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Western Kentucky UniversityTopSCHOLAR®
Masters Theses & Specialist Projects Graduate School
Summer 2017
The Effect of Disclosure of Suicide Attempt onSuicide RiskMichael Matthew McClayWestern Kentucky University, [email protected]
Follow this and additional works at: http://digitalcommons.wku.edu/theses
Part of the Social Psychology Commons
This Thesis is brought to you for free and open access by TopSCHOLAR®. It has been accepted for inclusion in Masters Theses & Specialist Projects byan authorized administrator of TopSCHOLAR®. For more information, please contact [email protected].
Recommended CitationMcClay, Michael Matthew, "The Effect of Disclosure of Suicide Attempt on Suicide Risk" (2017). Masters Theses & Specialist Projects.Paper 2031.http://digitalcommons.wku.edu/theses/2031
THE EFFECT OF DISCLOSURE OF SUICIDE ATTEMPT ON SUICIDE RISK
A Thesis
Presented to
The Faculty of the Psychological Science Masters of Science Program
Western Kentucky University
Bowling Green, Kentucky
In Partial Fulfillment
Of the Requirements for the Degree
Masters of Science
By
Michael Matthew McClay
August 2017
iii
ACKNOWLEDGEMENTS
To my parents for supporting me on a new adventure; to Dr. Amy Brausch for
channeling my interests into a research question and putting up with my chaotic approach
to my work; to Dr. Stephen O’Connor for taking a chance on a kid with no experience; to
Dr. Aaron Wichman for your enthusiasm and willingness to help; to Angelica for keeping
me in graduate school every time I thought I would not finish; to Erin, Cody, Sarah, and
Brittany for showing me the ropes; to Jamie for sleeping through the coffee maker during
my manic writing sessions; to Kandice, Emily, Sherry, Natalie, and the rest of the Risk
Behaviors Lab for welcoming me into a new home; to my cohort for your commiseration;
to Justin for the miles of conversations that led me here; to Drs. Ivelina Naydenova,
James Morgan, David Carscaddon, and Paula Qualls for believing I could do this,
grounding me in reality, and supporting my tumultuous decision to change career paths:
Thank you.
iv
CONTENTS
List of Tables.......................................................................................................................v
List of Figures.....................................................................................................................vi
Abstract…..........................................................................................................................vii
Introduction..........................................................................................................................1
Method...............................................................................................................................18
Results................................................................................................................................28
Discussion..........................................................................................................................50
Limitations.........................................................................................................................58
Conclusions........................................................................................................................59
References................................................................................................................……..60
Appendix A........................................................................................................................75
Appendix B........................................................................................................................78
Appendix C........................................................................................................................82
Appendix D........................................................................................................................86
v
LIST OF TABLES
Table 1. Demographics and Sample Characteristics by Disclosure Group.......................30
Table 2. Descriptive Statistics for Study Variables...........................................................30
Table 3. Zero-Order Correlations……..............................................................................31
Table 4. The Effects of Dichotomous DSA and Social Support on Measures of Proximal
Suicide Risk.........................................................................................................32
Table 5. The Effects of Dichotomous Social DSA and Social Support on Measures of
Proximal Suicide Risk.........................................................................................34
Table 6. The Effects of DSA-Count and Social Support on Measures of Proximal
Suicide Risk.........................................................................................................36
Table 7. The Effects of Social DSA-Count and Social Support on Measures of Proximal
Suicide Risk.........................................................................................................39
vi
LIST OF FIGURES
Figure 1. Indirect Effects of Dichotomous Social DSA on Depression……...………….43
Figure 2. Indirect Effects of Dichotomous Social DSA on Perceived Burdensomeness...44
Figure 3. Indirect Effects of Dichotomous Social DSA on Thwarted Belongingness.......44
Figure 4. Indirect Effects of Social DSA-Count on Depression………………………....47
Figure 5. Indirect Effects of Social DSA-Count on Perceived Burdensomeness………..48
Figure 6. Indirect Effects of Social DSA-Count on Thwarted Belongingness…………..49
vii
THE EFFECT OF SUICIDE ATTEMPT DISCLOSURE ON SUICIDE RISK
Michael McClay August 2017 88 Pages
Directed by: Amy Brausch, Aaron Wichman, and Stephen O’Connor
Department of Psychological Sciences Western Kentucky University
Survivors of suicide attempts are at increased risk for future suicide, and there are
few empirically validated treatments designed to reduce suicidal thoughts and behaviors
among this population. The Interpersonal Psychological Theory of Suicide proposed that
reducing suicidal individuals’ feelings of burdensomeness on others and
disconnectedness from others will decrease the desire for suicide. Disclosing one’s
history of suicidal behavior to a trusted confidant has been found to have a positive
impact on depression symptoms, so the present study sought to evaluate the benefits of
disclosing on measures of social support and proximal suicide risk described by the
Interpersonal Psychological Theory of Suicide. Data were collected from 99
undergraduate students who reported at least one lifetime suicide attempt. Results
indicated that disclosing one’s history of suicide attempt to one or two confidants had a
positive indirect effect on depression, Perceived Burdensomeness, and Thwarted
Belongingness via a pathway mediated by peer social support. However, disclosing to 3
individuals attenuated these positive effects. Results support existing treatments that
incorporate disclosure of suicide attempt history or active suicidal ideation as a suicide
prevention technique and recommend the use of disclosure as a way to facilitate
increased social connectedness, thereby reducing desire for suicide.
1
Introduction
Global estimates state that approximately 800,000 people die by suicide per year
annually (World Health Organization, 2014), and the Centers for Disease Control lists
suicide as the second leading cause of death for individuals between the ages of 10-34
(Centers for Disease Control, 2014). Although decades of research have highlighted a
myriad of factors that increase risk for suicide (deemed “risk factors;” Harris &
Barraclough, 1997), it is well understood that the presence of risk factors alone is not
sufficient to prospectively predict death by suicide (Tucker, Crowley, Davidson, &
Gutierrez, 2015). Newer etiological models of suicide have identified the necessity of two
overarching components for engagement in suicidal behavior: suicidal desire and
capability to enact self-harm (Joiner, 2005; Klonsky & May, 2015; O’Connor, 2011).
These theories help explain the previously documented high rate of recurrence for
individuals with prior suicide attempts, who are up to 38 times more likely to make a
suicide attempt than individuals in the general population (Harris & Barraclough, 1997),
by taking into account their previous experience with suicidal behavior as well as
distressing life circumstances.
Suicide-specific treatment research has focused on intervening with survivors of
suicide attempts because of their high risk for future suicide attempts (Jobes, Au, &
Siegelman, 2015), and this emerging field requires research into beneficial behaviors and
effective components of current treatments. A recent estimate indicates that
approximately 90% of individuals who have previously attempted suicide will disclose
this status to close friends or relatives (Frey, Hans, & Cerel, 2016b). Given the substantial
2
influence of interpersonal factors in the development of suicidal desire (Joiner, 2005) and
the positive impact of disclosure of stigmatized statuses (the interpersonal
communication of a personality trait that devalues one in the eyes of others, Chaudoir &
Quinn, 2010), treatment research may benefit from understanding the factors that
influence disclosure of suicide attempt as well as the outcomes associated with
disclosure. Although disclosure of suicidal thoughts and behaviors may occur during
safety planning for suicidal clients, it is not prescribed by clinicians outside of crisis
prevention (Jobes, 2016; Stanley & Brown, 2012). Therefore, it is unclear if disclosure
plays any role in positive outcomes following treatment for suicidal behaviors. The
present study sought to evaluate the impact of previous suicide attempt disclosure on
current suicide risk.
Etiology of Suicidal Behavior
Previous research on suicide has focused on identifying risk factors that elevate an
individual’s likelihood to experience suicidal thoughts and behaviors. Over 100 unique
risk factors for suicide have been identified, consisting of psychiatric disorders,
personality characteristics, deficits/predispositions in cognitive functioning, social
factors, and negative life events (Kessler, Borges, & Walters, 1999; O’Connor & Nock,
2014). However, these risk factors have been found to poorly differentiate between those
who will and will not progress from suicidal thoughts to suicidal behavior (Klonsky &
May, 2014)
One theoretical model that helps explain the progression from suicidal desire to
action is the Interpersonal Psychological Theory of Suicide (IPTS; Van Orden et al.,
2010). The IPTS posits that suicidal desire occurs when the constructs of perceived
3
burdensomeness and thwarted belongingness overlap. Perceived Burdensomeness refers
to an individual’s belief that ending his or her own life will improve circumstances for
others, and Thwarted Belongingness is broadly related to an individual’s belief in his or
her own isolation and social disconnectedness. The IPTS further asserts that moving from
suicidal ideation to completed suicide mandates an acquired capability for suicide, which
is required to overcome natural human tendencies to protect one’s own life. Acquired
capability is accumulated by desensitization to painful events via repeated direct and
indirect exposure, and it is a developmental construct that, once obtained, remains stable
throughout the lifetime (Joiner, 2005).
Perceived Burdensomeness and Thwarted Belongingness. Empirical evidence
supports the association of suicidal ideation with Perceived Burdensomeness and
Thwarted Belongingness as well as the interaction between these two constructs (Van
Orden, Cukrowicz, Witte, & Joiner, 2012; Van Orden, Witte, Gordon, Bender, & Joiner
2008). Specifically, Perceived Burdensomeness has been found to be moderately to
strongly correlated with suicidal ideation within samples of undergraduate college
students, older adults, adult outpatients, sexual minorities, and ethnically diverse samples
(Bryan, Morrow, Anestis, & Joiner, 2010; Cukrowicz, Cheavens, Van Orden, Ragain, &
Cook, 2011; Garza & Pettit, 2010; O’Keefe et al., 2014; Plodehrl et al., 2014; Hill &
Pettit, 2012; Van Orden, Lynam, Hollar, & Joiner, 2006; Van Orden et al., 2008).
Thwarted Belongingness similarly correlates moderately to strongly with suicidal
ideation among samples of undergraduate college students, adult outpatients, military
samples, sexual minorities, and ethnically diverse samples (Van Orden et al., 2006; Garza
& Pettit, 2010; Hill & Pettit, 2012; O’Keefe et al., 2014; Plodehrl et al., 2014; Van Orden
4
et al., 2008). Preliminary studies demonstrating the correlation between suicidal ideation
and IPTS constructs of perceived interpersonal deficits offer construct validity, but in
order to demonstrate its efficacy as an etiological theory, the IPTS must also demonstrate
its ability to explain the pathway to suicidal behavior from a variety of risk factors, as
originally hypothesized (Van Orden et al., 2010).
The IPTS has demonstrated its ability to predict suicidal ideation above and
beyond traditional risk factors that are considered salient predictors of suicidal ideation
(e.g. psychiatric disorders, hopelessness; Van Orden et al., 2006; Christensen, Batterham,
Soubelet, Mackinnon, 2013). Furthermore, Perceived Burdensomeness and/or Thwarted
Belongingness have been found to mediate the association between a variety of
traditional risk factors and suicidal ideation, such as alcohol-related problems (Lamis &
Malone, 2011), depressive symptoms (Jahn, Cukrowicz, Linton, & Prabhu, 2010), sexual
minority status (Hill & Pettit, 2012), childhood abuse (Puzia, Kraines, Liu, & Kleiman,
2014), attachment security (Venta, Mellick, Schatte, & Sharp, 2014), and maladaptive
personality characteristics (Rasmussen, Slish, Wingate, Davidson, & Grant, 2012). These
findings indicate that the constructs of perceived interpersonal deficits asserted in the
IPTS partially explain the pathway between traditional risk factors and suicidal ideation.
The array of correlational evidence supporting the IPTS indicates its potential
utility in treatment. However, the IPTS does not have evidence that Perceived
Burdensomeness or Thwarted Belongingness cause suicidal thoughts and behaviors.
Suicidal individuals may not always attribute their due suicidal ideation to their feelings
of Perceived Burdensomeness or Thwarted Belongingness (Tucker et al., 2015). Clinical
science has begun to suggest that experimental interventions aimed at reducing suicidal
5
ideation and attempts need to incorporate treatment that is specifically focused on
reducing the effects of theoretical constructs purported to be associated with suicidal
ideation, such as Perceived Burdensomeness and Thwarted Belongingness (Tucker et al.,
2015). As there are relatively few studies examining suicide-specific treatment strategies
(Jobes et al., 2015), a body of literature must be developed that identifies components of
treatment to be included in suicide-specific interventions. It may be that disclosure of
stigmatized status as a suicide attempt survivor to close family or friends has a direct or
indirect positive effect on Perceived Burdensomeness or Thwarted Belongingness, and
therefore should be incorporated into suicide specific treatment interventions.
Acquired Capability for Suicide. Preliminary evidence has supported the
validity of the acquired capability for suicide as a construct that allows individuals to
overcome innate desires to protect their own lives (Van Orden et al., 2010). The most
salient evidence of the construct validity for ACS are findings demonstrating elevated
levels of ACS among individuals with a history of combat exposure (Bryan, Cukrowicz,
West, & Morrow, 2010), non-suicidal self-injury (NSSI; Franklin Hessel, & Prinstein,
2011; Willoughby, Heffer, & Hamza, 2015), and suicide attempts (Van Orden et al.,
2008). Despite measurement difficulties and concerns about psychometric validity of the
Acquired Capability Scale (for a full discussion, see Ribeiro et al., 2014) the construct of
acquired capability is still useful to explain the heightened risk for suicide in individuals
with prior suicide attempts (Harris & Barraclough, 1997). Previous results have found
that 35-44% of suicide decedents have a prior suicide attempt; therefore, research that
identifies behaviors associated with positive outcomes of treatment for suicide attempt
survivors is needed (Anestis, 2016; Isometsa & Lonqvist, 1998).
6
Stigmatized Status
Stigmatized statuses can be defined as real or perceived attributes that devalue an
individual in the eyes of others (Crocker, Major, & Steele, 1998), and the negative effects
of stigma can be experienced as a wide variety of achievement, health, and self-esteem
consequences (Major & O’Brien, 2005). Common stereotypes about mental illness that
influence discrimination include public perceptions of the mentally ill as dangerous to
themselves or others (Pescosolido, Monahan, Link, Stueve, & Kikuzawa, 1999),
unstable/frightening (Link, Phelan, Bresnahan, Stueve, & Pescolido, 1999), and being
worthy of blame for their mental disorders (Schomerus et al., 2012). Recent meta-
analyses conducted on several nationally representative samples demonstrate that
stereotypes about mental illness are resistant to change over time (Pescosolido et al.,
2010; Phelan, Link, Stueve, & Pescosolido, 2000; Schomerus et al., 2012). These
stereotypes can result in a variety of social, workplace, and healthcare discrimination
(Clement et al., 2014; Clement et al., 2015; Corrigan & Kleinlein, 2005; Hemmens,
Miller, Burton, & Milner 2002; Wahl, 1999; Wahl, Wood, & Richards, 2002). Public
perceptions of the mentally ill as dangerous, unstable, and incapable of making decisions
have experienced very little reduction in recent years, and in some reports, rates have
increased, despite increased understanding of neurobiological bases for mental illnesses
(Pescosolido et al., 2010, Schomerus et al., 2012).
The immutability of public perceptions has led some researchers to focus on a
more malleable and modifiable construct, self-stigma (Corrigan et al., 2012). Self-stigma
is the process by which individuals endorse and internalize negative, self-relevant
stereotypes about their stigmatized status (Corrigan & Watson, 2002). Self-stigma is
7
particularly salient for individuals with mental illness due to the concealable nature of
mental illness and the exacerbating effects self-stigma can have on traits that may already
be in deficit among those with mental illnesses (e.g., self-efficacy, self-esteem; Corrigan
& Rao, 2012). Approximately one-third of adult outpatients with serious mental illness
report moderate to high self-stigma (Ritsher & Phelan, 2004; West, Yanos, Smith, Roe, &
Lysaker, 2011). Specifically, community samples indicate that 42% of people diagnosed
with schizophrenia and 22% of people diagnosed with depression or bipolar disorder
experience moderate to high levels of self-stigma (Brohan, Elgie, Sartorius, Thornicroft,
& GAMIANA-Europe Study Group, 2010; Brohan, Gauci, Sartorius, Thornicroft, &
GAMIANA-Europe Study Group, 2011).
In outpatient samples, self-stigma is moderately correlated with lower self-
esteem, self-efficacy, and hopefulness, while controlling for depression symptoms
(Corrigan et al., 2012). Due to the well-established link between hopelessness and suicide
(Beck, Weissman, Lester, & Trexler, 1974), these results demonstrate that reducing the
effects of self-stigma may also reduce suicidal thoughts and behaviors among individuals
with mental illnesses. It is hypothesized that guided, or clinician-facilitated, disclosure of
mental illness may be an effective strategy for managing the negative effects of self-
stigma (Corrigan et al., 2010), and results from a randomized controlled trial
implementing a guided disclosure program have demonstrated a positive impact on stress
related to disclosure and stigma (Rusch et al., 2014). These results support guided
disclosure of prior suicidal thoughts and behaviors within a therapeutic setting.
In addition to stigma and self-stigma accumulated due to potential mental illness,
individuals who have survived a suicide attempt can encounter suicide stigma as well
8
(Hanschmidt, Lehnig, Riedel-Heller, & Kersting, 2016). The general public labels suicide
attempt survivors as selfish, immoral, and cowardly, among other negative stereotypes
(Batterham, Christensen, & Calear, 2013). Stigma towards suicide attempt survivors and
those with mental illnesses similarly manifests as a desire for social distance (Pescosolido
et al., 2010; Lester & Walker, 2006), but suicide stigma is not characterized by fear or
belief of the stigmatized individual causing harm to others (Corrigan, Markowitz,
Watson, Rowan, & Kubiak, 2003). Suicide stigma may be especially damaging because
the perpetrators have no need to protect themselves from the stigmatized individual and
because suicide attempt survivors are highly likely to have a mental illness, which
confers increased stigmatization.
Experiences of public stigma affect the majority of individuals with a history of
suicidal thoughts and behaviors, but rates differ across different sources of stigma (Frey
Hans, & Cerel, 2016a). Perceived stigma from mental health providers is much lower
(21-23%) than perceived stigma from social networks (28-57%) or healthcare providers
(22-61%). However, these sources are not uniform because the largest contributions to
social network stigma come from family members (57%), and the largest contributions to
healthcare stigma come from emergency department staff (61%; Frey et al., 2016a).
A number of studies have found an association between self-stigma and suicidal
thoughts/behaviors (Reynders, Kerkhof, Molenberghs, & Van Audenhove, 2013; Oexle
et al., 2016; Scocco, Toffol, & Preti, 2016). On a large scale, self-stigma has been found
at greater levels within geographic regions with higher rates of completed suicide
(Reynders et al., 2013). At the individual level, self-stigma prospectively predicts
increased levels of suicidal ideation among disabled adults (Oexle et al., 2016), and a
9
prior history of suicide attempts is associated with greater suicide stigma among
hospitalized suicide attempt survivors. The direction of these relationships is unclear. It
may be that suicide stigma contributes to increased suicidal ideation/attempts, but it is
also possible that increased suicidal ideation/attempts result in greater acceptance of
suicide-related stereotypes. Regardless, suicide attempt survivors are likely to benefit
from programs or interventions designed to reduce self-stigma associated with their prior
history of suicidal behavior.
Disclosure
The traditional disclosure experiment first implemented by Pennebaker and Beall
(1986) employed a writing task in which participants were instructed to either describe
their feelings following an upsetting event or write about a trivial topic. Since then,
research evaluating the effects of disclosure has broadened to include verbal disclosure
tasks and a variety of different disclosure topics such as transitional experiences, medical
illnesses, grief, and experiences of discrimination (Frattarolli, 2006). Results from these
experiments have been mostly positive, highlighting both physiological and
psychological benefits, including improvements in depression, from experimental
disclosure. The benefits of disclosure have been largely attributed to cognitive
processing, suggesting that the act of identifying specific causes and assigning meaning is
the driving mechanism behind these benefits (Pennebaker, 1993; for a review and meta-
analysis see Frattarolli, 2006).
More recently, the potential benefits of disclosure have been applied to research
involving interpersonal disclosure of stigmatized statuses (Chaudoir & Quinn, 2010;
Talley & Bettencourt, 2011; Ullrich, Lutgendorf & Stapleton, 2003). Individuals who
10
identify as lesbian, gay, or bisexual (LGB) remain a stigmatized group in The United
States (Herek, Gillis & Cogan, 2009). Due to the concealable nature of this status, many
LGB individuals choose not to disclose this identity. However, this coping strategy may
contribute to increased psychological distress (Chaudoir & Quinn, 2010; Leserman,
DiSantostefano, Perkins, & Evans, 1994; Talley & Bettencourt, 2011; Ullrich, et al.,
2003). Higher disclosure of sexual identity (e.g., telling more people about one’s identity)
is associated with decreased depression symptoms and increased social support (Talley &
Betterncourt, 2011; Ullrich et al., 2003). Chaudoir et al. (2010) assert that one of the
mechanisms responsible for this association is a decreased fear of future disclosure,
which contributes to a state of chronic worry. However, positive results following
disclosure are contingent upon positive reaction to disclosure of stigmatized status from
social network members (Chaudoir et al., 2010; Rodriguez & Kelly, 2006).
As discussed above, individuals who suffer from mental illnesses represent
another group whose self-stigma may be ameliorated by guided disclosure (Corrigan et
al., 2010; Rusch et al., 2014). Disclosure of mental illness is negatively correlated with
perceived stigma and positively correlated with quality of life, indicating that disclosure
of mental illness may be an appropriate technique to improve a variety of outcomes.
(Corrigan et al., 2010). Additionally, a randomized controlled trial of guided disclosure of
mental illness, which consisted mostly of psychoeducation and discussion about the costs
and benefits of disclosure, group differences between treatment and control groups were
observed on several outcome measures (Rusch et al., 2014). The treatment group had
lower rates of secrecy, disclosure-related stress, and stigma stress as well as higher rates
of perceived benefits of disclosure. Overall, the results indicate a reduction in fear of
11
future disclosure, which has been suggested to be responsible for associations between
positive reactions to disclosure and increases in mental health outcomes (Chaudoir &
Quinn, 2010). This may indicate that the active component of the intervention is a
rehearsal of simulated positive reactions to disclosure. Unfortunately, individuals may
still experience negative reactions to their disclosure, which would attenuate the positive
effects. Preliminary findings suggesting positive effects of a mental illness disclosure
intervention are encouraging and suggest that similar designs can be employed in therapy
or interventions for individuals with suicide attempt history. However, further research is
needed in order to determine the benefits of disclosure among suicide attempt survivors.
Suicide Disclosure
Research evaluating the impact of disclosure of prior suicidal thoughts/behaviors
borrows from conceptual models of previous work assessing the positive effects of
disclosure of other stigmatized statuses. However, research evaluating the impact of
disclosing a history of suicidal thoughts and behaviors to trusted confidants has emerged
very recently, with most articles published in the current decade (e.g., Cukrowicz,
Duberstein, Vannoy, Lin, & Unutzer, 2014; Frey et al., 2016b; Fulginiti, Pahwa, Frey,
Rice, & Brekke, 2015). The dearth of research may be due to assumptions that disclosure
of suicidal thoughts and behaviors will contribute to suicide attempt clusters, multiple
rapid suicide attempts in a small geographic area (Gould, Petrie, Kleinman, &
Wallenstein, 1994). These are valid concerns, and future research should fill the gap in
the literature by assessing the potential for clustering effects associated with disclosures
of suicidal thoughts and behaviors to trusted confidants.
The present study concerns the effects of suicide attempt survivors informing a
12
trusted confidant that they have engaged in suicidal behavior (henceforth disclosure of
suicide attempt; DSA), but other definitions of disclosure exist in related contexts within
the literature. DSA is a behavior distinct but related to disclosure of suicidal ideation to
medical staff (e.g., Cukrowicz et al., 2014), disclosure of suicidal ideation to friends or
family (e.g., Fulginiti, et al., 2015), disclosure of intent to die to psychiatric consultation
following a medically serious injury with suicidal implications (e.g., Williams, Kores, &
Currier, 2011), and hiding suicidal ideation from others (Beck, Kovacs, & Weissman,
1979). However, findings about these related behaviors contribute to the scant body of
literature available to describe DSA, and further research into DSA will inform research
into these related behaviors as well.
Disclosure of Suicidal Ideation. Disclosure of suicidal ideation to friends,
family, or healthcare professionals has been acknowledged as an important component in
assessing suicide risk within the context of clinical practice and research since initial
attempts to measure suicidal ideation and intent (Beck, Schuyler, & Herman, 1974; Beck
et al., 1979). Items pertaining to disclosure of suicidal ideation on both the Suicide Intent
Scale and the Beck Scale for Suicidal Ideation are counted in the final score of each
measure. However, endorsing a suicidal ideation disclosure item decreases one’s score on
suicidal ideation and increases one’s suicidal intent score. Furthermore, these items have
demonstrated questionable psychometric validity in factor analytic studies (Beck, Brown,
& Steer, 1997; Beck et al., 1979; Holden & DeLisle, 2005; Mieczkowski et al., 1993;
Spirito, Stirling, Donaldson, & Arrigan, 1996). The poor psychometric qualities of items
pertaining to suicidal ideation disclosure and the general disagreement of its impact on
distinct but related measures of suicide risk indicate a need for further research.
13
A limited number of studies have analyzed the association between disclosure of
suicidal ideation and severity of suicidal ideation, but results suggest that disclosure
decreases suicidal ideation (Eskin, 2003). Turkish and Swedish adolescents with more
severe past suicidal ideation were more likely to disclose their ideation to others, and
those who had disclosed in the past had significantly lower current suicidal ideation than
those who did not. These findings suggest a hypothetical course of events wherein higher
levels of suicidal ideation lead to more disclosure and disclosure leads to decreased
suicidal ideation (Eskin, 2003). Similarly, Encrenaz et al., (2012) reported incremental
increases in rates of disclosure for individuals who endorsed suicidal planning and prior
suicide attempt compared to individuals who only reported suicidal ideation. These
results suggest that increased severity of suicidal thoughts/behaviors is associated with
higher likelihood to disclose this distress to others. Cukrowicz et al. (2014) expanded
these findings to include overall negative quality of life as a positive predictor of suicidal
ideation disclosure in addition to the findings of increased suicidal thoughts/behaviors as
a predictors of disclosure reported by (Encrenaz et al., 2012; Eskin, 2003). Taken
together, these findings suggest that greater distress and suicidal ideation are associated
with higher likelihood to disclose suicidal ideation. Unfortunately, more research is
needed to determine the effects of suicidal ideation disclosure on future suicidal ideation,
despite preliminary findings that suggest a beneficial impact on later suicidal ideation
(Eskin, 2003).
Although individual-level factors, such as quality of life, predict disclosure of
suicidal ideation, the quality of an individual’s social network may be an even stronger
predictor (Encrenaz et al., 2012; Eskin, 2003; Fulginiti et al., 2015; Husky et al., 2016).
14
Forty percent of French adults compared to over 75% of suicidal Swedish and Turkish
adolescents disclosed suicidal ideation to a friend or family member. Although Encrenaz
et al. (2012) recruited via telephone survey and Eskin et al. (2003) surveyed public
schools, the variability in rates of disclosure suggests that social and cultural differences
influence the likelihood that an individual will disclose suicidal ideation to a family
member or friend. Additionally, Americans who disclose their suicidal ideation report
increased numbers of trusted confidants (Husky et al., 2016). Using a social network
analysis of outpatients with serious mental illnesses and a history of suicidal ideation,
Fulginiti et al., (2015) found that relationship closeness and supportiveness of the
disclosure target were stronger predictors of intent to disclose ideation in the future than
most individual-level factors (e.g., symptom severity, psychosocial functioning, and self-
stigma). These findings are indicative of the selectivity that individuals employ when
they select others for disclosure, and they highlight the importance of accounting for
social factors when scientifically evaluating disclosure of suicidal ideation or guiding a
client’s disclosure of suicidal ideation in clinical practice.
Guided disclosure of suicidal ideation is considered an important component of a
variety of therapies used for treating suicidal desire (e.g., Bush et al., 2015; Jobes, 2006;
Stanley & Brown, 2012). These therapies include guided and selective disclosure as a
technique for crisis intervention in emergency situations, but there is currently a dearth of
empirical research analyzing whether or not disclosure itself is related to positive
psychological outcomes outside of crisis prevention. Moreover, these therapies do not
necessarily specify that a patient should disclose their status as a suicide attempt survivor,
which may be diminishing the effectiveness of the mechanisms that are likely to be
15
responsible for the positive outcomes associated with disclosure (e.g., decreasing self-
stigma, reducing fear of disclosure).
Suicide Attempt Disclosure. There is currently very little empirical research
evaluating the effect of suicide attempt disclosure (DSA) to social network members, and
there are no randomized controlled trials to evaluate its impact. Prior research has
focused retrospectively on how DSA and familial reaction to DSA impact future
depression symptomology (Frey et al., 2016b). Results indicate that DSA has no direct
effect on future depression but is indirectly associated with decreased depression via
positive family reaction. Also, Frey et al. (2016b) found that increased level of disclosure
content (e.g., precipitating circumstances, reason for attempting) was associated with
positive family reaction, and they interpret that this association may be indicative of a
positive feedback loop in which suicide disclosure is reinforced by positive reaction to
disclosure. Based on this interpretation, the driving mechanism for decreasing depression
symptomology is positive family reaction to disclosure because disclosure may only be
responsible for enabling the initial positive reaction to occur. Although depression is a
consistent predictor of increased suicide risk, these results highlight the importance of
evaluating the impact of prior DSA on current suicidal ideation and other proximal risk
factors for suicide, such as Perceived Burdensomeness and Thwarted Belongingness.
Furthermore, Frey et al. (2016b) only assessed family reaction to disclosure without
taking into account the impact of disclosure to other members of the suicidal individual’s
social network.
Social Support
16
Studies examining the effects disclosure of stigmatized status have found social
support to be negatively associated with depression (Frey et al., 2016b) and self-esteem
(Chaudoir & Quinn 2010). Also, results indicate that social support can have an impact
on the effect of disclosure on mental and physical health benefits (Chaudoir & Quinn,
2010; Frey et al., 2016b; Rodriguez & Kelly, 2006; Ullrich et al., 2003). These studies
suggest that individuals with higher levels of social support experience more benefits
from disclosure of stigmatized status. Specifically, it has been found that positive
response from the disclosure target mediates the positive association between disclosure
and mental health outcomes (Frey et al., 2016b; Chaudoir & Quinn, 2010) and that
satisfaction with social support moderates the positive association between disclosure and
physical health (Ullrich et al., 2003). These data, coupled with the positive association
between disclosure and social support (Talley & Bettencourt, 2011), suggest that social
support can affect the association between disclosure of suicide attempt and suicide risk.
Perceived social support has been found to be a protective factor against suicidal
ideation and suicide attempts (Chioqueta & Stiles, 2007; Kleiman & Liu, 2013), and a
number of studies have also found that social isolation is associated with increased
suicide risk (for an extensive list, see Van Orden et al., 2010). The mitigating effect of
perceived social support on suicide risk may be especially important for individuals who
have engaged in DSA. The experiences of suicide attempt survivors who disclose their
suicide attempt history to others are likely to be directly affected by their perception of
the social support network with which they interact. Attempt survivors who have high
perceived social support are likely to experience positive reactions from disclosure
targets that will subsequently decrease their levels of suicide risk. Alternatively,
17
individuals who are low in perceived social support may have different experiences. As
discussed above, 28-57% of individuals with past suicidal thoughts and behaviors will
receive stigmatizing contact from their social network. Therefore, lower perceived social
support is likely to lead to negative or stigmatizing reactions from disclosure targets,
which will in turn increase suicide risk in these individuals.
Rationale and Hypotheses
Previous research has identified positive direct and/or indirect effects of prior
disclosure of previous suicide attempt, mental illness, stigmatized sexual identity, and
other stigmatized statuses on mental health outcomes. Analyzing the effects of DSA on
measures of suicide risk may show similar effects for suicide attempt survivors. It was
hypothesized that DSA (as measured by the presence or absence of prior DSA and the
number of disclosure targets) would be negatively associated with depression, Perceived
Burdensomeness, Thwarted Belongingness, and measures of peer and familial social
support. It was expected that the correlation between DSA and peer support would be
larger than that of the association between DSA and family support because the sample
was comprised of undergraduate college students, who are more likely to live away from
their immediate families.
Positive reactions from family and friends following disclosure of stigmatized
status and suicide attempt history are associated with mental health benefits. Therefore, it
was expected that social support would moderate the association between suicide attempt
disclosure and suicide risk. It was expected that, at high levels of social support, DSA
would have a positive effect on measures on depression, Perceived Burdensomeness, and
Thwarted Belongingness. However, at low levels of social support, it was expected that
18
DSA would have a negative or non-significant effect on suicide risk. It was also expected
that the moderating effect of peer support would be stronger than the moderating effect of
family support.
Because of the lack of current research about the effects of DSA, an additional
exploratory hypothesis was included in order to assess the indirect effects of DSA on
depression, Perceived Burdensomeness, and Thwarted Belongingness through the
pathways of familial and peer social support. It was hypothesized that DSA would have a
negative indirect effect on depression, Perceived Burdensomeness, and Thwarted
Belongingness, such that those who disclosed to more disclosure targets would have
increased social support, which would be associated with decreased depression,
Perceived Burdensomeness, and Thwarted Belongingness. Additionally, it was expected
that the indirect effects of DSA on these outcome measures would be stronger via the
pathway of peer social support than familial social support.
Method
Participants
Participants consisted of undergraduate college students receiving course credit
for participating in survey research. The sample was partially comprised (n = 65) of
students who participated in a study evaluating self-injurious thoughts and behaviors
between the years of 2012 and 2016. The rest of the sample (n = 34) was recruited from
an ongoing study screening undergraduate participants for self-injurious thoughts and
behaviors. Only participants who endorsed at least one lifetime suicide attempt were
invited to participate. The total sample consisted of 99 undergraduate students with a
history of suicide attempt, but two participants were removed because they failed to
19
respond to questions about DSA. The final sample of 97 students had a mean age of
20.35 (SD = 4.63), was 79.4% female, and identified as 72.2% White/Caucasian, 12.4%
Black/African American, 8.2% Hispanic/Latino(a), 3.1% Asian, and 3.1% Multi-Ethnic
(Table 1).
Procedure
For the pre-existing sample of undergraduate college students, participants
registered for a time to come to the lab and were grouped with up to four other
participants. Upon arrival, participants read and signed an informed consent and were
given a battery of assessments to complete, which they were instructed to bring to the
research assistant upon completion. The researcher reviewed participants’ scores on
critical items measuring imminent risk for suicide before debriefing them according to
their risk. Low-risk participants were given an information sheet with instructions about
how to contact mental health services, and moderate-risk participants were asked if they
wanted assistance contacting mental health services. Finally, high-risk participants were
accompanied to the counseling and testing center by a research assistant.
Participants from the ongoing screening survey were invited to participate if they
responded with “I have attempted to kill myself, but did not really want to die,” or “I
have attempted to kill myself, and really hoped to die,” to the item “Have you ever (in
your lifetime) seriously thought about, or attempted to kill yourself (suicide)?” To qualify
for inclusion, participants must have also positively endorsed interest in participating in a
follow-up study and provided contact information when prompted by the screening
survey. Participants in the screening survey sample were invited to participate via email
by a research assistant, and a link to the additional online survey was provided. Upon
20
completion of another battery of questionnaires, participants were debriefed with
information about how to reach mental health services in the area as well as informed of
crisis hotline information. Participants were instructed to provide a mailing address to
which their $10 gift card was sent, and participation was monitored closely by a research
assistant to ensure that no participants forgot to provide this information.
Measures
Disclosure of Suicide Attempt. DSA was measured using the suicide attempt
subscale of the Self-Harm Behavior Questionnaire (SHBQ; Gutierrez et al., 2001;
Appendix A), a self-report questionnaire with subscales measuring the severity of a
variety of self-harm thoughts and behaviors. The SHBQ has demonstrated high internal
consistency (a = .96), and good construct validity. However, the current study made use
of two contextual, qualitative items to code two types of DSA measures, a dichotomous
measure and a count/ordinal measure. One item was used to code a dichotomous measure
of disclosure (“Did you tell anyone about your suicide attempt?”). The second item used
inquired about the people to whom the participant disclosed their suicide attempt history,
from which a count variable was coded (“Who did you tell?”).
Previous research has found that dichotomous measures of disclosure have
insufficient power (Corrigan et al., 2012), and sexual identity disclosure research has
used the number of different social network categories to whom a participant has
disclosed as a measure of the amount of disclosure (Talley & Bettencourt, 2011).
Therefore, the count variable was coded to represent the number of different categories of
social network member to which the participant has disclosed (DSA-Count). Specifically,
the scores on DSA-Count range from 0-12 and represent the following categories of
21
potential disclosure targets (henceforth, DSA targets): mental health worker, mother,
father, siblings, colleagues, best friend, relatives, close friend/friends, roommates,
employers, acquaintances, and strangers. These 12 categories are identical to those
outlined in Talley and Bettencourt’s (2011) study evaluating sexual identity disclosure
with the addition of “mental health worker,” due to the nature of DSA. However, because
the SHBQ does not specifically require participants to make an exhaustive list of all
social network members, conclusions drawn from analyses using DSA-Count are
considered tentative.
Previous research has found differences in disclosure rates to healthcare
professionals when compared to members of the social network (Husky et al., 2016), and
research evaluating the effects of DSA has focused exclusively on DSA to family
members without including healthcare professionals (Frey et al., 2016b). Because the
present study proposed that DSA has benefits on interpersonal deficits related to suicide
risk, it was important to consider DSA to members of the social network without
including healthcare professionals. Therefore, two additional measures of DSA were
coded in which healthcare professionals were excluded as DSA targets. These additional
measures of DSA and DSA-Count were termed Social DSA and Social DSA-Count.
Analyses using these exploratory measures were conducted post-hoc, so any conclusions
drawn are considered tentative.
Depression. Depression was measured using the 20-item self-report
questionnaire, Center for Epidemiological Studies-Depression scale (CES-D; Appendix
B; Radloff, 1977). The CES-D uses a 4-point likert scale measuring the frequency that
participants have experienced depression symptoms in the past week, and participants can
22
respond with “rarely or none of the time (0),” “some or a little of the time (1),”
“occasionally or a moderate amount of the time (2),” or “most or all of the time (3).” The
CES-D is a widely used measure for examining recent depression symptoms in the
general population that has been found to have good internal consistency reliability ( =
.85-.90), construct validity, and factor structure across a wide variety of samples. The
present sample demonstrated high internal consistency reliability ( = .91). The CES-D is
a good match to the criteria necessary for DSM-IV diagnosis of a major depressive
episode (Okun, Stein, Bauman, & Silver, 1996).
Perceived Burdensomeness and Thwarted Belongingness. Perceived
Burdensomeness and Thwarted Belongingness were measured with the 15-item
Interpersonal Needs Questionnaire (INQ-15; Appendix C; Van Orden et al., 2012), which
measures interpersonal deficits using a 7-point likert scale with responses ranging from
“not at all true for me” to “very true for me.” The INQ-15 is a revision of the original 25-
item Interpersonal Needs Questionnaire, which dropped several items due to poor factor
loadings. The 6 items pertaining to Perceived Burdensomeness and the 9 items pertaining
to Thwarted Belongingness that were retained demonstrated high factor loadings (.56 -
.84). The TB subscale has demonstrated good convergent validity due to its small to large
correlations with measures of loneliness, social support, and relatedness needs
satisfaction (Van Orden et al., 2012). Likewise, the Perceived Burdensomeness subscale
of the INQ-15 has demonstrated good convergent validity via small correlations with
measures of autonomy, competence, and responsibility to family. Perceived
Burdensomeness and Thwarted Belongingness demonstrated high internal consistency
reliability in the present sample ( = .94 and .92, respectively). As discussed above,
23
Perceived Burdensomeness and Thwarted Belongingness are symptoms of suicidal desire
in the widely studied IPTS. They are considered proximal risk factors for suicide.
Perceived Social Support. Perceived social support was measured using the
family alliance and peer acceptance and support subscales (henceforth, family support
and peer support) of the Reasons for Living Inventory for Adolescents (RFL-A;
Appendix D; Osman et al., 1998). The RFL-A is a 32-item self-report questionnaire with
items measuring the degree to which a statement is important to participants as a reason
for not making a suicide attempt using a 6-point scale that ranges from “not at all
important to me” to “very important to me.” These subscales have demonstrated good
internal consistency ( = .93-.95, = .89-.92), and have been found to be strongly
correlated with each other (r = .57).
Although using the RFL-A as a proxy measure of social support from family and
peers is a novel approach, the items on the RFL-A support this design with excellent
content validity. Items on the family support subscale assess the degree to which
participants’ feel that their families care about them, are enjoyable, are available in times
of need, listen to them, are close to them, and encourage/support them. Peer support
assesses the degree to which participants’ friends accept them, stand by them, are
reliable, care about them, and appreciate them. The items in these subscales and the
subscales themselves are very similar to those in the other measures of perceived social
support, such as the Multidimensional Scale of Perceived Social Support (Zimet, Dahlem,
Zimet, & Farley, 1988). Additionally, in the present sample, these subscales showed high
internal consistency reliability ( = .96 for family support and = .95 for peer support).
24
Time since suicide attempt. The most recent suicide attempt a participant has
made is theoretically the peak of their suicidal ideation, so any distress and clinical
variables are likely to have waned over time following their attempt via maturation
(Campbell & Stanley, 1971). Prior research has controlled for time since suicide attempt
when analyzing the effects of DSA, so it was tested for inclusion as a covariate in final
analyses. Time since suicide attempt was measured using the Risk History subscale of the
SHBQ, which calculates risk of suicide attempt by subtracting a participant’s current age
from their age when they made their most recent suicide attempt. The differences are
weighted such that <1 year is scored as a “4,” 1-2 years is scored as a “3,” and >2 years is
scored as a “2.” Note that higher scores are indicative of a more recent suicide attempt.
Analyses
Descriptive Statistics. Descriptive statistics assessed demographic characteristics
of the sample and DSA group differences on intervening variables (family support and
peer support) and outcome variables (depression, Perceived Burdensomeness, and
Thwarted Belongingness) between participants who had and had not disclosed suicide
attempt history. Additionally, zero-order correlations were calculated between all
predictor and outcome variables. In order to test for the inclusion of relevant covariates
identified by previous research, all outcome variables were analyzed for significant
associations with demographic variables and time since most recent suicide attempt using
chi-square tests of association and individual linear regression analyses (Frey et al.,
2016b).
Moderation Analyses. In order to evaluate the association between DSA and
suicide risk as well as the moderating effect of social support on this association,
25
moderated hierarchical linear regression analyses were conducted using the PROCESS
macro for SPSS 23 (Hayes, 2013). Moderated multiple regression tests the effect of one
moderator on the association between an independent and dependent variable by entering
the independent and moderator variables into the same step of a regression equation, or
regressing the dependent variable (depression) on the independent and moderator
variables (DSA and social support; Brown, 2016). Next, the dependent variable is
regressed on both the independent and moderator variables as well as the interaction
term, which is a simple product of the independent and moderator variables. To assess the
significance of the moderating effects, the change in R2 between the first and second
regression analysis is calculated, and a significant F-test will indicate a significant
moderating effect. Moderated multiple regression allows for the inclusion of covariates
by first regressing the dependent variable on any covariates and subsequently performing
the procedure laid out above. All assumptions of traditional multiple regression apply to
moderated multiple regression analysis, so the residual plots of all analyses were
evaluated visually for linearity and homogeneity of variance. Additionally, all variables
were assessed for outliers, skewness and kurtosis. Finally, an a priori power analysis
conducted using G*Power 3.1 indicated that a sample of 89 participants would provide
sufficient power to detect medium size effects with 95% accuracy (1 – β = .95) for all
moderation analyses (Faul, Erdfelder, Buchner, & Lang, 2009)
Six separate moderated multiple regression models were constructed to evaluate
the moderating effects of family support and peer support on the association between
DSA and depression, Perceived Burdensomeness, and Thwarted Belongingness, while
controlling for all relevant covariates. An additional six models were constructed to
26
evaluate the moderating effects of family support and peer support on the association
between DSA-Count and depression, Perceived Burdensomeness, and Thwarted
Belongingness, while controlling for all relevant covariates. After evaluating the
percentage of participants who disclosed their suicide attempt only to healthcare
professionals, an additional 12 post-hoc exploratory moderated multiple regression
models were constructed to evaluate the same moderating effects using the additional
measures of disclosure that excluded healthcare professionals as DSA targets: social DSA
and social DSA-Count. Both DSA and social DSA were coded for use in linear
regression such that nondisclosure = 0 and disclosure = 1. Due to their ordinal nature as
count variables, the coded vectors for both DSA-Count and social DSA-Count were
sequentially coded such that the number of coded vector variables (e.g., D1, D2, and D3)
coded as a “1” increased by one in correspondence with the number of disclosure targets
identified (i.e., zero DSA targets was coded as D1 = D2 = D3 = 0; one disclosure target
was coded as D1 = 1, D2 = D3 = 0, etc.). Although previous research has found family
reaction to DSA to mediate and not moderate the association between amount of
disclosure and depression, a moderation model was hypothesized due to the nature of the
proxy variables used in the current study (Frey et al., 2016b).
Mediation Analyses. After examining the zero-order correlations between the
variables of interest, it was determined that a mediation model may be a better fit for the
data. Moderate to strong correlations were observed between moderator and outcome
variables, indicating that these intervening variables may contribute to an indirect
pathway by which measures of DSA impact outcome variables. In order to test this
exploratory, post-hoc hypothesis, the mediating effects of social support on the
27
association between measures of DSA and all outcome variables were analyzed using
Hayes’s (2013) PROCESS macro to estimate indirect effects using bias-corrected
bootstrapped confidence intervals (with 5,000 repetitions). PROCESS employs a
bootstrapping procedure whereby the available sample is repeatedly resampled with
replacement to create an empirical representation of the data (Hayes, 2013). This
technique for assessing indirect effects was used because prior DSA research has used it
(Frey et al., 2016b), and simulation research has found it to be one of the most effective
ways to estimate indirect effects (Hayes, 2009).
The traditional method for mediation analysis put forth by Baron and Kenny
(1986) requires a significant direct effect of the independent variable on the dependent
variable (the c pathway; in this study, the effect of DSA on depression), significant
effects of the independent variable on the mediator variable (the a pathway; the effect of
DSA on social support), a significant effect of the mediator on the dependent variable
(the b pathway; the effect of social support on depression), a significant reduction in the c
pathway when introducing the mediator variable into the final model. However, newer
methods of mediation do not assert the necessity of all of these prerequisites in order to
reject the null (Hayes, 2009). The method used in this study involves using bootstrapping
to estimate indirect effects from the product of the a and b pathways 5,000 times,
ordering these estimates, and using the lower 2.5% and upper 2.5% of these estimates as
the bounds for the 95% confidence interval. Thus, rejecting the null of an indirect effect
of zero is achieved when the confidence intervals do not cross zero. Additionally, the
bootstrapping procedure employed by PROCESS eliminates the assumption of normality
in the sampling distribution and allows for multicategorical predictor variables. Power
28
analyses were not conducted for mediation analyses due to the empirical representation of
the data generated by the bootstrapped confidence intervals.
In order to evaluate the indirect effects of DSA, social DSA, and social DSA-
Count on depression, Perceived Burdensomeness, and Thwarted Belongingness via the
pathways of family support and social support, while controlling for all relevant
covariates, a series of 18 mediated multiple regression analyses were conducted. Coded
vectors for social DSA-Count were sequentially coded in the same way as they were for
moderation analyses. DSA-Count was excluded from mediation models because
estimates of bootstrapped confidence intervals and relative indirect effects failed to
converge due to low variability in the few participants (n = 4) reporting four or more
disclosure targets. The results of these mediation models are considered tentative because
these post-hoc hypotheses were added after initial analyses were conducted.
Missing Data
Although fewer than 10% of all cases had any missing values, missing data were
imputed using means imputation in order to maximize the available data in the small
sample size. However, 2 cases that failed to provide DSA data were excluded from all
analyses (N = 97). An additional 2 cases that failed to provide any data about DSA
targets were excluded from analyses using social DSA, DSA-Count and social DSA-
Count (N = 95). These variables were not imputed due to their categorical nature.
Results
Descriptive Statistics and Sample Characteristics
The final sample of 97 undergraduate students with a history of suicide attempt
had a mean age of 20.35 (SD = 4.63), was 79.4% female, and identified as 72.2%
29
White/Caucasian, 12.4% Black/African American, 8.2% Hispanic/Latino(a), 3.1% Asian,
and 3.1% Multi-Ethnic (Table 1). DSA was reported by 71% of participants, and social-
DSA was reported by 64% because 7 participants disclosed only to a healthcare
professional. Chi-square tests of association and independent samples t-tests revealed that
no demographic variables were associated with DSA, social DSA, DSA-Count, or social
DSA-Count. Evaluation of the distribution of all variables of interest indicated that all
variables were acceptably normally distributed (skewness and kurtosis = ±1), with the
exception of Thwarted Belongingness and both count measures of DSA (Table 2).
However, upon visual inspection of the distribution, the slight platykurtotic nature of the
distribution of Thwarted Belongingness was considered non-problematic. Both count
measures of DSA were positively skewed, supporting the treatment of these variables as
ordinal measures of DSA as opposed to continuous measures. Zero-order correlations
indicated that all intervening and outcome variables were significantly correlated (Table
3).
30
Table 1
Demographics and Sample Characteristics by Disclosure Group
Total DSA
(N = 97)
Social DSA
(N = 95)
Measure
(N=97)
Yes
(n=69)
No
(n=28)
Yes
(n=58)
No
(n=37)
Age (M) 20.38 19.82 21.71 19.58 21.68
Sex (% female) 79.40 81.40 73.10 79.30 78.40
Ethnicity (%)
White/Caucasian 72.20 73.10 71.40 75.90 67.60
Black/African-American 12.40 11.50 12.90 12.10 13.50
Hispanic/Latino(a) 8.20 7.70 8.60 6.90 8.10
Asian 3.10 3.80 2.90 1.70 5.40
Native American 1.00 3.80 - - 2.70
Multi-Ethnic 3.10 - 4.30 3.40 2.70
Depression 32.50 32.53 32.43 30.94 34.27
PB (M) 18.03 17.89 19.85 16.64 19.24
TB (M) 35.60 35.00 37.08 34.09 37.41
Family Support (M) 28.58 29.17 27.13 30.19 26.61
Peer Support (M) 24.32 25.40 21.66 26.19 21.61
Time Since Suicide Attempt 2.69 2.61 2.89 2.60 2.78 Note: PB = Perceived Burdensomeness, TB = Thwarted Belongingness.
Table 2
Descriptive Statistics for Study Variables
Measure M (SD) Skewness Kurtosis
Depression 32.50 (12.01) -.23 -.73
PB 18.03 (10.43) .56 -.87
TB 35.60 (12.14) .07 -1.10
Family Support 28.58 (10.80) -.61 -.77
Peer Support 24.32 (8.77) -.47 -.74
Time Since Suicide Attempt 2.69 (.80) .62 -1.15
DSA-Count 1.14 (1.11) 1.12 .64
Social DSA-Count .90 (.92) .96 .29 Note: PB = Perceived Burdensomeness, TB = Thwarted Belongingness.
31
Table 3
Zero-Order Correlations
Measure 1. 2. 3. 4. 5. 6. 7.
1. Depression -
2. PB .55** -
3. TB .64** .67** -
4. Family Support -.39** -.55** -.54** -
5. Peer Support -.35** -.40** -.72** .40** -
6. Time Since Suicide
Attempt
.30** .44** .31** -.31** -.35** -
7. DSA-Count -.08 -.16 -.14 .14 .21* -.20* -
8. Social DSA-Count -.20* -.19 -.16 .20 .24* -.19 .91** Note: * p < .05, ** p <. 01. Correlation coefficients for all analyses with DSA-Count and Social DSA-
Count were calculated using Spearman’s Rank-order coefficient. PB = Perceived Burdensomeness, TB =
Thwarted Belongingness.
Results from Moderation Analyses
DSA. There were no significant main effects of DSA on depression, Perceived
Burdensomeness, or Thwarted Belongingness (Table 4). Additionally, neither family
support nor peer support was found to moderate the association between DSA and
depression, Perceived Burdensomeness, or Thwarted Belongingness.
Social DSA. There were no significant main effects of S-DSA on depression,
Perceived Burdensomeness, or Thwarted Belongingness (Table 5). Additionally, neither
family support nor peer support was found to moderate the association between social
DSA and depression, Perceived Burdensomeness, or Thwarted Belongingness.
DSA-Count. There were no significant main effects of DSA-Count on
depression, Perceived Burdensomeness, or Thwarted Belongingness (Table 6).
Additionally, neither family support nor peer support was found to moderate the
association between DSA-Count and depression, Perceived Burdensomeness, or
Thwarted Belongingness.
32
Social DSA-Count. There were no significant main effects of social DSA-Count
on depression, Perceived Burdensomeness, or Thwarted Belongingness (Table 7).
Additionally, neither family support nor peer support was found to moderate the
association between social DSA-Count and depression, Perceived Burdensomeness, or
Thwarted Belongingness.
Table 4
The Effects of DSA and Social Support on Measures of Proximal Suicide Risk
Outcome Moderator B SE(B) df ΔF R2 ΔR2
Depression Family Support
I. 3 7.29 .19
Time Since SA 3.05 1.50
DSA 1.72 2.50
Family Support -.37 .11
II. 1 .94 .20 .01
Time Since SA 2.95 1.50
Family Support -.22 .19
DSA 7.84 6.80
DSA X Family Support -.22 .23
Depression Peer Support
I. 3 6.16 .17
Time Since SA 3.14 1.53
DSA 2.51 2.56
Peer Support -.41 .14
II. 1 .45 .17 .00
Time Since SA 3.20 1.54
DSA 6.84 6.95
Peer Support -.28 .24
DSA X Peer Support -.19 .28
PB Family Support
I. 3 14.52 .31
Time Since SA 1.72 5.01
DSA -1.08 1.99
Family Support -.65 .15
II. 1 1.71 .33 .01
Time Since SA 1.83 1.19
DSA -7.65 5.39
Family Support -.65 .15
DSA X Family Support .24 .18
33
Outcome Moderator B SE(B) df ΔF R2 ΔR2
PB Peer Support
I. 3 7.06 .19
Time Since SA 2.33 1.32
DSA -.43 2.20
Peer Support -.39 .12
II. 1 .85 .19 .01
Time Since SA 2.26 1.32
DSA -5.53 5.95
Peer Support -.54 .20
DSA X Peer Support .22 .24
TB Family Support
I. 3 18.57 .37
Time Since SA 4.70 1.33
DSA .27 2.22
Family Support -.50 .10
II. 1 .84 .38 .01
Time Since SA 4.79 1.34
DSA -4.87 6.05
Family Support -.63 .17
DSA X Family Support .19 .20
TB Peer Support
I. 3 40.10 .56
Time Since SA 3.55 1.12
DSA 2.30 1.87
Peer Support -.90 .10
II. 1 .00 .56 .00
Time Since SA 3.54 1.13
DSA 2.10 5.10
Peer Support -.91 .17
DSA X Peer Support .01 .21 Note: * p < .05, ** p <. 01. PB = Perceived Burdensomeness, TB = Thwarted Belongingness, SA= Suicide
Attempt
34
Table 5
The Effects of Dichotomous Social DSA and Social Support on Measures of Proximal
Suicide Risk
Outcome Moderator B SE(B) df ΔF R2 ΔR2
Depression Family Support
I. 3 7.14 .19
Time Since SA 2.88 1.49
Social DSA -.75 2.36
Family Support 5.63 .17
II. 1 1.12 .20 .01
Time Since SA 2.65 1.50
S-DSA 5.62 6.46
Family Support -.23 .17
Social DSA X Family
Support -.23 .22
Depression Peer Support
I. 3 5.78 .16
Time Since SA 2.99 1.53
Social DSA -.17 2.46
Peer Support -.38 .14
II. 1 .09 .16 .00
Time Since SA 2.96 1.54
Social DSA -2.07 6.88
Peer Support -.43 .22
Social DSA X Peer Support .08 .28
PB Family Support
I. 3 14.50 .32
Time Since SA 1.78 1.18
Social DSA -.92 1.88
Family Support -.48 .09
II. 1 .95 .33 .01
Time Since SA 1.95 1.20
Social DSA -5.59 5.14
Family Support -.58 .13
Social DSA X Family
Support .17 .17
35
Outcome Moderator B SE(B) df ΔF R2 ΔR2
PB Peer Support
I. 3 7.08 .19
Time Since SA 2.35 1.31
Social DSA -.68 2.10
Peer Support -.39 .12
II. 1 .76 .19 .01
Time Since SA 2.29 1.31
Social DSA -5.42 5.84
Peer Support -.51 .18
Social DSA X Peer Support .20 .23
TB Family Support
I. 3 18.66 .38
Time Since SA 4.64 1.32
Social DSA -1.00 2.09
Family Support -.49 .10
II. 1 .51 .38 .00
Time Since SA 4.78 1.34
Social DSA -4.83 .15
Family Support -.57 .15
Social DSA X Family
Support .14 .19
TB Peer Support
I. 3 39.43 .56
Time Since SA 3.41 1.12
Social DSA 1.46 1.80
Peer Support -.91 .11
II. 1 .03 .56 .00
Time Since SA 3.40 1.13
Social DSA .72 5.03
Peer Support -.93 .16
Social DSA X Peer Support .03 .20 Note: * p < .05, ** p <. 01. PB = Perceived Burdensomeness, TB = Thwarted Belongingness
36
Table 6
The Effects of DSA-Count and Social Support on Measures of Proximal Suicide Risk
Outcome Moderator B SE(B) df F R2 ΔR2
Depression Family
Support
I. 6 3.26 .18
Time Since SA 2.82 1.57
D1 2.03 2.72
D2 -2.52 4.35
D3 1.94 5.46
D4 -2.16 6.28
Family Support -.36 .11
II. 4 .65 .21 .03
Time Since SA 2.60 1.59
D1 4.96 7.84
D2 3.86 11.00
D3 7.16 13.89
D4 -22.06 19.87
Family Support -.22 .20
D1 X Family Support -.11 .26
D2 X Family Support -.22 .34
D3 X Family Support -.19 .44
D4 X Family Support .66 .60
Depression Peer
Support
I. 6 2.77 .16
Time Since SA 2.77 1.62
D1 2.52 2.78
D2 -.21 4.47
D3 -.78 5.65
D4 -1.01 6.43
Peer Support -.42 .15
II. 4 .20 .17 .01
Time Since SA 2.77 1.66
D1 8.62 7.93
D2 -3.99 31.79
D3 -3.30 32.81
D4 -.47 33.31
Peer Support -.30 .24
D1 X Peer Support -.26 .32
D2 X Peer Support .15 1.02
D3 X Peer Support .11 1.07
D4 X Peer Support -.04 1.15
37
Outcome Moderator B SE(B) df ΔF R2 ΔR2
PB Family
Support
I. 6 6.54 .31
Time Since SA 1.36 1.23
D1 -1.14 2.13
D2 -.63 3.40
D3 -1.14 4.27
D4 -.08 4.91
Family Support -.47 .09
II. 4 1.31 .35 .04
Time Since SA 1.31 1.23
D1 -11.19 6.04
D2 8.48 8.47
D3 -2.48 10.69
D4 -18.55 15.30
Family Support -.66 .15
D1 X Family Support .36 .20
D2 X Family Support -.31 .26
D3 X Family Support .04 .34
D4 X Family Support .58 .46
PB Peer
Support
I. 6 3.37 .19
Time Since SA 1.74 1.35
D1 -.78 2.32
D2 -.78 3.74
D3 1.75 4.72
D4 -3.77 5.37
Peer Support -.42 .13
II. 4 .42 .20 .02
Time Since SA 1.69 1.38
D1 -7.62 6.60
D2 -2.34 26.43
D3 8.10 27.28
D4 -10.37 27.70
Peer Support -.56 .20
D1 X Peer Support .29 .27
D2 X Peer Support .10 .85
D3 X Peer Support -.43 .89
D4 X Peer Support .41 .95
38
Outcome Moderator B SE(B) df ΔF R2 ΔR2
TB Family
Support
I. 6 9.16 .38
Time Since SA 4.59 1.38
D1 1.07 2.40
D2 -4.55 3.82
D3 4.37 4.80
D4 -4.25 5.52
Family Support -.49 .10
II. 4 .34 .39 .01
Time Since SA 4.65 1.41
D1 -2.94 6.95
D2 -6.16 9.74
D3 .47 12.30
D4 -4.76 17.60
Family Support -.63 .18
D1 X Family Support .15 .23
D2 X Family Support .05 .30
D3 X Family Support .14 .39
D4 X Family Support -.01 .53
TB Peer
Support
I. 6 19.07 .57
Time Since SA 3.21 1.18
D1 2.53 2.03
D2 .43 3.26
D3 -2.02 4.11
D4 -.23 4.68
Peer Support -.94 .11
II. 4 .55 .58 .01
Time Since SA 3.26 1.20
D1 1.18 5.73
D2 3.36 22.98
D3 4.88 23.71
D4 -25.27 24.07
Peer Support -.92 .18
D1 X Peer Support .05 .23
D2 X Peer Support -.11 .74
D3 X Peer Support -.31 .78
D4 X Peer Support .93 .83 Note: * p < .05, ** p <. 01. PB = Perceived Burdensomeness, TB = Thwarted Belongingness, SA= Suicide
Attempt
39
Table 7
The Effects of S-DSA-N and Social Support on Measures of Proximal Suicide Risk
Outcome Moderator B SE(B) df F R2 ΔR2
Depression Family
Support
I. 5 3.82 .18
Time Since SA 2.45 1.59
D1 -.55 2.60
D2 -2.14 4.37
D3 -.08 5.48
Family Support -.35 .11
II. 3 .58 .20 .02
Time Since SA 2.24 1.64
D1 2.82 7.37
D2 10.31 13.98
D3 -8.17 17.46
Family Support -.23 .17
D1 X Family Support -.13 .25
D2 X Family Support -.37 .40
D3 X Family Support .22 .52
Depression PAS
I. 5 3.25 .16
Time Since SA 2.21 1.67
D1 .21 2.70
D2 -1.67 4.45
D3 -1.83 5.66
Peer Support -.41 .16
II. 3 .15 .16 .00
Time Since SA 2.12 1.73
D1 -3.86 8.23
D2 10.29 25.72
D3 -9.17 27.25
Peer Support -.46 .22
D1 X Peer Support .17 .33
D2 X Peer Support -.41 .83
D3 X Peer Support .22 .90
40
Outcome Moderator B SE(B) df ΔF R2 ΔR2
PB Family
Support
I. 5 8.46 .33
Time Since SA .94 1.22
D1 -1.08 1.99
D2 .60 3.35
D3 -5.25 4.20
Family Support -.47 .09
II. 3 .62 .34 .01
Time Since SA 1.06 1.25
D1 -7.57 5.65
D2 7.67 10.71
D3 -12.36 13.38
Family Support -.59 .13
D1 X Family Support .23 .19
D2 X Family Support -.22 .31
D3 X Family Support .22 .40
PB PAS
I. 5 4.65 .21
Time Since SA 1.04 1.36
D1 -.44 2.21
D2 -5.40 3.64
D3 .85 4.64
Peer Support -6.76 .13
II. 3 1.30 .24 .04
Time Since SA .95 1.39
D1 -10.33 6.61
D2 24.03 20.65
D3 -16.22 21.87
Peer Support -.56 .18
D1 X Peer Support .40 .26
D2 X Peer Support -.80 .67
D3 X Peer Support .24 .72
41
Outcome Moderator B SE(B) df ΔF R2 ΔR2
TB Family
Support
I. 5 11.78 .40
Time Since SA 4.94 1.38
D1 -.49 2.25
D2 -6.32 3.79
D3 8.73 4.75
Family Support -.47 .10
II. 3 .56 .41 .01
Time Since SA 5.28 1.42
D1 -5.27 6.39
D2 -14.51 12.12
D3 21.95 15.14
Family Support -.57 .15
D1 X Family Support .17 .21
D2 X Family Support .24 .35
D3 X Family Support -.40 .45
TB Peer
Support
I. 5 23.38 .57
Time Since SA 3.16 1.21
D1 2.14 1.95
D2 -4.34 3.22
D3 3.52 4.10
Peer Support -.91 .11
II. 3 .57 .58 .01
Time Since SA 3.30 1.24
D1 -1.87 5.92
D2 -1.99 18.50
D3 11.92 19.60
Peer Support -.93 .16
D1 X Peer Support .16 .23
D2 X Peer Support -.10 .60
D3 X Peer Support -.34 .65 Note: * p < .05, ** p <. 01. PB = Perceived Burdensomeness, TB = Thwarted Belongingness
Results from Mediation Analyses
DSA. There were no significant direct effects of DSA on depression, Perceived
Burdensomeness, or Thwarted Belongingness. Additionally, there were no indirect
42
effects of DSA on depression, Perceived Burdensomeness, or Thwarted Belongingness
through the pathways of family support or peer support.
Social DSA. There were no significant direct effects of social DSA on depression,
Perceived Burdensomeness, or Thwarted Belongingness. There were significant indirect
effects of social DSA on depression, Perceived Burdensomeness, and Thwarted
Belongingness through the pathway of peer support, but there were no significant indirect
effects of social DSA on depression, Perceived Burdensomeness, or Thwarted
Belongingness through the pathway of family support. Results indicated that participants
who disclosed their suicide attempt history to at least one individual had higher scores on
peer support, which in turn was associated with decreased scores on depression,
Perceived Burdensomeness, and Thwarted Belongingness. While controlling for time
since suicide attempt, social DSA had a significant indirect effect on depression through
the pathway of peer support (B = -1.50, SE = 1.00, 95% BootCI = -4.21, -.13; Figure 1).
While controlling for time since suicide attempt, social DSA had a significant indirect
effect on Perceived Burdensomeness through the pathway of Peer Support (B = -1.58, SE
= .88, 95% BootCI = -3.87, -.28; Figure 2). While controlling for time since suicide
attempt, social DSA had a significant indirect effect on Thwarted Belongingness through
the pathway of peer support (B = -3.63, SE = 1.61, 95% CI = -7.10, -.75; Figure 3).
43
Dichotomous
Social DSA (excluding healthcare
professionals)
Depression
B = -2.60
Dichotomous
Social DSA (excluding healthcare
professionals)
Depression
Peer Support
B = 3.89*
Indirect Effects: B = -1.50;
95% BootCI = -4.21, -.13
B = -.38**
B = -1.10
Figure 1. Indirect effects of dichotomous social DSA on depression; *p < .05
**p < .01
44
Dichotomous
Social DSA (excluding healthcare
professionals)
Perceived
Burdensome-
ness
B = -2.00
Dichotomous
Social DSA (excluding healthcare
professionals)
Perceived
Burdensome-
ness
Peer Support
B = 3.89*
Indirect Effects: B = -1.58;
95% BootCI = -3.87, -.28
B = -.41**
B = -.42
Figure 2. Indirect effects of dichotomous social DSA on Perceived
Burdensomeness; *p < .05 **p < .01
Dichotomous
Social DSA (excluding healthcare
professionals)
Thwarted
Belongingness B = -2.14
Dichotomous
Social DSA (excluding healthcare
professionals)
Thwarted
Belongingness
Peer Support
B = 3.89*
Indirect Effects: B = -3.63;
95% BootCI = -7.10, -.75
B = -.93**
B = 1.50
Figure 3. Indirect effects of dichotomous social DSA on Thwarted Belongingness;
*p < .05 **p < .01
45
Social DSA-Count. There were no significant direct effects of social DSA-Count
on depression, Perceived Burdensomeness, or Thwarted Belongingness. There were
significant indirect effects of social DSA-Count on depression, Perceived
Burdensomeness, and Thwarted Belongingness through the pathway of peer support, but
there were no significant indirect effects of social DSA-Count on depression, Perceived
Burdensomeness, or Thwarted Belongingness through the pathway of family support.
Results indicated an additive relationship whereby individuals who disclosed to one or
two social network contacts had incrementally higher scores on peer support, which in
turn was associated with decreased scores on depression, Perceived Burdensomeness, and
Thwarted Belongingness. However, individuals who disclosed to 3 social network
contacts had significantly lower scores on peer support, which in turn was associated with
increased scores on depression, Perceived Burdensomeness, and Thwarted
Belongingness.
While controlling for time since suicide attempt and relative to the preceding
group, the indirect effects of a one-unit increase in social DSA-Count on depression
through the pathway of peer support were such that an increase from 0 to 1 was
associated with a decrease in depression of 1.55 (SE = 1.05, 95% BootCI = -4.44, -.13),
an increase from 1 to 2 was associated with an decrease in depression of 1.50 (SE = .93,
95% BootCI = -4.07, -.18), and an increase from 2 to 3 was associated with an increase in
depression of 3.13 (SE = 2.01, 95% BootCI = .18, 8.42; Figure 4).
While controlling for time since suicide attempt and relative to the preceding
group, the indirect effects of a one-unit increase in social DSA-Count on Perceived
Burdensomeness through the pathway of PAS were such that an increase from 0 to 1 was
46
associated with a decrease in Perceived Burdensomeness of 1.77 (SE = 1.02, 95% BootCI
= -4.35, -.25), an increase from 1 to 2 was associated with an decrease in Perceived
Burdensomeness of 1.71 (SE = .91, 95% BootCI = -3.95, -.31), and an increase from 2 to
3 was associated with an increase in Perceived Burdensomeness of 3.57 (SE = .49, 95%
BootCI = .43, 8.62; Figure 5).
While controlling for time since suicide attempt and relative to the preceding
group, the indirect effects of a one-unit increase in social DSA-Count on Thwarted
Belongingness through the pathway of peer support were such that an increase from 0 to
1 was associated with a decrease in Thwarted Belongingness of 3.52 (SE = 1.73, 95%
BootCI = -7.21, -.33) an increase from 1 to 2 was associated with an decrease in
Thwarted Belongingness of 3.41 (SE = 1.61, 95% BootCI = -6.87, -.44), and an increase
from 2 to 3 was associated with an increase in Thwarted Belongingness of 7.12 (SE =
3.33, 95% CI = .76, 13.90; Figure 6).
47
D1
(1 DSA target, excluding
healthcare
professionals)
Depression
B = -1.60
D2
(2 DSA targets, excluding
healthcare
professionals)
D3
(3 DSA targets, excluding
healthcare
professionals)
Social
DSA-Count
(excluding
healthcare
professionals)
B = -3.15
B = -1.38
D1
(1 DSA target,
excluding
healthcare
professionals)
Depression
B = 3.75
D2
(2 DSA targets, excluding
healthcare
professionals)
D3
(3 DSA targets, excluding
healthcare
professionals)
Social
DSA-Count
(excluding
healthcare
professionals)
Peer Support
B = -7.82*
B = 3.87*
B = -.49
B = -.40**
B = -1.40
B = -1.76
Indirect Effects
D1: B = -1.55, 95% Boot CI
= -4.44, -.13
D2: B = -1.50, 95% Boot CI
= -4.07, -.18
D3: B = 3.13, 95% Boot CI
= .19, 8.42
Figure 4. Indirect Effects of Social DSA-Count on Depression; *p < .05 **p < .01
48
D1
(1 DSA target, excluding
healthcare
professionals)
Perceived
Burdensome-
ness
B = -2.49
D2
(2 DSA targets, excluding
healthcare
professionals)
D3
(3 DSA targets, excluding
healthcare
professionals)
Social
DSA-Count
(excluding
healthcare
professionals)
B = -.76
B = -3.30
D1
(1 DSA target,
excluding
healthcare
professionals)
Perceived
Burdensome-
ness
B = 3.75
D2
(2 DSA targets, excluding
healthcare
professionals)
D3
(3 DSA targets, excluding
healthcare
professionals)
Social
DSA-Count
(excluding
healthcare
professionals)
Peer Support
B = -7.82*
B = 3.87*
B = .41
B = -.46**
B = .49
B = -6.86
Indirect Effects
D1: B = -1.77, 95% Boot CI
= -4.34, -.25
D2: B = -1.71, 95% Boot CI
= -3.95, -.31
D3: B = 3.57, 95% Boot CI
= .49, 8.62
Figure 4. Indirect Effects of Social DSA-Count on Perceived Burdensomeness; *p < .05
**p < .01
49
D1
(1 DSA target, excluding
healthcare
professionals)
Thwarted
Belonging-
ness
B = -1.87
D2
(2 DSA targets, excluding
healthcare
professionals)
D3
(3 DSA targets, excluding
healthcare
professionals)
Social
DSA-Count
(excluding
healthcare
professionals)
B = -7.65
B = 10.65
D1
(1 DSA target,
excluding
healthcare
professionals)
Thwarted
Belonging-
ness
B = 3.75
D2
(2 DSA targets, excluding
healthcare
professionals)
D3
(3 DSA targets, excluding
healthcare
professionals)
Social
DSA-Count
(excluding
healthcare
professionals)
Peer Support
B = -7.82*
B = 3.87*
B = 2.28
B = -.91**
B = -3.41
B = -4.48
Indirect Effects
D1: B = -3.52, 95% Boot CI
= -7.21, -.33
D2: B = -3.41, 95% Boot CI
= -6.87, -.44
D3: B = 7.12, 95% Boot CI
= .76, 13.90
Figure 4. Indirect Effects of Social DSA-Count on Thwarted Belongingness; *p < .05 **p < .01
50
Discussion
The present study sought to evaluate the impact of disclosing one’s prior suicide
attempt to others on suicide risk, as measured by depression, Perceived Burdensomeness,
and Thwarted Belongingness. It was hypothesized that any instance of disclosure and
more instances of disclosure would be associated with lower suicide risk. Additionally,
this study sought to evaluate the mediating and moderating effects of social support on
these associations; it was expected that higher levels of social support would increase the
association between DSA and suicide risk. Results indicated DSA had no direct effects
on suicide risk, and social support did not moderate this association. However, DSA was
indirectly associated with suicide risk through the pathway of social support.
DSA Prevalence
This is the first study to evaluate the prevalence of DSA among undergraduate
college students and assess the number of DSA targets to whom a survivor of a suicide
attempt has disclosed. The rates of DSA in the present sample (71%) were lower than
previous estimates (89%; Frey et al., 2016b), and they were even lower when healthcare
professionals were not counted as DSA targets (61%). Excluding healthcare professionals
is a more analogous comparison to prior research, which has only assessed DSA to social
contacts (Frey et al., 2016b). The lower rates in the present sample may be due to their
younger age. Although results indicated that the age of those who had disclosed their
suicide attempt were lower on average, the difference in prevalence rates in this study
may be due to undergraduate college students having had less life experience during
which to disclose their suicide attempt. Alternatively, it may be that the recruitment
techniques employed by prior research (surveying suicide prevention outreach websites)
51
biased the samples to have higher rates of disclosure (Frey et al., 2016b). Future research
will need to confirm these prevalence rates and evaluate differences in a variety of
samples.
Consistent with prior research assessing suicidal ideation disclosure, a majority of
participants in the present study (90%) disclosed their suicide attempt to two or fewer
DSA targets (Encrenaz et al., 2012). Regardless of the inclusion of healthcare
professionals, bivariate analyses indicated that number of DSA targets was correlated
with peer support (DSA-Count: r = .22; Social DSA-Count: r = .24). These results were
expected, and they support similar findings of a positive association between lifetime
suicidal ideation disclosure and number of trusted confidants/social connectedness
(Husky et al., 2016). Increases in DSA may lead to increases in peer support, but this
positive association may also be indicative of strong preexisting relationships with peers.
It is worth noting that regardless of the inclusion of healthcare professionals as DSA
targets, the correlation between number of DSA targets and family support was non-
significant. This difference may also be due to the characteristics of the present sample of
undergraduate students, who are likely to have stronger relationships with peers than
family. It may be that students are more likely to engage in DSA with peers than family,
explaining the difference in results.
Moderation Analyses
Neither peer support nor family support were significant moderators of the
association between DSA and suicide risk. Results were non-significant regardless of
dichotomous or count measurement and inclusion or exclusion of healthcare
professionals as DSA targets. These non-significant results are likely due to the moderate
52
to strong negative correlations between family support and measures of suicide risk (r = -
.39 to -.54) as well as the moderate to strong negative correlations between peer support
and suicide risk (r = -.35 to -.72). Prior to the introduction of the interaction term into
moderation models, the significant predictors, time since suicide attempt and family or
peer support, accounted for 18% to 58% of the total variance in the models. Although
bivariate analyses indicated a significant correlation between number of DSA targets and
depression when healthcare professionals were excluded as DSA targets, this main effect
was not significant when time since suicide attempt and social support measures were
included in the models.
Prior research has found non-significant results when testing the moderating
effects of similar variables; Frey et al. (2016b) found that family reaction to DSA did not
moderate the non-significant association between amount of disclosure and depression
scores. Despite this, moderation analyses were proposed because family support and peer
support are not completely analogous to family reaction to DSA, and they are likely to be
higher-order constructs that influence the variable. Considering the high rates of
perceived stigma reported by survivors of suicide attempts and the exacerbating effects of
self-stigma on suicidal ideation (Frey et al., 2016a; Oexle et al., 2016), it was expected
that some DSA would result in negative outcomes. It was expected that these negative
experiences following DSA would be assessed via measures of social support and
contribute to the moderating effect. Contrary to hypotheses, it appears that survivors of
suicide attempts are very selective about their DSA targets, as evidenced by the median
of two DSA targets and the correlation between number of DSA targets and family/peer
support, when excluding healthcare DSA targets. These results may not generalize to
53
survivors of very serious suicide attempts, who would have less choice about DSA
targets. Survivors whose injuries were severe enough to warrant the use of an emergency
contact by medical staff may have more negative experiences with DSA because of
unsolicited family attention and emergency room stigmatization (Frey et al., 2016a).
Future research needs to evaluate the impact of medical severity on results.
Mediation Analyses
Mediation analyses indicated significant indirect effects of both social DSA and
social DSA-Count on depression, Perceived Burdensomeness and Thwarted
belongingness, through the pathway of peer support. However, these indirect effects were
non-significant when healthcare professionals were included as DSA targets. Healthcare
professionals were only included as DSA targets for analyses conducted using the
dichotomous measure of DSA because bootstrap models failed to converge when
healthcare professionals were included in DSA targets for the count measure of DSA
(DSA-Count). Additionally, no significant indirect effects of any measure of DSA were
found via the pathway of family support.
Dichotomous Social DSA. Results showed that social DSA was significantly
associated with increases in peer support, which was, in turn, negatively associated with
depression, Perceived Burdensomeness and Thwarted Belongingness. These results
confirm and expand previous findings of a negative indirect effect of the amount of DSA
on depression via the pathway of family reaction to DSA (Frey et al., 2016b). Even while
controlling for the positive association between time since suicide attempt and peer
support, results indicated a positive association between DSA and peer support (the a
pathway). These effects are not surprising because similar positive associations have been
54
found when evaluating the impact of sexual identity disclosure, mental illness disclosure,
and suicidal ideation disclosure on social support (Corrigan et al., 2010; Husky et al.,
2016; Talley & Bettencourt, 2011). Although the reaction individuals received to their
DSA was not assessed by the current study, the significant effects of the a pathway in
these models is likely due to a positive reaction from the DSA target. The significant
effects of the b pathways (associations between peer support and suicide risk) in all
mediation models analyzing the effects of social DSA were also expected. Joiner’s
(2005) IPTS asserts that social disconnectedness is the primary cause of suicidal ideation,
so these findings support the underlying mechanism of the model.
The significant indirect effects of dichotomous social DSA on suicide risk suggest
that DSA may be an effective component of suicide-focused therapy. Suicide attempt
survivors have demonstrated increased rates of Thwarted Belongingness and Perceived
Burdensomeness (Van Orden et al., 2008), so therapeutic interventions that result in
reductions of these perceptions are likely to result in lower suicidal desire. The present
study supports the use of interventions that employ the use of safety plans, which often
involve identifying social contacts to intervene during suicidal crises (Jobes, 2016;
Stanley & Brown, 2012). Social DSA may occur during the use of a crisis contact or
creation of a safety plan in preparation for a crisis. Given the results of the present study,
social DSA may be partially responsible for the effectiveness of these empirically backed
interventions. Social DSA may facilitate means restriction by social network members,
an effective way to decrease suicide attempts (Mann et al., 2005), so future research
should evaluate the mitigating effect of social DSA on future suicide attempts.
55
Although the proposed model of this study argues that social DSA leads to
increased peer social support and subsequently decreased suicide risk, it may be that
individuals who have a stronger social support system in place are more likely to disclose
their suicide attempt. However, this is unlikely when considering the results of Eskin
(2003), which indicated lower current suicidal ideation in adolescents who had disclosed
their past suicidal ideation to peers. Future research evaluating the longitudinal effects of
social DSA on measures of social support and suicide risk may be able to add weight to
the proposed model.
The non-significant indirect effects found when family support was used as a
mediator may be indicative of the importance of peer support as protective factor against
suicide in undergraduate survivors of suicide attempts. This may be because social DSA
is more likely to occur with peers than family. Results may also be representative of
negative family reactions to social DSA in this sample, thereby resulting in minimal
increases in social support to facilitate decreased suicide risk. Future research should
evaluate these associations in different samples, and use existing measures that assess the
reactions of individuals to DSA (Frey et al., 2016b).
Additional non-significant indirect effects were found when analyzing the effects
of dichotomous DSA when including healthcare professionals. These null results support
the mediation model proposed by Frey et al. (2016) because DSA to healthcare
professionals was not included in their study. These non-significant findings highlight the
importance of the impact of social DSA on social support and the importance of
improving social support in survivors of suicide attempts. Social DSA may be a single-
dose concrete action that has a positive impact on social support. Additionally, DSA to
56
healthcare professionals other than mental health professionals is likely to result in
stigmatizing reactions (Frey et al., 2016a), which may be responsible for the non-
significant indirect effects when these DSA targets are included in analyses.
The non-significant direct effects of DSA and social DSA on suicide risk may be
indicative of the previously established importance of reaction to DSA from the DSA
target (Frey et al., 2016b). These results suggest that DSA itself is not sufficient for
decreasing suicide risk. A positive outcome following DSA may be contingent upon the
discloser’s ability to select a DSA target who will react well to the information presented
to them. In order to understand what drives these associations, future research must
assess an individual’s motivation to select a DSA target.
Social DSA Count. Results indicated that increases in number of social DSA
targets from zero to two were associated with increased peer support, which were
subsequently associated with decreased depression, Perceived Burdensomeness, and
Thwarted Belongingness. However, an increase of two to three social DSA targets was
significantly negatively associated with peer support, which was subsequently positively
associated with depression, Perceived Burdensomeness and Thwarted Belongingness. In
fact, an increase from two to three social DSA targets had indirect effects on measures of
suicide risk that were strong enough to completely cancel out the effects of increases
from zero to two social DSA targets. An estimate of the net change from zero to 3 social
DSA targets, was approximately zero. Results were similar to dichotomous social DSA
results in that the indirect effects on Thwarted Belongingness were stronger than that of
depression and Perceived Burdensomeness.
57
The indirect effects of number of social DSA targets on suicide risk via the
pathway of peer support suggest that social DSA to a third target individual attenuates the
positive effects of social DSA to prior targets. Stated differently, individuals who disclose
their suicide attempt to 3 social DSA targets and zero DSA targets are likely to have
similar scores on measures of depression, Perceived Burdensomeness, and Thwarted
Belongingness. These results are surprising, but they may explain the lack of significant
bivariate correlations between number of DSA targets and suicide risk.
There are a number of ways to interpret these results. It may be that individuals
who disclose to three social DSA targets have received negative reactions to their DSA
from their prior disclosures and are continuing to seek social support from their peers or
family. This interpretation challenges the theory proposed by Frey et al. (2016b) positing
a feedback loop wherein positive reactions to DSA beget increased future DSA.
Alternatively, increasing numbers of social DSA targets inevitably increases the odds of
social DSA to an individual who responds negatively, which may result in stigmatization
and increased suicide risk. It may also be that individuals who disclose to three social
DSA targets experience increased distress, which motivates their continued social DSA to
additional targets.
Regardless of the interpretation of these results, it is clear that social DSA is a
behavior that should be guided by clinicians. Positive results were found in a recent RCT
testing group therapy that employed non-directive discussions of the benefits and
detriments of potentially disclosing diagnoses of serious mental illness to social contacts
(Rusch et al., 2014). A similarly non-directive approach may be appropriate for clients
experiencing depression, Perceived Burdensomeness, and Thwarted Belongingness. For
58
clients who are motivated by a desire to increase social support and decrease self-stigma
during treatment for suicidal ideation, social DSA to a carefully selected social contact or
two may be encouraged as a means of safety planning and social support building.
Limitations
There are a number of limitations to the present study. Most notably, this study
was limited by its cross-sectional design. Although any DSA that participants engaged in
must have happened prior to assessment, conclusions about the impact of DSA on social
support and suicide risk must be considered tentative. DSA research will benefit from
longitudinal and/or experimental designs because improvements following DSA can be
assessed. Low variability in the number of DSA targets reported by each participant may
have biased results by introducing random error to the DSA-Count results and not
accurately representing the effects of disclosing to two and three DSA targets in the
dichotomous DSA results. Although there were enough participants who disclosed to two
and three DSA targets to allow bootstrapping (Fisher & Hall, 1991), these results should
be considered extremely tentative. If these participants are not representative of the
general population, then results are not valid.
Several proxy variables were used in the present study because a large portion of
the data was collected for a previous study. The use of a dichotomous measure of DSA
decreased power, but the significant results add weight to the findings of Frey et al.,
(2016b). Using a participant’s number of DSA targets as a metric for the amount of DSA
they engage in is a novel concept that needs replication. Future research should measure
the amount of information disclosed to each DSA target to see which of these has a
stronger positive impact on social support and, subsequently, suicide risk. Additionally,
59
the SHBQ contains vague wording that may not accurately assess the number of DSA
targets. Using the RFL-A as a measure of social support was unique to this study; future
work should measure social support using validated measures of peer and family social
support. It may also be relevant to assess the effects of DSA on participants’ relationships
with their DSA target following DSA because this is likely to affect outcomes.
Depression, Perceived Burdensomeness, and Thwarted Belongingness are not proxy
measures, but this study still lacks a measure of current suicidal ideation. Future research
needs to assess this outcome in order to more directly assess suicide risk.
Sample characteristics limit the generalizability of the present study. There is a
potential for type II error because a sample of 97 does not provide sufficient power to
detect small effects in moderation analyses. Although demographic characteristics did not
appear to affect results, the sample was primarily White/Caucasian women who were
taking undergraduate courses at the time of the study. Future research should collect data
from larger, more diverse samples in order to validate these results.
Conclusion
The disclosure of prior suicidal behavior to a trusted confidant, or social DSA is a
concrete action that can improve social connectedness with peers, thus facilitating a
decrease in suicide risk. However, social DSA to more than two social network members
may attenuate the positive impact of social DSA. Results support the use of safety
planning techniques that often incorporate social DSA. However, clinicians working with
clients who have survived a suicide attempt should approach social DSA with caution in
order to prevent stigmatization from poor social DSA choices.
60
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Appendix A
Self-Harm Behavior Questionnaire (Gutierrez et al., 2001)
A lot of people do things which are dangerous and might get them hurt. There are many
reasons why people take these risks. Often people take risks without thinking about the
fact that they might get hurt. Sometimes, however, people hurt themselves on purpose.
We are interested in learning more about the ways in which you may have intentionally
or unintentionally hurt yourself. We are also interested in trying to understand why
people your age may do some of these dangerous things. It is important for you to
understand that if you tell us about things you’ve done which may have been unsafe or
make it possible that you may not be able to keep yourself safe, we will encourage you to
discuss this with a counselor or other confidant in order to keep you safe in the future.
Please circle YES or NO in response to each question and answer the follow-up
questions. For questions where you are asked who you told something to do not give
specific names. We only want to know if it was someone like a parent, teacher, doctor,
etc.
Things you may have actually done to yourself on purpose.
1. Have you ever hurt yourself on purpose? (e.g., scratched yourself with finger nails or
sharp object)
Times you hurt yourself badly on purpose or tried to kill yourself.
2. Have you ever attempted suicide? YES NO
If no, go on to question #4.
If yes, how?
____________________________________________________________________
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________________________________________________________________________
(Note: If you took pills, what kind? __________________ how many? ______________
over how long a period of time did you take them? ______________________________)
a. How many times have you attempted suicide? ______________________
b. When was the most recent attempt? (write your age) ___
c. Did you tell anyone about the attempt? YES NO
Who? __________________________
d. Did you require medical attention after the attempt? YES NO
If yes, were you hospitalized over night or longer? YES NO
How long were you hospitalized? ______________________________
e. Did you talk to a counselor or some other person like that after your attempt?
YES NO Who? __________________________
3. If you attempted suicide, please answer the following:
a. What other things were going on in your life around the time that you tried to kill
yourself?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
b. Did you actually want to die? YES NO
c. Were you hoping for a specific reaction to your attempt? YES NO
If yes, what was the reaction you were looking for? ______________________________
________________________________________________________________________
________________________________________________________________________
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d. Did you get the reaction you wanted? YES NO
e. Who knew about your attempt? ________________________
78
Appendix B
Center For Epidemiologic Studies—Depression Scale (Radloff 1977)
Circle the number of each statement which best describes how often you felt or behaved
this way – DURING THE PAST WEEK.
1. I was bothered by things that usually don’t bother me
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
2. I did not feel like eating; my appetite was poor
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
3. I felt that I could not shake off the blues even with help from my family and friends
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
4. I felt that I was just as good as other people
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
5. I had trouble keeping my mind on what I was doing
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
6. I felt depressed
79
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
7. I felt that everything I did was an effort
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
8. I felt hopeful about the future
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
9. I thought my life had been a failure
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
10. I felt fearful
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
11. My sleep was restless
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
12. I was happy
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
80
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
13. I talked less than usual
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
14. I felt lonely
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
15. People were unfriendly
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
16. I enjoyed life
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
17. I had crying spells
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
18. I felt sad
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
81
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7) days
19. I felt that people disliked me
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
20. I could not get “going”
0) Rarely or none of the time (less than 1 day)
1) Some or a little of the time (1-2 days)
2) Occasionally or a moderate amount of the time (3-4 days)
3) Most or all of the time (5-7 days)
82
Appendix C
Interpersonal Needs Questionnaire (Van Orden et al., 2012)
The following questions ask you to think about yourself and other people. Please respond
to each question by using your own current beliefs and experiences, NOT what you think
is true in general, or what might be true for other people. Please base your responses on
how you’ve been feeling recently. Use the rating scale to find the number that best
matches how you feel and circle that number. There are no right or wrong answers: we
are interested in what you think and feel.
1. These days the people in my life would be better off if I were gone
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
2. These days, people in my life would be happier without me
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
3. These days, I think I am a burden on society
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
4. These days, I think my death would be a relief to the people in my life
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
5. These days, the people in my life wish they could be rid of me
84
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
6. These days, I think I make things worse for the people in my life
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
7. These days, other people care about me
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
8. These days, I feel like I belong
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
9. These days, I rarely interact with people I care about
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
10. These days, I have many caring and supportive friends
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
11. These days, I feel disconnected from other people
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
12. These days, I often feel like an outside in social gatherings
85
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
13. These days, there are people I can turn to in times of need
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
14. These days, I am close to other people
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
15. These days, I have at least one satisfying interaction everyday
1 2 3 4 5 6 7
Not at all true for me Somewhat true for me Very true for me
*Note: Items 7, 8, 10, 13, 14, and 15 are reverse coded.
Perceived Burdensomeness: 1-6
Thwarted Belongingness: 7-15
86
Appendix D
Reasons for Living Inventory-Adolescent (Osman et al., 1998)
This questionnaire lists specific reasons that people sometimes give for not
making a suicide attempt, if the thought were to occur to them or if someone were to
suggest it to them. Please read each statement carefully, and then choose a number that
best describes how important each reason is to you for not making a suicide attempt.
Use the scale below and circle the appropriate number in the space to the right of
each statement. Please use the whole range of choices so as to not rate only at the middle
(2, 3, 4, 5), or only at the extremes (1, 6)
How important to you is this reason for not making a suicide attempt?
Not
at a
ll i
mport
ant
Quit
e unim
port
ant
Som
ewhat
unim
port
ant
Som
ewhat
im
port
ant
Quit
e Im
port
ant
Extr
emel
y I
mport
ant
1) Whenever I have a problem, I can
turn to my family for support or
advice
1 2 3 4 5 6
2) It would be painful and frightening to
take my own life
1 2 3 4 5 6
3) I accept myself for what I am 1 2 3 4 5 6
4) I have a lot to look forward to 1 2 3 4 5 6
5) My friends stand by me whenever I
have a problem
1 2 3 4 5 6
87
6) I feel loved and accepted by my
close friends
1 2 3 4 5 6
7) I feel emotionally close to my family 1 2 3 4 5 6
8) I am afraid to die, so I would not
consider killing myself
1 2 3 4 5 6
9) I like myself just the way I am 1 2 3 4 5 6
10) My friends care a lot about me 1 2 3 4 5 6
11) I would like to accomplish my plans
or goals in the future
1 2 3 4 5 6
12) My family takes the time to listen
to my experiences at school, work, or
home
1 2 3 4 5 6
13) I expect many good things to happen
to me in the future
1 2 3 4 5 6
14) I am satisfied with myself 1 2 3 4 5 6
15) I am hopeful about my 1 2 3 4 5 6
16) I believe my friends appreciate me
when I am with them.
1 2 3 4 5 6
17) I enjoy being with my family. 1 2 3 4 5 6
18) I feel that I am an okay person. 1 2 3 4 5 6
19) I expect to be successful in the
future.
1 2 3 4 5 6
20) The thought of killing myself scares
me.
1 2 3 4 5 6
21) I am afraid of using any method to
kill myself.
1 2 3 4 5 6
22) I can count on my friends to help if
I have a problem.
1 2 3 4 5 6
88
23) Most of the time, my family
encourages and supports my plans or
goals.
1 2 3 4 5 6
24) My family cares about the way I
feel.
1 2 3 4 5 6
25) My future looks quite hopeful and
promising.
1 2 3 4 5 6
26) I am afraid of killing myself. 1 2 3 4 5 6
27) My friends accept me for what I
really am.
1 2 3 4 5 6
28) I have many plans I am looking
forward to carrying out in the future.
1 2 3 4 5 6
29) I feel good about myself. 1 2 3 4 5 6
30) My family cares a lot about what
happens to me.
1 2 3 4 5 6
31) I am happy with myself. 1 2 3 4 5 6
32) I would be frightened or afraid to
make plans for killing myself.
1 2 3 4 5 6
Family Alliance: 1, 7, 12, 17, 23, 24, 30
Peer Acceptance Scale: 5, 6, 10, 16, 22, 27
Future Optimism Scale: 13, 19, 15, 28, 25, 11, 4
Suicide-Related Concerns: 20, 26, 28, 21, 8, 2
Self-Acceptance: 9, 18, 31, 29, 14, 3