The effectiveness and underlying mechanisms of a psychological treatment for people who lost loved ones in the Plane Crash Ukraine

Almost 300 people died after the Plane Crash in Ukraine on the 17th of
July 2014. Acute grief complaints are the expected response to the loss of a
loved one. Acute grief reactions decrease to an acceptable level after 6 months
for the vast majority (Bonanno, et al., 2002; Bonanno, Wortman, & Nesse, 2004).
When grief reactions persist or increase it can be defined as Persistent
Complex Bereavement Disorder (PCBD) (Shear, et al., 2011). Approximately 5 to
10% of bereaved individuals develop PCBD (Middleton, Raphael, Burnett, &
Martinek, 1998; Prigerson, et al., 2009). For those who lost a loved one due to
a disaster, estimated percentages of PCBD range from 40 to 70% (Ghaffari-Nejad,
Ahmadi-Mousavi, Gandomkar, & Reihani-Kermani, 2007; Neria, et al., 2007). PCBD
is associated with, yet distinct from Posttraumatic Stress Disorder (PTSD) and
major depressive disorder (MDD) (Boelen, van de Schoot, van den Hout, de
Keijser & van den Bout, 2010; Prigerson, et. al., 1996).
Various interventions are developed for those who experience a distorted
grieving process. However, many intervention-studies lacked a strong design and
results are unstable (Currier, Holland & Neimeyer, 2010). More robust research
into the effectiveness of grief treatments is needed to adequately support
bereaved persons who develop psychopathology.
The effectiveness of cognitive behavioral therapy (CBT) and eye movement
desensitization and reprocessing (EMDR) in the treatment of PTSD and related
disorders has been studied in diverse populations (see for example the review
of Ponniah & Hollon, 2009). Preliminary results of an intervention study among
homicidally bereaved persons with PCBD show the beneficial effect of CBT
combined with EMDR (van Denderen, de Keijser, & Boelen, in preparation). The
CBT-part of the latter study aims at changing maladaptive thoughts and
diminishing avoidance behavior, while EMDR aims at integrating intrusive
memories that are related to the loss. We hypothesize, based on previous
studies, that CBT and EMDR are effective in reducing PCBD as well as PTSD and
MDD among bereaved persons who lost a relative due to the Plane Crash Ukraine.

The primary aim of this study is to evaluate the effectiveness of CBT and EMDR
in reducing PCBD, depression and posttraumatic stress complaints in relatives
of the Plane Crash Ukraine victims. The second aim is to study to what extent
the treatment effect is mediated by reduction of maladaptive thoughts,
avoidance behavior and/or intrusive memories.

By conducting a two-arm (intervention after 18 months versus intervention after
21 months) randomized controlled trial, we aim to fulfill both study
objectives. The participants are asked to fill in questionnaires prior to the
treatment and within one week, 12 and 24 weeks post treatment.

The intervention consists of eight sessions: Session 1 is an introductory
session, in session 2 mourning in the family is discussed. In session 3, 4, and
5 eye movement disensitization and reproccessing (EMDR) is applied, which take
up to 90 minutes. In session 6, 7, and 8, cognitive behavioral therapy (CBT) is
used. These sessions last up to 45 minutes.

By handing out a manual (based on the manual of the homicide-study) the
participant will receive psycho-education and learn how to handle maladaptive
thoughts.

Filling in the questionnaires could evoke painful thoughts or feelings related
to the death of the loved one(s). The treatment could lead to a temporary
increase in distress. Different studies with trauma victims and bereaved
individuals showed that CBT and/or EMDR does not lead to increase of
psychological distress after treatment (Currier, Holland, & Neimeyer, 2010;
Ponniah & Hollon, 2009).