Internet-based cognitive-behavioral therapy for complicated grief: a randomized controlled trial

The effectiveness of online cognitive behavioral treatment in routine clinical practice

CONTEXT

Randomized controlled trails have identified online cognitive behavioral therapy as an efficacious intervention in the management of common mental health disorders.

OBJECTIVE

To assess the effectiveness of online CBT for different mental disorders in routine clinical practice.

DESIGN

An uncontrolled before-after study, with measurements at baseline, posttest, 6-week follow-up, and 1-year follow-up.

PARTICIPANTS & SETTING

1500 adult patients (female: 67%; mean age: 40 years) with a GP referral for psychotherapy were treated at a Dutch online mental health clinic for symptoms of depression (n = 413), panic disorder (n = 139), posttraumatic stress (n = 478), or burnout (n = 470).

INTERVENTIONS

Manualized, web-based, therapist-assisted CBT, of which the efficacy was previously demonstrated in a series of controlled trials. Standardized duration of treatment varied from 5 weeks (online CBT for Posttraumatic stress) to 16 weeks (online CBT for Depression).

MAIN OUTCOME MEASURES

Validated self-report questionnaires of specific and general psychopathology, including the Beck Depression Inventory, the Impact of Event Scale, the Panic Disorder Severity Scale-Self Report, the Oldenburg Burnout Inventory, and the Depression Anxiety Stress Scales.

RESULTS

Treatment adherence was 71% (n = 1071). Study attrition was 21% at posttest, 33% at 6-week FU and 65% at 1-year FU. Mixed-model repeated measures regression identified large short-term reductions in all measures of primary symptoms (d = 1.9±0.2 to d = 1.2±0.2; P<.001), which sustained up to one year after treatment. At posttest, rates of reliable improvement and recovery were 71% and 52% in the completer sample (full sample: 55%/40%). Patient satisfaction was high.

CONCLUSIONS

Results suggest that online therapist-assisted CBT may be as effective in routine practice as it is in clinical trials. Although pre-treatment withdrawal and long-term outcomes require further study, results warrant continued implementation of online CBT.

Online working alliance predicts treatment outcome for posttraumatic stress symptoms in Arab war-traumatized patients

BACKGROUND

Previous studies have shown that Internet-based interventions for posttraumatic stress disorder are feasible. However, little is known about how therapeutic process factors impact online interventions in war and conflict regions.

OBJECTIVE

This study aims to assess the quality of the working alliance at midtreatment and posttreatment and its relationship with therapy outcome in an Internet-based cognitive-behavioral intervention for Arabic-speaking traumatized patients.

METHODS

A trial was conducted from January 2009 to August 2011 with patients recruited specifically in Iraq. Fifty-five participants with posttraumatic stress symptoms completed the Working Alliance Inventory (WAI) after at least session 4. Participants' mean age was 27.7 years (SD = 6.9); 78% of participants were females. Participants received two weekly 45-min Internet-based cognitive-behavioral interventions over a 5-week period. The main outcome measures were the Posttraumatic Diagnostic Scale (PDS) and the WAI.

RESULTS

High ratings of the therapeutic alliance were obtained early in treatment, and results remained stable from sessions 4 to 10, indicating that it was possible to establish a positive and stable online therapeutic relationship. The working alliance at both assessment points predicted treatment outcome for posttraumatic stress symptoms.

CONCLUSIONS

Despite the instability of the settings and patients' ongoing exposure to human right violations through war and dictatorships, it was possible to establish a stable online therapeutic relationship.

Late-life bereavement and complicated grief: a proposed comprehensive framework

OBJECTIVES

The construct of complicated grief (CG) has garnered increased empirical attention since it has been proposed as a diagnostic category for the upcoming Diagnostic and Statistical Manual of Mental Disorders-V. The aim of this article is to critically examine construct validity in light of a proposed conceptual framework, with special emphasis on understanding late-life bereavement.

METHOD

This is a review article that critically examined current bereavement and grief models. We explored discriminant and convergent validity between CG and uncomplicated grief (UG) and other psychopathological constructs in terms of symptom intensity, symptom trajectories, bereavement outcomes, and treatment response.

RESULTS

The findings from this review show mixed support for differentiating CG from other outcomes of bereavement for the following reasons: (1) a clear boundary between CG and UG has not been adequately supported, (2) symptoms of CG and bereavement-related depression and anxiety overlap, although there is some evidence of incremental validity in that CG symptoms predict global functioning above and beyond symptoms of depression, and (3) the treatment literature demonstrated that general grief interventions and treatment targeted for improving depression are ineffective at treating symptoms of CG, whereas interventions specially tailored to treating CG have been moderately effective. The findings also emphasize the importance of considering pre-bereavement circumstances, such as preexisting depression, in the conceptualization of broader bereavement outcome.

CONCLUSION

There were mixed findings supporting the construct validation of CG. A comprehensive framework that emphasizes pre-bereavement circumstances was proposed in order to better predict various grief trajectories and outcomes of late-life loss.

Treatment Alternatives for Overweight and Obesity: The Role of Online Interventions

This review examines the application of online interventions to the treatment of obesity. The unprecedented prevalence rates of overweight and obesity worldwide are indicative of the need to develop efficacious treatment alternatives. While research suggests that diet, physical activity and behaviour therapy are core components of effective obesity treatment programs, their ability to penetrate large portions of the population is limited. The empirically verified effectiveness of online interventions for disorders such as depression and social phobia, coupled with unparalleled rates of internet access, suggest that online interventions for overweight and obesity are a feasible and logical treatment modality. A limited number of randomised controlled trials reviewed in this article have evaluated the efficacy of this treatment alternative. Results are promising and encourage further use, development and empirical research in this area.

Internet-Based Self-Management of Generalised Anxiety Disorder: A Preliminary Study

Despite the continuing development of effective cognitive and behavioural interventions for Generalised Anxiety Disorder (GAD) less attention has been paid to the important issue of improving treatment accessibility and affordability. Self-management approaches that utilise the convenience of the Internet may provide a means by which more people can avail themselves of effective treatments. To date, studies examining the effectiveness of such approaches for GAD lag behind the work conducted with other clinical problems. This study describes the response of three individuals with a primary diagnosis of GAD to an Internet-based treatment completed at their own pace. The intervention (‘What? Me Worry!?!; Saulsman, Nathan, Lim, and Correia, 2005) combines several cognitive and behavioural components with the inclusion of a significant metacognitive component. All participants achieved clinically significant improvement on measures of worry, GAD symptomatology, and metacognitions. Moreover, none of the participants met the diagnostic criteria for GAD at the completion of the study. A larger randomised controlled trial of this intervention is indicated.

Life Will Never Be the Same Again: Examining Grief in Survivors Bereaved by Young Suicide

This article explores existing assumptions about the nature of bereavement by suicide. Drawing on data from a U.K. study of student suicide, we hope to contribute to a fuller understanding of the uniqueness of bereavement by suicide and new pathways for grief research. In this article we argue that bereavement by suicide has a number of common themes and characteristics. Analyzed in accordance with Jordan's (2001) review, our data supports the idea that the thematic content of the grief associated with suicide bereavement is distinctive and guilt is a particularly important feature. We argue that no other type of death is likely to bestow this particular negative emotion on survivors in equivalent measure. Findings on the impact of social processes and family systems were mixed. Explanations to account for these data along with recommendations for intervention and research are discussed.

Efficacy of an Internet-based intervention for posttraumatic stress disorder in Iraq: a pilot study

In the past 20 years, war and human rights violations have led to high rates of exposure to traumatic events among the Iraqi population. Due to the ongoing violence, many physicians and mental health professionals have left Iraq in recent years. The Internet offers new possibilities for the psychological treatment of posttraumatic stress disorder (PTSD) in conflict areas. A therapist-supported cognitive-behavioral treatment manual that has been evaluated in Western countries was translated into Arabic and culturally adapted. The treatment was conducted via the Internet by Arabic-speaking therapists and was evaluated in an uncontrolled pilot study with 15 participants. Main outcome measures were PTSD (Posttraumatic Diagnostic Scale (PDS)), depression, anxiety (Hopkins Symptom Check List-25 (HSCL-25)), and quality of life (EUROHIS). The intervention resulted in a highly significant decrease in symptoms of PTSD, depression, and anxiety. Quality of life was higher at posttreatment. All treatment effect sizes were in the large range, indicating a significant improvement in mental health symptoms and quality of life. Preliminary clinical evidence indicates that new technologies can be used to provide humanitarian aid in the form of e-mental health services, even in areas that remain highly unstable.

Recent trends in the treatment of prolonged grief

PURPOSE OF REVIEW

Treatment for prolonged grief has been controversial. However, recent studies have clarified several key issues, offering important guidance to clinicians. This review summarizes the most recent evidence on the efficacy of grief treatments, moderators of treatment response, and new treatment approaches.

RECENT FINDINGS

Recent research findings highlight that grief therapy is efficacious when targeted to adult and child grievers with persistent and elevated levels of distress. However, when grief therapy is applied as a universal intervention, it has minimal to no benefits, either for adults or for children. Earlier intervention for children is associated with greater efficacy. In recent studies, therapies employing cognitive-behavioral techniques, such as cognitive restructuring and exposure, have shown particularly robust effects in ameliorating grief symptoms. Other intervention approaches, including pharmacotherapy, internet-based, family-based, and preventive, have shown initial promise, but insufficient data exist to validate their efficacy to date.

SUMMARY

Prolonged grief, a pattern of persistent and elevated distress following a loss, is increasingly recognized as an independent form of psychopathology that is responsive to treatment. Therapies that employ cognitive-behavioral techniques are efficacious in ameliorating the symptoms of prolonged grief and should be more widely used. However, grief therapy should not be deployed as a blanket intervention for all grievers. Antidepressant medication may serve a useful adjunctive role in grief therapy completion and in reducing bereavement-related depression.

The working alliance in a randomized controlled trial comparing online with face-to-face cognitive-behavioral therapy for depression

BACKGROUND

Although numerous efficacy studies in recent years have found internet-based interventions for depression to be effective, there has been scant consideration of therapeutic process factors in the online setting. In face-to face therapy, the quality of the working alliance explains variance in treatment outcome. However, little is yet known about the impact of the working alliance in internet-based interventions, particularly as compared with face-to-face therapy.

METHODS

This study explored the working alliance between client and therapist in the middle and at the end of a cognitive-behavioral intervention for depression. The participants were randomized to an internet-based treatment group (n = 25) or face-to-face group (n = 28). Both groups received the same cognitive behavioral therapy over an 8-week timeframe. Participants completed the Beck Depression Inventory (BDI) post-treatment and the Working Alliance Inventory at mid- and post- treatment. Therapists completed the therapist version of the Working Alliance Inventory at post-treatment.

RESULTS

With the exception of therapists' ratings of the tasks subscale, which were significantly higher in the online group, the two groups' ratings of the working alliance did not differ significantly. Further, significant correlations were found between clients' ratings of the working alliance and therapy outcome at post-treatment in the online group and at both mid- and post-treatment in the face-to-face group. Correlation analysis revealed that the working alliance ratings did not significantly predict the BDI residual gain score in either group.

CONCLUSIONS

Contrary to what might have been expected, the working alliance in the online group was comparable to that in the face-to-face group. However, the results showed no significant relations between the BDI residual gain score and the working alliance ratings in either group.

TRIAL REGISTRATION

ACTRN12611000563965.

Reconstructing meaning in bereavement: summary of a research program

Bereavement, in the form of the loss of a significant attachment figure, disrupts the self-narratives of survivors and typically pitches them into an unsought quest for meaning in the loss, as well as in their changed lives. A growing body of research on diverse groups - bereaved parents, young people, elderly - suffering loss through both natural and violent death, documents the link between the inability to find meaning in the experience and the intensity of complicated grief they suffer. This article reviews the literature, arguing that the processes of sense-making and benefit-finding play a crucial role in bereavement adaptation for many of the bereaved, and accordingly, that interventions that facilitate processes of meaning reconstruction can support effective psychotherapy for those struggling with intense and prolonged grief.

Efficacy of cognitive behavioral internet-based therapy in parents after the loss of a child during pregnancy: pilot data from a randomized controlled trial

The loss of a child during pregnancy can be a traumatic event associated with long-lasting grief and psychological distress. This study examined the efficacy of an internet-based cognitive behavioral therapy program for mothers after pregnancy loss. In a randomized controlled trial with a waiting list control group, 83 participants who had lost a child during pregnancy were randomly allocated either to 5 weeks of internet therapy or to a 5-week waiting condition. Within a manualized cognitive behavioral treatment program, participants wrote ten essays on loss-specific topics. Posttraumatic stress, grief, and general psychopathology, especially depression, were assessed pretreatment, posttreatment, and at 3-month follow-up. Intention-to-treat analyses and completer analyses were performed. Relative to controls, participants in the treatment group showed significant improvements in posttraumatic stress, grief, depression, and overall mental health, but not in anxiety or somatization. Medium to large effect sizes were observed, and the improvement was maintained at 3-month follow-up. This internet-based cognitive behavioral therapy program represents an effective treatment approach with stable effects for women after pregnancy loss. Implementation of the program can thus help to improve the health care provision for mothers in this traumatic loss situation.

Grief in children and adolescents bereaved by sudden parental death

CONTEXT

Major advances have been made in our understanding of the phenomenology and course of grief in adults. However, little is known about the course of grief in children and adolescents.

OBJECTIVE

We report on the course of children's and adolescents' grief reactions after sudden parental death and the effect of those reactions on subsequent psychiatric and functional status.

DESIGN

Longitudinal study (July 1, 2002, through January 16, 2007) of bereaved children, adolescents, and families, with yearly comprehensive assessments as long as 3 years after parental death.

SETTING

Bereaved children and adolescents and their surviving parents recruited through coroners' records and a newspaper advertisement.

PARTICIPANTS

A total of 182 parentally bereaved children and adolescents aged 7 through 18 years whose parent died due to suicide, unintentional injury, or sudden natural causes.

MAIN OUTCOME MEASURES

Grief, functional impairment, and incident depression.

RESULTS

Three distinct trajectories of grief reactions were observed in the study participants. In 1 group, which consisted of 10.4% of the sample, grief reactions showed no change 33 months after death. Children and adolescents with prolonged grief reactions had higher rates of previous personal history of depression. Prolonged grief made unique contributions to increased levels of functional impairment, even after controlling for the clinical characteristics before and after the death. Conversely, prolonged grief in children, adolescents, and the surviving caregiver predisposed children and adolescents to an increased hazard of incident depression. Another group (30.8%) showed increased grief reactions 9 months after the death, which gradually decreased over time. Despite this finding, grief reactions in this group also were associated with functional impairment and increased risk of incident depression.

CONCLUSIONS

Grief reactions abate over time for most children and adolescents bereaved by sudden parental death; however, a subset shows increased or prolonged grief reactions, which in turn increases the risk of functional impairment and depression. Research regarding interventions designed to relieve the burden of grief in bereaved children and adolescents are needed. Such efforts also should assess and address grief reactions in the surviving parent.

Effectiveness of an inpatient group therapy for comorbid complicated grief disorder

We investigated whether inpatients suffering from comorbid complicated grief disorder benefited from an additional manualized nine-session group intervention. For this purpose, 50 patients participating in the additional complicated grief intervention were compared with 22 control patients who received treatment as usual. After grief intervention, we found large effect sizes with regard to improvement in complicated grief symptoms. Because we found no differences regarding overall mental distress and depressive symptoms (between the two groups), the grief intervention seems to be highly specific.

The virtual dream: rewriting stories of loss and grief

In this article, the authors introduce the virtual dream, a technique that entails writing a brief spontaneous dreamlike story on themes of loss, using a flexible set of assigned elements of setting and characterization to scaffold the writing. After providing several examples of virtual dreams written by workshop participants, the authors analyze the frequency of important narrative features in a diverse sample of 143 stories to demonstrate the feasibility and reliability of coding such accounts for clinical or research purposes. Finally, we conclude with some remarks on the therapeutic use of the virtual dream, whether as a prompt for personal reflection on themes of loss, as an exercise in the context of grief workshops or support groups, or as a homework assignment in grief counseling or therapy.

Pilot study on traumatic grief treatment program for Japanese women bereaved by violent death

This pilot study aimed to refine a treatment approach for traumatic grief due to violent loss. Our Traumatic Grief Treatment Program, a modification of Shear's complicated grief treatment (Shear et al., 2005), comprises psychoeducation, in vivo exposure, imaginal exposure, discussion of memories about and imaginal conversation with the deceased. Thirteen of 15 Japanese women suffering from posttraumatic stress disorder (PTSD) due to traumatic grief completed 12 to 16 weekly individual sessions based on their therapists' recommendations. Assessment scales included the Inventory of Complicated Grief, the Impact of Event Scale-Revised, and the Center for Epidemiologic Studies Depression Scale. There was significant reduction in symptom severity at treatment end, and symptom levels remained low throughout the 12-month follow-up period. Based on Jacobson's Reliable Change Index, 46% showed change on all 3 measures. These findings suggest that our treatment model may be feasible for treating traumatic grief with PTSD in non-Western settings.

Internet-based treatment after pregnancy loss: concept and case study

The loss of a child during pregnancy results in significant psychological stress for many women, and may lead to long-lasting grief and psychological illnesses. However, only a small percentage of those affected seek or receive traditional forms of psychological treatment, and therefore novel treatment approaches and methods are required. This article introduces an Internet-based psychotherapy programme for patients after pregnancy loss. The five-week intervention comprises two components: structured writing disclosure and cognitive-behavioural therapy. Communication between the therapist and patient is text-based and asynchronous. The writing protocol consists of three treatment phases: self-confrontation, cognitive reappraisal and social sharing. A case report is presented to illustrate the course of the treatment and clinical considerations associated with delivering Internet-based interventions to patients after pregnancy loss.

Efficacy of telehealth treatments for posttraumatic stress-related symptoms: a meta-analysis

This meta-analysis summarizes the findings of outcome research on the degree to which telehealth treatments reduce posttraumatic stress disorder (PTSD)-related symptoms. In a search of the literature, 13 studies were identified for inclusion in the meta-analysis and were coded for relevant variables. A total of 725 participants were included. Results indicate that telehealth treatments are associated with significant pre- to postreduction in PTSD symptoms (d = 0.99, 95% confidence interval [CI]: 0.87-1.11, p < .001), and result in superior treatment effects relative to a wait-list comparison condition (d = 1.01, 95% CI: 0.76-1.26, p < .001). However, no significant findings were obtained for telehealth intervention relative to a supportive counseling telehealth comparison condition (d = 0.11, 95% CI: - 0.38 to 0.60, p = .67), and telehealth intervention produced an inferior outcome relative to a face-to-face intervention (d = - 0.68, 95% CI: - 0.39 to - 0.98, p < .001). Findings for depression symptom severity outcome were generally consistent with those for PTSD outcome. Telehealth interventions produced a significant within-group effect size (d = 0.98, 95% CI: 0.86 to 1.10, p < .001) and superior effect relative to wait-list comparison condition (d = 0.80, 95% CI: 0.56-1.05, p < .001). Relative to face-to-face interventions, telehealth treatments produced comparable depression outcome effects (d = 0.13, 95% CI: - 0.55 to 0.28, p = .53). Taken together, these findings support the use of telehealth treatments for individuals with PTSD-related symptoms.

Autobiographical memory following cognitive behaviour therapy for complicated grief

A deficit in the ability to retrieve specific autobiographical memories has been linked to a number of negative consequences, including poor problem solving skills, reduced ability to imagine the future, and the onset of symptoms following trauma. This study investigated the impact of cognitive behaviour therapy (CBT) on memory retrieval specificity in patients with Complicated Grief (CG). Twenty individuals with CG who were seeking treatment were administered an autobiographical memory task (AMT) before and after completing a 10-week CBT program. Pre-treatment retrieval specificity did not predict treatment outcome. However, there was a significant correlation between symptom reduction and increased specific retrieval to positive cues following treatment. These results suggest that overgeneral retrieval in CG can be modified by CBT, and may point to one means by which CBT can alleviate CG symptoms.

Risks for complicated grief in family caregivers

Complicated grief (CG) is a recently recognized disorder experienced by the bereaved and characterized by intense distress that interferes with functioning. Estimates indicate that about 20 % of bereaved individuals may develop CG. Family caregivers of those who are chronically ill may face unique risks for CG, such as pre-death stressors associated with caregiving. In this article, existing literature on CG in family caregivers is reviewed to identify pre-bereavement risk factors for the disorder. Implications for practice are also discussed, including both preventive interventions that could be instituted before the ill person's death and therapeutic techniques for treating CG after the death.

Treatment of complicated grief

Following the death of a loved one, a small group of grievers develop an abnormal grieving style, termed complicated or prolonged grief. In the effort to establish complicated grief as a disorder in DSM and ICD, several attempts have been made over the past two decades to establish symptom criteria for this form of grieving. Complicated grief is different from depression and PTSD yet often comorbid with other psychological disorders. Meta-analyses of grief interventions show small to medium effect sizes, with only few studies yielding large effect sizes. In this article, an integrative cognitive behavioral treatment manual for complicated grief disorder (CG-CBT) of 25 individual sessions is described. Three treatment phases, each entailing several treatment strategies, allow patients to stabilize, explore, and confront the most painful aspects of the loss, and finally to integrate and transform their grief. Core aspects are cognitive restructuring and confrontation. Special attention is given to practical exercises. This article includes the case report of a woman whose daughter committed suicide.

How the Internet is changing the experience of bereavement by suicide: A qualitative study in the UK

The aim of this qualitative study was to explore how Internet support may be changing the experiences of people who have been bereaved by suicide. Forty narrative interviews about the (whole) experience of being bereaved by suicide were conducted with a maximum variation sample of people living in the UK. Interviews were transcribed for thematic analysis. The analysis explores several ways in which the Internet has made a difference to the aftermath of the death. These include the use of e-mail and social networking sites to inform others about the death, making sense of the events and gaining support from an Internet community of others who had been similarly bereaved and setting up website memorials. A few people preferred not to use the Internet for this purpose or had no access to a computer. Few adverse consequences of Internet communities were mentioned. In conclusion we found evidence that the Internet is transforming the experience of bereavement by suicide, most dramatically through providing access to other people’s experiences.

Ethical dilemmas in online research and treatment of sexually abused adolescents

BACKGROUND

In a recent uncontrolled trial of a new therapist-assisted Web-based treatment of adolescent victims of sexual abuse, the treatment effects were found to be promising. However, the study suffered a large pretreatment withdrawal rate that appeared to emanate from reluctance among the participants to disclose their identity and obtain their parents' consent.

OBJECTIVE

Our objectives were to confirm the effects of the online treatment in a controlled trial and to evaluate measures to reduce pretreatment withdrawal in vulnerable populations including young victims of sexual abuse.

METHODS

The study was designed as a within-subject baseline-controlled trial. Effects of an 8-week attention-placebo intervention were contrasted with the effects of an 8-week treatment episode. Several measures were taken to reduce pretreatment dropout.

RESULTS

Pretreatment withdrawal was reduced but remained high (82/106, 77%). On the other hand, treatment dropout was low (4 out of 24 participants), and improvement during treatment showed significantly higher effects than during the attention placebo control period (net effect sizes between 0.5 and 1.6).

CONCLUSIONS

In treatment of vulnerable young populations, caregivers and researchers will have to come to terms with high pretreatment withdrawal rates. Possible measures may reduce pretreatment withdrawal to some degree. Providing full anonymity is not a viable option since it is incompatible with the professional responsibility of the caregiver and restricts research possibilities.

The younger sibling of PTSD: similarities and differences between complicated grief and posttraumatic stress disorder

Just as traumatic experiences may lead to posttraumatic stress disorder (PTSD) in some individuals, grief may also be a serious health concern for individuals who have experienced bereavement. At present, neither the DSM-IV nor the ICD-10 recognizes any form of grief as a mental disorder. The aim of this review is to summarize recent advances in definition, assessment, prevention, and treatment of complicated grief disorder (CGD) and to compare CGD with PTSD. Four areas are identified to be of importance to clinicians and researchers: (a) the recently proposed consensus criteria of CGD for DSM-V and ICD-11, (b) available assessment instruments, (c) recent prevention and treatment techniques and related effectiveness studies, and (d) emerging disorder models and research on risks and protective factors. This review focuses on the similarities and differences between CGD and PTSD and highlights how a PTSD-related understanding aids the investigation and clinical management of CGD.

Personal goals and prolonged grief disorder symptoms

Prolonged grief disorder (PGD, previously called complicated grief) is a debilitating condition that can develop following the loss of a loved one. The present study investigated the relationship between different features of personal goals of bereaved individuals and PGD symptom severity. To this end, 160 bereaved people were asked to write down seven important personal goals and to complete self-report measures of PGD and depression symptom severity. With respect to the form of goals, the findings showed that more severe PGD symptomatology was associated with lower specificity of goals, a reduced sense of control over achieving goals and a lower perceived likelihood of achieving goals. With respect to the content of the goals, it was found that mourners with more severe levels of PGD symptoms reported more goals that were associated with loss (compared with goals unrelated to the loss), more goals related to feeling states and less goals related to work/education and close relationships. Implications of these findings are discussed. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Message: • The severity of prolonged grief disorder (PGD) symptoms after bereavement is associated with different features of personal goals, including reduced specificity of goals, lower perceived probability and controllability of achieving goals and an enhanced focus on loss-related goals and goals related to feeling states. • In the treatment of PGD, it could be useful to change the negative beliefs that patients have about the probability and controllability of achieving goals and to help them in finding ways to achieve valued goals. • As recovery from loss hinges (in part) on the person's ability to continue (or restore) activities that are satisfying and meaningful, it could furthermore be fruitful to help patients to reduce their focus on 'inward-directed' goals (associated with their own feelings) and to increase their focus on 'outward-directed' goals (related to social, recreational and occupational activities).

What can low and high technologies do for late-life mental disorders?

PURPOSE OF REVIEW

To identify and review the latest research in the use of low and high technology in the areas of mood disorders, psychosis, normal ageing, mild cognitive impairment and dementia.

RECENT FINDINGS

Technology use varied in type and extent of use across the different areas that have been reviewed. Telepsychiatry, internet-delivered therapy programs and bright-light therapy were used in managing symptoms associated with depression. In psychosis, multisensory therapy, reminiscence and virtual cognitive stimulation showed some benefits. Navigation aids and computerized diaries assisted in maintaining independence in the normally ageing and mildly cognitively impaired, although the benefits of cognitive stimulation are yet to be consistently established. By far, dementia technology received the most research attention. Benefits in this population included reductions in behavioural and psychological symptoms and carer burden and increased independence, task engagement and safety.

SUMMARY

Research in the use of low and high technology in late-life mental disorders continues to evolve in its scope and innovation. To progress the accessibility and acceptability of technology, involvement of stakeholders and users in the design and application, as well as examination of cost-effectiveness and robust methodologically designed studies are necessary.

An examination of stage theory of grief among individuals bereaved by natural and violent causes: a meaning-oriented contribution

Despite its popularity, few attempts have been made to empirically test the stage theory of grief. The most prominent of these attempts was conducted by Maciejewski, Zhang, Block, and Prigerson (2007), who found that different states of grieving may peak in a sequence that is consistent with stage theory. The present study aimed to provide a conceptual replication and extension of these findings by examining the association between time since loss and five grief Indicators (focusing on disbelief, anger, yearning, depression, and acceptance), among an ethnically diverse sample of young adults who had been bereaved by natural (n=441) and violent (n=173) causes. We also examined the potential salience of meaning-making and assessed the extent to which participants had made sense of their losses. In general, limited support was found for stage theory, alongside some evidence of an "anniversary reaction" marked by heightened distress and reduced acceptance for participants approaching the second anniversary of the death. Overall, sense-making emerged as a much stronger predictor of grief Indicators than time since loss, highlighting the relevance of a meaning-oriented perspective.

Internet Method in Bereavement Research: Comparison of Online and Offline Surveys

This study examines the reliability and validity of internet research in bereavement. Recent literature demonstrates an increased interest in utilizing a more convenient, inexpensive, and rapid internet method to collect data and recruit bereaved participants. For researchers, the internet offers the possibility to learn more about grief from the growing online community of bereaved people. To explore the possible use of internet tools in bereavement research, this study compares online survey method with traditional paper-and-pencil method in grief assessment. One group of bereaved adults ( N = 84) was recruited and completed the survey by mail, and another group of bereaved adults ( N =262) was recruited and completed the same set of questions via internet. The collected data were analyzed to identify both similarities and differences between the two samples' responses and the psychometric characteristics of the Core Bereavement Items inventory (CBI; Burnett, Middleton, Raphael, & Martinek, 1997). Significant differences were found between the two samples in relation to time since loss, cause of death, and relationship to deceased, demonstrating a greater variability in the internet sample. Other demographic characteristics, as well as the grief and meaning making scores, did not differ significantly. In addition, no relevant differences were found in the psychometric properties of the CBI. These findings suggest that the internet-based methods can be a suitable and valid alternative to more traditional paper-and-pencil methods.

An internet tool to normalize grief

This research evaluated the efficacy of a psycho-educational Internet self-help tool to educate and support recently (1-6 months) bereaved individuals. The goal of the website was to help users normalize their grief to enhance their adaptive adjustment. A randomized controlled trial evaluated the gains in social cognitive theory constructs and state anxiety. Compared to the control group (N = 34), treatment participants (N = 33) reported significant multivariate gains (eta-square = .191). Significant program effects were obtained on all three outcome measures: attitude (eta-square = .177), self-efficacy (eta-square = .106), and state anxiety (eta-square = .083). These findings suggest the potential efficacy of an Internet-based grief support tool to enhance adaptive adjustment of the bereaved.

Coping versus grieving in a "death-accepting" society: AIDS-bereaved women living with HIV in Indonesia

The aim of this study was to understand how AIDS-bereaved women in Indonesia cope in a society where death is believed to be fated. Data analyses were conducted based on the women’s interview transcripts and journal entries. Each of the women experienced at least three traumatic life events. The most challenging experience was learning that they have contracted a disease they regarded as associated with prostitution. Given the short lapse of time between their husbands’ deaths and learning about their seropositivity, biographical disruption appeared to have acted as an ‘analgesic’, while concerns to protect their children seemed to have triggered biographical reinforcement. This phenomenon may have brought about a positive bereavement outcome. Specific counselling programmes for women affected by HIV/AIDS are needed, but emphasis should first be placed on improving their wellbeing and their perception of stigma.

Grief Therapy

The loss of a loved one carries serious consequences for the physical and emotional well-being of many of the bereaved. It is therefore not surprising that to mitigate the impact of loss and promote successful adaptation, various forms of grief therapy have been proposed. However, controversies about the effectiveness of bereavement interventions have arisen, in part because previous reviews have relied on small samples of studies, which makes drawing inferences about the evidence base for bereavement interventions precarious at best. Drawing on a recent comprehensive analysis of over 60 controlled studies, we attempt to offer a more definitive view, and we discuss moderators associated with more effective bereavement interventions. Finally, we conclude by considering several theoretically informed approaches that hold promise for the further refinement of evidence-based therapies for bereavement complications, and we suggest some future directions for grief research and intervention.

Complicated grief in patients with unipolar depression

BACKGROUND

The loss of a close family member (e.g. child or spouse) has been shown to be one of the most stressful life-events increasing the risk of affective disorders. In the present study, we investigated for the first time the frequency of complicated grief in psychiatric inpatients with unipolar depression. Further, the study was aimed to identify characteristics predicting a complicated grief reaction in depressed patients.

METHODS

In a sample of 73 DSM-IV diagnosed unipolar affective disordered inpatients grief, depression, anxiety and psychological stress reaction were assessed.

RESULTS

A high prevalence of loss and impairing complicated grief was found in this sample of unipolar depressed patients. Depressed patients with complicated grief were more severely depressed than depressed patients without complicated grief reactions. Higher traumatic stress and close family membership of the lost person were associated with higher severity of grief.

CONCLUSIONS

Comorbid complicated grief appears to contribute to greater severity and poorer functioning in unipolar depressed patients and should be specifically addressed in psychotherapeutic treatment.

Internet-based interventions for traumatic stress-related mental health problems: a review and suggestion for future research

Exposure to potentially traumatic events is a common occurrence. Most individuals exposed to such an event are resilient or recover rapidly, although some individuals develop psychological problems that warrant treatment. However, a small percentage of individuals seek traditional treatment, thereby calling for novel approaches or methodologies of treatment. The present paper provides a comprehensive and critical review of the extant literature on computerized and internet-based interventions (IBIs) for traumatic stress-related conditions (i.e., panic disorder, posttraumatic stress disorder/complicated grief, depression, comorbid anxiety and depression, alcohol abuse, smoking cessation). Generally, computerized or IBIs for depression and anxiety are yielding effect sizes that are comparable to traditional psychosocial treatment. Interventions aimed at alcohol and smoking cessation generally have lower effect sizes than do IBIs for anxiety and depression. Most interventions reviewed in this paper included common components (e.g., were developed through a cognitive behavioral framework and included psychoeducation, cognitive restructuring, goal setting, exposure). Therefore, it is possible that these shared features may in part account for symptom reduction. Little is known regarding mechanisms of change. Future directions for novel web-based approaches to treatment are provided.