Internet-Based Exposure and Behavioral Activation for Complicated Grief and Rumination: A Randomized Controlled Trial
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This study examined the effectiveness and feasibility of therapist-guided Internet-delivered exposure (EX) and behavioral activation (BA) for complicated grief and rumination. Forty-seven bereaved individuals with elevated levels of complicated grief and grief rumination were randomly assigned to three conditions: EX (N=18), BA (N=17), or a waiting-list (N=12). Treatment groups received 6 homework assignments over 6 to 8weeks. Intention-to-treat analyses showed that EX reduced complicated grief, posttraumatic stress, depression, grief rumination, and brooding levels relative to the control group at posttreatment (d=0.7-1.2). BA lowered complicated grief, posttraumatic stress, and grief rumination levels at posttreatment (d=0.8-0.9). At 3-month follow-up, effects of EX were maintained on complicated grief and grief rumination (d=0.6-1.2), and for BA on complicated grief, posttraumatic stress, and grief rumination (d=0.8-0.9). EX reduced depression more strongly than BA (d=0.6). Completers analyses corroborated results for EX, and partially those for BA, but no group differences were detected. BA suffered from high dropout (59%), relative to EX (33%) and the waiting-list (17%). Feasibility appeared higher for EX than BA. Results supported potential applicability of online exposure but not behavioral activation to decrease complicated grief and rumination.
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Exposure treatments including exercises to confront thoughts about permanence of separation reduced complicated grief symptoms relative to waitlist and active control groups, with large effects.
“Exposure treatments, including exercises to confront oneself with thoughts about permanence of separation from the deceased, reduced CG symptoms relative to waitlist and active control groups, yielding large effects (Boelen et al., 2007; Eisma, Boelen, et al., 2015)”
From Emotion Regulatory Strategies in Complicated Grief: A Systematic Review (2021) · cites this paper as Eisma, Boelen, et al., 2015
The Exposure section describes exercises involving avoided aspects of the loss, and the main analyses report a large reduction in complicated grief symptoms relative to the waitlist control (d = 0.8). The copy does not specifically describe an exercise about the permanence of separation. In “Exposure Versus Behavioral Activation at Posttest and Follow-up,” it reports no significant difference in complicated grief outcomes between exposure and the active behavioral-activation group. (LLM, conf=0.88)
Experimental — accuracy not yet measuredRCTs on CBT demonstrated that CBT treatments yield moderate to large effects on grief rumination and depressive rumination.
“RCTs on CBT further demonstrated the importance of rumination by showing that CBT treatments yield moderate to large effects on grief rumination and depressive rumination (Boelen et al., 2011; Eisma, Boelen, et al., 2015).”
From Emotion Regulatory Strategies in Complicated Grief: A Systematic Review (2021) · cites this paper as Eisma, Boelen, et al., 2015
An RCT demonstrated in an intention-to-treat analysis that a module of behavioral activation led to large reductions of complicated grief symptoms relative to a waitlist group.
“Causal evidence for a role of depressive avoidance in CG was provided in an RCT of Eisma, Boelen, et al. (2015), which demonstrated in an intention-to-treat analysis that a module of behavioral activation led to large reductions of CG symptoms relative to a waitlist group.”
From Emotion Regulatory Strategies in Complicated Grief: A Systematic Review (2021) · cites this paper as Eisma, Boelen, et al. (2015)
RCTs demonstrated that exposure for complicated grief causes reductions in rumination.
“and RCTs demonstrated that exposure for CG causes reductions in rumination (Boelen et al., 2007; Eisma, Boelen, et al., 2015).”
From Emotion Regulatory Strategies in Complicated Grief: A Systematic Review (2021) · cites this paper as Eisma, Boelen, et al., 2015
Only one RCT demonstrated that exposure versus waitlist reduced depressive rumination.
“Moreover, only one RCT demonstrated that exposure (vs. waitlist) reduced depressive rumination (Eisma, Boelen, et al., 2015).”
From Emotion Regulatory Strategies in Complicated Grief: A Systematic Review (2021) · cites this paper as Eisma, Boelen, et al., 2015
Multiple RCTs showed that exposure to cognitively avoided aspects of the loss strongly reduced complicated grief symptoms relative to active or inactive control groups.
“Particularly notable was the finding that multiple RCTs showed that exposure to cognitively avoided aspects of the loss strongly reduced CG symptoms relative to active or inactive control groups (Boelen et al., 2007; Bryant et al., 2014, 2017; Eisma, Boelen, et al., 2015).”
From Emotion Regulatory Strategies in Complicated Grief: A Systematic Review (2021) · cites this paper as Eisma, Boelen, et al., 2015
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- Authors
- Eisma, M. C., Boelen, P. A., van den Bout, J., Stroebe, W., Schut, H. A. W., Lancee, J., & Stroebe, M. S.
- Affiliations
- Utrecht University (NL)
- University of Groningen (NL)
- University of Amsterdam (NL)
- Corresponding author
- Eisma, Maarten C.
- ORCID
- Venue
- Behavior Therapy
- Publisher
- Elsevier BV
- Published
- 2015-11
- Volume
- 46
- Issue
- 6
- Pages
- 729-748
- ISSN
- 0005-7894 (ISSN-L)
- OpenAlex
- W428237933
- Cited by
- 185
- References
- 66
- Citations by year
- 2026: 13 · 2025: 23 · 2024: 23 · 2023: 25 · 2022: 17 · 2021: 20 · 2020: 19 · 2019: 10 · 2018: 14 · 2017: 12 · 2016: 7 · 2015: 2
- FWCI
- 14.49
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Behavior Therapy (publishedVersion)
- PubMed (publishedVersion)
- UvA-DARE (University of Amsterdam) (publishedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (publishedVersion, other-oa)
- Utrecht University Repository (Utrecht University) (submittedVersion, other-oa)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Funders
- ZonMw (91208009)
- Nederlandse Organisatie voor Wetenschappelijk Onderzoek
- Topics
- Social Sciences › Psychology › Clinical Psychology › Grief, Bereavement, and Mental Health
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- complicated grief, behavioral activation, bereavement, post-traumatic stress, depression, brooding, internet-based cognitive behavioral therapy, treatment feasibility, dropout
- MeSH terms
- Rumination, Cognitive, Adaptation, Psychological, Adult, Female, Grief, Humans, Male, Middle Aged, Psychiatric Status Rating Scales, Therapy, Computer-Assisted, Cognitive Behavioral Therapy, Treatment Outcome, Internet
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