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J Korean Acad Psychiatr Ment Health Nurs > Volume 33(2); 2024 > Article
Kang and Kim: Development and Effectiveness of Motivational Interviewing-Cognitive Behavioral Therapy integrated Counseling Program for Reducing Suicidal Ideation



This study aimed to develop a counseling program called Motivational Interviewing-Cognitive Behavioral Therapy Integrated Counseling Program (MICBT-CP) and evaluate its effectiveness in post-case management of individuals who have attempted suicide.


Twenty-eight participants with a history of suicide attempts and high scores on Beck’s Scale for Suicidal Ideation were divided into three groups: an experimental group (EG), control group 1 (CG1), and control group 2 (CG2). Each group received different interventions: MICBT-CP for the EG, cognitive-behavioral treatment-based case management (CBT-CM) for CG1, and general case management (GCM) for CG2. Measurements of suicidal ideation, depression, hopelessness, problem-solving competence, life motivation, and perceived motivation were taken at baseline (T1), 6 weeks (T2), and 18 weeks (T3).


Significant improvements in life motivation, perceived motivation, and problem-solving competence were observed in the EG compared to CG1 and CG2. Moreover, the EG showed significant reductions in suicidal ideation, hopelessness, and depression. The treatment of CG2 with GCM did not yield significant results, indicating the limitations of current GCM in post-suicide attempt case management.


The study emphasizes the need for effective programs such as MICBT-CP and improved practitioner skills in post-suicide case management.


South Korea has experienced rapid economic growth in a short period and was successful in gaining membership in the Organization for Economic Cooperation and Development’s (OECD) Development Assistance Committee in 2010. But, In 2022, Korea’s suicide rate [1] reached 25.2 per 100,000, the highest among OECD nations. Now, South Korea needs to improve the quality of life of its citizens to match its status as a developed country. As a result of this, In 2023, the government introduced the 5th Suicide Prevention Basic Plan to improve high-risk group identification and post-suicide case management [2]. As a key takeaway, mental health centers offer counseling services for individuals who have attempted suicide. However, postmanagement counseling programs for suicide attempters are insufficient, and there is also a lack of support for the development of practitioner competencies [3]. In reality, the situation heavily depends on the individual capacity of the personnel responsible for suicide prevention tasks [4,5].
In Korea, the re-attempt rate within one month after a suicide attempt is 38.3%[6], so early counseling programs are important to prevent further attempts. However, the development of counseling programs for suicide attempters in Korea is insufficient. According to a previous study, 98.3% of domestic suicide prevention counselors reported that there are not enough services to meet the needs of suicide attempters [3]. Therefore, to effectively carry out the post-management of suicide attempters, it is necessary to develop a counseling program suitable for the post-management of suicide attempters.
Various factors [7] contribute to suicidal ideation among suicide attempters, including hopelessness, problem-solving ability, depression, and perfectionism. Addressing ambivalence regarding life and death, particularly at the onset of the interview, is crucial [4,5]. The suicide attempters must identify a reason to live to engage effectively with the professional. Failure to find such a reason impedes the initiation of follow-up and counseling processes. Therefore, addressing ambivalence early on is imperative for facilitating successful intervention and support. Therefore, this study adopts an integrated approach of Motivational Interviewing (MI) and Cognitive Behavioral Therapy (CBT) to tailor counseling services for suicide attempters.
MI, known for enhancing intrinsic motivation and resolving ambivalence, has proven efficacy in short-term interventions [8] and when combined with other therapeutic modalities [9,10]. CBT, also an evidence-based practice, reduces suicidal ideation and behaviors [11]. Integrated CBTMI studies have shown improved participant engagement [12]. This combined approach offers promise in addressing the psychological complexities of suicide attempters, providing a comprehensive strategy for effective intervention. Thus, the integrated approach of MI and CBT may represent an effective strategy for reducing suicidal ideation, resolving ambivalence about life and death, and fostering participation in case management counseling for individuals who have attempted suicide. This integrated approach could be complementary, as MI plays a key role in enhancing a person’s motivation to live, while CBT strategies can address the specificity lacking in MI strategies for preventing suicide recurrence [13]. However, Korea has yet to develop a counseling program integrating MI and CBT to manage suicide attempters. Existing research [14] primarily utilizes group counseling formats, which may not effectively address complex issues in individual suicide attempters.
Therefore, this study developed a MICBT-CP program to reduce suicidal ideation and assessed its effectiveness in addressing suicide-related variables such as suicidal ideation, depression, hopelessness, problem-solving ability, life motivation, and perceived motivation. The purpose of this study is to provide evidence-based interventions to mediate suicide-related variables, including preventing re-attempts, increasing motivation to live, and reducing suicidal ideation.


1. Study Design

This study examined the effectiveness of motivational interviewing-cognitive behavioral therapy integrated counseling program (MICBT-CP) using quasi-experimental research design.
To control the control variables that interfere with the internal validity of the study, the measurement time was the same between the experimental group, comparison group 1, and comparison group 2, and there was sufficient time between the pretest, posttest, and follow-up test. In particular, during the study period, the outside activities of the study participants were highly restricted due to COVID-19, and it cannot be excluded that this natural event affected the psychological factors of the study participants. The impact of COVID-19 was controlled for history by comparing the experimental and control groups at the same time, with the same conditions at all three study sites.

2. Participants

The subjects of this study were recruited from individuals registered at mental health centers, as individual contact with researchers was difficult due to the nature of the research participants, who were suicide attempters.
Inclusion criteria were for adults aged 19 to 65 who had attempted suicide within the past year among those registered at three mental health centers in Korea and receiving case management. Additionally, the subjects were people who had never participated in this program or similar programs before, and this was confirmed by the case manager in charge. This included individuals who scored 9 or higher on Beck’s Suicidal Ideation Scale [15], which indicates a high level of suicidal ideation.
G Power3.1.9.7 was used to calculate the number of research subjects. With effect size=0.25, probability of error=0.05, power=0.95, number of groups=3, and number of measurements=6, the total number of subjects required was 36. With a dropout rate of 10%, the total number of subjects expected to be recruited was 40. Forty-nine subjects from three mental health centers met the inclusion criteria, of which 35 participants agreed to participate in the study. They were included in the experimental group (EG), control group 1 (CG1), and control group 2 (CG2) for each center, and the following treatment was performed to verify the effectiveness of the MICBT-CP developed in this study (EG=10, CG1=13, CG2=12).
The experimental group (EG) received 6 sessions of 1:1 MICBT-CP individual counseling and case management, and comparison group 1 (CG 1) received 6 sessions of 1:1 cognitive behavioral program and case management (CBT-CM). Comparison Group 2 (CG2) only received general case management (GCM) provided by suicide prevention staff at a mental health center. Among the 35 people who participated in the study, there were no dropouts in the experimental group (EG) (dropout=0), while a total of 7 dropouts occurred in control group 1 (CG1) (dropout=5) and control group 2 (CG2) (dropout=2). As a result, the total number of participants group was 28: 10 in the experimental group (EG), 8 in comparison group 1 (CG1), and 10 in comparison group 2 (CG2). In the case of CG1, a dropout rate of 38% was observed, which is similar to the dropout rates reported in previous CBT studies ranging from 30~40%. In the case of CG2, 16% dropped out, which occurred as a result of refusal to respond to surveys among participants in general case management. The total dropout rate in this study was 8%. Data from dropouts were excluded from the analysis.
To prioritize participant safety and protect subjects, suicide risk assessments were conducted at each session, taking into consideration the possibility of participants being suicide attempters.

3. Development of a Motivation-Interviewing Cognitive-Behavioral Counseling Program

To develop MICBT-CP, we initially reviewed theoretical models related to motivational interviewing and cognitive behavioral therapy [7,12,13]. Drawing from previous studies and literature, the preliminary program consisted of 6 sessions (2 MI sessions and 4 CBT sessions), each lasting 60 minutes. The preliminary program has been developed by a researcher and preliminary research has been carried out. Results of the preliminary study showed that high-risk suicide groups with interpersonal difficulties were less effective in applying for the preliminary program. Based on these results, we focused more specifically on emotional aspects and cognitive coping. To this end, we modified the preliminary program to reflect the components of dialectical behavior therapy. The program that underwent preliminary research later received preliminary certification as a suicide prevention program from the Ministry of Health and Welfare and the Korea Suicide Prevention Foundation. Finally, in 2022, this program received the final certification from the Ministry of Health and Welfare as the first case management counseling program for suicide attempts in Korea.
The final 6-session MICBT-CP (Table 1) was developed based on findings from the preliminary study [5]. Sessions 1 and 2 of MICBT-CP were grounded in MI principles, while sessions 3 to 6 incorporated CBT strategies. Session 1, titled the “building relationships and evoking life motivation” phase, Session 2, titled “building a change plan,” Sessions 3 and 4 concentrates on developing cognitive coping skills through the utilization of CBT strategies. Session 5 aims to develop emotional coping skills through the utilization of the emotion regulation module of Dialectical Behavior Therapy (DBT). Lastly, session 6 focuses on developing behavioral coping skills. It employs DBT interpersonal effectiveness skills to develop strategies for managing stress. Suicide risk assessment, agenda setting, summarization, feedback, and homework assignments were integral components of every session.

4. Data Collection and Intervention

Data collection was conducted for 18 weeks, from June 15th to October 20th, 2020. This period was the COVID-19 pandemic period, and quarantine rules were strictly observed when conducting individual programs for research subjects.
For the experimental group (EG), the researcher conducted a home visit with a case manager, explained the purpose of the study, and obtained consent for participation in the MICBT-CP. For control group1 (CG1) and control group2 (CG2), the case manager visited the participant and obtained consent to participate in cognitive behavioral treatment-based case management (CBT-CM) (CG1) and general case management (GCM) (CG2), respectively.
The interventions for the three groups were conducted for six weeks at each center. The researcher provided the MICBT-CP directly to EG at mental health center A. CBT-CM for CG1 and GCM for CG2 were administered by case managers at mental health centers B and C, respectively. The CBT-CM program for CG1 was restructured into 6 sessions by the researcher based on the 10-session CBT program [18]. The researcher provided an 8-hour training session for the case manager to deliver the CBT-CM intervention for CG1, ensuring they were fully prepared for its implementation. GCM for CG2 involves delivering standard general case management services. Data were collected at three-time points: pre-intervention (T1), 6 weeks (T2), and 18 weeks (T3) by an external case manager, distinct from the interventionist.

5. Measurements

The instrument for this study used six key variables in four domains (motivation, cognition, emotion, and behavior) related to suicidal behavior as follows.

1) Motivation variables

(1) Life motivation (LM)

To assess LM, the Korean version [19] of the Life Satisfaction Motivation Scale (LSMS) developed by Diener et al. [20] was employed. This scale comprises 5 questions rated on a 7-point Likert scale ranging from 1 (very low) to 7 (very high). A total score of 35 points is possible, with higher scores indicating greater motivation for life satisfaction. The internal reliability coefficient for this study was Cronbach’s ⍺=.91.

(2) Perceived motivation (PM)

PM was measured using the Numerical Rating Scale (NRS), a measure of suicide attempters’ motivation to change. It is a three-item, 10-point scale (0 not ready to change to 10 very ready to change). Higher scores indicate greater readiness to change. Internal reliability of this study was Cronbach’s ⍺=.90.

2) Cognitive variables

(1) Suicidal ideation (SI)

For SI, the Korean version [21] of the Scale for Suicidal Ideation (SSI) developed by Beck et al. [15] was utilized. It comprises 19 items rated on a 3-point Likert scale (0 for no suicidal ideation to 2 for high suicidal ideation). Total scores ranged from 0 to 38, with higher scores indicating greater suicidal ideation. Internal reliability of the previous study [21] was Cronbach’s ⍺=.87 and Internal reliability of this study was Cronbach’s ⍺=.90.

(2) Hopelessness (HPLS)

To measure HPLS, the Korean version [21] of the Beck Hopelessness Scale (BHS) developed by Beck & Weissman [22] was employed. It consists of 20 items rated on a 2-point scale (0 for yes and 1 for no), with total scores ranging from 0 to 20. Higher scores signify increased hopelessness. Internal reliability of the previous study [21] was Cronbach’s ⍺=.81 and Internal reliability of this study was Cronbach’s ⍺=.98.

3) Emotional variable

(1) Depression (DEP)

For DEP, the Korean version of the CES-D (The Center for Epidemiologic Studies Depression Scale) [23,24] was employed. It is a 20-item, 4-point Likert scale (0 very rarely to 3 most of the time) with a total score ranging from 0 to 60. Higher scores denote more severe depression. Internal reliability of the previous study [24] was Cronbach’s ⍺=.89 and Internal reliability of this study was Cronbach’s ⍺=.92.

4) Behavioral Variable

(1) Problem solving competency (PSC)

For PSC, the Korean version of the Problem Solving Inventory (PSI) developed by Heppner and Peterson [25, 26] was employed. It comprises 32 items rated on a 6-point Likert scale (1 not at all to 6 very much), resulting in a total score ranging from 32 to 192. Higher scores reflect greater positive problem-solving ability. Internal reliability of the previous study [26] was Cronbach’s ⍺=.92 and Internal reliability of this study was Cronbach’s ⍺=.93.

6. Data Analysis

The data were analyzed using SPSS version 26.0. Frequency analysis was employed to identify the demographic characteristics of the participants. The ShapiroWilk test assessed the normality of EG, CG1, and CG2, while the Kruskal-Wallis test examined homogeneity. Differences between and within groups of EG, CG1, and CG2 were assessed using the Kruskal-Wallis and Friedman tests, respectively, with Bonferroni post hoc testing.

7. Ethical Consideration

IRB approval (1040621-202005-HR-015) was obtained from the University of D Institutional Review Board to approve the study. Participants received a briefing on the study’s purpose, privacy protection, anonymity, and the option to withdraw at any time.

8. Researcher Preparation

The researcher worked in suicide prevention counseling at a mental health welfare center for seven years. also The researcher, a certified mental health professional (level 1), supervises cognitive behavioral therapy counseling and motivational interviewing trainer.


1. Participants’ Characteristics

In CG1, 62.5% of participants were male, while 70% and 60% of participants were female in EG and CG2, respectively. Each group consisted of half participants aged 40 or older and the remainder in their 20s or 30s. Across all three groups, there were many single individuals, with over 50% having a high school education or less. Over 70% were unemployed, and over 60% had a history of psychiatric hospitalization. Concerning the most recent suicide attempt method, 50% of EG and CG2 reported ‘poison’, while 62.5% of CG1 reported ‘self-harm with substances’. Depressive disorders constituted a significant portion of psychiatric diagnoses.

2. Test of Homogeneity and Normality

The Shapiro-Wilk test was utilized to examine sample distributions. Except for HPLS in CG1 (p=.023) and CG2 (p<.001), all other psychological variables in EG, CG1, and CG2 met normal distribution criteria. The Kruskal-Wallis test evaluated the homogeneity of six variables across EG, CG1, and CG2, with no statistically significant differences detected (Table 2).

3. Verification of Differences between Groups over Time (T1, T2, T3)

The Kruskal-Wallis test compared mean rank differences among three groups (EG-CG1-CG2) for six variables at three-time points (T1, T2, T3). At T2 (6 weeks), four variables (PM, SI, HPLS, and PSC) showed significant differences between groups (EG-CG1-CG2), and At T3 (18 weeks), all of variables (LM, PM, SI, HPLS, DEP, and PSC) showed significant differences between groups (EG-CG1-CG2) (Table 2).

4. Post Hoc Test between Groups

The Kruskal-Wallis test assessed group differences for significant variables at T2 and T3, followed by Bonferroni’s post hoc test to further examine any identified differences (Table 3).
At T3, significant differences were observed in LM between EG-CG2 (x2=9.95, p=.006) and EG-CG1 (x2=8.38, p=.030). Additionally, DEP exhibited significant differences only between EG-CG2 (x2=-10.50, p=.004).
At T2, PM showed significant changes between EG-CG2 (x2=10.55, p=.004), and at T3, between EG-CG2 (x2=12.70, p=.001), EG-CG1 (x2=8.97, p=.021). SI exhibited significant changes at T2 between EG-CG2 (x2=-9.45, p=.010), at T3 between EG-CG2 (x2=-13.85, p<.001), EG-CG1 (x2=-2.16, p=.030). HPLS showed significant changes at T2 between EG-CG2 (x2=-8.90, p=.015), EG-CG1 (x2=-9.00, p=.020), and at T3 between EG-CG2 (x2=-12.45, p=.001). PSC showed significant changes at T2 between EG-CG2 (x2=7.35, p=.046), EG-CG1 (x2=9.01, p=.021), and at T3 between EG-CG2 (x2=7.45, p=.043), EG-CG1 (x2=8.53, p=.028). Based on the post-hoc test results, EG showed significant differences from both CG1 and CG2 in all comparison tests, indicating the most significant changes in mean rank scores for EG. In contrast, differences between CG1 and CG2 did not show significant differences across all variables, suggesting the effectiveness of MICBT-CP.

5. Verification of Differences within Groups Over Time (T1, T2, T3)

For each of the three groups, Friedman tests were conducted to assess within-group differences across six variables over time (T1, T2, T3) (Table 4).
The validation results indicated significant differences in LM (x2=16.71, p<.001), PM (x2=17.56, p<.001), DEP (x2=11.12, p=.004), and PSC (x2=12.60, p=.002) only within the EG, with no significant differences observed in CG1 and CG2 (Table 4). This suggests that MICBT-CP has significant effectiveness for these four variables. In the case of SI and HPLS, significant differences were observed between the EG and CG1 groups. This indicates the effectiveness of MICBT-CP and CBT-CM interventions in alleviating suicide ideation and hopelessness. Both variables showed a decreasing trend in mean rank scores over time in both EG and CG1, with the reduction being more pronounced in the EG compared to CG1 at T3.
This suggests that in the case of SI and HPLS, MICBT-CP may be expected to have better effectiveness compared to CBT-CM. MICBT-CP (EG) was effective across all six variables, while CBT-CM demonstrated significant effectiveness solely for SI and HPLS (Table 4).

6. Post-hoc Testing for Within-Group Differences in the EG

Based on the results of within-group difference tests, Bonferroni tests were conducted using the Friedman test to examine differences across T1-T2-T3 for variables demonstrating significant differences within the experimental group (EG) (Table 5). Post-hoc tests for the EG revealed significant differences in mean ranks for suicidal ideation (SI) across all time points: T1 (2.90) - T2 (2.00) (x2=0.90, p=.044), T1 (2.90) - T3 (1.30) (x2=1.80, p<.001), T2 (2.00) - T3 (1.30) (x2=0.90, p=.044). Significant differences in life motivation (LM), perceived motivation (PM), hopelessness (HPLS), depression (DEP), and problem-solving competency (PSC) were observed only between T1-T2 and T1-T3. This indicates that MICBT-CP is effective in enhancing LM, PM, and PSC while reducing SI, DEP and HPLS. From these findings, it can be inferred that MICBT-CP may significantly reduce suicidal ideation and hopelessness, as well as depression, while boosting motivation for life, perceived motivation, and problem-solving abilities.


The objective of this study was to develop and evaluate the effectiveness of an integrated Motivational Interviewing-Cognitive Behavior Therapy-Counselling Program (MICBT-CP) aimed at reducing suicidal ideation among individuals with a history of suicide attempts during postsuicide case management. The development of MICBT-CP involved two key stages: expert group validation and national certification. It has been granted final approval by the Ministry of Health and Welfare as a certified domestic post-attempt suicide management program.
MICBT-CP was administered to 10 domestic suicide attempters (EG) over a span of 6 sessions. Its effectiveness was assessed by comparing it with groups receiving CBT-CM (CG1) and GCM (CG2) at baseline (T1), 6 weeks (T2), and 18 weeks (T3). The results revealed significant increases in life motivation (LM), perceived motivation (PM), and problem-solving competency (PSC) within the EG receiving MICBT-CP at both 6 weeks (T2) and 18 weeks (T3). Furthermore, there were significant decreases observed in suicidal ideation (SI), hopelessness (HPLS), and depression (DEP). The specific discussion is as follows.
Significant increases were observed in the EG that received MICBT-CP compared to control groups CG1 and CG2 in terms of Life Motivation (LM) and Perceived Motivation (PM). Previous studies focusing on LM, which applied MI [4,5], have reported improvements in motivation for change among individuals at risk of suicide, resulting in reduced suicidal ideation. These findings suggest that the MI approach may effectively access intrinsic resources from suicide attempters, help them identify reasons to live, and evoke positive statements about life (change talk), ultimately enhancing their confidence and intrinsic motivation. The analysis results of PM, which explores the meaning of life, confidence, and preparation for life, are also consistent with previous studies using MI [4,5]. MICBT-CP, grounded in MI from the program’s inception, aids individuals who have attempted suicide in recognizing the value of life over death and building confidence to embrace life. Furthermore, it facilitates readiness for life by nurturing an appreciation for life’s importance over death, resolving ambivalence toward life and death, improving readiness for life, and bolstering confidence. Therefore, it can be inferred that the MI approach to deal with ambivalence about life and death is effective in promoting LM and PM.
The effectiveness of MICBT-CP in reducing suicidal ideation (SI) was also evident in the experimental group (EG) compared to control groups CG1 and CG2, aligning with findings from cognitive-behavioral theory studies [5,11] and motivational interviewing research [4,5]. Notably, CG1 (CBT-CM) also showed a significant decrease in SI, echoing results from cognitive therapy studies [11,18] and emphasizing CBT-CM’s impact on reducing SI. However, CG2 (GCM) did not exhibit a significant difference in SI, consistent with previous studies [4,5], indicating limitations in current post-attempt suicide care approaches. These results are different from previous studies that reported the significance of case management for suicide attempters [27]. The characteristics of the research subjects are diverse, and there are differences in the intensity and expertise of case management, making it difficult to compare directly with previous studies. However, we note that Diego and Travis’s study [27] involved interventions by experienced and skilled case managers. Currently, in Korea, case management for suicide attempters is conducted by mental health center staff according to protocols provided by the Korean foundation for suicide prevention [2]. However, the capacity and proficiency of service providers have not been confirmed. Therefore, the results of this study indicate the need to reassess and strengthen the proficiency of general case managers. Furthermore, from the perspective of program content, the 2013 National Suicide Survey reported that 37.8% of suicide attempters attributed their actions to factors other than psychiatric issues, emphasizing the need for comprehensive strategies beyond psychiatric approaches [3]. In this context, it would be necessary to examine whether the current case management protocols address the multifaceted issues surrounding suicide. MICBT-CP could be considered as one alternative to complement the current applied case management strategies.
The experimental group (EG) showed significant reductions in the key emotional variables, HPLS and DEP, while receiving MICBT-CP. HPLS and DEP are important negative emotions for suicide attempters. Previous research focusing on emotional intervention for suicide attempters [28] indicated that “lack of motivation to engage in pleasurable activities (positive emotions)” predicts suicidal ideation. Furthermore, it emphasizes the importance of interventions aimed at enhancing positive emotions rather than reducing negative ones. The MI approach in MICBTCP is based on positive and strength-based perspectives, reflecting and acknowledging the positive attributes of participants, enhancing self-efficacy through affirmation, and helping individuals identify positive internal resources [8]. The MI approach focuses on positive emotions such as self-efficacy and is based on the strengths perspective that individuals have resources, make their own choices and take responsibility [8]. Therefore, it can be speculated that the effectiveness of HPLS and DEP reduction in this MICBT-CP was largely contributed by the MI approach.
Additionally, HPLS was significantly reduced in CG1 who received CBT-CM, corroborating the previously reported effectiveness of CBT [11,18]. However, CG2, which received general case management (GCM), did not achieve any significant effect, consistent with previous studies [4,5]. This indicates that post-attempt suicide management using GCM has limitations.
Meanwhile, unlike previous cognitive behavioral therapy studies [29], DEP did not show significant differences in CG2 using CBT-CM, which requires further observation in future studies. This suggests that cognitive intervention alone has limitations in intervening with the complexities of suicide attempters.
In the case of Problem solving competency (PSC), there was a significant increase in EG using MICBT-CP compared to CG1 and CG2. This is in line with previous studies [26] that have demonstrated significant improvements in problem-solving skills through CBT. In individuals with low problem-solving competence (PSC), rumination, a cognitive risk factor associated with suicide, may contribute to suicidal ideation through depressive symptoms [30]. Rumination has been extensively studied as a cognitive risk factor that increases the risk of suicidal ideation and attempts [30]. Recent research has highlighted the relationship between rumination and suicidal ideation and attempts, particularly in individuals with passive problem solving or inadequate problem solving skills [30]. In this context, the improvement in problem-solving skills observed in the EG undergoing MICBT-CP is significant, as it provides motivational-cognitive-behavioral modules capable of positively influencing the cognitive mechanisms that link cognitive risk factor (e.g., rumination) in suicide attempters to suicidal ideation.
The aforementioned findings affirm the effectiveness of MICBT-CP in reducing suicidal ideation (SI), hopelessness (HPLS), and depression (DEP), while also enhancing life motivation (LM), perceived motivation (PM), and problem-solving competency (PSC). Based on these results, we propose the following recommendations. First, since MICBT-CP is effective up to 3 months after intervention, we suggest establishing a systematic training program that MICBT-CP can be used in practice. Second, it was not easy to obtain research consent from suicide attempters. This is also a limitation of this study. Therefore, follow-up studies need to consider overcoming limitations in accessing data on subjects at high risk of suicide. Third, CG2, the group that only implemented general case management (GCM), did not show significant improvement in all variables. This suggests limitations of current GCM and highlights the need for research to identify the essential competencies of practitioners. Future research should focus on improving practitioners’ counseling skills and developing strategies to effectively manage complex variables related to suicide.


As of 2023, Korea has the highest suicide rate among OECD countries [1]. Current suicide prevention efforts in Korea are focused on universal approaches such as gatekeeper training, and evidence-based customized strategies are still lacking. Motivational Interviewing (MI) helps individuals who lack the motivation or problem-solving skills essential for suicide attempters. Integrating Motivational Interviewing (MI) with Cognitive Behavioral Therapy (CBT) adds significance not only in enhancing program participation motivation but also in enhancing the effectiveness of MI itself. It emphasizes helping suicide attempters to enhance their positive inner strength based on a positive perspective toward the participants. We hope that MICBT-CP will serve as a starting point for an intervention strategy to alleviate suicidal thoughts in suicide attempters, find motivation and meaning in life, and help them choose life rather than death.


The authors declared no conflicts of interest.


Conceptualization or/and Methodology: Kang, HY
Data curation or/and Analysis: Kang, HY
Funding acquisition: NA
Investigation: Kang, HY
Project administration or/and Supervision: Kang, HY & Kim, HJ
Resources or/and Software: Kang, HY & Kim, HJ
Validation: Kang, HY & Kim, HJ
Visualization: Kim, HJ
Writing: original draft or/and review & editing: Kang, HY & Kim, HJ

Table 1.
Motivational Interviewing-Cognitive Behavioral Therapy Integrated Counseling Program (MICBT-CP)
Goal Objective Session Contents Strategies
1. Evoking motivation 1. Enhancing 1. Building relationships and evoking and life motivation ∙ Engaging ∙ Assessment* : suicidal ideation and suicide risk
∙ Exploring suicidal thoughts ∙ Evocative open-ended questioning, scale question,
∙ Evoking motive of life and support commitment of life ∙ Evoking change talk, reflecting change talk.
∙ Building up safety plan ∙ Exchanging information (ask-offer-ask strategy)
∙ Facilitating between-session assignments: creating a list of my strengths.
2. Building a change plan ∙ Engaging ∙ Facilitating between-session assignments: creating a plan for my changes.
∙ Links to previous sessions, reviewing assignment
∙ Exploring values (Module 1) or Setting life goals (Modules 2) ∙ Summary and feedback
∙ Writing a plan for change
2. Reducing suicidal thoughts (based on CBT) 1. Enhancing cognitive coping skills 3. Developing cognitive coping skills 1 ∙ Engaging ∙ Facilitating between-session assignments: writing my cognitive management plan.
∙ Links to previous sessions, reviewing assignment
∙ Agenda setting and discussing agenda-related topics (developing cognitive strategies): case conceptualization and finding helpful thoughts ∙ Summary and feedback
4. Developing cognitive coping skills 2 ∙ Engaging ∙ Facilitating between-session assignments: writing my cognitive management plan.
∙ Links to previous sessions, reviewing assignment
∙ Agenda setting and discussing agenda-related topics (developing cognitive strategies continue): finding helpful thoughts ∙ Summary and feedback
2. Enhancing emotional coping skills 5. Developing emotional coping skills ∙ Engaging ∙ Facilitating between-session assignments: writing my emotion regulation plan.
∙ Links to previous sessions, reviewing assignment
∙ Agenda setting and discussing agenda-related topics (developing emotion strategies): exchange information about emotion regulation module based on Dialectical Behavior Therapy (DBT) (mindfulness, distraction skills, crisis survival skills, self-soothing skills) ∙ Summary and feedback
3. Enhancing behavioral coping skills 6. Developing behavioral coping skills ∙ Engaging ∙ Facilitating between-session assignments: writing self-care activity sheet
∙ Links to previous sessions, reviewing assignment
∙ Agenda setting and discussing agenda-related topics (Coping strategies and exploring alternatives) ∙ Summary and feedback
∙ Developing Interpersonal Effectiveness Skills based on Dialectical Behavior Therapy (DBT)
∙ Writing a plan of action

* Applies at all sessions.

Table 2.
Verification of Differences between Groups Over Time (T1, T2, T3) (N=28)
Variables Groups T1
Measuring time EG (n=10)
CG1 (n=8)
CG 2 (n=10)
x2 p
M±SD M±SD M±SD Mean rank Mean rank Mean rank
LM EG 4.82±0.65 6.20±0.84 6.56±0.57 T1 13.50 14.25 15.70 0.37 .831
CG1 4.92±1.83 4.62±2.16 5.00±1.91 T2 18.15 11.44 13.30 3.33 .189
CG2 5.10±1.29 5.52±1.02 5.02±1.23 T3 20.45 12.06 10.50 8.44 .015
PM EG 5.50±2.47 7.26±2.40 7.96±1.89 T1 18.25 13.69 11.40 3.58 .167
CG1 3.91±2.88 4.50±3.08 4.45±3.20 T2 20.40 12.94 9.85 8.64 .013
CG2 3.13±2.22 3.33±2.66 2.93±2.20 T3 21.60 12.63 8.90 12.53 .002
SI EG 0.81±0.35 0.54±0.44 0.26±0.37 T1 10.50 14.88 18.20 4.43 .109
CG1 1.02±0.36 0.79±0.32 0.80±0.34 T2 10.10 13.69 19.55 6.73 .035
CG2 1.20±0.40 1.12±0.43 1.13±0.41 T3 7.15 15.56 21.00 14.52 .001
HPLS EG 0.57±0.27 0.20±0.30 0.17±0.28 T1 10.45 16.44 17.00 3.86 .145
CG1 0.73±0.37 0.60±0.43 0.58±0.37 T2 8.75 17.75 17.65 7.74 .050
CG2 0.82±0.28 0.70±0.32 0.80±0.32 T3 7.95 15.31 20.40 11.83 .003
DEP EG 1.85±0.63 0.97±0.83 0.86±0.79 T1 13.20 13.00 17.00 1.44 .485
CG1 1.80±0.62 1.72±0.49 1.61±0.52 T2 9.60 16.31 17.95 5.70 .058
CG2 2.09±0.74 1.86±0.78 1.96±0.83 T3 8.85 15.50 19.35 8.32 .016
PSC EG 3.45±0.80 3.95±0.63 4.02±0.88 T1 17.05 10.56 15.10 2.84 .241
CG1 2.81±0.72 3.03±0.97 2.95±0.89 T2 19.70 10.69 12.35 6.40 .041
CG2 3.28±0.65 3.31±0.56 3.07±0.62 T3 19.60 11.06 12.15 6.07 .048

CG1=comparison group 1; CG2=comparison group 2; DEP=depression; EG=experimetal group; HPLS=hopelessness; LM=life motivation; M=mean; PM=percieved motivaion; PSC=problem solving competency; SD=standard deviation; SI=suicidal ideation; T1=baseline; T2=6 weeks; T3=18 weeks.

Table 3.
Post Hoc Test between Groups (N=28)
Variables Measuring time Groups Mean rank x2 p
LM T3 EG-CG2 20.45-10.50 9.95 .006
EG-CG1 20.45-12.06 8.38 .030
CG1-CG2 12.06-10.50 1.56 .686
PM T2 EG-CG2 20.40-9.85 10.55 .004
EG-CG1 20.40-12.94 7.46 .056
CG1-CG2 12.94-9.85 3.08 .428
T3 EG-CG2 21.60-8.90 12.70 .001
EG-CG1 21.60-12.63 8.97 .021
CG1-CG2 12.63-8.90 3.72 .339
SI T2 EG-CG2 10.10-19.55 -9.45 .010
EG-CG1 10.10-13.09 3.58 .357
CG1-CG2 13.09-19.55 -5.86 .132
T3 EG-CG2 7.15-21.00 -13.85 <.001
EG-CG1 7.15-15.56 -2.16 .030
CG1-CG2 15.56-21.00 -5.43 .161
HPLS T2 EG-CG2 8.75-17.65 -8.90 .015
EG-CG1 8.75-17.75 -9.00 .020
CG1-CG2 17.75-17.65 0.10 .979
T3 EG-CG2 7.95-20.40 -12.45 .001
EG-CG1 7.95-15.31 -7.36 .056
CG1-CG2 15.31-20.40 -5.08 .187
DEP T3 EG-CG2 8.85-19.35 -10.50 .004
EG-CG1 8.85-15.50 -6.65 .088
CG1-CG2 15.50-19.35 -3.85 .323
PSC T2 EG-CG2 19.70-12.35 7.35 .046
EG-CG1 19.70-10.69 9.01 .021
CG1-CG2 10.69-12.35 -1.66 .670
T3 EG-CG2 19.60-12.15 7.45 .043
EG-CG1 19.60-11.06 8.53 .028
CG1-CG2 11.06-12.15 -1.08 .780

CG1=comparison group 1; CG2=comparison group 2; DEP=depression; EG=experimetal group; HPLS=hopelessness; LM=life motivation; PM=percieved motivaion; SI=suicidal ideation; PSC=problem solving competency; T1=baseline; T2=6 weeks; T3=18 weeks.

Table 4.
Verification of Differences Within Groups Over Time (T1, T2 T3) (N=28)
Variables Groups T1
x2 p
Mean rank (range) Mean rank (range) Mean rank (range)
LM EG 1.10 (4.00~6.00) 2.25 (4.80~7.00) 2.65 (5.40~7.00) 16.71 <.001
CG1 2.19 (2.60~7.00) 1.88 (1.80~7.00) 1.94 (2.00~7.00) 0.63 .727
CG2 1.65 (3.20~7.00) 2.50 (3.80~7.00) 1.85 (3.00~700) 4.15 .125
PM EG 1.00 (2.00~9.00) 2.25 (3.00~10.00) 2.75 (4.67~10.00) 17.56 <.001
CG1 1.81 (0.00~8.33) 1.94 (0.67~8.33) 2.25 (1.00~8.67) 0.86 .648
CG2 2.35 (0.67~8.00) 1.85 (0.00~7.33) 1.80 (0.00~7.67) 2.00 .368
SI EG 2.90 (0.26~1.26) 2.00 (0.00~1.26) 1.30 (0.00~0.85) 18.00 <.001
CG1 2.81 (0.58~1.53) 1.63 (0.37~1.21) 1.56 (0.26~1.26) 8.75 .013
CG2 2.25 (0.42~1.89) 1.90 (0.42~1.79) 1.85 (0.21~1.79) 1.00 .607
HPLS EG 3.00 (0.10~1.00) 1.70 (0.00~0.90) 1.30 (0.00~0.85) 18.58 <.001
CG1 2.56 (0.00~1.00) 1.94 (0.00~1.00) 1.50 (0.00~1.00) 6.95 .031
CG2 2.00 (0.05~1.00) 1.65 (0.00~1.00) 2.35 (0.00~1.00) 3.06 .216
DEP EG 2.85 (0.65~2.45) 1.55 (0.05~2.45) 1.60 (0.00~2.55) 11.12 .004
CG1 2.44 (0.70~2.50) 2.00 (1.15~2.40) 1.56 (0.65~2.30) 3.16 .206
CG2 2.10 (0.70~3.00) 1.85 (0.55~2.90) 2.05 (0.50~3.00) 0.37 .828
PSC EG 1.10 (2.03~4.69) 2.30 (2.78~4.94) 2.60 (2.19~5.13) 12.60 .002
CG1 1.69 (1.91~3.78) 2.13 (1.69~4.25) 2.19 (1.72~4.44) 1.22 .542
CG2 2.05 (2.28~4.41) 2.25 (2.41~4.44) 1.70 (2.31~4.03) 1.63 .442

CG1=comparison group 1; CG2=comparison group 2; DEP=depression; EG=experimetal group; HPLS=hopelessness; LM=life motivation; PM=percieved motivaion; SI=suicidal ideation; PSC=problem solving competency; T1=baseline; T2=6 weeks; T3=18 weeks.

Table 5.
Post Hoc Test of Within-Group Differences for Experimental Group (N=10)
Group Variables Measuring time Within group Mean rank x2 p
EG (N=10) LM T1-T2 1.10 (4.00~6.00) 2.25 (4.80~7.00) -1.15 .010
T1-T3 1.10 (4.00~6.00) 2.65 (5.40~7.00) -1.55 .001
T2-T3 2.25 (4.80~7.00) 2.65 (5.40~7.00) -0.40 .371
PM T1-T2 1.00 (2.00~9.00) 2.25 (3.00~10.00) -1.25 .005
T1-T3 1.00 (2.00~9.00) 2.75 (4.67~10.00) -1.75 <.001
T2-T3 2.25 (3.00~10.00) 2.75 (4.67~10.00) -0.50 .264
SI T1-T2 2.90 (0.26~1.26) 2.00 (0.00~1.26) 0.90 .044
T1-T3 2.90 (0.26~1.26) 1.30 (0.00~0.85) 1.80 <.001
T2-T3 2.00 (0.00~1.26) 1.30 (0.00~0.85) 0.90 .044
HPLS T1-T2 3.00 (0.10~1.00) 1.70 (0.00~0.90) 1.30 .004
T1-T3 3.00 (0.10~1.00) 1.30 (0.00~0.85) 1.70 <.001
T2-T3 1.70 (0.00~0.90) 1.30 (0.00~0.85) 0.40 .371
DEP T1-T2 2.85 (0.65~2.45) 1.55 (0.05~2.45) 1.30 .004
T1-T3 2.85 (0.65~2.45) 1.60 (0.00~2.55) 1.25 .005
T2-T3 1.55 (0.05~2.45) 1.60 (0.00~2.55) -0.05 .911
PSC T1-T2 1.10 (2.03~4.69) 2.30 (2.78~4.94) -1.20 .007
T1-T3 1.10 (2.03~4.69) 2.60 (2.19~5.13) -1.50 .001
T2-T3 2.30 (2.78~4.94) 2.60 (2.19~5.13) -0.30 .502

DEP=depression; EG=experimetal group; HPLS=hopelessness; LM=life motivation; PM=percieved motivaion; SI=suicidal ideation; PSC=problem solving competency; T1=baseline; T2=6 weeks; T3=18 weeks.


1. Korea Foundation for suicide prevention. South Korea Suicide Facts. Korea Foundation for Suicide Prevention Online [Internet]. 2024 [cited 2024 June 17]. Available from: https://kfsp-datazoom.or.kr

2. Ministry of Health and Welfare. Guidelines for suicide prevention. Guidelines Report. Sejong City: Ministry of Health and Welfare; 2024. March Report No. 11-1352000-003146-10

3. Korea Institute for Health and Social Affairs. Reinforcing the care programs for the suicide attempters in Korea. Research reports. Sejong: Korea Institute for Health and Social Affairs; 2017. December Report No. 2017-28

4. Kang HY, Lee HJ. The effect of motivational interviewing program on self-efficacy and suicidal Ideation of suicide attempters. Mental Health and Social Work. 2017;45(1):116-143.https://doi.org/10.24301/mhsw.2017.
5. Kang HY, Lee HJ. The impact of motivation enhancing-CBT program on suicide prevention among suicide attempters. Mental Health and Social Work. 2017;45(4):139-165.https://doi.org/10.24301/mhsw.2017.
6. Youn JH. Factors associated with repeat suicide attempt in emergency department. [dissertation]. [Incheon]: Gachon University; 2017. p. 60

7. Wenzel A, Beck AT. A cognitive model of suicidal behavior: theory and treatment. Applied and Preventive Psychology. 2008;12(4):189-201.https://doi.org/10.1016/j.appsy.2008.05.001
8. Miller WR, Rollnick S. Motivational interviewing: helping people change and grow. 4nd ed. NewYork: The Guilford press; 2023. p. 338

9. Riper H, Andersson G, Hunter SB, Wit J, Berking M, Cujjpers P. Treatment of comorbid alcohol use disorders and depression with cognitive-behavioural therapy and motivational interviewing: a meta-analysis. Addiction. 2013;109(3):394-406.https://doi.org/10.1111/add.12441
crossref pmid pmc
10. Hettema J, Steele J, Miller WR. Motivational interviewing. Annual Review of Clinical Psychology. 2005;1: 91-111.https://doi.org/10.1146/annurev.clinpsy.1.102803.143833
crossref pmid
11. Leavey K, Hawkins R. Is cognitive behavioral therapy effective in reducing suicidal ideation and behavior when delivered face-to-face or via e-health? a systematic review and meta-analysis. Cognitive Behavior Therapy. 2017;46(5):353-374.https://doi.org/10.1080/16506073.2017.1332095
12. Westra HA, Constantino MJ, Antony MM. Integrating motivational interviewing with cognitive-behavior therapy for severe generalized anxiety disorder: an allegiance-controlled randomized clinical trial. Journal of Consulting and Clinical Psychology. 2016;84(9):768-782.https://doi.org/10.1037/ccp0000098
crossref pmid
13. Naar S, Safren SA. Motivational interviewing and CBT: combining strategies for maximum effectiveness. NewYork: The Guilford Press; 2017. p. 242

14. Kim SY, Kim TY, Ji E. Meta-analysis of the effectiveness of suicide prevention programs in Korea: comparison between risk groups and general groups. Korean Journal of Counseling. 2022;23(1):113-138.https://doi.org/10.15703/kjc.23.1.202202.113
15. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the scale for suicide ideation. Journal of Consulting and Clinical Psychology. 1979;47(2):343-352.https://doi.org/10.1037//0022-006x.47.2.343
crossref pmid
16. Kim JW, Seo WS, Lee JH, Kim HC, Lee KH, Won SH. Characteristics of suicide attempters admitted to the emergency departments of university hospitals: demographic and psychosocial data. Journal of the Korean Society of Biological Therapies in Psychiatry. 2015;21(2):95-104.https://uci.org/G704-001697.2015.21.2.007

17. McMillan D, Gilbody S, Beresford E, Neilly L. Can we predict suicide and non-fatal self-harm with the Beck hopelessness scale? a meta-analysis. Psychological Medicine. 2007;37(6):769-778.https://doi.org/10.1017/s0033291706009664
crossref pmid
18. Park JH. Development and evaluation of a crisis intervention program for suicide attempters. Journal of Korean Academy of Psychiatric Mental Health Nursing. 2013;22(4):368-376.https://doi.org/10.12934/jkpmhn.2013.22.4.368
19. Kim JH, Lim SK, Kim SJ, You JM, Suh KH, Kim M, et al. Types of experience of positive affect and negative affect. STRESS. 2008;16(4):343-350.https://www.kci.go.kr/kciportal/ci/sereArticleSearch/ciSereArtiView.kci?sereArticleSearchBean.artiId=ART001307806

20. Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. Journal of Personality Assessment. 1985;49(1):71-75.https://doi.org/10.1207/s15327752jpa4901_13
crossref pmid
21. Shin MS, Park KB, Oh KJ, Kim ZS. A study of suicidal ideation among high school students: the structural relation among depression, hopelessness, and suicidal ideation. Korean Journal of Clinical Psychology. 1990;9(1):1-19.https://uci.org/I410-ECN-0102-2009-180-006918248

22. Beck AT, Weissman A, Trexler L. The measurement of pessimism: the hopelessness scale. Journal of Consulting and Clinical Psychology. 1974;42(6):861-865.https://doi.org/10.1037/h0037562
crossref pmid
23. Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Applied Psychological Measurement. 1977;1(3):385-401.https://doi.org/10.1177/014662167700100306
24. Cho MD, Kim KH. Diagnostic validity of the CES-D (Korean Version) in the assessment of DSM-III-R major depression. Journal of Korean Neuropsychiatric Association. 1993;32(3):381-399.https://scholar.kyobobook.co.kr/article/detail/4050026315758

25. Heppner PP, Petersen CH. The development and implications of a personal problem solving inventory. Journal of Counseling Psychology. 1982;29(1):66-75.https://doi.org/10.1037/0022-0167.29.1.66
26. Park HJ, Jeong DY. Clusters of perfectionists and their characteristics in procrastination, problem-solving appraisal, and interpersonal problems. The Korea Journal of Counseling. 2010;11(3):975-991.https://doi.org/10.15703/kjc.11.3.201009.975
27. De Leo D, Heller T. Intensive case management in suicide attempters following discharge from inpatient psychiatric care. Australian Journal of Psychiatry Health,. 2007;13(3):49-58.https://doi.org/10.1071/PY07038
28. Craske MG, Meuret AE, Ritz T, Treanor M, Dour H, Rosenfield D. Positive affect treatment for depression and anxiety: a randomized clinical trial for a core feature of anhedonia. Journal of Consulting & Clinical Psychology. 2019;87(5):457-471.https://doi.org:10.1037/ccp0000396
crossref pmid
29. Power PJ, Mills BR, Herrman T, Davern M, Henry L, Yuen HP, et al. Suicide prevention in first episode psychosis: the development of a randomised controlled trial of cognitive therapy for acutely suicidal patients with early psychosis. Australian and New Zealand Journal of Psychiatry. 2003;37(4):414-420.https://doi.org/10.1046/j.1440-1614.2003.01209.x
crossref pmid
30. Beverlin RW, Regina M. Prospective relation between ruminative subtypes and suicide ideation: moderating role of problem solving. Cognitive Therapy and Research. 2003;47(4):574-586.https://doi.org/10.1007/s10608-023-10373-w


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