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Internet-Based Cognitive-Behavioral Therapy for Complicated Grief: A Randomized Controlled Trial
Abstract
The present study investigates the efficacy of an Internet-based cognitive-behavioral therapy program for bereaved people suffering complicated grief. The program combines established methods of psychotherapy with new technology--therapists and patients communicated exclusively by e-mail. Bereaved individuals diagnosed with complicated grief (n = 55) were randomly assigned to either the treatment group or a waiting list control condition. The 5-week intervention consisted of three modules: (1) exposure to bereavement cues; (2) cognitive reappraisal; and (3) integration and restoration. The Impact of Event Scale (IES), a failure to adapt scale, and the depression and anxiety subscales of the Brief Symptom Inventory (BSI) were used to assess treatment outcomes. Participants in the treatment group (n = 26) improved significantly relative to participants in the waiting condition on symptoms of intrusion, avoidance, maladaptive behavior, and general psychopathology, and showed a large treatment effect. Follow-up results show that this improvement was maintained after 3 months.
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“A further recent study examining the efficacy of an Internet-based cognitive behavioral therapy for mothers after pregnancy loss67 showed positive treatment effects, with the intervention group showing significantly reduced symptoms of grief, PTSD, and depression after treatment relative to the waiting-list group, and this symptom reduction was maintained at 3-month followup.68,69”
From Complicated grief after perinatal loss (2012) · cites this paper as [67]
In the citing paper
“Currently, data on the efficacy of ICBT are available for a wide range of psychological disorders, including stress-related disorders [19–23].”
From An internet-based intervention for adjustment disorder (TAO): Study protocol for a randomized controlled trial (2018) · cites this paper as [22]
In the citing paper
“The treatment group was found to have improved significantly in relation to subjects on the waitlist as regards symptoms such as intrusion, advoidance, maladaptive behavior, and psychopathology in general (Wagner, Knaevelsrud, & Maercker, 2006).”
From Prolonged grief disorder treatment: An approach to COVID-19 grief (2023) · cites this paper as Wagner et al., 2006
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“Studies on writing and grief have shown best results in both adults and adolescents when specific strategies for grief processing were offered (Lichtenthal & Cruess, 2010; Wagner et al., 2006; Kalantari et al., 2012).”
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“based cognitive behavioral therapy focusing on grief (Wagner et al. 2006).”
BackgroundRumination moderates the role of meaning in the development of prolonged grief symptomatology
Milman, E. J., Neimeyer, R. A., Fitzpatrick, M. R., MacKinnon, C. J., Muis, K. R., & Cohen, S. R. (2019) · Journal of Clinical Psychology · doi:10.1002/jclp.22751 · Cited by 48
Boelen, P. A., Eisma, M. C., Smid, G. E., de Keijser, J., & Lenferink, L. I. M. (2020) · Journal of Loss and Trauma · doi:10.1080/15325024.2020.1793547 · Cited by 38
“…view of the future), and (c) help patients consolidate the lessons they have learned during therapy (e.g., by encouraging them to make minutes of each session and eventually to summarize the lessons they learned that may be used when the pain returns; Cummings et al., 2014; Wagner et al., 2006).”
BackgroundKaiser, J., Nagl, M., Hoffmann, R., Linde, K., & Kersting, A. (2022) · JMIR Mental Health · doi:10.2196/27642 · Cited by 52
“An asynchronous web-based intervention designed for the treatment of posttraumatic stress and PGD [39,40] has been successfully adapted by the research group to several specific bereavement situations such as pregnancy loss [38] or suicide bereavement [41].”
MethodHaßdenteufel, K., Müller, M., Abele, H., Brucker, S. Y., Graf, J., Zipfel, S., Bauer, A., Jakubowski, P., Pauluschke‐Fröhlich, J., Wallwiener, M., et al. (2023) · Psychiatry Research · doi:10.1016/j.psychres.2023.115599 · Cited by 40
“Combined electronic-based mindfulness interventions provide easily accessible, cost-effective, and anonymous treatment and prevention tools in pregnancy applying cognitive behavioral and psychoeducational approaches (Kersting et al., 2013) (Wagner et al., 2006).”
Boelen, P. (2016) · European Journal of Psychotraumatology · doi:10.3402/ejpt.v7.32609 · Cited by 38
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Thieleman, K., & Cacciatore, J. (2013) · Research on Social Work Practice · doi:10.1177/1049731512474695 · Cited by 37
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“One 5 week internet-based intervention consisted of two writing assignments a week of approximately 45 min [12].”
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“Research into online grief interventions started with a randomized controlled trial showing that email delivered therapeutic writing exercises based on cognitive-behavioral principles (versus a waitlist control) reduced post-traumatic stress, anxiety, and depression symptoms (Wagner et al., 2006).”
BackgroundPilot study on traumatic grief treatment program for Japanese women bereaved by violent death
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van Rosmalen-Nooijens, K. A. W. L., Wong, S. L. F., Prins, J. B., & Lagro‐Janssen, A. L. M. (2017) · Journal of Medical Internet Research · doi:10.2196/jmir.6004 · Cited by 31
“Internet-based intervention have been shown to be cost-effective in different health problems [39-43], including mental health in an adolescent population [44-46].”
BackgroundMethodAutobiographical memory following cognitive behaviour therapy for complicated grief
Maccallum, F., & Bryant, R. A. (2010) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2010.08.006 · Cited by 34
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“Email: meichsner@psych.uni-frankfurt.de, ks2394@columbia.edu Mechanisms of change are often categorized into specific and common factors (Cuijpers et al., 2019; Lambert, 1992; Wampold, 2001).”
What can low and high technologies do for late-life mental disorders?
Westphal, A., Dingjan, P. G., & Attoe, R. (2010) · Current Opinion in Psychiatry · doi:10.1097/yco.0b013e32833d74d4 · Cited by 27
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Tolstikova, K., & Chartier, B. M. (2010) · OMEGA - Journal of Death and Dying · doi:10.2190/om.60.4.b · Cited by 27
“In addition, an internet-based treatment approach for bereaved individuals was presented by Wagner, Knaevelsrud, and Maercker (2006).”
BackgroundMethodTreatment gap in bereavement care: (Online) bereavement support needs and use after traumatic loss
Lenferink, L. I. M., de Keijser, J., Eisma, M. C., Smid, G. E., & Boelen, P. A. (2020) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2544 · Cited by 35
“Several studies have shown that online CBT-based interventions successfully alleviate pathological grief and PTSD symptoms (Eisma et al., 2015; Kersting et al., 2013; Wagner et al., 2006).”
BackgroundAcierno, R., Kauffman, B. Y., Muzzy, W., Tejada, M. H., & Lejuez, C. (2021) · The American journal of hospice & palliative care · doi:10.1177/1049909121989021 · Cited by 20
Complicated grief after bereavement
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Follow-up outcome in short-term group therapy for complicated grief.
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van Velsen, L., Cabrita, M., den Akker, H. O., Brandl, L., Isaac, J., Suárez-Gómez, M., Gouveia, A., de Sousa, R. D., Rodrigues, A. M., Canhão, H. M., et al. (2020) · JMIR Research Protocols · doi:10.2196/19344 · Cited by 21
“Internet-based options have also started to emerge (eg, [13-16]).”
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She, W. J., Ang, C. S., Neimeyer, R. A., Burke, L. A., Zhang, Y., Jatowt, A., Kawai, Y., Hu, J., Rauterberg, M., Prigerson, H. G., et al. (2022) · IEEE Access · doi:10.1109/access.2022.3163311 · Cited by 28
“In addition, psychologists are also offering grief interventions or advice through emails or their personal page [40]–[42], showing great potential of technology to support coping with bereavement.”
BackgroundThe Virtual Dream: Rewriting Stories of Loss and Grief
Neimeyer, R. A., Torres, C., & Smith, D. C. (2011) · Death Studies · doi:10.1080/07481187.2011.570596 · Cited by 21
“Although the evidence base for the efficacy of some of the more general narrative methods for ameliorating the pain of bereavement is equivocal (Neimeyer, van Dyke, & Pennebaker, 2009 ), recent research points to the efficacy of specifically tailored narrative techniques that focus on retelling and processing the stor…”
BackgroundInternettherapie: Möglichkeiten und Grenzen
Kersting, A., Schlicht, S., & Kroker, K. (2009) · Der Nervenarzt · doi:10.1007/s00115-009-2721-5 · Cited by 21
Factors of Seeking Professional Psychological Help by the Bereaved by Suicide
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“Research reveals that opening up emotions related to complicated bereavement can help to unblock the grief process (Wagner et al., 2006) and a tendency to openly discuss the death accounts for less grief difficulties (Feigelman et al., 2018).”
BackgroundLetter Writing as a Clinical Tool in Grief Psychotherapy
Larsen, L. H. (2022) · OMEGA - Journal of Death and Dying · doi:10.1177/00302228211070155 · Cited by 26
“Several effective treatment protocols (e.g. Boelen et al., 2007; Eisma et al., 2015; Wagner et al., 2006) incorporate letter writing, but a thorough discussion of the reasons why letter writing is a bene fi cial tool is not typically discussed in any great detail.”
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Self-citationReconstructing the self in the wake of loss: a dialogical contribution
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“As far as we know, only four clinical trials examined the effectiveness of online grief-specific CBT-based interventions for reducing distress in bereaved people (Eisma et al., 2015; Kersting et al., 2013; Litz et al., 2014; Wagner et al., 2006).”
BackgroundNiemeyer, H., Knaevelsrud, C., Schumacher, S., Engel, S., Kuester, A., Burchert, S., Muschalla, B., Weiss, D., Spies, J., Rau, H., et al. (2020) · BMC Psychiatry · doi:10.1186/s12888-020-02595-z · Cited by 22
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“Interapy was adapted for PGD [46] and its efficacy was shown for various groups of bereaved individuals showing medium to large treatment effects [46, 47].”
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“In addition, guided internet interventions for prolonged grief symptoms have demonstrated their efficacy with effect sizes in the moderate to large range [3-6].”
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Lange, A., & Ruwaard, J. (2010) · Journal of Medical Internet Research · doi:10.2196/jmir.1455 · Cited by 21
Traumatic grief research and care in the aftermath of the COVID-19 pandemic
Djelantik, A. A. A. M. J., Bui, É., O’Connor, M., Rosner, R., Robinaugh, D. J., Simon, N. M., & Boelen, P. A. (2021) · European Journal of Psychotraumatology · doi:10.1080/20008198.2021.1957272 · Cited by 28
“Wagner, Knaevelsrud, and Maercker (2006) were among the first to study the impact of an online CBT-based writing treatment, focusing on exposure, altering maladaptive cognitions, and restoration-oriented coping.”
BackgroundTur, C., Campos, D., Suso‐Ribera, C., Kazlauskas, E., Castilla, D., Zaragozá, I., García‐Palacios, A., & Quero, S. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100558 · Cited by 19
Reconstructing meaning in bereavement: summary of a research program
Neimeyer, R. A. (2011) · Estudos de Psicologia (Campinas) · doi:10.1590/s0103-166x2011000400002 · Cited by 18
Lenferink, L. I. M., de Keijser, J., Eisma, M. C., Smid, G. E., & Boelen, P. A. (2020) · BMJ Open · doi:10.1136/bmjopen-2019-035050 · Cited by 19
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Grief: Lessons from the Past, Visions for the Future
Parkes, C. M. (2010) · Psychologica Belgica · doi:10.5334/pb-50-1-2-7 · Cited by 17
Internet-Based Self-Management of Generalised Anxiety Disorder: A Preliminary Study
Draper, M., Rees, C. S., & Nathan, P. R. (2008) · Behaviour Change · doi:10.1375/bech.25.4.229 · Cited by 17
Damar, A. P., & du Plessis, G. (2010) · Journal of Asian and African Studies · doi:10.1177/0021909610373904 · Cited by 16
Internet Interventions in Clinical Psychology
Andersson, G., & Carlbring, P. (2021) · Elsevier eBooks · doi:10.1016/b978-0-12-818697-8.00211-9 · Cited by 18
Parental Grief Expression in Online Cancer Support Groups
Elder, J., & Burke, L. A. (2015) · Illness Crisis & Loss · doi:10.1177/1054137315576617 · Cited by 17
Personal goals and prolonged grief disorder symptoms
Boelen, P. A. (2010) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.731 · Cited by 16
Jahani, L., Abolhassani, S., Babaee, S., & Omranifard, V. (2022) · BMC Nursing · doi:10.1186/s12912-022-00980-5 · Cited by 17
“Compassion has been used by various researchers in a variety of ways, including in-person [24–26] or not in-person [27, 28].”
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van Rosmalen-Nooijens, K. A. W. L., Prins, J. B., Vergeer, M., Wong, S. L. F., & Lagro-Janssen, A. L. M. (2013) · BMC Public Health · doi:10.1186/1471-2458-13-226 · Cited by 15
“For the calculation of de sample size of the RCT, we searched for studies investigating internet-based methods with the Impact of Event Scale (IES) as a primary outcome measurement [52-55].”
MethodDigital Interventions for PTSD Symptoms in the General Population: a Review
Stefanopoulou, E., Lewis, D., Mughal, A., & Larkin, J. (2020) · Psychiatric Quarterly · doi:10.1007/s11126-020-09745-2 · Cited by 16
Suicide Bereavement Online: Sharing Memories, Seeking Support, and Exchanging Hope
Krysinska, K. E., & Andriessen, K. (2013) · Palgrave Macmillan UK eBooks · doi:10.1057/9781137351692_11 · Cited by 15
Glickman, K., Shear, M. K., & Wall, M. (2016) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.1940 · Cited by 18
de la Rie, S. M., Fiet, A. V. S., Bos, J. B. A., Mooren, N., Smid, G. E., & Gersons, B. P. R. (2021) · European Journal of Psychotraumatology · doi:10.1080/20008198.2021.1929026 · Cited by 15
Kho, Y., Kane, R. T., Priddis, L. E., & Hudson, J. (2015) · PLoS ONE · doi:10.1371/journal.pone.0133703 · Cited by 14
Prolonged grief disorder: Nature, risk-factors, assessment, and cognitive-behavioural treatment
Boelen, P. A. (2023) · Psychosomatic Medicine and General Practice · doi:10.26766/pmgp.v7i2.375 · Cited by 13
“Wagner et al. (2006) were among the first to do so.”
BackgroundDifferences in meanings made according to prolonged grief symptomatology
Breen, L., Karangoda, M. D., Kane, R., Howting, D. A., & Aoun, S. (2018) · Death Studies · doi:10.1080/07481187.2017.1328467 · Cited by 12
Chen, M. A., & Fagundes, C. P. (2022) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2022.105618 · Cited by 18
Siddaway, A. P., Meiser‐Stedman, R., Chester, V., Finn, J., Leary, C. O., Peck, D. F., & Loveridge, C. (2022) · Depression and Anxiety · doi:10.1002/da.23272 · Cited by 14
“…Knaevelsrud & Maercker, 2009; Knaevelsrud et al., 2015, 2017; Lange et al., 2003; Latif et al., 2021; Lehavot et al., 2021; Lewis et al., 2017; Litz et al., 2007; Nieminen et al., 2016; Sloan et al., 2012; Spence et al., 2011; Tables 1 and 2 (Acosta, 2017; Vinke et al., 2019; Wagner et al., 2006).”
BackgroundInfluentialExploring current service provision for Prolonged Grief Disorder and suggestions for future advances
Smith, L., Kalus, C., Russell, P., & Skinner, T. C. (2009) · Mortality · doi:10.1080/13576270802591251 · Cited by 15
“Alternatively, where empirical research is available (Shear et al., 2001; Wagner et al., 2006), there are significant absences in apparent links to the justification of such approaches with related theoretical understanding.”
BackgroundPsychosocial Interventions for Chronic Pain
Roy, R. G. (2008) · Springer eBooks · doi:10.1007/978-0-387-76296-8 · Cited by 16
Narrative Exposure Therapy to treat traumatic stress in Middle Eastern refugees: A clinical trial
Hijazi, A. M. (2012) · Human Biology · Cited by 13
The meaning in loss protocol: A clinical trial of online grief therapy
Batista, J., Alves, D., Pires, N., Silva, J. R., Mendes, I., Magalhães, C., Rosa, C., Oliveira, J. T., Gonçalves, M. M., & Neimeyer, R. A. (2025) · Death Studies · doi:10.1080/07481187.2024.2370633 · Cited by 12
“For example, Wagner et al.’s (2006) 5-week telehealth protocol for PGD, combining exposure to bereavement cues, cognitive reappraisal, and integration and restoration activities, demonstrated efficacy in treating PGD at a follow-up of 1.5 years (Wagner et al., 2007), showing the potential of…”
InfluentialBrandl, L., Cabrita, M., Brodbeck, J., Heylen, D., & van Velsen, L. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100534 · Cited by 12
“Internet-based (mental e-health) interventions have been shown to be effective in treating mental illnesses, including complicated grief (Brodbeck et al., 2017; Carlbring et al., 2018; Eisma et al., 2015; Wagner et al., 2006).”
BackgroundFeasibility and acceptability of a mobile app for prolonged grief disorder symptoms
Aeschlimann, A., Gordillo, N., Ueno, T., Maercker, A. R. A., & Killikelly, C. (2024) · Clinical Psychology in Europe · doi:10.32872/cpe.10881 · Cited by 12
“It could also be used in conjunction with existing online grief interventions (Wagner et al., 2006).”
BackgroundSelf-citationComplicated Grief in Canada: Exploring the Client and Professional Landscape
Thompson, M., Whiteman, A. D., Loucks, K. D., & Daudt, H. (2017) · Journal of Loss and Trauma · doi:10.1080/15325024.2017.1358574 · Cited by 12
Duelo: evaluación, diagnóstico y tratamiento
Pérez, A. B., Gil‐Juliá, B., & Ballester, R. (2008) · DOAJ (DOAJ: Directory of Open Access Journals) · Cited by 12
Maercker, A. R. A., & Heim, E. (2016) · Zurich Open Repository and Archive (University of Zurich) · doi:10.5167/uzh-150551 · Cited by 13
Self-citationGrief and Life Disruption in Young Adults with Advanced Cancer
Trevino, K. M., Maciejewski, P. K., Fasciano, K. M., & Prigerson, H. G. (2011) · Journal of Adolescent and Young Adult Oncology · doi:10.1089/jayao.2011.0024 · Cited by 12
Lenferink, L. I. M., Piersma, E., de Keijser, J., Smid, G. E., & Boelen, P. A. (2017) · European Journal of Psychotraumatology · doi:10.1080/20008198.2017.1388710 · Cited by 12
Internetbasierte Psychotherapie “Interapy„
Wagner, B., & Lange, A. (2008) · Springer eBooks · doi:10.1007/978-3-540-75736-8_9 · Cited by 13
Self-citationLatent classes of posttraumatic stress symptoms in two samples of bereaved people.
Lenferink, L., de Keijser, J., van Denderen, M., & Boelen, P. (2019) · International Journal of Stress Management · doi:10.1037/str0000121 · Cited by 12
Piazza-Bonin, E., Neimeyer, R. A., Alves, D., Smigelsky, M. A., & Crunk, A. E. (2016) · Journal of Constructivist Psychology · doi:10.1080/10720537.2015.1118712 · Cited by 12
Healthcare and the Effect of Technology
Kabene, S. (2010) · Advances in healthcare information systems and administration book series · doi:10.4018/978-1-61520-733-6 · Cited by 17
“Cintron, Phillips, and Hamel (2006); Jacobi • et al. (2007); and Wagner, Knaevelsrud, and Maercker (2006) looked at Internet applications that could be accessed directly by the patient with three involving randomized trials.”
Background
Metadata
- Authors
- Wagner, B., Knaevelsrud, C., & Maercker, A.
- Affiliations
- University of Zurich (CH)
- Corresponding author
- Wagner, Birgit
- Venue
- Death Studies
- Publisher
- Informa UK Limited
- Published
- 2006-06
- Volume
- 30
- Issue
- 5
- Pages
- 429-453
- ISSN
- 0748-1187 (ISSN-L)
- 1091-7683
- OpenAlex
- W2018552270
- Cited by
- 376
- References
- 63
- Citations by year
- 2026: 5 · 2025: 17 · 2024: 18 · 2023: 18 · 2022: 17 · 2021: 20 · 2020: 25 · 2019: 13 · 2018: 16 · 2017: 25 · 2016: 19 · 2015: 24 · 2014: 18 · 2013: 21 · 2012: 22
- FWCI
- 16.22
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Death Studies (publishedVersion)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Grief, Bereavement, and Mental Health
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Anthropology › Death, Funerary Practices, and Mourning
- Keywords
- complicated grief, internet-based cognitive behavioral therapy, bereavement, cognitive reappraisal, avoidance, depression, anxiety, maintenance of treatment effects
- MeSH terms
- Adaptation, Psychological, Austria, Behavior Therapy, Germany, Grief, Humans, Switzerland, Therapy, Computer-Assisted, Treatment Outcome, Internet, Electronic Mail
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