A Qualitative Study of Grief among Family Members of Missing Persons in Southern Sri Lanka

The psychological and social issues experienced by family members of missing persons are different from normal grief following the death of a loved one. The term “Ambiguous loss” describes this psychological phenomenon. “Ambiguous loss” acts as a barrier to adjusting to grief, leading to symptoms of depression and intra and interpersonal relational conicts. An in-depth understanding of this subjective experience is important. A qualitative study was conducted among close family members of persons who had gone missing during the civil conict and the 2004 tsunami in southern Sri Lanka. Purposive and snowballing sampling methods were used to recruit the participants. In-depth interviews were recorded with the help of a semi-structured guide, after informed consent. The recordings were transcribed and thematically analyzed by three independent investigators. The investigators met to code the themes and ground them through reexivity. The triangulation process involved cross-checking with the interviewees. Theoretical sample saturation was achieved with 24 family members of missing persons. Responders were mothers, fathers, wives, husbands, and siblings of missing individuals. Six predominant themes were identied. They lacked closure, hope, guilt, helplessness, perpetual suffering, and effects due to gender roles.


Introduction
When someone goes missing and unaccounted for, the family members left behind are on a perpetual mission to clarify the fate of the missing individual (1). They contemplate all the possibilities, but the nality of the death of a loved one is elusive and they constantly vacillate between hope and despair (1,2). The grief process is not initiated since there is no dead body. This unique suffering experienced by family members of missing individuals is described by the term "Ambiguous loss" (1). The loss of a loved one is in itself, di cult. When ambiguity is added to it, the results are agonizing and immobilizing (1). Furthermore, 'ambiguous loss' is compounded by legal, nancial and social rami cations (3,4). Therefore, Page 3/18 'ambiguous loss' is a different kind of loss from a loss by bereavement (5). In depth understanding of the lived personal experience of close family members is necessary to support and meet the needs of these persons who are unable to achieve closure. Sri Lanka has experienced many civil con icts and the 2004 Indian Ocean Tsunami, which led to a large number of deaths and many others being classi ed as missing individuals as their mortal remains could not be found (6).
A broader ethnographic understanding of the psychological and social effects on the close family members of those classi ed as 'missing' is necessary, to address the needs of these affected individuals. There are also a growing number of such individuals globally in con ict areas and in post disaster situations. Resolving the problems in families of missing individuals is an important facet of the post war reconciliation process as issues related to missing persons act as reminders of past con ict (3).

Aims of the study
The aim of our study was to understand the psychological nature of grief through qualitative means, in family members whose loved ones disappeared in the context of civil con ict between 1987 -1990 and the Indian Ocean Tsunami of 2004 in southern Sri Lanka.

Conceptual framework
We aimed to conceptualize the experience of grief and understand the emotional and social needs of family members of missing persons. A good understanding of their lived experience and needs enable health care professionals to plan an effective intervention. Previous qualitative studies have shown that the grief experienced by family members of missing individuals is different from loss through death of a family member. These studies, however, are mostly from high income countries and the experience of family members of missing persons in the south Asian context may be different considering the diverse cultural and socioeconomic factors.

Study design and sampling
Ethical approval for the study was obtained from the ethical review committee of the Faculty of Medicine, University of Kelaniya. Family members of missing individuals from Galle, Matara and Hambantota districts were identi ed with the help of the Grama Niladhari (local administrative o cer). First degree relatives of missing persons were interviewed after informed written consent. Purposive sampling method was used due to the sensitive nature of the research topic. The sampling tried to achieve maximum variation in terms of age, relationship to the missing individual, gender, social class, context in which the missing took place, ethnicity and religion.

Data collection
We interviewed 24 persons between January and September 2015 to achieve data saturation. The ethnographic research methodology included semi-structured and in-depth face to face interviews which were tape recorded. The in-depth interviews and participant observation methods also facilitated triangulation.
Semi-structured interviews focused on socio-demographic factors of the missing individual and interviewee, the situations in which disappearance had occurred, their belief in the fate of the missing individual, psychosocial needs, the ways of coping and those who helped in their di cult situation. The interviews were conducted in a safe space mostly in the home of the interviewee in a sensitive manner while accounting for the social and cultural context. The interviewee was given permission to stop the interview at any point if they found the interview to be emotionally overwhelming. Initially, the interview started with general questions and then moved on to more speci c information.
Data collection was conducted by two medical doctors who had post graduate quali cation in Psychiatry.
Steps were taken to minimize the interviewee perceiving the researcher as someone who would offer nancial or other aid. It was also made clear that it was not a diagnostic interview with a view to providing medical or psychological therapy. The researchers had prior training to avoid a clinical interview pattern that could potentially introduce clinically driven misconceptions. Interviews were conducted in a place chosen by the interviewee to minimize the impact of an unfamiliar backdrop.
We have taken many steps to assure methodological rigor, including prolonged engagement with interviewees, ensuring detailed description from participants, negative case analysis, co-coding of transcripts and use of an audit trail.
Interviews were conducted in Sinhala language, which is the main language spoken by people in southern Sri Lanka. Each interview lasted approximately 1 hour. Measures were taken to assure the privacy of participants and the information gathered. The researchers did not ask direct or probing questions and facilitated the ow of information. At the end of the interview, the interviewees were given an opportunity to express any additional concerns or thoughts.

Data analysis
Anonymised audio recorded interviews were transcribed. We used re ective approach during analysis. Each transcript was analyzed by two researchers. Manual coding was done instead of computer program-based coding due to non-availability of qualitative analytic software. Transcripts were read through multiple times with codes generated by grouping relevant phrases and words together. Grounding of the themes was done by line-by-line analysis and constant comparison by two researchers.
Information from each section was compared and grouped until similar themes were identi ed. Constant comparison of thematic codes was performed. Final thematic framework was discussed among the research team to arrive at a consensus. Final thematic framework and consensus were cross checked again with the interviewees.

Results And Discussion
The majority of interviewees were mothers (13) followed by fathers (4). The age range was 44 years to 81 years. Disappearances had taken place between 1988 and 2004. None of the interviewees had a history of mental disorder. The characteristics of the missing persons are listed in Table 01. The characteristics of those interviewed are listed in Table 02.  Thematic analysis The following themes emerged in the interviews: Lack of closure, hope, guilt, helplessness, perpetual suffering, gendered effect of the missing person. Ambiguous nature of the loss of the loved one.

Hope
Hope was a way of maintaining connectedness to the missing person.
Giving up on hope implied the acceptance that the missing person would not return alive.
Helped deal with the pain.

Guilt
It was wrongful to be joyful and enjoy life.
Helplessness Lack of reliable information about the missing person despite trying for many years.
Financial and bureaucratic barriers to seeking justice.
Financial hardships secondary to losing breadwinner of the family and spending large sums of money to search for the missing loved one.

Perpetual suffering
Experiencing intense psychological distress including prolonged grief, depression and suicidal ideation for decades.

Gendered effects
The economic, social and psychological impact on female family members seemed higher.

Lack of closure
The nature of the grief is complex. It vacillates between searching for the missing, while also having given up.
A mother said, "If my son is alive, he will somehow come to see me. Even if he was tightened up with 7 iron chains, he will nd the way home. Now it is more than 25 years since he became unaccounted for…. So, I don't think he is alive. We are giving alms annually in remembrance of him. But we have not given up searching for him…I went to a fortune teller last week also to nd out if my son is alive somewhere".
The lack of closure and ambiguity is further highlighted by the statement of this sister of the loved one. "It is nearly 27 years since my brother disappeared. We do religious activities and bless him. But we did not perform death rituals or give Panshukuula (A Buddhist blessing performed after death). It is bad if we do such things to someone alive. Our uncles and villagers asked us to give alms to Buddhist priests and invoke merits. My parents and I don't want to do that since we believe that he is alive somewhere." There is a reluctance to give in to complete grief.

Holding on to hope
Hope is pivotal to the experience and fuels the ceaseless emotional search to reconnect with the missing loved one. The following statement by the sister of an abducted male, shows the yearnings of a mother. "My brother was abducted by men in military uniform in 1989. He had just completed his ordinary level exam with eight distinctions. My mother was continuously in a mission to nd him… it was her daily routine until her death. She has never allowed us to close the front door of our house, believing that my brother would return home." Connectedness to the missing person can be enhanced by hope, which in turn may assist the complicated bereavement reaction (7).
Hope gives a reason to the survivor to continue living. A father of an army soldier said, "Believing that my son will return, helps to keep me going". It also helps mitigate the pain. A father said, "I have a belief and feeling that whatever people said, my son is alive. Actually speaking, I did not experience an unbearable shock since I believe that my son is alive somewhere. The idea in my mind is that I need to search for my son more and more".
Hope is enhanced by clutching to selective reinforcers. "I think my son is alive. I have been searching for him for more than 25 years. We listen to fortune tellers and do all sorts of sorcery. Fortune tellers say that my son is alive. A fortune teller said that he would de nitely return home. Then we went to a place where they do some sorcery called "Anjanam Eli". That person also con rmed that my son is alive and is in good health. He further said he could clearly see him alive".

Guilt
The guilt precluded normal life and the ability to move forward. A mother said, "I haven't cooked milk rice (a traditional meal) or participated in any festive event so far. How can I be happy without my son?".

Helplessness
They faced numerous hardships. A wife said, "My children and I were left with no income after the disappearance of my husband. My husband planted jack trees in our garden. We ate jack fruit when there was nothing to eat. I do not hesitate to say this publicly. We ate plain bread and drank water. My sister helped me from time to time. She gave us rice whenever she could".
The nancial resources were further depleted in the quest for the missing person. "I lost my son 25 years ago. We lost all our sources of income, as we spent time looking for evidence of my missing son. We sold all our properties one by one. Now we don't have any. We are now struggling to meet our day-to-day expenses".
The efforts at seeking justice were fruitless. A wife said, "I went to make a complaint. They chased me away. We could not make a complaint. But, I took courage and went again with a neighbour. They chased us away again. So, I did not to seek justice. On the other hand, we did not have money to le a court case either".

Perpetual suffering
The emotional distress is relentless.

Gendered effects
The effect of loss was more pronounced in females. A mother said, "If my son had been with me, things would have been much better for me. He would have taken me to the doctor, and I am sure he would have been there for me in my di culties".
The traditional gender roles impacted on their lives. A wife said, "It was with great di culty that I brought up my children. Now they are grown up. I struggled a lot to feed them. My husband provided for the family. In his absence we were all helpless. I got some nancial aid from his relatives. It took so many years to get the money we were entitled to have, from his employer. It was a huge challenge for me to go through the bureaucratic processes".

The needs of family members of missing persons
In the semi structured interview, the pressing need in eleven respondents was to know the fate of the missing individual. Even then, whether such knowledge would console the living is questionable. As one mother summed it up, "I just want my son. I don't want anything else".
Others identi ed nancial needs and the need for psychological support. Of the 24 interviewees, 13 felt they were stigmatized and marginalized by the rest of the community.

Discussion
'Ambiguous loss' disenfranchises the normal grief process and leads to a prolonged 'vacillating grief'. A grief which vacillates between hope and despair. The lack of a closure, mitigating any efforts to move on through the interplay of guilt and the denial of the inevitable. An intense helplessness and perpetual suffering that struggles to make sense of the predicament and to attain cognitive consonance in the midst of uncertainty. The phenomenon captured by the term "living in limbo" (Holmes, 2008).
Lack of closure is fundamental and a recent study from Sri Lanka showed that even subsequent con rmation of death prevented psychological morbidity in the form of depressive disorder and prolonged grief (6). In 20 out of the 24 interviewed, no religious or farewell ceremonies had been performed for the missing person. Such ceremonies undoubtedly facilitate closure(9, 10).
Family members of missing individuals often reject offers of death certi cates or accept reparations, since it is contrary to their hope due to the lack of closure.
In Sri Lankan culture, people turn to fortune tellers to know the possible outcome during uncertainty. The false information provided by fortune tellers, renews hope. This further confounds the situation and leads to a renewed effort to seek out the missing person spending large sums of money by selling their property or borrowing.

Prolonged suffering
Bowlby described that failed attempts to restore missing relationships often results in perpetual distress and agony (11). This perpetual suffering was evident in our ndings. It had psychological and psychosomatic rami cations. The higher risk of developing physical and mental illness in the context of chronic stress is well documented (5).
Studies on psychological consequences of family members of missing persons are limited (5). A study done in Bosnia and Herzegovina reported that symptoms of post-traumatic stress disorder(PTSD) was signi cantly higher in wives of missing individuals than in those who had been exposed to other traumatic experiences during the political unrest in their country (12). Most of the research looking at psychological morbidity has focused on PTSD. But, ambiguous loss is essentially a relational issue and the trauma is ongoing.
A study done by ICRC in Sri Lanka reported that family members of missing individuals experience a high level of psychological morbidity. Of 321 participants, 51% showed anxiety symptoms, 58% showed symptoms of depression and 15% showed symptoms of PTSD (13). Professor Pauline Boss showed that people who experience ambiguous loss are at a higher risk of developing depression, anxiety disorders, and substance use disorders (1,14). However, these studies focused on symptoms of mental illnesses and categorical diagnoses was not made.
Caution should be exercised when making a diagnosis in family members of missing persons. When they are screened for depressive disorder, prolonged grief disorder or PTSD, it should be kept in mind that symptoms of ambiguous loss can be attributed to mental disorders. On the other hand, most symptoms of depression, prolonged grief disorder and PTSD tend to overlap (15).
Survivor guilt impedes on enjoying life as before. Family members left behind believe that they give up on the missing person if they started living normally. They do not attend festive events such as weddings and do not cook food that they prepare for festive events. This creates self-imposed barriers to their happiness.

Role of Gender
There is a gendered impact on disappearances (16). When the disappearances occur in the context of civil con icts the majority of disappeared persons are males (16). Therefore, the economic, social and psychological impact on female family members is relatively high (17,18).
Disappearances cause greater impact on older females (16). In most cultures, children, especially male children, support their parents in their senior ages. When their children become unaccounted for, they are deprived of security and nancial support which could have been received if their missing son had lived with them (16).
Wives face the dual challenge of managing the family responsibilities in the absence of the missing husband, and the grief stemming from the loss (16). There can be many bureaucratic hurdles in accessing the husband's salary, bank account, and other properties in the absence of a death certi cate (16). In some cultures, bodily markings are used to signify the status of marriage. In Tamil culture in Sri Lanka, married women are expected to wear 'thali' (a jewellery item) and kungumappottu (a red mark on the forehead) (16). When a widow or a wife of a disappeared person wears such bodily markings, the symbols are considered as an ill omen. As a result, wives of missing persons do not enjoy the same privileges as their married counterparts, which may discourage them from attending public events (16).

Family roles
Families in southern Sri Lanka live with their extended family which can be helpful in many ways in the face of adversities. At the same time, living with an extended family can be a great source of stress as well. The majority of interviewees in our study identi ed that their family members are helpful when coping with the stress of ambiguous loss. However, some mothers whose sons went missing reported that family members blame them and remove the photograph of the missing son as they are always mourning looking at the son's photograph.
When a family member is physically absent, but psychologically present most of the time, the family members' perception of who is inside or outside the family system is blurred. Ambiguous loss confuses boundaries of family members resulting in boundary ambiguity. Most of the missing individuals are young males in southern Sri Lanka (5). In Sri Lankan culture, male partners ensure the protection of the family. In their absence, families feel that they are not safe as before (13). In the absence of the breadwinner of the family, others have to take the responsibility of earning money which can be quite challenging. Hence ambiguous loss disturbs relationships and dynamics of everyday life in the family.

Limitations
It should be noted that there may have been other losses and stressful events which may have cumulatively affected the grieving process. The sampling is from a speci c geographical location and socio-cultural context.
There is also a possibility that the researcher could have been perceived as someone who could deliver assistance or compensation to the interviewees. This could lead to exaggeration of the impact of the disappearance. Some families were involved in socio-political activities to determine the truth or seek justice with regard to the missing individual.

Conclusions
Family members of missing individuals experience a unique kind of grief, vastly different from grief following bereavement. Lack of closure, holding on to hope, guilt, helplessness, perpetual suffering and gender roles impact the loved ones of the missing. There is a vacillation between hope and despair that prevents acceptance of the loss. The individuals are essentially "locked-in grief", unable to move on. Declarations