Online cognitive behavioral therapy for traumatically bereaved people: A randomized waitlist-controlled trial

The primary aim of this study is to evaluate the effectiveness of an online CBT (vs. waitlist controls), in terms of reductions in PCBD, PTSD, and depression symptom-levels, for people who lost significant others due to traffic accidents. Our primary hypothesis is that people in the online CBT condition will show larger reductions in PCBD, PTSD, and depression symptom levels post-treatment than people in the waiting list control condition. The second aim is to explore to what extent treatment reductions in symptom levels during treatment are associated with reductions of negative cognitions and avoidance behaviors and the experience of fewer accident-related stressors. Lastly the effect of the quality of the therapeutic alliance as perceived by the participant and therapist on treatment effects and drop-out rates will be explored. A two-arm (online CBT and waiting list) open label parallel randomized controlled trial will be conducted. Participants are asked to fill in questionnaires pre-treatment, and 12 and 20 weeks after enrollment in the study. Eligible for participation are people who lost a family member, spouse, or friend at least one year earlier due to a traffic accident and report clinically relevant levels of PCBD, PTSD, and/or depression.

We expect that people allocated to the online CBT condition will show larger reduction at post-treatment assessments in symptom-levels PCBD, PTSD, and depression compared to waitlist controls (Hypothesis 1). We expect that greater reductions in symptom-levels of PCBD, PTSD, and depression for online CBT compared with waitlist controls will be related to reductions in negative cognitions (i.e., negative grief-related thoughts and self-efficacy), avoidance behaviour (i.e., depressive and anxious avoidance), state anger, and a sense of unrealness (Hypothesis 2a). In addition, we expect that accident-related stressors negatively impact symptom reductions of PCBD, PTSD, and depression for online CBT compared with waitlist controls (Hypothesis 2b). We expect that higher levels of therapeutic alliance are associated with better treatment outcomes and that higher dropout rates are related to lower therapeutic alliance (Hypothesis 3).

Pretreatment and 12 weeks and 20 weeks post-allocation

The online intervention is based on the cognitive behavioral model of complicated grief (Boelen, van den Hout, & van den Bout, 2006). This model states that disturbed grief, even after a long period of time, persists because of three modifiable interacting processes, namely 1) problems with elaborating and integrating the loss; 2) negative cognitions and catastrophic misinterpretations of one's own grieving reactions; 3) anxious and depressive avoidance behavior. Recent reviews (Boelen & Smid, 2017; Doering & Eisma, 2016) show that cognitive behavioral therapy (CBT) is an effective form of treatment. Online CBT (Eisma et al., 2015), in which a client is accompanied by a therapist via the internet, also appears to be effective. CBT consists of the following parts: • Psycho-education about common grief reactions and processes that might foster or hamper recovery in bereavement. • Exposure to counter avoidance. • Cognitive restructuring to identify and change unhelpful thoughts. • Behavioral activation, which consists of reengaging in previously valued activities (e.g., social or recreational activities). Picking up and continuing meaningful activities helps to break down inactivity and depressive avoidance of activities. All components together strengthen the elaboration and thus the integration of the loss in the autobiographical memory and thereby reduce PCBD.