Implementing an Interpersonal Theory of Suicide Treatment Approach to Improve Outcomes in Suicidal Youth

Suicide is the second leading cause of death among adolescents in the United States, with rates that have continued to increase over the past several years. Theoretical models of suicide have arisen in order to provide an organizing framework to better understand this phenomenon. Among them, the Interpersonal Psychological Theory of Suicide (IPTS; Joiner, 2005) has gathered significant empirical support. This theory proposes two interpersonal constructs that serve as a final common pathway to understanding suicidal ideation: thwarted belongingness and perceived burdensomeness. There has been limited translation of core themes of this theory to clinical care and there are few theory informed interventions present in the field of suicide prevention overall. We aimed to address this gap in the literature by intentionally targeting cognitions related to perceived burdensomeness with a series of novel interventions by conducting two separate studies. In Study 1 we first gathered information about the manifestation of perceived burdensomeness among suicidal adolescents from teens, their parents, and clinicians working with this population through a series of qualitative interviews. Results from these interviews indicated a need for an enhanced model of perceived burdensomeness highlighting potential mechanisms of change that may be harnessed during therapeutic interventions. Possible clinical interventions operating through these pathways were then developed for examination. In Study 2, a clinical trial was conducted in an intensive outpatient program (IOP) administering evidence-based care for suicidal youth. Participants were 124 adolescents who completed measures on IPTS variables, depressive symptoms, and suicide risk at intake, discharge, and one-month follow-up. The control arm of the study consisted of the treatment provided by the unchanged IOP and the experimental arm added the study interventions to standard care. Results demonstrated that the intervention did not result in a significant difference in perceived burdensomeness or suicide risk between the control and experimental arms. However, there was a difference between groups on thwarted belongingness, with a greater drop in the experimental condition from intake to discharge. Furthermore, the study interventions indicated a small effect size on the majority of study variables. Feasibility and acceptability ratings from study clinicians were supplemented by qualitative exit interviews with parents and adolescents. Feedback gathered during this stage of the study provided support for several of the study interventions and endorsed them as worthwhile additions to the IOP. During exploratory analyses with a sample combining the experimental and control groups, results indicated that the pathway by which suicide risk changes from intake to discharge is through a change in perceived burdensomeness and depressive symptoms. From discharge to one-month follow-up, the pathway explaining a change in suicide risk includes both a change in thwarted belongingness and perceived burdensomeness with a change in depressive symptoms. This finding supports the notion of IPTS variables contributing unique variance to changes in suicide risk even when depressive symptoms are included in the model. Results also support the trend in the literature emphasizing the proximal role of perceived burdensomeness to suicide risk and capitalizing on the need to better target this construct in a clinical setting. This study adds to the literature by being the first to utilize the construct of perceived burdensomeness in clinical interventions for suicidal youth and effectively translating theory to clinical application.