Grief-specific interventions in cognitive-behavioral therapy for dementia caregivers: towards managing pre-death grief, loss, and change

Among the most debilitating aspects of dementia caregiving is the experience of pre-death grief, i.e., caregivers’ emotional response to losses over the caregiving trajectory. Yet, caregivers are often unaware that their symptoms can be attributed to grief or try to avoid painful reactions. In the light of results that found pre-death grief to be related to caregiver burden and depression, interventions that facilitate dementia caregivers’ coping with pre-death grief are called for. Against this background, the objectives of this dissertation were threefold: It was the first objective to provide insights into how intervention strategies rooted in CBT principles can be applied by therapists to specifically target pre-death grief. Based on these results, a grief-specific intervention module was developed and integrated into an intervention program. The second objective was to evaluate this intervention’s effectiveness regarding caregivers’ coping with pre-death grief. As an important prerequisite for the analysis of treatment effects, it was the third objective to develop an instrument for the measurement of pre-death grief. These objectives were met in three empirical studies that were conducted within the scope of two randomized-controlled trials evaluating the effectiveness of a cognitive-behavioral intervention for dementia caregivers in Germany. The results of these studies illustrate how grief-specific interventions can be designed to facilitate caregivers’ coping with pre-death grief, and support the effectiveness of the comprehensive intervention program. The dissertation further adds two instruments to the field of pre-death grief: A category system for the qualitative assessment of grief intervention strategies and a scale for quantitative measurement of pre-death grief, the Caregiver Grief Scale. Implications for clinical practice as well as future directions of research to support caregivers’ management of grief are outlined

Clients' and therapists' experiences of five general change mechanisms during an Internet‐based cognitive behavioral intervention for family caregivers

Objectives Despite its efficacy, little is known about what makes Internet‐based cognitive behavioral therapy (iCBT) effective. We, therefore, analyze participants' and therapists' experiences of Grawe's five general change mechanisms (alliance, resource activation, clarification, problem actuation, mastery) during an iCBT intervention for family dementia caregivers, and how their experiences were related to treatment outcomes. Method Participants ( N  = 30) exchanged eight weekly messages with a therapist via an Internet platform. We used the Bern Post Session Report to assess participants' and therapists' experiences of the general change mechanisms after each session. Results Treatment outcomes were associated with therapists' overall experiences of alliance, clarification, and mastery. Participants experienced more problem actuation than therapists. Only participants' and therapists' experiences of clarification over time differed. Conclusions Grawe's general change mechanisms are also relevant for iCBT. We recommend considering Grawe's framework when designing Internet‐based therapeutic interventions and when training therapists to deliver such interventions

Associations between sleep problems and posttraumatic stress symptoms, social functioning, and quality of life in refugees with posttraumatic stress disorder

Many patients with posttraumatic stress disorder (PTSD) suffer from sleep problems, leading to impairments in social functioning and quality of life. Refugees are at high risk for sleep problems due to stressful life circumstances and a high PTSD prevalence. However, limited data on the frequency of sleep problems in refugees with diagnosed PTSD exist. This study examined the frequency of sleep problems in refugees with PTSD and their associations with symptoms of PTSD. Additionally, we investigated the contribution of sleep problems to social functioning and quality of life. Participants (N = 70) were refugees from different countries of origin currently living in Germany. All participants met the criteria for PTSD and completed measures of PTSD symptom severity, subjective sleep problems, social impairment, and quality of life. There was a very high frequency of sleep problems in the sample (100%), and sleep problems were significantly associated with both clinician-rated, r = .47, and self-rated, r = .30, PTSD symptom severity after controlling for overlapping items. Contrary to expectations, sleep problems did not predict social impairment, d = 0.16, nor quality of life, d = 0.13, beyond the effect of other PTSD symptoms. The findings highlight the widespread frequency of sleep problems among refugees. Future studies should assess the causal nature of the association between sleep problems and measures of psychosocial functioning in more detail and examine its dynamic change over time

A clinician rating to diagnose CPTSD according to ICD-11 and to evaluate CPTSD symptom severity: Complex PTSD Item Set additional to the CAPS (COPISAC)

Background: Researchers who wish to study stress-related disorders need to use valid, reliable, and sensitive instruments and the Clinician-administered PTSD Scale (CAPS) constitutes the gold standard in the assessment of posttraumatic stress disorder (PTSD). While the CAPS corresponds with PTSD criteria according to the DSM-5, researchers face a challenge with the forthcoming ICD-11: ICD-11 introduces the new diagnosis Complex PTSD (CPTSD) that does not exist in DSM-5. Objective: Researchers as well as clinicians will need to assess the incidence and prevalence of CPTSD and will want to evaluate treatment effects according to both criteria sets. However, using two clinician-rated interviews is often not feasible and a burden to patients, particularly in psychotherapy research. Method & Results: We have therefore developed the Complex PTSD Item Set additional to the CAPS (COPISAC). This clinician rating is an easy-to-use and economic addition to the CAPS that permits assessing diagnosis and evaluating symptom severity of CPTSD. COPISAC consists of three items that assess disturbances in self-regulation including prompts for symptom description and frequency, and two additional items assessing impairment. Diagnostic status and severity ratings for CPTSD are possible. Items that account for the specific forms of trauma which the ICD-11 describes as precursors of CPTSD (e.g. torture, being enslaved) are further suggested as additions to the Life Events Checklist. Conclusion: With an introduction of COPISAC at this point, we aim at suggesting an easy transition into diagnosing CPTSD and evaluating its course over treatment

Evaluation of telephone-based acceptance and commitment therapy for caregivers of persons with dementia

Objectives. Family caregivers of persons with dementia (PwD) experience high levels of distress. We used a randomized-controlled trial to investigate the effects of telephone-based acceptance and commitment therapy (tbACT) for family caregivers. Methods. In total, N=81 caregivers were randomly allocated to an intervention group (tbACT) or a control group (CG). The intervention consisted of eight weekly sessions of tbACT. Depression, anxiety, physical symptoms, pre-death grief, care-related thoughts, acceptance, quality of life, coping and well-being were assessed pre- and post- intervention, and six-months later. Results. Compared to CG participants, tbACT participants had lower depressive symptoms; fewer physical symptoms (rheumatic pain); better physical health; more resource utilization (coping with daily hassles, social support); better coping with the care situation and better emotional well-being post-intervention. For caregivers with clinically-relevant depressive symptoms at baseline, the tbACT intervention additionally improved psychological health and decreased dysfunctional care-related standards post-intervention. At six-months follow-up, tbACT participants had less pre-death grief, fewer physical symptoms, and more utilization of resources related to coping with daily hassles. Conclusions. tbACT is an accessible and effective psychotherapeutic intervention for family caregivers of PwD. Clinical Implications. Most effects of tbACT were not maintained six-months after the intervention, suggesting that booster sessions may be helpful

Cluster analysis of prolonged grief, posttraumatic stress, and depression symptoms in bereaved asylum seekers and refugees

Background: Refugees and asylum seekers are frequently exposed to loss in addition to a variety of other stressors and often display high levels of various psychological symptoms. Objective: It was the aim of this study to determine clusters of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression symptoms in bereaved refugees and asylum seekers and identify predictors of cluster membership. Method: Bereaved refugees and asylum seekers in Germany (N = 92) were assessed with interview-based questionnaires for PGD, PTSD, and depressive symptoms. We used cluster analysis to distinguish symptom profiles and logistic regression analyses to identify predictors of cluster membership. Results: We found a three-cluster-solution. The PGD-cluster (30%) was characterized predominantly by PGD symptoms, while the PGD/PTSD-cluster (32%) had high PGD and PTSD and moderate depressive symptoms. The resilient cluster (38%) showed low symptoms overall. Insecure residence status predicted membership in the PGD and PGD/PTSD clusters relative to the resilient cluster, whilst higher attachment anxiety and a longer duration of stay was more often experienced by members of the PGD/PTSD cluster. Conclusion: Findings extend the current evidence to support different symptom profiles among bereaved refugees and asylum seekers in Europe. Attachment- and migration-related variables can distinguish between these profiles

Prolonged grief in refugees living in Germany confronted with ambiguous or confirmed loss

People often disappear in the context of displacement or armed conflicts. Although such an ambiguous loss is accompanied by persistent uncertainty about the whereabouts, the psychological consequences are not well understood. This study investigated the effects of ambiguous compared to a confirmed loss on prolonged grief disorder (PGD) and its correlates in refugees to Germany