1 Introduction

In Australia, 10–15% of older adults living in the community experience anxiety or depression (Haralambous et al., 2009). Moreover, there is evidence to suggest that sub-threshold depressive symptoms begin to worsen when individuals reach their mid-sixties (Sutin et al., 2013), and continue to decline with age (Sutin et al., 2013; Vahia et al., 2010). This decline in mood in older adulthood may be linked to the increased incidence of physical health issues in old age, which in turn have been associated with low mood (Shtompel et al., 2014; Steptoe et al., 2015). To date, most research has focussed on a disease model that aims to ameliorate suffering in individuals with diagnosed disorders (Gable & Haidt, 2005), often neglecting interventions that aim to enhance wellbeing (Ranzijn, 2002). Proactively improving the wellbeing of older adults may protect these individuals from advancing to clinically significant levels of distress. For instance, early psychological intervention can reduce rates of incident depression by up to 25% over 1–2 years (Reynolds et al., 2012).

Dignity Therapy – a brief psychotherapy originally designed for terminally-ill patients – may represent a viable intervention to enhance an older adult’s wellbeing (Chochinov, 2012; Chochinov et al., 2005). Dignity Therapy is a semi-structured intervention guided by a series of questions that aim to engender a sense of meaning and purpose. The sessions are audio recorded and transcribed, and the final product is edited by the therapist and made into a Generativity (legacy) Document, which then is given to patients to share with their loved ones. Consistently high levels of acceptability have been reported in previous Dignity Therapy studies (Fitchett et al., 2015) including participants with cancer (Vergo et al., 2014) and motor neurone disease (Bentley et al., 2014). While the evidence of the efficacy of Dignity Therapy is mixed (Fitchett et al., 2015; Martínez et al., 2017), it appears that Dignity Therapy is effective in enhancing wellbeing (specifically, a sense that life is meaningful) for cancer patients (Vergo et al., 2014) and for individuals living in older adult care homes (Hall et al., 2012). Vuksanovic et al.’s (2017) study involving individuals with advanced terminal illnesses found that participants that received Dignity Therapy reported improved generativity scores after completing the program. In contrast, waitlist controls and participants who completed a life review intervention without creating a legacy document did not report changes in generativity, suggesting that the Dignity Therapy may enhance wellbeing by providing respondents an opportunity to record their legacy. However, little is known of the potential efficacy of Dignity Therapy for enhancing wellbeing in community-dwelling older adults.

Despite the promise of Dignity Therapy, it is not widely used in clinical practice, perhaps due to the significant time costs involved – up to 15 h spent to deliver and transcribe the program (Hall et al., 2012). Recently, Bentley et al. (2020) piloted an online Dignity Therapy for individuals with terminal illness. They found that their program was feasible and acceptable, and the online format helped reduce financial and time costs. Bentley et al. employed a flexible approach in which some of their participants completed the program via email, whilst others had telehealth sessions. Hence, it is not yet known if Dignity Therapy when delivered wholly via telehealth is acceptable, practicable and beneficial for non-terminal older adults.

The COVID-19 pandemic has highlighted the need for telehealth-based interventions (Zhou et al., 2020). However, it is important to determine the suitability of different online modalities for different populations. In this study, we pilot a Telehealth Dignity Therapy (TDT) program. The findings from our study will be used for future larger-scale quantitative investigations into the efficacy of our program. Specifically, we aim to assess the suitability of TDT for community-dwelling older adults and assess the program’s:

  1. 1.

    Acceptability (e.g., How satisfied are participants with TDT?)

  2. 2.

    Practicality (e.g., How timely is the implementation of TDT compared to other Dignity Therapy programs? Did any attrition occur?)

  3. 3.

    Potential benefits (e.g., How did participants benefit from their involvement in TDT?)

2 Methods

2.1 Study Design

This study employed a mixed methods pilot study design. Semi-structured interviews and post-intervention surveys were used to evaluate the research questions.

2.2 Recruitment and Eligibility

A convenience sampling strategy was used via a study advertisement sent to individuals on the mailing list of the Swinburne Wellbeing Clinic – a network of researchers, clinicians, aged care workers, individuals interested in late-life mental health, older adults and their families. Interested participants contacted the researcher via email to express their interest in the study. Then, a telehealth screening interview was used to assess their eligibility for the study: (a) aged 60 years or older (or 50 years for individuals of Indigenous or Torres Strait Island descent), (b) fluent English-speaking ability, (c) currently living in the community in Australia, (d) have proficient computer skills (e.g., completing online surveys, email correspondence, undertaking online video calls), and (e) cognitive capacity to participate in the program as measured via an equivalent score of 24 or greater (out of 30) on the Structured Mini-Mental Status Examination (SMMSE; Molloy and Standish, 1997). After screening, participants provided their informed consent via an online form. Ethics approval for this study was obtained from the Swinburne University Human Research Ethics Committee.

2.3 Setting

The study was conducted from September to November 2020. All participants resided in metropolitan Melbourne, Australia at the time of the study. During this time, Melbourne was subject to COVID-restrictions, including a “hard lockdown” until October 26 which meant that participants were only allowed to leave their home for four permitted reasons: shopping for essential goods or services, to work or study if not possible from home, seeking or providing care, and for outdoor exercise up to two hours a day. Four of the five participants completed the entire program under these lockdown conditions, while the final participant (“Wayne”) completed the study under less restrictions (i.e., individuals can leave home for any reason within a 25 km travel radius).

2.4 Measures

During screening, demographic details were collected including gender, age, country of birth, education level, employment status, and living arrangements. In addition, participants completed a shortened 20-item version of the SMMSE (Molloy & Standish, 1997), modified by removing items (questions 2d, 2e, 6, 7, 9, 10, 11 and 12) that could not be administered by video-conference. Revised scores were calculated by converting the shortened score to a percentage, then comparing this against an equivalent score of 24 out of 30 on the full SMMSE (pass mark was an equivalent score of 24/30 = 80%), as per the SMMSE guidelines (IHACPA, 2019). The time spent administering sessions, transcribing sessions, and compiling the final generativity documents was recorded. In addition, within one week of finishing the program, participants completed a shortened version of the Participant Feedback Questionnaire used in previous Dignity Therapy research (Bentley et al., 2020; Chochinov et al., 2011), removing items that were not directly relevant to a community sample, or more relevant to the terminally ill (e.g., “DT increased my will to live”).

2.5 Procedure

Screening, TDT sessions and feedback interviews were completed online via Coviu, a secure video-based telehealth platform, except for when connection difficulties occurred, at which time the session continued via telephone. The one-hour TDT sessions were conducted weekly and guided by the ten questions outlined by Chochinov (2012). All TDT sessions were delivered by JF, a PhD candidate and provisional psychologist with experience delivering Dignity Therapy face-to-face in residential aged care.

Sessions were audio recorded and transcribed using the artificial intelligence powered Otter.ai and errors were corrected by JF. The transcript was further edited to improve the flow and readability of the text (e.g., removing superfluous speech such as “um”, placing events in chronological order). After participants communicated that they were satisfied that all questions had been answered, JF compiled the transcripts together into a single Generativity Document, making several minor adjustments again to improve the flow and readability of the writing. Then, JF emailed the Generativity Document to the participant to read over before meeting again to discuss any changes or additions the participant wanted to make. Finally, each participant’s Generativity Document was bound and mailed to them as a memento.

Participant feedback interviews were conducted by JF after each TDT session, asking participants about any practical issues that arose for them. After the completion of TDT sessions for the participant, JF and the participant met on two to three occasions (one week to three-months post-program). Participants were interviewed on several occasions across different timepoints in order to thoroughly investigate the immediate and longer-term benefits of the program. Feedback interviews were conducted via videoconferencing, averaged 19-minutes in duration per session, and followed a semi-structured interview guide (see Appendix) prompting participants to describe the effects they had experienced as a direct result of their participation.

2.6 Analysis

Data were analysed using Braun and Clarke’s (2006, 2019a) six-stage reflexive thematic analysis (RTA) process. This form of RTA highlights the active role of researcher(s) in generating themes within the data, and the inherent subjectivity of this process. RTA was chosen due to its potential to uncover rich descriptions of the data. Moreover, the flexibility of RTA allows an approach which is both deductive – driven by pre-existing theory and research questions (e.g., benefits), and inductive – allowing the themes to arise from the data. Themes were generated at a semantic level, focussing primarily on the explicit language used by participants, although consideration was given to the latent concepts and assumptions underlying the data.

We estimated that each participant would participate in four interviews (two following each TDT session and two following the entire program), totalling 20 interviews in total across five participants. Guidelines for adequate sample sizes within qualitative research vary significantly, often, a minimum of six to twelve interviews is advocated to achieve saturation (Guest et al., 2006). However, Braun and Clarke (2019b) advise that their form of RTA is not consistent with notions of saturation, as meaning is generated throughout analysis, rather than extracted from the data.

Qualitative analysis was conducted by JF (B.Sc Hons) and BE (PhD) – male psychology researchers with qualitative research experience. First, JF and BE familiarised themselves with the data, reading the transcripts in-full several times. Then, initial codes and themes were generated, before these themes were iteratively refined by both JF and BE through regular meetings, discussing the current theme map aiming to attain richer descriptions of the data, and deliberating how best to name, define and demarcate themes. This paper was drafted in accordance with guidelines set out in Standards for Reporting Qualitative Research (SRQR; O’Brien et al., 2014).

3 Results

3.1 Participant Demographics

Thirty-seven prospective participants expressed their interest in the study. The first five were selected to be screened for the current study, while the remaining were placed on a waitlist for a future study. All five participants (four females, one male; Mage = 73.77 years) were found eligible to participate and consented to the study. No attrition occurred during the study, i.e., all participants successfully completed TDT. See Table 1 for demographic information of the sample.

Table 1 Participant demographics
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3.2 Modalities Used

All sessions were completed via telehealth, except for two sessions when internet connections difficulties arose, and the session continued via voice-call. After all Dignity Therapy sessions were completed, the participants were emailed their Generativity Documents and the editing process was conducted via email.

3.3 Acceptability

Participants’ reported acceptability of TDT is presented in Table 2, alongside data from a pilot for an online Dignity Therapy for individuals with terminal illness conducted by Bentley et al. (2020).

Table 2 Results of participant feedback questionnaire compared to Dignity Therapy online for people with terminal illness (Bentley et al.(2020))
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3.4 Practicality

On average, the researcher providing TDT spent approximately eight hours conducting the therapy protocol per participant, comprising approximately 2.4 h conducting TDT sessions with each participant, 4.5 h transcribing sessions (editing errors from the automatically generated transcription), and 1.5 h editing Generativity Documents. The average word count of the Generativity Document was approximately 7000 words, which was approximately 3000 less than in Bentley et al. (2020). See Table 3 for more detailed statistics for both the present study and Bentley et al.

Table 3 Therapist time and word length statistics for the present study compared to Bentley et al. (2020)
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All five participants reported no “major” technological issues, while four of five participants described “minor” problems including: internet connection issues (unresolved for two sessions which continued via phone), problems editing their Generativity Documents on Microsoft Word (e.g., using Track Changes), and issues related to iPad-desktop compatibility. Despite this, all issues were resolved promptly, and all five participants commented that the numerous benefits outweighed these minor setbacks; e.g., the convenience of not having to travel to and from sessions, the comfort of completing sessions at-home in a safe and nurturing environment.

All five participants completed the entirety of TDT, creating a Generativity Document in 2.4 sessions, on average (range = 2–3 sessions).

3.5 Benefits

Participants reported experiencing several benefits from TDT. Thematic analysis identified five themes in the data: inscribing one’s legacy, a deeper connection to others, triggering new self-insight, an integrated and strengthened view of self, and accepting the past with self-compassion.

3.5.1 Inscribing One’s Legacy

Participants spoke about how TDT provided them a unique opportunity to document their stories. Moreover, the Generativity Document acted as a physical legacy that could be passed on to loved ones and future generations. Rochelle stated:

I really enjoyed telling my story. It felt good to get it all out, to bring it to light, and have it all written down…My daughter seemed to like reading it. I think she got plenty out of it. (Rochelle)

Pippa reported that she had grown up in a culture that did not promote the “sharing of feelings”. She stated that the process of TDT and the therapist acting as a conduit to her loved ones provided her an opportunity to communicate sensitive matters that she would have felt uncomfortable discussing otherwise.

I like the idea of having a record that tells my family things that I’m not good at expressing face-to-face. (Pippa)

Wayne spoke about how he would have appreciated if his parents had participated in a similar project before they passed away. He stated that TDT provided him an opportunity to “not make the same mistake” and inscribe his legacy for his family.

It would have been nice to have known a little bit more about my parents’ view of the world. [My Generativity Document] is just a bit of a family record, if you like. Something that documents what I would like to pass on to other people… I think writing down some of life’s lessons can be very useful for other people. I think stories told in a narrative sense tend to last longer, more than a person’s life history. (Wayne)

In addition, Wayne used TDT as an opportunity to “supplement” his financial will.

Making a will requires quite a bit of thought. So I think it would be nice in some way to be able to write it out like I am here and to discuss it with them at some point… The will is more of a physical thing, whereas this document is more emotional; a story in context. So it’s putting flesh onto the will, if you like. And that’s the attraction of it, really. This document adds so much more than a simple will. (Wayne)

Taken together, the process of TDT afforded participants a unique opportunity to communicate with their loved ones in a manner they might not normally engage in face-to-face. In doing so, participants were able to inscribe their legacy the way they would like to.

3.5.2 A Deeper Connection to Others

The TDT process triggered conversations for several participants that helped them deepen their existing relationships and express gratitude for their friends and family. Pippa stated:

[TDT] helped me to be a bit more explicit with people at times… to open up and say, “I hope you really do know how much I love you, how much I’ve appreciated the support and help you’ve given me over the years, and how much I hope that I’ve been a similar support to you.”

… I felt comfortable showing it to [name removed] and saying to her for the first time, that for a long time I’ve thought of her as a sister by choice, if not by blood. And it’s not easy for me to say things like that to people. So I was really pleased that I managed to get it out. And I think she was very touched by it. (Pippa)

Additionally, several participants mentioned that the “intimate” connection forged with the TDT therapist was beneficial to them.

With my husband, we wouldn’t have talked at that level, very much at all, in all the time that we were together. It would take something really significant happening, like the death of a family member, before we would really get down to that level of intimacy – that mental intimacy, intimacy of the soul. (Sarah)

I’m honoured that I met you and you took the time to listen to me… I just thought it was going to be a little bit of a story of the things that I had told you, and that was it. Then I started reading it, and I realised I’d forgotten the way that I had spoken and what I had actually said. And I realised that, that I don’t know anyone that I have spoken to in such depth all about me. So it was a really precious time for me. (Wendy)

Participants reported their surprise and appreciation at the intimate nature of the content of TDT sessions, while TDT provided Pippa an opportunity to express her gratitude to a friend. In both cases, TDT helped create and strengthen bonds between the participants and others.

3.5.3 Triggering New Self-insight

Several participants highlighted the value of the dynamic exchange between themselves and the therapist, with such “feedback” from a willing listener, helping to trigger new self-insight.

One does quite an amount of self-analysis, especially during periods like this, when you’re stuck at home [during COVID-related lockdown]. I’ve been doing a lot of internal reflecting, and I think that this particular experience was kind of icing on the cake. And because it was shared; not an isolated self-experience. You know, talking to myself is different to talking to somebody else, like you. By doing it with you, I can get that feedback. Yes, it’s like playing tennis, hitting the ball against the wall instead of just practicing serving by yourself… So now, what we did together was more of the same [self-analysis], but in a different room with a different coloured light on. (Sarah)

We’re so used to being inside our own head and going down the same old path. Which is the value of someone like you to just gently ask “what about this?”, you know, someone there to walk with you… it reminded me of things. You know, how often do we sit down and consider what we’ve done? I appreciated that. (Wendy)

Pippa mentioned that TDT helped “challenge” long-existing patterns of behaviour, causing her to reflect and make necessary changes.

I think it’s been helpful for me as a process because, as I said, there are a lot of things that sort of came up that I’ve clarified for myself. Never having thought about them, questioned them, challenged them. Thinking that this is the way things are, and this is the way I am. And I think it has made me consider some of these things and think about how I might have done better, might have done more, might have made things easier on myself over the years. (Pippa)

In each of the cases highlighted above, and during interviews with other participants, they reported that the process of TDT – involving a dynamic “dance” of conversation – helped them see things from a new perspective, and challenge long-lasting patterns of behaviour and thought.

3.5.4 An Integrated and Strengthened View of Self

Several participants spoke about how the process of recounting their life narrative helped them to integrate the events of their lives – both the “positive and negative” – into a cohesive narrative.

[TDT] does let you reflect on those difficult things. And to say that, while yes, they were painful, they were difficult, they were not things that you would have wished on yourself or anyone else; but they weren’t entirely negative, you got something out of it somewhere. As I say, you can’t pay for experience. And that’s it, each thing gave you something new and different: another tool, another skill, another deeper understanding, another barrier that you didn’t fall down on. So I think it has been valuable to be allowed to look at those things in a more positive light instead of just the gloominess of it all. (Pippa)

[While reading my Generativity Document], I realised that I really like this person who I am today. And it took decades to get to that point. I mean, I still muck up, but that’s okay. I still like me. And I realised that all of those things that have happened in the past are like mulch. I’m not a gardener, but it’s like mulch – it’s all the shitty, horrible things. All the things that I thought that I could have done without, you know, I didn’t need that in my life at the time. And yet, if I didn’t experience them then the fruit that has grown from that, I would not have. It’s about coming to who I am today… and this [TDT] has been a valuable journey for me. (Wendy)

Some participants also shared how the TDT process helped engender a sense of personal resilience and strength. Rochelle stated:

I didn’t know what to expect when I first signed up for this study. And it was surprising the things that came out and the things that I learned about myself… I’m very resilient. (Rochelle)

This theme of resilience and inner resolve was also exemplified by Pippa who shared that she had recently been isolating herself from her friends and family due to some health concerns and the COVID restrictions, causing her to feel “down on [herself]”. However, by going through TDT and reflecting on her own story, she was able to realise that this behaviour was not aligned with the resilient and proactive approach to life that she had displayed in the past.

I was actually reading through the story you sent me last month. And I thought to myself: this isn’t you, hiding in your room, saying no to everything, sooking out because things aren’t going your way. This is not what you’ve done all your life. Why are you doing it now? So I joined the local pool, I’m going to hydrotherapy three times a week. And I’ve also signed up to do some volunteering.

… It’s not a thing I’ve ever really reflected on, because it’s always been, well, I’m stuck – what do I do? Do I sit still or do I go? And in the past, I’d go, because you’ve got to keep moving. I used to think that that just sort of happened. It wasn’t until I was reading the story that I remembered well, no, it doesn’t just happen. [In the past], you actually pulled your socks up and went out and did it. It really is an outcome from this. I think it would have taken me a lot longer to have got myself together and done something about it without that. (Pippa)

The process of TDT, and reflecting on the events of their life, helped participants integrate their narrative into a unified whole. Also, re-reading Generativity Documents appeared to engender a strengthened sense of self, and participants reported that this was above and beyond what may have occurred if the conversations were not transcribed and read at a later date.

3.5.5 Accepting the Past with Self-compassion

Participants spoke about how TDT helped them to accept and come to terms with the past.

… it has brought back memories of my childhood. Some good, some bad. I think it’s good to face these memories and to learn to live with them. I think I’ve become more accepting of them. If you can’t change it, you might as well accept it, right? (Rochelle)

[TDT] has helped put things in place, rather than having to lug all that around. Now I can say, I’ve nailed these issues down. I’ve thought about them, I’ve put them down. I no longer have to worry about them, and I’m comfortable with everything. I’ve come to terms with it, and resolved it. (Wayne)

Additionally, Wendy shared details of her childhood and a newfound compassion for her younger self.

As I read my story, I allowed myself to feel that ‘fragile-ness’ for That-Me. So yes, [TDT has] helped me to be more sensitive to myself… I’ve always been quite interested, intrigued, about my reactions as I grew up, and wondered why I kept on making the same mistakes again and again. But [TDT provided] that time of reflection and contemplation. I was able to look back into my time when I was in the two different homes as a baby. And even though maybe, intellectually, I may have understood it, but it’s almost as though, I lived it. (Wendy)

Wendy and other participants reported that they had always understood many of the lessons they had gleaned over the course of TDT from an intellectual standpoint, however, TDT helped transform this cognitive understanding to an emotional, or experientially lived, insight.

4 Discussion

We found that TDT was an acceptable and practical intervention that provided perceived benefits for participants. Compared to Bentley et al.’s (2020) online Dignity Therapy program for individuals with terminal illness, participants appeared to report similar levels of satisfaction with TDT. This suggests that community-dwelling adults experience Dignity Therapy in similar manner compared to the population that Dignity Therapy was originally designed for (terminally ill patients). In addition, the length of Generativity Documents in the present study was approximately 3000 words less than Bentley et al. Therefore, it appears that community-dwelling older adults produce more succinct documents, when compared to terminally-ill patients. Although this difference could be due to document editing and question delivery.

The time spent by the therapist completing TDT was marginally less than the equivalent statistic in Bentley et al. (2020). Bentley et al. noted that two (of six) participants in their study chose to solely engage via email, and these participants required less therapist time than the other telehealth participants. Conducting the procedure entirely via telehealth in the present study did not result in an additional time burden for the therapist, indicating that TDT is at least as timely and cost-effective as other online Dignity Therapy alternatives, and quicker than other face-to-face Dignity Therapy programs which can require up to 15 h of therapist time per participant (Hall et al., 2012). The timely nature of our study could also partially be due to the artificial intelligence software (Otter.ai) we used to automatically transcribe sessions, although significant time (4.5 h per participant) was still spent by the therapist correcting errors in the automatically generated transcripts.

Participants experienced TDT as an acceptable and practical program to engage with. Such high levels of acceptability are consistent with other dignity therapy research conducted face-to-face and with other populations (Bentley et al., 2014; Fitchett et al., 2015; Vergo et al., 2014), indicating that community-dwelling older adults experience TDT in a similar manner, and that conducting the program online did not negatively impact acceptability. Participants described several minor technological setbacks related to TDT, including issues resolving Track Changes and compatibility between iPad and desktop programs. Future studies should consider pre-empting similar technological issues occurring, and create a guide that addresses common problems. Nonetheless, all issues were resolved quickly, and all participants expressed their satisfaction with the online format. Further, no attrition occurred during the study, indicating these issues were manageable. Participants stated that the benefits of the online format outweighed the additional costs associated with face-to-face therapy (e.g., transport costs, convenience and comfort). Our findings suggest that the technological barriers for older adults engaging in telehealth (Kruse et al., 2020) are surmountable and the online modality can deliver significant benefits to this population. Taken together, these findings indicate that TDT is an acceptable and practical program for community-dwelling older adults.

In terms of potential benefits, all participants reported positive outcomes occurring as a result of their participation in the study. Participants commented on TDT helping them to strengthen existing relationships and to feel “heard”. Additionally, the TDT process provided an opportunity for participants to inscribe their own legacy for themselves and family members. It appears that this desire is not unique to those with terminal illness, and may represent a desire for those without prognosticated shortened lifespans. However, one participant planned to formalise this process in combination with his financial will, which may represent an approach that is unique to community-dwelling older adults that are afforded more time (compared to those with terminal illnesses) to consider the narrative they would like to communicate, and the legacy they would like to leave behind. The empathic and two-way communication between the therapist and participant also appeared to create an environment that fostered self-reflection and growth. Moreover, the TDT process helped participants view their lives through a narrative lens, appreciating their lives as a unified whole, making sense of their past sufferings and helping them forge a heightened sense of self-efficacy and resilience. Last, TDT appeared to enable participants to observe their past with a heightened sense of acceptance and self-compassion, rather than resistance and self-criticism. These reported benefits suggest that Dignity Therapy is an effective method for boosting the wellbeing of community-dwelling older adults.

4.1 Limitations

There are several limitations to the current study. Foremost, the impact of COVID-related restrictions and the climate of uncertainty and loneliness that such restrictions engendered should be carefully considered. Considering the links between social connection and wellbeing (Courtin & Knapp, 2017; Steptoe & Fancourt; 2019), it is possible that our findings are attributable to the assuagement of such loneliness and may not be replicable during other times. Second, the small sample size of the present study also limits the generalisability of our findings. Future research should apply TDT to a larger sample and to employ psychometric measures of wellbeing to quantify the efficacy of the program for community-dwelling older adults. Third, the same researcher conducted the TDT sessions and feedback interviews, which may have biased findings as participants may have been less likely to criticise TDT. Fourth, it is unknown whether the unique process of TDT helped foster the wellbeing of participants, or if participants reported improvements due to more generalised effects related to the therapeutic relationship (Chochinov et al., 2011; Rudilla et al., 2016). Therefore, future research should compare the effectiveness of TDT against other therapeutic approaches.

5 Conclusion

Nonetheless, the findings in the present study are promising and point toward the potential of TDT as a brief and effective life review therapy that may protect community-dwelling older adults from advancing to mental illness. Further, considering the increasing need for telehealth-based services (Zhou et al., 2020), our research puts forward TDT as a potential intervention that can be delivered remotely in an effective manner. It is imperative that more research focusses on preventative interventions so that therapists are able to proactively combat sub-clinical emotional distress, potentially lessening the proportion of individuals that advance to a diagnosable mental illness. In doing so, therapists can be afforded a larger toolkit to apply to individuals experiencing differing levels of emotions distress, thus not only ameliorating the negative ramifications of our rapidly ageing society, but also fostering a milieu of wellbeing and flourishing into late life.