Family Counseling After Suicide Eases Self-Blame But Not Grief

GRONINGEN, The Netherlands, April 19 -- Cognitive behavior counseling for families and spouses bereaved by suicide helped relieve feelings of blame but failed to reduce complicated grief or depression, researchers here reported.

A chance to reflect on and acknowledge loved ones' difficulties pre-suicide may have helped relatives realize they did nothing wrong, psychiatric nurse Marieke de Groot of the University of Groningen here, and colleagues, reported online in BMJ.

Informing relatives of the psychiatric context of suicidal behavior might also have challenged their perceptions of guilt and self-blame, the researchers said.

Symptoms last for at least two months and cause considerable impairment, including lengthy psychiatric illness. However, people bereaved by suicide are even more vulnerable to psychiatric effects and require effective help, the researchers said.

Up to 15% of all naturally bereaved people develop complicated grief, with symptoms such as purposelessness, a sense of detachment, yearning, disbelief, and bitterness related to the death,

To study the effectiveness of family-based grief counseling, the investigators undertook a cluster randomized controlled trial, with follow-up at 13 months after the suicide.

The cognitive behavior counseling program at the patients' homes, three to six months after the suicide, consisted of four two-hour sessions, with a psychiatric nurse trained in cognitive therapy. Patients came from generalist practices in Holland from Sept. 1, 1999 to Jan. 1, 2002.

Of the suicides, 69% were reported by coroners. The main reason for families refusing to take part was the wish to put the event behind them, although it remained unclear to what extent this was colored by the physician's perception, the researchers said.

The counseling program sought to offer a frame of reference for the participants' grief, engage them in emotional processing, enhance effective interaction, and improve problem solving. Participants were provided with a manual with information on suicide and bereavement after suicide, homework, a bibliography, and addresses for additional help.

The study, included 122 first-degree relatives (older than 15) and spouses of 70 people who had committed suicide. Of these, 39 families (68 participants) were allocated to the intervention, while 31 families (54 participants) received usual care and served as controls.

The intervention did not reduce self-reported complicated grief (mean difference ?0.61, 95% confidence interval ?6.05 to 4.83; P=0.82), suicidal thoughts, or depression, the researchers reported.

However, after adjusting baseline inequalities, the researchers saw a trend toward reduced perception of being to blame for the suicide (odds ratio 0.18, 0.05 to 0.67; P=0.01) as well as a nonsignificant trend toward reduction in so-called maladaptive grief reactions (OR 0.39, 0.15 to 1.01; P=0.06).

The decrease in maladaptive grief reactions was more complicated, as was the definition. Although less common in the intervention group (22% versus 32%), the differences were more significant after controlling for baseline inequalities

Maladaptive grief reactions were based on the criteria for complicated grief and measured on scores of frequency and intensity ranging from zero to four. Maladaptive grief was diagnosed if both the frequency and intensity of a reaction were equal to or higher than three.

Subsequently, the scores were changed to a yes-no format and the presence of maladaptive grief reaction was defined as at least one positive response.

Of those in the intervention group, after counseling 22% had maladaptive grief reactions. That number is remarkably close to the prevalence of complicated grief at 13 months in naturally bereaved people. Thus the intervention may have reduced the level of grief to that seen among people enduring a more ordinary loss, the investigators wrote.

The trend toward a mild beneficial effect of the counseling program on maladaptive grief reactions and blame may have resulted from a reduction in negative thinking and avoidance behavior, the researchers said. This might have improved family problem solving, as shown in a previous study of naturally bereaved families. In addition, having a chance to reflect on their loved one's earlier problems may have helped the relatives realize that it wasn't their fault.

One potential limitation of the study was the considerable number of families that refused to take part, including a 25% dropout rate. Efforts to recruit families could not depend on the severity of symptoms as this was unknown before inclusion. Additionally, monitored audiotapes did not suggest section bias with regard to family functioning.

The authors suggested that different prevention strategies aimed at this high-risk population might determine the best way to reduce the risk of suicide among people bereaved by suicide. Broadening the counseling program, they said by including strategies targeting depression or suicidal thoughts might be reasonable because skills needed to concentrate on counseling, such as reading, exercising, and discussing issues, might be adversely affected by depression, resulting in lower treatment response.