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A CBT-Based Psychoeducational Intervention for Suicide Survivors

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DOI: 10.1027/0227-5910/a000252 · Source: PubMed

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 Research Trends

A CBT-Based Psychoeducational
Intervention for Suicide Survivors
A Cluster Randomized Controlled Study
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Ciska Wittouck1, Sara Van Autreve2, Gwendolyn Portzky2,

and Kees van Heeringen2
1
Institute for International Research on Criminal Policy, Department of Penal Law and Criminology,
Ghent University, Belgium,
2
Unit for Suicide Research, Department of Psychiatry and Medical Psychology, Ghent University, Belgium

Abstract. Background: Bereavement following suicide is associated with an increased vulnerability for depression, complicated grief, suicidal
ideation, and suicide. There is, however, a paucity of studies of the effects of interventions in suicide survivors. Aims: This study therefore ex-
amined the effects of a cognitive behavioral therapy (CBT)-based psychoeducational intervention on depression, complicated grief, and suicide
risk factors in suicide survivors. Method: In total, 83 suicide survivors were randomized to the intervention or the control condition in a cluster
randomized controlled trial. Primary outcome measures included maladaptive grief reactions, depression, suicidal ideation, and hopelessness.
Secondary outcome measures included grief-related cognitions and coping styles. Results: There was no significant effect of the intervention on
the outcome measures. However, the intensity of symptoms of grief, depressive symptoms, and passive coping styles decreased significantly in
the intervention group but not in the control group. Conclusion: The CBT-based psychoeducational intervention has no significant effect on the
development of complicated grief reactions, depression, and suicide risk factors among suicide survivors. The intervention may, however, serve
as supportive counseling for suicide survivors.

Keywords: suicide, prevention, survivor, depression, grief, CBT

Bereavement is a universal human experience, which is
commonly associated with psychiatric symptoms such as
loss of appetite, sleep disturbances, and low mood (Stroe-
be, Schut, & Stroebe, 2007). These grief symptoms com-
monly do not constitute a psychiatric disorder and may
resolve without formal mental health treatment (Bonanno
et al., 2007; Bonanno et al., 2002; Middleton, Burnett,
Raphael, & Martinek, 1996; Zhang, El-Jawahri, & Priger-
son, 2004). However, bereaved individuals are at increased
risk of depression and complicated grief (Agerbo, 2005;
Latham & Prigerson, 2004; Neria et al., 2007).
Although grief after suicide does not appear to dif-
fer from grief due to other causes of death (Ellenbogen
& Gratton, 2001), bereavement following the suicide of a
loved one is potentially more difficult to cope with due to
an interaction of social and psychological factors. These
factors include a limited availability of social support (El-
lenbogen & Gratton, 2001; Jordan, 2001), specific themes
of the grief (Ellenbogen & Gratton, 2001; Jordan, 2001;
Sveen & Walby, 2008), and family disruption (Jordan,
2001), which make suicide survivors more vulnerable for
physical complaints and emotional problems, such as de-
pression, complicated grief 1, suicidal ideation (de Groot,
de Keijser, & Neeleman, 2006), and suicide (Agerbo,
2005; Ajdacic-Gross et al., 2008). These findings clearly
implicate that care for suicide survivors may be an impor-
tant component of the prevention of depression and suicide
(Jordan, 2001; Jordan & McMenamy, 2004).
Promoting the mental health of people bereaved
through suicide therefore is a key aim of national suicide
prevention strategies (see, e.g., HM Government, 2012).
There is, however, a paucity of studies on the effects of sup-
portive interventions in suicide survivors. A recent system-
atic review of the eight available studies provided evidence
of some benefit (McDaid, Trowman, Golder, Hawton, &
Sowden, 2008). Substantial methodological problems
were, however, identified in all but one of the studies. The
methodologically sound study (de Groot et al., 2007) used

1 “Complicated Grief (or Prolonged Grief Disorder) is a debilitating disorder, defined as a combination of separation distress and cognitive, emotional and
behavioral symptoms that can develop after the death of a significant other. The symptoms must last for at least 6 months and cause significant impairment
in social, occupational and other important areas of functioning.” (Prigerson, Vanderwerker, & Maciejewski, 2008, p. 167)

© 2014 Hogrefe Publishing Crisis 2014; Vol. 35(3):193–201

DOI: 10.1027/0227-5910/a000252
 194 C. Wittouck et al.: A CBT-Based Psychoeducational Intervention for Suicide Survivors
a cluster randomized controlled design to examine the effec-
tiveness of a cognitive behavioral grief counseling program
for families bereaved by suicide. No beneficial effect of the
counseling program on complicated grief, depression, and
suicidal ideation could be demonstrated at 1-year follow-up,
possibly due to an adverse effect of depression on skills to
concentrate on counseling (reading, exercising, discussing
issues). However, the study found a mild beneficial effect
on maladaptive grief reactions and blame, possibly due to
reduced negative cognitions, avoidant behaviors, and feel-
ings of guilt and self-blame. Unfortunately, these potentially
mediating factors, which could be the target of cognitive-
behavioral interventions, were not assessed in this study.
Therefore, a cognitive behavioral therapy (CBT)-based
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
program with an emphasis on psychoeducation was devel-
oped, the effects of which are studied in the current cluster
randomized trial in suicide survivors. The primary aim of
our study was to test the hypothesis that a CBT-based psy-
choeducational program provides added benefit to care-
as-usual in reducing maladaptive grief reactions including
self-blame, depressive symptoms, and suicidal ideation
and hopelessness. The secondary aim was to test the hy-
pothesis that the psychoeducational program provides add-
ed benefit by reducing negative cognitions and maladap-
tive coping behavior including avoidance behaviors.
Method
Study Design
This study was a cluster randomized controlled trial with
two study groups, that is, an intervention group and a con-
trol group, conducted at the University Department of Psy-
chiatry at Ghent University Hospital. The ethical board of
Ghent University Hospital approved the study. All partic-
ipants were extensively informed about the study proce-
dure, and agreed to sign informed consent. Since the pri-
vacy law in Belgium is quite stringent, the research team
was not allowed to contact suicide survivors themselves
in order to invite them to participate in the study. Partic-
ipants were thus recruited through police victim services
and primary health-care victim services. In addition, an
announcement of the study was published on websites of
several relevant organizations, and all employees and stu-
dents of the Faculty of Medicine of the Ghent University
were informed about the study through a mailing. Finally,
brochures were sent to all Flemish libraries. Suicide sur-
vivors interested in study participation could contact the
researchers without any obligation. As a consequence of
this procedure of recruitment, no information is available
on the total number of suicide survivors reached through-
out the recruitment period.
Assessments took place using semistructured inter-
views during two home visits by a clinical psychologist,
at baseline (home visit 1 [H1], at study entrance) and at
8 months’ follow-up (home visit 2 [H2], 8 months after
study entrance). Participants in the intervention group re-
Crisis 2014; Vol. 35(3):193–201
ceived four additional home visits, by a second clinical
psychologist, during which the CBT-based psychoeduca-
tional intervention took place. Allocation to study groups
was done using a computer-generated randomization pro-
cedure, and allocation was concealed in a sealed envelope
until the end of H1. Outcome measures were collected by
means of self-report questionnaires that were provided at
H1 and H2 and that had to be sent back by post. All par-
ticipants could appeal for “care-as-usual” in the course of
their participation in the study.
The 83 participants corresponded to 65 suicide cases.
Multiple survivors of one suicide were allocated to the
same study arm in order to avoid confounding of the re-
sults.
Inclusion Criteria
The loss of a loved one through suicide between 3 months
and 2 years before study participation was the main in-
clusion criterion for the study. There were no limitations
regarding kinship or relationship to the deceased, so that
both family members and friends could take part in the
study. Participants had to be 18 years or older and Dutch
speaking.
Participant Flowchart
Figure 1 shows the flow of participants during the study.
The research team was contacted by 86 eligible suicide
survivors, of whom 83 eventually were enrolled. The three
survivors, who were not enrolled, decided not to take part
in the study for personal reasons. Thirteen participants
(15.7%) dropped out of the study between baseline and
follow-up assessment. There were no significant differenc-
es between study completers and dropouts regarding study
group allocation, gender of participant and deceased, rela-
tionship to deceased (parent/partner vs. other), living to-
gether with deceased at time of death, being single, being a
parent, living situation, current employment, age of partic-
ipant and deceased, time since loss, and highest achieved
level of education.
Sample Characteristics
Table 1 shows characteristics of the participants in the total
group and in the study groups. No significant differences
were found between the intervention group and the control
group with respect to gender of participant and deceased,
age of participant and deceased, current employment, re-
lationship to deceased (parent/partner vs. other), and time
since loss. The two study groups differed, however, regard-
ing living situation and the highest achieved level of edu-
cation. Significantly fewer participants in the intervention
group lived alone at the time of the study in comparison
with control group participants. In addition, significantly
more participants in the intervention group received high
© 2014 Hogrefe Publishing
 C. Wittouck et al.: A CBT-Based Psychoeducational Intervention for Suicide Survivors 195

Eligible respondents Figure 1. Flowchart of participants.

n = 86

Home visit 1 (H1),

n = 83

Randomization
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Intervention group Control group

n = 47 n = 36

Lost to follow-up
Lost to intervention
n=5
n=8
‡ 4 no questionnaire
‡ 4 emotional reasons
‡ 1 uncooperative
‡ 2 no questionnaires
‡ 1 no suicide verdict
‡ 1 refused further
participation

Home visit 2 (H2)

n = 70

All included in analyses

school or less than high school education and significantly Hout, & van den Bout, 2006) was used as a rationale for
fewer participants in the intervention group went to col- the development of the intervention.
lege or university than control group participants.

Outcome Measures
The CBT-Based Psychoeducational
Intervention for Adult Suicide Survivors Semistructured Interview

The intervention, which took place during four 2-hr home
visits by a clinical psychologist, comprised psychoeduca-
tion regarding suicide, aspects of bereavement, specific
aspects of bereavement by suicide, and coping with be-
reavement. Psychoeducation concerning suicide contained
an illustration of the suicidal process (Retterstol, 1993)
and an explanation of a comprehensive explanatory mod-
el of suicidal behavior (Hawton & van Heeringen, 2009;
Mann, 2003). In addition, myths regarding content, course,
and cultural context of grief (Stroebe, Hansson, Stroebe,
& Schut, 2001) as well as the dual-process model of cop-
ing with bereavement (Stroebe & Schut, 1999) were dis-
cussed with participants. All information was integrated in
the participant’s personal story. The cognitive-behavioral
conceptualization of complicated grief (Boelen, van den
Participants were asked about the circumstances of the
death and about demographic information by means of a
semistructured interview.
Self-Report Questionnaires
Primary outcome measures included maladaptive grief re-
actions, depressive symptoms, suicidal ideation, and hope-
lessness. The Dutch version of the Inventory of Traumatic
Grief (ITG; Prigerson & Jacobs, 2001; Dutch version by
Boelen, van den Bout, de Keijser, & Hoijtink, 2003a) was
used to measure maladaptive grief symptoms. The ITG
assesses 29 maladaptive grief symptoms, the presence
of which has to be described in terms of never, seldom,

© 2014 Hogrefe Publishing Crisis 2014; Vol. 35(3):193–201

 196 C. Wittouck et al.: A CBT-Based Psychoeducational Intervention for Suicide Survivors

Table 1. Characteristics of participants by study group

Study groups
Total group Intervention group Control group
χ2 (df) p
Characteristics (n = 83) (n = 47) (n = 36)
Sex 1.450 (1) .228
Male 20 (24.1%) 9 (19.1%) 11 (30.6%)
Female 63 (75.9%) 38 (80.9%) 25 (69.4%)
Age (in years)* –0.570 (80)** .570
M (SD) 48.6 (13.3) 49.3 (13.8) 47.6 (12.8)
Living situation 4.196 (1) .041
Alone 13 (15.7%) 4 (8.5%) 9 (25.0%)
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Cohabitating 70 (84.3%) 43 (91.5%) 27 (75.0%)

Highest education* 10.087 (2) .006
Less than high school 11 (13.3%) 8 (17.0%) 3 (8.3%)
High school 28 (33.7%) 21 (44.7%) 7 (19.4%)
College/university 43 (51.8%) 17 (36.2%) 26 (72.2%)
Current employment 0.218 (1) .640
Working 46 (55.4%) 25 (53.2%) 21 (58.3%)
Not working 37 (44.6%) 22 (46.8%) 15 (41.7%)
Deceased is 9.125 (4) .058
Child 33 (39.7%) 20 (42.5%) 13 (36.1%)
Partner 20 (24.1%) 12 (25.5%) 8 (22.2%)
Parent 8 (9.6%) 1 (2.1%) 7 (19.5%)
Sibling 15 (18.1%) 8 (17.0%) 7 (19.5%)
Other 7 ( 8.5%) 6 (12.9%) 1 (2.7%)
Time since loss (in months) 1.936 (81)** .056
M (SD) 11.0 (6.1) 9.8 (5.7) 12.4 (6.3)
Age deceased (in years) (n = 65) (n = 35) (n = 30) –0.027 (63)** .978
M (SD) 41.5 (16.1) 41.5 (16.9) 41.4 (15.4)
Note. *1 missing. **t (df). Significant values given in bold.

Table 2. Pretest and follow-up scores for the control and intervention groups on the ITG, BDI-II, and BHS
Control group (CG) Wilc. Intervention group (IG) Wilc.
(n = 31) CG (n = 39) IG
Pretest Follow-up Pretest Follow-up
M (SD) M (SD) Z p M (SD) M (SD) Z p
ITG 75.8 (27.6) 74.0 (24.6) –0.669 .503 78.1 (23.3) 72.1 (22.7) –2.303 .021
BDI-II-NL 21.8 (13.7) 19.0 (10.8) –1.151 .250 18.6 (10.7) 15.4 (10.8) –2.794 .006
BHS 10.2 (6.6) 9.4 (6.6) –0.402 .688 8.9 (5.0) 8.2 (5.6) –1.197 .231
Notes. ITG = Inventory of Traumatic Grief. BDI-II-NL = Beck Depression Inventory. BHS = Beck Hopelessness Scale. Wilc. = Wilcoxon analysis.
Significant values given in bold.

sometimes, often, or always, resulting in a total score rang-
ing from 29 to 145. This inventory measures experiences
of complicated grief in a scale form, with higher scores
indicating a higher risk of complicated grief. Boelen and
colleagues (2003a) demonstrated the reliability and valid-
ity of the Dutch version of the ITG. The Beck Depression
Inventory (BDI-II-NL; Beck, Steer, & Brown, 2002) is a
21- item scale that examines the presence and severity of
depressive symptoms including suicidal ideation (item 9).
The BDI-II-NL has been proven reliable and valid. The
Beck Hopelessness Scale (BHS; Beck, Weismann, Lester,
& Trexle, 1974) measures an individual’s attitudes toward
the future. The 20 items can be answered with yes or no.
A total score of 9 or more indicates high hopelessness and

Crisis 2014; Vol. 35(3):193–201 © 2014 Hogrefe Publishing

 C. Wittouck et al.: A CBT-Based Psychoeducational Intervention for Suicide Survivors
is associated with a significantly increased risk of suicide
(Beck, Brown, Berchick, Stewart, & Steer, 1990). The psy-
chometric properties of the BHS are good (Brown, 2002).
Secondary outcome measures included negative cogni-
tions and maladaptive coping, including avoidance behav-
iors. The Grief Cognitions Questionnaire (CGQ; Boelen,
van den Bout, & van den Hout, 2003b) assesses negative
cognitions related to bereavement-related distress. The
questionnaire entails 38 items and nine subscales, repre-
senting nine categories of relevant cognitions (global nega-
tive beliefs about the self, global negative beliefs about the
world, global negative beliefs about life, global negative be-
liefs about the future, negative cognitions about self-blame,
negative cognitions about other people’s responses after the
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
loss, negative cognitions about the appropriateness of one’s
grief reactions, cognitions reflecting the importance of cher-
ishing the pain of the loss, and threatening interpretations
of one’s own reactions to the loss). The response format is
a 6-point rating scale, ranging from strongly disagree to
strongly agree. The CGQ shows adequate reliability and
validity (Boelen & Lensvelt-Mulders, 2005). The Utrecht
Coping List (UCL; Schreurs, van de Willige, Brosschot,
Tellegen, & Graus, 1993) was designed to assess different
aspects of coping using 47 items. The response format of
the coping list is a Likert scale with four categories: nev-
er or seldom; sometimes; often; very often. The UCL items
are divided into seven subscales: active coping (acting im-
mediately; trying to solve the problem with confidence and
goal-oriented), palliative coping (seeking diversion, e.g.,
smoking, drinking, recreation; engaging in other activities),
avoidance (avoiding the problem; waiting to see what will
happen), social support (confiding in others or help-seek-
ing behavior; seeking comfort and understanding in oth-
ers), passive reaction (worrying and ruminating about the
problem without being able to cope), emotional expression
(expressing annoyance or anger; venting one’s displeasure),
and cognitive coping (the use of reassuring and comforting
thoughts). The seven subscales show sufficient to good in-
ternal consistency and satisfactory validity.
Statistical Analyses
Results were analyzed using SPSS Statistics 19. We used t
tests and χ2 tests to detect significant differences between
study completers and dropouts, and between the inter-
vention group and the control group. The effects of the
intervention on the continuous outcome measures were
examined with a repeated measures analysis of variance
(ANOVA; 2 (time) × 2 (group), with time as the repeated
measure and group as the covariate. The effects of the in-
tervention on the dichotomous outcome measure (suicidal
ideation present vs. absent) were examined with a logistic
regression analysis controlling for baseline scores. In ad-
dition, Wilcoxon analyses were conducted to study change
over time in each study group separately.
After controlling separately for a large number of co-
variates (i.e., time since loss, living situation, education
level, relationship to deceased [parent/partner vs. other],
© 2014 Hogrefe Publishing
197
gender and age of participants), the results remained un-
changed. Thus, only the results of the analyses without co-
variates are presented in the results section.
Results
Primary Outcomes
Table 2 shows mean scores and standard deviations on
the ITG, BDI-II, and BHS at baseline and follow-up as-
sessment for the intervention group and the control group.
No significant differences were found between the two
study groups at baseline assessment. Repeated-measures
analyses of the ITG, BDI-II, and BHS data revealed no
significant Time × Group interaction effects. The analy-
ses showed a significant effect of time on scores on the
ITG (F(1,68) = 5.88; p < .05) and BDI-II (F(1,67) = 8.78; p <
.01). Logistic regression analysis, with the baseline value
of suicidal ideation entered as a covariate, revealed no sig-
nificant independent effect of the intervention on the oc-
currence of suicidal ideation (as measured with item 9 of
the BDI-II-NL) (Wald(1) = .436, p = .509).
Wilcoxon analyses for the study groups separately re-
vealed no significant differences between baseline and fol-
low-up assessment for the control group. In the interven-
tion group, significant decreases in the scores on the ITG
and BDI-II were found between baseline and follow-up
assessment (Table 2).
Secondary Outcomes
No significant differences between the study groups were
found at baseline for GCQ and UCL. Repeated-measures
analyses of the GCQ and UCL data revealed no significant
Time × Group interaction effects. The analyses showed a
significant effect of time for the scores on the UCL sub-
scale social support (F(1,68) = 6.38; p < .05), and a signif-
icant group effect on the UCL subscale passive reaction
(F(1,68) = 4.16; p < .05).
Wilcoxon analyses for the study groups separately
revealed no significant differences between baseline and
follow-up assessment for the control group. In the inter-
vention group, significant decreases in scores on several
subscales of the UCL were found between baseline and
follow-up assessments, that is, social support, passive re-
action, and emotional expression (Table 3).
Discussion
Suicide survivors are at risk of developing severe mental
health problems, and there is a pressing need for meth-
odologically sound randomized controlled trials to assess
the benefits of interventions for people bereaved through
suicide (McDaid et al., 2008). Thus, the effects of a CBT-
Crisis 2014; Vol. 35(3):193–201
 This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
198

Table 3. Pretest and follow-up scores for the control and intervention groups on the GCQ and UCL
Wilc. Wilc.
Control group (CG) (n = 31) Intervention group (IG) (n = 39)
CG IG

Pretest Follow-up Pretest Follow-up

M (SD) M (SD) Z p M (SD) M (SD) Z p

Crisis 2014; Vol. 35(3):193–201

GCQ

Negative beliefs about the self 9.1 (8.3) 9.3 (8.1) –0.145 .885 9.3 (8.3) 8.6 (7.4) –0.412 .680

Negative beliefs about the world 9.2 (6.0) 6.9 (6.7) –1.134 .257 5.1 (5.4) 4.9 (5.2) –0.206 .837

Negative beliefs about life 6.5 (6.8) 6.3 (7.3) –0.596 .551 5.4 (5.2) 4.8 (5.2) –1.130 .258

Negative beliefs about the future 11.0 (8.5) 10.0 (8.9) 0.390 .697 9.1 (6.7) 8.5 (7.1) –0.460 .645

Self-blame 10.2 (7.4) 10.3 (8.0) –0.046 .963 10.8 (8.2) 10.3 (7.6) –1.098 .272

Other people’s responses 5.3 (4.7) 5.8 (4.8) –0.646 .519 3.8 (3.2) 3.7 (3.8) –0.405 .685

Appropriateness of grief reactions 3.9 (3.7) 5.0 (4.4) –1.596 .110 3.1 (3.9) 3.6 (4.4) –0.938 .348

Cherishing the pain of the loss 3.9 (4.2) 4.2 (4.0) –0.880 .379 4.5 (3.8) 4.4 (4.3) –0.257 .797

Threatening grief interpretations 6.9 (5.5) 7.1 (5.9) –0.433 .665 6.7 (5.7) 6.0 (5.6) –1.145 .252

UCL

Active coping 17.3 (4.7) 16.4 (4.8) –1.280 .201 17.9 (3.8) 17.3 (3.5) –1.431 .153

Palliative coping 18.2 (4.0) 18.0 (3.5) –0.357 .721 18.3 (4.0) 17.2 (3.1) –1.661 .097

Avoidance 15.9 (3.1) 16.2 (3.1) –0.310 .756 15.4 (3.2) 15.3 (2.9) –0.299 .765

Social support 14.3 (3.3) 13.6 (4.2) –1.230 .219 14.3 (3.2) 13.0 (3.1) –3.098 .002

Passive reaction 14.7 (4.5) 14.6 (3.4) –0.057 .954 13.6 (3.5) 12.4 (3.8) –2.485 .013

Emotional expression 6.3 (1.9) 6.3 (1.9) –0.513 .608 6.0 (1.6) 5.3 (1.7) –2.917 .004
C. Wittouck et al.: A CBT-Based Psychoeducational Intervention for Suicide Survivors

Cognitive coping 11.3 (3.7) 11.2 (3.3) –0.266 .790 11.9 (2.6) 11.5 (2.4) –1.366 .172

Notes. GCQ = Grief Cognitions Questionnaire. UCL = Utrecht Coping List. Wilc. = Wilcoxon analysis. Significant values given in bold.

© 2014 Hogrefe Publishing

 C. Wittouck et al.: A CBT-Based Psychoeducational Intervention for Suicide Survivors
based psychoeducational intervention for suicide survivors
were studied, and it was hypothesized that the intervention
would reduce maladaptive grief reactions and depressive
symptoms including hopelessness and suicidal ideation. In
addition, it was hypothesized that exposure to the inter-
vention would be associated with a decrease in negative
bereavement-related cognitions and in maladaptive coping
reactions such as avoidance behaviors. The results of the
study can be summarized as follows.
The intervention did not yield significant improvement
on the primary and secondary outcome measures among
participating suicide survivors. However, the intensity of
symptoms of grief and depressive complaints of suicide
survivors decreased significantly in the intervention group
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but not in the control group. In addition, there was a signif-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
icant decrease in the use of a passive coping style (includ-
ing worrying and ruminating about a problem, not feeling
able to cope, and taking a gloomy view of things) and the
behavioral expression of (negative) feelings among survi-
vors in the intervention group but not in survivors in the
control group. Finally, survivors in the intervention group
but not those in the control group showed a significant de-
crease in social support seeking at follow-up.
Preceding a discussion of these findings, a number of
methodological issues need to be addressed. First, only a
small group of suicide survivors participated in the study,
possibly introducing selection and participation biases.
Certain features of the study participants may have had an
effect on the representativeness of the sample and thus on
the extent to which the findings are applicable to suicide
survivors in general. For instance, survivors who cope ad-
equately with their grief may be more willing to participate
in bereavement studies, while the most suffering survivors
may not be reached. In addition, the sample size may have
been too small to detect significant differences between
the two study groups. Secondly, the two home visits in
the control group may have biased the results. Differenc-
es in outcome measures between the two study groups at
follow-up could have been significant if there would not
have been any face-to-face contact with control group par-
ticipants. Research outcomes can indeed be influenced by
applied research methods (interviews vs. Questionnaires;
Sveen & Walby, 2008). Thirdly, the CBT-based psychoed-
ucational intervention consisted of four 2-hr sessions. It is
possible that outcomes would have been more beneficial if
more sessions were provided. Finally, the outcome meas-
ures all assessed grief-related emotional problems, while
more positively oriented concepts, like posttraumatic
growth or resilience, were not studied. Even if grief-related
emotional problems persist, a loss can generate positive
changes to one’s life (Calhoun, Tedeschi, Cann, & Hanks,
2010). Resilience can enhance recovery after loss (Bon-
nano, Westphal, & Mancini, 2011). Such positive changes
or resilience could have been encouraged through the in-
tervention.
The only previous methodologically sound study of
a CBT-based intervention in suicide survivors showed a
trend toward reduced maladaptive grief reactions and
blame, possibly due to fewer negative cognitions, avoidant
behaviors, and feelings of guilt and self-blame. Howev-
© 2014 Hogrefe Publishing
199
er, these potentially mediating factors, which could be the
target of cognitive-behavioral interventions, were not as-
sessed. Findings from the current study suggest a limited
contribution of changes in these cognitive, emotional, and
behavioral characteristics to explaining effects of CBT-
based interventions.
The findings thus support one of the conclusions of our
recent review of randomized controlled studies aiming at
the prevention and treatment of complicated grief, name-
ly, that the development of complicated grief apparently
cannot be prevented by means of psychotherapeutic inter-
ventions (Wittouck, Van Autreve, De Jaegere, Portzky, &
van Heeringen, 2011). However, this does not necessarily
mean that interventions aimed at the prevention of compli-
cated grief do not have any value. The absence or limited
effects of preventive grief interventions may not necessari-
ly reflect a lack of effect at an individual level.
Conclusion
The results from the current study suggest that CBT-based
psychoeducational interventions can serve as supportive
counseling for suicide survivors, who, for instance, may
gain more insight into their mourning process and develop
a better understanding of their emotional reactions. Meas-
ures of improvement are often quantitative measures of
(complicated) grief, anxiety, and depression, and the effect
of preventive grief interventions may not be situated in
these areas, but rather on a qualitative level, such as feel-
ing supported in their mourning process by comourners or
by a grief counselor. The finding of a reduction in social
support seeking among survivors in the intervention group
and not among those in the control group in the current
study is surprising, but could indeed be due to the expe-
rience of emotional support attributed to the intervention.
Moreover, if bereaved individuals feel the need for grief
counseling (either individually or in group), irrespective of
whether their grief reactions are to be regarded as normal
or complicated, they may very well benefit from a coun-
seling program. In addition, through offering counseling
services to suicide survivors, those developing or display-
ing complicated grief reactions can be recognized early
and be referred to grief therapy. The sooner an intervention
starts, the more beneficial the outcome may be.
Acknowledgments
This study was supported by a grant from Go for Happi-
ness. We would like to thank the study participants and
Prof. Georges Van Maele for helping with the statistical
analyses.
Crisis 2014; Vol. 35(3):193–201
 200 C. Wittouck et al.: A CBT-Based Psychoeducational Intervention for Suicide Survivors
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 C. Wittouck et al.: A CBT-Based Psychoeducational Intervention for Suicide Survivors 201

Received January 7, 2013
Revision received December 23, 2013
Accepted December 23, 2013
Published online May 30, 2014
About the authors
Ciska Wittouck is a clinical psychologist and a criminologist. She
works as a PhD researcher at the University of Ghent. Her main
research interests include forensic mental health, mentally ill of-
fenders, self-harm and suicide in prisons, judicial alternatives for
imprisonment, and forensic psychiatric assessment.
Centre. She is a professor of medical psychology at the Universi-
ty of Ghent, and a cognitive behavioral therapist at the Centre for
Eating Disorders at the University Hospital Ghent.
Kees van Heeringen, MD, PhD, is a professor of psychiatry at the
University of Ghent, Belgium. He is Chair of the Division of Psy-
chiatry and Medical Psychology at the Faculty of Medicine and
Health Sciences, and Director of the Unit for Suicide Research at
the University of Ghent.
C. van Heeringen

Sara Van Autreve is a clinical psychologist and PhD researcher University Hospital Gent 1K12F
De Pintelaan 185
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

at the Department of Psychiatry and Medical Psychology, Uni-

This document is copyrighted by the American Psychological Association or one of its allied publishers.

versity of Ghent. She is a clinical psychologist and cognitive be- 9000 Gent
havioral therapist. Belgium
Tel. +32 9 332-4330
Gwendolyn Portzky, MSc PhD, is coordinator of the Unit for Sui- Fax +32 9 332-4989
cide Research and coordinator of the Flemish Suicide Prevention E-mail cornelis.vanheeringen@ugent.be

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