Internet-Based Exposure and Behavioral Activation for Complicated Grief and Rumination: A Randomized Controlled Trial

doi:10.1016/j.beth.2015.05.007

Behavior Therapy

Volume 46, Issue 6, November 2015, Pages 729-748

https://doi.org/10.1016/j.beth.2015.05.007 Get rights and content

Highlights

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Research supports the effectiveness for face-to-face CBT for complicated grief
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Research on internet-based CBT for complicated grief is limited
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Online exposure (EX) and behavioral activation (BA) were examined in an RCT
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EX and BA reduced complicated grief and rumination at post-test and 3-month follow-up
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Intent-to-treat and completers analyses were consistent for EX but not for BA

Abstract

This study examined the effectiveness and feasibility of therapist-guided Internet-delivered exposure (EX) and behavioral activation (BA) for complicated grief and rumination. Forty-seven bereaved individuals with elevated levels of complicated grief and grief rumination were randomly assigned to three conditions: EX (N = 18), BA (N = 17), or a waiting-list (N = 12). Treatment groups received 6 homework assignments over 6 to 8 weeks. Intention-to-treat analyses showed that EX reduced complicated grief, posttraumatic stress, depression, grief rumination, and brooding levels relative to the control group at posttreatment (d = 0.7–1.2). BA lowered complicated grief, posttraumatic stress, and grief rumination levels at posttreatment (d = 0.8–0.9). At 3-month follow-up, effects of EX were maintained on complicated grief and grief rumination (d = 0.6–1.2), and for BA on complicated grief, posttraumatic stress, and grief rumination (d = 0.8–0.9). EX reduced depression more strongly than BA (d = 0.6). Completers analyses corroborated results for EX, and partially those for BA, but no group differences were detected. BA suffered from high dropout (59%), relative to EX (33%) and the waiting-list (17%). Feasibility appeared higher for EX than BA. Results supported potential applicability of online exposure but not behavioral activation to decrease complicated grief and rumination.

Section snippets

Study design

Ethical approval for the present study was provided by an official Dutch Ethical Review Board. Participants were recruited through advertisements on websites and Facebook pages of organizations for bereaved individuals, and on the content network of Google from May 2013 through January 2014. People who were interested in participation could link through to a website specifically designed for the current project. On this website they could read general information about the study (e.g., on goals

Randomization Check

Before conducting the main analyses, we performed a randomization check by comparing all groups at baseline on all variables using chi-square tests and ANOVAs. No baseline group differences were found on demographic and loss-related variables, or on levels of complicated grief, posttraumatic stress, anxiety, grief rumination and reflection. However, we did find significant baseline differences between groups on depressive symptoms, F(2, 44) = 3.49, p = .04, and brooding, F(2, 44) = 5.26, p = .01.

Discussion

In the current study, we set out to examine the effectiveness and feasibility of two different modules of brief therapist-guided online CBT for people experiencing elevated levels of complicated grief and grief rumination: exposure and behavioral activation. Our intention-to-treat analyses showed that, compared to a waiting list control group, each intervention resulted in large effects on the two core variables of interest, complicated grief and grief rumination, at postmeasurement, and that

Conflict of Interest Statement

The authors declare that there are no conflicts of interest.

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Letter to the editor: In-depth understanding of prolonged grief disorder: Analysis based on a development atlas
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The self-help app My Grief: Bereaved parents' experiences of helpfulness, satisfaction and usability
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Mobile health (mHealth) apps have been shown to be useful to monitor and reduce mental health problems across a variety of stress-related and affective disorders, yet research on the value of apps for prolonged grief is scarce. Therefore, the main aim of this study was to elucidate bereaved parents' experiences of using the self-help app My Grief with a focus on helpfulness, satisfaction, and usability. Data were derived from closed-ended and open-ended questions administered at the 3-month post-assessment of the intervention group (n = 67) within a randomized controlled trial testing the effects of access to the My Grief app. The sample consisted of 88 % women, with a mean age of 47 years, who predominantly lost their child to cancer (41 %), on average 4.8 years ago. Participating parents indicated that the My Grief app helped them increase their knowledge about prolonged grief and track their grief over time. The app was experienced as easy to navigate and around half of the parents used the app more than one day a week. Almost all parents were satisfied with the app and would recommend it to other parents in similar situations. The findings add to the knowledge base justifying mHealth within support systems for bereaved adults.
Self-guided online treatment of disturbed grief, posttraumatic stress, and depression in adults bereaved during the COVID-19 pandemic: A randomized controlled trial
2023, Behaviour Research and Therapy
This randomized-waitlist controlled trial is the first study examining short-term effects of a self-guided online grief-specific cognitive behavioral therapy (CBT) in reducing early persistent complex bereavement disorder (PCBD), posttraumatic stress disorder (PTSD), and depression symptoms in adults bereaved during the COVID-19 pandemic.
Sixty-five Dutch adults, bereaved at least three months earlier during the pandemic, with clinically-relevant PCBD, PTSD, and/or depression symptoms, were allocated to a treatment (n = 32) or waitlist condition (n = 33). Telephone interviews were conducted to assess PCBD, PTSD, and depression symptoms (using validated instruments) at baseline, post-treatment, and post-waiting period. Participants received an eight-week self-guided online grief-specific CBT including exposure, cognitive restructuring, and behavioral activation assignments. Analyses of covariance were performed.
Intention-to-treat analyses indicated that people in the intervention condition showed significantly lower PCBD (d = 0.90), PTSD (d = 0.71), and depression (d = 0.57) symptom-levels post-treatment relative to waitlist controls post-waiting, while taking baseline symptom-levels and use of professional psychological co-intervention into account.
The online CBT proved to be an effective intervention, reducing PCBD, PTSD, and depression symptoms. Pending replication of these findings, early online interventions may be widely implemented in practice to improve treatments for distressed bereaved people.
Cognitive-Behavioral Therapy for Complicated Grief Reactions: Treatment Protocol and Preliminary Findings From a Naturalistic Setting
2023, Cognitive and Behavioral Practice
In bereavement, some individuals develop complicated grief reactions (CGR), including symptoms of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression. Symptoms of PGD often co-occur with other complicated grief reactions, e.g., PTSD and depression, pointing to the need for a transdiagnostic understanding of CGR to inform treatment. In this paper, a transdiagnostic cognitive-behavioral therapy for CGR called “CBTgrief” is explained, including its theoretical framework and treatment content. CBTgrief is based on previous cognitive-behavioral conceptualizations of PGD, PTSD, and depression and includes 12 sessions consisting of exposure, cognitive restructuring, and behavioral activation. Preliminary findings of CBTgrief are evaluated in terms of feasibility, acceptability, and treatment satisfaction in a sample of eight older bereaved individuals treated for different types of CGR in a naturalistic clinical setting. Additionally, theory-driven hypotheses about changes in CGR and theoretical proposed core maintaining processes are evaluated using Bayesian informative hypotheses testing. Preliminary findings, limitations, implications, and future directions are discussed.
Factors Associated With Treatment Response in an Internet-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement
2023, Behavior Therapy
Internet-based psychological interventions have proven effective in the treatment of prolonged grief disorder (PGD). Yet, some patients do not benefit from treatment in a clinically significant way. We aimed to examine predictors of symptom reduction in an Internet-based intervention for PGD after cancer bereavement, in order to identify possible treatment mechanisms and discern directions for future intervention design. A secondary analysis of data from a randomized wait-list controlled trial on an Internet-based intervention for PGD after cancer bereavement was conducted. Multiple regression models were used (1) to test for the influence of pretreatment PGD, working alliance, avoidance and gender on PGD symptom reduction; and (2) to explore further predictors of treatment success with a best subset selection protocol. The regression models explained 18% (Model 1) and 34% (Model 2) of variance in symptom reduction. Participants with more favorable symptom change had more severe pretreatment PGD scores and better working alliance. Those with lower social support and less posttraumatic growth experienced more PGD symptom change. In conclusion, therapeutic alliance is an important factor that should be monitored and fostered. Findings regarding social support and posttraumatic growth need further replication and clarification.
LIVIA-FR: Implementation and evaluation of an Internet-based intervention for French-speaking people struggling to cope with the loss of their partner
2022, Annales Medico-Psychologiques
LIVIA est une intervention psychologique par Internet en dix modules sur une durée de trois mois pour personnes présentant une souffrance psychique après la perte de leur partenaire par décès, séparation ou divorce. Traduite d’un programme allemand dont l’efficacité a été démontrée par une étude randomisée contrôlée, la version française de LIVIA a été proposée en Suisse romande, en version non guidée, dans le cadre d’une étude d’implémentation pilote visant à en vérifier l’accueil.
Sur 148 personnes inscrites suite à une présentation du programme dans des journaux ou à la radio, 24 ont participé intégralement à l’essai clinique et ont fourni les mesures de prétest et posttest sur leurs symptômes de deuil, d’anxiété et de dépression, leurs modes d’adaptation à la perte, leur support social, leur sentiment de solitude ainsi que leur bien-être. Elles ont pu également exprimer leur degré de satisfaction vis-à-vis du programme et formuler des commentaires à son sujet.
La médiane de participation au programme est de six modules : dix personnes ont réalisé neuf à dix modules, cinq ont accompli moins de la moitié des séances prévues. Des bénéfices significatifs ont été observés sur les symptômes de deuil et sur les stratégies d’évitement. Aucune autre amélioration n’a été relevée sur la symptomatologie dépressive, anxieuse, sur le bien-être, la satisfaction existentielle ou encore la solitude. La satisfaction vis-à-vis de l'intervention est globalement bonne. Néanmoins, quelques points négatifs ont pu être relevés : les textes explicatifs ont été jugés complexes et les exercices de confrontation plutôt pénibles, surtout en l’absence de soutien d’une personne ressource. Ceux-ci ont pu favoriser la diminution de l’engagement dans le programme.
LIVIA, dans sa version française non guidée, permet de réduire la symptomatologie du deuil et les stratégies d’évitement suite à un décès ou une séparation. Le programme mérite cependant des améliorations pour satisfaire un public plus large et améliorer son adhésion à la démarche.
The loss of a partner, either by death or separation, is one of the most stressful life events. It predicts negative physical and psychological health consequences. Although most people are able to cope with it, however about ten percent show difficulties overcoming this painful event. Internet psychological interventions are increasingly present. They are as effective as traditional psychotherapies for a wide range of disorders, including complicated grief. They can improve the access to treatment, particularly where availability of therapists is low. Without such access the mental health of people with serious bereavement or separation difficulties, who for various reasons cannot benefit from a mental health professional, may deteriorate. Early access to an online intervention can thus be a useful and alternative way to diminish the risk of psychopathological trajectory for them. The goal is to evaluate the implementation of LIVIA, an unguided Internet-based intervention for French-speaking people struggling to cope with the loss of their partner through bereavement, divorce or separation. Brodbeck and colleagues have demonstrated its efficacy in the German guided version.
In this non-randomized clinical trial, 24 participants were included. They completed the French version of LIVIA, which contains ten modules including a psychoeducational section and exercises based on cognitive-behavioral techniques. The evolution of psychopathological symptoms such as grief, anxiety, and depression, as well as well-being were evaluated. Other parameters were measured: avoidance strategies, social support, loneliness and satisfaction regarding the program.
The median of program participation is six modules: ten people completed nine to ten modules, five completed less than half of the planned sessions. Clinical benefits were observed on grief symptoms and avoidance strategies. No other improvement was noted on depressive symptomatology, anxiety, well-being, life satisfaction or loneliness. The overall satisfaction with the intervention was good. Nevertheless, some negative points were noted: the explicative texts were considered to be complex and the confrontation exercises rather difficult, especially without the support of a resource person. These points could lead to a decrease in commitment to the program.
LIVIA, in its unguided French version, helps reduce grief symptoms and avoidance strategies following a death or separation. However, the program needs to be improved in order to satisfy a broader public and improve its adherence to the intervention.

View all citing articles on Scopus

^☆: This research was supported with a ZonMw TOP grant of the Dutch Association for Scientific Research (NWO), grant number: 91208009. We would like to thank Cor Nesse and Dienie van Wijngaarden for providing therapeutic assistance to our participants.

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Internet-Based Exposure and Behavioral Activation for Complicated Grief and Rumination: A Randomized Controlled Trial☆

Highlights

Abstract

Section snippets

Study design

Randomization Check

Discussion

Conflict of Interest Statement

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Lancet

Behavior Therapy

Psychiatry Research

Journal of Affective Disorders

Cognitive and Behavioral Practice

The Lancet

Behaviour Research and Therapy

Clinical Psychology Review

Diagnostic and statistical manual of mental disorders

What makes internet therapy work?

Cognitive Behaviour Therapy

Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis

PLoS ONE

Are the parts as good as the whole? A meta-analysis of component treatment studies

Journal of Consulting and Clinical Psychology

Treatment of complicated grief: A comparison between cognitive behaviour therapy and supportive counseling

Journal of Consulting and Clinical Psychology

Factors associated with outcome of cognitive-behavioral therapy for complicated grief: A preliminary study

Clinical Psychology and Psychotherapy

Anxious and depressive avoidance and symptoms of prolonged grief, depression and post-traumatic stress disorder

Psychologica Belgica

Reliability and validity of the Dutch version of the Inventory of Traumatic Grief (ITG)

Death Studies

A cognitive-behavioral conceptualization of complicated grief

Clinical Psychology: Science and Practice

Grief processing and deliberate grief avoidance: A prospective comparison of bereaved spouses and parents in the United States and the People’s Republic of China

Journal of Consulting and Clinical Psychology

Treating prolonged grief disorder a randomized controlled trial

JAMA Psychiatry

Statistical power analysis for the social sciences

The effectiveness of psychotherapeutic interventions for bereaved persons: A comprehensive quantitative review

Psychological Bulletin

Is rumination after bereavement linked with loss avoidance? Evidence from Eye-tracking

PLoS ONE

“Waarom is dit mij overkomen?” Ontwikkeling en validatie van de Utrechtse RouwRuminatieSchaal

Gedragstherapie

Avoidance processes mediate the relationship between rumination and symptoms of complicated grief and depression following loss

Journal of Abnormal Psychology

Development and psychometric evaluation of the Utrecht Grief Rumination Scale

Journal of Psychopathology and Behavioral Assessment