Contemp Fam Ther (2007) 29:187–190 DOI 10.1007/s10591-007-9046-y BOOK REVIEW Pauline Boss, Loss, Trauma, and Resilience: Therapeutic Work with Ambiguous Loss W. W. Norton & Co Inc, New York, 2006, 251 pp, Hardcover, $27.50, ISBN 9780393704495 Sandra A. Rigazio-DiGilio Æ Jennifer A. Barnett Published online: 20 July 2007
Springer Science+Business Media, LLC 2007 Persons are present to us less from the evidence of our senses than from the activity of our imaginations. Willard Waller (1938) Since her early days of conducting family therapy sessions while studying under Carl Whitaker in Wisconsin more than 30 years ago, Pauline Boss has provided clients and clinicians with insights into a phenomenon of loss that defies closure. Identified as Ambiguous Loss, she elaborated on this phenomenon in her first book, Ambiguous Loss: Learning to Live with Unresolved Grief (1999). Boss expands on this theoretical framework in her most recent book, Loss, Trauma, and Resilience: Therapeutic Work with Ambiguous Loss (2006), providing a careful exploration of the nuances behind her Ambiguous Loss Model as well as descriptive insights regarding her own process of becoming a therapist. This certainly may encourage students, practitioners, trainers, supervisors, and researchers to explore their personal level of sensitivity to the variety of loss experiences individuals and families may face over their life-span. For clinicians at all stages of development, Boss offers core questions to promote awareness of our competency and resiliency in treating the trauma associated with ambiguous loss: • • • • Who is in your psychological family? What ambiguous losses have you experienced? What type: Physical? Psychological? Both? What did it mean to you then? What does it mean now? Reflection on these questions is critical for therapists, allowing them to become increasingly aware of their own challenges with ambiguous loss and how these challenges S. A. Rigazio-DiGilio (&)
J. A. Barnett Department of Human Development and Family Studies: Marriage and Family Therapy Program, University of Connecticut, 348 Mansfield Road-Unit 2058, Storrs, CT 06269-2058, USA e-mail: srdigilio@comcast.net 123 188 Contemp Fam Ther (2007) 29:187–190 may influence their therapeutic practice. This reflective process is also meant to be growth producing. As Carlos Sluzki notes in his Foreword, Boss ‘‘encourages us, with kind hand and wise words, to do the same [reflect on the core questions above] with our own unavoidable ambiguous losses, helping us emerge from the journey with new clarities, new strengths, and new joys’’ (p. xv). Boss’s construct of the psychological family, as this relates to ambiguous loss, is important and extends into the wider reaches of a person’s sense of belonging. Members of our psychological family may include those who are with us physically but not able to interact with us, such as family members experiencing dementia, brain injury, addiction, depression, and other chronic illnesses. Members also may include those whose life-course is not yet certain, such as soldiers missing in action or unidentified victims of natural or human disasters. This expanded vision of family often has been neglected in favor of focusing on family members present in therapy and then incorrectly assuming that clients experiencing ambiguous loss need to move on: Typically, therapists are trained to see the physical structure of relationships and to think that if they are doing their job right, clients will get over their losses and reattach relatively quickly to someone who is physically present. The myth is that healthy people find closure.... When a loved one suddenly vanishes or is lost psychologically, a clinical approach for tolerating ambiguity rather than seeking closure is essential. (pp. 33–34) Boss emphasizes the importance of this concept, when she concludes Chapter One with the words: ‘‘The first step... is understanding that there is a psychological family’’ (p. 34). After the Introduction, Part I of the book provides three theoretical chapters, each dedicated to the foundational assumptions of Boss’s model: (1) working with the psychological family from a contextual and multicultural perspective; (2) providing a therapeutic context that encourages clients dealing with trauma and loss to tell their stories, to feel heard, and to be responded to empathically; and, (3) understanding and accessing the potentials of resiliency and strength-based approaches to treatment and prevention interventions. Part I ends with a case study that demonstrates Boss’s therapeutic methods, with careful attention given to translating these foundational assumptions into the actual practice of therapy. Building on the theoretical foundations in Part I, the second part of the book consists of six chapters and an Epilogue. Chapters four through Nine each address one key therapeutic goal that therapists should consider when working with clients experiencing distress related to ambiguous loss. In these chapters, Boss offers clear and operationalized concepts that can be: (1) empirically tested—both in practice and in clinical trials; (2) easily incorporated into clinical preparation programs and supervision; and, (3) applied directly to the here and now of clinical practice. In this way, Boss provides the tools necessary for clinicians at all stages of development to go into therapy with their ‘full self’ (i.e., to be totally present in therapy and not only halfway there, thinking of what to say next, answering the phone, etc.). In particular, Boss encourages this ‘full self’ stance when working with those coping with ambiguous loss, as otherwise they may be re-traumatized by their therapist’s actions and not return for future therapy sessions. Chapters Four and Five focus on helping clients find meaning and temper mastery and control, respectively. Boss writes, When the preferred solution is impossible, the goal instead is to temper one’s need for mastery. This means being able to accept an imperfect situation. It requires 123 Contemp Fam Ther (2007) 29:187–190 189 immense flexibility and the belief that one is choosing to accept and live with the ambiguity rather than continuing to perceive oneself as being the helpless victim of it. (p. 103) Chapters Six and Seven provide therapists clearly articulated guidelines for how to conduct treatment aimed at re-constructing identity and normalizing ambivalence. Building on the work of Erikson, Blumstein, Wynne, Reiss, Imber-Black, Walsh, Attneave, Hardy, McGoldrick, and others, Boss situates work across individual, couple, family, and community levels. Using a social constructionist approach that incorporates narrative, systemic, and dialectic methods, Boss demonstrates how to help clients acknowledge and manage the tensions from ambivalence at a level that prevents traumatization by accepting both negative and positive feelings associated with ambiguous loss. Chapters Eight and Nine help clinicians navigate the revision of attachments with lost family members and facilitate the surfacing of new hope in the face of their current situation. Closure, in the sense that finality has arrived, is unrealistic in these situations, and Boss conceptually and pragmatically guides therapists to help clients accept the paradox of simultaneous absence and presence. Through this acceptance, clients are able to see missing family members as active members of their psychological families and can find new sources of hope for their futures. The final chapter focuses on the personal work professionals need to consider in order to treat and understand the many faces that ambiguous loss might take. The core questions posed at the beginning of this review are explored and provide a vision of competent therapists who are prepared to deal with the ambivalence and unanswered questions associated with ambiguous loss experienced both by their clients and themselves. The importance of such self-knowledge is captured by an exercise Boss borrowed from Whitaker and enthusiastically shares with her students: ‘‘I get in the car and intentionally get lost—and then enjoy the mystery of not knowing where we are.... the experience of not knowing becomes associated with fun and is less fearsome when it later appears in real life’’ (p. 205). In a recent phone conversation, Boss shared that this exercise has become so integrated into her family’s life that her grandchildren now specifically ask to experience such journeys with her. Coming from ‘‘a background of high mastery,’’ it is remarkable that Boss has challenged the very notion of mastery in a way that touches future generations. ‘‘It is about taking a risk, not following a predestined map,’’ says Boss. Admittedly, ‘‘...things don’t always go our way... what’s surprising is that you can let that go and face the unknown; new and exciting things are around the corner,’’ encourages Boss (personal communication, July 6, 2007). Students reading this book will necessarily begin to explore their own comfort level in ambiguous territory. So much of being a student of marriage and family therapy involves looking for answers, for a way to conduct therapy. Boss acknowledged this and offers a reprieve, assuring that the clinician’s own comfort level with ambiguity, or being between two places (i.e., knowing and not knowing), is important. Clients are acutely aware, explained Boss: ‘‘I think they sense it, especially wounded, dying, and traumatized people... they’ll sense it if you’re a fake, if you’re pretending to know, but I think you have to have some of your own life experiences’’. Boss acknowledges that no two persons’ experiences can exactly mirror each other, but that with careful sharing and listening, commonalities can be found. The territory between our experiences and those of our clients is often ambiguous and should be explored openly as part of the therapeutic encounter. You can only take your clients as far as you are willing to go. A comprehensive MFT training 123 190 Contemp Fam Ther (2007) 29:187–190 program should include room for students to explore their own comfort level with ambiguity about their role, their work, and their own unresolved areas of grief and loss. Students, clinicians, trainers, supervisors, and researchers at all stages of practice will benefit from Boss’s knowledge of this difficult reality of life and the sensitive and comprehensive recommendations she makes for treatment and community support. All of us can gain deeper insight into our own professional domains by increasing our comfort with ambiguity and assuming a ‘‘not knowing’’ stance. Boss encourages this in the final section of her book when she discusses the self of the therapist. We are grateful to Boss for such a safe and important journey into our own issues with ambiguous loss and we are better professionals for having done so. In the second reviewer’s personal communication with Boss, Pauline mentioned that she is currently exploring some new territory herself: mindfulness, and, in particular, a mindbody connection. When Jennifer asked for a definition of mindfulness, Pauline simply replied ‘‘I am not sure just yet.’’ This made Jennifer smile, as she recognized that the message assumed both a collaborative stance—engaging a member of the future generation in her quest—and an acknowledgement that the journey of life-long learning is predicated on the belief that one will always have the privilege of learning from one’s own experiences as well as from one’s exchanges with others. 123