides a useful lens, which focuses less on pathology and more on resilience. It is a stress-based model which aims at prevention—the prevention of further trauma and stress and subsequent medical symptoms with whomever we work—individuals, couples, individual families, or groups of families in a community.
To illustrate ambiguous loss, its effects, and the resilience that allows survivors to move forward in a new way, we will use primarily the March 11, 2011 (3/11) disaster, officially called “The East Japan Great Earthquake,” which brought a devastating tsunami to the East Japan region, the most serious in the Iwate, Miyagi, and Fukushima prefectures (see Chap. 5, this volume), as well as the September 11, 2001, terrorist attacks on the USA (9/11) in New York City and Washington, D.C. Both the Japanese (3/11) and the New York City (9/11) events, plus all too many ensuing events such as the lost Malaysia Airlines Flight 370, create a unique suffering comprised of complex grief and long-term sorrow for individuals, families, and even entire communities.
Because grief therapies are insufficient and often offensive to people experiencing ambiguous loss, this chapter also focuses on how to help and support them to increase their tolerance for ambiguity and thus gain the resilience and strength for the long journey ahead .
The Difference Between Ambiguous Loss and Death
Ambiguous loss differs from death because it has no clarity, finality, or proof of death. However, as with some kinds of death, for example, a child’s, ambiguous loss often leads to a complicated grief . With the missing, however, it is not due to the untimeliness of death, but due to the lack of facts surrounding the loss. Without proof of death, families must construe their own ending to their traumatic story.
With loss ongoing and without finality, the grief process is beyond normal human expectation and thus challenges a family’s ability to find meaning in their suffering. Without facts, they cannot make sense of the loss. We think of the families of passengers and crew on the missing Malaysia Airlines Flight 370 who may have to live a lifetime without knowing the fate and whereabouts of their loved ones.
When a loved one is lost physically without verification of death or a body to bury, such loss is in essence a “complicated loss” and thus leads to symptoms of complicated grief. Through no fault of family members, this type of unclear loss understandably causes open-ended and long-term grief. It may resemble “malingering” but because there is no possibility of closure or even resolution, we must note: If the loss remains ambiguous, the cause of chronic sorrow and lingering grief lies in the type of loss experienced and not in the pathology of the persons who are grieving (Boss, 1999, 2004, 2006) .
The Difference Between Ambiguous Loss and Post-traumatic Disorder
Ambiguous loss is a traumatic loss and thus can lead to symptoms that are similar to those of post-traumatic stress disorder (PTSD): depression, anxiety, guilt, psychic numbing, flashbacks, and distressing dreams. There are differences, however, in how these symptoms are viewed and treated.
PTSD is viewed as an individual disorder. Based on the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) , it is medically defined, individually diagnosed, and individually treated. The family has not typically been involved. The therapeutic goal is to return the patient to health.
On the other hand, ambiguous loss is viewed as a relational disorder. It is a relational rupture that presumes a close relationship with the lost person. For this reason, relational interventions are most effective. For this trauma, family therapy and peer group meetings are recommended over individual therapy. The goal when treating ambiguous loss is to help family members and the family as a whole to find the resilience they need to live with long-term stress of ambiguity. That means empowering and remobilizing the family processes that involve decision making, day-to-day functioning, caring for one another, and finally, grieving what has been lost. While the treatment goal for PTSD has been recovery, the goal for ambiguous loss is resiliency (Boss, 2006) .
The Difference Between Depression and the Normal Sadness of Grief
To work effectively with families of the missing, we must first know the difference between depression and sadness. Depression involves an intense grief that interferes with daily functioning (eating, sleeping, working, etc.) and often contains aspects of the individual’s existing or preexisting conditions or disorders.
Symptoms of depression are a preoccupation with the lost person, difficulty finding meaning, putting life on hold, feelings of helplessness and hopelessness, and not accepting the loss. But family members with loved ones ambiguously lost also manifest these symptoms. Caution is required before a medical diagnosis of depression is warranted. Professionals may not see the sadness and sorrow of normal grieving because no visible death has occurred. Being sad when there is ambiguous loss is typical and should not be medicalized. While common treatment approaches to depression include talk therapy, often cognitive behavioral therapy (CBT) and medication, the treatment for the sadness of grief is human connection (Boss, 1999, 2006) . Professional therapeutic guidance may or may not be required, but it should involve systemic work.
Cultural Beliefs that Influence Coping with Ambiguous Loss: The Example of 3/11
To understand and help families distressed by ambiguous loss , we begin by asking what their perceptions are about the situation: “What does this situation mean to you?” In Japan, for example, we begin by determining how people perceive the phenomenon of a tsunami (see Chap. 5, this volume). From the second author’s perspective, many Japanese people think of a tsunami as unavoidable, but that they can make preparations to prevent or reduce disaster and loss.
There has been a phrase used in the tsunami-hit regions, “Tsunami, tendenko,” literally meaning “At the time of tsunami, each person runs away separately.” What this means is that in the event of a tsunami, the top priority is to save oneself. You have to be the first one to run to higher ground, so that people around you will also run. That is, by immediately running to save yourself, you inspire “tendenko” in others and in that way save others who might not see the urgency to escape to higher ground. (For more information, see Professor Toshitaka Katada’s YouTube interview, Don Productions TV, 2013.) While “tendenko” begins individualistically, it is a strategy that benefits the collective. Paradoxically, running to save oneself helps to save one’s family and community.
Today, there are even YouTube training sessions for students about “Tsunami, tendenko” because there have been so many sad stories of losing almost entire families in a tsunami. In 1993, for example, there was the case of the Kondo family in Hokkaido. Mrs. Kondo started to escape with her two children, but on the way to the hill, they made a detour to look for her mother. While looking for her mother, Mrs. Kondo and her children were swept away by the tsunami. In the meantime, her mother had already escaped up the hill and was safe. Mrs. Kondo’s family, which had included three generations, was now only her mother. This kind of tragedy has been reported so many times, and that is why “Tsunami tendenko” has been emphasized.
As a result of historically losing entire families (or nearly so), citizens are now taught to trust each other and save themselves first. In this unique way, the individual acts alone to become responsible to save not only his or her own life but also the life of the family itself.
On March 11, 2011, students of the elementary school and middle school in Kamaishi followed “tendenko.” They all ran up and away from the tsunami for 2 km, and thus 600 other lives were saved by such spontaneity. The adolescents and children saved their own lives while inspiring and helping others, young and elderly, to escape the rising water (NHK, 2013; Sashida, 2013) . Because their schools were located next to the ocean, they had routine training sessions to be able to judge how far they should run and how to make their points clear to family members who did not take the situation that seriously (NHK, 2013). In this area, even the young children and adolescents who were back home actually persuaded their family members to follow their judgment.
With such training, the Japanese people—school children included—traditionally have had a sense of at least some mastery and control over this occasional but terrible event. However, after the behemoth tsunami of 3/11 , people realize that it is even more challenging now to avoid disastrous outcomes from a tsunami. In 1896, the small town of Taro near Miyako in Iwate Prefecture experienced massive damage from a tsunami and lost 83 % of their population. In 1933, they experienced damage from another tsunami, losing 32 % of their population (Onishi & Ishiwatari, 2012). So in 1958, they started to build huge walls against future damage (Ito, 2011). When the tsunami of the Chilean earthquake hit this Japanese town of Taro in 1960, the walls saved the people (Wakefield, Ito, Toshio, Swanson, Revell, & Klein, 2013). As a result, they continued to build even higher and stronger walls until 1979, thinking that was the way to master and prevent disaster. Yet, in 2011, the tsunami waters on 3/11 breached even these higher walls. People now realized that disaster can occur despite preparation (Yoshimura, 2011). This increased their feelings of helplessness.
To increase such anxiety and worry for families even today, there is now more than a tsunami that can cause disaster for people living in the coastal areas. Ships and boats now carry chemicals and crude oils that can spill, a new threat bringing different kinds of damage in addition to a tsunami. Additionally and critically, the damaged Fukushima Daiichi Nuclear Power Plant was disabled by the 3/11 earthquake and tsunami and caused massive additional losses of homes, property, and communities due to radiation poisoning of ancestral farmlands. Indeed today, the prevention of loss and disaster and the preparation for coastal families is increasingly complex and challenging.
How do people experiencing ambiguous losses cope, not only from loved ones gone missing or deceased but also from their loss of home and community? People often talk directly to their dead relatives in a culture of ancestral worship (Ishii, 1996; Klass, 1996) . While there is also support from the community and helpful people around them who are physically present, families of the missing as well as the dead continue to feel support from ancestors who are kept psychologically present. These families do not talk much about their missing or dead in their daily lives, but they do feel supported by talking to an ancestor no longer here physically, but nevertheless, psychologically present.
In Japan, the deceased are regarded as Buddha after 49 days, and the bereaved often talk individually to those dead persons at a home altar asking them to keep the bereaved family safe. This tradition of ancestral worship is kept among not only Buddhists but also non-Buddhists. Such psychological connection with a loved one is useful in Japan. The family members of the missing sometimes talk silently to those ancestors in front of a home altar so that the ancestors will keep their eyes on the missing to help them stay safe (J. Yoshino, personal communication, August 18, 2014).
In addition, there is financial support from the government. This support, however, may inadvertently block coping and increase family stress. In order to receive financial compensation for their loss, families must accept the fact that a body has not been found—and that their loved one is dead! Some family members do accept the second term, and turn in the official form, but others may disagree with that decision, causing family conflict. (We note that this dynamic was also found in families after New York’s 9/11; see Boss, Beaulieu, Wieling, Turner, & LaCruz, 2003; and in the families of MIA pilots; see Boss, 1977, 1980) .
To prevent permanent family rifts and alienation, our therapeutic task then is to meet with the family as a whole and explain that it is all right for them to disagree on how they perceive the loss. From research, we now know that each person grieves in his or her own way (Neimeyer, Harris, Winokuer, & Thornton, 2011), but we must also recognize that each family member may perceive the loss, especially an ambiguous loss, in his or her own way (Ishii & Setou, 2014) . When loved ones vanish, with no facts available about their fates, it is no wonder that family members disagree about how to proceed. Without a body to bury, they have the added burden of needing to tolerate each other’s interpretations of the loss. We may have to repeat these ideas for families many times because they often believe that everyone in a family has to feel the same way.
In addition, many people, because of discrimination, prejudice, stigma, poverty, war, or terrorism have little or no mastery or control, and thus need first to be empowered before they can find the resiliency they need to move forward with their lives (Robins, 2010; Une 2014) . Across cultures and religions, the empowerment of people who live with ambiguous loss requires family and community support and professional education.
Religious and Secular Beliefs
In Japan, Buddhism is the dominant tradition when death occurs. While most Japanese people do not follow any one particular religion, most nevertheless follow the traditional rituals of Buddhism when a family member dies. Customs and traditions which are commonly observed are summarized by the second author: From the Obon tradition, serious attention is paid to the custom of visiting graves where people typically talk to the deceased family member. In addition, they maintain a role for the deceased by attending rites for them, which do not end with the funeral (for a fuller discussion, see Ishii, 1996, p. 225) .
With a clear and validated death, Buddhist beliefs offer opportunities to meet together for the bereaved. Those rituals are not only a wake and a funeral right after death but also the anniversary ceremonies for family and relatives that take place at the 1st, 3rd, 7th, and 13th years. On a daily basis, there is a custom for family members to place food and drink in front of their home altar and talk in silence to the dead. They do this individually. In addition, communities have annual ceremonies or festivals during Obon in summer to remember those who died.
The problem is that Buddhism does not provide any of these rituals to the families of the missing (Y. Taniyama, personal communication, August 28, 2014). While Buddhist priests may help such families to feel calm about the dead, this practice of not allowing families of the missing to meet together for these traditional grief rituals requires rethinking. In New York City, after 9/11 , there were similar restrictions at first. Some religions did not allow burial without a body, but after some discussion, church leaders reconsidered and ultimately allowed the burial of empty caskets or symbols representing the missing person. Especially for those who must live with the lifelong pain of a loved one gone missing, religious rituals of grief are often necessary to find some measure of peace. Presently in Japan, there are no ways to talk directly to a missing loved one in front of the home altar, but some family members, as they continue to talk to their deceased relatives, who are now turned into Buddha, ask them to take care of the missing person(s). This can provide a measure of comfort to the families of the missing.
For families who do not find solace from traditional religion, there are also secular beliefs. They may go to a medium (Takahashi, 2014; Yanagida & Suzuki, 2014) and ask about the missing person. The mediums are found in some regions and, in particular, in the coastal area where the 3/11 tsunami hit. The medium’s answer may give the family some sense of relief, so this is widely done in certain regions in East Japan (Sato, 2014) . Another experience, also nonreligious, is that one family member often talks to the missing person privately. One way is in a dream. That way, the surviving person feels relieved. But such dreams are not talked about openly. The experience of seeing the missing in dreams is kept private, very private. More generally among the Japanese, people do not talk about that experience with other family members, saying that is because they are worried what they saw in the dream might disappoint other family members (J. Yoshino, personal communication, August 18, 2014). When the dream gives some clue about the missing, for example, where the lost person is, how he or she is doing, or whether no more living, the dreamer may choose not to share this information with the family members. Typically, unless people know for sure that what they dreamt about will make everyone happy, they try not to talk about it. When the dreamer feels that he or she has a certain relationship with the missing person, they may not want to disclose this to other family members.