Psychological interventions for familymember and partners of murdered persons

There are indications that the circumstances surrounding a murder may lead to
complicated grief in survivors. Several factors negatively affect the course of
a grieving process. One of such is the manner of death: a sudden, violent,
destructive death that occurs in traumatic circumstances contribute to
complicated grief (Sprang, 2001): survivors of murder have a six times higher
change to experience complicated grief in comparison to persons who lost a
loved one through a natural cause of death. Survivors therefore have an
increased risk of physical and psychological symptoms, including intrusions
about the murdered person and the conditions (Dann Miller, 2002; Rynearson &
Geoffrey, 1999) and an increased risk of developing post-traumatic stress
disorder (PTSD). Based on the biobehavioral model of Shear et al (2006), it is
assumed that PTSD and complicated grief disrupt the normal grieving process, by
recurrent intrusive thoughts of the deceased and the circumstances surrounding
the death. Recently we developed a treatment program based on Murphy (2006) and
Marcus et al (2004), which makes use of EMDR (www.EMDR.nl, Solomon & Shapiro,
1997) and cognitive behavioral therapy (CBT), which are aimed to reduce anger
and intrusions.

There are few concrete figures about the number of people who suffer from
complicated grief, after their family member or partner is murdered. The study
done by Murphy (2005) gives some idea about the scale of the problem. Murphy
investigated the influence of different causes of death on the grieving process
of parents. 173 parents were observed, respectively 4, 12, 24 and 60 months
after their child was deceased by accident, homicide or suicide.
The study showed that parents whose child was murdered, experienced
significantly more PTSD symptoms than parents whose child died by accident or
suicide: 60% of women and 40% of men experienced PTSD symptoms four months
after their child was murdered. This group also experienced more mental stress,
less marital happiness and less acceptance of the death of their child.
Suicide survey also shows that families of people who committed suicide
experienced much more complicated grief after three months than families of
persons who died by a natural cause.

The present study aims to determine to what extent targeted help, according to
this treatment program, to relatives and partners of murdered people helps to
treat complicated grief and PTSD (Murphy, 2006, Shear et al 2006).
The first question being explored is whether the expected benefits of the
intervention on the grief of relatives and partners of a murdered person is due
to reducing the frequency of intrusions, reducing avoidance behavior, the
reduction of intrusive memories related to murder and correct dysfunctional
cognitions. Understanding these variables is not only theoretically important
but can also provide clues to adjust and increase effectiveness of the
intervention. In addition, we want to gain insight into the variables that may
mediate the intervention and variables that moderate the effectiveness of the
intervention.

Survivors in other populations have shown that contact with fellow sufferers
(Andriessen, 2004), meaning (Armour, 2004; Neimeijer, 2001) and resilience
(Bonanno, 2006; Salloum & Rynearson, 2006) have a positive effect on
bereavement. The influence of these factors has not been studied in survivors
of murder. The second question of this project is to what extent these factors
mediate the grieving process. These questions will be examined in the context
of the aforementioned intervention effectiveness research.
In a separate study we examine the impact of the intensity and the satisfaction
of revenge on the grieving process in the population here described. There is
little research known about the role of revenge after killing and the impact on
the grief of survivors. We do not know whether the responses are comparable to
murder and genocide in war. For this reason we take exploratory questions about
this subject in this study. We examine the extent to which revenge after
murder, the (lack) of satisfaction and related factors such as perceived
injustice and sense of loss affect the grieving process. The results of this
study may help to understand the emotional problems after murder (including
complicated grief) and the way to treat these problems.

This study aims to determine to which degree the offered help - according to
our treatment program - for familymembers and partners of murdered persons
helps to treat complicated grief and PTSD (Murphy, 2006, Shear et al 2006) and
to gain insight into which variables mediate and moderate the effectiveness of
the intervention.

Participants will be randomly assigned to the intervention or control group.
The intervention group is offered the intervention after the pre-measure. The
control group will receive a pre-, post and follow-up measurement and then,
nine months after the interventiongroup, the intervention is offered to them.
In this way, measure influence will be controlled and all respondents have the
opportunity to participate in the intervention.

We use repeated measurements, the minimum inclusion is 240 people (minimum
expected number of respondents after follow up: 88). For the data analysis, we
will mainly use variation analysis (ANOVA) with repeated measures to compare
the different groups over time. In each group must be at least 44 participants
included to achieve an adequate power (0.80 for a = 0.05) by a large effect
size. Based on previous research, we expect that only half of the initial
participants will participate in all measurement points. Taking this into
account, we will therefore recruit at least double the number of participants
(300 persons).

In our research we want to offer participants a combined intervention,
consisting of cognitive behavioral therapy and EMDR. This is partly based on a
cognitive behavioral theory of complicated grief (Boelen, van den Hout, & van
den Bout, 2006a). Boelen et al (2003) have found large differences between the
effects of natural and unnatural death and found that CBT is an effective
treatment for complicated grief. Boelen et al (2006) explain this with the
cognitive-behavioral conceptualization of complicated grief. In their model
about complicated grief, Boelen et al (2006) assumes that targeted cognitive
behavioral interventions can contribute to a reduction in emotional problems
after murder. Exposure to internal and external loss-related stimuli can
contribute for example to a reduction of fear and avoidance and to improve the
integration of the loss. Cognitive restructuring can help in changing
dysfunctional thinking patterns. In addition EMDR is used. Recent insights into
the effects of EMDR (Engelhard & Van den Hout, 2010) suggest that because of
the load on working memory in re-storing and retrieving negative memories, the
power of these memories is reduced by the additional stress of working with a
other task (eg eye fixations). Based on existing intervention study it is
assumed that exposure and cognitive techniques positively influence
respectively avoidance and cognitive distortion (Boelen et al 2007). It is
assumed that EMDR affect the memory of traumatic experiences (Solomon &
Shapiro, 1997). We want to examine to what extent the above mentioned mediating
factors can be influenced by intervention.

The intervention consists of: (i) introduction: psycho-education (1-2 meetings)
(II) Cognitive therapy and exposure (including EMDR) (6-8 meetings) (III)
rounding (1 meeting). Total 8 to 10 meetings.

The application of the described psychological intervention techniques -
cognitive therapy and exposure - has a healing effect on patients other than
the here described target group. We expect that the application to this target
group will not bring any additional burden or risk. Subjects will be asked to
fill in a questionnaire four times of about 45 minutes each time. This is an
additional burden which is asked to the participants prior to inclusion. We
think the benefits of participation in this investigation, a targeted
intervention to reduce symptoms, outweigh the disadvantage of this additional
burden. The participants in the waiting list control condition are first asked
to complete a questionnaire two times and receive after 9 months the
intervention. This waiting time can be stressful, but it is noted that subjects
in both conditions can continue to make use of usual case in addition to the
intervention, so no additional subjects are at risk.