Healing grief – an online self-help intervention programme for bereaved Chinese with prolonged grief: study protocol for a randomised controlled trial

Figures & data

Figure 1. Study flow from screening to follow-up. Monitoring refers to noticing whether participants have questions and assessing if participants need urgent help. Note: IG represents Internet-based intervention group and WCG represents waitlist-control group.

Table 1. Overview of Healing Grief.

Module	Session	Loss-oriented (LO)	Restoration-oriented (RO)	Approach
Understanding grief	1	L1: Monitoring grief		Psychoeducation Behavioral activation
	2	½ L2: Labelling emotions	½ R1: Self-care and mindfulness	Psychoeducation Behavioural activation
Saying goodbye	3	L3: Remembering the deceased		Expressive writing
	4	L4: Building a memory home		Expressive writing
Living in the moment	5		R2: Daily memorial rituals	Meaning reconstruction Behavioural activation
	6		R3: Dealing with survivor’s guilt	Psychoeducation Expressive writing
Continuing the bonds	7	L5: Writing to the deceased		Expressive writing Cognitive reappraisal
	8	L6: Building the continuing bond		Psychoeducation Expressive writing Cognitive reappraisal Meaning reconstruction
Facing it together	9		R4: Social support	Psychoeducation Behavioural activation
	10		R5: Assertiveness training	Psychoeducation Behavioural activation
Searching for meaning	11	½ L7: Writing to an imaginary friend	½ R6: Meaning reconstruction	Psychoeducation Expressive writing Cognitive reappraisal Meaning reconstruction
	12		R7: Benefit finding	Expressive writing Cognitive reappraisal Meaning reconstruction

Note: Each session begins with asking about the practice of the content of the last session and monitoring grief. L represents the loss-oriented component. R represents the restoration-oriented component.

Figure 2. Sample screenshots of Healing Grief include (a) the home page, (b) the interface for monitoring grief, (c) the interface for a session, and (d) the interface for keeping diaries.

Table 2. Measures.

Construct	Instrument (abbreviation)	Item No.	Rating Likert scale wording (scores)	Time frame	Reliability	T-1	T0	T1	T2
Screening variables
Psychiatric symptoms	DIPS	3	‘YES’ or ‘NO’	Last month	/	X
Substance abuse	CAGE Questionnaire	4	‘YES’ or ‘NO’	Last month	/	X
Suicidal ideation	BSI-CV	19	Anchor differs (0–2)	Last week & Lifetime	/	X
Sociodemographic and loss-related variables					/
Sociodemographic variables	/	6	/	Present			X
Loss-related variables	/	9	/	Present			X
Primary outcome
Effectiveness measure
PGD	IPGDS	14	Almost never–always (1–5)	Last month	α = 0.97		X	X	X
PTSD	PCL-5	20	Not at all–extremely (0–4)	Last month	α = 0.94		X	X	X
Anxiety	HADS-anxiety subscale	7	Anchor differs (0–4)	Last month	α = 0.77		X	X	X
Depression	HADS-depression subscale	7	Anchor differs (0–4)	Last month	α = 0.76		X	X	X
User experience characteristics
Usage of the intervention	/	3	/	Last 6 weeks	/			X
Perceptions of the intervention form	PCTQ-P (adapted version)	16	Strongly disagree-strongly agree (1–7)	Last 6 weeks	α = 0.92			X
Acceptability of the intervention content and intervention settings	/	10	Anchor differs (1–5)	Last 6 weeks	/			X
Future use intention	/	3	Not at all-extremely (1–5)
User experience interview	/	11	/	Last 6 weeks	/			X
Secondary outcomes
Posttraumatic growth	PTGI	21	Did not experience this change–experienced this change to a very great degree (0–5)	Since loss	α = 0.93		X	X	X
Dual coping process	DCI; Time spent; Oscillation	10	DCI: Not at all–very much (1–5) Time spent: no time–all of the time (1–100) Oscillation: extremely difficult to do so–extremely easy to do so (1–5)	Last week	α = 0.81 (LO) α = 0.75 (RO)		X	X	X
Grief rumination	UGRS	15	Never–very often (1–5)	Last month	α = 0.90		X	X	X
Mindfulness	MAAS	15	Almost always–almost never (1–6)	Present	α = 0.92		X	X	X
Continuing bond	CBS	19	Almost never–always (1–4)	Last month	α = 0.92		X	X	X

Note: PGD = Prolonged Grief Disorder; PTSD = Posttraumatic Stress Disorder; DIPS = German Diagnostic Interview for Psychiatric Symptoms (Margraf, Cwik, Pflug, et al., 2017; Margraf, Cwik, Suppiger, et al., 2017); CAGE Questionnaire = Cutting down, Annoyance by criticism, Guilty feelings, Eye-openers questionnaire (Ewing, 1984); BSI-CV = Beck Scale for Suicide Ideation-Chinese Version (Li et al., 2010); IPGDS = International ICD-11 Prolonged Grief Disorder Scale (Killikelly et al., 2020); PCL-5 = Posttraumatic Stress Disorder Checklist for DSM-5 (Cheng et al., 2020); HADS = Hospital Anxiety and Depression Scale (Ye & Xu, 1993); PTGI = Posttraumatic Growth Inventory Scale (Wang et al., 2011); DCI = Dual Coping Inventory (Tang & Chow, 2017); UGRS = Utrecht Grief Rumination Scale (Tang et al., 2019); MAAS = Mindful Attention Awareness Scale (Deng et al., 2012); CBS = Continuing Bond Scale (Yu et al., 2016); PCTQ-P = Perceptions of Computerized Therapy Questionnaire-Patient (Carper et al., 2014); LO = loss-oriented coping; RO = restoration-oriented coping; Time spent = Time spent in LO and RO; Oscillation = the oscillation between LO and RO; α = Cronbach's alpha.

Margraf, J., Cwik, J. C., Pflug, V., & Schneider, S. (2017). Structured clinical interviews for mental disorders across the life span: Psychometric quality and further developments of the DIPS open access interviews. Zeitschrift für Klinische Psychologie und Psychotherapie, 46(3), 176–186. https://doi.org/10.1026/1616-3443/a000430

 Web of Science ®Google Scholar

Margraf, J., Cwik, J. C., Suppiger, A., & Schneider, S. (2017). DIPS open access: Diagnostic interview for mental disorders. Mental Health Research and Treament Center, Ruhr-Universität Bochum.

 Google Scholar

Ewing, J. A. (1984). Detecting alcoholism. The CAGE questionnaire. JAMA: Journal of the American Medical Association, 252(14), 1905–1907. https://doi.org/10.1001/jama.252.14.1905

 PubMed Web of Science ®Google Scholar

Li, X.-Y., Phillips, M. R., Tong, Y.-S., Li, K.-J., Zhang, Y.-L., Zhang, Y.-P., Xu, D., & Niu, Y.-J. (2010). Reliability and validity of the Chinese version of Beck suicide ideation scale (BSI-CV) in adult community residents. Chinese Mental Health Journal, 24(4), 250–255. https://doi.org/10.3969/j.issn.1000-6729.2010.04.003

 Google Scholar

Killikelly, C., Zhou, N., Merzhvynska, M., Stelzer, E.-M., Dotschung, T., Rohner, S., Sun, L. H., & Maercker, A. (2020). Development of the international prolonged grief disorder scale for the ICD-11: Measurement of core symptoms and culture items adapted for chinese and german-speaking samples. Journal of Affective Disorders, 277, 568–576. https://doi.org/10.1016/j.jad.2020.08.057

 PubMed Web of Science ®Google Scholar

Cheng, P., Xu, L.-Z., Zheng, W.-H., Ng, R. M. K., Zhang, L., Li, L.-J., & Li, W.-H. (2020). Psychometric property study of the posttraumatic stress disorder checklist for DSM-5 (PCL-5) in Chinese healthcare workers during the outbreak of corona virus disease 2019. Journal of Affective Disorders, 277, 368–374. https://doi.org/10.1016/j.jad.2020.08.038

 PubMed Web of Science ®Google Scholar

Ye, W., & Xu, J. (1993). Application and evaluation of the hospital anxiety and depression scale in patients in general hospitals. Chinese Journal of Behavioral Medicine, 2(3), 17–19.

 Google Scholar

Wang, J., Chen, Y., Wang, Y., & Liu, X. (2011). Revision of the posttraumatic growth inventory and testing its reliability and validity. Journal of Nursing Science, 26(14), 26–29. https://doi.org/10.3870/hlxzz.2011.14.026

 Google Scholar

Tang, S., & Chow, A. Y. M. (2017). How do risk factors affect bereavement outcomes in later life? An exploration of the mediating role of dual process coping. Psychiatry Research, 255, 297–303. https://doi.org/10.1016/j.psychres.2017.06.001

 PubMed Web of Science ®Google Scholar

Tang, S., Eisma, M. C., Li, J., & Chow, A. Y. M. (2019). Psychometric evaluation of the Chinese version of the Utrecht Grief Rumination Scale. Clinical Psychology & Psychotherapy, 26(2), 262–272. https://doi.org/10.1002/cpp.2348

 PubMed Web of Science ®Google Scholar

Deng, Y.-Q., Li, S., Tang, Y.-Y., Zhu, L.-H., Ryan, R., & Brown, K. (2012). Psychometric properties of the Chinese translation of the mindful attention awareness scale (MAAS). Mindfulness, 3(1), 10–14. https://doi.org/10.1007/s12671-011-0074-1

 Web of Science ®Google Scholar

Yu, W., He, L., Xu, W., Wang, J., & Prigerson, H. G. (2016). How do attachment dimensions affect bereavement adjustment? A mediation model of continuing bonds. Psychiatry Research, 238, 93–99. https://doi.org/10.1016/j.psychres.2016.02.030

 PubMed Web of Science ®Google Scholar

Carper, M. M., McHugh, R. K., Murray, H. W., & Barlow, D. H. (2014). Psychometric analysis of the perceptions of computerized therapy questionnaire-patient version (PCTQ-P). Administration and Policy in Mental Health, 41(1), 104–113. https://doi.org/10.1007/s10488-012-0440-x

 PubMed Web of Science ®Google Scholar

Data availability statement

As this manuscript describes a study protocol, provision of a dataset is not applicable.