Laurent Berthoud
Liliane Efinger
Maya Kheyar
Valentino Pomini
Anik Debrot- Institute of Psychology, Faculty of Social and Political Sciences, University of Lausanne, Lausanne, Switzerland
Covid-19: A Breeding Ground for a Lack of Connection in Times of Grief
As we write these lines, the coronavirus-19 (COVID-19) pandemic has reportedly killed over 2'400'000 people, leaving many individuals and families in mourning throughout the world. The current context has put a major strain on people as it has drastically altered our daily lives and caused many societal challenges. We are experiencing much change and multiple losses. In addition to increased unemployment and financial difficulties, COVID-19 has required exceptional sanitary measures such as social distancing, confinement and quarantine, adding a painful sense of isolation to individuals and families in mourning (1). Simultaneously, this context has had a serious impact on couples, many countries reporting a significant increase in separations and divorces due to spending more time together confined and separating as a result of the exacerbation of pre-existing contextual vulnerabilities that were previously milder or latent (2), adding further grief to already distressing circumstances. Isolation and lack of connection are at the center of these life-changing events. They likely make the grieving and separation processes more complicated and difficult for people who are left alone, without the usual opportunities for interpersonal and social support.
Interpersonal loss, by death or separation, is common, but counts among the most stressful and painful life events possible (3). Both involve the loss of a meaningful relationship and may have significant health consequences, such as enhancing mortality risk and fostering mental or physical illnesses (4–6). Accumulating evidence indicates that interpersonal loss in divorce and breakups has numerous similarities with the grieving process after the death of a loved one. In both cases, symptoms of grief may occur, such as intrusive thoughts, ruminations, avoidance of situations or places reminiscent of the lost person, excessive idealization of the ended relationship, significant fatigue, some mental confusion coupled with the feeling of being lost, etc. (7–9).
Given the current circumstances that this could lead in the next few months to a potential explosion of cases of prolonged grief, it may prove relevant to provide easier access to preventive or even therapeutic psychological interventions for bereaved or separated individuals who are struggling with complicated grief symptoms and who feel the need or are seeking help to overcome their difficulties.
Filling the “Treatment Gap”: How Internet-Based Interventions can Help
The majority of bereaved people rely on family and friends for support (10, 11) and do not seek professional sources of help. Studies have shown that most individuals in need of mental health services will receive no treatment [also known as the “treatment gap,” see (12)]. Indeed, professional sources are the least used, due to a reported lack of information (e.g., “I've never heard of them”) and availability (e.g., “They're always too busy”). Moreover, professional help is also perceived as highly unhelpful [46% of the respondents found psychiatrists unhelpful, 21% for psychologists; (13)] primarily because of a lack of sensitivity (e.g., “I was told to go sit in the sun and pat the dog”). This highlights the need to improve the dissemination of information and to increase the availability of skilled professionals. Indeed, despite the high probability of experiencing a significant loss in life and the important number of people affected by complicated grief, many professionals do not possess sufficient training and competences (14).
Internet-based interventions (IBIs) represent a promising avenue to address the treatment gap. They are immediately accessible and can reach a large number of individuals. They also diversify the ways to deliver evidence-based treatments (15, 16). IBIs have been shown to be as effective as face-to-face therapies when done with guidance (17). These IBIs generally offer regular but limited personalized support from therapists who guide the patients through the intervention, by email or telephone or video, and rely on psychoeducation and CBT techniques. Guided IBIs, i.e., interventions that offer personalized guidance, are generally more effective than unguided ones [for a systematic review, see (18)]. Nevertheless, guided IBIs require significant human resources, which limits the implementation of the intervention on a large scale.
Although IBIs have only recently started focusing on grief-related symptoms, they have shown promising and stable results, demonstrating their feasibility and efficacy. A recent systematic review and meta-analysis (19) identified 7 RCTs (N = 1,257) on guided IBIs, all based on CBT, out of over 4,100 studies. Results showed a promising overall effect on grief reduction with significant moderate effects sizes (Hedge's g = 0.54; 95% CI: 0.30–0.78), stable over time from post to 3-month follow-up assessment. To the best of our knowledge, two IBIs targeting grief-related symptoms have been tested to date in an unguided format. In the first study, Dominick et al. (20) proposed an unguided intervention based on psychoeducation. The main goal was to normalize the grief reaction. Their intervention showed positive and significant results, but of small magnitude. In the second study, van der Houwen et al. (21) assessed an unguided intervention, in which participants were asked to complete written disclosure tasks. This 7-week intervention showed positive results on emotional loneliness, rumination and positive mood, however not on grief and depressive symptoms. Both studies showed fewer positive results than those obtained with the guided IBIs.
While most of the interventions were developed for people who were bereaved or suffering from PTSD, one study extented this treatment to other types of loss. Indeed, Brodbeck et al. (22) have developed a 10-week guided IBI, named LIVIA, to treat grief-related symptoms for people who lost their partner either by death or by separation/divorce. This program is based on CBT procedures and emphasizes both loss-focused interventions (e.g., exposure, cognitive reframing of the loss, etc.) and restoration-oriented tasks (e.g., selfcare, social reengagement, etc.) in line with the Dual Process Model of coping with bereavement (23, 24). LIVIA is not only demonstrated to be feasible for both grieving and separated or divorced individuals, but is also efficacious (25).
The Livia Programme
Few psychotherapists are trained in treating complicated grief (14). Given its prevalence, many people are in need of an intervention in their mother tongue. In 2018, French-speakers represented 5% of the world's population, i.e., 300 million people (26). Nevertheless, no empirically-assessed IBI for grief exists in French. Therefore, we translated the LIVIA programme from German into French. This led to the creation of LIVIA-FR (27), which was evaluated in an unguided format because of limited human resources, in order to test its feasibility in French culture and language. Results from a recent pilot study (28) details that out of 138 interested individuals, 39 participants began the study and 22 were selected for the analyses, 17 having dropped out or not completed a single session. The results showed significant reduction in grief symptoms and a tendency to decrease avoidance strategies. However, smaller effect sizes and higher drop-out rates than the original programme prompted us to develop an upgraded version of the programme, based on the LIVIA-FR participants' feedback and on the literature.
The new version of the programme, named LIVIA 2.0, is currently in development. Like its predecessors, it will consist of 10 sessions to be completed over 3 months. In order to improve the effectiveness of and adherence to the programme, which consists of promoting the autonomy of the participants completing it and reducing the risk of avoidance and drop-out due to feelings of failure, LIVIA 2.0 will include the following changes. First, guidance on demand will be implemented as it is a cost-effective alternative to guidance and will help better meet the participants' needs and expectations with the challenge of making the programme as effective as possible while optimizing the use of human resources (29). No research has been conducted to test the efficacy of a guidance on demand design in participants with complicated grief symptoms. Second, participants will experience greater freedom of navigation so as to choose the order in which they wish to complete the programme according to their needs and abilities. Participants will also receive a personalised recommendation based on the assessment of their priorities at the start of the programme. Third, programme interactivity will be enhanced by displaying a more user-friendly layout, as well as audio files, video files and exercises. This will replace the original textual and academic presentation. Fourth, automated emails will be included in the programme as they are beneficial to adherence and outcomes in IBIs (30). Fifth, the structure of the programme will no longer be linear but modular, addressing cognitions, emotions and behaviours. Sixth, a module addressing autobiographical memory and identity will be added (31) which are central processes that are affected by complicated grief (32, 33). Finally, self-assessment and promotion of the participants' resources will be carried out, using the AERES tool (34).
In the coming years, we have planned to compare the efficacy of LIVIA-FR and LIVIA 2.0. This study is supported by the Swiss National Science Foundation. It is hypothesised that LIVIA 2.0 will require less guidance than LIVIA-FR and be at least as efficient. A more refined exploration will be done on the short-term efficacy of each module by monitoring the participants' state throughout the programme. We also hope that this study will show that the envisaged improvements will be effective and will improve not only access but also, and above all, adherence to the programme.
Conclusion
Although grief is a natural response to loss, our social context plays a vital role in how we experience these events. Given the circumstances, there is clearly an urgency to offer support to people mourning. IBIs such as LIVIA are promising to meet needs that were already present but are not satisfied or exacerbated by the current sanitary crisis. With such uncertainty and insecurity because of COVID-19, having the support of a programme like LIVIA 2.0 can be “the lifebelt” that can help navigate these turbulent times. Indeed, the current pandemic context has made the grieving process harder. Isolation, social distancing and confinement all have significant effects as we feel as they rob us of relationships crucial to our well-being. The lack of relationships may lead to difficulties in coping with the fear of the unknown in an ambiguous crisis situation as COVID-19. Faced with loneliness, nothing can replace true human contact, but internet-based interventions may serve as an intermediary to build new relationships that may help to overcome mourning. Nevertheless, progress must be made not only in technology but also in the design of programmes to better target needs and offer relevant help to the greatest number. Traditional psychoeducational programmes are perhaps still too standardised and uniform today to respond to the variety of suffering and research has the potential to help guide technology in the right direction. And hopefully, we will be better equipped to support ourselves in times of loss as a result of this pandemic.
Author Contributions
LB and AD conceived the work. LB, AD, and LE made the literature search. LB drafted the paper. MK, LE, and VP revised the work. All authors provided approval of the version to be submitted.
Funding
This study was supported by the SNSF Grant 100014_182840/1 (AD).
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
References
1. Yahya AS, Khawaja S. Bereavement and grief during the COVID-19 pandemic. Primary Care Companion CNS Disord. (2020) 22:20com02661. doi: 10.4088/PCC.20com02661
2. Pietromonaco PR, Overall NC. Applying relationship science to evaluate how the COVID-19 pandemic may impact couples' relationships. Am Psychol. (2020). doi: 10.1037/amp0000714
3. Hobson CJ, Kamen J, Szostek J, Nethercut CM, Tiedmann JW, Wojnarowicz S. Stressful life events: a revision and update of the social readjustment rating scale. Int J Stress Manag. (1998) 5:1–23. doi: 10.1023/A:1022978019315
4. Bennett KM, Soulsby LK. Wellbeing in bereavement and widowhood. Illn Crisis Loss. (2012) 20:321–37. doi: 10.2190/IL.20.4.b
5. Sbarra DA, Hasselmo K, Bourassa KJ. Divorce and health: beyond individual differences. Curr Dir Psychol Sci. (2015) 24:109–13. doi: 10.1177/0963721414559125
6. Stroebe M, Schut H, Stroebe W. Health outcomes of bereavement. Lancet. (2007) 370:1960–73. doi: 10.1016/S0140-6736(07)61816-9
7. Clulow CF. Divorce as bereavement: similarities and differences. Fam Concil Courts Rev. (1990) 28:19–22. doi: 10.1111/j.174-1617.1990.tb01225.x
8. Davis D, Shaver PR, Vernon ML. Physical, emotional, and behavioral reactions to breaking up: the roles of gender, age, emotional involvement, and attachment style. Soc Pers Soc Psychol. (2003) 9:871–84. doi: 10.1177/0146167203029007006
9. Field T. Romantic breakups, heartbreak and bereavement. Psychology. (2011) 2:382–7. doi: 10.4236/psych.2011.24060
10. Aoun SM, Breen LJ, Howting DA, Rumbold B, McNamara B, Hegney D. Who needs bereavement support? A population based survey of bereavement risk and support need. PLoS ONE. (2015) 10:e0121101. doi: 10.1371/journal.pone.0121101
11. Logan EL, Thornton JA, Breen LJ. What determines supportive behaviors following bereavement? A systematic review and call to action. Death Studies. (2017) 42:104–14. doi: 10.1080/07481187.2017.1329760
12. Alonso J, Liu Z, Evans-Lacko S, Sadikova E, Sampson N, Chatterji S, et al. Treatment gap for anxiety disorders is global: results of the world mental health survey in 21 countries. Depress Anxiety. (2018) 35:195–208. doi: 10.1002/da.22711
13. Aoun SM, Breen LJ, White I, Rumbold B, Kellehear A. What sources of bereavement support are perceived helpful by bereaved people and why? Empirical evidence for the compassionate communities approach. Palliative Med. (2018) 32:1378–88. doi: 10.1177/0269216318774995
14. Ober AM, Granello DH, Wheaton JE. Grief counseling: an investigation of counselors' training, experience, and competencies. J Couns Dev. (2012) 90:150–9. doi: 10.1111/j.1556-6676.2012.00020.x
15. Andersson G. Internet interventions: past, present and future. Int Intervent. (2018) 12:181–8. doi: 10.1016/j.invent.2018.03.008
16. Kazdin AE. Addressing the treatment gap: a key challenge for extending evidence-based psychosocial interventions. Behav Res Ther. (2017) 88:7–18. doi: 10.1016/j.brat.2016.06.004
17. Andersson G, Titov N, Dear BF, Rozental A, Carlbring P. Internet-delivered psychological treatments: From innovation to implementation. World Psychiatry. (2019) 18:20–8. doi: 10.1002/wps.20610
18. Baumeister H, Reichler L, Munzinger M, Lin J. The impact of guidance on Internet-based mental health interventions: a systematic review. Int Interv. (2014) 1:205–15. doi: 10.1016/j.invent.2014.08.003
19. Wagner B, Rosenberg N, Hofmann L, Maass U. Web-based bereavement care: a systematic review and meta-analysis. Front Psychiatry. (2020) 11:525. doi: 10.3389/fpsyt.2020.00525
20. Dominick SA, Irvine AB, Beauchamp N, Seeley JR, Nolen-Hoeksema S, Doka KJ, et al. An internet tool to normalize grief. OMEGA (Westport). (2010) 60:71–87. doi: 10.2190/OM.60.1.d
21. van der Houwen K, Schut H, van den Bout J, Stroebe M, Stroebe W. The efficacy of a brief internet-based self-help intervention for the bereaved. Behav Res Ther. (2010) 48:359–67. doi: 10.1016/j.brat.2009.12.009
22. Brodbeck J, Berger T, Znoj HJ. An internet-based self-help intervention for older adults after marital bereavement, separation or divorce: study protocol for a randomized controlled trial. Trials. (2017) 18:21. doi: 10.1186/s13063-016-1759-5
23. Stroebe M, Schut H. The dual process model of coping with bereavement: rationale and description. Death Studies. (1999) 23:197–224. doi: 10.1080/074811899201046
24. Stroebe M, Schut H. The dual process model of coping with bereavement: a decade on. OMEGA J Death Dying. (2010) 61:273–89. doi: 10.2190/OM.61.4.b
25. Brodbeck J, Berger T, Biesold N, Rockstroh F, Znoj HJ. Evaluation of a guided internet-based self-help intervention for older adults after spousal bereavement or separation/divorce: a randomised controlled trial. J Aff Disord. (2019) 252:440–9. doi: 10.1016/j.jad.2019.04.008
26. Beck B, Marcoux R, Richard L, Wolff A. Estimation des populations francophones dans le monde en 2018 [Estimates of Francophone populations in the world in 2018]. Sources et démarches méthodologiques, Québec, Observatoire démographique et statistique de l'espace francophone, Université Laval, Note de recherche de l'ODSEF (2018).
27. Debrot A. LIVIA-FR: An Online Unguided Self-Help Intervention for People Struggling With Interpersonal Loss. Grant proposal, Switzerland (2017).
28. Efinger L, Debrot A, Pomini V. Implémentation et évaluation de LIVIA: Une intervention par internet pour des personnes francophones peinant à surmonter la perte de leur partenaire [Implementation and evaluation of LIVIA: An internet-based intervention for French-speaking people struggling to cope with the loss of their partner] (submitted).
29. Berger T, Caspar F, Richardson R, Kneubühler B, Sutter D, Andersson G. Internet-based treatment for social phobia: a randomized controlled trial comparing unguided with two types of guided self-help. Behav Res Ther. (2011) 49:158–69. doi: 10.1016/j.brat.2010.12.007
30. Titov N, Dear BF, Johnston L, Lorian C, Zou J, Wootton B, et al. Improving adherence and clinical outcomes in self-guided internet treatment for anxiety and depression: randomised controlled trial. PLoS ONE. (2013) 8:e62873. doi: 10.1371/journal.pone.0062873
31. Kheyar M. Intervention psychologique centrée sur la mémoire autobiographique pour les personnes éprouvant des difficultés à surmonter la perte d'un être cher [Psychological intervention focused on the autobiographical memory for people who have difficulty in overcoming the loss of a loved one]. Unpublished thesis project, Lausanne: University of Lausanne (2020).
32. Boelen PA, Huntjens RJC, van Deursen DS, van den Hout MA. Autobiographical memory specificity and symptoms of complicated grief, depression and posttraumatic stress disorder following loss. J Behav Ther Exp Psychiatry. (2010) 41:331–7. doi: 10.1016/j.jbtep.2010.03.003
33. Robinaugh DJ, McNally RJ. Remembering the past and envisioning the future in bereaved adults with and without complicated grief. Clin Psychol Sci. (2013) 1:290–300. doi: 10.1177/2167702613476027
Keywords: internet-based interventions for mental health, coronavirus—COVID-19, interpersonal loss, grief, mourning (bereavement), marital separation/divorce
Citation: Berthoud L, Efinger L, Kheyar M, Pomini V and Debrot A (2021) Hope May Come From Internet in Times of COVID-19: Building an Online Programme for Grief (LIVIA). Front. Psychiatry 12:626831. doi: 10.3389/fpsyt.2021.626831
Received: 06 November 2020; Accepted: 16 February 2021;
Published: 09 March 2021.
Edited by:
Lydia Gimenez-Llort, Autonomous University of Barcelona, SpainReviewed by:
Konstantinos E. Siomos, University of Thessaly, GreeceAli Abbas Samaha, Lebanese International University, Lebanon
Copyright © 2021 Berthoud, Efinger, Kheyar, Pomini and Debrot. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Laurent Berthoud, bGF1cmVudC5iZXJ0aG91ZCYjeDAwMDQwO3VuaWwuY2g=