Interpersonal Risk Factors, Sexual and Gender Minority Status, and Suicidal Ideation: Is BDSM Disclosure Protective?

Suicidal ideation is elevated among individuals who engage in BDSM practices and those with sexual and gender minority (SGM) identities. There is limited research on the intersectionality of these identities and how they relate to suicidal ideation, especially within a theoretical framework of suicide risk, such as the interpersonal theory of suicide. Thus, we tested the indirect relation between BDSM disclosure and suicidal ideation through thwarted belongingness and perceived burdensomeness, as well as the moderating role of SGM identity on these indirect associations. Participants were 125 (Mage = 28.27 years; 64% cisgender men) individuals recruited via online BDSM-related forums who endorsed BDSM involvement and recent suicidal ideation. Results indicated significant moderated mediation, such that BDSM disclosure was indirectly negatively related to suicidal ideation through lower thwarted belongingness, but not perceived burdensomeness, among SGM individuals. This was due to the significant relation between BDSM disclosure and thwarted belongingness. There were no significant moderated mediation or indirect effects related to perceived burdensomeness. We also provide supplemental analyses with positive ideation (i.e., positive thoughts toward life) as the criterion variable. In conclusion, BDSM disclosure appears to be protective against suicidal ideation through thwarted belongingness but only for SGM individuals. This work furthers our understanding of the impact of intersecting marginalized identities on suicide risk and resilience. Implications, limitations, and future directions are further discussed.

The Intervening Roles of Psychological Inflexibility and Functional Impairment in the Relation between Cancer-related Pain and Psychological Distress.

BACKGROUND: Psychological distress is a significant problem among patients with a diagnosis of cancer and is associated with elevated risk for mortality; however, not all patients with a diagnosis of cancer experience significant psychological distress. Cancer-related pain has been associated with greater psychological distress among patients with a cancer diagnosis (current or previous). The current study aimed to examine potential theoretical mechanisms (i.e., cognitive fusion, experiential avoidance, and functional impairment) as proposed by the psychological flexibility model, for the association between cancer-related pain and psychological distress. We hypothesized that cancer-related pain would be indirectly positively associated with psychological distress among patients with a cancer diagnosis (current or previous) through psychological inflexibility (i.e., cognitive fusion and experiential avoidance) related to pain and functional impairment, in serial. METHOD: Sixty-one adult outpatients diagnosed with cancer completed self-report assessments of cancer-related pain, psychological inflexibility related to pain, pain-related functional impairment, and psychological distress. RESULTS: Cancer-related pain was positively associated with psychological distress indirectly through greater pain-related psychological inflexibility (i.e., cognitive fusion and experiential avoidance) and functional impairment, in serial. Alternative models were explored but unsupported. CONCLUSION: Consistent with the psychological flexibility model, psychological inflexibility and functional impairment may be potential mechanisms underlying the association between cancer-related pain and psychological distress among patients with a cancer diagnosis (current or previous).

Do criminal associates impact psychiatric inpatients' social support and interpersonal needs?

Suicide risk is elevated among psychiatric inpatients; however, research has not examined moderators of the associations between perceived social support and thwarted belongingness (TB) and perceived burdensomeness (PB), such as involvement with criminal associates. Adult psychiatric inpatients (N = 142) completed assessments. Perceived social support was negatively associated with TB and PB; however, associates' criminal involvement did not moderate these associations. A significant interaction indicated a stronger negative association between perceived social support and TB when participants spent more time with associates. Therefore, time spent with associates, regardless of criminal involvement, may be a relevant interpersonal suicide risk factor.

Experiential avoidance, cognitive fusion, and suicide ideation among psychiatric inpatients: The role of thwarted interpersonal needs.

OBJECTIVE: The interpersonal theory of suicide posits the simultaneous presence of thwarted belongingness and perceived burdensomeness (i.e., thwarted interpersonal needs) leads to active suicide ideation. According to the psychological flexibility model, psychological inflexibility is in part a product of cognitive fusion (i.e., becoming entangled or wrapped up in one's thoughts) and experiential avoidance (i.e., avoidance of internal private experiences, which include thoughts and feelings). We hypothesized that thwarted belongingness and perceived burdensomeness, in parallel, would mediate the positive relation between experiential avoidance and suicide ideation and between cognitive fusion and suicide ideation. METHOD: Participants were 118 adult psychiatric inpatients who completed self-report assessments of thwarted interpersonal needs, cognitive fusion, experiential avoidance, and suicide ideation. RESULTS: Using bootstrapped parallel mediation regression procedures, results indicated thwarted belongingness and perceived burdensomeness mediated, in parallel, the positive relation between experiential avoidance and suicide ideation and between cognitive fusion and suicide ideation. Additionally, thwarted belongingness, but not perceived burdensomeness, independently mediated the relation between cognitive fusion and suicide ideation. CONCLUSION: The current findings indicate that psychological inflexibility variables are associated with increased thwarted interpersonal needs and suicide ideation. The findings of this study provide support for the integration of the interpersonal theory of suicide and psychological flexibility model to improve our conceptualization of suicide risk among psychiatric inpatients. Clinical or methodological significance summary: The findings of this study provide support for the integration of the interpersonal theory of suicide and psychological flexibility model to improve our conceptualization of suicide risk among psychiatric inpatients.

Suicide Risk Among BDSM Practitioners: The Role of Acquired Capability for Suicide.

OBJECTIVE: Bondage and discipline, dominance and submission, and sadomasochism (BDSM) practitioners are at increased risk for suicidal thoughts and behaviors. We hypothesized the association between (a) lifetime frequency of BDSM-related sexual behaviors and (b) BDSM identification and suicide attempt status would be mediated by acquired capability components (i.e., fearlessness about death and pain tolerance). Gender differences were examined. METHOD: Participants were 576 BDSM practitioners (meanage = 28.71; 66.7% male) recruited from online BDSM-related groups, cross-sectionally. RESULTS: Among males, the total indirect effect of acquired capability components in the relation between BDSM-related sexual behaviors and suicide attempt status was significant. The specific indirect effect of perceived pain tolerance in the relation between both BDSM-related sexual behaviors and BDSM identification and suicide attempt status was significant. There were no significant effects for females. Additionally, 12% reported a suicide attempt history. CONCLUSION: Among males, BDSM-related sexual behaviors and BDSM identification were associated with increased acquired capability components, which were positively associated with suicide attempt status.

The clinical application of suicide risk assessment: A theory-driven approach.

The interpersonal theory of suicide posits that thwarted belongingness (TB) and perceived burdensomeness (PB) increase suicide ideation; however, studies have found mixed results regarding this hypothesis among psychiatric inpatients. This study aimed to (a) demonstrate how assessing TB and PB using the Interpersonal Needs Questionnaire (INQ) can provide clinically useful information and (b) investigate how statistical methodology may impact the clinical application of the INQ. Participants were 139 (Sample 1) and 104 (Sample 2) psychiatric inpatients. In both samples, ordinal logistic regression results indicated TB and PB, separately, were significant predictors of suicide ideation-related outcomes; however, when examined as simultaneous predictors, TB was no longer a significant predictor. The interaction between TB and PB was not significant for either sample. Despite this, TB and PB scores provided clinically relevant information about suicide ideation-related outcomes. For example, the highest scores on TB and PB indicated a 93% and 95% chance of having some level of distress due to suicide ideation (Sample 1), a 91% and 92% chance of having some level of desire for death, and a 79% and 84% chance of having some level of desire for suicide, respectively (Sample 2). This study also proposes clinical cutoff scores for the INQ (for TB and PB, respectively, cutoff scores were 22 and 17 for distress due to suicide ideation, 33 and 17 for desire for death, and 31 and 22 for desire for suicide). Although these results indicate that multicollinearity between TB and PB may create interpretational ambiguity for clinicians, TB and PB may each be useful separate predictors of suicide ideation-related outcomes in psychiatric inpatient settings and should be incorporated into suicide risk assessment. KEY PRACTITIONER MESSAGE: The 15-item Interpersonal Needs Questionnaire (an assessment of thwarted belongingness and perceived burdensomeness) should be incorporated into suicide risk assessment. Among psychiatric inpatients, greater thwarted belongingness and perceived burdensomeness, as separate predictors, were associated with increased levels of distress due to suicide ideation, desire for death, and desire for suicide. The highest scores on thwarted belongingness and perceived burdensomeness indicated a 79% to 95% chance of experiencing an elevated level of distress due to suicide ideation, desire for death, or desire for suicide. Recommended clinical cutoff scores were provided. For example, thwarted belongingness cutoff score of 31 and perceived burdensomeness cutoff score of 22 maximized the sensitivity and specificity of the INQ to detect some level of desire for suicide.

Evaluating a Recovery-Oriented Intensive Outpatient Program for Veterans at Risk for Suicide.

Background: Suicide is the 10th leading cause of death in the United States and suicide risk is elevated among military veterans. Risk for suicide is inherently transdiagnostic, complex, and multifaceted, which means a comprehensive psychotherapeutic approach to risk mitigation is required. Aims: Our aims were to summarize findings from an evaluation of an interdisciplinary, recovery-oriented intensive outpatient program (IR-IOP) that includes evidence-based suicide prevention stategies for veterans with varying psychiatric diagnoses who are at risk for suicide. Method: Veterans completed the Patient Health Questionnaire-9 and the Beck Scale for Suicide Ideation prior to and following their participation in the IR-IOP. Results: A significant decrease in the severity of suicide ideation was found between pre- and posttreatment. Limitations: This program evaluation utilized archival data and, as such, there was not a control group and posttreatment follow-up data were not collected. Conclusion: Preliminary findings suggest an IR-IOP for veterans with heterogenous psychiatric diagnoses utilizing a multifaceted psychotherapeutic approach to suicide prevention may be effective in reducing suicide ideation.

Suicide Ideation and Thwarted Interpersonal Needs among Psychiatric Inpatients: A Network Approach.

We aimed to demonstrate the utility of an item-level network analysis approach to suicide risk by testing the interpersonal psychological theory of suicide (IPTS) among 402 psychiatric inpatients. We hypothesized specific thwarted belongingness (TB) or perceived burdensomeness (PB; Interpersonal Needs Questionnaire items) facets would positively relate to passive or active suicide ideation, and these facets would positively relate to each other and form distinct clusters. We also tested TB and PB facets central to the networks as predictors of suicide ideation compared to the full TB and PB subscales. Face-valid items congruent with latent constructs proposed by the IPTS (i.e., feelings of burden on society, feeling that one does not belong) were the only two facets uniquely predictive of passive and active suicide ideation. Facets of TB and PB did not form distinct clusters. Item-level network analysis may have important conceptual, assessment, predictive, and clinical implications for understanding suicide risk.

Suicide-Related Training, Self-Efficacy, and Mental Health Care Providers' Reactions Toward Suicidal Individuals.

Background: Mental health care providers commonly encounter suicide ideation and suicidal behaviors among their patients despite a frequent lack of adequate knowledge and competence regarding suicide risk management. Aims: This study examined the associations among self-perceived sufficiency of training, self-efficacy, anxiety, and attitudes related to working with suicidal individuals. Method: Participants were 289 mental health care providers who completed a self-report survey. Results: Path analysis results indicated that perceived sufficiency of training was indirectly associated with negative attitudes (i.e., avoidance and discomfort) and cognitive and somatic anxiety about working with suicidal individuals through assessment self-efficacy. Limitations: The current study utilized cross-sectional data, and there were occupational heterogeneity and geographical homogeneity among the mental health care providers sampled. Conclusion: These findings suggest that sufficient suicide-related training focused on risk assessment may decrease mental health professionals' negative and anxious reactions toward suicidal individuals and enhance confidence in suicide risk management.

The Interpersonal Needs Questionnaire: Statistical Considerations for Improved Clinical Application.

The interpersonal theory of suicide (ITS) has accumulated empirical support; however, less research has investigated the clinical utility of ITS constructs in suicide risk assessment. The current study sought to increase the clinical utility of the Interpersonal Needs Questionnaire (INQ), an assessment of thwarted belongingness (TB) and perceived burdensomeness (PB), among 318 adult psychiatric outpatients while considering statistical methodology (i.e., multicollinearity and partialling). Results emphasized PB in the prediction of concurrent desire for death/suicide when TB was simultaneously considered. The interaction between TB and PB did not enhance prediction of concurrent desire for death/suicide. Independently, PB was a stronger predictor than TB of concurrent desire for death/suicide in the total sample and gender subsamples. Estimated probabilities of concurrent desire for death/suicide across INQ scores and preliminary INQ clinical cutoff scores are provided to enhance clinical application. These findings suggest the INQ could provide valuable information for suicide risk assessment and conceptualization.

Rejection sensitivity and suicide ideation among psychiatric inpatients: An integration of two theoretical models.

Rejection is a direct threat to an individual's need to belong that has serious consequences for mental health. Rejection sensitivity may explain why some individuals are more likely to perceive rejection in social situations and experience subsequent psychological distress. The current study examined suicide ideation among psychiatric inpatients (N = 103) through the lenses of the rejection sensitivity model and the interpersonal theory of suicide. We hypothesized that rejection sensitivity would be indirectly associated with suicide ideation (i.e., a cognitive-affective reaction to social rejection) through greater perceptions of rejection (i.e., thwarted belongingness and perceived burdensomeness, constructs from the interpersonal theory of suicide), in parallel. Results from bootstrapped parallel mediation regression procedures indicated that the relation between rejection sensitivity and suicide ideation was significantly indirectly associated through the additive effect of thwarted belongingness and perceived burdensomeness, such that greater rejection sensitivity was associated with greater thwarted belongingness and perceived burdensomeness and subsequently greater suicide ideation. Further, rejection sensitivity was significantly indirectly associated with suicide ideation independently through thwarted belongingness, but not perceived burdensomeness. These findings provide support for the rejection sensitivity model and the interpersonal theory of suicide in an effort to advance our conceptualization of suicide risk among psychiatric inpatients.

Thwarted Interpersonal Needs and Suicide Ideation Distress Among Psychiatric Inpatients: The Moderating Role of Criminal Associates.

Psychiatric inpatients are at elevated risk of suicide, and approximately half are criminal justice-involved. Their involvement with criminal associates may be linked to increased suicide ideation distress; however, this has not been examined. This study tested main effects of, and interactions between, thwarted belongingness (TB) or perceived burdensomeness (PB), time spent with associates, and associates' criminal involvement predicting suicide ideation distress. In our study, psychiatric inpatients (n = 139) completed assessments cross-sectionally. Results indicated that TB, PB, and associates' criminal involvement were significantly related to greater suicide ideation distress. A significant three-way interaction indicated participants who endorsed high TB, spent more time with associates, and had associates high in criminal involvement had the greatest probability of "Extreme" suicide ideation distress. These findings suggest that spending time with criminal associates may increase suicide ideation distress more than not having social interactions. Implications and limitations of this study are discussed.

Thwarted interpersonal needs mediate the relation between facets of mindfulness and suicide ideation among psychiatric inpatients.

Previous research suggests a negative association between mindfulness and suicide ideation, yet limited research has examined the specific role of mindfulness on suicide ideation or attempted to link this construct with theory-driven risk factors for suicide among high-risk individuals. The current study examined the mediating role of thwarted interpersonal needs (i.e., thwarted belongingness and perceived burdensomeness) in the relation between facets of mindfulness and suicide ideation among psychiatric inpatients. Participants were 118 psychiatric inpatients who completed self-report assessments of mindfulness, thwarted belongingness, perceived burdensomeness, and suicide ideation. Results indicated that the additive effect of thwarted belongingness and perceived burdensomeness mediated the relation between the act with awareness, non-judging, and non-reactivity mindfulness facets, and suicide ideation. Facets of mindfulness appear to be differentially related to thwarted interpersonal needs and subsequent suicide ideation. Continued examination of specific facets of mindfulness, as they relate to suicide ideation, may highlight potentially important distinctions and better inform suicide risk assessment and treatment.

Feasibility of Assessing Suicide Ideation and History of Suicidal Behavior in Rural Communities.

Suicide in rural areas has not received significant attention in the research literature to this point, although suicide rates are higher among adults and older adults in rural areas than in urban areas. The aims of the study were as follows: (1) establish the feasibility of assessing suicide ideation and history of suicidal behavior; (2) determine preliminary estimates of the prevalence of suicide ideation, and history of suicide attempts; and (3) examine the effectiveness and acceptability of safety and referral plans for individuals whose responses indicated elevated suicide risk, in rural communities with limited access to referral care. Participants were 96 adults aged 40 to 85 years old (M = 57.34, SD = 11.47) residing in West Texas. Our results indicate that 26% of participants endorsed a lifetime history of suicide ideation and/or suicide attempt(s) and 12.5% reported suicide ideation in the past year. In addition, 93.4% of participants reported that participation in our suicide-focused study was an excellent or good experience. Results suggest that individuals in rural communities are willing to talk about suicide, found the experience helpful, and were satisfied with the referral process.

Retrospective Cyberbullying and Suicide Ideation: The Mediating Roles of Depressive Symptoms, Perceived Burdensomeness, and Thwarted Belongingness.

Research suggests that being cyberbullied is associated with increased risk for suicide ideation; however, few studies have examined the underlying mechanisms of this relation, and fewer have examined this relation within a theory of suicide. Specifically, the interpersonal theory of suicide posits that thwarted belongingness (indicated by loneliness and a lack of reciprocal caring relationships) and perceived burdensomeness (indicated by feelings of liability and self-hatred) increase risk for suicide ideation. The current study aimed to examine depressive symptoms, thwarted belongingness, and perceived burdensomeness as mediators between intensity of being cyberbullied and suicide ideation. Participants were college students ( N = 348) who completed assessments of retrospective peer victimization, thwarted interpersonal needs (i.e., thwarted belongingness and perceived burdensomeness), and suicide ideation. The results indicated that after adjusting for sexual orientation, depressive symptoms significantly mediated the relation between intensity of being cyberbullied and suicide ideation. Furthermore, depressive symptoms and perceived burdensomeness serially mediated the relation between intensity of being cyberbullied and suicide ideation; however, thwarted belongingness was not a significant mediator. Clinical and research implications, limitations, and future directions are discussed.

Mental Health Professionals' Suicide Risk Assessment and Management Practices.

BACKGROUND: Approximately 20% of suicide decedents have had contact with a mental health professional within 1 month prior to their death, and the majority of mental health professionals have treated suicidal individuals. Despite limited evidence-based training, mental health professionals make important clinical decisions related to suicide risk assessment and management. AIMS: The current study aimed to determine the frequency of suicide risk assessment and management practices and the association between fear of suicide-related outcomes or comfort working with suicidal individuals and adequacy of suicide risk management decisions among mental health professionals. METHOD: Mental health professionals completed self-report assessments of fear, comfort, and suicide risk assessment and management practices. RESULTS: Approximately one third of mental health professionals did not ask every patient about current or previous suicidal thoughts or behaviors. Further, comfort, but not fear, was positively associated with greater odds of conducting evidence-based suicide risk assessments at first appointments and adequacy of suicide risk management practices with patients reporting suicide ideation and a recent suicide attempt. LIMITATIONS: The study utilized a cross-sectional design and self-report questionnaires. CONCLUSION: Although the majority of mental health professionals report using evidenced-based practices, there appears to be variability in utilization of evidence-based practices.

Shame, Guilt, and Suicide Ideation among Bondage and Discipline, Dominance and Submission, and Sadomasochism Practitioners: Examining the Role of the Interpersonal Theory of Suicide.

To date, no study has examined rates of suicide ideation or theory-based risk factors for suicide ideation among bondage and discipline, dominance and submission, and sadomasochism (BDSM) practitioners. Participants were 321 adults that endorsed BDSM involvement. Thirty-seven percent of the sample indicated a nonzero level of suicide ideation. Thwarted belongingness and perceived burdensomeness (PB) were positively associated with suicide ideation and their interactive effect predicted additional variance in suicide ideation after adjusting for depressive symptoms. Overall, shame and guilt were positively associated with suicide ideation and these relations were mediated by thwarted belongingness and PB in parallel adjusting for depressive symptoms; however, there were some differences between demographic subgroups. Among BDSM practitioners, stigma-related internalized feelings (i.e., shame and guilt) may be associated with increased thwarted belongingness and PB, which are associated with suicide ideation.

A Psychometric Investigation of the Painful and Provocative Events Scale: Moving Forward.

Acquired capability for suicide is posited to develop through repeated exposure to physically painful and psychologically provocative events; however, there is limited research evaluating the assessment of painful and provocative events. The current study examined the factor structure, validity, and reliability of the Painful and Provocative Events Scale (PPES). Categorical exploratory and confirmatory factor analyses were conducted in a sample of undergraduate students (N = 732). A 15-item PPES with a 3-factor solution best fits the data; however, both the subscales derived from factor analyses yielded inconsistent validity and reliability. Despite addressing limitations of previous psychometric investigations of the PPES, the inconsistent findings of the current study suggest the theoretical reconceptualization of painful and provocative events and the subsequent development of a valid and reliable assessment of painful and provocative events is needed to take the place of current versions of the PPES.

Thwarted interpersonal needs and suicide ideation: Comparing psychiatric inpatients with bipolar and non-bipolar mood disorders.

Psychiatric inpatients are at heightened risk for suicide, and evidence suggests that psychiatric inpatients with bipolar mood disorders may be at greater risk for suicide ideation compared to those with non-bipolar mood disorders. There is a paucity of research directly comparing risk factors for suicide ideation in bipolar versus non-bipolar mood disorders in an inpatient sample. The current study sought to clarify the association between two constructs from the interpersonal theory of suicide (i.e., perceived burdensomeness and thwarted belongingness) in leading to suicide ideation among psychiatric inpatients with bipolar and non-bipolar mood disorders. Participants were (N=90) psychiatric inpatients with a bipolar (n = 20) or non-bipolar mood disorder (n=70; per their medical charts). Perceived burdensomeness, but not thwarted belongingness, was significantly associated with suicide ideation after adjusting for other covariates. This suggests perceived burdensomeness may play a key role in suicide ideation among psychiatric inpatients with any mood disorder and highlights the importance of assessment and intervention of perceived burdensomeness in this population. Contrary to our hypothesis, mood disorder group (i.e., bipolar versus non-bipolar) did not moderate the relations between perceived burdensomeness/thwarted belongingness and suicide ideation.