# CBT not effective for complicated grief in families affected by suicide



## David Baxter PhD (Apr 23, 2007)

CBT fails to alleviate complicated grief in families affected by suicide
23 April 2007
_Brit Med J_ 2007

Cognitive behavior therapy (CBT) does not reduce the risk for complicated grief, suicidal thoughts, or depression among families bereaved by suicide, say investigators.

However, this therapy may help prevent maladaptive grief reactions and perceptions of blame among first-degree relatives and spouses.

"The mild beneficial effect of our counseling program on maladaptive grief reactions and blame might be the result of reduced negative cognitions and avoidant behaviors," say Marieke de Groot, from the University of Groningen in The Netherlands, and colleagues.

"This might, in turn, have improved family problem solving," they add.

The researchers followed-up 122 first-degree relatives and spouses of 70 people who committed suicide over a 13-year period.

Thirty-nine families were randomly assigned to receive CBT, while the remaining 31 received usual care.

CBT was conducted by experienced psychiatric nurses who helped relatives to reference their grief reactions, engage in emotional processing, interact effectively, and problem solve.

CBT did not affect complicated grief. At the 13-month follow-up, average traumatic grief scores were 69.96 for those receiving CBT and 66.5 for the control group.

The two groups also had similar levels of depression, with Center for Epidemiologic Studies Depression scale scores of 14.2 for participants receiving CBT and 13.3 for controls.

Maladaptive grief reactions, however, were substantially rarer among relatives and spouses in the CBT group, at 22%, compared with 32% among controls.

The intervention also strongly reduced feelings of blame, with 15% of participants receiving CBT feeling they were to blame for the suicide, compared with 22% of controls.

"Having a chance in counseling to reflect on and acknowledge their loved one's difficulties before the suicide may have helped relatives to realize that they did nothing wrong," de Groot et al write in an advance online publication by the _British Medical Journal_.

"Informing relatives of the psychiatric context of suicidal behavior might have challenged their perceptions of guilt and self blame," they add.

"Thus, this counseling program can help to relieve the burdens associated with bereavement after suicide."

Full text [ PDF file]


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## Daniel (Apr 23, 2007)

A major limitation of the study, IMHO, is that the CBT group consisted of a significantly greater percentage of bereaved parents while the control group consisted of a significantly greater percentage of bereaved children.


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## David Baxter PhD (Apr 23, 2007)

My initial reaction was a total lack of surprise.

CBT is helpful in altering distorted or unrealistic thinking and consequently is a primary component of effective treatment for anxiety disorders, depression, and other conditions involving negative affect stemming at least partially from negative cognitions/self-talk.

Grief, whether due to suicide or other loss, may be complicated by such negative cognitions (e.g., self-blame, guilt, etc., as m,entioned in the article) but fundamentally it is an emotional and spiritual process where the primary goal is not altering perceptions or cognitions but acceptance of what has happened, coping with what has happened. I wouldn't expect CBT to have a major impact on grief _per se_.


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## ThatLady (Apr 23, 2007)

I agree, David. I wasn't surprised, myself, at the discovery made by this study. Grief is a natural thing. It's something we all do when we suffer a loss. It has nothing to do, really, with maladaptive behavior. Grief is a necessary process that must be dealt with by any and all who lose something, or someone dear. There's nothing maladaptive about grief and/or grieving in and of itself.


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## Cat Dancer (Apr 23, 2007)

David Baxter said:


> Grief, whether due to suicide or other loss, may be complicated by such negative cognitions (e.g., self-blame, guilt, etc., as m,entioned in the article) but fundamentally it is an emotional and spiritual process where the primary goal is not altering perceptions or cognitions but acceptance of what has happened, coping with what has happened. I wouldn't expect CBT to have a major impact on grief _per se_.



But wouldn't this also be true for something like rape or some other event that is also totally out of a person's control? You have to learn to cope with what has happened. Doesn't CBT help with that?


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## ThatLady (Apr 23, 2007)

While grief is a component in situations like rape, and other traumatic events, it isn't the main ingredient, Janet. It's a secondary reaction to what happened. Until the shock and feelings of violation that are created by incidents like rape are dealt with, grieving can't take place. You've got to get the real "uglies" out of the way for normal grieving to have a chance.


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## David Baxter PhD (Apr 23, 2007)

CBT helps with self-blame and guilt, and with unrealistic expectations of future risks, disasters, or catastrophes, etc. In that respect, in can bhelp with certain aspects of grief, depression, PTSD, OCD, generalized anxiety disorders, phobias, etc., etc.

So it's not totally useless, even with certain types of grief.

What I meant is that it's not going to help with the grief itself, only with the secondary "complications" of grief.

_Edit: Thatlady beat me to it... darn these slow fingers. _


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## ThatLady (Apr 23, 2007)

I had to laugh at your "slow fingers" remark, David. My mother had a brain tumor a few years ago. It was benign, but it caused quite a few problems before we could get her to go to the doctor and finally find out what the problem was (darned nurses!).

Mother used to be an avid gamer (online text-based RPGs). Just before the tumor was diagnosed and removed, she was becoming unable to type because of severe tremors (tremors run in our family anyway, and hers were getting a LOT worse). She griped and fussed constantly. Since the tumor has been removed, it's taken her awhile to be able to actually use the computer effectively. She just started to try again about six months ago and is slowly regaining some of her typing skills. She still gripes about her darned ol' "slow fingers"!


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## David Baxter PhD (Apr 23, 2007)

It's a ripoff of one of those "reasons for editing" things I saw on a forum a couple of yearts ago, where the poster had typed in "fat fingers".


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## Cat Dancer (Apr 23, 2007)

So this is just true for survivors of suicide, not for survivors of other types of loss?


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## David Baxter PhD (Apr 23, 2007)

No. What we're saying is that CBT may be helpful for secondary "complications" of ANY type of grief. But not for grief _per se_, not for the grief process itself.


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## Cat Dancer (Apr 23, 2007)

But THIS study was only about survivors of suicide? Or am I reading something wrong?


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## ThatLady (Apr 23, 2007)

It would be true, in my opinion, for any type of traumatic loss, Janet. When someone dies expectedly, as in the situation of an elderly person who's lived a wonderful life and passes from a known disease process, grieving usually proceeds normally. Occasionally, there will be complications, but not often.

When someone dies young, or dies unexpectedly or traumatically, there are often complications that must be dealt with before grief can take its natural course. There's misplaced anger, misplaced guilt, misplaced fear ... you name it. The major problem is the trauma. It gets in the way of the grieving process.


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## ThatLady (Apr 23, 2007)

Yes, Janet. This study was only about survivors who have lost family members to suicide. However, suicide is only one form of traumatic loss. All forms of traumatic loss involve complications that interfere with normal grieving. Those complications have to be treated first; otherwise, grieving cannot procede normally.


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