Cognitive behavioural therapy for psychopathology in relatives of missing persons: study protocol for a pilot randomised controlled trial

An Opportunity to Be Heard: Family Experiences of Coronial Investigations Into Missing People and Views on Best Practice

Experiences of 15 family members and friends of missing people of a coronial investigation into the suspected death of a missing person in New South Wales (NSW), Australia were examined via in-depth interviews. This study explored participant perceptions of the impact of coronial proceedings on well-being, and views on best practice approaches to families in the Coroner's Court. Transcripts were thematically analysed, yielding six key themes in participant experiences of inquests: (1) Opportunity to be heard, (2) A chance for education, (3) If you are human with me (sensitive treatment and language), (4) Timely investigations, (5) A public and formal court environment, and (6) Coronial outcomes. Overall, families benefitted from opportunities to have input and feel heard, compassionate treatment, and appropriate education about the process and available support services. A detriment on well-being was described when these factors were precluded. Some participants perceived positive outcomes arising from public awareness of cases of missing people, formalities that conveyed respect, and timeframes that enabled further investigation or preparation for the inquest. Others reported distress and trauma in response to significant delays that led to a loss of evidence, intrusive media and unknown persons in court, and unwelcoming, formal court environments. Some participants were profoundly distressed by a finding of death and by the procedures that followed the inquest, emphasising the need for post-inquest debriefing and ongoing support. These findings deepen our understanding of coronial practices, and of measures to prevent harm, that will be instructive to other coronial jurisdictions. Further research should examine family experiences in contexts where there are variable coronial proceedings or procedures that result in legal findings of death.

Cognitive behavioural therapy and mindfulness for relatives of missing persons: a pilot study

Objectives

Relatives of long-term missing persons need to deal with uncertainties related to the disappearance. These uncertainties may give rise to ruminative thinking about the causes and consequences of the loss. Focusing on tolerating uncertainties in treatment of relatives of missing persons might foster recovery. Adding mindfulness to cognitive behavioural therapy might serve this aim. The feasibility and potential effectiveness of cognitive behavioural therapy with mindfulness were evaluated in a pilot study. We aimed to detect changes in symptom levels and mindfulness from pre-treatment to 1 week, 12 weeks, and 24 weeks post-treatment.

Method

Dutch adults who experienced the disappearance of a significant other more than 3 months earlier and scored above clinical thresholds for psychological distress were eligible to participate. Participants were recruited from January 2015 to July 2016. Participants in the immediate treatment group started treatment after 1 week after randomization, whereas waiting list controls started the treatment after 12 weeks of waiting. Data from self-report measures as well as clinical diagnostic interviews (tapping persistent complex bereavement disorder, major depressive disorder, and posttraumatic stress disorder) were gathered among 17 relatives of missing persons with elevated symptom levels.

Results

The response rate (31.7%) was low, and dropout rate (47.1%) high. Cognitive behavioural therapy with mindfulness coincided with changes in psychopathology levels (Hedges’ g 0.35–1.09) and mindfulness (Hedges’ g − 0.10–0.41). Participants completing the treatment were satisfied with treatment quality and reported high treatment compliance.

Conclusions

Because of the limited research about effective treatments for relatives of missing persons and promising results of small and/or uncontrolled trials examining the effect of mindfulness-based treatment to target grief-related complaints, it seems valuable to continue investigating the effects of cognitive behavioural therapy with mindfulness on reducing post-loss psychopathology in future research. However, in order to increase the feasibility of future trials among relatives of missing persons, we recommend collaborating internationally and/or extending duration of recruitment phase, to maximize the sample size.

Trial registration

The Netherlands National Trial Register, NTR4732.

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0472-z) contains supplementary material, which is available to authorized users.

Prolonged grief disorder: Its co-occurrence with adjustment disorder and post-traumatic stress disorder in a bereaved Israeli general-population sample

BACKGROUND

Prolonged grief disorder (PGD) is a new disorder included in the WHO International Classification of Diseases 11th version (ICD-11). This study is the first to use these new ICD-11 PGD guidelines to examine prevalence rates, predictors of PGD and disorder co-occurrence with other stress-related disorders in a survey of 544 bereaved Israelis.

METHODS

Descriptive statistics, correlation, linear regression and mediation analysis examined the validity of the ICD-11 diagnostic algorithm.

RESULTS

Prevalence of PGD in the Israeli population sample is low (2%). The prevalence rate of post-traumatic stress disorder (PTSD) was 7.2% and for adjustment disorder (AjD) was 17.8%. A significant positive correlation found between scores on these measures indicates concurrent validity. Mediation analysis found that symptoms of PGD were predicted by serious life events, and significantly mediated by symptoms of PTSD and AjD. A regression analysis found significant predictors of PGD symptom severity, including socio-demographic and person-specific predictors.

LIMITATIONS

This study did not assess the index-death of the grief questionnaire. No conclusions could be made regarding the relationship between the type of loss and grief severity. Furthermore, the time since loss (time criterion) was not assessed.

CONCLUSIONS

This study is the first to examine prevalence rates of ICD-11 PGD in a population-based survey. The mediation relationship between serious life events, AjD, PTSD and PGD supports a vulnerability model of stress related disorders whereby the number of stressful life events may predict symptoms of stress related disorders.

I've changed, but I'm not less happy: Interview study among nonclinical relatives of long-term missing persons

Twenty-three nonclinical relatives of long-term missing persons were interviewed. Patterns of functioning over time were studied retrospectively by instructing participants to draw a graph that best described their pattern. Patterns most frequently drawn were a recovery and resilient/stable pattern. Participants were also asked to select 5 out of 15 cards referring to coping strategies, which they considered most helpful in dealing with the disappearance. Acceptance, emotional social support, mental disengagement, and venting emotions were most frequently chosen. This study provided some indication of coping strategies that could be strengthened in treatment for those in need of support.

Exploration of the Associations Between Responses to Affective States and Psychopathology in Two Samples of People Confronted With the Loss of a Loved One

Adaptive regulation of positive and negative affect after the loss of a loved one may foster recovery. In two studies, using similar methods but different samples, we explored the association between positive (i.e., dampening and enhancing) and negative (i.e., rumination) affect regulation strategies and symptoms levels of postloss psychopathology. Study 1 used data from 187 people confronted with the death of a loved one. In study 2, the sample consisted of 134 relatives of long-term missing persons. Participants completed self-reports tapping prolonged grief, depression, posttraumatic stress symptoms, and affect regulation strategies. Hierarchical regression analyses showed that both negative and positive affect regulation strategies explained significant amounts of variance symptom levels in both samples. In line with previous work, our results suggest that negative and positive affect regulation strategies relate to postloss psychopathology. Future research should explore how both affect regulation strategies may adequately be addressed in treatment.

Grief rumination mediates the association between self-compassion and psychopathology in relatives of missing persons

Background: The disappearance of a loved one is a unique type of loss, also termed 'ambiguous loss', which may heighten the risk for developing prolonged grief (PG), depression, and posttraumatic stress (PTS) symptoms. Little is known about protective and risk factors for psychopathology among relatives of missing persons. A potential protective factor is self-compassion, referring to openness toward and acceptance of one's own pain, failures, and inadequacies. One could reason that self-compassion is associated with lower levels of emotional distress following ambiguous loss, because it might serve as a buffer for getting entangled in ruminative thinking about the causes and consequences of the disappearance ('grief rumination'). Objective: In a sample of relatives of missing persons we aimed to examine (1) the prediction that greater self-compassion is related to lower symptom-levels of PG, depression, and PTS and (2) to what extent these associations are mediated by grief rumination. Method: Dutch and Belgian relatives of long-term missing persons (N = 137) completed self-report measures tapping self-compassion, grief rumination, PG, depression, and PTS. Mediation analyses were conducted. Results: Self-compassion was significantly, negatively, and moderately associated with PG, depression, and PTS levels. Grief rumination significantly mediated the associations of higher levels of self-compassion with lower levels of PG (a*b = -0.11), depression (a*b = -0.07), and PTS (a*b = -0.11). Specifically, 50%, 32%, and 32% of the effect of self-compassion on PG, depression, and PTS levels, respectively, was accounted for by grief rumination. Conclusions: Findings suggest that people with more self-compassion experience less severe psychopathology, in part because these people are less strongly inclined to engage in ruminative thinking related to the disappearance. Strengthening a self-compassionate attitude using, for instance, mindfulness-based interventions may therefore be a useful intervention to reduce emotional distress associated with the disappearance of a loved one.

Improving the understanding and treatment of complex grief: an important issue for psychotraumatology

In the Netherlands, every year 500,000 people are confronted with the death of a close relative. Many of these people experience little emotional distress. In some, bereavement precipitates severe grief, distress, and dysphoria. A small yet significant minority of bereaved individuals develops persistent and debilitating symptoms of persistent complex bereavement disorder (PCBD) (also termed prolonged grief disorder), posttraumatic stress disorder, and depression. Knowledge about early identification of, and preventive care for complex grief has increased. Moreover, in recent years there has been an increase in treatment options for people for whom loss leads to persistent psychological problems. That said, preventive and curative treatments are effective for some, but not all bereaved individuals experiencing distress and dysfunction following loss. This necessitates further research on the development, course, and treatment of various stages of complex grief, including PCBD.