An internet-based self-help intervention for older adults after marital bereavement, separation or divorce: study protocol for a randomized controlled trial
Brodbeck et al. Trials
An internet-based self-help intervention for older adults after marital bereavement, separation or divorce: study protocol for a randomized controlled trial
Jeannette Brodbeck 0
Thomas Berger 0
Hans Joerg Znoj 0
0 Department of Psychology, University of Bern , Fabrikstrasse 8, 3012 Bern , Switzerland
Background: Marital bereavement and separation or divorce are among the most stressful critical life events in later life. These events require a dissolution of social and emotional ties, adjustments in daily routine and changes in identity and perspectives for the future. After a normative grief or distress reaction, most individuals cope well with the loss. However, some develop a prolonged grief reaction. Internet-based self-help interventions have proved beneficial for a broad range of disorders, including complicated grief. Based on the task model and the dual-process model of coping with bereavement, we developed a guided internet-based self-help intervention for individuals who experienced marital bereavement, separation or divorce at least 6 months prior to enrolment. The intervention consists of 10 text-based self-help sessions and one supportive email a week. The primary purpose of this study is the evaluation of the feasibility and efficacy of the intervention compared with a waiting control group. The secondary purpose is to compare the effects in bereaved and separated participants. Furthermore, we aim to analyze other predictors, moderators and mediators of the outcome, such as age, psychological distress and intensity of use of the intervention. Methods: The design is a randomized controlled trial with a waiting control condition of 12 weeks and a 24-weeks follow-up. At least 72 widowed or separated participants will be recruited via our study website and internet forums. Primary outcomes are reductions in grief symptoms, depression and psychological distress. Secondary outcome measures are related to loneliness, satisfaction with life, embitterment and the sessions. Discussion: The trial will provide insights into the acceptance and efficacy of internet-based interventions among adults experiencing grief symptoms, psychological distress and adaptation problems in daily life after spousal bereavement, separation or divorce. Findings will add to existing knowledge by (1) evaluating an internet-based intervention specifically designed for spousal bereavement and its consequences; (2) testing whether this intervention is equally effective for individuals after separation or divorce; and (3) suggesting adaptations to improve the efficacy of the intervention, selective indication and adaptations for different needs. Trial registration: ClinicalTrials.gov, NCT02900534. Registered on 1 September 2016.
Bereavement; Depression; Divorce; Grief; Internet-based self-help; Older adults; Randomized controlled trial; Separation
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 .
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 . 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 . 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
webbased self-help programme with minimal but regular
therapist contact. In a recent meta-analysis, this
internetbased 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 . 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 . These factors may be especially
relevant for older adults. However, challenges of
internetbased 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 . 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
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 . 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
. 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 . 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
Based on the task model of mourning, and the
dualprocess model of coping with bereavement, we developed a
guided internet-based self-help intervention called LIVIA.
This intervention addresses individuals who experienced
marital bereavement or divorce at least 6 months prior to
enrolling in the study and are seeking help for coping with
prolonged grief symptoms, psychological distress or
adaptation problems in daily life.
This study adds to existing knowledge by (1)
evaluating an internet-based intervention specifically designed
for spousal bereavement and its consequences; (2)
testing whether this intervention is equally effective
for individuals who suffer from grief and psychological
or behavioural adaptation problems after a separation
or divorce; and (3) by including loss-oriented tasks,
i.e. exposure and cognitive reframing elements, as well
as restoration-oriented tasks, i.e. self-care, social
reengagement and goal-focused activities. The combination of both
components may increase effect sizes compared with
The severity of grief symptoms is not a criterion for
taking part in the study, but will be analyzed as a
moderator variable. We assume that the internet-based self-help
intervention leads to beneficial effects across the severity
dimension of distress. Individuals who have already
developed a prolonged grief disorder, but who are not willing to
see a counsellor or therapist, may benefit from the
comprehensive internet-delivered intervention. For individuals
with less severe distress, a timely intervention may help
to prevent the progress from a normal grief or separation
reaction to a prolonged grief disorder.
The objectives of the study are:
(1)To evaluate the effects of the guided internet-based
self-help programme compared with a waiting control
Grief symptoms, psychological distress and
depression (primary outcomes)
Loneliness, embitterment, satisfaction with life,
and session-related outcomes (secondary
(2)To analyze moderators for the efficacy of the
Spousal bereavement versus separation or divorce
Severity of grief symptoms, psychological distress
and depression at baseline
Age, sex and computer literacy
(3)To explore mediators for the efficacy of the
Frequency of use of the programme
This study is a randomized controlled trial with an
internet-based self-help intervention and a waiting
control condition. Figure 1 displays the study flowchart. The
study population are adults who experienced marital
bereavement or a separation or divorce more than 6
months prior to enrolment in the study. The self-help
intervention is embedded in a larger Swiss
populationbased longitudinal study on relationships in later life,
the LIVES study, IP 212 . The study coordinator
uses two separate lists for widowed and separated
individuals, to allocate participants to one of the conditions
based on computer generated random numbers using
Random.org . Participants in the waiting control
group receive access to the intervention 12 weeks after the
baseline interview. (The SPIRIT checklist is included as
Additional file 1.)
We specified the sample size needed for the different
analyses conducting a power analysis based on a
probability level of 0.05 and a power of 0.80 with G*Power
 and a power analysis calculator for structural
equation models . To test the efficacy of the intervention
compared with the control condition, we expected a
large effect of d = 0.80. Power analyses indicated a
necessary sample size of 42 individuals for this most basic
analysis. For the analysis of several predictor variables,
as well as moderation and mediation effects using
structural equation modelling, we assumed moderate effects
of r = 0.30. Power analyses resulted in a sample size of
Fig. 1 LIVIA flow chart study design
138 participants. Anticipating a drop-out rate of 40% at
the 6 month follow-up, we aim at recruiting between 72
and 220 participants at baseline.
Recruitment is based on the LIVES longitudinal study
and internet-self-help forums. All participants who reported
difficulties with adjustment after marital bereavement or
separation or divorce in the LIVES study receive an
information letter about the self-help programme, with a link to
the study website, from the LIVES study coordinator.
Additionally, information about the intervention with a
link to the study website is posted on several
internetbased self-help forums.
All interested adults are required to complete baseline
screening questionnaires and a telephone interview for
assessing eligibility prior to randomization.
Inclusion criteria are:
1. Experience of marital bereavement or a separation or divorce more than 6 months prior to enrolment in the study
2. Seeking help for coping with prolonged grief
symptoms, psychological distress or the psychosocial
adaptation to a life without the partner
3. Having access to an internet connection
4. Mastery of the German language
5. Provision of informed consent Exclusion criteria are:
1. Severe psychological or somatic disorders which
need immediate treatment and acute suicidality
(Beck Depression Inventory suicide item > 1 or
suicidal ideation in the telephone interview).
2. No emergency plan: in the telephone interview, an
emergency plan will be developed that specifies a
health care professional, to whom participants can
turn in an acute crisis. If no such person or health
care service can be found, individuals are excluded
from the intervention.
3. Concomitant psychotherapy, or prescribed drugs to treat depression or anxiety, if the prescription or dosage has changed in the month prior or during the self-help intervention.
4. Inability to follow the procedures of the study, e.g. due to comprehension problems.
Description of the intervention
The intervention is a guided 10-week internet-based
self-help programme. The 10 text-based sessions are
described in detail in Table 1. Participants are encouraged
to work through one session a week and to complete the
assignments. One session takes between 45 min and 60
min. The first two sessions include general information
about interpersonal loss and an assessment of the current
personal situation. Sessions 3 to 5 focus on resources and
restoration-oriented interventions for fostering positive
thoughts and emotions as well as self-care. Sessions 6 and
7 consist of loss-oriented interventions for accepting
memories and pain and address unfinished business.
Sessions 8 and 9 again include restoration-oriented
interventions, focusing on creating a new life without
the partner and social relationships. The last session
addresses the redefinition of the relationship to the
lost person. The sessions for bereaved and separated
or divorced participants are identical apart from
adaptations in the first session (psychoeducation) and the
sixth session (accepting memories and telling the story
of the loss).
During the work with the text-based sessions,
participants receive email support by psychologists of the
Department of Clinical Psychology and Psychotherapy
of the University of Bern. These weekly emails
acknowledge and motivate participants in their work with the
self-help programme and provide a weekly structure and
support for technical problems. Participants can contact
their supporters anytime with questions via a contact
button in the self-help programme. The email-supporters are
supervised by a fully trained psychotherapist.
Figure 2 (the SPIRIT figure schedule of enrolment,
interventions, and assessments) gives an overview of the
measures with the timing of the assessment. All
selfreport questionnaires are completed online. Baseline
measurement is at t0, post-measurement t1 is 12 weeks
after the start of the programme or waiting condition,
post-measurement t2 is after 24 weeks, and the
followup measure t3 will be completed only by the waiting
control group 24 weeks after their start of the
intervention, i.e. 36 weeks after baseline.
Primary outcome measures
Grief symptoms are assessed using the German version
of the Texas Revised Inventory of Grief . The Texas
Revised Inventory of Grief is a widely used measure to
assess the severity of grief symptoms. A recent factor
analysis identified three factors for emotional response,
thoughts, and non-acceptance regarding a loss . The
German version of the Texas Revised Inventory of Grief
is a 16-item measure to assess the severity of grief
symptoms, from 1 = completely true to 5 = completely false.
Psychopathological distress is assessed using the
German version of the Brief Symptom Inventory, a widely
used 53-item measure to assess a broad range of somatic
Table 1 Outline of the 10 self-help sessions of the internet-based intervention
2. Assessment of current situation
3. Fostering positive thoughts and emotions
4. Finding comfort
6. Accepting memories and pain
7. Unfinished business
8. Creating a new life without the partner
9. Social relationships
Information about the self-help intervention, grief reactions, reactions to separation, predictors
and treatment of complicated grief
Information about and assessment of emotions in the context of the interpersonal loss, changes
in life since the loss and obstacles for a positive adaptation
Information about emotion regulation and cognitive-behavioural strategies to promote positive
thoughts and emotions
Protocols for practising these strategies in daily life
Suggestions for self-soothing strategies and exercises to promote positive feelings (e.g. diary for
Checklists for current physical, emotional and practical self-care, formulation of self-care goals and
suggestions for implementing self-care behaviour in daily life
Writing tasks to integrate painful memories of the loss into the autobiographical memory and to
be able to tell the story of the loss
Identification of unfinished business and regrets, writing tasks to formulate unfinished business
and to find ways to put issues at rest
Clarifying current relationships using a sociogram
Defining goals related to social relationships, e.g. changing relationships, building up new
social contacts, and suggestions for promoting social well-being
Writing a farewell letter to the lost partner: saying good-bye and telling the lost partner about
the future importance of the loss and how the participant will continue life without the lost
Fig. 2 SPIRIT figure: schedule of enrolment, interventions, and assessments
and psychopathological symptoms within 7 days prior
to completing the questionnaire . Factors include
depressed mood, somatic symptoms, information
processing deficits, and interpersonal insecurity . Answer
categories range from 0 = not at all to 4 = very much.
Depressive symptoms are assessed with the German
version of the Beck Depression Inventory II . This
measure consists of 21 items on a scale from 0 to 3.
Secondary outcome measures
Loneliness is assessed using the De Jong Gierveld
Short Scale for Emotional and Social Loneliness
. This is a six-item scale with answer categories
from 0 = no to 5 = yes.
Embitterment is assessed with the short version of
the Embitterment Scale, which consists of six items
rated on a scale from 0 = I do not agree to 4 = I
Life satisfaction is assessed with the German version
of the Satisfaction with Life Scale [30, 31]. It consists
of five items with answer categories from 1 =
completely disagree to 7 = completely agree.
Session-related outcomes. We included nine items
related to specific sessions of the intervention, e.g.
self-rated knowledge about grief symptoms,
selfcare, self-soothing strategies, satisfaction with social
relationships or the current life situation. Items are
rated on scale from 1 = very little to 10 = very much.
Satisfaction with the self-help programme. Six items
assess the evaluation of the quality of and the
satisfaction with the intervention, and six items assess
effects of the intervention related to mechanisms
of change, i.e. mastery experiences, clarification
experiences or insight, problem actuation, and
resource activation. Response categories range
from 1 = not at all to 4 = very much.
Predictors and moderators
Computer literacy is assessed using the first seven
items of the Computer Literacy Scale for Older
Adults . They assess experiences with the
computer and the frequency with which participants
engage in different computer-related tasks.
Demographic variables include sex, age, education,
overall self-rated health, and details about the marital
history and the loss of the partner or the separation or
Criteria for a persistent complex bereavement
disorder according to the Diagnostic and Statistical
Manual of Mental Disorders  are assessed in the
Suicidality is assessed in the telephone interview
using the suicidality questions of the Brief
Psychiatric Rating Scale .
Adherence and completion data, as well as data on
the duration and the intensity of the use of the
selfhelp intervention are collected within the platform.
Data collection and management
Data are assessed using online-questionnaires programmed
in Qualtrics . Data integrity is enforced through a
variety of mechanisms, i.e. referential data rules, valid values,
range checks, and consistency checks. The option to
choose a value from a list of valid codes and a description
of what each code means is available where applicable.
Checks are applied at the time of data entry into a specific
field. In addition, data on the use of the self-help sessions
are collected within the platform. All data will be saved in
an anonymous way only identified by a code that is not
related to the participant’s identity. Servers are protected by
high-end firewall systems. Only the researchers directly
involved in the study have access to the data.
Analysis will be conducted according to the
intentionto-treat paradigm. Firstly, we will analyze the extent of
missing data, explore the missing data patterns and
determine the type of missing data (missing completely at
randomization, missing at randomization, not missing at
randomization). If the missing mechanism is missing at
randomization, we will use multilevel regression analyses,
which allow a different number of measurement points
per participants and are thus less sensitive to missing data.
We will include time (pre versus post-intervention
measures and post-intervention versus follow-up measures),
group (immediate access versus control condition), event
(bereavement versus separation or divorce) and
interaction terms as predictors of the outcome variables.
Cohens d will be calculated as effect size for all observed
outcome variables. To analyze the longitudinal interplay
of predictor variables, we will conduct structural equation
models. Analysis will be conducted in SPSS and Mplus.
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
Additional file 1: SPIRIT 2013 Checklist: recommended items to address
in a clinical trial protocol and related documents. (PDF 169 kb)
We thank Jacqueline Aebersold and Lara Staeubli for contributing to the
pilot study; Timo Stolz for the design of the logos; and all colleagues who
contributed to the development of the intervention.
This project was funded by the Swiss National Science Foundation grant
51NF40-160590 granted to Dario Spini. The Swiss National Science Foundation
had no role in the design of the study and collection, analysis, or interpretation
of data, or in writing the manuscript.
JB participated in the design of the study and the development of the
intervention, and drafted the manuscript. TB participated in the design of
the study and the development of the intervention, and programmed the
self-help intervention. HJZ conceived the study and participated in its design
and the development of the intervention. All authors read and approved the
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