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.

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.