Qualitative experiences with a suicide prevention intervention: voices from advocates and youth experiencing homelessness

Abstract

Suicide is a leading cause of death among youth experiencing homelessness (YEH) and prevention interventions are needed for nontraditional settings. This study presents the adaptation of Cognitive Therapy for Suicide Prevention (CTSP) within a supportive housing randomized trial for YEH (18 to 24 years). CTSP was delivered by trained youth advocates in community settings. Both youth (n = 11) and advocates (n = 5) were interviewed and shared perspectives on acceptability and feasibility. Advocates felt CTSP was easy to implement and could be integrated into advocacy sessions. Despite initial discomfort discussing suicide, YEH were open to CTSP, and advocates felt they understood and utilized the content. Advocates noted the importance of ensuring that youth’s basic needs were met first, the need for building rapport, and the challenges of limited time with YEH. Interventions to address suicide among YEH that are flexible and ensure youth feel cared about could be more acceptable and increase engagement.

Introduction

Youth who experience homelessness (YEH) have worse mental health outcomes compared to their housed counterparts, including higher prevalence of substance use disorders, depression, anxiety, and suicidal ideation (Baiden et al., 2024; Burke et al., 2023; Edidin et al., 2012). Suicide and drug overdose are leading causes of death among YEH (Auerswald et al., 2016; Roy et al., 2004). Experiences of trauma and victimization, both before and during periods of homelessness (Gaetz, 2004), contribute to a high prevalence of suicidal ideation and suicide attempts among YEH (Hadland et al., 2015). Access to and use of mental health treatment in traditional office-based settings is low, with only a minority of YEH in need of mental health care reporting receiving treatment (Semborski et al., 2022; Narendorf et al., 2017). Thus, delivery of suicide risk prevention to YEH can be challenging given barriers to accessing services in outpatient settings and difficulties navigating a fragmented and complex mental health treatment system. YEH often face significant barriers to accessing health care in traditional settings, such as lack of insurance coverage, unreliable transportation, other costs, or general mistrust of health care providers (Chelvakumar et al., 2017).

Due to the many obstacles YEH face in accessing traditional service settings (Chelvakumar et al., 2017; Gallardo et al., 2020), interventions to address suicide risk among YEH that are feasible, acceptable, and can be delivered in nontraditional settings are needed. Cognitive Therapy for Suicide Prevention (CTSP) is an evidence-based intervention that uses cognitive-behavioral therapy to assist high-risk individuals with identifying and utilizing more effective coping strategies to address their triggers for suicidal thoughts or behaviors (Brown et al., 2005; Slesnick et al., 2020; Wenzel & Beck, 2008). CTSP has been shown to be effective for addressing suicide risk among adults seeking care for a suicide attempt at an emergency room (Brown et al., 2005), as well as among YEH with suicidal ideation who received CTSP through a youth drop-in center therapist (Slesnick et al., 2020). While the previous study of CTSP among YEH demonstrated promise for reducing suicidal ideation (Slesnick et al., 2020), this intervention could only reach the youth who were able to attend therapy appointments in the drop-in center offices. However, YEH face many barriers to accessing services through drop-in centers or may not be aware of their availability in their area (Pedersen et al., 2016). Moreover, youth who are identified as at risk for suicide in a drop-in center, often have difficulty returning for appointments at regular intervals, limiting their intervention dose (Walsh et al., 2021).

Strengths-based outreach and advocacy (SBOA) is an intervention that has been tested previously and found effective for connecting YEH to services and reducing substance use (Guo & Slesnick, 2017; Slesnick et al., 2016). SBOA uses trained advocates, or outreach workers, to deliver a positive, strengths-based approach to intervention that puts youth in the center of identifying their goals and meeting their needs. The term “advocate” is used to be consistent with the model’s positive focus and that the advocate serves as an ally for youths in overcoming obstacles they face. Importantly, SBOA can be delivered in a range of settings including at drop-in centers, as well as in unsheltered locations in the community. Unlike traditional service providers, advocates are trained to meet youth where they are at, showing positive regard and walking alongside YEH as they navigate barriers to needed services or providing transportation. Using advocates trained in SBOA to deliver CTSP could further expand reach to suicide prevention interventions for YEH who are unable or unwilling to attend appointments in therapists’ offices.

Evidence-based interventions for suicide, such as CTSP, are likely to require adaptations to be “feasible” (e.g., whether it can be successfully delivered) and “acceptable” (e.g., whether stakeholders perceive it to be agreeable) (Proctor et al., 2011), in nontraditional mental health care settings such as street outreach models. Contextual adaptations are adjustments to the way an intervention is delivered including the format, setting, or personnel (Stirman et al., 2013; Wiltsey Stirman et al., 2019). These are distinct from content adaptations that modify intervention elements (e.g., removing, integrating, adding, condensing components). Adaptations to content or context can enhance feasibility and acceptability because they ensure a better fit between the intervention and its intended audience. For example, training advocates to deliver CTSP (a contextual adaptation) might improve the feasibility of implementing the intervention considering the unique workflows and resource constraints in outreach models. Moving CTSP to an outreach model (contextual adaptation) and integrating the intervention with others (content adaptation) might also remove service access barriers and make the intervention more acceptable to YEH. Together, these adaptations could expand the reach of evidence-based interventions. Understanding perspectives from YEH and advocates on such interventions and adaptations is also critical to identifying successful future implementation strategies.

The present study describes the experiences of YEH with receiving CTSP through a trained youth advocate over a six-month period, as well as the perspectives of advocates with experience delivering CTSP to YEH. Qualitative interviews among advocates and YEH were conducted to assess the feasibility and acceptability of adaptations to CTSP to allow delivery of this intervention through an advocate. Descriptive process measures of CTSP enrollment, session attendance, and length are also presented to characterize the overall reach of the intervention in the total samples of YEH who were eligible to receive it. Incorporating YEH’s perspectives into the feasibility and acceptability of CTSP is critical to understanding whether the intervention could be successful in addressing suicidal thoughts or behaviors in nontraditional settings.

Methods

Study sample and data collection

The current study focused on a subgroup of participants and study staff from a larger randomized controlled trial (n = 240) the “Housing, Opportunities, Motivation and Engagement” (HOME) trial (Slesnick et al., 2021). The HOME trial tested a supportive housing intervention combined with risk preventive services (n = 120), relative to risk preventive services without supportive housing (n = 120). Between 2020 and 2023, 240 youth were enrolled in the study for a 12-month period and received risk preventive services for the first six months of the study, with survey data collection occurring every 3 months. Youth were recruited for the parent study from a drop-in center, as well as other community locations and service sites (e.g., soup kitchens, libraries, or street locations) in Central Ohio. The eligibility criteria for the larger study included the following:

1. Between the ages of 18 to 24 years.

2. Youth met criteria for homelessness as defined by the McKinney-Vento Act as those who lack a fixed, regular, and adequate nighttime residence; lives in a welfare hotel, or place without regular sleeping accommodations; or lives in a shared residence with other persons due to the loss of one’s housing

3. Youth does not meet diagnostic criteria for Opioid Use Disorder (OUD), due to focus on prevention of OUD

The current study focused on the subgroup of youth who were offered CTSP. Cognitive Therapy for Suicide Prevention (CTSP) was offered to subjects in both arms of the randomized controlled trial if subjects had suicidal ideation or a past-year suicide attempt. Survey data from subjects’ baseline assessment were used, including demographic characteristics (e.g., age, race, ethnicity, sex, gender, sexual orientation) to characterize the larger sample of youth and those offered CTSP. Youth were eligible for CTSP if they were identified as having suicidal ideation during the first six months of the study (SSI-W score range: 0–38 points; SSI-W score >0 considered eligible), either on the baseline or three-month follow-up assessment, or if they reported a past-year suicide attempt. A threshold of SSI-W score >0 was selected to offer CTSP, given the high risk of suicide among YEH. After determining that youth were eligible, they were provided with information about the CTSP intervention and asked if they were interested in participating. A written informed consent process was followed and youth who consented were enrolled in the CTSP intervention. Of note, it was not a requirement of the parent study that youth participate in CTSP if they were eligible, therefore youth were free to continue with the larger study without choosing to participate in CTSP with their advocate.

The qualitative portion of this study included in-depth qualitative interviews with a convenience sample of 11 youth who were enrolled in the CTSP intervention, who received at least one CTSP session from their advocate alongside SBOA, and who volunteered to participate in the additional interview at the end of their study enrollment (e.g., after completing their 12-month survey). Advocates informed youth about the opportunity to participate in an additional qualitative interview for the study during the final month of their enrollment. If youth expressed interest, they were then contacted by the interviewer to schedule an interview. Among 20 youths who were approached to schedule an interview, 11 completed interviews. Nine youth who expressed initial interest in the interview were not interviewed due to non-response to scheduling requests. Additionally, all five advocates who maintained contact with the study, either still serving as an advocate or who had recently departed, were invited to participate and completed an interview. Interviews lasted approximately 30 minutes and were conducted virtually (by phone or Zoom), digitally recorded, and transcribed before analysis. Interviews were conducted by the team’s qualitative expert (BB) or trained qualitative interviewer (LJ) and followed semi-structured interview guides developed by the study team, which are available in Appendix 1. Content that overlapped both the advocate and youth interviews was used in the present study. Therefore, some of the questions that appeared in the youth interview were omitted from the analysis (e.g., experiences of homelessness and suicidality, COVID-19-related questions). Reporting of the qualitative interviews follows the COREQ guidelines for qualitative research (Tong et al., 2007). The study was reviewed and approved by the Ohio State University institutional review board. All subjects provided written informed consent to participate in the parent study and verbal consent to participate in the qualitative interview sub-study.

CTSP intervention procedures

The study offered eligible subjects the CTSP intervention, which included up to ten CTSP sessions with their advocate and additional booster sessions as needed (Chavez et al., 2021). Sessions included a focus on safety planning, developing a “hope kit,” building positive supports and alternative thinking and behaviors, and developing and practicing coping strategies for suicidal thinking. The first sessions are focused on establishing rapport, safety planning, and education around cognitive processes (Stanley et al., 2009). Sessions in the middle phase focus on cognitive restructuring and behavior change specific to suicide-related risks. In the final phase, sessions focused on relapse prevention and skills practice. Participants in need of additional mental health care are referred to mental health treatment services. Youth who enrolled in the CTSP intervention met with advocates over a six-month period, which aligned with the period during which SBOA and risk prevention services were delivered. This is also the timeline previously tested among YEH and found effective for reductions in suicidal ideation (Slesnick et al., 2020).

Description of CTSP adaptations

Adaptations to the CTSP delivery were made to improve acceptability of the intervention so that more youth would engage with the intervention, while maintaining fidelity to intervention content, and allowing delivery in diverse community settings. Adaptations were based on prior experience delivering CTSP to YEH, as well as input from the larger study team as the current project was implemented, which included experts in research, experts in CTSP, advocates, and YEH with lived experience (Wiltsey Stirman et al., 2019). As noted above, the use of CTSP among YEH had been piloted previously in a youth drop-in center (Slesnick et al., 2020). In that prior study, youth attended in-person therapy appointments with a therapist in offices located at the drop-in center (reflecting a modification to the setting). Therapists were trained to deliver CTSP and supervised biweekly. While having the CTSP sessions located in a youth drop-in center therapy offices removed some barriers to attendance, there were still challenges with youth attendance (Walsh et al., 2021). As a result, for the current project, the study team made additional adaptations to intervention delivery to allow for greater flexibility. In particular, the decision to allow trained youth advocates to deliver the CTSP allowed advocates (a personnel adaptation) to deliver the intervention during advocacy meetings in locations outside of the drop-in center (an additional setting adaptation).

Advocates were recruited as study staff who had backgrounds in social work, family therapy, or other related field, or who were in training to complete clinical degrees in these areas. For example, CTSP could be offered at other private meeting spaces in community locations (e.g., public libraries, outdoor spaces, youth housing, or while transporting youth to services, etc.). As soon as participants enrolled in CTSP, they were offered regular sessions with their advocate, which could occur weekly or biweekly, or more frequently if participants wanted to meet. The one-on-one sessions occurred with subjects’ assigned advocate who continued to meet with them regardless of whether they participated in CTSP to offer other risk prevention services. Any safety concerns followed a standardized emergency procedures protocol, including taking subjects to the hospital if warranted (Chavez et al., 2021). As the study launched, it became apparent that additional adaptations were also needed to overcome remaining barriers to youth engagement. The decision was made to allow the CTSP content to be woven into the advocacy sessions rather delivering them as “stand alone” sessions only. A noted advantage of having advocates deliver the CTSP was that the intervention content could be integrated with SBOA (a content adaptation), allowing advocates to more seamlessly deliver the CTSP when youth were comfortable with discussing suicide or as opportunities naturally arose during advocacy sessions. All adaptations were made to ensure that the intervention could reach more youth, while also maintaining fidelity to the core content of the evidence-based intervention. Author, Dr. Natasha Slesnick, conducted all training and weekly supervision in CTSP with advocates, including reviewing recorded sessions to ensure fidelity.

Analyses

Descriptive statistics were used to characterize the sample of youth who were eligible for and enrolled in the CTSP intervention overall. Youth characteristics are reported for those who were eligible for CTSP as well as process measures of engagement, including the percentage of enrollment (among those offered), session attendance, session length, and mode of delivery to characterize the feasibility, acceptability and reach of the intervention for YEH eligible for CTSP. Characteristics of youth offered CTSP and those not offered CTSP are reported for descriptive purposes in the overall sample.

The qualitative sub study focused on 11 YEH who had received CTSP (in combination with SBOA), as described above, as well as five advocates who delivered CTSP to YEH. Qualitative analysis followed Braun and Clarke’s (2006) procedures for thematic analysis. Each interview was coded by three independent coders (BB, LJ, or LC). First the coders read through transcripts and used open coding to identify initial codes and emerging themes. Following open coding the coding team met to discuss their initial findings and develop a shared codebook. During the second phase of coding, the coding team then each independently coded the transcripts using the shared codebook. During this phase the team met biweekly to review discrepancies in coding and come to consensus, adding new codes as needed. No new codes appeared in coding the later transcripts of YEH or advocates, suggesting that the completed interviews were sufficient for data collection. All qualitative coding and analyses were completed in NVivo 14. The qualitative analysis team (BB, LC, LJ) all identified as female. NS (female) and KK (male) served as the multi-PI team for the study and AB (female) was a researcher trained in social work. No individuals on the study team had a personal relationship with interview participants.

Results

Overall youth characteristics and intervention delivery

In the total sample of YEH enrolled in the HOME trial who were eligible for CTSP (n = 82), 67 (75%) consented to the intervention and were enrolled in CTSP. Most YEH who enrolled in CTSP were female and Black Non-Hispanic (Table 1). A high proportion of the sample was non-heterosexual (46.3%) or had a past-year suicide attempt (26.9%). The majority of YEH were enrolled after their baseline assessment for suicide risk (70.1%), though an additional 29.9% were enrolled after their 3-month interview because of a high score on the SSI-W or a past-year suicide attempt at each time point, respectively (Table 2). Most youth who enrolled in CTSP received at least one session with their advocate (79.1%), with the average number per subject being 2.6 sessions (SD = 2.6; IQR 1–4). The maximum number of completed sessions was 12. Although the average number of sessions for stand-alone CTSP and integrated (with SBOA) CTSP sessions were similar, the length of stand-alone sessions was longer, 18.3 vs. 11.0 minutes.

Table 1.

HOME study youth characteristics, by CTSP treatment enrollment.

	Enrolled in CTSP		Not Enrolled in CTSP
	n = 67		n = 173
Age, mean (SD)	20.9	(1.8)	21.1	(1.9)
Sex, n (%)
Male	22	(32.8)	101	(58.4)
Female	45	(67.2)	72	(41.6)
Gender, n (%)
Male	21	(31.3)	100	(57.8)
Female	37	(55.2)	71	(41.0)
Non-binary	9	(13.4)	1	(0.6)
Sexual orientation, n (%)
Heterosexual	36	(53.7)	141	(81.5)
Non-heterosexual	31	(46.3)	32	(18.5)
Race/ethnicity, n (%)
White non-hispanic	21	(31.3)	32	(18.6)
Black non-hispanic	31	(46.3)	105	(61.1)
Hispanic	7	(10.5)	16	(9.3)
Multiracial non-hispanic	4	(6.0)	7	(4.1)
Other	4	(6.0)	12	(7.0)
Suicidal ideation and behaviorsa
SSI-W score, mean (SD)	8.1	(7.6)	0.4	(1.4)
Past year suicide attempts, n (%)	18	(26.9)	10	(5.8)

^aMeasured at Baseline Assessment. SSI-W was completed at either baseline or 3-month assessment if not completed at baseline.

Table 2.

Receipt of CTSP among those enrolled in CTSP (n = 67).

	Total sample (N = 67)
Timing of enrollment
Offered CTSP at baseline, n (%)	47	(70.1)
Offered CTSP at 3 months, n (%)	20	(29.9)
Received any CTSP sessions, n (%)	53	(79.1)
Total sessions
Number of sessions attended, Mean SD	2.6	(2.7)
Session length (minutes), Mean SD	24.0	(18.3)
Stand-alone CTSP Sessions
Number of stand-alone sessions, Mean SD	1.3	(1.9)
Session length (minutes), Mean SD	18.3	(20.1)
Integrated CTSP sessions with advocacy
Number of integrated sessions, Mean SD	1.3	(2.3)
Session length (minutes), Mean SD	11.0	(16.0)

Qualitative study

Themes reflecting youths’ experiences of receiving CTSP

A subgroup of youth from the larger study participated in the qualitative interviews (n = 11), and approximately half of those interviewed were Black and a majority were female (Table 3). Overall, youth reported a positive perception of the CTSP intervention. All youth had previous experiences with counseling and in many cases in-patient hospitalization due to suicidal ideation and attempts. In general, youth tended to believe CTSP provided a more positive experience than their previous experiences of receiving care related to risk of suicide. The section below summarizes the positive and negative aspects youth identified regarding CTSP.

Table 3.

Demographic characteristics of qualitatative interview participants.

Participant ID	Role	Gender	Race/ethnicity
A1	Advocate	Female	Multiracial, Hispanic
A2	Advocate	Male	White
A3	Advocate	Male	White
A4	Advocate	Male	Multiracial
A5	Advocate	Female	White
Y1	Youth	Female	African American
Y2	Youth	Female	African American
Y3	Youth	Female	African American
Y4	Youth	Female	White
Y5	Youth	Female	White
Y6	Youth	Female	Multiracial
Y7	Youth	Female	African American
Y8	Youth	Male	African American
Y9	Youth	Female	White
Y10	Youth	Female	White
Y11	Youth	Male	African American

Safe and positive engagement with advocate

When asked about the most helpful aspect of CTSP most youth did not identify a specific skill or component of intervention. Instead, youth tended to focus on the connection and support they felt from their advocate. Many youth emphasized the importance of feeling like someone listened to them. As one youth noted, “he actually listened to me, umm, and he actually tried to help. More than just sitting there listening and not saying anything.” (Y4) It seemed in previous experiences of seeking care youth did not always feel listened to or understood, so their experience with the current study felt different. As one youth noted, “there’s a lot of people that don’t really listen and I could tell that he was listening, because of the way that he responds. And he’s actually, you know, taking the time outcause I think I called him like that-weird hour and he actually called me back.” (Y2) Feeling like their advocate was truly listening to them made youth feel cared about which seemed to be an essential component of engaging in the intervention. For example, one youth explained, “She really wanted to get to know me like as a person … it feels like she genuinely cares, you know what I mean.” (Y8) They went on to explain that feeling like their advocate cared about them made it easier for them to talk.

Perceived usefulness of the intervention

A big focus of CTSP is to help youth identify and replace negative thoughts. Youth were not asked directly about this in the interview, but when discussing helpful aspects of the intervention many youths noted that their advocate had worked on helping them with negative thoughts. One youth explained, “I told her about … how my thoughts were very pessimistic, they [the thoughts were] trying to attack and she would just, you know, I mean tell me ways to just deal with that … like guidance on how to fight it.” (Y8) Youth also noted that their advocate tried to help them identify or build on their coping skills to help manage their emotions when they felt overwhelmed. For example, one youth discussed how her advocate encouraged her to get back into writing, she explained, “He just basically told me to figure out what makes you feel better in those situations when you feel like that. And actually, I’ve started doing that. I told him writing was good for me. And girl, I’ve been writing so much, it’s crazy.” (Y4)

Discomfort discussing suicide

Some youth reported a general discomfort or disinterest in talking about their suicidal behavioral/thoughts if they were not currently feeling suicidal. One youth explained that if they were not currently feeling suicidal then they did not like to talk about their suicidal ideation because they worried it might trigger them to start feeling suicidal again, they explained, “If I’m not feeling suicidal, I won’t want to talk about it. Because … if he brings it up … of course it’s gonna bring up … umm … thoughts and stuff and I just don’t want to … be doing that again.” (Y7) While not a part of the interview questions, many youths disclosed significant experiences of childhood trauma had contributed to their suicidal behavior. Consequently, discussing suicidal ideation had the potential to also trigger memories of their trauma experiences which could be further dysregulating. It is likely this general disinterest of potentially upsetting topics may have contributed to the low rates of session completion among youth.

Level of care

Most youth reported they were satisfied with the intervention length and number of sessions offered. As noted above, most participants did not complete all available sessions. However, one youth did express significant dissatisfaction with the length of the intervention. In particular, she noted how challenging it was to develop a trusting relationship with her advocate and then “just have that end 6 months later,” she explained, “I do have trust issues and … I actually trusted to open up to. And then here we are six months later and I have to literally walk away from the person I trusted.” (Y6) Overall, her experience highlighted the potential need for longer interventions. Similarly, there was some indication that some youth needed a higher level of care than what was offered by CTSP. While not identified as a challenge by youth, two youth discussed instances when their advocate had to help them receive inpatient care due to their risk of suicide.

Themes reflecting advocates’ experiences of delivering CTSP

Overall, advocates who participated in the qualitative interviews (n = 5) reported that implementing CTSP with their YEH clients was feasible and that having an intervention to address suicide was a critical need for YEH given the high rates of suicidal ideation. However, advocates also noted some challenges and necessary adaptations that should be considered when implementing CTSP with YEH.

Learning and implementing CTSP

Advocates differed on how easy they believed CTSP was to learn depending on their prior clinical training. Most advocates shared they had prior clinical experience that they believed helped make it easier for them to learn CTSP. For example, when explaining their experience learning CTSP, one advocate believed their prior Cognitive Behavioral Therapy (CBT) experience had made it easy to learn CTSP, “I had a background in trauma-informed care, CBT and things like that, so integrating suicide prevention was just another step to it, which wasn’t really different.” (A4) However, one advocate was a counseling student and explained that at first, they felt overwhelmed trying to implement CTSP. They said, “It seemed a lot more complicated at first, but then over time you kind of get used to the different parts of it.” (A2)

While all advocates indicated they were able to learn and understand the intervention protocol, some advocates noted they still felt some stress when first implementing it with clients. As one advocated noted, “I knew all of that stuff, but then when it was time for me to implement it, I think that I was just a little bit nervous because of the seriousness of talking to someone about suicidal ideation. I didn’t wanna misstep or bring up any triggers or anything like that.” (A4) Additionally, advocates reported doing CTSP with YEH worked better if it was integrated into their other advocacy work, which they noted added another layer of learning.

In addition to completing the CTSP training, advocates reported the on-going supervision and review of session recordings was important given the stressful and complicated nature of implementing CTSP with YEH. One advocate explained, “at first I didn’t feel as confident. But, like, meeting with [supervisor], I think really helped me feel more confident and hearing her tell me what I-what I did right and what I needed to improve like made it seem very doable.” (A2) Similarly, another advocate explained their supervisor was helpful in helping them figure out how to integrate CTSP into their advocacy work, she noted, “[supervisor] has a great way of explaining it, and like helping us figure out how to just interweave and-and get it into the conversation.” (A1)

Difficulty discussing suicide

Advocates reported that they had some clients who were not interested in doing CTSP. Some advocates reported having clients who would become disengaged if they asked about doing a CTSP session, as one advocate explained, “I just feel like if I would go into a STEP session [CTSP intervention session], she would not want to see me. She does not want me to do that, you know? And like is not interested in going there. And that would have hindered our relationship just because of how much like, really, honestly, like how much trauma and everything she’s been through.” (A1) Similarly, one advocate also mirrored some of the youths’ statements about how youth may not want to talk about suicide when they are having a good day because it might bring their mood down, she explained, “going there right when someone is feeling really positive and actually has a place to stay for a few days, that’s not under the bridge, outside in the freezing coldbringing in how depressed they really feel under the surface is like inappropriate at certain times.” (A1)

Flexible delivery

Since youth appeared reluctant to engage in CTSP sessions, advocates tried to find ways to make it feel less intimidating to youth. All of the advocates discussed how they had to learn to adapt the structure of CTSP to meet the needs of their clients. As one advocate commented, “the structure is for you. The structure isn’t for them.” (A5) Thus, the advocate notes that the CTSP session structure was a good framework for delivering the intervention but needed to be personalized to each youths’ individual needs. Advocates discussed how the nature of homelessness is often chaotic and unpredictable, so trying to balance that with a structured intervention like CTSP required them to be flexible. Advocates also noted that they often were not able to complete all CTSP sessions with their clients, but still felt the intervention was helpful. As one advocate explained, “Sometimes it’s challenging to get scheduled all of the sessions that are recommended, but I think that even with just one session, it makes a difference for the youth, especially when you come from that empathetic place.” (A4) Overall, advocates tended to focus on following the general framework of CTSP while making adaptations to fit their client’s needs. One advocate explained, “I think it is good to be there as a framework. I would say that not everyone’s going to be open to engaging with it. Everyone’s going to engage with it on different levels. I think it is important to be receptive of that and then also see where there’s a little bit of wiggle room.” (A3)

CTSP in nontraditional settings

In addition to adapting the structure of CTSP, advocates also found their clients were more receptive to engaging in CTSP if it was done more informally, for example rather than setting up an appointment to do a CTSP session, advocates would add it into their conversations in less formal settings. As one advocate explained, “A lot of times, I know myself and my colleagues, we would integrate the CTSP session into peer advocacy. We would be going to take them to a housing appointment, or we would be on our way to a doctor’s appointment, and at some point we would integrate the conversation about the CTSP intervention versus saying, okay, let’s sit down and have a CTSP Intervention.” (A4) Overall, advocates believed adapting the intervention to be provided in less formal settings was a key component of increasing the acceptability of CTSP with their clients. As one advocate explained, “we were going with, like okay, let’s schedule STEP [CTSP intervention], we were finding it was more no-shows or more challenging to have meaningful conversation, but when we integrate it into regular conversation, I think that that helps us be able to increase the number of sessions that we were able to provide to the different clients.” (A4)

Need for additional intervention

In the current study CTSP was provided in addition to SBOA and advocates believed this was a good combination because it allowed them to also help youth address their basic needs by connecting them to services and find housing. As one advocate explained, “I think that like the fact that we are also able to be advocates at the same time and work on their goals, it makes it balance out, because what they really need is housing and like security and like positive relationships.” (A1) Advocates recognized that youth prioritized getting their basic needs met and thus would have been less likely to engage in their relationship if they had not also been providing SBOA, as one advocate explained, “We’re in a unique situation where we provide advocacy, whether it be helping them to find housing, helping them get connected to services for different medical needs, which includes mental health needs and things like that. Prioritizing that I found was more helpful in the CTSP intervention than me sitting down and talking to them about triggers and coping.” (A4) Advocates also recognized experiences of trauma contributed to suicidality for their clients and believed many youths would benefit from longer and more comprehensive therapy than what is provided. One advocate explained that while she believed CTSP was helpful it was probably not enough for some clients, “I feel like a lot of cases they would have benefited from a licensed counselor for longer-term counseling. But as a temporary thing, I think that it [CTSP] was able to meet like the needs of in the very least, like having someone that’s willing to-to listen to them and be like empathetic.” (A2) Overall, while advocates said they believed CTSP could be used by agencies serving YEH, they also emphasized the importance of it being part of a more comprehensive approach. As one advocate explained, “The CTSP is good, but it’s not the only thing … I think it’s just so important to look at the whole picture and help in as many different ways as possible.” (A3)

Discussion

Although there is a critical need for interventions to address suicidal ideation and suicide risk among YEH, studies do not routinely report on the adaptations needed to enhance acceptability of evidence-based interventions for YEH, and feasibility of implementation in community settings. In the present study, both the context and content of Cognitive Therapy for Suicide Prevention (CTSP) was adapted to be delivered in youth drop-in centers and through advocates for YEH. The adapted CTSP was perceived positively, and both youth receiving it and advocates delivering it felt that it was helpful. However, both youth and advocates also pointed to challenges, including the difficulty of discussing suicide and some challenges related to the timeline. These findings can inform efforts to adapt interventions to be delivered in nontraditional settings, such as through youth advocates, and to increase engagement of marginalized YEH in evidence-based prevention interventions. The adaptations made to the intervention appeared to have been well received and may have facilitated youth engagement.

One of the main adaptations made to the delivery of CTSP before enrolling any subjects, was the decision to deliver the intervention through trained advocates rather than through therapists in an office-based setting (a contextual adaptation to personnel and setting). This allowed youth to receive the intervention with their advocate alongside the delivery of SBOA (a content adaptation that integrated intervention elements). Using SBOA as a base for youth engagement and rapport building may have also facilitated trust and enabled further engagement with the difficult topic of suicide. Together with their advocate, youth were able to first focus on addressing basic needs and alleviating some of the stressors associated with a focus on survival, which may have also alleviated stressors and triggers for suicidal thoughts. As youths’ trust in their advocate increased, youth may have been able to more fully engage in the CTSP content. These findings build on previous work, which has identified social support from trusted individuals as key to protecting against suicide risk among YEH (Fulginiti et al., 2022; Kidd & Carroll, 2007). Many interventions delivered to YEH often point to a need for trust building as a critical first step, particularly for addressing mental health or other stigmatized conditions (Lynch et al., 2017; Santa Maria et al., 2019). This was echoed in the present study as well, with both youth and advocates pointing to the importance of establishing trust before talking about suicide. Thus, the findings of the present study build further evidence for the need to adapt interventions for YEH in ways that can enhance rapport building.

Prior negative experiences with mental health treatment were endorsed by many youths. These findings are consistent with other studies among YEH and other transition age youth that have highlighted negative treatment experiences as a source of unmet treatment needs (McCormick et al., 2022). It may be challenging for YEH to overcome negative prior experiences with the mental health treatment system to get the help that they need, especially when this care is not tailored to their needs and delivered in a developmentally appropriate way (Hudson et al., 2008). The positive experiences youth described in qualitative interviews point to the acceptability of the intervention and opportunities that similar intervention adaptations may offer to improving intervention reach, especially if interventionists are appropriately trained and demonstrate empathy toward YEH. Thus, it may be even more reason to deliver CTSP in a more flexible, and nontraditional manner that is receptive to youths’ needs and readiness to engage in the intervention. Outreach services, which typically occur in street or unsheltered locations and include engagement, case management, and focus on immediate needs, offer opportunities to engage those youth who are not currently connected to services and potentially reach those who are not receiving mental health care.

Both youth and advocates noted challenges with the timing and length of the CTSP delivery in the present study. Advocates noted that youth may not have been ready to receive the intervention, and as a result, restricting the delivery of the intervention to a six-month period may not have allowed YEH enough time to benefit. The timeframe of enrollment in the intervention (baseline or 3 months) allowed flexibility when youth begin receiving the intervention. Yet, the requirement that the CTSP be completed within six months of enrollment appeared to not have been long enough for some youth. Although advocates noted that even a brief session could have some benefits for youth and offered tools that they could use. Future studies could evaluate the ideal timeframe for delivering and engaging YEH in suicide prevention interventions to enable all youth who might benefit access to the intervention for an adequate time. In addition, when services such as CTSP are delivered through nontraditional providers (e.g., advocates), care must be given to the transition period when the service ends to avoid any potential harm to youth who may feel disoriented when care is interrupted. Future work could look more closely at the individual advocate and youth relationships to understand what could drive some challenges with rapport building and establishing trust that could hinder youth from receiving the full intervention as intended. Although the optimal number of CTSP sessions for youth is unknown, the receipt of CTSP for YEH in the present study was on average low. Lower dose of the intervention may limit youths’ abilities to gain important skills outside of times of crisis.

There are potential limitations to this study that should be considered. First, youth were interviewed who chose to take part in CTSP to learn more about how the intervention, and its adaptations, were received. These youth were all engaged in a supportive housing trial, and we do not know how their experiences would have differed had they not been participating in that larger study. For example, it is possible that experiences would have differed if CTSP was not integrated with a housing study. Nevertheless, learning from youths’ and service providers’ experiences with delivering an embedded CTSP intervention with other services may be more realistic to what the needs are of YEH and how an intervention could be feasibly delivered. In addition, the qualitative interviews included volunteer participants, and it is unknown whether their views are representative of those from individuals not choosing to take part in the interviews. It is possible that social desirability bias may have influenced the interviews and that more negative views of the intervention were not shared. In the future, studies might consider other methods of data collection, such as focus groups, which might elicit different or more rich perspectives from YEH who could feel more empowered to share intervention challenges.

In conclusion, greater flexibility in program delivery could be particularly critical to reaching YEH at risk for suicide. Rather than requiring YEH to attend therapy visits in office-based settings, it may be necessary to think more broadly about ways to reach youth through nontraditional settings. The delivery of CTSP through trained advocates appeared to be both feasible and acceptable to youth and may be a model that could be used for other interventions intended for marginalized populations of YEH.

Supplementary Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10852352.2025.2544394.