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Suicide talk as a vital sign: a theory-informed examination of individual and relational factors that influence suicidal disclosure

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Suicide talk as a vital sign: a theory-informed examination of individual and relational factors that influence suicidal disclosure

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Content i

SUICIDE TALK AS A VITAL SIGN: A THEORY-INFORMED EXAMINATION OF INDIVIDUAL
AND RELATIONAL FACTORS THAT INFLUENCE SUICIDAL DISCLOSURE

by

Anthony Fulginiti

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)

AUGUST 2016

ii
DEDICATION

To my wife, Kayla and son, Alexander
You are the light of my life

To my sister, Kerri and brother, Larry
For always being there for me

To my late brother, Allan
You are missed

To those who have thought about or lost a loved one to suicide
You are not alone

iii
ACKNOWLEDGMENTS
When I think about this academic journey, I am not sure whether to characterize my
position today as being on the cusp or precipice of something! With that said, I feel
privileged for being given the opportunity to take this journey and cross paths with so
many people who have helped me to be in the position that I am today. This dissertation
would not be what it is without the efforts of my distinguished dissertation chair (Dr. John
Brekke) and committee members (Drs. Eric Rice, Concepcion Barrio, and Gerald Davison). I
would not be the scholar that I am without many people who have invested their time and
energy in me. I have offered brief thoughts on a few people who I hope to emulate in
different ways to evolve as a scholar. They are all amazing, humble, and generous scholars
but the thing I will remember most is how much I just enjoy being in the room with them.
I want to thank my academic mentor, Dr. John Brekke, for supporting and
encouraging me to take risks that have been integral to the completion of this dissertation
study and, more so, my development as a scholar. There have been many bumps (or
mountains) in the road but I never felt any doubt that he would stand behind me in staying
the course to pursue my passion for suicide prevention. I will always be grateful to him for
the learning opportunities and perspective on scholarship that he has provided me.
I would like to express my gratitude to Dr. Eric Rice. He has been a steadfast
supporter of mine who has been instrumental to my understanding and appreciation of
social network theory and methodology. I will always remember our first network meeting
in which he was doing matrix algebra, which I experienced with the same awe as a child
watching a rabbit pulled from a hat. Perhaps more than anything else, I have appreciated
the many musings that we have shared over the years.
iv
I want to extend my appreciation to Dr. Concepcion Barrio, who has been unfailingly
accommodating and helpful over the years. This support was even extended after making
her sit through a presentation on suicide theory that spanned two weeks (technically two
class periods)!
I wish to acknowledge Dr. Jeremy Goldbach. I am indebted to him for
wholeheartedly welcoming me to join his research team and for placing tremendous trust
in me, which has bolstered my sense of confidence and expertise.
I am thankful for Dr. Shelley Levin, who has helped me to develop as an instructor.
Her teaching mentorship has been invaluable and has prepared me with foundational skills
that will undoubtedly be necessary to succeed throughout my academic career.
I want to send a shout out to the members of my cohort (Hsun-Ta Hsu, Megan
Finno-Valasquez, Elizabeth Siantz, Amy He, Hyunsung Oh, and James Simon). I could not
have picked a more wonderful group of people to share this doctoral experience.
I am grateful for everything that has been given to me by the SMISQL Research
Cluster, the USC Social Work Program, Dr. Michalle Mor Barak (Program Director), and
Malinda Sampson (Program Manager). This has been an opportunity to fulfill my dream.
Lastly, I want to thank my loving family (Kayla, Alex, Kerri, Larry, Mike, Cheryl, and
Phyllis). No words can articulate what they mean to me but I know one thing…I could not
have made it through this journey without them.
I cannot properly thank everyone who has contributed to my journey (e.g., Lisa
Davis, Rohini Pahwa, Liat Kriegel) but I want readers to know that I have the fondest
thoughts and utmost respect for all those who have traversed this topsy-turvy world with
me.
v
TABLE OF CONTENTS

DEDICATION ii

ACKNOWLEDGMENTS iii

LIST OF TABLES vii

LIST OF FIGURES viii

ABSTRACT ix

CHAPTER ONE: INTRODUCTION AND OVERVIEW 1
Background of the Problem 1
Purpose and Contributions of the Current Study 3
Specific Aims and Hypotheses 6
Overview of Methodology 10
Organization of the Study 10

CHAPTER TWO: LITERATURE REVIEW AND THEORETICAL BACKGROUND 12
Suicide as a Public Health Problem 12
Attempt Survivors & Ideators with SMI as Vulnerable Population 13
Disclosure and Disclosure Decisions With Concealable Stigmatized Identities 16
Suicidal Disclosure: A Brief Review of the Literature 18
Suicidal Disclosure: Implications for Suicide Prevention 25
Social Networks, Suicide, and Disclosure 27
The Disclosure Decision Making-Model (DD-MM) 30
Motivation for Suicidal Disclosure 34
Summary: What We Know and (More so) Don’t Know About Suicidal Disclosure 37
Restatement of Specific Aims and Hypotheses 43

CHAPTER THREE: METHODS 47
Data Source Overview 47
Preliminary and Pilot Studies 47
Recruitment of the Sample for the Current Study 49
Post-Informed Consent Procedures 50
Ethical Approach to the Study 51
Data Collection 52
Measures 55
Data Analysis 67

CHAPTER FOUR: RESULTS 73
Description of the Sample 73
Results for Research Aim 1: To describe the patterns of prior and intended
suicidal disclosure
82
Results for Research Aim 2: To examine the association between non-theory 87
vi
informed factors and intended disclosure
Results for Research Aims 3-5: To examine the association between DD-MM
factors (i.e. theoretical factors) and intended disclosure
91
Results for Research Aim 6: To identify reasons for and against disclosure of
suicide-related cognition
98
Ancillary Analysis: Brief Comment about First Disclosures 100
Summary of Results 101

CHAPTER FIVE: DISCUSSION 103
Disclosure Patterns: Prevalence Across Levels, Cognition and Relationships 103
Without Theory, What Do We Know About Disclosure? 109
With Theory, What Do We Know About Disclosure? 112
A Story of Many Motivations 120
Implications for Practice 122
Study Limitations and Strengths 125
Future Directions for Research 126
Conclusions 127

REFERENCES 128

APPENDIX A 158

APPENDIX B 161

vii
LIST OF TABLES

Table 1: A systematic review of studies examining prevalence rates of suicidal
communication

21
Table 2: Descriptive statistics of non-theory-informed individual characteristics
of participants in the sample

75
Table 3: Descriptive statistics of non-theory-informed social network
characteristics of participants in the sample

77
Table 4: Descriptive statistics of Disclosure Decision-Making Model individual
characteristics of participants in the sample

79
Table 5: Descriptive statistics of Disclosure Decision-Making Model social
network characteristics of participants in the sample

81
Table 6: Prevalence of Suicidal Disclosure and Disclosure Network Instability

83
Table 7: Prevalence of Intended Disclosure By Type of Suicidal Cognition

84
Table 8: Prevalence of Intended Disclosure By Type of Relationship Inside Social
Networks

87
Table 9: Univariable regression analyses examining intended disclosure using a
non-theory-informed approach

89
Table 10: Multivariable regression analysis examining intended disclosure using a
non-theory-informed approach

91
Table 11: Univariable regression analyses examining intended disclosure using
the Disclosure Decision-Making Model approach

93
Table 12: Multivariable regression analyses examining intended disclosure using
the Disclosure Decision-Making Model approach

94
Table 13: Multivariable regression analyses examining intended disclosure using
non-theory-informed and theory-informed approaches

97
Table 14: Reasons for and Against Disclosure of Suicidal Cognition 100

viii
LIST OF FIGURES

Figure 1: Multi-level conceptualization of disclosure using social network
methods

4
Figure 2: Types of Suicidal Cognition and the Suicide Risk Continuum

4
Figure 3: Basic Depiction of the Disclosure Decision-Making Model 5
Figure 4: Detailed Depiction of the Disclosure Decision-Making Model with
Hypotheses

9
Figure 5: An illustration of the adapted multi-level disclosure decision-making
model (DM-DD) with operationalization using social network
methodology

34
Figure 6: An illustration of individual-level versus relational-level prevalence

38
Figure 7: Intended Disclosure Prevalence by Cognition Type 84

ix
ABSTRACT

The disclosure of suicidal thoughts is integral to effective suicide risk management.
Despite the fact that every disclosure occurs in the context of a relationship, scholarship on
suicidal disclosure has almost exclusively focused on the individual doing the disclosing
and not the relationship context in which disclosures are made. This has meant asking
about how common it is for people to disclose (i.e., individual-level prevalence) and
individual characteristics that affect disclosure. Recognizing that people selectively disclose
to members of their social networks raises important unanswered questions about the
extent to which people disclose in their social networks (i.e., relational-level prevalence)
and network characteristics (e.g., member or relationship attributes) that affect disclosure.
Research has also generally neglected to consider that people may adopt different
disclosure practices depending on the type of suicidal cognition. Lastly, this literature has
lacked a theoretical basis and has minimally explored disclosure motivations. The
objectives of this study were to: (a) describe disclosure patterns across people,
relationships and type of suicidal cognition; (b) examine the contribution of sets of non-
theory and theory-informed (i.e., Disclosure Decision-Making Model; DD-MM) individual
and network variables in explaining intended disclosure; and (c) explore reasons for and
against disclosure.
The study used data from 45 individuals (Level 2 sample size) with a serious mental
illness and a history of suicidal ideation or attempt who nominated 347 social network
members (Level 1 sample size). Participants were recruited from a large outpatient mental
health center and completed a self-report survey and social network interview. Basic
descriptive statistics were used to examine patterns of disclosure—the prevalence
x
(individual- and relational-level) and consistency of disclosure (across type of suicidal
cognition and relationship status)—and motivations related to disclosure. A series of
multilevel univariable and multivariable linear regression analyses were used to identify
correlates of intended disclosure. Sets of non-theory-informed variables and theory-
informed variables (i.e., DD-MM) were examined separately and then together.
Nearly all people disclosed suicidal cognition in the past and intended to do so in the
future, with approximately half of social network members being viewed as attractive
confidants. Intended disclosure varied as a function of suicidal cognition type, with a higher
proportion of people being inclined to disclose less serious (i.e., active thoughts) than more
serious (i.e., intent/plan) types of suicidal cognition (96% vs. 82%) and with a higher
proportion of network members viewed as prospective confidants for less serious than
more serious types of suicidal cognition (43% vs. 30%). The theory-informed variables (i.e.,
DD-MM) explained triple the between-person variance in intended disclosure as the non-
theory informed variables (26% vs. 8%) and double the within-person variance (40% vs.
20%). Consistent with prior work, social support and relationship status were identified as
non-theory correlates of intended disclosure. All DD-MM components—the Assessment of
Information (Phobic Anxiety, Suicide Stigma), Assessment of Receiver (Relational Quality,
Anticipated Outcome) and Assessment of Disclosure Efficacy—were associated with
intended disclosure. Getting help, advice or support and catharsis were identified as major
reasons for disclosure while shame about suicidal thoughts and fear of rejection were
identified as major reasons for non-disclosure. Clinicians could benefit from integrating
social network methods into safety planning to assess the likelihood of disclosure and to
xi
identify network members likely to be pursued for disclosure. The Disclosure Decision-
Making Model appears to hold promise for informing disclosure intervention development.
1
CHAPTER ONE:
INTRODUCTION AND OVERVIEW
Background of the Problem
Suicide is a serious and persistent public health problem that disproportionately
affects people with serious and persistent mental illness. In the general population, 13 per
100,000 will die by suicide each year (McIntosh & Drapeau, 2014), accounting for an
annual loss of over 40,000 lives (WHO, 2014). Having a serious mental illness carries an
expected suicide risk 8.5 to 20 times that of the general population (Harris & Barraclough,
1997). People who have experienced suicidal ideation (Baca-Garcia et al., 2011; Mundt et
al., 2013) or survived a suicide attempt and have a serious mental illness are at particularly
high long-term risk of suicide (Tidemalm, Langstrom, Lichtenstein, & Runeson, 2008).
Many people experience enduring suicidal ideation (Borges, Angst, Nock, Ruscio, &
Kessler, 2008), even while in mental health treatment (Seo et al., 2014). A critical but often
overlooked issue is that people do not necessarily share their suicidal thoughts. Without
disclosure, which acts as a proverbial red flag for serious suicidal behavior (Maris, Berman,
& Silverman, 2000), individuals harboring suicidal ideation are less likely to be identified as
posing a risk and provided with treatments designed to resolve that risk (Fulginiti, Pahwa,
Frey, Rice, & Brekke, 2015).
Although the disclosure of suicidal ideation provides a window of opportunity for
suicide prevention (Owen et al., 2012), it is an underdeveloped area of suicide research
(Zhou & Jia, 2012). Studies on suicidal disclosure have tended to treat disclosure as a
dichotomous phenomenon, which has manifested in investigations that narrowly
conceptualize disclosure as an individual-level characteristic (e.g., discloser vs. non-
2
discloser) and, relatedly, almost exclusively focus on individual-level correlates (Fulginiti et
al., 2015). Therefore, despite that every disclosure occurs in the context of a relationship,
prior work has generally failed to consider that people are likely to selectively disclose to
members of their social networks—an indication of within-person differences in
disclosure—and, relatedly, that network characteristics
1
(e.g., network member or
relationship attributes) are likely to influence disclosure decisions.
Studies on suicidal disclosure have also tended to investigate a single type of
suicidal cognition (most commonly suicidal intent), which, in combination with the rapidly
evolving lexicon of suicide terms and the frequent failure to define such terms within
studies (Silverman et al., 2007), makes it difficult to know how common it is for people to
disclose different types of suicidal cognition (e.g., non-specific active suicidal thoughts vs.
plan). This is a critical oversight when taking into account that different types of suicidal
cognition confer different levels of suicide risk (e.g., Mundt et al., 2013)—the traditional
risk continuum situates suicidal intent and plan as being more proximal to suicidal
behavior than active suicidal thoughts (Baca-Garcia et al., 2011; Posner et al., 2008).
Therefore, despite that differential disclosure across cognition type can affect the accuracy
of suicide risk assessment and, consequently, the nature of risk management strategies,
prior work has not shed adequate light on the matter.
Studies on suicidal disclosure have also exclusively adopted an atheoretical
approach, which likely stems, at least in part, from the fact that disclosure has been
understood as a personal attribute (e.g., Kovacs, Beck, & Weissman, 1976) and that
disclosure has not been recognized as involving a decision-making process. This stands in

1
Network variables can refer to characteristics of network members (i.e., alter attributes), characteristics of relationships
(i.e., dyadic or relational attributes), and the “whole network” (i.e., network attributes).
3
stark contrast to research on other concealable stigmatized statuses (CSS) or identities
(CSI), such as HIV/AIDS, wherein an impressive body of theoretical work has been
developed to explain disclosure (e.g., Chaudoir & Fisher, 2010; Clair, Beatty, & MacLean,
2005). Despite that people experiencing suicidal thoughts can be understood as possessing
a concealable stigmatized status or identity (i.e., “suicidal ideator”), prior work has not
sought to explore the viability of any CSS or CSI theoretical models to understand suicidal
disclosure in this vulnerable population. Presumably stemming from the same reasons
driving the adoption of an atheoretical approach, studies on suicidal disclosure have also
sparingly explored disclosure motivations.
Purpose and Contributions of the Current Study
Broadly speaking, the purpose of the current study was to examine patterns,
correlates, and motivations for suicidal disclosure. The current study advanced existing
knowledge of suicidal disclosure in the following significant ways:
1. It focused on community-dwelling people with serious mental illness and lived
experience with suicidal crises—a particularly vulnerable population in which
disclosure is poorly understood.
2. It cast disclosure as a multi-level phenomenon, which is consistent with the notion
that understanding disclosure requires the consideration of discloser attributes (i.e.,
individual-level) as well as the context in which the disclosure occurs (i.e., network-
level). See Figure 1 below for illustration.
3. It used social network methodology, which permitted a more comprehensive and
refined way to obtain information on disclosure and potential correlates of
disclosure on multiple levels. This set the stage for describing between-person (i.e.,
4
individual-level) and within-person differences (i.e., network-level) in disclosure
patterns and identifying factors about the individual, their social network members,
and relationships with their social network members that could affect disclosure.
See Figure 1 below for illustration.

Figure 1. Multi-level conceptualization of disclosure using social network
methods

4. It assessed for disclosure tendencies across different types of suicidal cognition (i.e.,
non-specific active suicidal thoughts; intent; plan), which provided insight into
whether people disclose differently depending on their location on the suicide risk
continuum. See Figure 2 below for illustration.

5
Figure 2. Types of Suicidal Cognition and the Suicide Risk Continuum
5. It addressed perhaps the starkest limitation of the extant suicidal disclosure
literature, namely the lack of theory-informed research and, in doing so, forwarded
an understanding of suicidal disclosure as a decision-making process. This study
was informed by the Disclosure Decision-Making Model (DD-MM), which was
developed to understand the disclosure of stigmatizing health and mental health
conditions but has not been applied in a suicide context. This model proposes that
disclosure decisions are driven by the discloser’s assessment of the following: (i) the
information under consideration for disclosure (i.e., information about the
psychological status being disclosed); (ii) the prospective receiver of the
information (i.e., relationship quality with receiver and anticipated
reaction/outcome of disclosing to the receiver); and (iii) the discloser’s sense of
efficacy or belief in his/her ability to communicate that information in the context of
a given relationship.

Figure 3. Basic Depiction of the Disclosure Decision-Making Model
6
6. It included a broader range of variables than previously investigated, including
many that were (i.e., DD-MM factors) and were not informed by theory (e.g.,
disclosure distress, perceived burdensomeness).
7. It included a continuous rather than dichotomous measure of suicidal disclosure,
which helped to make meaningful comparisons in explanatory power (e.g., model fit,
variance explained) between a non-theory-informed approach and a theory-
informed approach.
8. Informed by a functional model of disclosure, it explored self-, other-, and
relationship-oriented reasons for and against disclosure, which provided a
preliminary perspective on suicidal disclosure motivation.

The knowledge gained from the current study will help to develop better disclosure
assessment and intervention strategies, thus increasing the likelihood that existing suicide
risk can be effectively managed.
Specific Aims and Hypotheses
AIM 1: To describe the patterns of suicidal disclosure
The purpose of Aim 1 is to characterize the prevalence and consistency of disclosure across
suicidal cognition type and relationship type in a multi-level context. The subaims are
immediately below. This aim is largely exploratory and thus does not justify any hypotheses.
1a) To determine the proportion of people disclosing to at least 1 person in their social
network (i.e., individual-level disclosure prevalence)
1b) To determine the proportion of social network members identified as confidants
for disclosure (i.e., relational-level disclosure prevalence)
1c) To describe the disclosure prevalence of different types of suicidal cognition
7
1d) To describe the disclosure prevalence in the context of different types of
relationships inside and outside of social networks
Aim 2: To examine the association between a set of non-theory-informed variables
and intended suicidal disclosure
The purpose of Aim 2 is to identify correlates and quantify the explanatory power of a
disclosure model using a non-theory-informed approach. Variables were primarily considered
for inclusion if they met any of the following three criteria: (a) individual-level variables being
in “common use” (defined in Chapter 2) in prior suicidal disclosure research; (b) individual-
level variables commonly linked to suicide outcomes; or (c) network-level variables included
in prior network research of suicidal disclosure. Because the primary aim of this dissertation
is to examine the association between the Disclosure Decision-Making Model variables and
intended suicidal disclosure, the set of non-theory-informed variables is not meant to be
inclusive of all variables meeting the aforementioned criteria. It is meant to approximate the
atheoretical, “scattershot” approach that has traditionally been used in research on suicidal
disclosure. Another way to think about this aim is that it is predominantly meant to serve as a
standard of comparison for the subsequent Disclosure Decision-Making Model approach. This
aim is largely exploratory and thus does not justify any hypotheses.
Aim 3: To examine the association between the information component of the
Disclosure Decision-Making Model and intended suicidal disclosure
The purpose of Aim 3 is self-evident. The subaims are immediately below followed by
hypotheses for these subaims. See Figure 4 for illustration of DD-MM and related hypotheses.
3a) To examine the association between stigma of suicide and intended disclosure
8
Hypothesis 1a: Higher levels of stigma will be associated with decreased disclosure
intent
3b) To examine the association between symptom severity and intended disclosure
Hypothesis 1b: Greater severity of symptoms will be associated with increased
disclosure intent
Aim 4: To examine the association between the receiver component of the Disclosure
Decision-Making Model and intended suicidal disclosure
The purpose of Aim 4 is self-evident. The subaims are immediately below followed by
hypotheses for these subaims. See Figure 4 for illustration of DD-MM and related hypotheses.
4a) To examine the association between the quality of relationship with prospective
confidant and intended disclosure
Hypothesis 2a: Higher relational quality will be associated with increased disclosure
intent
4b) To examine the association between the anticipated reaction (comprised of
anticipated response and anticipated outcome) of the prospective confidant and
intended disclosure
Hypothesis 2b: More positive anticipated reaction will be associated with increased
disclosure intent
Aim 5: To examine the association between the disclosure efficacy component of the
Disclosure Decision-Making Model and intended suicidal disclosure
The purpose of Aim 5 is self-evident. The hypothesis for this aim is immediately below. See
Figure 4 for illustration of DD-MM and related hypotheses.
9
Hypothesis 3: Higher disclosure efficacy will be associated with increased disclosure
intent
Aim 6: To describe reasons for and against the suicidal disclosure
The purpose of Aim 6 is self-evident. This aim is largely exploratory and thus does not justify
any hypotheses.

Figure 4. Detailed Depiction of the Disclosure Decision-Making Model (DD-MM) with
Hypotheses. This figure illustrates the constituent components of the DD-MM in a
multi-level context and their associated hypotheses. Note the asterisk (*) for the
stigma of suicide variable. Although stigma of suicide is illustrated as operating
exclusively at the individual-level, we propose that stigma operates at both the
individual-level and relational-level.

10
Overview of Methodology
The current study employed an innovative combination of survey and social-
network methodologies to explore the disclosure of suicidal cognition. Using a purposive
sampling strategy, this study recruited 45 adults with a serious mental illness (i.e., Bipolar
Disorder, Major Depressive Disorder, Schizophrenia) and lived experience with a suicidal
crisis (i.e., prior suicide attempt or cognition) from a large outpatient mental health agency
in southern California. Participants completed a social network interview and a self-report
survey. The social network interview consisted of asking people to identify members of
their social network and then asking about characteristics of and relationships with their
social network members. The self-report survey consisted of a battery of questionnaires
that assessed a broad range of demographic, psychiatric, psychosocial and disclosure-
related characteristics. In a multilevel context, the social network interview obtained
information at Level 1 and the self-report survey obtained information at Level 2.
Descriptive statistics were used for Aim 1 and Aim 6 whereas multilevel regression
modeling was used for Aims 2-5.
Organization of the Study
This dissertation is organized into five chapters. The present chapter (Chapter 1)
provides a brief background of suicide as a public health problem and discussed suicidal
disclosure as a viable solution. The chapter then highlighted major gaps in the literature on
disclosure and then defined the purpose, contributions, and aims of the current study,
which largely sought to address the major gaps in the disclosure literature. Chapter 2
provides an in-depth literature review on suicide in populations of people with serious
mental illness and lived experience with suicidal crises; the issue of disclosure decision-
11
making among people with concealable stigmatized statuses; the issue of suicidal
disclosure and implications for suicide prevention; the relationship between social
networks, suicide, and disclosure; and theoretical models of disclosure decision making,
with an emphasis on the Disclosure Decision-Making Model (DD-MM). Chapter 3 provides a
detailed description of preliminary work that informed the current study and then reviews
the current study methodology, including, among other things, the recruitment, data
collection and analytic strategy. Chapter 4 provides a complete account of the results for
the current study, including a description of the sample and findings pertaining to each of
the study aims. Chapter 5 provides a discussion of the findings, implications for practice,
study limitations and strengths, directions for future research, and concluding remarks.

12
CHAPTER TWO:
LITERATURE REVIEW AND THEORETICAL BACKGROUND
Suicide as a Public Health Problem
Suicide is a significant public health concern that exacts a devastating national toll
(Nock et al., 2008), with annual direct and indirect costs in the United States estimated to
range from $11.8 billion (Goldsmith et al., 2002) to $34.6 billion (Centers for Disease
Control [CDC], 2012). To grasp the scope of the problem, it is imperative to keep in mind
that there are consequences associated with the entire suicide continuum, which stretches
from suicidal ideation to suicide attempt to death by suicide (Lewinsohn, Rohde, & Seeley,
1996). Suicide is the 10
th
leading cause of death in the U.S. (CDC, 2012), accounting for an
annual loss of over 40,000 lives (World Health Organization [WHO], 2014). For
perspective, the death toll from suicide in the U.S. exceeds that of HIV/AIDS (Goldsmith et
al., 2002), homicide, automobile/transportation accidents, and prostate cancer while being
responsible for only slightly fewer deaths than breast cancer (CDC, 2012). Regrettably, not
only have U.S. suicide rates not shown any appreciable signs of decline over the past 50
years (National Action Alliance for Suicide Prevention, 2014), there is evidence suggesting
that suicide deaths are expected to increase over the next several decades (Nock et al.,
2008). These undesirable trends have continued despite consistent public and private
research funding that has included $40 million annually from the National Institutes of
Health and $20 million over the past decade from the American Foundation for Suicide
Prevention (National Action Alliance for Suicide Prevention, 2014).
In addition to the startling number of deaths by suicide, there are considerably more
individuals who survive a suicide attempt (i.e., attempt survivors). For every death by
13
suicide, an estimated 20 (WHO, 2014) to 25 (McIntosh & Drapeau, 2014) individuals
engage in a suicide attempt. Each year, approximately 650,000 hospital visits are
attributable to suicide attempts (Goldsmith et al., 2002; National Action Alliance for Suicide
Prevention, 2014) and an estimated 1 million individuals report making a suicide attempt
(WHO, 2014). Aside from individuals who engage in suicidal behavior, there are many
more individuals who endorse having thoughts of suicide (i.e., “suicidal ideators”).
Evidence from a relatively recent systematic review suggests that anywhere from 2.1% to
10% of individuals in the general population report suicidal ideation in the past 12 months
alone (Nock et al., 2008). This translates to approximately 9.4 million people seriously
contemplating suicide in a 12-month period (Substance Abuse and Mental Health Services
Administration [SAMHSA], 2015). To make matters worse, these rates are likely
underestimates given that most suicidal crises, including attempted (Ploderl, Kralovec,
Yazdi, & Fartacek, 2011; Saiz et al., 2014; Williams, 1997) and completed suicide are
underreported (U.S. Department of Health and Human Services Office of the Surgeon
General & National Action Alliance for Suicide Prevention, 2012).
Attempt Survivors and Ideators with Serious Mental Illness as Vulnerable Population
Paramount to prioritizing the allocation of resources for suicide prevention efforts
is the identification of subgroups that may be particularly vulnerable to suicide outcomes.
Although there are a multitude of groups at elevated risk for suicide compared to the
general population (e.g., incarcerated population; Goldsmith et al., 2002), the distribution
of suicide risk is disproportionately concentrated among individuals with serious mental
illness (Harris & Barraclough, 1997; Bostwick & Pankratz, 2000). For the sake of clarity,
serious mental illness (SMI) can be defined as any diagnosed mental disorder that
14
substantially and adversely interferes with functioning (SAMHSA, 2014). The magnitude of
the suicide-related mortality in this population can be better appreciated when considering
that the lifetime risk for suicide among people with a serious mental illness ranges from
4% to 8% (Litts, Radke, & Silverman, 2008) and that there are 9.8 million people living
with a serious mental illness (SAMHSA, 2015).
Although suicide is a leading cause of death for nearly every category of serious
mental illness (Litts, Radke, & Silverman, 2008), certain diagnoses are associated with
greater risk than others (Joiner, Van Orden, Witte, & Rudd, 2009). Schizophrenia and mood
disorders are among the “big five” disorders that confer the greatest risk of suicide (Joiner
et al., 2009; U.S. Department of Health and Human Services Office of the Surgeon General &
National Action Alliance for Suicide Prevention, 2012). Mood disorders alone are said to
account for 60% of all deaths by suicide (U.S. Department of Health and Human Services
Office of the Surgeon General & National Action Alliance for Suicide Prevention, 2012). The
lifetime risk of suicide is approximately 6% among people with mood disorders (Inskip,
Harris, & Barraclough, 1998) and 5% among people with Schizophrenia (Palmer, Pankratz,
& Bostwick, 2005), with rates reported at 15% or higher in some studies (Bostwick &
Pankratz, 2000; Siris, 2001). This means that Schizophrenia, Bipolar Disorder and Major
Depressive Disorder carry an expected suicide risk 8.5 to 20 times that of the general
population (Harris & Barraclough, 1997). With lifetime prevalence rates for Schizophrenia
at 1%, Bipolar Disorder at 1% (Merikangas et al., 2007) and Major Depressive Disorder at
17% (Kessler et al., 2005), it is clear that a sizable number of individuals constitute this at-
risk population. It should be pointed out that being in mental health treatment does not
negate risk, which is exemplified by a noteworthy review of 30 studies finding that 30% of
15
suicides occurred among people receiving some form of mental health treatment (Luoma,
Martin, & Pearson, 2002). Of course, those who are especially troubled might be especially
motivated to enter treatment.
While there is no denying the strong relationship between mental illness and
suicide, there is also a well-established link between a history of lived experience with
suicidal crisis (i.e., a history of suicide attempt or suicidal cognition) and later suicidal
behavior. A history of suicide attempt is arguably the most robust predictor for death by
suicide (Van Orden et al., 2010), even when controlling for the “kitchen sink” of other risk
factors (Joiner et al., 2005). Individuals with a suicide attempt history carry an expected
suicide risk 30-40 times that of the general population (Harris & Barraclough, 1997).
Although 85% to 90% of those that attempt suicide do not die (Rudd, Joiner, & Rajad,
1996), suicide attempt survivors cross a threshold that appears to have an enduring effect
on their vulnerability for later suicide. In fact, several longitudinal studies have shown that
attempt survivors remain at heightened risk for death by suicide at five (Beautrais, Joyce, &
Mulder, 2003), ten (Nordentoft et al., 1993), and twenty years post index attempt
(Bjornaas, Jacobsen, Haldorsen, & Ekeberg, 2009). This long-term elevation in suicide risk
is particularly true for attempt survivors with SMIs (Tidemalm et al., 2008). In addition to
attempt survivors, there is also no denying that people having struggled with suicidal
thoughts (i.e., “suicidal ideators”) represent a concerning group with an elevated risk for
subsequent suicidal behavior (Baca-Garcia et al., 2011). With 1 million people attempting
suicide (WHO, 2014) and 9.4 million people contemplating suicide on an annual basis
(SAMHSA, 2015), there is a burgeoning population of individuals with lived experience in
suicidal crisis who are at risk for dying by suicide.
16
Disclosure and Disclosure Decisions With Concealable Stigmatized Identities
Although there is widespread agreement that disclosure is central to social
interaction (Chaudoir & Fisher, 2010), there has been considerable variation about how to
define disclosure (Chaudoir & Fisher, 2010). Jourard (1971), in one of the earliest known
definitions, characterized disclosure as the “act of making yourself manifest, showing
yourself so that others can perceive you” (p.19). These definitions were notably broad,
leading subsequent scholars to narrow the use of the term “disclosure”. Therefore, recent
conceptualizations of disclosure indicate that the term should be narrowly applied to
private information
2
, which consists of information about the self that is not readily
accessible by others (Derlega, Metts, Petronio, & Margulis, 1993). Furthermore, whereas
early definitions of disclosure could encompass verbal, non-verbal (Chaudoir & Fisher,
2010), voluntary and involuntary forms of sharing (Greene, Derlega, & Mathews, 2006),
contemporary work restrictively applies the term to the intentional, verbal sharing of
information (Derlega et al., 1993; Greene, Derlega, & Mathews, 2006). In line with this
reconceptualization and associated theoretical advances on disclosure (e.g.,
Communication Privacy Management; Petronio, 2002), disclosure can be understood as a
strategy for managing private information.
For most of the storied history of the construct, disclosure was viewed as an
overwhelmingly positive behavior. An “ideology of openness” (Parks, 1982), which has
traditionally pervaded the scholarly literature, furthers the notion that completely open
communication is inherently good and implies that anything less than completely open
communication (e.g., non-disclosure, secret-keeping, topic avoidance) is inherently bad

2
Informed by notable work, we subsume secrets under the term “private information” (Greene, Derlega, Yep, & Petronio,
2003).
17
(Cupach & Spitzberg, 2007). Meta-analytic work offers an empirical basis for this positive
perspective, finding that disclosure carries benefits in the form of improving mental health,
health, and overall functioning (Frattaroli, 2006). A more balanced perspective recognizes
that although disclosure is generally helpful, there can also be significant costs to
disclosure, such as making an individual susceptible to stigmatization (Cupach & Spitzberg,
2007) and exploitation (Derlega et al., 1993). The potential for mixed outcomes and the
associated feelings of vulnerability manifest in decision-making that is not nearly as
straightforward as previously believed (i.e., to disclose is good and to not disclose is bad),
often requiring demanding and daunting mental calculus.
Making decisions about disclosure is particularly complex for individuals who
possess concealable stigmatized identities (CSIs) or statuses (CSSs), namely those with
personal information that is socially devalued but ordinarily unobservable to others and
readily capable of being hidden (Chaudoir & Fisher, 2010). Examples of CSIs in the
literature include, among others, people with mental illness, people with HIV/AIDS, people
with a current or previous substance abuse problem, people with a history of incarceration,
people of minority sexual orientation, and people with a chronic illness (Quinn &
Earnshaw, 2013). As implied in the name, the criteria for a CSI are that it is capable of
being concealed and that it is highly stigmatized. Interestingly, suicide attempt survivors
and “suicidal ideators” (i.e., people with suicidal cognition) have not been discussed as
having a CSI despite compelling indications that the two criteria for a CSI are met. First,
although a multitude of circumstances can threaten to expose their hidden identity (e.g.,
mandated hospitalization, visible scars from a suicide attempt), it seems reasonable to
conclude that one’s status as a suicide attempt survivor or “suicidal ideator” is generally
18
concealable. Second, an extensive body of work speaks to the pervasive stigma of suicide
(Pompili, Innamorati, & Tatarelli, 2009; Scocco, Castriotta, Toffol, & Preti, 2012; Sudak,
Maxim, & Carpenter, 2008; Witte, Smith, & Joiner, 2010). In fact, the threat of
stigmatization has proven to be somewhat ubiquitous, occurring at the hands of loved ones
within personal social networks (e.g., Wolk-Wasserman, 1986) as well as professionals
within care systems (e.g., Saunders, Hawton, Fortune, & Farrell, 2012; Taylor et al., 2009),
underscoring the elusiveness of a safe space for disclosure. Conceptualizing suicide attempt
survivors and “suicidal ideators” as having a concealable stigmatized identity or status
implies that these individuals are likely grappling with taxing disclosure decisions. Because
suicidal cognition is commonly recurrent (Baldessarini, Pompili, & Tondo, 2012), persistent
(Borges et al., 2008), and poses an active risk for suicide, the focus of this dissertation is on
the disclosure of one’s status as a “suicidal ideator”.
Suicidal Disclosure: A Brief Review of the Literature
The concept of “suicidal disclosure” can be difficult to trace, in large part, because
multiple terms are used to refer to a similar phenomenon. However, a review of the
literature makes it readily apparent that current researchers have used the term “suicidal
disclosure” as a synonym for “suicidal communication”, which has been of interest in the
field of Suicidology for over half of a century now. Suicidal communication can be
understood as any interpersonal act of expressing or conveying the existence of suicidal
cognition (Silverman et al., 2007). Investigators have long sought to understand suicidal
communication in the form of both verbal and behavioral (e.g., suicide notes)
communication. Given that the term “suicidal disclosure” has been used interchangeably
with but much less often than the term “suicidal communication”, the current state of
19
knowledge on “suicidal disclosure” must be informed predominantly by studies of “suicidal
communication”. The following paragraphs provide a brief review of the extant literature,
which is largely comprised of studies on suicidal communication. After the literature
review, I argue for the purposeful use of the term “suicidal disclosure” in lieu of “suicidal
communication”.
Rooted in the concern that unrevealed suicidal cognition undermines opportunities
for altering suicidal trajectories, longstanding efforts have been made to understand the
prevalence and patterns of suicidal communication. Based on my review, there have been
more than 50 studies that reported some measure of suicidal communication prevalence.
The mean prevalence rate across all studies was found to be just over 52% (SD=21%). See
Table 1 for the complete listing of study rates grouped according to population (i.e., suicide
decedent, attempt survivor, and other populations). In addition to yielding a mean
prevalence rate across studies, this review led to several other key observations and
findings. First, the majority of studies on suicidal communication involved samples of
suicidal decedents, with less work focusing on attempt survivors and people who had not
necessarily engaged in suicidal behavior (e.g., suicidal ideators). Second, the rate of
suicidal communication was marginally higher among people who died by suicide than in
other groups. Third, there was considerable variation in rates of suicidal communication
across studies. Although the marked variation in prevalence rates across studies makes it
difficult to draw clear conclusions about the magnitude of the non-communication problem
(which equates to the size of a non-communicating population), it is crucial to remember
that our point estimate represents the best approximate of the true population prevalence
and that the rate for just over two-thirds of studies (1 SD) falls between 31% and 73%—
20
this suggests that the non-communication problem is common enough to warrant
attention. Aside from elucidating disclosure prevalence rates, studies to date also indicate
that individuals who do decide to communicate typically communicate only with 1 or 2
confidants (Encrenaz et al., 2012; Martin et al., 2013; Robins et al., 1959; Rudestam, 1971).
Taken as a whole, disclosure patterns can be summarized by saying that even though there
is considerable uncertainty about how common it is for people to completely conceal their
suicidal cognition, there is more certainty that people are highly selective whenever they
choose to reveal it.

(INTENTIONALLY BLANK)

21
Table 1
A review of studies examining prevalence rates of suicidal communication (n=49)
Other Populations*
(n=8)
Attempt Survivors
(n=14)
Suicide Decedents
(n=27)
Author Year Rate (%) Author Year Rate (%) Author Year Rate (%)
Reifman 1995 14 Brent 1988 3 Sam 1993 16
Knott 1998 40 Yessler 1960 25 Brent 1988 26
Anand 1983 46 Schmidt 1954 27 Zhou 2012 28
Eskin 2003 49 Fairbank 1932 33 Yessler 1960 30
Encrenaz 2012 49 Rivlin 2013 33 Wheat 1960 36
DeLong 1961 53 Ojehagen 1991 34 Runeson 1992 41
Stevenson 1972 67 Kovacs 1976 34 Martin 2013 43
Fowler 1979 72 Wasserman 1986 40 Groholt 1997 48
Handwerk 1998 40 Kraft 1976 50
Wasserman 2008 53 Canter 2004 50
Dorpat 1963 53 Hulten 1998 53
Kar 2010 74 Rudestam 1972 54
Portzky 2008 95 Eisele 1987 58
Pollack 1938 100 Portzky 2008 58
Houston 2001 59
Pollack 1938 59
Rudestam 1971 62
Martunnen 1992 60
DeLeo 2007 63
Robins 1959 69
DeLeo 2012 69
Vail 1959 69
Martunnen 1995 74
Owens 2012 79
Dorpat 1960 83
Murphy 1992 86
Asgard 1990 88
M(SD): 48(18)% M(SD): 46(27)% M(SD): 56(19)%
Note. Eight other studies with suicide decedents were identified but the original sources were inaccessible.
Secondary sources reported prevalence rates for those studies that ranged from 26% to 75%. Those studies
were not included in the analysis above because this author could not confirm their rates. With that said, the
M(SD) of these 8 studies is 51.6 (20.5), which is close to the rate for decedents in studies whose rates could be
confirmed. Refer to Appendix A for details regarding how the review of studies was conducted. A list of
references for the studies that are in this table are available upon request from the author.
* These studies included populations that were not recruited on the basis of suicidal behavior (e.g., inpatient
psychiatric populations, high school students, general population).

22
Aside from the work on general communication prevalence and patterns, the extant
literature can be organized in accordance with several early but forward-thinking
frameworks (Bernstein, 1979; Robins et al., 1959). These frameworks suggest that
understanding suicidal communication generally requires the consideration of the person
sending the communication (i.e., the discloser), the content of the communication (e.g., type
of suicidal cognition disclosed), the confidant receiving the communication (i.e., disclosure
target or receiver), and the confidant’s response to the communication (i.e., disclosure
reaction). The majority of research has focused on the discloser.
In terms of the discloser, tenuous evidence was found for the relationship between
various sociodemographic and clinical characteristics and suicidal communication. To
arrive at this conclusion, a comprehensive literature review was conducted to locate
studies that used any measure of association to investigate correlates of suicidal
communication. Twenty-three studies that included over 60 different variables were
located. Interestingly, only five sociodemographic variables (i.e., age, gender, marital status,
education, race/ethnicity) and four clinical factors (i.e., psychiatric diagnosis, prior attempt,
depression, and psychiatric hospitalization) were included in at least three studies (see
Appendix A for details of the review). In reference to sociodemographic variables, no
studies found an association between disclosure and education while mixed evidence was
found for age (e.g., Encrenaz et al., 2012; Zhou & Jia, 2012), gender (e.g., Encrenaz et al.,
2012; Handwerk et al., 1998), marital status (e.g., Martin et al., 2013; Rudestam, 1972), and
culture (e.g., Eskin, 2003; Morrison & Downey, 2000; Yessler, 1960). Mixed evidence was
also found for all clinical variables (e.g., DeLeo & Klieve, 2007; Runeson, 1990; Reifman &
Windle, 1995; Stevenson et al., 1972; Zhou & Jia, 2012). Out of all sociodemographic and
23
clinical variables, only prior hospitalization was found to be associated with disclosure in
more than half of the studies in which it was included; people with prior inpatient
hospitalization exhibited greater suicidal communication (Runeson, 1990; Stevenson et al.,
1972).
In terms of the content of the communication, studies have generally assessed the
prevalence and patterns of communicating a single type of suicidal cognition. For
perspective, there are different types of suicidal cognition (e.g., non-specific active suicidal
thoughts; suicide intent; suicide plan) that indicate different levels of suicide risk. On a
suicide risk continuum, non-specific active suicidal thoughts are commonly understood to
suggest greater distance from suicidal behavior than suicidal intent and plan. Example
statements for each type of suicidal cognition are as follows: (a) non-specific active suicidal
thoughts (e.g., “I am having thoughts about killing myself); (b) suicidal intent (e.g., “I am
going to kill myself); (c) suicidal plan (e.g., “I am going to shoot myself tonight in my house
when my parents go out”). To date, studies have tended to focus on suicidal intent (for an
exception, see Canter, Giles & Nicol, 2004; DeLong & Robins, 1961; Robins et al., 1959). This
means that extant research tends to offer a descriptive perspective on communication
practices related to a particular type of suicidal cognition that falls on the middle of the risk
continuum, which may or may not generalize to lower or higher risk suicidal cognition.
Furthermore, this narrow focus does not necessarily reflect how common it is for people to
disclose ANY type of suicidal cognition (i.e., global prevalence), which is vital to know
because it tells us how common it is for people to at least be disclosing something that is
more likely to put them on the radar for risk assessment.
24
In terms of the disclosure target, research has overwhelmingly focused on
describing disclosure patterns across different types of relationships and shown that
individuals most commonly communicate their suicidal cognition with a spouse/partner
(Robins et al., 1959; Martin et al., 2013; Stevenson et al., 1972) or friends/family (Barnes,
Ikeda, & Kresnow, 2001; Encrenaz et al., 2012; Martin et al., 2013; Robins et al., 1959). For
example, studies reporting disclosure rates by relationship status have found that upwards
of 60% of people disclose to their spouses (Robins et al., 1959); 51% to friends/family
(Robins et al., 1959); 41% to medical doctors (Barnes et al., 2001); 14% to mental health
professionals (Barnes et al., 2001); and 6% for others (Encrenaz et al., 2012). These rates,
although variable across studies, raise questions about the extent to which sheer frequency
of contact is related to disclosure.
In terms of the disclosure reactions, even though promising evidence exists that
people are capable of responding in positive and supportive ways to suicidal disclosure
(e.g., Eskin, 2003; Paukert & Pettit, 2007; Wagner, Aiken, Mullaley, & Tobin, 2000), it is
equally clear that negative or unfavorable reactions are also quite common. For example,
attempt survivors and their social network members often avoid talking about the suicidal
crisis altogether (Magne-Ingvar & Ojehagen, 1999). Furthermore, confidants commonly
react to disclosures with ambivalence, anger, and anxiety (Cowgell, 1977; Wagner et al.,
2000; Wolk-Wasserman, 1986), which can completely compromise communication
(Cowgell, 1977; Rudestam, 1971; Wolk-Wasserman, 1986). The most frequently reported
invalidating reaction that has been exhibited by confidants is silence (Magne-Ingvar &
Ojehagen, 1999; Wolk-Wasserman, 1986).
25
To adequately capture the sensitive nature of the information being shared and the
vulnerability of the individual sharing it, I will refer to “verbal suicidal communication” as
“suicidal disclosure”
3
. Although some may argue that the use of the term “suicidal
disclosure” in lieu of “suicidal communication” is an exercise in semantic sleight-of-hand, I
would argue that speaking in the language of “disclosure” carries a powerful message that
talking about suicide can be highly stigmatizing and, consequently, that making decisions
about whether or not to reveal one’s status as a “suicidal ideator” (i.e., CSI) can be stressful.
A related benefit of speaking the language of “disclosure” is that it provides a conceptual
link to a range of theoretical models that seek to explain how people make decisions about
disclosing CSIs (e.g., mental illness, HIV/AIDS). The inclusion of such theoretical models can
help redress the stark absence of theory-driven research in studies of suicidal
communication. Having addressed my position on and preference for using of the term
“suicidal disclosure”, I will hereafter refrain from using the term “suicidal communication”.
Suicidal Disclosure: Implications for Suicide Prevention
The alarming figures pertaining to suicide worldwide have prompted considerable
prevention efforts (Mann et al., 2005). The disclosure of suicidal cognition can play a
pivotal role in processes that are central in preventing suicidal behavior, namely help-
seeking for suicidal symptoms (DeLuca & Wyman, 2012) as well as the detection and
management/treatment of suicidal symptoms (Cukrowicz, Duberstein, Vannoy, Lin, &
Unutzer, 2014). In terms of help-seeking, available research indicates that most individuals
with suicidal ideation do not perceive a need for treatment (Brook, Klap, Liao, & Wells,
2006) and do not seek help (Bruffaerts et al., 2011). Suicidal disclosure can potentially

3
This is consistent with the CSI literature in defining “disclosure” as the intentional, verbal sharing of sensitive
information with others (Chaudoir & Fisher, 2010).
26
prompt a dialogue that leads to reframing suicidal cognition as something that needs
treatment and elicit a social response that leads to increased help-seeking behavior. In
terms of the detection of suicidal symptoms, researchers commonly express concern about
“hidden ideators”, which refer to individuals who do not report their suicidal cognition
(e.g., Bryan, 2011). With high value placed on the advancement of strategies that can
identify “hidden ideators” (Bryan, 2011), it seems rather intuitive to develop efforts that
promote disclosure. Although recent strides have been made to identify behavioral
markers for suicidal behavior (Nock et al., 2010), the reality is that disclosure is likely to
remain critical to risk assessment in the foreseeable future. In terms of the
management/treatment of suicidal symptoms, evidence suggests that most individuals
experiencing suicidal ideation do not receive treatment for mental health issues (e.g.,
emotion regulation, distress, depression; Brook et al., 2006; Bruffaerts et al., 2011).
Suicidal disclosure can motivate an optimal treatment response that specifically targets
suicidal symptoms rather than exclusively focusing on the treatment of mental disorder
(National Action Alliance for Suicide Prevention, 2012). In short, disclosure can facilitate
getting “help” and getting the “right help”.
Aside from the impact that suicidal disclosure can have on seeking and getting help
in the mental health system, there are several other potential advantages of suicidal
disclosure. First, disclosure can provide an opportunity to obtain social support,
particularly from others who share a similar suicide history. Suicide attempt survivors
describe that they often experience a sense of isolation and are without a confidant in
whom they can openly confide about their suicidal cognition (National Suicide Prevention
Lifeline, 2007). Research has long emphasized the value of social support in helping to
27
alleviate all sorts of human woes (e.g., Cohen & Wills, 1985). Second, disclosure can
potentially reduce stress associated with keeping the secret of having suicidal cognition or
having attempted suicide in the past. Without being able to share what some may consider
a “horrible secret” (Shea, 1999), individuals are often left suffering in silence (Chehil &
Kutcher, 2012). The benefits of sharing the secret of one’s suicidal experiences,
particularly among similar others, may be active ingredients in the Maytree Program
which, using a befriending approach in the context of voluntary 4-night stays for
individuals in current suicidal crises, has been shown to improve subjective well-being and
symptoms (Briggs, Webb, Buhagiar, & Braun, 2007). Third, the disclosure of one’s suicide
experience, whether in the form of suicidal cognition or attempt history, can potentially
reduce stigma toward suicide. Direct contact with members of a stigmatized group has
been shown to be more effective than protest and education anti-stigmatization strategies,
at least among those with mental illness (Corrigan et al., 2001; Corrigan & Kosyluk, 2013),
making disclosure a potentially promising mechanism for targeting societal stigma toward
suicide. The anti-stigmatization campaign entitled, “Suicide Shouldn’t be a Secret” (Witte,
Smith, & Joiner, 2010), perhaps says it best.
Social Networks, Suicide, and Disclosure
Knowing that disclosure can be pivotal to suicide prevention and that social
relationships serve as the context for disclosure (Fulginiti et al., 2015) is consistent with an
impressive body of theory and research linking social relationships to prevention and
recovery (e.g., Perry & Pescosolido, 2015). Social networks, which can be defined as a set of
connections or linkages among social entities, such as people or organizations (Valente,
28
2010), represent a valuable way to understand social relationships and the impact of social
relationships on outcomes (Smith & Christakis, 2008).
Generally speaking, there are two major types of social network studies, referred to
as egocentric and sociometric. Egocentric network studies consist of obtaining information
from a focal individual (i.e., the ego) about their direct social ties (Smith & Christakis, 2008;
Valente, 2010). Sociometric network studies consist of obtaining information from all
members of a social group or community, which permits an assessment of direct and
indirect social ties (Smith & Christakis, 2008). Distinct from studies of social support, which
traditionally operationalized social networks as an individual-level characteristic (e.g., How
much support does Person A get from their network? How much support does Person B get
from their network?), social network studies treat the characteristics of network members
and social ties to (and among) social network members as the object of interest (e.g., How
much support does Person A get from Network Member 1, 2…n? How much support does
Person B get from Network Member 1, 2…n?; Smith & Christakis, 2008). In doing so, the
social network approach can better identify influential forces that operate within a given
social context (e.g., network, community), making it highly useful for delineating
mechanisms or targets for intervention (Pescosolido, 2011).
Ever since Emile Durkheim’s seminal work on social integration (1951), the
relationship between social connectedness and suicidal phenomena has been the subject of
much attention (CDC, 2011). The concept of connectedness refers to both subjective and
structural aspects of social affiliation; subjective connectedness generally involves
subjective assessments about perceived affiliation (i.e., individual-level characteristic)
whereas structural connectedness generally involves social network assessments about
29
actual affiliation (i.e., network-level characteristics; Whitlock, Wyman, & Moore, 2014).
Suicide research has overwhelmingly focused on subjective connectedness (Whitlock,
Wyman, & Moore, 2014), which, unfortunately, can help to shape the impression that
suicide is the problem of an isolated actor. In truth, contrary to the finding that people who
die by suicide often perceive being isolated (Van Orden et al., 2010), the reality is that they
are often not literally isolated. For every death by suicide, a conservative estimate suggests
that there are six family members and friends that are left behind (AAS, 2007). Relatedly,
research on social integration among people with serious mental illness often emphasizes
that these individuals are poorly integrated into the community (Ware, Hopper, Tugenberg,
Dickey, & Fisher, 2007), which could lead to the impression that they are socially
disconnected or situated on the fringes of society. However, this is an oversimplified
perspective of connectedness in this group, illustrated by the recent finding that people
with serious mental illness are more psychologically integrated into mental health
networks but more physically and socially integrated into non-mental health networks
(Pahwa et al., 2014). In truth, even though research has found that the social networks of
people with serious mental illness can be characterized as being smaller, less supportive,
and having higher attrition or turnover (Goldberg, Rollins, & Lehman, 2003; Hawkins &
Abrams, 2007; Perry, 2012), the reality is that they are still embedded in social networks.
Recognizing that people who are in suicidal crisis and have a serious mental illness
are embedded in social networks is a key insight because interdependence or
interconnectedness between people can affect their morbidity and mortality (Smith &
Christakis, 2008). However, the nature of the relationship between social networks and
suicide is complicated, with evidence indicating that social connections can amplify as well
30
as attenuate suicide risk. For example, the clustering of suicidal behavior (i.e., contagion) is
an indication of risk amplification (e.g., Baller & Richardson, 2002; de Leo & Heller, 2008)
whereas research linking greater social integration, in the form of higher density social
networks, to less suicidal ideation is an indication of risk attenuation (Kuramoto, Wilcox, &
Latkin, 2013). There are many mechanisms whereby social connectedness can
differentially affect such outcomes (e.g., delivery of social support; social influence;
resource access; Smith & Christakis, 2008), including by influencing care pathways
(Pescosolido, 2014). Care pathways are undoubtedly influenced by, among other things, the
extent of available resources and the use of appropriate resources in the social network to
match a given need. Although we know that the utility of a social network is dependent on
the activation of social ties to access “latent” network resources (Lin, 1999) and that people
tend to access certain ties for specific functions (i.e., functional specificity; Cutrona &
Russell, 1990), the absence of social network studies on suicidal disclosure means that little
is known about social tie activation (i.e., mobilizing network members) for disclosure or
selective disclosure processes operating in the networks of people with serious mental
illness and lived experience with suicidal crisis.
The Disclosure Decision Making-Model (DD-MM) Applied to “Suicidal Ideator” Status
Although the disclosure of suicidal cognition has clear implications for suicide
prevention, the author is not aware of any theoretical work exploring how disclosure
decisions about suicidal cognition are made. However, as referenced earlier, there is an
impressive body of work on disclosure decision-making related to other CSIs. In fact, a
comprehensive, albeit not systematic, review of the literature revealed fourteen disclosure
decision-making models. These theoretical models, many of which seek to explain
31
disclosure decisions among individuals with other stigmatized identities, conditions, and
statuses, were reviewed for potential application to “suicidal ideator” status (e.g., Chaudoir
& Fisher, 2010; Clair et al., 2005; Derlega, Winstead, Greene, Serovich, & Elwood, 2004;
Omarzu, 2000; Ragins, 2008; Serovich, 2001; Serovich, Lim, & Mason, 2008).
Unfortunately, few of these models have received empirical support and/or are amenable
to empirical examination (for exceptions, see Afifi & Steuber, 2009; Greene, 2009).
The Disclosure Decision-Making Model (DD-MM) was developed, in part, to advance
a model that could explain disclosure across changing goals/contexts and would permit
more rigorous scientific evaluation (e.g., having testable hypotheses) (Greene, 2009). The
DD-MM is an information management model that assumes we strategically manage our
private information and is principally applicable to disclosure decisions about
psychological or physical health topics or “conditions” (Greene, 2009). Rooted in the
notion that there needs be greater understanding of disclosure decision-making in
situations of mental health uncertainty, the DD-MM appears particularly applicable to
individuals harboring suicidal cognition, a state that is defined by arguably the most
profound of all mental health uncertainties, namely ambivalence about wanting to live or
die (Shneidman, 1993). The DD-MM proposes that disclosure consists of making three
assessments: (i) an assessment of information, which refers to information related to the
psychological status being disclosed (ii) an assessment of the receiver, which refers to the
relationship quality with a prospective confidant and the anticipated reactions/outcomes
of disclosing to a prospective confidant, and (iii) an assessment of efficacy, which refers to
the discloser’s belief that he/she can perform the act of disclosure to a given target
(Greene, 2009). The DD-MM is largely consistent with extant suicidal disclosure research,
32
acknowledging the role of the discloser and the disclosure confidant (relationship with
target as well as reaction of target to disclosure) in making decisions about disclosure.
Each of these assessments is complex. An assessment of information entails an
evaluation of five information components (i.e., stigma, symptom severity, prognosis,
preparation, and relevance to others), of which stigma and symptom severity are the most
well-established and ostensibly applicable to “suicidal ideator” status. Knowing that
suicide is highly stigmatized (Witte et al., 2010), more so in certain cultures than others
(Eskin, 2003; Morrison & Downey, 2000), and that certain proximal symptom correlates of
suicide (e.g., depression) may affect disclosure (e.g., Zhou & Jia, 2012) provides suggestive
evidence of the applicability of this part of the model to this population. An assessment of
the receiver for the disclosure entails an evaluation of the relationship quality with and
anticipated reaction (i.e., anticipated responses/outcomes) of a prospective confidant
(Greene, 2009). In the context of the DD-MM, anticipated responses are viewed as the
immediate responses to the disclosure whereas anticipated outcomes are viewed as the
longer-term effects of the disclosure (Greene, 2009). Knowing that certain types of
relationships are key to suicidal disclosure (Barnes, Ikeda, & Kresnow, 2001; Encrenaz et
al., 2012) and that individuals refrain from sharing their suicidal experiences due to fear of
being belittled or treated differently (National Suicide Prevention Lifeline, 2007) provides
suggestive evidence of the applicability of this part of the model to this population. An
assessment of disclosure efficacy entails an evaluation of the individual’s perceived ability
to share a specific type of information with a specific confidant (Greene, 2009). Knowing
that suicidal disclosure has been considered a learnable skill (Linehan, 1993; Wasserman
33
et al., 2008) provides suggestive evidence of the applicability of this part of the model to
this population.
An important point of emphasis for the current study is the consideration of DD-MM
in a multi-level framework. As it is conceptualized, DD-MM implies that an individual’s
assessment of information occurs at the individual-level, indicating that individuals make
an assessment about the riskiness of the information and that higher risk information
decreases the likelihood of disclosing to everyone in the social network. However, DD-MM
also points out that the assessment of the receiver and assessment of disclosure efficacy
are performed in reference to a specific social network member. Knowing that individuals
are embedded in social networks implies that disclosure should ideally be examined in a
multi-level framework, accounting for the assessment of information that is occurring at
the individual-level and the assessment of the receiver and disclosure efficacy that is
occurring at the relational-level. Given that disclosure is an activity that invariably occurs
in the context of a social relationship, the study of disclosure should account for both
individual and relational factors in a multi-level framework (Rice et al., 2009). Refer to
Figure 5 for an illustration of the multi-level model.
34

Figure 5. An illustration of the adapted multi-level disclosure decision-making
model (DM-DD) with operationalization using social network methodology. Note the
asterisk (*) for the “Assess Information” component of the DD-MM. This component
is comprised of psychiatric symptom severity and stigma of suicide. Although
psychiatric symptom severity is conceptualized as operating exclusively at the
individual-level, we propose that stigma operates at both the individual-level and
relational-level.

Motivation for Suicidal Disclosure
Although the Disclosure Decision-Making Model was specifically developed to
understand disclosure independent of changing goals or motivation (Greene, 2009),
exploring the potential role of motivation in the suicidal disclosure process is still a
worthwhile endeavor given the notable conceptual and empirical work on the subject (e.g.,
Chaudoir & Fisher, 2010).
35
A motivational component, in the form of goals or reasons, has been featured in
numerous theoretical models seeking to explain disclosure (i.e., Chaudoir & Fisher, 2010;
Clair et al., 2005; Omarzu, 2000; Toth & Dewa, 2014). Early work framed disclosure as a
functional behavior that served as a mechanism to pursue goals and indicated that people
disclose for approval, intimacy, relief, identity, or control (Derlega & Grzelak, 1979).
Omarzu (2000) extended this general perspective by indicating that the accessibility of
different types of social rewards (e.g., an opportunity to get social approval) actually
activates the disclosure decision-making process. Clair and colleagues (2005) identified
similar motives for disclosure (i.e., maintain self-esteem/cope with stress; develop
relationships; arrange accommodation; influence social change), subsuming personal
motives under individual differences that, in combination with the
interpersonal/environmental context, affect disclosure decisions. Toth and Dewa (2014)
framed reasons for disclosure (i.e., interpersonal or other-oriented; work-related;
personal) as being part of an information gathering process that precedes a cost-benefit
analysis in the decision-making process. Adding to the prior theoretical work proposing
that motives affect the decision to disclose, the Disclosure Processes Model (DPM) also
suggests that reasons for disclosure can influence the outcomes of the disclosure (Chaudoir
& Fisher, 2010).
In trying to understand the impact of motivation on disclosure and disclosure
outcomes, there have been two particularly helpful ways of classifying goals in the
disclosure literature. Informed by a functional perspective of disclosure, Derlega and
colleagues (1993) proposed that the reasons people choose to disclose or not disclose can
be understood as being focused on the self, other, or relationship. Similarly, Garcia and
36
Crocker (2008) suggest that people tend to be oriented toward egosystem or ecosystem
goals (i.e., self-image- or compassion-oriented relationship goals)—people oriented toward
egosystem goals are focused on satiating their own needs and prioritize their own needs
over the needs of others whereas people who adopt ecosystem goals are focused on
satiating the needs of others and prioritize others’ needs and their own needs. Generally,
people who adopt ecosystem (i.e., other-oriented) goals elicit more positive reactions to
disclosure and experience more positive outcomes in other domains (e.g., health, mental
health, relationship) than those who adopt egosystem (i.e., self-oriented) goals (Chaudoir &
Fisher, 2010; Garcia & Crocker, 2008). There is some indication that people with
egosystem goals disclose less than people with ecosystem goals (Garcia & Crocker, 2008).
Of note, there are other ways to classify goals or motivation (e.g., approach/avoidance).
Although there are exceptions (e.g., Garcia & Crocker, 2008), studies pertaining to
disclosure motives among people with stigmatized statuses have often been descriptive in
nature (Chaudoir & Fisher, 2010). Informed by the functional perspective of disclosure,
Derlega and colleagues conducted a series of studies to delineate specific self-, other-, and
relationship-oriented reasons for and against disclosure among people with HIV/AIDS
(Derlega & Winstead, 2001; Derlega et al., 2004; Derlega, Winstead, & Folk-Barron, 2000;
Derlega, Winstead, Greene, Serovich, & Elwood, 2002). This research identified the
following specific reasons for disclosure: catharsis and seeking help (i.e., self-oriented);
duty to inform and educating others (i.e., other-oriented); testing others’ reactions,
building relationships, and shared experiences (i.e., relationship-oriented). Additionally,
this research identified the following specific reasons for non-disclosure: self-blame, fear of
rejection, privacy, communication difficulty (i.e., self-oriented); protecting others (i.e.,
37
other-oriented); superficial relationship (i.e., relationship-oriented). Of note, this
functionalist classification system can easily accommodate the majority of disclosure
motives identified by the disclosure theories reviewed earlier in this section.
Similar to research on disclosure goals among people with other stigmatized
statuses, investigations into the disclosure goals of suicidal ideators have been largely
descriptive in nature. The few studies that exist on the subject of motivation focus on
reasons for non-disclosure. In a sample of college students, the major reasons (in order) for
non-disclosure of suicidal cognition that emerged from qualitative interviews included the
perception that their suicidal thoughts were not serious (i.e., low risk), not wanting to
worry or burden others, preference for privacy, lack of utility, stigma, shame, and other
repercussions (Burton, Hess, & Becker, 2012). In an international sample of high school
students, the major reasons for non-disclosure selected from a pre-determined list of
reasons (in order) included the lack of utility, fear of what others would think of them (i.e.,
stigma/shame), perception that their suicidal thoughts were not serious, and fear of what
others would think about their family (Eskin, 2003).
Summary: What We Know and (More so) Don’t Know About Suicidal Disclosure
The study of suicidal disclosure remains less mature than other branches of
Suicidology (Zhou & Jia, 2012). Aside from the fact that we clearly do not know enough
about suicidal disclosure in the highly vulnerable population of people with serious mental
illness and lived experience with suicidal crisis, there are several areas in which this
underdevelopment is particularly noteworthy.
Although my review of prevalence rates clearly demonstrates that researchers have
long been interested in knowing how common it is for people in suicidal crisis to
38
communicate about their suicidal cognition (i.e., individual-level prevalence), no studies
except the preliminary study for this dissertation (see Methods section) have investigated
how common it is for social network members to be identified as confidants for disclosure
(i.e., relational-level prevalence). Social network studies capable of assessing the relational-
level disclosure prevalence of other stigmatized statuses (primarily HIV/AIDS) have found
that participants disclose to between 54% and 75% of social network members
(Cederbaum, Rice, Craddock, Pimental, & Beaver, 2015; Hoover et al., 2016; Latkin et al.,
2012; Rice et al., 2009; Tieu et al., 2015; Zang, He, & Liu, 2015). If relational-level
prevalence is interpreted as an indication of transparency to social network members
about suicide risk status then this metric can help to understand the potential readiness of
personal social networks to intervene or, alternatively, the potential burden on personal
social networks. See Figure 6 for a visual depiction of individual-level and relational-level
prevalence.

Figure 6. An illustration of individual-level versus relational-level prevalence. This
39
figure illustrates the units that are used to calculate the proportions that represent
disclosure prevalence rates in a multi-level context.

Turning to an issue of communication content, although there is available
information about patterns of communicating suicidal cognition, it is difficult to ascertain
how common it is for people to disclose different types of suicidal cognition (i.e., active
suicidal thoughts, plan, and intent). The state of the suicide nomenclature over time has
certainly contributed to the ambiguity surrounding the disclosure of different types of
suicidal cognition. Most suicide researchers have lamented the absence of definitions or the
presence of contradictory definitions pertaining to suicide-related terms, which make
comparisons across studies downright untenable (Silverman et al., 2007). The laudable
nomenclature developed by O’Carroll and colleagues (1996) as well as Silverman and
colleagues (2007) does little to resolve nomenclature issues that arise when comparing
studies that predate these recent advancements. To put it simply, it is impossible to know
what most researchers meant with terms like suicidal ideation, intent, and plan (and all
suicidal behaviors), which makes it impossible to assess whether disclosure prevalence
varies across suicidal cognition types. Even if we take the suicide-related terms at face
value (i.e., we impute our contemporary meanings into terms missing explicit definitions),
most studies claim to be about the communication of suicidal intent
4
, which might not
translate to the other major types of suicidal cognition, including non-specific active suicidal
thoughts
5
and plan
6
(Posner et al., 2008). Given that different types of suicidal cognition
signal being at different points on a suicide risk continuum or trajectory (e.g., Mundt et al.,

4
Suicidal intent refers to thoughts that indicate some level of determination to kill oneself (Silverman et al., 2007).
5
Non-specific active suicidal thoughts refer to general thoughts that indicate a desire to end one’s life or kill oneself
(Posner et al., 2008).
6
Suicidal plan refers to thoughts that indicate a designed set of actions to kill oneself (Silverman et al., 2007).
40
2013)—with suicidal plan being nearest to suicidal behavior and active suicidal thoughts
being furthest from suicidal behavior (Baca-Garcia et al., 2011; Posner et al., 2008)—not
knowing whether disclosure practices are contingent upon cognition type represents a
knowledge gap with potentially dangerous implications. After all, differential disclosure
across cognition type can impact the accuracy of suicide risk assessment and associated
risk management strategies.
Turning to an issue related to the discloser, although the comprehensive literature
review discussed earlier revealed very tenuous support for the association between
individual characteristics and suicidal disclosure, there are vital steps that still need to
taken before any confident conclusions can be drawn about the role of individual
characteristics. The reality is that there are three plausible explanations for the tenuous
findings, including that: (a) the “right” individual-level characteristics have not yet been
studied; (b) the relationship between individual-level characteristics and disclosure is
indirect; and/or (c) individual-level characteristics simply do not play a major role in
disclosure. Given that studies of suicidal disclosure have not included a number of
individual-level variables found to strongly influence the disclosure of other stigmatized
statuses, such as perceived stigma and social support (Smith, Rossetto, & Peterson, 2008;
Rice et al., 2009), it seems prudent to test their predictive value in a suicide context.
Clarifying the role of individual characteristics in suicidal disclosure practices is key to
designing appropriate clinical strategies to help facilitate disclosure. It should be noted that
the striking inconsistency in the sets of individual-level variables across studies
compromises efforts to understand the isolated or relative influence of variables.
41
Turning to an issue related to the disclosure target, although we know that
individuals tend to selectively disclose to people in certain social roles (e.g.,
spouse/partner; Martin et al., 2013; Robins et al., 1959), almost nothing else is known
about the association between the characteristics of confidants or characteristics of the
relationship with confidants and suicidal disclosure. This is perplexing given that
disclosure necessarily occurs between two people that share some form of social tie
7
and
that social network studies of other stigmatized statuses have shown that the attributes of
and relationships with social network members affect disclosure (e.g., Rice et al., 2009).
Research on privacy management also clearly demonstrates that certain relationship
qualities (e.g., trust) promote disclosure (Derlega et al., 1993). Although the previous work
on social roles is helpful because it can guide targeted interventions for groups occupying
social roles that are attractive or unattractive as prospective confidants, there are two
things that deserve consideration for the current study. First, the distribution of social roles
in the social networks of a given population could influence patterns of disclosure. In the
case of people with serious mental illness, their social networks tend to be comprised of
more family but less spouses/partners, which arguably alters the landscape of highly-
valued prospective confidants. Second, by exclusively assessing social roles, the implicit
assumption is that all people occupying a social role are alike. This could lead to broad-
based and inefficient intervention efforts based on role status instead of targeted efforts
based on better indicators of confidant attractiveness. Relatedly, this could result in
overlooking more mutable relationship factors that could benefit from intervention (e.g.,
social support).

7
This can even refer to a temporary tie or exchange, which is reflected in Simmel’s (1950) proposition that it may be
easier to open up with a “passing stranger” than friends or family.
42
Turning to an issue related to disclosure reactions, although extant studies provide
descriptive accounts of common disclosure reactions, no known studies have investigated
the association between anticipated disclosure reactions and suicidal disclosure. This is a
major shortcoming given that research on other stigmatized statuses has shown that
disclosure reaction is central to understanding disclosure decision-making and outcomes
(Chaudoir & Fisher, 2010). For example, experimental research that involves people with
other stigmatized statuses indicates that the benefits of disclosure are not observed when
reactions are neutral or negative (Lepore, Ragan, & Jones, 2000; Rodriguez & Kelly, 2006).
Knowing that anticipated reactions figure in the mental calculus of risk assessment when
making disclosure decisions about other stigmatized statuses (Greene, 2009), it is crucial to
investigate their role in suicidal disclosure.
Turning to methodological issues, there are two points that deserve attention. Given
the pronounced tendency to treat disclosure as a dichotomous personal attribute or
behavior, disclosure has predominantly been assessed using dichotomous measures. Using
a dichotomous measure of disclosure as an outcome makes evaluating the explanatory
power of a set of variables (e.g., variance explained) more challenging than if a continuous
measure of disclosure were used as an outcome. Research also indicates that using a
continuous measure for intent is more appropriate than a dichotomous measure. In
addition, although prior studies have demonstrated the relevance of individual (e.g.,
discloser correlates) and relational factors (e.g., disclosure target correlates, disclosure
reactions), these factors have not been assessed using a method that can obtain
information that permits an appropriate examination of their relative influence on suicidal
disclosure; social network methodology is ideal for obtaining information about individuals
43
and their social ties and is amenable to the appropriate treatment of disclosure with
multilevel modeling (e.g., Snijders, Spreen, & Zwaagstra, 1995).
Turning lastly to issues of theory and disclosure motivations in the context of
suicidal disclosure, two brief comments can capture the state of the literature in these
areas. First, although there is an impressive body of conceptual and theoretical work on
disclosure of other stigmatized statuses, there has been no known theory-driven research
that seeks to explain suicidal disclosure. Second, although there have been studies that
investigate motives pertaining to suicidal disclosure, the studies that exist have exclusively
focused on reasons against disclosure. Therefore, in contrast to research on other
stigmatized statuses, there is no known work on motivations for suicidal disclosure that
incorporates reasons for and against disclosure. Also, no known studies have focused on
disclosure motivations in a high-risk sample of people with serious mental illness.
Specific Aims and Hypotheses
Based on the suicidal disclosure literature, the purposes of this study are to
elucidate patterns of and motivations related to suicidal disclosure and to better
understand the role of individual and relationship factors in suicidal disclosure. Aside from
the descriptive aims to explore disclosure patterns and motivations as well as the aim to
investigate disclosure using a set of non-theory-informed variables (for comparison
purposes), the specific aims and hypotheses are informed by the Disclosure Decision-
Making Model, which provides an organizing framework that is consistent with extant
suicidal disclosure and, critically, is amenable to rigorous scientific examination. The
specific aims and hypotheses are restated immediately below.

44
AIM 1: To describe the patterns of suicidal disclosure
The purpose of Aim 1 is to characterize the prevalence and consistency of disclosure across
suicidal cognition type and relationship type in a multi-level context. The subaims are
immediately below. This aim is largely exploratory and thus does not justify any hypotheses.
1a) To determine the proportion of people disclosing to at least 1 person in their social
network (i.e., individual-level disclosure prevalence)
1b) To determine the proportion of social network members identified as confidants
for disclosure (i.e., relational-level disclosure prevalence)
1c) To describe the disclosure prevalence of different types of suicidal cognition
1d) To describe the disclosure prevalence in the context of different types of
relationships inside and outside of social networks
Aim 2: To examine the association between a set of non-theory-informed variables
and intended suicidal disclosure
The purpose of Aim 2 is to identify correlates and quantify the explanatory power of a
disclosure model using a non-theory-informed approach. Variables were primarily considered
for inclusion if they met any of the following three criteria: (a) individual-level variables being
in “common use” (defined in Chapter 2) in prior suicidal disclosure research; (b) individual-
level variables commonly linked to suicide outcomes; or (c) network-level variables included
in prior network research of suicidal disclosure. Because the primary aim of this dissertation
is to examine the association between the Disclosure Decision-Making Model variables and
suicidal disclosure, the set of non-theory-informed variables is not meant to be inclusive of all
variables meeting the aforementioned criteria. It is meant to approximate the atheoretical,
“scattershot” approach that has traditionally been used in research on suicidal disclosure.
45
Another way to think about this aim is that it is predominantly meant to serve as a standard
of comparison for the subsequent Disclosure Decision-Making Model approach. This aim is
largely exploratory and thus does not justify any hypotheses.
Aim 3: To examine the association between the information component of the
Disclosure Decision-Making Model and intended suicidal disclosure
The purpose of Aim 3 is self-evident. The subaims are immediately below followed by
hypotheses for these subaims. See Figure 4 for illustration of DD-MM and related hypotheses.
3a) To examine the association between stigma of suicide and intended disclosure
Hypothesis 1a: Higher levels of stigma will be associated with decreased disclosure
intent
3b) To examine the association between symptom severity and intended disclosure
Hypothesis 1b: Greater severity of symptoms will be associated with increased
disclosure intent
Aim 4: To examine the association between the receiver component of the Disclosure
Decision-Making Model and intended suicidal disclosure
The purpose of Aim 4 is self-evident. The subaims are immediately below followed by
hypotheses for these subaims. See Figure 4 for illustration of DD-MM and related hypotheses.
4a) To examine the association between the quality of relationship with prospective
confidant and intended disclosure
Hypothesis 2a: Higher relational quality will be associated with increased disclosure
intent
4b) To examine the association between the anticipated reaction (comprised of
anticipated response and anticipated outcome) of the prospective confidant and
46
intended disclosure
Hypothesis 2b: More positive anticipated reaction will be associated with increased
disclosure intent
Aim 5: To examine the association between the disclosure efficacy component of the
Disclosure Decision-Making Model and intended suicidal disclosure
The purpose of Aim 5 is self-evident. The hypothesis for this aim is immediately below. See
Figure 4 for illustration of DD-MM and related hypotheses.
Hypothesis 3: Higher disclosure efficacy will be associated with increased disclosure
intent
Aim 6: To describe reasons for and against the suicidal disclosure
The purpose of Aim 6 is self-evident. This aim is largely exploratory and thus does not justify
any hypotheses.

47
CHAPTER THREE:
METHODS
Data Source Overview
This dissertation was a cross-sectional study that sought to understand patterns and
correlates of suicidal disclosure among people with a serious mental illness who had
survived a prior suicidal crisis (i.e., a history of suicidal ideation or suicide attempt). The
study employed a social network interview and a battery of self-report measures. This
dissertation represents the first study to comprehensively examine patterns of suicidal
disclosure and to adopt a theory-informed approach to identify factors that influence
suicidal disclosure. To inform the dissertation, the following two research-related activities
were undertaken. First, a preliminary study was conducted to establish the value of using
social network methodology and incorporating both individual and relationship data in the
study of suicidal disclosure. Second, a pilot study was conducted to test the study logistics
and the viability of the measurement protocol in the study setting.
The PI for the current study is the author of the dissertation. The study received
approval from the Institutional Review Board at the University of Southern California and
from the Human Subjects Committee at the Los Angeles County Department of Mental
Health. All study materials are available from the author upon request.
Preliminary and Pilot Studies
The preliminary study used data gathered during the course of a parent study that
focused on understanding the community integration of people with serious mental illness.
Using survey and social network data, the preliminary study focused on exploring suicidal
disclosure patterns and identifying individual-level and relational-level correlates of
48
disclosure in the context of a multilevel framework. The sample for the study was recruited
from two mental health clinics in Los Angeles County and consisted of 30 individuals (Level
2) who nominated 436 network members (Level 1). The majority of individuals had
disclosed their suicidal thoughts to someone in the past (77%), and they all indicated an
intention to disclose to someone in their social network if they were to experience suicidal
thoughts in the future. Interestingly, less than one-quarter of social network members were
identified as prior or intended confidants for disclosure. This meant that the participants
adopted a highly selective process of disclosure (1-2 confidants). Multilevel modeling
revealed that individual factors were less central to disclosure than relational factors.
People of color reported significantly lower disclosure intentions than people who
identified as Non-Hispanic White. Compared to family members, mental health
professionals were more likely to be identified as targets for intended disclosure. Social
network members who were perceived as sources of social support were identified as
more attractive targets for intended disclosure than social network members not perceived
as sources of social support (Fulginiti et al., 2015).
The pilot study included 5 people with a serious mental illness and a history of
suicide attempt who were recruited from a suicide attempt survivors group at a large
mental health center in southern California. The purpose of the pilot was to test the study
instrument and logistics. This included asking about the clarity of directions; clarity and
completeness of survey questions; the overall experience with and burden of the interview
process; and recommendations for changes to the process. The total time of pilot
interviews was between 75 and 100 minutes. Although the study procedures were well-
tolerated and the feedback was overwhelmingly positive (e.g., participants expressing an
49
interest in hearing about the findings), a decision was made to make two minor
modifications to the data collection processes to decrease the length of the interview. First,
a response sheet was developed to expedite the collection of the social network data.
Second, because the majority of social network interview questions had Likert-scale
response options, a couple of participants reported that it was somewhat challenging to
remember the question while thinking about their response in reference to each social
network member. To address this issue, laminated cards for each social network interview
question were created and placed in front of the participant while they were responding.
Recruitment of the Sample for the Current Study
The current study was conducted at a single site of a large mental health agency in
southern California. Before beginning the study, several meetings were held with agency
staff to gain approval for the study, to inform them about study logistics, to get their
suggestions, and to enlist their participation in study recruitment.
The sample for the current study was comprised of 45 individuals receiving
traditional outpatient psychiatric care services (i.e., medication management, therapy or
counseling, and case management) in the context of an office setting. A purposive sampling
strategy was employed. To be eligible for the study, individuals had to meet the following
inclusion criteria: (1) have a history of suicide attempt or suicidal ideation; (2) have been
diagnosed with one of three serious mental illnesses, including Major Depressive Disorder,
Bipolar Disorder, or Schizophrenia; (3) be an adult that is at least 18 years of age; (4) be
English-speaking; (5) and be an existing client at the agency where the recruitment was
undertaken.
50
In an effort to maximize confidentiality, clinicians at the agency were asked to
identify and refer all individuals who met the inclusion criteria and were interested in
participating in the study. To bolster the recruitment process, the PI and agency
supervisors worked with clinicians and intake staff to promote consistent screening and
referral efforts. Laminated cards with inclusion criteria and a script for introducing the
study were distributed to clinicians. Upon receipt of a referral, the PI contacted the
prospective participant to confirm their interest and schedule a meeting to obtain informed
consent and complete the data collection. The informed consent and data collection
procedures were completed during a single meeting at the mental health agency. In terms
of duration, interviews ranged from approximately 60 to 75 minutes. Modifications to the
social network procedures based on the pilot study helped to shorten the overall interview
time by, on average, 15 minutes. The PI conducted all interviews.
The data reported herein were collected between July of 2015 and February of
2016. During that timeframe, 53 individuals who met criteria for the study were referred
to the PI. The PI was able to successfully establish contact with 47 of the 53 individuals. Of
the 47 individuals who were approached by the PI, only 2 declined to participate.
Therefore, the participation rate was 96% for the present study, with a final sample of 45.
Post-Informed Consent Procedures
Pre-Briefing & De-Briefing Activity. Informed by the work of Linehan and
colleagues (2012), each consented individual was engaged in a short pre-briefing activity
(1-2 minutes) before data collection and a de-briefing activity (1-2 minutes) after data
collection. The pre-briefing activity consisted of asking participants to identify a “mood
induction activity” (e.g., listening to soothing music, taking a quiet break) that would be
51
helpful in the event that they felt uncomfortable during the interview. The de-briefing
activity consisted of offering a “mood induction activity” to participants after the interview
and asking them about their experience with the research interview.
Suicide Risk Screening & Management. All participants were screened for suicide
risk before beginning data collection to ensure that participants entering the research
interview were not in need of immediate clinical intervention. Every participant was asked
an initial question, derived from the PHQ-9 questionnaire, that assessed for frequency of
suicidal thoughts over the past 2 weeks, ranging from 0 (“Not at All”) to 3 (“Nearly Every
Day”). Informed by the work of Simon and colleagues (2013), a score of 2 (“More than Half
the Days”) or 3 (“Nearly Every Day”) was set as a threshold for immediate referral to an on-
site mental health provider. A score of 1 (“Several Days”) prompted a second question,
informed by Linehan and colleagues (2012), which asked about whether or not the
participant was bothered by or thought that he/she might act on their suicidal thoughts. An
affirmative response to the second question also represented a threshold for immediate
referral to an on-site mental health provider. As part of the protocol, all participants were
provided with contact information for the National Suicide Prevention Lifeline at the end of
the interview in case they needed assistance in the future.
Ethical Approach to the Study
Although only a minority of participants experience distress following participation
in psychiatric research (Jorm, Kelly, & Morgan, 2007) and participation in suicide-related
research does not increase the risk for suicidal ideation or suicidal behavior (Smith,
Poindexter, & Cukrowicz, 2010; Eynan et al., 2013; Reynolds et al., 2006), the study
protocol was developed to be consistent with recommendations for the ethical conduct of
52
suicide-related research (e.g. Lakeman & Fitzgerald, 2009a; Lakeman & Fitzgerald, 2009b;
Vannoy et al., 2010) to maximize participant comfort and safety.
The study protocol was consistent with the following recommendations: (a) there
was a clear procedure for assessing and managing suicide risk; (b) the informed consent
process included a clear explanation that the topic of suicide would be discussed as part of
the study and about the boundaries of confidentiality; (c) there was an opportunity for pre-
briefing and de-briefing; (d) the only research staff member working on the project (the PI)
was a trained clinician who had completed a graduate-level, clinical Master of Social Work
program and had experience working with this population; (e) clinical support was
available at all times during interviews by conducting the interviews at the mental health
agency where participants received psychiatric care; (f) participants were provided with
the contact information for the National Suicide Prevention Lifeline in case they needed
assistance at any time in the future.
Data Collection
The data collection consisted of two distinct parts, Part 1: Social Network Interview
(hereafter referred to as “Network Interview”) and Part 2: Self-Report Survey (hereafter
referred to as “Survey”). Each part of the data collection procedure (Network Interview and
Survey) is described immediately below. A measures section then describes each measure
in detail and indicates whether that measure was used as part of network interview or
survey.
Part 1: Social Network Interview. A social network interview script was used to
gather information about the characteristics of participants’ social networks, including
information about participants’ network members, relationships with network members,
53
and overall social networks (i.e., network-level variables). A “Name Generator” (described
below) was used to obtain a list of nominated persons that comprise the social network of
the participant. After participants finished nominating persons in their social network, a
“Name Interpreter” was used to ask about their relationship with (network- or relational-
level variables) and attributes of each nominated person. The questions primarily focused
on assessing the outcome of interest (e.g., intended disclosure inside network) and the
Disclosure Decision-Making Model variables (i.e., stigma, relationship quality, anticipated
reaction, and disclosure efficacy) but also assessed for a set of non-theory-informed
variables (e.g., relationship type, social support) based on their inclusion in our preliminary
social network study of suicidal disclosure (Fulginiti et al., 2015) or their general relevance
in network studies (e.g., Granovetter, 1973; McPherson, Smith-Lovin, & Cook, 2001). All
responses to the network interview questions were recorded on a large piece of paper and
accompanying response sheet. The Network Interview yielded “egocentric” network data.
Examples of studies using similar network methodology in the SMI population can be
referenced elsewhere (Biegel, Pernice-Duca, Chang, & Angelo, 2013; Chang et al., 2014).
The Name Generator that was used in this study read as follows: “Think about the
last month. I want to know about the people you have spent time with or talked with (in-
person; phone; email;text;online). This could include people who helped you out or you
helped out, people who made you feel good or bad, and others who have played a part in
your life” (Biegel et al., 2013). Subsequently, a list of possible network member roles was
read to the participant, which included, “friends; family; case worker or other agency staff;
people you know from your neighborhood; boyfriend/girlfriend; husband/wife; intimate
partner; people from school; people from work”.
54
The name generator in this study was selected for several reasons. First, it has been
used (Biegel et al., 2013) and refined over the course of several years in this population (D.
Biegel, personal communication, May 29, 2014), which is beneficial because social network
studies are relatively uncommon among people with serious mental illness. Second, it
addresses a criticism of most name generators, namely that they tend to neglect negative,
conflictive, or aversive social exchanges or relationships; this can bias the network toward
the inclusion of “positive” relationships (Straits, 2000). The use of this more balanced name
generator was considered to be particularly vital among people with serious mental illness
whose social relationships can often be strained and produce negative social capital (i.e.,
conflict, demands; Hawkins & Abrams, 2007). Third, it used a timeframe (“last month”) that
helps to maximize measurement precision; for example, there is minimal discrepancy
between global estimates of network size (i.e., Asking the participant, “How many people
have you interacted with in the last 30 days?”) and network size calculated based on
naming network members (Directing the participant to “Tell me the names of everyone you
interacted with in the last 30 days” and then summing the number of people in the
network) over a 30-day period but greater discrepancy with longer measurement windows
(Bell, Belli-McQueen, & Haider, 2007).
Part 2: Self-Report Survey. A self-report survey was used to gather information
pertaining to characteristics of the individual participants (i.e., individual-level variables).
The survey focused primarily on assessing the outcome of interest (i.e., intended disclosure
outside network as well as Reasons for and Against Suicidal Disclosure) and the Disclosure
Decision-Making Model variables (i.e., stigma toward suicidal behavior and psychiatric
symptom severity) but also assessed for a set of non-theory-informed variables that have
55
been in common usage in suicidal disclosure research (e.g., age and psychiatric
hospitalization) or have been associated with suicide outcomes (e.g., hopelessness and
perceived burdensomeness).
Measures
Suicidal Disclosure. Intent to disclose suicidal cognition and prior disclosure of
suicidal cognition were assessed. Suicidal disclosure was also assessed both inside and
outside of participants’ personal social networks. The disclosure measures are reviewed in
the following order: (a) intended disclosure inside network; (b) intended disclosure outside
network; (c) prior disclosure inside network; (d) prior disclosure outside network.
Intended Disclosure Inside Social Network (Network Interview Measure). Intent
to disclose suicidal cognition inside the social network was measured with 3 questions. The
specific questions asked about their intent to disclose non-specific active suicidal thoughts,
suicidal plan, and suicidal intent. An example question for non-specific active suicidal
thoughts read as follows, “If you were to have thoughts about killing yourself in the future,
how likely is it that you would talk to the person about those thoughts?” Each question was
asked in reference to each social network member and rated on a 7-point Likert scale,
which ranges from 1 (Extremely unlikely) to 7 (Extremely likely). Item scores were added
to create a sum score that ranged from 3 to 21, with higher scores indicating a higher
likelihood of disclosing suicidal cognition. The items were developed by the author for this
study but were informed by the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et
al., 2008) and the General Help-Seeking Questionnaire (GHSQ; Wilson, Deane, Ciarrochi, &
Rickwood, 2007). The internal reliability (Cronbach’s alpha) for the measure was .87 in the
current study.
56
Intended Disclosure Outside Social Network (Survey Measure). Intent to disclose
suicidal cognition outside of the social network was assessed with an adapted version of
the General Help-Seeking Questionnaire (GHSQ; Wilson et al., 2007). The GHSQ was
originally developed to measure the intent to seek help for suicidal cognition and was
adapted to measure the intent to disclose suicidal cognition. The purpose of including this
measure in the current study was to assess the intent to disclose suicidal cognition to
different types of services or people occupying different types of social roles that may not
be defined in a participant’s current social network. Each item is measured on a 7-point
Likert scale that ranges from 1 (Extremely unlikely) to 7 (Extremely likely) and indicates
the intent to disclose to a particular type of service or social role. Consistent with the GHSQ
authors’ recommendation (Wilson et al., 2007), the sources were adapted to the target
population of the study. The current study used data from six items, meaning that
participants were asked about their intent to disclose to six different types of services and
social roles; this included medical doctor, spiritual counselor, peer suicide attempt
survivor, phone helpline, online help service, and emergency room.
Prior Disclosure Inside Social Network (Network Interview Measure). Prior
disclosure of suicidal cognition inside the social network was measured with 3 questions.
First, participants were asked whether they disclosed their prior suicidal cognition to each
of their social network members. Second, participants were asked to indicate whom they
first told about their suicidal cognition; this provided information about how many “first
confidants” were still in the social networks of participants. Third, participants were asked
about the overall quality of their first disclosure experience (rated from 1=Very negative to
57
5=Very positive). Chaudoir and Fisher (2010) informed the use of the item pertaining to
quality of prior disclosure.
Prior Disclosure Outside Social Network (Survey Measure). Prior disclosure of
suicidal cognition outside of the social network was assessed with a single question. The
question asked the participant to indicate how many people they disclosed to in the past
who were not included in their current social network (i.e., the network identified by the
network interview).
Information Component of DD-MM. The Information Component of the
Disclosure Decision-Making Model was comprised of an assessment of perceived stigma of
suicidal behavior and psychiatric symptom severity.
Stigma of Suicidal Behavior (Survey Measure). The perceived stigma of suicidal
behavior was measured with the 12-item Stigma of Suicide Attempt scale (STOSA; Scocco et
al., 2012). This scale was adapted from the Devaluation–Discrimination scale (Link et al.,
1989) that assessed general attitudes toward mental illness by asking what “most people”
would think, which is a semantic structure that is expected to limit social desirability bias
due to the indirect approach of measuring a sensitive issue (Scocco et al., 2012). For each
item, the respondent was asked to read a statement about someone who attempted suicide
and rate how much they agree or disagree with the statement, ranging from 1 (Totally
agree) to 4 (Totally disagree). Item scores were added to create a sum score that ranged
from 12 to 48, with higher scores indicating higher perceived levels of stigma toward
people who attempt suicide. The psychometric properties of the scale were originally
studied and shown to be acceptable among psychiatric outpatients (Scocco et al., 2012).
The internal reliability (Cronbach’s alpha) for the measure was .86 in the current study.
58
Psychiatric Symptom Severity (Survey Measure). Psychiatric Symptom Severity
was assessed with the Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983),
which is a 53-item self-report questionnaire that measures psychiatric symptom distress.
For each item, the respondent was asked the extent to which he/she experienced distress
related to the defined symptom over the past week, ranging from 1 (Not at all) to 5
(Extremely). The scale has been used extensively in studies focusing on the population of
individuals with serious mental illness (e.g., Brekke, Levin, Wolkon, Sobel, & Slade, 2003;
Long, Harring, Brekke, Test, & Greenberg, 2007). The BSI permits the calculation of global
psychiatric symptom severity as well as nine subscales. Good alpha coefficients have been
reported for all nine subscales, ranging from .71 to .85 (Croog et al., 1986; Derogatis &
Melisaratos, 1983). The internal reliabilities (Cronbach’s alpha) for the global scale and
subscales in the current study are as follows: global psychiatric severity (.81); Somatization
(.79); Obsessive-Compulsive (.68); Interpersonal Sensitivity (.64); Depression (.81);
Anxiety (.73); Hostility (.64); Phobic Anxiety (.70); Paranoid Ideation (.55); Psychoticism
(.65).
Receiver Component of DD-MM. The Receiver Component of the Disclosure
Decision-Making Model was comprised of an assessment of relational quality with each
social network member and the anticipated reaction—which itself is constituted of
anticipated response and anticipated outcome—of each social network member to a
suicide-related disclosure. Anticipated response refers to the short-term consequences of
the disclosure (e.g., How will the social network member immediately react to the
participant’s disclosure?) whereas anticipated outcome refers to the longer-term
59
consequences of the disclosure (e.g., Will the social network member view the participant
differently in the long run because of the disclosure?)
Relational Quality (Network Interview Measure). The perceived quality of
relationships with social network members was measured with 4 items. Participants were
asked to rate the extent to which they agree or disagree with the following statements: (1) I
enjoy spending time with this person (2) I am not close to this person (3) This person’s
opinion is important to me (4) This relationship is satisfying to me. Each statement was
rated on a 5-point Likert scale, which ranges from 1 (Strongly agree) to 5 (Strongly
disagree). Item scores were added to create a sum score that ranged from 4 to 20, with
higher scores indicating a better perceived quality of relationship. The developers of the
DD-MM and their colleagues have employed similar measures, which were adapted from
from Vangelisti and Caughlin (1997), in their research (e.g., Greene et al., 2012). Similar
questions have been used in studies that focus on individuals with a serious mental illness
and employ social network methodology (Beigel et al., 2013). The internal reliability
(Cronbach’s alpha) for the measure was .81 in the current study.
Anticipated Response (Network Interview Measure). The anticipated response of
social network members to a suicide-related disclosure was measured with 6 items.
Participants were asked to rate the extent to which they agree or disagree with the
following statements: (1) This person would immediately offer me emotional support; (2)
This person would immediately judge me; (3) This person would immediately have a
positive emotional reaction; (4) At first, this person would have a negative emotional
reaction; (5) At first, this person would refuse to discuss the information; and (6) Initially,
this person would avoid talking about this information. Each statement was rated on a 6-
60
point Likert scale, which ranges from 1 (Strongly agree) to 6 (Strongly disagree). Item
scores were added to create a sum score that ranged from 6 to 36, with higher scores
indicating an expectation of more favorable responses to suicidal disclosure. Magsamen-
Conrad’s innovative work (2012) informed the selection of items for this measure. The
internal reliability (Cronbach’s alpha) for the measure was .84 in this study. For descriptive
purposes, these items could be further grouped into the following types of responses: social
support (Items 1 and 2); emotional reaction (Items 3 and 4); and avoidance (Items 5 and
6). Refer to Magsamen-Conrad (2014) for an excellent discussion of anticipated responses.
Anticipated Outcome (Network Interview Measure). The anticipated outcome of
sharing suicidal cognition with social network members was measured with 6 items.
Participants were asked to rate the extent to which they agree or disagree with the
following statements: (1) Revealing this information would ultimately harm the way this
person sees me; (2) Telling would negatively affect how this person would feel about me
down the road; (3) It would ultimately hurt this person’s feelings if he/she knew the
information; (4) Ultimately, this person would worry about me if I told him/her; (5) Telling
the information to this person would ultimately hurt our relationship; and (6) Ultimately,
this person would no longer like me if he/she knew the information. Each statement was
rated on a 6-point Likert scale, which ranges from 1 (Strongly agree) to 6 (Strongly
disagree). Item scores were added to create a sum score that ranged from 6 to 36, with
higher scores indicating an expectation of more favorable outcomes following suicidal
disclosure. Magsamen-Conrad’s innovative work (2012) informed the selection of items for
this measure. The internal reliability (Cronbach’s alpha) for the measure was .80 in this
study. For descriptive purposes, these items could be further grouped into the following
61
types of outcomes: discloser-oriented (Items 1 and 2); receiver-oriented (Items 3 and 4);
and relationship-oriented (Items 5 and 6). Refer to Magsamen-Conrad (2014) for an
excellent discussion of anticipated outcomes.
Disclosure Efficacy Component of DD-MM. The Disclosure Efficacy Component of
the Disclosure Decision-Making Model was comprised exclusively of an assessment of one’s
perceived disclosure efficacy when sharing suicidal cognition with each network member.
Suicidal Disclosure Efficacy (Network Interview Measure). Perceived efficacy
about disclosing suicidal cognition to social network members was measured with 3 items.
Participants were asked to rate the extent to which they agree or disagree with the
following statements: (1) I would have trouble finding the right words if I tried to share
this information with this person; (2) I would get tongue-tied if I tried to share this
information with my friend; and (3) I wouldn’t know how to put this information into
words. Each statement was rated on a 5-point Likert scale, which ranges from 1 (Strongly
agree) to 5 (Strongly disagree). Item scores were added to create a sum score that ranged
from 3 to 15, with higher scores indicating a higher perceived level of efficacy with
communicating about their suicidal cognition. The developers of the DD-MM and their
colleagues have employed similar measures (e.g., Greene et al., 2012; Magsamen-Conrad,
2012). The internal reliability (Cronbach’s alpha) for the measure was .94 in this study.
Non-Theory-Informed Variables (Network Interview and Survey Measures).
The set of non-theory-informed variables were selected for any of the following reasons:
(1) individual-level variables being in “common use” (defined in Chapter 2) in prior
suicidal disclosure research; (2) individual-level variables commonly linked to suicide
outcomes; or (3) network-level variables included in prior network research of suicidal
62
disclosure (i.e., my preliminary study). To reiterate, this is not intended to be an exhaustive
list of variables meeting these criteria because such a list would be prohibitively long for
inclusion. Of note, some variables meet more than one of these criteria (e.g., prior suicide
attempt meets criteria 1 and 2) but are only included in one category below to limit
redundancy.
Variables from Prior Suicidal Disclosure Research. Sociodemographic variables
that have been commonly studied in prior suicidal disclosure research include age, gender,
marital status, education, and race/ethnicity. Participants were asked to state their age,
which was treated as a continuous variable for analysis. Participants were asked to
indicate their gender, which was dichotomized into values of 0 (male) and 1 (female) for
analysis. Participants were asked to indicate their marital status, with response options
that included 6 categories: now married; widowed; divorced; separated; never married;
and living with a partner. The marital status variable was dichotomized into whether an
individual had ever been married (coded 1) or had never been married (coded 0).
Participants were asked to indicate their educational background, with response options
that included 5 categories: some high school or less; high school diploma or equivalent;
vocational college or some college; graduation/degree; professional or post graduation
degree. The education variable was dichotomized into whether an individual had
completed high school or less (coded 0) or more than high school (coded 1). Participants
were asked to indicate their race/ethnicity status, which was then dichotomized into
whether they identified as Non-Hispanic White (coded 0) or a person of color (coded 1).
Clinical variables that have been commonly studied in prior suicidal disclosure
research include psychiatric diagnosis, prior suicide attempt, and prior psychiatric
63
hospitalization. Participants were referred with a diagnosis of Major Depressive Disorder,
Bipolar Disorder or Schizophrenia, which was confirmed during the informed consent
process. Prior suicide attempt was assessed with the question, “How many times have you
attempted suicide?”. The suicide attempt variable was dichotomized into whether an
individual had never attempted suicide (coded 0) or attempted suicide (coded 1). Prior
psychiatric hospitalization was assessed with the question, “Have you ever been
hospitalized in a psychiatric hospital?”
Variables Linked to Suicide Outcomes. Variables linked to suicide outcomes that
were included in the current study were as follows: (1) Hopelessness; (2) Perceived
Burdensomeness; (3) Thwarted Belongingness; (4) Social Support; and (5) Distress
Disclosure.
Hopelessness was measured using the 20-item, self-report Beck Hopelessness Scale
(Beck, Weissman, Lester, & Trexler, 1974). For each item, the respondent was asked to
read a statement about their expectations of the short- or long-term future and indicate
whether they believe the statement to be true (coded 0) or false (coded 1). Item scores
were added to create a sum score that ranged from 0 to 20, with higher scores indicating
greater hopelessness. The scale has been used extensively in studies focusing on the
population of individuals with serious mental illness (e.g., Corrigan, Rafacz, & Rüsch, 2011;
Lysaker, Roe, & Yanos, 2007). The internal reliability (Cronbach’s alpha) for the measure
was .87 in this study.
Perceived burdensomeness and thwarted belongingness were measured using the 10-
item Interpersonal Needs Questionnaire (INQ; Van Orden, Cuckrowicz, Witte, & Joiner,
2012). The subscales for thwarted belongingness and perceived burdensomeness each
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contained 5 items. For each item, the respondent is asked to read a statement and rate how
true the statement is for them, ranging from 1 (Not at all true for me) to 7 (Very true for
me). Item scores were added to create a sum score for each subscale that ranged from 5 to
35, with higher scores indicating greater thwarted belongingness or perceived
burdensomeness. The scale has been used in several studies with outpatients in a clinical
mental health setting (Van Orden et al., 2008; Van Orden et al., 2012). The internal
reliabilities (Cronbach’s alpha) for the thwarted belongingness and perceived
burdensomeness subscales were .81 and .88 in the current study, respectively.
Social support was measured using the 4-item Medical Outcomes Study Social
Support Survey (MOSSS; Sherbourne & Stewart, 1991), which measures how often
different types of social support are available to the respondent. Each item is rated on a 5-
point Likert scale, ranging from 1 (None of the time) to 5 (All of the time). Item scores were
added to create a sum score that ranged from 4 to 20, with higher scores indicating greater
perceived social support. The scale has been used extensively in studies focusing on the
population of individuals with serious mental illness, albeit more often in the longer format
(e.g. Davis & Brekke, 2014). The internal reliability (Cronbach’s alpha) for the measure was
.70 in the current study.
Distress Disclosure was measured using the 12-item Distress Disclosure Index (DDI;
Kahn & Hessling, 2001), which measures one’s general tendency to disclose distressing
emotions or information. Each item is rated on a 5-point Likert scale, ranging from 1
(Strongly agree) to 5 (Strongly disagree). Item scores were added to create a sum score
that ranged from 5 to 60, with higher scores indicating more disclosure-related distress
65
and thus a lower tendency to disclose distressing information. The internal reliability
(Cronbach’s alpha) for the measure was .85 in this study.
Social Network Variables From My Preliminary Study. The social network
variables from my preliminary study included in the current study were as follows: (1)
relationship status (2) relationship availability (3) relationship duration (4) perceived level
of social support from network member and (5) various demographic characteristics of
network members and measures of homophily (for Age, Gender, Race/Ethnicity, Mental
Health Peer, and Suicide Peer). For reference, homophily refers to the tendency to
associate with similar others (McPherson, Smith-Lovin, & Cook, 2001) and thus measures
of homophily assess whether participants have similar characteristics as their social
network members.
1. For relationship status or type, participants were asked, “What is the relationship
between you and this person?”, with response options that consisted of a pre-
determined list of statuses, including family member, friend, romantic
partner/spouse; mental health professional, spiritual advisor, acquaintance, or
other.
2. Relationship availability was measured with an item using a 4-point scale that asked,
“How frequently do you have contact with this person?”, with higher scores
indicating less frequent contact.
3. Relationship duration was measured with an item that asked, “How long have you
known this person?”. It was recorded in any way that was preferred by the
respondent and then converted to months as a common metric.
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4. Social support was assessed with the 4-item MOS Social Support Survey (MOSSS;
Sherbourne & Stewart, 1991), which was described above, but adapted for use in
the social network interview. An example question is, “Who (if anyone) loves you
and makes you feel wanted?”, and network members were either endorsed (coded
1) or not endorsed (coded 0) as being a provider of support. Item scores were
added to create a sum score that ranged from 0 to 4, with higher scores indicating
greater perceived social support from a given network member.
5. Measures of relational homophily, which indicated whether the participant and
network member matched on an attribute, were created with dichotomous
variables for age, gender, race, mental health peer status, and suicide peer status. To
qualify as a match on age, the participant and network member had to be within 5
years of one another. To qualify as a match on gender, the participant and network
member had to endorse the same gender. Match on race/ethnicity was indicated by
a response to the question, “Who do you consider as being from the same racial or
ethnic group as you?”. Match on mental health peer status was measured with the
item, “Who here (if anyone) has received mental health services?”. Match on
suicide peer status was measured with the item, “Who here (if anyone) has thought
about or attempted suicide?”.
Reasons for and Against Disclosure. Reasons for and against disclosure were
assessed in two ways. First, participants were presented with a list of possible reasons for
disclosure as well as a list of possible reasons for non-disclosure and were asked to rate
each reason on a 5-point Likert scale from “not at all a reason” to “very likely a reason”
67
(Derlega et al., 2004). Second, participants were asked to endorse 3 reasons from each list
as being their “top 3” most important reasons for disclosure and non-disclosure.
Statistical Analyses
The current study collected data using a self-report survey and a social network
interview. The self-report survey collected information about the characteristics of the
participant (individual-level information). The network interview collected “egocentric”
social network data or data on the individual-specific social networks of participants— this
included information about the characteristics of participant network members,
relationships with network members and overall social network (network-level
information). A multi-level conceptualization of the data is reasonable because network
members are nested in the network of a given participant. Descriptive analyses that were
not related to specific aims and analyses related to the specific aims of the current study
are described immediately below. Stata 14 (2015) was used for all analyses.
Descriptive Analyses Not Related to Specific Aims. The descriptive analyses
consisted of calculating proportions for dichotomous or categorical variables and
appropriate measures of central tendency for continuous variables. However, although
continuous measures of global anticipated response and anticipated outcome were used in
regression analyses, each of the constituent items for these constructs were also
dichotomized and organized into subcategories for meaningful descriptive purposes.
Anticipated responses could be understood as: support-related (Items 1 and 2); emotion-
related (Items 3 and 4); and avoidance-related (Items 5 and 6). Anticipated outcomes could
be understood as: discloser-oriented (Items 1 and 2); receiver-oriented (Items 3 and 4);
and relationship-oriented (Items 5 and 6). When dichotomized, these items provided
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interesting insight into the proportion of different responses and outcomes expected from
disclosure to social network members.
Unless otherwise indicated, variables are described using item means, which is
calculated by taking the sum score of a scale and dividing it by the number of items in the
scale; this approach is recommended for certain measures (e.g., the Brief Symptom
Inventory) and has the advantage of keeping the descriptive measure in a scale with clear
anchors (e.g., item mean of 3 on a measure with items that range from 1 to 7 rather than a
sum score mean of 30 on a measure with a sum score that ranges from 10 to 60).
AIM 1: To describe the patterns of suicidal disclosure
The analyses related to prevalence consisted of calculating proportions at the
individual-level and network-level (or relational-level). As a reminder, individual-level
prevalence indicates the proportion of all participants who are inclined to disclose to at
least 1 social network member (discloser vs. non-discloser) whereas relational-level
prevalence indicates the proportion of all social network members who are attractive as
confidants for disclosure (confidant vs. non-confidant). Individual- and relational-level
prevalence was calculated for prior disclosure and intended disclosure of suicidal
cognition.
Relational-level prevalence of prior disclosure was calculated without any
intermediate steps (e.g., data management or transformation); this straightforward
calculation of a proportion was possible because prior disclosure was measured with a
dichotomous variable at the network level. Individual-level prevalence of prior disclosure
was calculated in two steps. First, a dichotomous variable for whether a participant
69
disclosed to any of their network members was created using information from the prior
disclosure variable measured at the network level. Second, the proportion was calculated.
Relational-level prevalence of intended disclosure was calculated in two steps. First,
because the intent to disclose variable was measured on a 7-point Likert scale, a decision
had to be made regarding an optimal cutpoint for dichotomization. The decision was made
to include the midpoint with the “unlikely to disclose” response options because evidence
suggests that midpoint ratings of risky options with potential for mixed outcomes (e.g.,
disclosure scenario) can indicate conflicting feelings or ambivalence (Nowlis, Kahn, & Dhar,
2002) and research links ambivalence or uncertainty to non-disclosure (Checton & Greene,
2012). This meant that values 1 through 4 were coded as 0 (unlikely to disclose) and values
5 through 7 were coded as 1 (likely to disclose). After a dichotomous variable for intended
disclosure was created, a straightforward calculation of a proportion was possible because
intended disclosure was measured at the network level. Individual-level prevalence of
intended disclosure was calculated in two steps. First, a dichotomous variable for whether a
participant intended to disclose to any of their network members was created using
information from the dichotomized intended disclosure variable measured at the network
level. Second, the proportion was calculated.
Prevalence of intended disclosure for different types of suicidal cognition was
calculated in the same fashion as previously described. This required the creation of
dichotomous variables for disclosure of non-specific active suicidal thoughts, intent, and
plan followed by the calculation of proportions at the relational-level and individual-level.
Prevalence of intended disclosure across different relationship types was calculated
in the same fashion as previously described. This required the creation of a dichotomous
70
variable for suicidal cognition (i.e., Disclose Any Type of Cognition vs. Disclose No Type of
Cognition) followed by the calculation of proportions at the relational-level and individual-
level for different types of relationships.
AIMS 2-5: To examine the association between non-theory-informed variables
and theory-informed variables (in the form of DD-MM components) and
intended suicidal disclosure
Although a multi-level conceptualization of the data is reasonable because
information about network members and relationships with network members are nested
within individual-specific egocentric networks, the data had to be empirically examined to
determine if multilevel modeling (MLM; Bryk & Raudenbush, 1987) was indicated. This
involved introducing a random intercept into the model (i.e., fully unconditional means
model) and fitting it to the data using maximum likelihood estimation, which partitioned
the within and between variance of the disclosure outcome variable. Likelihood ratio tests
were used to test whether the model with the random intercept provided a better model fit
than the model without the random intercept; a significant likelihood ratio test is an
indication that MLM is more appropriate than traditional regression analysis. The use of
MLM can account for clustering within individual-specific networks, thus avoiding the
underestimation of standard errors and incorrect statistical inference.
After determining the need for MLM, bivariate analyses (in the form of univariable
regression analyses) were performed to examine the association between disclosure and
each individual- and relational-level variable (including non-theory-informed and DD-MM-
informed variables). Any variable found to be significantly associated with disclosure at
71
the p<.05 level in bivariate analyses were included in the multivariate analysis (in the form
of multivariable regression analyses).
To aid in the comparison between non-theory-informed variables and the variables
informed by the Disclosure Decision-Making Model, a fully unconditional means model was
fit to the data followed by a series of multivariate models. Specifically, three multivariate
regression models were fit to the data, including a “non-theory only” model, a “DD-MM
only” model and a “Combined” model. Although this is likely self-evident, the “non-theory
only” model was exclusively comprised of non-theory-informed variables; the “DD-MM
only” model was exclusively comprised of DD-MM variables; and the Combined model was
comprised of non-theory-informed and DD-MM variables. Model comparisons were made
using multiple fit indices, including deviance, Akaike information criterion (AIC), and
Bayesian information criterion (BIC). Refer to Appendix B for the model equations.
AIMS 6: To describe reasons for and against the suicidal disclosure
Reasons for and against suicidal disclosure were summarized in two ways because
reasons for and against suicidal disclosure were measured in two ways. As a reminder,
participants were asked to rate a list of reasons on a continuous scale and then asked to
whether each reason was among their “top 3” most important reasons. Means and
standard deviations were used to summarize the reasons that were rated on a continuous
scale. Proportions were used to summarize the “top 3” reasons that were rated on a
dichotomous scale.
Power Considerations
The issue of power analysis in multi-level modeling is recognized as a challenge
(Scherbaum & Ferreter, 2009). While there are no uniform guidelines in the literature,
72
Maas and Hox (2005) found accurate and unbiased estimates for regression coefficients
and their standard errors along with variance components with a sample size as small as
30 at the highest level (Level 2 in our study) of the model. As a reminder, the Level 2
sample size in the current study is 45, representing the number of participants in the
sample. The Level 1 sample size in the current study is 347, representing the number of
social network members nominated by participants in the sample.

73
CHAPTER FOUR:
RESULTS
The overarching aims of the study were to examine patterns of suicidal disclosure as
well as to identify individual and relational factors associated with suicidal disclosure. After
a description of the sample, the specific aims and subaims, along with any accompanying
hypotheses, are addressed. There are two major classifications that have been used to
organize the results below. First, variables in the study are classified as either theory-
informed or non-theory-informed, which respectively refer to variables that are or are not
included in the Disclosure Decision-Making Model. This classification serves to highlight
the constituent parts of Disclosure Decision-Making Model, which is valuable because
employing a theoretical approach distinguishes this study from prior work. Second,
variables in the study are classified as either individual characteristics (i.e., refers to
features of the participant) or social network characteristics (i.e., refers to features of the
participants’ network members, relationships with network members, and overall social
networks). This classification serves to highlight the multi-level nature of disclosure,
including those variables operating at different levels, which is valuable because employing
a multi-level approach distinguishes this study from prior work.
Description of the Sample
Non-theory-informed variables (individual characteristics). Descriptive
statistics for the non-theory-informed individual characteristics of the sample can be found
in Table 2. Individuals in the sample, on average, were nearly 47 years of age. The sample
was comprised of slightly more people who identify as female and non-Hispanic White.
Just over half report never having been married. Of those endorsing a history of marriage
74
(n=22), only one person remained married, with the majority being divorced (n=16; 73%).
The sample almost exclusively consisted of individuals with a diagnosis of a major mood
disorder (MDD or BPD). Individuals, on average, had been living with a psychiatric illness
for nearly two decades, with approximately two-thirds reporting a prior psychiatric
hospitalization. The sample, on average, attended the outpatient psychiatric agency on a
weekly or biweekly basis. The sample reported rather low burdensomeness, moderate
thwarted belongingness and moderate disclosure distress. In terms of hopelessness, the
mean score of 9.42 is slightly higher than a cutoff used to indicate moderate severity, which
is predictive of later suicide (Beck & Steer, 1988). The sample endorsed having social
support available some of the time. Of note, two-thirds of the sample identified as suicide
attempt survivors while one-third of the sample identified as suicidal ideators with no
history of attempt.

(INTENTIONALLY BLANK)

75
Table 2
Descriptive statistics of non-theory-informed individual characteristics of participants in the
sample (n = 45)

Mean (SD) n (%)
Sociodemographic Factors
Age (in years) 46.90 (14.20)
Gender
Male 19 (42.2)
Female 26 (57.8)
Race/Ethnicity
Non-Hispanic White 27 (60.0)
People of Color 18 (40.0)
Latino 4 (9.1)
African American 3 (6.8)
Multiracial 11 (25.0)
High School Ed. or Less 16 (35.5)
Relationship status
Ever Married 22 (49.9)
Never Married 23 (51.1)
Psychiatric/Psychosocial Factors
Psychiatric Diagnosis
Major Depressive Disorder 26 (57.8)
Bipolar I Disorder 15 (33.3)
Schizophrenia-Spectrum Disorder 4 (8.9)
Psychiatric Hospitalization
Lifetime Hospitalization 30 (66.7)
Number of Hospitalizations (median) 2
Quality of Hospitalization 3.03 (1.16)
Duration of Illness (In Years) 19.84 (15.01)
Clinic Attendance Frequency 2.45 (0.87)
Perceived Burdensomeness
a, e
2.75 (1.42)
Thwarted Belongingness
a, e
4.04 (1.36)
Hopelessness
b
9.43 (4.82)
Social Support
c, e
3.06 (0.83)
Disclosure Distress
d, e
2.87 (0.73)
Lived Suicide Experience Factors
Suicide Attempt Survivor 30 (66.7)
Number of Attempts (median) 2
Suicide Ideator Survivor (No Attempt) 15 (33.3)
a
Interpersonal Needs Questionnaire (Van Orden et al., 2012): Item Score Range (1-7): Higher = More
Burdensomeness/Thwarted Belongingness
b
Beck Hopelessness Scale (Beck et al., 1974): Sum Score Range (1-20): Higher = More Hopeless
c
MOS Social Support Survey (Sherbourne & Stewart, 1991): Item Score Range (1-5): Higher = More Support
d
Disclosure Distress Index (Kahn & Hessling, 2001): Item Score Range (1-5): Higher = More Distress
e
These numbers represent the mean score per item, which is calculated by dividing the sum score by the
number of items in the scale or subscale. This permits easier interpretation than displaying sum scores
because item scores have clear anchors.
76
Non-theory-informed variables (social network characteristics). Descriptive
statistics for the non-theory-informed social network characteristics of the sample can be
found in Table 3. The social network members, also referred to as “alters”, had an average
age and gender composition similar to that of participants. In terms of relationship type,
friends occupied the largest segment of social networks (43%), followed by family (29%),
mental health providers (16%), intimate partners (9%), and others (4%). Network
members, on average, were available for less than two different types of social support,
with tangible support being least accessible (from 29% of network members) and
emotional support being the most accessible (from 51% of network members). Network
members clearly tended to share similar racial/ethnic background with participants, with
some homophily noted for gender and more heterophily for age. Just over one-third of
network members were identified as having a history of receiving mental health services
while slightly more than one-fifth of network members were identified as having a history
of suicidal ideation or attempt. Participants, on average, nominated eight social network
members.

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77
Table 3
Descriptive statistics of non-theory-informed social network characteristics of participants in
the sample

Mean (SD) n (%)
Alter/Relational Characteristics (n=347)
Alter Age 46.28 (16.80)
Alter Female 208 (59.9)
Relationship Type
a

Family Member 98 (28.2)
Friend 149 (42.9)
Intimate Partner 31 (8.9)
Mental Health Professional 55 (15.9)
Acquaintance/Other 14 (4.0)
Social Support Availability
b
1.67 (1.41)
Tangible 102 (29.4)
Information 149 (42.9)
Recreation 151 (43.5)
Affection 178 (51.3)
Duration of Relationship (in months)
c
120
Frequency of Contact
d
1.41 (1.01)
Homophilous Social Ties
e

Same Age 132 (38.0)
Same Gender 195 (56.2)
Same Race/Ethnicity 227 (65.4)
Mental Health History Peer 132 (38.0)
Suicide-Related History Peer 77 (22.2)
Whole Network Characteristics (n=45)
Network Size 7.88 (3.74)
a
Relationship type was assessed for the whole social network with the item, “What is the relationship
between you and this person?”
b
Availability of social support from network members was measured with four questions that assessed for
different types of social support. The responses were summed to provide an index of social support (range 0-
4). The proportion of social network members available to provide each type of support was also calculated.
c
Duration of relationship was assessed with the item, “How long have you known this person?”
d
Frequency of contact was assessed with the item, “How frequently do you have a contact with this person?”,
with scores ranging from 1 (almost every day) to 4 (less than once a month).
e
Social ties between a participant and each social network member was assessed for each type of homophily.
A tie is homophilous if the participant and network member share a given characteristic (coded as 1) and
heterophilous if the participant and network member do not share a given characteristic (coded as 0).

78
Disclosure Decision-Making Model variables (individual characteristics).
Descriptive statistics for the theory-informed individual characteristics of the sample can
be found in Table 4. The Information Component of the Disclosure Decision-Making Model,
which operates at least partly at the individual-level, includes stigma and psychiatric
symptom severity. Based on the item score mean of 2.88, participants, on average,
indicated the most people would agree with stigmatizing characterizations of attempt
survivors. Based on the item score means for the Brief Symptom Inventory’s global
severity index and nine symptom dimensions, which generally fall between the value of 1
and 2, participants largely reported being distressed by symptoms between “a little bit”
and “moderately”. The exceptions to this range consist of participants endorsing slightly
less distress related to hostility and slightly more distress related to obsessive-compulsive
symptoms. These item score means fall between the 50
th
and 60
th
percentile of scores from
an outpatient psychiatric population (Derogatis, 1993), meaning that the symptom severity
observed in the current study’s sample was comparable to that of a similar population.

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79
Table 4
Descriptive statistics of Disclosure Decision-Making Model individual characteristics of
participants in the sample (n=45)

Mean (SD)
Information Component
Stigma
a, c

Toward Suicidal Behavior

2.88 (0.66)
Psychiatric Symptom Severity
b, c

Global Severity

1.57 (0.50)
Depression

1.64 (0.76)
Psychoticism 1.45 (0.71)
Interpersonal Sensitivity 1.98 (0.86)
Somatization

1.37 (0.88)
Anxiety 1.86 (0.82)
Phobic Anxiety

1.46 (0.92)
Obsessive-Compulsive 2.40 (0.74)
Paranoid Ideation 1.34 (0.72)
Hostility

0.82 (0.60)
a
Stigma of Suicide Attempt Scale (Scocco et al., 2012): Item Score Range (1-4): Higher = More Stigma
b
Brief Symptom Inventory (Derogatis & Melisaratos, 1983). Item Score Range (0-4): Higher = More Severe
c
These numbers represent the mean score per item, which is calculated by dividing the sum score by the
number of items in the scale or subscale. This permits easier interpretation than displaying sum scores
because item scores have clear anchors.

Disclosure Decision-Making Model variables (social network characteristics).
Descriptive statistics for the theory-informed social network characteristics of the sample
can be found in Table 5. All Components of the Disclosure Decision-Making Model—the
Information, Receiver, and Disclosure Efficacy Components—operate at least partly at the
relational-level. In terms of the Information Component, which is exclusively captured by
stigma at the relational-level, the mean score of 2 indicates that social network members
are perceived as being inclined to disagree with the stigmatization of people who attempt
suicide. The Receiver Component of the Disclosure Decision-Making Model includes
relational quality and anticipated reaction (comprised of both anticipated responses and
anticipated outcomes). The mean score of nearly 4 on the relational quality scale indicates
80
that participants generally agree with favorable statements about relationships with their
social network members. Mean scores of slightly greater than 4 on the anticipated
response and anticipated outcome scales indicate that participants disagree with negative
reaction expectancies of their social network members. Because the constituent items of
these scales could be dichotomized in a meaningful way (i.e., categories of agree and
disagree), it was also revealing to calculate the proportion of network members endorsing
different types of anticipated responses and outcomes. In terms of anticipated responses,
80% of network members were expected to be emotionally supportive upon disclosure;
35% of network members were expected to have a negative emotional reaction upon
disclosure; and approximately one-quarter of their network members were expected to
avoid or refuse to talk about the subject upon disclosure. In terms of anticipated outcomes,
29% of network members were expected to change their perception toward the participant
in a way that could be a threat to their identity post disclosure; 38% of network members
were expected to sacrifice by having their feelings hurt by the disclosure with another 84%
expected to experience pain by having to endure worry post disclosure; and around one-
fifth of disclosures to network members were expected to have negative consequences for
the relationship, such as decreased liking or adverse change in relationship. In terms of the
Disclosure Efficacy Component, participants, on average, endorsed moderate feelings of
efficacy toward disclosing to their social network members.

81
Table 5
Descriptive statistics of Disclosure Decision-Making Model social network characteristics of
participants in the sample

Mean (SD) n (%)
Information Component
Alter Stigma Toward Suicidal Behavior
a
2.00 (1.23)
Receiver Component
Relationship Quality

3.83 (0.89)
Anticipated Response
b
4.34 (1.25)
Support-Related Type
Emotionally Supportive 277 (79.8)
Judgmental 98 (28.2)
Emotion-Related Type

Negative Emotion 120 (34.6)
Positive Emotion 220 (63.4)
Avoidant-Related Type

Avoidance 101 (29.1)
Refusal to Talk 78 (22.5)
Anticipated Outcome
b
4.16 (1.01)
Negative Outcome for Self

Identity Threat 99 (28.5)
Differential Treatment 90 (25.9)
Negative Outcome for Receiver

Receiver Sacrifice 133 (38.3)
Receiver Pain 292 (84.2)
Negative Outcome for Relationship

Reduced Liking 73 (21.0)
Change Relationship 54 (15.6)
Disclosure Efficacy Component
Disclosure Efficacy

3.02 (1.47)
a
Item from Stigma of Suicide Attempt Scale (Scocco et al., 2012). Participants were asked to indicate the
extent to which each social network member would agree or disagree with the statement, “This person would
think less of a person who has thought about or attempted suicide”. The item is rated on a scale ranging from
1 (Totally Disagree) to 5 (Totally Agree). Higher scores represent higher levels of stigma.
b
The original scale for these items ranges from 1 (Strongly Agree) to 6 (Strongly Disagree). To provide a more
practical interpretation, these items were dichotomized to calculate the proportion of different types of
responses and outcomes expected from disclosure to social network members.

82
Results for Research Aim 1: To describe the patterns of prior and intended suicidal
disclosure
The first aim of the study was to elucidate historical (i.e., past) and intended (i.e.,
future) patterns of suicidal disclosure. The investigation of these patterns consisted of
calculating disclosure prevalence and the extent to which disclosure varied as a function of
suicidal cognition type and relationship type.
Disclosure prevalence. Consistent with the multilevel nature of this study,
individual- and relational-level prevalence of historical and intended disclosure were
examined (Table 6). Individual-level disclosure prevalence, which represents a Level 2
metric, indicates the proportion of participants who have disclosed to at least one social
network member. Relational-level disclosure prevalence, which represents a Level 1
metric, indicates the proportion of all social network members who have been confidants
for disclosure.
In regard to past suicidal thoughts, approximately 87% of the participants had
disclosed to someone in their social network (i.e., individual-level prevalence), with 54% of
social network members across participant networks being identified as confidants for
such disclosures (i.e., relational-level prevalence). In regard to future suicidal thoughts,
almost all participants indicated the intent to disclose to someone in their social network
(i.e., individual-level prevalence), with 50% of social network members across participant
networks being identified as confidants for intended disclosure (i.e., relational-level
prevalence).
The median number of confidants for disclosure was 4 people inside of their current
social network. The median number of confidants for prior disclosure outside of their
83
current social network was 3 people. Taking into account the number of confidants inside
and outside of current social networks, participants have shared their suicidal thoughts
with, on average, 7 people.
Table 6

Prevalence of Historical and Intended Disclosure of Suicidal Cognition

n (%)
Historical Disclosure Prevalence
Individual-Level Metric (n=45)
a

Disclosers 39 (86.7)
Non-Disclosers 6 (13.3)
Relational-Level Metric (n=347)
b

# Social Network Members Disclosed To 188 (54.2)
# Social Network Members Not Disclosed To 159 (45.8)
Intended Disclosure

Prevalence
c

Individual-Level Metric (n=45)
a

Disclosers 44 (97.8)
Non-Disclosers 1 (2.3)
Relational-Level Metric (n=347)
b

# Social Network Members Disclosed To 175 (50.4)
# Social Network Members Not Disclosed To 172 (49.6)
a
Individual-level prevalence is a metric for disclosure at Level 2. The sample size at Level 2 is 45.
b
Relational-level prevalence is a metric for disclosure at Level 1. The sample size at Level 1 is 347.
c
Intended disclosure was calculated by dichotomizing the mean score for overall suicide-related cognition,
which ranged from 1 (extremely unlikely) to 7 (extremely likely). Given that uncertainty is typically viewed as
contributing to non-disclosure, a cutoff score 5 was used to distinguish probable non-disclosure from
probable disclosure, meaning that the “neutral” or midpoint score was combined with the “unlikely” scores.
Of note, the midpoint was endorsed by approximately 10% of social network members. Excluding the
midpoint responses or combining them with the “likely” scores would not substantially affect the conclusions
drawn from these rates.

Prevalence of intended disclosure by type of suicidal cognition. Although
concerns regarding accurate recall disallowed the assessment of past disclosure of
different types of suicidal cognition, the extent to which intended disclosure varied by type
of suicidal cognition could be explored (Table 7). Lower disclosure prevalence was
observed for plan and intent than active thoughts at both the individual- and relational-
84
level. At the individual-level, while nearly all participants endorsed intent to disclose active
thoughts, four out of every five participants endorsed intent to disclose plan or intent. At
the relational-level, while 43% of network members are identified as confidants for active
thoughts, barely 30% are identified as confidants for plan or intent. See Figure 7 for a
visual representation of disclosure prevalence by type of suicidal cognition.
Table 7
Prevalence of Intended Disclosure By Type of Suicidal Cognition

Active Thoughts
n (%)
Plan
n (%)
Intent
n (%)
Individual Prevalence (n=45)
a, c

Disclosers 43 (95.6) 37 (82.2) 37 (82.2)
Non-Disclosers 2 (4.4) 8 (18.8) 8 (18.8)
Relational Prevalence (n=347)
b, c

Network Members Disclosed To 148 (42.7) 105 (30.3) 107 (30.8)
Network Members Not Disclosed To

199 (57.3) 242 (69.7) 240 (69.2)
a
Individual-level prevalence is a metric for disclosure at Level 2. The sample size at Level 2 is 45.
b
Relational-level prevalence is a metric for disclosure at Level 1. The sample size at Level 1 is 347.
c
Intended disclosure variables were calculated by dichotomizing the items, which ranged from 1 (extremely
unlikely) to 7 (extremely likely). Given that uncertainty is typically viewed as contributing to non-disclosure,
a cutoff score 5 was used to distinguish probable non-disclosure from probable disclosure, meaning that the
“neutral” or midpoint score was combined with the “unlikely” scores. Of note, the midpoint was endorsed
by approximately 10% of social network members. Excluding the midpoint responses or combining them
with the “likely” scores would not substantially affect the conclusions drawn from these rates.

Figure 7. Intended Disclosure Prevalence by Cognition Type. The black circles
represent disclosure whereas the non-black circles represent non-disclosure.
85
Prevalence of intended disclosure by type of relationship. Intended disclosure
by relationship status was assessed inside and outside of participant social networks. As a
reminder, disclosure inside social networks was investigated by calculating the prevalence
of intended disclosure to network members of different relationship types (i.e., family,
intimate partner, friend, mental health professional or other) while disclosure outside
social networks was investigated by calculating the prevalence of intended disclosure for a
broader range of relationship types (e.g., medical doctor, spiritual counselor) and crisis
service outlets (e.g., phone helpline, emergency room) that would not necessarily appear
inside social networks. Disclosure inside networks could be assessed at both the
individual- and relational-level while disclosure outside networks could only be assessed at
the individual-level.
Inside the network, individual-level prevalence rates were highest for mental health
providers and friends (see Table 8). Almost all participants with mental health providers in
their network indicated an intention to disclose to at least one of them (89%). Three out of
every four participants who have friends in their network indicated an intention to disclose
to at least one of them. Individual-level prevalence rates were lowest for intimate partners,
family members, and “others”. Approximately two out of every three participants with
family members or intimate partners in their networks indicated an intention to disclose to
at least one of them. One out of every four participants with “others” in their social
networks indicated an intention to disclose to at least one of them.
Inside the network, relational-level prevalence rates were highest for mental health
providers and intimate partners (see Table 8). Four out of every five network members
identified as mental health professionals were intended targets for disclosure. Almost two-
86
thirds of the network members identified as intimate partners were intended targets for
disclosure. Relational-level prevalence rates were lowest for friends, family members, and
others. Half of the friends identified in these social networks were intended targets for
disclosure. Approximately one out of every three network members identified as family
members were intended targets for disclosure. One out of very five network members
identified as “others” were intended targets for disclosure.
Outside the network, the individual-level prevalence rate was highest for disclosing
to people with lived experience in suicidal crisis (e.g., attempt survivors). In fact, 75%
(n=33) of participants indicated that they would likely disclose to an attempt survivor if
they experienced suicidal thoughts in the future. Just under half of participants indicated
that they would likely disclose to a medical doctor (n=18; 41%), spiritual counselor (n=20;
46%) and use a crisis helpline (n=18; 41%). Individual-level prevalence rates were lowest
for the emergency room and online help service. Less than one-third of participants (n=14;
32%) indicated that they would likely use the emergency room as a place for disclosure
and barely one-fifth of participants (n=10; 23%) indicated that they would likely disclose
on an online help or crisis service.

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87
Table 8

Prevalence of Intended Disclosure By Type of Relationship Inside Social Networks

n (%)
Individual-Level Metric (n=45)
a, c

Family (n=39) 24 (61.5)
Intimate Partner (n=14) 9 (64.3)
Friend (n=40) 31 (77.5)
Mental Health Provider (n=35) 31 (88.6)
Other (e.g. Acquaintance) (n=19) 5 (26.3)
Relational-Level Metric (n=347)
b, c

Family (n=98) 38 (38.8)
Intimate Partner (n=14) 9 (64.3)
Friend (n=149) 77 (51.7)
Mental Health Provider (n=55) 45 (81.2)
Other (e.g. Acquaintance) (n=31) 6 (19.4)
a
Individual-level prevalence is a metric for disclosure at Level 2. The sample size at Level 2 is 45.
b
Relational-level prevalence is a metric for disclosure at Level 1. The sample size at Level 1 is 347.
c
Intended disclosure variables were calculated by dichotomizing the items, which ranged from 1 (extremely
unlikely) to 7 (extremely likely). Given that uncertainty is typically viewed as contributing to non-disclosure,
a cutoff score 5 was used to distinguish probable non-disclosure from probable disclosure, meaning that the
“neutral” or midpoint score was combined with the “unlikely” scores. Of note, the midpoint was endorsed
by approximately 10% of social network members. Excluding the midpoint responses or combining them
with the “likely” scores would not substantially affect the conclusions drawn from these rates.

Results for Research Aim 2: To examine the association between non-theory-
informed factors and intended disclosure
Univariable regression results. A number of non-theory informed variables were
related to intended disclosure in univariable regression models (i.e., bivariate analyses)
(Table 9). In terms of individual characteristics, gender and disclosure distress were found
to be significantly associated with intended disclosure. Females were found to exhibit
lower disclosure intention than males by nearly 2 points (p=.038). A one-unit increase in
88
disclosure distress was found to be associated with a .12 point decrease in disclosure
intention (p=.024).
In terms of alter/relational characteristics, social support, relationship type,
relationship duration, frequency of contact, age homophily and race/ethnicity homophily
were found to be significantly associated with intended disclosure. There was a positive
relationship between availability of social support from a social network member and
intended disclosure to that network member (b=1.40, p<.001). Individuals were more
intent on disclosing to friends (b=2.61, p<.001), intimate partners (b=3.48 p=.01), and
mental health professionals (b=6.77, p<.001) than family members. An increase in
relationship duration was associated with a decrease in disclosure intention (b=-.01,
p=.007). An increase in frequency of contact was associated with increased disclosure
intention (b=.72, p=.016). While disclosure intention was higher to network members
sharing the same age than to those network members not sharing the same age (b=1.28,
p=.034), disclosure intention was lower to network members sharing the same
race/ethnicity than to those network members not sharing the same race/ethnicity
(b=2.00, p=.003).

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89
Table 9
Univariable regression analyses examining intended disclosure using a non-theory-informed
approach

b (SE)
INDIVIDUAL CHARACTERISTICS
Sociodemographic Factors
Age (in years) 0.01 (0.03)
Female -1.90 (0.92) *
People of Color -0.05 (0.98)
Greater than High School Ed. 0.28 (1.00)
Ever Married 0.91 (0.95)
Employed 0.28 (1.00)
Psychiatric/Psychosocial Factors
Prior Psychiatric Hospitalization -1.37 (1.01)
Duration of Illness (In Years) -0.04 (0.03)
Clinic Attendance Frequency 0.65 (0.56)
Perceived Burdensomeness
a
0.03 (0.07)
Thwarted Belongingness
a
-0.11 (0.07)

Hopelessness
b
-0.07 (0.10)
Social Support
c
0.25 (0.14)
Disclosure Distress
d
-0.12 (0.05) *
Suicide Attempt Survivor -1.00 (0.96)
ALTER/RELATIONAL CHARACTERISTICS
Alter Age -0.02 (0.02)
Alter Female 0.98 (0.59)
Alter Social Support

1.40 (0.21) ***
Relationship Type (ref grp=family)

Friend 2.61 (0.64) ***
Intimate Partner 3.48 (1.35) ***
Mental Health Professional 6.77 (0.82) *
Acquaintance/Other -0.45 (1.01)
Duration of Relationship (in months) -0.01 (0.00) **
Frequency of Contact .72 (0.30) *
Homophilous Social Ties
Same Age 1.28 (0.60) *
Same Gender 0.12 (0.58)
Same Race/Ethnicity -2.00 (0.69) **
Mental Health History Peer 0.55 (0.60)
Suicide-Related History Peer 0.92 (0.71)
WHOLE NETWORK CHARACTERISTICS
Network Size -0.13 (0.12)
*p<.05, **p<.01, ***p<.001

a
Interpersonal Needs Questionnaire (INQ; Van Orden, Cuckrowicz, Witte, & Joiner, 2012).
b
Beck Hopelessness Scale (BHS; Beck, Weissman, Lester, & Trexler, 1974).

c
Medical Outcomes Study Social Support Survey (MOSSS; Sherbourne & Stewart, 1991).
d
Disclosure Distress Index (DDI; Kahn & Hessling, 2001).

90
Multivariable regression results. In the context of the multivariable regression
analysis (Table 10), only alter social support and relationship type remained significantly
associated with intended disclosure. The strength of the relationship between these
variables and disclosure intent also remained largely unchanged. A one-unit increase in
social support from any given social network member was associated with a 1.60 point
increase in intended disclosure to that network member (p<.001). Compared to family
members, individuals were more intent on disclosing to friends (b=2.61, p<.001) and
mental health professionals (b=6.77, p<.001). Using the unconditional means model as a
baseline for comparison (Model 1), the set of non-theory-informed variables explained
approximately 8% of the variation in disclosure intent between participants and 20% of the
variation in disclosure intent between network members within participants.

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91
Table 10
Multivariable regression analysis examining intended disclosure using a non-theory-informed
approach

Model 1 Model 2
b (SE) b (SE)
INDIVIDUAL CHARACTERISTICS
Female -.85 (.87)
Disclosure Distress
a
-.05 (.05)
ALTER/RELATIONAL CHARACTERISTICS
Alter Social Support 1.60 (.20) ***
Relationship Type (ref grp=family)
Friend 2.36 (.72) **
Intimate Partner 2.31 (1.32)
Mental Health Professional 8.40 (.95) ***
Acquaintance/Other 1.66 (1.05)
Duration of Relationship (in months) .02 (.01)
Frequency of Contact .27 (.25)
Homophilous Social Ties
Same Age .63 (.51)
Same Race/Ethnicity -.63 (.61)
Random Effects
Level 1 (Within Person) 5.12 (.21) 4.08 (.17)
Level 2 (Between Person) 2.53 (.48) 2.32 (.37)
Pseudo R
2
/Model Fit
Level 1 (Within Person) -- .203
Level 2 (Between Person) -- .083
*p<.05, **p<.01, ***p<.001

a
Disclosure Distress Index (DDI; Kahn & Hessling, 2001).

Results for Research Aims 3-5: To examine the association between DD-MM factors
(i.e., theoretical factors) and intended disclosure
Consistent with the Disclosure Decision-Making Model, the following hypotheses
were made: (a) higher levels of stigma will be associated with decreased disclosure intent;
(b) greater severity of symptoms will be associated with increased disclosure intent; (c)
higher relational quality will be associated with increased disclosure intent; (d) more
positive anticipated reaction (responses and outcomes) will be associated with increased
92
disclosure intent; and (e) higher disclosure efficacy will be associated with increased
disclosure intent. All of these hypotheses received at least partial support.
Univariable regression results. A number of theory informed variables from the
Disclosure Decision-Making Model were related to intended disclosure in univariable
regression models (i.e., bivariate analyses) (Table 11). In terms of individual
characteristics, perceived stigma toward suicide and phobic anxiety were found to be
significantly associated with intended disclosure. An increase in perceived stigma toward
suicide was associated with a decrease in intended disclosure (b= -.13, p=.032). An
increase in phobic anxiety was associated with an increase in intended disclosure (b=.24,
p=.017).
In terms of alter/relational characteristics, alter stigma toward suicide attempt,
relationship quality, anticipated response, anticipated outcome and disclosure efficacy
were found to be significantly associated with intended disclosure. An increase in network
member disagreement with stigmatizing attitudes toward suicide attempt was associated
with an increase in intended disclosure (b=2.31, p<.001). Better relationship quality was
associated with intended disclosure (b=.89, p<.001). An increase in the favorability of
anticipated responses (b=.39, p<.001) and outcomes (b=.58, p<.001) were associated with
intended disclosure. Higher levels of disclosure efficacy was associated with intended
disclosure (b=.91, p<.001).

93
Table 11
Univariable regression analyses examining intended disclosure using the Disclosure Decision-
Making Model approach

b (SE)
INDIVIDUAL CHARACTERISTICS OF DD-MM
Information Component
Stigma Toward Suicidal Behavior
a
-0.13 (0.06) *
Psychiatric Symptom Severity
b

Global Severity

0.02 (0.02)
Depression

-0.04 (0.10)
Psychoticism 0.10 (0.13)
Interpersonal Sensitivity 0.24 (0.13)
Somatization

0.03 (0.08)
Anxiety 0.04 (0.10)
Phobic Anxiety

0.24 (0.10) *
Obsessive-Compulsive 0.05 (0.11)
Paranoid Ideation 0.14 (0.13)
Hostility

0.14 (0.16)
ALTER/RELATIONAL CHARACTERISTICS OF DD-MM
Information Component
Alter Stigma Toward Attempt
a

2.31 (0.20) ***
Receiver Component
Relationship Quality

0.89 (0.07) ***
Anticipated Reaction
Anticipated Response

0.39 (0.03) ***
Anticipated Outcome

0.58 (0.04) ***
Disclosure Efficacy Component
Disclosure Efficacy

0.91 (0.05) ***
*p<.05, **p<.01, ***p<.001

a
Stigma of Suicide Attempt Scale (STOSA; Scocco, Castriotta, Toffol, & Preti, 2012).
b
Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983).

Multivariable regression results. With the exception of individual-level
perception of stigma toward suicide and anticipated response, all Disclosure Decision-
Making Model variables significantly associated with intended disclosure in the univariable
regression models retained their significance in the multivariable regression model (Table
12). In terms of the Information Component of the DD-MM, positive associations were
found between both phobic anxiety (b=.21, p=.004) and disagreement with stigmatizing
attitudes toward suicide attempt (b=.43, p=.043) and disclosure intent. In terms of the
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Receiver Component of the DD-MM, positive associations were observed between both
relationship quality (b=.40 p<.001) and anticipated outcome (b=.15, p=.002) and disclosure
intent. In terms of the Disclosure Efficacy Component of the DD-MM, a positive association
was found between disclosure efficacy and intended disclosure (b=.64, p<.001). Using the
unconditional means model as a baseline for comparison (Model 1), the Disclosure
Decision-Making Model variables explained approximately 26% of the variation in
disclosure intent between participants and 40% of the variation in disclosure intent
between network members within participants.
Table 12
Multivariable regression analyses examining intended disclosure using the Disclosure
Decision-Making Model approach

Model 1 Model 2
b (SE) b (SE)
INDIVIDUAL CHARACTERISTICS
Information Component
Stigma Toward Suicidal Behavior
a
-.01 (.05)
Psychiatric Symptom Severity
Phobic Anxiety
b
.21 (.07) **
ALTER/RELATIONAL CHARACTERISTICS
Information Component
Alter Stigma Toward Suicidal Behavior
a
.43 (.21) *
Receiver Component
Relationship Quality

.40 (.07) ***
Anticipated Reaction
Anticipated Response

.03 (.04)
Anticipated Outcome

.15 (.05) **
Disclosure Efficacy Component
Disclosure Efficacy

.64 (.05) ***
Random Effects
Level 1 (Within Person) 5.12 (.21) 3.06 (.12)
Level 2 (Between Person) 2.53 (.48) 1.87 (.28)
Pseudo R
2
/Model Fit
Level 1 (Within Person) -- .402
Level 2 (Between Person) -- .260
*p<.05, **p<.01, ***p<.001
a
Stigma of Suicide Attempt Scale (STOSA; Scocco, Castriotta, Toffol, & Preti, 2012).
b
Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983).
95

Table 13 provides a series of multivariable models to examine intended disclosure.
Results from the fully unconditional means model (Model 1) justified the inclusion of a
random intercept for intended disclosure (LR Test χ
2
(1)= 33.06, p<.001; ICC=.33). Model 2
represents the previously reviewed multivariable model that was not theory-informed
while Model 3 represents the previously reviewed multivariable model that was theory-
informed with the Disclosure Decision-Making Model variables. Since these models have
already been reviewed above, I have refrained from reporting the details of those same
results here. Model 4 is the final model that includes variables that were and were not
theory informed. The results in this “combined” (theory + non-theory factors)
multivariable model largely mirrored that of the exclusively non-theory (Model 2) and
theory (Model 3) informed models. In terms of non-theory-informed factors, alter social
support and relationship type were still significant, though with attenuated effects.
In terms of the Information Component of the DD-MM, psychiatric symptom
severity and stigma were linked to disclosure intent. A one-unit increase in phobic anxiety
was associated with a .21 point increase in intended disclosure (p=.003). A one-unit
increase in disagreement with stigmatizing attitudes toward suicide attempt was
associated with a .38 point increase in intended disclosure (p=.062), suggesting a trend
level effect. In terms of the Receiver Component of the DD-MM, relational quality and
anticipated reaction were linked to disclosure intent. A one-unit increase in relational
quality was associated with a .32 point increase in intended disclosure (p<.001). A one-
unit increase in favorable anticipated outcome was associated with a .15 point increase in
intended disclosure (p=.001). In terms of the Disclosure Efficacy Component of the DD-
MM, a one-unit increase in disclosure efficacy was associated with a .57 point increase in
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intended disclosure (p<.001). Using the unconditional means model as a baseline for
comparison (Model 1), the final model explained approximately 29% of the variation in
disclosure intent between participants and 43% of the variation in disclosure intent
between network members within participants.
According to all three model fit indices (deviance, AIC, BIC), Models 2, 3 and 4 were
a better fit than Model 1, suggesting there is value in non-theory-informed, theory-
informed and combined approaches in explaining intended disclosure. However, despite a
comparable number of variables in the non-theory-informed model (Model 2) and the DD-
MM model (Model 2), the DD-MM model explained twice as much within-person variation
and over three times as much between person variation. Relatedly, the DD-MM model
(Model 3) provided a better fit than the non-theory-informed model (Model 2) across all fit
indices. Of note, although the combined model (Model 4) indeed was found to explain
greater variation than the other models, the extent to which the combined model was a
better fit than the alternative models was less clear. The combined model (Model 4) was
clearly a better fit across all fit indices than the non-theory-informed model (Model 2) but
there were mixed findings for fit when comparing the combined model (Model 4) with the
DD-MM model (Model 3). The deviance metric and AIC suggested that Model 4 was a better
fit than Model 3 while the BIC suggested that Model 3 was a better fit than Model 4.

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Table 13
Multivariable regression analyses examining intended disclosure using non-theory-informed
and theory-informed approaches
Model 1 Model 2 Model 3 Model 4
b (SE) b (SE) b (SE) b (SE)
NON-THEORY FACTORS
Female -.85 (.87) -.58 (.67)
Disclosure Distress
a
-.05 (.05) .02 (.04)
Alter Social Support 1.60 (.20) *** .57 (.16) ***
Relationship Type (ref grp=family)
Friend 2.36 (.72) ** .62 (.53)
Intimate Partner 2.31 (1.32) 1.06 (.96)
Mental Health Professional 8.40 (.95) *** 3.08 (.76) ***
Acquaintance/Other 1.66 (1.05) .18 (.77)
Duration of Relationship (in months) .02 (.01) .02(.01)
Frequency of Contact -.27 (.25) .06 (.18)
Homophilous Social Ties
Same Age .63 (.51) -.25 (.37)
Same Race/Ethnicity -.63 (.61) -.68 (.45)
DD-MM FACTORS
Information Component
Stigma Toward Suicidal Behavior
b
-.01 (.05) -.01 (.05)
Psychiatric Symptom Severity
c

Phobic Anxiety .21 (.07) ** .21 (.07) **
Information Component
Alter Stigma Toward Attempt
b
.43 (.21) * .39 (.21)
†
Receiver Component
Relationship Quality

.40 (.07) *** .32 (.07) ***
Anticipated Reaction
Anticipated Response

.03 (.04) -.05 (.04)
Anticipated Outcome

.15 (.05) ** .15 (.05) **
Disclosure Efficacy Component
Disclosure Efficacy

.64 (.05) *** .57 (.05) ***
Random Effects
Level 1 (Within Person) 5.12 (.21) 4.08 (.17) 3.06 (.12) 2.91 (.12)
Level 2 (Between Person) 2.53 (.48) 2.32 (.37) 1.87 (.28) 1.80 (.27)
Pseudo R
2
/Model Fit
Level 1 (Within Person) -- .203 .402 .432
Level 2 (Between Person) -- .083 .260 .289
Deviance (-2LL) 2163.65 2015.11 1819.3 1784.69
df 3 14 10 21
Δ Deviance from Model 1 --- 148.54 *** 344.35 *** 378.96 ***
Δ Deviance from Model 2 --- --- --- 230.42 ***
Δ Deviance from Model 3 --- --- --- 34.61 ***
AIC 2169.66 2043.11 1839.32 1826.69
BIC 2181.20 2070.00 1877.81 1907.53
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†
p<.10, *p<.05, **p<.01, ***p<.001
a
Disclosure Distress Index (DDI; Kahn & Hessling, 2001).
b
Stigma of Suicide Attempt Scale (STOSA; Scocco, Castriotta, Toffol, & Preti, 2012).
c
Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983).

Results for Research Aim 6: To identify reasons for and against disclosure of suicide-
related cognition
Table 14 provides a summary of the findings related to reasons for and against the
disclosure of suicide-related cognition. As a reminder, reasons for and against disclosure
were assessed in two ways. First, participants were presented with a list of possible
reasons for disclosure as well as a list of possible reasons for non-disclosure and were
asked to rate each reason on a Likert scale from “not at all a reason” (coded 1) to “very
likely a reason” (coded 5). Second, participants were asked to endorse 3 reasons from each
list as being their “top 3” most important reasons for disclosure and non-disclosure; each
reason was either in the participant’s top 3 reasons (coded 1) or not (coded 0).
The reasons for disclosure with the highest mean rating were getting help, advice or
support, having a shared background and venting or expressing feelings. These reasons
were rated as “likely a reason” or “very likely a reason” for disclosure. Consistent with
these results, a distinct assessment of participants’ top 3 reasons for disclosure revealed
the highest number of top 3 nominations for these same reasons. In fact, over three-
fourths of participants indicated that venting or expressing feelings (77%) as well as
getting help, advice or support (84%) were among their top 3 reasons for disclosure.
Interestingly, educating others about lived experience was nominated among the top 3
reasons by over one-third of the participants. The reasons for disclosure with the lowest
mean rating were having the obligation to tell others and to test others reactions. These
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were rated as “not likely a reason”. These results were also reinforced by the assessment
of the top 3 reasons, with no participants rating the obligation to tell others among their
top 3 reasons for disclosure and only one participant indicating that testing others’
reactions was among their top 3 reasons for disclosure.
The reasons for non-disclosure with the highest mean rating were fear of rejection,
shame about suicidal thoughts, and fear of hospitalization. These reasons were rated as
“likely a reason” or “very likely a reason” for non-disclosure. Consistent with these results,
a distinct assessment of participants’ top 3 reasons for non-disclosure revealed the highest
number of top 3 nominations for these same reasons. Nearly 71% of participants endorsed
the shame of suicidal thoughts as among their top 3 reasons for non-disclosure and 64% of
participants endorsed fear of rejection among their top 3 reasons for non-disclosure.
Interestingly, approximately 41% of participants indicated that feeling uncomfortable
talking about suicidal thoughts was among their top 3 reasons for non-disclosure. The
reason for non-disclosure with the lowest mean rating—the only reason from the list with
a mean rating less than “likely a reason”—was the belief that suicidal thoughts are not that
serious. In an assessment of the top 3 reasons for non-disclosure, only 7% indicated that
the belief that suicidal thoughts are not that serious was among their top 3 reasons for non-
disclosure. Similarly, only 9% of participants indicated that a belief in their right to privacy
was among their top 3 reasons for non-disclosure. The belief that one could cope with
suicidal thoughts without any help was the only other reason on the list endorsed by less
than one-third of the participants as being among their top 3 reasons for non-disclosure.

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Table 14

Reasons for and Against Disclosure of Suicidal Cognition (n=45)

Mean (SD) n (%)
a

Reasons for Disclosure
Vent or Express Feelings 4.02 (1.11) 34 (77.3)
Get Help, Advice, or Support 4.35 (0.77) 37 (84.1)
Educate Others About Lived Experience 3.34 (1.16) 17 (38.6)
Obligation to Tell 1.91 (0.91) 0 (0.0)
Test Reaction 2.41 (1.13) 1 (2.3)
Trusted/Close relationship 3.75 (1.33) 20 (45.5)
Shared background/experiences 4.09 (1.01) 23 (52.3)
Reasons Against Disclosure
Fear of Rejection 4.63 (0.75) 28 (63.6)
Belief in Right to Privacy 3.86 (1.15) 4 (9.1)
Shame about Suicidal Thoughts 4.61 (0.62) 31 (70.5)
Uncomfortable Talking About Suicidal Thoughts 4.05 (1.14) 18 (40.9)
Telling will Upset or Worry Confidant 4.14 (0.93) 16 (36.4)
Belief that Suicidal Thoughts are Not Serious 2.61 (1.17) 3 (6.8)
Belief in Coping Without Any Help 3.70 (1.13) 12 (27.3)
Fear of Hospitalization 4.34 (0.99) 20 (45.5)
a
This represents the proportion of the sample endorsing each reason among their top three reasons for and
against disclosure.

Ancillary Analysis: Brief Comment about First Disclosures
Because research has linked the quality of first disclosure experiences to positive
outcomes (e.g., self-esteem; Chaudoir & Quinn, 2010), I also asked participants about their
first disclosure experience. Participants characterized their first disclosure experiences as
slightly better than neutral, with a mean rating of 3.39 (SD=0.99) on scale from 1 to 5, with
1 being negative and 5 being positive. Thought about in a different way, approximately
20% of participants reported that their first disclosure experience was negative, 30%
characterized their first disclosure experience in a neutral way, and 50% reported that
101
their first disclosure experience was positive. Just over one-third of participants (n=17;
38%) indicated that the confidant with whom they first shared their suicidal cognition was
still a member of their current social network.
Summary of Results
Nearly all participants had or were intent on disclosing to someone in their network
and roughly half of their network members were viewed as attractive confidants for
disclosure. However, their intended disclosure varied depending on the type of suicidal
cognition and the type of social role/service outlet inside and outside of their social
networks. Intended disclosure prevalence was highest for mental health professionals and
lowest for family members and acquaintances/others inside networks. Intended disclosure
was highest for suicide attempt survivors and lowest for emergency rooms and online
services outside networks. Disclosure prevalence was lower for more serious types of
suicidal cognition (i.e., intent/plan).
In terms of the non-theory-informed analysis, only relationship type and social
support were found to be associated with intended disclosure across bivariate and
multivariate models; compared with family members, mental health professionals were
more attractive for intended disclosure and network members perceived as sources of
greater social support were more attractive for intended disclosure. In terms of the DD-
MM-informed analysis, the hypotheses were largely supported across bivariate and
multivariate models; there were positive associations between level of phobic anxiety (but
not global severity and other symptom domains), quality of relationship, favorability of
anticipated outcome (but not anticipated response), and disclosure efficacy and intended
disclosure; there was a negative association between perceived network member stigma
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(but not global perception of stigma) and intended disclosure. Overall, the DD-MM model
explained twice as much within-person variation and over three times as much between-
person variation as the non-theory-informed model. Catharsis and getting help were the
most important reasons for disclosure whereas fear of rejection and shame about suicidal
thoughts were the most important reasons for non-disclosure.

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CHAPTER FIVE:
DISCUSSION
The nondisclosure of suicidal thoughts can cause great harm by virtue of
compromising the ability to effectively detect and manage suicide risk (Cukrowicz et al.,
2014), which means that facilitating disclosure is integral to suicide prevention (Fulginiti et
al., 2015). The current study elucidated the patterns, correlates and motivations for
suicidal disclosure. The application of social network methodology and integration of
theory in a multilevel study of suicidal disclosure represented a novel approach that holds
promise for improving our understanding of disclosure and developing assessment and
intervention strategies that address disclosure.
Disclosure Patterns: Prevalence Across Levels, Cognition and Relationships
Aim 1 of this study sought to describe patterns of suicidal disclosure, including the
prevalence and consistency of disclosure across levels (individual-level and relational-
level), type of suicidal cognition, and relationships. There are a number of findings that
carry particular importance. First, the current study found a very high rate of individual-
level disclosure, with nearly 90% of participants indicating that they had disclosed suicidal
cognition to someone in the past and almost everyone indicating that they would do so in
the future if they were to experience a recurrence of suicidal cognition. This disclosure rate
is higher than the rates found in the vast majority of other studies in my review of the
literature on disclosure prevalence (See Table 1). If this high rate of disclosure were to be
replicated in a larger and more representative sample then it could be argued that concerns
about “hidden ideators”—people who do not disclose to anyone—in this population are
less warranted. Interestingly, Edwin Shneidman, the forefather of modern day Suicidology,
104
long ago asserted that communication is the common interpersonal act in suicide
(Shneidman, 1993), suggesting that suicidal disclosure invariably occurred before suicide.
Another consideration is that the only two studies of disclosure using social network
methodology (including the current study) have found similarly high rates. This raises the
possibility that utilizing a social network assessment, which typically includes interview
methods that improve recall (e.g., multiple prompts; Brewer, 2002), could result in more
complete data, producing higher individual-level disclosure rates (Fulginiti et al., 2015).
Second, the current study found that approximately 50% of social network
members were identified as confidants for suicidal disclosure (i.e., relational-level
disclosure prevalence), meaning that every participant disclosed to about 4 social network
members. This indicates that participants disclosed their suicidal cognition rather broadly
in their social networks. Given that disclosure can provide opportunities for intervention,
finding a pattern of broad disclosure in a high-risk group of people with a serious mental
illness and lived experience with a suicidal crisis is reassuring. The most obvious potential
benefit of broader disclosure is that disclosing to more people could increase the likelihood
of the discloser receiving help. Because many suicidal crises emerge and escalate to suicide
over short timeframes (e.g., Simon et al., 2001; Wojnar et al., 2009) and because confidants
can be unresponsive to such disclosure (Cowgell, 1977; Rudestam, 1971; Wolk-
Wasserman, 1986), it is critical to develop safety plans that offer broad and, whenever
possible, redundant coverage of confidant availability—this type of coverage is more
feasible with more confidants. Knowing that suicidal disclosure can be burdensome to
confidants (Jones et al., 1995), broader disclosure could also be favorable because a larger
pool of confidants can potentially be leveraged to coordinate opportunities for confidants
105
to work together and share the strain of managing crises. Instead of reaching out to the
same person in every crisis, there could be a cycling of confidants or the simultaneous
activation of multiple confidants. With the advent of new applications, such as My3, which
stores the contact information of 3 people to be activated during crisis
(Link2HealthSolutions, 2013), it is feasible that such an application could be programmed
to maintain a cycling or “team activation” system. Although there are certainly benefits to a
larger pool of confidants, having more confidants also means that more options need to be
weighed when making the decision about whom to contact. This should be taken into
account given that research on decision-making, albeit not in the context of choosing
confidants, suggests that having too many alternatives can result in choice overload, which
can paradoxically hinder rather than facilitate making a choice (Chernev, Bockenholt, &
Goodman, 2015).
Although the current study found that nearly all participants intended to disclose to
someone and that such disclosure would be rather broad in their social networks, the study
also revealed that intended disclosure rates varied as a function of cognition type. Lower
individual-level and relational-level disclosure prevalence rates were observed for suicidal
plan and intent compared to active suicidal thoughts. This suggests that participants adopt
a more restrictive approach to disclosure for more serious types of suicidal cognition.
There are potentially dire implications associated with disclosing active suicidal thoughts
but not disclosing suicidal plan or intent. After all, research has shown that suicidal
plans/preparation but not suicidal desire/ideation could be an indicator of heightened risk
for future suicide (Joiner, Rudd, & Rajab, 1997). This is better appreciated when taking into
account the response of systems that commonly encounter people in suicidal crisis. For
106
example, the standard risk assessment—reflecting evidence-informed Suicide Risk
Assessment Standards (Joiner et al., 2007)—of national crisis hotlines serving the general
population (i.e., National Suicide Prevention Lifeline) as well as high-risk subpopulations
(e.g., The Trevor Project) hinges on questions regarding suicidal intent. Furthermore,
many triage systems (e.g., Fort Carson, New York State Office of Mental Health) treat
suicidal plan or intent as an emergency clinical situation whereas they treat active suicidal
thoughts (without plan or intent) with a routine behavioral health referral.
Given prior work on descriptive patterns of disclosure across different types of
relationships or social roles (e.g., Encrenaz et al., 2012; Martin et al., 2013), it was
reasonable to expect and find that participants’ disclosure varied across relationship types
inside of personal social networks. However, the multi-level perspective on disclosure
prevalence extended what we know from previous research. Our findings pertaining to
individual-level prevalence highlight that one out of every three participants who have
family members and intimate partners in their social networks are unlikely to disclose to
anyone occupying those social roles. The findings pertaining to relational-level prevalence
also highlight that social network members who occupy certain social roles are commonly
perceived as attractive confidants (e.g., mental health professionals) whereas others are
not (e.g., family members). Collectively, these results suggest that assessments of disclosure
likelihood could benefit from assessing social network composition. For example, if we
know that a high-risk client has a small social network comprised entirely of family
members, it might signal a need for close supervision because there could be little, if any,
disclosure in that context. These results also raise concerns about the efficiency of
gatekeeper programs—which train people in suicide risk recognition and referral skills—
107
that broadly target people for training based on their relationship or role type (e.g., family
member, teacher, etc.) without accounting for the makeup of personal social networks or
the viability of people in certain social roles as confidants.
Several key observations involved disclosure outside of personal social networks.
Cast in the broadest terms, it was encouraging that many participants were likely to
disclose their suicidal thoughts to people occupying different social roles as well as to
different service outlets. Finding that a vast majority of participants perceived attempt
survivors as a potentially good resource for disclosure is promising because of the recent
upsurge in activity aimed at addressing the needs of attempt survivors (e.g., National
Suicide Prevention Lifeline, 2007; U.S. Department of Health and Human Services Office of
the Surgeon General and National Action Alliance for Suicide Prevention, 2012). The
increased advocacy for attempt survivors and the accompanying increase in visibility
would seem to bode well for people who might seek to engage a peer with a history of
having lived through a suicidal crisis. Furthermore, disclosure could beget more disclosure
as peer networks grow. Finding that nearly half of participants endorsed medical
physicians, spiritual advisors and crisis lines as likely targets for disclosure is also a good
sign, albeit for different reasons. As many as three-fourths of people who complete suicide
have had an appointment a primary care physician in a previous month (Luoma et al.,
2002), meaning that physicians are often positioned in highly influential windows of near-
term suicide risk. Many mental health consumers rely on spirituality when coping with
suicidal thoughts (Alexander et al., 2009) and religion can protect against suicidal behavior
(Lawrence, Oquendo, & Stanley, 2016), meaning that spiritual advisors can be
indispensible resources during suicidal crises. There is also an ever-expanding network of
108
crisis line services (Gould et al., 2012), including specialized services for high-risk
populations, like veterans (e.g., Knox, Kemp, McKeon, & Katz, 2012) and LGBT youth (e.g.
The Trevor Project; Weber, 2010), meaning that such services are widely accessible during
times of need.
Unfortunately, not all services were viewed as being equally attractive for reaching
out in times of crisis. Emergency room and online services fared relatively poorly for
suicidal disclosures. Finding that emergency rooms were rated as poor sites for disclosure
is disconcerting given that emergency rooms have become the “de facto” delivery system
for mental health care (Litts et al., 2008). However, the low valuation of emergency rooms
could stem from insensitive treatment received in that environment. For example, a study
by the National Alliance on Mental Illness found that over half of patients with serious
mental illness and nearly one-third of their family members reported feeling stigmatized
following a suicide attempt (Cerel et al., 2006). With that said, an increase in calls for
provider training (e.g., National Action Alliance for Suicide Prevention, 2014) and evidence
that training can reduce stigmatizing attitudes among providers (Botega et al., 2007; Chan,
Chien, & Tso, 2009; Saunders, Hawton, Fortune, & Farrell, 2012) offers hope that
perceptions of emergency rooms can change over time. In terms of online crisis services,
given research showing that older age is associated with a preference for offline health
information seeking (Cotton & Gupta, 2004; DeAndrea, 2015), the fact that our sample is
middle-aged could be the reason for these low ratings. However, research has also found
that a very small proportion of young people actually prefer online mental health treatment
(Bradford & Rickwood, 2014) and that young people hold similar favorability ratings of
109
online and face-to-face help-seeking for suicidality (Seward & Harris, 2016), meaning that
online crisis services could be rated as poor sites for disclosure across age groups.
Without Theory, What Do We Know About Disclosure?
Aim 2 of the study consisted of completing an analysis of disclosure using a set of
non-theory-informed variables. The purpose of this aim was to provide a standard of
comparison for the subsequent theory-informed model as well to quantify the extent to
which a set of non-theory-informed variables could explain disclosure. As a reminder, no
hypotheses were made in relation to Aim 2 of the study because the mixed findings that
have pervaded the disclosure literature and an atheoretical approach did not justify such
propositions. A number of conclusions can be drawn from the analysis of non-theory-
informed variables.
First, the characteristics of network members and the nature of the relationship
with network members played a more central role in disclosure than the characteristics of
individuals. Interestingly, although many of these variables—duration of relationship,
frequency of contact, age homophily, race homophily, social support, relationship type—
were associated with disclosure in bivariate analyses, only social support and relationship
type were found to retain their significance in multivariate analyses. This is line with the
results of the only other known social network study on suicidal disclosure (e.g., Fulginiti et
al., 2015).
Finding that people intend to disclose to network members who are perceived as
being sources of greater social support is not only intuitive but also bolstered by a well-
established empirical base outside of the suicide context. The link between disclosure and
social support has been widely supported by meta-analytic findings in the literature of
110
another highly stigmatized status, HIV/AIDS (Smith et al., 2008). Fortunately, stemming
from the link between social support and positive outcomes (e.g., Norman, Windell,
Manchanda, Harricharan, & Northcott, 2012), efforts to improve social support among
people with serious mental illness as well as those with lived suicide-related experience
have been undertaken. For example, the Compeer Model adopted an intentional friendship
approach that matched community volunteers to people with serious mental illness
(McCorkle, Rogers, Dunn, Lyass, & Wan, 2008) and the Maytree Program adopted a
befriending approach that linked people in suicidal crises to one another (Briggs et al.,
2007). Participation in peer support groups has also been shown to increase the size of
social networks among people with serious mental illness (Davidson et al., 1999).
Reflecting greater awareness of the unique support needs of people with lived suicide-
related experience, there has been the addition of a suicide attempt survivor support group
to the best practices registry of the Suicide Prevention Resource Center (Didi Hirsch
Suicide Prevention Center, 2014) and the emergence of websites (e.g., livethroughthis.org;
talkingaboutsuicide.com; attempsurvivors.org; lifelineforattemptsurvivors.org) that
provide attempt survivors with an opportunity to share their recovery journeys with one
another. It is promising that many different interventions, programs and resources to
enhance support are available because cultivating supportive relationships with social
network members could serve to facilitate suicidal disclosure.
Although prior work has largely failed to include variables pertaining to relational
characteristics, several prior investigations have explored the distribution of confidants by
relationship type (e.g., Encrenaz et al., 2012; Martin et al., 2013), which does appear to
factor into intended suicidal disclosure. As with our prior work (Fulginiti et al., 2015), the
111
current study found that participants were more willing to disclose to mental health
professionals. There is an upside and a downside to this finding. The upside is that mental
health professionals are likely to be far better prepared to assess and manage risk than
family members when faced with disclosures about suicide (Fulginiti et al., 2015). With
that said, it is vital to consider that there are major deficits in training mental health
professionals to deal with suicide risk (Schmitz et al., 2012), meaning that more needs to be
done to ensure that these high-value targets are able to effectively navigate high-risk
situations. The downside is that mental health professionals represent a relatively small
proportion of social networks, meaning that the highest valued confidants for disclosure
could very well be less available for those very disclosures. Traditional wisdom has been to
help people with serious mental illness integrate into the general community (Pahwa et al.,
2014) but this finding raises the possibility that greater integration into the mental health
community could promote safety.
Second, individual characteristics were found to play a rather small role in the
intent to disclose suicidal cognition. In fact, despite including a broad range of
sociodemographic and psychiatric/psychosocial variables in the analysis, only two
individual-level characteristics were even found to be significant in bivariate analyses.
Finding that individual characteristics were not shown to be particularly influential in the
current study is not entirely surprising given that no individual characteristics have been
consistently linked to suicidal disclosure. Furthermore, if indeed relational characteristics
are pivotal to suicidal disclosure, the omission of relational characteristics from prior work
calls into question even the known tenuous findings surrounding individual characteristics.
With that said, it would be premature to suggest that individual characteristics are not
112
influential in any way. Others have posited the idea that certain individual characteristics
(e.g., biological sex) might not directly influence intent, albeit in relation to help-seeking
rather than disclosure intent (e.g., Vogel, Wester, Wei, & Boysen, 2005). The current study
did find that gender and distress disclosure were associated with suicidal disclosure at the
bivariate level. It could very well be the case that the effects of individual characteristics,
such as gender and disclosure distress, on suicidal disclosure are mediated by other key
variables. Additionally, the moderating influence of individual characteristics is a viable
consideration that has not been adequately explored.
Lastly, the set of non-theory-informed variables did not explain a great deal of
variance in disclosure intent. In fact, the non-theory approach accounted for less than one-
tenth of the difference in disclosure between participants and less than one-quarter of the
difference in disclosure between network members (within participants). Because prior
literature has predominantly used dichotomous measures of disclosure (e.g., Encrenaz et
al., 2012) or relied on bivariate analyses (e.g., Martin et al., 2013), no known prior work has
assessed the extent to which a set of non-theory-informed variables explained disclosure.
Finding that a fairly large set of variables explains very little variance raises valid questions
about the “individual-centric” and atheoretical approach that has been traditionally used in
prior work and highlights the need for novel thinking on suicidal disclosure. In fact, this
result lent further justification to the multilevel, theory-informed approach that was also
examined in the current study.
With Theory, What Do We Know About Disclosure?
Aim 3 of the study consisted of completing an analysis of disclosure using a set of
variables informed by the Disclosure Decision-Making Model (DD-MM). The purpose of this
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aim was to test a set of hypotheses informed by the DD-MM and to quantify the extent to
which the DD-MM variables could explain disclosure. The following discussion will address
each of the three DD-MM assessment components and their constituent parts—Assessment
of Information (i.e., Stigma, Symptom Severity), Assessment of Receiver (i.e., Quality of
Relationship, Anticipated Reaction) and Assessment of Disclosure Efficacy. There are two
major overarching points, which will become evident in the following discussion, that are
helpful to highlight at the outset for context: (1) all DD-MM components were at least
partially supported; and (2) the assessments of receiver and disclosure efficacy were more
central in disclosure decision-making than the assessment of information.
Thinking about the first part of the Information Assessment, there was mixed
evidence for the hypothesized negative relationship between levels of suicide stigma and
intended suicidal disclosure. Knowing that people fear being stigmatized by prospective
confidants (National Suicide Prevention Lifeline, 2007; Smith et al., 2008) and worry about
the leakage of disclosed information to third parties (Derlega et al., 1993) suggests that
people are likely to make an assessment of stigmatized attitudes held by a prospective
confidant and stigma pervading the broader social network or environment when making
their disclosure decision. Although an individual’s overall perception of stigma toward
suicide (i.e., individual-level measure) and their perception of network members’ stigma
(i.e., relational-level measure) were indeed found to be associated with intention to
disclose suicidal cognition at the bivariate level, only perception of network members’
stigma remained marginally associated with disclosure at the multivariate level. The fact
that suicide stigma at the relational level remained marginally significant but suicide
stigma at the individual level did not prompts some intriguing considerations. From a
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research standpoint, it suggests that there is value in operationalizing the same variable
(e.g., stigma) on more than one analytical level when trying to understand complex
outcomes or phenomena that are suspected to have a multi-level influence. From a clinical
and program planning standpoint, it suggests that people who have lived through suicidal
crises might benefit from addressing suicide-specific stigma in their personal social
networks as a complement to broader anti-stigma messaging campaigns (e.g., Dumesnil &
Verger, 2009; Niederkrotenthaler, Reidenberg, Till, & Gould, 2014).
Thinking about the second part of the Information Assessment, there was also mixed
evidence for the hypothesized positive relationship between psychiatric symptom severity
and intended suicidal disclosure. The Disclosure Decision-Making Model and other
disclosure theories, such as the Fever Model (Stiles, 1987), hypothesize that worse
symptoms tend to promote disclosure. Finding that phobic anxiety was related to intended
disclosure but that overall psychiatric symptom severity and other symptom clusters (i.e.,
somatization, obsessive-compulsive, anxiety, depressive, hostility, paranoia, psychoticism
hopelessness) were not makes for a difficult interpretation. One possible explanation
comes from research examining the relationship between agoraphobia, which
approximates phobic anxiety (Derogitis, 1993), and help-seeking. An argument has been
made that symptoms accompanying agoraphobia are particularly impairing, which
motivates greater help-seeking (Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996). It
could very well be that people who experience more symptoms of phobic anxiety are apt to
seek help more and disclose more in the process of doing so. The fact that no other
significant associations were found between global or cluster-specific symptom severity
and disclosure could simply be further empirical evidence that this link is either tenuous or
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more complicated than we currently understand. After all, there has been mixed evidence
for the relationship between depression and suicidal disclosure (Frey, Hans, & Cerel, 2015;
Zhou & Jia, 2012), and we recently found no evidence of a relationship between global
psychiatric severity and disclosure (Fulginiti et al., 2015). Lastly, even though theories have
proposed a positive relationship between symptom severity and disclosure (Stiles, 1987),
there is evidence that distress is actually negatively associated with help-seeking (Vogel,
Wester, Wei, & Boysen, 2005). Overall, these findings raise questions about the existence
and nature of the link between psychiatric symptoms and intended suicidal disclosure.
Thinking about the first part of the Receiver Assessment, there was evidence
supporting the hypothesized positive association between relationship quality and
intended suicidal disclosure. This is a rather intuitive finding that is consistent with a
strong body of research showing that people tend to disclose personal and private
information to others with whom they are emotionally close and can trust (Kelly, 2002;
Petronio, 2002; Vangelisti & Caughlin, 1997; Vangelisti, Caughlin, & Timmerman, 2001).
Although no prior work examined the role of relationship quality in suicidal disclosure,
studies involving people with other stigmatized statuses, particularly HIV, have indicated
that relational quality features centrally in the willingness to disclose, intent to disclose,
and disclosure behavior (Greene & Serovich, 1996; Klitzman, 1999). Given that relational
quality was found to carry weight in the intended disclosure of suicidal thoughts, it was
heartening to find that participants reported high quality relationships with network
members—this finding echoes results found in other network studies of people with
serious mental illness (e.g., Biegel et al., 2013; Fulginiti et al, 2015). Even though the good
quality of participants’ relationships with their current social network members make good
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dyadic contexts for disclosure, there is more interpersonal loss (Davidson & Stayner, 1997;
Wright, Gronfein, & Owens, 2000) and instability in the social networks of people with
serious mental illness (Biegel, Tracy, & Song, 1995), which should be taken into account
when trying to identify prospective confidants for disclosure over time (e.g., safety
planning).
Thinking about the second part of the Receiver Assessment, there was bivariate but
NOT multivariate evidence supporting the hypothesized positive relationship between the
favorability of anticipated responses and intended disclosure. This suggests that as sensible
as it might seem to assume that disclosure decisions are influenced by expectations about
how a confidant will immediately respond to a disclosure, there are other factors more
central to intended suicidal disclosure. This finding should not automatically be
accompanied by a sigh of relief. After all, prior work tells us that aversive responses, in the
form of strong emotions or avoidance, to the disclosure of suicide-related experiences
frequently occur—many confidants respond with ambivalence, anger, hostility, and anxiety
(Cowgell, 1977; Wagner et al., 2000; Wolk-Wasserman, 1986) or react by joking or trying
to talk about something else, changing the subject or saying nothing at all (Eskin, 2003;
Magne-Ingvar & Ojehagen, 1999; Wagner et al., 2000; Wolk-Wasserman, 1986). Even if the
anticipation of aversive responses does not affect intended disclosure, it seems reasonable
to worry that such responses may detrimentally affect other important outcomes. Keeping
this in mind, it was reassuring to find that the vast majority of social network members
were expected to have a favorable response (e.g., positive emotions, emotional support) to
the disclosure but nonetheless concerning that approximately one-third of network
members were expected to have an aversive response to disclosure (e.g., negative
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emotions, avoidance). This concern is magnified when accounting for the fact that the
anticipation of negative responses to revealing other stigmatized statuses has been linked
to psychological distress and illness (Quinn & Chaudoir, 2009). In addition to the possibility
that anticipated responses may affect other outcomes, we cannot rule out that such
responses may affect disclosure in indirect ways that were not investigated. Of note,
although prior studies have identified different types of responses, the current study is the
first to quantify the extent to which different types of responses are expected throughout
social networks and to examine the association between anticipated response and intended
suicidal disclosure.
Thinking about the third part of the Receiver Assessment, the current study was able
to provide a preliminary impression about the nature and role of anticipated outcomes in
suicidal disclosure, which has been previously unexamined. The takeaway point is that
there was evidence supporting the hypothesized positive relationship between the
favorability of anticipated outcomes and suicidal disclosure. Therefore, it is important to
remember that efforts to facilitate disclosure should involve asking people what they think
will happen in the longer-term if they open up about suicidal experiences. From a
descriptive standpoint, it was interesting to find that participants expected their disclosure
about suicidal thoughts to result in considerably greater negative outcomes for confidants
(especially worrying confidants) than for their sense of self or relationships. Finding that
participants expect their disclosure to have an adverse impact on a sizable proportion of
their network members could be highly problematic when factoring in the relationship
between perceived burdensomeness and suicide (e.g., Van Orden et al., 2010). These
results highlight that disclosure could create circumstances that exacerbate suicide risk by
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making the discloser feel as though they have burdened the confidant and, consequently,
making the discloser feel guilty for doing so. This sense of burden might be more keenly
felt by people who have a serious mental illness or exhibit suicidal symptoms given that
their social networks report experiencing substantial burden (Foldemo, Gullberg, Ek, &
Bogren, 2005; Jones et al., 1995; Kjellin & Ostman, 2005; Maurin & Boyd, 1990; McDonell,
Short, Berry, & Dyck, 2003). Finding that participants expect their disclosure to lead to
negative self and relationship outcomes with around one out of every four social network
members should also be regarded as potentially troublesome. Because people are more
motivated to avoid negative self-definition than to pursue positive self-definition
(Baumeister, Bratslavasky, Finkenauer, & Vohs, 2001), the risk of tainting one’s self-image
by sharing suicide-related experiences with others could outweigh other considerations
when deliberating about whether to disclose.
Thinking about the only part of the Efficacy Assessment, there was evidence
supporting the hypothesized positive relationship between disclosure efficacy and intended
disclosure. This is consistent with research finding that efficacy affects the intent to
perform (Basen-Engquist & Parcel, 1992; Tolma, Reininger, Evans, & Urdea, 2006) and
actual engagement in health-promoting behavior (e.g., Hsu et al., 2015; Montanaro & Bryan,
2014). Identifying efficacy as an important factor in disclosure decision-making is
promising because there is a wealth of information available to guide intervention and
program planning to address efficacy. Informed by the work of Bandura (1977), clinical
efforts can facilitate greater efficacy by, among other things, demonstrating a behavior,
practicing a behavior, and providing verbal reinforcement or feedback for a behavior
(Champion & Skinner, 2008). With efficacy being tagged as influential in health promotion,
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many interventions have been developed to target efficacy to affect a wide variety of
behavioral outcomes (e.g., HIV-protective behaviors) (DiClemente et al., 2004; Jans &
Becker, 1984; Siegel, Aten, & Enaharo, 2001). There are also a few examples of
interventions targeting disclosure efficacy to facilitate revelations about other stigmatized
issues, such as mental illness (e.g., Rusch et al., 2014) and HIV/AIDs (e.g., Greene,
Carpenter, Catona, & Magsamen-Conrad, 2013; Murphy, Armistead, Marelich, Payne, &
Herbeck, 2011). Even though no interventions have been developed to address efficacy for
suicidal disclosure, our findings along with prior research suggests that could be a viable
target for intervention development and program planning.
Lastly, the Disclosure Decision-Making Model (DD-MM) explained a fair amount of
variance in disclosure intent. The DD-MM accounted for more than one-quarter of the
difference in disclosure between participants and more than one-third of the difference in
disclosure between network members (within participants). Finding that a fairly small set
of variables explains a modest degree variance is promising, particularly given that this is
the first study to test the DD-MM in the context of suicidal disclosure and that this study did
not test for more complicated relationships (e.g. mediation, moderation) among the
variables. The fact that the model explained a fair amount of variance and, relatedly, that all
of the DD-MM hypotheses received at least partial support, provides an empirical basis for
conducting larger studies using the DD-MM to test more sophisticated relationships in
seeking to understand suicidal disclosure.

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A Story of Many Motivations
No known studies have explored reasons for disclosure and only a couple of known
studies have explored reasons for non-disclosure in a suicide context—none among people
with serious mental illness—making the current study a meaningful step forward. The
major reasons for disclosure identified in the current study were catharsis, to get help,
advice or support and peer relationships. Although not in a suicide context, these reasons
are certainly not unprecedented. Catharsis has long been viewed as a central reason for
disclosure, most notably in the context of the Fever Model (Stiles, 1987). Seeking support
and the attractiveness of peer relationships for disclosure are also common reasons for
disclosure among people with other stigmatized statuses (Greene, Derlega, Yep, & Petronio,
2003). Taken together, these motivations appear well-suited as a target for peer
programming, such as support groups. Although there are very few support settings
designed to address the needs of people that have lived through suicidal crisis, the recent
manualization and listing of an attempt survivor support group in the Suicide Prevention
Resource Center’s best practices registry (Didi Hirsch Suicide Prevention Center, 2014) is a
welcome step for guiding the development and increasing the availability of those settings.
In terms of reasons for non-disclosure, there were points of convergence and
divergence from prior research on the subject. Similar to prior work with adolescents and
young adults (Burton et al., 2012; Eskin, 2003), fear of rejection, shame, and not wanting to
worry others were raised as important reasons for non-disclosure. These are ostensibly
legitimate reasons to withhold information about one’s suicidal ideation or behavior in
light of the fact that it is not uncommon for confidants to react in unhelpful or stigmatizing
ways (Magne-Ingvar & Ojehagen, 1999; Wolk-Wasserman, 1986) and to experience burden
121
following disclosure (Kjellin & Ostman, 2005; McDonell et al., 2003). This suggests that
working with prospective confidants to respond in more validating ways and to figure out
better ways to “care for the caregivers” to lessen their burden could remove some of the
barriers for concealment. Distinct from prior work with adolescents and young adults
(Burton et al., 2012; Eskin, 2003), the perception that suicidal thoughts are not serious and
preference for privacy were not highly rated among reasons for non-disclosure. Given that
the sample for the current study is comprised of adults who are engaged in treatment and
have a rather long duration of illness, it could be that they have higher mental health
literacy and they are less guarded about mental health matters.
Although certain reasons for and against disclosure were more highly rated than
others, it is easy to recognize that many reasons were highly rated. In fact, 11 out of 15
reasons were rated as approximately a 4 (“likely a reason”) on a scale from 1 to 5. Although
research has classified goals in many different ways (e.g., self-, other-, relationship-focused;
egosystem vs. ecosystem), there was no clear pattern along such lines that could be drawn
in this case. With that said, it is valuable to reflect on these findings in the context of
multiple goals theory. A multiple goals theory assumes that communication is purposeful,
multiple goals are pursued at the same time, and that such goals often conflict (Caughlin,
2010). This is an important consideration because there may be consequences and
challenges that come with possessing multiple goals. For instance, some research suggests
that engaging in a given activity driven by more than one motivation can result in more
stress and less satisfaction with the activity (Kiviniemi, Snyder, & Omoto, 2002). Others
suggest that the consequences of a multiply motivated disclosure really depend on
disclosure management. This management can undoubtedly take many forms, including
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“balancing” reasons for and against disclosure by making shared decisions to set
parameters around things such as the frequency of talk or specific content about a subject
(Goldsmith, Miller, & Caughlin, 2007) or in cultivating messages that attempt to effectively
satisfy multiple goals (Caughlin et al., 2009). Working with suicidal ideators and attempt
survivors to figure out the best way to balance their motivations and craft messages that
can elicit the most favorable confidant responses to meet their needs is a worthwhile
clinical endeavor.
Implications for Practice
Although different implications have been mentioned over the course of the prior
discussion, it is critical to emphasize that the current study findings have broad practice
implications for disclosure assessment and intervention. First, the study findings suggest
that clinicians could benefit from using social network methods to assess the likelihood of
disclosure as well as to identify social network members likely to be pursued for
disclosure. A network assessment of disclosure can give clinicians a sense of how visible
the client is to others when it comes to sending warning signs of suicide. It can also
complement traditional safety planning, which includes asking people to identify select
members of their social networks to be contacted during crises (e.g., Stanley & Brown,
2012). In short, safety planning results in a narrow nomination of network members for
disclosure purposes and is therefore limited in that it does not assess the overall
availability of the network to assume the role of confidant. Although having more
confidants is not necessarily better than having fewer confidants, it is hard to imagine that
the overall availability of the network is inconsequential in the context of suicidal
disclosure. For example, the My3 application involves asking people to identify 3 people
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who they can reach out to during crises (Link2HealthSolutions, 2013). However, one client
might report that they only have 3 possible confidants whereas another client might report
that they have 7 confidants. In the case of the latter client, the information about the 4
other prospective confidants is never collected with something like the My3 application.
Why not profile and collect contact information for all network members identified as
prospective disclosure confidants? With the use of adapted autodialing software, the
person could then press a button and cycle through their list of all viable confidants until
someone is reached for support. By helping to identify confidant availability, the network
assessment can also be used to guide targeted training to improve confidant preparedness
regarding what to do if their loved one opens up about having suicidal thoughts. For
example, network assessments can be used to identify network members who have
existing relationships with one another, which could be used to efficiently guide the
delivery of trainings in pre-existing groups; a potential benefit of group training is that it
could help to build cohesiveness and efficacy among the members in collectively
responding to such disclosures.
Second, the findings from the current study provide guidance for the development
of a suicide-related disclosure intervention. The factors identified in the current study that
appear particularly well-suited as targets for intervention include social support, stigma,
relational quality, anticipated outcomes and disclosure efficacy. There are many different
ways that such factors could be addressed. A number of interventions and decision-aids
have recently been developed to help people with stigmatized statuses, including HIV
(Greene et al., 2013; Murphy et al., 2011) and mental illness (Brohan, Henderson, Slade, &
Thornicroft, 2014; Rusch et al., 2014), make disclosure decisions. The Brief Disclosure
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Intervention (BDI) appears particularly promising for application to a suicide context
because it was developed to address many of the factors that comprise the Disclosure
Decision-Making Model (e.g., anticipated reactions, anticipated outcomes, disclosure
efficacy). The BDI is group intervention that uses a progressive, three-phase, motivational
interviewing approach to help participants learn about different options and techniques for
sharing, contemplate the pros and cons of sharing, and practice sharing (Greene et al.,
2013). Given the finding that peer support groups can increase the size of social networks
among people with serious mental illness (Davidson et al., 1999), the group context itself
lends well to addressing relational quality and social support. It should be noted that
although relationship type is less malleable and therefore questionable as a target for
intervention, if studies can identify mutable factors that make people occupying certain
social roles (e.g., family members) less attractive as confidants than people occupying other
social roles (e.g., mental health professionals), then those factors could indeed be
addressed.
It should be noted that a social network interview could simultaneously function as
an intervention. Although no formal evaluation was performed to explore whether the
social network interview impacted any participant outcomes in the current study, it was a
pleasant surprise to find that approximately one-fifth (18%; n=8) of the participants
spontaneously voiced that the network interview raised their awareness about the degree
of support that they had available to them. A few participants even asked about whether
they could take a picture of their network map to reference when they needed a reminder
that they were not alone. The potential for social network mapping to act as both an
assessment and intervention tool is yet unexamined. However, genograms (e.g.,
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McGoldrick, Gerson, & Shellenberger, 1999) and ecomaps (e.g., Hodge, 2000), which
similarly explore interrelationships among different social entities or domains, have been
shown capable of functioning in both an assessment and intervention capacity (e.g., Hodge
& Williams, 2002; Peters, Hoskins, Prindiville, Kenen,& Greene, 2006). If a social network
interview were found to have positive effects on interviewees then the prospect of a
network-informed disclosure intervention is even more compelling.
Study Limitations and Strengths
The current study had several limitations. First, the study assesses intended
disclosure within a social network defined within a relatively recent timeframe (i.e., prior
month), which is beneficial for assessing a broad range of social ties and doing so with less
bias (Bell et al., 2007) but might not capture social ties that are infrequently encountered
or accessed. Second, the recruitment strategy required referral from a mental health
provider, meaning that participants were arguably more inclined to disclose (i.e., selection
bias). Third, certain variables that have been garnering increased attention in the literature
on disclosure of other stigmatized statuses (e.g., response uncertainty) were not included
in the current study because they were not constituent parts of the disclosure theory under
investigation and to limit participant burden. Lastly, the small sample size, utilization of
purposive sampling, and single recruitment site narrow the generalizability of the findings.
Relatedly, this study was conducted in the context of an agency that has well-developed
suicide prevention services, which could affect disclosure rates and might not be
representative of other samples of people with serious mental illness who are engaged in
treatment.
126
Although the current study was not without limitations, it also advanced the field of
suicidal disclosure in numerous meaningful ways. First, the study provided insight into
interpersonal and intranetwork patterns of disclosure. Second, the study explored the
intent to disclose different types of suicidal cognition (e.g., active suicidal thoughts, plan,
and intent) and types of social relationships/service outlets. Third, the study utilized and
established the viability of the Disclosure Decision-Making Model in understanding
intended disclosure of suicidal cognition. Fourth, the study employed social network
methodology, which permitted the appropriate inclusion of both individual and relational
level characteristics in understanding disclosure. Fifth, the study added to our
understanding of motivations related to suicidal disclosure. Lastly, the study focused on
people with serious mental illness and lived experience with suicidal crises, which
represent a particularly vulnerable group.
Future Directions for Research
A major deficit exists in our ability to explain suicidal disclosure. Recognition of this
deficit means that there are many available research opportunities to develop our
understanding of such disclosure. It is critical to determine the extent to which disclosure
intent translates to actual disclosure behavior. Relatedly, it is important to examine
whether the correlates of disclosure intent found in the current study are also correlates of
actual disclosure behavior. Follow-up studies could also benefit from the use of
methodology, such as Ecological Momentary Assessment, that can capture real-time
assessments of phenomena over time (Shiffman, Stone, & Hufford, 2008). Ecological
Momentary Assessment, which has been underutilized in both suicide (Davidson, Anestis,
& Gutierrez, 2016) and disclosure research, has the potential to: (a) limit retrospective bias
127
related to reporting prior disclosure; (b) evaluate fluctuations in intent and disclosure over
time; and (c) ensure that changes in social networks are accounted for in assessment of
disclosure. This methodology can also be used to investigate other important components
of disclosure, such as frequency, breadth, and depth of disclosure. Another important step
will be to assess disclosure intent and disclosure behavior in other high-risk populations
(e.g., LGBT youth) and during high-risk critical junctures (e.g., post-hospitalization). Lastly,
DD-MM is essentially a rationale choice model and aspects of alternative models should be
considered (Network Episode Model; Pescosolido, 1992).
Conclusions
The decision to disclose suicidal thoughts is a poorly understood process that is
consequential for identifying and managing suicide risk. Although people with serious
mental illness and lived experience are at high risk for suicide, the subject of disclosure has
received remarkably scant attention in this population. The current study revealed that
most individuals are inclined to share their suicidal thoughts and do so rather broadly.
However, the prevalence of disclosure was lower with more severe suicidal cognition,
raising concern about the ability to accurately assess suicide risk without developing
interventions to promote broad and uniform disclosure across types of suicidal cognition.
Furthermore, certain social relationships were found to more attractive for intended
disclosure (e.g., mental health professionals) than others (e.g., family members), providing
guidance for targeted training or safety planning. Intervention development can be
informed by the Disclosure Decision-Making Model, which was found to be a viable model
for improving our understanding of suicidal disclosure.

128
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Appendix A
To bolster the foundation of this dissertation, I conducted a review on prevalence of
suicidal communication and disclosure as well as correlates of suicidal communication and
disclosure using Google Scholar. A review was performed for any articles published before
the search date, which was September 29, 2014. The following search terms were used:
(“suicidal communication” or “suicidal disclosure”). The search for “suicidal
communication” yielded 398 hits while the search for “suicidal disclosure” yielded 35 hits.
The body of the text was searched to capture appropriate articles because scoping searches
revealed that many articles that reported prevalence would have been omitted with a
search that was restricted to title/abstract. Articles located in the Google Scholar search
were also reviewed to identify any relevant cited work that was not detected during the
Google Scholar search.
Of the 433 reviewed articles, 49 (11%) articles included a measure of prevalence or
provided information from which prevalence information could be derived. The prevalence
information for these studies can be found in Table 1. Only the first author and dates of
studies are listed for clarity. An additional 8 articles were identified but the original
sources were inaccessible. Summary statistics for those 8 articles are provided in a note
under Table 1. The specific prevalence rates for those 8 studies were as follows: [Gibbs
(1961): 26%]; [Stengel (1958): 34%]; [Beisser (1961): 51%]; [Engelhardt (1965): 69%];
[Farberow (1950): 75%]; [Pokorny (1960): 75%]; [Leblhuber (1983): 28%]; [Shafii
(1985): 55%]. References for all articles are available upon request from this author.
Of the 433 reviewed articles, 23 (5%) articles included a measure of association.
Because a very large set of variables was identified during the review, a decision had to be
159
made regarding the variables that would be included in the dissertation study. Of the 59
variables identified during the review, 66% of the variables (n=39) appeared in only 1
study and 19% appeared in 2 studies (n=11). It was decided that any variables included in
at least 3 prior studies would be considered a “common” variable for investigations of
suicidal communication. Although this is a very low threshold as a raw frequency to be
classified as “common”, inclusion in 3 prior studies is a high frequency from a relative
standpoint. In fact, only 15% (n=9) of the variables appeared in 3 or more studies. The two
most commonly included variables (i.e., age and psychiatric diagnosis) were included in 8
studies. A list of all investigated correlates and the number of studies in which they were
included can be referenced in Table A1 below. References for all articles are available upon
request from this author.

160
Table A1. Review of Variables Investigated as Correlates in Suicidal Communication Research: Toward Identifying a
“Common Set of Variables” (n=23)

Variables n Variables n
Sociodemographic Variables Suicide-Specific Variables
Age 8 History of Attempt/# of Attempts 6
Gender 7 Lethality of Suicide Attempt 2
Marital Status 6 Suicide note 2
Education 5 Attempt vs Suicide 1
Culture/Indigenousness 4 Suicidal Plan 1
Religion 2 Suicidal Intent 1
Income 2 Suicidal Method 1
Occupation 2 Suicidal Ideation 1
Employment 1 Wish to die 1
Living Situation 1 Prior Suicidal Communication 1
Housing 1 More Self-Pain Infliction NSSI 1
Town Size 1 Family History Variables
Sexual Orientation 1 Family Suicide 2
Role Status 1 Family Drug Use 2
Number of Children 1 Family Psychiatric Problems 1
Clinical Variables Family Psychiatric Hospitalization 1
Psychiatric Diagnosis 8 Parent Death 1
Psychiatric Hospitalization 3 Family Economic 1
Depression 3 Number of children family of origin 1
Alcohol Use 2 Relocation As Child 1
Hopelessness 2 Other Health/Psychosocial Variables
Length of Stay in Facility 1 Social Support 2
Number of Psychiatric Episodes 1 Work Difficulty 2
Psychiatric Contact 1 Health 1
Age at First Psychiatric Diagnosis 1 Medication 1
History of Drug Use 1 Prior Week Visit Doctor 1
Substance Use Frequency 1 Medical Hospitalization 1
Substance Use Versatility 1 Memory Difficulty 1
Sexual Difficulty 1
Financial Difficulty 1
Job Instability 1
Frequent Relocation 1
Unusual Activity 1
Social Activity 1
Note. The variables that are bold-face and italicized indicate studies that have been included in at least 3 studies,
which are referred to herein as “common” variables.
161
Appendix B

Figure B1. Formulas for the Multivariate Multilevel Models Examining Suicidal
Disclosure

Abstract (if available)

Abstract The disclosure of suicidal thoughts is integral to effective suicide risk management. Despite the fact that every disclosure occurs in the context of a relationship, scholarship on suicidal disclosure has almost exclusively focused on the individual doing the disclosing and not the relationship context in which disclosures are made. This has meant asking about how common it is for people to disclose (i.e., individual-level prevalence) and individual characteristics that affect disclosure. Recognizing that people selectively disclose to members of their social networks raises important unanswered questions about the extent to which people disclose in their social networks (i.e., relational-level prevalence) and network characteristics (e.g., member or relationship attributes) that affect disclosure. Research has also generally neglected to consider that people may adopt different disclosure practices depending on the type of suicidal cognition. Lastly, this literature has lacked a theoretical basis and has minimally explored disclosure motivations. The objectives of this study were to: (a) describe disclosure patterns across people, relationships and type of suicidal cognition

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Core Title Suicide talk as a vital sign: a theory-informed examination of individual and relational factors that influence suicidal disclosure

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Defense Date 05/05/2016

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Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA