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‘An all-consuming cumulonimbus of pain’ : a scoping review exploring the impact of ambiguous loss when someone is missing and the counselling interventions relevant to the experience


Abstract and Figures

2019 marks the twentieth anniversary of the 1999 landmark publication Ambiguous loss: learning to live with unresolved grief by Emeritus Professor Pauline Boss. The book, and its exploration of uncertainty, has invited ambiguous loss into the grief counselling space, as a way to provide specialised care for families and friends of missing people. This scoping review aims to examine the breadth of literature regarding counselling interventions from the previous work of Boss to the present day, as a way to enhance quality of life for people left behind when someone is missing. The literature highlights the experience of trauma relating to complicated mourning, as well as opportunities for post-traumatic growth while people wait for news of their loved ones. The results of the review, and suggestions for future research and therapeutic interventions, demonstrate that families of missing people need specialised support when they access grief counselling. The review demonstrates how counsellors can extend their knowledge of grief interventions and learn to tolerate uncertainty themselves in order to provide support to this important group of individuals post-loss and potentially prior to a confirmed bereavement.
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Bereavement Care
ISSN: 0268-2621 (Print) 1944-8279 (Online) Journal homepage:
‘An all-consuming cumulonimbus of pain’: a scoping
review exploring the impact of ambiguous loss
when someone is missing and the counselling
interventions relevant to the experience
Dr Sarah Wayland & Myfanwy Maple(Professor)
To cite this article: Dr Sarah Wayland & Myfanwy Maple(Professor) (2020) ‘An�all-consuming
cumulonimbus�of�pain’: a scoping review exploring the impact of ambiguous loss when someone
is missing and the counselling interventions relevant to the experience, Bereavement Care, 39:1,
21-29, DOI: 10.1080/02682621.2020.1728089
To link to this article:
View supplementary material
Published online: 30 Mar 2020.
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An all-consuming cumulonimbus
of pain’: a scoping review exploring
the impact of ambiguous loss
when someone is missing and the
counselling interventions relevant
to the experience
When someone is missing, a signicant proportion
of people connected to the person will be
impacted by the loss. Australian research
identies that for each person missing 12 people will be
signicantly affected (Dadich, 2003). The loss is referred to
as ambiguous – dened by Boss (1999) as ‘unending, not
knowing’ (p. 65). The ambiguity is connected to uncertainty
as to when the loss will end and whether its nality will
be conrmed. The experience of ambiguous loss can have
profound impacts on the people left behind and can shape
the way they seek help to live with their loss.
Australian police jurisdictions dene a missing person as
someone whose whereabouts are unknown and for whose
safety and wellbeing there are concerns (James, Anderson,
& Putt, 2008). From a vulnerable population health
perspective, those most likely to go missing are ‘persons
with a mental illness, persons expressing suicidal ideation,
Abstract: 2019 marks the twentieth anniversary of the 1999 landmark publication Ambiguous loss: learning to live with
unresolved grief by Emeritus Professor Pauline Boss. The book, and its exploration of uncertainty, has invited ambiguous
loss into the grief counselling space, as a way to provide specialised care for families and friends of missing people. This
scoping review aims to examine the breadth of literature regarding counselling interventions from the previous work of
Boss to the present day, as a way to enhance quality of life for people left behind when someone is missing. The literature
highlights the experience of trauma relating to complicated mourning, as well as opportunities for post-traumatic growth
while people wait for news of their loved ones. The results of the review, and suggestions for future research and
therapeutic interventions, demonstrate that families of missing people need specialised support when they access grief
counselling. The review demonstrates how counsellors can extend their knowledge of grief interventions and learn to
tolerate uncertainty themselves in order to provide support to this important group of individuals post-loss and potentially
prior to a confirmed bereavement.
Keywords: ambiguous loss, unresolved loss, complicated mourning, missing people
Dr Sarah Wayland
Lecturer, Sydney School of Health
Sciences, Faculty of Medicine and
Health, University of Sydney,
Professor Myfanwy Maple
Professor in Social Work, School of
Health, University of New England,
Volume 39 No 1 21
© 2020 Cruse Bereavement Care DOI: 10.1080/02682621.2020.1728089© 2020 Cruse Bereavement Care DOI: 10.1080/02682621.2020.1728089
and those with dementia, an intellectual or physical
disability or people who need lifesaving medication.
Additional groups that may be at an elevated risk of
harm include persons known or thought to have been
last located in potentially life-threatening environmental
conditions (e.g. ‘lost at sea’) (Bricknell & Renshaw, 2016,
p.18). Almost all reports of people going missing in
Australia were successfully resolved (98%), with missing
people primarily located alive (Bricknell & Renshaw,
2016). Whilethe statistics reinforce that most of those who
do vanish return, a small percentage remain missing longer
term – that is, for longer than six months (Bricknell &
Renshaw, 2016).
The UK National Police Chiefs’ Council (NPCC)
denition identies a missing person similarly to Australia,
with the additional denition of those who are absent –
including people from hospitals, care facilities or statutory
organisations. The denition states that a missing person
is one whose ‘whereabouts cannot be established and
where the circumstances are out of character or the context
suggests the person may be the subject of crime or at risk
of harm to themselves or others’ (NCA, 2017). England,
Wales and Scotland recorded 242,317 missing incidents
in 2015, which equates to 368 people a day (NCA, 2017).
Similar population statistics exist for the United States, with
reports of returned missing people remaining similar to that
of Australia (Wayland, 2015). The phenomena of going
missing occurs in every country in the world, extending
to incidents where people have vanished due to political
intervention, mass disappearances during times of war or
unstable migration (Edkins, 2011). While the experiences
of ambiguity are broad, for the purposes of this article the
experience of missing relates to an individual absent from
their usual life, where family and friends are awaiting news
of their location.
What is known from the literature is that presentations of
families of missing people are similar to those of people who
have experienced a sudden and traumatic death (Wayland,
2015). Wayland (2015) notes that in exploring the experience
of hope for families of missing people, people often go back
to their last interaction with the missing person, pointing
out the moment where they no longer live in the before, a
space where the missing person’s whereabouts are known.
They are then forced with a jarring reminder that that they
now populate the after. The after is a space where people’s
worldviews can shift (Wayland, 2015), where they have less
certainty about where a loved one is. The reaction to the loss
requires a new pathway of coping for people left behind with
Boss and Yeats (2014) noting that people need to engage in
‘both/and thinking’ in the sense of a person being both dead
and maybe not dead (p. 67).
This review aims to identify three key research questions.
What is ambiguous loss, how does it differ from grief and
bereavement where a level of certainty exists, and what are
the therapeutic interventions required to help people? The
aim of the scoping review is to present the literature, the
methodological processes utilised in studies and the quality
and or limitations of the studies located (see Table 1).
Figure 1: PRISMA results.
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© 2020 Cruse Bereavement Care
The scoping review explores the impact of an ambiguous
loss when a loved one is missing and how these ndings
can be applied to the ways in which counselling is
delivered. Further, the review aims to highlight the complex
skillset required by counsellors and support workers
when responding to families and friends left behind
when someone is missing. The scoping review concludes
that ambiguous loss may be poorly understood from a
therapeutic perspective; however advancements over the
last two decades provide clinical interventions that have
the capacity to enhance the wellbeing of those living with
the loss of a missing person. This article is conceptualised
through the lens of the Australian experience. However,
it seeks ways to present information regarding similar
jurisdictions internationally
Search strategy
The scoping review of the literature followed the
framework of Arksey and O’Malley (2005). The ve-stage
framework assisted in reviewing the available literature
with the aim of identifying and then disseminating
relevant research ndings. The ve-stage process sought to
identify the initial research question – what we understand
the experience of being missing may mean to families
of missing people, since the publication of Boss’s (1999)
landmark exploration of ambiguous loss. From there the
additional four stages of the framework identied relevant
studies, explored study selection, charted the data and
then summarised the results in the form of a thematic
The review of the literature was conducted across
two health-related databases – CINAHL and ProQuest.
Keyword searches were completed using the terms
‘missing persons’ and then rening to missing person AND
ambiguous loss. Initial keyword searches that explored
ambiguous loss + counselling + families of missing people
yielded no results. A broader focus on missing persons
was conducted and then the abstracts were individually
Key concepts from the review of the literature, combined
with unpublished PhD theses, alongside hand searching of
grey literature from the Families and Friends of Missing
Persons Unit (FFMPU – an Australian based counselling
service) and Missing People UK (a London-based not-for-
prot service that provides support to people left behind)
were consolidated and have been identied within this
article. This strategy resulted in a total of 72 papers being
located, extracted and reviewed. Eight additional grey
literature reports were also sourced to identify material
that may be more easily accessible to health professionals.
Duplicates were omitted and the remaining papers and
reports/theses screened for relevance.
Inclusion criteria included literature pertaining to the
experience of ambiguous loss where a person was missing
including incidents relating to children and young people
published post-1999. Texts published before Boss (1999)
were excluded as a way to identify how Boss’s work
impacted studies from then onwards.
Exclusion criteria included literature pertaining to
ambiguous loss in circumstances where it did not relate
to a person missing, e.g. pet grief, grief associated with
a psychological loss such as traumatic brain injury,
Alzheimer’s and dementia. Texts that sought to explore
the experience of ambiguous loss that were not written in
English were excluded due to time constraints.
A nal count of 20 papers post-screening were included
and then analysed as a way to explore the studies. All
the papers were either qualitative studies or mixed
methodological approaches. There were no randomised
control trials retrieved.
How was the literature analysed?
The process of reviewing the literature in order to explore
the results of the review was completed by ‘charting
the data’ (Arksey & O’Malley, 2005), where key pieces
of information relevant to the research questions were
thematically analysed. The lead researcher built a picture of
themes, by coding using NVivo software, selecting evidence
focusing on the key research questions noted above.
Below is a descriptive analysis of the themes noted in
reviewing the literature (Table 1). The review located 20
texts to assist in exploring the role and shift of therapeutic
interventions for those left behind when someone is missing.
In this section the concepts of ambiguity are dened,
through the lens of bereavement and grief. Secondly the
review identies common reactions of families as a segue
to exploring interventions that have been demonstrated in
the literature to enhance the lives of those left behind. Data
extracted from the studies included in analysis have been
attached in the appendix (online supplementary material).
What is ambiguous loss?
Emeritus Professor Pauline Boss developed the concept
‘ambiguous loss’ in response to her work with families
post-war and in family migration. She identied that when
a missing person is physically absent there is ‘uncertainty
as to whether the loss will be nal’ (1999, p. 6). In
Glassock’s work (2011) on the Australian experience of
ambiguous loss he identied that the disappearance of a
person leaves a mark on the psychological wellbeing of
people left behind; that there are shattered assumptions
about how the world ‘should work’ and that the family is
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forever changed by the absence. Glassock (2011) found
that the type of loss was unique and not well managed
by grief counsellors – that a new model of intervention
was required that allowed people to explore their loss
without being forced to accept that the loss was forever.
In a technical report provided for counsellors, police and
the media when working with families of missing people
in Australia, Wayland (2019) noted – via a review of the
literature and a survey of families currently living with the
loss of a missing person – that families, when they reach
out for therapeutic care, often have negative experiences
that can impact their emotional wellbeing, stating that their
loss is ‘an all-consuming cumulonimbus of pain, disruption,
confusion, doubt and worry’ and a type of fear that families
shared ‘that it will hover over you and your family for the
rest of your lives’ (p. 16).
What is the difference between ambiguous
loss and grief?
Wayland, Maple, McKay, and Glassock (2016) in a
review of the literature exploring the differences between
bereavement and ambiguous loss, noted that when a
person is missing hope and ambiguity are closely aligned;
Table 1: Thematic analysis of findings
Primary theme Sub-themes and other notes relevant for counsellors
Theme 1: Defining the experience
What is ambiguous loss? Ambiguous loss is an unresolved grief, or grief with no ending (Boss, 1999).
Lived experience of complicated or anticipatory mourning, as well as disenfranchised grief may
also be useful to apply in therapeutic engagement.
What is the difference between
ambiguous loss and grief?
Betz and Thorngren (2006) note that the family’s capacity to ‘move on’ is ‘not a sign of
immobility or inability to deal effectively with a situation, but the powerlessness exacerbated by
the uncertainty’ (p. 362).
Glassock (2006) noted that existing grief models can create taboo/censorship when families
want to openly discuss the possibility that the missing person may not be dead.
Theme 2: Mapping reactions
How do families and friends of
missing people react?
Stress or anxiety about the whereabouts of the person (Boss, 1999, 2010).
Avoidance about the potential eventualities of the loss (Boss, 1999).
The reaction to waiting and the loss of control of a situation can be traumatised by the nature of
the disappearance, as well as the imaginings as to what might be occurring for the person while
their whereabouts are unknown (Wayland, 2015; Lenferink, 2018).
Intense sadness that no matter how hard they search they cannot locate the person (Glassock,
Confusion about the practical processes involved in searching or administering the affairs of the
missing person (Clark et al., 2009).
Unhelpful terms for families
of missing people seeking
therapeutic support
Boss (2002) notes that the quest for closure can create therapeutic resistance for families.
Hofmeister and Navarro (2017) suggest closure is a useful term when there are ‘true absolutes’,
not where human relationships are present.
Acceptance of the loss, without evidence to prove end of life is unhelpful to families. However,
Lenferink (2018) notes that acceptance of the current ambiguity may be helpful to explore
Wayland (2015) notes that hope, as a positive action, is not consistent with the experiences of
families of missing people. Hope can be destructive for those left behind and is also linked to
both the return of the missing person and the hope for capacity to survive the unknown.
What about support needs for
people who have someone
missing in the longer term?
Parr and Stevenson (2015) note the need to pay attention to celebrate the life of the missing
person so that memories of the absent person can be bought into the present. Wayland (2007)
notes that celebrating ‘so far’ allows people to feel they are not memorialising the lost person
nor conceding they are gone forever.
Glassock (2009) notes that absence of spiritual and religious rituals that honour unresolved
loss. Exploration of ways to honour the loss – individually, as a family or in community require
therapeutic exploration.
Lindberg Falk (2010) also identifies the need to recognise cultural variations in order to find
‘solace in grief’ where uncertainty exists.
Theme 3: Evidenced based interventions which require more research regarding effectiveness
Potential therapeutic
intervention as noted by the
Cognitive behavioural therapy with mindfulness (CBT-M) ABC-X model of family stress Acceptance
and commitment therapy (ACT) Mindful self-compassion.
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within hope is a potential for return, and families have
ideas of a nal resolution, or for life to return to how it
was pre-loss. Likewise, Betz and colleagues (2006) note
that the family’s capacity to ‘move on’ is ‘not a sign of
immobility or inability to deal effectively with a situation,
but the powerlessness exacerbated by the uncertainty’
(p. 362). Glassock (2006) noted that existing grief models,
experienced by some families of missing people when
accessing counselling support, created a sense of taboo in
terms of entertaining the possibility that the missing person
may not be dead; that counselling was unhelpful if closure,
in relation to accepting the loss, was the goal.
The literature reveals that the following therapeutic
concepts are useful when supporting those who have
someone missing:
Ambiguous loss – the term ‘ambiguous loss’ (sometimes
interchangeably referred to as ‘unresolved grief’ in the
literature) identies the physical absence of the individual
without conrmation as to whether or not the loss has
nality or a known outcome (Boss, 1999, 2002, 2018).
Anticipatory mourning – Rando’s (2000) exploration of
complicated mourning does have some relevance for families
of missing people as it allows a space for exploring grief
without making people feel as if they are ‘failing’ at the tasks
of mourning, because it acknowledges all of the complexity
that comes with a unique type of loss like missing.
Disenfranchised grief – Doka (2002) denes
disenfranchised grief as a type of grief that is not commonly
recognised by the community, where ambiguous loss falls
outside of the ‘expected’ losses experienced in our lifetime.
The stigma that can come from this type of loss – because
of people’s hidden beliefs about how people should manage
their loss, and the lack of understanding from the support
professionals tasked with responding to them – can mean
that the additional layer of stress can be created by a loss
that is poorly understood.
How do families and friends of missing people
react emotionally?
From the review of the literature the reaction by families
of missing people highlight experiences of stress or anxiety
about the whereabouts of the person (Glassock, 2006). In
addition, the reaction to waiting (and the loss of control of
a situation) can be worsened by the imaginings as to what
might be occurring for the person while their whereabouts
are unknown (Wayland, 2015). The literature also states
that intense sadness persists when a family cannot locate
the person no matter how hard they commit to searching
(Glassock, 2006), as well as disconnection from the
community as people go about their lives, unaffected by
the loss they are consumed by (Wayland, 2015). Clark,
Warburton, and Tilse (2009) also note that confusion
about the practical processes involved in searching or
administering the affairs of the missing person also impact
their emotional wellbeing.
The review of the literature also highlighted that those
living with ambiguous loss for extended periods of time may
experience a heightened risk for developing prolonged grief,
depression and post-traumatic stress symptoms (Lenferink,
van Denderen, de Keijser, Wessel, & Boelen, 2016, 2018).
In the following section concepts that are typical of
responses by others are included, to assist counsellors
in developing awareness about ways in which families
may learn to live with this unique type of loss. Betz and
colleagues (2006) noted that families may hesitate to share
their grief because of shame, because they fear judgement,
or believing they should be able to survive or be resilient to
their loss.
Hofmeister and Navarro (2017) note, when identifying
how forensic scientists can better support families of
missing people, that ‘closure is a good term for real estate
and business deals in which there are true absolutes and
clear conclusions, but it is not a valid term for human
relationships’ (p. 36)
Boss (2002) notes the paradox that pressure for
closure imposed upon families of missing people actually
creates more resistance from families. The literature notes
that families may feel hard-pressed to set aside hopeful
resolution ideas because the quest for closure and being
realistic about the person being located alive after a
signicant period of time has lapsed is held fast by those
around them. This suggess supporters need to be patient,
have respect and acknowledge the complexity of the
processes that people go through while waiting for news.
Lenferink (2018) notes that ‘openness and understanding
towards one’s suffering, accepting that the disappearance is
uncontrollable and receiving emotional support from others’
(p. 247) seem helpful. This may mean that the term ‘acceptance’
might be better used in another way – an acceptance of the
current state of uncertainty needing to be embraced; and while
that might be distressing, it is the distress that needs acceptance
not acceptance that a person will never return.
Identifying hope as a positive response
Wayland (2015) noted that ideas of hope change
over time for families of missing people. Hope and
exploring what hope means, individually, can allow for
opportunities of self-discovery in terms of opportunities
for post-traumatic growth. The ability to gradually learn
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new ways to live with ambiguous loss is slow. Support
people can be cautious about introducing hope, with
concerns expressed about offering false hope to people
(Wayland, 2015). For some, it is that hope hurts, for
others it can be that hope is the glue that holds the
liminal space together (Wayland, 2015).
Perhaps most relevant to all health professionals,
Lenferink (2018) noted in her exploration of prolonged
grief symptoms of families of missing people that people
with more self-compassion experience less psychopathology,
and that this is enhanced by a capacity to stop themselves
engaging in ruminative thinking (meaning less time
spent trying to work through the ‘what ifs’) and that
mindfulness-based interventions can assist in re-training or
training families to embrace life post-loss. In addition the
work of Heeke, Stammel, and Knaevelstrud (2014), who
conducted a cross sectional study in Columbia exploring
the presentations of families left behind following forced
disappearances, alongside those who were bereaved due to
armed conict, found that the inclusion of hope (that the
person would return) for those where a disappearance had
occurred was characterised by higher rates of prolonged
grief disorder, than those who had certainty regarding their
loss. While the generalisability of these ndings are limited
they do highlight the need to better understand the long-
term presentations of families and friends of people who
remain missing.
What about support needs for people who have
a loved one who is missing in the longer term?
Wayland (2015) explored shifting notions of hope for
families of missing people whose loved one was missing
for longer than 12 months. The conclusion of that study
identied that there was a continuum of loss for families
left behind and that over time a gradual learning to shift
hope for the missing person to hope for the left behind (or
hope for themselves) was identied.
Lenferink (2018), in exploring the grief reactions of
families of missing people from a clinical perspective, notes
that not having access to grief rituals and the accompanying
‘uncertainty and disorientation’ of having someone
missing can provoke a stress reaction. This means that the
experience of waiting, and the impact on the person left
behind, is compromised when uncertainty exists.
These multiple reactions – stress, fear anxiety,
uncertainty – all run alongside the lived experience of
missing someone. An evaluation of the Australian-based
FFMPU (2015) identied that the goal of providing
counselling support to families of missing people in the long
term needs to centre on the fact that the loss has occurred
rather than hope for the situation to be resolved. For
those families where remains are located, there needs to be
awareness that their response to location of remains only
offers physical reunication for the family. However it may
not offer nality, as questions about the reasons for going
missing or their death may remain unanswered.
Celebrating the life of the person not currently
Wayland (2007) introduced the concept of a ‘celebration, so
far’, through interactions with families of missing people,
as a chance to acknowledge their loss through community-
based celebrations by dening that they are currently not
here, but may not be permanently gone. In an academic
exploration in witnessing and interviewing families of
missing people, Parr and Stevenson (2015) note that
attention should be paid to the person by celebrating them.
These celebrations might be in the form of story-telling,
photography, lm or events. It allows people to remember
that the absent can be brought in to the present.
Spirituality, religion and rituals
Glassock (2009) noted in his study that the funeral is the
most common ritual attached to loss. However, in the
case of missing people, a funeral is not an appropriate
way to acknowledge the loss, regardless of how long
they have been gone. It is important to note that there
are currently no designated rituals for people to employ
when a person is missing. Yet, with support, rituals can be
developed with family members to provide remembrance.
In exploring the rituals surrounding death in disaster
situations where people are unaccounted, Beder (2002)
offers reinforcement that an outdated model of grief-
working requiring steps or stages is not relevant in these
ambiguous situations.
Cultural explorations of missing and rituals were
developed from reecting on the work with Thai survivors
of the 2004 Boxing Day tsunami. The families left behind
turned to Buddhist monks to help nd ‘solace in their
grief’ (Lindberg Falk, 2010). The recovery process was
centred upon ceremonies and rituals that allowed for
old and new rituals to merge in a way to honour the
grief where bodies had not been located. The monks, in
consultation with families, arranged ‘counterfeit’ funerals
where families displayed pictures, burned pieces of paper
with the missing persons’ names on and used the ritual as
a way to communicate openly their thoughts about the
missing person. Some who believed the missing person
might still be found opposed the counterfeit funerals –
reinforcing the importance of acknowledging the role of
societal pressure even when the clues noted that the family
felt differently to what the community believed, and
that different people will experience missing in a variety
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Therapeutic intervention as noted by the
Cognitive behavioural therapy with mindfulness (CBT-M),
as noted by Lenferink (2018), is a strategy that uses
the basic principles of CBT alongside meditation skills
to recognise ‘thinking traps’ or grief ruminations and
challenge persistent or unhelpful thoughts. Lenferink
(2018) notes that the inclusion of this intervention may
be important especially in terms of the presentation of
negative cognitions and avoidance behaviours of families
of missing people.’
ABC-X model of family stress – most suited for
family groups responding to the loss of a missing person.
The model, as noted by Betz (2006), is useful due to its
broad systemic approach where people can have shared
perceptions of loss and helping people redene or create
new meaning and rituals surrounding their loss.
Acceptance and commitment therapy – as noted by
Wayland (2007, 2015) this model helps people to reect
and understand their core values and the ways in which
these values assist in living a meaningful life alongside
Mindful self-compassion, as noted by Lenferink
(2018), is an intervention that may enhance a person’s
capacity for emotional wellbeing. The strategy allows
the counsellor to help people acknowledge their
difcult thoughts and feelings and to acknowledge the
vulnerability that accompanies the loss of a missing
person. This can also be used alongside compassion-
focused therapy (CFT).
Reaction and response to uncertainty and trauma when
a person vanishes is not reliant on the relationship
type, the length of time the person is absent or the
reasons as to why the person may have intentionally or
unintentionally left (Biehal, Mitchell, & Wade, 2003).
The helpfulness of interventions must be characterised
by an understanding of the evidence base regarding
ambiguous loss, and awareness about the differences
between grief and ambiguity regarding the loss of a loved
one (Boss, 2002; Boss & Yeats, 2014). The role of the
counsellor, or grief worker, is to shift and move with
those reactions, and to learn to sit with a sense of ‘not
knowing’; this may be assisted by clinical supervision
and some revisiting of core values regarding what occurs
when all of the necessary components of loss may be
absent, yet the feeling of loss is pervasive (Wayland,
2015). The role of the counsellor is to identify that the
concepts useful in exploring the lived experience of loss
are available, as well as the therapeutic modalities and
approaches to respond better to families and friends of
missing people seeking counselling for their loss. Boss
(1999) tells us that closure is not the goal in providing
support to people left behind, but that remaining person-
centred and open to learning about the loss, even if it
extends long term, is the key.
The concepts and modalities identied in the scoping
review may assist as necessary inclusions in the toolbox
of the counsellor, alongside understanding the place and
space occupied by the missing person and the role of the
community in exacerbating a sense of disenfranchised loss
that can be complicated by the lack of outcomes regarding
the investigation.
Boss (2010) asserts that ‘grief is frozen, life is out on
hold, and people are traumatised’ (p. 137) when someone
is missing, however it is important when presenting the
complexity of counselling interventions that we do not
inadvertently send a message to families of missing people
that it is not possible to live a meaningful life while they
wait for news about a missing person. Exploring ways of
sitting with the loss may be key to providing supportive
interventions for people left behind when someone is
missing. In the years since the release of Boss’s book
(1999) counsellors have combined new ideas regarding
mindfulness and acceptance of the liminal space, thus
providing greater opportunities to support people left
Limitations of the review
There are two areas of limitations – one regarding the
approach – a scoping review – and the other being the
ways in which ambiguous loss continues to be a poorly
researched area.
First, the choice of review, in terms of selecting a scoping
review, may have overlooked papers that may have been
noted in a systematic review. However, given the relative
niche area of this type of loss, and the need to identify
literature for this project that would be applicable to health
professionals, a scoping review was most benecial.
More broadly the literature identies a signicant
dearth of studies that seek to understand and validate
the psychotherapeutic interventions that may reduce the
levels of distress for those left behind when a loved one is
The data extraction table (see appendix) identies
20 papers or technical reports reviewed relating to the
approach to therapeutic interventions for counsellors.
In order to better understand the role and impact of
therapeutic interventions the research needs to map longer
term reactions to ambiguous loss on people’s wellbeing as
well as include control groups to identify what is optimal to
minimise potential maladaptive strategies and live alongside
their ambiguous loss. This is a signicant limitation of
the scope to effect change in the lives of those living with
ambiguous loss.
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© 2020 Cruse Bereavement Care
The scoping review concludes that ambiguous
loss may be poorly understood from a therapeutic
perspective. However advancements over the last
two decades provide clinical interventions that have
the capacity to enhance the wellbeing of those living
with the loss of a missing person. What was revealed
from this review is the detailed practical information
(forensic and otherwise) that people must engage
with and navigate when living with the loss of a
missing person. What needs to occur from a practice
and research perspective is the incorporation of a
module of learning in understanding the complexity
of delivering relevant strategies to assist counsellors to
understand the inclusion of uncertainty in experiences
of loss. Research evaluation of these educational
opportunities, and the capacity for those with lived
experience to co-construct how these modules should
be taught, is essential in terms of developing a clearer
health partnership with those who have experience of
ambiguous loss.
Living with the disappearance of a person can have a
signicant impact on all aspects of life, and for extended
periods. In the therapeutic space counsellors who have
expertise in trauma and griefwork, as well as those
who specialise in family therapy or family conict,
would also be able to provide assistance. The literature
identied in this article suggests that counsellors can
prepare for individuals or families before their rst
session by being well-versed in evidence-based models
of trauma, grief and loss as well as on their own
thoughts of ambiguity. The literature concludes that
the goal for the counsellor might be to set aside what
they think they know about the experience of having
someone missing, challenge the assumptions that may
come from those thoughts and truly listen to help
people challenge the ruminations that arise. Boss (1999)
told the therapeutic community that closure is not the
goal, remaining person-centred and open to learning
about the loss, even if it extends long term, this is
This study was funded by the National Missing Persons
Coordination Centre, Australian Federal Police, to produce
an e-book for counsellors and support providers who
engage with families and friends of missing people. In
addition, the authors also engaged a sensitivity reader
who has lived experience in the loss of a missing loved
one, who provided insight into the writing to ensure it
represented how to live with loss. This review assisted in
the development of the e-book but has not been published
Supplemental data
Supplemental data for this article can be accessed here.
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... Those who are reported missing are likely to return within 1 month, with long-term missing people (defined as missing for longer than 3 months) accounting for 2,600 Australians at present. A nation-wide audit led by the Australian Federal Police (AFP) National DNA Program for Unidentified and Missing Persons (AFP Program) has recently recorded 850 unidentified humans remain in Australia; a higher figure than initial estimates of 500 (2,3). The expectation is that some of these unknown remains will be linked to known missing persons, who in some cases have been absent for decades (1). ...
... The experience of being "left behind" when someone is missing is viewed as a traumatic event characterized by reactions of waiting and loss of control, irrespective of the length of time the person is missing (16). Research identifies that the longer-term impact of having someone missing does not present like grief and loss reactions, where the loss is able to be managed over time (3). Ambiguous loss, where the person remains missing, can exist for decades given families do not have the necessary information to be able to state with certainty that a person will or will not come home, in addition to thoughts about being alive or deceased (17). ...
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The trauma of having a family member missing is commonly described as an ambiguous loss where the finality of the loss is not realized, as is experienced with a death. There is uncertainty due to the trauma of the absence and subsequent police investigation, leading to physical and emotional impacts for the aftercare of those left behind. There are 850 unidentified human remains and 2,600 long-term missing persons cases in Australia. The Australian Federal Police (AFP) National DNA Program for Unidentified and Missing Persons aims to scientifically link these cases using modern DNA techniques and databases. A DNA-led identification effort may assist to provide answers to Australian families searching for missing relatives, but may also contribute to the trauma experienced by these families. A literature review demonstrated empirical research for the development of scientific best practices for the collection of reference DNA samples for forensic purposes, but minimal evidence about the impact of reference DNA sample collection on kin when attempting to identify the deceased remains of missing people in non-mass casualty situations. The aim of this study was to develop an academically robust understanding of the unique impact of reference DNA sample collection on families of missing persons and support pathways tailored to the experience. This study involved 26 Australian families of long-term missing (ranging from 1 to 20+ years) people in Australia anonymously completing a mixed-methods online survey about their experiences of providing reference DNA samples to aid missing persons investigations. Respondents were representative of a range of ages, genders and relationships to the missing individual. The thematic analysis of the survey results identified the provision of a reference DNA sample: (1) resembles an overt act of hope as families perceive their sample assists the investigation, whilst also being traumatic, triggered by the prospect of scientifically matching their missing family member to a set of unknown human remains; (2) can cause immediate interpersonal impacts and ongoing impacts to families' wellbeing; and (3) can be improved by considering the environment where the sample is collected, professionalism of the police officer collecting the sample, timeliness of the provision of the sample, level of support provided during and after sample collection, and effective communication of forensic procedures and processes as they relate to the missing persons investigation. The study concludes that the complexity associated with provision of family reference samples requires the development and implementation of best practice guidelines, including psycho-education strategies to be used by practitioners to minimize the vicarious trauma for relatives already traumatized by the loss of their missing family member. These guidelines would support the objectives of the AFP Program and benefit all routine missing persons investigations.
... At least 90% of those people are located within a relatively short timeframe, usually in 48 hours, yet just under half will go missing again (Sidebottom et al., 2019). There are significant social, economic and health-related costs to the person absent, police, families left behind and the wider community, yet to date, international research has primarily focussed on search and rescue techniques, or the grief experiences of those left behind rather than the health and wellbeing of those who are lost (Wayland and Maple, 2020). Missing cases are complex, with each circumstance influenced by an individual's current level of functioning, social determinants of health and nuances between escaping from, or running to, a new location. ...
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When a person is reported missing there are substantial costs for the individual, their family and society. This paper conceptualises the experience of missing persons episodes, through a public health approach. This then allows police, stakeholders and the community to engage in discussions about who is vulnerable to going missing by intervening in a way that addresses risk. Historically, a missing persons episode involves an absence, typically followed by police involvement in consultation with next of kin with establishing the whereabouts of the missing person being the primary focus. Yet, the risk factors of going missing relate more to the psychosocial aspects that trigger a disappearance-family disconnection, mental health, poverty, intergenerational trauma. A narrative review of the literature reflects that the police are public health interventionists regarding social issues; however, this concept is untested in a missing persons context. Successful examples of public health approaches in the injury and violence prevention fields demonstrate that a public health approach is critical to address risk and protective factors. In a context of going missing (and the aftermath of a missing episode), enhanced awareness of the social and economic costs of an absence may prevent future episodes. This paper proposes a conceptual framework to address key challenges and risk factors in missing persons cases. The paper also proposes a future framework that emphasises shared responsibility between police working alongside public health and social care agencies to better support those at risk of going missing while fully engaging with the experiences of those who return.
... This type of experience can lead to the stigmatization of grieving families, as their grief management practices do not align with people's expectations about loss, and this, in turn, can lead to additional stress amongst family members as their loss is not socially acknowledged [41,42]. Because the phenomenon of ambiguous loss is still poorly understood and susceptible to clichés, families do not often share their emotions with others for fear that they will misunderstand these feelings or minimise the situation. ...
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This article presents the results of a qualitative study aiming to consider the relationship between ambiguous loss and anticipatory mourning amongst relatives of missing people in Italy. Eight people participated in the research, narrating their experiences of losing a beloved person (one found alive, three found dead, and four still missing). Findings suggest the presence of a particular form of ambiguous loss, characterised by traits typical of both prolonged and traumatic grief. These findings describe how families are faced with an emotional vortex related to a never-ending wait, and how the mourning is solved only when the missing person is found dead or alive. The discovery of a corpse is traumatic but it allows mourners to fully recognise their grief. When a person is found, it changes the relationship in a positive way. When neither of these events happen, mourners have two different kinds of reactions: they experience either a prolonged grief or a drive to solve their suffering by helping other people (post-traumatic growth). In this study, it is highlighted how a community can be useful or detrimental in this process, and the importance of psychological and social support to prevent significant clinical outcomes is stressed.
In some Australian and international jurisdictions, coroners can deliver a legal determination of death whilst a person remains missing. Empirical attention to this unique area of law is sparse. Semi-structured interviews with 22 coronial professionals in New South Wales (NSW), Australia revealed their views about suspected death inquests, the impact of this judicial process on family well-being and measures to support and inform relatives in the coroner’s court. Thematic analysis yielded five themes: (1) Information to the greatest extent possible; (2) Timeliness; (3) Opportunity to share their views; (4) In the public arena; and (5) Treat people like human beings. The professionals believed that relatives derive therapeutic benefit from timely, sensitive, comprehensible proceedings with opportunities for ritual, meaningful participation and fresh evidence whereas insensitive, incomprehensible and/or untimely proceedings magnify distress. Our findings promote understanding of trauma-informed practices which could mitigate harm to court participants and benefit other courts and jurisdictions.
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Through a mixed methods research design the study sought to explore: • What might be the best practice guidelines for providing crisis and ongoing counselling to families of missing people? • What advancements have there been in the counselling field that may be relevant to families and friends of missing people in Australia? • How can information regarding supportive interventions be conveyed appropriately to health professionals seeking to support this population group?
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This dissertation provides insights in consequences of, and psychological care after the disappearance of a significant other. In contrast with previous research on this topic, we focused on disappearances outside the context of armed conflict. A survey-study among 137 Dutch and Belgian people showed that 58% passed clinically relevant thresholds for prolonged grief disorder, posttraumatic stress disorder, and/or depression, on average 15 years post-disappearance. In contrast with an assumption that the disappearance of a significant other is the most traumatic loss, a comparative study showed that prolonged grief and posttraumatic stress levels were significantly higher in homicidally bereaved individuals than in relatives of long-term missing persons. Findings from three correlational survey-studies indicated that, similar to bereaved individuals, relatives of missing persons who experience more negative cognitions, and engage in more avoidance behaviors and ruminative thinking are more likely to experience elevated distress. Our findings also suggested that enhancing positive affect and being more self-compassionate are potential protective factors for experiencing distress post-disappearance. An interview-study among 23 people indicated that, according to relatives with little to no symptoms looking back on responses to the disappearance, learning to tolerate uncertainty is of utmost importance. These findings offer tentative support for our efforts to develop and evaluate the feasibility and potential effectiveness of cognitive behavioural therapy with elements of mindfulness (CBT+M) for relatives of missing persons with elevated distress-levels. Based on a pilot study among 17 people we concluded that CBT+M yields promising effects and that more research on this approach is justified. See for more information:
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Abstract Background Traumatic loss (e.g., homicide) is associated with elevated prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD). Several studies comparing relatives of missing persons with homicidally bereaved individuals showed inconsistent results about the difference in PGD- and PTSD-levels between the groups. These studies were conducted in the context of armed conflict, which may confound the results. The current study aims to compare PGD- and PTSD-levels between the groups outside the context of armed conflict. Methods Relatives of long-term missing persons (n = 134) and homicidally bereaved individuals (n = 331) completed self-report measures of PGD and PTSD. Multilevel regression modelling was used to compare symptom scores between the groups. Results Homicidally bereaved individuals reported significantly higher levels of PGD (d = 0.86) and PTSD (d = 0.28) than relatives of missing persons, when taking relevant covariates (i.e., gender, time since loss, and kinship to the disappeared/deceased person) into account. Limitations A limitation of this study is the use of self-report measures instead of clinical interviews. Conclusion Prior studies among relatives of missing persons and homicidally bereaved individuals in the context of armed conflict may not be generalizable to similar samples outside these contexts. Future research is needed to further explore differences in bereavement-related psychopathology between different groups and correlates and treatment of this psychopathology.
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Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7]. In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA Completing a Systematic Review Is an Iterative Process The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
Stories of the missing offer profound insights into the tension between how political systems see us and how we see each other. The search for people who go missing as a result of war, political violence, genocide, or natural disaster reveals how forms of governance that objectify the person are challenged. Contemporary political systems treat persons instrumentally, as objects to be administered rather than as singular beings: the apparatus of government recognizes categories, not people. In contrast, relatives of the missing demand that authorities focus on a particular person: families and friends are looking for someone who to them is unique and irreplaceable. In Missing, Jenny Edkins highlights stories from a range of circumstances that shed light on this critical tension: the aftermath of World War II, when millions in Europe were displaced; the period following the fall of the World Trade Center towers in Manhattan in 2001 and the bombings in London in 2005; searches for military personnel missing in action; the thousands of political "disappearances" in Latin America; and in more quotidian circumstances where people walk out on their families and disappear of their own volition. When someone goes missing we often find that we didn't know them as well as we thought: there is a sense in which we are "missing" even to our nearest and dearest and even when we are present, not absent. In this thought-provoking book, Edkins investigates what this more profound "missingness" might mean in political terms.
Families of the missing often have no facts to clarify whether their loved one is alive or dead, or if dead, where the remains are located. Such loss is called “ambiguous loss”, and those suffering from it will usually resist change and will continue to hope that the missing person will return. As this article will endeavour to explain, our goal as professionals working with the families of the missing is to help them shift to another way of thinking that allows them to live well despite ambiguous loss. To do this, we must acknowledge that the source of suffering – the ambiguity – lies outside the family. The article offers a psychosocial model with six guidelines focusing on meaning, mastery, identity, ambivalence, attachment, and finding new hope.
Forensic humanitarian action is aimed at alleviating suffering and maintaining human dignity, with the victims and their families at the core. International recommendations emphasize the importance of psychological support and psychosocial work as an integral part of forensic investigations into missing persons. Psychosocial action does not simply refer to emotional support but is based on the idea of the individual being the holder of rights, encouraging decision taking, affirming actions, and elaborating personal and collective histories. In this framework, forensics and psychosocial sciences need to work in complementary and coordinated interaction for the benefit of the families and communities. For forensic investigations to be restorative – their ultimate humanitarian objective – there are certain additional conditions apart from those of scientific quality and ethics: respect, information and coordination are among the main pillars for forensic action with a psychosocial approach, taking into account the need to treat on an individual and collective level the continuous psychological affectations caused by the disappearance of a loved one. On this basis, psychological and psychosocial accompaniment of the victims can contribute to the victims’ healing process and also improve the forensic investigations themselves. This article, which is based on the experience of two decades of practical forensic and psychosocial work in the field, explains the main psychological effects of disappearances and the resulting needs. It gives a short historical overview of the origins and developments in psychosocial support and a perspective in relation to the search for missing persons and forensic interventions in Latin America. It goes on to demonstrate how coordinated interaction among the forensic and psychosocial fields strengthens both of them to the benefit of the affected families, groups and communities. Finally, it takes up some of the international recommendations of best practices with particular significance for the implementation of a psychosocial approach in forensic investigations.