Unpacking the Meaning of Closeness, Reconsidering the Concept of Impact in Suicide Exposure, and Expanding Beyond Bereavement: "Just, I Hope You Don't Forget About Us".

Suicide exposure research has relied on samples of treatment-seeking kin, resulting in an attachment-based model centering bereavement as the most significant form of impact and obscuring other forms of significant and life-altering impact. From a community-based sample (N = 3010) exposed to suicide, we examine a subset (n = 104) with perceived high impact from the death yet low reported closeness to the person who died and analyze qualitative comments (n = 50). On average and out of 5.00, participants rated closeness as 1.56 but impact of death as 4.51. We illustrate dimensions of low closeness and identify themes on the meaning of impact: impact through society and systemic circumstances, impact through history and repeated exposure, impact through other people, impact as a motivator for reflection or change, and impact through shared resonance. Participants reported impact of death as significant or devastating, yet none of their comments reflected experiences typical of bereavement.

What's in a word? Clarifying terminology on suicide-related communication.

Efforts to clarify suicide terminology fail to address nuances in suicide-related communication, often relying on poorly-defined terms or implying communication exists primarily as manipulation. In the present paper, we review examples from existing literature and explore how personal suicide-related communication differs from prevention and exposure communication. We also separate definitions for five common types of personal-suicide-related communication: (a) suicide-related disclosure, (b) suicide-related notification, (c) unintended suicide-related communication, (d) coerced suicide-related communication, and (e) conditional suicide-related communication. Finally, we provide specific ways in which standardized definitions can enhance both research and clinical efforts in the future.

Are the "Right" People Selected for First Disclosures About Suicidal Thoughts? Exploring What We Know About Advance Care Planning in the Context of Safety Planning.

Nominating primary confidants (i.e., safety plan nominees) is central to safety planning for suicide but there is a dearth of research about such confidants-a serious oversight given their high-leverage position to affect pathways into clinical care. Informed by advance care planning (ACP) work, this study examined differences between social network members who were and were not identified as primary confidants on attributes that could impact their effectiveness in a helping role. Using social network methodology, information was collected from 41 individuals with affective disorders about the 332 people and relationships in their networks. Logistic regression analysis revealed that being perceived as capable of managing stress and prioritizing the participant's best interests over one's own increased the odds of being a primary confidant. Clinicians working with suicidal individuals may benefit from integrating ACP principles-which recognize the thoughtful selection of nominees based on specific attributes-into their safety planning procedures.

Exploring suicide-related disclosure motivation and the impact on mechanisms linked to suicide.

Suicide-related disclosure enables improved risk management but disclosure motivations are understudied. This study identified reasons for and against disclosing suicidal thoughts and examined their link to future disclosure and interpersonal needs among 44 people receiving psychiatric care. The most endorsed reasons for disclosure (approach-motivations) included help-seeking, shared background, and catharsis. The most endorsed reasons against disclosure (avoidance-motivations) included fear of rejection, shame, and hospitalization. Higher mean approach motivation was associated with more disclosure intent and less burdensomeness. No associations with avoidance motivation were observed. Programming that seeks to orient people toward approach motivation holds promise for attenuating suicide risk.

Talking about suicide may not be enough: family reaction as a mediator between disclosure and interpersonal needs.

BACKGROUND: Although most people who make an attempt do not die, attempt survivors remain at particularly elevated risk for suicide in the short- and long-term. Moreover, the research on suicide-related disclosure and subsequent family reactions on risk factors for the development of suicidal desire is limited. AIMS: This study examined the relationships between disclosure, family reaction and two interpersonal needs connected to the development of suicidal desire. METHODS: Data from 74 attempt survivors who participated in a larger study were analyzed to assess the relationships between degree of suicide-related disclosure, quality of family reaction and thwarted belongingness and perceived burdensomeness. RESULTS: Results indicated that higher rates of disclosure predicted more positive family reactions, which in turn predicted lower levels of thwarted belongingness and perceived burdensomeness. Although there was no direct relationship between disclosure and the outcome variables, bootstrapping analyses indicated that family reaction mediated the relationship between disclosure and both belongingness and burdensomeness. CONCLUSIONS: These findings suggest the need for more family interventions that promote healthy reactions following suicide-related disclosure in order to facilitate the recovery and treatment process.

Review of family-based treatments from 2010 to 2019 for suicidal ideation and behavior.

Suicide ideation and behavior are pervasive public health issues. Given that positive interpersonal relationships can be a protective factor against suicide risk, we conducted a systematic review to examine peer-reviewed publications from 2010 to 2019 that included empirical data, tested an intervention with at least some family component, and included a suicide-related outcome measure. We reviewed and synthesized findings from 22 articles covering 7 intervention categories with 12 interventions to examine the treatment components and the quality of evidence to support them. Using Southam-Gerow and Prinstein's (Child Adolesc Psychol 43:16, 2014) guidelines, we identified two well-established intervention categories that met the highest standards for interventions and three probably efficacious intervention categories. All interventions found focused solely on suicide risk in adolescent populations. More studies are needed for adult populations and to explore the role of family moderators and mediators to test whether suicide outcomes are reduced by improvement in the family environment.

Public Health Surveillance of Youth Suicide Attempts: Challenges and Opportunities.

BACKGROUND: Surveillance of youth suicide attempts presents many challenges. To assess common data sources that capture information about youth suicidal behavior, we compared counts of high school students who reported (a) a suicide attempt and (b) an injurious suicide attempt, requiring medical treatment in the previous twelve months, with counts of suicide deaths and intentional self-injuries obtained from administrative data sources. METHOD: Youth Risk Behavior Surveillance System (YRBSS), high school enrollments, and vital statistics were used to estimate the ratio of suicide attempts to suicide deaths among Kentucky high school students. YRBSS and enrollment data were used to estimate the number of Kentucky high school students who received medical treatment following a suicide attempt, which was compared with hospital and emergency department (ED) discharges for intentional self-injury from administrative claim records. RESULTS: We estimated 943 students reporting a suicide attempt for every suicide death, a result that is higher than previous estimates for youth. Self-reported suicide attempts resulting in medical treatment were 7.5 times higher than self-injuries reported in claims records. CONCLUSION: Future research should address concerns about undocumented cases of intentional self-injury in administrative claims systems; patient encounters in nonhospital settings for injuries resulting from a suicide attempt; and validity of Youth Risk Behavior Survey questions on suicidal behavior.

"Nobody Hears a Silent Cry for Help": Suicide Attempt Survivors' Experiences of Disclosing During and After a Crisis.

Suicide remains an important public health issue across the globe. Until recently the medically dominated field of suicide prevention has neglected first-hand accounts of suicidal thoughts and behaviors from those who have survived prior suicide attempts. This qualitative research provides insight into the experience of suicide attempt, highlighting difficulties with disclosure of suicidal thinking prior to, and after, suicide attempts. Semi-structured interviews were undertaken with 31 adult suicide attempt survivors. The focus of the interviews was to explore their experience of suicide attempt and recovery. This paper reports on the complexity involved in disclosing suicidal thoughts or behavior prior to, at the time, or post attempt; the role that help seeking has when someone is acutely suicidal; and the challenges people have in finding their voice at these critical junctures. These factors are both inter- and intra-personal, and are influenced by stigma and lack of understanding of the suicidal state.

Anticipated Suicide Stigma, Secrecy, and Suicidality among Suicide Attempt Survivors.

OBJECTIVE: Suicidal behavior is stigmatized, and suicide attempt survivors often keep their experiences secret. Although secrecy can protect from discrimination, research from related fields suggests that both the experience of stigma and secrecy can contribute to suicidality. Although suicide attempt survivors are at high risk for reattempt, research investigating the link between suicide stigma and suicidality among this group is rare. METHOD: A community sample of 159 suicide attempt survivors participated in an online survey in the US. We used multiple linear regression models to test the association between anticipated suicide stigma and current suicidality, as well as a path model to test the mediating effect of secrecy. RESULTS: After controlling for age, sex, number of lifetime suicide attempts, and time since the most recent suicide attempt, anticipated suicide stigma was significantly associated with increased suicidality. In a controlled path model, this link was partially mediated by increased secrecy. CONCLUSION: These results provide initial support that anticipated suicide stigma, and secrecy can contribute to suicidality among suicide attempt survivors. Therefore, programs to support suicide attempt survivors in coping with suicide stigma and secrecy, as well as interventions to reduce harmful aspects of public suicide stigma, could contribute to suicide prevention.

Suicidal Ideation and Behavior Among Youth Victims of Sex Trafficking in Kentuckiana.

Background: Youth experiencing homelessness are at risk for sex trafficking and mental health concerns. Aims: More information is needed to elucidate the prevalence and characteristics of suicidal ideation and behavior among youth experiencing sex trafficking. Method: The present study examined suicidal ideation and behavior in a convenience sample of 128 youths experiencing homelessness aged 12-25 years in metropolitan Louisville, Kentucky, and southern Indiana. Participants were asked seven questions regarding suicidal ideation and attempts as part of an enhanced version of the 60-item Youth Experiences Survey (YES). Results: Approximately 53% of the sample reported experiencing suicidal ideation at some point in their lifetime and the odds of a youth experiencing homelessness who had experienced sex trafficking reporting suicidal ideation was 3.87 times higher than the odds of a youth experiencing homelessness who had not experienced sex trafficking. Additionally, of those who reported experiencing suicidal ideation, the majority (84.4%) reported they had attempted suicide in their lifetime. Limitations: This study relied on a convenience sample of youth receiving services in the Kentuckiana region and brief, self-report measures yielding categorical data. Conclusion: Programs servicing youth experiencing homelessness should require additional training and resources regarding the identification, screening, and assessment of youth who are at risk of or who have experienced sex trafficking in order to more quickly connect youth with much-needed, trauma-informed services.

Recipients of Suicide-Related Disclosure: The Link between Disclosure and Posttraumatic Growth for Suicide Attempt Survivors.

It is important to explore factors that could help or hinder one's wellbeing following a suicide attempt, which could yield not only negative consequences but also posttraumatic growth (PTG; positive changes following a traumatic event). The present study used a multivariate analysis of covariance (MANCOVA) to test the relationship between disclosure, PTG, and posttraumatic depreciation among suicide attempt survivors when controlling for time since attempt and to test whether these effects remained after controlling for quality of support from family and friends. Suicide attempt survivors (n = 159) completed an online survey about their experiences. Increases in disclosure to family and friends but not to healthcare providers predicted changes in PTG. The effects of family disclosure remained even after controlling for quality of support. Disclosure to healthcare providers demonstrated some statistical effects on PTG, yet in the opposite direction and only after controlling for quality of support. The control variables-time since attempt and quality of support-were the only variables that predicted a change in posttraumatic depreciation. These findings suggest there is value in disclosing one's personal story to family regardless of whether one receives supportive responses and that social support can impact one's PTG.

Treatment For Suicidal Thoughts and Behavior: A Review of Family-Based Interventions.

The purpose of this article is to review the scientific evidence on the effects of family based interventions for suicidal ideation and behavior. We conducted an extensive search of electronic databases using a comprehensive search strategy. This search resulted in 16 studies that tested 13 interventions for treating suicidal ideation and behavior using family based interventions. Of the interventions identified, three yielded an overall improvement in suicidal ideation and behavior while an additional three interventions produced partial improvement in mental health symptoms. These studies targeted suicidal ideation and behavior in youth or adolescents while no studies examined family interventions for adults with suicidal ideation and behavior. The limitations of these studies and the need for additional research are examined.

Testing the psychometric properties of the self-harm and suicide disclosure scale.

Suicide-related disclosure is an important component of identifying individuals at risk for suicide. However, no standardized measures exist to assess the degree to which individuals have disclosed suicide-related experiences. Therefore, the present study tested the psychometric properties of the Self-Harm and Suicide Disclosure Scale. A sample of 142 individuals, predominantly female and Caucasian, with ages ranging from 18-77 who had experienced suicidal ideation or behavior in their lifetime completed online surveys. A Rasch model analysis was used to test the item and individual separation and reliability and model fit of the instrument's use for disclosure to both family and nonfamily members. Analyses indicated strong item separation and reliability. Items were removed to improve model fit, resulting in two revised instruments. Findings indicate the Revised Suicide and Self-Harm Disclosure Scales are appropriate measures for assessing the depth of suicide-related disclosure. Future studies should attempt to replicate these findings with a more diverse sample.

Exploring lived experience in gender and sexual minority suicide attempt survivors.

Gender and sexual minorities (GSM) are at a higher risk for victimization, discrimination, and emotional distress. GSM also face unique stressors that contribute to negative mental health outcomes, such as family and interpersonal rejection, ostracism and isolation, and internalized gender and sexual stigma. Suicide attempt survivors often experience similar stigma and isolation after an attempt. However, little is known about the specific experiences of GSM individuals who attempt suicide. Transcripts of interviews with 25 GSM attempt survivors conducted as part of the Live Through This project were analyzed using an interpretive phenomenological approach. Five themes that capture the lived experience of suicidality of the participants were identified in the interviews: (a) intersecting identities, (b) identity concealment, (c) internalized stigma and self-hate, (d) the social environment, and (e) the importance of peer support. Findings highlight the compounding stigma that occurs when individuals identify as both a GSM and a suicide attempt survivor. Implications for clinical work include the need for additional peer support for individuals who maintain the dual identity of GSM and suicide attempt survivor. Moreover, there is a need for mental health, crisis, and support resources and services tailored for GSM individuals that emphasize the importance of peer support in healing and recovery after a suicide attempt and in preventing future suicidal behavior. This important information can help us develop strategies to prevent suicide among the GSM population and to provide support for GSM suicide attempt survivors. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

An Interpretive Phenomenological Inquiry of Family and Friend Reactions to Suicide Disclosure.

Suicide attempt survivors' interpretations of reactions to attempts are understudied, yet could inform prevention efforts concerning subsequent attempts. Interviews with 40 attempt survivors about family and friend reactions were analyzed using interpretive phenomenological techniques. Three distinct patterns emerged as follows: (a) Stigmatizing statements and emphasis on reactor's feelings were interpreted as signs that attempt survivors were a burden to others, (b) avoidant reactions and excessive monitoring were interpreted as cues that suicidal behavior must remain hidden to not be a burden, and (c) asking questions and projecting strength were interpreted as signs that attempt survivors belonged and were not a burden. These findings highlight the importance of working with family and friends to encourage reactions that reduce the risk of future attempts.

Attitudes toward Assisted Suicide: Does Family Context Matter?

Little is known about how family-related contextual variables impact attitudes toward assisted suicide. A probability sample (N = 272) responded to a multiple-segment factorial vignette designed to examine the effects of 6 variables-patient sex, age, type of illness, relationship status, parenthood status, and family support-on attitudes toward physician- and family-assisted suicide. Respondents were more likely to support physician-assisted suicide if they heard about an older patient or a patient experiencing physical pain than a younger patient or one suffering from depression, respectively. For family-assisted suicide, respondent support was higher when the patient had physical pain than depression, and when the patient's spouse or friend was supportive of the wish to die than unsupportive. Attitudes about physician and family obligation to inform others were affected by type of illness, relationship status, family support, and respondent education and religiosity. The experience of pain, motivations for family involvement, confidentiality issues, and physicians' biases concerning assisted suicide are discussed.

Perceptions of Suicide Stigma.

BACKGROUND: Previous research has failed to examine perceptions of stigma experienced by individuals with a history of suicidal behavior, and few studies have examined how stigma is experienced based on whether it was perceived from treatment providers or social network members. AIMS: This study examined stigma experienced by individuals with previous suicidal behavior from both treatment providers and individuals in one's social and family networks. METHOD: Individuals (n = 156) with a lifetime history of suicidal behavior were recruited through the American Association of Suicidology listserv. RESULTS: Respondents reported the highest rates of perceived stigma with a close family member (57.1%) and emergency department personnel (56.6%). Results indicated that individuals with previous suicidal behavior were more likely to experience stigma from non-mental health providers and social network members than from mental health providers. A hierarchical regression model including both source and type of stigma accounted for more variance (R(2) = .14) in depression symptomology than a model (R(2) = .06) with only type of stigma. Prevalence of stigma perceived from social network members was the best predictor of depression symptom severity. CONCLUSION: These findings highlight the need for future research on how social network members react to suicide disclosure and potential interventions for improving interactions following disclosure.

Suicide Disclosure in Suicide Attempt Survivors: Does Family Reaction Moderate or Mediate Disclosure's Effect on Depression?

Existing literature has found a link between disclosure of a stigmatized identity and improved mental health; however, research on the impact of suicide disclosure to family members is scarce. Suicide attempt survivors (n = 74) in the United States were examined to assess whether family reaction moderates or mediates the relationship between suicide disclosure and subsequent depression symptoms. Family reaction did not moderate but did mediate the relationship between disclosure and depression symptoms while controlling for time since most recent attempt. Higher rates of disclosure predicted more positive family reactions, which in turn predicted less severe depression symptoms. Findings indicate that family members can play an essential role in the recovery process after an attempt occurs, which has important implications for both researchers and clinicians who seek to decrease stigma for attempt survivors while simultaneously decreasing the likelihood of future attempts.

What Factors Influence the Decision to Share Suicidal Thoughts? A Multilevel Social Network Analysis of Disclosure Among Individuals with Serious Mental Illness.

Nondisclosure of suicidal thoughts limits suicide risk management. Consistent with disclosure models for other stigmatized statuses, understanding suicidal disclosure requires accounting for features of the discloser (individual factors) and the discloser-recipient relationship (relational factors). In a sample of 30 adults with schizophrenia, bipolar disorder, or major depressive disorder (Level 2) who nominated 436 social network members (Level 1), we examined disclosure patterns and identified individual and relational correlates of disclosure intent. Most individuals disclosed in the past (77%; n = 23) and all intended on disclosing (100%; n = 30). Disclosure was highly selective, with 14% (n = 62) of network members identified as prior confidants and 23% (n = 99) identified as intended confidants. Multilevel modeling indicated that relational factors were more central to disclosure than individual factors. Network members who were prior confidants and who provided social support were attractive targets for intended disclosure. Our findings suggest that "targeted" gatekeeper training may be a promising strategy and reveal relational characteristics to identify "high-probability confidants."

The effects of domestic violence allegations on custody evaluators' recommendations.

Judges and attorneys often request professional assessments from child custody evaluators when allegations of adult domestic violence (DV) have been made, but it is unclear whether and how evaluators' recommendations are impacted by these allegations. Custody evaluators (N = 607) in the United States responded to a multiple-segment factorial vignette designed to examine the effects of 2 key factors in DV allegations: type of alleged violence (conflict-based, control-based) and counterallegations (none, mutual, and female-initiated). Effects of control- versus conflict-based DV allegations by the mother on custody recommendations were small and the majority of evaluators recommended joint custody regardless of violence type. Reported confidence in making a recommendation increased once the father responded to the allegation, but to a smaller degree when a counterallegation of mutual or female-initiated violence was made. Evaluators were no more skeptical about the potential motive of a counterallegation in the context of controlling behavior than in the context of conflict-based behavior. Overall, results indicate that most custody evaluators are not sufficiently sensitized to distinguish between situational couple violence and coercive controlling behavior, and the postseparation safety of mothers and their children may therefore be jeopardized.