Coping strategies as a causal mediator of the effect of loss-related memory characteristics and negative loss-related appraisals on symptoms of PGD, PTSD and depression.

BACKGROUND: Psychological models of posttraumatic stress disorder (PTSD) and prolonged grief disorder (PGD) make predictions about the role of unhelpful coping strategies in maintaining difficulties by blocking self-correction of negative appraisals and memory integration following stressful life events like bereavement. However, few studies have tested these predictions directly. METHOD: We used counterfactually based causal mediation to assess whether unhelpful coping strategies mediated the relationship between (1) loss-related memory characteristics and/or (2) negative grief-related appraisals and symptoms of PGD, PTSD and depression using a three-wave longitudinal sample (N = 275). Appraisals and memory characteristics were measured at time point 1, unhelpful coping strategies at T2, and symptom variables at T3. Additionally, multiple mediation analyses within a structural equation modelling (SEM) framework assessed which types of coping strategies differentially mediated symptoms of PGD, PTSD and depression. RESULTS: Coping strategies mediated the relationship between negative appraisals and memory characteristics and symptoms of PGD, PTSD and depression after adjusting for demographics and loss characteristics. Sensitivity analyses suggested that these results were most robust for PGD, followed by PTSD and then depression. Multiple mediation analyses suggested that all four subscales (avoidance, proximity seeking, loss rumination and injustice rumination) individually mediated the effect of memory characteristics and appraisals on PGD. CONCLUSIONS: These results suggest that core predictions of the cognitive model for PTSD and the cognitive behavioural model of PGD are useful in predicting symptoms of post-loss mental health problems in the first 12-18 months after loss. Targeting unhelpful coping strategies is likely to reduce symptoms of PGD, PTSD and depression.

How the bereaved behave: a cross-cultural study of emotional display behaviours and rules.

Cultural norms may dictate how grief is displayed. The present study explores the display behaviours and rules in the bereavement context from a cross-cultural perspective. 86 German-speaking Swiss and 99 Chinese bereaved people who lost their first-degree relative completed the adapted bereavement version of the Display Rules Assessment Inventory. Results indicated that the German-speaking Swiss bereaved displayed more emotions than the Chinese bereaved. The Chinese bereaved, but not the German-speaking Swiss bereaved, thought that bereaved people should display more emotions than they actually did when they were with their close others (but not when they were alone). Bereaved people endorsed more emotional expression "when alone" than "when with close others", demonstrating a social disconnection tendency, which was more evident in the Chinese sample. Bereaved people endorsed more expression of positive emotions (e.g. affection/love) and less expression of powerful negative emotions (e.g. blame/guilt, anger) across cultures. Compared to their Chinese counterparts, the German-speaking Swiss sample indicated more actual expressions for most emotion types (i.e. joy/happiness, affection/love, sadness, anger, and denial) but thought bereaved people should express more joy/happiness and less blame/guilt. The results suggest that bereaved people's display behaviours and rules are influenced by culture, situation, and type of emotion.

Existential isolation and prolonged grief in bereaved people: The moderating role of culture.

OBJECTIVE: Existential isolation refers to an individual's awareness of the unbridgeable gulf between oneself, other people and the world. This kind of isolation has been found to be higher in individuals with nonnormative experiences, such as racial or sexual minorities. Bereaved individuals may experience a stronger sense of existential isolation and feel that no one shares their feelings or perceptions. However, research on bereaved people's experiences of existential isolation and its effects on post-loss adaptation is scarce. This study aims to validate the German and Chinese versions of the Existential Isolation Scale, investigate cultural and gender differences in existential isolation and explore the associations between existential isolation and prolonged grief symptoms in German-speaking and Chinese bereaved individuals. METHODS: A cross-sectional study with 267 Chinese and 158 German-speaking bereaved participants was conducted. The participants completed self-report questionnaires assessing existential isolation, prolonged grief symptoms, social networks, loneliness and social acknowledgement. RESULTS: The results indicated that the German and Chinese versions of the Existential Isolation Scale demonstrated adequate validity and reliability. No cultural or gender differences (or their interaction) were found for existential isolation. Higher existential isolation was associated with elevated prolonged grief symptoms, which was further moderated by the cultural group. The relationship between existential isolation and prolonged grief symptoms was significant for the German-speaking bereaved people but not significant for those from China. CONCLUSION: The findings highlight the role of existential isolation in the adaptation to bereavement and how different cultural backgrounds moderate the effect of existential isolation on post-loss reactions. Theoretical and practical implications are discussed.

Support needs and barriers to accessing support: Baseline results of a mixed-methods national survey of people bereaved during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic is a mass bereavement event which has profoundly disrupted grief experiences. Understanding support needs and access to support among people bereaved at this time is crucial to ensuring appropriate bereavement support infrastructure. AIM: To investigate grief experiences, support needs and use of formal and informal bereavement support among people bereaved during the pandemic. DESIGN: Baseline results from a longitudinal survey. Support needs and experiences of accessing support are reported using descriptive statistics and thematic analysis of free-text data. SETTING/PARTICIPANTS: 711 adults bereaved in the UK between March and December 2020, recruited via media, social media, national associations and community/charitable organisations. RESULTS: High-level needs for emotional support were identified. Most participants had not sought support from bereavement services (59%, n = 422) or their General-Practitioner (60%, n = 428). Of participants who had sought such support, over half experienced difficulties accessing bereavement services (56%, n = 149)/General-Practitioner support (52%, n = 135). About 51% reported high/severe vulnerability in grief; among these, 74% were not accessing bereavement or mental-health services. Barriers included limited availability, lack of appropriate support, discomfort asking for help and not knowing how to access services. About 39% (n = 279) experienced difficulties getting support from family/friends, including relational challenges, little face-to-face contact and disrupted collective mourning. The perceived uniqueness of pandemic bereavement and wider societal strains exacerbated their isolation. CONCLUSIONS: People bereaved during the pandemic have high levels of support needs alongside difficulties accessing support. We recommend increased provision and tailoring of bereavement services, improved information on support options and social/educational initiatives to bolster informal support and ameliorate isolation.

Treatment Efficacy for Veterans With Posttraumatic Stress Disorder: Latent Class Trajectories of Treatment Response and Their Predictors.

Evidence suggests that veterans with posttraumatic stress disorder (PTSD) have a poorer treatment response than nonveterans.  In this study, we explored heterogeneity in treatment response for 960 veterans in the United Kingdom with PTSD who had been offered a residential intervention consisting of a mixture of group sessions and individual trauma-focused cognitive behavioral therapy (TF-CBT). The primary outcome was PTSD score on the Impact of Event Scale-Revised (IES-R).  Covariates included depression, anxiety, anger, alcohol misuse, functional impairment, and sociodemographic characteristics.  Follow-up occurred posttreatment at set time points for 12 months.  We present predictors of PTSD severity at posttreatment and follow-up obtained using a latent class growth analysis to identify different treatment trajectories.  Multinomial logistic regression models were used to identify covariates predicting class membership, and five classes were identified. Of participants, 71.3% belonged to three classes showing positive treatment responses, and 1.2% showed initial improvement but later relapsed. Additionally, 27.5% of participants were identified within a treatment-resistant class that showed little change in severity of presentation. Depression, anxiety, and having had a combat role during military service increased the likelihood of membership in the treatment-resistant class, odds ratios (ORs) = 1.12-1.53, 1.16-1.32, and 2.89, respectively. Additionally, participants in the treatment-resistant class had higher pretreatment PTSD scores for reexperiencing, avoidance, and hyperarousal symptoms, ORs = 5.24, 2.62, and 3.86, respectively. Findings suggest the importance of triaging individuals and offering interventions tailored to severity of presentation.

Conducting research in clinical psychology practice: Barriers, facilitators, and recommendations.

OBJECTIVES: The combination of clinical psychologists' therapeutic expertise and research training means that they are in an ideal position to be conducting high-quality research projects. However, despite these skills and the documented benefits of research to services and service users, research activity in practice remains low. This article aims to give an overview of the advantages of, and difficulties in conducting research in clinical practice. METHOD: We reviewed the relevant literature on barriers to research and reflected on our clinical and research experiences in a range of contexts to offer practical recommendations. RESULTS: We considered factors involved in the planning, sourcing support, implementation, and dissemination phases of research, and outline suggestions to improve the feasibility of research projects in post-qualification roles. CONCLUSIONS: We suggest that research leadership is particularly important within clinical psychology to ensure the profession's continued visibility and influence within health settings. PRACTITIONER POINTS: Clinical implications Emerging evidence suggests that clinical settings that foster research are associated with better patient outcomes. Suggestions to increase the feasibility of research projects in clinical settings are detailed. Limitations The present recommendations are drawn from the authors' practical experience and may need adaptation to individual practitioners' settings. This study does not attempt to assess the efficacy of the strategies suggested.

Impaired allocentric spatial processing in posttraumatic stress disorder.

A neurobiological dual representation model of PTSD proposes that reduced hippocampus-dependent contextual processing contributes to intrusive imagery due to a loss of control over hippocampus-independent sensory and affective representations. We investigated whether PTSD sufferers show impaired allocentric spatial processing indicative of reduced hippocampal functioning. Trauma-exposed individuals with (N=29) and without (N=30) a diagnosis of PTSD completed two tests of spatial processing: a topographical recognition task comprising perceptual and memory components, and a test of memory for objects' locations within a virtual environment in which the test is from either the same viewpoint as presentation (solvable with egocentric memory) or a different viewpoint (requiring allocentric memory). Participants in the PTSD group performed significantly worse on allocentric spatial processing than trauma-exposed controls. Groups performed comparably on egocentric memory and non-spatial memory for lists of objects. Exposure to repeated incident trauma was also associated with significantly worse spatial processing in the PTSD group. Results show a selective impairment in allocentric spatial processing, implicating weak hippocampal functioning, as predicted by a neurobiological dual representation model of PTSD. These findings have important clinical implications for cognitive therapy.

From loss to disorder: The influence of maladaptive coping on prolonged grief.

Research indicates that post-bereavement coping strategies can be adaptive or maladaptive. Understanding which strategies lead to poorer outcomes is an important clinical and theoretical question with the potential to guide intervention. The Oxford Grief - Coping Strategies scale was developed from interviews with bereaved people with and without prolonged grief disorder (PGD) to assess the frequency of maladaptive cognitive and behavioural strategies after bereavement. Factorial and psychometric validity were assessed using exploratory and confirmatory factor analysis (N = 676). A three-wave cross-lagged panel model (N = 275) was used to assess the predictive validity of the tool in explaining symptoms of PGD. Results supported a four-factor solution (Avoidance, Proximity Seeking, Loss Rumination, Injustice Rumination) with good psychometric properties. The OG-CS predicted prospective symptoms of PGD in the short-term (6-12 months) and long term (12-18 months), controlling for baseline symptoms and autocorrelations. Subscale analyses demonstrated that the use of coping strategies predicted ICD-11 PGD in both the short-term and the long-term. However, avoidance was not predictive of outcomes early in the grieving process. At 6-12 months, avoidance predicted PGD at 12-18 months.

The relationship between social acknowledgment and prolonged grief symptoms: a multiple mediation effect of beliefs about the goodness and controllability of grief-related emotions.

Background: Social acknowledgment is a protective factor for survivors of trauma. However, the role of social acknowledgment in association with prolonged grief symptoms has not yet been established.Objectives: The current study aims to explore the relationship between social acknowledgment and prolonged grief via two beliefs foundational to how people think about grief-related emotions (1) goodness (i.e. whether emotions are desirable, useful, or unwanted and harmful), and (2) controllability (i.e. whether emotions are regulated according to our will or involuntary, arising of their own accord). These effects were explored in two different cultural samples of bereaved people.Methods: One hundred and fifty-four German-speaking and two hundred and sixty-two Chinese bereaved people who lost their loved ones completed questionnaires assessing social acknowledgment, beliefs about the goodness and controllability of grief-related emotions, and prolonged grief symptoms.Results: Correlation analyses showed that social acknowledgment was positively linked with stronger beliefs about the goodness and controllability of grief-related emotions and negatively related to prolonged grief symptoms. Beliefs about the goodness and controllability of grief-related emotions correlated negatively with prolonged grief symptoms. Multiple mediation analyses suggested that beliefs about the controllability and goodness of grief-related emotions mediated the link between social acknowledgment and prolonged grief symptoms. Cultural groups did not moderate the above model.Conclusion: Social acknowledgment may be related to bereavement adjustment consequences via the roles of beliefs about the goodness and controllability of grief-related emotions. These effects seem to be consistent cross-culturally.

Social acknowledgment correlated positively with stronger beliefs about the goodness and controllability of grief-related emotions and negatively with prolonged grief symptoms.Beliefs about the goodness and controllability of grief-related emotions were negatively linked with prolonged grief symptoms.Beliefs about the controllability and goodness of grief-related emotions mediated the relationship between social acknowledgment and prolonged grief symptoms. The model presented cross-cultural consistency.

Psychometric Characteristics of the Oxford Grief Memory Characteristics Scale and Its Relationship With Symptoms of ICD-11 and DSM-5-TR Prolonged Grief Disorder.

Difficulties with loss-related memories are hypothesised to be an important feature of severe and enduring grief reactions according to clinical and theoretical models. However, to date, there are no self-report instruments that capture the different aspects of memory relevant to grieving and adaptation after bereavement over time. The Oxford Grief-Memory characteristics scale (OG-M) was developed using interviews with bereaved individuals and was subject to exploratory and confirmatory factor analyses in a community sample (N = 676). Results indicated the scale was unidimensional and demonstrated excellent psychometric properties. The impact of memory characteristics on symptoms of Prolonged Grief Disorder (PGD) according to both ICD-11 and DSM-5-TR criteria were investigated using cross-lagged structural equation modelling in a three-wave longitudinal sample (N = 275) at baseline and 6 and 12 months later. Results indicated that loss-related memory characteristics predicted future symptoms of PGD after controlling for autoregressions, and concurrent associations between symptoms and memory characteristics. Cross-lagged associations between memory characteristics and symptoms were significant in the first 6 months of follow-up. After that, memory characteristics predicted future symptoms, but not the other way round. Theoretical and clinical utility of the scale and its features are discussed.

Prolonged grief and posttraumatic stress disorder following the loss of a significant other: An investigation of cognitive and behavioural differences.

BACKGROUND: Cognitive behavioural correlates to bereavement-related mental health problems such a Prolonged Grief Disorder (PGD) and Posttraumatic Stress Disorder (PTSD) are of theoretical and clinical importance. METHODS: Individuals bereaved at least six months (N = 647) completed measures of loss-related cognitions and behaviours (i.e., loss-related memory characteristics, negative appraisals, coping strategies, grief resilience, and perceived social disconnection) and measures of PGD and PTSD symptoms. Individuals were assigned to one of four groups depending on probable clinical diagnoses (No-PGD/PTSD, PTSD, PGD, PGD+PTSD). RESULTS: Results indicated that higher loss-related memory characteristics and lower grief resilience increased the likelihood of a clinical problem. The PGD and PGD+PTSD groups reported significantly higher loss-related memory characteristics and appraisals compared to the PTSD group. Social disconnection increased the likelihood of comorbid PGD+PTSD in comparison to any other group. CONCLUSIONS: Results indicate cognitive differences between loss-related cognitions, memory characteristics and coping strategies between PGD and PTSD, and points to distinct cognitive correlates to psychopathology following loss.

Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale.

Although the concept of pathological grief dates back at least as far as Freud's "Mourning and Melancholia", there has been opposition to its recognition as a distinct mental disorder. Resistance has been overcome by evidence demonstrating that distinctive symptoms of prolonged grief disorder (PGD) - an attachment disturbance featuring yearning for the deceased, loss of meaning and identity disruption - can endure, prove distressing and disabling, and require targeted treatment. In acknowledgement of this evidence, the American Psychiatric Association Assembly has recently voted to include PGD as a new mental disorder in the DSM-5-TR. We tested the validity of the new DSM criteria for PGD and of an adapted version of our PG-13 scale, the PG-13-Revised (PG-13-R), designed to map onto these criteria, using data from investigations conducted at Yale University (N=270), Utrecht University (N=163) and Oxford University (N=239). Baseline assessments were performed at 12-24 months post-loss; follow-up assessments took place 5.3-12.0 months later. Results indicated that the PG-13-R grief symptoms represent a unidimensional construct, with high degrees of internal consistency (Cronbach's alpha = 0.83, 0.90 and 0.93, for Yale, Utrecht and Oxford, respectively). The DSM PGD diagnosis was distinct from post-traumatic stress disorder (phi=0.12), major depressive disorder (phi=0.25) and generalized anxiety disorder (phi=0.26) at baseline. Temporal stability was remarkable for this diagnosis (r=0.86, p<0.001). Kappa agreement between a PG-13-R threshold symptom summary score of 30 and the DSM symptom criterion for PGD was 0.70-0.89 across the datasets. Both the DSM PGD diagnosis and the PG-13-R symptom summary score at baseline were significantly associated (p<0.05) with symptoms and diagnoses of major depressive disorder, post-traumatic stress disorder and/or generalized anxiety disorder, suicidal ideation, worse quality of life and functional impairments at baseline and at follow-up, in the Yale, Utrecht and Oxford datasets. Overall, the DSM-5-TR criteria for PGD and the PG-13-R both proved reliable and valid measures for the classification of bereaved individuals with maladaptive grief responses.

Cognitive predictors of grief trajectories in the first months of loss: A latent growth mixture model.

OBJECTIVE: The identification of modifiable cognitive antecedents of trajectories of grief is of clinical and theoretical interest. METHOD: The study gathered 3-wave data on 275 bereaved adults in the first 12-18 months postloss (T1 = 0-6 months, T2 = 6-12 months, T3 = 12-18 months). Participants completed measures of grief severity, cognitive factors (loss-related memory characteristics, negative appraisals, unhelpful coping strategies, and grief resilience), as well as measures of interpersonal individual differences (attachment and dependency). Latent growth mixture modeling was used to identify classes of grief trajectories. Predictors of class membership were identified using multinomial logistic regression and multigroup structural equation modeling. RESULTS: Four latent classes were identified: 3 high grief classes (Stable, Low Adaptation, and High Adaptation) and a low grief class (Low Grief). When considered separately, variance in all four cognitive factors predicted membership of the high grief classes. When considered together, membership of the high grief classes was predicted by higher mean scores on memory characteristics. More negative appraisals predicted low or no adaptation from high grief severity. Losing a child also predicted membership to the stable class. Fast adaptation of high grief was predicted by a pattern of high memory characteristics but low engagement with unhelpful coping strategies. CONCLUSIONS: The findings have implications for clinical practice and point to early cognitive predictors of adaptation patterns in grief. Findings are consistent with cognitive models highlighting the importance of characteristics of memory, negative appraisals, and unhelpful coping strategies in the adaptation to highly negative life events. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

A qualitative analysis of loss-related memories after cancer loss: a comparison of bereaved people with and without prolonged grief disorder.

Objective: The study aimed to explore the content and features of loss-related memories in a sample of individuals bereaved by cancer with and without a probable diagnosis of prolonged grief disorder/persistent complex bereavement disorder (PGD/PCBD). Methods: Semi-structured interviews with 28 bereaved adults (PGD/PCBD = 12, NoPGD/PCBD = 16) were analysed using thematic analysis. Results: Three superordinate themes were identified: (1) intrusive imagery, (2) qualities of memory, and (3) triggers. Results showed that individuals suffering from probable PGD/PCBD reported a predominance of negative and upsetting memories, happy memories triggering pain and more negative intrusive imagery than those without PGD/PCBD. Conclusions: Bereavement by cancer can result in troubling intrusive memories that overshadow positive memories. Sufferers of PGD/PCBD are more likely to experience loss-related memories as negative and upsetting. Clinical approaches that utilise memory processing may be of particular relevance in this group.

Objetivo: El estudio tuvo como objetivo explorar el contenido y las características de los recuerdos relacionados con la pérdida en una muestra de personas viviendo un duelo por cáncer con y sin un diagnóstico probable de trastorno de duelo prolongado/trastorno de duelo complejo persistente (PGD/PCBD).Métodos: Se analizaron entrevistas semiestructuradas con 28 adultos dolientes (PGD/PCBD = 12, NoPGD/PCBD = 16) mediante análisis temático.Resultados: Se identificaron tres temas supraordinados: (1) imágenes intrusivas, (2) cualidades de la memoria y (3) gatillantes. Los resultados mostraron que las personas que padecen un probable PGD/PCBD informaron un predominio de recuerdos negativos y molestos, recuerdos felices que desencadenan dolour y más imágenes intrusivas negativas que aquellos sin PGD/PCBD.Conclusiones: El duelo por cáncer puede provocar recuerdos intrusivos problemáticos que eclipsan los recuerdos positivos. Las víctimas de PGD/PCBD tienen más probabilidades de experimentar los recuerdos relacionados con la pérdida como negativos y molestos. Los enfoques clínicos que utilizan el procesamiento de memoria pueden ser de particular relevancia en este grupo.

The Masking of Mourning: Social Disconnection After Bereavement and Its Role in Psychological Distress.

Social support has been shown to facilitate adaptation after bereavement in some studies but not others. A felt sense of social disconnection may act as a barrier to the utilization of social support, perhaps explaining these discrepancies. Factorial and psychometric validity of the Oxford Grief-Social Disconnection Scale (OG-SD) was tested in a bereaved sample (N = 676). A three-factor solution (negative interpretation of others' reactions to grief expression, altered social self, and safety in solitude) fit the data best and demonstrated excellent psychometric validity. A second three-wave longitudinal sample (N = 275) recruited 0 to 6 months following loss and followed up 6 and 12 months later completed measures of prolonged grief disorder, posttraumatic stress disorder, depression, and the OG-SD at each time point. High levels of baseline social disconnection were associated with concurrently high psychological distress. The extent to which social disconnection declined over time predicted resolution of psychological distress.

Effectiveness of a Cancer Bereavement Therapeutic Group.

This study examined the effectiveness of a novel cancer bereavement group. Twenty-seven participants attended a sixsession cancer bereavement therapeutic group. Data were collected at baseline, intervention completion, and three-month follow-up. Grief intensity and symptoms of posttraumatic stress disorder (PTSD), depression, and anxiety were reduced postintervention, and self-compassion increased. At follow-up, improvement remained for grief, PTSD, and depression. A small quasi-experimental waiting-list comparison group showed no change on any measure between baseline and waiting-list end. This study provides preliminary evidence that a brief therapeutic group is an effective intervention for cancer bereavement.

Conducting ethical internet-based research with vulnerable populations: a qualitative study of bereaved participants' experiences of online questionnaires.

Background: Bereavement can be considered a potentially traumatic experience, and concerns have been raised about conducting grief research responsibly online. Objective: Given that online research introduces new methodological opportunities and challenges, we aimed to develop a greater understanding of how bereaved individuals experience participation in online research. Method: One day after participation in an online grief study, 876 participants, bereaved on average for 40 months, received a 'check-in' email to support well-being and offer further contact if needed. Although not explicitly asked to respond if no help was needed, 300 participants sent email replies, with only six requesting support. These responses were analysed qualitatively using content analysis. Results: Results suggested that participants found it acceptable to be asked about their grief and while difficult emotions were frequently described in response to the questionnaires, these reactions were temporary. A range of positive reactions was also reported, including new realizations arising from completing the research and changes in thinking related to grief. Participants also wrote about their appreciation for the study and how it was carried out, as well as a desire to contribute more to the study and to help others in a similar position. Conclusions: We suggest that the use of the check-in email to support well-being following study completion, along with advice on preparing to take part, contributed to positive experiences of participation and we recommend these strategies for future studies. These findings could allay clinical concerns about conducting online research with vulnerable populations, as well as raising questions about the possible therapeutic impact of measurement.

Antecedentes: El duelo se puede considerar una experiencia potencialmente traumática, y han surgido preocupaciones respecto a la realización responsable de investigaciones de duelo en línea. Objetivo: Dado que la investigación en línea plantea nuevas oportunidades y desafíos metodológicos, intentamos ampliar la comprensión sobre cómo las personas en duelo experimentan la participación en investigación en línea. Método: Un día después de participar en un estudio de duelo en línea, 876 participantes en duelo, con un promedio de pérdida de 40 meses, recibieron un correo electrónico de 'registro' para apoyar el bienestar y ofrecer contacto adicional de ser necesario. Aunque no se les pidió explícitamente a los participantes que respondieran si no necesitaban ayuda, 300 enviaron respuestas por correo electrónico, con sólo seis de ellos solicitando apoyo. Estas respuestas se analizaron cualitativamente mediante análisis de contenido. Resultados: Los resultados sugirieron que los participantes consideraron aceptable que se les preguntara sobre su dolor y, aunque frecuentemente se describieron emociones difíciles en respuesta a los cuestionarios, estas reacciones fueron temporales. También se reportaron una serie de reacciones positivas, incluyendo nuevos entendimientos derivados de la finalización de la investigación y cambios en el pensamiento relacionado con el duelo. Los participantes también escribieron acerca de su apreciación por el estudio y su ejecución, así como el deseo de contribuir más al estudio y ayudar a otros en una posición similar. Conclusiones: Sugerimos que el uso del correo electrónico de registro para apoyar el bienestar seguido de la participación en el estudio, junto con consejos sobre cómo prepararse para participar, contribuyó a experiencias positivas de participación, y recomendamos el uso de estas estrategias para estudios futuros. Estos hallazgos podrían disipar las preocupaciones clínicas sobre la realización de investigaciones en línea con poblaciones vulnerables, así como plantear preguntas sobre el posible impacto terapéutico de las mediciones.

An adapted imaginal exposure approach to traditional methods used within trauma-focused cognitive behavioural therapy, trialled with a veteran population.

Trauma-focused cognitive behavioural therapy (TF-CBT) is beneficial for individuals with post-traumatic stress disorder (PTSD); however, a subset of clients struggle to engage with traditional methods, due to high levels of avoidance and dissociation. This paper aims to describe an adapted approach to imaginal reliving and prolonged exposure, to facilitate subsequent cognitive updating. The paper demonstrates the technique with veterans, who are a client group that may struggle with some aspects of traditionally implemented TF-CBT. Two case studies are described, both with PTSD symptoms stemming from traumatic military experiences. An adapted exposure technique is utilized to address the barriers of high dissociation, poor access to trauma-related cognitions and fixed intrusive imagery. The approach involved three stages: (1) reliving the trauma outdoors, (2) manipulating the perspectives of the imagery, and (3) restructuring the narrative with new perspectives. Both clients showed decreased dissociation and improved toleration of their traumatic imagery. Improvement of PTSD symptoms and quality-of-life functioning was observed for both clients on objective measures. Adapting TF-CBT to have a stronger emphasis on grounding and allocentric processing may be helpful for a subset of patients with PTSD that present with high levels of dissociation and avoidance. Further research and investigation into alternative populations is needed.