Imagine waking up every day not knowing whether to grieve or to hope. Whether to set a place at the table or quietly put the extra plate away. Whether to say “is” or “was.”

 

This is the territory of ambiguous loss — and it is, as family therapist and researcher Dr. Pauline Boss describes it, the most psychologically painful kind of loss human beings can experience. Not because the person has died, but precisely because they haven’t. Because there is no body, no funeral, no casserole on the doorstep, no cultural script to follow. Just an unresolvable, ongoing question mark where a person you love used to stand.

 

As clinicians — and as human beings — we encounter this kind of loss far more often than we may realize. And we have an important role to play in supporting our clients through it.

What Is Ambiguous Loss?

Ambiguous loss is a concept developed by Dr. Pauline Boss, a family therapist and researcher who first observed it in the families of soldiers missing in action during the Vietnam War. She noticed that these families weren’t moving through grief the way bereaved families did. They were stuck — frozen between mourning and hoping, unable to reorganize their lives around a loss that had never been confirmed (Boss, 2007).

 

Over decades, Boss identified two distinct types of ambiguous loss:

• Type 1: Physical absence with psychological presence — the person is gone from your life but never gone from your mind. You don’t know if they are alive or dead.
• Type 2: Psychological absence with physical presence — the person is right there in front of you, but the person you knew is not. Their body is present; their self is somewhere else.

 

Critically, Boss’s framework holds that the therapeutic goal in ambiguous loss is not resolution — because resolution is often impossible. It is the building of resilience: the capacity to keep living fully even when questions remain unanswered (Boss & Yeats, 2014).

 

Type 1 Ambiguous Loss: The Guthrie Family, “We Will Not Rest”

In February 2026, millions of Americans watched Savannah Guthrie — NBC’s beloved Today show co-anchor — step away from her desk to search for her 84-year-old mother, Nancy Guthrie, who had been abducted from her home near Tucson, Arizona. As of this writing, Nancy has not been found.

 

 

In a tearful public video, Savannah addressed the person who took her mother. “We beg you now to return our mother to us,” she said. “This is the only way we will have peace.”

 

 

What the Guthrie family is living through is a textbook, heartbreaking example of Type 1 ambiguous loss. Nancy is physically gone — but she is psychologically everywhere. Savannah and her siblings cannot mourn. They cannot move forward. They exist in a suspended state between hope and dread, oscillating between speaking of their mother in the present tense (“She is our shining light, she is our matriarch, she’s all we have”) and slipping, without quite meaning to, into the past tense.

 

 

This oscillation between tenses — between “she is” and “she was” — is itself a hallmark of ambiguous grief. The brain, under extreme uncertainty, reaches for structure, for a way to create even momentary containment from the chaos of not knowing.

 

 

There is no funeral to attend. No ritual to participate in. No socially sanctioned way to grieve someone who might still be alive. And so the grief becomes disenfranchised — invisible, unacknowledged, and without a roadmap.

 

 

Other examples of Type 1 ambiguous loss include: families of soldiers missing in action, adult children who have been estranged or have “ghosted” their parents, parents who abandoned their children, loved ones lost to incarceration, and families of those who have disappeared without explanation. In every case, the grief is real — but the world rarely validates it, because the death has not been confirmed.

Type 2 Ambiguous Loss- Dementia: “I Don’t Recognize You Anymore”

Now imagine a different kind of loss. Your husband is sitting across the breakfast table from you. You can see him. You can touch his hand. He is alive.

 

But when you say his name, he doesn’t respond with recognition. The man who knew your children’s birthdays by heart, who always made you laugh, who called you by a nickname only he used — he looks like your husband. But in many ways he’s not the person you married.

 

This is Type 2 ambiguous loss — an emotional reality of dementia caregiving.

 

Research on dementia caregivers consistently finds that the grief they carry is not analogous to post-death bereavement. It begins long before physical death, unfolds incrementally over years — sometimes a decade or more — and is shaped by the progressive disappearance of the person’s psychological self (Loukissa et al., 2022). Every new symptom, every forgetting, every moment of non-recognition is its own small death — and the caregiver must grieve it alone, often without acknowledgment, because the person is still alive.

 

The losses pile up. Loss of the relationship as it was. Loss of shared future and life plans. Loss of reciprocity — of being known, being remembered, being loved back in the way you were loved before. Loss of a partner. Loss of the person who affirmed your identity and your place in the world.

 

And yet, there is no funeral. No socially recognized moment of loss. Friends and family may say things like “At least you still have him” or “She’s still with you.” The caregiver is left holding an enormous grief with nowhere to put it.

 

Type 2 ambiguous loss is also the experience of family members navigating a loved one’s severe mental illness, substance use disorder, or traumatic brain injury. The person is present. But the person you knew — the version who could be fully in relationship with you — may feel impossibly far away.

 

 

Ambiguous Loss- The Grief That Has No Name

 

When grief is not named, it does not disappear. It goes underground.

 

I think about how often clients come to us carrying losses that have never been acknowledged — even by themselves. A daughter whose mother has lived with severe depression for thirty years. A husband whose wife developed a serious alcohol use disorder after retirement. A son whose father with advanced Parkinson’s no longer recognizes his face. These clients may present with anxiety, depression, or chronic stress. They may not present as “grieving” at all. But underneath, ambiguous loss is often the organizing wound.

 

What makes ambiguous loss uniquely painful — and uniquely clinically important — is that it generates what Kenneth Doka called disenfranchised grief: grief that is not acknowledged, socially validated, or publicly mourned (Boss & Yeats, 2014). When a loved one dies, the world makes room for your loss. When a loved one is lost in ways the world cannot see, you are often left to grieve silently — and to wonder whether what you’re feeling is even legitimate.

 

“Am I allowed to grieve him when he’s still alive?” clients will sometimes ask. “Should I be grateful she’s still here instead?” These questions are not signs of pathology. They are signs of ambiguous loss doing what it does: leaving people stranded in uncertainty, without permission to feel what they feel.

 

In my clinical work with older adults and their families, I have found that naming the loss — saying the words “ambiguous loss” and explaining what it means — is often its own therapeutic intervention. It provides a framework. It lifts the invisible shame. It says: this is real, this is recognized, and you are not alone.

 

 

Ambiguous Loss in the Therapy Room: Our Role as Clinicians

When a family member comes to us for support around a loved one’s dementia, mental illness, or substance use disorder, the presenting concerns are often practical: How do I manage difficult behaviors? How do I cope with caregiver stress? How do I make good decisions about care?

 

But running beneath all of it — often unexplored, often unacknowledged — is grief.

 

Research confirms that pre-death grief is highly prevalent in family caregivers of people with dementia and is associated with depression, social isolation, and heightened risk for complicated bereavement after the person eventually dies (Liew et al., 2019). In fact, because the ambiguous losses of caregiving so often go unnamed and unprocessed, they can arrive with unexpected force after physical death — catching the bereaved caregiver off guard at a time when the world expects them to be “done.”

 

As clinicians, we can change this. When a client who is caring for a parent with advancing dementia describes feeling disconnected, lost, or strangely empty — we can name what we are hearing. When an adult child describes their father’s alcoholism in clinical, detached terms that sound more like a case summary than a human story — we can ask about the loss beneath the words. When a spouse talks about living with someone whose mental illness has fundamentally changed who they are — we can create space for the grief that may not yet have been given permission to exist.

 

This is not about redirecting clinical focus. It is about recognizing that the loss is always there in our work with these family members — even when it is never mentioned. Acknowledging it is not a detour. It is often the most direct path to the heart of what brought the client to our door.

 

 

Ambiguous Loss vs. Anticipatory Grief: An Important Distinction

 

One of the most common clinical questions I get — and one I want to name explicitly — is treating ambiguous loss and anticipatory grief as the same thing. They are related, they can co-exist, and they are often confused. But they are fundamentally different experiences, and getting the distinction right shapes how we treat.

 

Anticipatory grief is grief that runs ahead of an expected death. It was first described by Lindemann in the 1940s and elaborated by Rando and others. The defining feature is a known endpoint: death is certain, and the grief occurs in anticipation of it. There is a destination, even if it is a devastating one. And when the death eventually comes, it tends to confirm and close the grief — providing the social permission, the ritual, and the acknowledgment that allow bereavement to unfold (Garand et al., 2012).

 

Ambiguous loss, by contrast, is defined precisely by the absence of any such endpoint. There is no confirmed loss, no clear moment when the loss occurred, and no cultural permission to grieve at all. The grief has no destination to move toward — and that is exactly what makes it so psychologically destabilizing.

 

Here is a way I often think about it:

• Anticipatory grief asks: “How do I prepare for a loss I know is coming?” It is future-tense grief — mourning who the person will no longer be.
• Ambiguous loss asks: “How do I grieve a loss I cannot confirm?” It is present-tense grief — mourning who the person is right now, and the relationship as it no longer exists.

 

In dementia caregiving, both are often active at the same time — and each deserves its own clinical attention. A spouse caring for a partner in the middle stages of Alzheimer’s disease may simultaneously be grieving the person’s lost psychological self (ambiguous loss — present, ongoing, without resolution) and dreading the approach of physical death (anticipatory grief — future-oriented, preparing for a known endpoint). Collapsing these into a single category misses half of what the caregiver is carrying.

 

The clinical stakes matter here. When we apply an anticipatory grief framework to what is actually ambiguous loss, we inadvertently push clients toward closure that is structurally unavailable to them. We may — without meaning to — communicate that resolution is possible if they just do the right kind of grief work. And when closure doesn’t come, the client is left feeling like they have failed. The grief becomes not only painful but shameful.

 

There is also a paradox worth naming that I find deeply important: because the ambiguous losses of dementia caregiving are so rarely acknowledged or processed, they often do not surface until after the person physically dies. The world expects the bereaved caregiver to feel relief, or to transition into “normal” grieving — but instead, they find themselves flooded. The losses they carried silently for years finally have permission to be felt. This is not complicated grief in the pathological sense. It is grief that was simply delayed, because there was no room for it before.

 

Understanding this distinction — and naming both types when both are present — is one of the most practical and compassionate things we can offer our clients. It validates what they are actually experiencing, rather than asking them to fit their grief into a framework that does not quite fit.

 

 

What Helps: Therapeutic Principles for Ambiguous Loss

Dr. Boss and her colleagues have developed a set of therapeutic guidelines for working with ambiguous loss that I find orienting in my own clinical work. They center on six key domains (Boss & Yeats, 2014):

• Meaning — helping clients find personal and cultural meaning in a situation that defies easy explanation
• Mastery — restoring a sense of agency where it remains possible, even when so much feels out of control
• Identity — supporting reconstruction of self when the relationships that defined us have been fundamentally altered
• Ambivalence — normalizing the contradictory, complex feelings that ambiguous loss produces: love and grief, devotion and resentment, relief and shame
• Attachment — helping clients find a “both/and” relationship with the person they are losing: neither frozen in the past nor cutting off, but adapting
• Hope — cultivating realistic, situationally grounded hope that does not require certainty to sustain

 

The both/and framing is one I return to again and again in my work. The person with dementia is both the person you have always loved and the changed person in front of you. The missing mother is both absent and psychologically present every hour of the day. Grief and love can, and do, coexist. You do not have to choose.

 

For more than a decade, I worked with people with spinal cord injuries ranging from incomplete paraplegia to complete quadriplegia, and one of the most complex clinical tasks was holding hope for improvement — “I want to walk again” — alongside the daily reality of “I cannot walk today.” In therapy with people living with life-altering medical conditions, so much of our work centers on helping them live a meaningful life alongside grief, loss, chronic pain, and other physical and psychological changes. When resolution is not possible, the question becomes: How do we help clients live fully within the uncertainty?

 

Acceptance and Commitment Therapy (ACT) has emerged as a particularly well-suited approach for ambiguous loss, because its central premise — that a meaningful life can be lived alongside pain, not only after it has been resolved — mirrors what ambiguous loss asks of us.

 

But you do not have to consider yourself an ACT therapist to work this way. I am not an ACT therapist, and yet most of my work with people facing life-altering medical problems has held this focus: How do we build a life worth living in the midst of sorrow, grief, and uncertainty?

 

Group therapy is another powerful modality — particularly for dementia caregivers, whose grief is so often invisible to the people around them. The experience of sitting with others who say, “Yes, I know exactly what you mean,” can be profoundly normalizing. Peer witness often carries more healing weight than clinical validation alone. In these spaces, communal meaning-making becomes possible: people begin to place their experiences in a shared narrative, which can foster both healing and post-traumatic growth.

 

 

How do we build a life worth living in the midst of sorrow, grief, and uncertainty?

 

 

Ambiguous Loss – “I’m going to stay with you in the uncertainty”

There is something profound that can happen for a person the moment their experience of ambiguous loss is finally named. When someone finally says: “That is a loss. What you are feeling is grief. It is real, and it deserves space”

 

If you’re like me, you probably refreshed the news again and again to see whether Savannah Guthrie’s mother had been found — searching for resolution, for peace, for some organization to the chaos. Imagine leaving our clients to do this alone.

 

Ambiguity, by its nature, is uncertainty: no clear ending, no clear beginning, no clear rules for how to feel. When ambiguous loss is identified and validated, that uncertainty is no longer something the person has to navigate alone or explain away. Their experience becomes a little more understandable, organized, and speakable.

 

As therapists, we have an important role, not to offer false promises or reassure them that everything will be “alright,” but to say: “Your grief is valid, and you are not alone.” We become a steady presence alongside them. We say: I see you. I see your loss. And I am going to stay with you in the uncertainty — not to fix it, not to resolve it, but to help you find the ground beneath your feet.

 

That is not a small thing. It is how, together, we turn unspeakable loss into language, into connection, and into a life worth living even in the midst of uncertainty.