An internet-based self-help intervention for older adults after marital bereavement, separation or divorce: study protocol for a randomized controlled trial

Marital bereavement and separation or divorce are among the most stressful critical life events in later life. Both events imply a dissolution of social and emotional ties. This deeply affects the attachment system, and requires acceptance of the loss as well as the formation of a new identity and a new perspective for the future. Both events involve the adaptation of daily routines, which can be even more challenging when social, physical and financial resources decline in later life [1].

Grief and psychological distress after bereavement or divorce are normative reactions. For most people, grief intensity weakens to a manageable degree within several weeks or months. After the most intensive period, grief is still present but the loss becomes gradually integrated and no longer hinders the processes of ongoing life. However, some individuals are less able to cope with bereavement or divorce and show severe prolonged grief symptoms or adaptation problems lasting more than 6 months [2–5]. Some individuals even develop a persistent complex bereavement disorder, which is characterized by separation distress, frequent or disabling cognitive, emotional and behavioural symptoms, such as avoidance of reminders of the loved one, difficulties moving on with life and functional impairment [6, 7].

Several theoretical models describe factors that are crucial for an adaptive adjustment to bereavement. The task model identifies four tasks of mourning, namely, accepting the reality of the loss, experiencing the pain of grief, adjusting to an environment without the deceased person, and withdrawing emotional energy and reinvesting it in another relationship [8]. The dual-process model of coping with bereavement posits that a dynamic coping process oscillating between loss-oriented tasks, such as grief work, and restoration-oriented tasks, such as attending to life changes, is essential for adjustment [9]. Coping with loss-oriented tasks involves positive reappraisal versus rumination, revisions of personal goals, positive and negative event interpretation, and expressing emotions toward the deceased. Restoration-oriented coping is focused on attending to life changes, engaging in new activities, distracting from grief, and finding new roles and identities.

These models also provide a theoretical background for interventions ranging from self-help groups and pastoral care to psychotherapy. Cognitive-behavioural interventions for complicated grief are often based on three components: (1) exposure, e.g. the confrontational technique of ‘revisiting’ the deceased person or telling the story of the loss; (2) cognitive reappraisal or restructuring of individual dysfunctional thoughts (e.g., guilt, anger) associated with the loss; and (3) integration and restoration [10, 11]. Internet-based interventions increasingly complement grief counselling or therapy [12–15]. The majority of internet interventions combine the presentation of a web-based self-help programme with minimal but regular therapist contact. In a recent meta-analysis, this internet-based guided self-help approach has proved to be as effective as face-to-face therapy for depressive symptoms, social anxiety disorder and other psychological or somatic disorders [16]. Furthermore, internet-based interventions have advantages over face-to-face therapy. Benefits of internet-based approaches are low threshold accessibility, flexible usage, independent of time and place, usage at a self-determined pace, a high level of autonomy and privacy, and lower costs [17]. These factors may be especially relevant for older adults. However, challenges of internet-based interventions include technological problems and lower computer literacy or unease using computers, which may be more prevalent in old age.

Exposure, cognitive reappraisal, and integration and restoration as treatment components have also been implemented and evaluated in two randomized controlled trials of internet-based self-help interventions for complicated grief after bereavement. One 5 week internet-based intervention consisted of two writing assignments a week of approximately 45 min [12]. After every second assignment, participants received an email from a therapist with personal feedback and further instructions. This intervention addressed individuals who experienced symptoms of intrusion, avoidance, or maladaptive behaviour after the death of a significant other. The average age of the 55 participants was 37 years; all were women; 61% had lost a child and 10% their spouses. Effect sizes (Cohens d) for the comparison with the waiting group ranged from 0.96–1.74 for different outcome measures. Follow-up measures at 18 months confirmed the stability of these effects [18].

Another internet-based intervention comprised five structured confrontational writing assignments for individuals who experienced the death of a first-degree relative and who were significantly distressed [13]. The average age of the 757 participants was 43 years; 94% were women; 43% lost a child and 30% their spouses. Effect sizes ranged from 0.19 for emotional loneliness to 0.30 for positive mood for short-term follow-up and 0.25 and 0.23 for long-term follow-ups. These effects were mediated by lower rumination. However, grief and depressive symptoms did not improve. Risk and baseline distress were not confirmed as moderators.

In contrast with these two studies, Litz and colleagues evaluated an internet-based intervention focusing on self-care, social reengagement and goal-focused activities [14]. No formal exposure or cognitive reappraisal was included. Their randomized controlled trial targeted participants between 3 and 6 months after loss and aimed at exploring whether their intervention could prevent prolonged grief disorder. The intervention consisted of 18 sessions covering about 6 weeks, an initial phone call, and periodic brief emails from a therapist. The average age of the 84 participants was 55 years; 68% were women; 78% lost their spouses. The intervention resulted in Cohens d of 1.10 for the reduction in prolonged grief, 0.71 for depression and 0.51 for anxiety.

Finally, a recent study compared an internet-based exposure and behavioural activation treatment [15]. The therapist-guided interventions consisted of six homework assignments over 6–8 weeks and a short feedback after each assignment. The 47 participants were randomly allocated to the two active treatment conditions and a waiting control group. The mean age was 46 years; 92% were women; 40% reported the death of a partner and 60% reported other losses. Both interventions reduced complicated grief, post-traumatic stress, and grief rumination, but only exposure had an effect on depression and brooding levels relative to the control group. Effect sizes ranged between d = 0.07 and d = 1.2. The effects of both interventions were maintained at the 3-month follow-up assessment. To the best of our knowledge, no internet-based self-help intervention has been evaluated for divorced individuals.

The results of this study will provide insight into the acceptance and efficacy of an internet-based self-help intervention for adults who experience grief symptoms, psychological distress or adjustment problems in daily life after marital bereavement or separation or divorce. The outcomes for bereaved and separated or divorced participants will be compared. The analysis of other moderator variables may further aid future selective indication and adaptations for different needs.

Limitations of this study include the self-selectivity of the sample. It may be possible that older adults who are willing to take part in an internet-based self-help intervention have more cognitive resources and a higher education level.